East-West Medicine: Towards a More Complete Integrative Paradigm

East-West Medicine: Towards a More Complete Integrative Paradigm

When Rudyard Kipling wrote, “East is East and West is West and ne’er the twain shall meet,” he could not have predicted the era of global communications that is simultaneously bringing together disparate cultures and diminishing their distinctive identities. While medicine advances on many fronts, including genomic research and immunological treatment of cancer, one of the frontiers must surely also be cross-cultural. After a century during which traditional Chinese medicine had been on the defensive in its homeland, the People’s Republic of China after 1949 determined to preserve serviceable elements of the tradition that were not inconsistent with Western scientific medicine (1) , according to Chairman Mao’s dictum to “let the past serve the present.” In the modern era, acupuncture was introduced to the West through an article on the front page of the New York Times in 1971 by the reporter James Reston, who accompanied Richard Nixon on his historic trip to China, describing the elimination of his post-operative pain after an emergency appendectomy at a Beijing hospital through the anesthesia produced by three acupuncture needles.

Currently, China could be considered to have the world’s most completely integrative medical system, with Western-style allopathic practitioners routinely working alongside traditional-style practitioners in hospitals and clinics, each type of practitioner required to train in the other’s style of medicine as well as their own. In the West, naturopathic physicians required to study basic medical sciences and clinical medicine, as well as “nature cure” modalities, in many cases have also completed training in traditional Chinese medicine, and are therefore uniquely positioned to accomplish a three-way, most complete integration of not only allopathic and naturopathic traditions, but also Eastern and Western medicine.

According to an article published in a Korean-language medical journal, the integration of Traditional Chinese Medicine (TCM) and Western medicine began 400 years ago. In the modern era, the concept of what is now routinely termed Integration of Traditional Chinese and Western Medicine (ITCWM) took root following the establishment of the People’s Republic of China, particularly through research leading to the eradication of epidemic diseases such as schistomiasis. Following a lapse in progress during the period of Cultural Revolution, China established an Institute of ITCMWM and departments of ITCMWM in hospitals and medical schools, to foster research in clinical practice and book publications. (2) Chinese researchers have established diagnostic classifications of PCOS, differentiating anovulation from hyper-androgenism, based on the differentiation of TCM syndromes of Kidney Yin Deficiency with Phlegm Blockage and Blood Stasis from Kidney Deficiency with Liver Qi Stagnation.(3) An article in the Journal of Integrative Medicine has brought attention to the parallels between the modern Western approach of “precision medicine” and the personalized style of treatment provided by the TCM model. (4) An Integrated Western and Chinese medical approach to glucolipid metabolic disease encompasses the Chinese medical concept of liver dysfunction in metabolic and emotional regulation leading to endogenous production of Dampness and Phlegm.(5)

Numerous research studies, primarily randomized controlled trials, have compared the effectiveness of the integrated East-West medical model with the effect of Western medicine by itself. When traditional acupuncture was combined with conventional rehabilitation therapy and compared with rehabilitation therapy alone for treatment of shoulder hand syndrome after stroke in 20 studies involving 1918 participants, the combined therapy significantly reduced pain on a visual analogue scale, improved limb movement and the performance of activities of daily living with a 95 percent confidence interval for the mean difference (6). For 60 hospital patients diagnosed with thoracolumbar burst fracture, randomly assigned to “three-step reduction (TSR) therapy of integrated of Chinese and Western medicine” or posterior open (PO) surgery, results showed reduction of the fracture, rebuilding the height of the centrum, recovering the biomechanical function of the spine, and reducing bleeding better in the TSR group than the PO group (P< 0.05) (7). In treatment of 89 patients with delayed encephalopathy after acute carbon monoxide poisoning, randomly divided groups received either hyperbaric oxygen (HBO) therapy alone or HBO in combination with granules of the Chinese traditional herbal formula, XingZhiYiNao. The groups were compared on activities of daily living (ADL), cognitive function, and the impairment degree of cerebral white matter. On all measures, efficacy of the combined treatment group was superior to that of the HBO group ( P< 0.05) (8). A total of 60 patients with diabetic xeropthalmia were randomly assigned to a control group of Western medical treatment alone or an experimental group of treatment with traditional Chinese and Western medicine. With 95 percent confidence, the combined treatment was effective in reducing inflammatory biomarkers and reducing
corneal injuries (9).

Other research studies have been mainly on ITCWM treatment of cases of cancer and severe acute respiratory syndrome (SARS). A retrospective study was conducted on 67 patients with Stage II-IIIA Non-Small-Cell Lung Cancer after radical surgery from two Chinese hospitals treated either with conventional chemotherapy alone or traditional Chinese medicine integrated with chemotherapy. With a 95 percent confidence level, the study concluded that addition of TCM therapy reduced the rate of tumor recurrence and metastasis and prolonged median disease-free survival (10). In a study of 54 castration-resistant prostate cancer patients, a randomly selected control group was treated by endocrine therapy (bicalutamide and goserelin), chemotherapy (docetaxel) and oral prednisone, while an experimental group received the same treatment with the addition of the Fuyang Huayu traditional Chinese medical herbal prescription for tonifying yang and dispersing blood stasis. Comparing the two groups of patients, Karnofsky, FACT-P and TCM symptoms scores were all significantly improved in the trial group but not in the control group (11). In animal and histological research on cell lines in vitro and in vivo of pancreatic cancer, an aggressive disease with a particularly poor prognosis, treatment with gemcitabine, a chemotherapy agent, was combined with baicalein, a type of bioflavinoid originally isolated from the roots of the Chinese herbs scutellaria baicalensis and scutellaria lateriflora. The results demonstrated that the inhibitory effect of gemcitabine on pancreatic cancer cells and promotion of apoptosis were enhanced by the combined use with baicalein (12). Also, a meta-analysis of 27 articles with randomized trials involving 4,368 patients was conducted on mammary gland hyperplasia, a common breast condition that confers an increased risk of carcinoma. The results showed with a high level of statistical significance that the combined treatment of tamoxifen with the Chinese herbal formula Ru-Pi-Xiao achieved better therapeutic effects than tamoxifen alone, and furthermore suggested that this combination could prove the level of progesterone and decrease the size of breast lump to a greater extent, providing a possible pharmacodynamic mechanism for the combination (13).

In a controlled study of 49 patients with SARS, one group was treated with antibiotic, antiviral and other drugs, while the other was treated with an ITCWM combined protocol. Treatment of the latter group was superior in terms of symptom improvement, shortened therapeutic course, recovery of immune function and absorption of lung inflammation, and decreased dosage of medication required (14). In another study, 48 hospital patients diagnosed with SARS were randomly divided into a corticosteroid treatment group and a combined ITCWM treatment group. The hospitalization time, body temperature stabilization time, and time of corticosteroid use were shorter in the trial group than in the control group (P<0.05) (15). These findings were confirmed by another controlled study involving glucocorticoid treatment of SARS in 461 patients compared with the integrated approach. In the ITCWM group, the average time in hospital and duration of pneumonia were shortened, mortality fell and average dosage of glucocorticoid was decreased, with a statistically significant difference in favor of the integrated therapy group (16).

The classical theoretical underpinning of acupuncture and Chinese herbal medicine has featured Taoist philosophical concepts of energetic phases and correspondences in nature (Yin and Yang, Five Elements), but this system that has not developed significantly in 1000 years has been minimized in modern official Chinese government pronouncements, while paradoxically the complete traditional theoretical system is the version taught at over 100 professional colleges of acupuncture and Chinese medicine in Western countries. According to Paul Unschuld, a prominent historian of Chinese medicine, this Western variant of Chinese medicine is “conditioned more by the expectations and demands of a Western population than by the marshalling of scientific evidence.” (17) Or, in other words, “a medical system develops its theories and gains and maintains the acceptance of the community it serves not by its clinical effectiveness but by the acceptability of its underlying ideas.” (18)

The need for such a conceptual alternative to modern biomedicine has arisen partly from the reaction to well-publicized negative aspects of chemical agents and technology and alienating aspects of a medical system based on a nineteenth century industrial/mechanical rather than a holistic model and a medical culture of an expert elite whose training and practice have not emphasized the doctor-patient interaction. The result, according to Unschuld, is “a conceptual adaptation to Western fears.” (19) Medical choices in popular consciousness are thus placed in the realm of belief, similar to religious preferences, dependent more on family or cultural environment than on scientific data.

At the same time, there has been limited scientific acceptance of acupuncture, in spite of its long professed effectiveness, since it does not fit the double-blind controlled experimental model that is best suited to provide a scientific stamp of approval to marketable drugs. This raises the question of what constitutes evidence in the era of “evidence-based medicine.” Is evidence-based medicine necessarily the most effective medicine? Do most allopathic physicians even practice evidence-based medicine or is it more honored in the word than the deed? According to a report from the Office of Technology Assessment of the United States Congress, 10-15 percent of medical practice is based on controlled clinical studies.(20) Furthermore, the most downloaded study from the Public Library of Science states the following:
“Published research findings are sometimes refuted by subsequent evidence, with ensuing confusion and disappointment. Refutation and controversy are seen across the range of research designs, from clinical trials … to the most modern molecular research. There is increasing concern that in modern research, false findings may be the majority of … of published research claims … It can be proven that most claimed research findings are false.” (21)

At the same time, Marcia Angell, editor of the New England Journal of Medicine, agrees that such journals constitute “primarily a marketing machine.” (22) Ample documentation can be provided for publication bias, i.e. publication of only the positive studies supporting a particular drug, while ignoring the negative studies, and stating “evidence-based” decisions based on a biased sample. (23) (24) Currently, “10 to 30 percent of the world’s health care is delivered by conventional Western methods; the remaining 70 to 90 percent is rendered by alternative modes of treatment.” (25) Herbalists and acupuncturists Michael and Lesley Tierra proclaim on the basis of a vast empirical accumulation an “integrated system of Planetary Herbology”, Incorporating Western naturopathy, the early American Thompsonian system, Chinese herbal medicine, Ayurvedic Medicine of East India, Native American herbology, Middle Eastern Unani Medicine, Tibetan Medicine, as well as the folk medical traditions of many cultures worldwide. (26) Considering the exclusiveness of Western medical orthodoxy in its training and practice, perhaps it is appropriate to quote Shakespeare: “There is more in heaven and earth than is dreamt of in your philosophy.” Is there in fact an alternative science or a non-Western body of scientific knowledge? Joseph Needham, the Cambridge biochemistry scholar whose biography describes him as “The Man Who Loved China”, (27) is often credited with the single greatest work of scholarship, “Science and Civilization in Ancient China,” now posthumously extending to more than 22 volumes. (28) Each volume deals with a different branch of ancient Chinese scientific knowledge, such as nautical science, astronomy and astrology, botany and other biological science, etc. One could learn, for example, that in the eleventh century, there was a Chinese practice of using powder derived from aging smallpox scabs for inoculation, although the credit for smallpox vaccination usually goes to Edward Jenner (1796). (29)

How is such a body of knowledge acquired and verified as a basis for practical application, if not by the experimental method? Evidence may also be empirical, i.e. based on trial and error over an extended period. “The empiricist precedes the man of science, and the work of empiricism finally gives us data that enables man to formulate laws, until at last science is born.” (30) Apparently, as the survey of the Office of Technology Assessment indicates, modern Western physicians, along with the rest of the world, past and present, depend primarily on applying what has worked through their experience. An extension of the empirical method in the modern era is statistical evaluation, and in fact most of the published evidence for the effectiveness of traditional Chinese acupuncture and herbal medicine is based on the statistical weight of evidence of therapeutic effects on several hundreds or thousands of subjects.

It is well know that many of the drugs utilized in the pharmacopeia of Western allopathic medicine are derived by extracting the chemical part of a drug and later synthesizing it. Examples are aspirin from willow trees, digitalis from foxglove and reserpine from rauwolfia. (31) In fact, the farther one extends back into antiquity, even beyond Hippocrates to the Sumerians, Babylonians and to prehistoric Neolithic times, the more Eastern and Western empirical medical traditions coincide, particularly on the points enunciated by naturopathic physicians: 1) vis medicatrix naturae (the healing power of nature); 2) use of natural therapeutic agents, such as air, water, sunlight, diet and herbs; 3) emphasis on prevention; 4) using the least invasive or harmful agents; 5) the doctor as health educator; and 6) treating the whole person, recognizing emotional causes of physical disorders.

When the choice between a traditional empirical system and a modern allopathic system is available, how is a decision made? Arthur Kleinman, psychiatrist and medical anthropologist, conducted an inter-cultural study of medical systems available to modern Taiwanese residents, finding that Western medical practitioners are chosen when people believe that they need a drug medication, whereas traditional Chinese medical practitioners or temple fortune-tellers are consulted when the need is felt
for a personal emotional interaction. (32)

What would an integrative East-West naturopathic-allopathic encounter between physician and patient look like? There would be considerable overlap of the two approaches in history-taking and examination. Traditionally in China, assessment of internal states was based on examination of external inspection of the pulse, face and tongue and palpation of the pulse and acupuncture meridian points. This Eastern-style physical inspection would accompany Western examination of vital signs, along with review of systems. A naturopathic practitioner might include palpation of Chapman reflexes on the trunk area, reflecting the condition of internal organs, as well as evaluation of spinal alignment. Both traditions could utilize symptoms survey questionnaires, including a questionnaire to evaluate the Ayurvedic dosha (body type or constitution), i. e. vata, pitta or kapha (corresponding to dominance of nervous system, digestive-circulatory systems, or body tissues and structure) Findings from the history and physical examination could reveal, from the Eastern perspective, for example, indications of internal heat (Yin Deficiency or Pitta dominance), usually reflecting inflammation or infection. For the same patient, the Western exam might show elevated temperature or blood pressure or pain (localized or general). The East-West physician could seek corroboration of these findings through electrodermal testing of meridian extremity points, bioresonance testing, and through laboratory tests – in addition to basic CBC and metabolic panel, additionally ordering CRP, ESR, viral antibodies (HSV, EBV), or in some cases expanded thyroid and adrenal panels. Considering a different scenario, for the East-West physician, a pale tongue and weak pulse (Blood Deficiency in Chinese medicine) could correspond to anemia or infertility or several other conditions.

For the most complete individual health profile, the integrative practitioner could order additional panels for mineral and heavy metal analysis, comprehensive amino acids and organic acids, food and environmental allergies, digestive stool analysis and chemical toxins. Some would now add a genomic profile as well. Of course, each test leads to individual prescription of specific nutrients or therapeutic protocols, while the accumulation of test data, taken in combination with data on blood type, Ayurvedic
dosha, body measurements, medical history and symptoms, could generate a complete individual Prescription Food Plan. This process would require a software program such as Food Pharmacy, which permits inputs for all medical conditions, laboratory data, nutrient imbalances and allergens and produces a comprehensive color-coded list of dietary items that benefit or aggravate one’s individual conditions. Such a plan would fulfill Hippocrates’ injunction to “let one’s food be medicine and one’s
medicine be food.” Maintaining a diet that truly fits one’s body would address current health issues, prevent more serious conditions in the future and maintain stable weight and metabolism.

While this integrative nutritional prescription could be considered the ultimate lifestyle goal, the integrative East-West physician would in every interaction with patients attempt to maintain an open understanding and application of the fullest possible scope of medical-cultural principles and practices from Eastern and Western sources.

REFERENCES

1. Unschuld, P. Chinese Medicine. Boston: Paradigm; 1998: 2
2. Shin, SS. Development of integrated traditional Chinese and Western medicine and change of medical policy in China. Uisahak 1999; 8(2): 207-32
3. Yu J, Yu CQ, Cao Q, Wang L, Wang WJ, Zhou LR, Li J, Qian QH. Consensus on the integrated traditional Chinese and Western medical criteria of diagnostic classification in polycystic ovary syndrome. J Integr med 2017 Mar; 15(2): 102-109
4. Wang WJ, Zhang T. Integration of traditional Chinese medicine and Western medicine in the era of precision medicine. J Integr Med 2017 Jan 15 (1): 1-7
5. Guo J. Research progress on prevention and treatment of glucolipid metabolic disease with integrated traditional Chinese and Western medicine. Chin J Integr Med. 2017 Jun; 23(6): 403-409

17. Unschuld, 123.
18. Wiseman, Nigel in Translator’s Forward to Unschuld, vii
19. Unschuld, 113
20. Assessing the efficacy and safety of medical technologies. Congress of the United States Office of Technology Assessment Archive, Sept 1978: 7.
21. Ioannis JPA. Why most published research findings are false. PLOS Medicine 2005 2(8): 124
22. Angell, M. Industry-sponsored clinical research: a broken system. JAMA 2008; Sep 3: 300 (9): 1069-71
23. Turner EH et al. Selective publication of antidepressant trials and its influence on apparent efficacy. New Eng J Med 2008; 358: 252-260
24. Doshi P, Jefferson T, Del Mar C. The imperative to share clinical study reports: recommendations from the Tamiflu experience. PLOS Med 2012; 9(4) 201
25. Alternative Medicine: Expanding Medical Horizons. A Report to the National Institutes of Health on Alternative Medical Systems and Practices in the United States. (Washington,D.C.: U.S. Government Printing Office, 1994). NIH Publication No. 94-066
26. Tierra, M. The East-West Herb Course 1996: 1
27. Winchester, S. The Man Who Loved China. Harper Perennial 2008
28. Needham, J. Science and Civilization in Ancient China. Press Syndicate, University of Cambridge 1954
29. Ibid, 6: 134
30. Lloyd J. Quoted in Tierra, M. The East-West Herb Course 1996:3
31. Tierra,M. 4
32. Kleinman, A. Patients and healers in the context of culture. Berkeley: Univ of Calif Press 1980