In May, the WHO’s World Health Assembly gathered to set the course for the next year in global health. But some in the scientific community are concerned: for the first time in its history, the Assembly endorsed changes to its International Classification of Disease list — and included traditional medicine diagnoses in its pages.
Its critics are vehement. Op-eds from Scientific American to Forbes Magazine have widely condemned the move as antithetical to the World Health Organisation’s commitment to evidence-based medicine, a desertion of duty to uphold the highest scientific standards. The WHO on the other hand argues that inclusion in the list is not an endorsement, but a valuable framework for testing and research.
Are alternative remedies really creeping into the WHO, pushed by private interests as some researchers fear? Or are the latest changes an important expansion of the definition of care?
In with the old?
Traditional medicine is booming as the the popularity of “wellness” booms around the Western world. Today, some estimate the industry is worth around $60 billion a year. But its rise has been driven by the conjunction of different trends.
According to the South China Morning Post, it’s increasingly seen as a form of soft power by some senior Chinese officials, a cultural export to compliment the millions of goods the country exports every year. In 2018, Chinese state media announced the construction of 57 traditional medicine centres across the world, from the United Arab Emirates to Germany.
But it’s also filling a void: traditional medicine is stepping into the vast gaps in access to high quality healthcare around the world. Half of the world’s population cannot access essential health services, according to a report by the WHO and World Bank, with 100 million forced into extreme poverty due to the cost of paying for healthcare. Traditional medicine offers an affordable healthcare access option in lieu of universal healthcare.
A spokesperson for the WHO stressed that the inclusion of traditional medicine in the ICD compendium was not an endorsement of its validity, but documents such as the 2014-2023 WHO traditional medicine strategy clearly signal that traditional medicine is creeping into at least some parts of the WHO lexicon.
A spokesperson for the WHO said: “Being rooted in cultures, traditional medicine has greater outreach as it is more acceptable, accessible and affordable for the general public as well as remote populations.”
“Delivery of safe and qualified traditional medicine services within existing healthcare networks could improve health outcomes at primary health care and contribute to achieving universal health coverage,” the spokesperson continued.
But for David Colquhoun, Emeritus Professor of Pharmacology at University College London, expanding access to treatments that have no basis in the evidence base is a pointless mission.
“WHO documents now speak of ‘traditional medicines of proven quality, safety and efficacy’, which I object to because there aren’t any,” he said.
A few traditional practices have enjoyed a smattering of positive results in clinical trials, he said, but no alternative practice stood up when put through larger-scale meta analysis, including treatments such as acupuncture which have undergone hundreds of clinical evaluations.
Meta-analyses have revealed no or “minimal” difference in pain relief between acupuncture delivered by specialists and “sham acupuncture”.
Colquhoun argues that any improvements experienced by people using traditional medicine can be explained by placebo effects, or regression to the mean, a statistical term for the phenomenon whereby an extreme result for a subject of a study tends to be followed by a much less extreme one.
Steven Novella, Assistant Professor of Neurology at Yale University, echoed Colquhoun’s concerns. “[Traditional medicine] is a pre-scientific form of medicine that is not strictly science-based and is not in the best interest of patients,” he said.
Until traditional remedies deliver evidence of clinical benefits of the standards that ordinary medical products are expected to meet, they have no place in the WHO, he argued.
“The WHO has a critical role in promoting health care and defending the health of vulnerable populations worldwide. They should not give in to political pressure to endorse or promote treatments that are not adequately scientifically demonstrated to be safe and effective.”
For Novella, traditional medicine is little more than a feat of marketing: “Anything shown to be useful would not be alternative,” he said, “The whole point of alternative marketing is to lower or even remove the science-based standard of care, and to change the rules of acceptance. It is about process — and the alternative process is flawed by design.”
The push for inclusion within national health systems and care networks is precisely what worries some of traditional medicine’s critics, who point out that the practice is not simply without evidence of its benefits, but that it can cause significant harm to both people and the planet.
Aristolochic acid, a compound found in numerous herbal medicines, has been linked to significantly higher rates of cancer in some areas of south-east Asia. Traditional medicine’s demand for rhino horns has partially contributed to the extinction of the white rhino across swathes of the world; the pangolin too is facing extinction thanks to its popularity among alternative medicine practitioners. (A WHO spokesperson condemned the use of any endangered species in traditional medicine.)
But even critics concede that traditional medicine seems to fulfil a function for some people — even if it’s nothing more than “doing something rather than nothing” in the words of David Colquhoun.
“Evidence based medicine has achieved some miraculous things, but for some things, very little progress has been made at all. When it comes to treating lower back pain, or problems such as depression, we have very few remedies,” he said.
But that’s no reason to integrate it into global health systems, he continued: “When people are desperate, they clutch at straws, and that’s what this is: clutching at straws.”
The popularity of traditional medicine — and its integration into the world’s health systems — is unlikely to wane in coming years.
Traditional medicine’s position at the confluence of Chinese foreign policy interests, the startling gaps in universal health coverage, and a range of conditions that medicine can’t yet fix suggest that its reach is only likely to grow.
Critics of traditional medicine won’t give up. But until universal health coverage becomes a reality, alternative remedies are unlikely to fade away. — Edward Siddons
(Picture credit: Matt Briney/Unsplash)