Talking sense about our ancient art & science

Charles Buck

Member: Cheshire

In the true spirit of our recycling age, ten years on we invited Charles Buck to revisit, revise and remind us of some nicely relevant arguments he first laid down in a series of four articles in The Acupuncturist. So tell us now, Charlie, what do we need to do to get some respect?

Ever stumbled across one of those quackbuster diatribes and noticed a little misinformation and medico-scientific bigotry?

Backward looking

Critics say we use oriental nonsense theories and that Chinese medicine (CM) offers no rational concept of disease and pathology. Biomedicine is more ‘real’ as it offers detailed descriptions of pathology. We know this is untrue – but our responses rarely appear robust or connected to a real understanding of the tradition. We maybe need to reflect on the narratives we present.

Sometimes holistic doctrines derived from naturopathy are grafted onto CM. The pitch ‘we don’t treat diseases…’ misrepresents China’s healing traditions. We DO treat diseases and the way we do this is by recognising and treating underlying patterns. The study of symptoms, pathology and disease has always been an integral part of CM. Besides the qi-based explanatory models of health and disease that form one pillar of our practice, China’s physicians also studied the material nature of disease. This work stands up well to modern biomedical scrutiny, even though some was written long ago.

Here are some examples of CM pathology study.

In 326 CE Ge Hong described many diseases. About smallpox, he wrote: ‘The lesions look like burns covered with a white starchy material and whose surface reforms as soon as it is broken. If not treated immediately most people will die, those who survive will be left with purple-black scars.’

Later, Qian Yi (1023-1108) published a detailed account of the symptoms, diagnosis and treatment of chicken pox, measles, scarlet fever and smallpox. Similar discussions of pathology exist for most illnesses.

Chao Yuanfang (581-618 CE) wrote a 52-volume text on pathology – On the Causes and Symptoms of Illness – which gave accurate descriptions of 1,732 diseases. On diabetes he wrote: ‘Wasting-thirsting involves unremitting thirst with polyuria, sufferers often have carbuncles and gangrene…. This is a disease with sweet urine that often starts in those who become obese having overindulged in sweet and rich food.’ This description could safely be copied into a modern biomedical text.

Centuries after its publication, Chao’s pathology text was translated into Arabic and became part of Avicenna’s medical works which spread to the west and helped found biomedical pathology. Yes! Modern medical pathology is rooted in the work of China’s ancient physicians.

So we can challenge the assertion that CM lacks any basis in medical fact and the rational study of pathology. We can drop the naturopaths’ we don’t treat diseases thing. CM pioneered the pathology science and has a long tradition of scholarly study of disease and pathology to partner our energetic explanatory model.

‘Everyone at work thinks I’m mad coming for acupuncture!’

Despite decades of work we still have some way to go before we are perceived by many as serious and effective medical professionals. For many we are the wacky brigade. ‘Everyone at work thinks I’m mad coming for acupuncture!’

Ironically, acupuncture can seem more plausible to the medically literate than it does to the Clapham Omnibus Person. But while most doctors know its value for some conditions, fewer seem to like actual acupuncturists – an issue we should ponder on perhaps. We should reflect on ways to improve our act and facilitate the acceptance of traditional acupuncture.

Important though it is, characterising what we do in terms of our qi-based models too easily downplays the fact that the tradition included pragmatic study of disease states. We become vulnerable to suggestions that CM is unreal, that we are living in an oriental cloud cuckoo land that provides no rational understanding of disease. But we are not mad acuflakes! In truth, China had plenty of dysentery, smallpox, boils and haemorrhoids and treated things sensibly and seriously. Medical pathology is just as much a part of the historical tradition as all the energetic stuff.

Do we also need to reflect on the level of criticality we apply to the tradition we espouse? Grasping a nettle here… could it be that critics have a point when they suggest we have an overly credulous acceptance of ancient ideas? How often do we ask ourselves, is this fact actually true? For all its sins, science accepts that its truths are tentative, always open to challenge and change. In theory at least, biomedicine faces up to the fact that some of its medical teachings are wrong. As the famed Edwardian medical grandee Sir William Osler used to say to his students, ‘By the time you get into practice a half of what you have learned will be proved wrong – we just don’t yet know which half’.

How often do we cast a critical eye over our theories? Are the teachings all correct, all of the time? I once conducted a search and failed to find a single formal critical appraisal of acupuncture doctrine in our CM literature in the west! This lays us open to criticism and goes against the spirit of the greatest architects of CM.

True Chinese medicine is pragmatic, rational and investigational in spirit. Throughout history it was those who challenged established doctrine when it failed to match up with clinical reality who made some of the greatest contributions. During devastating epidemics some had the audacity to challenge classical Han dynasty theories when they did not work, putting criticality above blind respect for ancient doctrine; the result was the founding of a new branch of medical theory. Ideas that were important at one point in history can become obsolete in another. We should openly debate and research such questions.

The Journal of Chinese Medicine (JCM) did publish one article that aimed to test the raw food weakens spleen qi idea. The conclusion was that it didn’t; indeed, those eating raw food ended up having slightly stronger spleen qi! Probably in Han dynasty China uncooked food got a bad reputation due to ‘night soil’ contamination and this became enshrined in medical lore. Today your Waitrose lettuce is unlikely to give you dysentery. Ignore critical investigation and we are indeed simply custodians of a fossilised, complacent and sometimes mistaken medical system. A critical outlook surely has greater integrity, it shows that we care about the validity of what we provide to our patients. Politically, a critical mindset makes us less vulnerable to accusations of delusion or backwardness. It might lead to a subtle change in our collective voice, away from ‘the human body has energy channels and a balance of yin and yang…’ to a more tentative ‘healthcare can be modelled in this time-served way and we research this system for the modern world…’. Personally, I believe that what we do is primarily a rational medicine, not a mystical belief system, and that we should seek ways to demonstrate this and, as a profession, to embody this through a culture of criticality.

Questions of anatomy

It is a well-known and amusing fact in sceptic-world that acupuncture is silly because the ancient Chinese didn’t have a clue about anatomy. But is this true? And even if it were true, how much does it really matter in actual day-to-day medical practice? We really do have to straighten the record on anatomy. It was in the 1840s that anatomy became the main area that western physicians chose to use as evidence of the superiority of their medicine over China’s version. In turn, China’s physicians pointed out that biomedicine’s weakness lay in the scant attention it paid to understanding and regulating function. But the westerners couldn’t see what on earth the Chinese were on about so they assumed it was nonsense. China had a reasonable understanding of anatomy for over 2,000 years but to classical physicians much of that knowledge did not seem crucial. Butchers knew anatomy, also medical tradespeople such as midwives, bonesetters, haemorrhoid experts and battlefield trauma specialists. Aside from Hua Tuo’s alleged surgical exploits circa CE 200, the messy giblet stuff was not the domain of the silkclad classical physician. You could always call on the haemorrhoid specialists, or midwives, and if you needed wounds drained Portrait of Ge Hong: woodcut attributed to a Tang dynasty (618-907) of pus you could see a specialist sores doctor. Unfortunately, their knowledge has mostly creator, Gan Bozong been lost, having been entrusted to the less literate professions.

We will struggle to influence people via rational debate and by reference to the evidence

Anyway, for much of history the biggest concerns were lifethreatening epidemics; having names for all the body’s bits of gristle doesn’t help much there. Still, it is reasonable to say that for two millennia China’s understanding of anatomy has exceeded that of the West.

The Mawangdui manuscripts (168 BCE) named some neck muscles:

muscle: ce yang; translation: slanted-lateral yang; probably:trapezius

muscle: heng yang; translation: enduring yang; probably: sacrospinalis

muscle: ce yin; translation: slanted yin; probably: scalenes

muscle: qian yin; translation: front yin; probably: sternocleidomastoid

There are also records of formal human dissection in the Han dynasty and the Neijing often mentions the internal organs. This extract from Wang Mang’s biography may have been a source of the Neijing descriptions of the digestive tract and of blood circulation: ‘[in 206 BCE] After Wang Sunjing was captured in battle the Emperor ordered that his body be dissected by a butcher and a court physician. His internal organs were measured and the course of the blood vessels traced using a strip of bamboo. This was done to improve the treatment of disease.’

Anatomical knowledge advanced in Song dynasty works – the Chart of Mr Ou Xifan’s Organs was published in 1045, then the Collected Truths Chart based on the dissections of 55 cadavers. Another more accurate text based on new dissections was published by Yang Jie in 1113 and gave a reasonable account of internal human anatomy.

The reason this issue became the chosen battleground in the 1840s was because at that moment in history anatomy was perhaps the single area where biomedicine was demonstrably superior. But while admittedly the Chinese texts lacked the precision of the later European anatomists, anatomy is not everything; the most crucial measures of a medicine are clinical safety and efficacy. Ironically, in terms of therapeutics, at that time Chinese medicine was superior to its western counterpart and its treatments hold up well in contrast to those of western medicine, most of which would be considered ineffective or dangerous today. Western anatomy may have been obsessively detailed but it was not always a great help in practical therapeutics.

Portrait of Ge Hong: woodcut attributed to a Tang dynasty (618-907) creator, Gan Bozong

The belief problem

If CM advocacy is to succeed we need to understand how beliefs are formed. We need to learn how to influence beliefs. We need to recognise that our pre-existing gut-level beliefs are much stronger than facts in determining how we process information.

I’m not talking here about religious faiths but cognitive science of belief, the way that our minds create simple rules to help us function in the world.

Beliefs are often revealed when people say things like A means B, or X is Y. We mostly learn these beliefs without noticing but we then have a deep sense that they are true: such beliefs profoundly bias even what we consider our most rational conclusions and our ability to interpret facts.

People often have strong beliefs about acupuncture, views that are rarely altered by the supply of facts! We imagine people will be convinced by facts – but in reality, supplying facts seems to make people even more entrenched in their existing views. Understanding this particular fact is crucial in smoothing our progress into mainstream healthcare in the West. Even intelligent people in positions of influence suffer from belief bias.

Beliefs can trigger emotional responses in milliseconds, they can kick in so quickly that we have responded before we are even aware of it. OK, we might weigh things up analytically too, but this comes later, works slower, and even then, our emotions colour things. Reflex emotional responses set us on a course of thinking that's highly biased, especially on topics we feel strongly about. You may have noticed that some people actually get cross when they hear what we do!

Challenge beliefs and associations come to mind – instantly we recall ideas that match our existing beliefs and we formulate arguments to challenge the threatening idea. We imagine we are thinking objectively, whereas actually we are just solidifying our existing prejudices, perhaps by giving greater weight to evidence that supports our beliefs and debunking arguments that challenge these beliefs.

Our unconscious beliefs set links to our sense of self, alien ideas can feel like they threaten our very identity so our first instinct is to reject. We resist belief change even when the facts say otherwise. And so our advocacy must do more than just tell people stuff.

In science, peer review tries to tackle this problem by subjecting new ideas to a quality control process so the best ideas can prevail through consensus. Unfortunately, peer reviewers are just as prone to belief biases as anybody else. Experts and the public alike are unduly influenced by those perceived as having status, gravitas, charisma and fame. Even scientific truth is not really truth but a current consensus arrived at through belief processes that we have only a vague awareness of. Scientific truth is not really truth but rather a special form of mythology, the outcome of a Darwinian struggle between the beliefs of individual scientists.

Long-time CAM critic Edzard Ernst showed us this. He wrote two versions of a clinical trial of a slimming treatment. The text was identical except that in one paper the treatment was a chemical and in the other it was described as a herb extract. Submitting the two versions for peer review to journals worldwide he found that the herb version was five times more likely to be rejected by the peer reviewers. Judgement of the quality of the science was strongly influenced by subconscious belief-based biases, in this case that a chemical product is inherently more scientifically valid than a herb product. The reader too brings personal belief biases to the reading process. So, the ‘scientific consensus’ is fatally flawed by human nature.

All this means that we will struggle to influence people via rational debate and by reference to the evidence. Simply doing more and better research doesn't change things as much as we might expect. Modern medicine is a belief system, firmly wedded to its own ingrained mythologies and is not especially amenable to change.

So what’s our strategy?

It dawned on me a while ago that the ultimate function of research is to alter beliefs. If we do research and beliefs remain unchanged then the research has failed – we have wasted our time and money. Our profession has literally billions of euros worth of research in print but the impact has been lacking. If we want evidence to be influential it has to be presented in ways that don't trigger contrarian emotional reactions and should be framed to resonate with the recipient’s mindset, outlook and beliefs.

Pitching to those who value hierarchies, we can use authorities. For those who value science we have to invoke influencers whose science credentials count for something. For those who dislike the otherness of CM we should adjust our use of language to prevent prejudicial belief hackles being too easily raised.

Conservative thinkers and policymakers will embrace CM more easily if information comes via credible or charismatic authorities who can set things in the context of different values from those normally espoused by alternative therapists. Politicians need to hear messages from those they give social proof to, such as bigger politicians or economists.

To succeed in our moves toward fuller recognition, and respect, I suggest we need to reconsider our approach, both collective and individual. We have to make a strong coherent and persuasive case to our patients, on our websites and also at a national level.

We must also box clever in understanding the way belief change happens. Only then can we communicate the true extent of the tradition more accurately, have proper criticality, and convey effectively the profound wisdom to be found in the traditional explanatory model.