Symposium “Exploring Traditional Medicine”

Opening ceremony

The meeting was opened by IAMP co-chair, Lai Meng Looi, who highlighted the fact that soaring healthcare costs in many countries mean that they are investigating the potential of traditional healthcare practices such as Ayurveda from India or Chinese traditional medicine (TCM), both of which are based on thousands of years’ of accumulated wisdom. She also thanked the reviewers, nominated by IAMP member academies, for selecting the case studies to be presented at the meeting, especially those attending who would also help to critically review the presentations.

Also at the opening ceremony, Daiming Fan, vice president of CAE, noted that, in the case of TCM: “There are those who argue that it is not science-based. It is true that we have not identified the scientific evidence for how it works. We must start to do that.” He also proposed a future integrated approach – the development of innovations from a merging of Western and traditional medical practices.

Boli Zhang, CACMS president, also accepted that the methodologies of TCM have not been standardized and that there are still many questions relating to safety and efficacy. “Traditional medicine can be effective”, he said, “and we must carry on traditional practices while improving them, using modern techniques to generate scientific evidence and identify solutions.”

Established 60 years ago, this is exactly the mission of CACMS, which currently employs 6,000 staff spread across 13 research institutes and two hospitals.

“Traditional medicine attracts both uncritical enthusiasm and uninformed criticism,” said Bernhard Schwartländer, representation of the World Health Organization (WHO) in China, during his opening address. “But it is arrogant to ignore thousands of years of wisdom. We need to explore it and exploit it. After all, 40% of the population of China and 80% of the population of Africa are using traditional medicines.”

The WHO, via a resolution taken at its 2014 World Health Assembly, has a strategy for traditional medicine, and recognizes the role it can play in national healthcare systems.

 “But there are still many gaps and grey areas in traditional medicine practices”, he added. “We need to build the evidence – what works and what doesn’t, develop standards and regulatory frameworks, undertake controlled clinical trials, and find innovative ways of documenting the evidence base, such as ‘big data’.” Schwartländer ended by expressing his hopes that the experts assembled in Beijing by IAMP and its partners could help galvanize this process.

“We still have traditional medicine after thousands of years because it is safe and effective,” claimed Wenming Yu, deputy director of the State Administration of Traditional Chinese Medicine (SATCM). “TCM is, in fact, both traditional and modern as it makes good use of modern developments and has been enriched over the years. Our hope now is that, with IAMP, CAE and others, we can push ahead with the global development of traditional medicine, boost international cooperation in the subject, and contribute to the global development of medical practice.”

The symposium

The symposium itself, held on 23-24 September, featured 24 presentations from the invited experts. More than 300 people registered to attend the event, many of them students and scholars of the CACMS institutes, but also presidents and vice presidents of CACMS institutes, as well as presidents of four Beijing-based TCM hospitals and editors of TCM journals.

The first session included seven presentations on clinical aspects. Boli Zhang, for example, highlighted that studies following good clinical practices and rigorous ethical standards had been carried out on Qi-Shen-Yi-Qi, a traditional medication for heart conditions. This formula can inhibit the inflammatory reaction, improve blood lipid content, and alter the structure of plaque tissue in the blood vessels, said Boli. A trial with more than 3,000 patients also demonstrated that it was as effective as aspirin, the allopathic drug of choice for certain heart conditions, but with less severe side effects. Qi-Shen-Yi-Qi has now been on the market for 15 years.

From Tanzania, Jichola Masanja introduced his research into the effects of Prunus africana on benign prostate hyperplasia. Using standard international Prostate symptom scoring system (IPSS) and measured for quality of life (QoL), his 80-patient study, however, showed no improvement in IPPS or QoL when compared to a placebo treatment.

In the session on acupuncture and moxibustion, one of the four papers presented also focused on benign prostate hyperplasia. More than 80 patients aged between 50 and 70 and showing mild to moderate signs of benign prostate hyperplasia were enrolled in the study, which included two treatment groups. One group received acupuncture with electrostimulation at the prescribed points (acupoints), while the other group received a similar treatment but with needles inserted at other sites. By the sixth week of treatment, and carried over 16 sessions through to the 18th week, IPSS scores improved for the acupoint group.

“Electrostimulation was the same in both groups, so it must be the acupoint that accounts for the difference in IPSS,” concluded Zhishun Liu of the Guang’an Men Hospital, CACMS.

Two additional randomized control trials illustrating positive results with acupuncture were described, one for functional dyspepsia and another for migraine prophylaxis.  Fanrong Liang of Chengdu University of TCM, for example, elicited significant changes in dyspepsia symptom index for the patients receiving acupuncture compared to those who were subjected to sham acupuncture and, using PET-CT (positron emission tomography-computed tomography), further demonstrated changes in the central nervous system in those who responded to the treatment.  These findings have recently been published in the mainstream scientific literature.

The session on public health featured two presentations, from Nceba Gqaleni, South Africa, and Senaka Pilapitya, Sri Lanka.

Comparing these two countries and China shows the different amounts of integration of traditional medicine into mainstream medical practices. While TCM is widely adopted and supported at government level in China, there is no government support for traditional medicine practitioners in South Africa. Gqaleni, for example, described a project designed to educate practitioners working in the large ‘informal’ heath sector in South Africa through five-day courses followed by two-years where trainers would work alongside the traditional practitioners. “The aim,” confirmed Gqaleni, “is to integrate health messages so that interventions on HIV or tuberculosis, for example, are consistent. Participants also learn how to protect themselves, for example when working with coughing TB patients.”

In Sri Lanka, as described by Pilapitya, the system of integration is more advanced, with a Ministry of Indigenous Medicine regulating the process. Even so, there are thousands of unregulated traditional medicine practitioners in the country who are technically operating illegally. The challenge is to identify these, register them and eventually regulate them, ensuring that only those who are qualified continue to practice.

In the meantime, a pilot project in Anuradhapura, Sri Lanka’s largest region, has trained 55 so-called health promotion officers’ via a university-certified 6-month course. (Another 55 are currently receiving training). These officers work in the community, typically with ageing patients and perhaps those being rehabilitated after strokes, often referring to Ayurveda techniques. In parallel, mainstream medical doctors in the country are being introduced to Ayurveda with positive results. The 127th Congress of the Sri Lanka Medical Association, for example, included a special side-event on traditional medicine that was well received.

Of the eight papers on drug discovery, two novel approaches were particularly interesting.  Aiping Lu of the Hong Kong Baptist University attempted to bridge the classification concepts of the mainstream International Classification of Diseases (ICD) and traditional Chinese medicine’s Zheng system, while Shao Li of Tsinghua University demonstrated a network target approach for deciphering TCM in the era of ‘big data’. ust be the acupoint that accounts for the difference in IPSS,” concluded Zhishun Liu of the Guang’an Men Hospital, CACMS.

In the final session, on pharmacology, a range of commercially available products based on ethnobotanical knowledge and follow-up scientific evaluation were introduced. These included Fanalarofy and Fanalanendo, two products patented in Madagascar to treat convulsions, epilepsy and headaches, with ingredients derived from the endemic resurrection plant (Myrothamnus moschatus). Likewise, Ebenezer Farombi introduced Kolaviron (derived from Garcinia kola), now being marketed in Nigeria. His studies show that Kolaviron has potent antioxidant activities that can help in modulating chemopreventive or chemoprotective effects in the liver, brain or testes.

Finally, a herbal tea, Primus, is now on sale in Croatia after medical historian Stella Fatovic-Ferencis tracked down an old recipe that referred to cancer-healing properties of the burr parsley (Caucalis platycarpos). A combination of investigative work in the field to track down the rare plant, and in the lab to uncover the properties of its component compounds, contributed to the launch of this product. The start-up company that produces Primus, Fitofarmacija, also now grows burr parsley in efforts to ensure supplies.

These three examples, plus several of the others presented, confirm that developing products from traditional medicines can be done, but it is difficult – without ‘unlimited funds’ – to refine those products into single-component pharmaceuticals required in allopathic medicine. Instead they are often marketed locally, and often not as medicines but under labels such as ‘functional foods’ or ‘supplements.’  Despite big pharma’s interest in natural products (with a high proportion of products released over the past 30 years being derived from naturally-occurring compounds), the cost-benefit ratio of building on small-scale laboratory studies and local releases of herbal products are not attractive to multinational companies, while local companies are often non-existent or lack the resources to develop their own products for an international market.

Summing up, Lai Meng Looi noted: “From the very first we noted accurate attention to controlled trials, the search for ethical approvals both institutionally and nationally, and that outcomes were measured using objective international standards. There was also a willingness to see traditional medicine with new eyes, including through the use of ‘big data’.

“Even though several of the studies presented have been published in reputable journals, others still require further validation to address some of the questions raised,” she continued. “These uncertainties refer to issues such as potential toxicity, long-term side effects, and the interaction of traditional medicines with other drugs. Other challenges, too, were raised during the meeting and will need further consideration, including the regulation of traditional medicine practitioners, quality control of traditional medicines, the conservation of the source plants of traditional products, and intellectual property rights – including the feedback of benefits to the communities of origin and not just to commercial companies.”

Lab visits / Hospital tour

The final day of the symposium provided the opportunity for the delegates from outside China to visit three CACMS institutes: the Institute of Acupuncture and Moxibustion, the Institute of Chinese Materia Medica, and Data Centre of TCM.

While many of the visiting experts were familiar with the practice of acupuncture, few of the countries represented had integrated it into their national healthcare systems. There was great interest, therefore, in seeing some of the experimental practices that are being used to validate and improve acupuncture procedures. Among the 156 staff members are 28 researchers and 52 assistant researchers responsible for managing 125 research projects, many of them funded by the National Natural Science Foundation, the main funding agency for scientific research in China.

Moxibustion involves burning ‘moxa’, or dried mugwort (Artemisia argyi), which is applied indirectly via acupuncture needles, or burnt on the patient's skin. It plays an important role in the traditional medical systems of China.

The Institute of Chinese Materia Medica, CACMS, is one of the oldest national institutions engaged in research on Chinese materia medica. In 1983, it was recognized as a WHO Collaborating Centre for Traditional Medicine. With more than 400 staff, the institute focuses on the identification, preparation, biotechnology, quality control, pharmacology and toxicology of Chinese materia medica. Using a high-tech array of equipment such as gene sequencers, nuclear magnetic resonance (NMR) spectrometers, liquid chromatography-mass spectroscopy systems, and others, the institute has averaged an output of more than 100 research papers per year over the past three years.

CACMS’ Data Centre of TCM has a shorter history, being formally established in 2014. It collects, stores and assists with the retrieval of patient data from 16 collaborating hospitals around China. It also uses the latest data mining and analysis techniques to extract information from these huge data sets.

The final day of the event, 24 September, included a visit to Giang’anmen Hospital, part of the CACMS system, and a TCM manufacturing base of the Beijing Tong RenTang Group – the largest TCM producer in China and which is listed on the Shanghai stock exchange.

Giang’anmen Hospital, one of more than 3,000 TCM hospitals in China, has 600 beds and treats 10,000 outpatients per day. Doctors practicing there must first obtain medical degrees before specializing in TCM.

The IAMP delegation was introduced to some of the procedures in use in the hospital, including acupuncture – as an alternative to drugs – to help sedate a patient suffering from Parkinson’s disease, and a method to relieve back pain using heat – in this case fire – to drive volatile compounds from a herbal mixture through the skin to the site of the pain.

The hospital’s pharmacy is responsible for preparing the herbal concoctions prescribed by the doctors from a stock of 600 different material medica. Carefully weighing the correct proportions of each constituent, typically aqueous extracts are prepared for each patient.

“The information provided by the professor who conducted us through the facility and the other who informed us how the hospital manages its patients with the use of clinical doctors trained in herbal medicine and herbal products was inspiring,” confirmed one of the invited experts, Festus Tolu of the Kenya Medical Research Institute, after his trip to Beijing.

For people requiring – or seeking – less personalized treatment, there is also a huge market in China – and elsewhere – for TCM products. China exports some 240,000 tons of medicines annually, of which 200,000 tons are traded as raw herbs. In 2010, China’s TCM market was estimated at RMB317.2 billion (more than US$40 billion), and it is estimated that the total TCM market in China will rise to more than US$100 billion by 2025.

Indeed, more than 3,000 enterprises are engaged in processing TCMs, and leading companies are quoted on the international stock exchanges in Shanghai and Hong Kong. The largest company is the Beijing Tong RenTang Group (TRT), and symposium participants also had an opportunity to visit one of their production bases in the city where they learned that they also have more than 800 retail stores in China, and more than two dozen joint-venture stores in 15 other countries.

IAMP-next

Following the symposium, the lab visits, and the tours of the hospital and the manufacturing facility, the IAMP delegates were certainly left with the impression that TCM is taken seriously in China and that there are opportunities for collaboration with both their national research systems to develop new drugs, herbal remedies or functional foods, and their national healthcare systems as they seek to integrate and regulate traditional medical practices within their current healthcare structures.

“We will continue to talk, to share and to collaborate with our partners and develop new ways to work together,” confirmed Lai Meng Looi at the conclusion of the symposium. “It will be important to cultivate the new friendships formed here in Beijing and to follow up with the different projects. I hope this symposium will mark a new beginning and offer new impetus to overcome the remaining barriers between different medical systems, allowing us to further tap and harness traditional medicine and provide it with the recognition that it deserves.”

For IAMP, the next step in this project is to develop the case studies presented during the symposium into a book that will be made freely available in hard copy and online. Publication is set for early/mid 2016. IAMP will also continue to work with its member academies while it continues to explore the synergies between traditional and allopathic medical systems.