Review Article Singapore Med J 2001 Vol 42(10) : 487-492 Understanding Traditional Chinese Medicine – A Doctor’s Viewpoint N K Ho ABSTRACT mainstream medicine. Some call it Western Medicine. Generally modern medicine practitioners (doctors) Singapore is a cosmopolitan country and its 1a are trained in the universities, medical schools population comprises the Chinese, Malays, Indians, and hospitals where they are taught basic medical and others such as the Eurasians. In this heteroge- sciences and clinical skills. Modern medicine is neous, multi-racial, multi-lingual and multi-cultural also known in US as conventional medicine. society, medical treatment is also varied. People can seek modern (mainstream, western) medicine or 2. CAM or complementary and alternative medicine traditional medicine when they are sick. Usually they The term “complementary and alternative medicine” first seek modern medicine. Some turn to tradi- (CAM) reflects the nature of treatment that it tional medicine as complementary treatment or complements modern medicine, or used as an alternative treatment. Traditional medicine is alternative(1,2). CAM is not recognised as the here to stay in this country. In November 2000, the dominant medical system (main stream). Therefore Traditional Chinese Medicine (TCM) Practitioners 1bit is not available in hospitals, or reimbursable by Bill was passed in the Singapore Parliament. health insurance companies, the employers and Health care providers, including doctors, would others. Professional practice registration is usually benefit from a good knowledge of both modern and not required and a monitoring organisation or traditional medicine. Practitioners in traditional independent audit systems are usually lacking. medicine should also learn modern medicine. CAM relies on anecdotal evidence and the Keywords: complementary and alternative practitioners of CAM show little understanding medicine (CAM), herbal medicine, acupuncture, of the need for controlled clinical trials. They also moxibustion, Singapore lack the knowledge of how to do valid evaluations (3) Singapore Med J 2001 Vol 42(10):487-492 of their techniques scientifically . More individuals being treated with modern INTRODUCTION medicine also seek other types of medicine. CAM is The primary aim of an individual when he becomes considered synonymous with traditional medicine. ill is to get well as soon as possible. To him it does not Some have labelled it as “unconventional medicine”. matter what particular type of medical treatment he has to use. What a patient wants is to receive a THE FDA AND HERBAL MEDICINES non-invasive treatment that is free of side effects. Also, Many practitioners of traditional medicine claim medical treatment should not cause him discomfort that the FDA (US Food and Drugs Administration) KK Women s & and pain, and where possible is cheap and affordable. approve the herbs they prescribe. This may send Children s Hospital a wrong message to the public or the consumers. In 100 Bukit Timah Road Though modern medicine is asserted to be scientific Singapore 229899 and widely accepted as the mainstream medicine, 1994, two conferences were organised by the US FDA. N K Ho, MMed many countries approve traditional medicine. Doctors The FDA asserted that 1) Herbs are not medicines (Paediatrics), FAMS, but foods; 2) Data based on traditional use of herbs FRACP should therefore have good understanding of not Senior Consultant, only modern medicine, but also traditional medicine has no validity; 3) Assessment standards outside Clinical Associate Professor & Associate commonly used by its people. America (including those in Europe) are inferior to Dean American ones; 4) Assessment of herbal medicines Correspondence to: TERMINOLOGY should be as rigorous as for pharmaceutical drugs Dr Ho Nai Kiong Tel: (65) 732 4718 1. Modern medicine, mainstream medicine and and must include randomised-controlled trials (RCT); Fax: (65) 733 8306 Email: honk@ conventional medicine and 5) Herbal medicines should be liable for the same pacific.net.sg Modern medicine is considered by many as the sort of development costs as pharmaceuticals. Chinese Singapore Med J 2001 Vol 42(10) : 488 herbs would be classified as “Dietary Supplements” TRADITIONAL CHINESE MEDICINE (TCM) and2a would be regulated as such. Finally the FDA The 2b Chinese consider modern medicine as Western considers that no efficacy of herbal medicines has medicine (xi yi) because modern medicine origi- been proven and most benefits are likely to be placebo. nated from the Western world in contrast to Chinese medicine (zhong yi). Many people here term THE PREVALENCE OF TRADITIONAL MEDICINE traditional medicine as TCM or Traditional Chinese Strictly speaking, there is no alternative medicine. There Medicine. is only scientifically proven, evidence-based medicine There are many types of TCM, namely, Acupuncture supported by solid data. There should be one type of , moxibustion , herbal medicine , medicine or treatment that makes people well, from acupressure , qigong , oriental massage which all doctors should learn. Many people still , diet , etc. Acupuncture and herbal medicine consider traditional medicine as unproven medicine are more popularly known and commonly practised. for which scientific evidence is lacking(4). The World In acupuncture, specific areas of the skin (acupoints) Health Organisation estimates that four billion people are penetrated with thin metallic needles, which are or 80% of the world’s population presently use herbal then manipulated manually or by electrical stimulation. medicine3a for some aspect of primary health care(5). This 3b technique claims to be effective for chronic lung Traditional or complementary medicine is very diseases, alcoholism, relief of pain (post-operative and popular even in the West. In a recent survey, it was back pain), nausea, drug detoxification, urticaria, found that in Europe, 50% of the French and German nicotine withdrawal syndrome, etc. There was clear use complementary medicine; and 77% of the German evidence that acupuncture was effective in relieving pain clinics use acupuncture; In Belgium, 74% of postoperative chemotherapy-associated nausea and acupuncture treatments and 84% of homeopathic vomiting and postoperative dental pain in adults(11). treatments are carried out by medical doctors. Forty- There are other situations e.g. addiction, stroke seven percent of medical doctors in the Netherlands rehabilitation, headache, menstrual cramps, tennis practise some form of complementary therapy. elbow, fibromyalgia, osteoarthritis, low back pain, carpal In 1990 there were 60 million Americans who tunnel syndrome, asthma, etc for which acupuncture used alternative medical therapies, costing $13.7 billion. plays a role as adjunctive treatment. More controlled More people opted for alternative medicine (425 studies however, are needed. million) than primary care physicians (388 million). Some consider acupuncture more “scientific” because A4a recent survey reported that American adults using it 4bhas demonstrated functional MRI evidence. The CAM increased from 34% in 1990 to 42% in 1997(6,7). brain activity in real time can be visualised. The visual This figure may not be accurate. More than 70% cortex activity can be observed when the somatic of the patients did not tell their doctors that they areas are stimulated electrically. Cho demonstrated had visited practitioners of alternative medicine. the correlation between activation of specific areas of With such an enormous number of patients going for brain cortices and corresponding acupoint stimulation alternative medicine, an Office of Alternative Medicine predicted by ancient acupuncture literature. It is (OAM) was set up in 1992 to do scientific evaluation possible to show lineage between somato-visceral of alternative medicine(8). regulation and the corresponding brain function(12). Acupuncture was noted to be effective in treating TCM PRACTICE IN SINGAPORE some types of pain in adults, such as migraine, back In Singapore, the practice of TCM is confined mainly pain, and dental pain(13). However, in acupuncture, to outpatient care. Forty-five percent of Singaporeans controlled studies fail to support its efficacy. Some have consulted TCM, as per a survey conducted by the suspect whether it is a placebo effect. Some consider Ministry5a of Health Singapore in 1994; 12% or 10,000 that 5b there might be acupuncture-induced analgesia of daily outpatient attendance was estimated to be seen with the release of opioids e.g. endorphin, enkephalin, by TCM practitioners, the majority of whom were dynorphin, mobilisation of neuropeptides(14). Acu- trained locally by TCM schools(9). The number of puncture may adjust visceral function and modulate traditional medicine clinics operated by TCM immune response. practitioners grew by 59% between 1990 and 1998. In Moxibustion is less well known compared with 1998, the total income of TCM practitioners was S$57.6 acupuncture. In moxibustion, change of skin million, an increase of 21% amounting to 9.7% of all temperature occurs at acupoints, which are heat- the health clinics(10). Rationally, for provision of better stimulated by burning compressed herbal powders health care, only those physicians properly trained in at these sites. It was postulated that moxibustion works TCM should be allowed to practise TCM in our country. by heat-mediated neuronal release of nitric oxide 489 : 2001 Vol 42(10) Singapore Med J (NO) and stimulation of somato-visceral reflex.