Steven Salzberg, a friend of this blog and Director of the Center for Bioinformatics and Computational Biology at the University of Maryland, is on the editorial boards of three of the many journals published by BioMed Central (BMC), an important source of open-access, peer-reviewed biomedical reports. He is disturbed by the presence of two other journals under the BMC umbrella: Chinese Medicine and BMC Complementary and Alternative Medicine. A couple of days ago, on his Forbes science blog, Dr. Salzberg explained why. Here are some excerpts:

The Chinese Medicine journal promotes, according to its own mission statement, studies of “acupuncture, Tui-na, Qi-qong, Tai Chi Quan, energy research,” and other nonsense. Tui na, for example, supposedly “affects the flow of energy by holding and pressing the body at acupressure points.”

Right. What is this doing in a scientific journal?… I support BMC…But their corporate leaders seem to care more about expanding their stable than about maintaining the integrity of science. Chinese Medicine simply does not belong in the company of respectable scientific journals.

Forming a scientific journal whose goal is to validate antiquated, unproven superstitions is simply not science, whatever the editors of Chinese Medicine claim.

BMC should be embarrassed to be publishing journals that promote anti-scientific theories and otherwise muddy the literature. By supporting these journals, they undermine the credibility of many excellent BMC journals. They should cut these journals loose.

Matthew Cockerill, a molecular biologist and self-described skeptic who is Managing Director of BMC, responded. Quoting Tim Minchin’s poem Storm (“You know what they call alternative medicine that’s been proved to work?…Medicine”), he wrote:

Well-known examples of “alternative medicines” that have made the transition to “medicine” include aspirin (explicitly cited in ‘Storm’) and artemisinin, a compound identified in a type of traditional Chinese herbal medicine, derivatives of which are now used to treat malaria.

Clearly for this transition to be possible, there must be a way for effective aspects of Complementary/Alternative Medicine (CAM) to prove themselves and to become “Medicine”. Journals focused on evaluating CAM are not the only approach to doing this (such research might also be published in a regular medical journal), but they are one valid approach…

… Regular medical journals may tend to be dismissive of anything with CAM-associations…

In a second comment (which at the time of this writing is unavailable, but Dr. Salzberg sent me a copy) Dr. Cockerill continued:

Steven,

In your post you suggest that journals relating to complementary/alternative medicine (CAM) including Traditional Chinese Medicine have no place in BioMed Central’s portfolio, and your broader implication is that these fields represent nothing but pseudoscience and are unworthy of (or indeed are incompatible with) scientific investigation.

BioMed Central does not share this view. We accept that this is a challenging and controversial area, and that one of the problems to be addressed is that much CAM research is lacking in scientific rigor. However, to dismiss all aspects of CAM out-of-hand and to exclude research on CAM from scientific discourse would only give ammunition to those who try to characterize the scientific process as being close-minded and based on presumptions which are not open to question.

You refer to BMC Complementary and Alternative Medicine as a “pseudoscience journal” which “promote[s] anti-scientific theories”, but this is really not the case.

Dr. Cockerill argued that standards of peer-review and methodological rigor for that journal are not different from those for the rest of the BMC group. He named Edzard Ernst as a member of the editorial board. More:

Moving to the field of Traditional Chinese Medicine – while it is true that there are some aspects of TCM as traditionally practiced that are likely to hold only anthropological/psychological interest from a scientific point of view, it is also clear that there are many active ingredients in traditional Chinese Herbal Medicine (CHM) which are worthy of further investigation in terms of biological mechanism and clinical effectiveness. This is an area that has attracted significant funding from commercial and public sources – see for example this article from Science magazine in 2003. http://www.sciencemag.org/content/299/5604/188.long

Looking at articles published in the journal Chinese Medicine, the evaluation of active components within herbal remedies accounts for a large fraction of research articles published, and this cannot easily be dismissed as either irrelevant or inherently pseudoscientific.

In an earlier email to Steven Salzberg, Dr. Cockerill had written:

The major problem I have with such a blanket dismissal is that it lumps everything together as being equally valueless, whereas the goal of the scientific process is to winnow the wheat (however rare) from the chaff…

If you look at articles published in Chinese Medicine, you will find little if anything on “Energy fields” (not a fruitful area for scientific investigation, I quite agree, and not something which I believe should be in the scope of the journal), but a great deal on biochemical and functional genomic work in relation to traditional herbal medicine, which is quite a different matter.

Bait and Switch: the Yin and the Yang

Sigh. Where to begin? Let’s start by trying a slight revision of Dr. Cockerill’s own words: The major problem I have with such a blanket acceptance is that it lumps everything together as being equally valuable, whereas the goal of the scientific process is to winnow the wheat (however rare) from the chaff…

That’s more like it. I imagine that Dr. Cockerill will find that statement unfair, in that it fails to acknowledge that there may be reports in the two journals that disconfirm hypotheses that are not fruitful for scientific investigation (if you catch my drift). I concede that, but the point here is a different one: Dr. Salzberg objects to including anti-scientific topics in the journals precisely because doing so gives the appearance that real scientists believe that they must be intriguing enough to warrant space in real biomedical journals.

But they are not: it is clear, after a moment’s reflection, that natural products research is the ONLY worthwhile scientific endeavor within the editorial purview of Chinese Medicine, so why pretend that it justifies the rest? Matthew Cockerill may agree that “energy fields” should not be included; nevertheless they are—which was Dr. Salzberg’s point. Tim Minchin, bless his heart, probably doesn’t realize that his statement about “alternative medicine that’s been proved to work” is itself purely hypothetical: there has yet to be an example of such a medicine. Dr. Cockerill ought to know that, as I will explain a bit later in this piece.

An Article Brings Homeopathy to Mind

I have little time to investigate the non-[natural products pharmacology] articles in Chinese Medicine; Dr. Salzberg cited one, which he characterized as “a laughably bad study.” I’ll tell you a bit about another, just published in January:

Misdiagnosis and undiagnosis due to pattern similarity in Chinese medicine: a stochastic simulation study using pattern differentiation algorithm

The article is nearly incoherent. Passages such as this abound:

In Chinese medicine, diagnosis is also important. Practitioners recognise and label nosological conditions based on inspection (Ip, wang), auscultation and olfaction (AO, wen), inquiry (Iq, wen) and palpation (P, qie), also known as the Four Examinations (Sizhen). According to traditional literature, these methods should be applied in order to enhance recovery of the patients. Manifestations (ie signs and symptoms) collected from patients are interpreted using Chinese medicine theories (eg eight principles, five phases, vital substances, six channels, four levels, triple burner and Zangfu), which were developed on the basis of some observations of Nature. Similar to Western medicine, the collected manifestations are interpreted collectively; however, diagnosis is established through a pattern differentiation process whereby a unique, stable manifestation profile is obtained for the identification of a pattern among other diagnostic hypotheses.

The article appears to torture statistics to show that each additional Examination among the Four confers a slightly greater degree of certainty that the examiner will not confuse two different “diagnoses” (in the TCM sense of the term). At least I think that’s the point. But the investigator didn’t determine this by testing actual practitioners, as far as I can tell; he did it using “a stochastic computational simulation based on Monte Carlo method implemented for patient simulation from ZFSP in a dataset.” And a good thing, too, because if there’s anything useful to be gleaned from this paper, it’s found in references 19-24. They show, unsurprisingly, that there isn’t much agreement from one TCM practitioner to the next about either “diagnoses” or treatments.

Hmmm. No surprise when you consider what those diagnoses, i.e., patterns, involve. Here is the pattern of “Deficient Cold of Small Intestine…often discussed as Deficient Spleen Qi,” according to Ted Kaptchuk, an American who seems to have invented the “OMD” degree that won him a professorship at the Harvard Medical School, and who is on the editorial board of Chinese Medicine:

Signs: slight, persistent discomfort in lower abdomen; gurgling noises in abdomen; watery stools.

Tongue: pale material; thin white moss

Pulse: empty

Here is the pattern of “Deficient Cold in Stomach…often called Deficient Spleen Yang”:

Signs: chronic diarrhea; slight persistent pain in epigastrium; discomfort relieved by warmth, eating, and touching; shy; easily influenced by others

Tongue: pale material; most white moss

Pulse: deep or moderate without strength

And so on, for hundreds of patterns. According to Kaptchuk, “pulse examination can be the most important of the Four Examinations and is crucial to pattern discernment in general.” Paul Unschuld, a prolific historian of Chinese medicine, explains how this is done:

The physician has the choice of either feeling the (radial) pulse with three fingers or with one finger. Using three fingers, light pressure with the index finger above the imaginary line level with the styloid process allows him to feel the state of the lung and heart, greater pressure with the middle finger on the imaginary line enables him to feel the state of the spleen, and greater pressure still with the ring finger allows him to feel the liver and kidney. According to a third (and certainly not the last) variant, he can, with one finger, apply a pressure equal to the weight of three beans to feel the lung, a pressure of six beans to feel the heart, a pressure of nine beans to feel the spleen, a pressure of twelve beans to feel the liver, and finally a pressure that brings the fingertip almost to the bone, to feel the kidney.

What does “correct” pattern recognition mean, in the practical sense? Well, it means that the correct therapeutic intervention will occur. Kaptchuk again:

The goal of all treatment methods in Chinese medicine is to rebalance those aspects of the body’s Yin and Yang whose harmonious proportion and movement have become disordered…inappropriate anger such as that characterized by excessive Liver activity must be calmed…insufficient activity, say of the Kidney Yang, must be tonified to avoid lack of sexual energy…If there is not enough Qi in the Lungs, it must be replenished…If the Qi in the Spleen descends, causing chronic diarrhea, it must be lifted; if the Qi of the stomach ascends, it causing nausea, it must be sent down. Stagnant Qi must be moved…Too much Cold in the Kidney must be warmed; extra Fire in the Lungs must be cooled. Whatever is out of balance must be rebalanced. The complementary aspects of Yin and Yang must be harmonious.

Here’s how it’s done:

…the insertion of very fine needles into points along the Meridians can rebalance bodily disharmonies. A related technique [is] moxibustion…The action of the needles or of moxibustion affects the Qi and Blood in the Meridians, thus affecting all the fundamental textures and Organs. The needles can reduce what is excessive, increase what is deficient, warm what is cold, cool what is hot, circulate what is stagnant, move what is congealed, stabilize what is reckless, raise what is falling, and lower what is rising.

OK, enough already. Is it not obvious that this is the classic assortment of metaphors, myths, traditions, and appeals to authority that is common to the medicine of pre-scientific cultures? Were Chinese medicine theories developed on the basis of some observations of Nature? I don’t think so.

The claims regarding pulse examination are quite fanciful, to say the least: that changing the pressure of the examining finger would allow the practitioner to feel the state of the various, named organs is hard to conceive, given what is now known about anatomy and physiology; it’s also clear that pre-modern Chinese physicians would have had no way test this claim. There is a smattering of empirically gathered symptoms and signs that are based on history taking and external examinations, some of which are repeatable and might have eventually become useful, if pre-modern Chinese medicine had pursued anatomy, physiology, and pathology before those fields were developed elsewhere—thus making that aspect of “TCM” moot.

Funny: the “patterns” remind me of another conspicuous pre-scientific “school” of medicine: homeopathy, with its elaborate ‘symptom’-gathering scheme, its voluminous repertories, rubrics, and simillima. And, of course, its lack of agreement from one homeopath to the next regarding the ‘correct’ constellation of ‘symptoms’ and therefore the correct ‘remedy.’

Pharmacognosy is neither “CAM” nor “Chinese Medicine”

Dr. Cockerill’s other points are a mixture of reason and misunderstanding. Legitimate natural products research is not “CAM,” and should neither be billed as such (or as some other misnomer such as “Chinese Medicine”) nor should it be purported to justify “CAM,” which, if anything, hinders such research. Aspirin is not an example of an “alternative medicine that made the transition to medicine” any more than quinine or atropine or digoxin are such examples. Nor is artemisinin. Everyone with a modicum of education knows that many useful drugs have been, and will continue to be, derived from natural sources, exactly as biology would predict. This is completely unsurprising. The term “alternative medicine,” along with its various synonyms, refers to a recent political and quasi-religious movement, not to a longstanding branch of drug development that is scientific and that has not required the help of pseudoscientific zealots to pursue its investigations.

If Chinese Medicine were limited to pharmacognosy and had a more appropriate title—Asian Pharmacognosy, for example, referring to the geographic origin of the products studied, not to some pre-scientific medical ‘system’—I’d have little problem with it, assuming that the natural products reports are as rigorous as Cockerill claims them to be.

“Chinese Medicine” is a misnomer in several ways. First, the medicine overwhelmingly used in China today is modern, scientific medicine. Second, pre-scientific Chinese Medicine was not one or even a few schools of medicine but many disparate schools, occurring at various times over millennia and in various places over a huge geographical region. Some schools were completely unrelated or even contradictory. There was much influence from abroad, including India and Greece. Third, the term “Traditional Chinese Medicine” was coined only about 55 years ago in the PRC, mainly for pitching to (gullible) Westerners. It heralded something that, paradoxically, had never before been true in China: a forced standardization, such as to make ‘Chinese Medicine’ appear to be something that it was not: a conceptual whole.

Last Thoughts

I’m running out of gas, but another straw man used by the “CAM” movement, repeated by Matthew Cockerill, is that “Regular medical journals may tend to be dismissive of anything with CAM-associations.” There was a time in the 1990s when editors of the major journals had to answer this charge on a regular basis, and each time it went something like this:

Dr. Siegel’s charge that medical journals will not publish studies of alternative medicine comes out of thin air. Journals compete avidly to publish important new clinical research, if it is rigorously done. As we indicated in our editorial, the problem with the studies funded by the Office of Alternative Medicine in 1993 was not their size, as suggested by Dr. Cherkin and Ms. Street, but their quality.

In fact, major medical journals have, to their own embarrassment and to the detriment of uninformed readers, bent over backward to accommodate substandard “CAM” treatises.

“CAM” advocacy journals, moreover, have become far more evident in the past few years, thanks in part to political pressure applied by anti-intellectual demagogues such as Dan Burton—even as the only journal committed to an appropriate, skeptical view of “CAM” was excluded from listing by the US National Library of Medicine after similar political pressure.

Perhaps someone else will look at some of the articles in BMC Complementary and Alternative Medicine. I have neither the time nor the inclination, but I would like to reiterate a point that Steven Salzberg and we have all made at one time or another: even the subsequent publication of a reasonable scientific report doesn’t justify creating a journal for the purpose of “helping aspects of CAM prove themselves.” If there’s scientific promise for some new way to solve a problem, and if a legitimate study is done, there are plenty of opportunities to report it in the medical literature.