Donkeys are a hot item in Africa. In recent years, the prices of animals and their skins have risen so much that people have been stealing them. Some countries, including Niger, Tanzania and Botswana, have resorted to export bans to preserve their donkey populations. And last month, the Nigerian government moved to make the slaughter and export of donkeys illegal there.
This donkey rush is fueled by the 15 billion yuan ($2.2 billion) annual market for ejiao, a gelatin obtained by boiling donkey skins. It is a popular ingredient in Traditional Chinese Medicine (TCM), believed to stop bleeding and fight coughs and cancer. Demand has grown in recent decades as China’s wealthy population has grown: a 250 gram can can sell for a few hundred dollars. As prices have risen and donkey populations have shrunk in China (from 9.4 million in 1996 to 4.6 million in 2016), the country has turned to Africa. Other animals are more threatened. China’s appetite for TCM remedies has helped push species such as tigers, rhinos, seahorses and pangolins to the brink of extinction.
This situation is all the more troubling given that there is little evidence that preparations made from these animal products actually deliver the promised benefits. TCM is based on unfounded theories of meridians and qi. Most Western-trained physicians and medical researchers view TCM practices with skepticism: there is no substantial evidence that most of them work, and there are signs that a few do harm.
Signals regarding TCM from the Chinese government are conflicting. On the one hand, China displays a belief in evidence-based medicine and has invested millions of yuan in programs devoted to the modernization and standardization of TCM. That’s welcome — but so far, these programs have given only a veneer of legitimacy to treatments that haven’t been rigorously tested in randomized, controlled clinical trials. On the other hand, MTC is a big business that receives strong support from the government. Last January, the Chinese government lowered import duties on donkey skins from 5% to 2% to ensure supply. He enthusiastically promotes TCM around the world, often on the back of his massive Belt and Road Initiative, and he stifles criticism of TCM at home.
These mixed signals are now being mirrored ominously by the World Health Organization (WHO), which last week approved a new version of its International Classification of Diseases, a highly influential document that categorizes and assigns codes to medical conditions. , and is used internationally to decide how doctors diagnose conditions and whether insurance companies will pay to treat them. The latest version, ICD-11, is the first to include a chapter on TCM – part of a warming up of the practice under former director-general Margaret Chan, who led the WHO from 2006 to 2017.
TCM practitioners around the world have celebrated its incorporation into the document as crucial to the international dissemination of the system. China too. On May 26, a government newspaper called it a “major milestone for the internationalization of TCM” and a huge help in establishing TCM centers around the world.
Moreover, criticism rains down on the WHO. The organization defended its position. In an April 4 statement, she insisted that the TCM chapter does not deal with particular remedies. Rather, it aims to give doctors the ability to diagnose patients using both traditional Chinese medicine and Western medicine — what it calls “optional dual coding.” These categories “do not reference – or endorse – any form of processing,” the statement said.
Traditional medicine should certainly not be dismissed: sometimes that is all that is available in many parts of the world. Some life-saving therapies come from natural products, and there are undoubtedly others. Famous, the reference antimalarial drug, artemisinin, was discovered in China – isolated from sweet wormwood (Artemisia annual), an herb used in TCM. It is also important to distinguish harmful practices from those that may not work but are relatively benign, and those that may work but have not been rigorously tested.
Even so, the WHO chapter on traditional medicine risks backfiring. It is broad and detailed, and risks legitimizing an unfounded underlying philosophy and some unscientific practices. It may only contain diagnostic criteria, but once diagnosed with a condition labeled TCM, people will likely be prescribed TCM remedies. Whatever its goals, the WHO chapter is unlikely to do more than fuel the expansion of sales of largely unproven treatments.
In advocating for the inclusion of TCM, the WHO referred to a mission of “evidence-based information sharing”. Everyone can agree on the desire to expand health care, and to do so in an evidence-based way. Gathering more evidence on TCM requires sustained and rigorous basic and clinical research to distinguish between harmful practices, those that show promise, and those that have only a placebo effect. WHO’s association with drugs that are not properly tested and may even be harmful is unacceptable to the agency that has the greatest responsibility and power to protect human health.