Commentary: If TCM really works, why are some still sceptical about it?

SINGAPORE: If you live in Singapore, there is a good chance you’ve encountered more than one style of medicine. You’ve most likely been to see a conventional medical doctor at a polyclinic or private hospital at least once in your life. There’s also a good chance you have also seen some kind of alternative or traditional medical practitioner.

In fact, about half of Singaporeans have visited a Traditional Chinese Medicine (TCM) practitioner in the past, Health Minister Ong Ye Kung said in 2022. The Ministry of Health (MOH) is also looking at how TCM can play a role in Healthier SG’s preventive care initiative.

Singapore’s medical landscape is pluralistic and multicultural, just like its population. TCM and Western medicine have co-existed alongside one another for many years, yet they have never been fully integrated.

Some recent moves, like the new Chinese Medicine degree offered at Nanyang Technological University - the first such programme to be conferred locally in Singapore - as well as a new structured training programme by MOH that will see selected TCM practitioners go through clinical rotations, may change that.

INTEGRATIVE MEDICINE: THE BEST OF BOTH WORLDS?

What does it mean for two systems of medicine to be integrated?

In its ideal form, integrative medicine seeks to combine Western medicine with traditional, complementary and alternative therapies for a more holistic healthcare system.

Proponents argue that this benefits patients by increasing the range of choice and allowing them to tailor treatment to their needs and values. Integrative medicine can also allow for better coordination across treatments and methodologies to potentially reduce side effects. For instance, patients can minimise the side effects of chemotherapy by incorporating acupuncture or massage.

Additionally, integrating traditional practices may offer alternative treatments for conditions that are not well-addressed by Western medicine alone. For example, patients with many chronic conditions like fibromyalgia, migraines, and chronic fatigue syndrome have been observed to find relief through TCM.

Integration offers some benefits to practitioners of traditional medicines as well. For them, integration with conventional medicine can mean an increase in the perceived legitimacy of their practice, and also, not inconsequentially, an increase in the number of patients and income that they can access.

Even so, some TCM practitioners are sceptical. For them, what matters is respect for the authenticity of the traditional medicine itself. Because integration often entails fitting into the dominant medical paradigm (biomedicine), this can mean that traditional practices are forced to water down or modify their practice to conform to expectations.

Many hospitals in Singapore already offer integrated medicine to some extent. For example, Sengkang’s General Hospital, National University Hospital, Singapore General Hospital, Tan Tock Seng Hospital and Khoo Teck Puat Hospital all offer acupuncture services alongside the conventional medical services.

While it’s true that patients can and often do access both TCM and conventional medicine in Singapore, currently, each tradition of medicine operates in its own domain. This means practitioners rarely, if ever, actively collaborate with regard to the care of a patient. In fact, many people who consume traditional medicine are hesitant to disclose their use of it to their biomedical doctors, often because they do not want to be shamed or scolded for being “backward”.

But with Healthier SG’s emphasis on coordinated care planning, this may change. Though we have yet to see how it will play out, this could mean more active dialogue between conventional medical doctors and TCM practitioners.

For patients, better coordination between a family doctor and a TCM doctor could help avoid possible negative interactions between certain herbal remedies and pharmaceuticals. If patients were previously reticent to share or disclose their use of these herbs, they could have been exposed to undue risks. But with better coordination across care, these risks could be more effectively minimised.

WHAT WILL THIS MEAN FOR TCM?

However, there are some stumbling blocks to effective integration as well. One principal difficulty comes at a very fundamental level: TCM and modern medicine do not share a common understanding of disease, nor do they understand the human body in the same terms.

Where biomedicine sees nerves and organs, TCM sees meridians and qi – and these differences are more than merely linguistic. Qi, as a concept, does not map on to any concrete property that science can measure. This means, at minimum, there is a very challenging gap that would need to be bridged in order for TCM practitioners and family doctors to communicate with one another and coordinate care effectively.

A further challenge comes with the lack of standardisation of TCM treatments. As Harvard Medical School’s Ted Kaptchuk describes in his book, The Web That Has No Weaver, six patients with stomach ulcers (as diagnosed by a conventional doctor) could be diagnosed with six different unique syndromes in TCM, each with its own herbal remedy.

While in some sense, this lack of standardisation can be considered a plus – TCM offers highly personalised and tailored treatments – it also makes it more challenging to assess the efficacy of a treatment for a given condition. This, in turn, makes collaboration even more difficult, since the standards of efficacy within Western medicine are not easily applied to TCM or other traditional medical practices.

WHY IS TCM REGARDED BY SOME AS SECOND-CLASS?

It is likely this lack of shared worldview and lack of standardisation that have led many sceptics to treat TCM and other traditional medical practices with suspicion. As a consequence, even in the multicultural Singaporean context, and even in the hospitals where acupuncture is offered, there is a sense that TCM is relegated to a kind of second-class status.

Conventional medical doctors maintain the position of power and authority, and TCM comes in only as an adjunct or supplement to their care. This is far from an egalitarian picture of collaboration across traditions.

Can this situation be changed? Perhaps.

Research into traditional medicines and the value of traditional medical knowledge has been gaining in prevalence. In fact, in 2015 the Nobel Prize in Physiology or Medicine went to a Chinese pharmacologist, Tu Youyou, for her work on artemisinin (a drug which can significantly reduce the mortality rate of patients suffering from malaria) and one which she identified through investigating TCM pharmacological literature.

Since then, traditional medicines are continuing to gain international recognition and respect. Notably, the World Health Organization held its first ever global summit for traditional medicine in August of 2023. With respectful engagement and research, there is hope of more egalitarian exchanges between traditions like TCM and biomedicine.

But as traditional medicines become more mainstream, it is also worth thinking of the long-term impact. While practitioners may see a higher demand for their services and a resulting boost in employment, will integration also spell the end of their tradition, if it loses its original meaning?

For patients, will access to a wider array of treatment options come at the cost of a dilution in the very features that made those additional practices worth including in the first place?

Thus, where integration cannot be managed on a truly level playing field, it cannot deliver on its promises - and may instead deliver exactly what the sceptics have feared: Less effective care, and more wasted resources.

Dr Kathryn Muyskens is Research Fellow, Centre for Biomedical Ethics, NUS.