A Review of Traditional Chinese Medicine Through The Lens of COVID-19

By Ng Chi Wai, Jessie

Traditional Chinese medicine (TCM) surfaced around 4000 years ago during the Xia and Shang dynasties (2070-1046 BC), and underwent further development in the Ming and Qing dynasties (1368-1912 AD). In Chinese history, TCM has fought against a lot of epidemics and pandemics, and through the accumulation of generational experiences, has developed methods for effective therapeutics. In the Song dynasty (960-1270 AD), practitioners had battled against smallpox with variolation, an inoculation procedure to introduce a small, protective infection – a process drawing many similarities to the work of Edward Jenner to combat smallpox. In the COVID-19 pandemic, a combination of TCM and western medicine may have reduced mortality and increased cure rate, and as such, the application of TCM is expected to become a source of great global interest.

Vastly different from western medicine, the fundamental theory of TCM is based on philosophical thinking (Luo et al., 2020), which emphasizes “balance”, referring largely to the concept of restoring harmony between yin and yang, somewhat similar to the emphasis on processes such as homeostasis in western medicine. This ancient medicinal approach operated on the theory that when the delicate “balance” of the human body is broken and cannot be restored, diseases occur. In the perspective of TCM, COVID-19 is classified as a plaque caused by special epidemic toxins. The pathogenesis of COVID-19 is thought to be the result of interactions of dampness, toxins, heat and stasis (Luo et al., 2020). With the prerequisite of treating patients holistically, as an organic whole in TCM, the TCM treatment plans (Zhao et al., 2020) for COVID-19 also focus on organs besides the lungs, such as the spleen, liver and heart, and research has found there may indeed be a strong connection (Zhao et al., 2020). TCM divides COVID-19 into four stages – early, advanced, critical and recovery, and different treatments would be applied accordingly. In addition, TCM provides a treatment plan for asymptomatic individuals.

In terms of treatment, decoction, acupuncture and external treatments feature heavily. Qingfei Paidu decoction (Zhao et al., 2020) is the most commonly used treatment and has shown some impressive results. In a study of 98 patients in Sichuan, China, after a 9-day treatment with the decoction, the total effective rate was found to be 92.09%, with a recovery rate of 41.13% and an efficacy rate of 26.92%. Another controlled study (Guo et al., 2020) on Xuebijing Injection involving 42 patients was carried out in Chongqing, China and showed significant improvements in terms of IL-6 (a pro-inflammatory cytokine) levels, body temperature, CT imaging results and the time taken to produce a negative nucleic acid test. The improvement is particularly obvious in severe patients. Lianhua Qingwen Capsule (Runfeng et al., 2020) has also been proven to significantly inhibit SARS-CoV-2 replication and remarkably suppress pro-inflammatory cytokine production at mRNA stages. 

Towards prevention of COVID-19, TCM aims to protect the lungs and improve other organ functions. One therapeutic example is Yupingfeng San (Xu and Zhang, 2020), which is a patented ancient herbal medicine that has been proven in studies to be able to regulate immune function by protecting lung qi and preventing the invasion of pathogenic qi, where qi can be roughly translated to energy. It is also worth noting that decoctions and incense were used on the medical staff, aside from other regular preventive measures, and there has yet to be a reliable study conducted on these additional measures to prove their effectiveness. 

Recent years have seen a rising interest in modernizing TCM in the hopes of being able to systematically review and unleash the potential of TCM. However, one of the main obstacles lies in the  lack of standardization (Wang, Guo and Li, 2016): the technical standardization of formulation, the systematic standardization of efficacy and quality and international standardization. One review pointed out that, due to adulteration, misidentification, mislabelling or contamination (Zhou et al., 2019) caused by the lack of standardization, serious health consequences could occur. There was a case where herbs of two different species were misidentified and led to permanent peripheral neuropathy in the patient. Non-standardized nomenclature in the labelling of herbs could also pose safety concerns as it may be more difficult to trace its species, pharmaceutical and botanical names and thus lead to misidentification and mislabelling. 

Standardization of dosage (Wang, Guo and Li, 2016) should also be prioritised, or else this may pose health risks to consumers. This point is well-illustrated by the fact that there has been at least a dozen deaths and acute cardiovascular diseases caused by the over-dosage of ephedra, or Mahuang as it is called in Chinese. Herbs produced from different places could have different concentrations of the active ingredient, and again, it would pose a major health threat to the public if there are no standards set for the quality of therapeutic products. An overview of 26 high-quality systematic reviews summarized and evaluated the contamination of Chinese herbal medicine in 2013, and concluded that a significant portion were contaminated,  and these contaminants may pose serious adverse effects. Therefore, more stringent testing and control measures on the quality of herbs would be required to progress the reach of TCM. The difference in regulations between different countries may also affect the associated health risks. In Asian countries like China, Korea and Japan, where TCM is much more popular than in the western world, there are well-established regulations on herbal medicine and practitioners. However, in most western countries, they lack national regulation, and this highlights the need for international standardization.

To achieve the modernization of TCM, another challenge that must be overcome is the lack of understanding of TCM’s modality (Wang, Guo and Li, 2016). The theoretical basis and the understanding of the human body within TCM are grossly different from that of modern western medicine. For instance, there are specific terminologies that are not interchangeable and are difficult to specifically translate, like qi, yin and yang and essence etc., and these differences pose great difficulties in the exchange and discussion of knowledge and research findings,  and may in turn hinder international cooperation.

Since 2009, there has been a committee (TC249) under the International Organization for Standardization (ISO) dedicated to the standardization of TCM, through the establishment of universal standards for the quality and safety of raw materials, products and medical informatics. This committee has published 64 ISO standards and has 31 ISO standards under development to date (ISO, 2020). Aside from the TC249 committee under the ISO, several TCM standardization teams have been established in recent years in China and there has been a marked increase in awareness of the importance of TCM standardization. Modernization of TCM surely still has a long way to go, but this may provide some hope in the prospects of TCM standardization, and could be the key to fostering the collaboration between TCM and western medicine.

References:

Zhao, Z., Li, Y., Zhou, L., Zhou, X., Xie, B., Zhang, W. and Sun, J. (2020). Prevention and treatment of COVID-19 using Traditional Chinese Medicine: A review. Phytomedicine, p.153308.

Luo, H., Gao, Y., Zou, J., Zhang, S., Chen, H., Liu, Q., Tan, D., Han, Y., Zhao, Y. and Wang, S. (2020). Reflections on treatment of COVID-19 with traditional Chinese medicine. Chinese Medicine, 15(1).

Xu, J. and Zhang, Y. (2020). Traditional Chinese Medicine treatment of COVID-19. Complementary Therapies in Clinical Practice, p.101165.

Wang, J., Guo, Y. and Li, G.L. (2016). Current Status of Standardization of Traditional Chinese Medicine in China. [online] Evidence-Based Complementary and Alternative Medicine. Available at: https://www.hindawi.com/journals/ecam/2016/9123103/ [Accessed 10 Nov. 2020].

Zhou, X., Li, C.-G., Chang, D. and Bensoussan, A. (2019). Current Status and Major Challenges to the Safety and Efficacy Presented by Chinese Herbal Medicine. Medicines, [online] 6(1), p.14. Available at: https://europepmc.org/articles/PMC6473719/ [Accessed 17 Sep. 2019].

ISO. (n.d.). ISO/TC 249 – Traditional Chinese medicine. [online] Available at: https://www.iso.org/committee/598435.html [Accessed 10 Nov. 2020].

Guo, H., Zheng, J., Huang, G., Xiang, Y., Lang, C., Li, B., Huang, D., Sun, Q., Luo, Y., Zhang, Y., Huang, L., Fang, W., Zheng, Y. and Wan, S. (2020). Xuebijing injection in the treatment of COVID-19: a retrospective case-control study. Annals of Palliative Medicine, [online] 9(5), pp.3235–3248. Available at: http://apm.amegroups.com/article/view/51467/html [Accessed 10 Nov. 2020].

Runfeng, L., Yunlong, H., Jicheng, H., Weiqi, P., Qinhai, M., Yongxia, S., Chufang, L., Jin, Z., Zhenhua, J., Haiming, J., Kui, Z., Shuxiang, H., Jun, D., Xiaobo, L., Xiaotao, H., Lin, W., Nanshan, Z. and Zifeng, Y. (2020). Lianhuaqingwen exerts anti-viral and anti-inflammatory activity against novel coronavirus (SARS-CoV-2). Pharmacological Research, 156, p.104761.

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