Traditional Chinese Medicine’s grip on Singaporean society,Earnest Lim Yuan,The Skeptic

She woke up early on a Saturday morning with a migraine. Two hours later, twenty needles were sticking out of her face. If we found ourselves in this situation, popping an aspirin and heading back to bed would be the first course of action for most of us. For Vanessa, a 22-year-old Chinese Singaporean pursuing her Master’s Degree in Applied Finance, needles are her source of relief in such distressing times.

Surprisingly, she is not alone. In a highly educated and modern society like Singapore, sticking needles in one’s face and body is a commonly-sought-after alternative medical treatment. As acupuncture and is one of Traditional Chinese Medicine’s (TCM) five tenets, and believers claim it can cure ailments by rebalancing one’s energy flow via the insertion of thin needles into specific points in the body, known as meridians. The list of benefits touted by practitioners range from curing migraines to schizophrenia.

This miracle cure, of course, does not work. However, inserting needles into one’s body is just the tip of the 2000-year-old practice of TCM. practitioners also prescribe various treatments, such as consuming different herbs and animal parts including bear bile, rhino horns and tiger bones.

As a Chinese Singaporean myself, I have vivid memories of the various foul-tasting concoctions given to me by my family. One particularly offensive culprit is ‘Ling Yang Jiao’ or antelope horn. Whenever I had a fever, my grandfather would boil thin strips of horn shavings with water and strain them for me to consume. The flavour is akin to drinking water boiled with several months’ worth of toenail clippings. Imagine my lack of surprise when I grew up to learn that antelope horn is made of keratin, the same protein that forms human nails and hair. 

Acupuncture needles in a patient – note that the practitioner is not wearing gloves (Photo by Katherine Hanlon on Unsplash)

Strangely, even with access to high-quality and affordable healthcare, TCM remains extremely popular in Singapore. There are over 2,200 TCM clinics on an island approximately half the size of London. A study by the Singapore Medical Journal (SMJ) found that 84% of patients suffering from chronic pain use some form of alternative medicine, of which the most common is TCM.

As with many other forms of alternative medicine, the greatest danger of TCM is its potential to harm the patient. In 2018, a physician was fined and suspended after investigations revealed he advised a patient to delay chemotherapy for her rapidly spreading cancer, and to take 50 capsules of ginger pills instead. This delay reduced the patient’s chances of receiving adequate treatment, resulting in her death soon after. The TCM practitioner was suspended by the regulatory body, who claimed the doctor had “exceeded the limits of his own competence.” 

Another common health risk posed by TCM is the prescription of Chinese Proprietary Medicine (CPM). CPM recommendations have not changed significantly for thousands of years. For traditionalists, this is a testament to its effectiveness; to the rest of us, it is a dreadful realisation. CPM relies on an outdated, unproven, untested methodology to determine which herb or animal part gets dispensed to the patient. For instance, each CPM ingredient is classified based on its ability to affect the patient’s energy, or ‘Qi‘. Classifications also include the ingredient’s taste, with sweeter tasting herbs such as liquorice classified as a neutral and nourishing ingredient.

CPM ingredients do not go through the same rigorous tests and safety standards that conventional medicine goes through. Patients may receive varying doses and combinations of substances at the discretion of the practitioner. If any pharmaceutical company were to introduce products in the same manner, they could expect a mountain of lawsuits and charges against them.

Modern medicines that are commercially available have undergone years of clinical trials to ensure their safety. CPM ingredients do not undergo the same process and are notorious for containing high levels of dangerous chemical substances such as lead, arsenic and others. In 2015, the Health Sciences Authority (HSA) of Singapore found that an ointment prescribed by practitioners used to treat eczema contained very high levels of arsenic.

Furthermore, the possible herb-drug interaction effects remain relatively unknown due to a lack of research. As patients in Singapore commonly take CPM together with modern medicine, the possible negative consequences are aplenty. The SMJ has recommended that “avoidance may be the only solution to negative herb-drug interactions” due to CPM’s potential to hinder the effectiveness of conventional medicine. 

Thankfully, most visits to a TCM do not end in death. However, if a patient is shelling out at least £50 for a consultation and a concoction of boiled herbs and animal parts, they would be better off visiting a regular doctor. Although £50 does not sound exorbitant, the average cost of visiting a public clinic in Singapore is just £8. Furthermore, private clinics are highly accessible and affordable; there are over 1,800 general practitioner clinics in Singapore, with the average consultation costing the same as a TCM clinic visit. These prices do not include national healthcare subsidies, which can’t be used for TCM. A lack of access to affordable healthcare is no longer a reason for Singaporeans to look for alternative medical treatment.

It is puzzling why, despite the ease of access to affordable healthcare, TCM remains popular in Singapore. Perhaps the answer to this mystery can be found in its name. Firstly, TCM is an ancient tradition with roots in Chinese culture, and ethnic Chinese make up 75.8% of Singapore’s population. TCM made its way onto the island in the 19th century when early Chinese migrants immigrated for work. It remained the de facto medical treatment for the Chinese population for over a hundred years due to lack of access to higher quality healthcare.

The practice of visiting TCM clinics continued for generations, even with the introduction of modern medicine. Its role eventually evolved to supplement modern medicine, rather than replace it. When asked why she continued to seek out TCM treatment, Vanessa, the student I spoke to, told me:

My grandparents and parents believe that it works, so they advise me to seek treatment from the practitioner they go to.

Although she visits the doctor and seeks out proper healthcare, Vanessa views TCM treatments as a supplement. When I asked my parents and grandfather why they used TCM treatments, their view was the same: TCM treatment was introduced to them by their elders, and that it worked together with modern medicine.

The practice cemented its place in Singaporean society when the Singapore parliament passed the “Chinese Physicians Act” and created the “Traditional Chinese Medicine Practitioners’ Board (TCMPB). This law introduced regulation for the industry and gave TCM the needed legal status and credibility required to expand its reach.

The second reason for TCM’s surge in popularity in Singapore and around the world is the influence of China on the world stage. The Chinese Communist Party (CCP) sought to legitimise TCM in the annals of global healthcare by influencing the World Health Organisation (WHO). From 2006 to 2017, the WHO was led by Margaret Chan, who served as its Director-General, representing the People’s Republic of China (PRC). In 2016, she praised China’s efforts in campaigning for broader acceptance of TCM’s practices. This move was part of the CCP’s strategic plan to export TCM to the rest of the world; in China alone, the industry is worth $130 billion.

In 2017, China’s President, Xi Jinping, visited the WHO’s headquarters for the first time. He brought with him a bronze acupuncture statue that showed acupuncture marks on the body as a gift to the global healthcare organisation. In April 2019, the WHO included details about TCM in the 11th version of the International Statistical Classification of Diseases and Related Health Problems (ICD). This move drew criticism from medical professionals; the Scientific American magazine called the move “an egregious lapse in evidence-based thinking and practice.”. 

The WHO claims that TCM’s inclusion into the ICD is “not an endorsement of the scientific validity of any Traditional Medicine practice or the efficacy of any Traditional Medicine intervention”. However, the move conferred an undeniable level of legitimacy on the practice. It misleads consumers globally into thinking that TCM and its practices have undergone requisite clinical trials to prove its efficacy. Recognition by the premier global healthcare authority further cemented TCM in the eyes of Singaporean consumers.

The last reason for TCM’s popularity in Singapore is the term “medicine”. This misnomer also gives an air of legitimacy to the unproven practice. On hearing this term, a lay person might not think twice about using TCM, or consuming concoctions doled out by practitioners, given the influence from family members and the apparent stamp of approval from medical bodies.

A quick Google search on the efficacy of TCM shows thousands of studies proving and disproving the seemingly endless practices contained within TCM. One 2010 study on mice showed that acupuncture reduces the pain rodents experienced due to increased adenosine levels. However, the same study also proved that other physical mechanisms such as pinching or applying pressure would trigger similar adenosine responses, casting doubt on the impact of the needles.

Vanessa’s grandmother, who has arthritis, experienced this first-hand. She sees a licensed physiotherapist and a TCM practitioner for her condition. After visiting the TCM for acupuncture treatment, her pain subsides for several days, while the physiotherapist sessions act as a long-term solution. She attributes the pain relief to acupuncture treatment, further reinforcing the notion that it works. It’s easy to see why people would continue seeking TCM treatment in such situations. There is too much information for the average consumer to trawl through to get a clear answer to TCM’s supposed healing abilities.

Furthermore, CPM is highly regulated in Singapore by the Health Sciences Authority (HSA), the statutory board whose role includes regulating medical products, under which CPM falls in Singapore. HSA’s website even warns consumers of the danger of unregulated CPM, with case studies of consumers who consumed unapproved CPM products and ended up with severe health problems. The stringent regulation by HSA gives Singaporean consumers the impression that CPM works. However, the regulation only goes so far as to ensure the products are not harmful. These combined factors result in Singaporean consumers seeking TCM as a legitimate medical treatment, albeit in combination with modern medicine. 

In every culture throughout history, charlatans and snake oil salesmen have touted miracle cures claiming to cure a host of ailments. And in every one of those instances, a victim always ends up poorer, injured, or dead. TCM, like all other alternative medicine, is not an exception. It is not an ancient medicinal secret hoarded by Confucian societies that modern science is unable to decipher; it is a harmful, pseudoscientific practice draped with a thin veil of eastern mysticism. Separating the wheat from the chaff is not easy, especially for people going through medical crises and are clamouring for a solution.

The confluence of forces that drive TCM’s adoption in Singapore is more potent than one could imagine. Even a modern city with a well-educated populace that has access to affordable healthcare is not immune. Unfortunately, in an industry where regulation is perceived to be stringent, the pseudoscientific practice of TCM has firmly planted a flag of legitimacy in the minds of Singaporeans.

Healthy scepticism, in this instance, goes beyond a maxim to mean something quite literal. It pays to think twice if sticking needles in one’s face or drinking the horn of an antelope, is in fact, a good idea. In all the research conducted by scientists, there is still no good evidence in favour of TCM. For a practice that has been around for thousands of years, it does not bode well that scientists worldwide are unable to demonstrate that TCM is a legitimate medical solution.

In the wise words of musician and well-known skeptic Tim Minchin:

By definition, alternative medicine has either not been proved to work, or been proved not to work. Do you know what they call alternative medicine that has been proved to work? Medicine.

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Despite having access to high-quality and affordable healthcare, Traditional Chinese Medicine remains extremely popular in Singapore
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