Traditional Chinese medicine is a ‘gem’ of the country’s scientific heritage.”
—President of China Xi Jinping
Since its founding in 1948, maintenance of the International Classification of Diseases (ICD) report is among the many tasks allocated to the World Health Organization (WHO). The ICD was initially started by the U.S. International Statistical Institute as the International List of Causes of Death. More than 100 countries worldwide use the ICD currently for morbidity and mortality statistics. But the ICD also serves an important financial role: the ICD is being used as a basis for reimbursement policies and allocation of national funding for almost 70 percent of global healthcare costs.
On June 18, 2018, the WHO published a draft of the eleventh version, ICD-11. New additions to the ICD-11 included “gaming disorder,” a reclassification of gender dysphoria, and the chance to register diagnostic terminologies and syndromes used in so-called traditional medicine (TM). In January 2019, representatives of WHO member states further prepared the embedding of the proposed ICD-11, which was presented to the World Health Assembly in May 2019. If everything goes as planned, the new ICD-11 will be put into use on January 1, 2022. Curiously, according to member state representatives, no discussion was expected in the Assembly on this highly remarkable extension of the ICD. And indeed their prediction came true: the proposal was accepted unanimously and without any debate.
Traditional Chinese Medicine in the ICD-11
The WHO has dedicated a full chapter in ICD-11 to traditional Chinese medicine (TCM) diagnoses and syndromes. This means that from 2022 onward, official reporting can be performed for diagnoses such as the bladder meridian syndrome, which is supposedly characterized by severe headache, neck- and lower-back pain, excessive tearing, a stuffy nose, and a numb little toe. Another example: triple energized meridian dysfunction, a syndrome that it claims is characterized by deafness, tinnitus, swelling and obstruction of the throat, and reduced use of the ring finger (Hong-Zhou et al. 2013).
Given the pseudoscientific character of TCM and the impossibility of integrating this Chinese taxonomy and its concepts into modern medicine, we had expected a substantial turmoil following the announcement of ICD-11 by the WHO (WHO 2018). However, it attracted, with a few exceptions, very little attention and commotion, even in the medical community (Gorski 2018; Scientific American Editors 2019; WHO 1984; WHO 1993; Maassen 2018).
What Preceded ICD-11?
A retrospective look at the history of the WHO illustrates how TM and in particular TCM gained a foothold within the WHO. The Alma Ata conference in 1978, with its slogan “Health for all in the year 2000,” stated that TM had a place in primary care. Between 1984 and 2007, the WHO made several attempts to standardize the various nomenclatures used within TCM as practiced in China, Japan, and Korea with the aim of promoting its acceptance. The last official WHO-endorsed standard on this topic dates from 2007 and included the description of fourteen meridians, 361 classical acupuncture points, eight extra meridians, forty-eight extra points, and fourteen acupuncture lines on the skull (WHO 2007).
The WHO Traditional Medicine Strategy 2002–2005 policy plan was published in May 2002. The document praised countries such as China, North Korea, and South Korea because they managed to have TM fully integrated into their health system. It presented the native flora as an undiscovered source of new medicines, of which the supposed benefits should be protected as intellectual property. The resentment against “Western” medicine can be felt on every page. Dr. Xiaorui Zhang, a former barefoot doctor1 who later studied medicine in the United States, was one of the main persons responsible for this policy plan, which became “the first global strategy on traditional and alternative medicine.” When we confronted then Dutch Minister of Health Hans Hoogervorst with this scandalous WHO endorsement of TCM, he plainly replied that every member state is free to ignore the recommendations by the WHO, which has no supranational powers.
The report Acupuncture: Review and Analysis of Reports on Controlled Clinical Trials, also under WHO auspices, appeared in 2003. It asserted that the efficacy of acupuncture in acute dysentery, hay fever, leucopenia, anovulation, and rheumatoid arthritis, among other ailments, had been proven. This uncritical review was performed without any kind of peer review by non-acupuncturists. In 2014, this scandalous report was tacitly removed from the WHO website, but it was never formally retracted. At the end of November 2004, Zhang distributed a similar draft report on homeopathy. It was offered for review to a few homeopaths, but its contents were leaked. This overview, Homeopathy: Review and Analysis of Reports on Controlled Clinical Trials, was as prejudiced as the report on acupuncture: various indications were mentioned for which efficacy of homeopathy was said to have been demonstrated, e.g., tropical diarrhea in children, hay fever, incipient flu, fibromyalgia, and intestinal paralysis after abdominal surgery. The report also proposed unscientific and mythological explanations for the mechanism of action of submolecular diluted substances (diluted to the point where not even a single molecule of the alleged effective ingredient should remain). It never came to a final version of the report, possibly also as a result of criticism originating from Dutch and Flemish quackery fighters (Renckens 2005). WHO TM coordinator Zhang wrote a weak reply in the Dutch daily newspaper NRC Handelsblad in answer to our criticism (Zhang 2005), but nevertheless the WHO homeopathy report was aborted. We reported this affair in the Skeptical Inquirer (Renckens et al. 2005).
In 2014, the WHO Traditional Medicine Strategy 2014–2023 appeared with content comparable to that of its predecessor from 2002: no reliance on evidence; instead, an emphasis on “real-life studies,” reimbursements by health insurers, and commercialization of TCM (Dorlo et al. 2015).
TCM as Part of the ICD
Already in 2010, the WHO had indicated that it was aiming to merge TCM-diagnoses into the ICD (WHO 2010). This planned integration of the International Classification of Traditional Medicine (ICTM) into the “family of other WHO-classifications” would eventually “enable unification of the conventional and the traditional medicine classifications” and “will facilitate enhanced acceptance” of TM, as stated in the WHO Background Document on ICTM (WHO 2010). On March 3, 2011, the WHO published the list of experts who should further give shape to the ICTM. Among a variety of Asian TCM-enthusiasts there was also the Dutch ethnopharmacologist Peter de Smet. The planned ICTM was going to be based on the WHO International Standard Terminologies on Traditional Medicine in the Western Pacific from 2007, which contains around 3,000 items. What the exact details will be of the TM-modules that will be featured in the ICD-11 is still unknown.
Outside the WHO domain, the Chinese government is pursuing a similar agenda—TCM as an export product—by attempts to have an International Organization for Standardization (ISO) certification for, for example, TCM herbs and sterilization procedures for acupuncture needles (Dorlo and Timmerman 2009). These attempts fit the overall goal of the Chinese government to enlarge China’s herbal exports and to gain recognition for Chinese herbs, given that the Chinese herbs will never be able to receive a formal medical product registration for European or U.S. markets due to the “strict” requirements to demonstrate efficacy and safety. At this moment, ISO standards provide a false aura of reliability to thirty-three TCM products and “activities” of planting, from the sowing of ginseng seeds to an infrared moxibustion device, and another forty-three standards are in the making (International Organization for Standardization 2019). In a direct meeting between then WHO Director-General Margaret Chan and President Xi Jinping, the latter said straightforwardly that he counted on a good collaboration between China and WHO and that he expected the WHO would help with “promoting TCM and Chinese herbs to foreign countries.” The Chinese government lobbied Chan repeatedly while attempting to increase TCM’s acceptancy and suitability for export. This culminated, among other things, in the publication of purely commercial paid advertising supplements in Nature in 2011 and Science in 2014, in which the pseudoscientific articles received an approval in a preface written by then WHO Director-General Margaret Chan. (See David Gorski, “Science Sells Out: Advertising Traditional Chinese Medicine in Three Supplements,” Skeptical Inquirer, May/June 2015.) In 2017, the value of the growing Chinese export of medicinal herbs had peaked to $295 million (Cyranoski 2018).
There are no public debates in the World Health Assembly around WHO policy plans, such as the ICD-11, but these plans are prepared by WHO administrators, and their acceptance is the result of consensus. The Dutch representatives at WHO do not hesitate to point out that policy recommendations by WHO are not binding for any of its member states and the TM modules in the ICD-11 will therefore probably remain unused in the Netherlands and many other Western countries. Nevertheless, these kinds of consensus approvals and the apparent cynicism among WHO member state representatives grants international and highly regarded status to quacks and makes their practices potentially more viable for monetary reimbursement. This is especially so as the ICD-11 is used as a blueprint for this in many countries worldwide. Countries with less functional medical regulatory authorities might embrace TCM on the basis of the explicit WHO approval. TCM is already spreading widely across Africa (The Economist Editors 2018). If patients with HIV, tuberculosis, or malaria seek treatment at the increasing number of TCM clinics, they are risking their lives. For HIV, it has been shown that the complementary use of TM—in this case traditional medicine of African origin—has a negative effect on the success of conventional antiretroviral treatment, even if both approaches are combined (Moshabela et al. 2017).
Instead of cheering the use of TM, the WHO should strive to ensure that truly effective medical care, unhindered by TM mythology, becomes available and accessible worldwide, a situation that can be achieved by a fair and global distribution of wealth and economic growth. Critical WHO officials and member state representatives who favor evidence-based medicine should operate with this state of mind and should be instructed by their governments to distance their countries—for instance with minority reports disagreeing with reprehensible WHO initiatives.
Our Published Paper and a Rebuttal
An article similar to this one was published by us in Dutch in the Dutch medical journal Medisch Contact on February 28, 2019 (Renckens and Dorlo 2019). Peter de Smet, the aforementioned expert member of the ICTM Project Advisory Group (WHO 2011), reacted and defended the inclusion of TM in the ICD by arguing that TM diagnoses and interventions are still widely used worldwide and that this implementation could yield useful epidemiological information. The exact details of the TM inclusion in the ICD-11 are still shrouded with mystery, but the fact that even interventions would be part of the ICD-11 was a surprise to us. Apparently, the aforementioned WHO International Standard Terminologies on Traditional Medicine in the Western Pacific (2007) will be used for this purpose. In this document, twenty-one therapeutic principles and 347 treatment methods are mentioned. Two examples of these treatments: the eight methods, a collective term for diaphoresis, emesis, purgation, mediation, warming, clearing, tonification, and resolution; or: disperse wind and discharge heat, a therapeutic method to treat externally contracted wind with interior heat by using exterior-releasing medicinals and heat-clearing medicinals in combination. In addition, de Smet insisted that the efficacy of TM interventions for certain TM diagnoses could be investigated. However, to his regret, creation of the list of TM interventions had been delayed.
Our publication also caught the attention of Henk van Gerven, a member of the Dutch parliament on behalf of the Socialist Party. He asked the Minister of Health various written questions about the WHO policy and general state of affairs. The Minister stated that, within WHO, the Netherlands did not provide an opinion on TM in the ICD and left that to member state Romania, which responded on behalf of all the EU member states. The Western countries chose to comply with the wishes of the countries where TM is still being used. He also pointed out that entering the TM data for national health statistics is optional and that the Netherlands will further ignore this option. The Minister also stated that China’s push for expansion of the ICD had been driven, at least partially, by commercial considerations, i.e., export of TCM products.
As expected, the ICD-11 was adopted at the 72nd World Health Assembly, and it will be implemented as planned in 2022. Although WHO spokesman Tarik Jasarevic stated that the inclusion of TM in the ICD is not an endorsement of its scientific validity, proponents of complementary and alternative medicine (CAM) will of course misuse the inclusion as such (Hunt 2019). A WHO News Release on this subject stated that the “ICD-11 is now fit for many uses, including clinical recording, primary care, patient safety, antimicrobial resistance, resource allocation, reimbursement, casemix, in addition to mortality and morbidity statistics.” The enormous goodwill for TM and CAM within the WHO is evidenced by the warm welcome given quacky organizations such as EUROCAM (representing, among others, various homeopathy associations), the World Naturopathic Federation, and the World Chiropractic Association (World Naturopathic Federation 2019). All these organizations were invited by the WHO to attend the World Health Assembly, where it released the WHO Global Report on Traditional and Complementary Medicine 2019. This report calls the fact that 88 percent of all member states have formally developed policies, laws, regulations, programs, and offices for TM and CAM “a unique milestone.”
That political and economic considerations play a more important role within WHO than medical evidence-based science remains difficult to comprehend and accept. This unfortunate fact should lead to discussion and reflection on the role and position that member states have within the WHO. That prescientific mythological concepts now have gained a serious position in the WHO morbidity and mortality classification and statistics can be regarded as a direct failure of the political consensus-strategy.
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