Dr Qun Shao: can Chinese Herbal Medicine break into accepted Western healthcare? - September 2007

They are an ancient and holistic system of health and healing based on the notion of harmony and balance and employing the ideas of moderation and prevention.

Dr Qun Shao, Computational Officer at the University's Institute of Pharmaceutical Innovation (IPI), is helping to interpret their mysterious healing powers as part of a pan-UK research effort to develop these medicines and bring them more into mainstream healthcare. Dr Shao, who was born and brought up in China, has used Traditional Chinese Medicines all his life.

If you visit the British Museum you will find a section describing a case about Chinese doctors treating HIV patients with therapies based on Traditional Chinese Medicine (TCM) in Africa since the 1980s.

In a UK NHS environment at the South Western Hospital in Brixton, the use of TCM has been successful for treatment of pain, drug dependence and strokes. These are some examples of how the influence of TCM is extending outside of China to other countries across the globe.

Nowadays in almost any cities or towns in the UK there are TCM clinics and herbal shops selling traditional Chinese medicine as well as providing consultancy service, acupuncture (Zhenjiu) and related medical massage (Tuina). Although orthodox Western medical doctors keep warning people that TCM are not yet well understood and unexpected side-effect exist, many patients persistently keep visiting TCM shops for help.

The potential demand for TCM has led to an increasing number of TCM clinics opening in high street markets in the past 10 years in the UK, Europe and the USA. The trend reflects a surge of consumer interest in alternative therapies to complement or replace Western drug treatment, especially when it comes to caring for chronic problems against which Western medicine may seem to be ineffective. In particular, several scientific studies backing the effectiveness of TCM in treating certain disorders such as eczema, psoriasis and inflammatory bowel disease have helped fuel the boom in its popularity.

What is TCM?

TCM is a complete system of health-care with its own unique theories of anatomy, health, and treatment. It emphasizes diet and prevention and using acupuncture, herbal medicine, massage, and exercise; and focuses on stimulating the body's natural curative powers. The basic theory of Chinese medicine attempts to explain the nature of life cycle and disease changes. It includes five theories: Yin and Yang, the five elements, how to direct one's strength, zangfu (internal body organs), and Channels. It also researches dialectics, and explains why diseases occur, how to diagnose and prevent diseases, and how to keep the body healthy.

TCM is largely based on the philosophical concept that the human body is a small universe with a set of complete and sophisticated interconnected systems, and that those systems usually work in balance to maintain the healthy function of the human body. The balance of yin and yang is considered with respect to qi ("breath", "life force", or "spiritual energy"), blood, jing ("kidney essence" or "semen"), other bodily fluids, the Five elements, emotions, and the soul or spirit (shen).

TCM seeks to harmonize and rebalance the entire human system rather than to treat just symptoms. Since proper internal balance is considered to be the key to human health, TCM strives to cure disease by restoring that balance and therefore allowing the body to repair itself. Its continuing medical goal is to detect and correct abnormalities before they cause permanent physical damage.

In Western medicine, patients with similar complaints or diseases will usually receive virtually the same treatment. In TCM however, the physician treats the patient and not the condition, believing that identical diseases can have entirely different causes.

Using TCM in the West

In terms of the principles upon which it is based and the methods used, TCM, therefore, is considered by many in the West to be a radically different system of healthcare. However, unlike Western medicine at its best, TCM is not able to render the kind of emergency crisis intervention that saves lives during physical traumas. Nonetheless, it works best at achieving its goal of practicing preventive medicine.

A major part of TCM is the herbal medicine which mainly consists of natural medicines and processed ones, namely medicines made from herbal, animal, mineral, and some chemical and biological substances. Some herbs have known active ingredients which are also used in western pharmaceuticals. For example, ma huang, or ephedra, contains ephedrine and pseudoephedrine.

However, due to the risk of adverse impact on the cardiovascular system and some deaths linked to consumption of extracts in high doses, the use of ephedra is restricted in the United States. Another example, Chinese wormwood (qinghao) was originally the source for the discovery of artemisinin, which is now used worldwide to treat multi-drug resistant strains of falciparum malaria.

With increasing demand of TCM type of therapies, the medical profession in the west have expressed both interests and concerns on the use and practice of TCM. Quality, efficacy, and safety of TCM have been commonly quoted among the main concerns.

To address these issues, the Chinese government has had a 'National Champion' in place since the 1980s on TCM modernisation, strongly endorsing in the implementation of good agricultural, sourcing, laboratory and manufacturing practices, as well as effective clinical trial practices.

Whilst these practices have improved the quality and safety of TCM products and despite the strenuous efforts of China, scepticism in the West still remains and TCM products are finding it difficult to enter the mainstream healthcare system. As a result, most Chinese herbal medicines have been marketed as functional food in the West, which undervalues its clinical effect and damages its image.

Active ingredients

Based on the Western medicinal principle, extracting active ingredients from TCM herbs have inevitably been the major part of the research related to TCM. However, single compounds isolated from organic solvents are either too toxic or have decreased or no activities. Most TCMs are used as aqueous decoctions (i.e. herbal tea) or as aqueous-ethanolic extracts prepared from the mixture of up to 20 herbs.

A traditional Chinese herbal formula (Fufang) typically contains four classes of ingredients, arranged in a hierarchical order:

1. a chief, the principal ingredient chosen for the patient's specific illness
2. a deputy, to reinforce the chief's action or treat a coexisting condition
3. an assistant, to counteract side effects of the first two ingredients
4. an envoy, to harmonize all the other ingredients and convey them to the parts of the body that they are to treat.

Currently, most activities have focused on trying to fit TCM into a Western medicine system, which is unlikely to realise the true value of TCM as it is based on a very different philosophy.

Research value

TCM theories have been established and developed on the ground of ancient philosophical concept when the modern scientific methodology on pharmaceutical and clinical evaluation was not available. Thus, the explanation of clinical outcome of TCM therapies based on these concepts is difficult to be accepted by modern biopharmaceutical science. The current lack of mechanistic understanding for these therapies has been the major constraint for the development and moderation of TCM.

As a result, novel TCM compounds and effective therapies are not discovered and transferred into a modern pharmaceutical dosage forms. The future solution in TCM modernisation lies on the integration of TCM philosophy into the design of modernised TCM products.

This will require Chinese TCM and Western researchers of multi-disciplinarity working together with the aim to develop a theoretical foundation for explaining the clinical outcome of TCM therapies using modern biopharmaceutical theory, pharmacokinetic evaluation, advanced analytical science and innovative computational techniques.

An example is the research consortium formed by a number of leading institutes in the UK (including Cambridge University, London School of Pharmacy and Guy's and St Thomas's Medical Toxicology Unit) and China to support the establishment of a TCM research centre funded by both Chinese public and private sources. Each member institute contributes with their research strengths in complementary areas. As one of the members, the Institute of Pharmaceutical Innovation (IPI) provides the advanced computational capability to interpret high dimensional experimental data with the aim of explaining the complex interactive relationships among the TCM therapies, formulations, demographic characteristic to pharmacokinetic data and clinical efficacy.

The IPI is a leading centre for pharmaceutical applications of Artificial Intelligence (AI) and Knowledge Engineering (KE) technologies, including Artificial Neural Networks (ANNs), neurofuzzy logic, genetic algorithms, genetic programming, visualisation and expert systems.

AI technologies, such as ANNs, are valuable in detecting complex, often hidden, relationships between a set of inputs and outputs, and in estimating the magnitude of the relationships without knowledge of mathematical descriptions of the dependency between inputs and outputs.

AI and KE tools have been used widely at the IPI for pharmaceuticals, such as in formulation design, process understanding, PK/PD modelling, in vitro/in vivo correlations, and the technologies can cope with historical, fractured and missing data.

With the complexity of TCM formulations, clinical practice and patient demographics, the laboratory and clinical analyses will provide complex and diverse data sets which will be a major challenge for data interpretation and new knowledge discovery. AI and KE can provide the solution, and will be used to interrogate and model generated data to establish underlying relationships between specific TCM components, patient characteristics and important metabolic responses associated with beneficial or adverse clinical effects.

I believe that, with improved communication between China and the West, increasing acceptance of TCM philosophy in the West and collaborative research breaking through, the contribution of TCM to the medicine development will significantly benefit the wellbeing of the Western population.