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March 2010 "Complementary Medicine" Letters to the Editor
East vs. West
Editor:
Dr. Narda Robinson, in her recent Complementary Medicine column [“Freedom from Folklore,” January 2010], addresses an implied “folklore” associated with an “aggressive marketing of Chinese veterinary herbs in the U.S.” that “clouds the longstanding tradition of Western veterinary herbal medicine.”
She asks, “Why should we turn over our patients’ health and well-being to a primitive and poorly understood system of Chinese medicine when we can reclaim our heritage of herbal prescribing and still provide quality health care?” She also says we may introduce “Asian herbs” if they meet muster, or decide that no herbs can replace the benefits of medication for a given illness.”
In support of this theme, the author proceeds through a listing of select remedies and provides her interpretation of scientific basis for their use through citation of literature. The author’s article received two online comments as of Jan. 29 to which she replied online: “Please provide the literature citations that back up your statements. Otherwise, it’s just more belief systems and testimonials. I think we’ve seen enough of those by now. It’s time for facts that are supported by evidence.”
In fact, the cited articles mainly provide support for use of the substances considered, both Chinese and Western in origin, and the author not only adds negativity unsupported by literature citations but also misrepresents the main conclusions of some of the important citations, as described below. The result is that most of the article has little or nothing to do with the introductory and concluding allegations about “aggressive marketing,” “primitive and poorly understood system” and “folklore that has taken root,” and the listed “evidence” is the result of a biased cherry-picking of statements from the literature that misrepresents the main thrust of the papers cited. The author’s original article is not made of “facts that are supported by evidence” in any objective sense, and is editorial and subjective in nature.
The second sentence of the article cites (footnote 1) an alternative medicine journal article to say that the authors acknowledge the need for medical practitioners to explain and justify their own systems of practice. In fact the cited work reports on a study investigating the reproducibility of diagnostic observations within TCM examination methods, and finds a more balanced conclusion: “This poses a challenge for TCM practitioners to improve their clinical practice and demonstrates to Western medical practitioners that TCM does in part rest on a rigorous and objective empirical basis.”
The first substance considered is Botswellia (this is not a Chinese herb) and the author cites (footnote 2) that it gave significant clinical improvement for dogs suffering joint pain, and then (footnotes 4, 5, 6) to say that “side effects of boswellia can include nausea and diarrhea.”
The main conclusion of (4) is that in a double-blind, placebo-controlled study, 70 percent of treated patients showed improvement of disease (bronchial asthma) symptoms whereas only 27 percent of the control group patients showed improvement; the main conclusion of the randomized double-blind placebo-controlled crossover study (5) is that Boswellia serrata extract “is recommended in the treatment of patients of osteoarthritis of the knee with possible therapeutic use in other arthritis; the main conclusion of the open multicenter veterinary clinical trial (6) that “a standardized preparation can be recommended as a herbal dietary supplement providing symptomatic support in canine osteoarthritic disease.”
The second substance considered is ginger, and after citing works attributing positive responses the author states the caveat that ginger might offset chemotherapy drugs’ anti-cancer benefits without citing any works. The same occurs in the third substance considered, valerian root (not a Chinese herb), with the unsupported caveat this time “problems may surface when herbs such as valerian add to the sedating effects of anesthetics, barbiturates, opioids and other CNS depressants.” The fourth substance is ginseng (this is a Chinese herb) that in the author’s article includes three different types and eight separate papers are cited to positive recommendation for these herbs.
The next topic is immune stimulants. Regarding Echinacea (not a Chinese herb) the author cites (footnote 18) to positive result and then (footnote 19) to say “it may interfere with chemotherapy when given to dogs with lymphoma.” The cited article carefully summarizes the laboratory and clinical results pertaining to interactions between Echinacea and transport proteins, with mixed results, including “no botanical-drug interactions have been documented” and “these laboratory data indicate that this botanical is likely to inhibit drug transport by both Pgp and other transport proteins.” The interference with lymphoma treatment is Dr. Robinson’s inference. Regarding “Asian mushrooms” (sic; these are not exclusively Asian items) the author cites (21) to say “the same concerns (as with Echinacea) hold about administering them to dogs with lymphoma.” In fact (21) does not address interference or interaction at all, but seeks to evaluate supplement effectiveness on neutropenia, treatment outcome, and quality of life. The main conclusion is that the “therapy relieves many of the symptoms usually associated with chemotherapy and allowed the dogs to maintain a quality of life more closely related to their norm. These results indicate that further research into nonspecific immune-modulation therapy as an adjunct to chemotherapy is warranted, with the goal of improving the quality of care and quality of life that we can deliver to our canine cancer patients.” The author cites (22) to in support of “For other types of canine cancer, no proof exists that mushroom mixtures can replace conventional chemotherapy.” The article (22) reports a study of the effectiveness of Maitake PETfraction as a single agent for treatment of lymphoma in dogs, and congruent with Dr. Robinson’s point, this article’s findings are that the treatment did not decrease lymph node sizes greater than 50% in any of the dogs. Other than this article that was itself funded by the Maitake Products corporation, Dr. Robinson does not cite any articles indicating that mushroom mixtures are proposed as a replacement for chemotherapy. This is an honest report of an exploratory study sponsored by a mushroom producer; it is not aggressive marketing. The author recites (21) as (23) and concludes with another unsubstantiated caveat, “but the question remains about the cost of countering toxicity on chemotherapy’s effectiveness.” without citation.
The author concludes with a section titled “Natural Not Always Safe” in which she cites negative impacts of comfrey, pennyroyal and alpha lipoic acid, in some cases in gruesome detail. None of these are Chinese herbs. Again the author’s stage is set without any citation. In fact a quick web search on pennyroyal and flea treatment brings up the first site with the similar title of Dr. Robinson’s section, “ ‘Natural’ Does Not Always Mean Safe!’ that reminds, “For example, pennyroyal oil used to be recommended for flea control by natural flea control proponents, but it’s been discovered that pennyroyal oil is a liver toxin and can be fatal to your cat.” Dr. Robinson suggests that alpha lipoic acid has “earlier assurances of safety” and cites (32) and (33) in support: only (33) conveys “earlier assurances of safety” but most ironically (33) is firmly in the context of Western medicine and not a product of TCM. Dr. Robinson’s statement that “Holistic websites push ALA for peripheral neuropathy, adding, diabetes mellitus, congnitive dysfunction, cataracts, glaucoma and painful mouth in people and animals” is not only unsubstantiated but has nothing to do with Chinese herbs or TCM.
In summary, Dr. Robinson’s article is an inconsistent blend of remonstration against a perceived threat of Chinese medicine, with a misrepresentation of a host of citations, only a few of which involve Chinese medicine, that in fact show that alternative techniques have provided a rich source of positive treatments (and not because of Western provenance of some such treatments, e.g., in the case of alpha lipoic acid). Her one-sided and unbalanced representation of (footnote 1) to suggest that their “research further illuminated the disparity in objectivity and reliability between Western medical and Eastern diagnostic approaches” is in fact revealed in the reverse sense by her own article specifically for Chinese medicine because all the cited studies of Chinese medicine give in fact positive results.
The result is that Dr. Robinson’s thesis is ultimately as absent of real literature citations as the online notes she so labels, and this is important for VPN readers to know. Taken at face value her article is misleading. Because of its negative tone, wrapped in specious interpretation of literature that is actually misrepresented, it may contribute to the inhibition of learning by conventional practitioners and the expansion of research by investigators to continue to establish the scientific basis for TCM and CAM, just when such is in fact called for by the literature cited. An objective assessment of the literature cited shows that her goal to “reclaim our heritage of herbal prescribing “would be better served by an open-minded and integrative construction of a new heritage.
Signe E. Beebe, DVM
Integrated Veterinary Center
Sacramento, Calif.
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History Offers Proof
Editor:
I’m concerned about the side effects of Dr. Narda Robinson’s “Freedom from Folklore” article.
Dr. Robinson quotes a recent paper (O’Brien, 2009) saying that traditional Chinese medicine “clouds the longstanding tradition of Western veterinary herbal medicine.” I’m wondering what her definition of “Western veterinary herbal medicine” is.
Western veterinary herbal medicine has a 2,000-plus-year tradition, encompassing ancient Roman practices and Dark Ages livestock management. American veterinary herbal medicine has a tradition of perhaps 200 years, most of it dependant upon the folklore of field practitioners, most recently augmented by a few scientific analyses.
Dr. Robinson writes that the study “further illuminated the disparity in objectivity and reliability between Western medical and Eastern diagnostic approaches,” but she has created a false dichotomy. We don’t really have Western and Eastern approaches; we have both scientific medical and traditional approaches.
Traditional approaches are being studied systematically in the field of ethnomedicine. Ethnoveterinary medicine has grown with the increasing interest in developing traditional methods of livestock management in developing countries. Treatment systems that have been established over centuries of use presumably deserve study because local populations believe them to be effective, and local populations may be in a better position to judge than distant scientists judging a single treatment out of context. Ethnoveterinary medicine publications found in Medline have grown yearly, from one in 2000 to an average of eight annually from 2006 until now.
Dr. Robinson asks “why should we turn over our patients’ health and well-being to a primitive and poorly understood system of Chinese medicine when we can reclaim our heritage of herbal prescribing and still provide quality health care? … By first establishing a clear-cut diagnosis, we can determine whether plant-based compounds will offer safe and appropriate treatment.”
Few veterinarians using TCM eschew reaching a medical diagnosis or using effective conventional treatments; most use the system on animals that have not responded to conventional care and have few options for relief.
The paper Dr. Robinson cited concludes: “Certain features of the TCM system … are highly objective and repeatable, such as detection of the presence of shen, character of breath sounds and pulse speed” and “These findings are not unlike those associated with assessments of reliability of Western medical diagnostic techniques and tests, where reliability has also been found to be variable.”
The author concludes, “Only science will free the veterinary profession from the folklore that has taken root.”
I wholeheartedly agree that science will free us to use herbs from a more educated point of view. But throwing out ethnoveterinary knowledge harms patient care. I’ve even heard from one Chinese American veterinarian who was offended that Dr. Robinson’s harangue against TCM was racist.
TCM has its place in veterinary medicine until science catches up and can explain its effects.
Susan G. Wynn, DVM
Georgia Veterinary Specialists
Sandy Springs Ga.
Nutrition Resident, University of Tennessee
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Give TCM a Chance
Editor:
Dr. Narda Robinson’s sweeping generalization about traditional medicine being unsafe and undesirable is not supported by surveys and the scientific literature.
A recent study in Australia among all practitioners using Chinese herbal medicine and acupuncture showed that when points and herbs were prescribed according to the conventional medical model, the rate of adverse events doubled. The authors specifically cite a lack of knowledge of Traditional Chinese Medicine by MDs as one possible explanation for their findings (Bensoussan et al, 2000). Other studies in the treatment of ITP (as an example) show a higher effectiveness of Chinese herbal medicine when prescribed first according to traditional indications, and only then according to biomedical indications. In contrast, outcomes were poorer in patients where TCM theory was not applied in the treatment selection process (Yang et al, 1995).
Ironically for Dr. Robinson, the studies on ginseng, Boswellia and ginger that now abound in the scientific literature were originally inspired by case outcomes following their prescription according to traditional guidelines. This discovery of the worth of these plants (and many others) long pre-dated our western exploration of them, undermining Dr. Robinson’s accusations that the traditional medical systems that derived them are unsophisticated.
Clinical experience with these herbs continues to accrue. I don’t believe Dr. Robinson’s opinions in this column are reflective of the rest of the complementary and alternative medicine field, which is that the best approach to alternative medicine is an integrative one that attempts to reconcile scientific knowledge with traditional use.
Steve Marsden DVM, ND, MSOM, Lac, Dipl. CH, AHG, CVA
Edmonton, Alberta
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An Opinion of One
Editor:
I have subscribed to your publication for over 10 years. It appears to be a publication with the purpose of informing veterinarians about the latest veterinary news, product breakthroughs, and clinical articles.
As a Chinese veterinary herbal medicine and acupuncture practitioner, I prioritize finding and reading Dr. Narda Robinson’s Complementary Medicine columns. Her columns seem inconsistent with the scope of the journal: to inform veterinarians in a positive and non-biased way about recent advances in veterinary medicine and products.
I have read some of her published articles elsewhere on the neuroanatomic description of and explanation of action of acupuncture points, which in my opinion are meticulously well done. However, her columns in your journal, rather than being objective, seem more of an editorial reflection.
Herbal medicine has been used and experientially proven over thousands of years. The medical community is just now catching up with scientific, more evidence-based and ethnomedicine-based studies on the specific biochemical actions of herbal formulas and their constituent herbs. I have cases too numerous to count where Western medicine has failed and Traditional Chinese Medicine has improved the quality of life and sometimes affected a cure.
I, and my clients, see efficacy in this approach. I find that Dr. Robinson’s viewpoint reflects “contempt prior to investigation.” Perhaps she could use her scientific skill in investigating the biochemical actions of herbs?
A suggestion: If you are going to allow such a biased viewpoint, maybe you could allow either rebuttals published in the newsmagazine, or have rotation between more than one TCVM practitioner to present a variety of knowledge, rather than the opinion of one.
Jodi Van Tine, MA, DVM, CVA, CVCHM
Holistic Veterinary Medicine Clinic,
Citrus Heights, Calif.
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Dr. Robinson’s Response:
You suggest, concerning my professional activities, “Perhaps she could use her scientific skill in investigating the biochemical actions of herbs?”
Indeed, I am scientifically and rigorously investigating the value of a botanical mixture for lameness in dogs, in a randomized, placebo-controlled, blinded trial here at Colorado State University.
In response to your critique about my Complementary Medicine columns, there are already plenty of glowing, pro-holistic articles out there written by others; in fact, the Internet and holistic journals are saturated with them.
What’s needed is precisely what I offer: a scientific- and evidence-based look at the pros and cons of holistic care. Not everything holistic is safe, natural, effective or medically justified. Veterinarians and their staff need to know the facts, not hear more belief systems based on folklore.
Testimonials, no matter how many are submitted or how loud they are shouted, do not add substance. Publish your results about the cures you claim from TCM in peer-reviewed medical journals and that will be something worth reading.
Narda Robinson DO, DVM, MS, Dipl. ABMA, FAAMA
Colorado State University
Fort Collins, Colo.
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March 2010 "Complementary Medicine" Letters to the Editor
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