Science Communication in the Debate about ‘Poison’ in Traditional Chinese Medicine

Abstract

At the end of 2017, research revealed that herbal remedies containing aristolochic acid may cause liver cancer. This triggered a wide debate on ‘poison’ in traditional Chinese medicine. The popular TV show A Bite of China 3 also put the safety issue of traditional Chinese medicines as tonic food in the spotlight of public opinion. In fact, there are many misunderstandings about poison in descriptions of food safety and medicine safety on the internet and WeChat. From the perspective of science communication, our understanding of poison and its uses should transcend the monism of Western science.

1. Introduction

In recent years, with the frequent outbreak of health-related issues as typified by the melamine incident, the Sudan red dye incident and reports of various adverse drug reactions, there has been growing public insecurity about food and drugs. ¹ Driven by the wide spread of internet media and WeChat, the issue of poison in traditional Chinese medicines has become a hot topic of public controversy and concern. On China's Baidu search engine, searching with ‘traditional Chinese medicines’ and ‘poison’ as keywords can turn out more than 35 million results. The list of topics for discussion includes the traditional Chinese medicine ‘Yuxingcao’ (Houttuynia cordata), the household-name drugs ‘Longdan Xiegan Pill’ (‘Bolus of Gentian for Purging Liver-Fire’) and ‘Liuwei Dihuang Pill’ (‘Six-Ingredient Rehmannia Pill’), the state's top secret formula ‘Yunnan Baiyao’ and many others. The controversy about the efficacy, toxicity and side effects of traditional Chinese medicines has existed for a long time, continuously causing public concern and discussion about the safety of the medicines.

The 2017 ‘aristolochic acid incident’ is a typical example. Aristolochic acids have caused controversy several times. In the 1990s, Belgian women who took diet pills containing aristolochic acid developed kidney failure, which triggered the ‘Chinese herbs nephropathy’ incident. In 2003, reports emerged that Caulis aristolochiae manshuriensis in the Longdan Xiegan Pill formula contains aristolochic acid, which can lead to kidney diseases. That year, China's State Food and Drug Administration abolished the medicinal standard for Caulis aristolochiae manshuriensis (Lin, 2017). Not long ago, the notion that ‘aristolochic acid can cause liver cancer’ went viral once again. It originated from a paper entitled ‘Aristolochic acids and their derivatives are widely implicated in liver cancers in Taiwan and throughout Asia’ published in Science Translational Medicine on 18 October 2017 (Ng et al., 2017). The editor of the journal recommended the paper in an editorial titled ‘The dark side of an herbal medicine’. The authors of the paper believed that there was ‘a decisive link’ between aristolochic acids and liver cancer. A subsequent seminar of experts on traditional Chinese medicine unanimously concluded that ‘The paper hints at a signal of strong risk of aristolochic acids causing liver cancer, but there is a lack of strong direct evidence of the relationship between the two’ (Liu, 2017). However, as soon as the paper was published, some media and websites added fuel to the fire, once again arousing public doubts about the safety of traditional Chinese medicines and triggering a wide debate on the efficacy, toxicity and side effects of the medicines.

With the broadcasting of A Bite of China 3, the Chinese herbal medicine ‘Yuxingcao’ has made it to the hot search list on Weibo. A popular science article titled ‘Adding these items to food can cause poisoning, and accidents happen every year’ from a WeChat public account with more than 100,000 readers has continued the heated debate on the toxicity of Chinese herbal medicines. Among these controversies on public media, there is a common view that traditional Chinese medicine lacks the objective, experimental and verifiable scientific basis of modern Western medicine and that the clinical and side effects of traditional Chinese medicines are not very clear:

With the deepening of toxicological research on Western medicines, academia once considered the toxicity of drugs as ‘something causing damage to the body and a pathological phenomenon, which generally has nothing to do with the therapeutic effect’. The result is that people avoid toxic traditional Chinese medicines and even exaggerate the toxicity of the medicines. (Yu, 2006, p. 79)

Consequently, there are public calls for a ban on the use of toxic traditional Chinese medicines. Some have even gone for the extreme view of ‘abandoning traditional Chinese medicine but keeping Chinese drugs’.

The above cases reflect people's continuing concern and general anxiety about food and drug safety, as well as the resulting debates between proponents of traditional medicine and modern Western medicine. Those debates focus on one core concept: poison. If we study the concept of poison in modern Western and other alternative medicines, such as traditional Chinese medicine, we find that there is no unified concept of poison: the understanding of poison varies. Consequently, there also exist significant differences in the principles and ways of using or removing poison (Bao and Liu, 2017). Further analysis of the public's understanding of poison involves research in the field of science communication. The communication of issues involving poison is unique: it is different from the communication of simple, clear and undisputed scientific knowledge. Those controversies also reflect the widespread misreading and misunderstanding of poison by the public. Indeed, there are many problems in the communication of information about poison, but those problems have not received due attention from scholars. In the CNKI database (www.cnki.net), 3,050 articles on the subjects of ‘traditional Chinese medicines’ and ‘poison’ can be retrieved. Almost all of them are specialized studies in the medical and pharmaceutical fields. Yet there are few studies on this topic in the field of science communication.

From the perspective of science communication, behind the current communication about poison are many issues concerning the philosophy of science (in this case, medicine):

• •

  What is poison? Judging from the media reports and what people discuss on the internet and in everyday life, people seem to tacitly accept that there is a common concept of poison. In fact, not everyone has detailed, full and in-depth knowledge of this concept.

  •

  How is poison viewed and treated in different medical theories and practices? For example, how is poison understood in traditional Chinese medicine, Mongolian medicine, Tibetan medicine, Uygur medicine and Zhuang medicine?

  •

  If these non-Western types of alternative medicine have been accepted in China's national health safety standards, is there any rationality in the understanding of poison in other types of medicine that are not contemporary Western medicine?

  •

  Is only one unified standard used to define poison? At a deeper level, people's understanding of and attitudes towards medical knowledge of different discipline systems involves their stance in interpreting ‘the body’ and ‘medical science and drugs’; that is, it is about whether they adopt the philosophical position of monism or pluralism.

  There are many other issues here. If these fundamental issues cannot be effectively analysed and solved, it is possible that chaotic debates over poison will continue.

  2. The concept and understanding of poison

  Modern Western medicine and traditional Chinese medicine share some understanding of poison, but also differ markedly in some respects.

  2.1 What is poison?

  Poison is a complex concept. Over human history, life and poison have always gone hand in hand. According to historical records, human beings first discovered poison by accident when they searched for and collected food. In ancient times, identifying and avoiding eating poisonous substances was an important precondition for human survival and reproduction.

  The discovery of poison soon resulted in a variety of social and cultural orientations (Shi, 2012, p. 397). When people of insight began to collect and collate experiences and lessons concerning the use of some plants, some poisonous plants began to be used as drugs. Animal drugs and mineral drugs had a similar process of formation and discovery.

  Huainanzi-Xiuwuxun recorded that Yan Emperor Shennong ‘tried to taste the flavours of hundreds of herbs … so that he could tell people what herbs to take and what herbs to avoid. In one day, he could come across 70 types of poison.’ Records of Emperors had similar descriptions: Shennong ‘tasted herbs and popularized medicine to cure diseases and save lives. People use herbal medicine every day without knowing the know-how behind. Thus Shennong wrote four volumes of works on herbal medicine.’ Those volumes vividly recorded the process of discovering poison from cases of poisoning and then turning that into knowledge of drugs (as cited in Shi, 2012, pp. 397–398).

  Other countries, such as India, Greece and Egypt, also had ancient cultures of using poisonous substances. In summary, poison and medicine originate from the long-term human practice in production, life and medical care (Shi, 2012, p. 399). As some scholars summed up, ‘As a typical representative, poison symbolizes the incredible complex adaptability of living things on the earth. All kinds of poison that emerge at all periods of times are worshipful and even awesome forces’ (Beliveau and Gingras, 2015, p. 148).

  2.2 Poison as understood in traditional Chinese medicine

  Traditional Chinese medicine has rich humanistic connotations. Through the experience and academic development of generations of doctors, traditional Chinese medicine has formed a concept of poison with complex and changeable connotations and denotations (Wu, 2018). Shuowen Jiezi (Interpretation of Chinese Words) explains that ‘poison, meaning a concentration of things, refers to poisonous weeds.’ In other words, the initial meaning of poison is poisonous weeds. China's earliest medical prescription book, Wushi'er Bingfang (Recipes for Fifty-Two Ailments), recorded the collection and preparation of poisonous drugs and the Chinese medicine used to treat wounds caused by poisonous arrows, and put forward the obscure concept of etiological poison.

  Beginning with Huangdi Neijing—Suwen (The Yellow Emperor's Classic of Medicine— Basic Questions), the concept of poison experienced significant development, extending from simple poisonous herbs to etiology, pathogenesis, treatment, drug performance and other aspects (Zhu and Wu, 2009). Various pre-Qin scholars generalized the meaning of poison from different perspectives, dividing it into Yin and Yang, chronic and acute, internal and external.

  In the development of traditional Chinese medicine, its understanding of poison has been constantly enriched, and it now encompasses complex and extensive meanings. To sum up, these meanings include mainly the following types:

3. Diverse understandings of poison in different medical theories

In different medical systems, such as in Western medicine and traditional Chinese medicine, there are different definitions of poison. And understandings of poison in traditional Chinese medicine and other non-Western alternative medicines are reasonable.

3.1 Differences in the concept of poison in different medical theories

Through the above analysis, we find that there is a clear similarity between the traditional Chinese medical system and the Western medical system in their understandings of poison. Although there are great differences between the two in their definitions and treatments of poison, they both agree that poison is a relative concept. Whether a drug is toxic and, if it is, its level of toxicity depends on its properties, its dosage and length of usage, and the physiological and pathological state of the individual. If handled properly, poison can be used to treat and prevent diseases. On the other hand, non-poisonous things can also cause diseases. Despite this agreement, the two medical systems still have obvious differences at the operational level. They are mainly reflected in the following aspects.

First, the definition of poison. The study of poison in modern Western medicine is mainly done through empirical research. In Western medicine, poison is a substance that can be detected by experimental means and the chemical composition and content of which can be analysed. However, this is a much broader concept in traditional Chinese medicine. The categorization and understanding of poison in traditional Chinese medicine are different from those in Western medicine. Both systems agree that poison means the poison of drugs, but poison in traditional Chinese medicine also includes disease-causing poison, pathogenic poison and pathological poison.

Second, the use of poison. Western medicine is more inclined to avoid using poison. Especially in Western drugs, substances and elements defined as toxic should be avoided as much as possible (Bao and Liu, 2017), but cannot be completely avoided in practice. In contrast, traditional Chinese medicine adopts a relatively inclusive attitude towards poison. Many materials considered to be toxic are widely used and will not be completely abandoned. In ancient China, there were doctors who were good at using poisonous drugs. For example, Bian Que would perform operations after anaesthetizing patients with poisonous wine. Zhang Zhongjing was good at using highly poisonous traditional Chinese drugs. In his Shanghan Zabing Lun (Treatise on Febrile and Miscellaneous Diseases), more than one-third of the prescriptions (119 in all) were mainly poisonous or poison-containing traditional Chinese drugs, such as Aconitum decoction and Ephedra decoction (Shi, 2012, p. 546). In other words, although Western medicine generally acknowledges the relativity of poison, it tends to equate poison with harm and tries to avoid it or not use it directly in medical practice. Although the narrow concept of poison in traditional Chinese medicine is similar to the understanding of poison in Western medicine, it does not equate poison with harm. Even if poison is classified as harmful, traditional Chinese medicine still has appropriate means to eliminate, adjust or reduce its toxic and side effects.

Third, ways of removing poison. Based on its understanding of and attitude towards poison, traditional Chinese medicine pays attention to the dialectical use of poison and restricts its side effects through preparation, compatibility and other means. Take Caulis aristolochiae manshuriensis containing aristolochic acids as an example. Existing research shows that aristolochic acid A in Caulis aristolochiae manshuriensis after vinegar, alkali and salt processing is lower than that of the raw material, and that alkali processing produces the lowest levels (Zhang et al., 2012). In addition, a large number of studies have shown that the combination of Longdan Xiegan Pill and Daochisan can alleviate the nephrotoxicity of Caulis aristolochiae manshuriensis when compared with single drugs (Zhou and Pan, 2009). In contrast, Western medicine emphasizes the control of poison and tries to avoid its direct use or limit its dosage. When poison has to be used, there will be a detailed list of the side effects explaining various possible impacts. It is therefore not difficult to understand why, under the Western medical system, there is advocacy to prohibit the use of controversial Chinese drugs such as those containing aristolochic acids.

3.2 Rationality in the understandings of poison in traditional Chinese medicine and other non-Western alternative medicines

Anthropological research has found and pointed out that ‘we firmly believe that our own knowledge system reflects the law of nature, that it is a system progressing through experimental accumulation, and that our own biology is natural and descriptive rather than fundamentally cultural and classified’ (Good, 2010). So we are accustomed to centring on our own knowledge system to evaluate or even negate other knowledge systems. This is the reason for the long-standing debate between Chinese and Western medicine. In fact, traditional Chinese medicine has a long history of knowledge of poison and its efficacy, which has rich connotations. It is a methodology of poison control and efficacy enhancement developed through the long clinical practice of the Chinese nation fighting against diseases. It possesses dialectic characteristics and advantages (Peng et al., 2017). Other ethnic medicines, such as Mongolian medicine, Zhuang medicine and Uygur medicine, are nationally recognized in China. Their medical theories and practices show their own cultural backgrounds and local characteristics. In other words, their theoretical systems all have consistency and rationality.

Adopting a broad view in understanding and accepting local ethnic medicine is the mainstream view in the international research field of the history and the philosophy of science. The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine by Professor Kuriyama Shigehisa, a Japanese-born Harvard University professor, is a comparative study of different medical knowledge systems and is authoritative in the study of Chinese medical history (Kuriyama, 2009). Kuriyama chose three interesting perspectives to compare: the way of touch, the method of observation and the state of being. For example, the first chapter talks about pulse. Traditional Chinese medicine includes the tradition of pulse diagnosis; while ancient Greek medicine also pays attention to the pulse, but its focus is on the rate and intensity of pulse beats. Although both are concerned with the pulse, traditional Chinese medicine has highly different focal points from ancient Greek medicine because the theoretical underpinnings and experience-based ways of practice behind the two are different. From the same three fingers used for pulse diagnosis, ancient Greek medicine will get the frequency and rate of the heartbeat only, while traditional Chinese medicine will elicit more information. In addition to the codable items, such information also includes many non-codable items, such as the smoothness and non-smoothness of the pulse. From all this information, traditional Chinese medicine can read people's physical condition.

Here is another example. In traditional Chinese medicine, when the body is in a state of deficiency, ways to make up such deficiency are needed. However, Western medicine has used a separate set of therapies of its own, such as ‘bloodletting’ therapy. Bloodletting implies a state of surplus. One is concerned with deficiency, while the other is worried about surplus, which makes them completely different in their ways of diagnosis and treatment.

All these methods are related to local traditional cultures. Using wonderful examples, Kuriyama's book shows that different cultures and medicines under them use diversified understandings of the body, and each has its own rationale.

Similarly, poison in the medical system is a theory- and culture-dependent concept. It is precisely because of this dependence that ‘people's understandings of poison, which seems to have similar referents under different discourse systems (including in medical and pharmaceutical descriptions and everyday language), has always been diverse and different from each other.’ (Bao and Liu, 2017) Moreover, it also shows that various understandings of poison under different medical backgrounds are all rational.

4. Philosophical standpoints behind disputes and differences

As we have seen, different medical systems have different understandings of poison, which in turn results in different ways of using and removing poison. Further analysis will involve a core question mentioned earlier: Is there a unique concept of poison that can be abstracted without relying on any specific theoretical system? According to our analysis, the answer to this question is ‘No’. In other words, under different medical backgrounds, the answers to, the understandings of and the practices concerning this question are all different. Against different backdrops of cultural dissemination and medical theories, the connotations and referents of poison are different.

Fundamentally, there is an issue of philosophical standpoint behind these differences. From a pluralistic medical standpoint, the concept of poison has multiple attributes that are theory- and culture-dependent, just like the concepts of drugs and symptoms. It is precisely because of the overlapping content between different concepts, which is widely spread and interpreted, that there seems to exist an abstract, universal or monistic illusion of poison (Bao and Liu, 2017). In fact, there is no concept and understanding of poison as a sole standard that transcends different cultures and different medical theoretical systems. Therefore, one cannot simply use the concepts of Western medical theory to understand, evaluate and deal with issues in other medical systems, such as traditional Chinese medicine. It is even less desirable to ban all Chinese drugs because a certain drug is considered to contain toxic ingredients from the perspective of Western medical theory, or even abandon the theoretical system of traditional Chinese medicine.

In the real world, one reason why some people have doubts about traditional Chinese medicine is that they do not know that poison can be reduced through processing and compatibility. They are also affected by some social factors:

• •

  An education environment in which a pluralistic science (medicine) standpoint is missing. After the dissemination of Western learning to China, Western medicine entered China. From the initial stage when traditional Chinese medicine was strong and Western medicine was weak to a point of balance between the two and to the present, Western medicine has gradually become the mainstream medicine (Lei, Li and Zeng, 2011, p. 3). The wide trust in and admiration of Western medicine are reflected in both formal school education and the mass media.

  •

  The negative impact of the abuse and misuse of traditional Chinese medicines. Common practices such as self-designed prescriptions, blind worship of folk prescriptions and the use of traditional Chinese medicines as daily food essentially do not conform to the theory or medication principles of traditional Chinese medicine and thus will cause adverse consequences or toxic reactions. However, all of those bad effects are attributed to Chinese medical theory and traditional Chinese drugs, and are treated as evidence of the inherent problems in the treatment of toxicity in traditional Chinese medicine and drugs.

  •

  The theory and criteria of Western medicine used to measure traditional Chinese medicine and drugs. In fact, the side effects of Western medicine are also attributable to poison, but the occurrence and functional mechanisms of toxicity are well researched in Western toxicology (such as in research based on double-blind experiments), with a clear logic of argument. By contrast, despite their clinical efficacy, the dialectic compatibility and complex multi-target medication model of traditional Chinese medicines are difficult to verify and explain with modern scientific (and medical) theory. Therefore, if one holds the monistic position of Western science (and medicine), one thinks that there is only one truth. Specifically, if a person thinks that the understanding of poison in Western science (and medicine) is such a truth, and that other views different from it are all fallacies, that person will consider the traditional Chinese medicine system, which cannot be explained by the theory and criteria of Western medicine, as problematic or even wrong.

  From the perspective of paradigm theory in the philosophy of science, traditional Chinese medicine and Western medicine belong to different theoretical systems under different paradigms and have a certain incommensurability between them. The formation and development of traditional Chinese drugs is the product of long practical experience. It is closely related to the traditional social culture of the Chinese nation and inseparable from the theoretical system of traditional Chinese medicine. If traditional Chinese drugs break away from the guidance of the theory of traditional Chinese medicine, they will merely become ‘grass roots and tree barks’ with no medicinal value and will no longer be Chinese drugs in the traditional sense. Many current criticisms of the poison in traditional Chinese drugs and the extreme notion of ‘abandoning traditional Chinese medicine but keeping the Chinese drugs’ are fundamentally based on the incorrect use of the Western medical paradigm and theory to understand and evaluate issues in the paradigm of traditional Chinese medicine. Under this monistic position, ‘traditional Chinese medicine and other types of traditional medicine can never be properly treated, or developed as desired. Therefore, what needs to be changed urgently is first and foremost a question of standpoint’ (Bao and Liu, 2017).

  5. A possible way to resolve disputes from the perspective of science communication

  From the above analysis of debates over poison, we can conclude that it is of great practical significance to pay attention to and analyse the phenomenon from the perspective of science communication.

  First, those debates reveal the prevailing monistic position of Western science in the media's and the public's understanding of poison. This is a view that only Western medicine that conforms to modern scientific theory and testing standards is the correct position, and that other medical systems that cannot be explained and tested by Western medical theory must be negated and rejected. Such views and attitudes are problematic and even wrong. In fact, this has much to do with the current environment in our society, where scientific and medical education is missing.

  Second, the analysis of those debates suggests that one cannot only emphasize the knowledge of poison within the system of a single discipline (Western medicine). Rather, a pluralistic medical view should be adopted, and the concept and practice concerning poison in different types of medicine should be treated equally. According to the development trend in science communication research, in promoting the public understanding of science, what needs to be understood is not merely scientific knowledge. Knowledge is not even the primary thing. Rather, it requires the communication of a pluralistic view of science in a broad sense so as to promote people's overall understanding of science as a human, cultural and social activity. Public understanding of science (and medicine) also has its cultural and social attributes.

  Finally, researchers and practitioners of science communication should, in addition to having a comprehensive understanding of all kinds of relevant knowledge rather than simply ignoring the knowledge systems they are not familiar with, ‘adjust their philosophical standpoints and especially change their views of scientism and monism on medicine, drugs and toxicity’ (Bao and Liu, 2017). They should fully realize that there are problems if science communication is done only by taking the monistic standpoint of Western science. Science communication requires not only the dissemination of knowledge, but also the communication of relevant philosophical views. It requires us to focus on issues closely related to everyday life, emphasize the importance of concepts such as local knowledge, and pay attention to the differences of science communication in different cultures and contexts. Such a change in science communicators' ideas and positions will become a possible solution to the current disputes.

Funding

This study is funded by the Dynamic Research on Foreign Science Communication Theory and Classical Cases project supported by the China Association for Science and Technology (no. TDSSQMKXSZXD2018-11).