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An ICD Code for the Running Piglets!

… animals are divided into (a) those that belong to the emperor; (b) embalmed ones; (c) those that are trained; (d) suckling pigs; (e) mermaids; (f) fabulous ones; (g) stray dogs; (h) those that are included in this classification; (i) those that tremble as if they were mad; (j) innumerable ones; (k) those drawn with a very fine camel’s-hair brush; (l) etcetera; (m) those that have just broken the flower vase; (n) those that at a distance resemble flies.

– Jorge Luis Borges (1899–1986)1

Not too long ago, I came across a disease taxonomy proposed by a certain East-West Medical Research Institute (EWMRI), that includes the kind of fantastic afflictions — such as “running piglet” disorder — fit for the best Borgesian list.

This obscure institute, located at Kyung Hee University in Seoul, Korea, is one of the 800 WHO Collaborating Centres designated to carry out various activities in support of the Organization’s programs. With the collaboration of China, Japan, Vietnam, Australia, and the US, this center is working to incorporate medieval Asian disease nomenclature to the 11th version of the International Classification of Disease (ICD-11).

The proposed taxonomy that has resulted from the collaboration is called the International Classification of Traditional Medicine (ICTM). It resembles a shopping list made by randomly mixing a medical dictionary with Harry Potter, and reads like a Surrealist poem penned in a marathon Automatic Writing session. Right after influenza, dysentery, and cholera, one can find miasmatic malaria (瘴瘧)… pestilence (瘟疫)… plum-pit qi (梅核氣)… running piglet (奔豚)… wasting-thirst (消渴)… T-shaped malnutrition (丁奚疳)… umbilical wind (臍風)… syndrome of liver fire blazing the ear (肝火燔耳證) (ouch!)… and many other astonishing entries, which I invite you to browse for your own amusement — or dismay.

The 2007 version of the WHO International Standard Terminologies on Traditional Medicine in the Western Pacific Region lists the proposed disease categories on pages 162 to 203.

The proposal suggests that “a future ICTM could comprise not only East Asian Traditional Medicine but traditional medicine practices from other WHO regions… such as India, Sri Lanka and Africa.” This leaves us to wonder whether “pacing zombie swagger” may figure as a possible entry if the ICTM decides to include the Caribbean one day?!

I recognize that the Korean research institute, the Kyung Hee University, and the health care community in Asian countries are free to believe in the existence of pestilence or miasmatic malaria, and can treat their populations with incantations, amulets, talismans, lancing, or even bloodletting, if they so choose. But what really concerns me is the possibility that these medieval views on disease might someday become legitimized in the US, not only because they fit New Age ideas and ideals, but also because they bear WHO’s seal of approval.

Traditional acupuncturists in many US states already practice medicine based on medieval views similar to those expressed by Avicenna (c. 980–1037) in the 1025 Canon of Medicine, which — although ingenious for its time — was already obsolete in the 17th century. This “medical primitivism” (the rejection of science-based and industrialized medicine) is the result of the counterculture of the 1960s, postmodern ideology, and the New Age movement. Trough political pressure, primitivism has increasingly become an acceptable form of healthcare in the US under the guise of “alternative” or “Oriental” medicine. An ICD that includes the “running piglet” might reinforce this political momentum, and might further the resurrection and re-legitimation of notions that are closer to fantasy than reality.

Indeed, as Jeannie Kang, an acupuncturist in Los Angeles, CA, and the head of the American Association of Acupuncture and Oriental Medicine (AAAOM) Korean Advisory Council, writes in Qi-Unity Report:

Incorporating traditional medicine into the ICD coding system for medical records and billing is an essential prerequisite for advancement of traditional medicine into the mainstream medical system. The WHO has agreed to work with a standardized terminology on the basic terms it has identified.

The last WHO meeting to discuss the ICTM was held in the Philippines, February 7–11, 2011.

I find that this “standardized terminology” bears a significant — and instructive — resemblance to the outlandish bestiary that Borges recounts in The Analytical Language of John Wilkins. Borges, whose Magical Realism blends facts and fiction liberally, attributes the passage he cites to an elusive Chinese encyclopedia called The Celestial Emporium of Benevolent Knowledge.

The naive oddity of the underlying logic of association that yields the Celestial Emporium‘s taxonomy has inspired considerable commentary, notably by the philosopher Michel Foucault, who writes in The Order of Things that it shatters “all the familiar landmarks of thought — our thought, the thought that bears the stamp of our age and our geography.”2 But more pertinently, the clinical psychologist, Louis A Sass, writes in Madness and Modernism that such oddity of thinking shows the signs of a typical schizophrenic thought pattern.3

Different cultures at different stages of their development have used different logics of association to categorize illnesses. Prior the advent of modern science, disease taxonomies (nosologies) were predominantly based on symptoms, and identified by means of vernacular naming systems. “Running piglet” is, for instance, a Chinese agrarian metaphor that indicates a panic attack. However, scientific nosology is predominantly based on etiology (causative agent) or pathogenesis (causative mechanism), except for idiopathic conditions. As a result, most ancient categories have disappeared: they are obsolete. “Melancholia” (meaning “excess of black bile”) is an example. Other categories are archaic: that is, when the name is used in modern nosology, it refers to a significantly different category. Malaria (originally meaning “bad air”) is a good example. The proposed addition to the ICD11 ignores this important paradigm shift.

Therefore, tossing modern and obsolete categories together into a single system of categorization, like the proposed ICTM, departs from common-sense, loses coherence, fragments into contradictory points of view, and ultimately turns into a “word salad”: a mixture of words and expressions that, while seemingly meaningful, actually carries no significance.

Lastly, I think the illogical nosology for which the AAAOM is “very excited” is the product of a style of thought that is, at best, idiosyncratic and odd. At worst, it is the hallmark of the cognitive slippage and technophobic delusions that characterize the modern apologists of unscientific medicine(s). In all, it is a significant leap away from reason, in the direction of the Dark Ages.

With special thanks to Kristin Koster, PhD, for her valuable contribution.

REFERENCES

  1. Borges, Jorge Luis (Author), Weinberger, Eliot (Editor). ‘The Analytical Language of John Wilkins’ in Selected Nonfictions. Penguin Books. 1999. Return to text
  2. Foucault, Michel. The Order of Things: An Archaeology of Human Sciences. Tavistock. 1985. Return to text
  3. Sass, Louis A. Madness and Modernism: Insanity in the Light of Modern Art, Literature and Thought. Harvard University Press. 1998. Return to text

Posted in: Acupuncture, Basic Science, Science and Medicine

Leave a Comment (269) ↓

269 thoughts on “An ICD Code for the Running Piglets!

  1. Kultakutri says:

    Erm, well, one little nasty comment.

    How more rational and sciencey is the name of panic attack, referring to the pagan god Pan whose appearance made people scared shitless, to disease/syndrome/wtf of running piglets?

    If you get bored, find an etymologic dictionary and peruse it freely. You will find most interesting facts about what we’re actually saying if we dig deep enough. My fave is culture, that oh-so-noble thing, which has the same pedigree as yours truly: go back in history and you’ll end up knee deep in mud. Derives from colere, tend the field.

    Anyway, I won’t criticize words. The concept, on the other hand…. has anyone said something about a pile of crap already?

  2. I don’t quite get what’s going on. Are they just associating old names to real diseases, like calling congestive heart failure “dropsy”? In that case, “wasting thirst” sounds like a perfectly reasonable name for diabetes.

    Or are they saying that there’s a parallel system for understanding disease and that wasting thirst and diabetes are fundamentally distinct?

    Years ago when the new territory of Nunavut was organizing its educational system and curriculum, there was a completely legitimate debate over whether biology textbooks written in Inuktituk should use latinate terms or the Inuktituk vocabulary developed for naming parts of a seal. Is there a parallel here or are you describing something else?

  3. daijiyobu says:

    I hope there’s “damp brain.”

    Really needed.

    -r.c.

  4. NYUDDS says:

    “. But what really concerns me is the possibility that these medieval views on disease might someday become legitimized in the US, not only because they fit New Age ideas and ideals, but also because they bear WHO’s seal of approval.”
    Kavoussi raises a salient point that has two important consequences:
    First, legitimization of alternative views and methods have already gained a formidable beachfront by being incorporated into several medical and dental school curricula and as services at several teaching hospitals and medical centers. The money necessary to keep these “centers” operating always seems to be available. It seems that scientific credibility is for sale.
    http://scienceblogs.com/insolence/2007/11/the_woo_aggregator.php

    Second, these practitioners may have deficiencies, but patience is not one of them. Nor is an evangelical fervor. They promote their field in every possible way: conversation, interviews, magazine articles, TV, seminars, print items, spoksepeople, patients, anecdotes, legislative pressure (cards, letters, e-mails, money, direct contact, telephone etc.) The holy grail? Exactly what Kavoussi said… and then some. Utilizing many different approaches toward licensure, provider numbers, insurance acceptance and beyond.

    I’m sure we all have heard about the camel who “just wanted to put his nose under the tent” to keep warm. Think of many, many camels asking many people to let them under their(our) tent. Some are succeeding.

  5. I also don’t get it. from WHO “The World Health Assembly adopted in 1967 the WHO Nomenclature Regulations that stipulate use of ICD in its most current revision for mortality and morbidity statistics by all Member States.

    The ICD is the international standard diagnostic classification for all general epidemiological, many health management purposes and clinical use. These include the analysis of the general health situation of population groups and monitoring of the incidence and prevalence of diseases and other health problems in relation to other variables such as the characteristics and circumstances of the individuals affected, reimbursement, resource allocation, quality and guidelines.

    So if Korean or Chinese traditional medicine practitioners suddenly starts diagnosing an increase of deaths from “syndrome of liver fire blazing the ear ” We don’t want to know?

    I don’t have the time to look into it now, But it was my understanding that because many parts of the world don’t have good access to modern health care, that WHO has reached out to local medicine people in some areas. It’s hard to communicate with these practitioners, if you don’t have a record of the language, diagnoses that they are using.

    But hey! I’m all for science based medicine available for everyone in the world, even the out of the way rural communities in Afghanistan, China, Kazakhstan, etc.

    I know of one organization that provides conventional surgeries for children in these regions (and others.) http://www.smiletrain.org working in cleft lip and palate. Perhaps other readers know of other organizations who provide good quality health care in these regions.

    So possibly, instead of being “free to believe in the existence of pestilence or miasmatic malaria,” and being treated “with incantations, amulets, talismans, lancing, or even bloodletting, if they so choose. ” they will also be free to be treated with the proven therapies that are currently unavailable many.

  6. Jan Willem Nienhuys says:

    I always thought that Borges’ funny list came out of a painter’s manual.

  7. Harriet Hall says:

    Diagnostic categories have always been somewhat arbitrary and are often not based on an understanding of the underlying physiology and pathology. The whole point of naming diagnoses is so that different practitioners can recognize the same condition. It doesn’t really matter what we call a condition as long as we can be consistent and effective in identifying and treating it. If running piglet is truly equivalent to panic attacks (I suspect it isn’t) it could be offered as a synonym or a translation; anything more than that is suspect.

  8. lazarus sleeping says:

    Let he who has ears hear and he who has eyes see. It is obvious to anyone that this is a vast conspiracy by the Secret World Government using their WHO puppet. They are setting up artificial selection pressures by legitimizing ‘traditional medicine’ to control populations and attempt to assuage the pending population vs food supply vs energy supply crisis. They know we need less people on the planet. What better way than to let populations self-select for extinction through gullibility, willful ignorance and blind faith in authority? How can groups blame their government for the spread of disease and death when these same groups lobbied for the right to spread disease and death cleverly disguised as traditional medicine? As a side benefit, there is a positive correlation between woo and religion so I may have over-spent on my JW proof, reinforced bunker door.

    Just kidding.

    Or am I? the proof’s not out there. See for yourself.

  9. Ben Kavoussi says:

    @Alison Cummins,

    They are indeed saying that there’s a parallel system for understanding disease. “Wasting thirst” is the name for a certain pathological condition that involves vapors (qi) from the liver affecting the heart!

    This parallel system is from pre-scientific times, prior to the germ theory of disease. They still believe disease is caused by a disturbance in the balance of organs and homours.

    This is also how Galen or Avicenna described diseases: a disturbance of humours. It is called humoural pathology or humourism.

    The running piglet disorder is similar to a panic attack, yet it is described as a “stagnant liver condition where the qi will rise up and interfere with the heart causing palpitations, anxiety, fear a/or dizziness.” (!?)

  10. Ben Kavoussi says:

    @ Harriet Hall

    I agree with you. But the running piglet is “stagnant liver condition where the qi will rise up and interfere with the heart causing palpitations, anxiety, fear a/or dizziness.

    Steaming Bone Disorder is “a condition of deep internal heat arising from severe yin deficiency. The patient will describe a heat that seems to come from the bones.”

    etc.

    The problem is not in the terminology, the problem is in the classification system.

    They classify disease base on which organs and humours are affected.

  11. Ben Kavoussi says:

    @ micheleinmichigan

    The problem is that TCM practitioners in the US are trying to bring this here! This is why Jeannie Kang, a Los Angeles acupuncturist and the American Association of Acupuncture and Oriental Medicine have gotten involved.

    They want to us it in “medical records and billing” and bring TCM “into the mainstream medical system,” based on the fact that WHO has accepted the terminology!

    This is outrageous!

  12. Ben Kavoussi says:

    @ NYUDDS

    Thank you, you are absolutely right. Just imagine a WHO seal of approval behind all the conversation, interviews, magazine articles, TV, etc.

    The rumors are that American acupuncturists have given over one million dollars to the East-West Medical Research Institute to come up with this proposal, so they can bring it to the US in order to justify the traditional premises of acupuncture.

  13. Ben Kavoussi says:

    @ Kultakutri

    You are right about our terminology also having outdated worldviews. Bu this is not about the terminology, its is about disease understanding.

    When TCM practitioners talk about miasmatic malaria, they are talking miasmatic “bad air” (mal aeria), not malaria as we understand it today.

  14. Ben Kavoussi – My problem is that your article is rather long on snark and rather short on information.

    I have read your article three times and beyond a Korean University Collaborating with WHO to add a list of traditional medicine diagnoses to the ICD and an influential acupuncturist in California being happy about it, I still genuinely don’t get your real point.

    I’d suggest you to write an outline of the real issues that are worthy of addressing, address them and save the ‘let’s make fun of the names those backward foreigners come up with’ for the bar.

  15. Also BK “The rumors are that American acupuncturists have given over one million dollars to the East-West Medical Research Institute to come up with this proposal, so they can bring it to the US in order to justify the traditional premises of acupuncture.”

    Really?!

    Also, that Obama isn’t a U.S. citizen. Why won’t he show us his birth certificate? Rumors are great, aren’t they?

  16. David Gorski says:

    Michele,

    Q: Don’t you find the views in the interview that Ben cited to be disturbing? I know I do. Here’s the link again:

    http://www.aaaomonline.info/qiunity/08/01/1b.html

  17. Mark P says:

    Kultakutri:

    How more rational and sciencey is the name of panic attack

    Panic attack is no longer considered a disease or condition. At best it might be considered a symptom.

    It’s original etymology is meaningless, as we no longer associate it with Pan, or any other supernatural origin.

    The advance made in the West to finding the actual physical origins of illness, so that we no longer consider “panic” or “melancholy” to be diseases, was hard fought. We should resist any back-sliding, and that means opposing the introduction of non-scientific concepts of disease.

    If the Third World cannot diagnose disease correctly, how can it hope to cure it? And it can’t hope to diagnose disease if it uses incorrect concepts of how diseases arise.

  18. pmoran says:

    CAM thrives mainly on unmet medical needs, but it is helped along by ever-changing fashion and novelty, the “forbidden fruit” illusion, and the innate mystique of some of its methods.

    Thus it is that Australia may have unwittingly (or witlessly) stumbled upon a way of defusing one aspect of it — make it commonplace!

    For many years now any Australian doctor can perform acupuncture and get a small (actually pathetic) fee from our Medicare system. I suspect it was brought in to stop doctors milking the system by charging higher consultation fees for such repeated visits.

    Fifteen per cent of family doctors now provide acupuncture —

    http://www.mja.com.au/public/issues/aug17/easthope/easthope.html

    yet we we seem to be getting along just fine. Few reports of harm, and no one is getting too excited about anything. Perhaps there IS more than one way to skin these cats!

    Note how quickly scientific medicine has lost a lot of the mystique it once had, in the heady days of heroic TV doctors like Dr Kildare and Ben Casey. We are as likely now to be cleverly diminished by being referred to as practitioners of “traditional medicine”, as though our methods are already fossilized in time.

    (Loved the Borges quote — so apt!)

  19. Can we have some clarity on why the list is being compiled and what its intended use is? (Thanks for looking into it, micheleinmichigan.) You would sound much less racist if you could explain the program’s purpose objectively and then objectively explain why it was not the best way to achieve the stated purpose.

    I still have no idea whether there is a risk/benefit balancing act going on, with the benefits going to people who have limited access to qualified medical care today and the risks going to Californians who want to treat diabetes with acupuncture. (As per micheleinmichigan’s conjecture.)

    If there are no benefits, then explain why not. (If there are no benefits, then why does the WHO think there are? What mistake are they making?) If there are benefits, then explain why they are less significant than the risks.

    Or do you simply not care? Perhaps this is a really smart program that will have great benefits but that doesn’t matter to you because the benefits won’t be accruing to you?

    But as it is, your post makes you look really, really bad. Complete with racial hierarchy. (You think that traditional Asian medical terminology is bad? Just wait – traditional black people’s medical terminology could be next!)

    If there is something you want to tell us about, please just tell us about it.

  20. Ben Kavoussi says:

    @ micheleinmichigan

    Here we go:

    1- A Korean University is collaborating with WHO to add a list of traditional medicine diagnoses to the ICD 11.

    2. These diagnoses are based on medieval worldviews, that were already outdated in 17th-century Europe.

    3. The American Association of Acupuncture and Oriental Medicine (AAAOM) represented by an influential acupuncturist in California would like to use it in the US.

    4. They are using the WHO seal of approval to legitimize this diagnosis.

    5. They hope this will make their “word salad” mainstream, so they can use it in medical records and bill insurances for it

    6. This is like going back 500 years.

    7. Someone who goes to an acupuncturist and pays $600 for a 10 session regimen for his “running piglet syndrome” or “steaming bone disorder” cannot get a second opinion form a physician because the diagnosis is in 15th-century language!

    I hope this helps.

  21. Harriet Hall says:

    Critics of this article, please read it again. There is nothing racist in it. The point is clear: it describes a resurgence of Medieval, pre-scientific thinking infiltrating into a modern institution. The whole premise of this blog is that science-based medicine is a good thing. If anyone thinks this “leap away from reason” for the ICD-11 is a good thing, it’s up to them to explain why.

  22. Ben Kavoussi says:

    @ Alison Cummins

    Traditional Chinese medicine or TCM is based on an outdated worldviews that come from Chinese astrology and alchemy. Is is similar to the medicine of Galen and Avicenna.

    I know a lot about TCM and other Asian medicines. I have a degree in it and I have a license to practice it!

    I also grew up using traditional medicines, because I was born and raised in ASIA! I am sure you are aware of the fact that Asia does not mean China. Asia starts in Istanbul.

    The purpose of this site and the philosophy of all the blogger is that ALL unscientific medicines are dubious, unless we have proof of the efficacy of a treatment in a double-blind placebo controlled study.

  23. David Gorski says:

    Fifteen per cent of family doctors now provide acupuncture —

    http://www.mja.com.au/public/issues/aug17/easthope/easthope.html

    –yet we we seem to be getting along just fine. Few reports of harm, and no one is getting too excited about anything. Perhaps there IS more than one way to skin these cats!

    Hmmmm. Let me think about this.

    Hey, a most excellent solution, Ted! Just give up and allow pseudoscience into medicine, coopting it from the CAMsters, so to speak! I guess I might as well stop complaining about the quackademic medicine finding its way into academia and embrace it wholeheartedly. Heck, why worry about all that science? Learn about qi, the law of similars, and the like. It’s so much easier. Just embrace acupuncture, reiki, homeopathy, and whatever else strikes one’s fancy. That’ll be so much easier, too, won’t it? And potentially very profitable, too! Cash on the barrelhead, no haggling with insurance companies, pay as you go, what could be better? None of that pesky trying to educate patients about science. No need to; just stick a few needles in ‘em or give ‘em magic water. None of that annoying trying to adhere to science-based guidelines. Who needs that stuff anyway?

    Yes, I know I’m being sarcastic, and some readers have made it abundantly clear that they do not like sarcasm or anything that has even a whiff of derision. However, in this case I thought it was justified to use a bit of sarcasm to get my point across pointedly, so to speak. I’ll tone it down a bit now and ask the deadly serious question behind my diversion into a bit of sarcasm: Where does it end? A little acupuncture? That’s OK to mix in with the science-based medicine? Alright, what else? What about homeopathy? If not homeopathy, then why not? What’s wrong with homeopathy and not acupuncture? What about reiki? Therapeutic touch (which is neither touch nor therapeutic)?

    Seriously, as of the paragraph above and this paragraph, I am not being sarcastic in the least. All I want are some concrete, discrete answers as to what CAM modalities are acceptable to “integrate” with science-based medicine, which ones are not, where we draw the line between the two, and on what basis. If I’m to agree with your suggestion, I will need some guidelines, because, right now, I can’t think of any that would distinguish between the flavors of pseudoscience that should be “integrated” into our practices.

    In other words, I am not sure that you have thought this answer through. I could be wrong, though, of course, in which case, if you have I want to know the results of your thought processes. I really do. Or maybe you were just joking, in which case I apologize. I couldn’t tell if you were only half-joking or not serious at all.

  24. David Gorski says:

    The purpose of this site and the philosophy of all the blogger is that ALL unscientific medicines are dubious, unless we have proof of the efficacy of a treatment in a double-blind placebo controlled study.

    Uh, no, Ben. Not quite. Not all science-based medicine is demonstrable in a double-blind, placebo-controlled study. Most surgical interventions, for instance, are not. Does that make them unscientific? No. Science-based medicine involves looking at the totality of scientific evidence, and sometimes there just aren’t any double-blind RCTs. In such cases, we have to use the evidence we have.

  25. Ben Kavoussi says:

    @ Alison Cummins

    One more thing: this article is not about the efficacy of Asian medicines. It is about the classification of diseases.

    Providers of TCM in many states, like CA, do not (and legally cannot) diagnose diseases. Also they cannot claim that they can cure any diseases.

    But they have a workaround.

    They use medieval Asian nomenclature so they cannot be charged with breaking the law. What they diagnose and threat (like the running piglet syndrome is not classified as a disease)

    Now, the WHO is has a proposal to add medieval Asian nomenclature to the ICD 11.

    TCM providers are all excited because they hope this will legitimize their medieval worldviews.

    They are also planning to use it in patient records and billing.

    I hope this helps.

  26. Ben Kavoussi says:

    @ David Gorski

    In this context, by unscientific medicines, I mean medicine that is based on metaphysical notions, such as qi or prana, or based on outdated worldviews, such as humoral pathology.

    I was not referring to surgery.

    An herb or a traditional modality has be validated through clinical trails for it to considered efficacious. The fact that the traditional healers say that “benefits the liver” or “augments qi” is not going to give it true validity! It only allows for formulate a research hypothesis.

  27. Ben Kavoussi,

    You still aren’t saying anything about the WHO program, so I am guessing: you actually think the WHO program is fine and this post isn’t criticizing it. Your post is to share your alarm about how it might be co-opted by TCM practitioners in the US.

    Am I getting closer?

    Not sure why you thought it was necessary to clarify in your response to me that you weren’t writing about the efficacy of Asian medicines, or that there’s more to Asia than China. I didn’t ask you to elaborate on the efficacy of traditional medicine, I asked you to elaborate on the stated purpose of the WHO program. And I never referred to China.

  28. Ben Kavoussi says:

    For those of you who have imagined racism in this article, I have to tell you that I am a Western-educated Trukmen, and that Ben Kavoussi is an Americanized version of my given name.

    Trukmens are Turkic people located in the Central Asian states of Turkmenistan, Afghanistan, and northeastern Iran. They are related to the mongols.

    Many people in Central and Far-Eastern Asia believe that traditional medicines are based on superstitions and outdated worldviews.

    That includes me.

    So, please do not read more into my articles that what is explicitly stated about unscientific worldviews that are from the era of Genghis Khan!

  29. Ben Kavoussi says:

    @ Alison Cummins

    Yes, yes, that’s it. The WHO program in Asia is not my concern and this post isn’t criticizing it at all.

    I am utterly alarmed about the fact that the WHO approval might give it a false sense of legitimacy.

    TCM practitioners in the US are planing to use the WHO’s proposal to bring the nomenclature here. This is why Jeannie Kang writes:

    “Incorporating traditional medicine into the ICD coding system for medical records and billing is an essential prerequisite for advancement of traditional medicine into the mainstream medical system.”

    She is talking about medical records, billing and the mainstream medical system right here in the US!

  30. More request for clarification:

    “They are indeed saying that there’s a parallel system for understanding disease. “Wasting thirst” is the name for a certain pathological condition that involves vapors (qi) from the liver affecting the heart!”

    To understand better: traditional practitioners obviously say this, but do the WHO and Kyung Hee say it too?

  31. Ben Kavoussi,

    Ok, thanks, that helps hugely.

    Thank you!

  32. “# Ben Kavoussion 26 Feb 2011 at 8:30 pm

    “Yes, yes, that’s it. The WHO program in Asia is not my concern and this post isn’t criticizing it at all.

    I am utterly alarmed about the fact that the WHO approval might give it a false sense of legitimacy.”

    No, now I understand even less. Is there a source for how the WHO is using these TCM diagnoses? ARE they legitimizing the diagnoses or are they using the information about the diagnoses to educate themselves and other what kinds of diagnoses they may come across in areas where TCM is common and track diseases where there may be overlap? Or something else, heck. I’m not a doctor, I don’t know.

    One reason that I ask this is because when we adopted our children, we received their medical records. My son’s was Chinese and was pretty straightforward conventional medicine. But my daughter’s was Russian medicine, which has a lot of diagnoses that we just don’t do here in the U.S. Luckily we were able to consult a doctor who was familiar with Russian orphanage medical records and could tell us what to take seriously, what not to, etc. I don’t think that being familiar with the information legitimizes it. I think if large populations of people are using a particular kind of medicine, WHO has to be informed and track data from that medicine.

    On the other hand, if WHO is spending large sums of moneys to set up TCM hospitals to treat these diagnoses. that’s problematic, IMO.

    I’d just kinda like to have that info clearly shown in the article.

  33. David Gorski

    Michele,

    Q: Don’t you find the views in the interview that Ben cited to be disturbing? I know I do. Here’s the link again:

    http://www.aaaomonline.info/qiunity/08/01/1b.html

    Yes and no, My problem is in order to be alarmed at the interview, I have to trust that Jeannie Kang is presenting how the system works factually and is a good judge of how a revised ICD will effect TCM in the U.S. I just don’t know enough about the situation to judge for myself. What if Jeannie Kang is just spinning this ICD revision to make herself and her organization look good? Like all the politicians proclaim victory after every presidential debate…

    How does the WHO ICD effect U.S. insurance payment systems? Does it? That’s why I’m saying more information is needed. The dots need connecting.

  34. David Gorski says:

    In this context, by unscientific medicines, I mean medicine that is based on metaphysical notions, such as qi or prana, or based on outdated worldviews, such as humoral pathology.
    I was not referring to surgery.

    You missed my point. Surgical interventions were merely an example I used to illustrate my point that science-based medicine is much more than randomized, double-blind placebo-controlled trials.

  35. Dr Benway says:

    This nomenclature thing looks to me like an end-run around current scientific standards and scope of practice laws.

    Remember Mr. Cruise: “We don’t need to ask permission from the authorities. We are the authorities.”

    A similar end run seems to be happening within behavioral health, with the appearance of novel professional degrees using non-protected terms such as “psychotherapeutic counselor” and “life coach.”

    The new programs come with new accreditation boards as well, so one can train at a “fully accredited e-learning program.” There are new journals, new research organizations applying for grants to study the effect of various items and structured “study materials.” This alternate mental health world looks almost like what goes on within academia, except it’s outside where no one wanders by and asks challenging questions.

    There’s a 12 hour program you can take to become certified as a “Mental Health First Aid” responder, which will allow you to rush to scenes of, um, upsetting events, I guess.

    There’s something called “TIR” (can’t recall what the acronym stands for) which is about providing services to people with a history of “trauma.”

    At my job people were training all last week in something called the [redacted] System™, which to my eye seems more appropriate for “corporate team building” than for a facility with doctors and nurses where words must actually have actual meanings.

    I expect these end runs to be effective in the same way the Gish Gallop is effective: time crunch. No one will have the time needed to refute the basis for so many proprietary degree programs. No one will have the energy for stripping thousands of their newly minted degrees.

    Similarly, once a few hundred naturopaths are up and running with their own ICD-11 TCM codes, there will be neither the time nor the energy needed to dismantling the new structure.

    This isn’t a grass roots demand from the ground up. This is an organized top-down assault upon science-based healthcare. It’s a theocratic wedge strategy with mental health as its entry point.

  36. Ben Kavoussi says:

    @ micheleinmichigan

    Here is the final version of the “WHO International Standard Terminologies on Traditional Medicine in the Western Pacific Region.” They abbreviate traditional medicine as TRM.

    http://www.wpro.who.int/NR/rdonlyres/14B298C6-518D-4C00-BE02-FC31EADE3791/0/WHOIST_26JUNE_FINAL.pdf

    In the introduction, the document states that In 2004… WHO Regional Office for the Western Pacific initiated projects promoting the proper use of traditional medicine under the theme of “Standardization with evidence-based approaches.”

    It then states that

    “Objectives of this document are to:

    (1) Provide a common nomenclature for better understanding, education, training, practice and research
    in TRM.
    2) Facilitate information exchange in TRM among Member States.

    Though TRM is now spread worldwide and an increasing number of people outside Asia have a profound understanding
    of TRM, there still exists a considerable variation in the levels of knowledge and clinical proficiency. The purpose of
    this document is to provide a standardized nomenclature that will be suitable for: researchers, educators, practitioners,
    regulators and students in the field of TRM. It will thus assist in raising standards within TRM and, also, be of use to
    those who are not familiar with TRM, such as Western medical practitioners.”

    Now look at pages 30-75: Cause of Disease and then Mechanism of Disease. It is all explained in terms of yin. yang, wind, cold, fire, etc.

    This is primitivism in medicine.

  37. Ben Kavoussi says:

    @ David Gorski

    I agree with you. Sorry I missed the point.

  38. Dr Benway says:

    Some info regarding the TCM practitioners’ game plan vis a vis Medicare, dated 11/09. Not sure if the nomenclature issue is specifically addressed in the .pdf as I was too lazy to read the whole thing.

    ***
    How will HR646 affect me if I currently don’t see Medicare beneficiaries and I don’t intend to treat then in the future?

    25 Medicare is the baseline from which all other insurance plans and third party reimbursement systems take their cues. Passage of this bill will provide federally endorsed national recognition of AOM and will provide acupuncturists with more patients and referrals from physicians as AOM expands its influence in the medical community. In addition, it will increase practice opportunities in hospitals and other facilities that previously would not allow acupuncturists to become credentialed because due to a lack of funding for services. Acupuncture will become mainstream and available as a revenue generating system for hospitals and other facilities.

    26 Inclusion in Medicare will open the doors to access in other insurance plans based on what Medicare covers. NOTE: Not only seniors are covered by Medicare; those who are disabled due to certain diseases or conditions are also Medicare beneficiaries. AOM professionals provide critical access to non-medication pain management.

    http://www.aaaomonline.info/medicare_fact_book.pdf

  39. Ben Kavoussi says:

    @ Dr Benway

    YES. This is indeed an end run — meaning a bypass by deceit or trickery.

    And YES, this isn’t a grass roots demand from the ground up.

    From what I have heard (I don’t have any proof, yet), “this top-down assault upon science-based healthcare” — as you pertinently assess — was partly financed by TCM providers in the US.

    There are aground 30,000 TCM providers in the US. About half do not work in TCM and do something else to pay their heavy student loans.

    The rest are providing care based on metaphysical notions such yin and yang and the 5-elements, which are rooted in Chinese astrology and alchemy.

    Now professional organizations are trying to legitimize these views by any means (end runs is the right word!) so they can bill insurances for “steaming bone disorder,” “restless organ” or other such hogwash!

    This is insane!

  40. Dr Benway says:

    …yet we we seem to be getting along just fine. Few reports of harm, and no one is getting too excited about anything. Perhaps there IS more than one way to skin these cats!

    “These cats” = US medical schools. You can’t skin those cats because they’re the boss.

    With science we can appeal to evidence to settle our differences. Apart from that, things get ugly. I find it painful, sharing care of an autistic patient with a DAN! doctor.

    I have a preadolescent boy at the facility where I work on hydrocortisone for adrenal fatigue. Sh_t like that makes it hard for me to sleep at night, particularly when the higher ups don’t really see a problem with such “novelty.”

    Either we have rules of evidence that matter, or they don’t matter.

  41. Ben Kavoussi says:

    @ Dr Benway

    This is it. The purpose is to legitimize nonsense or a bill.

    HR646 will allow AOM (new word for TCM) providers to bill Medicare and federal employees for yang edema, consumptive disease or bone-steaming fever!

    How did we get to his point? Are we the only voice of reason here?

  42. pmoran says:

    David: Hey, a most excellent solution, Ted! Just give up and allow pseudoscience into medicine, coopting it from the CAMsters, so to speak!

    My comments were clearly not a plea for the widespread application of any particular strategy.

    They were intended to add to other evidence challenging a key skeptic doctrine: that nasty effects must inevitably flow on from any level of even selective association with, or toleration of, or subsumption of CAM methods. They were intended to challenge the slippery slope arguments that you seem to have had in mind when responding.

    I think it is utterly ridiculous to suggest that science is seriously under threat from this stuff. The logic of the scientific approach is too solid, and we must stop judging the general public by the extremes we encounter within healthfraud debate.

    I can understand the outrage when nonsense seems to be creeping into hallowed institutions but I predict the reaction when it comes will be violent. Some of the actual methods may yet find a niche in practical medicine as a means of delivering extra non-specific nurturing to any that need it, if we prize patient outcomes over selected scientific niceties.

    Elsewhere I have been trying to point out that CAM, and its use, has very little to do with science. It truly doesn’t need it and it doesn’t really understand it. Yet that is all that the skeptic usually wants to talk to.

    This while we are up against such complex and multi-faceted matters that I can only get one or two pieces of the jigsaw into place on paper at a time. I thus far only have glimpses of the final picture and I am not sure what that will say. Perhaps it doesn’t matter a lot what we do — the pendulum will swing back and forth under momenta over which we have little control.

    But I am confident that science will out in the end.

  43. pmoran says:

    The following might be a good place to start if you want to seriously understand what I am on about.

    When we anguish about an asthmatic dying under licensed naturopathic medical care whose failure is that? Do we ever ask whether it is in part ours? Why would we not ask that, in the face of other evidence that we are not that good at getting effective messages across in some of the areas where we would like to have influence?

    Which leads to: can we do better in keeping the public safe from the extremes of CAM? I am not sure that we can without a change of concept and of tactics. Even if we are wholly right in all things, which is arguable, being right doesn’t guarantee desired outcomes in a terribly complex social, legal and scientific environment.

    I fear that our “shining knight” kit of skeptical assumptions urges us on to even more strident and absolute opposition to CAM. This overlooks the possibility that our message is part of the problem given the terrain in which it has to operate (which I have also tried to characterize elsewhere — there is a reasonably coherent whole in all this ) .

    That message may not merely be unsaleable where it counts.

    It’s absolutism may manoeuvre politicians, patients, board members and some clinicians into thinking they have to make all-or-nothing decisions, when what might really be needed is surgical precision in identifying what is important, what is not, and what a realistic ends also deliver the best outcomes for the public. The science will look after itself, which is fortunate when we are the only ones to really udnerstand it.

    I am very happy to be challenged on this. I would be pleased to give it all up if I could see fatal flaws.

  44. Dr Benway says:

    I can understand the outrage when nonsense seems to be creeping into hallowed institutions but I predict the reaction when it comes will be violent.

    Dude you are totally stuck on some planet that isn’t mine.

  45. Dr Benway says:

    Whoa. Sh_t just got real. Anons are threatening to take on the Koch brothers because of the Wisconsin govenor’s union busting shenanigans.

    Could be a troll though. Anons usually don’t warn targets until after they’ve invaded and run off with their loot.

    I realize the Kochs aren’t relevant to SBM right now, but they could be. The brothers aren’t exactly pro-science.

  46. WilliamOBLivion says:

    “There’s a 12 hour program you can take to become certified as a “Mental Health First Aid” responder, which will allow you to rush to scenes of, um, upsetting events, I guess.”

    Wouldn’t even have to rush as I’m usually at the scene. Often as the cause.

    “I realize the Kochs aren’t relevant to SBM right now, but they could be. The brothers aren’t exactly pro-science.”

    Ooooohhh…The Evil Koch Brothers.

    Lesse, they fund that evil right wing anti-science show Nova that runs on…Oh, PBS. Uh. Never mind.

    Other than spitting out random CNN/DNC talking points do you have any evidence for that?

    Or are you just engaging in group-signalling, showing you’re one of the crowed?

  47. Ben Kavoussi,

    Now I’m really confused. You quote the “WHO Standard Terminologies” as follows:

    “In the introduction, the document states that In 2004… WHO Regional Office for the Western Pacific initiated projects promoting the proper use of traditional medicine under the theme of “Standardization with evidence-based approaches.””

    How can you not be against it?

    After much prodding, you finally cough up that the program is prescriptive, not just descriptive, which is a crucial piece of information entirely missing from your post.

    Yest you say you have no criticism of the WHO statement that there is a proper use of AOM? I don’t get it.

  48. BK – Thank you. I am getting a clearer picture. So while one part of the ICD could be considered okay IMO (educating conventional medical pratictioners, if they need to understand TCM terminolgogy) another area, educating TCM pratitioners on a standard TCM approach, not okay.

    Just one last piece of the puzzle to build a good case for your article (as I see it.) Show some evidence that WHO ICD codes effect medicare reimbursement or other insurance payments. Sorry if this is there somewhere, and I missed it.

  49. Ben Kavoussi says:

    @ Alison Cummins

    I am currently only concerned with its impact in the US.

  50. Ben Kavoussi says:

    @ micheleinmichigan

    I never said one part of the ICD could be considered okay. If other countries choose to use a different ICD, that is their problem, they must have some complex reason for it.

    I clearly state in the post that “what really concerns me is the possibility that these medieval views on disease might someday become legitimized in the US, not only because they fit New Age ideas and ideals, but also because they bear WHO’s seal of approval.”

    How much more clear can I be?

    There are tens of thousands of TCM providers in the US who are already providing care based on metaphysical notions such yin and yang, etc.

    TCM professional organizations want to bill insurances for non-standard diagnosis of disease. They want to pass a bill that would allow it:

    http://www.aaaomonline.info/medicare_fact_book.pdf

    I hope this helps.

  51. BK – No, you didn’t say one part of the ICD was okay. I did, that’s why I said “IMO”.

    Like alison said, one part is descriptive, one part prescriptive. I find the descriptive, okay, not necessarily legitimizing TCM, but providing information. Similar to the way that sex education can not be considered to legitimize teen sexual activity. Prescriptive content could be considered to legitimize TCM, not okay.

    But, if you are concerned about the HR646, why is your article about the ICD?

    I can see I’m being annoying, but I am genuinely looking for the evidence needed to support your thesis, which seems to be ‘Kyung Hee University in Seoul, Korea, in collaboration with WHO, is creating an ICD* that will legitimize TCM (which is based on non-scientific principles**) to organizations using the ICD*. This will make it easier for TCM practitioners to bill for procedures in the U.S***”?

    I do not need to hear how unscientific TCM is. I get that.

    *point were you have shown evidence
    **Since I’ve seen other evidence to the effect that TCM isn’t based on scientific principles, I didn’t need it here.
    ***last point without evidence, unless I missed it.

    Perhaps I’m missing the point. If your sole point is that TCM is unscientific, then the talk about the WHO ICD seems to be a distraction.

  52. Harriet Hall says:

    The criticisms of this post are unreasonable; some of them seem to amount to willful misunderstanding. The purpose of the ICD is not to increase cross-cultural understanding. Ben’s points are valid without having to show that ICD codes affect Medicare reimbursement. And he certainly did not show any evidence of racism. I don’t understand where the hostility is coming from.

  53. Dr. Benway, I’ve always kinda longed for a life coach. Sounds so alluring doesn’t? Someone who can coach you through life like a good dance teacher can take you through a routine?

    Sadly, it seems very unlikely that someone you pay could do that, life being what it is (a bit more complex than a dance routine).

    I think what I really need is a good mentor. Too bad they are alot harder to come by and they don’t post ads in the yellow pages.

  54. Harriet Hall says:

    The point is not that TCM is unscientific, it is that it is irrational to integrate modern terminology with obsolete conceptions of illness, and that kind of thinking can only undermine the scientific enterprise.

  55. Ben Kavoussi says:

    @ Harriet Hall

    Thank you for bringing this up. I am very surprised about the hostility too. Several open-minded TCM practitioners read the draft and did not find it offensive. This is not about efficacy, its about a parallel classification of disease that is not based on scientific etiology.

    Perhaps people do not like the Borges analogy, or the fact that I mention schizophrenic though process.

    ??

  56. Ben Kavoussi says:

    @ micheleinmichigan

    This is not about presenting concrete evidence that TCM practitioners are about to bill for procedures in the US.

    It is to express a concern about a possibility:

    “what really concerns me is the possibility that these medieval views on disease might someday become legitimized in the US…”

    Just a possibility.

  57. Ben Kavoussi says:

    # Alison Cummins

    “After much prodding, you finally cough up that the program is prescriptive, not just descriptive, which is a crucial piece of information entirely missing from your post.”

    I am sorry, I did not know this was an interrogation session.

  58. David Gorski says:

    I can see I’m being annoying, but I am genuinely looking for the evidence needed to support your thesis, which seems to be ‘Kyung Hee University in Seoul, Korea, in collaboration with WHO, is creating an ICD* that will legitimize TCM (which is based on non-scientific principles**) to organizations using the ICD*. This will make it easier for TCM practitioners to bill for procedures in the U.S***”?

    If it doesn’t have an ICD code, you can’t bill an insurance company or the government for it. It’s that simple. There is no reason to want an ICD code other than to be able to bill for a procedure.

  59. David Gorski says:

    I can understand the outrage when nonsense seems to be creeping into hallowed institutions but I predict the reaction when it comes will be violent.

    You’re actually quite mistaken here. As we have documented thus far time and time again, the reaction of “hallowed institutions” to pseudoscience and quackery has been to acquiesce without even whimper. Not violent at all!

  60. Harriet Hall – How I perceive the actions of WHO and how those actions may effect those of us in the U.S. may effect how I vote and how I donate money.

    If asking for details and evidence to support accusation seems hostile to you, then I guess we are in disagreement.

    I will admit, though, that BK seems to be a victim of my high expectations of SBM. Honestly, I feel the article was below the standards normally posted here. In fact, It is not as good as others by BK that I have read.

    But since we’re assuming hostility, where there is none, it seems pointless to pursue the matter further.

  61. pmoran says:

    David and Dr Benway, I said “when” the reaction comes to pseudoscience. My ruminations predict that it will as CAM continues to fail to deliver on once proud claims.

    Most of the methods based upon pseudioscience will also fade back into their usual under-current so long as their placebo-related influences don’t prove stronger than we now can show.

    Also I can only go on what I see. When I see academic institutions or integrative medicine clinics holding out that Hulda Clark can cure cancer or that naturopaths can cure type 1 diabetes you will be watching my back as I disappear into the breach.

    So far their behaviour is broadly permitted by how my jigsaw is shaping. I am sure there will be instances that exceed my tolerance, because there can be large sums of money involved, especially in America.

    Otherwise the only ground being given up is where it is safe to do so, the science is least clear, where there may be genuine non-specific benefits for the patients. I

    It is perhaps a pity about the money, because in most health care settings the best argument against dabbling in CAM is that there are nearly always better things for the money to do. The science argument and the “it doesn’t work” assertion don’t seem to be effective while ever some people are claiming to be relying upon the methods, and it is not absolutely clear that they are NOT being helped in small ways.

  62. David Gorski – “If it doesn’t have an ICD code, you can’t bill an insurance company or the government for it. It’s that simple. There is no reason to want an ICD code other than to be able to bill for a procedure.”

    Ah, so the insurance codes and medicare payments are dependent on the ICD codes! Thank you.

  63. Ben Kavoussi says:

    @ micheleinmichigan

    Thank you for the clarifications. There were no accusations.

    Nosology must be based on scientific etiology and pathogenesis, otherwise we are not practicing science- and evidence-based medicine.

    This article is not about the efficacy of TCM or acupuncture. It was only about a proposed nosology.

    I am sorry, the intended audience was not the general public, and I think some of the frustration might come from that.

    I hope this helps.

  64. JMB says:

    It is possible for the HCFA (US Medicare and Medicaid reimbursement authority) to freeze the standards at the ICD-9 standard. This would avoid facilitating reimbursement for CAM under Medicare/Medicaid in the US, and save about a billion dollars of the cost that it will take to upgrade from ICD-9 to ICD-10 (or 11)! Because of the cost, no healthcare providers (except TCM CAM providers) will willingly spend the money to upgrade (the estimate for our small group alone will be $50000). If the HCFA won’t require it, private insurers won’t do it either.

    Now, I will venture a ridiculous conspiracy theory. Imagine some people have figured CAM is cheaper than science based medicine (after all it is cheaper to diagnose syndrome of liver fire blazing the ear than mastoiditis). Imagine these people have also changed outcome measures from measures of curing disease and preventing disability or death, to measures that heavily weight patient short term satisfaction (questionnaires given to patients immediately after discharge from the hospital or office). Now the stage is set for significant increases in federal support for CAM.

    It is quite annoying to someone who believes in SBM to see healthcare dollars wasted on CAM. I don’t think our politicians share the same viewpoint. I won’t be surprised to see ICD-11 adopted by those forward thinking healthcare panels in Washington.

  65. nybgrus says:

    @pmoran:

    You are sorely mistaken. As Gorski has pointed out, there is an ever increasing acceptance of CAM into academia. In fact, I have had arguments with the professor of integrative medicine at MY medical school! He had a slide trying to tell us that acupuncture is a viable treatment modality and should be considered. He listed 7 articles from spiffy sounding journals. Then I did something almost nobody ever does – I LOOKED UP the articles. The #1 reference had a huge red paragraph that said “This information is outdated and kept up only for historical purposes…” 3 more were articles HE wrote. The remainder were equivocal articles. Now, imagine this is being presented to a group of people studying to become doctors. At some point, these individuals will become doctors (shocking, I know). And they will recall that the institution at which they trained unreservedly bashed into them that acupuncture is a valid modality. Then you have another lecturer explaining EBM to us and hammering in how amazingly useful RCTs are, how bench science doesn’t scale up to clinical applications in most cases, and how anything less that a case-control or cohort study is basically crap. How is a crop of physicians supposed to separate the chaff from the seed?

    You say “when the reaction comes” – it is here and there is no reaction. We find this worrisome. VERY worrisome. It reminds me of the plot of the remake of “V”

    Science IS under attack from these CAMsters. Science is antithetical to their existence so they must attack. And they do so cleverly through political means to gain a wedge into academia. You claim that science will correct itself – it almost always does. However, there are PEOPLE that are actually DOING the science. As noted in my opening paragraph if you teach those very same people that the science supports acupuncture and give them a paradigm for interpreting studies that slants towards favoring equivocal RCTs for homeopathy over the basic science that precludes it what do you get? A lot of bad science. Will it correct itself eventually? Yes. Probably. But you go on to claim:

    “When we anguish about an asthmatic dying under licensed naturopathic medical care whose failure is that? Do we ever ask whether it is in part ours? Why would we not ask that, in the face of other evidence that we are not that good at getting effective messages across in some of the areas where we would like to have influence?”

    Yes! You are correct. That IS a failing on our part and we ARE partly to blame. Even one death from an asthmatic being treated by a naturopath because that person had a bad experience/poor education from US is intolerable. Yet in the same breadth you basically say “Let the CAM enter our academia and eventually it will correct itself. Science will win out.”

    Science will win out – at the cost of how much mortality and morbidity along the way? You cannot expect to see something happening and just assume that the process will fix itself ultimately so, in essence, to just not worry about it and let the system reset. Forget about the lives damaged and lost along the way – that is just downright lazy and wishful thinking.

  66. BK “I am sorry, the intended audience was not the general public, and I think some of the frustration might come from that.

    I hope this helps.I am sorry, the intended audience was not the general public, and I think some of the frustration might come from that.

    I hope this helps.”

    Yes, I think that was the issue. I usually try to stay away from the articles written for doctors/science folks alone, but I did not catch that was the case this time.

  67. sorry for the double quote paste.

  68. Ben Kavoussi says:

    @ micheleinmichigan

    Here are some more clarifications:

    I cannot stress enough the crucial role a logic of association plays in defining and structuring knowledge. Without an appropriate logic of association we cannot have a proper classification system (taxonomy).

    Mendeleev’s periodic periodic table of elements is the taxonomy that is at the core of modern chemistry. It is based on the number of protons in an elements. The properties of an elements and its reactivity are predictable based on this taxonomy. If you reorganize the elements any different way it would not be scientific.

    The taxonomy in biology is based on evolution and common ancestry. There are no other ways to classify organisms, unless you are writing a Borgesian fiction!

    And there are no other ways to classify diseases than based on biomedical sciences.

    There were in the past pre-scientific methods of organizing the elements, the living things, and disease, but the old clarification systems were refuted and replaced by scientific taxonomy.

    The proposed classification of traditional medicines is based on outdated worldviews, when people believed that there are 4 or 5 elements, and when the deficiency or access in these elements were believed to caused disease. In TCM, disease are classified in categories such as “deficiency of heat” or “excess of wind” or “deficiency of water,” etc.

    I made fun of this thinking pattern by comparing it to Borges’ writing, but do not let the humor (which is, by the way, an outdated medical term) sidetrack you.

    Taxonomies are at the very heart of any science and resurrecting an old logic of association in the name of “alternative worldviews” is a giant step backwards.

  69. Ben Kavoussi says:

    @ JMB

    Thank you for bringing this up. I hope the medical community in the US reacts to the introduction of codes for traditional medicines in ICD, one way or another.

  70. RE hostility: I get cranky when I’m confused, so I will assume the “hostility” comment is partly directed at me. But micheleinmichigan is probably the least hostile person I have encountered online, and she had trouble understanding the post too. Her questions are the same as mine. If my incomprehension is hostile, then so is hers.

    To dismiss her questions as “hostility” and “willful misunderstanding” rather than recognizing her laudable persistence in attempting to understand an unclear post, is to reject feedback from a reliable source.

    I expect better from people promoting science.

  71. Ben Kavoussi says:

    @ Alison Cummins

    Sorry about the confusion. This post is about taxonomy and nosolgy, and nothing more.

    Unless someone understands the importance of classification criteria in biology and medicine, the text remains esoteric.

    The logics of association used in pre-scientific worldviews are no longer valid for modern nosolgy.

    The advocates of TCM are trying to resurrect an outdated nosolgy so they can bill insurance and medicare in US.

    That’s all!

  72. nybgrus says:

    For me, that message was very clear – but I have a very strong background in biology, particularly evolutionary biology and zoology as well so I reckon that for me it was inherent to the post and I framed my reading of it in that sense.

    I also have a background in hospital work and medical billing and I know that not only are the codes imperative for being able to bill for services, but their descriptions are important since if you can stretch a case to make it fit a code that is higher paying you can “up-bill.” This is often the basis for fraud, but can be legitimately used since, as you can imagine, not every treatment falls precisely into the proscribed codes for billing. In cases where the bulk of the treatment (or intervention, what-have-you) is in a lower paying code but there were still some extra supplies, time, etc needed, then your profit margin decreases (or even reverses) unless you can reasonably place it in a higher billing code. Additionally, when a physician (or any HCW) writes a report of the case, it goes to a medical billing office that reads the report and then determines all applicable billing codes, tabulates them, and then generates a summary bill from this. THAT is what gets sent to the insurance companies et al for compensation.

    The more vague the descriptions the more things can plop into that code. Adding codes for diseases with descriptions such as steaming bone disease open the door for the ability to bill for just about anything since who are YOU Mr. Science Person to tell me when a bone is steaming and when it isn’t?

    At least, that is my take on it – correct me if I am wrong Ben.

    Lastly, I can see how people can easily miss that point. I often stress to people that it is very, VERY, VERRRRY important to define precisely what it is you are talking about so it can be understood in context. Taxonomy is one facet of this and it is very important. A modern usage in taxonomy and classification of pretty much anything, really, is vital to confident communication and progress. Resurrecting dead and disproven taxonomy of disease is completely counterproductive. It would be like me, as a surgeon, telling my patient that there biliary colic secondary to cholelithiasis was black bile percolating through the liver and rising to the brain causing nausea and pain. How does one go about treating that?

    My understanding is that these codes are to add NEW diseases and descriptions – NOT to “translate” a disease into a different language. Am I correct here as well Ben?

    Thanks for the post, and please, let there be no animosity here. Both Allison and Michele are excellent and conscientious posters. Ben writes great articles. This is merely an opportunity for the posters to learn some more about taxonomy and classification and Ben to learn more about how to communicate more effectively to an audience outside his realm of expertise (or at least to be cognizant of such things and put a l’il disclaimer up top). Anyways, hope I haven’t overstepped my boundaries in saying that and I hope my understanding is correct and commentary useful.

    Best!

  73. Harriet Hall says:

    If people don’t understand something in a post, it is more appropriate to politely ask for clarification than to accuse the writer of poor writing skills (with disparaging comments like “”the article was below the standards”). The accusation of racism was totally gratuitous and inappropriate. I thought this was a high quality post and the arguments were apparently very clear to all of the commenters except for a couple of individuals who may have had a smaller than average knowledge base. This was not written for specialists but for the average reader of SBM who has a good fund of general knowledge.

  74. Harriet Hall,

    Please look at micheleinmichigan’s and my first comments (they are nos 2 and 3) and explain how they were not polite requests for clarification.

    You say that she and I are not the intended audience for sciencebasedmedicine.org because we have a smaller than average knowledge base. Journalists are part of the intended audience for sciencebasedmedicine.org. Are you certain that the average journalist fully understands the relationship between the ICTM and HR646, between the WHO and the HCFA, and couldn’t benefit from even a single sentence connecting dots in the OP?

    I would have thought that as members of the general public we might serve a useful purpose when we point out that a post is unintelligible to us. Going forward, shall we refrain from asking questions when we don’t understand something on the basis that if we don’t understand then we aren’t supposed to understand? Perhaps moderating comments to exclude the riff-raff so that conversations won’t be derailed would help. Or more simply, just ban our ignorant IPs.

    Alternatively, a couple of courteous dot-connecting sentences in response to questions by interested laypeople.

    Allegations of racism: the post sounds bad. This is feedback. I don’t know Ben Kavoussi personally so I cannot comment on him personally, but the zombie crack upset me. Feedback. I could elaborate but this is not the forum for it and I won’t. If you don’t care how writing is perceived by readers, fine, but then don’t complain when readers perceive things you wish they wouldn’t.

  75. Sorry, that would be Nos 2 and 5.

  76. BK – When I was at the grocery store last night I got a sneeking suspicion*. Returning home I looked up one of my son’s medical test requisition and there it was right on the form “ICD code diagnose”. I feel foolish.

    Re-reading your article with an accurate understanding of the use of the ICD code here in the U.S., brings a completely different angle to the article for me and enables me to understand the information there. I even get the menagerie reference! (okay, that was probably helped by you last post)

    So, I was completely wrong in calling your article below the standards usually posted here. I’m sorry. If I ever run into you in person, I owe you a drink.

    *not an actual memory, more of a “it would be just my luck…”

  77. Ben Kavoussi says:

    @ micheleinmichigan

    Thank you for the explanation.

    This article is not about medicine in Asia (I mean regular medicine)

    It is about disease taxonomy in Traditional Chinese Medicine (TCM), also called Oriental Medicine (OM), or more recently Asian medicine, due to political correctness.

    Like any other traditional medicine, it is based on unscientific worldviews.

    An ICD code for an unscientific disease category has the potential to legitimize an outdated view on disease.

    The WHO has created these codes for some reason, but TCM providers want to use them in the US, and bill insurances for absurdities such as liver fire blazing the ear!

    I hope this clarifies things for you and Alison Cummins.

  78. Harriet Hall – human being can not address the issues of race, gender, xenophobia or nationalism unless we are willing to talk about it. Alison did not say that BK was racist and she didn’t even dwell on the her statement that the “running piglet” jokes sounded racist.

    Sometime, we all say things that don’t sound how we mean them. This is even more likely to happen when a statement is taken out of context or loses context due to a misunderstand.

    Particularly in matters of race or nationality, our personal experience may limit our ability to understand how a person of another race or nationality perceives a comment. If I make a mistake in that regard, I would like someone, in the know, to point it out to me, (yes, even if that means the person has to say I sound racist.) at least so that I can evaluate my statement taking into consideration new information and see if I agree.

    It is often uncomfortable. But, I can’t think of another way to deal with the issue, instead of ignoring it. Can you?

  79. Ben Kavoussi says:

    @ micheleinmichigan

    According to one TCM site, the Running Piglet Disorder is a TCM term which some consider similar to a western panic attack.

    The author states that it comes from “stagnant Liver conditions where the Qi will rise up and interfere with the Heart/Chest causing palpitations, anxiety, fear a/or dizziness.”

    What would you like to know more about the Running Piglet Disorder?

  80. WilliamLawrenceUtridge says:

    Meh, I thought the article made sense, on first reading and after re-reading the article and all comments I still thought it made sense. Helps if you know what the ICD is.

    The approach makes sense if it’s one-way, if we use the STTM to identify valid conditions and give them the proper diagnostic name – “wasting thirst = diabetes; umbilical wind = NE*”

    The only real use is to indicate to traditional practitioners that “wasting thirst” is what we call diabetes, and we have effective interventions for it – insulin and exercise. It may hurt the feelings of many traditional practitioners to say their nosology is mostly worthless, but I consistently feel there is little reason to respect this sort of thinking as anything but a historical curiosity.

    *NE = No equivalent in scientific medicine.

  81. cervantes says:

    However, scientific nosology is predominantly based on etiology (causative agent) or pathogenesis (causative mechanism), except for idiopathic conditions.

    This is absolutely not true in psychiatry. DSM diagnoses are based on lists of symptoms (most of which are not even clearly measurable but just the impressions of a clinician). Psychiatric diagnosis, in fact, explicitly eschews etiology and pathogenesis as criteria. Once we understand pathogenesis, the diagnosis ceases to be psychiatric at all and is handed off to some other specialty, often neurology.

  82. Ben Kavoussi says:

    @ Alison Cummins,

    The discussion here is about the inclusion of traditional (folk) disease categories (such as the running piglets) into the standard classifications or disease: ICD.

    Objecting to the inclusion of Chinese, Arabic, African or Native American or any other type of folk medicine into a scientific taxonomy has nothing to do with racism.

    Some of the comments you have made here have diverted the discussion from the main topic!

    Please be considerate, and stick to the topic. Thank you.

  83. @BenKavoussi,

    I’m good on the poor running piglet.

    My last response was addressed to Harriet Hall’s criticism of Alison Cummins comment, not at your initial article or any of your subsequent comments.

    I will leave that aside now.

    But since I am still logged into the comments section, I would like to make a suggestion.

    I don’t know if this is within your area of interest, but I have read brief references to TCM and it’s impact on the environment due to it’s use of some animal parts. If the SBM editors think it appropriate for this venue, I would interested in reading a more extensive article on that topic.

  84. Ben Kavoussi says:

    @ cervantes

    Yes, you are right. Thank you. I should have mentioned psychiatry.

    Thank you for the clarification.

    Until the 18th-century, physicians used to categorize people based on their “complexion” ( meaning the mixture of humours)!

    The categories were: Choleric (influenced by yellow bile), Phlegmatic ( influenced by phlegm), Sanguine (influenced by blood) and Melancholic (influenced by black bile, an imaginary secretion of the spleen).

    Traditional medicines are based on this type of thinking.

    An ICD code that includes traditional medicine codes will bring these obsolete notions back!

  85. Ben Kavoussi says:

    @ micheleinmichigan

    Excellent suggestion. I actually have an article in the works about credulity towards animals for their organs.

    I has very very disturbing images, which will shock many readers!

    I expected a heated debate!

  86. US says:

    The most disturbing part about this article is how fact is mixed with absolute fiction. The few truths scattered among the article make it impossible to dismiss it as trash, but there is so much that is incorrect that it’s hard not to see it as intentional slandering.

    Let’s assume, however, that Mr Kavoussi just doesn’t know that he has misinformation, however, and that when the record is set straight, all will be well.

    First, the WHO Standard International Terminologies on Traditional Medicine in the Western Pacific Region was a document published in 2008. It was an attempt to create a glossary to document what traditional medicine practitioners are using, and though it was a courageous and bold effort, it was also a dismal failure that is never used and rarely referenced. Importantly, however, this is not the same thing as the ICTM, which is a document that will not be published until about 2014. Long story short, the list of terms posted here and the list of diagnostic entities in ICTM are not the same.

    Second, the WHO Standard International Terminologies on Traditional Medicine in the Western Pacific Region was published by the WHO WPRO Regional Office in Manila, Philippines. There was a meeting held in Korea in 2005, but there were also meetings in Beijing and Tokyo. Perhaps Mr Kavoussi found information related to that one meeting at Kyung Hee University and was confused as to the origin of the document?

    Third, in the comments it was suggested that the AAAOM gave a million dollars to Kyung Hee University to get this moving. This is patently false, and this is one place where I really think Mr Kavoussi should have been careful before making such an inaccurate statement. AAAOM is a non-profit, professional association and their finances are public record. A quick check shows that they have given nothing to the ICTM project (or the 2008 publication), nor do they have anything like a million dollars in their budget that they could give, even if they wanted to. Plus, there is a US AOM community that is referenced as participating in the ICTM, but AAAOM doesn’t appear to be a participant at all.

    Fourth, the project does seem to be an attempt to collect statistics on TM use, not a justification of the validity or efficacy. Perhaps when we actually have information on TM, we will be able to know which parts of it work and which parts should be abandoned. Did you know that with every update of ICD, codes are changed or added. . . or even deleted if they are not considered diseases anymore? Some of my favorite deletions have included “Poisoning by antidepressants” and “Homosexuality”, both of which used to be considered diseases by normal medicine. Hmm, maybe it’s a good thing they keep updating this book.

    Fifth, East Asian TM does not appear to include incantations, amulets, or talismans as treatment options. I do believe that lancing is used, but it is also considered a regular medicine treatment to release pus or pressure buildup (ever heard of lancing a boil?). Also, bloodletting actually WAS a medieval treatment. . . that which evolved into current medicine . . but not so much a East Asian traditional medicine practice. They also still use bloodletting, and leeches, in modern surgery. Just ask anyone who has had a severed limb reattached!

    Lastly, and just as a side point, this really shouldn’t be considered “Medieval Asian Terminology”. “Medieval” refers to the middle ages, a period of time roughly falling between 500 and 1500 BC, and is generally considered to be very Eurocentric. As the TM practices included in the initial draft of the ICTM began well before this period. . . and are still being widely used today. . . and were developed in East Asia not Europe, they could be ancient, modern, lasting, historical, traditional, and many other things, but not really medieval by any stretch of the word.

    So, why should you listen to me? Why do I have this information and Mr Kouvoussi does not? Let me introduce you to the miracle of. . . Google! Oh, and a dictionary.

    A quick search shows the WHO Note for the Media about the project on 7 December 2010 (http://www.who.int/mediacentre/news/notes/2010/trad_medicine_20101207/en/index.html) and the associated video message (http://www.youtube.com/watch?v=NVj7XS-WmDU)

    One can also find all sorts of other information, too, such as the project plan, records and documents from all the meetings, financial records, etc. It’s all so easy!

    Given the wealth of information on the project available directly from WHO, I am surprised that Mr Kavoussi chose to base his blog post on an interview in a trade journal. . . particularly one that appears to be at least 3 years old (note that the Dr Choi who Ms Kang mentioned has been retired since 2008).

    In terms of whether or not it’s real or it works, I don’t really have a comment. The truth is that right now we don’t have the evidence. . . but insufficient evidence is not the same as evidence against. Until we actually have some good information (positive or negative) anything that is said is just a personal guess, anyway.

    So, Mr Kavoussi, why didn’t you find this information before writing your blog post? What do you have to say now?

  87. Anthro says:

    @WilliamObivion

    The PBS Nova program, funded by David Koch, has generated a lot of controversy actually for statements made in the program that are credited to his influence (unscientific statements). Sorry I can’t be more specific–I will investigate and try to post a link. This was the subject of aPBS Ombudsman column I read a while back, but I can’t recall the details off hand.

  88. Ben Kavoussi says:

    @ WilliamLawrenceUtridge,

    Indeed, traditional nosologies are worthless, because they are the product of a “medical gaze” that is outdated.

    But the proponents of TCM want to legitimize their traditional nosoloy “for medical records and billings” as a representative of the American Association of Acupuncture and Oriental Medicine (AAAOM) Korean Advisory Council writes!

    I find this unbelievable!

    1. Harriet Hall says:

      An analogy occurred to me. What if there were a proposal to change the periodic table to incorporate phlogiston or to classify the elements in terms of “hot, cold, wet, dry” or yin vs yang? It wouldn’t matter whether the new information was actually used with unfortunate consequences or whether it helped people understand the thinking of the proponents. It would just be wrong.

  89. Ben Kavoussi says:

    @ US

    Thank you for your comments.

    I believe I state that “American acupuncturists have given over one million dollars…”

    Where did you see that I stated that AAAOM gave one million dollars to the Korean university?

    I think I am not the one who is distorting the facts!

  90. Anthro says:

    This is the crux of the controversy. I can’t locate the exact Ombudsman’s column because it’s not indexed.

    This quote is from the Jane Meyer article in the New Yorker that exposed the Kochs to a wider audience.

    The David H. Koch Hall of Human Origins, at the Smithsonian’s National Museum of Natural History, is a multimedia exploration of the theory that mankind evolved in response to climate change. At the main entrance, viewers are confronted with a giant graph charting the Earth’s temperature over the past ten million years, which notes that it is far cooler now than it was ten thousand years ago. Overhead, the text reads, “HUMANS EVOLVED IN RESPONSE TO A CHANGING WORLD.” The message, as amplified by the exhibit’s Web site, is that “key human adaptations evolved in response to environmental instability.” Only at the end of the exhibit, under the headline “OUR SURVIVAL CHALLENGE,” is it noted that levels of carbon dioxide are higher now than they have ever been, and that they are projected to increase dramatically in the next century. No cause is given for this development; no mention is made of any possible role played by fossil fuels. The exhibit makes it seem part of a natural continuum. The accompanying text says, “During the period in which humans evolved, Earth’s temperature and the amount of carbon dioxide in the atmosphere fluctuated together.” An interactive game in the exhibit suggests that humans will continue to adapt to climate change in the future. People may build “underground cities,” developing “short, compact bodies” or “curved spines,” so that “moving around in tight spaces will be no problem.”
    ————

    These ideas were included in the NOVA program on Human Evolution which was funded by David Koch.

    Sorry that this may seem off-topic, but I didn’t want to let it stand that the Kochs are somehow interested in science because they fund NOVA–they are interested in injecting their own climate change denier ideas into science in the same way that the proposal discussed here is an attempt to introduce something very unscientific into the medical system.

  91. Ben Kavoussi says:

    @ US

    Concerning bloodletting in Asia please refer to this video called “Chinese fire jar bloodletting”

    [embed width="400" height="330"] http://www.youtube.com/watch?v=MiYi_5BvhJg?rel=0 [/embed]

    There is also my post on the subject:

    http://www.sciencebasedmedicine.org/?p=7599

    Again, I think I am not the one who is distorting the facts!

  92. Ben Kavoussi says:

    @ US

    Here’s the link to Chinese bloodletting.

    http://www.youtube.com/watch?v=MiYi_5BvhJg?rel=0

  93. Ben Kavoussi: “Objecting to the inclusion of Chinese, Arabic, African or Native American or any other type of folk medicine into a scientific taxonomy has nothing to do with racism.”

    Agreed!

  94. David Gorski says:

    @US

    That video you included disturbed me almost as much as Ben’s references. Quite frankly, from my perspective, that video supports Ben’s assertions more than it does yours.

  95. S.C. former shruggie says:

    I’m sure this has been covered before, but this is sheer crazy. Political equality for right and wrong answers to questions of fact is apparently well on its way. A sort of “veracity and inanity living together in harmony” if you will.

  96. Harriet Hall: “An analogy occurred to me. What if there were a proposal to change the periodic table to incorporate phlogiston or to classify the elements in terms of “hot, cold, wet, dry” or yin vs yang? It wouldn’t matter whether the new information was actually used with unfortunate consequences or whether it helped people understand the thinking of the proponents. It would just be wrong.”

    Agreed!

    A chart that compared alchemical understandings of elements with modern ones might be useful to medievalists. If someone is “making a chart,” I want to know whether they are actually proposing the incorporation of earth, air, wind and fire into the modern periodic table or making a handy-dandy quick reference chart for academics reading alchemical texts. Then I can decide whether we are looking at a problem or not.

    The original post made it sound (to me) like someone was compiling a handy-dandy quick reference chart, and the link between that and outrage was not clear. Which is why I asked for more information so I could understand the thought process. I was quite aware that I was missing some links and I needed help to fill in the blanks. For some reason wanting to understand and not having the tools is “wilful misunderstanding.”

    Ninety comments later, we seem to have gotten to a place where most (not all) commenters on the thread seem to be saying the proposal is to “modify the modern periodic table.” In that case I understand the outrage perfectly. It makes sense without further explanation.

    I don’t know why this has to be so complicated. I ask what I think are simple, straightforward questions about the stated purpose of the exercise and I get replies that “this post is not about the effectiveness of TCM.” OOnly Ben Kavoussi and @US have mentioned effectiveness. I never did, so I am untterly bewildered about how effectiveness came into responses to my questions.

    I try to be as clear and unambiguous as I can, and I am clearly failing utterly.

  97. S.C. former shruggie says:

    On the internet, no one can hear your tone of voice. Misreading others intentions is pretty common.

    Also not helping: concern trolls.

  98. Harriet Hall says:

    Alison,

    Ben’s post specifically mentioned “tossing modern and obsolete categories together into a single system of categorization.” He said nothing about compiling a handy-dandy quick reference chart for better cross-cultural understanding. It seems to me that you missed the point and read something into his post that wasn’t there. Now we are all on the same wavelength, which is good; but the whole kerfuffle might have been avoided by more careful reading and less intention to find fault.

  99. Ben Kavoussi says:

    @Harriet Hall

    Excellent, right on, thank you.

    What you just wrote is actually more than an analogy.

    Just like modern medicine is based on chemistry and human biology, medieval medicine was based on alchemy and astrology.

    And just like medical students spend years learning chemistry and human biology before they learn medicine, until the late 18th-century, medical students learned alchemy and astrology.

    Do you know where Nostradamus learned astrology? At the university of medicine of Montpelier.

    The fundamental rationale for TCM is Chinese alchemy and astrology, and mixing TCM concepts and modern nosology is mixing alchemy and chemistry!

  100. Harriet Hall – could we let it lie? please.

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