Last week, I discussed Chinese herbs and the flu, and the difficulties I had in finding excellent studies either for or against their effectiveness. After that post, I was introduced to Dr Greg Livingston, an American doctor trained in Chinese Medicine and practicing in Hangzhou. We’ve had a fascinating discussion via email that I wanted to share with you:

Dr Livingston: As you mentioned, ganmao in Chinese Medicine (CM) is not
actually a diagnosis. CM diagnoses what in Chinese is called a 证,
sometimes translated as “syndrome” or “pattern”, and ganmao is merely
a 病, or “disease”. CM treatment is not based on “disease”, but rather
on “syndrome”. Since, as you mentioned, there are many different
possible “syndromes” that could present when someone comes down with
ganmao (such as wind-cold, wind-heat, etc), there are many different
types of treatment, and there is no one-size-fits-all treatment for
ganmao, or any other disease for the matter, in CM. Thus in Chinese we
say 同病异治- same disease, different treatment. Furthermore, CM
infectious disease theory, of which ganmao is a part, is extremely
complex, and to be well versed and clinically effective in it requires
years and years of study and practice.

As for the OTC CM preparations you mentioned, I don’t personally find
any of them to be very effective. There are a couple reasons for this.

First, because they are prepared medicines there is no way to modify
them to fit the patient’s “syndrome”, so even if used by a competent
CM physician based on solid diagnosis, unless the remedy somehow
perfectly fits the patient, results will be less than optimal.

Second, these preparations are generally just not as strong as loose
herb prescriptions. The latter of course also have the further
advantage of being tailored to fit the patient.

Third, many of these preparations are based not on CM ideas of herb
function/traditional pharmacology, but on western medicine/modern
pharmacology. Ban Lan Gen Ke Li is a prime example: it’s used solely
because it has anti-viral properties, not because of it’s traditional
actions and indications. Chinese herbs used in this manner cease to be
Chinese Medicine, and are just Chinese herbs used according to western
medicine. One can of course do this, but the advantages of proper CM
methodology are not used, and the anti-viral function is quite mild,
so this method is really neither here nor there, and it’s quite
ineffective. In fact, Banlangen Keli/Chongji, etc, is really only
useful to try and prevent ganmao, is moderately effective at best for
this purpose, and is completely worthless for treating people who
already have ganmao. In fact, I also think it’s almost useless to
prevent ganmao as well. Other preparations such as Shuang Huang Lian
Kou Fu Ye are also based on this methodology, and are moderately
effective at best.

Ganmao Qingre Keli is for wind cold with a bit of internal heat.
Because many ganmao are the result of wind cold, this one is actually
not too bad for early stage wind cold ganmao with slight chills and
aversion to wind and cold, mild cough, runny nose, etc.

Yin Qiao Jie Du Pian is for wind heat ganmao, with very very mild
chills, slight aversion to heat, slight thirst, mild cough, runny
nose, etc.

However, ganmao symptoms and “syndromes” change very rapidly, so it’s
much more complicated than this. And there are actually 100’s of
prescriptions for ganmao as there are so many different ways it can
present, so limiting oneself to these few preparations is a guaranteed
path to mediocre efficacy. Similarly, if a non-MD were to only “learn”
how to use a couple antibiotics they would also be less than optimally
effective, to say the least.

As for studies, there are certainly many studies in Chinese, but
probably not much in English. But again, because CM is by nature
individualistic, it doesn’t lend itself to RTC style studies, the
object of which is to eliminate as much individual variation as
possible. Therefore, a study of 100 people with ganmao using one
preparation is bound to show mixed results: the small number of
patients that are perfectly fit for the prescription will do well,
those that are more or less fit for it will do ok, those that aren’t
fit will do poorly, and some people that have a completely opposite
syndrome with suffer side effects. So, RTC studies don’t mean much for
CM physicians. If you want to take CM herbs and do RTC studies on
their effectiveness, you can of course do that, but this is not CM,
and is not an evaluation of CM, but rather just an evaluation of an
herb’s modern pharmacological function.

Me: Your insights are very helpful. It seems that indeed I may never be comfortable in recommending CM for my patients, in terms of those basic TongRen-style famous packaged formulas. We do have a TCM doc here and I will make more recommendations to see him directly. Although, I’m still disturbed that I won’t be able to recommend more packaged items. After all, it’s only pharmacology. Plenty of western OTC Rx can be very effective; we know that Tylenol or ibuprofen is extremely effective for fever in almost everyone. Why would we assume that all these famous CM packaged products are “weaker” than individual CM Rx?

Actually, it isn’t “only” pharmacology. If you use Chinese herbs based
purely on modern pharmacological knowledge of the herbs, then you are
not using them according to CM principles, and thus they cease to be
Chinese Medicine and become the same as pharmaceutical drugs, only
weaker in most cases. Of course pharmacology is always at play- it’s
not that “intention” (“intending” to use an herb according to CM or
according to modern pharmacology) changes what that herb does to your
body! The key point is diagnosis, and since western medicine doesn’t
differentiate/diagnose in the same way as CM, the medicine isn’t
applied in the same manner/situation. This is really the key point. If
these prepared medicines are given in the appropriate situation (as
determined by CM diagnostic and treatment methodology) they can be
quite effective, although as I mentioned earlier, they are generally
not as effective as bulk-herb prescriptions/decoctions because: 1)
they are not tailored to the individual; 2) the dose is typically
smaller than bulk-herb formulas/decoctions.

Me: If And if the evidence for things like banlangen is so weak, why does every Beijinger, including my staff and my wife, take them?

People in China all have heard that banlangen has antiviral properties
(it does, but pretty mild), it’s been marketed and promoted as a
ganmao remedy, and it’s often an ingredient in government endorsed
ganmao prophylactic formulas, so the overall impression is that it’s
good for ganmao. But in my own experience, and that of many of my
teachers and colleagues, it is really only useful in prophylaxis, and
for this it is quite mild, but that’s not to say ineffective.
Furthermore, this use is not a traditional use of the herb, but one
based purely on pharmacological knowledge, and so it cannot be
considered Chinese Medicine, even though it is a Chinese herb. This is
an allopathic use of the herb, which is of course fine, but not really
that effective. CM can be used to prevent ganmao, and can be quite
effective (I take herbs often for this purpose, and rarely get sick
even when people around me are all sick), but again, it must be done
according to CM principles (otherwise it’s not CM, hehe) in order to
get decent results. Simply, what CM does in this regard is strengthen
and harmonize physiological function, which, among other things,
improves immune system function.

Me: By the way, I take these medicines myself! My wife is a Beijinger and every time I have ganmao she makes me take one banlangen and one ganmao package, 3 times a day. I wish I could say I notice a difference, as it’s always hard to tell with ganmao whether I’d be getting better anyway.

If you don’t notice a difference then I would say there is not much
effect. If ganmao is treated properly with CM, it is quite effective.
If treated at the first sign, most ganmao can be cured in a day or
two, or at the very least be prevented from developing into a full
blown ganmao. If later stage, it should noticeably reduce symptoms and
speed up recovery time. Anything less than that is a poor result
unless it’s due to a particularly nasty strain of flu, or to a
patient’s weak or debilitated constitution.

The Bottom Line

Thanks so much, Greg, for your insight. After your comments, I’m now even less sure that I’ll be able to properly prescribe any Chinese medicines without more proper training. I think I will ultimately become what you describe as a more allopathic doctor using certain pre-made Chinese medicines if there is good evidence. Yes, as you say, it wouldn’t any longer be considered a traditional Chinese medical use, but I’m comfortable with that, as long as the data is there and the disease condition is clear. And, if my patients are more interested in Chinese medical care, I will send them to our TCM doctor here, Dr David Zhang.