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.