‘The Duke’, Good medicine & Moxibustion’ – a viewpoint

“We want to be on the winning team,

but if we do so by turning our backs on the losers, then it surely is not worth it.

So we must set about fighting the long defeat.”

Paul Farmer MD

So who exactly is the Duke (of the title above)? It’s the jazz maestro Duke Ellington no less - almost certainly the greatest jazz composer and big band leader of all time. There’s a famous story that gets regularly repeated about him – how he was once asked what his favourite sort of music was – and his reply was pretty smart. He said that there are actually only two types of music: there’s good music – and the ‘other kind’.

So this is the theme of this op-ed piece. It was also the background theme of our talk on World Acupuncture Day (WADO) at UNESCO HQ in Paris last week – a consideration of this same question in terms of our own music (the sweet music of acupuncture and moxibustion).

UNESCO’s list of ‘intangible’ cultural treasures for humanity

The WADO event was officially commemorating an anniversary for acumoxa (and please note – this related to acupuncture AND moxa, i.e. not just acupuncture![i]) – of it being included in UNESCO’s list of intangible cultural treasures for humanity. This award was patently seen as being something that deserved formal commemoration. Well, it may seem like churlish ingratitude given that we were invited to speak at the event (and we’re happy to run this risk) but we’re convinced that (as a community) we’re not just seriously missing a trick if we are remotely satisfied with being an intangible treasure - in fact we may be doing a disservice to a quarter of humanity if we do so. The truth is that we believe that our medicine is actually very tangible indeed (and what’s more we think that moxa may yet have a special place in this tangibility).

The origins of acumoxa

Acumoxa casts long shadows right back into pre-history so it has always provided plenty of scope for fantasy. We want to avoid doing this in this piece, but still we want to touch into the earliest traces of its existence using evidence from archaeology. We want to do so because this evidence suggests how both acupuncture and the channel theory that underpins it originally developed: specifically that both developed directly out of moxa therapy.

So when does acupuncture itself actually date from? Well according to the current analysis of the written record it’s understood to emerge pretty much wholesale with the three so-called classics of acumoxa – the Neijing Suwen, the Neijing Lingshu, and the Nanjing. According to expert Paul Unschuld, in fact, these texts pretty much mark the beginnings of the systematic [non-demonic] Chinese medical acumoxa that we recognise today.

What’s interesting is that the two Neijing texts also refer to some other earlier texts in passing – but oddly there’s no mention of either of two moxa texts that were previously unknown before being found in the excavation of a Chinese prince’s tomb in 1973. This tomb is known to have been closed in 168BCE (i.e. before the Neijing texts, in other words), so it’s interesting that they weren’t referred to, nor moxa mentioned that much, in the Neijing, particularly because these two texts (that, we should repeat, were lost until 1973) very clearly directly influenced what we have inherited today. Given the textual content of Lingshu 10 (a key chapter on qi circulation in the channels) we can say this pretty incontrovertibly, in fact. This chapter first described the channel circuit as we recognise it today but with only a little examination it's clear that parts of this chapter were very clearly lifted direct from the moxa texts. Both of these two previously ‘lost’ moxa texts, for instance, describe ‘vessels’ (mai) coursing up and down the body which are without question direct precedents to the model of circulation of qi in channels (jing) that first emerged fully in Lingshu 10. Given their obvious fundamental influence on acupuncture (including uncannily similar textual structure and even some identical phrasing), the omission of any reference them in the Suwen or Lingshu suggests something slightly suspicious: perhaps acknowledging them didn’t entirely suit the agenda of the Neijing authors. So had Han dynasty acupuncture physicians adapted moxa vessel theory, then developed it to a new level of qi circulation in channels for regulation by acupuncture and then carefully ‘forgotten’ to mention how they’d done it?

It very much looks like it...

How this links up with acumoxa today

This idea gets to the heart of what we had to say in our presentations at UNESCO and WADO last week. We think that those innovative scholar physicians may have deliberately brushed over their tracks for reasons that may be a little questionable, and may even have been of ‘the other kind’ (using the Duke’s terminology). This is because we believe that relegating moxa to second place to acupuncture by barely mentioning it may have been of both financial and reputational value to the scholar-physicians who were developing the emerging complex practice of acupuncture. It certainly meant that acupuncture was of great therapeutic value to the elite Chinese classes, but it may not have been of wider benefit to the majority of people living in Han China (because Paul Unschuld also reckons that early acupuncture was restricted to the richest in society). It certainly wouldn’t, for instance, have helped provide what we now refer to as ‘Universal Health Care’ – in fact it probably relegated moxa practice to the lower strata of society while elevating acupuncture to benefit the elite.

There were a few consistent exceptions that acupuncture just couldn’t seem to match moxa in, however: for emergency or last resort treatment, for longevity, and for chronic intractable disease which (certainly since the 7th century and the ‘Moxibustion Method for Consumptive Diseases’ text) definitely included tuberculosis.

So much for looking backwards in time!

We must ask you to keep thinking about this while we come back to the 21st century, however. This is because (just maybe) what was done to moxa at the time of the Han is being innocently and unwittingly repeated with our valuation of acumoxa today - and if so then we can also reflect on what this might mean for practising ‘good’ medicine as opposed to the ‘other kind’ today.

So fast forward two millennia onwards to 2008 – to the year when the world was facing economic meltdown and to when the optimistic idea that capitalism could be of ultimate benefit-to-all took a massive body blow.

Adding in Climate Change

And then fast forward another seven years to Paris in 2015 with the Climate Agreement when almost all of the countries of the world agreed to do something about climate change – to try to mitigate its effects by drastically reducing the emissions of greenhouse gases. It is vital to appreciate how economic regression and climate change together pose such a massive threat to the future health and welfare of the world’s poor – the so-called 'bottom billion' who are already most at mercy of ill-health and who still have least benefit of and access to the wonders of modern medicine.

So (in this respect) fast forward also to 21st century tuberculosis, mankind’s oldest infectious enemy and what it has morphed into in our own era.

To put it in a single sentence, TB is an airborne disease which anyone can get, but generally only poor people die from (and somewhere around 2 million of them do so each and every year). Two other things are worth briefly mentioning about it. One is that it is curable in most cases. The other is that it is morphing into strains that are resistant to the standard drugs. In most instances it can thankfully still be cured with old (well-out-of-patent) drugs that are very cheap and effective if support is good. Given the terrible rolling death toll, however, it’s also not unreasonable to suggest that TB is biomedicine’s unacknowledged nightmare – and it’s biggest failure.

Moxafrica

By pure coincidence, 2008 (the year of financial meltdown) also happened to be the same year that we founded Moxafrica. This was specifically to investigate whether moxa might help combat the growing threat from multi-drug resistant tuberculosis (MDR-TB) – essentially to attempt to answer a simple question: if moxa had really helped patients recover from TB in the years before TB drugs were discovered, then could it possibly help today in cases when the drugs aren’t working?

So the real issue that we at Moxafrica have been focused on has always been this secondary pandemic which has emerged from within this first one – a drug-resistant TB pandemic that is NOT so easily curable, and for which the drugs needed for treatment are not cheap and are generally unaffordable in the countries in which they’re needed. Today it’s reckoned that around one-in-every twenty TB cases are drug-resistant, but we also know that this number is quietly (and largely invisibly) rising all the time (and that it may well be more anyway because surveillance data is still so poor). We can also say that of these MDR-TB cases, at best only one-in-nine see successful treatment outcomes (these data come straight from the WHO and may well be underestimations, by the way). It’s an appalling situation.

There’s a very good reason for this invisible uncertainty, by the way: it’s because most TB occurs where there’s most poverty (because TB preys most mercilessly on people with weakened immune systems, and people who live in poverty generally have weaker immune systems than the rest of us). They also have dramatically less health infrastructure available to them if they get sick – both to diagnose drug-resistance, and to treat it.

But there is another important connection to be made here, because these self-same people living in these same TB endemic countries are also among those most at risk from the effects of climate change. In other words we can reasonably make direct geographical links between TB, poverty and Climate Change, and, what’s more we can make some prognoses of our own about what this might mean.

Inequality and injustice

It has been said that the hardest truth about climate change is that it won’t affect all of us the same, and this is something that is also most definitely true about MDR-TB. It certainly felt right to be identifying this last week in Paris, the home of egalité, fraternité and liberté, because the truth is that it’s rampant inequality which lies at the heart of all of this, not just in terms of individual median incomes or national GDP’s, but also in terms of health provision. Unlike most of us and our easy access to the Duke’s ‘good’ music, when it comes to access to good healthcare far too many members of our human family still don’t have access to much good medicine at all. Sadly this remains a fundamental aspect of the world we live in – and we suggest that (if we as acumoxa practitioners give any sort of a real damn about human health) then we have to seriously think about our place in this world.

If you’re unlucky enough to be infected with a drug-resistant strain of TB, for instance, you really only want to be living in a country that’s got a highly developed health service – because that’s what’s needed to treat MDR-TB. And (guess what?), it’s these self-same countries with most health provision where the least MDR-TB exists!

There are appalling injustices and inequalities here that surely we can no longer shy away from.

Here is what the World Bank predicts for the sub-Sahara from a temperature hike of two degrees Celsius (one that we’re already on track for): a staggering 40-80% reduction in crop growing areas. If this prediction proves correct it will massively impact on those same hosts of humanity that are already the most impoverished, who already are experiencing socio-economic regression, whose immune systems are already the weakest, who already die the most frequently from TB, and whose health provision is the most remote from what we here in Western Europe might consider the norm (and our human right).

But this isn’t just about TB (though it does give us some pointers)

So do we have any answers to all to this in the canons of our medicine? Do we have any tools or techniques that might help reduce these appalling gaps in health provision in the modern era, and if so, how can they best be put to use?

Please don’t let us give the impression that the fruits (so far) of Moxafrica’s work allow us to offer any conclusive answers. As far as TB is concerned, however, we do at least have the positive results of a Ugandan study on moxa and TB published in a peer-reviewed journal, but this study also only looked at responses in TB patients who were drug-susceptible. But we also have the results of a second study conducted by our colleagues in the North Korean Ministry of Health, who (based on the findings from Uganda) conducted their own moxa/TB study using a higher-powered moxa dosage looking only at MDR-TB cases. (The DPRK has an immense problem with MDR-TB).

The North Koreans recorded some significant differences in symptom reductions in their MDR-TB patients during treatment – comparing a control group treated with their standard drug therapy with a group having the same drug therapy plus moxa. They recorded a significant reduction in symptoms in the moxa group (90% reporting symptoms disappearing compared to 64% in the control), as well as a much faster manifestation of these reductions when they occurred (seen in an average of 49 days with moxa instead of 82 with just the drugs). It’s certainly possible to suggest that these two findings alone give a potent possibility of reductions in human suffering.

But there was more – relating to the percentage rates of recovery that the North Koreans recorded: with 85% of moxa patients recovering successfully as against 60%. Please bear in mind that this was for infections of MDR-TB for which the most recently reported global average success rate with drugs is only a very meagre 55%. In fact, the current global average for easier-to-treat drug-susceptible TB is only 81% - so these DPRK data tentatively suggest that moxa could possibly hike success rates for MDR-TB up near the current global success rates for ‘normal’ TB. What’s more, if this can be corroborated, it could do so easily, and very cheaply.

The material cost of doing this, by the way, is 20 to 30 US dollars’ worth of moxa per patient.

We realise, of course, that this is quite a claim to make, which is why these findings urgently need testing with further research. This is the major reason why we want to share these findings and why we wanted to speak in Paris last week, in the hope of finding others who might want to get engaged.

It’s also worth briefly considering the comparative strengths that adjunctive moxa may offer in the treatment of TB. It’s safe, cheap, highly adaptable, and can be used at any point of care. It is easily sustainable, easily taught, doesn’t depend on technical and expensive diagnostics, and won’t stoke further drug resistance. New drugs (while they are still vital) don’t tick any of these boxes.

In other words, it’s highly appropriate as a tool where resources are poor.

So what about acumoxa and other health problems?

This, of course, is so far all in relation to moxa and TB therapy, but something similar might just be the case for other infectious diseases, for other anti-microbial resistant infections, for instance, or indeed for non-communicable killer conditions including cancer and chemotherapy support, or for managing Type 2 Diabetes. There is a lot of opportunity for investigation here but only if we care (and dare) to take up the challenge.

Which brings us right back to our starting point, to that great jazz man Edward Kennedy Ellington – because we can now refine the question that was posed to him, and ask:

Which parts of our medicine might be the ‘good’ parts in terms of their being of most potential service to humanity, and which parts are the ‘other kind’ – which may be of more service to the currently more privileged members of our human family which already have the majority access to the fruits of science and medical research - medicine which, if our world was a more equitable place in which to live, would surely be the right of all of us.

We started by suggesting that moxa may have been quietly side-lined to the advantage of early acupuncture physicians and the benefit of the Han dynasty elite. In Paris we couldn’t help but wonder if echoes of this shape-shifting persist today in terms of how we project our own medicine. In the UK, for instance – a country which prides itself on its National Health Service – the therapy is mainly used privately by the country’s middle classes, largely by a slice of society that has been mischievously called the ‘healthy and wealthy’ or the ‘worried well’, and so far too little effort has been made to adapt it to address the real health needs caused by the increasing poverty gaps of the last decade.

And if we come back to last week’s WADO conference in Paris, can’t we validly ask whether acumoxa really belongs in UNESCO’s list of intangible cultural heritage at all? Because acumoxa is surely alive and well, should need little protection, and furthermore is evolving as we speak. Meanwhile there is a desperate need for affordable, appropriate and adaptable medical care out there and this need is going to become more acute in the coming decades – so surely it is our moral duty to take a better (coherent and strategic) look at this.

What this means for all aspects of medicine

Quite possibly, the threat of drug-resistant TB (in a diabolical concert with the immense threats from climate change and a destabilising world) finally changes things for all of us. Seen together they might finally force us to recognise our wider human interdependence, to realise that we are not (and should never have been) so inoculated from the lives of others. Seen together, they may even force us to acknowledge not just that the poor do exist (even though they don’t consume enough or fit into our economic models – and especially despite the fact that they can’t afford our patented high-tech medicines). In fact, seen together it may even force us to recognise that, if indeed the poor are to be further denied the right to the benefits of science and biomedicine by dint of circumstance, then we ourselves can and must review what we can offer them in its place.

Article 27 of the 1948 Universal Declaration of Human Rights

Incidentally, on World Acupuncture Day last Thursday we even came across a plaque on the wall right outside the entrance to the UNESCO building in Paris. It specifically noted Article 27 of the 1948 Universal Declaration of Human Rights which said that “Everyone has the right … to share in scientific achievement and its benefits”. Sounds reasonable for sure, but since this plainly isn’t happening (at a quite terrible scale) in terms of the provision of medicine, then why aren’t we thinking about helping to do something about this with the (tangible) tools we know something about?

Dr Paul Farmer (who was quoted at the start of this piece) has stressed that it’s simply an issue of ‘moral clarity’ to respond to someone’s suffering if one has the tools to do so. It’s hard to argue with this, but perhaps we as acumoxa practitioners can add to this idea ourselves. We suggested last week in Paris that we may have many tools that might be appropriate in alleviating or even eradicating suffering at the most remote points of care (more than we might imagine!). And we added that we risk being accused of moral deficiency if we don’t go actively looking for what these might be and how they can really be best put to use in the service of mankind in today’s increasingly fragile world. Almost certainly we will never succeed in our quest to the degree that we might wish to, but we can at least positively engage in the most glorious of (what Dr Farmer might call) ‘long defeats’ in the process of trying.

Finally, a quote from E F Schumacher (the economist author of 'Small is Beautiful') which seems to sum this all up for us:

'We must do what we conceive to be the right thing and not bother our heads or burden our souls with whether we’re going to be successful. Because if we don’t do the right thing we will be doing the wrong thing and we will just be part of the disease and not the cure.'

(Aren’t those two sentences just about the sweetest of music you ever heard, Duke?)

[i] We remain dismayed how often the Chinese compound word zhenjiu – (which literally means acupuncture and moxa or ‘acumoxa’) is still so frequently misleadingly transliterated just as ‘acupuncture’ – something which surely echoes what we suggest the Han scholar physicians did to moxa two millennia ago. This mistranslation doesn't just occur in the media it also occurs in most modern texts on acupuncture. What's worse, it also regularly occurred at UNESCO in the simultaneous translations on World Acupuncture Day from Chinese into both English and French! This unfortunate sleight of hand seems especially disappointing since the 2010 award by UNESCO was explicitly for both acupuncture AND for moxa!!