January 17, 2023

Why do people still believe Chinese traditional medicine woks? A few thoughts on human intuition Vs. scientific thinking.

I spent more than 5 years of my life living in Taiwan and among the many curious things that I've seen were daily scenes of the local population engaging in or with Chinese traditional medicine in one way or another. In parallel to this, for many years I've been thinking about how to more correctly think about the world so that I am not affected by my own bias, preconceptions, lack of information etc. to arrive to what a lot of philosophers have rightfully called 'truth' - which is basically another way of saying to understand what is really going on. Be it in the world of language studies, international relations, quantum mechanics or trying to more accurately understand the current state of society or predict future economic development. 

https://waitbutwhy.com/2019/09/thinking-ladder.html

Very conveniently, these two things beautifully connected in the video at the beginning of this article, the title of which translates into How can you still believe in Chinese traditional medicine? It's a video by a popular Chinese science communicator and veteran TV personality Luo Zhenyu. His work is similar in topics, scope and depth to Lex Fridman, Tim Urban or Ali Bandari

In it, Luo Zhenyu first admits that he does not believe in Chinese traditional medicine and then proceeds to logically, step by step, explain why and, what is equally or more interesting, explain how human thought has developed over the centuries to do exactly what I am trying to do - try to learn how to understand reality for what it really is and not what I perceive it to be.  

I've seen the video about 3 or 4 years ago and I've been always willing to go back to it and watch it again more carefully.  A friend of mine was interested in the topic but doesn't speak Mandarin and since I wanted to take notes watching this video anyway, I made a summary in English for her which got so long that I decided to publish it on my blog. 

Summary

In the video Luo Zhenyu first says, in general, that talking about Chinese traditional medicine is quite a sensitive thing in the Chinese culture and he's afraid that people will trash him. In a way, Chinese traditional medicine, he says, is almost like a religion to some. While when it comes to many other topics, Chinese can discuss and accept other opinions, when it comes to Chinese traditional medicine it very easily sparks arguments and sometimes even physical altercations and he says that it's very important to talk about why this is happening to understand something more important than the actual argument about whether Chinese traditional medicine works or not. 

He says at the start he doesn't believe in Chinese traditional medicine. When Chinese people hear something like this, their first reaction often is "So.. how did your grandfather survive if it doesn't work? How did all our ancestors survive?"

Simple logic, he says:

1) Chinese traditional medicine is 2000-2200 years old. Humans are several million years old. So.. how did these people survive?

2) Europeans don't have Chinese traditional medicine, how did they survive?

3) Other animals, especially higher mammals like gorillas etc. don't have Chinese traditional medicine, how did they survive until today?

Living organisms that reproduce survive because of evolution. If you are fit for your environment you survive, if not you don't. It's that easy, Luo Zhenyu says.

But why did we have to mention this? It's because of why it happens that even though there is simple logic like this, not only that there are people who believe in Chinese traditional medicine, there are people who get angry when you tell them it doesn't work. 

Their reasoning is:

"But I tried it and it worked on me."

"My neighbour tried it too and it worked for him as well."

"For my cousin too."

"I know so many people who tried it and it worked."

And I say to them: "I also saw, I also heard."

But this is a much deeper problem than you think. Let me explain, Luo Zhenyu says.

First let's look at how medicine and scientific thought evolved. Throughout history, when trying to figure out whether some medicine or treatment worked for some condition or disease, people were basically trying to establish a positive cause and effect relationship. 

For instance, some place in their body hurt, they stuck a needle into that place (acupuncture treatment) and when the place stopped hurting, they established a positive cause and effect relationship. Meaning - when this place hurts, if I stick a needle into it, it will stop hurting = the needle works in that case. They then applied this concept to other areas, not only needles. If people had some kind of a stomach pain and took a certain type of medication and the pain went away, for them it meant the pill worked and people in the past called this 'medical science'.

But one very important thing that needs to be mentioned is: establishing a positive cause and effect relationship this way, based on intuition, is not a reliable tool to examine reality. 

Humans living on Earth need the intuition to help them establish a positive cause and effect relationship in their everyday lives, because it is a very practical tool which can help them survive and make quick decisions. I'm thirsty > I drink water > I'm not thirsty anymore. I throw a stone at that lion > that lion runs away. But intuition only works in very simple situations like these. If we are in situations that are just a bit more complicated this reasoning is not reliable. 

Example: In autumn, leaves on trees turn yellow. When the wind blows, it blows the leaves off trees. Question: does the fall in temperature in autumn cause the leaves to become yellow and fall easily? Of course no. We know that the falling of leaves is a result of a very complicated biological mechanism inside trees. 

But some people would say: "No. I saw it with my own eyes. The temperature went down and I saw the leaves turn yellow and then fall every year, year by year."

Only on this one example you can see, that no matter how long the time of the observation, if the situation is more complex, if you only use intuition and try to establish a positive cause and effect, it's not reliable. 

But whether leaves fall because it's cold or don't it's not so important. Let's look at what this can lead to when transferred to the human society.

Example: solar eclipse. The first record of a solar eclipse in Chinese history in Ancient China says, that when the solar eclipse suddenly happened, everyone was upset and the king was looking for who was responsible for this among his servants. He found the responsible astronomer who was drunk and didn't know about the eclipse. The king got mad and had him executed. In Ancient China, when something this important happened in the sky, for the people it was a sign from the heavens that the King was not doing well. 

So the king also thought the heavens were mad at him and was trying to do something to appease them. How? Wearing special clothes, organising special heaven appeasing ceremonies, beating drums and so on. And because of the nature of the solar eclipse, as he did all this, the eclipse just passed. This caused successive kings and emperors to believe these heaven appeasing ceremonies worked and do the same thing. Eclipse came > heaven appeasing ceremony > eclipse passed > it works. They thought this was a positive cause and effect relationship. We know now how a solar eclipse works, and whatever people do on Earth to make it go faster or slower to go away is irrelevant.

He mentioned another similar story of his friend who had some cheek inflammation and his head was all bloated. His Chinese traditional medicine doctor recommended writing the Chinese character 'tiger' on his cheek, and his reasoning was "you eat pork, this is the spirit of the pork that is in your cheeks, we need the tiger to scare it away". And the disease really went away. The thing is, the cheek inflammation is caused by a self limiting virus, meaning it would go away eventually anyway, whether you write the tiger Chinese character on your cheeks or not. However, his friend still established a cause and effect relationship between the character and the disease going away because he used his simple intuition on a complex problem. And the thing is that a lot of treatments in Chinese traditional medicine were invented like this. 

Let's talk more about the cause and effect perception in complex situation by people in our society. For instance earthquakes. According to our best scientific knowledge, earthquakes cannot be predicted because the movement of the earth's crust is too complex. There are however a lot of people who say: yes we can predict earthquakes. Look.. days before the earthquake, the behaviour of a lot of animals is very strange. Sometimes, suddenly too many frogs appear on the streets, cicadas are flying erratically, sometimes even clouds that look like earthquakes appear in the sky. This is not limited to China. There is a record, that in Ancient Greece, before one big earthquake, the streets were full of mice. So.. if this is the way to predict earthquakes, what do we need scientists for? 

Actually already in the 70's there was a big study in the USA that proved that animals cannot predict earthquakes. So why are people so prone to believing these things? Because of something that is called a 'psychological focus effect'. It's basically that people are able to, after something 'big' happens, go back and remember all the strange things, one by one, that happened before the thing happened. 

Anyone who has a dog knows that a dog just acts weird daily. There is no relationship between a dog acting weird and an earthquake. We just perceive it that way, because after something big like an earthquake happens we have the ability to remember all the strange things that happened before it. 

This example again shows, that no matter how long the observation, no matter how direct the cause effect relationship might seem to us, if we only base our analysis on intuition, it's not reliable.

Humans realised this quite early on in history. They realised that they needed something better and more reliable to determine whether some cause really lead to an effect or not. Hippocrates in ancient Greece for instance said: "People! don't believe in superstition. Don't believe that gods and bad spirits caused your sickness. If you are sick it means that your 4 inner fluids (blood, urine etc) and outer 4 elements (wind, fire, water, earth) are not in balance. Does this remind you of something? Exactly.. it's very close to the Chinese concept of Yin and Yang and the 5 elements: metal, wood, water, fire, earth. When Ancient Chinese set up the 5 elements premise they said "look, humans also have exactly 5 organs: heart, liver, spleen, lungs, kidneys. Just look at medication we use - we can also group it into 5 groups: very cold, cold, warm, hot, room temperature. And then based on this the whole field of Chinese traditional medicine just exploded: acupuncture, herbal medicine and so on. 

The problem is, this rich body of Chinese traditional medicine was still based on intuition when trying to establish a positive cause and effect relationship, which is not a reliable way of understanding what is really going on.

So what can be done?

Westerners were the first who made improvements in this regard. 

In 1747, there was a British ship sailing the Pacific ocean and on the ship an epidemic of Scorbutus broke out. This disease has been the 'nightmare' of sailors ever since long distance sailing was invented. For centuries there was no cure for it and sometimes entire ship crews died because of this disease. So what was different on this British ship in 1747 Luo Zhenyu asks? 

You have to remember that at that time, Britain was just like China at that time. Treatments for diseases were developed based on intuition and simple observation. Medication worked with some people, but sometimes the same medication given to another person sick with the same disease just didn't work. 

So how to establish a more correct cause and effect relationship Luo Zhenyu asks? Why was this ship different? Because there was a Scottish doctor on the ship, who had an important idea. What if I do a group study, he thought. Separate sick sailors into groups. He separated 12 very sick sailors into 6 groups of 2. First he gave them all the same food, let's say beef broth, so that they wouldn't die of hunger and then he tried all the know treatments for Scorbutus at that time based on intuition and observation and gave each group a different treatment and observed what happened. For instance, Group 1: eat lemons, Group 2: drink diluted sulphuric aid, Group 3: drink sea water and so on. 

After 6 days something interesting happened. The group, and only the group, that ate lemons completely recovered. No one else. He repeated the experiment and he always arrived at the same outcome. Those who ate lemons recovered and no one else.

Why? Now we of course know. Scorbutus is actually a disease caused by the deficiency of Vitamin C, which is found in abundance in lemons and the entire mechanism of how Scorbutus is developed is so complicated, that it was fully understood only a few years ago. The Scottish doctor of course had no way of knowing this but he didn't need to. The only thing he needed to discover was the correct treatment. 

However when we look at our topic, why people still believe in Chinese traditional medicine, even after this breakthrough and convincing results, it took a very long time for the public to accept, that eating lemons or drinking lemon water would prevent Scorbutus on long distance sailing trips. It was long after the death of the doctor that people started accepting that lemon juice was preventing this disease. So you see it can take sometimes take a long time to implement a breakthrough discovery in treatment into real life. 

Be as it may, the Scottish doctor's discovery solved big problems and even played a role in Great Britain becoming a naval superpower. Was the Scottish doctor a genius? Not really, but he did manage to do a very simple and effective experiment that yielded a result which reflected reality best. 

So, the first conclusion is, when we are in a complex situation (not as simple as I am thirsty > I drink water > I am not thirsty anymore), one way how to understand the real cause of an effect is an experiment with different groups (a so called "comparative study"). So simple, yet in the history of Chinese traditional medicine it has never been done. 

Actually, this thing the Scottish doctor did, seemingly so simple, had a far greater impact on science than people at the time thought. 

For instance, in Europe at that time, a typical way to cure a large number of diseases was to drain blood from people (up to 3 litres, while the average person has 5-6 litres of blood). Was it effective? No one studied it. Experience showed: some people got cured and have been cured for centuries. So this treatment kept being used. And it was a real 'science' at that time. For instance, if you had problems with your liver, you were supposed to let the blood be drained from your left wrist. If you had problems with your back, you were supposed to drain blood from the back of your knee. Time, amount, place of draining of the blood, everything was a 'science'. Westerners believed this treatment for maybe up to thousands of years. 

Did people believe this treatment worked in modern times as well? Yes. For instance Stalin underwent it as late as 1953. Draining blood as treatment for all sorts of diseases reached it's peak popularity at the end of the 18th century (right at the time when the Scottish doctor tried his group experiment for the first time). 

For instance in the USA there was one very famous doctor. It was said that 3 out of 4 doctors in the USA were his students. He strongly believed in draining blood from people as a treatment. One time, a hepatitis epidemic broke out in his city and he, instead of encouraging people to leave, stopped everyone and told them that they should all go to his clinic and that he would drain blood from them all and that they would be fine. So they started draining blood - hundreds of litres every day. One journalist however thought this was just not right and he went to the city and did a survey. He simply tried to find out who survived and who died and found out that most people who died were treated by draining blood at the doctor's clinic. This was basically also a comparative group study. 

Another example is George Washington himself. When he retired, he got a very simple throat infection. He deeply believed in draining blood as a treatment so he first started draining it himself, when his conditioned worsened, he called the above mentioned expert doctor in blood draining and in total they drained 3.7 litres of blood. George Washington then died. This is probably the most famous example of blood draining gone wrong. 

How did humanity get rid of this practice? 10 years after Washington's death, there was another Scottish doctor, called Hamilton, and he did a comparative study like the Scottish doctor with lemons on the ship did. He took 300 people, separated them into 3 groups of 100 with the same disease. Group 1 drained blood, Groups 2 and 3 didn't. 3 people in total died in groups 2 and 3, 35 people died in group 1. An incredible difference. He wrote a paper about the results of his study, but as before, it took a long time until it was accepted that blood draining wasn't good at all and more importantly, that establishing a positive cause and effect relationships in complex situations based on intuition is not a reliable tool to study reality.

Another 10 years later a French doctor did a study with 2000 patients about blood draining as a treatment and that's when finally people started to accept that it was wrong, no matter what our ancestors were telling us, no matter that some people drain blood and get well. 

So 'group comparative study' this scientific 'knife' was able to cut off wrong trends and thinking that was thousands of years old. But is this tool enough for us to understand reality and cause and effect better? No it isn't. Things and especially humans and their psychology are complex beyond imagination.

We had to wait a little, until the middle of the 20th century, until one American doctor discovered the Placebo effect. Today we know the great power of placebo, but back then it was unknown. You give a sick person a pill which has corn flour inside instead of the real medication and tell the patient it is the real pill the patient gets well as if it was the real pill itself. With some diseases, Placebo treatment can cure up to 70% of patients. So actually.. there are some diseases that really need no 'real' medication at all. It's enough that a patient is convinced that something is going to help him or her and it works. This is how we can understand why our ancestors trusted Chinese traditional medicine so much. A lot of it just worked because of placebo and not because it really worked. 

How was Placebo discovered? This American doctor was a doctor in the Army during World war 2. In south Italy during an intense battle, suddenly there were too many wounded soldiers that needed Morphine but the doctor ran out of it. He didn't know what to do, he talked to the nurse and they just said: "well.. let's just lie to them. We will inject them with medical salt water and tell them that it's Morphine." He thought he would just comfort the soldiers like this, but again something very interesting happened. After telling the soldiers that they would get injected with Morphine but injecting them with medical salt water, injured soldiers in pain stopped hurting and screaming. Naturally, the doctor was very surprised.

After the World War 2 was over, this American doctor spent a huge amount of time studying the placebo effect and he came to the conclusion that when doing a comparative study, scientists should add another group, treated with placebo only, to completely rule out its effects on the results. A group, which has the same disease as other groups, a group which is told will get treated with the same pill as other groups, but instead will receive a fake pill. If the result of the real-pill group is much better than the result of the fake-pill placebo group, only then can we conclude that the pill is really effective. 

This is called a "blind study". But later it was discovered, that even this was not enough. Why? Because the doctor knows which pill is real and which pill is fake. Think about it - if you are a doctor testing two sets of pills, one is real and one is fake, and you have two groups of patients who are equally ill, you will treat the ones to whom you give real pills with more care, and the ones with fake pills with less care, because you know the pill is fake anyway. Patients are sensitive to signals like this and they pick them up and this influences the results of study. Or if, for instance, you are a scientist testing the intelligence of your rats by putting them into a maze and want to test how many find the correct way out and how quickly they do it and you see one of your rats that you know is intelligent accidentally take a wrong turn right at the start, you might turn that rat in the correct direction since you know the rat is more intelligent and only made an accidental mistake. 

So scientists realised, it's not enough that just the patients don't know whether the pills that they are taking are real or fake, doctors also cannot know which pills are real or fake. This is called a double-blinded study. 

Is this enough? No, we still need to be more careful. You will find that if patients for the study are not chosen randomly, some doctors will choose only a certain type of people for their study influencing the results. So, to the word "double blinded" we need to add "randomised". 

Then people realised that, too, was not enough. Because if we have only a small number of people participating in the study, the result of the study will not be precise. So in modern science, if scientists want to determine whether a new pill really is effective or not, the most reliable study that we have today is a so-called "large sample randomised double blinded comparative study". 

The American FDA for instance, when it decides to admit a new drug for clinical trials to evaluate whether the drug is effective and safe, FDA does it through "large sample randomised double blinded comparative studies" usually taking several years and spending millions of dollars on them. Only then does it allow the drug to be safely released to the public. 

So you see, determining real cause and effect in our complex world, we need to very careful, methodical, scientific and in many cases it is extremely time and money consuming even in the world today and intuition is often just insufficient. And even with these studies and this much money and time spent, modern medicine is trying to continue testing these drugs in studies to keep improving. 

One other example:

There is myth that old violins, like the Stradivarius violins, have the most beautiful sound and that modern violins just cannot reproduce it. Stradivarius violins cost millions of dollars sometimes, however, when they did a blind test, took a bunch of modern violins, mixed in some old Stradivarius violins with them, brought in some professional violin players and didn't tell the judges or the violinists which violin was which, the result was that the judges thought the best sounding violins were the new cheaper ones, not the million dollar Stradivarius old ones. 

How to be more accurate in understanding reality, think in scientific way:

1) Work with raw data. Measure something and if someone else doesn't think it's correct that person can measure it too and see. 

2) Talk about facts and logic, not opinions and intuition.

3) Be open to changing your mind.

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