WHO International Standard Terminologies on Traditional Chinese Medicine: Use in Context, Creatively

Abstract

BACKGROUND Communicating with clarity is no easy task, but it matters.[1] It is particularly challenging to translate the terminologies of traditional medicine and use them precisely in integrative medicine communications—often the first step towards further interaction and integration. As a result, “lost in translation” and “confused in translation” are common,[2–4] and there has long been a yearning call for reliable standards to guide the translation of traditional medicine terminologies.[5,6] World Health Organization (WHO), the United Nation's health agency, is well-placed to answer this call, as part of its efforts in developing comprehensive standards pertinent to traditional and integrative medicines. Since 1991, WHO has published a series of technical guidelines on herbal medicines and acupuncture, cumulating into the publication of its general guidelines for methodologies on research and evaluation of traditional medicine in 2000.[7] Since then, WHO has accelerated its efforts in devising guidelines and publishing state-of-the-art reports, as exemplified by two editions of its traditional medicine strategy[8,9] guidelines on acupuncture safety, training and practice,[10,11] guidelines on good herbal manufacturing practices and quality control of herbal medicines,[12,13] and a global report on traditional medicine.[14] In 2007, the WHO Regional Office for the Western Pacific published the first edition of international standard terminologies on traditional medicine in the region, particularly focused on traditional Chinese medicine (TCM);[15] and in March 2022, WHO published its international standard terminologies solely dedicated to TCM.[16] This new WHO standard, along with the WHO standard nomenclature of acupuncture points and meridians[17,18] and the inclusion of traditional medicine conditions in the 11th Revision of the WHO International Classification of Diseases (ICD-11),[19] can be expected to play a major role in harmonising and modernising integrative Chinese medicine communications internationally. A MASTERPIECE OF UPDATING AND HARMONISATION In my opinion, the new standard can be regarded as an updated and re-focused edition of the widely cited 2007 standard,[15] after absorbing from and harmonising with a World Federation of Chinese Medicine Societies (WFCMS) international standard Chinese-English TCM nomenclature published in 2008,[20] TCM-related national standards from China, scholarly publications on TCM terminologies, as well as the ICD-11, which has been in global use since January 2022.[19] In 453 pages, the handbook covers TCM fundamental theories, diagnoses, therapies, interventions, disorders, patterns, prevention, health preservation and rehabilitation, including 28 main categorisation terms and 3387 specific terms, for most of which concise definitions are provided. The WHO must be heartily commended for accomplishing such a monumental project, by breaking barriers and assembling the latest research outcomes, and by harmonising terminologies with existing WHO standards, such as ICD-11, and national standards in China, the birthplace and the biggest TCM market of the world. By focusing on TCM only, this new standard has avoided some inevitable conflicts of the 2007 standard, which was supposed to cover all traditional medicines in the WHO Western Pacific Region, but in fact, mainly covers TCM.[15] With this refreshed focus, the standard focuses on translations between two languages, including corresponding English terms, Chinese terms (in Chinese characters) and Pinyin terms (in accented Chinese Pinyin), as well as the English definition of the term. The corresponding terms in English, Chinese and Pinyin share the same term catalogue number (WGM#1-3415), indicating that they are equivalent and can be optionally used in different contexts to mean the same thing, or used complementarily, if necessary. To encourage the use of standard terms, the inclusion of synonyms has been minimised in this new standard. Of course, by focusing on TCM only, the applicability of this standard will be more limited, compared with the 2007 standard. However, experiences and lessons learnt from developing this standard will hopefully facilitate the development of more standards on terminologies of other traditional medicines in the future. The English terms in the new standard can be categorised into four types: (1) those displayed as the same words used in biomedicine, with the same or very similar meanings, such as “chronic cough” (WGM2#1675), asthma (WGM2#1677) and urinary retention (WGM2#1699); (2) those in the form of unaccented Pinyin, such as Yin, Yang and Qi; (3) those displayed as mixtures of unaccented Pinyin and generic English words, such as “Yin and Yang reciprocally root” (WGM2#11), “Yin and Yang mutually transform” (WGM2#13) and “extreme Yang transforming into Yin” (WGM2#15); and (4) those containing terms used in biomedicine, but with different meanings, e.g. the words “kidney”, “heart” and “spleen” in “kidney water” (WGM2#1700), “Clear heat in the heart and kidney” (WGM2#2347)”, “tonify the spleen and kidney” (WGM2#2437)”. Among these terms, the first type is the least problematic in integrative medicine and can be directly used without additional definition, but these terms are very few. The second and third types of terms do not directly conflict with terms used in biomedicine, but they might mean little to readers without a TCM training background, thus, a clear definition might be needed to make sense and to achieve the goal of “communication with clarity”. The fourth type seems to be the most problematic. According to Dr. Qi Zhang, Head of the Unit of Traditional, Complementary and Integrative Medicine (TCIM), Department of Integrated Health Services, WHO, the development of this new terminology standard followed six key principles: (1) Providing comprehensive definition for all terms included; (2) use of English as the primary language; (3) building on the related work and following WHO relevant principles; (4) keeping the integrity of the theoretical framework of TCM; (5) keeping definitions concise and clear, and focusing on the underlying, core terms in TCM; and (6) full use of the resources of professional domestic and international organisations of TCM, and WHO Collaborating Centres and Expert Panel for TCIM.[16] These important principles have clearly contributed to the success of the project as a whole. In particular, the use of English as the primary language has made it more suitable for international use, such as in English magazines and journals on TCM and integrative Chinese medicine. However, the indigenous terminologies of TCM are in Chinese. If any English terms were ambiguously translated from their corresponding Chinese terms, this would significantly reduce clarity in communications, risking “lost” and “confused” in translation. Does this hazard remain in the new standard? “KIDNEY” AND “SHEN” The word “kidney” appeared 423 times in the standard terminologies, including in terms, synonyms or definitions of terms. “Kidney” is mainly a functional concept in TCM, while the word is an anatomic concept in biomedicine. “Kidney” in TCM and biomedicine has overlapping structural bases and functions, thus the word “kidney” in TCM and biomedicine differs. Meanwhile, the corresponding Chinese character of shen appeared 104 times, among which 98 were translated into “kidney”, with a few exceptions: To harmonise with the WHO standard nomenclature of acupuncture points and meridians,[17,18] “Shen Shu Xu Tan” and “Shen Shu Lou” are translated into “deficiency phlegm at Shenshu (BL 23)” (WGM2#1493) and “fistula at Shenshu (BL 23)” (WGM2#1494), respectively. Here, Shenshu is translated into the unaccented Pinyin name of the acupuncture point, further supplemented by its WHO standard code (BL 23). “Shen Yong” is translated into “renal abscess” (WGM2#1703), which is defined as “a condition (secondary to an abscess in Jingmen (GB 25) or other body parts) characterised by sudden chills, fever, and severe lower back pain. Weak, hesitant urine stream, painful urination and pain in the renal area and costovertebral angle to percussion may also be present. Often occurs when toxins from the abscess affect the kidney.” In this term, “renal” is the adjective form of “kidney”, and its meaning is similar to the use of “kidney” in the translation of shen lao into “kidney tuberculosis” (WGM2#1487), which is “characterised by frequent, painful urination, low back soreness, and bloody urine. Associated symptoms include tidal fever, night sweats and flushed cheeks. This condition often occurs when the bacterium Mycobacterium tuberculosis affects the kidney through the bloodstream and consumes Qi and Yin”. In both cases, the terms “renal abscess” and “kidney tuberculosis” are similar to the symptoms and signs of renal abscess and kidney tuberculosis in biomedicine, without direct evidence of kidney involvement or bacterial infection. To minimise ambiguity, such subtle differences should be clearly noted. “Shen Yan Fan Hua” is translated into “penile cancer” (WGM2# 2195), which is “characterised by papulae or solid nodules on the skin or in the tissues of the penis, accompanied by foul smelling discharge from the penis. It is often caused by constitutional deficiency of the liver and kidney, exuberant ministerial fire due to worry or anger, blood dryness in the liver meridian and stagnant pathogenic fire”. Here, the Chinese Pinyin term Shen Yan Fan Hua is a condition of the penis, rather than the kidney in biomedicine. Although translated into “penile cancer”, by the given definition, this TCM clinical diagnosis does not necessarily imply the availability of pathological or cytological evidence of cancer. For clarity, wherever the term shen yan fan hua or “penile cancer” is used, special notes should be added to indicate the above aspects. “Shen Nang Feng” is translated into “scrotal eczema” (WGM2#1953), which is “characterised by severe itching (sometimes pain), erythema, scaling, skin lesions with sometimes oozing rash on the scrotum. Often results from downward flow of damp heat along the liver meridian or wind affecting the scrotal region”. Here, the Chinese Pinyin term Shen Nang Feng is a condition of the scrotum, rather than the kidney in biomedicine. Finally, “Shen Zhuo” is translated into “lower back pain due to cold dampness” (WGM2#1814), which is “characterised by lower back pain and heaviness with a cold sensation and difficulty turning over. Often occurs when cold dampness obstructs the meridians in the low back”. In this case, the Chinese Pinyin term Shen Zhuo has little relevance with the kidney in biomedicine. In addition to the above standard terms, “Shen Ji Qi” is one of the synonyms of “Ben Tun”, which is translated into “running piglet” (WGM2#2170). This term must be clearly defined. Otherwise, it could hardly be understood in the context of integrative medicine and biomedical science. The condition is “characterised by Qi rushing up from the lower abdomen to the chest and throat. Panic, abdominal pain or alternating chills and fever may also be present. Often results from ascending of Yin cold Qi from the kidney, fear/fright or ascending of liver Qi along the meridian pathway”. In this definition, “the kidney” is clearly a TCM concept distinct from its meaning in biomedicine. Thus, both standard terms and their definitions might need some clarification from experts who understand both TCM and Western medicine. USE IN CONTEXT From a scientific perspective, it would be ideal that each terminology is unique, standardised and clearly defined, leaving no room for ambiguity. However, the specificity of terminologies is often context-dependent. A good example highlighting the importance of historical contexts on terminologies is the conceptual shifts of TCM terminology, cumulating into subtle differences of a term in classical TCM, e.g. as defined in the Yellow Emperor's Inner Classic, and in modernised TCM, which has adapted to and partially converged with biomedicine.[21,22] Noting such differences and defining them accordingly will be necessary to avoid “lost or confused in translation”. Context-dependent narratives can be needed for both TCM-specific and generic terminologies. For the latter, a simple example is a context-dependent use and interpretation of “traditional medicine”, “Western medicine” and “conventional medicine”. Although both “Western medicine” and “conventional medicine” interchangeably refer to biomedicine, for obvious geo-cultural reasons, “conventional medicine” is preferentially used in the Western world, while “Western medicine” is more widely used in the Eastern world. Based on a WHO definition, traditional medicine refers to age-old medical traditions worldwide. It is the knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures used in the maintenance of health, as well as in the prevention, diagnosis, improvement or treatment of illnesses.[8,9] As such, in most scenarios, “traditional medicine” is used as opposed to “conventional medicine”. However, from a historic perspective, today's convention may become future's tradition, and “traditional medicine” in a prospective article can indeed be today's “conventional medicine”.[23] Therefore, geo-cultural and historic contexts do have important influences in determining the selection of terminologies, and context-dependent interpretation of terminologies may always have an important role to play in integrative medicine and related science communication. USE CREATIVELY Taking the correct geo-cultural and historic contexts into consideration, the WHO standard terminologies can indeed be used creatively, to differentiate any nuanced differences and avoid ambiguity. In this way, the chance of conflicts, confusion, disdain and angst can be minimised, scientific rigour maintained, and life-threatening consequences avoided in integrative medicine. Again, let us use the word kidney as an example. If it is used in the context of integrative medicine, where the TCM term kidney and its namesake in biomedicine are used in the same article or even side by side, e.g. in Integrative Medicine in Nephrology and Andrology, or in any other contexts where the readership is diverse, how can readers understand which “kidney” refers to a TCM concept and which is biomedical? If it is a TCM term, what is its relationship with its namesake in biomedicine? In these contexts, my suggestions are as follows: Formatting to differentiate All TCM terms containing conventional medicine terms with different meanings should be differentiated from their modern counterparts by using quotation marks (e.g. “kidney”) or italicised fonts (e.g. kidney) and their differences from their modern counterparts must be clearly explained in the main texts (e.g. Background, Introduction, Methodology), in footnotes and side panels, or in glossary lists, boxes or tables. Use Pinyin terms, if necessary In contexts where the TCM concept of “kidney” and the conventional medicine concept of the kidney must be used side by side, it may be preferable to use Pinyin terms, i.e., accented Pinyin names to avoid confusion caused by two different forms of the kidney, as we experimented before.[24] Define properly Regardless of the format of a TCM term, unless it means the same as in biomedicine, it is always highly desirable to define them clearly, so that non-TCM experts can understand them without incurring conflicts. The WHO handbook definitions of standard terms offer the basis for this, but additional efforts will be needed to avoid using TCM terms to define TCM terms so that non-TCM experts can understand. If possible, it will be important to use scientific evidence to illustrate the scientific basis of the relevant terms. CONCLUDING REMARK So far, only three comprehensive international guidelines pertinent to TCM terminologies are published—the 2007 edition of WHO international standard terminologies for traditional medicine in the WHO Western Pacific Regional Office,[15] the 2008 edition of WFCMS international standard Chinese-English TCM nomenclature,[20] and the 2022 edition of WHO international standard TCM terminologies.[16] Building on the former two, the latter has harmonised with ICD-11 and the latest national standards from China and absorbed the latest research outcomes, thus it represents the state of the art in TCM terminologies and English translation, and its dissemination and use should be prioritized. Despite this, the 2022 edition of WHO TCM terminologies do not entirely replace the other two—the 2007 edition of WHO standards include 3543 terms and the 2008 edition of WFCMS standards include 6526 terms, both greater than the 3415 terms included in the latest WHO standards. Hence, at least for those terms not covered by the latest WHO TCM terminologies, the other two standards still have important roles to play. In addition to these general standards, the International Standardization Organization (ISO) committee on TCM (ISO/TC 249) has collaborated with the WFCMS to develop specialist guidelines on Chinese materia medica (CMM), a bipartite TCM vocabulary (ISO 18662-1:2017 and ISO 18662-2:2020), TCM coding rules (ISO 18668-1:2016), and codes for decoction pieces (ISO 18668-2:2017), CMM (ISO 18668-3:2017) and granule forms of individual medicinal for pre scriptions (ISO 18668-4:2017). Under development include guidelines on TCM vocabulary on the efficacy of CMM (ISO/WD 18662-3) and for abdominal diagnostics (ISO/CD TS 23961-3). As an ongoing initiative, these ISO guidelines are neither comprehensive nor complete, thus they cannot serve as general guidelines for TCM-related translation and communication. Instead, these ISO standards aim to support the work of the ISO/TC 249, and have succeeded in supporting the publications of more than 80 international standards on quality, safety, and traditional processing of raw materials and manufactured TCM products, with 27 more standards being actively drafted.[25] The Good Practice in TCM (GP-TCM) project, an EU-China collaborative consortium supported by the European Union and its successor, the GP-TCM Research Association, etc., have also committed to promoting good practice in naming and quality control of botanical materials in studies on botanical products.[26–28] Since the publication of the GP-TCM guideline on reviewing and publishing studies on herbal medicine, esp. TCM and CMM, a decade has passed.[27] We recently evaluated the implementation of the guideline in a selected area of research in the past 5 years. Only a minority of publications have complied with the guideline.[29] The message is clear: it is important to develop standards and guidelines, but this is insufficient. Additional efforts are needed to facilitate implementation, feedback and measurement of adherence and impact. Recently, the WHO Western Pacific Region Office published a framework report to promote harnessing traditional and complementary medicine for achieving health and well-being of the region in the post-COVID era.[30] To enable TCM a bigger role in the WHO Traditional Medicine strategies,[9] we must make the best use of existing guidelines and standards and innovate further from there. In this process, the WHO, WFCMS, ISO, GP-TCM Research Association, China National Administration of TCM, as well as every one of us will have a role to play.