Earlier this week, the Nobel Prize in Physiology or Medicine was awarded to Youyou Tu for her discovery of the anti-malaria compound Artemisinin, as well as to William C. Campbell and Satoshi Ōmura for their discovery of a novel therapy for roundworm. Artemisinin, as some of you might know, is a compound derived from traditional Chinese medicine, which is why, to my irritation, it didn't take long for headlines like How traditional Chinese medicine finally won its Nobel Prize, What the 2015 Nobel Prizes mean for traditional Chinese medicine, and A Medical Breakthrough Made Possible By Ancient Chinese Remedies Just Won A Nobel Prize. In each of these there is, to a varying degree, an underlying implication (in one case not even an implication) that somehow the awarding of the Nobel Prize this year to Tu is a vindication of not just Artemisinin, but of the entire system of traditional Chinese medicine. I will argue that it is nothing of the sort, but rather a vindication of the modern science of pharmacology, specifically pharmacognosy, the branch of pharmacology that concerns itself with finding medicines in natural products.
In one glaring example of the crowing of how this Nobel Prize somehow "vindicates" TCM and shows how it is becoming accepted by "Western" scientists, Sam P.K. Collins writes at ThinkProgress about how "Western" doctors "didn't catch on" to Artemisinin until the 1980s (Youyou Tu had worked on it in the late 1960s and 1970s) and the World Health Organization didn't recommend it for malaria until 24 years later, going on to claim:
Despite its more than 4,000-year history, detractors say traditional Chinese medicine stems from a superstition-based culture that predates modern medicine. They also say the medicine’s reliance on anecdotal evidence goes against what the reliability of scientifically controlled experiments that have proven the efficacy of conventional medicines and therapies.
However, Chinese medical practitioners have pushed back against that view, arguing that opening up to traditional medicine could help advance conventional treatments — especially as developments of new medications are hampered by a lengthy research process and growing drug resistance has rendered some drugs useless.
Note the argument from antiquity, the implication that, because TCM has been around thousands of years, there must be something to it. There is a false dichotomy there, as well. TCM is indeed based on prescientific views of how the human body works and how diseases develop that is very much like the idea of the four humors in what I like to call "traditional European medicine" promulgated by Hippocrates and his followers. After all, in TCM there are the "five elements" thought to be associated with disorders of various organs and the activity of what are known as the Six Pernicious Influences: Heat, Cold, Wind, Dampness, Dryness and Summer Heat. These are thought to cause "imbalance" in the body and thus disease. Indeed, the very basis of TCM is far more philosophical than scientific, the idea being to restore "balance" to the body, perhaps in much the way that the Chosen One would restore balance to the Force, often with much the same effect.
To Collins, the awarding of the Nobel Prize to Tu is both a vindication of TCM and an indication that the tide is turning in terms of acceptance of TCM by "Western" science. Citing a keynote address by Dr. George Y.C. Wong at a TCM conference in 2012 (an address full of tropes about TCM, so much so that it might be worht addressing in a separate blog post) about how, "unlike Western medicine, ancient Chinese treatments take into account patients’ individual characteristics and the connection between the body and mind," Collins declares:
Three years later, that’s becoming more of a possibility. As more Americans grow distrustful of doctors, traditional Chinese medicine and other non-Western practices have grown in appeal. One survey conducted earlier this year showed that young cancer patients eager to ease the symptoms and side effects of chemotherapy have turned to traditional treatment. In response, hospitals across the country have started to integrate their health care with Eastern-based treatments and therapies — including acupuncture, massage therapy, and herbal medicine. And some medical schools now include these practices in their curricula, creating a field known as “complementary medicine,” which allows doctors to infuse conventional and alternative medical practices to their patients’ liking.
Globally, the medical community may be changing its tune. Tu counted among three recipients of the Nobel Prize in medicine, all of whom used natural-based remedies against parasites. William Campbell, an Irish-born researcher who lives in New Jersey, and Satoshi Omura, who is from Japan, both won for their discovery of avermectin, which was developed into ivermectin, a treatment for river blindness. These drugs have replaced their quinine-based counterparts which have proven ineffective in years past.
This is, of course, an old tune, one we've been hearing for a long time, how TCM is really valid, how it is being proven scientifically and embraced by the masses outside of China. Of course, forgotten in such descriptions is how, in China itself, TCM is increasingly being abandoned for scientific medicine and how TCM as we now know it is actually a creation of Mao Zedong, who, lacking sufficient resources after World War II and into the 1950s and 1960s to provide "Western"-style scientific medicine to all of his people, enlisted "barefoot doctors" practicing TCM and advocated the "integration" of TCM with "Western medicine" in a prescient foreshadowing of how alternative medicine evolved into "complementary and alternative medicine" (CAM) and then into "integrative medicine." Mao himself did not use TCM and did not believe it worked, finding the Five Element concept implausible and stating bluntly, "Even though I believe we should promote Chinese medicine, I personally do not believe in it. I don’t take Chinese medicine.”
My citing this history should in no way be viewed as viewed as an attempt to denigrate Tu's accomplishment. Rather, I point it out because there is a long history of TCM advocates latching on to one discovery that appears to show that there is medical value in something in TCM and trying to argue that it means that we should take seriously the rest of the prescientific edifice of TCM, the pseudoscientific baggage that comes along with the occasional pearl. Indeed, this sort of argument was on full display earlier this year when Science shamefully published a multi-part supplement that was basically an advertisement for TCM research. In fact, Tu deserves all the honors she has received over the last few years, first with the Lasker Award in 2011 and now with the Nobel Prize in 2015.
While the concepts behind TCM are prescientific and superstition-ridden, the one area of TCM, as is the case with other kinds of folk medicine, is the natural products used by folk medicine healers to treat various conditions. Indeed, in the case of TCM and other traditions, such as Ayurveda, I tend to like to separate the herbal medicine component from everything else, because it is there, regardless of the philosophy that spawned the treatments, that actual useful medicines might be found. The tools that find such medicines includes pharmacognosy, and that's what happened here. A little history is in order.
In the US and most developed countries, malaria is not much of a problem because the mosquitos that carry it thrive in tropical and subtropical climates, such as Sub-Saharan Africa, Asia, and Latin America. There the disease is associated with poverty and reaps a horrible toll every year. Indeed, the WHO estimates that there were close to 200 million cases of malaria worldwide in 2013, resultin in 584,000 to 855,000 deaths, the vast majority in Africa. Because the disease affects those living in tropical regions so heavily, it is often forgotten in developed nations just how many people suffer and die every year from the disease.
In the 1950s, attempts to eradicate malaria failed because of the emergence of a chloroquine-resistant strains of Plasmodium falciparum, the parasite that causes malaria. At the time chloroquine was the main drug used to treat malaria, and this resistance led to a resurgence of malaria in tropical regions, including North Vietnam and parts of China. There was a vital need for new anti-malarials, which led the Chinese government in 1967 to set up a national project against malaria under the leadership of what was called Project 523. Youyou Tu herself told the tale in a fascinating article published in Nature Medicine in 2011 after she had won the Lasker Prize. Tu had the necessary qualifications to head this project, having graduated from the Beijing Medical University School of Pharmacy in 1955 and been involved in the research of Chinese hebal medicine in the China Academy of Chinese Medical Sciences (previously known as the Academy of Traditional Chinese Medicine). From 1959 to 1962, she had participated in a training course in Chinese medicine especially designed for professionals with backgrounds in "Western" medicine, which led her to see the potential in TCM herbal remedies.
She described the process thusly:
During the first stage of our work, we investigated more than 2,000 Chinese herb preparations and identified 640 hits that had possible antimalarial activities. More than 380 extracts obtained from ~200 Chinese herbs were evaluated against a mouse model of malaria. However, progress was not smooth, and no significant results emerged easily.
The turning point came when an Artemisia annua L. extract showed a promising degree of inhibition against parasite growth. However, this observation was not reproducible in subsequent experiments and appeared to be contradictory to what was recorded in the literature.
One notes that, to identify these 2,000 TCM herbal preparations, Tu scoured TCM texts. Here's where the insight from a TCM text came in:
Seeking an explanation, we carried out an intensive review of the literature. The only reference relevant to use of qinghao (the Chinese name of Artemisia annua L.) for alleviating malaria symptoms appeared in Ge Hong's A Handbook of Prescriptions for Emergencies: “A handful of qinghao immersed with 2 liters of water, wring out the juice and drink it all” (Fig. 1). This sentence gave me the idea that the heating involved in the conventional extraction step we had used might have destroyed the active components, and that extraction at a lower temperature might be necessary to preserve antimalarial activity. Indeed, we obtained much better activity after switching to a lower-temperature procedure.
When I read this passage, I note two things. First, qinghao was not used in TCM to treat malaria, only to lower fever; indeed, its whole plant extract does not result in a sufficiently high concentration of the active ingredient to treat malaria. Basically, Youyou Tu and her team scoured TCM texts to identify anything used to treat fever. Second, I wasn't exactly sure how that particular passage led to the insight that heating the extract was degrading the active component of Artemisinin. After all, all that was in that text was a lack of a mention of heating the extract, and noticing an absence of a step is a different thing than noting the presence of a step in preparing an extract, after all. When I see a recollection like this, I tend to suspect that the person relating the memory was already thinking along those lines anyway and that the text jarred something in Tu's brain to cause the proverbial lightbulb to go off. There's nothing wrong with that, but she could just as easily have been wrong about this. Fortunately, she was not. This new method of preparation led to Tu's being able to separate the extract into its acidic and neutral portions. On October 4, 1971, Tu isolated a nontoxic neutral extract that was 100% effective against parasitemia in mice infected with Plasmodium berghei and in monkeys infected with Plasmodium cynomolgi. Next, because it was during the Cultural Revolution and there were "no practical ways to perform clinical trials of new drugs," Tu and her colleagues volunteered to be the first to take the extract. After determining that it was safe for human consumption, they began testing it in patients infected with both Plasmodium vivax and P. falciparum. The results were encouraging. In patients treated with the extract, fever rapidly declined, as did the number of parasites detected in the blood, which did not happen in patients receiving chloroquine.
But Tu was still not done, and this is the message frequently forgotten by advocates who latch on to this Nobel Prize as a vindication of TCM. Pharmacognosy led to the discovery of Artemisinin, but it took medicinal chemistry to turn this compound into a usable, useful drug. Sources rich in the molecule had to be identified, methods of isolating it on a large scale developed, and a stable formulation produced. As Tu put it, her team now had to go from molecule to drug:
In keeping with Goldstein's view, the discovery of artemisinin was the first step in our advancement—the revelation. We then went on to experience the second step—creation—by turning the natural molecule into a drug.
We had found that, in the genus Artemisia, only the species A. annua and its fresh leaves in the alabastrum stage contain abundant artemisinin. My team, however, used an Artemisia local to Beijing that contained relatively small amounts of the compound. For pharmaceutical production, we urgently required an Artemisia rich in artemisinin. The collaborators in the nationwide Project 523 found an A. annua L. native to the Sichuan province that met this requirement.
The first formulation we tested in patients was tablets, which yielded unsatisfactory results. We found out in subsequent work that this was due to the poor disintegration of an inappropriately formulated tablet produced in an old compressing machine. We shifted to a new preparation—a capsule of pure artemisinin—that had satisfactory clinical efficacy. The road leading toward the creation of a new antimalarial drug opened again.
As Kausik Datta notes, Tu was also using medicinal chemistry to modify Artemisinin to improve it:
In the true tradition of proficient medicinal chemists, Tu wasn't satisfied with existing qinghaosu [the Chinese name for Artemisinin]; as early as in 1973, she had already chemically modified Artemisinin to dihydroartemisinin. Overcoming the initial concerns about its chemical stability, she found that this substance was stable, possessed ten-fold higher anti-malarial potential than Artemisinin, reduced the risk of recurrence, and provided the opportunity to develop newer Artemisinin derivatives through chemical modifications.
Several of the articles touting Tu's Nobel Prize implied that the reason Artemisinin wasn't accepted right away in the "West" was prejudice against TCM. It turns out that Tu's results were not published internationally until 1979. As Tu put it in her Nature Medicine article, the chemical structure of Artemisinin was determined in 1975 and published in 1977, but "the prevailing environment in China at the time restrained the publication of any papers concerning qinghaosu, with the exception of several published in Chinese." After publication in 1979, Tu presented her group's work in 1981 at the Scientific Working Group on the Chemotherapy of Malaria in Beijing, sponsored by the United Nations Development Programme, the World Bank and the World Health Organization (WHO). She noted that the "efficacy of artemisinin and its derivatives in treating several thousand patients infected with malaria in China attracted worldwide attention in the 1980s"21.
Indeed, WHO representatives at the conference were very impressed with what they heard. They immediately approached the Chinese government for samples of the plant and details of the extraction process, so that they could replicate the findings reported. This is, of course, what scientists do when they hear of a highly promising new treatment like this. However, at the time, the Chinese government was reluctant to share these details, and, as Maude et al put it in a description of the history of Artemisinin, "further collaboration did not occur at that time." It's likely that Cold War politics and the insular nature of the Chinese government was a bigger factor in the delay in acceptance of Tu's findings by the rest of the world than distrust of the source of the drug. After all, scientists have been screening various natural products and extracts for pharmacological activity against diseases such as cancer for many decades, and many of our most useful drugs were derived or modified from natural compounds.
Tu's accomplishment is remarkable and definitely deserving of the Nobel Prize, as it is a triumph or modern pharmacognosy and medicinal chemistry. Unfortunately, even the Nobel press release about Tu's award seems to imply that this discovery was due to TCM. Yes, there may well be more pearls like Artemisinin in the thousands of herbal remedies used in TCM, but they will only be identified and validated by rigorous science of the sort applied by Tu nearly five decades ago. What is also forgotten is what a small proportion of these compounds will actually pass this test of rigorous science. Remember, Tu screened over 2,000 compounds, only a third of which showed any promise and only one of which became a useful drug. TCM herbalists tend to forget this and skip the steps that Tu went through over several years of hard work. They also tend to forget that the validation as a safe and effective medicine of an active compound derived from a TCM herbal preparation does not validate the mystical ideas that underlie TCM and are the basis for all of its non-herbal practices. Science works. Mysticism does not.
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The article I saw on this made it very clear that the Nobel was for the isolation and synthesis of the active drug, not for the TCM influence.
I have no problem with the idea that various cultures have empirically discovered certain plants that are pharmacologically active. Better of course to isolate and synthesize the active ingredients, for the sake of purity and control of dosage.
Hopefully the mainstream media will get the story right, but we can expect the usual crowd of charlatans to spin it to suit themselves. Only question is which charlatan will be first-to-market with a "supplement" based on this. I'll bet it's Mike Adams. That's a safe bet.
I was hoping you'd write about this. Every TV news article I've seen had the same opening - Western medicine finally accepts a tradition Chinese drug, or something very similar. And every time I heard it, I thought, "Orac will write about this, and use actual facts." Thank you.
I'm more than a little surprised that anyone with any knowledge of biochem wouldn't have considered the consequences of using only hot extraction methods, right at the very beginning. Perhaps there was a little too much adherence to traditional methods, rather than long-established scientific methods.
Looks like artemisinin is already be sold in mass production as a:
"NutriCology® Artemisinin is an easy-to-take hypoallergenic dietary supplement delivering 200 mg of Artemisinin per serving. Chinese herbalists have used this herbal supplement for some 2,000 years to support immune health. It is a wonderful, go-to immune tonic found in many herbalists' supply." (sold by a vitamin company online, of course)
Meanwhile, the WHO is worried about resistance developing by P. falciparum to artemisinin.
Gee...thanks TCM quacks for helping to ruin a good thing.
The key point is one you have made before: Science-based medicine is glad to accept any treatment proposed by alt-med types, whether TCM or otherwise, that holds up under rigorous testing. Here, we have an example of something that passed the test. It is notable because such successes are so rare.
Also worth noting is that, when Dr. Tu was doing her initial work, she didn't publish in English, as she automatically would have done if she were doing similar work today. Many Ph.D. programs used to have foreign language requirements because a large fraction of the literature was in languages other than English. Sometimes, as in Dr. Tu's case and for many scientists in the USSR, this was for political reasons. There are historical reasons: leading-edge research as recently as the 1930s would more often be published in German than in English. Many non-scientists, and more than a few scientists, forget this history. At least German and Russian are Indo-European languages with alphabets, so they aren't as difficult for Westerners to learn as Chinese.
For those who have seen articles that praise the supposed TCM aspect:
Did any of them mention quinine - something that might be regarded as western traditional medicine?
Many news sources also neglected to mention the heavy contribution from industry to these discoveries. It took a lot of work by many people to turn these extracts into drugs.
See the discussion and Bernard Munos' comment at: http://blogs.sciencemag.org/pipeline/archives/2015/10/05/natural-produc…
Listening to the announcement and press conference was painful when it had to be explained several times to journalists that Tu's work was not proof that traditional medicine worked.
And someday, if the discovery of Taxol were to warrant a Nobel Prize, it would be a vindication of the Yew tree.
Ibuprofen vindicates all allopathic medicine.
@#9 (Marry Me, Mindy):
And of the willow tree for aspirin, the cinchona tree for quinine, and the Madagascar periwinkle for vincristine and vinblastine - and so on.
NHK (the Japanese equivalent of the BBC) showed a clip in which a (non-Japanese) commentator suggested that Professor Tu had received little recognition until comparatively recently because she lacked "the three Ds" (a doctorate; foreign training - I don't remember quite how this is a D, but it was explained; and something else): she didn't fit into the Chinese academic establishment. Datta (cited in the original post) notes in his article that she is still not a member of any of the Chinese National Academies.
So, out of 2,000 products, they found one that had some effect, as long as you didn't prepare it the way the texts said to prepare it. You know, I don't think I like the odds there.
Not to mention penicillin and the many other antibiotics that came from soil extracts and whatnot. Those Ancient Chinese docs would have done better had they bothered to check out the mold on their rice.
Almost nobody of her generation fits into the Chinese academic establishment. There was this unpleasant business called the Cultural Revolution going on, so most if not all Chinese universities were closed, and unless you were otherwise politically impeccable your Ph.D. degree would have been sufficient to make you suspect. China-USSR relations had started to chill by then, so getting a Russian or other East European doctorate wasn't an option. China's relations with the West hadn't thawed yet, so getting an American or West European doctorate wasn't an option either. Chinese graduate students started appearing in US universities in the early 1980s, and today it's common for Chinese to come to the US for undergraduate degrees (there are enough of them at my local university to support an Asian grocery store in an otherwise white-bread town).
Of course this demonstrates that the Cultural Revolution ended up wasting a lot of talent.
"Red mold rice/red yeast rice" (rice fermented with Monascus purpureus) contains the cholesterol-lowering compound lovastatin, along with some other statins (monacolins). It's apparently a health food in China, but is banned in the US if it has more than nominal statin content.
October 7, 2015
It's an extremely poor example of that. TCM wasn't proposing anything: it was trundling happily along as it forever does, utterly uninterested and uncritical in determining which of its 'treatments' actually work or how they might be improved.
It's a much better example of an science-based researcher patiently spelunking the great rambling sinkholes of low-quality, anecdotal folk medicine, searching for recognizable hints of where and how there might be some interesting pharmacological activity possibly going on, then mercilessly beating on it until the active compound - if it does indeed turn out to exist - has been identified, extracted, synthesized, and improved.
If anything, the alt-med peddlers will dismiss the final pHARMa-manufactured result** as vastly inferior to their own wholesome organic all-natural treatment, due to souless reductionist science destroying its magical "whole-plant/animal/mineral" holisticism in their evil uncaring pursuit of patents and profit.
As Orac says, this is just a particularly good example of plain old pharmacognosy doing its job exactly as it's designed to do. The only credit TCM deserves is for inadvertently nudging the original researcher in what has ultimately proved to be a highly productive direction (as opposed to sending the poor sod up its infinitely more common dead ends). But this is only marginally more credit that you'd afford a stopped clock for at least being right twice a day; and curse the craven and fictitious press for presenting otherwise, just because a thrilling mystical narrative sells better to its idiot audiences than the slow undramatic truth.
(** While still crowing how it proves the efficacy of their own garbage product, of course. Never let it be said they aren't rigorously consistent in their own inconsistency.)
Many thanks to Orac for explaining the correct story, which is the same old story as for western real drugs.
ok. your comment about 'the chosen one' made me think of Tu isolating Artemisinin in parallel with the Episode 1 scene where they're testing Anakin for midichlorians. And, of course, all of the following fan-angst. "Stop trying to put scientific explanations to my fantasy world, you're ruining the magic!"
ok, at least in my head it seemed fitting.
Hope you enjoyed your day off from RI, recharged your batteries, etc. Kudos to the blinking box for having the wisdom to take care of itself. I've long been amazed by your ability to do all that you do, and I would still be so if new RI posts appeared, say 2-3 times a week instead of 5.
I hope I speak for more than a few minions in saying our appreciation for the blog, and desire that long may it run, means we're all for whatever it takes to keep the box free from dangers of burnout inducing overload, and realize that this is "a hobby", energy is a finite resource, and you have more important things to do.
Every RI post is a gift to public discourse. However often we get them, it's all good.
Be well, good sir.
So, out of 2,000 products, they found one that had some effect, as long as you didn’t prepare it the way the texts said to prepare it. You know, I don’t think I like the odds there.
To put it another way, Professor Tu discovered that 99.95% of products promoted by TCM practitioners are worthless.
I want to agree with sadmar. Also, RI is getting me back to where I used to be. My commenting on your articles is the result of my health returning from battling prostate cancer and being grossly overweight (I've been told there is a link between the two). I've lost over 170 lbs and weighed 337 this morning; which is lightest I've been in over 12 years, I still have at least 112 lbs to lose.
It feels good to be more alive and thank you for allowing my posts.
I would like to point out that Treditional Chinese Medicine use liquid mercury as a way to prolong life. As a matter of fact, Mercury was used on some emperor, including China's first emperor.
I would like to see what the Alties think about Mercury.
Yep--that's right. Lovastatin was first found in a strain of penicillium mold by Akira Endo in Japan back in the '70s, and again shortly later by researchers at Smith-Kline and Merck.
Naturally, the Nobel committee saw fit to recognize two other people (Brown & Goldstein) for their work on cholesterol metabolism instead.
Looking for new drugs by mining natural sources (mold, soil, plants, etc) or by investigating traditional medicines, is still done, but is less popular than it was a few decades ago. The returns have been diminishing for a quite a while.
herr doktor bimler@21:
And yet the Chinese have been very successfully selling those products for thousands of years. This is clear irrefutable proof of Big Pharma's massive incompetence: discarding 1999 perfectly saleable medical products just because they don't work.
Checkmate, pharma shills!
@ Rich Bly
I had Rouen-Y gastric-bypass bariatric surgery in 2010. I just made the minimum BMI to qualify for insurance coverage, and I probably wouldn't have done it for weight loss alone, but once I heard it would fix my awful problems with GERD (and attendant increased risk of nasty death to esophageal cancer) I was in.
Just as there's massive social stigma attached to obesity, there are powerful stigma against addressing it with surgery. The problem is exacerbated by the fact bariatrics can be a lucrative practice, and you hear plenty of horror stories about patients left worse-off by cut-and-run surgeons of dubious competence. Thankfully, my PCP knew was who, steered me away from the bozos in-town, and sent me an hour up the road to a guy running a "Center of Excellence" – which included an incredibly thorough pre-and-post-op program with dieticians, psychologists and mandatory support groups – leading to an long-term success-rate that was, indeed, excellent.
Not being an MD, I'm not recommending surgery for anyone for anything. I can only suggest that it's worth looking into, and report that many of the negatives you might hear associated with it are not significant concerns if you have the right doctor.
Glad to hear you're making progress, in any event!
Just another commenter happy to see you've written about this. I saw the write-up about the prize on Vox and read some of it anxiously until I saw they weren't going with the "Yay TCM" approach and in reading it it was very obvious Dr. Tu was working scientifically in her search for a remedy.
To treat my prostate cancer I had to loose over 100 lbs and the only way to this in time frame was to have bariatric surgery. I went through the process at U Of WA and was approved for surgery. However, my med insurance would not cover the surgery even with letters from my docs concerning the need to loose the weight for treatment or I might die. U of W wanted between 100,000 and 120,000 dollars for the surgery. I ended up going to Mexico and the cost was $5700 or about 20 times less.
I just wanted to throw this out there. Both points of this argument have their valid points, however this article posted here isn't a complete story. The way herbal chinese medicine works is through herbal formulations, not just single herbs. Yes each herb has its own properties (medicinal and others), however it is the combination of herbs together that create synergistic effects. In the same way that those in labs are working hard to extract specific molecules for treatment, combination treatment therapies are just as valid. For every drug/drug reaction or drug/herb reaction, there are millions of herb/herb reactions going on and by combining them opens the potential to unlock new chemical events within the body, those that possibly cannot be fully synthesized in a lab due to the environment inside ones body. Just food for thought.
Your excellent piece reminded me of the time I used the phrase "Chinese traditional medicine" in reference to an area of my research, only to be asked in disdain if I didn't mean TCM. When I attempted to explain the difference, pointing out that what most know as TCM is a recent extrapolation of Chairman Mao to offer inexpensive medicine to the masses, the young herbalist with whom I was speaking accused me of being steeped in western rational thinking and against the 'movement', giving new meaning to the phrase, communist propaganda. Not being soluble in water, what role artemisinin played, if any in the traditional use of the plant for fever must be called into question. For that matter, whether the plant is effective in lowering fever outside of those caused by malaria would also need to be examined.
@ Tim K: As incredible as it may seem, certain adherents of ayurvedic medicine believe mercury or cinnabar can be 'purified' to render it non-toxic, which may explain why high levels of mercury have turned up in some ayurvedic herbal products sold in the West. Go to PubMed and enter "mercury AND ayrurvedic" to see what I mean.
@Soro - I've heard people say things about the synergistic effects of chemicals within a single plant or those in a combination of plants. While this sounds plausible, I'm left with questions:
1. Has this ever been shown to be true in a rigorous way with the treatments in question?
2. Is there anything in the system of TCM that allows people to find those combinations by anything other than trial and error? If so, what is it and how was that shown to be true.
My Dad did a brief stint in synthesizing potential compounds from plants for medical use.
Scientists do understand and look for synergistic effects. One big part of does A treat B is looking at causation.
Is A necessary for B to get better,
Is A sufficient for B to get better (can it do it all by itself).
When you find that A is not in anyway sufficient you don't stop. Especially when whole plant extract is sufficient. You go looking for what is the combination that does it.
So this whole scientists cannot believe or understand synergy. For example in toxicology, one of my areas of expertise, where we note that compound A has X amount of toxic effect and compound B has Y amount of the same toxic effect but if you take A and B you don't get X+Y amount of toxic effect you get twice the additive toxicity or 3 times or 4 times...why so many things say don't drink alcohol when taking this medication. Usually the biggest warnings are when the effects are more than additive because scientists know synergistic effects can sometimes happen.
Now we don't believe they must in every case always happen so the more and more you add to one thing that you suspect might work the better the resulting combination must be. (so many proprietary blends out there that seem to be if you throw the whole kitchen sink of herbs in there it must be better even when what little we know of the active compounds suggest they may be antagonistic rather than synergistic).
Back to my Dad, when A wasn't doing it on his own he started investigating what is the combination that is needed for the desired effect. He didn't just say well if A can't do it by itself no matter what other data I have I will just stop because science demands that one and only one thing at a time can ever be used because reductionism or some such.
It is possible that TCM herbal formulations exhibit synergistic effects, but you have to actually demonstrate that synergy exists in a particular formulation. The basis for the combination of herbs (the "king, minister, assistant, messenger" system) is the same mysticism that permeates the rest of TCM, rather than a scientific and evidence-based basis. As one promoter of alternative medicine explains it, "TCM herbs are not prescribed on the basis of their chemistry, as we would understand it in the West. Instead, they are used to introduce certain influences into the body, in order to balance and harmonize the patient's vital energy" (http://www.drpelletier.com/TBAM/excerpts/036-Chinese_Herbal.html). This is nonsense, of course, since the chemistry completely accounts for the action of botanical medicines. Therefore, there is no reason to expect any special synergy in these formulations, and rigorous evidence needs to be provided for claims of synergy, rather just assuming them to be true.
It's not just alcohol that can have a synergenic effect on some medications, but something like grapefruit-juice just as well, as my dad knows. Something he doesn't really like.
herr doktor bimler@ 21: 99.95% were worthless for what: treating malaria, or doing anything at all? I'm inclined to think it's the former, because the probability of a match between a specific disease and a specific source of compounds is always going to be low.
TimK @ 23: Mercury for longevity: That is the _perfect_ comeback to anti-vaxers who freak out about Thimerosal. "Do you believe in traditional Chinese medicine? Yes? Well, one of the traditional longevity drugs was mercury, so..."
Or to really rub it in: "...and do you also believe in homeopathy? Well, Thimerosal is a homeopathic dose of mercury, so it ought to be especially good as a life-extending drug!"
Lighthorse @ 30: There appears to be a strain of Maoism in some parts of the political left in the USA. It's subtle, but if one knows the material, one can spot it. That may account for some of what you observed, and I'm inclined to think it does, based on the herbalist's use of the word "movement."
Anyone who doesn't like "Western rational thinking" is welcome to explain why it doesn't work. (Asking them on the spot would be interesting.) And here I'm not talking about examples such as "rationalism can't tell you which music is better." Of course it can't, and it doesn't purport to do so.
So in that respect, what Tu did (isolate the active ingredient) is in fact not at all like "herbal chinese medicine." In fact, it sounds an awful lot like what those damned Western reductionists do, doesn't it?
Here's what I always wonder. Considering that that we are looking at 2000 mixtures for what is likely evidence of anti-pyretic effect. From which we select 600 mixtures. The question becomes how many of these fevers were actually malaria. If the majority weren't - then the fact that these mixtures were part of TCM seems like it could have occurred simply by chance.
Also, if they had to go through 600 to find a promising mixture - then it doesn't say very much about ethnomedicine in general.
Not really; although it's not "ethnomedicine," the NCI program that yielded Taxol and Camptothecin went through over 100,000 plant samples.
Even in Europe herbalists used mixtures of herbs to treat all sorts of ailments. Rarely, this mixtures had some sort of beneficial effect.
The English physician William Withering is credited for introducing foxglove as a treatment for "dropsy". Truly, he was shown by a herbalist how to treat the illness with a mixture of herbs, and it goes to his credit to have shown that the active ingredient were foxglove leaves.
The other herbs were of no use, even if his herbalist was using them since always.
Of course, today foxgloves leaves are not used anymore. We use nice little chemical pills with 0.2 mg of active drug.
Called it! Me@17:
Grapefruit juice is known to contain a whole bunch of organic compounds that affect chemical metabolism. The grapefruit compounds do this by interacting with enzymes in the liver and digestive system. The liver enzymes are there to metabolize all the toxic things that you eat or otherwise shove into your body, so your body can remove them and you won't kill yourself with that all-natural salad.
These grapefruit compounds can change how the liver metabolizes the drug or food chemical. This can make some drugs more active and others less active.
To make it more interesting, there's a lot of genetic variation on the liver enzymes. This variation often accounts for why people vary in how well they respond to a given drug or react to eating a food, and the types of side effects that they experience.
It's not really synergism at all--even a single chemical can interact with the body in a variety of ways. Investigating these and other interactions are why drug development takes time and many types of animal and clinical trials.
If a single chemical give complicated results in different people, then just imagine what happens when you put a complex mixture into your body.
Lecture over--hope you found this useful.
The way herbal chinese medicine works is through herbal formulations, not just single herbs. Yes each herb has its own properties (medicinal and others), however it is the combination of herbs together that create synergistic effects.
You'd think that after all that empirical observation of the effects of herbal combinations, they would have given up prescribing Aristolochia after noticing that it causes cancer no matter what it's combined with.
And thank goodness too. Nicely purified and precisely measured Digoxin is dangerous enough as it is.
Post-structuralism in action:
Language is a social construction. Linguistic expressions have multiple possible meanings, which get closed-off and narrowed-down by the exercise of social power, creating ideological effects in the 'preferred meaning' that remains.
So, here we are, using 'traditional medicine' to refer to something we know isn't traditional at all, and has a dubious claim to being medicine as well. But what are we supposed to do? The signifer 'TCM' has just been repeated, by so many people, in so many places, so many, many, many times, eventually it just sticks to the signified whether we like it or not. You protest for awhile: come up with alternate terms, or bracket the usage with quotation marks or appending 'so-called' to the front. But it gets old, and you wind up looking like some nit-picky pedant. So, eventually, you choose straightforward communication on the topic, which means employing the common terms the majority is using without making a fuss about it. And, thus, one more little grain of sand falls onto the social-construction pressure plate gradually tweaking the general sense of 'traditional' and 'medicine.' But when it comes down to any of us as individuals – trying to communicate, well, something else – we're just one against many, and our choices amount to a lose-lose, a problem either way.
Scientists tend to hold to an unexamined and naive logical positivism in the first place, and when confronted with post-structuralism, just double-down on it's central premise: the possibility of 'a neutral description language'. That is, they reject any notion that their language is anything but natural, transparent, reference to objective reality, reject that it too is an ideological social construction.
The problem, philosophically, is that continental thinkers recognized the central dilemma decades ago, and the logical positivists of the Vienna Circle set out to silence their critics by creating 'neutral description language' that would hold up as such under scrutiny and critique. They couldn't, and eventually threw in the towel.
Politically, the problem is that since when writers like Derrida and Barthes employed post-stucturalist theory in the form of criticism they called 'deconstruction', they focused on language use that supported social injustice – thus giving the impression that the application of power to rein in semiosis was always bad, and freeing all the 'repressed' meanings was always good. But Derrida was a Marxist. As such, he believed power was not always necessarily corrupt, that it could be taken by 'the people' and directed toward progress to a more just, equal, and democratic social order. Whether he himself articulated that in relation to deconstruction is irrelevant. 'Birmingham School' cultural studies mixes Derrida's insights along with Gramsci, Althusser, and a bunch of other folks to come up with the notion that "language is a site of struggle" between different social and cultural forces. It's not 'lose-lose'. The 'good guys' may be the underdogs, but the fight isn't over, and there's still opportunities for victory – which necessarily means bending language to the service of the greater good.
Not that I know how to do that. I'm just guessing scientists would look on the notion of 'bending language' for any purpose with a jaundiced eye. And I think that's a mistake.
For all of its claims to 'just the facts' objecticity, at base science justifies itself by contending it serves the greater good. The facile exclamation "Science Works!" is generally followed by a listing of presumed-beneficial scientific achievements. This is blatant cherry-picking, as it takes virtually no effort whatsoever to come up with a different list where science did indeed 'work', but to serve many of the worst human impulses, and/or in ways that generated great harm as 'unintended consequences'.
However, it strikes me that sbm-advocacy has a moral center, whether its proponents like to admit it or not. Sbm discourse tends to focus on the factual/scientific 'wrongness' of woo. But a trollish commenter in another thread recently asked, "With all the many and mammoth wrongs in this world, why this focus...?" (my emphasis). While I take that query to be intended as a snarky rhetorical question, I also take it to be worth a serious answer. For factual/scientific wrongs are many and mammoth as well, ranging far beyond those addressed by the larger community of skeptics, and certainly of this blog. Why this focus? Why these scientific wrongs?
Is it not because woo hurts people so often? Steals their savings, their health, their lives? Is it not further that it preys on the weak, those least capable of helping themselves?
Yet even for Orac, who makes no effort I can see to hide his moral contempt for woo, 'the wrong of harm' often plays weak second-fiddle to 'the wrong of fact'. To me anyway this is cart-before-horse, especially in terms of reaching the non-science-literate general public. The 'wrong of harm' ought take the lead, and the 'wrong of fact' ought to be the backing support. IMHO.
Anyway, back to being stuck with 'traditional medicine' as a signifier for acupuncture and herbal hoo-hah. One of the things that happens over time with language is that in everyday usage, terms like this lose the connotations of their original referents. That's already beginning to happen with 'traditional medicine'. What's good about that formulation from an anti-woo POV is that it leaves the 'Chinese' out of it, as attacking anything associated with a racial Other is going to pose problems. The word 'traditional' already is anything but a straightforward positive. In uses like 'traditional marriage' it already evokes a conflict between forward-moving ideas and a retrograde nostalgia for an idealized past that never really existed.
Now, I'm not meaning to criticize anyone in sbm-land for how they've addressed or used the notion of 'traditional medicine', I just started thinking about it by chance reaction, and have been trying to work through those thoughts as I write. Anyway, here's my tentative conclusion: The opposition has captured the term "traditional medicine'. Any attempt to re-capture it, or explain why it's unwarranted (Mao, etc.) actually works i favor of the opposition by re-inforcing the positive connotations of 'traditional'. The proper rhetorical strategies would be either to abet the complete detachment of the term from any connotation beyond its current use, or to leverage the negative ones. 'Traditional Transportation' = donkey. 'Traditional Underwear' = corset "Traditional Bathroom" = open dung heap (etc. etc.); so why would I choose 'traditional medicine' over 'modern science'? Something like that. I.e. illustrating the problems of "argument from antiquity" in cutting analogies.
Oh boy, you're just another man speaking over the words of the woman who discovered it herself. You don't even realize you're doing it, but she said it was from TCM herself and you're going to say your opinion is more important than that?
Tu called artemisinin "a gift for the world’s people from traditional Chinese medicine," and urged researchers to turn to herbs in the search for cures for infectious diseases.
I looked up the original text of Ge Hong's "Handbook" and in context, it does distinguish between "immersion" and "boiling". Indeed, a few lines down it says:
Another recipe: Dichroa febrifuga 0.15kg. Use alcohol 3 litres, immerse 2-3 days, take out 300g and make the patient drink it. The patient would vomit it up; give a patient who is starting to get a fever 200g, and the fever will break. Using old wine is also fine. In an emergency, can alternatively boil [the remedy]. (My translation)
The last sentence is key.
I know it seems ambiguous how the handbook doesn't specify not to heat the water, but this was ~300AD and the written Chinese of the time would still be influenced by the very concise Classical form of the language (developed when writing was an expensive endeavor).
The Handbook itself is actually pretty hilarious, with remedies such as "split a pea pod, write 'sun' on on half and 'moon' on the other. Take one in each hand and you will be cured as soon as you swallow them; eat when the sun is shining inside from the northern window, don't let anyone else know."
"To cure any fever, this is the way: pick up a cock and for one hour make it make loud sounds; there's none [fever] that this won't cure".
"Take a spider. Mix with food into a ball and swallow."
And those are all fever remedies.
For reviving someone who suddenly "dies" (might include sudden loss of consciousness), we have:
"Cut off the tail of a pig, gather the blood and make the patient drink it. Then tie it up and use it as a pillow for the patient."
And advice that seem actually reasonable:
"Use a tube to blow into the throat, have multiple people alternate. Upon the air getting through, the person will live."
The Handbook includes many uses for excretions of various animals (including humans), and they seem most numerous in the section that deals with ingested poisons? Perhaps it's because they induce emesis? In one recipe, it even describes how to recognize the mouse droppings required ("the ones that are pointy at both ends, they are what we want"). I can't imagine a modern worshipper of TCM wanting to try them out.
As a one last aside, I think "liter" is a mistranslation from applying modern Chinese (where the character does translate to "liter") to near-Classical Chinese, where the unit might have described a significantly different amount. Because otherwise the handbook would have as a remedy for poison, "warm a liter of lard and make the patient drink it all."
@13 (Anthony): Actually, the claim is that initial extractions were ineffective because they deviated from the cold extraction method described in the Handbook. I also don't think the researchers had to go through 2000 herbs. If that number refers to the remedies listed in the books they consulted (as opposed to only the ones they seriously considered), a lot could have been rejected out of hand (e.g. write something on a body part and perform a ritual). And of the herbal remedies remaining, one might expect that some common herbs are present in multiple recipes if only because the books copied each other.
@#23 (Tim K): I think they used mercuric compounds instead of liquid mercury, because the Chinese word for the elixir referred, in (even) more ancient days, to a red stone (cinnabar?) and the stuff is usually depicted as a round pill.
And my two cents on the topic:
If we accept the premise that the rate of effective remedies in the old Chinese books is higher than random, we can treat it as a system with low signal to noise ratio, produced by large numbers of abysmally low quality studies. And guess what is really, really good at increasing the signal to noise ratio? Modern science armed with the extremely powerful tool that we call statistics. So we should run all the old remedies through scientific experiments, starting from the most promising ones; the ones that are not validated go into the discard pile. After the first round, model factors that predict effectiveness of a remedy and estimate the chance that each remedy in the discard pile was rejected in error, allowing us to reassess whether any of these merit a second chance (I believe this is an application of a posteriori Bayesian statistics).
"If we accept the premise that the rate of effective remedies in the old Chinese books is higher than random, we can treat it as a system with low signal to noise ratio, produced by large numbers of abysmally low quality studies."
We need to define what "higher than random" means in this context. Higher than simply picking some other chemical at random? Probably but I'm not certain that's really a fair comparison. TCM does add some information beyond chance (in this particular context) but I doubt it has much at all to do with medicinal effect. I suspect what a lot of ethnomedicine adds are more basic things like how well this is tolerated.
It's also worth mentioning that even a large series of low-quality studies do not necessarily increase the likelihood of one's hypothesis.
I would expect that the most obvious comparison would be to other plants, i.e. they would be more likely to have a medicinal effect on what they've been traditionally used for than a randomly selected plant. I suspect they would fare worse against designed compounds, but I don't know where the balance lays. I think you made a very good point about tolerability--which, now that I think about it, is a strong point in favour of testing these remedies, because lower probability of efficacy can be counterweighed by reduced risk of serious side effects.
I envision a large series of low-quality studies as flipping a set of coins, the vast majority of which are fair and a few of which are weighed to increase the likelihood of getting heads. In each study, you flip a coin a few times and make a guess on whether or not the coin is weighed, without the benefit of statistics. In this scenario, we would very many false positives and probably a few false negatives as well, but the set of coins you consider "weighed" probably has a larger proportion of weighed coins than the set we started out with. I think this is a meaningful, if over-simplified, abstraction of Chinese traditional medicine.
Of course, whether or not the resulting concentration of weighed coins is at a useful level is a different question, to which I do not have an answer.
It's worth noting that Dr. Tu is not a fluent English speaker, and may well be using "Traditional Chinese medicine" to mean Chinese herbal medicine rather than the hot/cold/wind etc. set of ideas. What is certain is that artemisin doesn't contain bear gall (for example), and patients are given it without someone first worrying about whether they have too much yang.
Sadmar # 46
Sadmar post looks nearly as long as Orac’s, but it seems to me that its core meaning is his will to shift SBM-advocates’ attention towards the harm that Alt Med can do, instead that focusing on the truth content of Alt Med practitioners.
This could be a sane proposal, if people who are expected to read SBM blogs were those more in need to be convinced that SBM is more useful than Alt Med to care for ill people.
Unfortunately, people that “know” that Alt Med is better will not be convinced from any quantity of evidence, so don’t bother to look up SBM blogs .
I think Orac has chosen a very useful mission: to inform people who may not know how to explain the strange facts that are heard of (Ben Carson’s advocacy of antivaxxers’ ideas, patients’ and parents’ choice that brings to dire results…).
I believe that evolution has endowed every social species with the means to obtain their social target: not to be put too far from alpha animal. In other species this target is mostly arrived to by means of physical force: the stronger wins. In our species it is got with rationality (both theoretical and practical): the less clever is kept lower in the social ladder.
When would be rational people read Orac thundering about the lack of rationality of Alt Med practitioners, they are delighted to hear that there are people on a far lower step than theirs. At least, so am I.
Impressive ad-hom you got there, buddy. You can't rebut Orac's criticism so attack him as a mansplainer instead. So how does it feel, hiding behind the skirts of a woman just 'cos you're too damn chicken for a science fight?
I am merely a human observer, but I have found this notion to be largely untrue.
Dr. Tu's discovery bears out a principle that a nurse I worked with succinctly expressed as "Even a blind pig sometimes finds an acorn." This is not a reference to Dr. Tu, but to the idea that rarely something valuable can be found in folk medicine.
The discovery of the vinca alkaloids used in cancer chemotherapy was mentioned above. They were originally derived from the Madagascar periwinkle, and found in a pharmacognosy expedition to that island - where it was used for stomach upset, not for cancer.
This is an especially bad time for TCM to get a boost, coming as it does with the news that the abundance of the TP53 gene in elephants appears to account for their low cancer rate. It's just what elephants needed - another excuse for the stupid and greedy to decimate the world's elephant population. I bet it won't be long before some charlatan or other will promote their product as increasing TP53 levels.
the news that the abundance of the TP53 gene in elephants appears to account for their low cancer rate
I see there's a proliferation of "Why Elephants Don't Get Cancer " headlines from journalists determined to drag the world down to their level of ignorance. Missing the point that elephants *do* get cancer, but they don't *all* get it despite their risk factors.
TP53 is also involved in Huntingdon's chorea, so wildly upregulating an apoptosis pathway is not necessarily a good thing.
First of all, I am totally excited that a woman whose specialty is related to my own has been awarded a Nobel, even if it’s Medicine & Physiology instead of the Chemistry prize.
That said, I agree with Orac that it’s not about “traditional Chinese medicine.” It’s “traditional medicinal chemistry.” We take leads wherever we can find them – other companies’ patents, dirt brought back from fellow chemists’ exotic vacations, plant or animal biological defense mechanisms, traditional medicinal literature. One has to start somewhere.
I first came across artemisinin in the 1990s in the synthetic chemistry literature. There were publications on both working towards the total synthesis and syntheses of analogs. I remember reading these papers because the chemical structure is kind of cool and challenging, and because even then I was aware that resistance of malaria to other treatments (e.g., quinine) was an issue – making artemisinin an exciting target molecule for organic synthesis, even to a recently graduated bachelor’s level research associate.
Developing new successful treatments for any condition is a challenge. If one is discovered and developed, does it matter what was the inspiration for its discovery? Yes, only in the sense that maybe that area may yield more discoveries. The next discovery will still need to be developed, and that’s still going to require science.
JP # 54
May be the current crop of Republican hopefuls will change your belief.
Or do they not seem the most clever in the bunch?
Below is article from the http://barfblog.com concerning traditional Indian medicine. How soon will this be the latest wooist craze in the US?
India’s Hindus won’t eat cows, but might drink their pee
Posted on October 10, 2015 by Doug Powell
In a concrete-block factory a few miles from one of the holiest spots on the Ganges, workers in hairnets and beanies slap caps on bottles zipping down an assembly line. A few feet further, another group sticks on no-nonsense, pharmaceutical-looking labels that read, “Divya Godhan Ark.”
Divya Godhan Ark.urineThe room reverberates with a droning, mechanical whir, and it’s redolent with a distinctive smell — like when you first open a jar of multivitamins, combined with a gas station men’s room.
That’s because the clear liquid in the bottles is purified cow’s urine — quite possibly the fastest growing alternative medicine in India these days.
“Cow’s urine is a diuretic. It helps in detoxification of the body, and many other beneficial effects are described in the Sanskrit scriptures, such as helping to expel excess bile,” says Anil Kumar, a vaidya — practitioner of Ayurvedic medicine — employed by the company Divya Pharmacy.
An Indian woman who tried to bring cow urine into the country [NZ] was fined $400 for not declaring it.
Because cows are so hard to find in New Zealand.
Well, yes. There was some good reason the cow's kidneys wanted all of this stuff outside rather than inside. Who are we to question bovine wisdom?
India needs toilet paper more than it needs cow pee.
herr doktor bimler@61: Not sacred ones.
(Unless you count Peter Jackson.)
No offense to the blind, but how can you make those who were born blind truly understand red, blue, green and color in general? Often times, the TCM deniers sound so much like the blind trying to deny the existence, or, more accurately, the experience of color (again apologies to the blind; this is an analogy only).
Worse still, these TCM deniers 1) purposely put on the blinders that make themselves blind to the myriad of evidence (unlike the blind who have no way of seeing color); 2) most of the deniers are not even qualified to make an educated judgment of TCM: If you want to criticize the the string theory as hogwash, you must first have a Ph.D-level in-depth understanding of theoretical physics; you are not qualified to attack it after perusing a few pop science books or spend a weekend surfing the net reading up on they lazy man and the dummy's guide to theoretical physics. Yet, this is precisely what these TCM naysayers are doing. Which one of you have any true understanding of TCM to qualify you to attack TCM?
(And FYI, to become a qualified TCM practitioner in China, for example, you need to study in a TCM university for 5 years and then have a number of years of residency before you can even apply for a doctor's license.)
65 "...blind to the myriad of evidence..."
So, enlighten us with all this high quality evidence.
"...If you want to criticize the the string theory as hogwash, you must first have a Ph.D-level in-depth understanding of theoretical physics..."
Nonsense. You only need to ask one question: does string theory make testable predictions? No credentials required.
Often times, the TCM deniers sound so much like the blind trying to deny the existence, or, more accurately, the experience of color
It is easy to convince a cone achromat that colour is a valid phenomenon; he or she sees the evidence of other people making it to make useful distinctions. In this analogy, all the TCM practitioner needs to do is cure patients at a better rate than the placebo effect.
It would also be helpful to show that the underlying principles of TCM are in some way useful in diagnosing and treating illness.
@ herr doctor bimler:
I had many interesting conversations with a such a gentleman because my aunt married one. He often hilariously described how he had studied up in advance to appear as though he had no problem and how at sea he was when having to choose clothes. When I "tested" him he seemed to not have a clue other than lighter vs darker. Despite this, he managed to have meaningful employment in culinary arts, electronics and investigation ( a black and white private eye? yes!)
He was totally fabulous in many other ways as well.