The future of traditional Chinese medicine (TCM) could see research move to an efficacy-driven approach. But many poor people (both Chinese and from other nations), rely on herbal medicine for basic health care, and an absence of reliable evidence of efficacy for these treatments is likely to aggravate the entrenched inequity in access to effective care for poor people. The issues are discussed in a Comment which forms part of The Lancet Series on Health System Reform in China, written by Dr Jin-Ling Tang, Chinese University of Hong Kong, China, and colleagues.

While randomised trials have shown efficacy for some TCM therapies, the efficacy of most evaluated TCM therapies remains uncertain, often due to low methodological quality of trials. These trials are published in Chinese, are inaccessible to Western doctors, and often not included in systematic reviews. The authors say TCM trials could be improved by adopting the bias-reduction points in the CONSORT guidelines, and, meanwhile, patients, intervention, comparator and outcome must be carefully chosen to ensure the clinical value of the results. Regarding the comparator, the authors note: “It is important to compare TCM with a placebo or an intervention of proven efficacy.” They add: “A real challenge is how to interpret and generalise the findings from trials of TCM delivered in the traditional way, in which the same patients are treated differently over time.”

The authors say that international collaborations and dialogues between practitioners of TCM or western medicine are important to further improve the quality and significance of TCM trials. They also note that TCM has some adverse effects, with the main reason for this being ‘contamination and inappropriate use rather than inherent risks with the herbs themselves.’ An example given is the use of raw or unprocessed Radix aconite lateralis, which is toxic to the heart and can cause severe irregular heartbeat. The authors say: “In a sceptical environment, it would be a mistake to dismiss effective therapies on the basis of adverse effects rather benefit-harm ratios.”

They conclude: “Particularly in developing countries, over 80% of the populations depend on herbal medicine for basic health care. An absence of efficacy for these treatments is likely to aggravate the entrenched inequity in access to effective care for poor people.”