Imagine the joy of three million people in Hong Kong when, this weekend, they received their “United we Fight the Virus” kits. It is not clear why the remaining four million were deprived of these kits but, given that I know a leading nursing academic and his family who received theirs it may be that the remaining population are considered dispensable. The kits contain COVID-19 rapid tests and KN95 masks and two packs of a traditional Chinese medicine (TCM) called Lianhua Qingwen Jiaonang (LQJ) which will, allegedly, “clear scourge, remove toxin, diffuse the lung and discharge heat”. Apart from the fact that the Legislative Council of Hong Kong has not bothered to ask a native English speaker to check the above description of the purported action of LQJ, it appears that it has also not consulted anyone with any knowledge of medicine – real medicine – what any of that means.
“Clear scourge” is simply Chinglish gobbledegook; “diffuse the lung” is biologically meaningless and “discharge heat” defies the laws of thermodynamics. Whether or not LQJ is capable of the claim that it will “remove toxin” is another matter. But, notwithstanding that if something is “removed” it must go somewhere which is not specified, at least this is testable. In terms of “removal”, in conventional medical terms this means metabolic removal by “first pass” metabolic breakdown in the liver, commonly engaging the services of a liver microsome enzyme known as cytochrome P450. Otherwise, toxins are removed by the kidneys and excreted in the urine. How LQJ is involved in that process is unknown.
Lest the Hong Kong recipients of the Covid kits are in any doubt about when to use their supply of LQJ, they are advised that the indications are that it can be used for: “Patterns of heat toxin assailing the lung, manifested as fever, aversion to cold, muscle soreness, stuffy and runny nose, cough, headache, dry and sore throat, reddish tongue, and yellow or yellow and greasy tongue coating.” All they needed to add was ‘feeling a bit iffy’ and ‘having the sniffles’ and they would have had a full set of vague symptoms that would turn even the most resilient person towards the medicine cupboard.
But what about the testable claim that LQJ can “remove toxin”? One systematic review and meta-analysis which supports the anti-toxin action of LQJ was published in PLOS One by authors from mainland China, notably including only studies from mainland China. It concludes that: “The treatment of new pneumonia with traditional Chinese medicine lotus clearing plague can be used as an effective therapy to improve the clinical symptoms of new coronary pneumonia.” A promising conclusion, albeit couched in poorly edited Chinglish, and it should be noted that the “coronary” pneumonia means ‘coronavirus pneumonia’ as this was a review of studies on COVID-19.
As with many such reviews, the claims of efficacy in the abstract are not supported when the article is read in depth. Even within the abstract, the results section states: “A total of two articles were identified, including 154 patients.” It should be noted that two articles is the absolute minimum number for a meta-analysis according to the Cochrane Collaboration, which, essentially, sets the gold standard methodology for systematic review and meta-analysis. Thus, the minimum criteria were achieved but a deeper dive into the studies reveals a fatal flaw in both studies included. While the assessors of the outcomes of the included studies were blinded to whether the participants were in the treatment or control groups, as shown in Table 2 of the PLOS One article, the trial personnel and, crucially, the participants were not blinded. Therefore, randomised these trials these may have been but double-blinded – which is the gold standard for testing medications – they were not. Knowing whether or not you are receiving a treatment is important as the placebo effect comes into play, especially where a range of subjective symptoms is being assessed.
In terms of the outcome of treatment of people purportedly infected with COVID-19, a primary outcome was not specified for the studies included in the review as would be required, for example, by PROSPERO. This is to prevent what is referred to as ‘fishing’ for significant results amongst secondary outcomes.
The PLOS One article presents analyses in forest plots of a range of vague symptoms such as “fever”, “cough”, “fatigue” and “chest tightness”, all of which are subjective and none of which, even in constellation, are cardinal signs of COVID-19. None of the outcomes was the presence of the COVID-19 virus by, for example, a lateral flow test. Finally, the article includes funnel plots which are designed to detect publication bias – the phenomenon of burying studies which do not support the effect of the treatment, also referred to as the “bottom drawer phenomenon“. On this point, the Cochrane Collaboration is unambiguous in its handbook that the minimum number of studies required for a meaningful funnel plot is ten. Thus, the funnel plots in the PLOS One study are entirely meaningless.
It is surely relevant to note that the authors of the study reported in PLOS One were from mainland China and that the studies included in the meta-analysis, regardless of the poor methodology in both studies included and in the meta-analysis itself, were both published by Chinese authors. It is not possible to ascertain the quality of the journals where the studies are reported as, remarkably, they are not listed in the reference list. It is also relevant to note that TCM is officially pushed as policy by the Chinese Government, despite the general lack of evidence for efficacy. However, the Chinese Government has that angle covered as it has a law that prevents criticism of TCM. The Chief Executive of Hong Kong, Carrie Lam Cheng Yuet-ngor, a Chinese Government approved appointee, also said: “The Government was open to the idea of giving part of its stockpile of oral antivirals to private clinics, which would join private hospitals in distributing the pills to infected residents.” The ‘antivirals’ (not demonstrated to have any such action) to which she refers are the traditional Chinese medicine LQJ. In the letter accompanying the Hong Kong Covid kit, in a typical act of Hong Kong Legislative Council arslikan, the Anti-Epidemic Team Hong Kong SAR says: “Thanks to the tremendous efforts of the Central Government in co-ordinating the procurement, production and transportation aspects, the SAR Government is able to timely purchase various medical supplies…”
It is worth noting that the TCM product LQJ included in the Hong Kong Covid pack is manufactured by Shijiazhuang Yiling Pharmaceutical Co., Ltd, which is located at 238 Tianshan Street High-Tech Zone Shijiazhuang, 050000 China. I can’t help thinking that Shijiazhuang Yiling Pharmaceutical Co. and the Chinese Government are cashing in on a rare opportunity via its puppet regime in the Special Administrative Region.
Here’s the letter in full from the Hong Kong SAR Government:
Dr. Roger Watson is Academic Dean of Nursing at Southwest Medical University, China. He has a PhD in biochemistry.
This article has been updated.