Treating Drug Resistant Tuberculosis with Direct Moxibustion in Resource Poor Environments - A Pilot Study
The Moxibustion Method for Consumptive Disease was the title of a tract from the seventh century. Written by a nebulous Tang physician named Cui Zhidi, the text was subsequently lost, but it was referred to by other authorsrepeatedly while it was still extant, exerting both interest and influence for several centuries. For us today it offers just the earliest reference to the treatment of what is quite clearly tuberculosis with direct moxibustion. Chapters 51and 73 of the Ling Shu both had suggested earlier that moxibstion might be indicated for intractable disease if needling failed (Jing Nuan 1993) – these references in the Ling Shu quite clearly came of age in Cui Zhidi’s text.
Our own interest in the subject was initially piqued by studying modern Japanese direct moxa techniques. Several references exist in the Japanese moxa literature from the first half of the twentieth century concerning its use in the treatment of TB. Today, with drugs available and effective, they appear as almost throw-away references of little relevance, but a profound question began to materialise for us from them: if moxa was effective in the treatment of TB in the days before the advent of antibiotics, might it have a role to play today in these potentially post-antibiotic days of drug resistant disease, and most particularly in African countries where medical resource and infrastructure is so poor?
In the early Chinese literature consumptive disease was referred to in descriptive ways. The names tell their own stories -"Passing from Door to Door Disease”, "Cadaverous Infixation”, "Steaming Bone Disease”, or simply "Lung Taxation”, (Wilcox 2008). In all cases that we have encountered in the historical literature,however, we have noted that the moxa was appliedin a far more aggressive fashion than anything we might conceivably use today. So whilst there is clear enduring evidence that moxa was used to treat TB (and indeed other intransigent disease) in East Asia,it is not clinically relevant. Japanese moxa techniques, however, have characteristics which challenge such an assumption: the moxa used is highly refined and burns at lower temperatures with much less risk of serious blistering, and the cones are tiny and half-rice-grain-sized (sometimes quite accurately described as mini-cautery). So we began searching out and reviewing the evidence from Japan.
Japan in the 1930’s was a very different country to the one we know today. The vast majority of the population was poor and lived on the land. TB was a common disease. It particularly decimated a strata of society which had much in common withAfrica today – low incomes, low levels of literacy, poor living conditions, little access to affordable or effective health care, poor diet and constitutionally weakened immune systems. There are quite well-known reports of moxibustion specialiststreating TB effectively with moxa from this time. Two names in particular stand out: Sawada Ken, and Hara Shimetaro.
Whilst Sawada is better known, it was Hara’s treatments whichinterested us most for several reasons. Firstly he was a medical doctor and his approach was therefore more scientific. Secondly his protocols were designed to be extremely simple and were intended to be done at home by patients and their relatives with point location easily mastered with little in the way of instruction. Thirdly, dosage was extremely light in terms of both sizeand numbers of cones, and therefore represented by far the most appropriate approach. Fourthly, his reports came with some interesting scientific research, despite the fact that his explanations of the mechanisms of responsemay be outdated (Hara 1929 & 1933).
Intrigued by theresponses he was finding in his patients (and he explicitly claimed that his treatment was curing TB if done over a long term) Hara conducted his own researchintoits effects on guinea pigs which he had deliberately infected with TB. Comparing groups of animalswith and without moxa treatment, andusing some withdeliberately delayed onset of treatment, he built up a picture of mortality rates andrecovery tendencies. His results remain persuasive to this day – dependent upon dosage, the moxa treatment clearly aidedrecovery from TB.
We readily recognised, of course, that his claims might be overstated and also that his research was only on animals, but his accounts of responses in his human patients provided us with incentive enough to look deeper into the Japanese literature.
Wefound no recent repetition of his experiments. Since the advent of TB drugs, there has been no apparent interest in Japan in further investigating moxa’s effects on tuberculosis. The disease, as in the West, has been quite adequately controlled by drugs,so no incentive exists. This particular tradition of treating the disease with moxa has quite simply died out along with the last of the practitioners from that era. Doctor Hara, however, and others who were his contemporaries, also investigated the wider effects of moxa on the immune system, particularly monitoring White Blood Cell counts, and there is plenty of more recent information on this subject right up to the present day which provides possible explanations for the apparent effectiveness of the treatment of TB in the 1930s, although little of it is in English. (Toyha et al. 2008; Young & Craig 2009 & 2010)
Tuberculosis is an age-old lethal infectious disease which particularly preys on the poor and those with weakened immune systems. Since the arrival of TB drugs, it has largely disappeared from the developed world, but in the developing world little has changed. In fact, in some regions the situation has dramatically worsened. The statistics surrounding the disease are extraordinary. The WHO estimates that 32% of the global population is latently infected by TB – with 10% of these expected to develop full-blown infectious disease. In Africa, this 32% figure is estimated to be as high as 80%, and, in the presence of HIV/AIDS, the 10% conversion figure ramps up to anywhere between 50% and 100% - there is quite simply no established figure. All that is known is that every time someone tries to have a proper look at it, the situation is agreed to be worse than previously reported. What is accepted is that the continental incidence of TB in Africa has increased five-fold just in the last fifteen years, and that the incidence of drug-resistant disease is basically unknown, but growing inexorably with literally nothing in place to fight it.
It was specifically in relation to drug-resistant strains of the disease that we began to consider that moxibustion might have particular applicability today. These strains have been appearing epidemically in the last twenty years, with an emerging threat of truly devastating effects from extensively resistant strains, XDR-TB. Appropriate and accurate chemotherapeutic antibiotic treatment (dependent upon complex and expensive diagnostic data) is critical, not only to treatment success, but, as importantly, to prevent further drug resistance. The standard treatment of drug susceptible TB uses four "first line” drugs which are now cheap and widely available. Treatment of drug resistant strains, however, employs any of around ten "second line” drugs. These drugs are in short supply globally, are very difficult to tolerate and are quite simply prohibitively expensive for most of Africa. They also require expensive diagnostics to accurately and effectively prescribe. Medecin Sans Frontieres estimates that as few as 1% of Africans have such drugs and diagnostics available to them. As resistance has become more complex, the hapless though well-intended misapplication of the existing drugs to treat drug-resistant disease in the absence of appropriate medical diagnostic resource has quite literally rendered a disease which was previously quite curable effectively incurable. No new drugs are appearing in the current pipeline, and new vaccines are proving problematic because of the mutations of the bacillus. Where latent rates of infection are already high (as in Africa) new vaccines may, in any case, prove inconsequential.
We came to realize that moxibustion might offer a non-pharmaceutical approach to treating TB with specific advantages: it is cheap, un-patentable and low-tech; its techniques can be effectively taught to patients and their carers in a few hours; and it requires no sophisticated or prohibitively expensive diagnostic infra-structure.
We began work in Kampala, Uganda, in March 2010, collaborating with a small team of specialist health workers at Kiswa health centre. Our first steps were to establish patient safety. We made sure that adequate explanations were provided to all those taking part, because we fully appreciated that all treatment contains some level of risk, and that with immune-compromised patients this should not be under-estimated. When we asked the sister at Kiswa what she had to offer her drug-failing patients, she offered us a sobering response: "Nothing”, she said, "we have nothing. We have to leave them to die”. With such a stark lack of alternatives, and such little choice for patients, our project had become ever more compelling.
We set out with the following questions in mind:
- Could local health workers be easily trained in moxibustion therapy and would they be able to train their patients
- Would patients accept the treatment and comply with the program?
- Would TB patients respond to moxibustion, as was suggested should happen from the Japanese documentation?
- Would there be positive interaction of moxa treatment with existing medication?
- How would patients whose drug treatment had failed respond to moxibustion?
- Would patients co-infected with HIV respond favourably?
HIV and TB together present the most desperate double-whammy of disease. Each disease negatively enhances the other and hastens its development, survival rates are reduced, and even the accurate diagnosis of either disease is rendered unreliable in the presence of both. Together, these two deadly diseases represent a medical nightmare – if coupled with drug-resistance they portend what has been recently described by some experts as a medical apocalypse.
The actual treatment, in the spirit of moxibustion, is quite simple. A ten point protocol is employed, based on the evidence available to us from the work of Doctor Hara from the 1930s. Two points are on the leg (bilateral Zusanli ST 36), which the patient is taught to self-administer, and a further eight are on the lower back (Dr Hara’s non-meridial "loin points”), which requires the help of a patient’s "buddy” who is also trained in basic moxibustion, and who is also meant to supervise the daily administration of TB drugs. (This is the nearest Uganda can manage to the DOTS+ policy for TB drug treatment, as advocated by the WHO because of the country’s simple lack of health workers). Dosage in terms of cone numbers is approached systematically, and is built up as the patient constitutionally recovers. Patients are encouraged to administer the treatment daily – if they are already on TB drugs, they are instructed to do the moxa alongside their medication regime; if they are not on any medication, they do the moxa on its own.
The responses we have recorded in Kampala are both exciting and encouraging. The total number of patients trained is actually unknown (but may approach almost 200). We asked the clinic staff to focus particularly on following the progress of a small number of patients so that we could get detailed information about them. We now have good follow-up data for 35 patients, most of whom we managed to talk to ourselves on at least 2 separate visits. The data we have collected is mainly anecdotal, describing each patient’s drug regime and symptoms. Unfortunately it has not been possible toobtain results of blood tests (although we may yet be able to retrospectively access CD4 data for HIV patients).
Detailed follow-up of the 35 patients
Out of the 35 patients, 18 patients were HIV +.
We were unable to ascertain any specific data on drug resistance. This is because of the lack of any available diagnostic resource locally. We were able to categorise patients as either relapsed or apparent drug failures based on their records, and it is reasonable to assume that some, if not many of these, would be drug resistant, although to what degree (DR, MDR or XDR – see end note 1) it is impossible to assess.
Less than 10 patients were definitely using moxa on the back points. Most were only using Zusanli ST 36 on the leg, usually because they had no buddy. In most cases scars could be seen to confirm regular use of moxa. Sometimes, however, the location of points was far from accurate and many of the leg points were too distal or too lateral. In spite of these factors, both of which we would have expected to reduce the efficacy of the treatment, all of these patients reported positive responses which were confirmed by the health workers.
In two cases people were doing their own back points. The locations in these cases were not at all accurate but in one case very large scars were observed. We have not encouraged continuation of this practice.
Drop out was large. We expected this. Treatment compliance generally to TB drugs is frustratingly poor, hugely contributing to the problems of drug-resistance. The following reasons for drop out were given:
- No buddy to do moxa treatment - many TB patients appear to be living on their own.
- Moxa was too difficult/fiddly to apply.
- Patient felt too ill/tired to bother.
- Patient drinking excessive alcohol.
- No results at first so patient gave up.
- Moxa was too painful.
- Two patients are known to have died.
- Some TB patients seem to re-register themselves at other clinics – a common source of frustration for clinic staff.
Duration of treatments:
By May 2011, the majority of the thirty-five patients had been using moxa for at least 7 months, and some for over a year. Seven patients started moxa at the same time as beginning their TB drug regime, but many had been on the drugs for some time before starting moxa.
Patients were assessed at the start of moxa treatment and then monthly (see end note 2). A simple questionnaire asked about symptoms, any noticeable improvements and any problems with the moxa treatment. In summary, the following observations were made:
- No adverse effects of moxa were reported.
- Most patients report unpleasant side effects developing after the start of their TB drug therapy. These were less marked or entirely absent if moxa was started at the same time.
- After starting moxa, 83% of patients reported improved appetite, weight gain, reduced pain (in joints or peripheral neuropathy), and 67% were not coughing at all. All of them had a general increase in strength and energy. Relief of other symptoms such as itching and poor libido was also reported by some patients.
- In patients who started moxa sometime after the TB drugs, there was a reduction in side effects which began sometimes only one or two weeks after starting moxa.
- Some patients stopped using moxa when they began to feel better, so some symptoms returned. They were encouraged by the clinic to start moxibustion again, and the symptoms soon reduced. This really convinced them of the benefits of moxa, and most patients wanted to continue using it after they had finished their drug course.
- Patients co-infected with HIV reported similar improvements with moxa to those having only TB.
- Clinic staff were quite convinced that the patients receiving moxa treatment recover from TB much faster than those on TB drugs alone and that the infectious periods are shorter.
Whilst we are unable to draw any specific conclusions from the above, we suggest that the following important hypotheses are possible and are worthy of further more targeted controlled enquiry:
- That compliance to standard TB treatment (which is one of the major problems for the containment of the disease because of the frequent pernicious side effects of the medication) might be improved if moxibustion were to be widely used alongside first line drugs. This could reduce the growing incidence of drug-resistance.
- That the infectious period of the disease might be shortened when moxa is used with drugs. This would be relatively simple to measure, and if proved would suggest that moxa might help reduce the spread of the disease in Africa.
- That patients co-infected with both TB and HIV/AIDS could particularly benefit from moxa treatment.
One further question has emerged. For patients with limited or moderate drug resistance (DR- or MDR-TB in which two of the four first line drugs become ineffective) it might be worth investigating whether moxa alongside the two remaining drugs might prove effective. Given the almost universal lack of second-line drugs in Africa, this just might offer the continent a serious treatment option. In the case of more extensive drug resistance (XDR-TB) we’re not so certain of the possibilities. Researching this appropriately will be difficult, but, particularly if we can find better circumstantial data, we will find ourselves vigorously advocating it.
For exactly this purpose, this March we began two parallel studies in South Africa, one in New Crossroads, a township of Capetown, South Africa, and the other at Robertson. Township rates of both co-infection and drug-resistance exceed those anywhere else on the planet. We hope to be able to access data that can be confirmed concerning the drug-resistant status of patients enrolled on these programmes – something we just haven’t had access to in Uganda because no diagnostic resource exists. If we are able to confirm the preliminary results we have obtained in Kampala with a similar cohort of patients in such an environment, we will have potentially identified a cheap low-tech treatment which can be implemented wherever resources are poor. It might help fight the emerging plague of drug-resistant TB, even at the coal face of the disease in the presence of HIV/AIDS.
In our last visit to Uganda we made a presentation at Makerere University Medical School’s Department of Pharmacology and Therapeutics. Makerere is one of Africa’s oldest and most reputable universities. As a result of the presentation, we are currently planning a collaboration with one of their Masters graduates to conduct a controlled pilot study which will form his Masters thesis. If this study proves positive, the Department intends to set up a programme of academically and scientifically rigorous research to attempt to confirm its findings. This is an immensely exciting prospect.
It is almost impossible to resist becoming over-excited by the project’s potential to describe the project’s potential, although we know well that we are still far away from anything which might constitute a home-run. For hundreds of thousands of patients moxa could offer the only realistic resource in the absence of any other available treatment - and could save lives. The academics at Makerere have told us quite explicitly that they simply cannot see a time when the expensive second-line drugs (required to treat drug-resistant TB) will be affordable in most of Africa. We have already seen patients recover their strength from states of emaciation and weakness, and seen family wage-earners go back to work and we do believe that some of these were drug resistant. If these effects are confirmable, there is potential positive social consequence to the entire southern half of Africa.
The stories that we have been told by those who consider themselves to be alive only because of this treatment already constitute for us an exciting new page in the lengthy annals of East Asian medicine; if they can be proved to be replicable across the continent, they constitute quite probably just the first page of a quite extraordinary new chapter, which would be written far from the medicine’s cultural home.
"Moxafrica” is the charity that was specifically set up to expedite this investigation. We would encourage anyone interested to browse the website www.moxafrica.org where further information can be obtained. We welcome comments and questions – please write to firstname.lastname@example.org.
Finally, we are under no illusions that funding for the next year’s work will be critical to the outcome of the project which is being expedited on a tiny budget. Donations, which are most desperately needed, can be made via the website, and we ask anyone interested in the project to consider making a donation.
1. These acronyms identify the degree of drug-resistance diagnosed through an expensive and lengthy process of culturing blood samples. They range from resistance to one drug (DR), to two drugs (MDR) and to three or more drugs (XDR). The instance of highest resistance anywhere globally was recorded in South Africa in 2005 with resistance to eleven drugs. It killed 52 of the 53 infected in a few weeks. This extreme strain was mercifully isolated and it burnt itself out.
2. Originally we had planned to harvest feedback from every single patient enrolled – with a planned maximum of 75-100. This became impossible when the project went into immediate enthusiastic overdrive after we’d returned from setting it up with the health workers enrolling up to 200, and frankly we lost control of hard and fast figures from that moment on. What we did in order to retrieve the situation was to keep a careful monitoring of thirty-five compliant patients out of the total cohort and this bunch form the basis for our conclusions. We’re well aware that this falls far short of a convincing study, but we should add that it was never the intention of this pilot study to gather hard and fast data which we want to leave for the subsequent university led research – it was to gather indicative answers to our basic questions.
Hara, Shimetaro. (1933). "Moxibustion Therapy effective for all Diseases” (Old Japanese) out of print.
Hara, Shimetaro. (1929) "Recovery tendencies of tuberculous animals treated with moxa” Fukuoka University Medical Journal. 1929; 22: 5. (Old Japanese).
Jing-Nuan, Wu. (1993). "Ling Shu or the Spiritual Pivot”. University of Hawai’i Press.
Tohya K, Fukazawa Y, Kasahara Y, Okuda M, Tahara S, Kuribayashi K. (2006). "Literature Documentation of Basic Research on Immunological Effect by Acupuncture and/or Moxibustion Treatment Immunological Research Committee for Acupuncture and Moxibustion”. Japan Journal of Acupuncture and Moxibustion; 56 (5); 767-778. (Japanese)
Wilcox, Lorraine. (2008). "The Power of Mugwort Fire”. Blue Poppy Press. 2008
Young M, Craig J. (2009). "Moxibustion and Immune Response – a Review Study. Part 1”. European Journal of Oriental Medicine; 6 (3)
Young M, Craig J. (2010). "Moxibustion and Immune Response – a Review Study. Part2”. European Journal of Oriental Medicine; 7 (1)
Merlin Young graduated originally from the College of Traditional Acupuncture (UK), and since then has been extensively studying Japanese acupuncture and moxibustion. Encountering Dr Paul Farmer’s extraordinary work in Haiti and Peru, he became particularly interested in the subject of drug resistance in tuberculosis and its intimate connections to the politics of global medicine. In 2008 he co-founded the Moxafrica charity to attempt to systematically investigate whether small-cone direct moxa might help in the fight against drug-resistant TB in the developing world.
Craig is a practicing acupuncturist in Galloway, Scotland. She has a background
in biological research and a PhD in plant sciences. She graduated from the
College of Traditional Acupuncture (UK), and followed this up by completing
both basic and advanced training in Toyohari acupuncture with Stephen Birch in
Amsterdam. She has taken part in relief acupuncture projects in both India and
Sri Lanka, and these experiences, together with a special interest in moxa
arising from her Toyohari training, provided the incentive and background to
her co-founding the Moxafrica charity.