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John G. Faughnan, M.D., M.S. Last revised @1997.
Herbal remedies are safe because they're natural. Like all natural cigarettes.
I heard one talk show too many, one magazine article over the limit. This is the result -- a personal critique of today's trendy "herbal remedies" and their intellectual foundation.
I am a family physician from a tradition of scientific allopathic medicine and rational skepticism. I think much of what is today called "alternative medicine" is, at best, effective placebo, and, at worst, fraud. This is an unpopular position in our era of cultural relativism, and it is not often heard. The popular press, the fashionable elite, and many physicians, have embraced herbel remedies and homeopathic medicines. Nonetheless, I feel a professional and cultural obligation to speak out, even if I run the risk of being unfashionable.
First, some background. There are many branches of the "healing arts". Healers range from shamans to transplant surgeons, over hundreds of cultures and thousands of years. The group commonly known as "physicians" in the United States belong largely to the allopathic tradition (osteopathic physicians are a related but distinct group). Our training is heavily influenced by reforms introduced in the early 20th century by Sir William Osler and by the "Flexner Report". Prior to that time allopathic medicine used a large variety of "patent medicines" analogous to the "herbal remedies" of today. These were concoctions of dubious value and frequent toxicity, which were heavily marketed for "fatigue, malaise, fever, cold, sore joints ...", etc. (Obesity was much less of an issue back then.)
Osler, Flexner, and many others brought science to the practice of medicine. The number of medicines used by well trained physicians shrank dramatically by 1920 -- from thousands of remedies to a tiny number of effective medicines. Then, slowly at first, new remedies were developed, tested, and added to the "pharmacopeia". Some of these came from herbal remedies (quinine), others were developed without known precedent. The 1940s brought the first widely effective antibiotics (penicillins), the 50s and 60s a large variety of medicines to control blood pressure, treat heart disease, and manage inflammation. This explosive growth has slowed somewhat in the past decade, but we now again have a very large pharmacopeia -- based largely on scientific principles.
The quality of medical science has also increased dramatically. Most of the studies performed in the 1960s would be unpublishable today; their quality would be judged unacceptably low. A wide range of early therapies were accepted on dubious evidence, and later painfully found to be harmful or ineffective (Thalidomide, gastric freezing, mammary artery ligation are all famous examples). More recently "evidence based medicine" has tested and found wanting many traditional medical practices, such as much of what was once called a "complete physical". I'm most proud of scientific medicine's willingness to slay its own "sacred cows", and to abandon cherished beliefs and set aside millions of dollars of research. When herbal medicine authorities likewise pronounce a popular herbal remedy worthless or toxic, then I'll be willing to look at the research they produce.
Scientific evidence in medicine is often very difficult to gather. We can't ethically study people the same way we study neutrons or fish. We gather some information from studies of "natural experiments" -- the relationship of selenium to cancer, for example. Our best evidence, however, comes from very expensive studies where a treatment and a placebo are given randomly to patients without either patient or physician knowing which is which. From those studies we've learned that a placebo alone, which is believed to have no biological activity, will improve many conditions by at least a third. (Example: reduce pain by 30% or more.)
From scientific studies of health and disease, we've confirmed the power of the mind-body connection. In some conditions, a person's belief can dramatically eliminate their symptoms (some fatigue, some pain conditions, warts). In others belief is important, but more limited (cancer, fractures, bacterial infections).
That's the tradition I come from. Other allopathic physicians hold less strongly to scientific methodology as a standard of proof, and are willing to accept other evidence, including "folk evidence", as proof. I feel folk evidence can suggest important areas for research, but, unless I am confident there's no possibility of harm, I cannot use it as a basis for treating patients. Chicken soup is OK, decongestants are usually acceptable, the herbal remedy of the minute is an unknown. If I know a "treatment" is safe and harmless, and I know a patient believes in it, then I can support its use -- I know the true power of the mind-body connection.
We know, however, from a hundred years of experience, that popular perceptions of effectiveness are very unreliable. Individual physician's perceptions of effectiveness are equally unreliable. Hundreds of popular remedies have been found, on careful study, to be ineffective or even harmful. Most of the medicines we used to treat a kind of bad heart rhythm during the 1970s and 1980s have been found to be dangerous and ineffective. Many heart specialists and patients believed very strongly that those were good medicines. It took a lot of time and money to prove otherwise.
Herbal remedies and many folk remedies have not survived even the weak scientific testing that researchers used in the 1920s, much less today's standards of study. If and when they do, they stop being alternative medicines and become part of our scientific therapies.
If all of today's "alternative medicines" were completely inactive, their widespread use would be only a modest problem. If a person believes in a remedy, and if that remedy is truly harmless, then using it will improve most conditions by about a third, and clear some up completely.
Unfortunately, we have reason to believe that they're not all inactive. Plants produce a wide variety of complex chemicals that mimic substances use by our own bodies. Many powerful medicines, poisons, and hallucinogens have been derived from plants. Evolution seems to have a somewhat limited range of designs, and tends to reuse molecular shapes in different species for different purposes. These substances have every imagineable effect, from hallucinations to sedation, from quick death violent vomiting.
Today's herbal remedies are not likely to have obvious seriously harmful effects. Even though they're completely unregulated and largely untested, that kind of obvious harm would get publicity. Obvious harm is more likely to come to people with unusual sensitivities, or when a herbal medicine taken in unusual combinations with allopthic medications or other herbal remedies. More subtle problems, such as birth defects, neurologic damage, and cancer, will be much harder to spot.
We just don't know what these substances are doing. They may be inactive, or they may have activity independent of their powerful belief effect. Their activity may match up with one of their advertised uses, or they may be effective for something completely different. They may be harmful in subtle or unsual ways. Toxic or beneficial effects will vary greatly from dose to dose; unmodified plant products do not have even the limited predictability of "traditional" medicines.
People taking herbal remedies are engaged in a gigantic natural experiment with untested substances. We will find out many interesting things from the problems these "remedies" cause. We'll also learn of some beneficial effects, that will be studied and turned into medicines I'll happily prescribe.
Ultimately, I feel that adults (but not children), should have the right to do a lot of risky things -- provided they are not deceived about the risks they are taking. Adults should be able to ski steep hills, eat fatty foods, take intoxicants when others are not at risk. Heck, they can even smoke if they do it outside. They can take all the odd drugs and herbs they want. But, they must be aware of what they're doing. They should know that a herbal remedy doesn't come from the same heritage as an antibiotic sold in the same pharmacy. They should know that legality is not proof of safety or effectiveness. Informed adults should know when their physician is acting within the tradition of scientific medicine, and when they're using other standards of evidence. They need to know they're participating in a giant experiment. When these things are well known, let the herbalists proceed. I'll be watching carefully from the sidelines.
I've had some excellent responses to this essay, from pro and anti-herbalists alike. A few thoughtful letters have pointed to some intriguing research possible value to various alternative therapies. In a less polemical piece I would make a stronger case for alternative and folk medicines as an inspiration for scientific research, but I wanted to make my concerns clear. As I mentioned above, when alternative medicine passes scientific tests, it's not alternative medicine anymore! It's regular medicine. I argue though against one standard for drug companies, and another for folk remedies. Many drugs have looked great in small studies, and even in somewhat large studies, only to fall short in a real clinical trial or in clinical practice.