MD, PhD, FMedSci, FSB, FRCP, FRCPEd

There are at least two dramatically different kinds of herbal medicine, and the proper distinction of the two is crucially important. The first type is supported by some reasonably sound evidence and essentially uses well-tested herbal remedies against specific conditions; this approach has been called by some experts RATIONAL PHYTOTHERAPY. An example is the use of St John’s Wort for depression.

The second type of herbal medicine. It entails consulting a herbal practitioner who takes a history, makes a diagnosis (usually according to obsolete concepts) and prescribes a mixture of several herbal remedies tailor-made to the characteristics of his patient. Thus 10 patients with the identical diagnosis (say depression) might receive 10 different mixtures of herbs. This is true for individualized herbalism of all traditions, e.g. Chinese, Indian or European, and virtually every herbalist you might consult will employ this individualized, traditional approach.

Many consumers know that, in principle, there is some reasonably good evidence for herbal medicine. They fail to appreciate, however, that this does only apply to (sections of) rational phytotherapy. So, they consult herbal practitioners in the belief that they are about to receive an evidence-based therapy. Nothing could be further from the truth! The individualised approach is not evidence-based; even if the individual extracts employed were all supported by sound data (which they frequently are not) the mixutres applied are clearly not.

And this is where the danger of traditional herbalism lies; over the years, herbalists have fooled us all with this fundamental misunderstanding. In the UK, they might even achieve statutory regulation on the back of this self-serving misconception. When this happens, we would have a situation where a completely unproven practice has obtained the same status as doctors, nurses and physiotherapists. If this is not grossly misleading for the consumer, I do not know what is!!!

Some claim that individualized herbalism cannot be tested in clinical trials. This notion can very easily be shown to be wrong: several such studies testing individualized herbalism have been published. To the dismay of traditional herbalists, their results fail to confirm that such treatments are effective for any condition.

Now a further trial has become available that importantly contributes to this knowledge-base. Its authors (all enthusiasts of individualized herbalism) randomized 102 patients suffering from hip or knee-osteoarthritis into two groups. The experimental group received tailor-made mixtures of 7 to 10 Chinese herbs which were traditionally assumed to be helpful. The control group took a mixture of plants known to be ineffective but tasting similar. After 20 weeks of treatment, there were no differences between the groups in any of the outcome measures: pain, stiffness and function. These results thus confirm that this approach is not effective. Not only that, it also carries more risks.

As individualized herbalism employs a multitude of ingredients, the dangers of adverse-effects and herb-drug interactionscontamination, adulteration etc. are bigger that those with the use of single herbal extracts. It seems to follow therefore that the risks of individualized herbalism do not outweigh its benefit.

My recommendations are thus fairly straight forward: if we consider herbal medicine, it is vital to differentiate between the two types. Rational phytotherapy might be fine – of course, depending on the remedy and the condition we are aiming to treat. Individualised or traditional herbalism is not fine; it is not demonstrably effective and has considerable risks. This means consulting a herbalist is not a reasonable approach to treating any human ailment. It also means that regulating herbalists (as we are about to do in the UK) is a seriously bad idea: the regulation of non-sense will result in non-sense!

 

140 Responses to Two types of herbal medicine: neglect the difference at your peril

  • Melissa D. Sylvan says:

    Hi, in reading this I am appalled at how pompous someone so ignorant can be. You obviously don’t know what you are talking about, yet you do it with such authority. I have little doubt that you probably have health issues that a “traditional” herbalist could help you with, if only you’d let them! Based on your picture I can see anger, depression, eyesight issues, and balding, surely there is more.

    There are thousands of years of positive, empirical evidence of traditional individualized herbalism and I have personally seen it work wonders when Western medicine was at a loss. You are missing out when you close your mind as you have.

    Best to you!

    • Alan Henness says:

      Melissa D. Sylvan said:

      I have little doubt that you probably have health issues that a “traditional” herbalist could help you with, if only you’d let them! Based on your picture I can see anger, depression, eyesight issues, and balding, surely there is more.

      Is that the usual level of rigour you apply when ‘diagnosing’ your paying customers?

      There are thousands of years of positive, empirical evidence of traditional individualized herbalism and I have personally seen it work wonders when Western medicine was at a loss.

      Therein lies a demonstration of your total lack of any understanding of science.

      You are missing out when you close your mind as you have.

      You need to open your mind to the benefits a scientific approach and the rigour it brings: being close-minded simply leads down the blind alley you seem to find yourself.

  • Guido Mase says:

    Although the regulatory framework in the UK is different than here in the US (where I am writing), I still believe the distinction made in this article is a false choice. As a practicing consulting herbalist, I employ rational phytotherapy and yet my clients and I still find agreement on using different herbal and nutritional suggestions for the same diagnosis (which is made by an MD, not by me). It is possible to consider the benefits of an herb such as St. Johnswort, or that of another such as golden root (Rhodiola rosea), and a client might choose to use either or both. Rational phytotherapists suggest individualized herbal support based on meeting the client and considering the specifics of the case. This is responsible practice, and is the same approach used by physicians.

    The author’s definition of the “second type” of herbalist hinges on the word “might” in this sentence: “Thus 10 patients with the identical diagnosis (say depression) might receive 10 different mixtures of herbs, none of which is evidence-based (i.e. contains St John’s Wort). ” The fact is that, in my practice and my experience working with herbalists, the herbs chosen do have a solid evidence base much of the time – and when they do not, they are safe, food-like plants such as chamomile which have been as much a part of our culture as coffee or black tea. Dangerous? Unlikely. Though coffee can make one feel a little crazy sometimes.
    Now, once the straw man of an herbalist who uses combinations that are never evidence-based is set up, it becomes fairly easy to knock it down with the (three or four) studies that have looked at individualized prescriptions for conditions. This, however, has no bearing on the actual practice of herbalism – which is based on thousands of clinical studies of botanicals, has a solid pharmacological research base outlining multiple confirmed mechanisms of action, and a traditional use record that complements, rather than contradicts, the modern literature.

    One is left to wonder where a rational phytotherapist might be found. In reading this article, it becomes evident that the author hasn’t really gone looking for one – or he would have discovered many both in the UK and elsewhere and would not make statements such as “… virtually every herbalist you might consult will employ this individualized, traditional approach”, statements that have no evidence to support them and that neglect the fact that an individualized approach can also be evidence-based. Voiced from an armchair perspective, the false choice runs the risk of holding medicine back from the use of tools that are effective, accessible, affordable, sustainable, and remarkably safe (especially when used with the guidance of someone who has taken the time to read the evidence, train in physiology, pharmacognosy, and pharmacology, and who interacts with the client on a personal level). Holding us back from valid botanical and nutritional therapies using unfounded arguments does a disservice to the client. It also does a disservice to the family practice physician who is looking for a competent and compassionate practitioner with whom to partner in achieving the best possible care for his or her patient. In this sense, arguments such as those presented in this post border on negligence.

    • edzard says:

      “The fact is that, in my practice and my experience working with herbalists, the herbs chosen do have a solid evidence base much of the time – and when they do not, they are safe”.
      i know of only about a dozen herbal medicines that are supported by SOLID EVIDENCE. so do you only use very few herbs for very few conditions, or do you and i have a different understanding of evidence?
      “fairly easy to knock it down with the (three or four) studies that have looked at individualized prescriptions for conditions.”
      i did not knock anything down with 3-4 studies, i conducted a systematic review of ALL trials available; do you have more or better evidence?
      “thousands of clinical studies of botanicals, has a solid pharmacological research base outlining multiple confirmed mechanisms of action, and a traditional use record that complements, rather than contradicts, the modern literature.”
      these studies do not refer to individualized herbalism – and that was exactly the point i was trying to make.
      “an individualized approach can also be evidence-based” please show us the evidence for it; our systematic review demonstrates the opposite.
      “armchair perspective” really???? i have done 20 years of full time research in this area! ad hominem?
      “disservice to the client. It also does a disservice to the family practice physician who is looking for a competent and compassionate practitioner with whom to partner in achieving the best possible care for his or her patient.” in my view, the truth about the lack of evidence for individualized herbalism is a valuable service to everyone; it might even save lives.

      • Guido Mase says:

        ” so do you only use very few herbs for very few conditions, or do you and i have a different understanding of evidence?”. While I do believe my understanding of solid evidence is slightly different from yours (for instance, I respect the evidence for Glycyrrhiza, Peonia, and Vitex in fertility and PCOS, though I’m not sure you would feel 100% the same), I do rely on just a few herbs in my work. To put it more accurately, my clients rely on just a few herbs as they are the ones making the choices. And while I will add an herbal tea blend (such as one made from Tilia inflorescence, a very traditional, delicious, and safe brew) or recommend herbs such as garlic or basil be included in the diet, these practices are more akin to an afternoon black tea than anything truly drug-like. Are you suggesting we shouldn’t be using oregano in our pasta sauce?

        “i did not knock anything down with 3-4 studies, i conducted a systematic review of ALL trials available” I am glad you took the time to review the research, found 3-4 studies involving Chinese medicine prescriptions that fit the inclusion criteria, and published the small review. While the review is interesting, your response leaves unaddressed my point that the herbalist who uses only individualized prescriptions that are not evidence-based is, actually, a straw man.

        “these studies do not refer to individualized herbalism – and that was exactly the point i was trying to make.” I have always respected the fact that you can acknowledge that there is an extensive research base for herbalism, Dr. Ernst. However, my point (still unaddressed) is that we can use multiple evidence-based herbs concomitantly, applying different ones or combinations thereof for the same condition. For instance, Glycrrhiza/Peonia in some cases of female infertility, Glycyrrhiza/Vitex in others. Are you perhaps suggesting that, in the case of osteoarthritis, physicians should use ibuprofen, acetaminophen, or surgery – but never all of the above together? Or that sulfonylureas and ACE inhibitors couldn’t be combined in a particular patient? When used rationally, remembering safety, and monitoring the possibility (rare) of pharmacological interactions, evidence-based herbal support can be individually tailored just as technological drugs can. Hence, your distinction is a false choice.

        By armchair perspective, I did not mean to call into question your research experience! I am calling in to question the amount of exposure to rational phytotherapists that you have had. Have you interviewed any or observed them in practice? I realized this cannot be done through computer-based research – but perhaps an email survey on UK herbal practice? Otherwise, I feel your statement that “virtually all” herbalists use individualized therapy (as you define it, which I believe is inaccurate as I describe above) has no evidence to support your burden of proof.

        The disservice is that, by setting up an artificial and inaccurate false choice (this point of mine is left unaddressed), you risk confusing patients and practitioners who might find some of the evidence-based herbal interventions to be valuable, accessible, and sustainable.

        • edzard says:

          the fact that we use basil for past sauce does not mean it has healing powers; it does not even necessarily mean it is safe as an extract.
          “While the review is interesting, your response leaves unaddressed my point that the herbalist who uses only individualized prescriptions that are not evidence-based is, actually, a straw man”…then show us the evidence!
          “my point (still unaddressed) is that we can use multiple evidence-based herbs concomitantly, applying different ones or combinations thereof for the same condition. For instance, Glycrrhiza/Peonia in some cases of female infertility, Glycyrrhiza/Vitex in others.”…again, where is the evidence [the fact that you were taught this at a herbal school does not elevate it to evidence!
          “I realized this cannot be done through computer-based research”…you really have no idea of what i have done; why do you express an opinion about it then?

          • Guido Mase says:

            I will leave the discussion of cuisine, the use of herbs and whole foods in traditional cuisine, and the health benefits for another day. This is a complex and fascinating subject that has been difficult for researchers, as the variables, synergies, and outcome measures are quite unwieldy (cf. the “French paradox”, for example). For your readers, I will simply pose the question: is garlic food, or medicine? Or both? Can food promote or harm health, or is it an irrelevant factor (beyond the obvious: malnutrition, vitamin and amino acid deficiencies, etc).

            I also recognize that, given the range of attacks on your credibility over the years, you might be a little defensive when your point are called into question. Please be assured that I have followed your research, and consider it quite rigorous and methodologically sound – though of course my opinion on your work is irrelevant. What matters to me is the use of good evidence to make statements; that is what I have been addressing in my response to your post.

            Your statements that an herbalist “might” use individualized prescriptions and that “virtually every” herbalist uses this approach lack citations. In fact, your postal survey conducted in 1998 (Traditional herbalists’ prescriptions for common clinical conditions: A survey of members of the UK National Institute of Medical Herbalists, Joanne Barnes, Edzard Ernst) identifies the precise pattern I am describing: key, evidence-based “point herbs” such as Vitex for PMS; Harpagophytum for arthritis; Mentha for IBS feature prominently, alongside safe, cuisine-like herbs such as chamomile. As you and your co-author point out, “some of these herbs have been tested in clinical trials”. The herbalists you surveyed in 1998 already show that the distinction you make is a false choice; as more research has emerged in the last 15 years, this has become even more pronounced. Perhaps it’s time for an updated survey!

            In my practice, for example, I have stopped recommending herbs such as Ginkgo biloba as evidence continues to show it lacks efficacy for diseases such as Alzheimer’s dementia. But I continue to suggest that Crataegus be used in heart failure, and I might even combine it with a tea of Tilia which, though it lacks evidence, has a long track record of use and no evidence showing it is harmful.

            Just because we combine multiple herbal preparations on a case-by-case basis does not mean we are not using evidence-based herbs in such combinations, and as your survey rightly points out, we do. I would respectfully ask that you gather evidence to prove your point that there exist two distinct types of herbalist, one of which never uses evidence-based herbs. I have yet to see anything to support that point. Why express an opinion on it then, especially when your previous work has uncovered the fact that most herbalists do use herbs that have a solid clinical research basis?

    • Alan Henness says:

      Guido Mase said:

      The fact is that, in my practice and my experience working with herbalists, the herbs chosen do have a solid evidence base much of the time – and when they do not, they are safe, food-like plants such as chamomile which have been as much a part of our culture as coffee or black tea.

      So, do NCCAM have it all wrong then?

      Dangerous? Unlikely.

      Unlikely? Based on what?

      • Guido Mase says:

        Alan, not sure what you mean about NCCAM. Do you have a piece of research or an NCCAM position paper you are referencing?

        Chamomile appears safe, when used according to traditional usage patterns, for the conditions in which it is indicated. A competent practitioner is needed to ensure that the above conditions are met, but that’s what herbalists are good at. And that’s what is so important: that the public have access to good information. Check it: http://www.nlm.nih.gov/medlineplus/druginfo/natural/752.html#Safety

        • Alan Henness says:

          Guido Mase said:

          Alan, not sure what you mean about NCCAM. Do you have a piece of research or an NCCAM position paper you are referencing?

          Surely you’re aware of their position on a variety of herbal products, including chamomile?

          What the Science Says
          Chamomile has not been well studied in people so there is little evidence to support its use for any condition.

          They then go on to talk about ‘early studies’ and when it ‘may be of some benefit’ but this is bizarre given their first statement.

          They say this about its safety:

          Side Effects and Cautions
          There are reports of allergic reactions in people who have eaten or come into contact with chamomile products. Reactions can include skin rashes, throat swelling, shortness of breath, and anaphylaxis (a life-threatening allergic reaction).
          People are more likely to experience allergic reactions to chamomile if they are allergic to related plants in the daisy family, which includes ragweed, chrysanthemums, marigolds, and daisies.

          That is in sharp contrast to what you said:

          The fact is that, in my practice and my experience working with herbalists, the herbs chosen do have a solid evidence base much of the time – and when they do not, they are safe, food-like plants such as chamomile which have been as much a part of our culture as coffee or black tea. Dangerous? Unlikely.

          Are NCCAM wrong?

          • Guido Mase says:

            Alan, please do not cherry-pick NCCAM’s statements on Chamomile to suit your argument. The first line on Chamomile reads: “Roman chamomile seems safe for most people when taken by mouth as medicine and in foods.” NCCAM are not wrong.
            As with anything in this world (cf. coffee!), there are situations where there can be risks. That’s why talking to someone about the herbs you’re interested in is important – rather than just starting up with them! Though, as NCCAM points out, most herbs seem safe, we still need herbalists to help folks ensure that they are used in the appropriate context with mindfulness of potential issues such as allergies, pregnancy, etc…

            I generally agree with NCCAM’s positions. A few herbs with a good research basis, and many others which, like chamomile, “appear safe” when taken orally in food-like ways.

            Stepping back from this diversion, can you speak to my points in this discussion, namely, that the distinction between a rational phytotherapist and a traditional herbalist is a false choice? That the traditional herbalist who never uses evidence-based herbal support is actually a straw man that, based on Dr. Ernst’s research, doesn’t exist?

          • Alan Henness says:

            Guido Mase said:

            Alan, please do not cherry-pick NCCAM’s statements on Chamomile to suit your argument. The first line on Chamomile reads: “Roman chamomile seems safe for most people when taken by mouth as medicine and in foods.” NCCAM are not wrong.

            Let’s look at what NCCAM says about chamomile:

            What the Science Says
            Chamomile has not been well studied in people so there is little evidence to support its use for any condition.
            Some early studies point to chamomile’s possible benefits for certain skin conditions and for mouth ulcers caused by chemotherapy or radiation.
            In combination with other herbs, chamomile may be of some benefit for upset stomach, for diarrhea in children, and for infants with colic.
            NCCAM-funded research includes studies of chamomile for generalized anxiety disorder and abdominal pain caused by children’s bowel disorders.

            That first sentence says it has not been well studied and there is little evidence to support its use for any condition.

            It then says, ‘Some early studies…possible benefit…may be of some benefit…’. Have they missed some evidence or do you think that is enough of a basis on which to make any claims to be able to treat people? Perhaps you’d like to tell us what you use it for?

            Side Effects and Cautions
            There are reports of allergic reactions in people who have eaten or come into contact with chamomile products. Reactions can include skin rashes, throat swelling, shortness of breath, and anaphylaxis (a life-threatening allergic reaction).
            People are more likely to experience allergic reactions to chamomile if they are allergic to related plants in the daisy family, which includes ragweed, chrysanthemums, marigolds, and daisies.

            Reports of allergic reactions… skin rashes, throat swelling, shortness of breath, and anaphylaxis…Why do you think it is safe? Maybe the NIH needs to review what it says and ensure some consistency.

          • Guido Mase says:

            Alan, your continued diversion from the argument I am making leads me to assume you have no response. The distinction between a traditional herbalist and an herbalist who uses rational phytotherapy is false. That is my only point here, though it contains some corollaries, and it remains un-refuted. Dr. Ernst’s survey of UK herbalists revealed use of evidence-based herbs for a limited range of conditions. The folks surveyed were traditional herbalists.

            The evidence put forth supporting the notion that traditional herbalists use individualized prescriptions (a survey from Australia, Casey M G, Adams J, Sibbritt D. An examination of the prescription and dispensing of medicine by Western herbal therapists: a national survey in Australia. Compl Ther Med 2007. 1513–20.20.), as cited in Ernst’s “Herbal medicine: buy one, get two free”, does not speak as to whether the herbs used in individualized prescriptions are evidence-based or not. The review used to substantiate the opinion that “consulting a herbalist is not a reasonable approach to treating any human ailment” really only speaks to using individualized Chinese herbal preparations for three conditions; as Thomas Easley rightly points out, it is fallacious to extrapolate from this limited sample, especially when previous research shows traditional herbalists use effective, evidence-based herbs.

            Traditional herbalists use evidence-based herbs that are effective. This is the ultimate point. I would love to continue discussion on this point, after which I’d be happy to entertain your side-concerns on the use of herbs such as Chamomile, Alan, as well as the advisability of herbal research funding for the NIH/NCCAM and whether it’s really getting us anywhere. One thing at a time!

          • Alan Henness says:

            Guido Mase said:

            The distinction between a traditional herbalist and an herbalist who uses rational phytotherapy is false

            I have made absolutely no mention of either ‘type’ of herbalist: I am pointing out the contrast between what you say and what NCCAM say about the safety and efficacy of chamomile. These ‘side-concerns’ are nothing of the sort, but are at the heart of the problem of basing practice on the best evidence.

            NCCAM state:

            Chamomile has not been well studied in people so there is little evidence to support its use for any condition.

            It then mentions some rather severe side effects. That does not seem to be an adequate basis for using chamomile for anyone. Have NCCAM evaluated the evidence incorrectly or too conservatively? Is any research being done to give chamomile an adequate evidence base so that herbalists know that what they are giving to their customers is both safe and likely to be efficacious?

          • Guido Mase says:

            Alan, my responses in this comment section are directed to Dr. Ernst’s distinction between the two types of herbalist. That’s the discussion at hand; the conversation regarding Chamomile’s safety is interesting and a good one to have, but that’s not the topic of the blog post! Let’s try to stay on topic. If you can engage on the subject matter presented in Dr. Ernst’s post, I’d be happy to join you, after which, perhaps there can be another post where we discuss the safety research on traditional, food-like plants. I’d be happy to write such a post myself to open the conversation, in this blog or my own, and invite you to contribute at that juncture.

            For now, as I’ve now asked you a few times: anything to add to the topic of conversation, namely, that traditional herbalists such as myself (and those who responded to Dr. Ernst’s survey) combine evidence-based herbs on a case-by-case, individualized basis much the same way as physicians do with pharmaceutical interventions, and that such an approach is simply good practice?

      • Guido Mase says:

        As I point out above in my response to Alan Henness, I agree with your point that traditional herbalists use individualized formulae. The straw man is based on the assumption that such formulae, as you state in the original post, are “…mixtures of herbs, none of which is evidence-based”. This statement requires a citation if it is to be taken beyond the scope of the three (four) trials of Chinese medicinal herbs for, one of which shows evidence that individualized formulae are better than placebo. As your 1998 survey points out, the preponderance of the herbs recommended by UK herbalists are evidence-based, even if they’re part of formulae.
        Perhaps your foot (feet) are made of clay?

        • edzard says:

          i have finally understood your point.
          …and changed my text slightly. it does not matter all that much whether the individual herbs are evidence-based; the mixtures clearly are not!

          • Guido Mase says:

            Following that logic, you should call out any practitioner who combines multiple evidence-based interventions in one patient, as we lack evidence for (as I pointed out earlier, point left un-refuted) the combination of, say, ARBs and SSRIs, though one can find them prescribed concomitantly. It is not unreasonable to recommend Harpagophytum, Salix and Vitex in a client with low back pain and PMS – this is an individualized combination, yet all the herbs used are evidence-based ( http://www.ncbi.nlm.nih.gov/pubmed/17202897 and http://www.ncbi.nlm.nih.gov/pubmed/21171936 ).
            Surely you realize that practitioners can recommend more than one evidence-based treatment at a time, and that along with taking safety, interactions, and the individual details of the case into consideration, this is actually how most health-care providers practice?

            This opinion lacks a citation. I have provided evidence to the contrary (actually, I have simply cited your own research, Dr. Ernst. You did all the work). More amendment to the blog post is required to avoid spreading incorrect information.

          • Guido Mase says:

            Alan, see my response above for why “it does not matter all that much whether the individual herbs are evidence-based; the mixtures clearly are not!” is meaningless. Health care providers mix evidence-based treatments all the time, despite lack of evidence that such mixtures are effective. Though I am glad we can all agree that traditional herbalists do indeed incorporate evidence-based herbal support in their practice.

        • edzard says:

          ok, then we have at least some agreement on some issues. as to the point about evidence-based hernal extracts being used by traditional herbalists, we might have to agree to disagree. i think that most herbalists use herbs that lack sound evidence; you may well be the laudable exception. to judge this properly, would you give us a list of the 30 herbs you use most regularly and for which reasons?

          • Guido Mase says:

            “as to the point about evidence-based hernal [sic] extracts being used by traditional herbalists, we might have to agree to disagree”. Dr. Ernst, the burden of proof is on your shoulders for the statement above and for others such as: “we would have a situation where a completely unproven practice has obtained the same status as doctors” (erroneous on a few levels); “This means consulting a herbalist is not a reasonable approach to treating any human ailment.” (simply incorrect).

            Your 1998 survey ( http://cat.inist.fr/?aModele=afficheN&cpsidt=2402524 ) identifies herbal extracts used by traditional herbalists that are evidence-based – in fact, the most commonly used ones (identified in your survey) have an extensive evidence base that includes good meta-review analyses. The fact that they are combined reflects the way health-care providers practice; to imply that physicians can understand and responsibly employ poly-pharmacological combinations of extremely powerful substances and that herbalists cannot understand and responsibly employ poly-herbal combinations of relatively mild substances is an extrapolation unsupported by evidence.

            So, in sum, though you may disagree with me, said disagreement is not only unsupported by evidence, there also exists evidence to the contrary. And while you are of course entitled to disagree, you are not acting responsibly by making statements such as the ones quoted above in a public forum, as a leading academic. To me it seems unprofessional. That’s not an ad-hominem attack, just an observation. It really only concerns me when it is applied to herbal medicine; many of your other categorical statements on other “alternative” modalities are incredibly well-supported by evidence, and provide us with a real and useful guide for practice and referral. The rational phytotherapist and the traditional herbalists are often one and the same, or at the very least, we really have no evidence that they are completely distinct, as you claim in your post.

            Regarding my “top herbs”, I love that question! I get asked all the time. I will respond below, in the main thread.

  • Erica Hollis says:

    You are so blinded by the so called “gold standard” of placebo controlled double blinded clinical trials as the only form of evidence that you seem never to look further. Even the best designed clinical trial relies on statistics to “prove” efficacy of drugs (or herbs). Having my first degree in mathematics with a lot of statistics in the first 2 years, the great majority of these so called gold standard trials employ some extremely dodgy statistical techniques to obtain the results the drug companies want (and as Ben Goldacre has highlighted) those that still don’t show the right results are suppressed.
    Even in well designed trials free of statistical trickery, the evidence can only ever be that some people benefitted from the drug (or herb) on trial, there will always be a significant minority for whom it had no effect or, worse still, had a disbenefit. We are all individuals, giving everyone the same medicine (be it drug or herb) for the so-called same condition (very may diagnoses are very far from clear cut) is like saying that everyone should wear the same size shoes because the help the average person to protect their feet – obvious nonsense. In my experience, in my second career as a herbalist, most of my clients have been the orthodox route and come out worse than they went in. If Ernst has his way, what choice will these people have in the future? I don’t claim to cure everyone but most of my clients keep coming back because they start feeling better, then they stop coming because they don’t need any further help but they send their friends to me with high expectations. Given that on the NHS people are treated for free but those coming to a herbalist have to pay for every visit and every herb, surely this in itself is evidence we are helping a large number of people or is Ernst so condescending he considers all the herbal clients are stupid fools looking to be duped? My clients include some high flyers in various industries who are not easily duped as well as desperate people who can hardly afford the only medicine that gives them any quality of life.

    • Simon Waters says:

      Erica, people pay for all manner of known not to work “medical” treatments, likely attribution bias plays a big role here, so of itself being paid or having clients get better is not evidence of effectiveness. If trials show no effect it suggests the methods trialled are ineffective. The response that makes sense is ‘those aren’t my methods’, if they are your methods time to re-examine what you do.

  • edzard says:

    i have done all sorts of other research – how can i be “blinded”?
    THE ONLY THING THAT IS WORSE THAN RCT-EVIDENCE IS NO EVIDENCE NAD RELYING ON THE NOTIONS YOU FAVOUR

  • Acleron says:

    I’m confused about rational phytotherapy. Even if there is proper evidence that an herb has an effect, without knowing the precise chemicals causing that effect, how can there be any quality control of dosage?

  • Frisby says:

    Hello,
    As safety and efficacy are paramount, can you tell us how many trials evaluating the safety of prescription drugs have been conducted over 50-60-70 years or the average lifespan of a human being in our society? Can you also explain, given that drugs undergo such rigorous scientific research, why so many have been withdrawn over safety concerns years after they have been released? Thank you

    • edzard says:

      the fact that drugs are withdrawn shows that pharmacovigilance is working ok – and that we need huge numbers to identify risks in clinical practice [and thus pre-clinical testing and trials are sadly not sufficient in many cases]

  • Peter Deadman says:

    One issue that often gets missed in responding to Ernst’s argument is that this is simply cultural racism. Individualised herbal prescriptions have been used in China for around two thousand years and some of the best medical and scientific minds of twenty centuries of Chinese civilisation have contributed to an ever-growing knowledge base. Individualised prescriptions continue to be used in hospitals and clinics throughout the country; millions of patients are treated every year and billions have historically been treated. Of course none of this necessarily meets the criteria of evidence-based medicine but any sincere scientist /observer should approach such a tradition differently – and more respectfully – than, say, crystal healing or ear candles (incidentally considerable numbers of research papers on Chinese herbs are published in numerous Chinese journals annually). In response to this incredible tradition, only a tiny number of trials have been conducted and the best Ernst can really say is that so far there is an absence or a paucity of evidence. So what? It will take much more than the scanty pickings Ernst uses to justify his self-comforting certainties to form any meaningful conclusions.

    • Dragonblaze says:

      I take it you’re not familiar with pharmacognosy? It is the branch of pharmacology that specialises in investigating and testing folk herbal remedies from all over the world. This is the evidence-based approach that can provide solid evidence for the efficacy of a given herb, and is how it should be done – instead of relying on anecdotes.

  • jim mcdonald says:

    If i can project my interpretation onto “armchair perspective”:

    It appears you are a researcher and not a practicing herbalist, who actively sees clients (and only gives depressed ones St Johns wort). The value of research is a different sort than the value of practice. For example, i’d rather have my car’s brakes replaced by someone with extensive experience doing so, and not by someone with extensive experience researching the replacement of brakes. Perhaps you would choose differently.

    And really, the be all end all value of herbalism lies in the results achieved by the people using it, and not in whether or not their results are validated by “SOLID EVIDENCE”. I don’t find that, say, clients whose chronic sinusitis has resolved care a whole lot if the yerba mansa they used lacks double blind, placebo controlled trials to justify their results. Relying only on and limiting one’s materia medica not only to just 12 plants but to limited uses of those 12 imposes unjustified constraints on the practice of herbalism based the limits of the system being used to declare validity. It’s great for the people whose depression st john’s wort helps, but leaves the people who would be better served by a plant no one has generated “SOLID EVIDENCE” for S.O.L.

    Feel free to correct me if I misread and you are a practicing clinical herbalist (i didn’t see that indicated in your bio).

    • Alan Henness says:

      Jim: You seem blissfully unaware of the problems associated with bias. Wikipedia has a good introductory article on some of the forms of bias that can affect perceived results – it is these that careful scientific methodology tries to eliminate or reduce so that accurate indications of effects can be determined.

      Although entirely irrelevant to whether there is any good evidence for anything, perhaps you could tell us whether you are a practising scientist as well as a herbalist? From your comments, it does not seem likely that you are. And if not, do you see the parallels with trying to tell Prof Ernst that, since he’s not a herbalist (but he is a doctor and a scientist), he can say nothing about the scientific evidence for their efficacy?

      • jim mcdonald says:

        any “regressivity” in my argument is overshadowed by the fact that when it comes down to it, people working with their clients and getting results makes a bigger difference than “the problems associated with bias”. I actually don’t even remotely care about bias. I care about helping people, if I’m able, and like to do so using herbs (because they fascinate me), individually combined for each and every person. Why would I even care if something that I can see helping people is affected by my bias towards it? I’m not looking at data and making assumptions, I’m seeing whether or not someone’s wart is going away, or if their chronic back pain improves. If someone has had an UTI for a year, and had no antibiotic touch it, and then takes Monarda fistulosa tincture and it resolves (confirmed by two separate tests) and doesn’t come back, do you think that person cares about bias either?

        In such a context, it’s just academic pontification. Maybe it matters more if the cerebral aspect of it is what your focus is – data – but if you’re in practice, what matters is that individual person you’re working with. If you’ve never had that relationship, you can comment on it all you like, but you’re still like the person whose never replaced brakes telling the person who does it for a living they’re doing it wrong. Or, maybe the mathematician trying to coach the composer of music. Professor Ernst can say whatever he likes about “the scientific evidence for their efficacy”. The fact that he has a comments field after his post invites comments, which I’ve decided to do (with little expectation of affecting any change in outlook), with the express purpose of declaring sentences like “Individualised or traditional herbalism is not fine; it is not demonstrably effective and has considerable risks. This means consulting a herbalist is not a reasonable approach to treating any human ailment” codswallop.

        Seriously, even Spock knew the limitations of logic: http://www.youtube.com/watch?v=wlMegqgGORY

  • karen white says:

    Again Mr Ernst in displaying your true colours, you have once again completely missed the point and demonstrated your total lack of understanding regarding the human body. In essence you are saying that ‘rational’ medicine requires the same approach to ‘disease’ as allopathic and that one pill fits all.
    This completely ignores the complexity of human beings and the causes regarding their suffering/ailments etc. Instead of seeing a person ‘labelled’ with a condition, an holistic view would be to see that the person in question is suffering with x and not that they are x. IE their root of ‘disease’ may be due to varying factors, which requires different approaches – ie addresses the underlying cause. This is one of the main reasons why allopathic medicine continually fails to address chronic conditions & why herbal medicine is utilised by so many successfully around the world.
    I am sorry that you hold such a narrow view, but until research methodology enters a new paradigm, its current draconian methods do not serve this branch of medicine. That’s all for now

  • Guido Mase says:

    Though I expect the justification might be based in your prerogative to cut off debate as you see fit, suppression is neither a valid argument nor is it helpful. A bit disappointing – considering you requested elaboration – but not surprising.
    I have always respected your work and appreciate your perspective on herbal medicine – it truly does help the community. Occasional over-reaches notwithstanding.

  • Peter Deadman says:

    Ernst’s argument is the equivalent of finding one study that says a particular intervention for breast cancer shows no effect and concluding that all Western medicine is rubbish. Like 50% of Western medicine, most Chinese medicine is not evidence based, but that is largely historical and economic. A worthy scientist keeps an open mind, respects – but not blindly – human discovery through means other than randomised testing and above all avoids the overweening arrogance typical of Ernst’s dismissal of a branch of human knowledge he knows little about.

  • karen lawton says:

    Hello to all,

    I fit into the quacks section of this debate I guess. I am a herbalist and work as a witch, my patients come to me mostly after seeing me dressed up at festivals in full garb black hatted, bosom under arm. They are fully aware that I am going to treat them with herbs that feel, intuitively right to me. No evidence base. Sometimes its the plant that I first catches my eye, or the plant that they mention that they end up takin away for treatment. I fully accept that I have an amazingly connective spirit and that the plants speak to me openly with love. This love flows through me and I hope it reaches you all. I work with no insurance as I believe in the ability of Spirit and I trust. I love pharmacognosy and was taught this by a brilliant teacher from Ghana, during one lecture he remembered a particular medicine man from his village, who couldn’t read or write but knew all the plants and was renowned locally for his skill of healing. World over there are many differing forms of healing ad if we want to start talking about dangerous, lets look first at evidence based pharmaceuticals like Roaccutane for example -seems that that is a wee bit more harmful than chamomile even if it is in a mix with tilia and vervain,………..
    love wild n wicked witch

    • Skepticat_UK says:

      I fully accept that I have an amazingly connective spirit and that the plants speak to me openly with love. This love flows through me and I hope it reaches you all.

      No. What’s reaching me is an image of someone who is a deluded, irresponsible egotist. This is confirmed after reading your blog: “I just kept thinking that there was no vaccine for what he’d just suffered and he pulled through, so he must be strong enough to fight off illness by himself.”

      if we want to start talking about dangerous, lets look first at evidence based pharmaceuticals like Roaccutane for example -seems that that is a wee bit more harmful than chamomile even if it is in a mix with tilia and vervain,

      This particular blog is about herbalism. No need to change the subject – unless you need to divert attention away from the countless victims who have suffered and died thanks to people like yourself.

    • Marie Reilly says:

      I am a medical herbalist with a masters degree in herbal medicine, and I believe that my clinical experience, and the collective experience of other herbalists, is a valid form of evidence on which to base clinical practice. Together with measures such as the adverse events reporting system operated by the National Institute of medical herbalists, this makes individual herbal medicine very safe when practiced by an appropriately trained practitioner. As I said in my comments below, orthodox medical physicians frequently used combinations of drugs, based only on the evidence profile of the individual drugs and with no RCT evidence for their specific combinations. Orthodox medicine, despite being based on RCT evidence, is well-know to be extremely dangerous, with reports of adverse drug reactions too numerous to mention. However, Ms Lawton’s comments above are really quite concerning, and clearly demonstrate a very pressing need for regulation in herbal medicine.

      • Alan Henness says:

        Marie Reilly said:

        I am a medical herbalist with a masters degree in herbal medicine, and I believe that my clinical experience, and the collective experience of other herbalists, is a valid form of evidence on which to base clinical practice.

        Where would you place robust independent evidence?

        Together with measures such as the adverse events reporting system operated by the National Institute of medical herbalists

        Maybe you could clarify a few things for me?
        The NIMH say:

        Research services
        NIMH runs a research department which responds rapidly to emerging issues relating to herb safety, responds to publications in scientific journals, provides a research perspective on stories in the media, operates the yellow card reporting system of adverse events, responds to research-related enquiries from NIMH members, and conducts systematic reviews of relevant literature.

        The Yellow Card scheme or just a yellow card scheme?

        If the latter, why do they feel it necessary to run a scheme separate from that of the medicines’ regulator? Do they inform the MHRA of all events reported to their scheme? Do they publish reports on incidents? Can the public report an adverse event to the NIMH’s scheme? Why is there no link that I can see to their scheme (or indeed to the MHRA’s scheme)?

        They also say they conduct systematic reviews. Can you point me to the pages on their website where the public can read these so we can make our own choices?

        You continued:

        …this makes individual herbal medicine very safe when practiced by an appropriately trained practitioner.

        It provides a mechanism for reporting an adverse event after the fact. While that will contribute to knowledge of safety (and allow practice to be modified or products withdrawn), it’s of no use if the data are not published. Has any herbal product ever been withdrawn or practice changed after consideration of adverse events?

        Orthodox medicine, despite being based on RCT evidence, is well-know to be extremely dangerous

        Extremely dangerous? What, all of it? And to suggest that this is somehow the fault of RCTs show a misunderstanding of RCTs and pharmacovigilance. However, at least many ‘orthodox’ medicines do have some RCT evidence, though it seems there isn’t that much RCT evidence for many herbal products. So it seems all we are left with is the personal judgement of herbalists.

        …with reports of adverse drug reactions too numerous to mention.

        No. The MHRA manage to publish them for all to see.

        However, Ms Lawton’s comments above are really quite concerning, and clearly demonstrate a very pressing need for regulation in herbal medicine.

        Indeed. And that regulation should get rid of the double standards we have at present where manufactured herbal products don’t have to supply evidence of efficacy and only supply limited data on safety: if any herbal product is used to treat medical conditions, it should have to pass the same evidential requirements as ‘orthodox’ medicines before being sold. Once we have those controls in place, we can then talk about the training of herbalists.

        • Marie Reilly says:

          My comment about the dangers associated with orthodox medicine was based on the high incidence of adverse reactions, compared to a very low incidence of adverse reactions to herbal medicines when prescribed by an appropriately trained practitioner. Why don’t you check it out for yourself. There is plenty of hard evidence for severe harm and even death being caused by the interventions of orthodox medical practitioners, (reports of adverse drug reactions too numerous to mention BY ME), and no incidence of severe harm being caused by herbal medicines when prescribed by a properly trained practitioner, registered with a recognised professional body.

  • Thomas Easley says:

    Dr. Edzard Ernst, thank you for your diligent research. If you’ll indulge my questions for a moment.

    You said in your article:
    “To the dismay of traditional herbalists, their results fail to confirm that such treatments are effective for any condition.”

    It seems to me that the studies you reviewed failed to confirm that the individualized TCM treatments for chemotherapy induced toxicity, osteoarthritis of the hip and knee, and IBS failed to work, or work better than standardized botanical treatments. I’m not sure how you can extrapolate that individualized botanical treatments for ALL conditions are ineffective based on these three published studies. It seems to me that there are many more conditions out there to be tested before a definitive statement is made on individualized treatments. It also seems to me that as the Lechner study stated determining the “efficacy of individually designed herbal formulas according to the rules of Traditional Chinese Medicine (TCM)” leaves many traditions of Herbalism, each with their own rules, to be tested.

    I can’t seem to find where the Hamblin study was ever published. Did it ever make it through peer review. I seem to remember some controversy as to the qualifications of the Herbalist making the recommendations. Or maybe it was the limitation of only 11 botanicals for an individualized study that caught some flak.

    Maybe a more accurate ending statement for your article would be something to the effect of…Seeking individualized TCM herbal treatment for IBS, Chemotherapy toxicity and Osteoarthritis of the knees and hip, by the practitioners involved in the above studies, is not demonstrably effective.

    Oh and you said “Rational phytotherapy might be fine”, but then go on to say “regulating herbalists (as we are about to do in the UK) is a seriously bad idea”. Do you have a proposal as to who should be practicing rational phytotherapy, since you don’t think herbalist do? Should rational phytotherapy be included in every medical school?

    • edzard says:

      am i really extrapolating or just applying the simple rule of medicine: if we do not have evidence, we should not make claims of efficacy, recommend the treatment, use the treatment etc?

      • Rachael Frost says:

        We should not make claims of efficacy when there is no evidence, however, it has emphatically put to me in many statistics classes that ‘no evidence of effect does not equal evidence of no effect’ and so stating that individualized herbal medicine is ineffective for all conditions is not a conclusion you can make given the lack of studies. With regards to Western herbal medicine alone, the Hamblin trial has an insufficient sample size to draw any conclusions (and to the best of my memory, uses within-group analysis so offers not insights on how groups compare), and the only other trial I’m aware of is also a pilot trial (that is not included in your review as you excluded waiting list controls). However, you distinguish between the two types of herbal medicine as a dichotomy and make no room for the herbal practitioner that uses the best available evidence with regards to individual herbs (which ranges wildly from clinical trials to in vitro studies to anecdotes), patient preferences and individual clinical experience – which is how Sackett describes evidence-based medicine. There does need to be lots more evidence on which to base herbal practice, but writing articles like this will dissuade funding bodies from funding research that is sorely needed! Also, you did not answer the question of who these rational phytotherapists are meant to be – herbalists, AHPs, doctors?

        • edzard says:

          yes, we all know about ABSENCE OF EVIDENCE IS NOT EVIDENCE OF ABSENCE.but this does not mean that, in health care, we can give the benefit of the doubt to unproven treatments.

          • Rachael Frost says:

            No, we research them, like every other dimension of healthcare. But this is an incredibly slow process! Its also hampered by lack of funding, lack of motivation by herbalists to undertake research and the removal of CAM teaching and research groups from universities. What do you suggest we do in the meantime? Other healthcare professions begun evidence-based practice by carrying out research based upon clinical experience and modifying practice upon the basis of that, rather than discarding absolutely everything they previously gained from clinical experience and refusing to practice unless there was a high quality RCT.

  • Susan Marynowski says:

    Quoting from an article in the Washington Monthly:
    “…doctors are making a lot of decisions about how to treat their patients without the benefit of data. One day medical historians will look back at many current medical practices and see twenty-first-century equivalents of bloodletting and leeches. According to the Institute of Medicine, perhaps half of medical practice is based on valid evidence. Dr. David Eddy, an expert in the field of medical evidence, thinks as little as 15 percent of what doctors do is based in good science. Or, as he recently told BusinessWeek, “The problem is, we don’t know what we’re doing.” (http://www.washingtonmonthly.com/features/2007/0710.brownlee.html)

    As both a scientist and an herbalist, I do my best to recommend remedies that have a strong evidence base -OR- a long history of safety in traditional uses. We are all doing our best to help people feel better with the best evidence available. Why not call for more evidence if that is what you want?

    • Alan Henness says:

      Susan Marynowski said:

      Dr. David Eddy, an expert in the field of medical evidence, thinks as little as 15 percent of what doctors do is based in good science.

      Eddy’s figure of 15% comes from a small survey of GPs in the north of England in 1961 – more than half a century ago. Fortunately for us, much has changed in the last 50 years. Wouldn’t you agree?

      But this survey was never intended to assess the degree to which GPs were evidence-based, but rather was looking at controlling prescribing costs in terms of generic versus proprietary drugs. As such, even then, it does not say what you think it does.

      The currently accepted figure is that around 80% of treatments used today are based on good evidence. What’s the figure for herbals treatments?

      • Thomas Easley says:

        Alan: where do you get that 80% of current medical treatments are based on good evidence?

        The BMJ says
        13 percent were found to be beneficial
        23 percent were likely to be beneficial
        Eight percent were as likely to be harmful as beneficial
        Six percent were unlikely to be beneficial
        Four percent were likely to be harmful or ineffective.
        46 percent unknown in their effectiveness
        http://clinicalevidence.bmj.com/x/index.html

        The Cochrane review says
        38 percent of treatments were positive
        62 percent were negative or showed “no evidence of effect.”
        http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=101041

        Those statistics put placebo’s outperforming many aspects of modern medicine.

        I’m not suggesting that alternative medicine doesn’t have a long ways to go, in fact I think all aspects of medicine have a long ways to go. But I don’t think that individualized herbalism should be dismissed out of hand because of a very small handful of poorly designed studies in very limited scenarios.

        Edzard said: if we do not have evidence, we should not make claims of efficacy, recommend the treatment, use the treatment etc?

        How much of modern medicine is prescribing drugs for off label use, the very nature of which means no scientific evidence. In the absence of evidence, the practitioner uses their best judgement to help their patient.

          • Alan Henness says:

            edzard said:

            we have gone over this ground so manytimes!
            do catch up; suffice to say that you misinterpret the BMJ data.

            Indeed. But it may be worth explaining it yet again.

            The bmj Clinical Evidence website says:

            We would like to emphasise that our categorisation of the effectiveness of treatments does not identify how often evidence-based and non-evidence-based treatments are used in practise. We only highlight how evidence based treatments are for certain indications, based on randomised controlled trials. As such, these data reflect how different treatments stand up evidence-based medicine and are not an audit of the extent to which treatments are used in practice or for other indications not assessed in Clinical Evidence.

            and

            Effectiveness of 3000 treatments as reported in randomised controlled trials selected by Clinical Evidence. This does not indicate how often treatments are used in healthcare settings or their effectiveness in individual patients.

            Prof Ernst has previously responded to this:

            * Firstly, the low percentage of proven treatments is partly due to the fact that this figure includes alternative medicine.
            * Secondly, the figure relates to all treatments even those that are very rarely used. If you look at the percentage of effective treatments that are actually in daily use, you arrive at figures around 80%.
            * Thirdly the process of applying science to medicine is relatively young – so we are looking at work in progress.
            * Fourthly, if one area is not optimal, this is no reason to allow another one to be even worse.

            (The website that quoted him is currently down, but I’m sure Prof Ernst can confirm this.)

            The 80% figure comes from: How much of general practice is based on evidence? and the studies it cites.

            How much of alternative therapy has robust evidence to substantiate their use?

  • Susan Marynowski says:

    I guess it all depends on how you define “evidence”…and that, sir, is something upon which you and I would probably disagree. I love science (and I hold an M.S. degree, so I have performed scientific analyses of my own), but I also believe that thousands of years of safe use of a food-like substance is also a valid form of evidence.

    Cheers then.

      • Susan Marynowski says:

        Of course not. That’s a silly question. I said “…thousands of year of SAFE use…” Bloodletting most certainly was not a safe practice, as evidenced by damage done.

        • Mojo says:

          It isn’t a silly question, because there is no real difference between their evidence and the evidence that you claim is valid: they are both variations on “long use = good”. People believed bloodletting was effective and safe enough to use, just as you believe that “food-like substances” are safe to use.

          Your “valid form of evidence” is no more valid than the evidence for bloodletting.

        • edzard says:

          i fear you are wrong: blood letting was deemed to be safe! as much as you think herbs are safe. the point is that evidence is needed for safety as well as for efficacy. without it we are just guessing.

  • edzard says:

    GUIDO MASE: if a doctor prescribes 3 different drugs, the patient might have 3 different grug-drug interactions and hopefully the doc knows what he is doing and has thought of this possibility.
    if a herbalist presctibes 3 different herbal extracts each of which might contain 5-20 pharmacologically active ingredients, the potential of herb-herb interactions [and herb-drug interactions, in case the patient also takes one or more drugs] is almost endless.
    this means that even evidenced-based herbs are unpredicatble when given as individualised mixtures.
    moreover, you might prescribe in the way you outlined it but how many herbalists do something entirely different? dry or cold remedies for wet or hot conditions conditions? or a mixture of chinese herbs to de-block your kidney chi? the variations are again endles.
    AND I DO MAINTAIN THAT THESE INDIVIDUALISED APPROACHES ARE NOT EVIDENCE-BASED.

    • Guido Mase says:

      ” if a doctor prescribes 3 different drugs, the patient might have 3 different grug-drug interactions and hopefully the doc knows what he is doing and has thought of this possibility.” I certainly do hope so. In the case of most physicians I’ve met, this seems to be the case. Though I have also observed that some patients who are seeing multiple specialists do sometimes end up with a poly-pharmacological cocktail that no one has thoroughly evaluated. In such cases, I immediately refer my client to a competent internist in my referral network; but I digress.

      “if a herbalist prescribes 3 different herbal extracts each of which might contain 5-20 pharmacologically active ingredients, the potential of herb-herb interactions [and herb-drug interactions, in case the patient also takes one or more drugs] is almost endless.” Potential is interesting stuff, but largely speculative. What’s clear is that a single herb is in and of itself a combination of multiple pharmacologically active ingredients (often way more than 5-20!), as you and others correctly point out. Yet these multi-ingredient herbs are studied and found to be valid, safe treatments. Similarly, as more and more polyherbal combinations are researched in their own right (take, for instance, the Chinese formula “free and easy wanderer” http://www.ncbi.nlm.nih.gov/pubmed/21820672 ), I look forward to incorporating them into my practice.

      “this means that even evidenced-based herbs are unpredicatble when given as individualised mixtures.” [citation required]

      The possibility that some herbalists may never use the principles of evidence-based medicine in their practice is not adequate evidence to support your claim that “… consulting a herbalist is not a reasonable approach to treating any human ailment. It also means that regulating herbalists (as we are about to do in the UK) is a seriously bad idea: the regulation of non-sense will result in non-sense!”. In fact, is it not the case that a regulatory framework could help advance the cause of rational phytotherapy? As we’ve established in our discussion, there are herbalists who use this approach. Your post, however, fails to make this clear (and in fact advances a contradictory view which is not based on fact and not adequately referenced). As the general practice physician is already overwhelmed, advancing opinions such as “consulting a herbalist is not a reasonable approach to treating any human ailment” does a disservice to patients and to medicine. A qualified, rational phytotherapist is a useful addition to the modern health-care team.

  • edzard says:

    “these multi-ingredient herbs are studied and found to be valid, safe treatments”….and my point is that, for most herbs, this is simply not true; it’s wishful thinking on the side of herbalists.
    “more and more polyherbal combinations are researched in their own right”…i don’t think this is correct either. there are exceptions but we ought to be VERY cautios with the chinese trials and the reviews thereof [i cannot read the otiginal chinese articles, can you?]
    “As we’ve established in our discussion, there are herbalists who use this approach”… i do not think we have established that at all; please give me a list of your 30 most regularly used herbs with the reasons for using them and i give you an evidence-based assessment of this list.

  • edzard says:

    GUIDO: irresponsible is to say that ind. herbalism is evidence-based. there is such a thing as the precautionary principle! even our survey [which was not specifically targeted at this] identified many popular herbs that are not evidence-based. thus it is responsible to warn that ind. herbalism is not evidence based – as i say we have to agree to disagree.
    i look forward to your list.

  • Guido Mase says:

    The fact that many herbs still lack an adequate research base does not imply that traditional herbalists do not use evidence-based herbs in their practice as a part of a rational phytotherapy, as you claim in your post. Your 1998 survey ( http://cat.inist.fr/?aModele=afficheN&cpsidt=2402524 ) in fact shows that they do. It isn’t much in the way of evidence, but the burden of proof isn’t on me to disprove your statements – it is on you to support them with evidence. I thought we had established this, and therefore, established that the traditional herbalist and the rational phytotherapist can, indeed, be one and the same person.

    I agree that Chinese trials and meta-reviews such as the one I quoted above are often dubious, as well as some trials on herbal remedies coming out of Iran (weird/incomplete methodologies as lot of the time), or some of the research on Rhodiola that is all authored by Panossian, who has a known conflict of interest. Many published trials are interesting to follow, but do not imply that the herb or combination being researched should be added into practice. However, it’s interesting to note that they still never identify adverse events at a rate greater than the placebo they are compared to. I do not use “free and easy wanderer” in my practice.

    “please give me a list of your 30 most regularly used herbs with the reasons for using them and i give you an evidence-based assessment of this list.” Dr. Ernst, this diversion, while amusing, is irrelevant! What I do in my practice, as we all know, would represent a review with an n of 1, which is a ridiculous way to assess the validity of a hypothesis. Nevertheless, I will make you this proposal: since your statements such as “… consulting a herbalist is not a reasonable approach to treating any human ailment” are unsupported by evidence (and, furthermore, there exists evidence to the contrary), if you edit and/or amend your blog post to reflect fact rather than opinion I’d be happy to indulge your desire to pass judgement on my practice. But for now, let’s stick to the topic.

    • edzard says:

      so you do read chinese?… me neither! but i collaborated with chinese researchers and we found the trials published in chinese of abominable quality and none ever reported a negative result http://www.ncbi.nlm.nih.gov/pubmed/?term=ernst+tang+bmj
      i will not change the text as you want because, as stated before, we differ on this point. my own survey does NOT show that most herbs used by UK herbalists are based on convincing evidence.
      shame that i will never see your list.
      as this discussion is quite boring now, i will end it with a statement you might not like
      ANY HERBALIST WHO USES MORE THAN ~ 12 DIFFERENT HERBS IS NOT EVIDENCE-BASED, AS GOOD EVIDENCE DOES NOT EXIST FOR MORE THAN THAT NUMBER.

  • Marie Reilly says:

    Your argument is completely flawed Mr. Ernst. Your assumption that RCT evidence makes orthodox medicine safe, while the lack of it makes individual treatment with herbal medicine unsafe, is entirely untrue. I would remind you that orthodox medical doctors use an “individual” approach in that they frequently prescribe a combination of many different pharmaceutical drugs, without having RCT evidence of the safety of this specific combination. I have seen many patients who have been prescribed well over 10 different orthodox medicines, with no evidence base for the combination used, and I have seen many drug combinations prescribed which have documented adverse reactions. Perhaps you could put your talent for research into looking at how many people experience harm or even death as a result of supposedly “evidence-based” orthodox medicine, compared to how many people have been harmed by herbal medicine when under the care of a qualified practitioner?

  • Guido Mase says:

    As I stated above, I agree with you on many trials coming out of China. There’s good evidence, as you point out, to dismiss many if not all. Again, off topic.

    Your survey shows that many herbs used are, and many others are not. Again, this was 15 years ago. The evidence and applications for herbs such as Curcuma and Crataegus have only increased since then; as I’ve mentioned, it might be time for an updated survey to test the hypotheses you advance.

    It follows that “consulting a herbalist is not a reasonable approach to treating any human ailment” is incorrect because it is unqualified and, as such, has no evidence to support it. I am sorry you are bored, but your disagreement with me remains based on your opinion/ideology, not evidence.
    Though it is off topic, I have to remark that it is interesting you find it boring to discuss the inaccuracies and over-reaches of your own comments, but seem quite entertained by adding useless (though, I must admit, sickly amusing) posts such as “well spotted, Watson!” and “she must be above average” to your discussion of the inaccuracies of others. Manners are important, but professionalism is too. Though I love it when people get to have fun (even at the expense of others? that one I’m not as sure about).

  • edzard says:

    it is boring because there are only so many ways of saying YOU ARE WRONG and answering NO, I AM NOT.
    but i begin to suspect something more interesting: perhaps you and i understand different things by the term EVIDENCE.
    curcuma is not and crataegus is no longer supported by strong evidence, in my view.
    where is your evidence?

  • Guido Mase says:

    Off topic again.
    I include Curcuma in my practice as a food-like agent, and though it makes my list of 30, it does so as one of the “safe, food-like adjuncts” I described in my first response to your post (cf. Chamomile). I do suggest these herbs for my clients when the therapeutic potential is being researched and starting to provide interesting results, as long as there is clear evidence of safety and a long track record of SAFE cuisine-based use as well. The evidence I was referring to pertains to Curcuma’s safety – which is stellar, when attention is paid to medications that may be co-administered and the existing diagnoses a client may have received.
    Crataegus is similar, though I also recommend it for folks who have received a diagnosis of heart failure. I do have to admit, Dr. Ernst, that I also sometimes go “off-label” and recommend it for folks who have risk factors for eventually developing heart failure – and this is because I feel that, based on the evidence, it is very safe when administered in the usual traditional context and, as always, with an eye to the client’s medication list. The evidence base is well-reviewed in Dahmer and Scott, 2010 ( http://www.aafp.org/afp/2010/0215/p465.html ). The bibliography includes the Cochrane meta-review you co-authored in 2008. I also am in the habit of recommending the use of apples and garlic in the diet, though I evaluate the olfactory predilections of the client and his/her immediate family first.

    While I know this diversion will be much more entertaining for you, I respectfully suggest that a valid response to “YOU ARE WRONG” can also be “Ok, there might be some truth to what you’re saying.” Let me suggest the rephrasing of “ANY HERBALIST WHO USES MORE THAN ~ 12 DIFFERENT HERBS IS NOT EVIDENCE-BASED, AS GOOD EVIDENCE DOES NOT EXIST FOR MORE THAN THAT NUMBER.” to the similar, but more accurate “Herbalists use ~ 12 different herbs that show evidence of efficacy and safety in treating human ailments, though they often combine them with others for which efficacy data is lacking.” To which the qualification might be added: “Preliminary research for the majority of these other herbs has found them generally safe when used in a traditional, food-like manner in the appropriate context”. And finally “But caveat emptor – not all herbalists are created equal. In terms of herbal practice, the use of evidence-based medicine operates on a continuum. It is possible that a regulatory framework might help patients choose more effectively from this continuum – though I don’t have high hopes.” [that last part is my opinion, as well]

    • edzard says:

      could i suggest that, on my blog, you grant me the right to decide what is off topic. this is clearly ON TOPIC, in my view.
      i think we finally have come to the crux of the matter: what you describe as evidence-based therapeutic decisions, i cannot.
      where is the evidence that curcuma is effective and for what indication? i certainly am not aware of it and you do not provide it. this makes it a non-evidence-based choice.
      whith crataegus it is a bit more difficult. we have done a cochrane review which concludes that “there is a significant benefit in symptom control and physiologic outcomes from hawthorn extract as an adjunctive treatment for chronic heart failure”. since then a very large and rigorous trial, sponsored by the leading manufacturer has become available. it shows that the extract “had no significant effect on the primary endpoint” [time to first cardiac event] http://www.ncbi.nlm.nih.gov/pubmed/19019730. since then, crataegus cannot be seen as solidly evidence-based for heart failure.
      so, you call yourself a rational herbalist but, judging from those 2 examples [not to mention the off label prescription], you are not evidence-based.

      • Guido Mase says:

        Regarding Crataegus, we are on the same page that it provides symptom control (dyspnea, exercise tolerance e.g.) in cases of heart failure. That’s the evidence I reference, which makes Crataegus a useful and effective remedy for treating a human ailment. Your point on cardiac mortality as a primary endpoint is valid, but different. Bringing it up is a common rhetorical technique, known as “moving the goalposts”. I don’t recommend Crataegus as a way to reduce time or frequency of cardiac events, I simply recommend it to improve quality of life – and for this there is ample evidence.

        Regarding Curcuma, as I pointed out in my first comment on this post, I often suggest foods and food-like herbs that might be tasty and fit well into my clients’ lives, as long as there is an impeccable track record of safety. Curcuma most definitely qualifies. The fact that there is emerging evidence, though largely preliminary, on Curcuma for conditions such as inflammatory bowel disease is an interesting side-point, but not the reason I recommend it. The reason is that cuisine, it seems, can have impact on health. We aren’t sure exactly how this is, or why, but certainly it is becoming clear that a life without fruits and vegetables can have negative health consequences. So this poses a conundrum: we certainly can’t recommend apples, tomatoes and broccoli, as there is no evidence of any therapeutic effect from these foods. Yet somehow, if all fruits and vegetables are removed from the diet, health suffers (this is well-reviewed here: http://www.ncbi.nlm.nih.gov/pubmed/22797986 , and in many other places). So in the end, my point is that Curcuma is like an apple: not used directly for treating a disease in the short-term, but safe and important as part of a diet rich in fruits and vegetables (and rhizomes). I follow emerging research on phytochemical synergy in traditional cuisine with interest, even though a comprehensive understanding continues to elude us. However, I do not tell my clients to remove all fruits and vegetables from their diet as no evidence exists for any one of them being useful for treating disease (with the exception, perhaps, of Avena – one of my “30″, though not a fruit or vegetable). That would be irresponsible and unsupported by evidence (in fact, there exists evidence to the contrary).

        Having been unable to refute my point that “consulting a herbalist is not a reasonable approach to treating any human ailment” is inaccurate (the only attempts have been diversions, and I have provided ample evidence that herbalists recommend plants that are clearly beneficial in treating human ailments), you return to my idea that using safe, food-like plants that lack an evidence base is an important part of my practice. I’ve got a great recipe for kale chips I like to suggest. Not to treat disease, but to add botanicals back into my clients’ lives to help achieve the goal of regular fruit and veg consumption. I’ve also got a nice recipe for curry – it features Curcuma prominently, for the same reason. As I stated in previous comments, this is a fascinating and interesting discussion. I would be very interested to hear if you have considered any methodologies for addressing these questions, because they’re tough. How can we get at answers here? Research on the “Mediterranean diet” has left me unconvinced. So how is it that when people stop eating fruits and vegetables health suffers? It doesn’t make any sense logically.

        I do not call myself a rational herbalist. I call myself a traditional herbalist. And, like most of my peers, I employ ethical, critical thinking in my work and I use herbs in my practice that are grounded in evidence to help effectively address human ailments. And curry. Lots of curry.

        • edzard says:

          i do not see that we are on the same page anywhere!
          crataegus: cardiac events are not cardiac mortality but include symptoms.
          curcuma: you seem to feel that its use is justified because it is a veg. with this spurious logic, any herbal remedy can be justified. THIS IS NOT WHAT I UNDERSTAND BY EVIDENCE.
          it took a while, but i think we have identifies where we were arguing accross purpose all the time.

          • Guido Mase says:

            According to the study you reference, “The primary outcome measure for treatment efficacy was the number of days between baseline and the first cardiac event, defined as a composite of cardiac death (sudden cardiac death, death due to progressive heart failure, fatal myocardial infarction), non-fatal myocardial infarction, or hospitalization due to progressive heart failure.” No reference to symptoms such as dyspnea and exercise intolerance as primary outcomes – unless, presumably, such symptoms cross the threshold of requiring hospitalization. My clients, by definition, do not cross that threshold. So we are left with the Cochrane meta-review that you co-authored which, to my understanding, finds that Crataeugus provides “… a significant benefit in symptom control and physiologic outcomes”. Please be clear when looking at study outcomes; as you know, it is dangerous to think a study says something about, for instance, symptoms of dyspnea or exercise intolerance when those were not the primary outcomes being researched.

            Thus, we remain on the same page that, for the primary endpoints of symptoms of heart failure, Crataegus is a reasonable and effective adjunct to conventional treatment based on the best available science to date. For preventing cardiac death, non-fatal MI, or heart-failure-related hospitalization, I agree with you that Crataegus seems not useful. However, based on the fact that it improves quality of life in the symptom areas researched, it would be unethical to withhold it if its use is indicated.

            It is not true that any remedy can be justified by my logic. Aristolochia, for instance, is unsafe as we have discovered. It may have been a part of traditional use, but good research has told us that, over time, it very probably raises the risk of bladder cancer significantly. The herbs and foods I recommend need to have a good safety record for me to incorporate them into my recommendations. They are on the same footing as apples and broccoli. Surely you aren’t trying to argue that we need to remove fruit and vegetables from our diets as there is no evidence to support the use of any individual fruit or vegetable? Or maybe you are?

  • Marie Reilly says:

    Professor Ernst, I would really like to know what it is that you are trying to achieve. It would appear that you would like to see herbalists put out of business, but for what reason? Are you really concerned about public safety? If indeed you do manage to outlaw the practice of herbal medicine, the likelihood is that people will increasingly access herbs, without the benefit of a proper diagnosis from a trained professional, from dubious sources on the internet. This dramatically increases the risks of individuals mis-diagnosing their complaint, choosing an inappropriate herb, and obtaining a product which is substituted or adulterated. The majority of adverse events involving herbs has been as a result of herbs purchased by individuals form dubious sources, whereas medical herbalists such as those registered with the National Institute of Medical Herbalists (NIMH) have an exemplary safety record. Therefore, if you do manage to put herbalists out of business, this is actually likely to have a very negative impact on public safety.

    You say that it is unsafe to use herbs which are not supported by RCT evidence, yet orthodox physicians frequently practice “off-list” prescribing in which a drug is prescribed for a condition for which no RCT evidence exists, on the basis of clinical experience. Medical Herbalists likewise base their use of herbs on their own clinical experience, and the clinical experience of generations of other herbalists, as well as on clinical trials, where these exist. NIMH also operate an adverse event reporting system to ensure that and adverse reactions to herbs are known by their members.

    You also claim that it is not acceptable to use combinations of herbs where there is no evidence to support that specific combination, however, orthodox physicians frequently prescribe numerous pharmaceutical drugs at the same time, with no evidence for the specific combination they use. Do you suggest that this practice should also be stopped?

    You seem to be very concerned about not making claims for efficacy without RCT evidence. However having seen thousands of patients during my career as a medical herbalist, I can tell you that many people who use orthodox medicines for which claims of benefit exist, have experienced no benefits whatsoever. Conversely I have patients who have experienced dramatic improvements in chronic and debilitating conditions as a result of the treatment I offer, and I believe it would be unethical to deny these people access to the only treatment that has proven to be beneficial for them and force them to return to a life of suffering. Individuals have the right to choose the form of healthcare which works for them. I have never had a serious adverse reaction occur to herbal treatment occur in my practice, and I doubt very much you would ever meet an orthodox physician who could make the same claim.

    So again I ask you, what are you trying to achieve? If you are truly concerned about public safety, then it might be more appropriate for you to research the real outcomes of individual herbal medicine, perhaps in comparison to orthodox medicine. How many people have actually been harmed by individual herbal medicine under the care of an appropriately qualified practitioner, compared to harm caused by self-prescribed herbs, or indeed by orthodox medical treatments for any given condition? I doubt you will be interested in this – The truth is that individual herbal medicine, when practiced by an appropriately qualified practitioner is effective, and it is extremely safe. I therefore can only conclude that this is does not have anything to do with public safety – it’s just a good old fashioned witch hunt.

    • Skepticat_UK says:

      Marie,

      I’m sure you know that chronic conditions sometimes clear up of their own accord and you also know about the placebo effect. So how do you know for sure that your patients’ improvements are a result of the treatment you’ve offered?

      Do you not see that the only way you can be sure is by testing it in a way that, as far as possible, eliminates other possibilities? That’s what the best RCTs do. This is not to deny that “clinical experience, and the collective experience of other herbalists, is a valid form of evidence”. Sackett who, with respect, I’m inclined to think has a greater understanding of the subject than you do, said evidence-based medicine is “about integrating individual clinical expertise and the best external evidence”. He doesn’t suggest that individual clinical experience alone suffices and the history of medicine is replete with examples of bad decisions made because of “clinical experience”.

      You ask EE what he is trying to achieve. What he is achieving – very successfully it would seem – is the raising of public awareness that most of the products and services offered under the general heading of CAM do not live up to the claims made for them and he is doing this not by the favoured quacks’ strategy of ad hominem plus ‘whataboutery’ but by pointing to the evidence.

      Your comments about orthodox medicine are a straw man. Instead of putting words into EE’s mouth, I’d recommend engaging with what he is actually saying. Here’s a summary of his main contentions:

      (1) there are at least two dramatically different kinds of herbal medicine, one of which is “supported by some reasonably sound evidence”; (2) failing to be aware of the distinction leads to people consulting practitioners whose whole practice (diagnosis and prescribing custom) is flawed; (3) contrary to what some claim, individualized herbalism CAN and HAVE been tested in clinical trials and have failed to prove effective for anything. (4) All things considered, “It seems to follow therefore that the risks of individualized herbalism do not outweigh its benefit” so consulting a herbalist is a waste of time.(5) The regulation of herbalism will give it a respectability it doesn’t deserve;

      So far you have failed to mount a half-decent challenge to any of these but have instead wasted a lot of words banging on about perceived problems of orthodox medicine, which have no bearing whatsoever on anything Edzard has written.

      • Guido Mase says:

        Skepticat, how do you reconcile your statement that “consulting a herbalist is a waste of time” with Dr. Ernst’s statements that, for instance, “there is a significant benefit in symptom control and physiologic outcomes from hawthorn extract as an adjunctive treatment for chronic heart failure” (Cochrane meta-review, 2008) and that, after surveying the herbs used by traditional UK herbalists in 1998, Dr. Ernst found that “some of these herbs have been tested in clinical trials”? As I have stated, it cannot be a waste of time to consult a practitioner who uses evidence-based treatments in an ethical and critical manner. Please refrain from making such statements, as they are logical leaps of faith and not grounded in evidence.

        Regarding point (3), as Dr. Ernst points out, individualized prescriptions for IBS were found superior to placebo. That is beside the point – but it makes your point (3) inaccurate as well.

        • edzard says:

          i have just pointed out that our conclusions from the cochrane review of hawthorn/crataegus are out-dated. so is out survey which you cite. why did you make such misleading comments?

          • Guido Mase says:

            I am simply quoting the most current research available. As I clearly point out above, the Cochrane meta-review is still the most current research available on the endpoints of symptoms of heart failure – dyspnea, exercise intolerance e.g. The “physiologic outcomes” part of your quote does appear to be outdated – but the rest of the quote certainly isn’t! It’s great.
            Regarding your survey, I agree it’s time for an update! But to assume its findings are incorrect now is simply an assumption without any evidence. I can’t guess, so I go with the best research available to date.

        • Skepticat_UK says:

          Guido,

          You’ve lifted that quote from my summary of the above blog’s main points – these are not my arguments, they are Edzard’s, though I don’t disagree with them. My statement that “consulting a herbalist is a waste of time” is simply another way of putting Edzard’s conclusion that “consulting a herbalist is not a reasonable approach to treating any human ailment”. Of course it’s not a waste of time to consult a practitioner who uses evidence-based treatments in an ethical and critical manner, if one can only find such a person.

      • Marie Reilly says:

        I have treated thousands of patients over many years of practice. Most come to me because they have had very little or no benefit from orthodox medicine, or because they have experienced adverse effects. It must be an incredible co-incidence if they all just happened to come to me just before their severe or chronic condition was about to clear up of its own accord! For many of my patients Herbal medicine is the only effective treatment option they have found. For example, Women with severe menopausal symptoms (such as sleeplessness, depression and anxiety) which leave them virtually unable to function, experience complete relief from symptoms within a few weeks. Their other option is HRT which is known to be associated with serious adverse effects including increased risk of stroke and breast cancer. You quite correctly say that “the risks of herbal medicine do not outweigh its benefits”. Indeed there is no hard evidence of harm being caused by herbal medicine when prescribed by an appropriately trained practitioner. I have never had an incidence of harm being caused to any of my patients, yet you would deny them the only thing that offers them relief from their debilitating symptoms because of lack of RCT evidence. The same story could be told of people with other debilitating conditions, such as rheumatoid arthritis, recurrent infections, migraines, pre-menstrual syndrome, PCOS, eczema. People who know that herbal medicine works, who have experienced no harm, and who would be forced to return to suffering, or to take drugs with known adverse effects (such as methotrexate, steroids, and HRT etc) because Skepticat demands proof by RCT. Ultimately you do not have the right to deny people their freedom to choose the type of medicine they wish to use.

        • Edzard says:

          there is little evidence of harm because there is no functioning adverse-effect surveillance system.
          there is no evidence [anecdotes are not evidence] of efficacy for many herbs.
          IN THSES CASES, THE RISK BENEFIT BALANCE FAILS TO BE POSITIVE

        • Skepticat_UK says:

          Oh nice try, Marie, but I notice that while you’ve been busy putting words into my mouth that I neither said nor implied, you haven’t actually answered the very simple question I put to you. Here it is again:

          How do you know for sure that your patients’ improvements are a result of the treatment you’ve offered?

          If all you have are anecdotes, we have no reason to think your treatments are any better than those offered by any other quack or witch doctor throughout history.

          • Marie Reilly says:

            I don’t really care whether any of you think my treatments are any better than a quack or a witch doctor, and I have not answered your questions because I do not believe you have any intention of even trying to understand my position, and I do not wish to waste my time. What I do care about is your attempts to restrict the freedom of people to choose the type of medicine they wish to avail of. Other than accusing me of putting words in your mouth, you have made no comment about what becomes of all the patients who experience relief from chronic health problems while being treated with herbal medicine, if you manage to discredit herbalists to the point that they are put out of business, particularly those patients who have found themselves unresponsive to or unable to tolerate orthodox treatments.

            It is only an opinion that RCT evidence is the “best” form of evidence. It may be a widely held one, especially by those who have the power to decide who gets regulated and who doesn’t, but it is an opinion nevertheless. Many drugs that have been tested and are supposedly “evidence based” later turn out to be unsafe. Most recently, the H1N1 vaccine was found to cause narcolepsy. Many people DO place more faith in the track record of a particular substance over many years, and in the anecdotal experience of practitioners and other individuals, and it is their right to do so. Most importantly, they trust their own experiences. They know how they felt before taking herbal medicine. They see differences when their prescriptions are changed (even when they don’t know they have been changed), they know how they feel if they stop taking it prematurely, and they know they feel better when they start taking it again. The effects are obvious and tangible, and for both the individuals and for any practitioner witnessing this over many years, it goes well beyond what could ever be achieved by a placebo effect. Again it is only an opinion that this sort of evidence “doesn’t count”.

            I am a medical herbalist, but I am also a parent and at times, a patient myself. I am not convinced that an RCT proves that a drug or intervention is necessarily safe or effective, and I am not happy to rely on this type of evidence when choosing healthcare for myself or my family. I trust what I see with my own eyes, after many years of experience in herbal medicine. I do not trust “evidence” based on research conducted over a short period of time by researchers who may well be biased. Clearly many people do prefer this type of evidence, and that is their right to avail of this type of “evidence-based” treatment. However I do not wish to be forced into a form of medicine I do not trust, any more than I would suspect you would like to be forced into using herbal medicine.

            The bottom line is that a great deal of harm is caused by what you call “evidence based” medicine, due to adverse effects that only emerge after long periods of use. Examples include HRT, which is now known to increase risk of breast cancer and stroke, bisphosphonates, which are now known to increase risk of osteonecrosis and complicated fractures, and H1N1 vaccine, which is now known to cause narcolepsy. I believe that individuals have the right to choose what type of medicine they can avail of, and that provided the type of evidence base is made clear (i.e. clinical trial/historical/anecdotal etc. ), they can make an informed personal choice. The bottom line is that individualised herbal medicine is NOT causing harm on anything like the scale of so called “evidence-based” orthodox medicine. In trying to undermine the work of herbalists or put them out of business by discrediting them, you are likely to increase the incidence of people self-diagnosing, self prescribing, and buying potentially harmful (adulterated or substituted) herbal remedies from unreliable sources on the internet.

            Professor Ernst’s comment below, in answering the question about what he hopes to achieve, certainly seems well-intentioned. However, in saying “i want therapeutic decisions and claims to be based on as good evidence as possible”, perhaps he should accept that some people have different opinions about what comprises “good evidence”, and to dictate that the type of evidence preferred by one group is the only type that counts, is not acceptable in a democratic society. Similarly, one could argue that much of evidence-based medicine has turned out not to have the safety or efficacy profile that it was originally thought to have, which could equally be interpreted as a “bogus claim”. Of course,consumers must be made aware of the type of evidence on which therapeutic decisions and claims for efficacy are based, but a democratic society, people still have the right to choose. Likewise it sounds fair that “i want the same standards to be applied in all types of health care”, however, this is not currently the case since if any herb was found to have the sort of adverse effects as bisphosphonates or HRT, they would immediately be banned (and rightly so), whereas the drugs I have mentioned are still widely used. Finally I would argue that when professor Ernst says “i want patients to benefit from the best available health care for their respective conditions” he needs to accept that for some individuals, the best treatment for them is individualised herbal medicine, and it is not acceptable to try to deny them access to the only thing they have found which benefits their condition.

          • Skepticat_UK says:

            Marie said,

            I don’t really care whether any of you think my treatments are any better than a quack or a witch doctor, and I have not answered your questions because I do not believe you have any  intention of even trying to understand my position, and I do not wish to waste my time. What I do care about is your attempts to restrict the freedom of people to choose the type of medicine they wish to avail of.

            Understand your position? It’s actually the position of your customers I’m concerned about. Unlike you, I don’t have an axe to grind one way or the other. I’m only a consumer of treatments, I don’t make a living out of them and the only thing I want to know is whether a treatment that I or any of my loved ones spends our hard-earned money on is safe and effective. What we are attempting to do is not “restrict the freedom of people to choose” but restrict the freedom of practitioners to boost their income by making unsupportable claims about the therapies they are promoting to us, the public.

             you have made no comment about what becomes of all the patients who experience relief from chronic health problems while being  treated with herbal medicine,

            I don’t know of any such people. I know of people who experience relief from chronic health problems without having any treatment whatsoever – indeed, I am one of those people. I know of people who’ve experienced relief from chronic health problems after getting counselling for some other thing that’s gone wrong in their lives – who’s to say it wasn’t the ‘talk therapy’ that made them better? Without testing we – and that includes you – can’t know for sure whether a treatment is effective or not.

            You say it is “only an opinion” that RCTs provide the best evidence. It is actually the consensus opinion of scientists, including those who don’t work for Big Pharma. You are at liberty to disagree and, as you are someone who makes a living from providing treatments that are presumably unsupported by such evidence, I completely understand your position on this one.

            However, your suggestion that ‘trusting what you see with your own eyes’ is more reliable than RCTs is….well, let’s just say ‘unconvincing’ and certainly doesn’t help me, as a consumer, to make an informed choice.

            Again it is only an opinion that this sort of evidence “doesn’t count”.

            What work are the quotation marks doing here? Nobody has said anything of the sort. In my first response to you I defined EBM according to Sackett. Have another read. It is getting tiresome having to ask you to stop attributing to people things they have not said.

            The bottom line is that a great deal of harm is caused by what you call “evidence based” medicine, due to adverse effects that only emerge after long periods of use. Examples include HRT,…

            You still seem to be having trouble grasping the concept of EBM; it is not synonymous with ‘any orthodox treatment’ as you seem to think. HRT is an interesting example because HRT was widely believed, in the early 1990s, not only to reduce unpleasant menopausal symptoms but also heart disease and osteoporosis. Do you know why this was widely believed? Because a large prospective cohort study and several other observational studies – ie not RCTs – suggested this was the case. Do you know how they found out that HRT actually increased the risks of heart disease and breast cancer? By conducting an RCT! (Rossouw et al, 2002) Since you claim you are  “not happy to rely on this type of evidence”, I’m surprised you embrace the results of this particular one so confidently.

            I believe that individuals have the right to choose what type of medicine they can avail of, and that provided the type of evidence base is made clear (i.e. clinical trial/historical/anecdotal etc. ), they can make an informed personal choice.

            Well it’s interesting that you should claim to believe this because this website attributes to you a list of ‘Helpful Herbs’ for which you make a number of very clear and specific claims but without any reference to any sort of evidence for these claims. And on this website you list a number of specific conditions, some of them serious, which you claim “respond well to herbal treatment” but again you don’t say how you arrived at that conclusion. With evidence like that, what option do we have other than to take your expressed belief that customers can make an “informed personal choice” but with a large grain of salt?

            In trying to undermine the work of herbalists or put them out of business by discrediting them…

            Discrediting them? Moi? You’re doing a great job of that all by yourself, mate.

    • edzard says:

      what do i want to achieve?
      i want therapeutic decisions and claims to be based on as good evidence as possible.
      i want consumers not to be mislead by bogus claims.
      i want the same standards to be applied in all types of health care.
      i want all health care practitioners to be critical, self-critical and abide by their code of ethics.
      i want patients to benefit from the best available health care for their respective conditions.
      i want us all to realise that we will never reach these aims, but that we nevertheless have to try as hard as we can.

  • edzard says:

    GUIDO: you cannot guess??? aren’t you guessing in your clinical practice all the time, as demonstrated by your last comments?
    Curcuma: i see, evidence-based means safe to you!?! what about efficacy? i had thought we are trying to do more GOOD than harm.

    • Guido Mase says:

      Dr. Ernst, I don’t know where I ever said I “guess” in my practice.
      I employ well-researched herbs, and use them for the indications for which they have been researched.
      I employ herbs from the traditional record as long as they have a documented track record of safety, even if they lack a specific evidence base. These herbs I use in order to increase my clients’ fruit and vegetable intake, and I use them alongside plants such as tomatoes, kale, broccoli, garlic, apples, blueberries and walnuts which also lack a specific evidence base. This strategy, because it’s safe and tasty, serves the goal of doing more GOOD without doing any HARM by increasing my clients’ fruit and veg intake – a proven, efficacious, safe approach to addressing human ailments.

      > Misquoting Holubarsch et al, 2008 re: Crataegus – unaddressed.
      > The fact that traditional herbalists use evidence-based herbs in their practice, often alone though often in combination with safe, food like herbs, meaning that consulting an herbalist can indeed be a valid approach to treating human ailments – unaddressed.
      > The flawed logic of suggesting people consume no fruits or veg because there is no fruit (except perhaps Crataegus) or vegetable the use of which is supported by evidence – unaddressed.

      • edzard says:

        you have provided more than enough confirmation of what i wrote about TRADITIONAL HERBALISTS in my post. in fact, i fail to understand why you challenged it in the first place.
        now that we have gone full circle and bored the pants off my readers, i declare this discussion between us exhausted and CLOSED

  • Edwina Hodkinson says:

    Mr Ernst
    I have read many of your papers with interest over the last ten years. Whilst I’m aware you are an esteemed professor of complementary and alternative medicine, I’m really intrigued to know what your experience is of CAM that qualifies you as an an “expert” and whether you have have you any qualifications, training, practical experience in CAM other than as researcher. I am always astounded that someone who is a professor can be so anti- CAM and why the views of those academics and researchers with vast amounts of experience and skill as CAM clinicians and researchers such as the highly respected Dr Peter Mackereth are not taken into consideration.

    You speak of the lack of evidence in Herbal practice. as an Ex nurse may I also point out the lack evidence in much of Orthodox practice (50%). How many life saving operations are performed by experienced and skilled surgeons that have not been extensively proven by randomised controlled trials and “evidence”. Their success is anecdodal and supported by the skill and expertise of the surgeon .

    • Alan Henness says:

      Edwina Hodkinson said:

      I also point out the lack evidence in much of Orthodox practice (50%).

      Can you give a source for that figure? And are you saying that, if that figure was correct, that it’s therefore OK for the evidence for herbals to be as poor? Or do you think herbalists might want to try to do better than that?

  • Edzard says:

    INTERESTING POINTS
    i have addressed them often and do it again:
    1) my expertise in CAM: i have learnt many CAMs hands on as a clinician and i have researched the area since 2 decades full time.
    2) dr peter mackereth, a cam researcher? as i did not know this author/expert, i did a quick medline search with his name and COMPLEMENTARY ALTERNATIVE MEDICINE. This resulted in 20 hits. none of the articles were in major journals and none were clinical trials as far as i can see. perhaps his papers are not THAT important after all?
    [the equivalent search with ERNST E resulted in 530 hits.]
    3) i am not anti-CAM [for instance, i have identified ~ 20 treatments which the NHS should pay for because they are based on good evidence http://www.ncbi.nlm.nih.gov/pubmed/18318982
    maybe you confuse anti with critical; i am a scientist, and an uncritical scientist is a contradiction in terms
    4) if it were my job to research conventional medicine, i would certainly lament the often shaky evidence in this area.

  • Miss Tickle says:

    So if you know that some herbs work, in practice not theory, and there hasn’t yet been any research done into the particular herb or combination of herbs for various reasons (including lack of interest by big pharma), a qualified medical herbalist (and all that that means regarding training and safety competence) should not use them until “science” catches up and confirms what was known all along, ie, that they work? All genuine healers /medics don’t want to do harm, and make sure they source their medicines appropriately and work safely.
    I think each person is different and their diseases equally so. If this wasn’t the case, why is there such a move (admittedly it seems in the US mainly at the moment) towards integrative medicine? You could argue orthodox biomedicine has reached its limit. Check out http://www.inimh.org which was founded in 2010.
    I think the idea that a disease is the same for each person as the reason for producing standardised medicines is potentially the paradigm that should be debated.

    • Skepticat_UK says:

      Miss Tickle thinks:

      …each person is different and their diseases equally so. If this wasn’t the case, why is there such a move (admittedly it seems in the US mainly at the moment) towards integrative medicine?

      Premise: There is a move towards integrative medicine, though mainly in the US.
      Conclusion: Therefore each person and their disease is different.

      Not great reasoning, if I may say so.

      It’s not clear what you actually mean by “move towards” and “integrative medicine” but, assuming you mean quack therapies are becoming more popular (in the US), there are several possible reasons for this and none of them necessarily support the notion a disease will be different for different people, in some way other than degree of severity and complications.

      You could argue orthodox biomedicine has reached its limit”.

      Could you? Let’s hear it. As altmed is appears to be losing credibility and popularity in the UK, could we not argue that altmed has reached its limit?

      • Miss Tickle says:

        Hi skeptikat_uk
        I did put a link which explains ‘integrative medicine’ quite well if u look around the site. Their library is full of academic journals as well. ‘Move towards’ is quite clear really, but I don’t mind if you want to be pedantic. I think things like the IMIMH are a ‘move forwards’ by the health community showing a willingness to consider and research different forms of healthcare that may then result in a positive synthesis for the benefit of the patient and therefore us all.
        Regarding your last comment, well, yes, I equally ask where is your evidence for such a comment. My comment is based on the facts like complications from prescribed medicine killing more people than heroine or cocaine in the US and the hundreds of thousands of hospital admissions due to side effects from medicines which compare to the hundreds for something like herbal medicine.
        I don’t think diseases are generic as each patient is unique in their presentation and therefore their treatment regime should be equally unique (if possible) to ensure maximum success. I think that could be called holistic and integrative, considering biopsychosocial factors as well as biomedical.
        I would concede that a generic approach might be generally more successful in say serious
        infectious disease but not in say for example endocrinological disease.
        Anyway I’m sure you’ll something to bite my ankles about but here’s hoping for more calm discussion.

        • Skepticat_UK says:

          Miss Tickle

          Thank you for your response. I questioned what you meant by those terms not because I “want to be pedantic” but because I wanted to be sure I didn’t misinterpret you. Happily, I see from the site you link to that I didn’t. By ‘integrative medicine’ you do indeed mean quack therapies. I see you define ‘moving towards’ as

          showing a willingness to consider and research different forms of healthcare that may then result in a positive synthesis for the benefit of the patient and therefore us all.

          Is that not what the American National Center for Complementary and Alternative Medicine has spent millions of dollars doing for the past twenty years? Are you aware that you are commenting on the blog of the world’s first professor of complementary medicine, who has spent many years researching them? The problem is that all this research has not resulted in “the positive synthesis for the benefit of the patient” that supporters of quackery were hoping for. As a result, we are moving away from quackery: demand is falling, homeopathic hospitals and clinics are closing, colleges that used to offer courses in CAM have stopped doing so and even our biggest high street chemist has reduced its stock of quack remedies and demoted them to the bottom shelf.

          I note with interest that your sole argument in support of your contention that “orthodox biomedicine has reached its limit” are unreferenced and unquantified assertions about the extent of harm caused by complications and side-effects of mainstream medicine in the US, compared to herbal medicine. Do you estimate that herbal medicine (or any other quack therapy) has saved more lives than orthodox medicine? If you do, and you can provide the stats, you have a killer argument. (No pun intended).

          Anyway I’m sure you’ll something to bite my ankles about but here’s hoping for more calm discussion.

          Probably not the best way to end a comment if you’re hoping for calm discussion but never mind.

          • Alan Henness says:

            Skepticat_UK said:

            Is that not what the American National Center for Complementary and Alternative Medicine has spent millions of dollars doing for the past twenty years?

            Not just millions, but over one BILLION dollars since its inception as the Office of Alternative Medicine in 1993, with nothing of any real value to show for any of it.

  • Edzard says:

    AND HERE IS HOW ‘THE BIOLOGIST’ [FEB/MARCH] ISSUE DESCRIBES THE VIEWS OF SIMON MILLS WHO IS A PROMINENT REPRESENTATIVE OF THE INDIVIDUALIZED/TRADITIONAL HERBALISM I WAS WRITING ABOUT:
    “DISEASE AND CONSTITUTIONAL MALADIES..[ARE]…UNDERSTOOD IN SIMPLE TERMS RELATED TO HOT, COLD, DAMP OR DRY. FOR EXAMPLE, COLD ITSELF IS SURVIVABLE, BUT BUT COLD AND DAMP LEADS TO ILLNESS. TREATMENT IS TO USE WARMING SPECIES…”
    SEE WHAT I MEAN? THIS HAS NOTHING TO DO WITH PHARMACOLOGY, SCIENCE, EVIDENCE…IT IS PURE HUMBUG!!!

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