MD, PhD, FMedSci, FSB, FRCP, FRCPEd

herbal medicine

The news that the use of Traditional Chinese Medicine (TCM) positively affects cancer survival might come as a surprise to many readers of this blog; but this is exactly what recent research has suggested. As it was published in one of the leading cancer journals, we should be able to trust the findings – or shouldn’t we?

The authors of this new study used the Taiwan National Health Insurance Research Database to conduct a retrospective population-based cohort study of patients with advanced breast cancer between 2001 and 2010. The patients were separated into TCM users and non-users, and the association between the use of TCM and patient survival was determined.

A total of 729 patients with advanced breast cancer receiving taxanes were included. Their mean age was 52.0 years; 115 patients were TCM users (15.8%) and 614 patients were TCM non-users. The mean follow-up was 2.8 years, with 277 deaths reported to occur during the 10-year period. Multivariate analysis demonstrated that, compared with non-users, the use of TCM was associated with a significantly decreased risk of all-cause mortality (adjusted hazards ratio [HR], 0.55 [95% confidence interval, 0.33-0.90] for TCM use of 30-180 days; adjusted HR, 0.46 [95% confidence interval, 0.27-0.78] for TCM use of > 180 days). Among the frequently used TCMs, those found to be most effective (lowest HRs) in reducing mortality were Bai Hua She She Cao, Ban Zhi Lian, and Huang Qi.

The authors of this paper are initially quite cautious and use adequate terminology when they write that TCM-use was associated with increased survival. But then they seem to get carried away by their enthusiasm and even name the TCM drugs which they thought were most effective in prolonging cancer survival. It is obvious that such causal extrapolations are well out of line with the evidence they produced (oh, how I wished that journal editors would finally wake up to such misleading language!) .

Of course, it is possible that some TCM drugs are effective cancer cures – but the data presented here certainly do NOT demonstrate anything like such an effect. And before such a far-reaching claim is being made, much more and much better research would be necessary.

The thing is, there are many alternative and plausible explanations for the observed phenomenon. For instance, it is conceivable that users and non-users of TCM in this study differed in many ways other than their medication, e.g. severity of cancer, adherence to conventional therapies, life-style, etc. And even if the researchers have used clever statistical methods to control for some of these variables, residual confounding can never be ruled out in such case-control studies.

Correlation is not causation, they say. Neglect of this elementary axiom makes for very poor science – in fact, it produces dangerous pseudoscience which could, like in the present case, lead a cancer patient straight up the garden path towards a premature death.

The aim of this survey was to investigate the use of alternative medicines (AMs) by Scottish healthcare professionals involved in the care of pregnant women, and to identify predictors of usage.

135 professionals (midwives, obstetricians, anaesthetists) involved in the care of pregnant women filled a questionnaire. A response rate of 87% was achieved. A third of respondents (32.5%) had recommended (prescribed, referred, or advised) the use of AMs to pregnant women. The most frequently recommended AMs modalities were: vitamins and minerals (excluding folic acid) (55%); massage (53%); homeopathy (50%); acupuncture (32%); yoga (32%); reflexology (26%); aromatherapy (24%); and herbal medicine (21%). Univariate analysis identified that those who recommended AMs were significantly more likely to be midwives who had been in post for more than 5 years, had received training in AMs, were interested in AMs, and were themselves users of AMs. However, the only variable retained in bivariate logistic regression was ‘personal use of AM’ (odds ratio of 8.2).

The authors draw the following conclusion: Despite the lack of safety or efficacy data, a wide variety of AM therapies are recommended to pregnant women by approximately a third of healthcare professionals, with those recommending the use of AMs being eight times more likely to be personal AM users.

There are virtually thousands of websites which recommend unproven treatments to pregnant women. This one may stand for the rest:

Chamomile, lemon balm, peppermint, and raspberry leaf are also effective in treating morning sickness. Other helpful herbs for pregnancy discomforts include:

  • dandelion leaf for water retention
  • lavender, mint, and slippery elm for heartburn
  • butcher’s broom, hawthorn, and yarrow, applied externally to varicose veins
  • garlic for high blood pressure
  • witch hazel, applied externally to haemorrhoids.

Our research has shown that midwives are particularly keen to recommend and often sell AMs to their patients. In fact, it would be difficult to find a midwife in the UK or elsewhere who is not involved in this sort of thing. Similarly, we have demonstrated that the advice given by herbalists is frequently not based on evidence and prone to harm the unborn child, the mother or both. Finally, we have pointed out that many of the AMs in question are by no means free of risks.

The most serious risk, I think, is that advice to use AM for health problems during pregnancy might delay adequate care for potentially serious conditions. For instance, the site quoted above advocates garlic for a pregnant women who develops high blood pressure during pregnancy and dandelion for water retention. These two abnormalities happen to be early signs that a pregnant women might be starting to develop eclampsia. Treating such serious conditions with a few unproven herbal remedies is dangerous and recommendations to do so are irresponsible.

I think the new survey discussed above suggests a worrying degree of sympathy amongst conventional healthcare professionals for unproven treatments. This is likely to render healthcare less effective and less safe and is not in the interest of patients.

Cancer patients are bombarded with information about supplements which allegedly are effective for their condition. I estimate that 99.99% of this information is unreliable and much of it is outright dangerous. So, there is an urgent need for trustworthy, objective information. But which source can we trust?

The authors of a recent article in ‘INTEGRATIVE CANCER THARAPIES’ (the first journal to spearhead and focus on a new and growing movement in cancer treatment. The journal emphasizes scientific understanding of alternative medicine and traditional medicine therapies, and their responsible integration with conventional health care. Integrative care includes therapeutic interventions in diet, lifestyle, exercise, stress care, and nutritional supplements, as well as experimental vaccines, chrono-chemotherapy, and other advanced treatments) review the issue of dietary supplements in the treatment of cancer patients. They claim that the optimal approach is to discuss both the facts and the uncertainty with the patient, in order to reach a mutually informed decision. This sounds promising, and we might thus trust them to deliver something reliable.

In order to enable doctors and other health care professionals to have such discussion, the authors then report on the work of the ‘Clinical Practice Committee’ of ‘The Society of Integrative Oncology’. This panel undertook the challenge of providing basic information to physicians who wish to discuss these issues with their patients. A list of supplements that have the best suggestions of benefit was constructed by leading researchers and clinicians who have experience in using these supplements:

  1. curcumin,
  2. glutamine,
  3. vitamin D,
  4. maitake mushrooms,
  5. fish oil,
  6. green tea,
  7. milk thistle,
  8. astragalus,
  9. melatonin,
  10. probiotics.

The authors claim that their review includes basic information on each supplement, such as evidence on effectiveness and clinical trials, adverse effects, and interactions with medications. The information was constructed to provide an up-to-date base of knowledge, so that physicians and other health care providers would be aware of the supplements and be able to discuss realistic expectations and potential benefits and risks (my emphasis).

At first glance, this task looks ambitious but laudable; however, after studying the paper in some detail, I must admit that I have considerable problems taking it seriously – and here is why.

The first question I ask myself when reading the abstract is: Who are these “leading researchers and clinicians”? Surely such a consensus exercise crucially depends on who is being consulted. The article itself does not reveal who these experts are, merely that they are all members of the ‘Society of Integrative Oncology’. A little research reveals this organisation to be devoted to integrating all sorts of alternative therapies into cancer care. If we assume that the experts are identical with the authors of the review; one should point out that most of them are proponents of alternative medicine. This lack of critical input seems more than a little disconcerting.

My next questions are: How did they identify the 10 supplements and how did they evaluate the evidence for or against them? The article informs us that a 5-step procedure was employed:

1. Each clinician in this project was requested to construct a list of supplements that they tend to use frequently in their practice.

2. An initial list of close to 25 supplements was constructed. This list included supplements that have suggestions of some possible benefit and likely to carry minimal risk in cancer care.

3. From that long list, the group agreed on the 10 leading supplements that have the best suggestions of benefit.

4. Each participant selected 1 to 2 supplements that they have interest and experience in their use and wrote a manuscript related to the selected supplement in a uniformed and agreed format. The agreed format was constructed to provide a base of knowledge, so physicians and other health care providers would be able to discuss realistic expectations and potential benefits and risks with patients and families that seek that kind of information.

5. The revised document was circulated among participants for revisions and comments.

This method might look fine to proponents of alternative medicine, but from a scientific point of view, it is seriously wanting. Essentially, they asked those experts who are in favour of a given supplement to write a report to justify his/her preference. This method is not just open bias, it formally invites bias.

Predictably then, the reviews of the 10 chosen supplements are woefully inadequate. These is no evidence of a systematic approach; the cited evidence is demonstrably cherry-picked; there is a complete lack of critical analysis; for several supplements, clinical data are virtually absent without the authors finding this embarrassing void a reason for concern; dosage recommendations are often vague and naïve, to say the least (for instance, for milk thistle: 200 to 400 mg per day – without indication of what the named weight range refers to, the fresh plant, dried powder, extract…?); safety data are incomplete and nobody seems to mind that supplements are not subject to systematic post-marketing surveillance; the text is full of naïve thinking and contradictions (e.g.”There are no reported side effects of the mushroom extracts or the Maitake D-fraction. As Maitake may lower blood sugar, it should be used with caution in patients with diabetes“); evidence suggesting that a given supplement might reduce the risk of cancer is presented as though this means it is an effective treatment for an existing cancer; cancer is usually treated as though it is one disease entity without any differentiation of different cancer types.

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. But I do wonder, isn’t being in favour of integrating half-baked nonsense into cancer care and being selected for one’s favourable attitude towards certain supplements already a conflict of interest?

In any case, the review is in my view not of sufficient rigor to form the basis for well-informed discussions with patients. The authors of the review cite a guideline by the ‘Society of Integrative Oncology’ for the use of supplements in cancer care which states: For cancer patients who wish to use nutritional supplements, including botanicals for purported antitumor effects, it is recommended that they consult a trained professional. During the consultation, the professional should provide support, discuss realistic expectations, and explore potential benefits and risks. It is recommended that use of those agents occur only in the context of clinical trials, recognized nutritional guidelines, clinical evaluation of the risk/benefit ratio based on available evidence, and close monitoring of adverse effects. It seems to me that, with this review, the authors have not adhered to their own guideline.

Criticising the work of others is perhaps not very difficult, however, doing a better job usually is. So, can I offer anything that is better than the above criticised review? The answer is YES. Our initiative ‘CAM cancer’ provides up-to-date, concise and evidence-based systematic reviews of many supplements and other alternative treatments that cancer patients are likely to hear about. Their conclusions are not nearly as uncritically positive as those of the article in ‘INTEGRATIVE CANCER THERAPIES’.

I happen to believe that it is important for cancer patients to have access to reliable information and that it is unethical to mislead them with biased accounts about the value of any treatment.

Times of celebration are often also times of over-indulgence and subsequent suffering. Who would not know, for instance, how a hangover can spoil one’s pleasure at the start of a new year? But where is the research that addresses this problem? Scientists seem to be cynically devoid of sympathy for the hangover-victim – well, not all scientists.

During the course of my research-career, I must have conducted well over 60 clinical trials, but none was remotely as entertaining as the one my Exeter-team did several years ago to test whether an artichoke extract is effective in preventing the signs and symptoms of alcohol-induced hangover.

We recruited healthy adult volunteers from our own ranks to participate in a randomized double-blind crossover trial. Participants received either 3 capsules of commercially available standardized artichoke extract or indistinguishable, inert placebo capsules immediately before and after alcohol exposure. After a 1-week washout period the volunteers received the opposite treatment. Each participant predefined the type and amount of alcoholic beverage that would give him/her a hangover and ate the same meal before commencing alcohol consumption on the two study days. The primary outcome measure was the difference in hangover severity scores between the artichoke extract and placebo interventions. Secondary outcome measures were differences between the interventions in scores using a mood profile questionnaire and cognitive performance tests administered 1 hour before and 10 hours after alcohol exposure.

The mean number of alcohol units consumed per person during treatment with artichoke extract and placebo were  10.7 and 10.5 respectively, equivalent to 1.2 g of alcohol per kilogram body weight. The volume of non-alcoholic drink consumed and the duration of sleep after the binge were similar during the artichoke extract and placebo interventions. The hangovers we experienced the mornings after our alcohol exposure were monumental but unaffected by the treatments. None of the outcome measures differed significantly between interventions. Adverse events of the treatment were rare and were mild and transient. Our results therefore suggested that artichoke extract is not effective in preventing the signs and symptoms of alcohol-induced hangover.

While it was great fun to obtain ethic’s approval and run this trial, the results of our two binges in the name of science were, of course, a disappointment. As diligent researchers we felt we had to do a little more for the poor victims of over-indulgence.

We thus decided to conduct a systematic review aimed at assessing the clinical evidence on the effectiveness of any medical intervention for preventing or treating alcohol hangover. We conducted systematic searches to identify all RCTs of any medical intervention for preventing or treating alcohol hangover. Fifteen potentially relevant trials were found. Seven publications failed to meet all inclusion criteria. Eight RCTs assessing 8 different interventions were reviewed. The agents tested were propranolol, tropisetron, tolfenamic acid, fructose or glucose as well as the dietary supplements Borago officinalis (borage), Cynara scolymus (artichoke), Opuntia ficus-indica (prickly pear), and a yeast based preparation. All studies were double blind. Significant intergroup differences for overall symptom scores and individual symptoms were reported only for tolfenamic acid, gamma linolenic acid from borage, and a yeast based preparation.

We concluded that the most effective way to avoid the symptoms of alcohol induced hangover is to practise abstinence or moderation.

WISE WORDS PERHAPS, BUT EASIER SAID THAN DONE, I’M SURE.

Web-sites have become a leading source of information on health matters. This is particularly true in the realm of alternative medicine. Conventional health care professionals often know too little about this subject to advise their patients, and alternative practitioners are usually too biased to be trusted. So many consumers turn to the Internet and hope that it offers information which is reliable. But is it?

American pharmacists published a study evaluating the quality of on-line information on herbal supplements. They conducted a search of 13 common herbals – including black cohosh, echinacea, garlic, ginkgo, ginseng, green tea, kava, saw palmetto, and St John’s wort - and reviewed the top 50 Web sites for each using a Google search. Subsequently, they analysed clinical claims, warnings, and other safety information.

A total of 1179 Web sites were examined in this way. Less than 8% of retail sites provided information regarding potential adverse effects, drug interactions, and other safety information; only 10.5% recommended consultation with a healthcare professional. Less than 3% cited scientific literature to support their claims.

The authors’ conclusions were worrying: Key safety information is still lacking from many online sources of herbal information. Certain nonretail site types may be more reliable, but physicians and other healthcare professionals should be aware of the variable quality of these sites to help patients make more informed decisions.

Having conducted my fair share of similar research (e.g. here or here or here or here), I can only concur with these conclusions. When it comes to health care, the Internet is a scary place! In the realm of alternative medicine, it is dominated by people who seem not to care much about anything other than their profits.

But what can be done to change this situation? How can we protect the public from Internet-charlatans? How can one control the Internet? I wish I knew! But there are nevertheless means of directing consumers to those sites which do offer reliable information. Kite-marking high quality sites might be one way of achieving this. This task would, of course, be huge and difficult, but in the interest of public safety, governments and other official institutions should consider tackling it.

Hypercholesterolemia is an important, independent risk factor for cardiovascular disease, according to a generally accepted wisdom. Measures to normalise elevated blood lipids include diet, exercise and drugs, of which statins are the most widely prescribed. But many people have become somewhat sceptical about the wide-spread use of statins: Traditionally, doctors have viewed statin drugs as the most effective way to lower high LDL cholesterol. But today researchers are starting to believe that statins may not be the magic bullet they’ve always been made out to be. Statins can cause severe adverse effects and some experts have questioned whether they generate more benefit than harm and suggested that ‘BIG PHARMA’ are pushing statins not for the benefit of public health but for maximising profit.

This begs the question: is there an alternative?

This RCT tested the efficacy of a dietary supplement providing 1.8 g/day esterified plant sterols and stanols to improve the fasting lipid profile of men and women with primary hypercholesterolemia. Repeated measures analysis of covariance was used to compare outcomes for sterol/stanol and placebo treatment conditions using the baseline value as a covariate. Thirty subjects were randomized and all of them completed the trial.

Baseline (mean±standard error of the mean) plasma lipid concentrations were: total cholesterol 236.6±4.2 mg/dL (6.11±0.11 mmol/L), high-density lipoprotein (HDL) cholesterol 56.8±3.0 mg/dL (1.47±0.08 mmol/L), LDL cholesterol 151.6±3.3 mg/dL (3.92±0.09 mmol/L), non-HDL cholesterol 179.7±4.6 mg/dL (4.64±0.12 mmol/L), and triglycerides 144.5±14.3 mg/dL (1.63±0.16 mmol/L). Mean placebo-adjusted reductions in plasma lipid levels were significant (P<0.01) for LDL cholesterol (-4.3%), non-HDL cholesterol (-4.1%), and total cholesterol (-3.5%), but not for triglycerides or HDL cholesterol.

The authors conclude that these results support the efficacy of 1.8 g/day esterified plant sterols/stanols in softgel capsules, administered as an adjunct to the National Cholesterol Education Program Therapeutic Lifestyle Changes diet, to augment reductions in atherogenic lipid levels in individuals with hypercholesterolemia.

These findings are encouraging but certainly not rock solid. The study was too small, and the effect sizes were less than impressive. A brand-new systematic review, however, provides much more convincing data.

Its aim was to quantify the LDL-cholesterol-lowering effect of plant sterols/stanols as supplements. Eight eligible clinical trials were identified. Among the trials with a duration between 4 and 6 weeks, plant sterol/stanol dose ranged from 1.0 to 3.0 g/day administrated mainly with the main meals (2 or 3 times/day). Intake of plant sterol/stanol supplements decreased LDL-cholesterol concentrations by 12 mg/dL (0.31 mmol/L) compared with placebo. Further analysis showed no significant difference between the LDL-cholesterol-lowering action of plant sterols/stanols supplements vs foods enriched with plant sterols/stanols. The authors concluded that plant sterol/stanol supplements as part of a healthy diet represent an effective means of delivering LDL-cholesterol-lowering similar to plant sterols/stanols delivered in various food formats.

Crucially, this positive verdict does not stand alone. Another recent review included 5 trials and concluded that a dose-effect relationship of plant stanols in higher doses than currently recommended has been demonstrated by recent clinical studies and a meta-analysis.

Plant sterols seem to be not just effective but also safe: none of the trials published to date reported significant adverse effects. The only concern is the potential decrease in the concentrations of lipid-soluble antioxidants and vitamins, including β-carotene, α-tocopherol, lutein, and α-carotene. It is currently not clear whether these effects are clinically relevant.

The relative merits of phytosterols versus statins are not easy to evaluate. We have hundreds of studies of statins but just a few of sterols. This means our knowledge in this area is incomplete. Statins can cause serious adverse effects but their effects on blood lipids is about one order of magnitude larger that those of sterols. There is plenty of evidence to show that statins lower the risk of cardiovascular disease, while such data are missing for phytosterols.

The choice between statins and plant sterols is thus not easy, particularly considering the often emotional arguments and hype used in the ‘cholesterol-debate’. Phytosterols offer one more alternative therapy for lowering LDL-cholesterol levels. They seem safe and have the added attraction of being ‘natural’ – but the lipid-effects are relatively small, the impact on cardiovascular morbidity and mortality is uncertain, and fairly high doses are required to see any lipid-lowering at all.

For those who know about the subject, this is an old hat, of course. But for many readers of this blog, it might be news: ‘Traditional’ Chinese Medicine (TCM) is not nearly as traditional as it pretends to be. In fact, it is an artefact of recent creation. The man who has been saying that for years is Professor Paul Unschuld, one of the leading sinologist worldwide and an expert who has written many books and journal articles on the subject.

During an interview given in 2004, he defined TCM as “an artificial system of health care ideas and practices generated between 1950 and 1973 by committees in the People’s Republic of China, with the aim of restructuring the vast and heterogenous heritage of Chinese traditional medicine in such a way that it fitted the principles–Marxist Maoist type democracy and modern science and technology on which the future of the PRC was to be built…[the Daoist underpinning for TCM] is incorrect for two reasons.  First . . . TCM is a product of Communist China.  Second, even if we were to apply the term TCM to pre-revolutionary Chinese medicine, the Daoist impact should be considered minimal.”

In a much more recent interview entitled INVENTION FROM THE FAR EAST which he gave to DER SPIEGEL (in German), he explained this in a little more detail (I have tried to translate his words as literally as possible):

What is being offered in our country to patients as TCM is a construct that was created in China on an office desk which has been altered further on its way to the West.

Already at the beginning of the 20th century, reformers and revolutionaries urged that the traditional medicine in China should be abolished and that the western form of medicine should be introduced instead. Traditional thinking was seen as backwards and it was held responsible for the oppressing superiority of the West. The introduction of Western natural sciences, medicine and technology was also thought later, after the foundation of the People’s Republic, to be essential for rendering the country competitive again. Since the traditional Chinese medicine could not be totally abolished then because it offered a living to many citizens, it was reduced to a kernel, which could be brought just about in line with the scientific orientation  of the future communist society. In the 1950s and 60s, an especially appointed commission had been working on this task. The filtrate which they created from the original medical tradition was hence forward to be called TCM vis a vis foreigners.

There is little more to add, I think - perhaps just two brief after-thoughts. TCM is a most lucrative export article for China. So don’t expect Chinese officials to rid TCM of the highly marketable ‘TRADITIONAL’ label. And remember: the appeal to tradition’ argument is a fallacy anyway.

We have probably all fallen into the trap of thinking that something which has stood the ‘test of time’, i.e. something that has been used for centuries with apparent success, must be ok. In alternative medicine, this belief is extremely wide-spread, and one could argue that the entire sector is built on it. Influential proponents of ‘traditional’ medicine like Prince Charles do their best to strengthen this assumption. Sadly, however, it is easily disclosed as a classical fallacy: things that have stood the ‘test of time’ might work, of course, but the ‘test of time’ is never a proof of anything.

A recent study brought this message home loud and clear. This trial tested the efficacy of Rhodiola crenulata (R. crenulata), a traditional remedy which has been used widely in the Himalayan areas and in Tibet to prevent acute mountain sickness . As no scientific studies of this traditional treatment existed, the researchers conducted a double-blind, placebo-controlled crossover RCT to test its efficacy in acute mountain sickness prevention.

Healthy adult volunteers were randomized to two treatment sequences, receiving either 800 mg R. crenulata extract or placebo daily for 7 days before ascent and two days during mountaineering. After a three-month wash-out period, they were crossed over to the alternate treatment. On each occasion, the participants ascended rapidly from 250 m to 3421 m. The primary outcome measure was the incidence of acute mountain sickness with headache and at least one of the symptoms of nausea or vomiting, fatigue, dizziness, or difficulty sleeping.

One hundred and two participants completed the trial. No significant differences in the incidence of acute mountain sickness were found between R. crenulata extract and placebo groups. If anything, the incidence of severe acute mountain sickness with Rhodiola extract was slightly higher compared to the one with placebo: 35.3% vs. 29.4%.

R. crenulata extract was not effective in reducing the incidence or severity of acute mountain sickness as compared to placebo.

Similar examples could be found by the dozen. They demonstrate very clearly that the notion of the ‘test of time’ is erroneous: a treatment which has a long history of usage is not necessarily effective (or safe) – not only that, it might be dangerous. The true value of a therapy cannot be judged by experience, to be sure, we need rigorous clinical trials. Acute mountain sickness is a potentially life-threatening condition for which there are reasonably effective treatments. If people relied on the ‘ancient wisdom’ instead of using a therapy that actually works, they might pay for their error with their lives. The sooner alternative medicine proponents realise that, the better.

Herbal medicine is popular. Consumers seem to be attracted by the notion that they are natural – and if it’s natural, it must be safe!!! But do we really know what is in the product that we might be buying? A recently published analytical study aimed to investigate herbal product integrity and authenticity with the goal of protecting consumers from health risks associated with product substitution and contamination.

The researchers used DNA barcoding to conduct a blind test of the authenticity for (i) 44 herbal   products representing 12 companies and 30 different species of herbs, and (ii) 50 leaf samples collected from 42 herbal species. They also assembled the first   standard reference material (SRM) herbal barcode library from 100 herbal species of   known provenance that were used to identify the unknown herbal products and leaf samples.

DNA barcodes from 91% of the herbal products and all leaf samples could be recovered. 59% of the products tested contained DNA barcodes from plant species not listed on the labels. 48% of the products could be authenticated but one-third of these also contained contaminants and or fillers not listed on the label. Product substitution occurred in 30 of the 44 products tested and only 2 of the 12 companies sold products without any substitution, contamination or fillers. Some of the contaminants we found pose serious health risks to consumers.

Based on these findings, the authors drew the following conclusions: Most of the herbal products tested were of poor quality, including considerable product substitution, contamination and use of fillers. These activities dilute the effectiveness of otherwise useful remedies, lowering the perceived value of all related products because of a lack of consumer confidence in them. We suggest that the herbal industry should embrace DNA barcoding for authenticating herbal products through testing of raw materials used in manufacturing products. The use of an SRM DNA herbal barcode library for testing bulk materials could provide a method for ‘best practices’ in the manufacturing of herbal products. This would provide consumers with safe, high quality herbal products.

These findings are fairly alarming. I have previously blogged about the fact that herbal products are far to often adulterated or contaminated. Now it seems that we have to add to this list of dangers the substitution of the herbal ingredient with a presumably less expensive but potentially toxic herb that should not legally be there at all.

One cannot very well write a blog about alternative medicine without giving full credit to the biggest and probably most determined champion of quackery who ever hugged a tree. Prince Charles certainly has done more than anyone else I know to let unproven treatments infiltrate real medicine. To honour his unique achievements, I am here presenting a fictitious interview with him. It never did take place, of course, and the questions I put to him are pure imagination. However, the ‘answers’ are in a way quite real: they have been taken unaltered from various speeches he made and articles he wrote. To avoid being accused of using dodgy sources which might have quoted him inaccurately or sympathetically, I have exclusively used HRH’s very own official website as a source for his comments. It seems safe to assume that HRH identifies with them more fully than with the many other statements he made on this subject.

I have not changed a single word in his statements and I have tried to avoid quoting him out of context; I did, however, take the liberty of putting sentences side by side which do not always originate from the same speech or article, i.e. I have used quotes from different communications to appear as though they originally were in sequence. It will be clear from the text that the fictitious interview is dated before Charles’ Foundation folded because of money laundering and fraud.

It is, of course, hugely tempting to comment on the various statements by Charles. However, I have resisted this temptation; I wanted the reader to enjoy his wisdom in its pure and unadulterated beauty. Anyone who feels like it will have plenty of opportunity to post comments, if they so wish.

To make clear what is what, my questions appear in italics, while his ‘answers’ are in Roman typeface.

 

Q I believe you have no training in science or medicine; yet you have long felt yourself expert enough to champion bizarre forms of therapies which many of our readers might call quackery.

As you know by now, this is an area to which I attach the greatest importance and where I have tried to make a particular contribution. For many years, the NHS has found complementary medicine an uncomfortable bedfellow – at best regarded as ‘fringe’ and in some quarters as ‘quack’; never viewed as a substitute for conventional medicine and rarely as a genuine partner in providing therapy.

I look back to the rather “lukewarm” response I received in 1983 as President of the British Medical Association when I first spoke about integration and complementary and alternative medicine. We have clearly travelled a very long way since that time.

Q Alternative medicine is mainly used by those who can afford it; at present, little of it is available on the NHS. Why do you want to change this situation? 

The very popularity of non-conventional approaches suggests that people are either dissatisfied with the kind of orthodox treatment they are receiving, or find genuine relief in such therapies. Whatever the case, it is only reasonable to try to identify the factors that are contributing to their increased use. And if advantages are found, clearly they should not be limited only to those people who can pay, but should be made more widely available on the NHS.

Q If with a capital “I”?

I believe it is because complementary and alternative approaches to healthcare bring a different emphasis to bear which often unlocks an individual’s inner resources to aid recovery or help to manage living with a serious chronic illness. It is also because complementary and alternative therapies often offer more effective and less intrusive ways of treating illness.

Q Really? Are you sure that they are more effective that conventional treatments? What is your evidence for that?

In 1997 the Foundation for Integrated Medicine, of which I am the president and founder, identified research and development based on rigorous scientific evidence as one of the keys to the medical establishment’s acceptance of non-conventional approaches. I believed then, as I do now, that the move to a more integrated provision of healthcare would ultimately benefit patients and their families.

Q But belief is hardly a good substitute for evidence. In this context, it is interesting to note that chiropractors and osteopaths received the same status as doctors and nurses in the UK. Is this another of your achievements? Was it based on belief or on evidence?

True healing is a synergy that comes not by courtesy of a medical diploma.

Q What do you mean?

As we know, the professions of Osteopathy and Chiropractice are now regulated in the same way as doctors and dentists, with their own Acts of Parliament. I’m very proud to have played a tiny role in trying to push for that Act of Parliament over the years. It has also been reassuring to see the progress being made by the other main complementary professions and I look forward to the further development of regulatory frameworks enabling high standards of training, clinical practice and professional behaviour.

Q Some might argue that statutory regulation made them not more professional but merely improved their status and thus prevented asking question about evidence. Why did they need to be regulated in that way?

The House of Lord’s Select Committee Report on Complementary and Alternative Medicine in 2000, quite sensibly recommended that only complementary professions which were statutorily regulated, or which had well-established arrangements for voluntary self-regulation, should be made available through the NHS.

Q Integrated healthcare seems to be your new buzz-word, what does it mean? Is it more than a passing fad?

Integrated Healthcare is, I believe, here to stay. The public want it and need it. It is not a takeover of the orthodox by CAM or the other way around, but is rather the bringing together of the best from both for the ultimate benefit of the patient.

Q Your lobby-group, Foundation for Integrated Medicine, what has it ever done to justify its existence?

In 1997 the steering group of The Foundation for Integrated Medicine (FIM), of which I am proud to be president, published a discussion document ‘Integrated Healthcare – A Way Forward for the Next Five Years?’

Q Sorry to interrupt, but if so many people are already using them, why do you feel compelled to promote unproven treatments even more? Why is ‘a way forward’ in promotion actually needed? Why did we need a lobby group like FIM?

Homoeopaths, osteopaths, reflexologists, acupuncturists, T’ai chi instructors, art therapists, chiropractors, herbalists and aromatherapists: these practitioners were working alongside NHS colleagues in acute hospitals, on children’s wards, in nursing homes and in particular in primary healthcare, in GP practices and health clinics up and down the country.

Q Exactly! Why then even more promotion of unproven treatments?

All well and good, perhaps, but if there are advantages in this approach, clearly they should not be limited only to those who can pay.

Q Yes, if again with a capital “I”, presumably . Anyway, do you believe these therapies should be tested like other treatments?

One of the obstacles always raised is that it is very difficult to trial complementary therapies in the rigorous randomised way that mainstream medicine deems to be the gold standard. This is ironic as there are, of course, un-evaluated orthodox practices which continue to be funded by the NHS.

Q Are you an expert on research methodology as well?

At the same time, we should be mindful that clinically controlled trials alone are not the only pre-requisites to apply a healthcare intervention. Consumer-based surveys can explore WHY people choose complementary and alternative medicine and tease out the therapeutic powers of belief and trust

These “rationalist selves” would be enormously relieved to see the effectiveness of these treatments proven through the “double-blind randomized controlled trial” – the gold-standard of medical research. However, we know that some complementary and alternative medicine disciplines (and indeed other forms of medical or surgical intervention) do not lend themselves to this research method.

Q Are you sure? This sounds like something someone who is ignorant of research methodology has told you.

… it has been suggested that we need a research method for complementary treatment that is, to use that awful expression, “fit for purpose”. Something that is entirely practical – what has been called “applied” research – which takes into account the whole person and the whole treatment as it is actually given in the surgery or the hospital. Something that might offer us a better idea of the cost-effectiveness of any given approach. It would also help to provide the right sort of evidence that health service commissioners require when they decide which services they wish to commission for their patients.

Q Hmm – anyway, would you promote unproven treatments even for serious conditions like cancer?

Two surveys have indicated that up to eighty per cent of cancer patients try alternative or complementary treatments at some stage following diagnosis and seventy-five per cent of patients would like to see complementary medicine available on the N.H.S.

Q Yes, but why the promotion?

There is a major role for complementary medicine in bowel cancer – as a support to more conventional approaches – in helping to prevent it through lifestyle changes, helping to boost our immune systems and in helping sufferers to come to terms with, and maintain, a sense of control over their own lives and wellbeing. My own Foundation For Integrated Medicine is, for example, involved in finding ways to integrate the best of complementary and alternative medicine.

Q And what do you understand by “the best”? In medicine, this term should mean “the most effective”, shouldn’t it?

Many cancer patients have turned to an integrated approach to managing their health, finding complementary therapies such as acupuncture, aromatherapy, reflexology and massage therapy extremely therapeutic. I know of one patient who turned to Gerson Therapy having been told that she was suffering from terminal cancer, and would not survive another course of chemotherapy. Happily, seven years later she is alive and well. So it is therefore vital that, rather than dismissing such experiences, we should further investigate the beneficial nature of these treatments.

Q Gerson? Is it ethical to promote an unproven starvation diet for cancer? 

…many patients use and believe in Gerson Therapy, yet more evidence needs to be available as to who might benefit or what adverse effects there might be. But, surely, we need to take a wider view of the most appropriate types of research methodology – a wider view of what research will help patients.

Q You are a very wealthy man; will you put your own money into the research that you regularly demand?

Complementary medicine is gaining a toehold on the rockface of medical science.

Q I beg your pardon.

Complementary medicine’s toehold is literally that, and it’s an inescapable fact that clinical trials, of the calibre that medical science demands, cost money. Figures from the Department of Complementary Medicine at the University of Exeter show that less than 8p out of every £100 of NHS funds for medical research was spent on complementary medicine. In 1998-99 the Medical Research Council spent no money on it at all, and in 1999 only 0.05% of the total research budget of UK medical charities went to this area.

Q HmmNature; you are very fond of all things natural, aren’t you?

The garden is designed to remind people of our interconnectedness with Nature and of the beneficial medicinal properties She provides through countless plants, flowers and trees. Throughout the 20th century so much ancient, accumulated, traditional wisdom has been thrown away – whether in the fields of medicine, architecture, agriculture or education. The baby was thrown out with the bathwater, so this garden is designed to bring the baby back again and to remind us of that priceless, traditional knowledge before we lose that rich store of Nature’s healing gifts for the benefit of our descendants.

When you think about it, what on earth is the point of throwing away our lifeline; of abandoning the priceless knowledge and wisdom accumulated over 1,000’s of years relating to the treatment of the human condition by natural means? It is sheer folly it seems to me to forget that we are a part of Nature and to imagine we can survive on this Earth as if we were merely a mechanical process divorced from, and in opposition to, the unity of the world around us.

Q …and herbalism?

Medical herbalists talk about ‘synergy’, the result of a complex mix of active ingredients in a plant that create a more powerful therapeutic effect together than if isolated. It’s a concept that has a wider application. As the 17th century poet John Donne famously wrote, “No man is an Island, entire of itself; every man is a piece of the Continent, a part of the main.”

Q I am not sure I understand; what does that mean?

Medical herbalists, who make up their own preparations from combinations of fresh or dried plants, believe that this mix within individual herbs as well as in traditional mixtures of plant medicines creates what is called synergy, in which all the chemical components contribute to the remedy’s specific therapeutic effects.

At a time when farmers everywhere are struggling to make ends meet, the development of a natural pharmacy of organically grown herbs offers an alternative means of earning a living. Yet without protective measures, herbs are easily adulterated or their quality compromised.

Q …and homeopathy?

I went to open the new Glasgow Homeopathic Hospital for instance a couple of years ago, I met a whole lot of students who were studying homeopathy, I think, and I’ve never forgotten when they said to me ‘Are you interested in homeopathy’ and I thought – I don’t know, why do I bother?

Q And why exactly do you bother, if I may ask?

By allowing patients treatment choice, negative emotions can, in part, be alleviated. Many complementary practitioners provide time, empathy, hope and reassurance – skills that are referred to as the “human effect” – which can improve the confidence of cancer patients, alter mindsets and produce major positive changes in the immune system. As a result the “human effect” can greatly prolong life: it has been demonstrated that in a variety of cancers, such as breast cancer, that attitude of mind can not only raise the quality of life but in some cases can even prolong life. At the same time, we need specific treatments that are designed to improve the quality of patients’ lives, and to provide relief from the unpleasant symptoms of cancer – anxiety; pain; sleeplessness; skin irritation; poor appetite; nausea and depression, to name but a few.

Q At heart you seem to be a vitalist who believes in a vital force or energy that interconnects anything with everything and determines our health.

Research in the new field of psychoneuroimmunology – or mind-body medicine as it is sometimes called – is discovering that there is a constant interplay between our emotions, thoughts and actions and our body systems. It seems that the food we eat, the air we breathe, the exercise we take, our relationships with other people, all have a direct bearing on our health and natural healing processes. Complementary medicine has always known this and I believe it is one of the reasons for its enormous popularity.

Q Clarence House made several statements assuring the British public that you never overstep your constitutional role by trying to influence health politics; they were having us on, weren’t they?

A few days ago I launched an initiative to promote the provision of more complementary medicine in the NHS. For many years I have been working towards this goal.

Q Does that mean these statements were wrong?

I am convinced there is no better moment than now to create a real integration of our healthcare, particularly when there is talk of a Patient-Centred NHS. So much ill-health and disease is due to the misery, stress and alienation we see in our community.

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