Herbal medicine – most remedies useless

[Blue Wode]

In today's news:



Traditional herbal remedies have never been more fashionable: sales have almost doubled in eight years. There's just one problem: science suggests that they don't work.

An estimated 16 million people use them, and surveys suggest that four out of five are satisfied with the results. Sales have almost doubled since 1999 to £191m, fostered by celebrities led by Prince Charles. There are at least 1,000 registered practitioners and an uncountable number who are unregistered. Can so many people be wrong?

The answer is yes, according to two experts who have launched the latest assault on herbal medicine, the practice of treating ailments with either a single "natural" plant, refined and standardised, or a concoction individually tailored to a patient's needs.

Dr Peter Canter and Professor Edzard Ernst from the Peninsula Medical School at the University of Exeter called yesterday for the sale of herbal medicines to be banned unless evidence of their efficacy can be shown. Where there are known risks and no evidence of benefit, there can be no justification for allowing them to remain on to the market, they said.

Read on…

http://news.independent.co.uk/health/article3024732.ece

[Asolepius]

The BBC (http://news.bbc.co.uk/1/hi/health/7024880.stm)could not even get Peter Canter's name right, and calls him Carter all the way through.

This is a tiny sample and generalisation must be limited. What it does demonstrate is that herbal medicine is not evidence-based, but it doesn't rule out the emergence of evidence in the future. I think it's very unlikely though, simply because the theory and methodology surrounding the practice are mystical and not science based.

[Blue Wode]

Here’s the paper:

A systematic review of randomised clinical trials of individualised herbal medicine in any indication.

R Guo, P H Canter, E Ernst, Post Grad Med J 2007;83:633-637

http://press.psprings.co.uk/pgmj/october/633_pj60202.pdf

[Asolepius]

Edzard Ernst also has an editorial in the same issue, where he draws a distinction between phytotherapy (evidence based), retail herbalism (over the counter stuff), and mystical herbalism. Not available online but I have read it.

[Deetee]

Ernst: "The gullibility of the public is monstrous."

:)

(True, but it might just antagonise them/us)

[Blue Wode]

Edzard Ernst also has an editorial in the same issue, where he draws a distinction between phytotherapy (evidence based), retail herbalism (over the counter stuff), and mystical herbalism. Not available online but I have read it.


You can find it here at the moment:

http://press.psprings.co.uk/pgmj/october/615_pj60780.pdf

[Deetee]

I should point out that this study does not show that herbal remedies themselves are ineffective, just that individualised herbal medicine has not been shown to be effective.

Ernst and Cantor did not look at single herb extracts or over-the counter type products.

[Blue Wode]

Thanks for clarification. Originally I had been focusing on the sub-title of the Independent article:



Traditional herbal remedies have never been more fashionable: sales have almost doubled in eight years. There's just one problem: science suggests that they don't work.

http://news.independent.co.uk/health/article3024732.ece

[Cainkane1]

In the old days the healers sometimes with a measure of success were able to treat certain diseases with herbal or plant based remedys. To this day certain primitive tribes are treated successfully with local medicines. Not entirely worthless but I'd ratyher go to a real doctor.

[lanienus]

Hummm-wait a minute-I know they work because I see alot of people in the special store buying all the special foods, additives, and remedies such as ear cleaning candles etc.
If the majority thinks it works, that is good enough for me! I follow my religion with the same logic.

[Bethany]

If herbal remedies work at all, it's most likely because of the placebo effect. So I say that if someone has tried all avenues of regular medicine to no avail and finds some relief through herbal stuff, then fine. The problem is making sure people turn to regular medicine first rather than to quackery. And making sure the quacks don't charge people too much for their placebos.

[Professor Yaffle]

Here's the Guardian article on the same topic (including a few examples of herbs that work and with dangerous side effects):

http://www.guardian.co.uk/medicine/story/0,,2183054,00.html?gusrc=rss&feed=networkfront

[Deetee]

Here's the Guardian article on the same topic (including a few examples of herbs that work and with dangerous side effects):

http://www.guardian.co.uk/medicine/story/0,,2183054,00.html?gusrc=rss&feed=networkfront
It quotes Ernst as saying

"In my view, self-medication for serious conditions is out of the question," said Professor Ernst. "A depressed patient who takes St John's wort and comes out of depression arguably gathers enough strength to commit suicide, so it is dangerous."

:rolleyes:

[Professor Yaffle]

Well that is a known risk with all anti depressants. Often the greatest risk period for suicide is when the drug has just started to have an effect. Your mood can still be terribly low, but your motivation levels have increased somewhat making you more likely to take action. Not sure that I necessarily agree with Ernst's point though. Every time I have been prescribed an AD I have been seen once a month to check how things were going, and I don't think that is close enough supervision to reduce that risk.

[JJM]

If herbal remedies work at all, it's most likely because of the placebo effect.Not quite. Some (many?) herbs have pharmaceutically active compounds. The problem is identifying those compounds and matching them with the condition to be treated. Short of that, there is probably a placebo effect (or, normal recovery).

I recently asked an academic pharmacognosist if there were any herbs that had been well-studied and shown effective- he only had two examples (offhand). So, you may be right that a lot of "herbal" effects are placebo or wishful thinking; but we still hope to find drugs in natural products.

So I say that if someone has tried all avenues of regular medicine to no avail and finds some relief through herbal stuff, then fine. The problem is making sure people turn to regular medicine first rather than to quackery. And making sure the quacks don't charge people too much for their placebos.Agreed.

[Professor Yaffle]

From the Guardian article I linked to:


What works - and the risks
Kava kava
For anxiety. Banned in Britain because of three deaths and six transplants resulting from liver toxicity
Ginkgo biloba
Leaves of the oldest living tree species - for dementia. Some concern over possible increased risk of brain haemorrhage
Devil's claw
For musculo-skeletal pain, such as backache. May increase stomach acid and should be avoided by people with ulcers
Saw palmetto
For enlarged prostate. Should not be taken with drugs like aspirin or warfarin which increase bleeding, and may interfere with the pill
St John's wort
For depression. Interacts with some conventional drugs, such as immune system suppressants, causing heart transplants to be rejected, and the pill
Valerian
For insomnia. High doses may cause a drug "hangover" effect
Hawthorn
For congestive heart disease. Too serious a condition for self-treatment
Willow bark
For pain relief. Consult doctor if you have asthma or ulcers
Andrographis paniculata
For the common cold. Not available in the UK
Echinacea
North American flower for the common cold. Some people have allergic reactions

[Physiotherapist]

If herbal remedies work at all, it's most likely because of the placebo effect. So I say that if someone has tried all avenues of regular medicine to no avail and finds some relief through herbal stuff, then fine. The problem is making sure people turn to regular medicine first rather than to quackery. And making sure the quacks don't charge people too much for their placebos.

Not so. Perhaps you are confusing herbs with homeopathy? Herbs actually do have a physical effect on the body.

As far as I know, medical herbalists are extremely well trained - some are trained in clinical diagnosis. Training does vary though.

[Naughtyhippo]

umm, why would people be taking saw palmetto (prostate enlargement) be taking the pill? or is saw palmetto ONLY effective for prostate enlargement but people take it for something else?

[Professor Yaffle]

Some women use it for PCOS related hirsutism (as it is anti androgenic) - but I don't know if research has shown it is effective for this. The extract I quoted is a little confusing in that respect; the cautions against use aren't necessarily relevant when taking it for the condition it is shown to be effective for, but are relevant when taking it for other conditons.

[Physiotherapist]

umm, why would people be taking saw palmetto (prostate enlargement) be taking the pill? or is saw palmetto ONLY effective for prostate enlargement but people take it for something else?


If you mean the contraceptive pill, then that is Wild Yam.

[Professor Yaffle]

If you mean the contraceptive pill, then that is Wild Yam.

What is?

ETA - I just looked up Wild Yam. We weren't talking about a herb that acts as a contraceptive, but a particular herb which can interfere with the action of the contraceptive pill.

[JJM]

{snip} Herbs actually do have a physical effect on the body.Some do- the question remains what those effects are, and whether they are safe. For example, ephedra suppressed appetites as advertised; unfortunately, at that dose it could cause serious death. On the other hand, an ineffective herbal treatment for warts might actually be useful for another condition. Herbalists are unlikely to find real uses for their products.

As far as I know, medical herbalists are extremely well trained - some are trained in clinical diagnosis. Training does vary though.Trained by whom, other misguided herbalists? Herbalists make thousands of unsubstantiated claims. Diagnosis?? They may think they have such training, as do chiropractors; but, at most, they learn "conversational" medical terms. For example, I know that "urticaria" is the medical term for "hives;" but I don't know what it suggests or what to do about it. All quacks overstate their abilities.

[JJM]

From the Guardian article I linked to:The Guardian cites known, effective herbs for certain indications. However, "known, effective" depends on one's standards. They list echinacea for colds, and saw palmetto for enlarged prostate. In those cases, the best clinical evidence shows them ineffective. In the other cases, I doubt there is any good clinical evidence. Most studies herbalists cite are of poor quality and/or too small. Newspapers can't discriminate between junk and the real thing.

[Professor Yaffle]

I think they probably got the list from Ernst himself, but where he said they were herbs where there is some research showing efficacy, they just changed that to "what works".

ETA: I think this because Ernst has written about these herbal remedies before: http://www.annals.org/cgi/content/abstract/136/1/42

[Physiotherapist]

Trained by whom, other misguided herbalists? Herbalists make thousands of unsubstantiated claims. Diagnosis?? They may think they have such training, as do chiropractors; but, at most, they learn "conversational" medical terms. For example, I know that "urticaria" is the medical term for "hives;" but I don't know what it suggests or what to do about it. All quacks overstate their abilities.


I am sorry to tell you that this is just not true. I know someone who underwent training in herbal medicine and during his course, he had to study biochemistry, physiology, pathology and differential diagnosis. He also had to study pharmacology, so her knew about herb and drug interactions. He was then taught clinical diagnosis by medical doctors. This involved a lot more than just learning conventional medical terms. He had to learn how to conduct a physical examination of a patient and this was a requirement of his final exam in which he was examined by a qualified medical doctor.

When he was treating patients in the student clinic, himself and his colleagues were required to undertake physical examination of patients as needed.

I would not call him a quack - he is extremely well qualified with a first degree, a Masters degree and he is just about to start his PhD.

[David Rodale]

How many here have used any herbal preparation at all?

Is the removal of moles, warts and skin cancer using herbal medicine a placebo effect? My family have used herbal preparations successfully for many years due to a family history of susceptibility to moles and skin cancer; must have all been in our imagination.

If it can't be fully explained, does that make it worthless? No argument on this subject is desired as I'm not interested in convincing anybody, just that I know from personal experience there is merit to herbal medicine, even if it's just the one we've used for the last 15 years.

[pgwenthold]

Hey, do you know what they call herbal medicine that works?

"medicine"

[JJM]

I think they probably got the list from Ernst himself, but where he said they were herbs where there is some research showing efficacy, they just changed that to "what works".

ETA: I think this because Ernst has written about these herbal remedies before: http://www.annals.org/cgi/content/abstract/136/1/42I see. that review predates the best research on echinacea and saw palmetto. Still, I suspect the "data" supporting the other herbs for "effectiveness" in the review are as feeble.

Thanks for the link.

[David Rodale]

Hey, do you know what they call herbal medicine that works?

"medicine"

That's what I call it too.

[JJM]

I am sorry to tell you that this is just not true. I know someone who underwent training in herbal medicine and during his course, he had to study biochemistry, physiology, pathology and differential diagnosis. He also had to study pharmacology, so her knew about herb and drug interactions. He was then taught clinical diagnosis by medical doctors. This involved a lot more than just learning conventional medical terms. He had to learn how to conduct a physical examination of a patient and this was a requirement of his final exam in which he was examined by a qualified medical doctor.

When he was treating patients in the student clinic, himself and his colleagues were required to undertake physical examination of patients as needed.

I would not call him a quack - he is extremely well qualified with a first degree, a Masters degree and he is just about to start his PhD.This is standard quack Public Relations. How can one learn reliable "herbology" when 99.99% of their claims are unsubstantiated? This person is a fool. You have been mislead. I repeat: quacks always overstate their qualifications. Get with the program, don't be a dupe.

Do you know what a "sophomore" is? (A "wise fool.") Among other things, it describes a person who has a "first degree" and a "masters" who thinks he knows medical diagnosis. Such a claim is an insult to educated, health professionals (such as you claim to be).

[David Rodale]

This is standard quack Public Relations. How can one learn reliable "herbology" when 99.99% of their claims are unsubstantiated? This person is a fool. You have been mislead. I repeat: quacks always overstate their qualifications. Get with the program, don't be a dupe.

Do you know what a "sophomore" is? (A "wise fool.") Among other things, it describes a person who has a "first degree" and a "masters" who thinks he knows medical diagnosis. Such a claim is an insult to educated, health professionals (such as you claim to be).

Ah yes, the "orthodoxy".

[Physiotherapist]

I don't think that anywhere has he overstated his qualifications - he actually does have a BSc (Hons) degree and an MSc. If he has the degrees, then this is not an overstatement?

As I stated previously, he was examined in clinical diagnosis by a qualified medical doctor and was expected to perform a full clinical examination on a patient that had been brought into the clinic and that he had never met before.

I do not claim to be a professional - I am a professional!!

[JJM]

I don't think that anywhere has he overstated his qualifications - he actually does have a BSc (Hons) degree and an MSc. If he has the degrees, then this is not an overstatement?One can get an accredited degree in astrology. No matter, your friend is a fool no matter what s/he studied if s/he subscribes to unfounded herbology.
As I stated previously, he was examined in clinical diagnosis by a qualified medical doctor and was expected to perform a full clinical examination on a patient that had been brought into the clinic and that he had never met before.

I do not claim to be a professional - I am a professional!!Then, you should be less easily fooled, and more insulted, by the claims of a sophomore. As I said, get with the program and don't be duped.

On the other hand, if you think your friend is qualified to recommend hundreds of herbs- point me to the hundreds of definitive, clinical studies (published in top medical journals) that support those recommendations. I submit to you that those articles do not exist. A well-trained herbologist is no different from a well-trained astrologer.

As for "supervised diagnosis"- probably the doctor was a quack and easily impressed. Any doctor associated with herbologists is likely to be substandard.

I can identify miliaria, xerostomy, etc.; that does not qualify me to diagnose (or treat) general, medical problems. It is just description. Maybe you should talk to a doctor about how much training it takes to be competent in diagnosis.

[fls]

I am sorry to tell you that this is just not true. I know someone who underwent training in herbal medicine and during his course, he had to study biochemistry, physiology, pathology and differential diagnosis. He also had to study pharmacology, so her knew about herb and drug interactions. He was then taught clinical diagnosis by medical doctors. This involved a lot more than just learning conventional medical terms. He had to learn how to conduct a physical examination of a patient and this was a requirement of his final exam in which he was examined by a qualified medical doctor.

When he was treating patients in the student clinic, himself and his colleagues were required to undertake physical examination of patients as needed.

I would not call him a quack - he is extremely well qualified with a first degree, a Masters degree and he is just about to start his PhD.

What is he qualified to do?

Linda

[fls]

Hey, do you know what they call herbal medicine that works?

"medicine"

Many of our conventional medicines have a botanical source (I read 25%, will track down the source if necessary), even some newer drugs. So it's not like the "orthodoxy" is uninterested in herbals generally. I wonder if that which falls under "herbal" is that which is left over after researchers have filtered out the good stuff. Hardly any of what's out there under "food supplements" shows any useful effects when subject to reasonable trials.

Does anyone know more about this area of research (how botanicals enter the conventional stream)?

Linda

[Pipirr]

How many here have used any herbal preparation at all?

Is the removal of moles, warts and skin cancer using herbal medicine a placebo effect? My family have used herbal preparations successfully for many years due to a family history of susceptibility to moles and skin cancer; must have all been in our imagination.



You can remove moles, warts etc. with herbal medicine?

What do you use?

[Mojo]

David Colquhoun (http://dcscience.net/?p=169) on this.

[pgwenthold]

Does anyone know more about this area of research (how botanicals enter the conventional stream)?

Linda



I know an awful lot about it. Scientists scour all over collecting things like plants, fungi, bacteria, and random sea critters from the bottom of the ocean, chop them up, and test the pieces against known disease cultures. Things that kill the diseases get tested further, generally to the point where the active part is isolated.

There's a great IMAX movie about caves where a woman from NC State, I think, has been gathering samples from the most exotic environments possible (including secluded regions of caves) to test for biological activity. She collects a few examples in the cave movie (although you aren't told that in fact those samples all got lost somehow :()

Whereas not a great fraction our drugs are biological directly, it is still the case that most do come from biological motiffs. A good example is aspirin (acetylsalicylic acid). The original active ingrediant isolated from plants is salicylic acid, but Alfred Bayer figured out that you can make it much more tolerable to the stomach by making the acetate ester, and that's where we got aspirin. Most of the drugs we have nowadays are, if not biological in origin, modified from the biological source (despite all the great claims of combinatorial chemistry and drug design, there are still few (if any) drugs that have been developed that way.

[Big Les]

One can get an accredited degree in astrology. No matter, your friend is a fool no matter what s/he studied if s/he subscribes to unfounded herbology.
Then, you should be less easily fooled, and more insulted, by the claims of a sophomore. As I said, get with the program and don't be duped.

On the other hand, if you think your friend is qualified to recommend hundreds of herbs- point me to the hundreds of definitive, clinical studies (published in top medical journals) that support those recommendations. I submit to you that those articles do not exist. A well-trained herbologist is no different from a well-trained astrologer.

As for "supervised diagnosis"- probably the doctor was a quack and easily impressed. Any doctor associated with herbologists is likely to be substandard.

I can identify miliaria, xerostomy, etc.; that does not qualify me to diagnose (or treat) general, medical problems. It is just description. Maybe you should talk to a doctor about how much training it takes to be competent in diagnosis.

Harsh but probably fair. The guy in question may be well educated and qualified, but unless those are medical qualifications they're irrelevant to the issue of herbalism and its validity. I have an otherwise unqualified friend (who also drinks the anti "big pharma" kool ade) who has managed to cultivate a "Dr so-and-so" label amongst her own friends for being "qualified" in herbalism - she seems to think that her 2-year distance learning course in this subject qualifies her to diagnose and treat illnesses; I am far from convinced. The treatments she offers appear to yield little benefit, and the woman herself must be the sickest "dr" I've ever met!

[Professor Yaffle]

You can remove moles, warts etc. with herbal medicine?

What do you use?

When I was a kid I got a wart on my hand, and the GP told me that the pharmacists were on strike so I wouldn't be able to get the usual medicine (I was very young so I don't know if I am recalling this correctly, but the upshot was that I couldn't get the medicine). She told me to try an old wives tale she knew of which was putting dandelion sap on it. The wart came off after using it for a few days, but I have no idea if it was the dandelion that did it, or if it was just going to get better anyway.

I didn't pittle the bed either...

[Deetee]

I am sorry to tell you that this is just not true. I know someone who underwent training in herbal medicine and during his course, he had to study biochemistry, physiology, pathology and differential diagnosis. He also had to study pharmacology, so her knew about herb and drug interactions. He was then taught clinical diagnosis by medical doctors. This involved a lot more than just learning conventional medical terms. He had to learn how to conduct a physical examination of a patient and this was a requirement of his final exam in which he was examined by a qualified medical doctor.

When he was treating patients in the student clinic, himself and his colleagues were required to undertake physical examination of patients as needed.

I would not call him a quack - he is extremely well qualified with a first degree, a Masters degree and he is just about to start his PhD.

From what I can gather from a look at the web, the curriculum for training in herbal medicine is quite comprehensive.
Here is an example (http://www.inst.org/herbal/index.htm?GoogleAd), with an extract here (http://www.inst.org/herbal/extract.pdf). You will see it covers drug interactions.
(But as Ernst has pointed out, it appears this is all for nothing, since there is no evidence this therapeutic approach actually helps anyone - its like training herbal mechanics by teaching them all about the internal combustion engine, and then giving them a diploma at the end that allows them to wave plant extracts over a broken down car bonnet to try and get it to start.)

However I very much doubt whether herbalists can be suitable people to diagnose conditions other than simple maladies at best.
Doctors take 6 years basic training before qualifying, and then in the UK at least a further 2 years of supervised foundation training before they get certification and can progress.
A course in herbal medicine does not make for a reliable source of advice when one is ill.

[Blue Wode]

Jayney Goddard, founder and president of The Complementary Medicines Association (CMA), is not pleased…



HERBAL MEDICINE IS FAR FROM ‘HOCUS POCUS’

Yesterday’s study claiming that individually tailored herbal medicines can’t be trusted, worryingly doesn’t seem to recognise there are around literally thousands of scientific trials on high street products that show herbal remedies do work and are far from ‘hocus pocus’.

A new book published by Collins reveals 10,000 scientific trials that show a wide range of herbal medicines are effective. The Complementary Medicines Association (CMA) founder and president Jayney Goddard spent many years researching and editing Complementary and Alternative Health: The Scientific Verdict on What Really Works and is adamant that this sort of proof cannot be ignored by the medical establishment.

Read on…
http://www.responsesource.com/releases/rel_display.php?relid=34218&hilite




Good grief, how did Guo, Canter and Ernst manage to overlook these scientific trials? :rolleyes:

[fls]

I know an awful lot about it. Scientists scour all over collecting things like plants, fungi, bacteria, and random sea critters from the bottom of the ocean, chop them up, and test the pieces against known disease cultures. Things that kill the diseases get tested further, generally to the point where the active part is isolated.

There's a great IMAX movie about caves where a woman from NC State, I think, has been gathering samples from the most exotic environments possible (including secluded regions of caves) to test for biological activity. She collects a few examples in the cave movie (although you aren't told that in fact those samples all got lost somehow :()

Whereas not a great fraction our drugs are biological directly, it is still the case that most do come from biological motiffs. A good example is aspirin (acetylsalicylic acid). The original active ingrediant isolated from plants is salicylic acid, but Alfred Bayer figured out that you can make it much more tolerable to the stomach by making the acetate ester, and that's where we got aspirin. Most of the drugs we have nowadays are, if not biological in origin, modified from the biological source (despite all the great claims of combinatorial chemistry and drug design, there are still few (if any) drugs that have been developed that way.

Thanks! That's what I was looking for.

So what about all the stuff sold now as food supplements based on traditional use? If you're doing a general search looking for activity, it seems like you'd go through all that stuff first. Has it already been picked through and what's left (the stuff on the shelves as herbals) is that which didn't show useful activity? Or do some show useful activity, but further research is divorced from the herbal preparation and focussed on the specific active ingredient until that original connection is obscured?

Also, do you have a general idea of the percent yield on what you described above - scientists collecting various biologicals as a starting point?

Linda

[Physiotherapist]

Most courses in herbal medicine are at least 3 years long, if not 4 years and as far as I know, they do study pharmacology and clinical diagnosis.

JJM,

Perhaps you have a worthless degree too?

The doctors that conduct the clinical exams at the end of the course are brought in from outside the university to guard against in house exams and 'substandard' doctors as you call them.

[Henners]

Most courses in herbal medicine are at least 3 years long, if not 4 years and as far as I know, they do study pharmacology and clinical diagnosis.


However, the way that the world works is that alternative medicines that work become part of mainstream medicine.

As time goes on herbal medicine will "own" less and less.

We may already have reached the point where they own absolutely nothing.

[Deetee]

Most courses in herbal medicine are at least 3 years long, if not 4 years and as far as I know, they do study pharmacology and clinical diagnosis.


The diploma course I cited takes 9 months as a distance learning module. £440 gets you a nice shiny diploma that persuades the gullible that you are a "medical" herbalist.

Diplomas seem to be ten a penny.
I am sure many herbalists have this as their only qualification.

The BSc in herbal medicine seems to be different, consisting of a 3 year home based distance learning programme. I wonder how many of the "qualified herbalists" in practice today can even boast of this qualification? Do you know?

PS - The BSc can be upgraded to an MSc with very little effort (eg 16 days per year for two and a half years (http://www.herbalmedicine.org.uk/rootpages/masters.shtml))

PPS - this BSc course (http://www.uel.ac.uk/programmes/hab/undergraduate/herbalmedicine-bsc.htm) claims:The introduction to herbal medicine provides background knowledge of the historical and current practice of herbal medicine and introduces the student to research via the evidence base associated with herbal medicine, providing an understanding of the different types of research and how to critically evaluate the evidence.
I wonder if Ernst's review indicating there are no proper research studies will form part of their evidence base?

[fls]

Most courses in herbal medicine are at least 3 years long, if not 4 years and as far as I know, they do study pharmacology and clinical diagnosis.

JJM,

Perhaps you have a worthless degree too?

The doctors that conduct the clinical exams at the end of the course are brought in from outside the university to guard against in house exams and 'substandard' doctors as you call them.

I'm wondering what the expectations are from that training - what activities are they qualified for? It would be quite inadequate for clinical diagnosis and treatment generally (these areas depends quite heavily not just on more knowledge than provided by that training, but on way more practice with expert feedback (I have a lot of experience in this area)). But I don't think that's what's expected of them (or rather "hope", I guess). That training seems reasonable for them to be able to work with a narrow group of clinical conditions after someone with adequate general training (such as a physician) has determined that they fall into this area, though. It's also possible that that training is adequate for a practitioner to realize when a patient may have a condition that falls outside of their area of knowledge/experience.

Linda

[Physiotherapist]

The University of East London is not the only university to offer courses in herbal medicine. The University of Middlesex used to offer a 4 year BSc (Hons) degree, I believe that it is a 3 year course now and the University of Westminster offers a 3 year BSc (Hons) degree in herbal medicine.

Most people who are serious about practicing herbal medicine will go to one of the universities and get a degree qualification, although I agree that there are some who have the 9 month Diploma as their only qualification in herbal medicine, which is not good enough as there is a lot to learn.

University courses have the clinical component too and students have to attend clinic from the first year of their degrees.

www.mdx.ac.uk
www.wmin.ac.uk

[Naughtyhippo]

Dandelion milk? I was told as a child never to ingest it as it was poisonous. Along with don't eat tar (makes you wonder what the neighbourhood children were getting up to eh?). Is it poisonous?

[Professor Yaffle]

Dandelion milk? I was told as a child never to ingest it as it was poisonous. Along with don't eat tar (makes you wonder what the neighbourhood children were getting up to eh?). Is it poisonous?

You don't ingest it, you apply it to the wart. I did a quick google and couldn't find anything to indicate that any part of the dandelion was poisonous. In fact I found plenty of recipes including dandelion greens (which some indicated included the stalks). We were always told not to touch the sap as it would make you wet the bed. In fact the local nickname for them was pittle-the-beds. Lots of websites listing folk remedies etc list dandelion for warts and as a diuretic.

[Physiotherapist]

These students do have clinical practice in a purpose built clinic, under tutor supervision. They are expected to case take and carry out a physical examination if required, so they know what they are treating and what herbs will be appropriate for the condition.

They do know when to refer on and when something is serious.

They also treat in close contact with a patient's doctor. Some patients come in after exhausting all conventional medical options, so they already have a diagnosis and want a different kind of herbal treatment.

[fls]

These students do have clinical practice in a purpose built clinic, under tutor supervision. They are expected to case take and carry out a physical examination if required, so they know what they are treating and what herbs will be appropriate for the condition.

Their clinical practice under tutor supervision is, at the most, 1/15th of the amount considered necessary to perform those same tasks as a physician.

They do know when to refer on and when something is serious.

I'm curious about how you know that?

Linda

[JJM]

Look at the paper that sparked this thread Conclusions: There is a sparsity of evidence regarding the effectiveness of individualised herbal medicine and no convincing evidence to support the use of individualised herbal medicine in any indication.What part of "no convincing evidence" do some people here not understand? No matter how assiduously one studies herbs- it is no more useful than studying astrology since nobody has shown any efficacy for any herb in a high quality study. One never knows "what herb is appropriate" for any condition.

Certainly, there are pharmacologically active compounds in herbs; but nobody knows what most of them are:
http://scienceblogs.com/terrasig/2007/07/another_botanical_clinical_tri.php
One cannot conduct a properly-controlled clinical study without knowing the active ingredient because one doesn't know if a, putative, active ingredient even exists in any given preparation.


As for claims about herbalists' qualifications in clinical diagnosis- chiropractors and naturopaths make the same, laughable, claims. Any doctor associated, in any way, with a quack program has dubious judgment.

[fls]

Look at the paper that sparked this thread What part of "no convincing evidence" do some people here not understand?

Sorry.

Linda

[Physiotherapist]

That may be the case, but as far as I know, they undertook their course of study because they wanted to become herbal medicine practitioners and not doctors. I think that the clinical exam that they perform is along the lines of what a family care physician would undertake or similar to what a GP would perform in the UK - which is not a lot really.

[Henners]

JJM:

One never knows "what herb is appropriate" for any condition.

Have you ever tried taking senna pods for depression?

[fls]

That may be the case, but as far as I know, they undertook their course of study because they wanted to become herbal medicine practitioners and not doctors. I think that the clinical exam that they perform is along the lines of what a family care physician would undertake or similar to what a GP would perform in the UK - which is not a lot really.

Well, I was talking about the minimum for a GP. It looks even more inadequate (if 1/15 wasn't sufficient) if you start doubling and tripling the amount of clincial training beyond that.

ETA: And in order not to piss JJM off, I have to ask again, what are they qualified for? Even if they can make reasonable diagnoses, they can't treat them appropriately unless the best treatment includes OTC drugs that they can then recommend or other general advice - something that's not specific to herbs anyway.

Linda

[David Rodale]

You can remove moles, warts etc. with herbal medicine?

What do you use?
C-Herb

[JJM]

That may be the case, but as far as I know, they undertook their course of study because they wanted to become herbal medicine practitioners and not doctors.This is the case for a lot of feeble-minded medical wannabes.
I think that the clinical exam that they perform is along the lines of what a family care physician would undertake or similar to what a GP would perform in the UK - which is not a lot really. Do you imagine that any medical professional is concerned with your opinion?

[Deetee]

Physiotherapist,
However the degree in herbalism is dressed up, it is ridiculous to think that following these study modules will enable someone to correctly ascertain an accurate medical diagnosis.

Taken at its simplest, you can train someone how to recognise a condition like a wart on a finger, but the informed layman can be trained to diagnose these things. In order to diagnose other conditions, you need medical training.

If someone visits a herbalist with symptoms of say diarrhoea, or headaches, what on earth makes you think that the herbalist trained in ayurveda will be able to take a relevant medical history and perform an examination to make a diagnosis that is half way decent? Will they know the cardinal signs that indicate gastro-intestinal malignancy, or which types of headache indicate subarachnoid hemmorrhage rather than stress? I think not. Doctors spend years of full time training in order to learn this stuff, and still more years specialising in particular fields such as general medicine or psychiatry.

Look what I found in the UCLAN fact sheet (http://www.uclan.ac.uk/courses/factsheets/health/nursing/4533.pdf)about their BSc:

Students will be expected to purchase a range
of equipment (stethoscope, diagnostic set,
patella hammer, etc) for their own use in
practising clinical examination in their second
year of full-time study, the cost of which
should not exceed £250.


Now, tell me, how will a BSc student in herbology be expected to train in the use of this equipment and properly use it to diagnose pathology? My guess is they will be taught to wave a stethoscope over someone's abdomen and pronounce they have found evil humours which need detoxifying with mandrake root.

[Physiotherapist]

fls,

'Piss JJM off' - well that's a laugh to start with!! Is he a complete moron? Seems like someone only has to say one thing that he dislikes or disagrees with and he soon flies off the handle!!

JJM, what do you claim to be qualified to do? I have a friend who is a graduate of one of the herbal medicine courses at university and he did not want to be a doctor. When he was deciding what to do, he applied to do medicine and was accepted, but declined the offer to study herbal medicine instead.

I really could not care less about what any medical professor thinks of my opinion. I am not a doctor, I am a physical therapist and sports massage therapist. I am stating my opinion, which I am perfectly entitled to do - so I could not care less!!

fls,

Graduates qualify as medical herbalists and they dispense herbal remedies from their pharmacy. This can be in the form of creams, dried herbs that can be used and taken as teas and then mostly as herbal tinctures.

Deettee,

A friend of mine is a graduate of one of the BSc courses in herbal medicine and they were taught how to use a stethascope properly. The whole point about the clinical skills, is that if he needs to, he can carry out an examination and can refer if he is unsure.

He does have a lot of satisfied clients.

How many doctors after 6 years medical training still get it wrong?!! Quite a few I suspect.

[fls]

fls,

'Piss JJM off' - well that's a laugh to start with!! Is he a complete moron? Seems like someone only has to say one thing that he dislikes or disagrees with and he soon flies off the handle!!

I was making a little joke. We've had some good discussions that started with disagreement and sometimes he has changed my mind based on the subsequent discussion.

fls,

Graduates qualify as medical herbalists and they dispense herbal remedies from their pharmacy. This can be in the form of creams, dried herbs that can be used and taken as teas and then mostly as herbal tinctures.

But that's sorta my point. Of what use is this? Sure he is skilled at implementing a complicated system of diagnosis and treatment. But without evidence that there is an effect specific to the treatment is there a point to learning and using this system?

He does have a lot of satisfied clients.

How many doctors after 6 years medical training still get it wrong?!! Quite a few I suspect.

Yes. And the beauty of it is that the system is set up to be able to identify when you are wrong. We try to take wishful thinking out of the equation, so we test and use treatments that don't depend upon chance and wishful thinking to work. We use objective tests for outcomes knowing that patient satisfaction does not really tell you what is happening to the underlying disease process.

Linda

[JJM]

{snip} Graduates qualify as medical herbalists and they dispense herbal remedies from their pharmacy. This can be in the form of creams, dried herbs ...This is another opportunity for you to cite the hundreds of high-quality studies that support their therapeutic claims. I won't hold my breath.
Deettee,

A friend of mine is a graduate of one of the BSc courses in herbal medicine and they were taught how to use a stethascope [sic] properly. [I learned that in high school. JJM] The whole point about the clinical skills, is that if he needs to, he can carry out an examination and can refer if he is unsure.

He does have a lot of satisfied clients.Satisfied customers is not the same as properly treated customers.

How many doctors after 6 years medical training still get it wrong?!! Quite a few I suspect.This is standard nonsense. The question is not the quality of medicine, quackery is the subject in this thread. We await your high-quality evidence supporting your herbal claims.

[fls]

How many doctors after 6 years medical training still get it wrong?!! Quite a few I suspect.

I wanted to add....have you really thought this through? If after 6 years of intensive training, doctors can still get it wrong, what does that suggest happens after receiving a small fraction of that training?

Linda

[JJM]

I wanted to add....have you really thought this through? If after 6 years of intensive training, doctors can still get it wrong, what does that suggest happens after receiving a small fraction of that training?

LindaOf course not- woo-meisters don't think things through (that would require critical thinking and could result in the realization that quackery fails), they parrot. Casting aspersions on real medicine is standard woo-practice. Soon, we'll be reading "So's your old man."

Isn't it enough that an herbalist learns the differential diagnosis of a green-apple bellyache vs full-blown agita?

Are the questions on the "Final" going to be this hard? It seems unfair ... After all, everyone can't be a Hermione Granger.

[Blue Wode]

This is interesting:


Ann Walker, director of the British Herbal Medicines Association, insisted that most herbalists were well-trained and knew when to refer patients. She said herbalists took a three or four-year degree course before accreditation.
She acknowledged the lack of proof of efficacy for individualised herbal medicine. "The evidence is scanty because the studies have only recently been started," she said. This did not mean there was no efficacy.

http://www.guardian.co.uk/medicine/story/0,,2183054,00.html




and let's not forget this...


there are around literally thousands of scientific trials on high street products that show herbal remedies do work and are far from ‘hocus pocus’.

A new book published by Collins reveals 10,000 scientific trials that show a wide range of herbal medicines are effective.

http://www.responsesource.com/releases/rel_display.php?relid=34218&hilite




However, according to Ben Goldacre in today’s Guardian…


Huge numbers of "trials" are produced, at great expense, but they are inept, they are not fair tests, they have inadequate blinding and randomisation, positive results alone are cherry-picked, and worse.

The problem with herbalists
http://www.guardian.co.uk/science/2007/oct/06/herbalists




He concludes that it's not funding that's to blame for the inadequate research on herbal remedies - it's the herbalist culture itself.

[Physiotherapist]

There is an American guy - Dr Michael Balick who runs the International Plant Science Centre in New York who has done and does ongoing work into herbs and herbal medicine.

He has written books on the subject too.

[Big Les]

As ever Ben Goldacre has the subject nailed (the above link).

Until a herbal practitioner can show that giving a whole plant instead of an extract really is better, they're making stuff up when they make those claims. Similarly, until they can show that using herbs at such low doses that they have no measurable effect is somehow beneficial, beyond the placebo, then they're shooting with the stars.

You can get the bits of herbalism that work in real, clinically proved medicine. Why do you need whole plants and vague hand-waving? In my view herbalists are blending woo with medicine - making (probably inadequate) diagnoses based somewhat upon medical practice, prescribing treatments with known active ingredients, but then veering right off the tracks by wrapping it all up in the sort of woo ritual and pseudoscience that all the other, totally baseless, forms of woo use (e.g. Bowen).

IOW it's medicine for those who don't like the cold clinical side of real medicine and/or are suspicious of big pharmaceutical companies. The problem is that to get their nice fluffy new age bedside manner placebo trimmings, they sacrifice the quality of treatment and efficacy of the "medicine". The end result for most patients is probably little different to homoeopathic treatment.

It is mainstream medicine, but it's mainstream medicine circa 1607.

[JJM]

I am an American guy writing, at this moment, from the Intergalactic Plant Science Centre; which I run (it's easy to hang a sign on a door).
Alas, I have not written a book; but I have perused Tyler's Honest Herbal. The late Varro Tyler was the Lily Distinguished Professor of Pharmacognosy at Purdue University. He was one of the world's foremost
scientists in the field, not just a guy with a sign on his door.
You can read some of his work at www.quackwatch.org

In Honest Herbal, Tyler reviews the literature on herbs, including clinical studies. Although clinical research was not his strong suit, the books serves as a record of what is available- and it is inferior, just as Ernst says.


I take it nobody here is going to contradict Ernst or Tyler, except with hand-waving.

[Physiotherapist]

The end result for most patients is probably little different to homoeopathic treatment.


And just how do you work that one out hey?!!

Everyone knows that homeopathy has nothing in it. However, herbal medicine in not diluted in the same way that homeopathy is - alcohol is used to extract the constituents from either dried or fresh herbs and then that becomes the herbal tincture with no dilution, so of course there is something in herbs, which is why caution is needed - has Ben Goldacre become confused between herbal medicine and homeopathy?!!

[Physiotherapist]

This is not evidence, but an anecdote.

A few years ago now, my wife was having a few problems with the menopause. She went to the doctor and all he could offer her was HRT, which she did not want to take. Instead, she went to see a fully qualified medical herbalist who gave her herbs and she has no further problems now.

[Unalienable]

She told me to try an old wives tale she knew of which was putting dandelion sap on it. The wart came off after using it for a few days.

Coincidentally, there was recently a discussion of the placebo effect with regards to the common wart virus here http://forums.randi.org/showthread.php?t=94856. Fascinating stuff. Even your immune system can be boosted by a good healthy dose of positive thinking.

By the way, a "real remedy" (i.e. better than placebo) for warts involves covering them from the air, e.g. with duct tape. For some reason the wart virus doesn't flourish without oxygen, but your skin cells will survive fine. With that in mind, any sticky substance could be a potential cure, including dandelion sap.

[Unalienable]

There are several very powerful medicinal herbs that not only work, they work wonders. Sadly they are all illegal. :-/

[Physiotherapist]

JJM,

Why don't you look Michael Balick up on Google, rather than just spewing out your pathetic comments and disparaging everyone's qualifications?

If you did, you would see from his CV that he is a Harvard graduate with a PhD or are you going to tell me that a PhD is worth nothing now?

He is a ethnobotanist, who has dedicated his whole life to this type of work and has written books and articles about his work.

The New York Botanical Gardens where he works is involved in research all the time on the healing properties of plants and how these can be harnessed.

Now tell me - what qualifications do you have exactly that put you above everyone else and have you dedicated your life to any worthy cause at all? NO, didn't think so!!!

[fls]

There is an American guy - Dr Michael Balick who runs the International Plant Science Centre in New York who has done and does ongoing work into herbs and herbal medicine.

He has written books on the subject too.

I don't deny that there is use from this line of inquiry. I just don't see what's wrong with continuing to incorporate it into evidence-based medicine instead of maintaining a separate inadequate-evidence-based medical practice.

Linda

[Big Les]

And just how do you work that one out hey?!!

Everyone knows that homeopathy has nothing in it. However, herbal medicine in not diluted in the same way that homeopathy is - alcohol is used to extract the constituents from either dried or fresh herbs and then that becomes the herbal tincture with no dilution, so of course there is something in herbs, which is why caution is needed - has Ben Goldacre become confused between herbal medicine and homeopathy?!!

I'm basing that mainly on this very OP - some individual plants have active ingredients that can be of benefit, but the process of applying this to a patient as far as herbalism goes doesn't seem to work, or at least there's no evidence that it does. The evidence for herbalism having positive effect is similar to that for homoeopathy - some people feel better after treatment. Well, lots of people feel better after homoeopathic treatment, bowen therapy, reiki, ear candling, you name it.

I'm not disputing that herbalism has the potential to have efficacy way more than homoeopathy. I'm saying that for this potential to be realised, you have to isolate the active ingredients and use proper diagnosis and methods of delivery to turn them into worthwhile treatments. This has already been done by conventional medicine. Herbalism is a touchy-feely anachronism, but it has the edge over conventional medicine when it comes to bedside manner and placebo effect. I have much less of a problem with it for this reason, and because there's a greater chance of a given treatment actually having an effect. But it's a hit-and-miss affair, and I don't think herbalists deserve to be equated with medical doctors, especially when it comes to their training and their professional set-up (lack of organisation, communication, meaningful trials etc).

I might trust my granny telling me to rub dock leaf on my nettle sting, and I'll trust a qualified doctor to treat a skin disease (for example). I won't pay somebody who is somewhere between the two to treat anything.

[JJM]

JJM,

Why don't you look Michael Balick up on Google, rather than just spewing out your pathetic comments and disparaging everyone's qualifications? {snip}The topic of this thread is clinical efficacy of herbs, and the reviews (especially Ernst's) that claim there is no reliable clinical evidence. Is it your position that Balick has published definitive clinical research that was overlooked? That would be what we need to see.

[sah]

There seem to be a number of questions being tackled/mixed up in this thread:
1. does Canter’s research disprove the validity of individualised herbal treatment ?
2. is herbal medicine voodoo or is there any evidence that it works?
3. are medical herbalists trained to BSc or MSc level in herbal medicine up to scratch or are they ‘quacks’?
4. Is herbal medicine research intrinsically inferior to orthodox research?
5. should placebo have a valid place in healing?


1. In this post I will only be able to start with issue 1. by replying to this comment by Deetee regarding the review by Canter et al:

“I should point out that this study does not show that herbal remedies themselves are ineffective, just that individualised herbal medicine has not been shown to be effective.”

First of all remember there were only 3 trials covered in this review, partly due to the paucity of solid research (more on why that should be so later on/tomorrow). Secondly, only the IBS trial compared individualised to non-individualised treatment, while the other 2 compared individualised herbal Tx to placebo only. One of those latter studies involved merely 20 Pts, of which 15 completed the trial. Anyway, regarding the study on IBS, Canter at al claim:

“Only one of the three studies indicated that individualised treatment was superior to placebo and this study is particularly important because it found that individualised treatment was inferior to standardised treatment.”

This was echoed by the BBC article:

"Tailored treatment did seem to work better than the placebo in IBS, but it
was not as effective as the standard treatment."

However, if you look at this study, you will find that Bensoussan et al report significant improvement in both groups (standard IBS prescription and individualised IBS prescription) compared to placebo, but

“While there were no significant differences between patients receiving standard or individualized treatment at the end of the treatment period, on follow-up, patients in the individualized treatment group had maintained more substantial improvement.” (my emphasis)

“Furthermore, the overall differences between standard and individualized CHM may be relatively small (as both are active treatments) and require larger sample sizes. This does not, however, account for the notable improvement that was maintained in the individualized CHM group after cessation of treatment.

One plausible explanation may be that the standard CHM formulation was suitably designed to treat the complex presentations of IBS but was incapable of successfully dealing with underlying causes for most patients as viewed by Chinese medicine. The tailored formulations may have permitted the herbalists to individually address these underlying causes and deficiencies.”

(Treatment of Irritable Bowel Syndrome With Chinese Herbal Medicine, Alan Bensoussan, MSc; Nick J. Talley, MD; Michael Hing, MBBS, FRACP; Robert Menzies, PhD; Anna Guo, PhD; Meng Ngu, PhD JAMA. 1998;280:1585-1589. full article available free on-line)

Why were the results of this study misreported by Canter et al ? (And likewise why did the BBC repeat it?) Could there have been a conflict of interest in this research? After all, the complementary section of the Peninsula Medical School (where Canter produced the paper in question) is funded by, amongst others, Lichtwer pharma, who produce so-called ‘standard’ herbal products, which are available OTC or in some cases, through GPs. (see the Peninsula Medical school website – sorry, can’t post the link!)

Such a biased representation of Bensoussan et al’s findings certainly raises questions. I suppose the problem is once any research has the label ‘peer reviewed’, we tend to stand in awe and ask no further questions.

In summary: of the 3 studies examined by Canter one showed individualised (Chinese) herbal treatment to be superior to the non-individualised herbal treatment, and one – based on only a sample of 20 subjects (of whom merely 15 finished the trial) - used European herbal medicine, while the third, which was in fact terminated early, also studied Chinese herbal medicine. Yet, despite such a miserable paucity of data, the authors feel competent to claim:

“Individualised herbal medicine, as practised in European medical herbalism, Chinese herbal medicine and Ayurvedic herbal medicine, has a very sparse evidence base and there is no convincing evidence that it is effective in any indication.”

This is a particularly startling claim when one considers that no trial on Ayurvedic medicine was included in their review. Looks a bit like bias to me, but then I’m not a researcher…

Time for lunch – I should maybe add that I am one of those medical herbalists myself (BSc Hons. from the University of Wales, probably awarded by a misled registrar…)
S.

[Blue Wode]

Hello sah, and welcome to the forum. Here are your links:

(Treatment of Irritable Bowel Syndrome With Chinese Herbal Medicine, Alan Bensoussan, MSc; Nick J. Talley, MD; Michael Hing, MBBS, FRACP; Robert Menzies, PhD; Anna Guo, PhD; Meng Ngu, PhD JAMA. 1998;280:1585-1589. full article available free on-line)

http://jama.ama-assn.org/cgi/content/full/280/18/1585


Could there have been a conflict of interest in this research? After all, the complementary section of the Peninsula Medical School (where Canter produced the paper in question) is funded by, amongst others, Lichtwer pharma, who produce so-called ‘standard’ herbal products, which are available OTC or in some cases, through GPs. (see the Peninsula Medical school website – sorry, can’t post the link!)

http://www.pms.ac.uk/compmed/funding.html

[fls]

Hi sah,

I think part of the problem is that what you see as biased reporting, those who are familiar with evaluating evidence-based medicines see as recognizing weakness.

For example, in the IBS study that Blue Wode provided a link to, one notices that the two treatment groups had a much higher drop-out rate than the placebo group. In such a small study, this could have quite a significant effect - enough to wipe out the differences if all of those who dropped out worsened (a reasonable assumption given that if they were improving they would be unlikely to drop out).

If you are unfamiliar with the scrutiny which evidence-based treatments are put through, it may have the appearance of bias. This is born out by my observation that it is inevitably a weak study that is held up as a symbol of unfair treatment, rather than a good study.

Linda

[sah]

Hi fls,

even if it is a reasonable assumption, the fact remains that this does not constitute evidence.

(On a purely anecdotal level: I have often had Pts not continuing treatment, and like you I assumed that the treatment had failed. However, when accidentally meeting these people (easy in a small town), they have (so far!) invariably apologised for not getting back to me, but that they were fine and felt no need to continue.)

The important point in evaluating any evidential findings is to remember that

"the process of giving evidence centres not just on telling the truth, but bending it to one's needs and interests, and while doing so maintaining a logically consistent line, free of errors, inconsistencies and contradictions." (Tom Inglis, Truth, power and lies, University College Dublin Press, 2003, p.93)

Evidence is always in support of a theory and used as part of an argument. Science is not value free, and in particular a relatively soft science like medicine. Accumulation of evidence builds towards a proof, but evidence in itself is only part of the process, not the proof ('truth') in and of itself. In this context, it is important to remember that 'evidence-based medicine' is a fairly new concept, which replaced the traditional medical paradigm based on authority not that long ago. (i.e. “eminence-based medicine”)

While evidence based medicine includes the use of RCTs, meta-analysis and systematic reviews, these do not stand on their own. The practice of evidence based medicine means integrating individual clinical expertise with such systematic research and with patient choice. It really is about using the best currently available information to make thoughtful and compassionate choices, and to be open to review one’s practices in the light of new findings.

Herbal medicine is based on tradition and the search for an evidence base through RCTs and pharmacological studies is fairly recent. However, tradition can be described as a body of extended anecdotal evidence, and as such it is a form of empirical evidence, in that it is based on reported sensory experience and observation. Clearly relying on tradition alone has major problems in so far as certifying accuracy and quantitative analysis are concerned, but that does not mean that it can necessarily be discounted off hand.

This can bring us to my original 2nd question (will continue 1. in another post): is herbal medicine voodoo or is there any evidence that it works? Clearly, to begin, we can state that there is a large body of traditional evidence to support the hypothesis that herbal medicine may work. Furthermore, the Monographs of the Commission E under the auspices of the German Government provide a certified database of approx. 250 plants of which there is proof of their safety and 'reasonable certainty' of their efficacy.

Re the alleged low quality of herbal medicine research, see:
J Clin Epidemiol. 2007 Aug;60(8):787-94. Epub 2007 Mar 26.Matched-pair study showed higher quality of placebo-controlled trials in Western phytotherapy than conventional medicine. Nartey L, Huwiler-Müntener K, Shang A, Liewald K, Jüni P, Egger M. PMID: 17606174 [PubMed - in process]

best wishes
S.

[sah]

Continuing point 1.
Moving on from the review by Canter (which can only be described as inconclusive) to Ernst. In his editorial Ernst dismisses traditional herbalists by claiming that combining herbs rather than giving ‘simples’ is potentially dangerous:

“[…] there is not a shred of scientific evidence to demonstrate that traditional herbalists do more good than harm”.

Where is the evidence that combining herbs has done harm to Pts? Obviously, herbs being ingested or otherwise absorbed, have an undeniable physiological effect (remember we are not talking about homeopathy here), and the usual precautions regarding dosage apply (after all you can kill yourself by drinking water) but with such very wide therapeutic ranges (excepting the handful of schedule 3 herbs rarely used in herbal practice) it is generally accepted that herbal medicine has a far superior track record on safety than orthodox medicine. If anybody claims otherwise, they have to supply the evidence to support that statement.

Isn’t the very first principle “do no harm”? What are all those iatrogenic deaths due to? Combining chamomile with nettles and milk thistle? Or are they due to a long list of prescription drugs which may be powerful but sadly often not very safe (never mind OTC paracetemol products)?

Pronouncing individualised herbal treatment as being both unsafe and ineffective on the basis of the presented/non-existent evidence is...(I'm looking for a word)...incomprehensible really.

S.

[fls]

Hi fls,

even if it is a reasonable assumption, the fact remains that this does not constitute evidence.

You've lost me as to what you're talking about.

(On a purely anecdotal level: I have often had Pts not continuing treatment, and like you I assumed that the treatment had failed. However, when accidentally meeting these people (easy in a small town), they have (so far!) invariably apologised for not getting back to me, but that they were fine and felt no need to continue.)

Yes. We cannot assume that we know anything of what happened to these patients. The experience of patients "lost to follow-up" in a clinical trial is different from that of clinical practice, though (researchers look into this sort of thing). And an honest researcher looks at how the range of plausible assumptions would affect her/his data before drawing conclusions.

The important point in evaluating any evidential findings is to remember that

"the process of giving evidence centres not just on telling the truth, but bending it to one's needs and interests, and while doing so maintaining a logically consistent line, free of errors, inconsistencies and contradictions." (Tom Inglis, Truth, power and lies, University College Dublin Press, 2003, p.93)

Evidence is always in support of a theory and used as part of an argument. Science is not value free, and in particular a relatively soft science like medicine. Accumulation of evidence builds towards a proof, but evidence in itself is only part of the process, not the proof ('truth') in and of itself. In this context, it is important to remember that 'evidence-based medicine' is a fairly new concept, which replaced the traditional medical paradigm based on authority not that long ago. (i.e. “eminence-based medicine”)

While evidence based medicine includes the use of RCTs, meta-analysis and systematic reviews, these do not stand on their own. The practice of evidence based medicine means integrating individual clinical expertise with such systematic research and with patient choice. It really is about using the best currently available information to make thoughtful and compassionate choices, and to be open to review one’s practices in the light of new findings.

I have no disagreement up to this point.

Herbal medicine is based on tradition and the search for an evidence base through RCTs and pharmacological studies is fairly recent. However, tradition can be described as a body of extended anecdotal evidence, and as such it is a form of empirical evidence, in that it is based on reported sensory experience and observation. Clearly relying on tradition alone has major problems in so far as certifying accuracy and quantitative analysis are concerned, but that does not mean that it can necessarily be discounted off hand.

This can bring us to my original 2nd question (will continue 1. in another post): is herbal medicine voodoo or is there any evidence that it works?

Since botanicals that came to us by way of traditional use are now part of conventional use, clearly it is reasonable to think that individual herbs may serve as a source of useful medicines. And, botanicals and other biological sources are an established area of research in the search for new drugs.

Clearly, to begin, we can state that there is a large body of traditional evidence to support the hypothesis that herbal medicine may work. Furthermore, the Monographs of the Commission E under the auspices of the German Government provide a certified database of approx. 250 plants of which there is proof of their safety and 'reasonable certainty' of their efficacy.

This simply goes back to what I wrote in my previous post. Treatments recommended in evidence-based medicine are held to higher standards than "reasonable certainty" given that otherwise we find ourselves wrong more often than right.

Re the alleged low quality of herbal medicine research, see:
J Clin Epidemiol. 2007 Aug;60(8):787-94. Epub 2007 Mar 26.Matched-pair study showed higher quality of placebo-controlled trials in Western phytotherapy than conventional medicine. Nartey L, Huwiler-Müntener K, Shang A, Liewald K, Jüni P, Egger M. PMID: 17606174 [PubMed - in process]

best wishes
S.

Interesting that you and they choose to come to that conclusion based on that review, considering that the conclusion is not supported by the evidence provided. The complaint against herbal medicine research is that a lot of the information on which claims of efficacy are based are not randomized or placebo-controlled or even trials. All that review demonstrates is that some randomized placebo-controlled trials exist in herbal medicine, but it does not address the issue that herbalists are willing to assume efficacy based on information that does not even remotely fulfill the criteria for evidence-based medicine. And the criteria for evidence-based medicine are not a set of arbitrary rules designed to keep herbalists from playing the game, but are based on the discovery that if we aren't careful, we end up being wrong more often than we are right.

Also, the criteria they used to identify "higher quality" trials is actually not very useful. It doesn't distinguish between errors of omission vs. errors of reporting - the former is more serious and more likely to be found in herbal medicine research, while the latter is not serious and more likely to be the case in conventional research. The other criteria that were listed are all important and that herbal medicine research did not do as well in those area should have been given more notice.

It's not a useful comparison. It's like taking the tallest people in China and comparing them to the height of people in the US and then saying, "see the Chinese aren't so short after all."

Linda

[fls]

Continuing point 1.
Moving on from the review by Canter (which can only be described as inconclusive) to Ernst. In his editorial Ernst dismisses traditional herbalists by claiming that combining herbs rather than giving ‘simples’ is potentially dangerous:

“[…] there is not a shred of scientific evidence to demonstrate that traditional herbalists do more good than harm”.

Where is the evidence that combining herbs has done harm to Pts? Obviously, herbs being ingested or otherwise absorbed, have an undeniable physiological effect (remember we are not talking about homeopathy here), and the usual precautions regarding dosage apply (after all you can kill yourself by drinking water) but with such very wide therapeutic ranges (excepting the handful of schedule 3 herbs rarely used in herbal practice) it is generally accepted that herbal medicine has a far superior track record on safety than orthodox medicine. If anybody claims otherwise, they have to supply the evidence to support that statement.

And therein lies the rub. So not only are we supposed to give herbal medicine a free ride when it comes to proving efficacy. Now we are also supposed to hold them to far laxer standards when it comes to harm. Since herbalists are not obliged to go actively looking for harm, they don't have to keep track of harm and now you want to make us come up with many more cases of harm than we would have to to deem a conventional product unsafe (the difference between proving safety and proving harm), is it any wonder that you can claim a superior track record?

Who was it that discovered Aristolochia was harmful? Herbalists or medical doctors?

Isn’t the very first principle “do no harm”? What are all those iatrogenic deaths due to? Combining chamomile with nettles and milk thistle? Or are they due to a long list of prescription drugs which may be powerful but sadly often not very safe (never mind OTC paracetemol products)?

That's the problem you run into when your products actually do something and when you actually try to figure out whether you are doing harm, rather than ignoring it.

Pronouncing individualised herbal treatment as being both unsafe and ineffective on the basis of the presented/non-existent evidence is...(I'm looking for a word)...incomprehensible really.

S.

Now we're back to my initial point, again. It's not incomphrensible to those who are used to working with evidence-based medicine.

Linda

[ChristineR]

I'm surprised that no one has mentioned what I consider to be the key point concerning herbal medicine, which is that there are billions of people who have no hope of getting their hands on any synthetic medicines at all and are pretty much limited to herbal and other public domain medicines.

Even if you have access to modern industrialized medicine you might prefer to treat yourself or not share your money with drug companies for a variety of reasons. Many people do have some rather extreme fantasies about the whole situation (i.e., Natural Cures THEY Don't Want You to Know About) but I don't think you can blame people for being suspicious.

[sah]

Hi fls,
not much time (none tomorrow either), so a quick reply now - re your first post: yes, i agree, there is still not enough research available, but contemporary western herbal medicine is in its infancy, there is a tiny community of people involved, with very limited resources, which poses a real barrier to conducting the sort of research you are expecting from it. At the same time, this, in my view, does not mean that we have to abandon the practice of herbal medicine until whenever such research is forthcoming, because of the long safety record and the large evidence base of tradition. The other thing is that herbal medicine does not have to be seen as such a threat to conventional medicine, as it is based on the same science, but takes a different ethical and therapeutic approach. (or maybe that is why it is seen as a threat? There seemed to be far less panic about it, when it was merely a few hippies practising mystical herbalism... )

re second post: perhaps i didn't make myself clear enough: members of my professional organisation actually do have an obligation to report any adverse effects under a yellow card scheme. A further pointer to the safety record is our very low insurance premium (compared to what my inlaw GP and consultant pay). While this is no measure of efficacy, it is at least an indicator of safety. likewise there are Pts who prefer a mere "reasonable certatinty" of efficacy combined with safety to proven efficacy plus side effects. Do they not have the right to choose?

Anyway, that'll have to do for now!
all the best
S.

[fls]

Hi fls,
not much time (none tomorrow either), so a quick reply now - re your first post: yes, i agree, there is still not enough research available, but contemporary western herbal medicine is in its infancy, there is a tiny community of people involved, with very limited resources, which poses a real barrier to conducting the sort of research you are expecting from it. At the same time, this, in my view, does not mean that we have to abandon the practice of herbal medicine until whenever such research is forthcoming, because of the long safety record and the large evidence base of tradition.

Why not? What's wrong with "first do no harm"?

The other thing is that herbal medicine does not have to be seen as such a threat to conventional medicine, as it is based on the same science, but takes a different ethical and therapeutic approach.

I don't see why it can't just be a part of conventional medicine, once studies have picked out the wheat from the chaff.

(or maybe that is why it is seen as a threat? There seemed to be far less panic about it, when it was merely a few hippies practising mystical herbalism... )

I suspect it's a matter of wise use of resources.

re second post: perhaps i didn't make myself clear enough: members of my professional organisation actually do have an obligation to report any adverse effects under a yellow card scheme.

And this yellow card scheme was in place the entire time your long safety record was accumulating?

A further pointer to the safety record is our very low insurance premium (compared to what my inlaw GP and consultant pay). While this is no measure of efficacy, it is at least an indicator of safety.

That's a novel argument. I think it more likely reflects the kind of people who use your services.

likewise there are Pts who prefer a mere "reasonable certatinty" of efficacy combined with safety to proven efficacy plus side effects. Do they not have the right to choose?

I don't think it's reasonable to misinform their choices. You can pretend that "tradition" provides some sort of meaningful information, but that idea has been proven wrong over and over again. Abandoning the idea is what finally led to the tremendous progress we've enjoyed in medicine. How many times do we have to learn that lesson?

Linda

[Blue Wode]

yes, i agree, there is still not enough research available, but contemporary western herbal medicine is in its infancy, there is a tiny community of people involved, with very limited resources, which poses a real barrier to conducting the sort of research you are expecting from it.


That doesn’t seem to be consistent with what Ben Goldacre had to say in his Bad Science column yesterday:


Huge numbers of "trials" are produced, at great expense, but they are inept, they are not fair tests, they have inadequate blinding and randomisation, positive results alone are cherry-picked, and worse.

http://www.guardian.co.uk/science/2007/oct/06/herbalists


[My bold]


Doesn’t that suggest that "resources" aren't really a stumbling block?


ETA: This seems to be the bottom line:

In Britain, said Professor Edzard Ernst, it was very doubtful that herbal medicines – either delivered by herbalists or bought from pharmacists – did more good than harm. His co-author, Peter Canter, said that the whole business should be stopped.

http://www.timesonline.co.uk/tol/news/uk/health/article2584643.ece

[Mojo]

Pronouncing individualised herbal treatment as being both unsafe and ineffective on the basis of the presented/non-existent evidence is...(I'm looking for a word)...incomprehensible really.


As is pronouncing it safe and effective on the same evidence. The onus is on its proponents to provide the evidence for this.

[Ivor the Engineer]

As is pronouncing it safe and effective on the same evidence. The onus is on its proponents to provide the evidence for this.

Yeah, the precautionary principle should apply for things you stick in your mouth (or elsewhere).

[Mojo]

yes, i agree, there is still not enough research available, but contemporary western herbal medicine is in its infancy, there is a tiny community of people involved, with very limited resources, which poses a real barrier to conducting the sort of research you are expecting from it. At the same time, this, in my view, does not mean that we have to abandon the practice of herbal medicine until whenever such research is forthcoming, because of the long safety record and the large evidence base of tradition.


You're trying to have it both ways here: you say that there's no real evidence because "contemporary Western herbal medicine is in its infancy" and there are so few people involved, but then go on to invoke "the long safety record and the large evidence base of tradition".

[JJM]

{snip} [I] agree, there is still not enough research available {snip} At the same time, this, in my view, does not mean that we have to abandon the practice of herbal medicine until whenever such research is forthcoming {snip}This makes no sense. "[N]ot enough research" greatly overstates the merely anecdotal nature of your hundreds of claims.

{snip} The other thing is that herbal medicine does not have to be seen as such a threat to conventional medicine, as it is based on the same science, {snip}The vastness of herbal "medicine" is not at all based in science. That is the point of the OP, the link I provided to TerraSigillata, and my analysis of Varro Tyler's book. That is the point of many others posting here. Purveyors of astrology, and feng shui, often claim (equally absurdly) to be scientific.

Herbalists are not a "threat" to conventional medicine, they are a threat to their customers. You (sah) never know what your customers are getting in their herbs (TerraSigillata, "Natural Causes" by Dan Hurley [Broadway Books, 2006]). You can also delay someone from seeking needed medical attention. Fortunately, most seriously ill people go to medical doctors.

[JonM]

A few points of clarification here: Even Ernst himself accepts the existence of what he terms ‘rational phytotherapy’, which is based on contemporary science, as distinct from what he terms ‘mystical herbalism’, which still clings to vitalism and so forth. The former is surely the basis of the discussion at hand, if I understand Sah correctly, and this is the kind of practice the Commission E monographs are aimed at.

As regards the precautionary principle, the evidence of tradition is at least a pointer towards precaution – remember that anecdotal evidence is still a form of evidence, even if it is a weak form. Medicine as a practice is a form of applied science, and levels of significance are nowhere near as rigorous as those required for physics, and certainly are a million miles away from mathematical proof. There is a good reason for this – the urgency of the issues at hand for the millions of sick people. To use a reductio ad absurdum, if we were to rigidly apply the precautionary principle, we would not be able to eat anything at all – do you really- really- know what you had for breakfast? The mechanisms of actions of many drugs are imperfectly understood, yet this urgency requires their usage in medical practice. There would have been no history of medicine if these standards were to be applied – drugs are regularly withdrawn after years of use despite ‘rigorous testing’. Medicine clearly isn’t ‘safe’, but people still work with it.

One feature of this discussion that I find striking is how much of the anti- herbal medicine rhetoric sounds like pseudoscientism – e.g. Canter can use a study that was not completed, one that had only 15 subjects, and another one where he directly contradicts the findings, and that’s ok. When someone suggests that perhaps this might be just a bit tendentious, they are slapped down with the suggestion that they might be unfamiliar with evaluating evidence-based medicine – this reminds me of the attempts to defend psychoanalysis from within its own circularity. Other examples include Canter’s extreme demand that herbal medicine as a practice be stopped until all its modalities are proven. Perhaps conventional medicine should be stopped until all of its safety problems and iatrogenic deaths have been eliminated.

This brings me to my main point: I think that this debate is not really about science at all. The practice of medicine, any kind of medicine, is a sociological phenomenon – that is, it is rooted in culture, politics and economics at least as much as, if not more than, science. As Christine R. pointed out, there are millions of people around the world with no access to anything other than herbal medicines. We live in a post-colonial world, and to dismiss non-western medical practices on the basis of one type of epistemology is at best politically naïve and can be read as cultural imperialism. Are you really suggesting that thousands of people working away doing their best to explore the mechanisms of the body over thousands of years in non-western practices have found out nothing useful? Is it also not the height of arrogance to further demand that they should immediately abandon their practice in order to comply with the demands of an economically powerful (and fairly new) western discipline?

Falsifiability demands that we acknowledge that our theories are just that – theories. They are our best current shot, but given new developments in research – but also (crucially) in culture, politics and economics- they will come to be outmoded. This in turn does not mean that the new models are any nearer the ‘truth’, but that they are a genuine attempt at describing reality. With ongoing developments in systems biology, materialist consciousness theories and other forms of non-linear dynamics, for example, it may come to pass that current drug therapies seem ludicrously crude and, yes, dangerous.

The sociological element in this debate is brought out starkly by JJM’s remark that “Satisfied customers is not the same as properly treated customers.” This demonstrates clearly the difference between an authoritarian approach and a more liberal individualistic approach. What is the purpose of medicine? Is it to help people to feel better, or to pronounce them to have been ‘properly’ treated, regardless of how they may feel?

As part of the long ‘civilising process’ (first described by Norbert Elias), Wouters and others have demonstrated a process of ‘informalisation’ that began in the early 20th century, that accompanied the increase of democracy and the continuing trend towards individualism. The advent of so-called ‘post-modernism’ saw the arrival of relativism into the social sciences, and the realisation that epistemology is always a hermeneutic process – a discourse or interpretation, rather than the ‘truth’ or ‘solid knowledge’. As a result, especially following the analyses of Foucault and Bourdieu, came intense interest in tracking the structures that enable the production of ‘knowledge’. After all, “power produces knowledge”. In other words, what we have here is a clash between epistemological systems, based on differing ethical systems – one more democratic, liberal and ‘touchy-feely’, and one more authoritarian, self-righteous and ‘expert’ based.

In plain English, the overall long-term social trend is towards more informal structures (e.g. the internet), less expert power (we can all Google almost anything) and structures based on individual choice. While the development of ‘evidence-based medicine’ was an attempt at moving in this direction (away from ‘eminence-based medicine’), it is by no means the end of the journey. The fact remains that there are A: many dissatisfied customers seeking other models; B; there are serious problems with iatrogenesis and safety, despite the rigorous scrutiny; C: there are also problems with vested interests, as occurs in any system still largely based on truth by authority – economic pressures, reputations at stake, and so on; D: there is a huge constituency unreachable by conventional medicine – are they simply to be left to rot?

In recent years a body of theorising has begun to use ‘liquid modernity’ (a phrase coined by Zygmunt Bauman) to describe the current state of play, where there is a sea of both post- and pre-modern ideologies and practices surrounding islands of recalcitrant modernity. As the sea warms, it is inevitable that these islands will sooner or later dissolve. Scientific discourse is just that, a discourse, with its own rules and values, and does not provide us with a complete picture of whatever reality may be. It may be coming pretty close, but the possibility remains that other discourses may be approaching the same point but from other angles. For example, could the medieval humoural system have been a crude attempt at describing the attractors in complex systems? Could it ever be worth revisiting this, or other former forms of ‘knowledge’, in the light of current understandings?

The ethical issue of viewing others as of equal status and intelligence is imperative here. I am disappointed at the level of bitchiness and certainty displayed here – after all, we are all only trying to do our best to understand an incredibly complex world. The ethic of authority that is still prevalent in much medical practice is a real problem, and this is an area where perhaps much can be learned from the practice of herbalism.

[JJM]

JonM,

In short- you have no more definitive, clinical evidence for the efficacy of herbal "therapy" than does anyone else.

BTW, anecdote (testimonial) is not weak evidence, it is not evidence. In addition, while I did not examine your every use of the term "theory," I did note that mostly you meant the common sense of it (i.e., "notion").

[Physiotherapist]

JonM,

A brilliantly constructed and well thought out post.

I agree that anecdotal evidence is weak evidence, but it is evidence all the same. Even conventional medicine demonstrates anecdotal evidence via the use of case studies - same thing.

JJM,

Your response shows that you have not bothered to read JonM's post at all.

[JJM]

{snip} JJM,

Your response shows that you have not bothered to read JonM's post at all.Did you see citations of definitive, clinical studies supporting the efficacy of herb "therapies?" I did not. I don't believe such data are cited in JonM's post.

[Physiotherapist]

JJM,

It is very unfortunate that you don't seem to be able to see that JonM in his post is trying to look 'outside the box' at the more sociological and cultural aspects of both medicine and herbal medicine.

I believe unfortunately, that you are one of the people he is referring to when he talks about the authoritarian and blinkered views of conventional medicine that just can't see past anything else.

You seem to have a black and white view of things and it is extremely sad that this seems to be so much of a stumbling block for you and that you can't read JonM's post for what it is trying to point out to you.

The world is not black and white and in the end randomised controlled trials will not tell you every single thing about the world as you seem to believe.

[JonM]

Sorry to contradict you, JJM, but a quick galnce at any textbook on critical thinking,evidentiary law, the historical method, etc., will demonstrate that anecdotal evidence is just that, evidence, albeit at the weakest level. Furthermore, many scientific enquiries begin by ascertaining the truth or otherwise of anecdotal evidence.

As regards theory, the generally accepted meaning runs somewhere along the lines of a set of hypotheses related by argument to explain a variety of connected phenomena. The argument can be based on a wide wide variety of logical and mathematical approaches, all of which require varying forms of evidence to buttress their claims. One of the key features of theory, especially in the social sciences, is that theory is often contrasted with praxis (hence your pejorative concept of theory as a 'notion'), as opposed to the practice of theoretical physics - where theory is all that there is.

As regards the more substantive point, I deliberately did not - and will not - engage in the business of posting 'citations of definitive, clinical studies', as I explicilty stated that I felt that this debate was not really about science at all, but rather about conflicting ethical systems. The fact that you seem unable to see this only illustrates my point about the authoritarianism in contemporary medicine. There has a major social cultural shift in terms of how we relate to other people over the last fifty years one with which medicine has signally failed to keep up with. At the heart of current ideas (theories?) of liberty is the notion of freedom of choice. As long as people do do not interfere with others or the common good, they should, as much as possible be allowed to live their lives as they see best. Absolutist decrees ('this should be stopped'), especially those dictated by an authoritarian discipline such as western medicine, can easily be seen as relics of fundamentalist religious attitudes, appropriate to the holders of 'the truth'.

[Mashuna]

As regards the more substantive point, I deliberately did not - and will not - engage in the business of posting 'citations of definitive, clinical studies', as I explicilty stated that I felt that this debate was not really about science at all, but rather about conflicting ethical systems. The fact that you seem unable to see this only illustrates my point about the authoritarianism in contemporary medicine. There has a major social cultural shift in terms of how we relate to other people over the last fifty years one with which medicine has signally failed to keep up with. At the heart of current ideas (theories?) of liberty is the notion of freedom of choice. As long as people do do not interfere with others or the common good, they should, as much as possible be allowed to live their lives as they see best. Absolutist decrees ('this should be stopped'), especially those dictated by an authoritarian discipline such as western medicine, can easily be seen as relics of fundamentalist religious attitudes, appropriate to the holders of 'the truth'.

I must say, I've seen (from the patient side only), a very different view of the medical profession. It has become much less authoritarian, with greater transparency over treatments. I've been offered a choice of which NHS hospital I want to receive treatment at, everything has been explained clearly to me, included a realistic estimate as to the chance of success of a particular treatment.

In contrast to this, I've been offered treatments by homeopaths, acupuncturists and natural nutritionists, all of whom have been certain that they knew what the real problem was, and that they were best placed to sort it out. They were the authoritarian keepers of mystical truth, and knew what was best for me.

In terms of 'freedom of choice' arguments, what's your take on misleading claims? For example, I'm happy for people to have a choice between different medical treatments for a particular ailment. However, I'd want some kind of system in place so that I could be confident that the medical treatments I was choosing between had been tested to ensure that their safety and efficacy claims were accurately represented.

[fls]

A few points of clarification here: Even Ernst himself accepts the existence of what he terms ‘rational phytotherapy’, which is based on contemporary science, as distinct from what he terms ‘mystical herbalism’, which still clings to vitalism and so forth. The former is surely the basis of the discussion at hand, if I understand Sah correctly, and this is the kind of practice the Commission E monographs are aimed at.

I agree that that is the focus.

As regards the precautionary principle, the evidence of tradition is at least a pointer towards precaution – remember that anecdotal evidence is still a form of evidence, even if it is a weak form. Medicine as a practice is a form of applied science, and levels of significance are nowhere near as rigorous as those required for physics, and certainly are a million miles away from mathematical proof. There is a good reason for this – the urgency of the issues at hand for the millions of sick people. To use a reductio ad absurdum, if we were to rigidly apply the precautionary principle, we would not be able to eat anything at all – do you really- really- know what you had for breakfast? The mechanisms of actions of many drugs are imperfectly understood, yet this urgency requires their usage in medical practice. There would have been no history of medicine if these standards were to be applied – drugs are regularly withdrawn after years of use despite ‘rigorous testing’. Medicine clearly isn’t ‘safe’, but people still work with it.

I'm not sure that it's an issue of urgency. I think that it's a matter of what kinds of observations can be made. Medicine is more aptly compared to social and biological sciences, than hard sciences.

One feature of this discussion that I find striking is how much of the anti- herbal medicine rhetoric sounds like pseudoscientism – e.g. Canter can use a study that was not completed, one that had only 15 subjects, and another one where he directly contradicts the findings, and that’s ok. When someone suggests that perhaps this might be just a bit tendentious, they are slapped down with the suggestion that they might be unfamiliar with evaluating evidence-based medicine – this reminds me of the attempts to defend psychoanalysis from within its own circularity. Other examples include Canter’s extreme demand that herbal medicine as a practice be stopped until all its modalities are proven. Perhaps conventional medicine should be stopped until all of its safety problems and iatrogenic deaths have been eliminated.

I think that you and SAH have misunderstood what Canter was doing, and my arguments using his work as a starting point. The idea behind medical practice and research is to discover ways in which we can improve health and reduce illness and death. And we have worked out ways that help gather this information. Ways that allow us to strip away those things that interfere with understanding the nature of the connection between a treatment and disease. We really only started to make progress in this area when we were willing to admit that chance and bias and wishful thinking can form patterns as readily as the true effect from a drug. What Canter is pointing out, is that the methods that allow us to strip away the interference have not been applied to the idea of individualized herbal treatments. That means that the entire body of "knowledge" that you keep referring to about herbal medicine, consists of interference. There may also be (and likely is) a signal in amongst all that noise. But the methods used by traditionalists are unable to tell the difference. It is hardly "psuedoscientific" to point out that the scientific method is our current best method for removing that noise.

This brings me to my main point: I think that this debate is not really about science at all. The practice of medicine, any kind of medicine, is a sociological phenomenon – that is, it is rooted in culture, politics and economics at least as much as, if not more than, science. As Christine R. pointed out, there are millions of people around the world with no access to anything other than herbal medicines. We live in a post-colonial world, and to dismiss non-western medical practices on the basis of one type of epistemology is at best politically naïve and can be read as cultural imperialism. Are you really suggesting that thousands of people working away doing their best to explore the mechanisms of the body over thousands of years in non-western practices have found out nothing useful?

I am suggesting that without the application of scientific methods, it is very difficult to separate the useful from the useless. Yes, I think they have found out something useful. They have also found out something useless. Which is which?

Is it also not the height of arrogance to further demand that they should immediately abandon their practice in order to comply with the demands of an economically powerful (and fairly new) western discipline?

I sympathize with those who do not have access to the best information or the products of scientific discovery. And I think that how we assist the developing world is worthy of discussion as well. But this thread really has been about discussing the use of herbal medicine in developed countries, where people do have access to a body of knowledge (and the resultant products) gathered in such a way as to distinguish between the useful and the useless.

Falsifiability demands that we acknowledge that our theories are just that – theories. They are our best current shot, but given new developments in research – but also (crucially) in culture, politics and economics- they will come to be outmoded. This in turn does not mean that the new models are any nearer the ‘truth’, but that they are a genuine attempt at describing reality. With ongoing developments in systems biology, materialist consciousness theories and other forms of non-linear dynamics, for example, it may come to pass that current drug therapies seem ludicrously crude and, yes, dangerous.

But really, what has that to do with herbal medicine? The body of "knowledge" that they have amassed hasn't a hope of being a genuine description of reality until subject to a process that allows for the elimination of false information.

The sociological element in this debate is brought out starkly by JJM’s remark that “Satisfied customers is not the same as properly treated customers.” This demonstrates clearly the difference between an authoritarian approach and a more liberal individualistic approach. What is the purpose of medicine? Is it to help people to feel better, or to pronounce them to have been ‘properly’ treated, regardless of how they may feel?

It is to help people feel better by actually affecting the underlying disease process, rather than by leaving the underlying disease process unchanged.

As part of the long ‘civilising process’ (first described by Norbert Elias), Wouters and others have demonstrated a process of ‘informalisation’ that began in the early 20th century, that accompanied the increase of democracy and the continuing trend towards individualism. The advent of so-called ‘post-modernism’ saw the arrival of relativism into the social sciences, and the realisation that epistemology is always a hermeneutic process – a discourse or interpretation, rather than the ‘truth’ or ‘solid knowledge’. As a result, especially following the analyses of Foucault and Bourdieu, came intense interest in tracking the structures that enable the production of ‘knowledge’. After all, “power produces knowledge”. In other words, what we have here is a clash between epistemological systems, based on differing ethical systems – one more democratic, liberal and ‘touchy-feely’, and one more authoritarian, self-righteous and ‘expert’ based.

Honestly, all I really care about is whether or not any particular method gives me a fighting chance of understanding reality. The "authoritarian, self-righteous and 'expert' based system" you deride has had unparalled results when it comes to actually helping people acheive health. You can call me all the names you want, and I will still choose a system that values making the attempt to understand reality over one that aligns itself with subjective impressions.

In plain English, the overall long-term social trend is towards more informal structures (e.g. the internet), less expert power (we can all Google almost anything) and structures based on individual choice. While the development of ‘evidence-based medicine’ was an attempt at moving in this direction (away from ‘eminence-based medicine’), it is by no means the end of the journey. The fact remains that there are A: many dissatisfied customers seeking other models;

If you find me a model with a similar record of success, I'd be happy to consider it. Seriously.

B; there are serious problems with iatrogenesis and safety, despite the rigorous scrutiny;

And do you think that less rigorous scrutiny leads to fewer problems?

C: there are also problems with vested interests, as occurs in any system still largely based on truth by authority – economic pressures, reputations at stake, and so on;

That's hardly confined to one side or the other.

D: there is a huge constituency unreachable by conventional medicine – are they simply to be left to rot?

No, but it really wasn't part of this discussion.

In recent years a body of theorising has begun to use ‘liquid modernity’ (a phrase coined by Zygmunt Bauman) to describe the current state of play, where there is a sea of both post- and pre-modern ideologies and practices surrounding islands of recalcitrant modernity. As the sea warms, it is inevitable that these islands will sooner or later dissolve. Scientific discourse is just that, a discourse, with its own rules and values, and does not provide us with a complete picture of whatever reality may be. It may be coming pretty close, but the possibility remains that other discourses may be approaching the same point but from other angles. For example, could the medieval humoural system have been a crude attempt at describing the attractors in complex systems? Could it ever be worth revisiting this, or other former forms of ‘knowledge’, in the light of current understandings?

Won't all these other forms of 'knowledge' end up being tested by science for their worth? Or did you have some other test in mind?

The ethical issue of viewing others as of equal st