The infiltration of pseudoscience and simply bad medicine into mainstream medicine continues. Hospitals are an easy breech point because they are run by administrators who may have more talent and interest in marketing than in science. Many hospitals in my area, for example, proudly display their “integrative” centers, offering nutrition advice and massage alongside more dubious offerings, such as reflexology and reiki.
So-called “alternative” treatments are tempting because they are often not covered by insurance, and so patients will have to pay cash for them, and they are often inexpensive to run – so they are a nice cash cow for hospitals.
The Wall Street Journal reports another, more serious, chapter in this infiltration – the opening of Chinese herbal clinics, specifically in the Cleveland Clinic. The article itself is reasonably balanced, and lacks the gushing anecdotes that most such pieces have, but could certainly have been more hard-hitting in terms of the serious problems with herbal medicine.
Herbal treatments are interesting from a scientific point of view because they are perhaps at the most plausible end of the CAM spectrum. The WSJ article would have benefited from stating explicitly that herbs are drugs. Their actions in the body are entirely pharmacological. This fact is often missed by proponents and in discussions of herbal remedies. They are drugs.
Herbs, however, are drugs that have not been adequately studied, whose active ingredients may not be known, that contain many chemicals, with unknown pharmacokinetics, dynamics, and drug-drug interactions. Dosing is nearly impossible to standardize. Bioavailability is anyone’s guess. And quality control is highly dubious. Other than that, they’re great.
I’m not sure why anyone would choose to take a poorly studied, dirty, variable, and poorly regulated combination of drugs with unknown efficacy. The answer, of course, must be marketing. People think herbs are “natural,” an irrelevant feature that does nothing to mitigate the many downsides of these dirty drugs. They are also reassured by the fact that they are part of an ancient and exotic medical system, the argument from antiquity. Of course, bloodletting also survived for thousands of years.
Plants are a perfectly reasonable source of potential pharmacological compounds. Much of the low-hanging fruit, of course, has already been picked. There is also huge incentive on the part of pharmaceutical companies to find other useful compounds in plants, and herbal remedies might provide a clue to potential targets. What’s left over are the dregs, what is now marketed as “herbal medicine.”
Many of the most popular herbal products, those that have been studies in rigorous clinical trials, have been found not to work. Gingko biloba does not work for memory or dementia. Echinacea does not work for the cold or flu. Black cohosh does not work for menopausal symptoms. Saw palmetto does not work for benign prostatic hypertrophy.
Perhaps the best candidate for an effective herbal remedy is St. John’s wort for depression. Apparently there is some anti-depressant effect from this herb, but only if you speak German (German studies are much more favorable than studies from other countries). Otherwise the benefits are mild and inconsistent. This is not surprising because St. John’s wort contains MAO inhibitors, which have a known antidepressant effect. They also have serious drug-drug interactions.
There are other herbs with promising preliminary results – but as readers of SBM know well, preliminary results are very unreliable and not predictive of the outcome of large rigorous trials.
The notion that herbs are somehow magically safe is very insidious. They are drugs with all the potential toxicity and drug-drug interactions of drugs. Perhaps they have the virtue, because their active ingredients are not purified, of generally having low doses of the chemicals they contain, but that cuts both ways, reducing useful effects and side effects alike.
Assuming lack of toxicity is largely based on the relative paucity of studies looking for toxicity. Toxicity from herbs, however, is not uncommon. Nephropathy (kidney damage) from Aristolochia, liver damage from kava-containing products, and black cohosh has also been linked to liver damage (here is a more extensive list of popular herbal products with known toxicities).
Toxicity can occur even when an herbal product is unadulterated and taken as intended. However, perhaps the biggest problem with the herbal industry is its poor regulation. There are problems with fungal contamination, mislabeling or mistranslating of herbs, and heavy metal contamination.
When buying herbal remedies off the shelf they are likely not even to contain what the label indicates. A recent study found that:
Most (59%) of the products tested contained DNA barcodes from plant species not listed on the labels. Although we were able to authenticate almost half (48%) of the products, one-third of these also contained contaminants and or fillers not listed on the label. Product substitution occurred in 30/44 of the products tested and only 2/12 companies had products without any substitution, contamination or fillers. Some of the contaminants we found pose serious health risks to consumers.
Therefore, even when a clinical trial, using carefully prepared and verified herbal preparations, finds some potential benefit, you cannot assume that a commercial product based on that herb will have the same effect. You may not even be getting the herb you think you are getting.
In his latest book, Paul Offit tells the story of attempting to regulate herbal product use in his hospital. Eventually he settled for one criterion, that the manufacturers provide documentation of what is actually in the products. They refused to do this. One has to wonder why.
How does an herbal clinic work in practice? The WSJ reports about the Cleveland Clinic, when asked for something for inflammation:
“Absolutely,” responded Ms. Roofener. “This is for pain, for digestion, for inflammation, all of the above,” she said, handing Ms. Lunka a bottle with capsules of an herbal combination called Xiao Yao San, which translates as free and easy wanderer. The capsules include about eight different herbs, including licorice, mint leaf and white peony root.
Not only does the preparation contain all the unrefined chemicals of a single herb, but a combination of many herbs. They also report:
At the Cleveland Clinic’s herbal center, new patients are given a one-hour consultation that may include a battery of questions (How’s your sleep? Body temperature? Ringing in your ears? Headaches?), a physical examination of the tongue, and the traditional Chinese method for pulse-taking (three fingers on each wrist to check different pulses corresponding to various organ systems). They are asked to sign a waiver acknowledging that “herbal supplements are not a substitute for a medical diagnosis.”
So – herbal remedies are not real medicines that treat actual diseases. They are just claimed to alleviate symptoms – without, of course, any evidence of efficacy except for the anecdotal experience of the practitioner. Pulse analysis, by the way, is nothing but a medical cold reading, not unlike iridology or any other bogus diagnostic method.
We advocate for high standards of science within medicine because that is the only way to offer patients the best chance of safe and effective treatments. It is also the only way to give proper informed consent, which requires transparency and reliable information.
It is a scandal that a hospital would offer a medical service to their patients that is not based on the best science has to offer, is based on numerous deceptions and misrepresentations, logical fallacies, and poor methods. In fact, they make patients sign wavers that essentially say that what they are providing is not real medicine.
Only the insanity of brilliant marketing can pull off such a deception.