by Steven Novella, MD
There is nothing more powerful than an idea, and nothing more potentially harmful than a false idea that everyone “knows” is true and therefore does not question. The current popularity of alternative medicine in general, and herbal remedies specifically, are based upon several such commonly accepted myths; chief among them is the idea that natural is equivalent to good. These myths, however, do not bear close rational scrutiny. They survive and flourish because they strike a cord with the human psyche. The multi-billion dollar health food industry has hit upon these myths as a brilliant marketing scheme and has served to reinforce them to the American public to such a degree that they have now become an inextricable part of our culture.
The Natural Myth
It is difficult to find a health food product that does not have the word “natural” incorporated into its name, its product labeling, or even the name of the company that manufactured it. Even many common supermarket products will proudly proclaim that they have all natural ingredients. Everyone knows that natural is better than”well, not natural. The problem is, no one can give a good working definition of what natural means.
Because of this problem with definition, there is no regulation of the use of the word “natural” in product labeling or advertisement. Any company can therefore call any of their products natural without fear of liability for false advertising. Health food companies are happy with this vagueness of terminology, because they can use the term natural to give their products a mythical sense of goodness without making specific claims.
Some will define natural as unprocessed or unaltered. Therefore, a leaf or root or fruit which is consumed without altering it from its harvested form is natural. The difficulty with this definition is that almost all products, whether food, supplement, or medicine, undergo some processing, so where can we objectively draw the line? If you process apples into apple juice, is that apple juice natural? What about wheat into bread, leaves into tea, or coffee beans into coffee? You may try to distinguish mere food preparation from processing, but you will find that again there is no clear line.
The concept of processing can be broken down into its different components, such as pulverizing, boiling, leaching, mixing, separating, purifying, etc. All of these processes are used in what we would consider simply cooking, but they are also the components of processing plants into tablets which are then marketed as pharmaceuticals.
If you then abandon the concept of natural meaning unprocessed as not useful and hopelessly confusing, you may alternatively define natural to mean occurring in nature. Here one runs into similar problems, however. The elements out of which all substances are made are, of course, all naturally occurring, therefore it is only meaningful to talk about molecules as natural or artificial. If a molecular substance is purified from among the hundreds which can be found in a particular plant, such as caffeine from coffee beans, is that substance no longer natural? What if it is minimally altered, just adding a couple of atoms to the molecular structure so that it is more easily absorbed into the body, but its biological activity is otherwise unchanged? What about combining two naturally occurring substances together to form a third novel compound? Such processes occur when boiling leaves to make a “natural” herbal tea.
Beyond the difficulty with definition, there is also no compelling reason to think that molecules which occur in nature have any advantage for human wellness over those which are the product of human ingenuity. Most substances naturally occurring in plants, for example, are deadly poisonous or will at least make you very sick. Plants contain hundreds of substances; some have minimal biological activity and are therefore just food. Others have pharmacological effects which are potentially useful if used correctly. Many others contain substances which are toxic to humans even in minute doses, such as arsenic, hemlock, and alkaloid poisons.
The substances that can be found in nature are primarily a product of chance, the vagaries of evolution. Plants evolve only to be more successful at surviving in their current environment, not for the benefit of one egocentric mammalian species. They have not been fine-tuned by nature to be good medicines or anything else. Fruit, for example, exists only as a bribe to compel animals into spreading seeds, which is the fruit”s real purpose. The chemical substances that are currently represented in plant or animal biochemistry are therefore purely a result of random chance, not any design serving man. There is therefore no logical reason to believe that “natural,” by any definition, is better.
Further, there is no difference in the chemical activity or any properties of a molecule which is extracted from a plant, or a molecule with the same structure that was created in a chemical laboratory atom by atom. There is no experiment that can be conducted, biological or otherwise, to distinguish these two substances, because their properties are solely determined by their chemical structure, not their derivation.
Therefore, the concept of natural is not a very useful one. It is both difficult to define precisely and, when closely examined, of no real intrinsic value. And yet, it is cited as the greatest single virtue of many alternative therapies. The psychological appeal, however, is obvious. There is a general fear in our culture of technology gone out of control. Toxins and “chemicals” in our environment are blamed almost abstractly for many of our current ills, often without any supporting evidence. Industrial pollutants darken our skies, acidify our rain, poison our waters, and threaten our health. It is no wonder that the idea of getting back to pure nature is so appealing to so many.
Herbs are drugs
Herbal remedies are enjoying an immense upsurge in popularity. Sales of St. Johns Wort (hypericum), an herb used to treat depression, now exceed those of Prozac in Germany, where the herb is chiefly produced. Its use is now also growing in the U.S., and it has received nothing but good press from the media. It is claimed, without clinical evidence, that the herb works as well as Prozac and other drugs marketed for depression but without the side effects. How is this possible? Because it is all-natural, we are told.
The distinction, however, between medicinal herbs and drugs is a false one. A drug is simply defined as any substance which has a physiological effect on the body other than its pure nutritional value. Caffeine is a drug, and so is alcohol. The term drug, however, has taken on a negative connotation, partly because of the recent war on illegal recreational drug use. The health food industry and proponents of alternative medicine have exploited and increased this negative connotation. They have then offered their herbal remedies as an alternative to drugs. But any herb that has a medicinal effect is, by definition, a drug.
Many of the pharmaceuticals currently in use by mainstream physicians are substances which are found in plants, or are derivatives of plant substances. Their chemical structure has been identified and analyzed, and every property of the drug that can be known has been investigated. This includes how and where it is absorbed into the system, how long it hangs around (a property called its half-life), where it goes, how it is stored, where and how it is metabolized, and how it is excreted. Also, as much as can be learned about the precise mechanism of action of the substance is investigated, including what tissues it affects, what receptors it binds to, what the side effects are, the signs of toxicity, and how much of the drug would be fatal.
This kind of information is obtained in experiments which are called preclinical (or animal-based) and phase I and phase II clinical (or human-based) trials. At this point, the work is just beginning, however. For now a phase III clinical trial must be completed, involving many patients in a double-blind placebo- controlled format to determine if the drug is safe and effective. If this is proven to the FDA”s satisfaction, the drug can then be marketed. Physicians can then prescribe the drugs, and they will have enough information to know exactly what dose to give their patients, what the resulting blood levels will be, how long the effect will last, what the interaction with other drugs will be, what beneficial physiological effect to expect, and what to look out for in terms of side effects.
Someone taking an herb for its alleged medicinal benefits, however, does not have any of this information. The active ingredient, if there is one, is mixed together with many other chemicals, many of which are undesirable. It is impossible to regulate dosing, for there will be tremendous variability from plant to plant, region to region, and season to season, in the exact constitution of the herb. And finally, the effects, toxicity, and other properties of the herb have not been studied in any controlled fashion. This is the worst kind of medicine.
Even in the best case scenario, if an herb exists with an active ingredient that has a desired effect with little side effects, this is no guarantee that it will be used properly. Drugs are only useful when they are combined with clinical knowledge and experience so that they can be used intelligently and with understanding.
Herbal medicinals, like hypericum, are drugs. Some have already been incorporated into mainstream medicine. Others have potential and should be studied properly. The practice of herbal medicine, however, is imprecise, unscientific, and sloppy. It is far more likely to cause harm than good. It is a multi-billion dollar industry, however, that has managed to evade FDA regulation, primarily because of political support due to the popular mystique of “natural” medicine.
Another popular claim of many alternative remedies is that they are based upon ancient knowledge. The popularity of the idea that an earlier golden era had greater wisdom than our current age is a certain sign of discontent and decline. It is another manifestation of a lack of faith in modern technology to solve the world”s problems. A hundred years ago, the industrial revolution promised to bring about a modern Utopia. This optimism, however, was premature, and today, as a society, we have a much more realistic idea of what technology can and cannot do, and what the costs of technology are.
Humans, however, tend to be diehard optimists. If technology has not delivered all we desire, then some will turn to another solution upon which to place their hopes. This is at least one factor in the current popularity of New Age philosophies. Many New Age gurus have turned to Eastern philosophy and ancient ideas, claiming that modern Western science does not have all the answers. Traditional Chinese Medicine (TCM) and Ayurveda are two alternative medicine beneficiaries of this trend.
Interestingly, there are those practitioners that even try to have it both ways. Despite the current fad of antirationalism, science still is a greatly respected institution in our culture. Its many successes cannot be denied. A new advertising strategy for alternative therapies is to claim that they are the coming together of ancient wisdom and modern science – the best of both worlds. This claim, however, is just another myth.
Ancient philosophies of medicine suffer from the fact that they were formulated at a time when virtually nothing was known about human anatomy or physiology, when the fields of genetics, biochemistry, and infectious disease did not even exist. One to three thousand years ago, when TCM and Ayurveda were born, it was not known that the brain was the seat of intelligence, that the heart pumped blood, and no one had any idea what the liver did. It was not even known that specific diseases existed, with their own signs and symptoms, causes, cures, and natural history. People were thought to suffer from their own personal and unique maladies.
Medical systems at this time were based upon philosophies, not science or evidence. Most of the philosophies were based upon spiritual or magical notions, such as the idea of Chi or life force central to TCM. Disease, they believed, was caused by imbalances or blockage of flow in these mystical forces. Equally mystical and fanciful methods, such as acupuncture, were invented to restore balance or unblock flow. The chance of any of these systems developing any truly useful therapies is very close to zero.
And yet proponents of these alternative practices will claim that the fact that they have survived and have been used for so many thousand years is testimony to their success. How could they have survived if they do not work, they argue. But history shows us that this claim is false. The humoral theory of disease, for example, dominated Western medicine for three thousand years. Until the advent of modern scientific medicine, Western doctors diagnosed imbalances in the four humors: blood, phlegm, green bile, and black bile. They treated these imbalances with emetics, cathartics, and blood letting. The utter failure of their treatments did not blunt their acceptance.
The only reason why the humoral theory is now dead is because its practitioners in the West changed from philosophy-based medicine to science-based medicine. Ayurveda and TCM survive because historically their practitioners never made that transition. No one would advocate a return to the practice of blood letting for the treatment of fevers, but this is equivalent to advocating a return to other outdated philosophies of medicine, such as TCM and Ayurveda.
Finally, let us remember that 100 years of science based medicine has doubled the human life expectancy from 40 to nearly 80 years. No philosophy based medicine can make that claim. Three thousand years of TCM and Ayurveda added not a single day of human life.
Health Care Freedom of Choice
Freedom is a cherished virtue, especially in America, the self-proclaimed modern defenders of democracy and freedom. Cries for freedom, therefore, always command our attention and sympathy. Defenders of alternative medicine have used this fact to their advantage, attempting to portray their battle for acceptance as a fight for freedom. The same defense was used earlier in this century when the creation of the FDA threatened to put Mom and Pop snake oil producers out of business. Fortunately for the American public, it did.
Making the debate about freedom of choice, however, is a deliberate misdirection. Mainstream physicians are strong supporters of patient”s rights, including their freedom to choose their health care providers, and to make all decisions regarding their care. There are those, however, who would try to confuse this freedom with the freedom of charlatans to practice fraud. No one should be free to present themselves as competent clinicians when they are not, or to offer the public remedies which have not met minimal standards of safety and effectiveness.
Still, defenders will argue that patients can read the labels, examine the evidence, and make informed decisions for themselves about alternative or any health care options. This is simply not realistic, however. Patients cannot and should not be expected to have a medical education in order to protect themselves from potentially harmful or useless treatments. Just as drivers should not be expected to be mechanics in order to ensure that their cars are safe, or engineers in order to ensure that the bridges they drive over will not collapse.
There is a system in place to ensure that medications, procedures, and devices are safe and effective. There are standards of care and practice guidelines which are based on the best scientific evidence available. Alternative practitioners, however, want to bypass this system in the name of freedom. What they are really defending, however, is their own freedom – their freedom to practice medicine without proper training and without the burden of doing the hard work and careful thinking necessary to practice the best medicine currently possible, or even to ensure that they are not doing more harm than good.
Alternative medicine is riding a wave of popularity that is powered in part by false and misleading, but psychologically appealing, notions. It is now a multi-billion dollar industry, with growing political power and increasingly the trappings of legitimacy. Alternative medicines, however, are not based upon the science which has brought us the incredible and undeniable success of modern medicine, but upon outdated ideas of which our predecessors worked hard to rid themselves. There are those, however, that would have us forsake our hard-won success, who wish to embrace false but comforting ideas, and lead us backwards into the darkness of an earlier age.