How do we know Traditional Herbal Medicine Works?

How do we Know Traditional Medicine Works?, by Adam Tate, May, 2019
How do we know traditional herbal medicine works?

Introduction
People often ask ‘but how do you know Traditional Medicine/Herbal Medicine works?’

Firstly, we need to clarify a few things. To begin with, Herbal Medicine, Folk Medicine, Naturopathy and Traditional Medicine are all quite different but may often be classed together by lay people.

Herbal Medicine relates to the use of Herbs (and other plants) as medicine, and may cover kitchen-medicine, folk medicine, traditional herbal medicine, herbs used in naturopathic medicine and well as modern phytotherapists who rely on proven effects of herbs. Thus, with such a wide scope, this definition ranges from use supported by modern research through to the use of herbs based purely on superstition, religious, or folk use.

Folk Medicine refers to the use of herbs by common people. It may be as ‘old wives’ medicine and kitchen medicine (simple remedies used from items readily available in the kitchen), or to simple empiric remedies, somewhat proven over the course of time. Camomile tea to promote rest being an example.

Naturopathy covers an ever-increasing range of proven and unproven therapies and medicines, only a small part of which is herbal. Herbal medicine used by naturopaths may include aspects of traditional medicine (ie. the continuation of use of a medicine for something that it’s been used for over centuries), but may also include use based on research, and sometimes using other rationale. Naturopaths, in general, don’t use traditional herbal formula, however, much to the detriment of their practice.

Traditional Medicine specifically refers to the medicine used in a culture over a long period of time. All the Traditional systems are based on philosophical understandings built up over millennia based on observation of man and nature. The theories are based on the accumulated knowledge by numerous physicians over vast periods of time, and the primary use of herbal medicine is in time-tested formula. Traditional Medicine can be confused with Folk Medicine. Folk traditions can be as old as Traditional Medicine, but Folk Medicine tends to be practiced by untrained lay people and thus may be magical or empirical by nature, usually lacking the rationale of Traditional Medical Theory..

In this article, we will focus on the last, Traditional Medicine.

What is Traditional Medicine?
Traditional Medicine covers a range of different theories. Even in one system, there is often a collection of over-lapping theories that together represent that form of Traditional Medicine. Traditional Chinese Medicine is a particularly strong example of this. This one branch of Traditional Medicine has the Yin-Yang, 5 Element, 8 Parameter, Meridian Theory and Organ-system to name only a few of the theoretical foundations.

These philosophical frameworks were basically ways of defining, categorizing and understanding the phenomenon of health and disease. Thus, you could if you wanted, view the philosophies as memory-enhancers, ways of memorizing ways that certain medicines had been found over time to effect certain conditions or symptoms.

The fact is, these philosophies were refined over time to make a framework that is reproducible, teachable and found to be clinically useful, which is why they are continuing to be used today, and in fact, their use is increasing.

It has to be understood that although some aspects of traditional medicine became obsolete, much of it has been verified time and time again which is why intelligent and well trained physicians over great distances of time and space have continued to use it.

Thus, Traditional Medical Theory is fluid, dynamic and changeable, adapting over time as new ideas and knowledge becomes available.

Research into Traditional Medicine
After studying Traditional and Herbal medicine for nearly three decades, a couple of things intrigue me. Firstly, that a large percentage of medicines traditionally used in traditional medicine are found to have phytochemicals, demonstrated activities, or clinical trials that support traditional use. To clarify this, every herb used over a great period of time, and especially if used in different cultures and regions, will have a great number of attributes applied to it. In the above statement, I am specifically referring to primary recognised functions that has been used by notable doctors of the past and has been used over vast periods. Such as the use of Gentian for Liver diseases, Rhubarb to clear Heat and Toxin, Motherwort as a herb for gynecological disorders etc.

In these cases, we are finding more and more support for traditional uses of traditional medicines. And why perhaps a lot of initial research into a herbal medicine will not be deemed to be good science to a critical eye, after several decades of ever-increasing intensity of herbal research, earlier research is continually being backed up by more recent research of better quality, and often verified by multiple papers.

This brings me to the second point. Now, after several decades of research into Traditional Medicine, perhaps headed by the rise of Traditional Chinese Medicine in both East and West, we are seeing a wider variety of good research that is reaching a high degree of specificity. Several decades ago a herbs may have proven to have antibacterial effects. Now, fractional tests reveal which fraction is active, and then the main active component of that fraction is being isolated to determine which phytochemical(s) are responsible. Clinical trials of traditional formula are becoming more common. A number of trials in developed countries have been conducted using Chinese Medicine for Hepatitis with good results, as an example.

Also, through online resources like PubMed, research from non-English speaking countries is becoming more available, and those countries are also picking up the quality of their research papers to be more accepted by rigorous scrutiny in developed countries. There is a large amount of research coming from countries like China, India, Iran, Russia, a lot of which is verifying traditional uses.

The critical and skeptical eye observing Traditional Medicine today is a good thing. It forces it to be more self-critical and answerable. Regulations by modern governments help protect the population from potentially dangerous traditional medicines. Even the open market, where a range of modern tested herbal medicines, vitamins and neutraceuticals, as well as other traditional medicines means that a traditional medicine should have either strong empirical and historical use, or modern research to back it up. And that’s exactly what’s happening more and more–traditional empirical uses that are established as effective by the practitioners using a formula for a specific use over centuries is being backed up and verified by modern research.

And often research is giving us more than what the traditional practitioners knew. For example, a number of traditional Liver remedies have shown hepato-protective effects, often proven effective against potent liver toxins such as carbon-tetrachloride. Thus being stronger than a typical liver remedy with cholagogue effects, these remedies have implications in areas where liver toxicity including environmental, metabolic, chemotherapeutic or alcohol-induced liver damage has occurred. Thus supporting traditional use while suggesting other new uses. A liver remedy with bitter chologogue effects may not be well suited to a cancer patient on chemotherapy, whereas a liver remedy with proven hepatoprotective effects may be readily implicated in cancer therapy including after use of chemotherapeutic agents.

Another clear thing that comes out of research in a large amount of herbal medicines is the importance of antioxidant effects. So many herbal medicines, from culinary herbs to potent herbs only used medicinally have shown potent antioxidant effects. Antioxidant effects can have a range of benefits. They relieve oxidative stress associated with cellular deterioration and aging. They can help detoxify cells, while many have other benefits such as antibacterial, immunomodulatory or anti-inflammatory effects, amongst others.

Research often also shows safety or toxicity of a given herbal medicine. In some cases potentially toxic compounds have been shown in herbs previously regarded as safe. One example are the pyrrolizidine alkaloids found in plants like Comfrey, Borage, Coltsfoot and others. While I personally don’t think their use needs to be limited or stopped, it does give the practitioner the knowledge that these herbs are not suitable in large doses, for long-term use, or in those with compromised liver function.

Extrapolation from the old sources
We can use several tactics to look for useful herbs, formulas and treatment from traditional texts.

If we are studying the text of a learned and respected physician who states that 2 medicines are effective for a complaint, perhaps we know that one of those medicines is verified by modern research. We may assume that similar efficacy could be observed based on our appraisal of the quality of the writings of the author.

This is certainly far from scientific proof, in fact would be laughed at from a critical eye. Yet this is exactly the type of approach that can and has been used to investigate or research new medicines.

Some sources were long regarded as impeccable. For example, the Syrian Christian Physician known in the West as Mesue, was often called ‘the Physicians Evangelist’, for the certainty of his writings and remedies. His remedies, in fact, formed the basis of the early London and European Pharmacopoeias, so effective and respected were his remedies. So with a source that was used so far and wide over the centuries, and yet constantly praised by recognised and well studied physicians, means that we can accept that a lot of his remedies will continue to be effective in clinical practice. Despite the passage of time, the majority of diseases are the same today, and of course the human body has also remained largely unchanged.

Researchers looking for ethnomedicines will often begin by asking local healers. In numerous instances, research conducted on those medicines will be found to support the traditional use which is exactly why researchers continue to use this method. Just as they ask the locals which herb, insect, snake or sea creature is toxic, as the locals know and the researchers expect to find potent chemicals in toxic species.

Classes of Compounds
From a pharmacological viewpoint, there are a number of classes of phytochemicals that appear repeatedly in herbal medicines. These classes can straight away hint at the effects of an herb based on the research of other herbal medicines with similar compounds.

Polysaccharides are found in a number of traditional tonic medicines and tend to have restorative and immuno-modulatory effects, and often also show anti-tumor or anti-cancer effects. Cardioactive glycosides have powerful effects on the cardiovascular system. Alkaloids can have diverse effects, but are often pharmacologically potent. Many alkaloids effect the nervous system, while many of our strongest antibacterial medicines are also derived from their alkaloid content. Some are narcotic while others are toxic. Tannins are common in many herbs and likewise have well studied effects. Likewise Phenols and Flavonoids are common in medicinal herbs and their effects are well studied. This is only a few examples of the numerous types of phytochemicals that can immediately suggest an effect once identified in an herb.

Numerous compounds appear repeatedly throughout herbal medicines and are well studied. So identifying an herb as a good source of one of these phytochemicals can give clearer markers as to the effects of the herb even though it may not be well studied itself.

So nowadays, the expected use and effect of many herbs can be extrapolated purely by major known ingredients. This also makes research to verify the efficacy more appealing to researchers: there is a precedent that a specific effect should be noted in a medicine due to its known components.

Specificity of Use
One thing research does help to achieve is specificity of use. For example, herbs and formulas used over a long period of time have numerous indications given by different sources. Modern sources such as modern pharmacopoeias give more precise indications based on strong empirical use, usually combined with some research to give good credibility for the indication.

Many traditional herbs to clear ‘Heat and Poison’ have long been used for various bacterial infections. Research can not only verify an antibacterial activity, but can show which types of bacteria (and therefore infections) an herb is most suited to.

Likewise with Cancer. A large number of herbs traditionally indicated for use in Cancer therapy have shown anti-tumor and anti-cancer activity. Black Nightshade, Agaric, Agrimony, Violet and Red Clover are examples. But by screening against various cancer cells, it can be noted which types of cancer are likely to be best treated by the herb. Especially when it comes to Cancers like Prostate or Cervical Cancer. These ‘hidden’ cancers would usually have escaped diagnosis in Traditional Medicine. Indeed, it’s only comparatively recently the Prostate Cancer was even recognised when compared to cancers like Breast cancer that were known well over 2000 years ago.

So known anti-cancer herbs can be specified into being effective for particular cancers by combining traditional knowledge with modern screening.

Many modern medicines are derived from Herbs
A large percentage of modern western pharmaceuticals continue to be derived from plants. Digoxin from Foxglove (Digitalis), Colchicine from Colchicum, Morphine from Opium, Aspirin (modified) from Willow bark, and Psudoephedrine from Ephedra, and the chemotherapy from Yew trees (Taxol) are a few of the many examples of compounds widely used in modern medicine derived from traditional medicines.

Isolated compounds are still widely used, and this is based on research finding the primary active compound and isolating it. However, in many instances, the complete herb, or herb in formula can be superior to using a single isolated compound. All herbs contain a large number of chemical compounds, trace minerals, vitamins etc. As a package, they often work better together than isolating a single ingredient. The isolated compound may be stronger for a particular effect, and may even have uses that are different to the use of the whole herb. For example, a number of Poppy alkaloids have been used, not all of them being narcotic and analgesic,

But the point is, modern western medicine still uses a large number of drugs derived from herbs, purely because they work. And in many cases, their use has been derived originally from traditional medicine uses.

This is perhaps the best way of demonstrating the effectiveness of not all, but at least some, traditional medicines; the fact that they are still being used in modern medicine on such a large scale.

The case of Chinese Medicine
Traditional Chinese Medicine (TCM) without a doubt, is the most effectively integrated, clinically verified and researched of any Traditional Medicine system. Since it was proclaimed a national treasure a few decades ago, it has been integrated into modern Chinese healthcare in a truly wonderful way. Patients today often get both modern western pharmaceuticals along with Traditional Remedies. In some cases, after years of research and trying various formulas, the Chinese physicians have discovered TCM to be more effective than the western treatment for the same condition. This is especially prevalent in chronic gastrointestinal diseases, but also in a range of other diseases. And what’s more, Herbal medicines often have similar or greater efficacy, with less side effects while being more cost effective.

A number of trials compare herbs or herbal compounds with modern medicines. It is common for the herbs or herbal formulas to have similar efficacy based on symptoms, blood tests, etc., often with less side effects.

Another thing with such integration into mainstream healthcare is the sheer number of patients to get data on, especially in China. A large ward in a Chinese hospital may focus on something as specific as Gall Bladder disease (cholecystitis and cholelithiasis). Over periods, experienced doctors have refined their formulas to get greater efficacy. Thus, the hospital has a kind of Empirical remedy, based on either a Traditional Formula, or Traditional Theory.

Is Traditional Medicine more effective than the other Herbal therapies?
Briefly, yes.

The Australian government commissioned reports to evaluate alternative and complimentary therapies to ascertain possibility of health insurance cover and rebates. The review accepted TCM but rejected (modern) Herbalism, Homeopathy and Naturopathy (and a host of other complimentary therapies) as not having enough evidence-based material to support accepting them as effective therapies. TCM practitioners in Australia are the only herbal therapy to be registered by the AHPRA (Australian Health Practitioner Regulation Agency), the same government body that registers Doctors and Dentists in that country.

As stated above, TCM is unique in its modern integration into healthcare and the large amount of research available to support it.

However, as we have demonstrated throughout this website, the underlying principles, materia medica and theories throughout the different traditions, along with the growing amount of supportive research on the other traditions, suggests that the effects of the other systems will show similar efficacy to TCM. And research from countries using these other traditional systems is verifying this.

Safety of Traditional Medicine
This is a big study in itself as there are so many factors, so many herbs and formulas, and so much variety in Traditional Medicine. For example, Ayurveda uses lots of mineral and metal preparations, some of which contain Lead, Mercury or Arsenic. They tend to be far more readily available and used than in other traditions, so safety concerns for Ayurveda needs to take this into account and will effect safety.

But we can again look at the Australian report. Complimentary medicines responsible for the most reported adverse effects were from Chiropractic (17.8%) and Naturopathy (13.2%), with Chinese Herbal Medicine only accounting for 7.4%, relatively low considering its extensive use in chronic and obstinate diseases and the stronger, potentially toxic medicines that it uses when compared to Naturopathy.

It’s worth noting that some of the examples of herbal medicines being dangerous have used traditional herbs, but were not traditional medicines. Years ago, a compound containing a Birthwort (Aristolchia spp.) caused toxic effects in a number of people which resulted in kidney damage and even kidney failure in some. This was widely reported, and even recently I have heard doctors say ‘Herbal medicine is not safe’, all based on this one case. It turned out to be a patent medicine for weight loss, not a traditional formula. Birthwort species are still commonly used in Unani and elsewhere, but used in moderation, in traditional compounds, and their use is not generally associated with toxic reactions.

Let’s not get carried away
To be clear and impartial, of course not all traditional medicine is verified by research. Not all uses of all herbs and formulas have been verified. That would probably take centuries more research to achieve. And of course not all herbs or formulas are safe.

Some traditional uses become obsolete, and that’s not only today. Even modern medicine has moved away from drugs and therapies that were common a few decades ago. Traditional Medicine is an ever-changing, ever-developing body of knowledge with both well-trained and poorly-trained practitioners.

For example, Traditional Medicine is often cited in such occasions as the Bloodletting of George Washington which is believed to have led to his death (although some now dispute this). He was reportedly bled 124–126 ounces (3.75 liters) in 10 hours. Any well-trained doctor of medicine, even 2000 years ago in ancient Greece, would never have bled that much. In fact, not nearly that much. And the bleeding would’ve been combined with herbal medicine, purging etc.

So this fatality was due to ‘traditional medicine’, but was probably administered by a physician without adequate training. The books are full of such stories. And yet, the great masters such as Hippocrates, Galen, Avicenna or numerous others had a high degree of understanding and were known to be remarkably effective healers. None of these physicians would every bleed such an amount.

The importance of good training
Today as ever we can see the importance of good training. In the modern world, the importance of a traditional practitioner having studied the sciences of anatomy, pathology, physiology and microbiology is obvious, and in fact, enhances the efficacy and safe use of traditional medicine.

This again is a strength of TCM, where many western trained TCM doctors will do internships in Chinese hospitals to evaluate efficacy and gain clinical experience in modern hospital settings.

Conclusion
Traditional Medicine contains a wealth of information gathered over millennia that is both clinical relevant and can be highly effective in the modern clinical setting. It has always been an ever-changing body of knowledge.

The expected efficacy depends on the practitioner. A well-trained physician with a good amount of clinical experience from any of the traditions will often be found to have a high degree of efficacy.

There is good evidence to support the statement made at the beginning of this article that a large and growing amount of research into traditional uses of herbs, formulas, and traditional therapies is verifying traditional uses.

So today, more than ever, we have the ability to take the best of the old, combine with the best of the new to elevate traditional medicine into a reformed and potent alternative and adjunct to modern western medicine in the modern world.

Resources and Further Reading
1. PubMed (US national library of medicine) is the ultimate online resource to look at research on Herbal and Traditional medicine.
2. Australian Government: National Institute of Complementary Medicine Submission regarding rebate for Natural Therapies
3. The Review of the Australian Government Rebate on Private Health Insurance for Natural Therapies
4. WHO: Herbal medicine research and global health: an ethical analysis

How do we know Traditional Herbal Medicine Works?

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