Chinese herb may cause cancer

Scott Gottlieb , New York

Doctors in Belgium have discovered that a Chinese herb, Aristolochia fangchi, already linked to kidney failure, may cause cancer as well.

Patients at a Belgian weight loss clinic were given this herb in error. Staff at the clinic had prescribed the herb Stephania tetrandra, but the pills that patients received also included aristolochia, possibly because of a manufacturing error. On average, the patients took the two herbs for about a year.

Of the patients who accidentally received the herb, 18 developed cancers of the urinary system, according to the report. These 18 patients had already experienced severe kidney failure as a result of taking another combination of two Chinese herbs (S tetrandra and Magnolia officinalis) and needed kidney dialysis or kidney transplants (New England Journal of Medicine 2000;342:1686-92).

The Chinese name for A fangchis is similar to that for S tetrandra, and it is often substituted for stephania. "Since there is virtually no control over the quality of these products, it is not unusual not to know what is actually in herbal preparations and dietary supplements," wrote Dr David Kessler, the former commissioner of the US Food and Drug Administration, in an accompanying editorial.

Dr Joelle Nortier from Université Libre de Bruxelles in Brussels, Belgium, and associates first became aware of the extent of the cancer risk after discovering a urinary system cancer in one of their patients undergoing transplantation.

The researchers then offered preventive removal of the kidneys and ureters to 43 other patients being treated for kidney disease that was related to treatment with Chinese herbs. Thirty nine patients accepted the offer, and that is when the 18 cancers were discovered, representing a cancer rate of 46

In 19 of the 21 patients without cancer, mild to moderate precancerous abnormalities were found in the ureters or kidneys, according to the report.

All the affected kidneys showed evidence of exposure to aristolochic acid, the harmful ingredient in A fangchi, and lower levels were found in some of the ureters. Only four samples contained evidence of exposure to ochratoxin A, a possible carcinogen sometimes found in S tetrandra.

The risk of cancer was greater for patients who had taken larger amounts of A fangchi, the investigators note. Eight of 24 patients who took 200 g or less had urinary system cancer, compared with 10 of 15 patients who took 201 grams or more.

"Our findings reinforce the idea that the use of natural herbal medicine may not be without risk," said Dr Nortier.

Cases of kidney failure from aristolochia have been reported in France, Britain, Spain, Japan, Taiwan, and the United States. Last month, the US Food and Drug Administration sent warning letters about the herb to doctors and to the supplement industry.

Traditional medicine

Traditional medicine refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being.

Countries in Africa, Asia and Latin America use traditional medicine (TM) to help meet some of their primary health care needs. In Africa, up to 80% of the population uses traditional medicine for primary health care. In industralized countries, adaptations of traditional medicine are termed “Complementary“ or “Alternative” (CAM).

Increasing use and popularity
TM has maintained its popularity in all regions of the developing world and its use is rapidly spreading in industrialized countries.

* In China, traditional herbal preparations account for 30%-50% of the total medicinal consumption.
* In Ghana, Mali, Nigeria and Zambia, the first line of treatment for 60% of children with high fever resulting from malaria is the use of herbal medicines at home.
* WHO estimates that in several African countries traditional birth attendants assist in the majority of births.
* In Europe, North America and other industrialized regions, over 50% of the population have used complementary or alternative medicine at least once.
* In San Francisco, London and South Africa, 75% of people living with HIV/AIDS use TM/CAM.
* 70% of the population in Canada have used complementary medicine at least once.
* In Germany, 90% of the population have used a natural remedy at some point in their life. Between 1995 and 2000, the number of doctors who had undergone special training in natural remedy medicine had almost doubled to 10 800.
* In the United States, 158 million of the adult population use complementary medicines and according to the USA Commission for Alternative and Complementary medicines, US $17 billion was spent on traditional remedies in 2000.
* In the United Kingdom, annual expenditure on alternative medicine is US$ 230 million.
* The global market for herbal medicines currently stands at over US $ 60 billion annually and is growing steadily.

Safety and efficacy issues
Scientific evidence from randomized clinical trials is only strong for many uses of acupuncture, some herbal medicines and for some of the manual therapies. Further research is needed to ascertain the efficacy and safety of several other practices and medicinal plants.

Unregulated or inappropriate use of traditional medicines and practices can have negative or dangerous effects.

For instance, the herb “Ma Huang” (Ephedra) is traditionally used in China to treat respiratory congestion. In the United States, the herb was marketed as a dietary aid, whose over dosage led to at least a dozen deaths, heart attacks and strokes.

In Belgium, at least 70 people required renal transplant or dialysis for interstitial fibrosis of the kidney after taking a herbal preparation made from the wrong species of plant as slimming treatment.

Biodiversity and sustainability
In addition to patient safety issues, there is the risk that a growing herbal market and its great commercial benefit might pose a threat to biodiversity through the over harvesting of the raw material for herbal medicines and other natural health care products. These practices, if not controlled, may lead to the extinction of endangered species and the destruction of natural habitats and resources.

Another related issue is that at present, the requirements for protection provided under international standards for patent law and by most national conventional patent laws are inadequate to protect traditional knowledge and biodiversity.

Tried and tested methods and products
* 25% of modern medicines are made from plants first used traditionally.
* Acupuncture has been proven effective in relieving postoperative pain, nausea during pregnancy, nausea and vomiting resulting from chemotherapy, and dental pain with extremely low side effects. It can also alleviate anxiety, panic disorders and insomnia.
* Yoga can reduce asthma attacks while Tai Ji techniques can help the elderly reduce their fear of falls.
* TM can also have impact on infectious diseases. For example, the Chinese herbal remedy Artemisia annua, used in China for almost 2000 years has been found to be effective against resistant malaria and could create a breakthrough in preventing almost one million deaths annually, most of them children, from severe malaria.
* In South Africa, the Medical Research Council is conducting studies on the efficacy of the plant Sutherlandia Microphylla in treating AIDS patients. Traditionally used as a tonic, this plant may increase energy, appetite and body mass in people living with HIV.

WHO efforts in promoting safe, effective and affordable traditional medicine

The World Health Organization launched its first ever comprehensive traditional medicine strategy in 2002. The strategy is designed to assist countries to:

* Develop national policies on the evaluation and regulation of TM/CAM practices;
* Create a stronger evidence base on the safety, efficacy and quality of the TAM/CAM products and practices;
* Ensure availability and affordability of TM/CAM including essential herbal medicines;
* Promote therapeutically sound use of TM/CAM by providers and consumers;
* Document traditional medicines and remedies.

At present, WHO is supporting clinical studies on antimalarials in three African countries; the studies are revealing good potential for herbal antimalarials.

Other collaboration is taking place with Burkina Faso, the Democratic Republic of the Congo, Ghana, Mali, Nigeria, Kenya, Uganda, and Zimbabwe in the research and evaluation of herbal treatments for HIV/ AIDS, malaria, sickle cell anaemia and Diabetes Mellitus.

In Tanzania, WHO, in collaboration with China, is providing technical support to the government for the production of antimalarials derived from the Chinese herb Artemisia annua. Local production of the medicine will bring the price of one dose down from US $6 or $7 to a more affordable $2.

In 2003, WHO support has so far facilitated the development and introduction of traditional and alternative health care curricula in seven tertiary education institutions in the Philippines.

Training workshops on the use of traditional medicines for selected diseases and disorders have also been organized in China, Mongolia and Vietnam.

Priorities for promoting the use of traditional medicines
Over one-third of the population in developing countries lack access to essential medicines. The provision of safe and effective TM/CAM therapies could become a critical tool to increase access to health care.

While China, the Democratic People’s Republic of Korea, the Republic of Korea and Vietnam have fully integrated traditional medicine into their health care systems, many countries are yet to collect and integrate standardized evidence on this type of health care.

70 countries have a national regulation on herbal medicines but the legislative control of medicinal plants has not evolved around a structured model. This is because medicinal products or herbs are defined differently in different countries and diverse approaches have been adopted with regard to licensing, dispensing, manufacturing and trading.

The limited scientific evidence about TM/CAM’s safety and efficacy as well as other considerations make it important for governments to:

* Formulate national policy and regulation for the proper use of TM/CAM and its integration into national health care systems in line with the provisions of the WHO strategies on Traditional Medicines;
* Establish regulatory mechanisms to control the safety and quality of products and of TM/CAM practice;
* Create awareness about safe and effective TM/CAM therapies among the public and consumers;
* Cultivate and conserve medicinal plants to ensure their sustainable use.

Arabian Herbal

The history of herbal medicine in the lands of Arabia is as old as history itself, as it is in other herbal histories. Ancient Arabian medicine has also been influencing other traditional medicinal practices for almost as long. Since the earliest written history, there are records of the Arabs using herbal medicinal cures, and one of the oldest recorded histories of this was Hammurabi’s code, from the 18th Century BC. Apparently the ancient Babylonians were fairly proficient at healing people, and it was their custom to have the sick and suffering lay by the side of the street so that the passers by could have a go at healing them. In ancient Mesopotamia (which covers what are Arabia and the areas of Sham today) traditional medicine was advanced and effective. There are tablets that have been found that go back as far as 3000 BC about ancient medicinal practices. In ancient Egypt, the recorded healing tradition goes back to the most ancient Pharaohs, which is estimated to be around the 3rd millennium BC.

Evidence
There is evidence of this on the pyramids, particularly the older ones, and the papyri that have been discovered over the years. But, in fact, herbal medicinal tradition went back much, much farther than that. Back to far before recorded history. In fact, there was a burial site that was discovered in 1960 from the times of ancient Iraq that had clear evidence of herbal medicaments being used all the way back as far as the times of around 60,000 years ago! Later on, the Arabian herbal tradition was influenced by Islamic medicine as well, which came about in the beginning, through the traditions of the Prophet Mohammad (PBUH) himself, and later, was carried on by other great physicians, such as Ibn Sina (known in the west as Avicenna), Razi, Al-Tabbari, and more. This ancient medical tradition carried over into the subsequent years, and during the Dark and the Middle Ages, it is said that Europeans were using what amounts to barbaric methods to treat illness, and the Arabs were already using extremely sophisticated, time-tested methods to treat patients.

They would treat with herbal medicine with expertise and aplomb. In ancient Arabian medicine, the practitioner would first diagnose the illness by observing and examining the patient and asking him questions. In Arabian medicine, dietary recommendations are tantamount to cure, and the ancient Arabs said that disease begins in the stomach. There is also a prophetic tradition in this regard. The ancient Arabian healers had a huge herbal pharmacopea in their expertise. They knew how to use hundreds of local natural herbs in their cures, and were also aware of many herbal usages from other nearby locations as well. There were slight differences in the practices of the doctors from different parts of the Arabian world, with the Bedouin also having their own special version of Arabian medicine, which concentrated on the herbs that were available to them in the desert regions.

Expertise
The Arabian medicinal tradition was so strong and effective that later physicians from all over the world were influenced directly by it, and openly studied their cures and comments with regard to the vast variety of diseases that the information covered. In Arabian traditional medicine there is vast evidence of surgeries taking place, and they were also experts when it came to diseases of the eye. The ancient Egyptians (as well as the Mesopotamians) had expertise in the field of eye diseases, and knew about surgery, as well as gynecology, and internal medicine. They were aware of medicaments that are still used today by Arabian traditional practitioners. It is said that there are some herbal remedies that are made with herbs taken from the desert that are better than any modern chemical medication found in the world today, and cure much faster. In traditional Arabian medicine there is also plenty of use of animal derived cures, for example, using the fat of the sheep for a special salve to help rid the body of arthritic pain. Also, important in Arabian traditional medicine is cupping, branding, and blood letting. (Although the Prophet Mohammad (PBUH) didn’t allow branding, he recommended both cupping and blood letting).

This is still being carried out up to the present time, and is extremely successful in its cure. In fact, many of the modern essential oils used today were discovered and used since ancient times in ancient Arabia and ancient Egypt (and other places around the Arabian Peninsula). Herbs such as myrrh, frankincense, and licorice are still being used right up to the present time, in modern Arabian lands, as well as in western herbal medicine and aromatherapy. In fact, right here in Kuwait, there is a government sponsored herbal medical center based on the ancient Arabian healing tradition, and anyone can go there with a referral from any polyclinic. So, if you are suffering from an illness, go and try some of their expertise and cures. Some of the cures come from a time practically as old as the age of humankind.

The History of Herbal Medicine

The history of herbology is inextricably intertwined with that of modern medicine. Many drugs listed as conventional medications were originally derived from plants. Salicylic acid, a precursor of aspirin, was originally derived from white willow bark and the meadowsweet plant. Cinchona bark is the source of malaria-fighting quinine. Vincristine, used to treat certain types of cancer, comes from periwinkle. The opium poppy yields morphine, codeine, and paregoric, a treatment for diarrhea Laudanum, a tincture of the opium poppy, was the favored tranquilizer in Victorian times. Even today, morphine-the most important alkaloid of the opium poppy-remains the standard against which new synthetic pain relieves are measured.

Prior to the discovery and subsequent synthesis of antibiotics, the herb echinacea (which comes from the plant commonly known as purple coneflower) was one of the most widely prescribed medicines in the United States. For centuries, herbalists prescribed echinacea to fight infection. Today, research confirms that the herb boosts the immune system by stimulating the production of disease-fighting white blood cells.

The use of plants as medicine is older than recorded history. As mute witness to this fact, marshmallow root, hyacinth, and yarrow have been found carefully tucked around the bones of a Stone Age man in Iraq. These three medicinal herbs continue to be used today. Marshmallow root is a demulcent herb, soothing to inflamed or irritated mucous membranes, such as a sore throat or irritated digestive tract. Hyacinth is a diuretic that encourages tissues to give up excess water. Yarrow is a time-honored cold and fever remedy that may once have been used much as aspirin is today.

In 2735 B.C., the Chinese emperor Shen Nung wrote an authoritative treatise on herbs that is still in use today. Shen Nung recommended the use of ma huang (known as ephedra in the Western world), for example, against respiratory distress. Ephedrine, extracted from ephedra, is widely used as a decongestant. You'll find it in its synthetic form, pseudoephedrine, in many allergy, sinus, and cold-relief medications produced by large pharmaceutical companies.

The records of King Hammurabi of Babylon (c. 1800 B.C.) include instructions for using medicinal plants. Hammurabi prescribed the use of mint for digestive disorders. Modern research has confirmed that peppermint does indeed relieve nausea and vomiting by mildly anesthetizing the lining of the stomach.

The entire Middle East has a rich history of herbal healing. There are texts surviving from the ancient cultures of Mesopotamia, Egypt, and India that describe and illustrate the use of many medicinal plant products, including castor oil, linseed oil, and white poppies. In the scriptural book of Ezekiel, which dates from the sixth century B.C., we find this admonition regarding plant life: ". . . and the fruit thereof shall be for meat, and leaf thereof for medicine." Egyptian hieroglyphs show physicians of the first and second centuries A.D. treating constipation with senna pods, and using caraway and peppermint to relieve digestive upsets.

Throughout the Middle Ages, home-grown botanicals were the only medicines readily available, and for centuries, no self-respecting household would be without a carefully tended and extensively used herb garden. For the most part, herbal healing lore was passed from generation to generation by word of mouth. Mother taught daughter; the village herbalist taught a promising apprentice.

By the seventeenth century, the knowledge of herbal medicine was widely disseminated throughout Europe. In 1649, Nicholas Culpeper wrote A Physical Directory, and a few years later produced The English Physician. This respected herbal pharmacopeia was one of the first manuals that the layperson could use for health care, and it is still widely referred to and quoted today. Culpeper had studied at Cambridge University and was meant to become a great doctor, in the academic sense of the word. Instead, he chose to apprentice to an apothecary and eventually set up his own shop. He served the poor people of London and became known as their neighborhood doctor. The herbal he created was meant for the layperson.

The first U.S. Pharmacopeia was published in 1820. This volume included an authoritative listing of herbal drugs, with descriptions of their properties, uses, dosages, and tests of purity. It was periodically revised and became the legal standard for medical compounds in 1906. But as Western medicine evolved from an art to a science in the nineteenth century, information that had at one time been widely available became the domain of comparatively few. Once scientific methods were developed to extract and synthesize the active ingredients in plants, pharmaceutical laboratories took over from providers of medicinal herbs as the producers of drugs. The use of herbs, which for most of history had been mainstream medical practice, began to be considered unscientific, or at least unconventional, and to fall into relative obscurity.