An ideological collision

One of the great things about being involved in a complementary or alternative system of medicine is that issues often arise that send us right back to basics. Just recently a number of my colleagues have been discussing some interesting ideas with me, and I thought you might like to listen in.

Imagine for a moment that as a practitioner of Chinese herbal medicine you have a patient with cancer. Your patient has discovered that she might benefit from taking a herb named, say, Bellicus, that has recently developed a high profile in the market place as enhancing the immune system. Your patient has done a lot of research into her condition. She brings you articles from the medical press and internet references that indicate the effectiveness of Bellicus in just such a case as hers, where the immune system is compromised. She asks that you prescribe Bellicus for her.

Traditional herb?

Bellicus is increasingly being used by herbalists, including some of your colleagues who practise Chinese herbal medicine. You decide to look this herb up in your Materia Medica, your exhaustive dictionary of Chinese herbs and their properties, developed over thousands of years. Unfortunately, Bellicus is not a Chinese name and you cannot discover a translation for it into Chinese, so it is difficult to source its actions in terms of traditional Chinese medicine. The genus of the herb is very familiar, but the specific species seems to be a lot harder to pin down. To make matters worse, the little experience cited by your colleagues on the effects of Bellicus in terms of Chinese medicine gives conflicting actions, one referring to it as bitter and warm to drain Cold Damp in the Bladder and another referring to it as bitter and cold and with an action of dispersing Heat in the Liver with Damp Heat underlying. The first action would be beneficial for your patient, the second would not.

On another front, however, the web is effusive about the effectiveness of Bellicus as an immune system booster (a western rather than a Chinese medicine concept) and cites a number of randomized controlled trials to illustrate this, explaining the herb in terms of its pharmacological actions.

You contact a colleague who has been using Bellicus in the hope that she can shed some light, or point you in the direction of some more appropriate research. She tells you that she has heard that on at least one occasion Bellicus was prescribed by a western herbalist and subsequently the patient suffered a setback in their condition. The difficulty that the practitioner faced, of course, was to know whether the setback was in any way related to the patient taking Bellicus. The patient had had a change of medication at the same time, which could well have produced the exacerbation in their condition on its own. Or (and this is where life gets really tricky) it was possible that the new medication modified the effect of Bellicus, or indeed that Bellicus and the new medication were competing for receptor sites, somehow modifying their effects in unexpected ways.

Your colleague points out that Bellicus, in spite of its apparent effectiveness, is not a Chinese herb. You discuss with her what constitutes a Chinese herb. Does it have to have been in the Materia Medica for 2000 years? Will 500 years be adequate? An ironic contrast here is the European parliament ruling last November, stating that a herb has to have been in use for 30 years to be called ‘traditional’. Perhaps the issue is one of practitioner training in the herb and the ability to demonstrate reasonable care and skill with reference to it. If we have not been trained to use the herb, by virtue of it neither being clearly labelled Chinese nor featuring in the Materia Medica, then perhaps we are neither insured nor indeed (according to the Supply of Good and Services Act) within the law. A sobering thought, you decide, and probably quite enough to make your decision for you with respect to your patient.

But, I wonder, how as a profession are we going to take the issue further? If we were to do a randomized controlled trial with Bellicus we might discover that it does indeed enhance the immune system. But we would still be little wiser as to how it might interact with other western medications. Indeed, many law suits the world over centre on precisely the unknown but potentially dangerous interactions between one drug and another. This is still very much an emerging area for study. The interactions between herbs and drugs are also largely unstudied. Not so the interactions of Chinese herbs with other Chinese herbs – witness the age of your Materia Medica.

The "whole person" effect

This leads to yet another point. Is there an inherent difference between a herb and a drug? Should we consider viewing them differently when we are looking at their actions and interactions? Consider for a moment the case of SARS, for the time being a specter largely of the past. Interestingly enough, one of the most effective treatments for SARS was a Chinese medicine herbal prescription.

A similar thing is noted with respect to malaria: many strains of malaria are now drug resistant and yet still responsive to artemesinin, Chinese wormwood, a Chinese herbal medicine. Although refined into a drug and administered without accompaniment only 30 years ago, it has been used as an effective remedy for malaria as part of a Chinese medicine prescription for thousands of years. The reason for this, put simply, is that a Chinese herbal medicine prescription is a complex entity with a number of different herbs combined to produce a dynamic effect that is not targeted acutely like a drug. In the manufacture of a drug the precise active ingredient is honed and targeted to a point of precision. This, sadly, has the drawback that when viruses or bacteria mutate (as they are born to do) they will become resistant to the thing that threatens their existence – in this case the drug. This precise targeting is not only unnecessary but actually undesirable in terms of Chinese herbal medicine.

Herbalists are looking for the broad picture, the whole person effect: each patient with SARS, with malaria, with cancer will be treated differently, depending on their symptoms, their constitution and the strength of their ability to respond. The herbal prescription is designed in detail to suit the patient. At the same time, the disease is rendered impotent, because its capacity for mutation is useless again the herbal prescription’s broad action pattern.

So, back to Bellicus. Would it be appropriate then to subject this new herb to a battery of research trials that would tell us whether Bellicus could be said to enhance the immune system? The answer is probably yes, only if we are intending to use it with a western diagnosis of immune system weakness and alongside other western treatment. If, on the other hand, we want to treat our patients more holistically, and we want to know how Bellicus interacts with other herbs at the same time as wanting to establish its properties in terms of a Chinese herbal medicine diagnosis, we are probably going to have to use a different sort of observational research over a longer period of time: something more in keeping with the traditional system that we espouse as practitioners of Chinese medicine. And, if this is indeed the case, we could also consider whether or not we actually need another herb that is bitter and warm to drain Cold Damp in the Bladder or bitter and cold and with an action of dispersing Heat in the Liver with Damp Heat underlying. If this is the effect we seek, consider how many tried and tested alternatives we already have in our 2000-herb Materia Medica.

Thus for your imaginary patient, and for the foreseeable future, you might consider it would be just as well not to use Bellicus. But if all herbalists were to go down this route, how would the Materia Medica ever expand or take advantage of new discoveries? Perhaps the professional solution is to use Bellicus with caution, to study the actions and interactions using a system of reporting within the profession that is subscribed to by other herbalists as well as yourself. Hopefully, in this way, we all keep taking small steps into the holistic medicine system of the future.