Herbs: Out of the Cauldron and Into the Clinic
I am pleased and honored to be able to join you to deliver the annual Otto Richter Memorial Speech for the International Herb Association. I had the pleasure of knowing Otto. In fact, my last fond memory of him was closing the bar during the wee hours of the morning at the Omni Hotel in Baltimore at an IHGMA conference about six years ago. If my memory serves me well, the other member of our drinking fest that evening was the grande dame and founder of this organization, our friend Portia Meares!
I think Otto would be pleased to see the state of the herb industry today. It has grown in ways that are almost unimaginable just a few years ago. If you will permit me, I would like to offer a few random recollections and perspectives on this incredible growth and perhaps several assessments for how I envision the bright future of herbal medicine in America today.
Back around 1980 at the suggestion of my friend and respected mentor Madalene Hill, former President of the Herb Society of American (HSA), I filled out a membership application to the South Texas unit of the HSA. This form included a stipulation which read that I should not answer any questions about the medicinal properties of herbs but instead would refer such questions to a qualified physician. At that time I wrote a big "No!" on the form and "see enclosed" referring to another sheet of paper on which I wrote something to the effect that if the HSA would give me the name or names of any qualified physician(s) who had a working knowledge of the therapeutic benefits of herbal medicines, I would gladly consider altering my response. I knew I was on pretty solid ground; the odds were definitely in my favor as there were few physicians in the U.S. who understood herbal medicines in those days. That was almost 20 years ago. Since then things have begun to change in a big way. However, despite considerable progress in this area, there are still relatively few MDs who are qualified by training in the area of medicinal herbs.
The Fast-Growing Medicinal Herb Market
I am one of the many people who frequently are asked "How big is the U.S. herb market?" and "What direction the herb market is going?" My answer to the latter now requires that I mention that it’s not what direction but directions that the market appears to be moving in simultaneously. The market is increasing on all fronts. This includes consumer purchases from health food stores, drugstores, grocery stores as well as mass market outlets. Increased demand is reflected in the growth of multilevel marketers; Amway is now selling herbs! So is Shaklee and many others. Herbalife recently announced that its total annual sales last year topped $1 billion, with a majority of those sales now being generated overseas. Then there are mail order houses where an undetermined amount of herbs are sold via mail-order advertising, direct mail flyers and catalogs.
On the level of the health professional, thousands of chiropractors, acupuncturists, dietitians, and even massage therapists are recommending and selling herbs. And now, even some physicians in private practice and those in managed care and health maintenance organizations are starting to recommend and distribute herbal products. One physician told me this past March while attending a workshop on herbs that I was presenting at the Harvard/Beth Israel Hospital Third Annual Conference on Alternative Medicine that he had recommended the substitution of saw palmetto extract tablets for Proscar (finasteride) for the treatment of symptoms of benign prostatic hyperplasia in older (i.e., over 50) and that his HMO had purportedly saved over one-half million dollars over the previous year!
What is going to happen when news of this type gets further distributed into the conventional health care system? It does not require a degree in higher math or intricate finance to understand the the economic implication of the judicious use of well researched herbs and phytomedicines is going to continue to drive the herbal agenda right into the center of the health care system, where and when the use of these products is appropriate.
Up until recently, much of what has driven the herb market is the philosophy that "natural is better." But it is no longer only the philosophical commitments of consumers that will stimulate herbs in mainstream conventional medicines, it is economics, pure and simple.
Today herbs are no longer seen as a fringe enterprise. It is no longer correct to say that they are going mainstream - they are mainstream! In 1994 herb sales constituted the fastest growing segment in drugstores and second fastest in drugstores and supermarkets combined. Although I do not have new figures to measure the growth in mass market, it appears from what I am told by those in that segment that the growth continues at a strong pace. Herbs in the mass market still account for only about 10 percent of the entire herb market but this figure is bound to change soon as the rapid growth continues.
In the mass market, where herbs formerly consisted of several brands of garlic and ginseng - still the two leading products in mass, respectively - entire shelves are dedicated to herb products. Some companies have their own display racks and at least two dozen top selling herbs are generally available in Wal-Mart, K-Mart, Target and other major mass market retailers. One can now walk into these stores and purchase capsules containing bilberry extract, dong quai, echinacea, ginger, ginkgo leaf extract, goldenseal root, hawthorn, milk thistle extract, saw palmetto, St. John’s wort, valerian and vitex fruits, among others.
Of course, herbal teas have been in the mass market for at least ten to fifteen years. Celestial Seasonings and Traditional Medicinal teas made inroads into the mass market in the early 1980’s. At that time this was a subject of considerable concern to many small independent health food retailers who incorrectly predicted the demise of the health food industry due to lower price competition from chain grocery stores. However, the health food industry is booming, both for the independent retailer as well as three large major chains which have gone public and are pursuing aggressive expansion strategies, buying up leading stores in key markets - Whole Foods Markets, wild Oats Markets and General Nutritional Centers.
Some of this growth is no doubt being fueled by various consumer attitudes and social factors that have been in place for many years. This includes the natural food movement, the environmental movement, distrust of conventional medicine, concern about the toxicity of many modern pharmaceutical drugs, reactions to the high cost of conventional medicine and related attitudes, including the passage of the Dietary Supplement Health and Education Act of 1994 (DSHEA).
Evidence of skyrocketing consumer use of herbals is evidenced by some of the surveys taken over the past few years. In 1993, Harvard’s David Eisenbergh made medical history with his survey of unconventional and alternative medicine use. This survey was published in the New England Journal of Medicine thereby giving it widespread coverage and increased credibility. His research indicated that 34% of Americans routinely select alternative medicine which he defined as non-hospital modalities, including massage, chiropractic and acupuncture. His survey of about 1500 people indicated that about 4% of Americans used herbs.
In 1994 a survey conducted by the Food and Drug Administration (FDA) estimated that about 8% of American used herbal products with in the previous year. However, another survey conducted by the Gallop Organization in 1995 estimated that 17% used herbs; this figure grew to 19% in 1996.
The big news now and the new figure that will become the conventional wisdom is from the survey by Prevention magazine and NBC news which was publicized by Prof. Varro Tyler on NBC’s Today Saturday on March 1, 1997. This survey estimated that about 60 million adult Americans have used herbs within the previous year all adult Americans. They also forecast that each spent about $54 per year, equaling about $3.24 billion in sales for 1996 - a new record and the highest estimate to date of the total retail herb market in the U.S.
Numerous survey s are conducted on an annual basis to determine consumer attitudes in this area. One survey conducted in 1996 for a manufacturer of herbal products assessed the attitudes of about 1000 mass market shoppers who were not yet buying and using herbs but were considering doing so in the next five years. These are categories of use for which they would employ herbs: Sixty percent said they would consider herbs for increasing energy, 56% for preventing colds, 54% for boosting immunity, and 43% for improving sleep.
Another survey of 330 readers of Let’s Live magazine tracked closely to the survey just noted: Although results varied widely, most indicated that they already use herbs to promote energy and well-being (22%), to boost the immune system (18%), cold/flu remedies (14%), stress relief (11%), and stomach/digestive aid (10%). The 40% of the same group said that herbs were very effective; 32% said they were extremely effective; and 20% found them fairly effective. Interestingly, none of the respondents said that herbs they used were not effective.
Increased Media Coverage
Other factors both pushing this growth and also reflecting it are the increased positive media coverage. For example, recent major stories include a major TV network news show featuring a positive report on the benefits and use of ginkgo standardized extract. In April Prime Time Live reported on the benefits of garlic in a story that included an interview with Herb Research Foundation President Rob McCaleb.
On January 20 the Wall Street Journal ran a front page article on the growing use of echinacea for colds and flus, which was followed by an article in March in the Boston Globe, as well as other articles in other major papers, e.g. the Detroit Free Press. St. Johns’ wort got a shot in the arm with a two-page spread in Newsweek in April and Dr. Andrew Weil, the poster-boy for the alternative medicine movement, was featured on the cover of a recent issue of TIME. What’s more, the May 19 issue of U.S. News & World Report carried a three-page article ("Nature’s Remedies") in which the forthcoming publication of the English translations of the German Commission E monographs was suggested as a possible solution to the regulatory dilemma of how to evaluate the safety and efficacy of herbs for their therapeutic potential.
Research and Professional Interest
Speaking of echinacea, interestingly, according to a survey in 1995 of 200 health food stores by whole Foods magazine the biggest selling herbs in the U.S. health food market are echinacea (#1), followed by garlic goldenseal, ginseng, ginkgo, saw palmetto, aloe ma huang, eleuthero (Siberian) ginseng, and cranberry. At least eight of these (excepting goldenseal and ma huang) have been scientifically researched to some moderate to significant degree. This gives rise to Prof. Tyler’s suggestion that the best selling herbs are usually those that are the best researched. By the way, in the mass market garlic, ginkgo, and ginseng are the leaders, all of which are fairly well researched phytomedicines in Europe.
To me the biggest and most exciting trend is the heightened herbal interest among conventional health professionals. Everywhere I look I am seeing signs of increased demand for authoritative information on herbs from pharmacists, physician, nurses, dieticians, and others, including chiropractors - a group of providers that has long been using herbs as part of their clinical practice.
I find it most interesting that both the keynote address at this conference and this Richter Memorial Lecture are being given by two herb magazine publishers. Both Linda Ligon and I are known in the herb field, at least in some respects, for the publications we produce. Herb Companion and Herbs for Health (H4H), on the one hand, and HerbalGram, on the other. Both Herbs for Health and HerbalGram are clearly devoted to the responsible use of medicinal herbs, Ms Ligon’s magazine being derived directly from an HerbalGram-like section that Steven Foster and I initially created for Herb Companion. The fantastic success of the medicinal herb information prompted Linda to create H4H. I am proud and grateful to be associated with this new consumer publication and I am most grateful to Linda and her staff at Interweave Press for their care in taking measures to ensure that the information in H4H is accurate and reliable. The success of H4H at the newsstand will no doubt increase America’s respect for and use of herbs as medicines.
In the past few months alone, I have spoken to numerous groups of Physicians, pharmacists, nurses, dieticians, chiropractors and other health practitioners - all of which are eagerly trying to learn as much clinical therapeutic information on herbs and phytomedicines as possible. There are a at least two major reasons for this: first, many practitioners are sincerely interested in natural medicines. Second, most of them, regardless of their level of personal or profession interest, are aware that consumers are using these product in ever-increasing numbers and that they are expecting and are using these products in ever-increasing numbers and that they are expecting and demanding their their healthcare providers know enough to give them reliable advice.
Continuing education (CE) of health professionals in the area of herbs is becoming a big enterprise with numerous universities, associations and for-profit businesses getting into the act.
The biggest area of growth in CE appears to be in the area of pharmacy. This is understandable. First, pharmacists are generally much easier to access than other health professionals: it’s relatively easy to ask your neighborhood pharmacist a question while you are in the drugstore or supermarket shopping for other items.
Second, for the past several years pharmacists continue to be ranked as the most trusted profession in America. Third, many pharmacists, especially those who are a bit "older" have had the opportunity to study pharmacognosy when it was formerly a required course in all pharmacy schools (about 20-30 years ago). So there are many who have a basic understanding of plant medicines and plant-derived drugs, although the biggest-selling herbs and phytomedicines in retail today were clearly not taught in pharmacognosy courses.
Pharmacy continuing education programs abound. The American Botanical Council was one of the first organization to offer pharmacy CE courses four years ago, in conjunction with the Texas Pharmacy Foundation, providing home study courses, lectures, as well as the highly-publicized "pharmacy from the Rainforest" ethnobotany ecotours to Belize, Costa Rica, the Peruvian Amazon and now, Africa.
For the past two years, herbal CE seminars have been offered at the American Pharmaceutical Association’s annual meetings. The Association of Natural Medicine Pharmacists has begun to attract pharmacist members from all over the U.S. into an organization designed to meet the educational needs of pharmacists interested in herbal medicine and related modalities.
A recent survey by the University of Mississippi of pharmacists attitudes about herbs indicated that despite growing awareness by the public and increased availability of herbal products in pharmacies, most pharmacists do not feel adequately trained in the area of understanding the benefits and potential risks of herbs.
Physicians have begun to step up the herb educational plate. Ironically, as mentioned before, few MDs in the U.S. have training in herbs. Harvard University has sponsored three alternative medicine seminars in which herbs are featured. Dr. Fredi Kronenberg of Columbia University has made history by offering the first five-day seminar on botanical medicine designed especially for MDs. And now there is a Program for Integrative Medicine at the University of Arizona School of Health Sciences under the leadership of Andrew Weil, M.D.
However, the situation in the U.S. is woefully inadequate compared to Germany. There is estimated that about 70% of all MDs routinely prescribe herbal medicines. The herbs and phytomedicines are in the main sold in pharmacies where the dispensing pharmacists are trained in phytomedicines. Since 1993 it is mandatory in Germany that all physicians graduating from medical school must pass a section of their board exams in phytotherapy as a precondition of practicing medicine. We have a long way to go in our medical curriculum before that can become a reality in the U.S.!
In December 1994 the U.S. government sponsored its first-ever conference on herbal medicines. The sponsors were the newly-created Office of Alternative Medicine at NIH (now called Office of Alternative and Complementary Medicine) and the FDA. The title of the three-page conference report published in the Journal of American Medical Association was revealing; it was titled "Growing Use of Medicinal Botanicals Forces Regulatory Scrutiny" - an acknowledgement that health professional and public health officials are trying to catch up with the consumer use of these natural medicines.
Herbal Monographs Help Improve Quality and Access to Information
Another significant development is the publication and availability of authoritative monographs by various organization in the U.S. and Europe. This trend will continue to increase the credibility of herbs. There is going to be a confluence of monographs from the following sources: First, there is the forthcoming availability of the English translations of the German government’s Commission E monographs, to be published by the American Botanical Council. Also, there is the intuition of both standards and therapeutic information monographs from the United States Pharmacopeia, the nation’s oldest compiler of standards for medicines, since 1820. There are now 50 therapeutic monographs produced by the Europe Scientific Cooperative on Phytotherapy (ESCOP), an attempt to develop harmonized monographs for leading phytomedicines sold in the European Union.
The world Health Organization (WHO) is publishing this year its first 25 monographs which deal with both standards for identity and analysis as well as therapeutic information on 25 medicinal herbs sold world wide. Finally, the new monographs from the American Herbal Pharmacopoeia - particularly the 32-page monograph on St. John’s Wort will become a significant contribution to the botanical literature. All these will create a flood of authoritative information that will enable industry to produce better quality herb products and health professionals to use them more effectively.
Professor has proposed that investment in research helps to stimulate sales of herbs and that such research is actually a good investment for the industry. Prof. Tyler would like to see the industry plow about 15 percent of its gross revenues into clinical and related research to help document the safety and efficacy of herbs and phytomedicines. I concur and I think it will be only a matter of time before we are able to see an increased level of funding of legitimate scientific research on botanicals coming from members of the U.S. herbal industry. In fact, this trend is already beginning as more companies are sponsoring clinical studies on their products at places like Bastyr University in Seattle but also at more conventional colleges of medicine and hospitals. Presumably, the results of such research will be published in medical and pharmaceutical journals here in the U.S. - something that is sorely lacking. This will have a definite impact on health professionals; this will influence them to consider employing the benefits of herbs and phytomedicines in modern clinical practice as well as supporting their patients in their self-selection of herbs on an over-the-counter basis.
The Future: Maintaining Sustainable Supply
What does this expanded market for herbs bode for sources of supply? Clearly, wild harvested herbs are the first concern, especially root crops of native American medicinal plants like goldenseal (Hydrastis canadensis), block cohosh (Cimicifuga racemose), and others.
The goldenseal issue has been particularly alarming. For several years now industry experts and conservation strategist have expressed concerns over the wild goldenseal population in the Eastern U.S., the only place in the world where this herb is native. The International Conservation Union has drafted an extensive monograph on goldenseal for submission to the Convention for International Trade in Endangered Species (CITES) to try to have it listed as a "threatened plant" one step short of but not yet "endangered".
Previous attempts to grow goldenseal commercially had met with limited success although now several growers are reporting the ability to produce the small supplies of the cultivated root. Several environmentally conscious companies like Sunny Mavor’s "Herbs for Kids" have abandoned the use of goldenseal as an ingredient in formulations, choosing instead to substitute berberine-containing roots like barberry (Berberis vulgaris), Oregon grape (Mahonia aquifolium) and goldthread or coptis (Coptis spp.). Frontier Cooperative Herbs has started a "Save the Goldenseal" campaign to alert the trade and consumers about the need for conserving this plant. As part of the campaign, Frontier will use only commercially cultivated goldenseal root in its products.
When I speak of herbs, I almost invariably consider them in a medicinal sense. However, I know that this not necessarily true for many people, especially some of the members of this organization.. As is obvious to most of us, the myriad uses of herbs deal with the human interaction with the natural world that surrounds us that beautiful plant kingdom, as botanists call it; quondam, as I frequently like to refer to it; or kingdom, as it is sometimes referred to by evolutionary biologists because it is really reminding us of that all living beings are invariably interconnected into this amazing and awe-inspiring fabric of life. Many herbalists believe that each and every plant has some type of nutritional and healing benefit. We, too, we are aware of it or not, like the plants, we are inextricably interconnected to each other and to all other forms of life. And, like the beautiful plants, each one of us is here to help contribute to the healing of ourselves and to each other, and , in a global sense, to the planet as a whole.
In my infrequent spare time, one of my favorite hobbies is to study the origin of English words. One of my favorite is to understand the origin of the word steward and stewardship. The word derives from the Indo-European word sta which means place, as in Afghanistan (place of the Afghans), Kazakhstan (place of the Kazars), Uzbekistan (place of the Uzbeks), and so on. Other words in English that derive from this include state, static, standard, stage, stadium, stall, stagnant, stanch, stem, establish, system, and many, many more. In old England the man who keep the pigs in their sty (formerly steg) was the stegwarden, which later become styward, or steward. Of course, the concept of stewardship today connotes much more than keeping track of the pigs, but I think it is constructive to keep the origin of this word in mind, lest we ever allow our beautiful Earth to turn into a pigsty!
When I first made the conscious decision to enter in to the herb market as my vocation in the early 1970’s, one of the reasons I chose a profession in herbs was that I knew that I would have the opportunity to meet unusual people, independent-minded people who were courageous enough to venture out of the limitations, confines and conventions that society usually places on us- people who combine first, an intellectual curiosity about the natural world, with, second, a profound respect for both wild and domesticated plants and animals, and third, people with genuine commitment to be of service to other humans, especially by promoting and offering healing plants and the sacred information on their responsible use. I believe Otto Richter was just such person and I also believe that most of us who are dedicated to the similar vision have the opportunity to honor Otto’s life by continuing in this wonderful direction.
Twenty years ago people saw many of us as quacks. Now we are called visionaries! I am confident that we all may continue this beautiful vision.