Why is health reporting so hard?

Why would anyone want to take something called "Devil's Claw?"

Cuz the devil is powerful strong!

"journalists are supposed to ask questions, preferably hard ones" is a story that journalists tell themselves and others about themselves. Anthropologists study such stories and have a technical term for them: "mythology".

If you follow the evidence, a journalist's job is to bring eyes (the product) to adjacent print advertisers (the customer). O'Connor delivers. Hard questions are only useful to a journalist insofar as they promote controversy. Not all journalists are exactly clear on what their job is. Some few exercise a personally felt but imaginary obligation to the reader. We are flattered by that, but it harms the journalist's career.

Large grocery chain stores have adopted a similar model: they deliver grocery shoppers (the product) to grocery suppliers (the customer). What they charge their customers for is shelf space. How effectively they bring in loose-walleted shoppers determines how much they can get for the shelf space.

In my opinion this kind of reporting is one of the biggest if not the main reason why science-based medicine is struggling in its war against quackery. It's not unreasonable for people to expect good science from the NY Times -- yes, it's an appeal to authority, but the average person reading this article is interested in his or her health and not necessarily a skeptical thinker. There has to be some authority for the general public to appeal to, and it's a shame that the Times proves itself to be a very bad one here.

Turns out there this thing called a "Bear Claw".

Helps with stomach pain.

With a woo-woo here, and a woo-woo there,
Here a woo, there a woo,
Everywhere a woo-woo.

Known for its anti-inflammatory effects

So then it's immunosuppressive. Do you have to take it with vitamin C and echinacea to boost your immune system?

NJ @6:
Turns out there this thing called a "Bear Claw".

Helps with stomach pain.

I think that only works if you use them in homeopathic amounts!

To all the snarky commenters hate to rain on your parade but there are studies that suggest that devils claw can be effective for back pain. How inconvenient.

So much for respect for science on this blog. How about:

Chrubasik S, Thanner J, Kunzel O, et al. Comparison of outcome measures during treatment with the proprietary Harpagophytum extract doloteffin in patients with pain in the lower back, knee or hip. Phytomedicine 2002;9:181-94.

Gagnier JJ, Chrubasik S, Manheimer E. Harpgophytum procumbens for osteoarthritis and low back pain: a systematic review. BMC Complement Altern Med 2004;4:13.

Chrubasik S, Kunzel O, Thanner J, et al. A 1-year follow-up after a pilot study with Doloteffin for low back pain. Phytomedicine 2005;12:1-9.

Did you happen to read the studies, oderb?

Ref 1 Chrubasik: no control group

Ref 2 Gagnier: a poorly done literature review

Ref 3 Chrubasik: a follow up survey on former users of devils claw.

I would definitely drink a mixed drink called "devil's claw".

Googling Ms. Chrubasik is at first really impressive. Comes up with a Prof. Dr. med. at the University Clinic of Freiburg. Only when you look at the details you notice she's working in the forensic medicine group, and her Prof. is an honorary title from the University of Sydney. She's still studying willow bark so, maybe someone should show her a pack of aspirin?

I think we should all traipse over the the NYT website and comment on the article in question.

On a side note, I had to stop reading the Well posts at the NYT because of the creeping woo factor. The last straw was the post about the Buteyko breathing technique -- with demos from YouTube. If my objectively-measured breathing ability drops by half, I want an actual medical doctor, O2, and cortisone, thanks.

This is reminiscent of your last post making false claims about the state of the science regarding echinacea. If you don't like the studies, why, they must be bad studies. Somehow. Or they must not exist. Sure, there are anecdotes for devil's claw. And there are lab studies of its pharmacologic actions. (No, a plant need not have molecules similar to already marketed pharmaceuticals to have useful bioactivity.) And there are animal toxicology and bioactivity studies.

There are also at least five double-blind placebo-controlled studies. This reporter may not have cited them because he/she was lazy, or because they're in European journals. Because those are not enormous studies - there is no possibility of doing such, without pharmaceutical company backing - their results are certainly not definitive. You are free to say it is still possible that the plant is inactive and these studies (like the animal studies) just by coincidence happened to have results supporting the plant's traditional use. But, if you want to be an honest blogger, you are not free to claim that this work is not "real research," that the lab and animal data you claim to want do not exist, or that there is no "external validation" of the plant's safety.

By the way, idiotic comment #1 exemplifies why some Americans are so unwilling to acknowledge research on herbs. It's called biophobia. "Why would anyone want to take something called devil's claw?" Well, because the fact that the fruits have large hooked, clawlike projections to ward off herbivores is irrelevant to the safety of a root extract. Does someone think a plant that's ever been named for the scary-wary devil must be magically poisonous? Yeesh.

Right. Orac has biophobia, that's his problem!

Bloody hell, I meant PalMD, not Orac. I really shouldn't dive-bomb blogs at lunch.

Nice collection of strawmen there, Jane. Must be easier to knock those down ("a plant need not have molecules similar to already marketed pharmaceuticals to have useful bioactivity" or "they're bad studies because PalMD doesn't like the outcome" or "plant named for the scary-way devil must be magically poisonous") than the arguments actually being made -- which are that the quality of the studies is so poor as to be worthless, therefore, this remains as a product lacking enough evidence to make the bold claims that a professional journalist is making.

On a more serious note, something with a name like "devil's claw" would be very marketable to the credulous, and would probably be more marketable under that name than under the plant's actual scientific name. This is because a name like "devil's claw" sounds like the sort of name some mystical medicine man/woman would call it. Conjures up images of tribalism. Plus, it sounds very powerful. Why *wouldn't* they want it?

I tried looking up the plant, but it's one of those overloaded plant names; it applies to several unrelated genuses. Harpagophytum appears to be the one used as an herbal remedy. Other less-marketable names include "wood spider", probably for the fact that it spreads by runner, and "grapple plant". It's related to sesame, and the part used medicinally is the tuber. I think there is indeed adequate anecdotal evidence to justify proper study, but the proper study has yet to be done, as far as I can tell. It's premature to make such bold claims. "Might help" would be better than "works particularly well". Wikipedia (take with a grain of salt) mentions interactions with warfarin and increase in stomach acids, so there are potential risks with it, which the Time article did not mention.

There is one other plant used medicinally which is sometimes called devil's claw -- Urtica dioica. It's more commonly known as stinging nettle, though. Has loads of medicinal uses, some with a fair amount of evidence to support them, though for the most part, better alternatives exist. No doubt some folks felt they'd been touched by the devil when they broke out in rashes after encounters with this plant.

The other plants which share the name devil's claw are members of the genus Proboscidea, which have hooks on their seed pods to enable distribution by passing animals. As far as I can tell, Proboscidea is not used medicinally.

As far as "biophobia" goes, I don't really care where a chemical comes from, as long as the preparation of it is consistent in dose and purity and "inactive" ingredients. (No ingredient is totally inactive; variations can affect uptake of the drug, which can be significant.) If it comes from a plant, fine, as long as it can be obtained in reasonable quantities without threatening the species, and as long as there is a practical means to adequately extract and purify it.

@Jane

1. Citations for your 5 RCTs please. Although since you say they are small scale they presumably wouldn't be enough to actually justify what this journo was doing ie plugging this treatment in a column.

You also say these 5 RCTs have a placebo group. This is a minimum requirement for testing for efficacy. Surely in practice you want to be comparing against standard treatment. Its not hugely useful being better than placebo but worse than everything else that already exists and is in use.

2.

Because those are not enormous studies - there is no possibility of doing such, without pharmaceutical company backing - their results are certainly not definitive.

The people flogging this stuff could try funding studies into it. Or perhaps they are happy selling this but dont want to do rigorous work.

Instead we get whining about how because big pharma aint funding studies (wonder why - maybe cos there's nothing promising?) they cant do proper RCTs.

Moreover since the large high quality studies in humans havent been done why isnt this mentioned in this piece as a reason not to be using this stuff?

If you're going to yell "strawman" when your views are challenged, you'd better read carefully to make sure you don't accidentally distort what your target has said.

1. It was PalMD who said "I'd like to see some lab data ... or at least chemical moieties similar to known drugs." I suspect that if the latter were present someone would quickly be claiming that that made the plant (though not the drugs) unsafe, but my point was that you must evaluate a traditional whole-plant extract based on its own activity and not on the presence of molecules you already think you understand. A plant's activity may well be based on molecules not individually usable as drugs, or not yet discovered to be usable as such, so the absence of drug-like molecules provides no basis for believing that the plant lacks value. Lab data on the extract is far more informative; PalMD falsely indicated that such did not exist for this plant.

2. Commenter #1, whom I suggested suffered from biophobia, was Pascale, not PalMD. The argument he seemed to be making - if you can call it an argument at all - was that if the Anglo-speaking common name included the word "devil," you should not want to consume it. This implies complete ignorance of the flora around him, for which our language features hundreds of fanciful common names that tell you nothing about a plant's safety or edibility. The name "devil's claw" was given to the plant by British colonials, not evil supplement marketers. Snotty comments about "medicine men" and "tribalism" aside, those who discovered the plant's activity - yes, they were mere Africans, hence "tribal" - didn't call it devil's claw, because they didn't speak English.

3. How do we, or you, or PalMD know that all those lab and animal studies, not to mention five placebo-controlled trials and the Vioxx comparator trial, were all "so poor as to be worthless"? Sure, none of those are definitive, nor is the whole body of evidence together definitive. That doesn't make every study "worthless." Have you or PalMD read them all, including the ones in German? If not, what is the source for an allegation that they are worthless? When we are simultaneously told that research on a disapproved practice doesn't exist and that it's all worthless (thereby impugning the honesty and competence of every scientist who gets results you don't like), I recognize this as just promotion of another type of "sectarian medicine". There's really no difference between that attitude and the attitude of people who will not accept studies showing vaccines to be safe and effective.

bexley - I don't waste time typing in information for denialists anymore, since prior experience has shown that it has no effect. You can consult Schultz et al's Rational Phytotherapy (2004) or the ESCOP monographs (2003) for a partial list of studies; I'm sure there are more recent references.

It's an interesting question what the appropriate comparator group should be. In America, a placebo is generally preferred (in part because it suits drug company interests). Europeans think active-comparator trials are more ethical. This has caused certain American-supremacists to claim European trials - at least of botanicals shown to be equal to drug arms - are worthless. Now you are claiming (ignoring the Vioxx trial) that methods using placebos are inadequate. This looks to me like a matter of moving the goalposts as fast as necessary.

Nobody is saying Pfizer should fund herb trials - they won't and, based on their bottom line, shouldn't. Supplement manufacturers who are actually making enough profit to support clinical studies certainly should do so, as you imply. (I hope that those who believe that will not then slander the scientists so supported by suggesting that their research data should be rejected.) But those studies are never going to include 10,000 people per arm. The money just isn't there. So there will always be a shred of doubt about the accuracy of the results (just as, in truth, there is with pharma studies).

There is no one true metric for evaluating whether a given combination of practical human experience, lab and animal studies, and practically feasible human trials is adequate to justify use of a botanical by Westerners who could substitute pharma drugs. It depends on a lot of factors - condition to be treated, cost, relative safety - and also on personal attitudes (e.g., whether you for philosophical reasons prefer single-compound drugs). If someone else weights the evidence differently than you do, that doesn't make them wrong.

How do we, or you, or PalMD know that all those lab and animal studies, not to mention five placebo-controlled trials and the Vioxx comparator trial, were all "so poor as to be worthless?

Well lab and animal studies are not the basis for recommending use in humans. Therefore while they are useful when asessing potential before testing in humans they shouldnt be used as the basis to recommend use in humans.

PalMD has already said the Vioxx trial has problems in that the comparator group wasnt receiving very much Vioxx and Vioxx isnt even used.

The 5 RCTs - you have already said they are small and placebo controlled (rather than comparing to other available treatments). Again not the basis for recommending use in Humans.

Often, the medical news presented in the media is derived straight from press releases, which often present biased or questionable points of view. The quality of fact checking is very poor.

A recent egrecious example were widely circulated reports suggesting that morphine, an opiod drug used for relief of pain, promotes cancer growth. This caused considerable worry among patients who are receiving this drug. However, a close examination reveals that there is essentially no meaningful evidence that morphine promotes cancer drug. Certainly, the amount of critical analysis in the news stories approached zero. The stories seem to have the intent of promoting relistor, a drug that blocks opiod receptors. More details on this reporting incident can be found here: http://www.geripal.org/2009/11/does-morphine-stimulate-cancer-growth.ht…

In America, a placebo is generally preferred (in part because it suits drug company interests). Europeans think active-comparator trials are more ethical.

Jane - to make this clear I AM european . I'm not shifting goalposts here.

Moreover I think you'll find that Orac at least has pointed out that active comparator terms are the only ethical way of doing cancer research (he was talking about testing CAM cancer cures at the time) and he is a Yank. Other bloggers here have said that placebo controlled trials from big pharma are things to be wary of when assessing their claims too as they will tend to look better for the drug being tested. Can't remember if PalMD has made this point before.

I notice I've been characterised as a denialist - so far you have failed to say why any of my arguments are actually wrong though. So this sounds like nothing more than an ad-hom and excuse not to cite the studies. I'm afraid Im not about to go and buy a book to find cites for these studies (over £50 on Amazon for Schultz's tome and over £120 for the monographs!).

But those studies are never going to include 10,000 people per arm.

Ok but what are they actually funding - anything at all? And right now we're not asking for 10000 per arm because its not clear to us that we even have preliminary studies justifying that large a trial yet.

BTW one other source of funding I forgot was NCCAM.

Sorry, Bexley, but it's not an ad hominem argument (see online definitions) to say that I do not waste my time rewriting available resources for people whose minds I believe to be, for the most part, made up. Sure, I could type out a list of citations, but what would that prove? Would you then demand that I type out each complete paper so you could bring your expert judgement of worth to bear on it? Especially if you're in Europe, you should be able to find some of the original research or summary descriptions online or in the nearest academic library, if you are genuinely interested in learning about the subject.

If you are European, your preference for active-comparator trials is fine, but you should be aware that Americans think differently. Yes, for immediately life-threatening diseases like cancer, active controls are used - which has its own problems - but for conditions like back pain, the usual American practice is to use a placebo. Americans have been known to automatically reject the several European studies showing the equivalence of St. John's wort to various SSRIs merely because they were herb-drug comparisons without a placebo group. (If that line comes up on this blog, perhaps you will step in to correct it.)

Likewise, PalMD is wrong about the Vioxx comparator study. The fact that the pharma arm was taken off the market (after the study was done) for toxicity that had been concealed by the manufacturer does not negate the fact that Vioxx was an effective analgesic and anti-inflammatory drug. The dose given was used in medical practice as a starting dose for similar conditions, and if that dose was no better than the botanical, that suggests either that the botanical works or that something is very wrong with the testing and marketing of drugs.

"Sure, I could type out a list of citations, but what would that prove?"

Well, we could see these mythical studies you're citing, which for one might prove your point. As it stands your argument consists "I know I'm right because studies I may or may not have read that I am unwilling to identify back up my assertions."

Sure, I could type out a list of citations, but what would that prove? Would you then demand that I type out each complete paper so you could bring your expert judgement of worth to bear on it?

Well I'd probably pass my non-specialist eyes over the abstracts.

Anyway I dug out the abstract of the Vioxx comparator trial I think people are discussing:

Chrubasik S et al. A randomized double-blind pilot study comparing Doloteffin and Vioxx in the treatment of low back pain. Rheumatology 2003; 42:141-8

http://www.ncbi.nlm.nih.gov/pubmed/12509627?itool=EntrezSystem2.PEntrez…

Each arm had only 44 patients - not enough to make the statement:

"The dose given was used in medical practice as a starting dose for similar conditions, and if that dose was no better than the botanical, that suggests either that the botanical works or that something is very wrong with the testing and marketing of drugs."

Finally you'll notice that Pal didnt criticise the trial for having an active comparator. He criticised because he felt that the dosage of Vioxx was fairly small and because now that Vioxx is off the market it isn't that helpful. This suggests that he isnt too worried by active comparators in general.

The Cochrane reviewers also noted that since Vioxx isn't on the market new studies would be needed.

Given the recent findings of severe adverse effects of Vioxx and its subsequent removal from the retail market, additional trials testing these herbal medicines against standard drugs (acetaminophen, NSAIDs) are needed.

http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004504/f…

They also said:

Clinical relevance

The clinical relevance of each study was independently assessed by two authors, using these five questions:
1. Are the patients described in detail so that you can decide whether they are comparable to those that you see in your practice?
2. Are the interventions and treatment settings described well enough so that you can provide the same for your patients?
3. Were all clinically relevant outcomes measured and reported?
4. Is the size of the effect clinically important?
5. Are the likely treatment benefits worth the potential harms?

...

Of the trials testing Harpagophytum Procumbens, two trials did not meet items four and five (Chrubasik 1999; Chrubasik 2003).

Therefore for this comparator trial the size of the effect may not be clinically important the likely treatment benefits may not be worth the potential harms.

So there may be something here but surely not enough for the journo to be plugging this.

JohnV - Wouldn't matter if I have read them or not, as I am not a biomedical researcher. A bunch of journal reviewers and editors read them; the opinions of those people are of far more value than mine. Or yours, because you presumably haven't read any of them, or your insinuation that I'm lying when I say studies have been conducted ("mythical") would be not just contemptible but an utterly baldfaced lie. To demonstrate the pointlessness of this demand for citations, let me just type up citations to one in vitro study:

Fiebich BL, Heinrich M, Hiller K-O, Kammerer N. Inhibition of TNF-alpha synthesis in LPS-stimulated primary human monocytes by Harpagophytum extract SteiHap 69. Phytomedicine 2001;8:28-30.

and to one animal study:

Lanhers MC, Fleurentin J, Mortier F, Vinche A, Younos C. Anti-inflammatory and analgesic effects of an aqueous extract of Harpagophytum procumbens. Planta Med 1992;58:117-123.

and to one human clinical trial:

Chrubasik S, Junck H, Breitschwerdt H, Conradt C, Zappe H. Effectiveness of Harpagophytum extract WS 1531 in the teratment of exacerbation of low back pain: a randomized, placebo-controlled, double-blind study. Eur J Anaesthesiol 1999;16:118-129.

There, now, what good does that do? Technically it does "prove my point", since my only point was that research has in fact been conducted. I did NOT claim that these studies, or the 51 references listed by ESCOP taken together, definitively proved the correctness of traditional knowledge about the plant; in fact, I said that they do not. You, however, have no rational basis for asserting that if these studies had positive results, it means the quality of the data generation or analysis must be, to quote Calli, "so poor as to be worthless."

If I spent an hour typing in the whole list, I fail to see how that would change matters at all, unless perhaps you were willing to admit that it was unlikely that that many different reviewers and journal editors were part of a great conspiracy to make worthless supplements look bioactive by publishing crappy or fraudulent research. Let me know if that's the case, and I'll see if I can find the time. Otherwise, why should I give myself carpal tunnel for nothing?

Its neither here nor there but you could consider typing the list in note pad and saving it as a text file, and thus when the question comes up you can cut and paste it instead of making a de novo production out of it.

What this proves is that there's something for us to take a look at at least. Next up is to see if my institute has access to any.

If you're going to yell "strawman" when your views are challenged, you'd better read carefully to make sure you don't accidentally distort what your target has said.

You say this, then go on to get nitpicky about who you were accusing of biophobia -- and then allege that I was accusing you of challenging my views? I had not posted prior to your post, so how could you have been responding to my views?

You have not made any substantive response to my accusations of strawmen. A strawman argument, for your edification, is where you attribute some claim to the other party so that you can refute it, when the other party has not in fact made that claim. My specific examples were:

"a plant need not have molecules similar to already marketed pharmaceuticals to have useful bioactivity" or "they're bad studies because PalMD doesn't like the outcome" or "plant named for the scary-way devil must be magically poisonous"

Admittedly, these were paraphrased, not quoted, so here are the direct quotes from your post:

No, a plant need not have molecules similar to already marketed pharmaceuticals to have useful bioactivity.
If you don't like the studies, why, they must be bad studies. Somehow.
Does someone think a plant that's ever been named for the scary-wary devil must be magically poisonous?

My point was that nobody actually made any of those three claims. The first one is patently absurd; one would have to be pretty closed-minded to think that all the possible therapeutic agents had been discovered. The second sounds like you're accusing folks (and PalMD in particular) of saying that if they don't like the outcome of a study, they reject it out of hand. This is not true; PalMD criticized studies on the basis of their quality, not their results. The third addresses Pascale, but is still a strawman. He never said that he thinks it might be poisonous with the word "devil" in the name; I think he was just poking fun at how goofy-sounding the name is. (And honestly, a lot of plants have pretty goofy names.)

1. It was PalMD who said "I'd like to see some lab data ... or at least chemical moieties similar to known drugs." I suspect that if the latter were present someone would quickly be claiming that that made the plant (though not the drugs) unsafe, but my point was that you must evaluate a traditional whole-plant extract based on its own activity and not on the presence of molecules you already think you understand.

Ah, I see where you're going wrong. You think he's saying that it has to have known medicinal compounds in it. That's not what he means -- and I think you know that, because you snipped out the part of his quote that indicates that's only one of the things he'd accept as evidence. He was simply saying that if someone can demonstrate that there's a compound in it which behaves chemically in a manner very similar to a known drug, that would be enough to convince him. It wouldn't require more extensive research. (Obviously, if it's a previously unknown compound, then it would take more research to know how it works. That's pretty self-evident.)

A plant's activity may well be based on molecules not individually usable as drugs, or not yet discovered to be usable as such, so the absence of drug-like molecules provides no basis for believing that the plant lacks value. Lab data on the extract is far more informative; PalMD falsely indicated that such did not exist for this plant.

No, he indicated that data of insufficient quality exists. He didn't go into greater detail in the OP, but he certainly did not indicate there is no data.

He also definitely did not say that there is an "absence of drug-like molecules" and that therefore it can have no value. I'm not sure what "drug-like molecules" is supposed to mean. It either acts as a drug or it doesn't.

2. Commenter #1, whom I suggested suffered from biophobia, was Pascale, not PalMD. The argument he seemed to be making - if you can call it an argument at all - was that if the Anglo-speaking common name included the word "devil," you should not want to consume it.

Not to be too snarky here, but I believe he was going for humor, and possibly addressing a perceived marketing problem when something is called "devil's claw". I tried to give a serious response to that in my last post (why such a name may actually be a marketing boost). You regarded those comments as "snotty", because you thought I was looking down my nose at tribal folks in Africa who, you say, discovered the plants activity. But if you read my post carefully, you'll see I wasn't talking about them. I was talking about the people who are marketing the product today. They do not care about the native tribesmen who were using this plant several centuries ago. They simply observe that there is a certain marketing value in making something appear more "natural" or "native" or "tribal". It's right up there with the fake Native American crap that recently killed a bunch of folks in a sweat lodge in Arizona. Real medicine men wouldn't promote that kind of BS. They have too much dignity to do that. It's the fake medicine men you have to worry about, who cash in on this kind of stuff.

You are correct that the name is old, given by British colonials, but it's not the only name this plant has had. Why do the modern promoters use this one, as opposed to its other names? I was just speculating that perhaps it is more marketable. Like "ma huang" instead of "ephedra", since the Chinese name sounds more "ancient Chinese secret" than the Greek name.

3. How do we, or you, or PalMD know that all those lab and animal studies, not to mention five placebo-controlled trials and the Vioxx comparator trial, were all "so poor as to be worthless"? Sure, none of those are definitive, nor is the whole body of evidence together definitive. That doesn't make every study "worthless." Have you or PalMD read them all, including the ones in German? If not, what is the source for an allegation that they are worthless? When we are simultaneously told that research on a disapproved practice doesn't exist and that it's all worthless (thereby impugning the honesty and competence of every scientist who gets results you don't like), I recognize this as just promotion of another type of "sectarian medicine". There's really no difference between that attitude and the attitude of people who will not accept studies showing vaccines to be safe and effective.

No difference? Really? We are open to being convinced that this product is indeed safe and effective. We're just waiting for that evidence. But rather than supplying this evidence, you just spend your time accusing us of being unfairly biased against something that doesn't conform to our worldviews. That's interesting, given that you are being considerably more defensive than anyone else in this thread.

How do we know that these studies are inadequate? Well, several folks, including PalMD in the very post that started this, gave their opinions. PalMD never alleged that there is no data, or that no studies have been done. He said so right in the OP. He said that the few studies that have been done were of poor quality, and briefly gave some objections. You have not responded to those objections; you've merely intimated that we're all closed-minded or something.

From your most recent post:
If I spent an hour typing in the whole list, I fail to see how that would change matters at all, unless perhaps you were willing to admit that it was unlikely that that many different reviewers and journal editors were part of a great conspiracy to make worthless supplements look bioactive by publishing crappy or fraudulent research.

I didn't see anybody claiming fraud. That's a very serious accusation, and not one to be made lightly. "Crappy" is more of a value judgement, and frankly, crappy research gets published all the time. More to the point, though, this research isn't uniformly crappy -- it's just very preliminary. Unfortunately, that tends to be the case for most alternative health research; they go far enough to show some small effect in a pilot study, and then apparently lose interest. It's very frustrating.

But it's not a conspiracy. It's how science works. Every drug, every therapy started out with little trials like these; if journals rejected them out of hand for not being really massive Phase III clinical trials, we'd never get anywhere. But there is an expectation that more research will be eventually conducted. Doctors can't prescribe without knowing what dose, what benefit to expect, any side effects or drug interactions, and so on. It is worth demanding more science.

How often would I have need to post it anywhere? Would I do the same for every other botanical that's been the subject of, in some cases, hundreds or thousands of studies? That is not my job! And if I were to post a huge reference section from a published book online, it would probably violate the copyright.

If ScienceBlogs wanted to pay me to write a blog about medicinal plants, yeah, I'd come up with twenty or thirty references for every post. But not for mere comments on someone else's blog. It is not your responsibility or mine to purchase volumes of ESCOP or ABC or AHP or WHO monographs to see what science has been done. It IS the responsibility of a blogger, if he wishes to put himself forward as an expert on that subject, to get himself access to at least one such source and look things up before he makes sweeping pronouncements.

My last message was directed to JohnV. I find little in Calli's new rant worthy of response. Twisting opponents' words freely, while yelling "strawman" to plausible interpretations of statements issued by your own side, is a mark of someone who will not listen to other perspectives with an open mind, and who therefore cannot participate in a genuine conversation on the subject.

Oh, Jane...you are verging into laughable territory:
If ScienceBlogs wanted to pay me to write a blog about medicinal plants, yeah, I'd come up with twenty or thirty references for every post.

First, blogging isn't how I make a living---it's a hobby. I respond to folks like you because I enjoy educating and writing. If I'm lucky, I'll make a few bucks from month to month.

This sort of special pleading is really pitiful. If you're going to make claims about a drug (and that's what any bioactive substance used to affect health is) it's up to you to back up your claims. I did a nice long pubmed search on the topic and read your references. There is some plausibility to the claim that devil's claw may do "something", but little credible in vivo human data to support anything in particular. If you can't be bothered to find the evidence that I somehow missed that you are so sure is out there, don't expect anyone to take you seriously.

Didn't suggest you made a living at it, PalMD; if blogging were more profitable than MDing I'd be astonished. You, like others of your ilk, resort all too quickly to attacking your opponents. I am not making health claims for devil's claw. I only stated that, to the extent your blog implied there had been no studies of bioactivity, animal studies or clinical trials, by stating that you'd "like to see" them, that was false. I don't have to do a lot of work to point out a simple error, nor does anyone have to take my word as being any kind of expert opinion. My comments were not intended to provide your readers with all knowledge on the subject - that's not my place or job - simply to let them know that if they want the whole truth, they'd better look it up themselves rather than relying solely on you. And further, to point out that the assertions of certain commenters that favorable studies they know nothing about must be "worthless" are simply faith-based.

Then there the question of whether human experience accumulated by persons not holding Western science degrees or using the latest scientific methods has any evidentiary value whatsoever. That does not imply that traditional knowledge is infallible. It only asks the question, is a plant that is valued by traditional healers to reduce inflammation any more likely to do so than a randomly selected plant? There has been some research on this, and the general answer is yes. That implies that the results of the best practically feasible clinical trials done on a botanical with substantial human use data should be weighted as being somewhat stronger than we would weight the same-size trials with a substance having no prior use for the given purpose. That may be perceived as defying a major tenet of scientism, or science-as-religion, so I doubt you'll embrace the concept - but it is fair for your readers to consider the issue.

Jane thanks for the cites. Getting to the point your original post said Pal was ignoring 5 RCTs and some in vitro and animal studies in his critique of the article.

To back up the RCT point up you cite Chrubasik 1999. This is one of the two studies on Devil's Claw that is used in the Cochrane Review (the Review is what is cited in the NYT article). Therefore it is one of the studies Pal is already aware of and Pal covers it (and the other study - Chrubasik 2003) as follows:

The author references a couple of small pilot studies with weak conclusions.

You'll notice that both studies that the NYT article relies on are assessed for clinical relevance by the Cochrane Review and the review says they weren't found to have effects that are clinically relevant nor were they found to have likely treatment benefits worth the potential harms. (see my post 28).

Which is why presumably why Pal said both studies showed weak effects.

So you still havent shown us that Pal has been ignoring RCTs - which ones (ie not Chrubasik 1999 or 2003) do you think have been ignored. You should note that unless they were published after the Cochrane Review the Review's authors also ignored them (presumably because they were too low quality or not RCTs).

Your other claim was that Pal has ignored animal studies and lab studies. Sorry but surely you don't think a doctor should be relying on animal and in vitro studies for safety and efficacy data? This is what is at stake given the article is plugging this drug's use in humans and it is what Pal is criticising the article for.

Abstract from a Devil's Claw clinical trial.

N=183, 3 groups, placebo responders=3, Devil's Claw responders =6 or =10. A one-tailed test was used and p=0.027! Tramadol was used for pain relief in all participants.

"Eur J Anaesthesiol. 1999 Feb;16(2):118-29.

Effectiveness of Harpagophytum extract WS 1531 in the treatment of exacerbation of low back pain: a randomized, placebo-controlled, double-blind study.
Chrubasik S, Junck H, Breitschwerdt H, Conradt C, Zappe H.

Department of Medical Biometry, University of Heidelberg, Germany.

Two daily doses of oral Harpagophytum extract WS 1531 (600 and 1200, respectively, containing 50 and 100 mg of the marker harpagoside) were compared with placebo over 4 weeks in a randomized, double-blind study in 197 patients with chronic susceptibility to back pain and current exacerbations that were producing pain worse than 5 on a 0-10 visual analogue scale. The principal outcome measure, based on pilot studies, was the number of patients who were pain free without the permitted rescue medication (tramadol) for 5 days out of the last week. The treatment and placebo groups were well matched in physical characteristics, in the severity of pain, duration, nature and accompaniments of their pain, the Arhus low back pain index and in laboratory indices of organ system function. A total of 183 patients completed the study. The numbers of pain-free patients were three, six and 10 in the placebo group (P), the Harpagophytum 600 group (H600) and the Harpagophytum 1200 group (H1200) respectively (P = 0.027, one-tailed Cochrane-Armitage test). The majority of responders' were patients who had suffered less than 42 days of pain, and subgroup analyses suggested that the effect was confined to patients with more severe and radiating pain accompanied by neurological deficit. However, subsidiary analyses, concentrating on the current pain component of the Arhus index, painted a slightly different picture, with the benefits seeming, if anything, to be greatest in the H600 group and in patients without more severe pain, radiation or neurological deficit. Patients with more pain tended to use more tramadol, but even severe and unbearable pain would not guarantee that tramadol would be used at all, and certainly not to the maximum permitted dose. There was no evidence for Harpagophytum-related side-effects, except possibly for mild and infrequent gastrointestinal symptoms."

PS. I love the throw away comment about side effects at the end. Virtually saying, "How could my treatment possibly have any side effects?"!

PPS. Let me get my calculator to work out 0.027 x 2 ....

This review of safety data claims to have found 28 clinical trials of Devil's Claw. Anyone got too much time on their hands?...

"Phytother Res. 2008 Feb;22(2):149-52.

Systematic review on the safety of Harpagophytum preparations for osteoarthritic and low back pain.
Vlachojannis J, Roufogalis BD, Chrubasik S.

Department of Orthodontics, Columbia University, 630 W 168th, VC 9, Rm 219 B 10032 NYC, NY, USA.

Harpagophytum products are a treatment option for osteoarthritic and low back pain. The aim of this study was to review the safety of treatment with Harpagophytum procumbens. The databases OVID(MEDLINE), PUBMED and COCHRANE COLLABORATION LIBRARY were searched back to 1985 for studies with Harpagophytum procumbens. Twenty-eight clinical trials were identified of which 20 stated adverse events. In none of the double-blind studies was the incidence of adverse events during treatment with Harpagophytum procumbens higher than during placebo treatment. Minor adverse events occurred in around 3% of the patients, mainly gastrointestinal adverse events. A few reports of acute toxicity were found but there were no reports on chronic toxicity. Since the dosage used in most of the studies is at the lower limit and since long-term treatment with Harpagophytum products is advisable, more safety data are urgently needed."

Jane, I'm sorry you considered that as a rant. I realized that you had taken offense at my first post, and so I was attempting to be more thorough, to avoid misunderstanding. I see now that it was hopeless. You will read what you want to read, regardless of what is actually written. You are obviously quite passionate on the subject of herbal medicines; there's nothing wrong with that, but I would urge you to try not to let your passion overwhelm you. You are making enemies out of people who are actually on the same side as you, by assuming them to have nefarious intentions just because they said something you don't entirely agree with.

As to your claim that I am twisting your words, perhaps you would care to explain what I misunderstood. Any misunderstanding was not intentional. I do note, however, that you have not even acknowledged that I corrected your misunderstanding of my words, much less apologized for it. You accused me of belittling tribal peoples, describing my words as "snotty", though I was talking about modern marketing types exploiting common social prejudices about tribal wisdom rather than the actual tribal peoples themselves (who rarely, if ever, get any benefit from this exploitation). Perhaps you can see why I find your protests about twisting of words disingenuous.

Calli - I don't assume you have nefarious motives. I assume that your preconceived ideas and philosophy place limits on the opinions you can hold or consider, which is no worse than you plainly assume for me. And like you, I think it would be hopeless for me to continue.

Bexley - PalMD will assume that any study with positive results either is a bad study, or shows "weak effects," or both. If you will reread my messages carefully, my point was not that the five human RCTs vs. placebo (the other twenty-some human studies are mostly open-label) were definitive - I don't know how many times I have to say that to be comprehended and believed - but that they existed. You wrote:

"Your other claim was that Pal has ignored animal studies and lab studies. Sorry but surely you don't think a doctor should be relying on animal and in vitro studies for safety and efficacy data?"

If you really want dialogue, you should pay attention to what people actually say, rather than "listening like a lawyer" only to spot points that you can disagree with, or twist into something that you can disagree with. Although the interpretation of animal studies for a product with extensive human use data can reasonably differ from the interpretation of similar studies on a novel molecule, I never suggested that animal studies provided proof of efficacy. My sole point was only that animal studies existed, contrary to PalMD's insinuation. (Your missing this point further convinces me that typing up a complete list of human trials would be a waste of time.)

OTOH, animal studies, combined with extensive human use and some clinical trial data, do provide meaningful evidence of safety. Not 100% proof, which never exists, but evidence strong enough to be taken into consideration by consumers. That's why animal toxicology studies are done. If an animal-welfare supporter suggested that results of those studies were not relevant to humans and they should therefore be banned, the medical industry would go berserk. That industry can't enshrine certain methods as mandatory for drug development then start claiming those methods have no value when "competitors" acquire the ability to use them.

Jane

1.

Pal was criticising the article's author for plugging devil's claw without enough evidence to do that responsibly. Your post said he ignored evidence in his post.

My point is that unless the studies you think he ignored show safety and efficacy then they are irrelevant to Pal's post and he is right not to mention them. In-vitro and animal studies cant show safety and efficacy so they are irrelevant to Pal's critique and your accusation that he has ignored them is unfair.

On the RCTs - you havent actually cited one that Pal has ignored. (Moreover the NYT article only cites the 2 Pal discusses).

I hope you understand what Im saying now.

2.

PalMD will assume that any study with positive results either is a bad study, or shows "weak effects," or both.

The article links to a Cochrane Review that uses two studies in reaching its conclusions on Devil's Claw. I've already quoted the review's comments on these two studies - the review says they weren't found to have effects that are clinically relevant nor were they found to have likely treatment benefits worth the potential harms.

Hence Pal's comment that they show "weak effects" is perfectly justified. Again I can't see any justification for your comment that Pal is unjustly dismissing studies out of hand.

If in-vitro mechanism and in-vivo animal studies provide no information whatsoever that would be useful to estimating a product's possible safety or efficacy, such that we are right to ignore them, why did PalMD say that he "would like to see" such studies, implying that it would have been a red flag if such had not in fact already been done? I am not surprised that you won't taking the trouble to read my posts carefully and accept that I mean what I say I do - but it appears that you aren't paying close attention to what PalMD says either. Though not himself a scientist, he is a dedicated champion of medical research as currently conducted in the U.S., where accepted cultural practices most certainly include animal studies and mechanism studies.

I really do not know why I'm bothering. This will absolutely be the end of my serving as your reference librarian. Here are three more human trials. Please note that I DO NOT say, or believe, that their results are definitive proof of efficacy. (Thus, anyone who says I said so will simply be lying. Hint, hint.) The point here is just that more studies exist than were referenced in a two-paragraph NYT article, since certain people pretend to be unwilling to believe that.

Goebel H, Heinze A, Ingwersen M, Niederberger U, Gerber D. Harpagophytum-Extrakt LI 174 (Teufelskralle) bei der Behandlung unspezifischer Rueckenschmerzen. Effekte auf die sensible, motorische und vaskulare Muskelreagibilitat. Schmerz 2001;15:10-18.

Chantre P, Cappelaere A, Leblan D, Guedon D, Vandermander J, Fournie B. Efficacy and tolerance of Harpagophytum procumbens versus diacerhein in treatment of osteoarthritis. Phytomedicine 7:177-183.

Guyader M. Les plantes antirhumatismales. Etude historique et pharmacologique, et etude clinique du nebulisat d'Harpagophytum procumbens D.C. chez 50 patients arthrosiques suivis en service hospitalier [Thesis]. Paris: Universite Pierre et Marie Curie, 1984.

Jane, the point is that in vivo studies provide justification for continuing to animal and human studies. Once you've got them, no need to keep at it. In order to ethically recommend the stuff to humans, we need convincing clinical studies, preferably, but not limited to, double-blind placebo-controlled RCTs. Then, the totality of evidence must be examined a la Cochrane. One somewhat positive study cannot "over-rule" the preponderance of data. In this case, there is little data to justify the claims made for devil's claw. Might this change? Sure, because the claims aren't implausible, just unsupported.

When you say "One somewhat positive study cannot 'over-rule' the preponderance of data," that implies that there are more negative than positive data. If that were true, avoiding any argument about what counts as "data," you would be correct to prefer the negative view. In this case, the preponderance of scientific evidence favors the traditional use, although research has been too limited to allow anyone to say that the science is settled. The existence of uncertainty does not mean one cannot rationally choose to use a botanical to try to alleviate any type of discomfort, or "ethically recommend the stuff" under any circumstances. That would be like saying science tells us we should never eat a traditional wild food that has not been fully studied by Western nutritionists. Science has no ability to make value judgements.

Ugh.

If one proposes to recommend use of a drug such as devils claw there should be good, consistent evidence for it's safety and efficacy. You have just restated that this is not the case, but that the goalposts should be moved to "the science isn't settled so we should use it".

That's bad medicine.

PalMD - Not at all. I restated that "good and consistent" evidence is a lower standard than "definitive" evidence, and that what constitutes "good and consistent" evidence depends both upon the specifics of a case and upon personal opinion. I believe that the totality of the evidence for safety for devil's claw - from animal toxicology tests, over two dozen human studies, and extensive human experience - is adequately good and consistent that if I had a persistent backache, I would not be afraid it was "too risky" to give devil's claw a try. You believe differently.

That's not a dispute that science can resolve. There is no set of facts, real or imaginable, that I could cite to prove that my opinion is "right" and yours is "wrong." I just object to your donning the mantle of science to claim that yours is the only opinion anyone can properly hold.

That's not a dispute that science can resolve. T

This is known as "special pleading". There is no reason to believe that. The question of the clinical efficacy and safety of any drug can be resolved via well-established means. We do it every day.

You are entitled to your own opinions, but not to your own facts.

Jane,

If you're arguing that different people have different risk tolerances, that's reasonable. Pain is subjective, and one person might think "I'll take even a risky pain med" and another might think "The pain is bad, but I don't want to die" and accept a lower risk.

But either of them should listen to "this has thus-and-such risks and isn't useful for your complaint" or "this costs $50/month and is absolutely useless," because that's not a matter of balancing priorities: there's no need for that subjectivity when one side of the scale is "this won't help at all" and the other is "it has known harmful effects."

Vicki - in a case where there is evidence to support those statements, you are absolutely correct. This was by no means one of those cases (e.g., I have no reason whatsoever to think using this product might kill me). The question here is only whether the favorable evidence is strong enough to prevent us from feeling required to abandon the traditional practice.

I try to understand that some "skeptics'" contemptuous attitudes towards other people's opinions, and occasional difficulty distinguishing facts from opinions, are influenced by their having argued till they're blue in the face with people who keep defending a practice even when it actually has been proven by unbiased science to do more harm than good. Chelation, for example, or coffee-enema cancer treatment (or, hey, lifetime HRT). In those cases, the facts are plentiful and solid and on their side, and the people who are arguing with them are almost certainly wrong, yet refuse to listen to reason. That must be aggravating in the extreme. Unfortunately, it also may encourage them to develop an exaggerated sense of certainty that they are right about other questions that are not so cut and dried, and that those who disagree with them on any issue are simply unreasonable.

I don't know whether it's a lack of resources, laziness, or ignorance that allows pieces like this one into the paper, but it doesn't change the craptastic nature of the piece.

None of the above. It's the fact that editors don't want to run pieces that aren't about an AMAZING NEW DISCOVERY THAT WILL KILL YOU NOW/ALLOW YOU TO LIVE FOREVER!!!111!!11!q!@@!!ELEVSNYTY!!111!!

Health writers know this, so they write all their articles within the confines of this paradgim.

That seems rather cynical and downright uncivil.

D00d, when reality itself is dominated by shit-ass incivility, it is neither cynical nor incivil to point that fact out.

Ben Goldacre says somthing similar about one of the English tabloids. He points out that they appear to be trying to classify every substance in the world as either causing or curing cancer.

they appear to be trying to classify every substance in the world as either causing or curing cancer.

Tricky, since a number of substances can do either, depending on how and under what circumstances they are used.

# 49 Comrade PhysioProf

I think you are giving them too much credit.

It is guaranteed that every fall an ivy covered fossil who has been cogitating something new to say about Xenophon all summer will have every thought driven out of his head by a bright eyed youngster wanting him to plod through their course catalog and give them a plan for life as a reporter/broadcaster.

They do this despite the large brass sign that says âCLASSICSâ over which the secretary has hung an enormous banner that screams âTHIS IS NOT THE COLLEGE OF JOURNALISMâ .

All reporting stinks because all journalists are congenital idiots.

# 48 Jane,

The jaundiced eye with which medicine looks at âtraditional herbal remediesâ is perhaps reactionary but certainly not just skepticism for its own sake. Ethnobotanists pressed the consumption of thousands of lab hours and untold millions by flogging undiscovered panaceas in rain forest pharmacies while completely ignoring that the ancient and tribal pharmacopeias are based on sympathetic magic, not results.

The more anthropomorphic or arabesque the plant, the more suspect the anecdotal evidence. How many women over how many thousands of years died using mandrakes to treat infertility just because the roots look like a baby?

Since water caltrops look weird, they are given to children throughout East Asia to cure fevers when all they really do is transmit giant intestinal parasites because they grow in cesspools.

When we know that a human intuition at a very basic level is at least wasteful and at most deadly skepticism is very properly applied to counter it.

Yet the "wasteful to deadly" intuition of ancient or tribal human beings sufficed to identify and learn how to utilize, and often cultivate and selectively breed, every edible plant you now consume plus thousands more. And west Asian physicians two thousand years ago had invented plastic surgery and cataract surgery. I would not be quick to assume that every medicine they discovered was nonsense.

Every healer, including Western physicians, does some things that have no actual value for cultural reasons. But it would be idiotically prejudiced to imagine that every culture but our own had a medical system devoted to "sympathetic magic, not results," suggesting that our own relatively recent ancestors, as well as everyone in nonwhite cultures, either did not care about results or lacked any capacity to notice real benefits or toxicity. Anyone who believes that is certainly free to foreswear the use of any pharmaceutical derived from a traditional medicinal plant.

I bet you or someone else will want to twist this into a claim by me that all traditional medicines work. Don't try. Of course not all traditional medicines work. Within the limits of practicality, the scientific method is the best available means of determining whether interesting observations (in many fields) actually hold up. That's what it is for. All parties therefore need to let it work (acknowledging the fact that funding and manpower are finite) and be prepared to accept the results even when they are culturally displeasing to us.

"I would not be quick to assume that every medicine they discovered was nonsense."

I don't make that assumption. I don't think anyone else is either.

"All parties therefore need to let it work (acknowledging the fact that funding and manpower are finite) and be prepared to accept the results even when they are culturally displeasing to us."

I don't understand this statement. Are you suggesting the scientific method is being undermined by racism or ethocentricity in the guise of skepticism?

Because that would be complete crap...if you were suggesting that.

Jane

Your argument boils down to special pleading (trying to play a culture card) backed up with straw men.

If you have a plant that you think does something you need to identify the actual substance or substances in combination from that plant that are the active substance/s. Many many medicines available now are the active ingredients found in plants. Get the usefull stuff out of the plant and you have something that can actually do something reliably. Chewing on roots is a bit hit and miss on the dose, if you catch my drift. Plus selectively bred plants or specially ground substances that make a nice smell or go poof in the fire all add to the theatre of healing without having any therapeutic benefit beyond a placebo.

Then you need to prove that the substance/s in question works, is safe and are cost-effective. Then it's not a traditional/herbal medicine, it's just actual medicine.

This is a new idea not because people didn't used to care about efficacy or safety (your straw man) but because they didn't have the tools to measure them. Routine clinical practice still doesn't have the tools to measure them unless the substance is immediately toxic or incredibly effective (like antibiotics for instance). You need some of that science stuff to sort it all out.

PS. Being a resident of the extreme East I can tell you there is no such thing as 'Western' Physicians. There's real physicians and there's special pleading quacks. What will the special pleading quacks do as the Chinese science machine rolls into gear and starts delivering the sort of healthcare advances that the Japanese have? I'm guessing that you'll keep calling real medicine 'western' as if it's all just some sort of post modern cultural construction and not the reason your still alive?

Prometheus - Yep, that's pretty much what I'm suggesting -usually substituting "cultural bias" for "racism." Over and over I have seen that when traditional knowledge of a botanical is confirmed by lab, animal, and human studies, even if enough clinical trials pile up to get an almost-unheard-of favorable Cochrane review, you can still find self-proclaimed skeptical defenders of science to yowl that those studies are all "worthless" and impugn the authors' competence and integrity. They are simply unwilling to believe that something they have been trained to so disapprove of might actually work.

Antipodean - One of the more bizarre intellectual habits of the Skeptic is to claim virtually anything opponents say is a "straw man." I've given up addressing trying to educate people out of thinking that's an adequate rejoinder to anything.

Now here is a cultural construction: "If you have a plant that you think does something you need to identify the actual substance or substances in combination from that plant that are the active substance/s." No, a scientist would understand that you can show a botanical extract to be effective long before you have elucidated the exact molecular mechanisms by which its various constituents produce that bioactivity - if indeed you ever fully understand that. The fact that you think this should be a requirement does not make it so; that is a belief, not a fact. No scientific study can provide proof that the drug-development model is the only proper source of medicines.

And while you're trying to defend your position via personal attacks, why would you assume that modern American medicine - note the greater specificity, as American orthodox MDs often treat European and Japanese medical practice as quackery - is for me "the reason your [sic!] still alive"? I have never had a life-threatening illness in my life; would we all die at birth without an MD standing by? It's been estimated that the vast majority of improvement in life expectance is due to public health advances, NOT to heroic medicine or prophylactic medicine. (To be sure, improved public health is to a large extent a product of science, but chlorinated water and handwashing hardly count as "modern medicine.")

"To be sure, improved public health is to a large extent a product of science, but chlorinated water and handwashing hardly count as "modern medicine."

Um yea they do.

The vilification of Ignaz Semmelweis and Oliver Wendell Holmes, Sr.? John Snow knocking off the pump handle?

Cholera and puerperal sepsis "hardly count"?

Now I'm really confused.

Are you sure we are the ones with the bias?

Jane, demanding actual evidence for safety and efficacy isn't a cultural construct (yes, it's dependent on "culture" to a certain extent---pre-scientific cultures didn't bother). There is no "special wisdom" in the ancients---that reveals more about your own biases.

The only way your approach has validity is if you assume that for the purposes of human health, there is no objective reality that can be measured and understood quantitatively.

Oh dear it appears I have made a typo of your/you're.

Jane presents another straw man argument using a non-existant scientist to critcise other scientists who keep telling you you're using straw man arguments. You can't sit there and claim an attempt to educate from a position of arrogant ignorance.

The method of action of a botanically derived substance is not required in order for it to be widely accepted as safe, effective and cost effective. You do however need to identify and extract the active substance out of the plant so that you can control the dose and the purity. Please go back and read that sentence again and then stop using straw man arguments- nobody said anything about exact molecular mechanisms. Just because you hallucinate a claim doesn't mean that I made it.

The method of action of aspirin was not discovered until 80 years after it went into mainstream production. They did however stop screwing around with willowbark tea so they could control the dose and purity of the active substance, salicylic acid.

American MDs do not treat their Japansese and European colleagues as quacks because everybody is using the same scientific rules. The practice of medicine differs between countries and health systems but everybody is still using statins for hypercholesterolemia. Statins by the way being a Japanese invention... so much for the vaunted evil ignorant western medicine label. If you knew the slightest thing about scientific medicine you'd know that it's a very international collegial activity.

"It's been estimated that the vast majority of improvement in life expectance is due to public health advances, NOT to heroic medicine or prophylactic medicine."
The largest gains to life expectancy in the 20th century were improvements in maternal and child health followed by the massive reductions in transmissible diseases caused by combinations of water sanitation, vaccination and antibiotics. The wisdom of the ancients/traditionals or whatever mythical past you pine for provided a 35 year life expectancy and a 30-50% chance of death during childbirth. Life was nasty brutish and short.

So herioc efforts surrounding childbirth and prophylactic medicine in the form of public health have in fact caused massive increases in life expectancy.

Or as an undergraduate t-shirt proclaimed to me earlier in the year "Science works"

Thank you, Jane, for your persistent, clear voice of reason and observational science in the face of petty guildsmanship and crank skepticism. The loudmouths don't appreciate you, but we do.

"The loudmouths don't appreciate you, but we do."

I assume 'we' is you and your former cellmate Kevin Trudeau.

Nathan, thanks.

Antipodean, I really just laugh at people who yell "straw man" in the same message where they erect two or three. It's not worth my effort to point out most of your flawed reasoning. Let me just ask whether American oncologists now use mushroom polysaccharide extracts as adjuvant chemotherapy for stomach cancer, since rigorous Japanese research has shown it to improve survival. Or, if Americans and Germans are "using the same scientific rules," and that's the only basis for decision-making, why do many German physicians prescribe St. John's Wort for depression, and feel that it has been adequately shown to be effective, while Americans do not? MDs are not robots; they are participants in a culture.

PalMD, it IS a cultural construct to demand scientific proof of efficacy before you do something - as you acknowledge, before science (in the broad sense) was invented, nobody could have had such an expectation. It is, by and large - to take the ideal example, when you have a choice of "well-proven" or "completely unproven" medicines, and you can tolerate the former - a good and useful concept, one well worth preserving. It's still a value, not a fact. Look, scientific studies can tell you whether a traditional food is nutritious or not; no study could tell you whether or not you should refuse to eat foods that have not been so studied.

The values issue here is what level of uncertainty is tolerable in a given circumstance, given that nothing is ever 100% certain. Imagine two firm believers in scientism who differ only in their opinions regarding a single conventional treatment. Say, statins (which were derived from a natural product, but never mind that). One thinks that prophylactic use in people with normal cholesterol is adequately supported; the other disagrees. They're looking at the same publications, but demand different levels of certainty. One feels that safety risks that were acceptable in secondary prevention are intolerable when inflicted on healthy people; the other thinks statins should be put in the water supply. They both acknowledge existing data; they just weight risks differently, and sometimes depending upon circumstances.

PalMD, is either of these individuals engaged in "special pleading"? Is either of them denying the existence of "objective [defined as quantifiable] reality"? No, they are just making different judgements about how much data are enough, and what the implications of the existing data are, based on personal and cultural values. All of us do that; we can't help it, nor should we try. The scientific method does one thing very well: it provides an organized means of gathering data about many (not all) important aspects of our world and quantifying the likelihood that our hypotheses about those subjects are true. That's it. It cannot provide us with a list of "correct" opinions. Therefore, the fact of disagreement does not imply that one party is less informed or less rational than the other.

I am a trained scientist, which I get the impression that most Skeptics are not, but I have no patience with people who use science as a club to beat everyone else into submission. Average people mistrust scientists, in part because they're sick of hearing "You're too stupid to comprehend real knowledge, much less contribute to it - just believe whatever I spoonfeed you - and keep those tax dollars coming." When what you're pushing is a fact, that might be one thing. When it's actually a value or opinion, that's another. People who aren't practiced at verbal argument may not consciously spot the bait and switch, but at some level they know their deepest preferences are what's really under attack.

Like I said, I have a little sympathy for those who have to spend much time arguing with stubborn people who are wrong on the facts. But it is not a wise response to see everyone whose opinions or values differ from yours as a caricature stupid woomeister and denigrate them just as viciously. Values vary so much that you will find the vast majority of the population pushed into the "enemy" camp, and that is not going to do you any good in the long run.

I've probably run on long enough here, so you all can have the last word. :-)

Perhaps in a more economical and succinct way you could explain why anyone should "value" setting the bar so damned low as to render science irrelevant. Because that is what you are arguing for, and as a "trained scientist" you should acknowledge that.

"I'm a trained scientist"

Ho ho ho.

I'm Santa Claus 'cause I thought I saw one once.