Herbal medicine takes root in Germany
Pam Harrison
[ en bref ]
Pam Harrison is a Toronto freelance writer.
CMAJ 1998;158:637-9
© 1998 Pam Harrison
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In brief
The sale of herbal medicine is a growth industry in Germany, where physicians routinely prescribe these products and annual sales have surpassed $2 billion. Pam Harrison says the rising popularity has been driven by German patients, who began demanding herbal alternatives to synthetic drugs. Medical schools responded by reintroducing lessons on a topic that had been phased out of the medical curriculum.
En bref
En Allemagne, où les médecins prescrivent couramment les produits de phytothérapie, l'industrie des plantes médicinales connaît une croissance fulgurante, les ventes annuelles dépassant les deux milliards de dollars. Pam Harrison explique que la popularité des simples s'explique du fait que les patients allemands exigent des produits naturels au lieu de médicament synthétiques. Les écoles de médecine ont réagi à la tendance en remettant au programme des cours sur le sujet qui avaient été autrefois graduellement éliminés.
If you're a German GP who diagnoses mild to moderate depression these days, chances are good your patients will be treated with St. John's wort, not a synthetic antidepressant product. German doctors prescribed almost 66 million daily doses of drugs containing St. John's wort — Hypericum perforatum — in 1994, and that number has undoubtedly risen since then. The expenditure, in Canadian dollars, was roughly $55 million.
The popularity of drugs such as St. John's wort is one reason for burgeoning growth in the use of phytopharmaceuticals in Europe, where sales now stand at an estimated $6 billion annually, including at least $2 billion in Germany; annual sales in Canada total less than $200 million. "I'd say close to 80% of German physicians regularly employ plant medications," Dr. Joerg Gruenwald of Berlin's Institute for Phytopharmaceuticals said in an interview.
The cost of about 40% of the herbal remedies currently prescribed by German physicians are covered by the health care system — a not inconsequential reason for their historically high acceptance among the country's physicians and patients. Behind this acceptance there also appears to lie a conviction that there is little to choose between drugs derived from plant sources and those produced synthetically.
"The tradition of physicians using herbs not only as foods but as active therapy has long roots in our history," says Dr. Wolf-Dietrich Hübner, clinical research director at Lichtwer Pharma in Berlin. "Herbal remedies were widely used by professionals until the rise of synthetic drugs in this century."
However, even with their rise the gentler botanical arts did not die out entirely as they did in North America: they were kept alive by pharmacists who continued to sell products derived from plants. Ten to 15 years ago, German patients began demanding alternatives to synthetic drugs and the country's medical schools soon felt compelled to reintroduce the phased-out topic of phytopharmacology. This meant that new physicians now had at least some exposure to complementary medicine. Today, new doctors can take a postgraduate course on natural healing, which comprises 4 weeks' instruction in herbal and other complementary medical practices. This is followed by a 3-month internship with a doctor of naturopathy.
Herbal medicines themselves are treated differently in Germany than in Canada. There, a herbal medicine must also be registered with the German equivalent of Canada's Health Protection Branch (HPB) before it is accepted as a therapeutic drug.
Acceptance of these "new" drugs in Germany became more formalized in the 1980s after a commission surveyed all safety and efficacy data involving herbal products being used as medicines. Based on the commission's evaluation of these data, more than 200 plant-product monographs were developed, which allow manufacturers to market products according to indications stated in the monographs. Health insurance companies generally pay for the drugs.
These moves have meant that German physicians have more confidence that the herbal medicines they prescribe are, indeed, therapeutically active and can serve as appropriate alternatives to synthetic drugs when treating milder or more chronic forms of disease.
Dr. Hans Joachim Rudolph, a Berlin-based internist and doctor of naturopathy, is confident that his holistic approach to patients' problems — part of which includes plant medicines — does work. Rudolph, who was trained in medical school when the principles of phytopharmacology, if taught at all, were soon forgotten, spent several years working in a hospital-based practice before deciding to pursue his growing interest in naturopathy.
When he did this, he also took a turn teaching the theory and application of phytopharmacology to medical students in Berlin. In one class students were taught the appropriate course of natural therapies for patients being treated in a special 80-bed hospital teaching unit. "As long as the disease being treated is not very severe, there is no doubt that these herbal drugs have therapeutic effects and they are less toxic for patients than synthetic drugs," says Rudolph.
One of his most important lessons has been that the use of natural therapies such as plant medicines creates a good rapport between physician and patient. "At certain acute stages of a disease we cannot expect too much from these plants," Rudolph stresses. "But when the disease is less active or in its chronic stages, herbal medicines can be very helpful and the results can be quite wonderful."
"It always depends on the severity of the disease," agrees Dr. Christel Schröter, a Berlin general practitioner, "but I like to start treatment with a plant medicine because many kinds of illnesses and diseases can be cured with these drugs."
In Germany, the key indicators for their use in primary care practices are colds, bronchial infections and coughs. Plant medicines are also commonly prescribed for irritable bowel syndrome, sleep disturbances, anxiety and depression. "Many people come to me because they're fed up with synthetic drugs and they want something that is more natural," explains Schröter.
Plant medicines are also safe to use in the treatment of some common childhood ailments; patient acceptance appears to be better than is generally reported for patients taking synthetic drugs.
"The problem is not that herbal products aren't biologically active, because they are," says Ken Keirstead, president of Planta Dei Pharma, a Canadian company based in New Brunswick. Rather, the problem is to ensure that any therapeutic claim accompanying a plant product is justified not only by scientific evidence but also by quality control. In Germany, issues surrounding quality control and standardization of herbal products are less of a concern than in Canada because ethical botanical manufacturers use the same high-quality production standards found in the synthetic-drug industry.
"Over the past 10 to 15 years we've been able to spend money on good clinical research that, at least the way we do it, is identical to the type of research carried out in the development of synthetic drugs," says Lichtwer Pharma's Hübner. This means that in Germany, products from botanical companies contain what their labels state and the efficacy for treating certain conditions has been validated in scientific studies.
With a few exceptions, the same can't be said for Canada. Here, says Dr. Frank Chandler, director of the College of Pharmacy at Dalhousie University, quality control is "a sham." Depending on where a plant is grown and the part used in the final product, consumers could end up buying a product that contains little if any of the plant in question.
"Herbal medicines can also be mislabelled, adulterated or contaminated," adds Chandler. Health claims regarding plant products, which in theory are not allowed if products are sold as food supplements, are at best promotional and at times fraudulent, he says.
As chair of an advisory committee on herbal medicine within Health Canada, Chandler is trying to introduce standardization so that herbal products can be more reliably integrated into medical practice. These efforts will not affect the over-the-counter sale of these products to consumers, but Chandler says that "if we can get quality products out to the public, we will have moved the whole field of herbal medicine forward megafold."
Dr. Brian Hardy, the coordinator of clinical programs in pharmacy at the Sunnybrook Health Science Centre in Toronto, says that "not a week goes by without someone asking me about some herbal medicine. We need good information so we can help patients with their decisions."
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