“I think I’ve accepted that the time has come to ask you for a prescription for antidepressants”, she said. “I never thought I’d be here; I’ve always managed but I’m in the depths of despair.” My heart went out to Penny, a private, thoughtful and generous woman who has been my patient for many years but who consults rarely.

Penny is in her early 80s now and was reeling in the aftermath of the death of her beloved daughter after caring for her overseas before she died from complications of cancer. Uprooted, unattached and disorientated, life no longer had meaning or any sense of purpose. “I knew one day the time would come, maybe this is it, the end of the line?”, she mused, more to herself. You may wonder how this story panned out.

If you work in primary care as I do you may know the likely path – perhaps a negotiation around a prescription, a referral to the local psychology service, ongoing attentive follow up, perhaps a resignation on all sides that this is how life will be. We have been there many times. But what if there is another way? What if we have what we need to do things differently, more imaginatively?

Before I share what happened next for Penny, let me tell you some other stories. Three ‘what if’ stories. First, how environmentalist Rob Hopkins co-founded Transition Town Totnes and the Transition Network.

He is the author of ‘From what is to what if: unleashing the power of the imagination to create the future we want (2019)’. Rob asked himself a ‘what if’ question when he founded Transition, a movement characterised by people self-organising to develop local projects which strengthen community resilience and reduce carbon emissions. It describes itself as a movement of real people coming together to reimagine and rebuild our world using ‘head, heart and hands’.

It began with two groups, in Kinsale in Ireland and Totnes in Devon, in 2006, growing to more than 1,300 initiatives across more than 50 countries. Initially focusing on concerns relating to climate change and peak oil, its remit has broadened to include groups working on food, energy, community relationships, engaging with the natural world, localising the economy, skill development and sharing. Writing in the Journal of Public Health, Rob suggests that Transition could help reduce the pressure on the NHS through reframing change, preventing disease, improving staff wellbeing and increasing local economic resilience (1,2).

Our second story is about Dr Michael Dixon, a GP in Cullompton, Devon. His numerous roles include National Clinical Lead for Social Prescribing, Medical Advisor to HRH the Prince of Wales and Chair of the College of Medicine. I heard about Michael as one of the growing number of GPs, who like Bromley-by-Bow’s Sir Sam Everington, had also asked himself a ‘what if’ question.

As a result, the green spaces around his practice are now used therapeutically and creatively for the benefit of patients and staff. Michael recalls: ‘No one had previously been in the medical profession in my family. I was keen to do a job that made a difference though my initial interest was more in the mind than the body.

My interest in complementary medicine developed after 10 years as a country doctor as I began to realise that there were so many gaps in what we could do for patients using only conventional medicine – for example patients with chronic tiredness, frequent infections, irritable bowel, premenstrual syndrome, depression, stress, back pain, neck pain and so many other conditions. It was frustrating to have such a limited range of options for treating conditions that I would see in surgery every day. It made my medicine more effective and colourful and restored my sense of self-worth as a doctor.’

The third ‘what if’ story, is my own, of a woman of mixed heritage, from everywhere and nowhere, a ‘mongrel’ as my father affectionately said. Since I first found my place in 1997 when I started working as a GP in Kentish Town, north London, I have witnessed a lot of change: progress through clinical advances and better technology certainly. But in stark contrast we find ourselves living in increasingly disconnected times, unmoored from a sense of place or belonging and exposed to bewildering arrays of consumerist choices that sometimes feel like no choice at all.

It seems we have lost a sense of who we are or what we should do; many people feel lonelier and more afraid. Like Michael, I see this expressed every day: in mental health problems, in the many chronic diseases born of our ‘modern’ lifestyles, addictions, persistent physical symptoms and chronic fatigue.

Sadly as a profession we may over-diagnose, and respond by supplying an expanding array of medications, unrealistic ‘magical’ cures or attempting to anaesthetise distress (3). Much is missing in the space humans now inhabit, whiplashed between extremes of passivity and constant unquestioning actions and reactions. No wonder we find solace where we can, getting lost in electronic worlds, overfed and undernourished, in bloated consumption whether of goods, gaming, gambling or chemical substances of one kind or another. If these ‘remedies’ are so good, why do so many people feel unhappy?

Can social prescribing be truly restorative? Perhaps help is at hand? Social prescribing is in vogue and huge hopes are being laid at the doors of the ‘growing army of social-prescribers’ tasked to help us on the frontline in primary care (4). But in primary care we are fatigued and sceptical, for we are used to empty promises. In reality though, is this sort of language helpful? Are we really in a battle, a fight with problems that needs fixing? Or might the notion of social prescribing act as an invitation to reflect, use our collective imagination and respond in other ways?

Change comes about at the margins. People in the centre are not going to be the big change makers. You’ve got to put yourself at the margins and be willing to risk in order to make change. But more importantly, you have got to approach differences with this notion that there is good in the other. That’s it. And if we can’t figure out how to do that – if there isn’t the crack in the middle where there’s some people on both sides who absolutely refuse to see the other as evil, this is going to continue.” – Frances Kissling, 2011

If it is to be used less like a traditional prescription, we have to be clear about the process of social prescribing and not focus only on its content. As an enthusiastic cook I see social prescribing’s content as the ingredients and the process as the recipe. And this recipe is just our starting point, for it’s when we cook together that we develop our skills.

So, when sipping from the cup of life, how do we want it to taste? What sort of an ingredient am I, are you: do we even know? And what part might we play in telling the story of cooking? All good recipes have been tried and tested, perhaps rooted in family and cultural history, but at the same time personalised so they become our own.

As an enthusiastic social prescription-maker, I have had to ask myself how to develop our own unique recipes for social prescribing. Perhaps we have to start by imagining what it would be like to be fully human and what we have lost along the way now that our social fabric is so threadbare. If we are to gather the yarn and start weaving together again we will need a safe base: places for integration and where we can reconnect to ourselves.

Places for re-embodying our minds, and understanding our thoughts and feelings so we can reconnect to each other, to our histories, to the world from which we have come. A place for embracing the wide mystery of our universe, so that we can hold life and its uncertainty with awe and wonder and not just fear.

This is not to say the journey will be easy. It will need courage, moral imagination (5,6) hospitality, humility, creativity and an openness to generous listening and adventurous civility in conversation. We need to hold our destination lightly, be open to possibilities, to change our minds at times, to develop the resilience and flexibility to negotiate the twists and turns that life inevitably holds.

We need to broaden our perspective, to look at what we are discarding and disregarding, moving from the linear to the circular. Nature can be our great teacher in this, the cycles of life, death and rebirth, the complexity of ecosystems, the fractals and patterns all around.

The Transition strapline is: ‘If we wait for governments, it’ll be too little, too late; if we act as individuals, it’ll be too little, but if we act as communities, it might be just enough, just in time.’ We need to move from a focus on ‘I’ to ‘we’ The African proverb reminds us: ‘If you want to go fast, go alone, if you want to go further, go together.’

My recipe for an NHS practice in transition

Nearly five years ago, we started a small project with big dreams. We called it The Listening Space. Inspired by the pioneers, Michael Dixon and Sam Everington, and with reference to the guiding principles of the Transition Network, we collaborated with patients, members of our local community and Transition Kentish Town. We crowd-funded, worked our own gift-economy, exchanging skills and time for food, good company and celebration.

We repurposed found objects and as we worked together to transform a large disused space in the courtyard of our urban general practice into a therapeutic garden, we found we had developed skills of many kinds, woven connections and made new relationships. We valued the journey, though we didn’t always know which way things would go, which can be anxiety provoking and threatening to those who like to have more concrete plans.

We decided to celebrate all the small gains along the way and not to be harsh about the things that have been less successful, seeing them instead as our good teachers. We are now so proud of our place of refuge and shelter, a place where we can free up our imaginations, a space where we can listen to what nature has to teach us.

And in opening up these possibilities, we have gained the confidence to generate new ideas, new branches from our roots. I am excited about the further possibilities opening up for our community in our latest collaboration with Jane Riddiford of Global Generation, expanding our reach by taking ‘story walks’ between the green spaces of north London.

A tree can be only as strong as the forest that surrounds it.” – Peter Wohlleben, 2016

When we started out, I felt like Penny – lost in a land without hope, burned out having been overburdened with mindless, misdirected work trapped within a system that increasingly cared for numbers rather than valuing care, in a climate of endless reorganisation, under relentless pressure from top-down initiatives.

I have found hope again by tending to the soil and working from the grassroots. I found myself ‘burning in’ to a more stable but energised place where my work regained coherence, meaning and purpose. The hours may be similar but the emphasis has shifted from the mechanistic pursuit of efficiency and outcomes, to a focus on real compassionate patient care. My joy has been restored.

In the greatest book ever written about general practice, A Fortunate Man (1967), John Berger (7) describes his friend John Sassall, a country doctor in the 1960s as ‘… a fortunate man because his work occupies and fulfils him; his work and his life are not separate’. Our project has grown, literally and figuratively. It expanded from our early gardening groups, into organised and impromptu gatherings and waiting room ‘crafternoons’, then came a poetry pharmacy and storywalking.

At the outbreak of the pandemic, galvanised by our knowledge of how to work as a good team, we were able to quickly set up a pop-up social kitchen, to feed staff and patients in need.

The role of the clinician has been to facilitate participation, to invite civility in conversation across diversity, to provide support and navigate difficulties when there is distress, or if inevitable tensions arise in group situations. Our social prescriber Jo, who facilitates and supports the various groups that have developed, acts as a true link-worker, a warm and welcoming connector between all of us in the practice. In this way our work can remain expansive.

We focus on working with our relationships and less transactionally, always aiming for more equal partnership with our patients, other community organisations, individuals and businesses. Through this participatory approach and by ensuring our activities are fun, inclusive and positive at their heart, we are growing the community we imagined, rather than building an army. As each participant finds their place we are learning to work supportively and to grow our resilience and ability to rise to the challenges we will all face.

We all, adults and children, have an obligation to daydream. We have an obligation to imagine. It is easy to pretend that nobody can change anything, that we are in a world in which society is huge and the individual is less than nothing: an atom in a wall, a grain of rice in a rice field. But the truth is, individuals change their world over and over, individuals make the future and they do it by imagining things can be different.” – Neil Gaiman, 2013

So, what of Penny? As I listened to her tale unfold and her self-diagnosis of depression, I gently suggested that perhaps in her situation, sadness was understandable. And sadness requires mainly gentle observant company and community. We talked of what once had nourished her, her love of nature, of gardening and of her teaching.

With our expanded outdoor ‘consulting room’ we were able to offer an alternative prescription. That evening, Penny and I met, wandered among the flowers, the herbs and the productive beds of The Listening Space. We spoke of other gardens, the power of nature to ground and to heal; and imagined together a different future path. Penny joined us the following day for a distanced, intergenerational gathering and walk between The Listening Space in Kentish Town and The Story Garden in King’s Cross.

I spoke to her in a follow-up appointment two weeks on from our more despairing conversation. ‘I can’t believe how different life looks. I didn’t think at this point in my life, there could be anything else. But I know where I am now and what I want to do with whatever time remains for me.’ Penny is now volunteering with us, a valued, worldly-wise elder in our community already sharing English conversational skills with those from other lands who are also growing roots in our re-generating and remembering community.

What if GP surgeries became catalysts for Transition? So how do we weave a stronger social fabric; how do we learn to mend, remake, grow it and sew it? I was fortunate enough to be in conversation with Rob and Michael as part of Rob’s podcast series ‘From What If to What Next’ (8), where we were given generous space to reimagine healthcare for the future and had carte blanche to suggest policies as ministers of the imagination. Perhaps you will listen and join us?

The system will collapse, if we refuse to buy what they are selling – their ideas, their version of history, their wars, their weapons, their notions of inevitability. Remember this, we be many, and they be few. They need us more than we need them. Another world is not only possible, she is on her way. On a quiet day, I can hear her breathing.” – Arundhati Roy, 2003

Penny is not my patient’s real name although she gave me full permission to share her story with you. She told me at our last meeting that she had spoken to her friends about what had happened to her and reported their collective wish to have care and treatment in practices like ours. Yet I do not believe we are all that unusual, though we have travelled into a less unfamiliar place.

Having explored the territory we are here to tell you about the wonderful view and invite you along. So I write this piece in ‘Penny’s’ honour and on behalf of all the future patients we may be better able to serve if only we free up our imaginations, let our compassionate, authentic human selves back into our work, knowing we too will find nourishment in the process. If we in general practice were to act as hubs and safe spaces for transition, what would our world be like?

1. Smith J, Hopkins R, Pencheon D. Could the Transition movement help solve the NHS’s problems?. https://academic.oup.com/jpubhealth/article/39/4/841/2631018. Published 2016. Accessed December 3, 2016.
2. Hopkins R. A healthy society is just as much about community as healthcare. The Guardian. Published 2014. Accessed August 17, 2022.
3. Heath I. Overdiagnosis: when good intentions meet vested interests–an essay by Iona Heath. BMJ. 2013;347(oct25 2):f6361-f6361. doi:10.1136/bmj.f6361
4. Support D. NHS England bids PCNs to hire ‘army’ of social prescribers. Pulse Today. https://www.pulsetoday.co.uk/news/workforce/nhs-england-bids-pcns-to-hire-army-of-social-prescribers/. Published 2022. Accessed August 17, 2022.
5. Sacks J, Sacks B. Morality: Restoring The Common Good In Divided Times. Hodder and Stoughton; 2020.
6. Novogratz J. Manifesto For A Moral Revolution.
7. Berger J, Mohr J. A Fortunate Man, The Story Of A Country Doctor. London: Penguin Press; 1967.
8. Myat J, Dixon M. From What If to What Next: Episode Four: What if doctors’ surgeries became catalysts for Transition?. SoundCloud. https://soundcloud.com/transition-culture/from-what-if-to-what-next-episode-four-what-if-doctors-surgeries-became-catalysts-for-transition. Published 2022. Accessed August 17, 2022.

Bibliography

1. Gaiman N. Neil Gaiman: Why our future depends on libraries, reading and daydreaming. the Guardian. https://www.theguardian.com/books/2013/oct/15/neil-gaiman-future-libraries-reading-daydreaming. Published 2022. Accessed August 17, 2022.
2. Heath I. Overdiagnosis: when good intentions meet vested interests–an essay by Iona Heath. BMJ. 2013;347(oct25 2):f6361-f6361. doi:10.1136/bmj.f6361
3. Hopkins R. From What Is To What If – Unleashing The Power Of Imagination To Create The Future We Want. Vermont: Chelsea Green Publishing; 2019.
4. Hopkins R. A healthy society is just as much about community as healthcare. the Guardian. https://www.theguardian.com/lifeandstyle/2014/jun/26/healthy-society-about-community-alongside-healthcare. Published 2014. Accessed August 17, 2022.
5. Kissling F. Frances Kissling — What Is Good in the Position of the Other. The On Being Project. https://onbeing.org/programs/frances-kissling-what-is-good-in-the-position-of-the-other-sep2018/. Published 2022. Accessed August 17, 2022.
6. Novogratz J. Manifesto For A Moral Revolution: Practices To Build A Better World. Henry Holt and Co; 2020.Rilke R. Letters To A Young Poet. Penguin; 2012.
7. Support D. NHS England bids PCNs to hire ‘army’ of social prescribers. Pulse Today. https://www.pulsetoday.co.uk/news/workforce/nhs-england-bids-pcns-to-hire-army-of-social-prescribers/. Published 2022. Accessed August 17, 2022.
8.  Wohlleben P, Flannery T, Billinghurst J. The Hidden Life Of Trees. Greystone Kids; 2016.

Critics of herbal medicine sometimes lead the public to believe that they should avoid herbal remedies because there is a lack of evidence about the safety or efficacy of medicinal herbs. They often resort to the somewhat exhausted mantra that “just because something is natural does not mean it is safe” (2,3,14,28).

This is on the face of it an accurate assessment, but it may also be a half-truth. It could equally be suggested that because something is natural it is more likely to be safe (due to its longevity of use without incident for example) rather than something which is unnatural, such as a synthetic drug made in a laboratory with all its inherent risks and unwanted side effects.

Indeed, it is because of the latter that the general public often seek a ‘natural alternative’ in the first place.

The general longevity of use in traditional practice over many centuries suggests the vast majority of herbal medicines when used appropriately by practicing herbalists are as safe as fruit and vegetables (indeed many of them are fruits and vegetables), with only a few stronger herbs employed in limited dosages.

Part of the problem is that some researchers chose to ignore the existence of the professional herbalist who is trained to flag any potential contraindications which might assuage at least some of the perennial concerns they raise. Instead, some prefer to put across their conflated concerns of an unsuspecting public stepping into the mire, and rather than suggest that the public consults with a professional herbalist; they play on fears and generate uncertainty (13,16). The objective of this type of criticism is to create a sense of doubt in the public eye, but is it all just smoke and mirrors?

While it’s true to say that some herbs such as Atropa belladonna are dangerous in the wrong hands, access to such plants is legally controlled and these herbs are unavailable to the general public. And while unsuspecting amateurs harvesting from incorrectly-identified species in the wild may cause problems for themselves, such misadventure is not in any way connected to professional herbal medicine.

By and large, the majority of herbs used by herbal practitioners are tried and true over long periods of time. A small selection of herbal medicines may be considered more medicinally “potent”, but the discerning herbal practitioner uses restricted doses and fixed durations of use for such herbal preparations and is trained to be aware of any potential toxicity.

The deconstruction of semantics aside, we are still left with the question – is there a lack of evidence for herbal medicine? In order to put this question into context, we might begin by examining the term “evidence” itself. Critics of herbal medicine believe that herbal medicine can only be understood through certain types of evidence.

In a court of law the defendant or prosecution presents corroborating evidence for particular statements to establish the foundations of their arguments. This corroborating evidence may come from diverse sources. The origins of evidence are less important than the strength of such evidence to convince a judge and jury. But what if the judge demanded that only evidence gathered from the City of London could be considered, even if the events around the case occurred outside the City of London? You would be correct to think that such a hypothetical situation would be ludicrous.

The term evidence-based medicine (EBM) became popular in the 1990s (31). It presents the case that all medical interventions should be “evidence-based”, with the double-blinded randomised controlled trial (RCT) considered the gold standard in clinical research. Systematic reviews and meta-analyses of RCTs (peer review) became the pinnacle of the new evidence hierarchy.

The clinician could then use this information to best inform their clinical judgement. However, evidenced-based medicine in this particular reading has a number of confounders and inconsistencies. Firstly, it implies that there was no evidence before EBM or if there was it was circumstantial (coming from outside the City of London in our earlier hypothetical scenario).

Secondly, it implies that evidence can only be assessed in a certain way and that this evidence is better than other types of evidence such as expert opinion. The imposing hierarchy of EBM is summarised in Figure 1 below:

On first glance it seems odd to put expert opinion at the bottom of the pyramid and place systematic reviews at the top. The concept of defining evidence in this way may well be a noble attempt to eliminate bias from influencing clinical decision making, but this itself is predicated upon the erroneous belief that bias can be completely eliminated. It seems more likely that bias may only be limited through these processes but only in carefully controlled laboratory conditions (creating internal validity) which unfortunately have little connection to what happens in the real world (lacking external validity).

The RCT is a methodology which is used in testing the efficacy of new drugs, treatments and health care services. The use of RCT research is considered highly effective by its supporters because it is thought to minimise allocation bias (Nunan, Heneghan and Spencer, 2018).

The significant characteristic of RCTs is that trials usually include a control experiment alongside the main treatment. These are known as placebo-controlled studies. They are used in comparing changes recorded in the active treatment group in order to ascertain that the placebo group that was not included in the treatment does not react in a similar manner. This serves the purpose of proving whether the active treatment actually had an impact on the active study group.  In this way it can be established whether or not a new drug is superior to placebo. But how do you establish a placebo?

Comparing a drug to a placebo in an RCT sometimes implies that the placebo effect has a fixed value, say 30%, so the new drug must be equal to or greater than placebo in terms of safety and effectiveness and yet placebo effects may be greater or lesser than 30% depending on many factors. For example, there may be more than one placebo effect depending on the circumstances, so placebo controls may actually potentially increase bias in some cases (9).

But let’s assume in a double blind randomised controlled trial that a new drug is found to be greater than placebo and no major adverse reactions are recorded. The trial and methodology should then be independently replicated and a statistically similar result would be expected. Replication trials should mimic the methodology of the original trial, and statistically similar results would either validate the original study or bring it into question. When we speak of gold standards, this extra layer of scrutiny would help to strengthen the clinical trial process. In turn systematic reviews and meta-analyses might include replication trials as specific inclusion criteria.

What if the RCTs are not independently replicated? The results may be unreliable, and the primary research data would be flawed? What if researchers later conducting a meta-analysis only include certain RCTs (some of which may be flawed) and not others (which may not be flawed) in a peer review? In that case secondary and tertiary research could also be flawed, casting shadows over the whole process.

What of researcher conflicts of interest; study cohorts which are not representative of the general public; unrealistic sample size; lack of preclinical screening for participants; use of unrealistic dosages or durations of use; and statistical bias? There are many problems with such a rigid methodology, if full checks and balances are not put in place.

Professor John Ioannidis put this into stark perspective with his highly influential paper Why Most Published Research Findings are False, which has become the most cited research paper of all time (19). Ioannidis argues that due to a lack of replication trials, statistical incongruence and the initial “truth” of a research question, most research may be false. If Ioannidis is correct, could this culture of false or erroneous data account for increasing iatrogenic events which now sees modern medicine as a leading cause of death in annual all-cause mortality statistics? (22) This would imply that there is a crisis in the current EBM paradigm.

On the other hand, expert opinion at the bottom of the EBM pyramid (Figure 1) might be in need of a paradigmatic reappraisal. Imagine a physician who has seen thousands of patients and developed successful healing strategies over many years in real world situations. Would it be advisable to value their expert opinion above the results of a potentially flawed clinical trial?

David Sackett, nominated by his peers as the “Father of EBM” for his pioneering work, describes EBM as an amalgam of the best systematic research, expert opinion and the patient’s rights and choices (29). If we follow Sackett’s description, we see a tripartite approach, not a single approach that favours filtered over unfiltered information but a multifaceted approach which values systematic research alongside expert opinion, and importantly brings in the vital component of patient experience and opinion.

Patient-centred care has become a popular term in modern medical parlance, and yet many patients do not feel satisfied by the care they receive under the current medical model. Patient satisfaction is an important and commonly used indicator for measuring quality of care. Disempowerment of the patient may occur because of long waiting times; the all too brief consultation process where empathy does not occur and where key information can be missed; but also because of side-effects and/or a lack of efficacy of prescribed medications and procedures (17).

Taking these comments into consideration, there are problems and obstacles within the current paradigm of EBM. We must also consider how useful this methodology is to herbal medicine in particular?

The RCT process is designed for pharmaceutical drugs within a reductionist paradigm, where a candidate drug with a single therapeutic target is examined. Clearly, the multi-constituent nature of herbs (with multiple therapeutic targets) does not fit easily into this model. Some researchers have tried, occasionally successfully, to put herbs through such scrutiny, but the cost and time involved may hardly be worth the effort, especially when it is often not reflective of or does not contribute to an understanding of the practice of herbal medicine.

Could the RCT process be reconfigured in such a way so as to examine the protocol a herbalist uses in clinical practice for a particular condition, and compared with an orthodox treatment, rather than testing a single herb or constituent against an imagined placebo? Might this provide evidence of the efficacy and safety of herbal medicine if it is designed to reflect actual practice?

Systematic research can be useful provided it is relevant to herbal practice. Where it is not relevant to practice it may be considered as “background information”. The danger of an obsessive approach to EBM and a paradigm enthralled to scientism is that it may also eclipse other important strands of evidence.

What if the playing field is levelled and we consider other strands of evidence equally and without imposing an EBM-like hierarchy? I propose an “evidence house” model for herbal medicine research on egalitarian lines, where each room yields key information which can establish a foundation of evidence upon which to build. In contemplating this approach I decided that I would examine those stems of evidence upon which I have drawn for practical information and which have since informed my practice and led to successful outcomes for my patients.

While some information offers very basic clues, my approach here is not be overly concerned with the initial ‘strength’ of the data, but rather whether or not these clues may in time provide practical, safe and effective outcomes in clinical practice through comparison and consolidation of other multiple strands of data.

I am alert to the potential weaknesses in such a model in a reductionist sense but I stress that a perceived deficiency in one room may be supported by strengths in another and that it is a combined or holistic approach that might provide the best evidence for herbal medicine. For example, a traditional practice may provide the original clue on how to use a particular herb or treat a certain condition.

On its own, this reference to a traditional use may be unsatisfactory but what if the clue is supported by evidence from one or more of the other rooms in the evidence house? And what if the original clue is not supported?

The six “rooms” for building the proposed evidence house are as follows.

1. Tradition
2. Folklore
3. Organoleptics
4. Phytochemistry
5. Systematic Research
6. Empiricism

Imagine an architect’s blueprint of a ground floor in which all 6 rooms share a “hallway”, meaning that they connect or integrate with each other holistically in the evidence “house”. Each has, or could be considered as having, various strengths and weaknesses and there may be ways of evaluating each of these for “structural integrity” and creating better insulation in time as the model is developed through further research.

All of these rooms alone have yielded clues which in time have led to practical results in my clinical practice, and this is the main criteria upon which I will draw in presenting this model. Some rooms have helped more than others but I reiterate that the room itself is not hierarchically more important as a singular evidence base.

What is important is how one room connects to the other rooms and how the collective gathering of information from multiple rooms leads to an evidence base for safe and effective health outcomes. This approach combines quantitative and qualitative data and both objective and subjective viewpoints. Let us consider each room as if we are viewing the house.

From the beginning of my dedication to herbal medicine, I learned from a tradition. By tradition I mean historical texts which were not lay commentaries but rather, practical guides written by professional practitioners intended as the furtherance of knowledge. These herbals were textbooks in schools of medicine across the world until relatively recent times, written by learned physicians and based on their own experiences and observations.

This differentiates tradition from folklore (the “room next door”) because it is based on the experiences of practitioners whose vocation in life was dedicated to the healing profession. These early physicians, in the cases of Dioscorides or Avicenna for example, were also well-travelled and drew upon other traditions outside of their locality, comparing and contrasting, amalgamating or rejecting different aspects of information and practice over long periods of time.

Their written wisdom is then passed down the generations to new students and apprentices who continue the tradition. In the case of the aforementioned authors, this process may occur over several centuries. Such authors, then, are not only important to herbalists but to the history of medicine itself.

Over the passage of time, we find new herbals appearing; sometimes blindly or lazily following the classic authors without scrutiny; sometimes challenging concepts or contributing new wisdom. The corpus of herbals is actually immense but it is possible to look at certain authors whose significance and contributions were such that they become historical beacons. It is possible to trace the use of a single herb over the centuries by giving precedence to such classical texts in the Western Herbal Tradition to show continuity of medicinal uses along with fresh approaches and scholarly commentary. Such a process has been neatly established by herbalists already (32).

One of the confounders in this approach discussed by these authors is the identification of a plant. Different common names, incomplete descriptions or poorly drawn figures may be misrepresentative of a plant when comparing one author with another in historical texts and cause dilemmas of identification and for tracing continuity, at least until the times of Linnaeus and the development of the standard Latin binomial classification of genus and species.

Such a pitfall has also been negotiated by a number of scholars such as Beck (6)in the case of Dioscorides, or (1) in the case of Avicenna, and is no longer as big of a problem problem in modern times with international acceptance of Latin binomial classification. In fact there is a research project at Kew Gardens being conducted to solve this very issue. A researcher can now chart the history of a plant’s medicinal uses over thousands of years.

Importantly, the use of what herbalists refer to as “energetics” is also a crucial and fundamental aspect of herbal medicine tradition because its application, irrespective of the herb or herbs used, is still pertinent today. This is all the more relevant because it is precisely this heuristic tool of energetics that allows for individualised protocols within a holistic paradigm. Compare a bespoke strategy such as this with the apparent one size fits all approach of allopathic medicine.

Energetic differentiation establishes principle qualities of disease using basic concepts such as hot, cold, dry or damp and variations thereof. Similarly, a herb or herbal formula can also be categorised as hot, cold, dry or damp or variations thereof. Part of the practitioner’s traditional role is to access the patient and decide which of these categories best relates to the patient’s symptoms in terms of having an excess or a deficiency of these basic qualities.

A patient could be too cold or too hot, but they could also be cold and dry, hot and dry, or hot and damp (but not cold and hot, or dry and damp. which are mutually incompatible). These conditions can progress and change so that someone who starts off too hot can become too cold in time. The practitioner must use pattern recognition to deduce the initial imbalance as well as the progress of that imbalance.

Once recognised through good case taking and diagnostic examination the physician uses herbs in a treatment of opposites, according to the appropriate action of the herbs. In rudimentary terms, the “strength” of the herbal protocol would also be surmised from the stage of disease progression as well as the patient’s individual predicament by using a system of degrees.

A person with the common cold may feel cold and shivery or hot and sweaty. This would require a different approach in each case. Compare this to allopathic medicine where there is no differentiation and both patients may receive the same antibiotic treatment. The traditional holistic approach does not end here.

The patient is also given adjunct advice whose remit is to challenge the potential causes of their condition, thereby treating both causes and symptoms in a holistic root and branch approach. In the Hippocratic school of thought, for example, we find reference to the 6 non-naturals – six areas of life over which the patient has some influence and which ultimately affects their health.

The non-naturals include fresh air; motion and rest; sleeping and waking; food and drink; excretion and detoxification and the passions/ emotions. Incorrect diet and lifestyle choices may lead to contra-naturals, or symptoms, in the Hippocratic model. In a sense then, traditional herbal medicine is not so much a system of healthcare as the practice of ‘life-care’.

This basic view of herbal tradition describes fundamental principles which are as valid today as they were in centuries past. By researching a herb in classic texts at various junctures in time, the researcher discovers uses, preparations, specific indications, energetics, dosages (though not always), contraindications, synergies with other herbs and other practical information developed over immense periods of time. This tried and true information can be applied practically, and it is a route by which many first find themselves intrigued by the possibilities of medicinal plants.

Although folklore is certainly a part of Tradition in its wider sense, it can also be treated separately. While the herbal Tradition can be discussed in terms of herbal medicine as a vocation and a profession, there are also myths and legends particularly in rural areas where local people (folk) carry on ancient oral traditions about the local use of plants (lore).

Such lore is often dismissed as archaic, superstitious or at best anecdotal but such accusations belie a partiality. Common people often filter their understanding of the world through the lens of local customs, beliefs and religions which create cultural meaning and identity. In dismissing folklore, one may also be dismissing the entire culture that goes with it!

A modern reader wanting to understand such a culture from an ethnobotanical perspective might embrace local customs, beliefs and religions as a means to set the scene for a wider cultural understanding within which such customs evolve.

For example, a piece of lore might call for the use of a herb for a particular condition but this may be accompanied by prayers, songs or magic rituals which the modern reader may feel is out of time or incongruent  within the current scientific paradigm. Therefore because of this “superstitious” misunderstanding of folk tradition in general, any suggestion of a folk cure being effective is often dismissed.

The American linguist Kenneth Pike saw a similar discrepancy in the anthropological sciences. He coined the terms Emic and Etic in his seminal 1967 text Language in Relation to a Unified Theory of the Structure of Human Behaviour to describe the difference between looking at the worldview of another through your own cultural lens to “establish an objective, scientific approach to the study of culture” (Etic) and looking at it within the context of “grasping the world according to one’s interlocutors’ particular points of view” (Emic). Emic assumes the role of “native perspective”; Etic the role of an “arm’s length” approach (27).

However, some scholars have begun to compare ancient descriptions with modern interpretations. This is an instance of taking a clue from one room and supporting it with clues from another. For example, researchers compared Ginger (Zingiber officinale) in Persian folk medicine with indications from contemporary research, concluding that modern uses of Ginger confirmed the traditional folk uses of Ginger. The research also revealed that there were other properties from traditional folk use which have yet to be elucidated in a modern context thereby offering more new clues for medicine (21).

In order to consider folklore as an evidence base I refer to my original criteria – does it yield practical information which can lead to safe and successful clinical outcomes? Ethnobotany is the study of human relationships to plants. A study of this subject may yield useful information when assuming an Emic approach, using Pike’s descriptors. This does not mean such a study is without its own inherent problems.

There may be discrepancies with the correct botanical identification of the plant in question if it is known by a local name which cannot easily be equated to its modern binomial taxonomy. There may be an absence of cultural context in regards to the customs and rituals which may accompany it. There may also be a dilution of the original practice over the generations. These confounders do not prevent the discovery of practical information.

For example, researchers considered a number of plants from 10^th century Anglo-Saxon texts for their potential use as antimicrobials. In the study, several preparations of Agrimonia eupatoria, Arctium minus and Potentilla reptans were screened for antimicrobial activity against gram-positive and gram negative bacteria (Watkins, Pendry, Sanchew-Madina and Corcoran, 2012).

The texts examined had previously been considered as having “little or no value to medical understanding” (8). The authors cross-referenced from several translations of the Anglo-Saxon texts to negotiate potential confounders and keep close to the original clinical indications. All plants demonstrated antibacterial efficacy and the authors concluded Anglo-Saxon texts may be a good source for rediscovering plants lost to current herbal practice (34).

An ethnobotanical study of Allen & Hatfield’s Medicinal Plants in Folk Tradition: An Ethnobotany of Britain and Ireland (2004) which has been gathered from multiple sources including the work of the Irish Folk Commission based on oral tradition, concluded that many of the plants studied may be potential sources for new therapies (10).

Ethnobotany is unfortunately an area of concern where indigenous information is stolen to discover interesting compounds for novel drug discovery. The term ‘biopiracy’ is sometimes used to describe this theft of cultural intellectual property from native cultures (4) If used respectfully, it offers data which can be cross-referenced with other ethnobotanical uses in other parts of the world, much like historical research of traditional use in established herbals, and provides clues which can be filtered through other rooms.

The term organoleptics refers to the use of the senses to acquire information. The skills of the wine taster or the perfumer who can detect and describe multiple flavours or scents are well known to modern culture. In the history of herbal medicine we also find reference to a concept known as the Doctrine of Signatures which infers that the shape of a plant or plant part may resemble a part of the body and so it must be intended for healing that part, by the signature of God. However, this may be an oversimplification.

The shape may be important, but so too is the taste of the herb, the scent of the herb, its colour, its texture, its location and so on. Rather than fixating on shape alone, information may be gathered and consolidated from multiple sensory experiences. For example, a sweet-tasting plant may reveal the presence of polysaccharides or a salty taste might reveal the presence of mineral salts such as magnesium and potassium. A bitter taste may reveal the presence of alkaloids. An aromatic scent might reveal the presence of terpenes. A yellow colour may indicate a connection to the liver; a red colour may indicate a connection to the heart and so on.

Philippus Theopastrus Bombastus Von Hohenheim (1493-1541) also known as Paracelsus wrote his famous comments on signatures in the text Supreme Mysteries of Nature (1656).

Jacob Boehme (1575-1624) wrote Signatua Re-rum (The Signatures of All Things) which was a contemporary work. TheGiambattista Della Porta (1535-1615) text Phytognomonica (1588) is even earlier, and mention must also be made of William Cole (1626-1662) and his book The Art of Simpling (1656) which serve as early works in regards to organoleptics, however these concepts and methods are much older than the 16^th century!

They developed independently across centuries in multiple cultural centres – Europe, China, America, India and Africa (12)). Many ancient tribes discovered the medical properties of plants in manners such as this, gaining empirical data from sensory information. The concept of entrainment with plants does not literally mean “talking to plants” but implies the tacit gathering of information between two living beings through sensory engagement.

Spending time in the company of plants is what Aristotle would call “learning by doing”. Developing the senses in this way may take years to learn but in time allows one to elucidate constituents and also to intuit from other information to create tacit patterns of association that can only come from direct encounters.

Modern research also confirms organoleptics.  De Medeiros et al., 2015 found significant associations between both taste and therapeutic indications (p<0.001); and smell and therapeutic indications (p<0.0001). (23) provide evidence for a highly significant association between the organoleptic properties of plants and the use of these species as medicine. Geck et al., 2017 show that organoleptics guide the choices of the therapeutic actions of medicinal plants.

Organoleptics is something of an art form but with careful practice, the novice can gain useful information of a practical nature, but for some this may take decades. However, initial clues from inspecting a plant, no matter how strange they may seem at first, can be compared with clues from other rooms.

It may seem tangential to consider phytochemistry as a singular source of evidence; however the effects of a plant’s primary and secondary constituents are now largely established in terms of their effects on the body. Taking an unfamiliar plant and researching its chemical composition allows a fundamental understanding of what a plant might do medicinally, once its phytochemistry can be elucidated.

This information can be found in research databases and with practice via organoleptic techniques. In the absence of historical record or clinical trials, knowing a plant’s phytochemistry can provide an understanding of both therapeutic qualities and potential cautions if toxic constituents are present.

Phytochemical analysis such as high performance liquid chromatography (HPLC) involves both qualitative and quantitative analysis of plant chemistry. While qualitative analysis is concerned with the presence or absence of a compound, quantitative analysis accounts for the quantity or the concentration of the compound present in the plant sample (15).

Several phytochemical databases already exist such as Phytochem and Duke’s, documenting qualitative and quantitative levels of primary and secondary compounds in plants. Considerable research has been done into singular constituents.

For example, alkaloids are now known to have a notable physiological effect on the body in general because they have a structural relationship with neurotransmitters such as dopamine or acetylcholine (33). Another family of phytochemicals, flavonoids, are similarly well documented and some constituents such as the polyphenolic compound quercetin have demonstrated antioxidant, antifungal, anti-carcinogenic, hepatoprotective, and cytotoxic activity (5).

When working with an unfamiliar plant, perhaps one which has little historical information or research, information as to its potential medical uses can be gained by knowing the range of secondary metabolites present and whether they are water soluble (hydrophilic) or fat soluble (lipophyllic) which would inform of the most appropriate solvent to use for crude extraction, depending on the intended actions.

One confounder, and perhaps the bane of this approach, is to see one constituent as having more importance than other constituents (much like the question if one type of evidence is superior to another). This is reductionism at work where value is placed on a single compound and medicines are standardised to meet very specific levels of this compound because it has been previously found to have a certain effect in cell lines for example.

The original medicine is thus modified, and may be considered a phytopharmaceutical. A case in point here may be Ginkgo biloba leaf, which does not have a long history in herbal medicine but systematic research has tended to use standardised extracts in past research and so some promote the standardised extracts accordingly. But, is there more to Ginkgo than gingkoflavones?

Plants generate compounds in the wild to deter pests and diseases or in reaction to its overall environment. The traditional use of a herbal medicine has been the use of the whole herb, plant part or crude extract where there will be seasonal and locational variability in constituents.

A plant’s medicinal actions occur when a combination of phytochemicals interacts with the epithelium on ingestion. It is the combination of actions, not one action in particular, that creates the healing effect. Indeed, when singular compounds are extracted side effects may ensue because a compound may be toxic or non-toxic depending on the presence of other constituents.

Phytochemistry can help to corroborate ancient uses in the absence of systematic research. Organoleptics can help to identify constituents and effects in a similar way. This is a good example of how the interrelationship between each room helps to improve the overall structure of the evidence house.

Modern forms of research such as double blind randomized controlled trials are not wholly applicable to herbal medicine because of their reductionist philosophical underpinning. A standard trial tends to investigate the effects of one compound on one molecular target. This is unsuitable because herbal preparations contain multiple constituents with multiple molecular targets. I have already discussed some other inherent problems earlier.

However, clinical trials can be designed in such a way so as to evaluate the herbalist “package” (the in depth consultation, the bespoke formula and tailored advice) and its effects on a particular health condition.

For example, a pilot study (n=45) was conducted by herbal practitioners to assess the effectiveness of professional herbal practice in the treatment of menopausal symptoms. All participants completed the study.

The treatment group (n=15) demonstrated a statistically and clinically significant reduction in menopausal symptoms compared to controls (n=30). Reduction in symptoms for the treated group was 9.05 points greater than that for the control group, CI 5.08-13.03, as were changes in vasomotor scores (mean 1.81, CI 1.00-2.62). Libido increased (mean 0.69, CI 0.38-0.99) in the group receiving herbal treatment (18).

Another study (n=120) into the alleviation of menopausal symptoms used a herbal formula containing Chamomilla recutita, Foeniculum vulgare and Crocus sativa (25). The formula was tested against placebo in different dosages in a randomized triple blind study.

After 12 weeks of daily treatment there were significant improvements in physical, psychological and urogenital domains in group B who had taken a dose of 1000 mg, 120 mg, 60 mg of the aforementioned herbs in drop form, whereas improvements in symptoms were less significant in the other dosage groups (Madhavian, Najmabadi, Hosseinzadeh, Mirziaean, Aval and Esmaeeli, 2019).

Such a trial is informative about dosage as well as the particular herbs that could be used to treat menopause. Bringing a greater emphasis to qualitative approaches helps to unpack other aspects of the herbal package, such as patient centred care through empathy and the length of time herbalist consultations typically afford (11).

Studies such as these are appropriate because they inform about herbal practice. Other studies which, for example, utilise a single isolated compound on a susceptible inbred animal at unrealistic doses are being geared towards the development of pharmaceutical drugs and have no bearing on actual practice. Unfortunately, background information such as this is sometimes used to justify or refute usage.

Qualitative studies, for example using questionnaires to access patient perceptions may also be valuable. Mixed-method research which utilises both quantitative and qualitative disciplines may also yield useful information, but the main criterion for any systematic research applies here – does it ultimately inform about herbal practice?

If we consider the EBM pyramid in its current form as a hierarchy of evidence, we may ask who decides which type of evidence is superior and which type of evidence is inferior, and what criteria are used to make these distinctions? On first glance it appears that these distinctions are made through an epistemological bias which favours one type of knowledge above another. It seems ironic that what we consider to be “expert opinion” is ranked at the very bottom of the EBM pyramid.

The term “expert” can also be misleading because it suggests complete knowledge of a subject which is not possible, but what is implied by EBM is that knowledge gained through empiricism is somehow inferior to knowledge gained from rationalism and quantitative data. The relegation of empirical knowledge in this way reveals an epistemological bias which may undervalue traditional herbal medicine (20).

Empiricism is the theory of knowledge which claims that most or all our knowledge is obtained through sensory experience over time, rather than through rational deduction (24). Therefore knowledge gained a priori is considered by empiricists to be inferior to knowledge gained a posteri in philosophical terms. Practitioners of traditional herbal medicine gained knowledge over the ages largely through empiricism. It is only with the development of reductionist philosophy, such as the mechanisation of the body as promoted by Descartes and the scientific method as espoused by Bacon that rationalism became prominent and increasingly dominant as a philosophical paradigm.

However, in herbal medicine empiricism always tends to the individualisation of treatment. Conversely, in reductionist medicine the individual patient is labelled with a disease (machine with broken part) and the emphasis is on more universal treatment protocols. Nonetheless a consequence of this approach may be to confound the concept of patient centred care within the current reading of EBM.

A holistic approach considers that a body is an interconnected whole with multiple influences that can affect any particular part. A “broken part” may therefore not be at fault in and of itself, nor are things always down to genetic “bad luck” (though of course with some conditions this is inevitable).

Rather illness is often caused by an ongoing homeostatic imbalance in one or more systems of the body. To focus solely on the perceived “broken part” misses this wider reality. It can also be argued that most diseases are consequences of poor diet and lifestyle choices (30).

To focus on “broken parts” as being self-responsible confirms rational medicine’s place as a system for a masking of symptoms rather than a removal of causes, and so confutes the perception of patient centred care by neglecting the bigger picture.

Rational philosophy contends that empiricism is subjective and that different observers may have different interpretations of the same object. The rationalists argue that elimination of bias, at least insofar as this is possible, helps to remove the doubt that may be caused by these conflicting views. Yet, by disengaging with causative factors and avoiding a holistic approach, the patient is not wholly treated, leaving room for error.

It is argued that a better approach may therefore be a combination of rationalism and empiricism as practiced by the 2^nd century Roman physician Galen (35). Indeed, central to the argument for an “evidence house” for herbal medicine is that we draw on multiple sources of evidence without preference.

What has become known as ‘practice-based evidence’ places greater emphasis on the experiential approach where the practitioner gains knowledge by working directly with patients rather than theorising about them. The practitioner learns over time what does or doesn’t work in real world conditions. After treating a number of patients with the same condition or similar symptoms, the practitioner learns to understand the triggers and drivers which lead to a particular imbalance.

In time the practitioner also notices that the same herbs or herbal combinations and particular adjunct advice may often be indicated for this condition. This empirical knowledge is therefore an important evidence base that is generated over time. It is the foundation upon which many of our classic herbals were written. The case-series which documents the herbal treatment of a condition in multiple patients is an evidence base that can be developed from such empirical data.

Practice-based evidence also bears some hallmarks of a long term clinical trial. Recently, researchers examined what are referred to as N=1 trials which incorporate much of the rigour of clinical trials, but are designed for individual patients. Individualising treatment interventions and outcomes in research designs is consistent with the movement towards patient-cantered care, according to the authors (7).

A more inclusive approach to evidence also encapsulates qualitative data from patient observations and narratives, creating space for involvement and therefore patient empowerment.

To ascertain evidence for the safety and efficacy of herbal medicines by systematic research alone is in and of itself a limited and limiting process. Such reductionism is inconsistent with the holistic paradigm of herbal medicine.

However, one form of research and evidence can be complimentary to another. A double blind randomised clinical trial may back up a historical use described in a classic herbal for example (26).  An ethnobotanical use may provide hypothesis for clinical research and so on.

Part of the problem with contemporary research into herbal medicine though is the focus on singular constituents perceived as active ingredients rather than the vocational practice of herbal medicine itself and what it has to offer. While the study of phytochemistry provides insight it is best served by focusing on the matrix of compounds rather than a singular compound. It can also help give weight to historical observations or folk practices.

In this more complex assessment of herbal medicine, we may be better served by drawing on a holistic perspective. The evidence house offers multiple rooms of information which connect into each other to form a whole foundation.

Each room may lead the researcher to practical information which can deliver successful outcomes, although each room taken alone has its own pros and cons. Information from one room can go some way to offsetting the limitations of another room in a complimentary manner. This prevents epistemological tensions and allows for a greater appreciation of traditional herbal medicine.

Further research could be done into each room and a potential weighting, the strength or weakness of evidence, could be quantified for each room but this may be a slip towards reductionism. Rather, a researcher might consider that where there is an obvious weakness in one room, there may be strengths in other rooms.

Drawing on all of these areas, and perhaps others not mentioned here, answers the question on how to access the safety and efficacy of a herbal medicine while attempting to avoid the clash of incongruent paradigms.

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The metabolic disease crisis afflicts a large part of the global population, particularly those in higher-income and emerging industrialised countries, and represents the single largest preventable, non-communicable disease burden in these countries (1).

The covid-19 pandemic has shone a spotlight on how a single viral pathogen can exploit comorbidities that are the result of metabolic dysfunction, creating havoc in its wake. It is surely also a reminder of the urgent need to address the underlying metabolic crisis, especially among younger members of society who will otherwise become extremely vulnerable both to chronic and infectious diseases.

Obesity, type 2 diabetes and ischaemic heart disease are three of the most pronounced downstream manifestations of the metabolic crisis.

However, increasingly, many types of cancer are considered to have a metabolic basis (2), while the rapid rise in prevalence of Alzheimer’s and dementia in industrialised countries is also thought to be, at least partially, mediated by metabolic disturbance, hence the increasingly common reference to type 3 diabetes (3).

There is overwhelming evidence that the causes are both variable, between individuals, yet are also multi-factorial, being a consequence of our poor adaptation to modern lifestyle and dietary patterns.

The Global Burden of Disease Study (2015) (4) identified four metabolic risk factors that are widely associated with the dysregulated metabolism that is typically associated with diet and lifestyle mediated metabolic diseases, these being:

1. Raised systolic blood pressure
2. Overweight and especially obesity
3. Hyperglycemia (high fasting blood glucose levels), and
4. Hyperlipidemia (high levels of fat in the blood).

These physiological risk factors are in turn associated with other physiological factors, as well as a broad array of social, environmental and genetic contributory factors. Given huge differences in the response both by individuals and different population groups to these multiple determinants of metabolic disease, there is little scientific consensus over which are the most important combination of factors for particularly diseases or population groups.  

This uncertainty is compounded by the common lack of clarity around the causality of non-communicable and metabolic diseases, that is much harder to ascertain than is the case of infectious (communicable) diseases.

Among the plethora of factors associated with the increased or reduced risk of metabolic diseases that contribute to many of the leading causes of preventable and premature deaths, notably ischemic heart disease, stroke, some cancers (breast, prostate, colorectal), obesity, type 2 diabetes and low bone mineral density, are the following:

• Dysregulated energy and glucose metabolism (5)
• Excessive and overly-frequent intake of sugars and refined carbohydrates, in association with reduced fibre intake, that contribute to chronically raised blood sugar (hyperglycaemia) and subsequently insulin resistance (6)
• Dysregulated lipid metabolism, in particular the inability to beta-oxidise (burn) fatty acids in adipose tissue and the development of non-alcoholic fatty liver (7)
• Dysregulated ‘cross-talk’ between adipocytes in adipose tissue (subcutaneous fat), macrophages (immune system) and neurons (nervous system) (8)
• Hormonal dysregulation of appetite, a complex process involving multiple hormones including grehlin (hunger), leptin (satiation) and adiponectin (fat burning). Apart from involving the endocrine system, it also involves the gut and its microbiome, the brain, the central and autonomic nervous systems, the immune system, adipose tissue and a large number of signalling compounds and nutrient-sensing systems such mTOR and AMPK (9)
• Low bone mineral density caused by disturbances to metabolism of calcium, other minerals and low circulating vitamin D status (10)
• Low grade, chronic systemic inflammation and oxidative stress (11)
• Chronic stress and inadequate quantity and quality of sleep (12)
• Exposure to air pollution and environmental toxins (13)
• The bidirectional relationship between physical inactivity and obesity (14)
• The prevalence of obesogenic environments and ‘anthropogens’ (human-made environments, their by-products and/or lifestyles encouraged by these, some of which may be detrimental to human health) (15)
• Social determinants of metabolic disease including socio-economic status, structural and cultural factors (16)
• The interplay of genetics and epigenetics in gene expression (17)

Not only are these associated factors both multiple and highly variable, very few have been identified as direct, causal factors. Several years ago, when metabolically-triggered low-grade systemic inflammation (sometimes referred to as ‘metainflammation’) was linked to obesity and chronic diseases like type 2 diabetes and ischaemic heart disease, there was hope that resolving inflammation alone would resolve these two great burdens of disease (18). 

More recently it has been found that metainflammation may or may not be associated with obesity while it is consistently connected with a range of lifestyle-related and environmental factors such as diet, inactivity, smoking, sleep, chronic stress and pollution exposure (19).

Leading Australian obesity and metabolic disease clinicians and researchers, Drs Garry Egger and John Dixon, accordingly suggested that “obesity may often be just an accomplice to, as much as a perpetrator of, many metabolic diseases” and that solutions should be directed to trying to reduce citizen exposure to anthropogens and obesogenic environments (20).

The same authors also provide a framework that can be used to help better understand the hierarchy of determinants. These can be classified as ‘downstream’ (i.e. cause), ‘midstream’ (i.e. cause of the cause) or ‘upstream’ (i.e. cause of the cause of the cause) (Figure 1).

Eggers & Dixon also tabulate, using the acronym NASTIE ODOURS, a wide range of determinants (Box 1) of chronic disease along with evidence of how specific factors may increase or decrease risk, or act as moderators (mediators).

BOX 1 – Lifestyle & environmental determinants (‘anthropogens’) of metabolic disease

N = Nutrition (lack of diversity, inadequate plant foods/phytonutrients, poor eating patterns, excess intake of refined carbohydrates
A = In(Activity) (e.g. sedentary behaviour/work, lack of stretching/dynamic movement)
S = Stress, anxiety and depression
T = Technology-induced pathology (e.g. screens, machinery, highly processed foods)
I = Inadequate sleep (quantity and quality)
E = Environment (political/economic, recreation and green spaces, pollution)
O = Occupation (e.g. social justics, work equality, security)
D = Drugs, smoking and alcohol
O and U = Over- and Under-exposure (e.g. sunlight, radiation, asbestos)
R = Relationships (e.g. companionship, peer support, love)
S = Social factors (e.g. poverty socio-economic status, education, security)

Adapted from Eggers & Dixon (2014) (20)

Despite the obvious difficulties in modifying some of the determinants of metabolic disease, such as underlying genetic predisposition or an individual’s place of residence or work, there are a very large number of factors that can be altered in ways that can, sometimes dramatically, improve health outcomes. Even an individual’s genetic predisposition can be altered by changing the inner and outer environment to which the individual is exposed, which in turn changes the pattern of gene expression (i.e. epigenetics) (21).

Four over-arching priorities are identified below. These are open to modification, optimal outcomes often being realised when interventions or protocols are personalised, following guidance by the individual’s health practitioner, around the specific needs, capacities and environments experienced by the individual.

For the purposes of this article, examples of possible interventions are drawn mainly from the fields of nutrition and herbal medicine. These interventions are of particular value given the multi-target, and often, multi-system actions, of nutrients and synergistic plant compounds.

Metabolic flexibility refers to the adaptive ability to have “a clear capacity to utilize lipid and carbohydrate fuels and to transition between them.” (22) When this capacity is lost, i.e. metabolic inflexibility occurs, an individual is usually primarily reliant on burning carbohydrates to produce adenosine triphosphate (ATP) via the mitochondria.

This inflexibility is associated with ‘metabolic syndrome’ that afflicts obese and type 2 diabetic individuals which is characterised by:

1. Excessive insulin response to elevated blood sugar.
2. A failure of skeletal muscle tissue to transition from using fatty acids (lipid) as an energy source during the fasting state and carbohydrate in the insulin-stimulated prandial state.
3. A tendency to store excess energy as fat (23).

Blood sugar spikes can be greatly reduced by eliminating or reducing consumption of sugars, refined carbohydrates (e.g. bread, rice, pasta), as well as starchy vegetables.  Moreover, extending the fasting intervals (e.g. at least 5 hours between eating intervals, 12-16 hour overnight fasts, or 8-hour time-restricted feeding) can help to re-educate the neuro-endocrine system to beta-oxidise fatty acids.

This adaptive process, that may take several weeks or even months, culminates in the liver-generating ketone bodies that can be used as an energy source, the process being referred to as ‘keto-adaptation’ (24). It is always non-existent in cases of non-alcoholic fatty liver disease (25).

Extremely helpful in supporting this process of keto-adaptation are herbal products that are able to blunt blood sugar responses following carbohydrate-containing meals. In this regard cinnamon has been intensively studied and used clinically, often used both as an infusion in tea or in powdered form in capsules. Not only has it been found to be able to reduce post-prandial blood-glucose spikes, it can also increase insulin sensitivity and reduce fat accumulation in the liver (26,27,28).

Trial data tends to be highly variable, this likely being the result of different profiles and concentrations of key bioactive constituents, such as chalcones, flavonoids, tannins and coumarins, these also varying between Cinnamomum species. Commonly used species include Cinnamomum zeylanicum (Ceylon cinnamon), aka Cinnamomum verum (true cinnamon), and Cinnamomum cassia (Saigon cinnamon), the latter often containing coumarins which may, at high intake levels, be of concern for those with variations of the CYP2A6 gene that impact coumarin metabolism (29).

With a wealth of historical use and trial data behind it, is triphala, the Ayurvedic combination of three fruits, namely amla (Emblica officanalis), haritaki (Terminalia chebula)and bibhitaki (Terminalia bellirica). The formula has been shown to act as a powerful antioxidant, anti-inflammatory and blood-sugar regulator (30). Another widely used combination is fruit extracts from haritaki, and the oleoresin of guggul (Commiphora wightii [formerly C. mukul]) and myrrh (Commiphora myrrha), widely available in a daily preparation of 200 mg of each (31).

Public health messaging often advises citizens to exercise more or be more active without underlying consideration of their metabolism and physiology. Many people who are inactive have sub-optimal energy yielding pathways and benefit from cofactors that facilitate function. These include a full array of bioactive, naturally-occurring forms of B vitamins as well as coenzyme Q10, all of these being cofactors in mitochondrial respiration via the Kreb’s cycle.

In addition to these micronutrients, research is increasingly pointing to an ever more diverse array of phytonutrients facilitating mitochondrial function and ATP generation. These phytonutrients are generally absent or very limited in simplified Western, processed food-based diets and an array were reviewed by Tao et al (2019) (32), as follows:

• Homoisoflavanone-1: a natural compound in the Chinese herbal medicine, Polygonatum odoratum
• Myricetin: a flavonol compound found in multiple herbs
• Esculetin: a natural coumarin compound found in traditional medicinal herbs
• Curcumin: the principle component of Curcuma longa rhizome/root
• [6]-Gingerol: the key bioactive component of ginger
• Triptolide: a natural product from Tripterygium wilfordii
• Thymoquinone: an active constituent of Nigella sativa seeds
• Epigallocatechin gallate (EGCG): a polyphenol from green tea
• Artepillin C: a bioactive component of Brazilian green propolis
• Allicin: predominant component of freshly crushed garlic
• Ganoderma atrum polysaccharide
• Ginsenosides: a major pharmacologically active ingredients of ginseng
• Jolkinolide B: a diterpenoid from Euphorbia fischeriana
• Withaferin A: a steroidal lactone of Withania somnifera (ashwagandha)
• Cucurbitacin B: a bioactive compound from Pedicellus melo.

There is increasing recognition in the scientific community that food serves much more than being a source of energy or calories for the body. Rather is provides the body with information – and critical to this is the diversity of nutrients provided by diverse, nutrient-dense diets, along with culinary and medicinal herbs. Furthermore, evidence is accumulating that suggests nutrition in the first 1000 days of lives is an important contributor to long-term healthspan (33).

Nutrient-density and dietary diversity have been shown to relate directly to the anti-inflammatory nature of diets (34).

Anti-inflammatory diets have been widely studied and tend to be plant-based, rich in polyphenols and fibre, while being lower in omega-6 fatty acids, sugars and refined or processed foods compared with conventional diets (35).

Given that every eating event triggers an inflammatory response in the body, anti-inflammatory dietary patterns are also generally associated with intermittent fasting or time-restricted feeding.

The damaging effects of stress are caused by the response to stress, rather than the stressor itself. Stress-modulating herbs, especially adaptogens (36), have been shown to be invaluable to help improve the stress response under conditions of persistent, chronic stress that are all too common in modern day lives.

Well studied and clinically-proven adaptogens include:

• Rhodiola rosea, root (37)
• Withania somnifera (ashwagandha), root (38)
• Panax quniquefolius, root (39)
• Schisandra chinensis, fruits, seeds (39)
• Eleutherococcus senticosus (Siberian ginseng), root (36)

Research since the 1980s has revealed ever more about the critical role of the endocannabinoid system (ECS) in maintaining balanced mood and a resilient stress response (40). This includes evidence of the deleterious role of chronic, psychoemotional stress on cannabinoid receptors in the brain and central nervous system (41). This provides good clinical justification for use of high quality, full spectrum CBD-standardised that cannabinoid receptors to help modulate the response of cannabinoid receptors in those exposed to such ongoing chronic stressors (42).

Additionally, several herbal medicines have been conclusively demonstrated to facilitate sleep duration and quality. These include:

• Valeriana officinalis (valerian) (43,44)
• Passiflora incarnata (passionflower) (45)
• Melissa officinalis (lemon balm) (44)
• Eschscholzia californica (Californian poppy) (44)
• Lavandula angustifolia (lavender) (44)

It is clear that top-down public health measures have had little impact on curtailing the spiral of metabolic disease that is running rampant through the majority of the industrialised world. The impact caused by SARS-CoV-2 is a reminder of how pathogens can interact with unhealthy, imbalanced body systems and cause severe disease and societal disruption.

While it may seem that proven solutions to the metabolic crisis are still wanting, there is copious clinical evidence of successes in reversing metabolic diseases, although little of this is adequately documented or published in peer reviewed journals. Adding to this difficulty is that the disease-centric nature of prevailing medical systems means that very little effort is expended studying dietary and lifestyle patterns associated with the healthiest populations, the research on the world’s ‘blue zones’ of exceptional longevity being an exception (46).

Self-care and practitioner-guided self-care, the democratisation and even digitisation of health are key elements of any solution to the crisis, as recognised by the Lancet Global Health Commission of 2018 (47) and others.

Central to this will be multi-factorial, whole system-focused approaches and interventions that include at their heart the diversification of natural, plant-based diets. Additionally, such strategies should include increased intake of sustainably produced phytonutrients and herbal medicines which are increasingly being shown to be capable of restoring homeostatic balance in those suffering the effects of metabolic disturbance or dysfunction.

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Polypharmacy, which can be defined as a patient being on 5 or more medicines is becoming increasingly common, especially amongst those who are 65 or older. This has arisen due to the increased use of preventative medication, and the increasing burden of chronic disease due to both longevity and the western lifestyle.

Research and guidelines have focused on single diseases resulting in patients with more than one illness being started on multiple medications, all individually indicated but in combination resulting in polypharmacy.

Some patients are prescribed 10 or even 15 medications and often experience marked side effects such as dizziness, indigestion, bowel problems, fatigue and falls. These patients have their symptoms controlled but they often do not have a good quality of life and don’t feel well.

In the UK between 2008 and 2015 the number of hospital admissions directly related to drug side effects increased by 53.4%, from 60,055 in 2008-2009 to 92,114 in 2014-2015. Every year in Europe an estimated 8.6 million unplanned hospital admissions occur as a result of drug side effects and in the US the harm resulting from medication errors is estimated at $42 billion dollars per annum (2).

Herbal medicines have an important role to play in reducing the drug burden of the population, especially when used alongside lifestyle changes, and the deprescribing of unnecessary medication. The targeted use of herbal medicines may also help to reduce the drugs bill, adverse drug reactions and encourage self-help.

Herbal medicine and humanity have enjoyed a close symbiotic relationship for millennium and today there are approximately 21,000 different plants used worldwide.

Some plant medicines are very potent with their therapeutic action coming from a relatively small number of powerful phytochemicals and have often formed the basis for drug development for example foxglove (Digitalis pupurea) and digitalis for heart failure and heart rate control, and belladonna (Atropa belladonna) and associated alkaloids as inhalers in chronic obstructive pulmonary disease.

However, many plant medicines represent a more complex range of actions containing 100s of potentially active principles which work in synergy, with it often being difficult to reliably isolate the “active” ingredient. These herbal medicines are well suited to the management of more complex illnesses as they are themselves inherently complex, whilst at the same time being biologically close to us, having evolved within the natural world. Herbal medicines at this end of the spectrum have a low side effect profile, and provided they are of good quality and attention is given to potential drug herb interactions are safe.

The evidence base for herbal medicine varies from Level I evidence where a plant has had enough research to allow for a systematic review of randomised controlled trials to Level IV evidence where the knowledge of the plant is based on experience and expert consensus (3). The majority of herbal medicine evidence is empirical being at Level IV, which is seen conventionally as having a lower level of validity when compared with Level I evidence.

However, the empirical basis of herbal medicine is particularly powerful as it spans centuries as opposed to decades and is also often cross cultural. A significant number of national guidelines such as NICE guidelines are partially based on Level IV expert consensus and so this can be considered an acceptable level of evidence, especially considering the low side effect profile of most plant medicines.

Diabetes and in particular Type 2 Diabetes mellitus is becoming a major health issue with an 80.1% increase in the prescribing of diabetic medication in the UK in the decade leading up to 2017, the overall cost of diabetes medication in 2016-17 being £983.7 million (4).

Herbal medicine has a role to play in diabetes with there being 400 herbal medicines which are believed to help diabetes (5).  

Plant medicines which have demonstrated an effect on diabetes in human clinical trials are Gymnema (Gymnema sylvestre) a herbal medicine used traditionally in Ayurvedic medicine (6), fenugreek (Trigonella Foenun-graecum) which has been used in the Middle East and India (7) and cinnamon (Cinnamomum zeylanicum) (8), all of which have beneficial effects on blood glucose levels.

Recent research into type 2 diabetes has also shown that a calorie restricted diet of 800 calories a day for a period of 3-5 months reversed diabetes in 46% (9), and it is likely that the addition of herbal medicines such as Gymnema, Fenugreek and Cinnamon would potentiate the effectiveness of diet in the treatment of type 2 diabetes.

Viral upper respiratory tract infections such as coughs, colds and ear infections are a common reason for patients to attend general practice, with time and patient pressures sometimes leading to unnecessary antibiotic prescribing. This increases the risk of antimicrobial resistance with there being a direct link between the amount of antibiotics prescribed in a community and antibiotic resistance.

It has been estimated that increasing antibiotic resistance could lead to 10 million deaths a year worldwide by 2050, with an estimated 25,000 people dying in Europe each year as a result of antibiotic resistant infections such as MRSA and E. Coli. (10).

The increased education of the public, GPs and Nurse Prescribers in the use of herbal medicines for the self-care of viral infections could lead to reduced antibiotic prescribing, with the use of herbal medicines such as Elderberry (Sambucus nigra fructus) in the treatment of viral upper respiratory tract symptoms including fever, nasal congestion, and headache (11).

In addition, there is evidence that Echinacea (Echinacea angustifolia/purpurea) can be used in the treatment and prevention of colds (12) and Andrographis (Andrographis paniculata) in reducing the symptoms of upper respiratory tract infections (13).

Mental health problems are increasingly prevalent in the UK population with antidepressants representing the biggest increase in prescription items in 2016. 64.7 million prescriptions for antidepressants were issued in 2015-16, with 3.7 million more anti-depressants being dispensed in 2016 than the previous year, and in 2015 anti-depressants cost the NHS £780,000 a day (1).

Herbal medicines have been used for mental health problems for centuries and can play an important role along with lifestyle changes, and psychological therapies in mild and moderate depression.

St John’s wort (Hypericum perforatum) has a high level of evidence (Level 1) with one meta-analysis of 29 trials showing it to be as effective as antidepressants in mild and moderate depression, and more effective than placebo in major depression, with fewer side effects than conventional antidepressants (14).

A 2017 meta-analysis of 27 clinical trials came to similar conclusions when comparing St John’s wort to Selective Serotonin Reuptake Inhibitors (SSRIs) such as citalopram (15). St John’s Wort however does need to be used with attention to the other medication which the patient is taking due to its potential interaction with medications such as the contraceptive pill and warfarin.

Rhodiola (Rhodiola rosea) has also been shown to effect depression (16) and is thought to have adaptogenic effects helping the immune and endocrine system to adjust to stress. Herbal medicines can also be helpful in anxiety with 21 plants having human clinical trial evidence of efficacy such as chamomile (Matricaria recutita), skullcap (Scutellaria lateriflora), passionflower (Passiflora incarnata), and ashwagandha (Withania somnifera) (17).

Ashwagandha has been shown to improve anxiety and stress compared to placebo (18) and the potential for adaptogenic herbal medicines such as ashwagandha and rhodiola along with others such as reishi (Ganoderma lucidum) to help reduce the adverse effects of stress is unique to herbal medicine and highly significant considering the prevalence of stress in the community. The humble chamomile tea (Matricaria recutita) is available from most food stores has been shown to reduce anxiety scores and is a good example of a readily available herbal medicine with significant self-care potential (19).

There can be no doubt that herbal medicines alongside the use of lifestyle medicine and the deprescribing of medications which are no longer indicated can play a critical role in healthcare and reducing a patient’s medication burden. Plant medicines can also play an important part in patient self-care, and the management of stress and mental health problems, as well as in preventative medicine.

There is an urgent need for better education of both the public and frontline health care professionals into the possible benefits of plant medicines, as well as more appropriate research into the use of herbal medicines, especially those which are commonly used by practitioners with good empirical effect but which have not attracted research.

1. NHS Digital, Prescriptions Dispensed in the Community – Statistics for England, 2006-2016, June 2017
2. WHO, Medication Without Harm, WHO Global Patient Safety Challenge, 2017
3. National Health and Medical Research Council (NHMRC). A Guide to the Development and Evaluation of Clinical Practice Guidelines. Commonwealth of Australia, Canberra, 1999.
4. NHS Digital, Prescribing for Diabetes in England – 2006/07 to 2016/17, Aug 2017
5. Kumar S. Mittal A. Babu D. Mittal A. Herbal Medicines for Diabetes Management and its Secondary Complications. Current Diabetes Reviews, 2021, 17, 437-456
6. Baskaran K. Ahamath K, Shanmugasundaram K. Antidiabetic Effect of a Leaf Extract from Gymnema Sylvestre In Non-Insulin-Dependent Diabetes Mellitus Patients Journal of Ethnopharmacology, 30 (1990) 295 – 305
7. Narsingh V. Usman K. Patel N. Arvind J. Sudhir D. et al. A multicenter clinical study to determine the efficacy of a novel fenugreek seed (Trigonella foenum-graecum) extract (FenfuroTM) in patients with type 2 diabetes. Food and Nutrition Research. Octo 2016 Vol.60 (1) p.32382-32382
8. Zare R. Nadjarzadeh A. Zarshenas MM.  Shams M. , Heydari MG,  Efficacy of cinnamon in patients with type II diabetes mellitus: A randomized controlled clinical trial. Clinical nutrition (Edinburgh, Scotland), 2019-04, Vol.38 (2), p.549-556
9. Lena ME. et al. Primary Care-led management for remission of type 2 diabetes (DiRECT): an open label cluster randomised trial. Lancet. Feb 2018 10;391 (10120):541-551
10. Public Health England, Health matters: antimicrobial resistance. Dec 2015. Health matters: antimicrobial resistance – GOV.UK (www.gov.uk)
11. Harnetta J. Oakes K. Carèa J. Leache M. Brown D.  Cramerg H et al. The effects of Sambucus nigra berry on acute respiratory viral infections: A rapid review of clinical studies. Advances in integrative medicine, 2020-12, Vol.7 (4), p.240-246
12. Jawad M. Schoop R. Suter A. Klein P.  Eccles R. Wahner-Roedler D. Safety and Efficacy Profile of Echinacea purpurea to Prevent Common Cold Episodes: A Randomized, Double-Blind, Placebo-Controlled Trial. Evidence-based complementary and alternative medicine, 2012-09-16, Vol.2012, p.841315-841315
13. Panel RC. Saxenaa R. Singh BP. Kumarc SC. Yadavc MPS. et al. A randomized double blind placebo controlled clinical evaluation of extract of Andrographis paniculata (KalmCold) in patients with uncomplicated upper respiratory tract infection. Phytomedicine Volume 17, Issues 3–4, March 2010, Pages 178-185
14. Linde K. Berner MM. Kriston L. St John’s Wort for Major Depression. 2008 Cochrane Database of Systematic Reviews, Issue 4.
15. Ng QX. Ventakatarayana N. et al. Clinical use of Hypericum perforatum (St John’s wort) in depression: A meta-analysis. Journal of Affective Disorders 1 March 2017, Vol 2010. Pages 211-221
16. Sarris J. Panossian A. Schweitzer I. Stough C. Scholey A. Herbal medicine for depression, anxiety and insomnia: A review of psychopharmacology and clinical evidence. European neuropsychopharmacology, 2011, Vol.21 (12), p.841-860
17. Sarris J. McIntyre E. Camfield DA. Plant-Based Medicines for Anxiety Disorders, Part 2: A Review of Clinical Studies with Supporting Preclinical Evidence. CNS drugs, 2013-08-01, Vol.27 (8), p.675-675
18. Pratt MA, Nanavati KB. et al. An alternative treatment for anxiety: a systematic review of human trial results reported for the Ayurvedic herb ashwagandha (Withania somnifera). Journal of Alternative and Complementary Medicine 2014 Dec;20(12):901-8
19. Keefe JR. Mao JJ. Soeller I. Li QS. Amsterdam JD. Short-term open-label chamomile (Matricaria chamomilla L.) therapy of moderate to severe generalized anxiety disorder. Phytomedicine (Stuttgart), 2016-12-15, Vol.23 (14), p.1699-1705

Prior to the advent of modern analytical chemistry, microscopic examination of crude herbal drugs, along with gross morphological and organoleptic assessment as described above, were the primary tools used for crude herb assessment.

European and American pharmacognosists put tremendous emphasis on the ability to identify plants to species microscopically, including those that that are closely related, detect adulterations, and, in some cases, even assess relative quality. According to noted American pharmacognosist Henry Kraemer (1908):

“The microscope furnishes the surest means of determining the identity of a powdered drug at our command…the microscope also furnishes the most reliable means for detecting and determining adulterants in powdered drugs… [and] detecting the presence of worm-eaten drugs or powders of certain classes of drugs which have been exhausted in whole or in part…”

Kraemer went so far as to say that even the time of gathering, method of drying, and length of time for which a botanical had been stored could  “be judged in many instances by the use of the microscope”. Additionally, there is great sensitivity in being able to detect adulterating species.

For example, many years ago there were numerous reports of the Chinese herb stephania (Stephania tetrandra) being mixed up with a different species of plant (Aristolochia fangchi), which contains the renal toxin and potential carcinogen aristolochic acid (AA). This adulteration was responsible for from several hundred to a few thousand deaths. With microscopic examination, the addition of as little as 0.3% of Aristolochia fangchi in a stephania sample can be detected by observation of the differing oxalate crystals that occur within the species (Upton 2006).

Discerning crude drug species microscopically reached a very high level of refinement and is reflected in numerous seminal texts on the subject in the middle 19–20^th centuries, most notably Berg (1865) and Meyer (1892) of Germany; Moeller of Austria (1890); Tschirch and Oesterle of Switzerland (1900); and microscopists of the UK and US such as Sayre (1917), Mansfield (1937), Greenish (1904), Kraemer (1920), and Youngken (1930), to name a few.

With advancements and evolution of analytical chemical techniques, first with paper chromatography followed by thin-layer chromatography (TLC) and then more quantitative techniques (liquid chromatography [LC], gas chromatography [GC], and finally molecular technologies (e.g., DNA), microscopy, like morphology and sensory assessment, as a scientifically valid analytical tool was regarded as outdated in the face of these more recent techniques.

However, seldom is one analytical technique inherently superior to another. The superiority or applicability of one analytical method over another is dependent upon the desired analytical endpoint. From this perspective, microscopy is as scientifically valid of an analytical tool as any other technique and is currently enjoying a resurgence in the US where it had fallen into almost complete neglect in previous decades.

The first of the chemical assessment techniques in most pharmacopoeias, Eastern and Western, is thin layer chromatography (TLC), and more recently, high performance TLC (HPTLC), and is primarily used as an identification assay.TLC and HPTLC analysis provide a snapshot of the constituent profile of crude plant drugs and has been a standard entry in pharmacopoeias for decades.

In previous decades, TLC as an analytical technique was very crude, had a limited degree of reproducibility, was cumbersome, and not very GMP-compliant. In more recent decades, the introduction of HPTLC has addressed many of these deficiencies. As a chemical analytical tool, HPTLC is extremely versatile and sensitive for the identification of many crude herbal drugs and is especially useful for the detection of adulterations, often with a very high degree of sensitivity.

However, it must be recognized that any chemical testing is a surrogate for identification as, in contrast to identifying the actual plant material botanically, morphologically, organoleptically, or microscopically; it is the chemical profile that is being identified not the plant. Closely related species of plants may be very similar chemically.

Additionally, the constituent profile of the plant can vary dramatically across the range of commercial materials that may be traded, variations occurring due to growing, harvesting or post-harvesting conditions, age of the plant, or extracting parameters. Identification of plants chemically is therefore limited and is most accurate when coupled with appropriate physical tests. For compliance with pharmacopoeia monographs, TLC/HPTLC or other quantitative assays are conducted in tandem with the physical tests outlined above.

Critical to any chemical testing methodology of medicinal plants is to look at the suite of constituents from the perspective of chromatographic fingerprinting and not only individual markers. The concept of chromatographic fingerprinting was developed primarily by Chinese phytochemists who recognized that the activity of a Chinese herb is in its collection of compounds not just the single active constituent approach typical of modern drugs.

Numerous papers have been published on the subject and provide guidance on appropriate ways to apply modern chemistry to the analysis of traditional herbal drugs (Fan et al. 2006; Liang et al. 2004; Xie et al. 2006, among others).

A critical starting point to chromatographic fingerprinting is to obtain multiple samples of the desired botanical that is grown, harvested, and dried in a manner that is optimal for the plant part. Such criteria are traditionally determined organoleptically by evaluating the color, smell, taste, texture, relative purity, and other physical characteristics of the plant. Optimal picking times can be informed by traditional literature, such as harvesting the flowering tops of St. John’s wort on the eve of St. John’s day (June 24).

While the specificity of a single day may not be required, in most growing areas, St. John’s day reflects a harvest time when the plant is in full bloom, the traditional time to harvest most flowers; roots and barks are typically harvested in the Spring or Fall; leaves, prior to flowering before the energy of the plant goes to flower, seed, and fruit production.

In Chinese herbal medicine, specific herbs must be gathered at a specific age, such as the roots of dang gui (Angelica sinensis) at a minimum of four years of age; or Chinese ginseng (Panax ginseng) at a minimum of five years of age. Optimal harvest times can be greatly informed by chemical analysis. Specifically regarding St. John’s wort, the highest concentration of the suite of St. John’s wort constituents including flavonoids and napthodinathrones are yielded during the budding and flowering stage (during blooming), the concentrations dropping dramatically after flowering and being higher in upper leaves than lower leaves (Tsitsina 1969).

Another critical aspect in developing chromatographic fingerprinting methodologies for medicinal plants is to obtain samples of closely related and potentially adulterating species that may be inadvertently traded for the authentic material.

Having multiple species of the same appropriate quality material, ideally from multiple regions for multiple years, allows the analyst to observe the variation inherent in natural products due to changing environmental conditions. Having closely related or adulterating species helps the analyst know if the chromatographic fingerprint is robust enough to identify the authentic from substitute species.

In recent decades, chromatographic fingerprinting techniques have been coupled with chemometric programs (Mok and Chau 2006, among others). These programs are designed to store and analyze multiple datapoints from multiple samples and provide statistically relevant comparative fingerprints that allow for developing relatively objective criteria for what constitutes an acceptable chromatographic fingerprint. Ideally, such determinations should be made based on the available clinical data that establishes the efficacy of the herbal drug being analyzed; without a clinically relevant correlation, even the chemical fingerprint is only a surrogate marker of quality.

It is important to recognize that much of the basic work in developing appropriate chromatographic fingerprints is best done in academic settings and is a very expensive and time-consuming process that does not allow for the high throughput testing often required by industry. Once done in academia, such testing criteria can then be codified into pharmacopoeia as a way to promote a consistent standard.

In addition to identity tests, most Western pharmacopoeial monographs require quantitative assays, many of which will correlate directly with the pharmacopoeial definition of the botanical drug ingredient and may or may not directly correlate with activity. Quantitative assays are often lacking in Eastern pharmacopoeias (e.g., Ayurvedic Pharmacopoeia; PPRC). In most cases, quantitative assays will quantify a specific compound that is correlated with a known active constituent or class of constituents.

Other compounds assayed are considered surrogate marker compounds for activity, other chosen compounds may reflect a constituent or class of constituents that provide a baseline of “quality” based on harvest or processing practices, which may or may not correlate with activity, and yet others will reflect other measures of “quality”, such as an organoleptic bitterness value for a particular botanical such as gentian root (Gentiana spp.) or a swelling index as discussed previously regarding mucilage content of slippery elm bark or flax seed.

As noted, very seldom is a single constituent correlated with the total activity of a particular botanical. Rather, the total extract or profile of the crude drug is considered the active ingredient or substance.

This is reflected in WHO documents (WHO 1991) and acknowledged by renowned medicinal plant researchers (e.g. see Mukherhee 2011; Wagner et al. 2009; Xie et al. 2013). For example, valerian root (Valeriana officinalis) is a sedative herb used at least since the 1st century (Pickering 1879). The essential oil was long considered to represent the active fraction.

However, early pharmacological work demonstrated that the essential oil fraction was only associated with approximately 1/3 of the total activity of the extract (Gstirmer and Kind 1951). Later, research demonstrated depressant activity of the dichloromethane extract but activity could not be attributed to either the valepotriates, valerenic acid, valeranone, or the essential oil (Krieglstein and Grusla 1988).

To date, the total activity of valerian has not been fully articulated though its efficacy in reducing the time required to fall asleep and to stay asleep is supported. Today, Western pharmacopoeias require quantitation of the essential oil fraction of valerian as the primary marker of quality.

St. John’s wort (Hypericum perforatum) provides another example of a plant whose efficacy as an antidepressant has been documented over a period of more than 2000 years, but for which the pharmacological mechanisms in humans have yet to be determined (Cott 2005). Thus, quantification of a single marker or group of markers should be viewed as representing only a portion of the activity of the whole plant or extract made therefrom.

Regarding quantitative assays, varying pharmacopoeias take different approaches in determining what compound(s) are to be assayed. For example, the pharmacopoeias of Germany and the US tend towards specificity of compounds favoring relatively sophisticated quantitative technologies such as HPLC in contrast to more generic technologies such as spectrophotometry. Whereas HPLC has greater accuracy in quantifying individual compounds, spectrophotometry groups like compounds together, often resulting in higher quantitative values as compared to HPLC.

Both technologies have strengths and weaknesses. HPLC offers greater accuracy in quantitation; this is its primary advantage. If used appropriately, HPLC can also be used for purposes of identification if the total chromatographic fingerprint of the plant is considered and thus has a greater chance of detecting adulterants. Spectrophotometric techniques, in grouping like compounds, may give a more accurate representation of the totality of the plant or extract, but has the distinct disadvantage of being easily fooled by purposeful admixtures of adulterants.

In the US, there are no requirements to follow any monograph standards for herbal supplements. Analysts and botanical dietary supplement manufacturers often attempt to perform a single test for all or most identity and quality testing, often times choosing the most economically feasible assay, but not always the most appropriate.

Such testing may or may not provide scientifically valid results for the desired analytical endpoint. In the EU, where there is a legal requirement to follow all aspects of the European Pharmacopoeia monographs, there appears to be a greater use of spectrophotometric methods, which are only employed after appropriate identity of the botanical ingredient has been confirmed. In the USP, there appears to be greater utilization of specific methods, requiring multiple analytes, greater time, and greater expense.

Another limitation of current pharmacopoeial works include the fact that many perceived independent standards are based on single proprietary products. In such cases, a sponsor submits analytical data, often of a proprietary extract, and the characterization of that proprietary extract becomes the standard for the botanical generically, but may not be widely applicable to generic products creating a false sense of independent verification.

However, also codification of a commercial proprietary product as a generic standard may provide an unfair advantage to the submitting manufacturer as all competitors then must either submit their own data for consideration of revision of the monograph (a lengthy process) or be encouraged to follow the standards of the their competitor, which they may not be able to do due to the proprietary nature of the original extract used. This is more of an issue in countries where the process is driven more by commercialism than science.

Some Chinese researchers propose a tiered approach to traditional Chinese herbal drug quality control development, recommending “elementary, intensive, and advanced” levels of testing. The “elementary” level reflects current standard requirements of pharmacopoeias that focus on basic identity, qualitative tests, and analysis of a single marker compound.

The “intensive” level includes multiple component analysis, including differentiation between “high” and “low” quality materials based on quantitative assays of a particular compound(s).

The “advanced” level proposes that the multiple component herbal medicine be subjected to formal pharmacological study but acknowledges the inherent lack of Western pharmacological models for assessing traditional Chinese actions of herbs such as to “expel wind” and “nourish kidney” (Xie and Li 2007).

Similarly, it has been proposed that the comparison of a crude herbal drug to a properly made well characterized extract is a more appropriate way to assess the quality of a Chinese herbal drug than to simply assay a single constituent (Xie et al. 2013). While these represent more appropriate ways to ensure the integrity of multi-component ingredients and formulas than the typical Western pharmacopoeial approach, they continue to depend on chemical analysis versus traditional herbal assessment skills and therefore, do not take into consideration the full suite of traditional assessment techniques.

Botanical identification

Botanical identification remains the primary technique for the identification of plants worldwide. While chemotaxonomy and DNA analysis have made great strides in altering the classifications of traditional taxonomy, neither technology has supplanted botany as the primary means of identifying medicinal plants. However, in virtually all official pharmacopoeias, botanical identification is not included as a required test with which to conform. The reason for this is that oftentimes the botanically unique characters of a specific plant are not intact in the crude plant drug.

Historically, different species of a specific genus of plant, and sometimes, different genera of plant, were used as a specific botanical drug. Rather than being referred to by its generic and specific name e.g., Salix purpurea, medicinal plants were described according to their Galenic names e.g., Cortex salicis, the Galenic name referring to the bark of varieties of willow that were historically used interchangeably without differentiation of species.

Such a practice is represented in most pharmacopoeias but is increasingly moving towards greater speciation. For example, in the European Pharmacopoeia, the bark of several species of Salix is allowed as long as the barks conform to the identity tests given and possess a minimum quantity of salicin (1.5%), the primary putative active constituent, and precursor to the development of acetyl salicylic acid (aspirin).

Conversely, in the US, where herbs are predominantly traded as ‘dietary supplements’ not ‘medicines’, for purposes of supplement labeling, the names of botanical ingredients must conform to Herbs of Commerce of the American Herbal Products Association (AHPA). The current edition of this text, rather than recommending use of Galenic or more common names (e.g. “willow bark”), mostly requires speciation such as crack willow (Salix fragilis), purple willow (Salix purpurea), white willow (Salix alba), etc.

Unfortunately, while conformity to the identification tests of pharmacopoeias for these barks can be assured, most of these barks cannot be identified to species when in their crude form as they are morphologically, organoleptically, chemically, and medicinally very similar, the very reason why the multiple species are used interchangeably. Thus, greater levels of specificity are often required for either academic or arbitrary regulatory reasons creating unnecessary impediments, to continued use of traditional herbal medicines.

Daodi (region specificity)

Daodi is a philosophy that is exclusively applied to the development of medicinal substances. Dao is an ancient Chinese unit of measure, which became applied to the development of districts. Di means earth or land and is applied to specific geographical regions.

According to Zhao et al. (2012), daodi medicinal materials are generally defined as medicinal materials produced in specific geographic regions under natural ecological and environmental conditions that are optimum for the growing of the plant, with particular attention to cultivation, harvesting, and processing techniques.

Daodi lead to quality and clinical effects that are considered to surpass those of the same botanical produced in a different region. The concept of daodi was used by early Chinese herbalists and codified by Sun Simiao in his Qian Jin Yi Fang (Supplement to the Formulas of a Thousand Gold Worth). According to Sun:

“When ancient doctors used medicinals they depended on the earth, therefore when the treated ten people they achieved results in nine. Although contemporary doctors understand the pulse and prescriptions, they discard the timing for harvesting medicinals. They are not familiar with the originating land or the freshness, aged nature, emptiness or fullness; therefore they only achieve results in five or six cases out of ten.”

Sun’s teachings underscore the importance of daodi, organoleptic assessment, and a quality control system that integrates the proper harvest time and source of the originating plant material. Furthermore, in the Ben Cao Pin Hui Jing Yao (Essentials of Chinese Materia Medica) of China’s Liu Wentai (1488–1505), specific attention was given to medicinal plant development that encompassed the sprouting of the plant, the land on which it was grown, the timing of planting and harvest, and potential substitutes.

Thus, prior to the development of formalized good manufacturing practices and prior to the adherence to mandatory pharmacopoeial standards, Chinese physicians recognized the need for strict adherence to quality control in ways that ensured the quality of the medicinal plant from the field to the medicine long before the advent of chemical analytical techniques. This care is reflected in the many grades of herbs that can be observed in any Chinese herbal pharmacy today.

Such principles reflect common sense in ensuring the quality of herbal drugs. Similar principles are being applied internationally and in a myriad of Good Agriculture and Collection Practices (GACP) developed by varying national and international bodies. The People’s Republic of China (PPRC) is perhaps most active in establishing good agricultural practices (GAP) for medicinal herbs and integrating them in medicinal plant production.

Similar to Sun’s observation in the Tang Dynasty, modern herbal practitioners are often not aware of the quality control needs of herbal medicines, and rather rely on industry to produce quality medicines, when much of the industry lacks the skills necessary to do so.

Daodi is an important concept to include in the development and selection of herbal medicines and there may be wisdom in codifying such principles in modern pharmacopoeias. According to Zhao et al. (2012), among the 500 most commonly used Chinese medicinal materials, approximately 200 are recognized as having daodi medicinal material specifications.

These 200 medicinal materials account for 80% of the total consumption of medicinal materials in China, making daodi a very important concept in modern herbal medicine GMPs. Today, the source and manner in which the botanical was grown and harvested is seldom considered by industry and regulators.

Molecular identification

In animals, a single barcoding region from the mitochondrial cytochrome c oxidase-1 gene can identify most species. In plants, no single barcoding region has been identified with sufficient resolution to identify most species, therefore a combination of at least two regions (barcodes) is required and use of other techniques in tandem provide greater levels of accuracy. Molecular techniques of medicinal plant identification are not currently included in most pharmacopoeia but some attempts have been made to consider their inclusion.

Like all analytical technologies, molecular analysis has strengths and weaknesses in crude plant identification. First and foremost it is solely a identification tool.

Whereas most all other methods provide both identity and quality assessments, molecular techniques is only for species identification. Among the technique’s strengths are its great sensitivity.

If the unique identifying primers for the particular target species has been appropriately developed, and the technique used is robust enough to filter DNA from non-target organisms (e.g., other plants, non-target plant parts, etc.), then it is an exceptionally powerful tool for identifying plant material to species and beyond, including the same species that have different genetic lineage, such as wild American ginseng (Panax quinquefolium) grown in Kentucky, versus the same species from cultivated root stock in Wisconsin, versus that grown in Canada.

A second advantage of molecular techniques is in detecting admixtures with other species with great sensitivity. A logistical advantage of the technique is that it uses very small amounts of material for analysis.

Among its weaknesses is also the technique’s great sensitivity. Molecular techniques have the ability to detect the presence of trace of insignificant amounts of non-target species, such as rice and pollen or a blade of grass, the results of which can be interpreted as ‘contamination’. In other cases, genetic material of a non-target species can be preferentially amplified over the genetic material of the target species, that can be inaccurately interpreted as an ‘adulteration’.

A significant disadvantage is its inability to discern different plant parts, a requirement of all medicinal plant GMPs. As with chemical analysis, DNA analysis will not detect the presence of non-organic contaminants that are readily detected organoleptically or microscopically.

Perhaps the greatest strength of genetic testing is in forensic analyses of plant material that is difficult to identify with standard testing methodologies or to detect the presence of difficult to find adulterations and contaminations.

Perhaps its greatest weakness, unlike virtually all other standard techniques from sensory assessment to chemistry, is its inability to offer any meaningful data regarding quality. It is purely an identification tool that is limited in its ability to discern plant parts, that works best in intact plant material, where most other techniques provide data points for both identification and quality of a crude plant or extract.

However, its utility in routine quality control is limited as was poignantly highlighted by researchers in Australia who applied various methods of genetic barcoding to various stages of the manufacture of medicinal plant products. The researchers attempted to determine if DNA barcoding was a useful routine test for the quality control of botanicals and genetically analyzed the ingredients throughout the manufacturing process from gathering of botanical vouchers to drying, to pulverizing, to extracting, to preparation of the finished product.

Even for vouchered specimens, a high of only 40% of specimens were able to be identified with DNA using one set of markers and a low of about 18% with another set of markers, determining that substantial degradation of DNA occurred in properly dried materials.

Let’s have a quick look at some of the reasons medicinal plants are so important to human culture and health.

• In health terms the use of plants is unsurpassed; they have the function of safely strengthening the tissues, immunity and integrity of the body whilst also offering the potential to safely cleanse, detoxify and clear wastes from the body.
• Cutting edge science suspects that one of the reasons for the rise in chronic degenerative diseases is our reduction in the use of plants in our diet. All traditional societies have used plants for healing and their high levels of protective ‘phytochemicals’ such as flavonoids, carotenes and essential oils have all been shown to protect our cells from environmental damage caused by pollution, stress and nutritional deficiencies.
• Herbs are an integral part of nature. They help to protect and increase the biodiversity of an ecosystem.
• They are a valuable part of the human relationship with nature and enhance our connection with the planet. The WHO states that up to 80% of the world’s population depend on herbal medicine as the primary form of medical healthcare.
• They offer health benefits in the form of traditional medical systems, folk medical systems and shamanic healing systems.
• They form a major resource for the healing of known and unknown diseases.
• They offer great financial benefits with the global market being estimated at £12 billion per annum.
• They offer spiritual benefits as guides and symbols of power.
• They protect indigenous cultural values and promote cultural integrity. Having knowledge of local herbal medicines promotes cultural uniqueness, respect and value.

It is estimated that the Ayurvedic pharmacopoeia includes upwards of 1250 species with approximately 300 of these in regular demand. Similar figures exist for Chinese, Physiomedical and Western herbal medicine. In India and Sri Lanka most herbs come from the wild. That is, in excess of 90% of herbal material used in Ayurveda comes from the forests, mountains and plains of the Indian sub-continent and are sourced in an unregulated manner. That is a heavy burden for nature to bear (Schippman 2004).

In other parts of the world there is similar pressure with 80% of species coming from the wild in China and up to 99% in Africa (Schippman 2004, Williams 1996). There is the well understood increasing pressure on natural habitats as global population increases. And, at the same time, there is increased financial pressure on low income communities and as herbal medicines offer a viable source of income this can lead to over-harvesting. It is estimated that global demand for herbals has sky rocketed in the last decade with demand increasing by 10-20% per annum.

The problem is that that is very difficult to monitor herbal collection. I have been involved with large scale cultivation and collection programmes for the last fifteen years and believe me it is difficult to monitor and manage. This problem is compounded by the fact that there is relatively little cultivation of herbal medicines.

Some examples of some species that are threatened:

• Liquorice (Glycyrrhiza glabra anduralensis) is a delicious sweet herb used to strengthen the adrenal glands, reduce inflammation and tonify the lungs. It grows all over the world. In the UK, Pontefract ‘licorice’ was famous in the last century. A large portion of that global supply has come fromaround the world such as China and Turkey. Its increased popularity and lack of controls on harvesting mean that Turkey is now suffering a shortage of wild Licorice.
• Jatamansi (Nardostachys jatamansi) or Indian spikenard only grows in the Himalayas between 3500-5000m altitude and is highly valued for its aromatic calming properties. Apart from its limited growing habitat it also takes three years to grow to full maturity and it has been thoroughly plundered to the extent that it has been listed on the CITES list as a species to be protected from international trade unless it has been cultivated. Despite this it can frequently be seen in some Ayurvedic products in the UK.
• Echinacea (Echinacea angustifolia), goldenseal (Hydrastis canadensis) and American ginseng (Panax quinqufolium) have all become endangered in the wild in America due to overharvesting due to consumer demand.

It might seem obvious but that is where they naturally grow. They often require very specific habitats and may be difficult to cultivate. Another reason is that herb prices are actually very low and so there is a lack of incentive for farmers to grow herbs as they can receive a greater income from conventional food crops.

Conversely, they are a relatively accessible source of income for poorer sections of society, to people without land or a regular job. In the higher altitude region of Nepal 100% of the families harvest herbs and it can account for 15-30% of their income.

Another piece of ‘herbal folklore’ is that some authorities consider herbs grown in the wild to be more potent and this is reflected in the higher price of up to 30% more being paid for wild collected American ginseng (Panax quinqufolium) in China as opposed to cultivated.

This makes sense if you consider that the healing properties of plants are often associated with their own abilities to protect themselves from invading bacteria and funguses that are rife in the wild. (It’s also why organic food is better for you but more about that another time.)

I think that cultivation of medicinal species should be encouraged on a massive scale to ensure that extra burdens on the wild are reduced. It could change farming. It could change how our world looks (most herbal medicines are stunningly beautiful).

Alongside this increase in cultivation, sustainable collection systems need to be established. This will help protect local communities and eco-systems.

I strongly believe that certification is needed to protect the future of herbal medicines. This certification would inform the consumer if these herbs have been sustainably grown and harvested.

At present organic certification along with FairWild certification are two solutions offering some objective assessment of control within the supply chain. If you buy uncertified products there is a chance that they come from an unsustainble source. A simple solution to this is to look for the Soil Association and/or the FairWild symbols on products.

The Fairwild certification is a recent scheme created by WWF, TRAFFIC, IUCN (International Union for the Conservation Nature) and the BfN (German Federal Agency for Nature Conservation) to ensure sustainable wild collection of herbs.

It is an example of incentive based conservation that has developed through the pioneering work of experts in managing sustainable livelihoods and eco-systems. It includes the principles of FairTrade, to ensure collectors are fairly treated and appropriately paid, with the practice of sustainable wild collection, ensuring the long-term survival of the species and the community. It ensures that the whole is considered: that people, the plants and the eco-system are all equally important. In this way FairWild certification can transform potentially destructive wild-harvesting practices into a powerful tool for conservation.

It is now well documented that organic foods and herbs have higher levels of secondary metabolite compounds than conventionally grown crops. It is these secondary metabolites that give the plants their therapeutic energetic effects.  For example, many alkaloids are bitter, polysaccharides are sweet and mustard glycosides are pungent. This means that in organic plants the ‘energetic qualities’ are more potent and thus more effective. When comparing organic to non-organic food, the mean positive difference in flavour of organic food between the following nutrients is known to be:

• Protein + 12.7%
• Beta-carotene + 53.6%
• Flavonoids + 38.4%
• Copper + 8.3%
• Magnesium + 7.1%
• Phosphorous + 6%
• Potassium + 2.5%
• Sodium + 8.7%
• Sulphur + 10.5%
• Zinc + 11.3%
• Phenolic compounds + 13.2%

A recently concluded European Union research programme concluded that, “Levels of a range of nutritionally desirable compounds (e.g. antioxidants, vitamins, glycosinolates) were shown to be higher in organic crops”. Conversely “Levels of nutritionally undesirable compounds (e.g. mycotoxins, glycoalkaloids, Cadmium and Nickel) were shown to be lower in organic crops”. The 2014 meta-analysis at Newcastle University by Leifert further validated these findings.

The Soil Association UK says “Organic farming and food systems are holistic, and are produced to work with nature rather than to rely on oil-based inputs such as fertilisers. Consumers who purchase organic products are not just buying food which has not been covered in pesticides (the average apple may be sprayed up to 16 times with as many as 30 different pesticides) they are supporting a system that has the highest welfare standards for animals, bans routine use of antibiotics and increases wildlife on farms.” Organic farming offers very clear health and environmental benefits.

I have found that another side-benefit of organic certification is that it necessitates a deeper relationship between the farmer and the trader. Because of the legal requirements, including testing for contaminants (microbiology, mycotoxins), Toxic Elements (heavy metals) and pestidicide residues, it is necessary to have a very close contact with the source of the plants to ensure that Good Agricultural and Collection Practices (GACP) are in place. This is really Good Manufacturing Practice (GMP) for farmers. It ensures quality, consistency and documentation. It ensures ‘transparency’ so that we as consumers know how each species is handled, what inputs have been added and that appropriate checks on quality have taken place.

At Pukka Herbs, we have spent the last fifteen years directly involved in establishing a detailed GACP and organic certification system that brings benefit to the farmer, plant quality and the end user. Through this system we know the name of the farmers, the exact location of cultivation and the date of harvest for all the organically certified species that we produce. It is an evolving process that has led to a much deeper confidence that nature is respected, that the farmers are well treated and the Ayurvedic plants that we produce are of the highest quality.

Traditional Herbal Medicine offers a multi dimensional solution to many of today’s health and ecological issues. One way of healing human suffering as well as reducing ecological destruction is to integrate traditional healing systems within primary health care.

The demand for herbal medicines will spur a whole range of herbal growing projects around the UK and the rest of the world which would employ hundreds of thousands of people, protect local ecosystems, absorb millions of tonnes of carbon, and create safe and effective medicines helping to make the UK and the world a healthier and happier place.

It would also ease the pressure on stretched NHS resources and redress the balance to an integrated medical system. This will reconnect us with the natural healing patterns of nature as well as heal the endemic destruction of the natural world.

So, despite the concerns mentioned above, I think that with the correct government supported conservation and cultivation efforts the preservation of our traditional herbal medicines is at the heart of the regeneration of an integrated health system as well as the regeneration of our ecosystem.

We can make this happen by demanding that we have access to natural herbal healthcare. We know that it is safer than pharmaceutical medicine. We know that it is effective. The herbal tradition is a time-tested and a positive solution for today’s chronic problems of weakened immunity. As our bodies face a radically new set of stressors herbal remedies are here to help us adapt and heal. Make herbs your first choice in healthcare for your own benefit and that of the planets.

We could follow the example of the Vrikshayurveda (the Science of Plantlife), a circa 16 Century CE text by Surapala:

“Knowing this truth one should undertake planting of trees since trees yield the means of attaining dharma (life duty), artha (wealth), kama (pleasure) and moksha (enlightenment).”

Protecting nature protects us.