Indigenous and traditional cultures

The most underrepresented of herbal medicine traditions in terms of national recognition among world cultures are indigenous traditions, and they are the most robust from the perspective of traditional integrity. These are represented by traditional African, Amazonian, South American, select North American herbal traditions, and other traditional herbalists whose primary regulatory pressures are based on who can successfully provide herbal health to their communities. The majority of traditional herbalists practice in rural areas, but for some, work also spills over into cities.

Botanicas are an example urban herbal workplace as herbal shops with histories tracing back to the ancient Aztec traditions that emerged as sanctuaries for Hispanic-Americans looking either for culturally-oriented healing practices or as alternatives where access to dominant health care services is limited (1). While there are efforts to bring regulations to traditional healers worldwide, true traditional herbal healers remain an integral part of communities and derive their legitimacy from community trust, not government oversight. At the same time, these healers follow well-established standards of training, ethics, and cultural restrictions rooted in their own traditions. 

In some African traditions, training is meticulous and requires several months to years depending on the ability of the student to learn (2). Traditionally, Ayurveda was learned through the Guru-Shishya Parampara/Gurukula system of education in which the student lived with the family of the teacher, sometimes for many years and remained devoted to that teacher throughout their life. They were expected to be steeped in the classic literal knowledge base of the vedas, samhitas, and nighantus, including the memorisation of hundreds of mantra and slokas that conveyed, not only the knowledge of anatomy, physiology, pathology, and treatment protocols, but mantra and invocations between student and teacher, teacher and student, harvesting of the plants, making of the medicines, and much more (3).

In China, in addition to having a similar apprenticeship model as in India, herbalists needed an intimate knowledge of the best sources of herbal medicine (dao di yao cai — “authentic regional medicinal materials”) (4). This concept refers to the understanding that the therapeutic quality and potency of a medicinal plant depend not only on its species, but also on the geographical origin, soil composition, climate, and traditional processing techniques associated with that region (4). 

In some indigenous North American traditions, grandmothers would not allow their students to pick an herb before they were 16 years old, because if they picked a herb for medicine without having the maturity to be in relationship with the plant it could foul the medicine. In most traditional cultures, it was the teacher who decided when the apprentice or student was ready to practice and the community subsequently accepted that individual as the next generation healer. From then, the new healer either succeeded or did not, based on her or his ability to offer their patients effective medicine. Conversely, traditionally across cultures, every household had family members who possessed greater or lesser degrees of folkloric knowledge to deal with everyday ills and spills, yet they would not specifically self-identify as being a healer or herbalist.

Herbs as supplements

While traditional and indigenous herbal practices continue to operate largely outside formal regulatory frameworks, the globalisation and commercialisation of medicinal plants has necessitated new approaches to oversight. As botanicals entered retail and international markets, regulators sought mechanisms to ensure consumer safety and quality without imposing the full evidentiary requirements of pharmaceutical approval. 

The US was the first country to adopt this formal regulatory model, which categorises botanicals as a subcategory of foods rather than therapeutic agents. This governs the trade of herbs that are in the public domain, without the need for pre-authorisation or formal toxicological studies due to precedent of historic use in the same manner as conventional foods are allowed without formal testing. In most countries, supplements are allowed to display ‘soft’ claims in herbal product packaging — such as “aids sleep” or “supports digestion”.

Herbal supplements, however, cannot be marketed for the prevention or treatment of any specified disease and must be manufactured with varying good manufacturing practices, among other regulatory requirements. Numerous countries including the US, members of the European Union (EU), and Japan, among others, regulate a variety of natural products as supplements. In this framework, herbs transition from a culturally governed, community-based practice to a commercially regulated domain, enabling broader public access while maintaining safety standards and acknowledging historical use.

Examples of herbs as supplements and the claims they are able to make under this regulation include St John’s wort (Hypericum perforatum) — “supports mood”, echinacea (Echinacea purpurea) — “supports immunity” , and milk thistle (Silybum marianum) — “supports liver health”.

Herbs as traditional medicines

In many countries, regulators recognised that certain herbal products had a long-standing history of safe and effective use. To accommodate this, frameworks were developed to formally acknowledge traditional medicines, which exist throughout Asia, Europe, and India. Ingredients used in traditional medicines must be safe for their intended use, must be documented as having been in the public domain for a material length of time, and are recognised for their traditional use. Traditional medicine products can be marketed as traditional medicines with specific claims depending on the extent of documentation supporting the claim, and varying models for assessing safety, efficacy, and product registration exist. 

In most of these countries, traditional medicines must be made according to traditional principles, with some countries (e.g., Japan) conforming strictly with exacting recipes (Kampo formulas), while others (e.g., China) allow for formula modification of individual patients. Canada maintains a unique regulatory framework of Natural Health Product that is much like the traditional medicine model. Similarly, Australia’s Therapeutic Goods Act 1989 governs complementary medicines under the Therapeutic Goods Administration (TGA), allowing herbal and vitamin products to be listed on the Australian Register of Therapeutic Goods (ARTG) when supported by traditional or low-risk evidence.

In most cases, the botanical ingredients used in traditional medicine products must comply with pharmacopoeial standards of the respective country, as well meet numerous other regulations (e.g., mandatory adverse effects reporting) (5). Until their exit from the EU, the UK was similarly beginning to implement the traditional medicine protocols of the EU. However, the UK also maintains their own Human Medicines Regulations (2012) specifically for products, while separate provisions exist in Ireland and elsewhere.

Examples of herbs under traditional medicines regulation in the UK include A. Vogel Echinaforce, containing echinacea (Echinacea purpurea), which under THR is permitted to state that it is “to relieve the symptoms of cold and flu-type infections”and Weleda’s Arnica Spray, containing arnica (Arnica montana) indicating its use “​​for the relief of minor sports injuries, bruises, muscular pain, stiffness and sprains”(5).

The same herb can be regulated differently depending on formulation, intended use, and presentation. In the US, valerian (Valeriana officinalis) sold as a dietary supplement may claim to “support relaxation” under food law. In the UK, a standardised extract marketed for “mild sleep disturbances” is regulated as a traditional herbal medicine under the THMPD, as in Canada under the Natural Health Products it may be labelled as “for relief of occasional sleeplessness (insomnia)”(6). So, intended use and presentation determine classification, which in turn defines allowable claims.

Botanical drugs

Some plant-derived products demonstrate sufficient evidence of safety and efficacy to qualify as therapeutic agents. Regulatory authorities, notably in the US, introduced a botanical drug approval process by which a drug of botanical origin, or some derivation of a plant or plant molecule, can attain formal drug approval by undergoing rigorous testing and approval similar to conventional pharmaceuticals (7). Examples of botanical drugs include Veregen, a topical FDA-approved treatment for genital warts derived from green tea (Camellia sinensis); Fulyzaq, a dragon’s blood tree (Croton lechleri) derivative approved by the FDA for non-infectious diarrhoea in HIV patient populations; and Qutenza, a topical chilli (Capsicum annum) preparation approved by the EMA for neuropathic pain and neuralgia (8,9).

Unlike the US, which maintains a distinct botanical drug category for plant-derived products supported by clinical evidence, the UK technically provides a similar pathway through full marketing authorisation. However, in practice, very few herbal products pursue this route due to the high financial demands and extensive clinical trial data requirements. Consequently, the UK market is dominated by two main categories: Herbs marketed as food supplements, and traditional herbal medicines registered under the Traditional Herbal Registration (THR) scheme. Thus, while a botanical drug pathway exists in principle, it is largely unused, meaning that the UK effectively operates with only two widely accessed regulatory categories.

Further to this, there is an idiosyncratic regulation in the UK permitting herbalists to prescribe unlicensed herbal remedies as magisterial prescriptions after a one-to-one consultation. However, there is no statutory or legally recognised definition of what constitutes a herbalist.

Different countries display varying degrees of acceptance of botanical medicines by health professionals and regulators. Generally speaking, Asia, India, and select countries in Africa, are strongly supportive of botanical medicine, while US regulatory and medical professionals are, generally, antagonistic towards botanical products. Canada and members of the EU can be described as moderately supportive of botanical medicine initiatives. However, Canada and the EU preferentially display a greater level of acceptance for Western herbs, and generally lack approval for most non-Western botanicals (e.g., Ayurvedic or Chinese medicines).

In the EU, this is in part owing to the requirement that herbal products must demonstrate a minimum of 30 years of medicinal use, including at least 15 years within the EU, to qualify for simplified registration — a requirement often less attainable for non-Western botanicals (10). Moreover, whereas quality control standards for multi-ingredient formulas are present in the respective pharmacopoeias of China and India, the European Pharmacopoeia, US Pharmacopeia, and others, have no entries for formulas outside of Western herbal traditions, and even Western herbal combinations are rarely included. This reflects a bias for single herb preparations over multi-ingredient formulations.

In the majority of countries, the trade of herbal products are overseen by the national regulatory authorities. The cost of approval of a traditional herbal medicine varies widely and is not clearly disclosed in the literature. but estimates range from more than $100,000 in England to $300,000,000 in the US, creating substantial barriers to market entry for new herbal medicine products (11). 

Market entry as a supplement is much less costly, generally only consisting of general business costs, while in some countries (e.g., Ghana) the government actively supports the safety and quality assessment of traditional medicines for traditional herbal medicine knowledge holders specifically to facilitate the availability of herbal products to consumers (12).

In most countries, individual herbalists are exempt from industry-mandated good manufacturing practices (GMPs), though the US Food and Drug Administration maintains the authority to require individual practitioners to meet the same GMPs as commercial manufacturers though to date, they have not imposed this requirement.

The World Health Organization (WHO) has supported the integration of traditional medicine practices including herbal medicines as integral to human health care for decades and have developed numerous works to advance traditional medicine globally. In 2023, WHO’s Gujarat Declaration proclaimed to all nations of the world that traditional medicine knowledge and the integration of traditional practices with modern medicine is critical to human health (13). This has created a directive for all countries to embrace traditional medicine knowledge, including botanical medicine.

While WHO can support these efforts, it is ultimately the responsibility of respective countries to implement WHO recommendations, and different countries do this to greater or lesser degrees with countries such as Bhutan, China, Ghana, India, Malaysia, and Turkey, to name a few, making great strides in advancing herbal medicine as a viable public healthcare option.

1. Tucker AO, Jules J. 2019. Aztec Botany, Agriculture, Trade, and Medicine: Flora of the Voynich Codex, Springer International Publishing, pp. 13-24, https://doi.org/10.1007/978-3-030-19377-5_2  
2. Mokgob MG. 2014. Understanding traditional African healing. Afr J Phys Health  Sep;20(Suppl 2):24-34.
3. Sihag J, Jain R. 2024. Enlightening the Principles of Traditional Learning Methods through Ayurveda. Journal of Ayurveda and Integrated Medical Sciences 9(1): 207-210.
4. Zhao ZZ, Guo P, Brand E. 2012. The formation of daodi medicinal materials. Journal of Ethnopharmacology 140: 476-481.
5. UK Government. Currently Approved Traditional Herbal Registrations (THRs) — granted to 06-08-2024. London, UK; 2024. Accessed October 2025. https://assets.publishing.service.gov.uk/media/66be02d13effd5b79ba49153/THRs_granted_to_06-08-2024_14-08-2024_final.pdf
6. Health Canada. Valerian Labelling Standard. Guidance: Valerian (Valeriana officinalis). Accessed October 14, 2025. https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/applications-submissions/guidance-documents/nonprescription-drugs-labelling-standards/valerian.html
7. Picking D. 2017. The Global Regulatory Framework for Medicinal Plants. Pharmacognosy, Fundamentals, Applications and Strategies: 663-675.
8. U.S. Food and Drug Administration. What is a botanical drug? Updated Jan 7, 2025. Accessed October 13, 2025. https://www.fda.gov/about-fda/cder-offices-and-divisions/what-botanical-drug
9. European Medicines Agency. Qutenza: EPAR – Product Information. Updated May 15, 2009. Accessed October 13, 2025. https://www.ema.europa.eu/en/medicines/human/EPAR/qutenza
10. European Medicines Agency. Herbal medicinal products. Published August 15, 2007. Accessed October 10, 2025. https://www.ema.europa.eu/en/human-regulatory-overview/herbal-medicinal-products
11. Medicines and Healthcare products Regulatory Agency (MHRA). Traditional Herbal Registration Scheme: Fees. London, UK; 2024. Accessed October 16, 2025. https://www.gov.uk/government/publications/traditional-herbal-registration-scheme-fees
12. Donor 2025, personal communication to AHP.
13. [WHO] World Health Organization. 2023. Gujarat Declaration. Traditional Medicine Global Summit. August 2023, Gujarat, India

In the last few months of 2025 in the UK, there was a newspaper article warning of the dangers of herbal supplements and a spate of blog and social media posts outraged about the Food Standards Agency (FSA) preventing sales of certain medicinal mushroom products. These events highlight the challenges associated with navigating the complex regulatory environment around herbal and fungal products and the tension between empowering people to have the freedom to access products while ensuring that the public are safe.

In December 2025, there were several social media posts and blogs about the banning of certain medicinal mushrooms from the UK market. A manufacturer was asked by the FSA to remove turkey tail (Trametes versicolor) mushrooms and cordyceps (Cordyceps militaris) mushrooms from their website. This is not the first time a producer has been caught out in the last few years, and the Advertising Standards Authority (ASA) wrote an article to provide guidance for companies wanting to use medicinal mushrooms in 2024 (1).

Turkey tail is a beautiful stripey fungus that grows across multiple parts of the globe and is thought to have benefits for the immune system (2). Its traditional use is best documented from China and Japan, but despite being a UK native fungus, there isn’t any documented traditional use of it in the UK. Modern research has focused on its use as an adjuvant to cancer chemotherapy (3). 

Cordyceps militaris is a species of cordyceps that has gained popularity as an alternative for Cordyceps sinensis (4). Cordyceps sinensis has become harder to find in the wild due to overharvesting in its native China and Tibet. The militaris species has become popular more recently, as its short lifecycle lends itself well to being cultivated for commercial purposes on grain substrate (4). This relative novelty is likely to be why it has been flagged as of unknown safety (Cordyceps sinensis is acceptable in food supplements), despite some evidence of its low toxicity (5). 

In the UK, over-the-counter herbal and mushroom supplements are sold as food supplements, which means that they are regulated by the FSA. The FSA aims to ensure that any items that are sold as food or food supplements are guaranteed to cause no harm. Whether a product has a health benefit is not considered. Since Brexit, the UK largely uses the European Food Standards Agency (EFSA) criteria for managing food legislation (6). This is simply because it was co-created with the UK and building legislation up from scratch would involve a huge amount of work. 

This separation of food from medicine in legislation is historical and practical — to preclude inaccurate, misleading, or completely unfounded claims, such as drinking bicarbonate of soda daily will cure cancer, or lemon juice will melt belly fat. However, it does mean that supplement companies who research the evidence for their herbal products and carefully formulate a capsule that they believe will provide benefit, can’t claim the type of benefit that would be considered medicinal. In the same way that a medicine can only be used to treat conditions where there is substantial evidence that it has a therapeutic effect. 

It is important to remember that when herbalists prescribe and dispense herbs, they are considered medicine. When herbs are sold in a shop or a market without a consultation, they are considered food supplements, even if they are identical to what a herbalist would prescribe after a consultation. 

When a supplement company is banned from selling something that isn’t really a food, or from making a claim that implies it is a medicine, it isn’t the same as preventing the public from accessing natural medicines. Medicinal herbs and mushrooms are still available to forage and purchase — over-the-counter for those that have been proven to be safe to use without medical advice or monitoring, or via a herbalist following a consultation  as part of a bespoke prescription for those with restrictions. This ensures safe access to foods and medicines, which, on the whole, is a system that works well. 

At least every few years there is a dramatic and sensationalist newspaper article about the dangers of herbal supplements. They comment on a handful of reports or a single account of people developing signs of liver harm.

Some common culprits include turmeric, green tea extracts and ashwagandha. Often, when a negative effect happens, the person affected has taken a high-dose concentrated extract of the herb. Though, this isn’t always the case. Sometimes a reasonable dose of herb has caused a reaction. 

It is very hard to attribute effects like raised liver enzymes to a specific medicine, food or herb. So, in many situations, there’s no certainty about what has caused the negative reaction. 

Idiosyncratic (unpredictable) drug-induced liver injuries (DILIs) are rare, but can be very serious (7). They likely result from a combination of complex interactions between multiple metabolic pathways that are unique to the individual involved and can involve reactive metabolic products, increases in reactive oxidative species, accumulated toxic metabolites or immune cascades being triggered (7). 

The drugs that most commonly cause DILI vary from country to country, with the most common culprits in the UK being antimicrobials and non-steroidal anti-inflammatories (7). In China, traditional Chinese medicine (TCM) is responsible for a majority of cases (7). In the US, antimicrobials and herbal dietary supplements are recorded as being responsible (7); it has been estimated that 20% of DILI in the US involve botanical dietary supplements, potentially alongside pharmaceutical drugs (8). Whether these differences in reported incidents are genuinely due to differing reactions in certain countries, or the different ways that adverse events are treated and reported is impossible to know.

The global herbal supplement industry is worth nearly US$8000 million (9). While most companies start out with lofty intentions to improve lives and have a positive impact on health, their overall purpose of selling products means that they always need more customers. Herbal products are not universally suitable for everyone; but  without advice or clinical guidance an individual can purchase herbal preparations online not knowing whether it is appropriate for them, potential reactions to expect, or what might be cause for concern.

Negative effects can and do very occasionally occur when a herbalist prescribes a herb for an individual. Yet, medical herbalists are trained to be aware of possible side effects and can advise their clients to anticipate potential outcomes. With regular check-ins with a herbalist, changes can be monitored and a prescription adjusted if the collaborative team of herbalist and client suspect that something isn’t right.

Resources such as the Our Health Directory from the College of Medicine, herbalist-led foundation courses in herbal self-care, and reliable information from the American Botanical Council and Herbal Reality are essential for people to feel empowered to look after themselves and their families. However, there will always be limits to what can be managed without professional clinical training.

The skill, knowledge and experience of medical herbalists are a rich resource to be respected and trusted. Taking herbs and medicinal mushrooms under the guidance of  a trained, supported and insured herbalist offers a safer means to explore these medicines, than to buy a product off the shelf that has been marketed via social media. 

1. Advertising Standards Authority. Shroom for Improvement? Navigating the advertising rules for functional mushrooms. 2024. https://www.asa.org.uk/news/shroom-for-improvement-navigating-the-advertising-rules-for-functional-mushrooms.html
2. Herbal Reality. Turkey Tail monograph. 2023. https://www.herbalreality.com/herb/turkey-tail/
3. Habtemariam S. Trametes versicolor (Synn. Coriolus versicolor) Polysaccharides in Cancer Therapy: Targets and Efficacy. Biomedicines. 2020;8(5):135. Published 2020 May 25. https://doi.org/10.3390/biomedicines8050135 
4. Behrens, J. The Sustainability of Cordyceps. 2024. https://www.herbalreality.com/herbalism/sustainability-social-welfare/species-specific-sustainability/the-sustainability-of-cordyceps/
5. Chrysostomou PP, Freeman E, Murphy MM, Chaudhary A, Siddiqui N, Daoust J. A toxicological assessment of Ganoderma lucidum and Cordyceps militaris mushroom powders. Front Toxicol. 2024;6:1469348. Published 2024 Oct 30. https://doi.org/10.3389/ftox.2024.1469348 
6. Verkerk, R. Navigating the regulatory landscape: An essential update for UK and EU herbal practitioners. 2025. https://www.herbalreality.com/herbalism/quality/navigating-the-regulatory-landscape-an-essential-update-for-uk-and-eu-herbal-practitioners/
7. Andrade RJ, Chalasani N, Björnsson ES, et al. Drug-induced liver injury. Nat Rev Dis Primers. 2019;5(1):58. Published 2019 Aug 22. https://doi.org/10.1038/s41572-019-0105-0 
8. Koturbash I, Yeager RP, Mitchell CA, et al. Botanical-induced toxicity: Liver injury and botanical-drug interactions. A report on a society of Toxicology Annual Meeting symposium. Regul Toxicol Pharmacol. 2024;153:105708. https://doi.org/10.1016/j.yrtph.2024.105708 
9. Global Market Statistics. Herbal Supplements Market Overview. 2025. https://www.globalmarketstatistics.com/market-reports/herbal-supplements-market-14939x 

Herbal Medicine has been around since the beginning of time, with animals and humans having interacted with plants for food and medicine from the earliest point of recorded history and beyond.

Herbal medicines are products made from botanicals, or plants, that are used to treat diseases or to support health, these can be called herbal or botanical products, or herbal/ phytomedicines. 

Herbal Medicine is often confused with Homeopathy, however whilst homeopaths and herbalists may use some of the same types of plants, these two practices and their prescriptions are very different.

Herbal Medicines are whole plant preparations. ’Whole plant’ meaning that the unrefined, raw plant matter is used to create the medicinal preparation, as opposed to the extraction of an isolated compound or chemical to create a drug (as with pharmaceuticals). Or as opposed to the highly diluted homeopathic medicines, which hold more of a ‘memory’ or ‘energetic’ quality than one of substance and chemistry.

In Herbal Medicine, plant parts such as leaves, flowers, seeds, roots, fruits and barks are used (not all at the same time, although a herbalist may sometimes use a blend of different plants or plant parts in a prescription). Herbal Medicines may also be seaweeds, algae or fungi.

Herbal Medicine is a profession in its own right. In the West, there are many professional training schools that combine biomedical and holistic sciences with practitioner development that is focused around clinical training. Enabling qualified herbal practitioners to go on and set up a practice where they are able to treat patients using a combined approach.

Anyone can call themselves a ‘Herbalist’. However, ‘Medical Herbalists’ along with clinical Chinese and Ayurvedic herbalists, are trained to a high degree level in medical subjects such as pathophysiology, diagnostics, physical examination etc, to a comprehensive standard with which they can safely work with patients. 

A qualified Herbalist qualifies through practitioner focused training centered around supervised clinical hours.

The professional training will usually be a BSc. (Hons) qualification or equivalent for example a level 6 diploma which takes them 3-4 years at least.

To find a training course or Medical Herbalist near you Herb Reality’s “Resources” page.

There are governing bodies for Herbalists such that can be found at The Herbal Alliance. Courses accredited by these governing bodies are of the highest quality as students must complete 2500 hours of class learning and 500 clinical hours

This is a saying often shared by the herbalist community to express ‘an ideal world’ modern relationship to the use of herbal medicines and herbalists.

Perhaps similar to a more community based lifestyle such as in historic times where our ancestors carried herbal knowledge about native medicines commonly used as home remedies. In an ideal world –  each household would have someone who is able to perform basic herbal first aid for minor illnesses at home, with a community Medical Herbalist to support those with more serious or long term conditions.

In the West, however, this knowledge is now much less common among the general population as it may have once been, even in our grandparent’s time. Meaning that we now have to actively re-engage with this information to return it into our lineage.

Many herbalists offer foraging walks, talks, workshops or short courses for those wanting to gain home herbalist knowledge that they can use for themselves and their close ones. As well as beginning a home library of herbal reference books, it is really worth reaching out to your local herbalist to see if they are sharing knowledge in their community. As well as running practice, this is another really important role in a herbalist’s work.

Herbal knowledge is a birthright to all of us, something that we in the West lost along the way. With the modernisation and reductionist scientific paradigm of medicine gripping society ever more firmly, herbalism was deemed ‘less medical’ and less important. However, as with much of our understanding now in the modern world, we see that returning to practices closer to nature, in structure and form serve both the health of the environment and our personal health in a truly sophisticated way. With this understanding, a future integrating natural and holistic approaches is well within sight.

With the correct use, many simple and short term illnesses can be effectively treated at home. It is advised however for more ongoing, chronic or serious illnesses, or where contraindications such as medications, pregnancies or breastfeeding need to be considered that a fully trained Medical Herbalist should be consulted.

Not only will a herbalist offer a thorough approach considering safety, a herbalist also understands that human health and the underlying causes of disease are often complex and unique to the individual.

Professional Herbalists are trained in diagnostics and pathophysiology and of course through training and practice will have a deeper understanding of the disease process and possible root causes that would inform them of the most effective approach to treatment. A herbalist is also trained to identify nutritional deficiencies or problems that may arise from our diets.

In the holistic understanding of disease a herbalist will seek to unravel the unique cause for illness or health imbalance, and in many cases through nutritional and supportive herbal intervention a herbalist will work to support their patient’s back to natural balance of health.

A herbalist treats each case individually, and therefore rarely will two people with the same condition receive the same medicine or treatment plan. This is because the holistic approach of treatment is more focused on restoring the health status of the patient based on their unique history, constitution and presenting complaints, rather than treating the symptoms i.e. where pain relief for migraines would be a symptomatic approach/ a holistic herbalist will look for cause of migraines (which can be varied) and work from there.

Consulting a professional herbalist is the best way to receive safe and effective herbal treatment.

Herbal Medicines can be used to effectively treat short term or acute illnesses at home, using simple and accessible herbs. Conveniently many are also culinary ingredients we may already have in our kitchens such as herbs, spices and foods.

A great starting point, as above mentioned is to gather a herbal reference library (book suggestions listed below). Seek out your local herbalist to see if they are offering herbal education, some accredited herbal schools and herbalists also offer online home herbalism courses which are a great way to begin your journey with herbs. Herbal Reality also offers many articles for specific conditions, as well as more general herbal healthcare.

There are a wide range of herbal medicines that can be held in a basic home first aid kit for which there are multiple applications. For example: elderflower, a safe effective medicine for treatment of seasonal allergies, which can also be used to support during a cold virus or fever; ginger – a common kitchen spice which is both excellent for sickness and nausea whilst also an excellent remedy to use during acute viral infection.

All herbs have a number of different uses, which means, just to learn about a handful of herbs there will be multiple ways they can be applied.

The most common first aid illnesses that, with the right use and dosage can be treated at home include (but are not limited to); common cold and flu, minor burns, cuts and grazes, bruises, minor infections such as conjunctivitis, gastroenteritis, acute stress etc. This said, it is always important that all the recommended safety guidelines are followed even with acute illness.

Herbs should also be used and incorporated into our daily lives, least not only when we experience ‘dis-ease’ or illness, but also as a means to support and maintain our health. This is the beauty of herbal medicine, herbs offer a multitude of active nutrients and compounds that can both increase our health resilience and can even help us prevent illness.

NOTE: To effectively and safely use herbs at home for first aid, it is important to understand first aid conditions, in particular any potential red flags or secondary complications i.e. infected wounds and ‘tracking’ which can occur when the blood becomes infected and lead to a serious condition called sepsis. Even where herbal remedies are used as a form of treatment, conventional first aid advice should always be followed.

Herbalists use a number of different preparations such as infusions (tea), tinctures (alcoholic extracts), decoctions (water), fresh plant, dried herb in form of a capsule, poultices, syrups and so on.

Many of the above preparations are easy to make for home use herbal remedies.

A herbalist will often create a blend of herbs to use in a patents prescription depending on the conditions and presentation of the individual case.

Herbs contain multiple, or sometimes hundreds of active compounds that work together to create an effect.

Some herbs compliment each other for example: compounds in black pepper support the metabolism of compounds found in turmeric, so they are often used together to enhance the effects of turmeric.

Herbal Medicines work via a mechanism of multiple compounds.

There are many unique energetic or vitalistic approaches to the understanding of Herbal Medicine found across the globe.

These traditional ‘energetic’ practices include those such as; TCM (Traditional Chinese medicine), Ayurvedic Medicine (India), Tibetan Medicine and Western Herbal Medicine.

As opposed to the more simple ‘actions’ of pharmaceuticals, herbs can affect multiple body systems. Herbs can also affect each person differently, this is often a reflection of our constitutional individuality.

Herbs can also have an amphoteric effect- meaning that they can have a balancing action i.e. a herb that will normalise both high or low levels in i.e. a hormonal condition.

The holistic approach to treating illness would be set out using herbal medicines and dietary and nutritional advice. The intention is to create a lasting resolution, that rebalances the body’s normal function.

Herbal medicines can be used to treat a wide range of conditions, from the acute or chronic, simple or serious, and of mind, body and spirit.

With care it can also be used safely along side orthodox medications and treatments. Very few side effects are reported for the proper use of Herbal Medicine. In fact sometimes they are utilized as complementary to pharmaceuticals to lessen their side effects.

Illness happens when we are out of balance and our work as herbalists is to facilitate the understanding of this imbalance with an aim to create a lasting resolution, that puts the individual back in charge of their health.

• Bartrams Encyclopaedia of Herbal Medicine – Thomas Bertram
• The Essential Book of Herbal Medicine – Simon Mills
• Herbal Remedies – Christopher Hedley and Non Shaw
• The Handmade Apothecary – Vicky Chown and Kim Walker
• Hedgerow Medicine – Julie Barlett-Bruton and Matthew Seal

Over the last two years we have seen a rise in popularity in foraging for food and medicine as people were spending more time outdoors and walking in nature during the pandemic. Whilst the country was forced to change from its normal routines in both work and life we witnessed a unanimous reawakening of the natural instinct to reconnect with our natural spaces.

This reawakened interest has so many benefits for us as individuals, foremost, reconnecting our relationship with the natural world. With this reconnection, comes a restored value, a sense of importance and appreciation for the offerings of nature.

With this surge of new interest however, it is important that we consider how we can learn most effectively considering our personal safety, sustainability and harvesting issues. So, let’s explore foraging through the eyes of professional foragers for some top tips on how to learn about the incredible world of foraging, creating a foundation of knowledge that can be confidently explored.

You can find all our foraging articles in our Foraging category.

Many will have already become familiar with their local wild spaces and will have a good idea of the types of plants that grow in them and some will be looking to learn the about their local habitats.

Whether you live near coastal paths and beaches, woodlands or forests, hedgerows or meadows or urban parks, it is important to form a connection to the land. Of course foremost for the purpose of observing the plants that one intends to forage as they change throughout the seasons, the habitats and species that interact with them, but also for understanding the land use so to avoid harvesting contaminated material.

The beginning of a foragers journey should always start with a period of observation, ideally over a year to observe how the plants change with the seasons. Plants can change dramatically as they leaf, flower and fruit throughout the seasons for example, leaf size and shape can change in a period of weeks, younger leaves sometime even comparatively different in shape and texture compared to the more mature leaves of the same plant.

Knowing your plant is also very important if you’re planning on harvesting roots, because the aerial parts are often dying or have died off completely by the time root harvesting season comes around (very early spring or autumn).

It is also important to learn about land use to identify if there are any potential contaminants that may effect ones harvest, for example from mining, farming or use of pesticides and herbicides etc.

Observing an area of land or a footpath in which one intends to gather from is an essential part of foraging safety. Coming to understand the way the land is being used will enable one to avoid any potentially toxic contamination of the plants being harvested.

Through spending time in these places, looking into the use of land through investigating types of farming that are taking place, any industrial history. This will sometimes be obvious with industrial buildings or ruins in sight. Sometimes unusual mounds of earth may indicate mining waste or landfill. The best way to be sure about this would be to contact the local council or landowner (if foraging from a public right of way).

With this surge of new interest it is important that we consider how we can learn most effectively considering our personal safety. Whilst there are many easily identifiable edible and medicinal plants, there are also a number of easily mistakable poisonous plants that anyone who is embarking on a foraging journey should be aware of.

Among the British and European flora grows some of the most deadly plants in the world, and they’re more common than many realize. So one must always begin their foraging journey learning safe practice in identification before anything is harvested or ingested.

Please note: Namely there are plants in the Carrot family (Apiaciae) that many professional foragers will warn about, therefore it is advised to avoid plants from this family if you are a beginner, taking good time to learn about them or seeking experienced guidance with regard to plants from this family.

Plant identification

Foragers and herbalists know the importance of learning basic botany and using a proper guide to identify plants correctly. So the first thing anyone who is interested in learning about foraging should do is get their hands on a comprehensive plant identification guide, such as a Collins guide to British and European Flora (if in UK), or any good flower guide.

These books contain a ‘key’ under which the individual botanical characteristics, such as leaf shape, flower colour, fragrance etc can be checked. Sometimes the difference between two plants can be discreet features such as having a solid or a hollow stem, number or shape of petals or sepals, presence or absence of fragrance and so on. Use of a proper key is the most accurate and effective way to confidently identify a plant.

A plant guide will contain detailed images and descriptions of all the plants found to grow in a specific region, country or continent. So after using the key one will at least know which plant family a plant specimen belongs to. Which can then be compared against a small number of similar plants in this genus to find what accurately fits the details shown in the book.

Plant identification apps

There are now a number of plant identification apps available, many are turning to these apps to help identify plants for foraging. However, can we rely on this as a way to safely advise on the edibility of a plant? If you ask any professional botanist, forager or herbalist, the answer will be no.

Unfortunately the inaccuracy of using these apps has been demonstrated time and time again, which has indeed led to serious cases of poisoning. These apps work by matching botanical characteristics of uploaded images. However, as you can see from above, often the differences between two plants are more discreet or sometimes invisible, such as fragrance, hollow stems, presence of fine hairs etc, these can not be translated through a digital image.

Plant identification apps can possibly be useful for guiding one towards a plant genus or species, just that they should never be used alone. Truthfully, the only foolproof way of identifying a plant is through proper use of a plant guide key. This invaluable knowledge is arguably the most sustainable and also the most rewarding, ultimately forging a deeper and more permanent understanding of the plant world.

You can also check out wildflowerfinder.org.uk

Many of the most popular edible and medicinal plants are common or well known as ‘weeds’, also plants that grow fairly abundantly in their natural habitats such as dandelion, nettle, plantain etc. However there are occasionally plants and fungi that are endangered or rare which will most likely be illegal to harvest in the UK, such as Lions Mane Mushroom, Centaury, Oak polypore etc.

Sometimes a plant is only locally endangered or uncommon i.e. not classified as rare or endangered but that it is not well established in the habitat or region. This is also something one must observe as they come to form a connection to any foraging territories.

Of course these plants should be left untouched. Alternatively, one may source through a trusted medicinal plant supplier or herbalist. It is also worth noting that there are usually other medicinal plants or combinations of, that could work effectively for the same condition or desired outcome. Again, a good herbalist would be able to offer advice or guidance here.

Even with the more common plants, we have to consider sustainability in harvesting, being mindful of the habitats and other species that are supported by them.

How much should I take?

As a rule of thumb foragers advise never to take more than one third of what is growing in a patch or area. This is because when one has harvested the required quantities for the intended purpose, it is essential that enough is left for the plant to regenerate itself in that patch.

If you need to harvest more, walk further and take smaller amounts from a number of different locations along the route, rather than all from the same place. This also ensures that there is enough left for the other species that interact with these plants.

We have a responsibility to consider all the complex processes happening in our natural spaces when we interact with them, especially where we plan to take something away, we want to ensure that we at least avoid having a negative impact, better still, we could even consider ways to benefit the environment.

Another rule of foraging is to always bring the book to the plant (as oppose to returning with cut specimens to identify at home). This is firstly because there are often factors about the habitat that are key for identification i.e. if the plant grows near a stream or a water source or a plant that grows in the shade as oppose to in a sunny position etc; all defining factors for identification.

Bringing a book to the plant is also important because one may take a plant and later find it to be a rare or endangered specimen.

One must also pay close attention whilst harvesting, always tracing the flower to the leaf, the leaf to the stem and the stem to the ground, taking care to ensure all plant parts are observed and that they match up.

It is possible otherwise to end up with the incorrect plants accidentally mixed in with a harvest i.e. harvesting elderflowers (an often shrubby tree, whose umbel like flowers can grow fairly low) among clumps of poisonous hemlock whose tall umbel flowers are up in amongst the low lying elderflowers, a mistake one would likely only make once (because hemlock is deadly!).

Therefore it is always advised to cut individual plant parts as opposed to grabbing clumps of leaves/ flowers. When taking a large harvest real attention must be taken so that everything that lands in your basket is what you had intended to forage.

Unfortunately finding good quality products can be difficult. Similar to food there are risks with contamination and spoilage.

There are potential risks in many areas; from microbial contamination (E.Coli, aflatoxins etc); heavy metal loads (lead, mercury, arsenic etc) either found at naturally high levels in the soil or from industrial contamination; potentially toxic extraneous materials harvested accidentally with the intended species (pyrrolizidine alkaloids, tropane alkaloids found in Boraginaceae, Asteraceae and Fabaceae and Solanaceae respectively).

Also our environment has unfortunately become polluted with many new-to-nature chemicals that are intentionally or unintentionally applied to crops; pesticides, fungicides and herbicides are persistent in our soils, water and atmosphere and high levels can occur due to over application or from wind-drift and floods.

Hence it is all too common for products to be contaminated. It is also possible that products have intentionally or accidentally been adulterated with incorrect species. The herbal industry faces similar challenges to the food industry; rice is often detected with high levels of arsenic, wheat with pyrrolizidine alkaloids, lentils with E. Coli – and all non-organic foods with pesticides.

Despite rigorous regulations across most countries all sorts of adulterants from sawdust to colouring dyes to pharmaceuticals have been found in over the counter herbal products. Another common problem is that botanical nomenclature is complex and plant names can be mixed up. This has led to poisonous plants being substituted in to products (1) which has lead to dangerous results.

Marker compounds

Plants have hundreds to thousands of secondary metabolites that make up the chemistry of their physiological effects; the essential oils, polyphenols, colourful pigments and array of other phytochemical families all combine to induce their effects. So just having the right species that is perfectly hygienic isn’t enough. You also need the right amount of the ‘actives’ to have an effect. This is where another difference in quality may come in.

What are food grade herbs?

Food grade herbs are typically used in food as the spice-mixes and teas you will find lining the shelves of supermarkets and natural health stores. They may also be used in some food supplements that are fine to use, but their contents and purity may or may not be pharmacopoeial grade.

What are pharmacopoeial grade herbs?

A pharmacopoeia is a collection of quality standards for herbs (as well as vitamins and drugs) that ensures the herbs are of the right quality and can meet the criteria to deliver their expected effects. For example, there is a European Pharmacopoeia, a British Pharmacopoeia, a United States Pharmacopoeia, and an Indian Pharmacopoeia.

How do herbs become pharmacopoeial grade?

To be classed as pharmacopoeial grade, further to the quality criteria mentioned above, the identity of the species must be verified using various microscopic techniques and specialist equipment, such as chromatography (you will all have done something similar to this in school chemistry lessons, using blotting paper).

High Performance Thin Layer Chromatography, Gas Chromatography, distillation, microscopic and organoleptic tests are all used to assess qualitative and quantitative measurement of the species. These methods ensure the right level of compounds, such as the active ingredients of essential oils, polyphenols or flavonoids. And it is these compounds that are associated with certain tastes and effects.

Here are some examples of the different quality if herbs available:

Standard Herb Name	Food Grade ISO 6571/1984	European Pharmacopoeia
Chamomile flowers (Matricaria recutita)	Min. 0.2% essential oil	0.4% essential oil Apigenin Min. 0.25%
Fennel seed (Sweet) (Foeniculum vulgare var. dulce)	Min. 1% essential oil	Min. 2% essential oil (with NLT 80% anethole and max 10% estragole and 7.5% fenchone)
Peppermint leaf (Mentha piperita)	Min. 0.6% essential oil	Cut Leaf Min. 0.9% essential oil Whole Leaf Min. 1.2% essential oil

It is a remarkable fact that 25% of the volume of herbs sold today are from the wild. Sadly much of this is unregulated trade with questionable sustainability or social welfare practices. The people that tend to collect herbs from the wild are often the most marginalised socially, economically and geographically.

It is important when buying herbs that you know that they are grown and harvested with the welfare of the ecosystem and the communities that are harvesting them in mind. Fortunately there are some very progressive action groups working on this; FairWild is the first wild certification organisation; United Plant Savers works to protect threatened medicinal species in the US; Plantlife promotes protection of plants in the UK. Find more information on sustainability in our article on Environmental Sustainability of Medicinal Herbs.

What to look for

Herbal supplement or Botanical supplements are regulated under Food Supplement regulations in the UK (Dietary Supplements in the USA). They have to meet all the standards you would expect any healthy food should meet; manufactured under hygienic conditions with tight specifications for microbial load, heavy metals, pesticides and other chemical contaminants. It should be what ‘it says on the tin’- the species should be correctly identified and it should be the correct part of the plant in the product.

Organically certified products that are organically certified have strict controls on traceability and on pesticide levels as well as human welfare standards.

FairWild certification ensures that wild plants have been harvested sustainably and the collectors and community paid fairly.

Some herbal products have a medical licence guaranteeing a level of quality. Across Europe the Traditional Herbal Registration certification mark is applied to products meeting.

Certification for Fair Trade also indicates a full-length value chain relationship enhancing the welfare of the workers and reflecting attention to detail in the ingredients.

Needless to say the world of e-commerce is a bit of a wild west so do be cautious when shopping online. For further information please read this excellent article on herbal quality by Roy Upton.

The body often metabolises herbs and pharmaceutical drugs through the same pathways. It is their influence on these systems that can affect their metabolism.

Interactions between herbs and drugs can occur in four different ways:

1. Additive: Increasing the effect of a drug
2. Reductive: Reducing the effect of a drug
3. Neutralising: Lessening the side-effect of a drug
4. Adverse: A herb and a drug can interact, mildly or severely, causing an undesirable effect

Pharmacodynamic interactions

Pharmacodynamic interactions occur between drugs and herbs in the body influencing how the drugs and herbs affect the body. If an interaction between a drug and a herb takes place then it may be synergistic or antagonistic resulting in an exaggerated or a lessened effect. Theoretically, drugs and herbs that have similar therapeutic activity have an increased potential of interacting.

The highest risk of interaction occurs when simultaneously using drugs and herbs that are anti-coagulant, anti-platelet, anti-diabetic, diuretic or sympathomimetic. Hence it is essential to speak with a herbalist and healthcare professional of taking such drugs and herbs together.

Other factors can be dangerous as well, specifically with gene interactions. For example, St John’s Wort, a herb commonly used for depression is known for interacting with the CYP450 enzyme family. This is very significant because it is this enzyme family that is responsible for metabolizing many drugs like warfarin and oral contraceptives.

Therefore, St John’s Wort inhibiting this enzyme family means that warfarin and oral contraceptives are not metabolized and their activity may be interfered with. Similarly because St John’s Wort is a selective serotonin reuptake inhibitor (SSRI) it should not be taken with Prozac, which is a pharmaceutical SSRI as this can lead to an excess of serotonin potentially leading to serotonin syndrome. Another example, finasteride and saw palmetto are both used to treat enlarged prostates, and so shouldn’t be taken concomitantly.

Pharmaceuticals or herbs with narrow therapeutic indexes can also be potentially dangerous to take together. When a drug has a narrow therapeutic index it means that the window between it not working at all, or becoming very dangerous or lethal is very small. Mixing herbs can disrupt how these are metabolised in the body, and even a slight increase of their levels in the body can be dangerous. Examples of these drugs include; lithium, carbamazepine, ciclosporin, digoxin, phenytoin, warfarin and theophylline.

Contraindications

Some herbs are contraindicated with certain illnesses and so one must check that a herb is safe to with a particular condition. For example, Panax ginseng root is controversial in hypertension, and in acute states such as mania and asthma attacks. Liquorice root is another herb associated with increasing blood pressure when used at high doses over long periods. Most herbs are fine, but each should be checked for their own toxicity and safety issues.  See our herb profiles for specific information. And always discuss with a qualified herbalist or your health provider if you have a specific condition.

It is strongly encouraged that when you are thinking of taking a herb or supplement that you check their interactions. There are some resources for this like books like Stockley’s Drug Interactions or our herb profiles.

Not all interactions have been investigated, but good guiding rules include: 

• If one is taking herbs and drugs for the same illness then discard one (e.g both to lower blood sugar).
• If one is taking herbs and drugs with opposite indications or effects (e.g one to increase and one to lower blood sugar), then do not take both.

When looking for quality products, there are some questions you can ask to help assure good quality. Firstly, a company should be able to tell you where the herbs have come from. If they do not know their supply chain, it leaves more space for contamination and adulteration.

They should also be able to tell you specifically which species are in their product. This means not just their common name (e.g Nettle) but the Latin binomial (Urtica dioica). Common names can indicate an array of different species hence why plant nomenclature is so complicated!

The Latin binomial assures that the correct medicinal species are being used, as some plants in the same family with similar names are not medicinal at all. A wonderful resource to be able to see a species different names, or a names different possible species is the Medicinal Plant Naming Services database. It is also important that the correct part of the plant is used and listed be it root, bark, leaf, flower, fruit or seed.

Additionally be mindful of the ingredients in the product. Many products are full of fillers such as anti-caking agents and bulking agents, synthetic colourings, and flavourings. Unnecessary ingredients indicate a poor-quality product and there is a good chance the plants in there are not good quality either.

Finally, we recommend seeing a qualified herbalist. Particularly if you are pregnant, breastfeeding elderly, seeking medicine foFinally, we recommend seeing a qualified herbalist. Particularly if you are pregnant, breastfeeding elderly, seeking medicine for a child or dealing with serious chronic conditions.

A qualified herbalist will know which herbs are safe for you to take in which doses, as well as be able to source you quality herbs. They will also be able to give you the best treatment plan you need to nurse your way back to optimum health. Find one in our resources section.

1. Tankeu S, Vermaak I, Chen W, Sandasi M, Viljoen A. Differentiation between two “fang ji” herbal medicines, Stephania tetrandra and the nephrotoxic Aristolochia fangchi, using hyperspectral imaging. Phytochemistry. 2016;122:213-222. doi:10.1016/j.phytochem.2015.11.008
2. Schippmann, U. W. E., Leaman, D., & Cunningham, A. B. (2006). A comparison of cultivation and wild collection of medicinal and aromatic plants under sustainability aspects. Frontis, 75-95.
3. Uwe Schippmann, Danna J. Leaman and A. B. Cunningham  Impact of Cultivation and Gathering of Medicinal Plants on Biodiversity: Global Trends and Issues FAO. 2002. Biodiversity and the Ecosystem Approach in Agriculture, Forestry and Fisheries. Satellite event on the occasion of the Ninth Regular Session of the Commission on Genetic Resources for Food and Agriculture. Rome, 12-13 October 2002. Inter-Departmental Working Group on Biological Diversity for Food and Agriculture. Rome
4. Brinker F. Herb Contraindications And Drug Interactions. Sandy, Or.: Eclectic Medical Publications; 1998.
5. Mills S, Bone K. The Essential Guide To Herbal Safety. St. Louis, Mo.: Elsevier Churchill Livingstone; 2005.

(As told to the author by Frank and Julia King-Ni-Vanuatu; Mélé Village, Efate Island, Vanuatu-July 2017)

Our story begins with two brothers Ben a farmer and Cassie a fisherman.  Each day Ben would rise early and work his crops in the forest, while his brother would fish when the tides allowed, and he would come and go with the water and bait and was often around the village during the day due to bad fishing or weather. One day Ben came home to find Cassie in bed with his wife and in a fit of rage killed his wife and his brother. He buried them in the earth behind his hut and went into a long state of depression so dark that he could not expose himself to the light nor could he sleep.

He had a dream that came during one of his long nights of restless sleep that a plant with heart shaped leaves spoke to him, and told him to get up and look for it in the forest behind his house where he buried his wife.

The next morning Ben got up and went looking for the plant and sure enough there it was sprouting branches that looked like the brown knuckles of his wife’s hands coming from the ground with green heart shaped veined leaves. It was the first time Ben had come out of his hut since the event and he began to have more dreams about the plant and seemed to sleep better and be more at ease just being around it.

The next night he dreamt that the plant told him that it was the spirit of his slain wife and that she forgave him for his rage and could help him with his heavy guilt, shame and lift the darkness that he was living with.

The plant told of how Ben should carve a board out of black wood to resemble her womb, and then of the plant with the heart shaped leaves, “pull up my feet and legs (roots) and grind them into the womb you will make out of dark wood and with a long, rounded piece of dead coral and some fresh rainwater until it forms a milky liquid that you should squeeze through coconut fibers and drink the liquid.

While you are drinking you will not think of me or think about sex and your wife, your sore muscles will be warmed by the drink and the pain will ease and I promise to keep you peaceful if you only remember to cut up my arms and hands at each joint and stick them into the earth to grow more and tell other men in the village how I make you feel and how to prepare me and how to grow more of me.”

And so, Ben did this…

He began to sleep well and went back to farming and told the men in the village about his dreams. They tried the drink together at night in the village hut and found that not only did it help them sleep, but it eased their sore muscles from working the forest gardens and waters all day. From then on Kava has been consumed and loved within the communities. That is the story of how Kava came to this Island and spread to the other islands.

The Medicinal plant Piper methysticum G. Forst is commonly referred to as Kava, ‘Awa, or Yaqona in Vanuatu, Hawaii, Fiji respectively. Kava relies on asexual propagation since it cannot produce a viable seed. After I heard and read about the various Kava origin stories, I wondered if the buried corpse of a woman was representative of the indigenous tribe’s explanation for how a plant could reproduce without a seed and why it made them feel at ease in body and mind.

The answer as with most things in the botanical world is not so simple and requires more research. It is a conversation better had in person for the ethnobotanical inquiry, preferably while in the Nakamal after a shell or two of Kava and certainly not via WhatsApp or Zoom.

The phytochemical research also continues, and volumes are dedicated to characterization and isolation still without complete agreement amongst analytical chemists. The plant that is thought to be the “Mother” of Piper methysticum G. Forst; Piper methysticum var. wichmannii is also an asexual or vegetative reproducer though it is physically much larger than the drinking varieties, grows more rapidly and is substituted intentionally and unintentionally for Noble or commonly consumed Varieties.

This plant is considered a spiritual and ceremonial plant in Vanuatu and typically has not been consumed for nakamal drinking but only used in ceremonies. On my last visit in 2017 I heard from several Ni Vanuatu that they were drinking “wild kava” P. methysticum var. wichmannii (‘wael kava’ in Bislama language). That they would drink from a plant normally reserved for spiritual and ceremonial practice is indicative of the strain on this plant in trade.

During my times visiting the islands with Frank and Julia King they began facilitating the transplanting of some Noble varieties on Efate from Pentecost and other island’s. This was because of various tropical storms, volcanic eruptions and cyclones damaging Kava crops specific to those islands (Efate, Pentecost and Ambrym in this case).

This left the islanders unable to work the crop with many other life preserving activities taking precedent, such as replanting food gardens, clearing debris and building water storage. The fresh kava trade between islands for drinking has extended into selling young shoots for cultivation.

For much of the known history of Kava dating back to the works recorded by early Botanist J.G. Forester who travelled on Captain Cook’s expeditions around the pacific Islands in 1777 each Island cultivated, harvested and traded varieties that were endemic to that Island with varieties such as Borogu and Borogu Temit predominant on Pentecost and varieties such as Pia being more predominant on Tanna.

There are 16 known folk cultivars of Kava that have been identified on Pentecost and about the same on Tanna but the reader must also consider the linguistic diversity of Vanuatu and the fact that there are over 20 different Islands that have cultivated Kava for centuries in a concentrated geographic area. There are 105 languages spoken in the archipelago of Vanuatu (the most of any Country by population) and cultivars are recorded in as many languages. The gathering and recording of this information have been long and laborious and a debt of gratitude is due to Dr. Vincent Lebot for his work (1,3).

As efforts to increase diversity and inclusion increase, they extend to the plants in addition to the people. Of interesting note here; the trip in 2017 was the first time I had seen Women in Nakamals and drinking Kava in public. Custom or “Kastom” a Bislama/Pigin word for culture, including religion, economics, art and magic, has not allowed native Vanuatu women to harvest, process or drink Kava with the exception of masticating rootstock on some occasions for ceremony.

Despite this strict adherence to Custom in conversations with locals on different islands, it is clear that some women do drink Kava regularly, they are just doing so in hiding. Now, attitudes are changing and the women I spoke with said for the better.

The Kava Origin story above is just one of many stories on the origin of Kava and I encourage the reader to find more information freely available online concerning this subject, or better yet, travel to any Kava bearing island in the South Pacific and ask for yourself. They will be happy to share their information with you and it’s a great thing to chat about after a shell or two.

Kava grows in some of the most beautiful tropical paradise locations known, Fiji, New Guinea, Tonga, Samoa, Hawaii, New Caledonia, Papua New Guinea, The Cook and Solomon Islands and Vanuatu among the jewels in this pacific treasure chest. This plant perhaps more than any other I’ve encountered represents the human, plant coevolutionary process in the most sublime of ways. It is a plant that prepared properly, from the correct species, relieves anxiety and opens certain areas of perception and the plant must be reproduced by humans.

It grows naturally where rainfall is plentiful (average 2,000 mm/yr). Ideal growing conditions are 21–35 °C and 70–100% relative humidity. Too much sunlight is harmful, especially in early growth. The beverage is prepared in commercial nakamals and villages using a mechanical grinder, most often a manual hand crank meat grinder.

The ground roots are then put into a mesh cloth, though one time in Mele village I helped prepare some of that night’s Kava and we used a pair of men’s mesh football shorts as a strainer (they were clean!), proving that necessity is the mother of invention. In the USA Kava is regulated as a dietary supplement and dried lateral root  stock in a powdered form and various extracts are available.

I do take an extract of Kava from time to time and there’s a slight feeling of warmth, an ease in tension without cognitive inhibition, this is more pronounced in the water extracted dried root preparations than from capsules or extracts. To emphasize the difference for this subject; when drinking fresh kava on Vanuatu, I have thought to be able to see the vacuoles opening and closing on the underside of plant leaves, breathing in CO2 and out oxygen molecules, so relaxed and calm amongst natives yet over 8,000 miles from my home on a dot of land in the South Pacific.

The experience of drinking fresh kava on the islands is not easily reproduced through even the best of Dried Kava preparations or extracts. The word Kava is thought to be from Tongan language meaning ‘bitter’ and in Hawaii it is ‘ava’, also meaning bitter as it is so indicated in almost all the languages that refer to this beverage (2). It’s not a flavor that one savors.

Spit troughs are common at the Nakamals in Vanuatu and there’s always some coconut meat, paw-paw (Papaya), or pineapple to cleanse the bitterness from the palate after knocking back a shell of fresh Kava. It is also a type of “prayer offering” to spit and cough after consuming and ask the kava spirits for good fortune. I am grateful to have access to Kava as we do in the US and feel for my fellow herbal enthusiasts in the UK that cannot so freely enjoy this plant.

In 2001 concerns about Kava’s safety were raised by European media reports of liver toxicity involving the use of Kava.

Then in 2002 the Office of Dietary Supplements issued this statement: “On March 25, 2002, the Food and Drug Administration (FDA) issued an advisory notifying consumers that kava-containing dietary supplements may be associated with severe liver injury.

The FDA reported that kava-containing products have been associated with liver-related injuries, including hepatitis, cirrhosis, and liver failure, in over 25 reports of adverse events in other countries. In the U.S., FDA received a report of a previously healthy young female who required liver transplantation, as well as several reports of liver-related injuries.” (8).

Though not “banned” in the US many companies subsequently stopped selling Kava and products and those that remained in the market were mandated to contain a detailed label warning relating to potential liver toxicity. Some researchers believe that extraction using solvents other than water create chemistries not found in traditional water extracts and these non-traditional extraction processes remove glutathione. This is a powerful antioxidant that the liver and plants produce to protect from peroxide and other free radical induced damage (7).

More research is needed in this area though The World Health Organization in it’s 2007 report on the safety and efficacy of Kava noted: “2.1.3. Products from water-based suspensions and further synthetic preparations should be developed and tested in clinical trials and consideration given to using these in preference to acetonic and ethanolic extracts.” (9).

Of interesting note are the lack of studies using water extracts of the peeled roots and rhizomes, to evaluate the safety of traditional preparation methods. The dangerous preparations recommended for the removal from the market in the UK and other countries were based on the evaluation of acetone and ethanol extracts, that did not respect or adhere to traditional extraction methods. This is despite WHO recommending studying water based traditional beverages.

One effort in the right direction was initiated in a study conducted in 2009 called The Kava Anxiety Depression Spectrum Study (KADSS). This was a 3-week placebo-controlled, double-blind, cross-over trial involving 60 adult participants (18–65) with elevated stable anxiety and varying levels of depressive symptoms. (4)

It is one of the only studies we are aware of using an aqueous extract of Kava. In the study the researchers from Queensland University in Brisbane, Australia and School of Health, University of New England, Armidale, Australia concluded in their summary:

“The study demonstrated that an aqueous extract of Kava was a safe and efficacious anxiolytic in participants with elevated, stable generalized anxiety and may also have antidepressant effects.

In accordance with our results, aqueous preparations of Kava may tentatively be recommended for intermittent or short-term use in people with generalized anxiety. In cases of regular use, liver function tests and clinical examinations should be periodically conducted, and dosages should not exceed 250 mg of kavalactones per day. Kava should preferably not be consumed with alcohol, benzodiazepines, or anticonvulsants.

This current study—and research that follows—may encourage the reassessment of Kava as a first-line treatment of anxiety. Such a decision would provide a significant expansion of viable treatment options for people with acute anxiety. It is necessary to continue more work in this area with aqueous extracts if we are to uncover the evidence contained in traditional preparations.”

One of the practical limitations of the study is the lack of preparations commonly available for aqueous extracts of Kava. The majority of preparations are Ethanolic Tinctures or straight powder/dried roots of Kava. It is however landmark in its efforts to approximate a traditional beverage, which to date had not previously been accomplished.

A notable 8-week randomized, double-blind multi-center placebo controlled clinical trial in 129 out-patients was conducted in 2003 using a 95% ethanolic extract of 400mg kava standardized to contain 30% kavapyrones at an average dose of 120mg (5). The study concluded that the preparation was well tolerated and as effective as Buspirone and Opipramol in the acute treatment of out-patients suffering from generalized anxiety disorder (GAD).

This study is encouraging for the types of preparations that are available in areas where commerce on extracts is allowed. More research on the solvent and aqueous preparations is needed and would hopefully lead to the development of safe, evidenced based therapeutics which also align with traditional preparations of the plant.

The first time I gave a native Pentecost islander a taste of an Ethanolic extract made from their harvests the reaction was one of amazement, a bit of worry and a bit of disbelief that it was actually Kava as they whooped out a loud “Kava Strongfala hafkrangke!!!” in Bislama, translating to “Crazy Strong Kava!!!”.

On my last trip to Vanuatu, I had the ultimate good grace to travel there with my son Cameron who was 22 at the time and studying Sustainable Tourism and Fisheries Biology at Colorado State University in Fort Collins, CO. One of the goals was to see some Kava “gardens” as they call them on the Island of Ambrym and for Cam to see firsthand the results of a study he had read for a fisheries class investigating the impact of commercial fishing and coral bleaching on Efate island (6).

We waited at the Port Vila International Airport for an 8 seat small engine flight to Ambrym Island with the customary live chicken in tow that I had become accustomed to on island visits with Frank. When we walked out to load the plane, Cam was asked to sit in the Co-Pilot seat up front as the Pilot needed proper weight distribution and he was about the same height and weight as our pilot, a nice young Fijian man about Cam’s age. The islands appeared and disappeared into the clouds amidst a turquoise coral backdrop with nothing but pelagic pacific waters as far as one could see on this thankfully clear day.

We landed safely coming into the Ulei Airport, a small grass landing strip emerging out of the palms with a brick building containing a latrine. I hugged Cam a little extra tightly in gratitude once we were taxing in and also marveled at the thought of the original islanders making that trek across treacherous waters in a hand hewn outrigger canoes.

We met the Chief of the village (Aram) that was farming the Kava who also ran a small shop with essentials that came in with the Kava trade. Aram was carrying a rifle which was something I had never seen on the islands before but was assured it was only to hunt fruit bats or Flying Foxes in the local language.

Such is life in the bush, but I would later learn that the rifle was in fact for our protection since a neighboring tribe had gotten word of this one’s success in trade with Kava to pharmaceutical companies and was making threats. The chief confided to me that his brother was sick with “stomach cancer” and it was putting a strain on harvesting and planting Kava since he was responsible for a small crew and becoming unable to work.

I immediately went to work scouring the landscape for plants I may recognize that may be beneficial and asked what he was doing for food and medicine. Later during that trip while hiking to the active Volcano (Benbow) as we made our way through the forested part of the Lahar, I spotted two species of fungi that surprised and delighted me: a Ganoderma species and Coriolus versicolor.

I made a mental note of their location, took some pictures, wrote a note in my journal but did not take any of them as I only wanted to ask the chief if he knew about them or if there was any use of them known to his tribe. Our Volcano guide from the village; Solomon had not known about them and said they don’t eat any of those since they don’t know if they are poisonous or not.

I showed the chief the photos who also had no experience with them when we returned to the village the next day told him how to prepare the fruiting bodies of those fungi (The Mushroom ‘caps’) if he felt inclined by making a decoction for his brother to drink for his stomach and vitality. He was grateful for my time and sharing and promised strong kava when we returned to the village nakamal that night to drink.

This exchange of knowledge and caring was facilitated through the business of botanicals and the plants themselves and is an unspoken language of unity that compels one to act with ethics and compassion. The plants take you on an amazing journey and the road maps for proper engagement can be found in the language of cultural tradition, the plants themselves, and the soil web connection that is emerging as the center of it all, facilitating a community of interconnectedness and interdependence.

1. Applequist, Wendy L.; Lebot, Vincent (25 April 2006). “Validation of Piper methysticum G. Forst var. wichmannii (Piperaceae)”. Novon: A Journal for Botanical Nomenclature. 16 (1): 3–4. doi:10.3417/1055-3177(2006)16[3:VOPMVW]2.0.CO;2
2. http://wehewehe.org/gsdl2.85/cgi-bin/hdict?a=d&d=D1669
3. Kava: The Pacific Drug, Vincent Lebot, Mark Merlin; Lamont Lindstrom. Copyright Date: 1992. Published by: Yale University Press. https://doi.org/10.2307/j.ctt211qwxb Pages: 256
4. Sarris J, Kavanagh DJ, Adams J, Bone K, Byrne G. Kava Anxiety Depression Spectrum Study (KADSS): a mixed methods RCT using an aqueous extract of Piper methysticum G. Forst. Complement Ther Med. 2009 Jun;17(3):176-8. doi: 10.1016/j.ctim.2009.01.001. Epub 2009 Feb 7. PMID: 19398072.
5. Boerner RJ, Sommer H, Berger W, Kuhn U, Schmidt U, Mannel M. Kava-Kava extract LI 150 is as effective as Opipramol and Buspirone in Generalised Anxiety Disorder–an 8-week randomized, double-blind multi-centre clinical trial in 129 out-patients. Phytomedicine. 2003;10 Suppl 4:38-49. doi: 10.1078/1433-187x-00309. PMID: 12807341.
6. https://www.icriforum.org/wp-content/uploads/2019/12/Pacific-Coral-Reefs-2011.pdf
7. Peter A. Whitton, Andrew Lau, Alicia Salisbury, Julie Whitehouse, Christine S. Evans: Kava lactones and the kava-kava controversy, Phytochemistry, Volume 64, Issue 3, 2003, Pages 673-679, ISSN 0031-9422, https://doi.org/10.1016/S0031-9422(03)00381-9.
8. https://ods.od.nih.gov/HealthInformation/kava.aspx
9. https://apps.who.int/iris/bitstream/handle/10665/43630/9789241595261_eng.pdf

Echinacea (Echinacea spp., Asteraceae)

Preparations made from aerial and root parts of echinacea, mainly E. angustifolia and E. purpurea, are popular and scientifically supported options for the prevention and treatment of the common cold. Echinacea extracts contain a mixture of compounds with cytokine-suppressing and -inducing effects, suggesting that echinacea extracts and alkaloids may be useful for treating allergic and inflammatory responses.

Echinacea extracts have also demonstrated immunosuppressive effects, which may be beneficial in COVID-19 patients where the inflammatory response is exacerbated. The risk of herb-drug interactions with echinacea is deemed low.

Elderberry (Sambucus nigra, Adoxaceae)

Elderberry juice has long been used as a diaphoretic in the treatment of the common cold. It also has immunomodulatory properties. Elderberry extracts have shown antiviral effects against influenza virus A and B in vitro and in human clinical trials. Despite these promising results, they cannot be extrapolated to suggest a positive effect in patients with COVID-19 as there are no scientific data available. The available evidence suggests there is a low risk of adverse effects when using elderberry before SARS-CoV-2 infection or in the early stages of infection.

South African geranium (SAG; Pelargonium sidoides, Geraniaceae)

SAG roots and rhizomes possess immunostimulant activity as assessed in several in vitro models. More than 30 clinical trials have been conducted with an SAG extract (Eps 7630^®; Umckaloabo^®; Dr. Willmar Schwabe GmbH & Co. KG; Karlsruhe, Germany) in the treatment of acute respiratory tract infections. The promising antiviral effects and strong safety profile of the extract warrant further clinical investigation.

Medicinal mushrooms and fungal preparations

Medicinal fungi are an expanding area of research, with oyster mushroom (Pleurotus ostreatus, Pleurotaceae); Ganoderma spp. (Ganodermataceae), chaga (Inonotus obliquus, Hymenochaetaceae); caterpillar fungus (Ophiocordyceps sinensis, Ophiocordycipitaceae); and maitake (hen-of-the-woods; Grifola frondosa, Meripilaceae) drawing the most interest.

Other mushrooms have been clinically studied with focuses on the treatment of cancers, immunological diseases, and immune-adjuvant therapy. Clinical and animal studies have demonstrated that the bioactive polysaccharides or polysaccharide-protein complex from medicinal fungi enhance innate and cell-mediated immune responses. Data with chemically well-defined fungal ingredients in COVID-19 patients are needed to evaluate whether specific fungi could be beneficial.

Adaptogens are natural compounds that increase the body’s adaptability, resilience, and survival in nonspecific ways. While more than 100 medicinal plants have been identified to possess apoptogenic activity, only a few have been shown to exhibit multitarget effects on the neuroendocrine-immune system.

These include andrographis (Andrographis paniculata, Acanthaceae), eleuthero (Eleutherococcus senticosus, Araliaceae), ginseng (Panax spp., Zingiberaceae), rhodiola (Rhodiola rosea, Crassulaceae), schisandra (Schisandra chinensis, Schisandraceae) and ashwagandha (Withania somnifera, Solanaceae).

In addition to affecting the immune response, the ability of these adaptogens to alleviate stress-induced mental and behavioral disorders is relevant as these conditions have increased due to the COVID-19 pandemic.

Licorice (Glycyrrhiza spp., Fabaceae)

Licorice spp., primarily Glycyrrhiza glabra, G. inflata, and G. uralensis, root contains bioactive compounds that possess anti-inflammatory and antiviral effects. β-Glycyrrhetinic acid, a metabolite of one of these components, may enhance the activity of hydrocortisone, suggesting that the coadministration may have a therapeutic effect in inflammatory lung diseases. More studies are needed to gain new insights on the potential role of licorice or its components in the treatment of COVID-19.

Turmeric (Curcuma longa, Zingiberaceae)

Curcumin, the main bioactive component of turmeric, has demonstrated activity against a variety of viruses by interfering with critical steps of the viral replication cycle. Curcumin also blocks cytokine release, which has translated to clinical improvements in animal models of diseases where a cytokine storm affects morbidity and mortality outcomes. Taken together, curcumin may theoretically be of benefit in COVID-19 pathophysiology and clinical manifestations.

Frankincense (Boswellia spp., Burseraceae)

Frankincense inhibits inflammation through the cyclooxygenase (COX) pathway. Most studies have reported moderate anti-inflammatory efficacy with frankincense as a mono-product and in combinations with other herbs, suggesting its use as a promising approach for the treatment of COVID-19-related inflammatory complications.

Salicylate drugs of botanical origin

A range of herbs contain salicylic acid derivatives. These include 

• Willow spp. Salicaceae
• meadowsweet (Filipendula ulmaria, Rosaceae)
• Birch (Betula spp., esp. Betula lenta, Betulaceae)
• Wintergreen (Gaultheria procumbens, Ericaceae) oil

While preparations derived from these botanicals are often used externally, there is no evidence for negative side effects in the context of COVID-19.

There exists no evidence that the immunomodulating herbs discussed here would exacerbate a cytokine storm, and herb-drug interactions are not expected.

Botanical drugs and supplements continue to gain interest from researchers as potential therapeutic agents for SARS-CoV-2 drug development. Still, research exploring the mechanisms of action and efficacy of these herbs in the content of SARS-CoV-2 exposure is needed. In either case, despite the lack of strong clinical data to support active recommendations, the current evidence suggests these botanicals are safe enough to permit use by the public with the appropriate caution.

The authors declare no conflicts of interest.

The economics of the conventional and even medicinal plant market aside, central to the needs of a patient is to have a botanical medicine that is first safe and secondarily effective for its intended use. In turn, the safety and efficacy of a botanical medicine requires adherence to good agricultural and manufacturing practices that encompass proper harvesting or cultivation, processing, identity, purity, quality, and potency.

Early herbalists devoted a great amount of time in the quality assessment of herbal drugs with specific emphasis placed on appropriate growing regions, harvest times, processing conditions, and the detection of inferior quality or adulterated materials. This was prior to the advent of chemistry and molecular techniques.

Herbal quality assessment was based on what an herbalist could discern through her or his senses; predominantly as reflected in the growing habit, color, aroma, feel, and taste of the plant. Most every consumer can recognize an apple from an orange as well as discern its relative quality. Every chef knows the not-so-subtle difference between fresh and dry ginger.

As chemical techniques developed, focus on the plant itself greatly diminished and the skills at discerning quality all but disappeared in Western herbal traditions and science, though has remained in more intact systems of Ayurveda and traditional Chinese medicine. Emphasis on quality shifted from the field to the laboratory; from human senses to mechanical methods of analysis; from the plant to isolated plant compounds.

Similarly, in the same time period, the use of herbal medicines was rapidly declining as use of chemical medicines was on the rise. In developed nations, the responsibility of herb quality passed from herbalists to medical doctors who became among the first teachers of materia medica, and then to pharmacognosists—pharmacists specialising in the development of drugs from natural products. Subsequently, this pharmacognostic knowledge was codified into national pharmacopoeias, which became the quality standard for drugs within national health care approval systems. Thus, modern drug approval systems, and subsequently, modern pharmacopoeias, were modeled for the needs of modern drugs not traditional herbal medicines or traditional healing systems.

In parallel, the economics of medicine changed with greater focus on research, specialization, technology, high cost drug approval processes, and a medical system more driven by research findings and profits than practitioner or patient need. This greatly influenced the way in which the practice of medicine and approval of medicinal agents evolved, including creating significant positive bias in pharmaceutical research and substantial negative bias against traditional medical practices overall and specifically herbal medicines.

Because of the importance traditional medical systems, as well as herbal medicines, play in world health the World Health Organization (WHO) reports that among the most salient benefits of both, are accessibility and affordability (WHO 1978; 2013). Applying the same regulatory models to traditional medicines as is applied to modern drugs negates these two advantages. WHO, however, does not explicitly recognize other very unique benefits of traditional medicines.

Specifically in the United States (US), arguably among the most technologically advanced of countries, 58% of consumers who use traditional healing modalities, do so not for the treatment of disease, but rather to “prevent future illness from occurring or to maintain health and vitality” (Eisenberg et al. 1998). Similar findings were reported in a later survey of dietary supplement users in the US in which “preservation of health was by far the most predictive indicator for use of herbal products and dietary supplements” (Marinac et al. 2007) and in a similar survey in Australia (MacLennan et al. 2002). There is not a single western drug in the world designed to “maintain health and vitality” or “preserve health”.

Another unique characteristic of traditional healing systems, especially, Ayurveda, traditional Chinese medicine (TCM), Unani, Tibetan, etc., is the utilization of a completely different diagnostic system than is applied in the West. Traditional systems are meant to be applied to the individual needs of the patient. This allows for an understanding of health and pathology and subsequently the development of unique therapeutic strategies, thus broadening patient options.

Additionally, amongst these healing traditions is an inherent belief of the relationship between human and environmental health, a belief completely integrated into the diagnostic construct of most herbal traditions, and completely ignored in modern medicine.

These traditional healing strategies are in stark contrast to the prevalence of Western conventional medical strategies, which are predominantly focused on disease management more than the promotion or restoration of health. The specificity inherent in western medical therapies gives those therapies a targeted focus, often to the neglect of the general health status of the individual.

Generally speaking, in western conventional medicine, if tissue or organ structures are not functioning properly the treatment is to basically attack them leading to the removal of tonsils (a first line of defense against infectious disease), gallbladders (integral to digestive and eliminative processes), cataracts; transplants of hearts, livers, and kidneys; radiation or poison (in cancers); or interfering with normal processes, such as pharmacological agents designed to either up regulate, down regulate, or otherwise completely obviate normal physiological processes.

A good example of this is the widespread use of anti-inflammatories, inflammation actually reflecting a biological response of the body to an inflammatory mediator.

Rather than seeking to identify and remove the inflammatory trigger, the conventional western medical strategy is to shut down, what ultimately is a healing response. From a natural health care perspective, such a strategy is the antithesis of what is needed to support human health. This does not mean there is no value in such a strategy.

Militaristic search and destroy therapies such as these are uniquely suited for crisis intervention and emergency medicine. Severed limbs, acute poisonings, intractable severe pain, ruptured organs, etc. respond well to a militaristic approach; in contrast, pregnancy does not, a fact reflected in the appalling high rate of infant mortality in the US, whose system of medicine is almost completely militaristic.

To have a medical system entirely based on militaristic therapies is inherently limited; a fact equally evidenced by the high rates of iatrogenesis, deaths due to pharmaceuticals, and chronic illness associated with modern health care systems. Perhaps of greatest consequence is that western medical strategies focus on the treatment of diseases not the treatment of people.

Thus, conventional and traditional healing practices represent two very different paradigms of medicine. Traditional healing practices offer a different paradigm and different therapeutic solutions than conventional medical care. This is precisely why traditional healing systems, and herbal medicines are growing in popularity. If the two systems can be harmonized there is a greater potential for healing than either system can deliver on its own.

However, regulating chamomile tea, valerian root, and hawthorn berry syrup, with their hundreds of compounds, in the same way as Prilosec, Ambien, and artificial hearts, disregards the fact that each botanical medicine has several hundred years of historical use, has been in the public domain for those several hundred years, and threatens to undermine the potential herbal medicines possess.

In contrast, a rigorous safety and efficacy evaluation is necessary for the chemicals used in modern drug development, as most have never been in human use. Whereas with botanicals that have been used for centuries, there is a reasonable basis based on human experience and, in many cases, formal scientific evaluation to assure there is a reasonable basis both for safety and efficacy, whereas in modern drug development, no basis at all for safety or efficacy exists, thus necessitating detailed scientific exploration of compounds that have never before existed prior to their being administered to humans; think broccoli and carrots for which no formal toxicology data exists.

Throughout much of the world herbal medicine is in transition from the collection and processing of crude herbal materials of varying strengths and potencies, such as are used as powders, teas, simple syrups, and extracts by local healers and communities to well characterized preparations made according to pharmacopoeial standards predominantly supplied through a highly regulated market.

The former more crude preparations are characteristic of undeveloped and developing nations, while the latter are typical of developed nations. Each country is at a different point in its evolution regarding herbal medicine. A new paradigm that takes into consideration the unique characters of herbal medicines is needed with a focus on the quality and sourcing of raw material based on the myriad of constituents found in single herbs and formulas.

Ironically, and perhaps most saliently, practitioners of traditional healing systems are seldom part of traditional health care policy decisions. Rather, commercial interests by traditional medicine producers often drive national and international health care policies, frequently leading to a restriction in materia medica and impeded access to herbal drugs. Thus, it is questionable whether traditional herbal medicine will thrive, and in many cases, survive within national health care systems.

If policy makers, regulatory bodies, medicinal plant researchers, and pharmacopoeias can once again place emphasis on the quality of the plant material itself rather than viewing herbal drugs as cocktails of chemicals to be pulled apart, isolated, and manipulated, there is a chance.

Similarly, medicinal plant research should reorient itself to investigate the traditional use of herbal medicines within the traditional healing system from whence they came, investigating the physiological and pharmacological subtleties that give the medicine its unique healing quality, rather than simply looking at the application of herbal drugs for Western disease patterns.

Truly honoring traditional healing systems and herbal medicines and maximizing their healing potential is an international challenge that minimally should be discussed as part of national and international health care policy if humankind is to continue to reap the benefits of medicinal plants based on the systems in which they were traditionally used.

Ephedra or ma huang, is provided commercially as the dried young stems of three species of perennial herbs, Ephedra sinica Stapf., E. equisetina Bge., or E. intermedia Schrenk + C.A. Meyer.  

Ephedra sinica is a native of northern China and Inner Mongolia. Each of the three species has slightly different appearances and characteristics.

E. sinica is the less branched, with nodes more spaced out on the stem. All samples are dry and brittle, with little odour and a slightly bitter taste.

Note: The North American ephedra E. nevadensis (known as Mormon tea), contains little or no ephedrine or other alkaloids.

Ma huang is mentioned in the Han dynasty Shen Nong Ben Cao Jing (Divine Farmer’s Classic of the Materia Medica) (1) for its benefits on lung obstructions like wheezing. Its principal action through Chinese traditions was as a heating medicine, to treat febrile congested catarrhal conditions of the respiratory system. It promotes sweating, calms dyspnoea and is indicated for ‘exterior repletion cold damage patterns with aversion to cold’ (2).

It features frequently in formulae recorded in the Shang Han Lun (on Cold Damage) (3) in which it is often combined for additional warming effect with cinnamon and ginger. In modern terms the old indications translate as some of the preliminary symptoms of ‘flu, at the stage where the patient is feeling chilled and is shivering, and when sweating has not yet broken out (when the body temperature is showing as high yet the person still feels chilled: this means the temperature is still rising).

Headaches and diffuse pains around the body which appear at this stage are additional indications for the use of this remedy. Its effect in such cases is to provide a considerable perspiration and to provide a feeling of warmth, this (vasodilation and diaphoresis) leading to a fall in actual body temperature.

Its virtues are also evident in dealing with symptoms of dyspnoea: breathlessness and a feeling of constriction in the chest, including asthma. It may be applied generally to associated conditions of hypersensitivity in the airways, such as allergic rhinitis (including hayfever and ragweed sensitivity).

The warming quality of this remedy however dominate all its other effects. It is reflected in its role as as a circulatory stimulant, in dispersing catarrhal congestion, and as a diaphoretic in fevers. Closely associated with the above is the action of ma huang on fluid accumulations in the body.

Whether through its diaphoretic or diuretic effects, it acts to relieve symptoms of oedema. The total combination means for example that as far as the lungs are concerned, the remedy is applicable to bronchial congestive conditions as well as to asthmatic drying of the airways, and that it is ideal for bronchial asthma.

Traditional doses range from 1-5 grams per day, with lower amounts in many classic formulae.

As with other traditional remedies there has been a modern adaptation in the use of ma huang to new indications. Other heroic remedies that have switched roles (and reduced doses) include hawthorn (from fever management to heart and vascular remedy), feverfew (to a migraine treatment), and valerian (from a robust convalescent tonic to a sleep remedy) and, in each case with a reduction in dose and extension of treatment time.

Ma huang has morphed into ‘ephedra’, a prime modern remedy for bronchospasm, especially associated with allergic conditions. From being a marvellous treatment for healthcare emergencies it became a remedy that could be used in the long term, and at lower doses. Modern herbal practitioners have found it also useful in other symptoms of allergy as well, such as urticaria and atopic eczema.

Ephedra sinica contains phenylalanine-derived protoalkaloids, notably ephedrine, pseudoephedrine, norephedrine, norpseudoephedrine, and l-methylephedrine. Pharmacopoeial specifications are that the herbs should contain not less than 1.25% of alkaloids calculated as ephedrine. Analyses show the range in commercial samples is between 0.5-2.5% and that ephedrine can account for between 30-90% of the alkaloid content; pseudoephedrine can go as high as 27%, though usually less (4).

Ephedrine is a sympathomimetic agent, acting indirectly to enhance the release of norepinephrine from sympathetic neurons, and directly by stimulating alpha and beta adrenergic receptors. It increases heart rate and cardiac output, and because it also constricts blood vessels, has a hypertensive effect.

In the lung, ephedrine acts via the beta-adrenergic receptors to relax bronchial smooth muscle, achieving an effect analogous to adrenaline without the need for injection. Because of its lipid solubility, ephedrine crosses the blood-brain barrier where it acts as a central nervous system stimulant, promoting both noradrenaline and dopamine levels (5). It has an action here comparable to amphetamines (6).

In the whole plant, this impact is qualified by the action of pseudoephedrine, the basis of a familiar decongestant medicine (e.g. Sudafed), which has more beta-adrenergic activity.

Although it is a banned in sports by the World Anti-Doping Agency (WADA) a recent meta-analysis (7) concluded that pseudoephedrine had minimal stimulant action, and is less hypertensive action than ephedrine. This means that blood supply to the skeletal muscle and periphery is increased, the bronchial airways are dilated, there is relaxation of the gut and reproductive musculature.

With the contribution of other constituents, e.g. alkaloids phenylpropanolamine (norephedrine), and cathine, as well as non-alkaloidal fractions that have demonstrated to be safer (8), this means that the whole herb does not have the same effects as the isolated ephedrine.

Dose levels in therapeutic use usually deliver less ephedrine than taken in isolation for weight loss or athletic performance. In traditional practice the higher doses in a range are generally applied to acute indications, in this case mostly fever management. Most herbal practice and traditional formulations provide ephedra at the lower end of the range, with modern western herbalists rarely prescribing more than 1g equivalent per day.

At this level the patient could be consuming between 10-25 mg of ephedrine equivalent. The highest therapeutic intake, for a high alkaloid yielding batch taken at maximum dose could be around 100mg per day. Doses under 50mg are not thought to raise blood pressure (9).

Clinical trials for ephedrine use daily doses ranging from 24-150mg. However commercial supplements can deliver many hundred milligrams.

Commercial decongestants like Sudafed deliver a dose of up to 240mg of pseudoephedrine, up to a hundred times that found in a daily dose of ephedra.

Even with a corresponding lower level of risk the herbal practitioner will be cautioned against the use of ephedra in cases of hypertension, a history of cardiovascular disease, and to use with care at the same time as antidepressant medication.

In 2001 the RAND Corporation (the USA’s largest independent health policy research organization, often used by government agencies) was engaged by the federal Agency for Healthcare Research and Quality to review the alarming increase in adverse case reports and litigation following the widespread use of ephedrine products in weight loss and athletic enhancement.

In 2003 Agency released the report of Rand’s Southern California Evidence-Based Practice Center (10) which concluded that there was evidence that these products are related to a two- or three-fold increase in side effects such as nausea, vomiting, jitteriness, and palpitations. Furthermore, the evidence suggested a link between these products and catastrophic events such as sudden death, heart attack or stroke.

RAND researchers based their findings on a detailed review of 52 clinical trials of ephedrine or herbal ephedra for weight loss or athletic performance in humans.

They searched the medical literature and other sources for both published and unpublished medical trials of the substances. They also analyzed more than 1,500 “adverse event reports” related to herbal ephedra and 125 such reports related to synthetic ephedrine-containing products, which were collected by the U.S. Food and Drug Administration. Researchers discovered 70 additional adverse events in the medical literature and received a computer file of more than 18,000 adverse events from Metabolife, a maker of ephedra products.

Paul Shekelle, the RAND and Veterans Affairs physician who headed the study noted that “with regard to catastrophic events, these findings are a strong signal that there is a link between use of ephedra or ephedrine and the occurrence of death, heart attack, stroke, seizures, and serious psychiatric symptoms…. It is more likely than not that there is a relationship, although the available evidence falls short of the conventional level of scientific proof.”

The RAND study also found some evidence of benefits of ephedra and ephedrine for weight loss. Dietary supplements containing ephedra, the drug ephedrine, and ephedrine plus caffeine promoted modest short-term weight loss, averaging about two pounds per month more than among people taking a placebo. However, none of the studies reviewed followed participants for longer than six months, less than the 12 months accepted as necessary to establish a drug’s value as a weight-loss aid.

Although many of the ephedra supplements and ephedrine products are taken for boosting athletic performance, researchers found no evidence that ephedra—and only a little evidence that ephedrine—enhances physical performance. They found no evidence that any of the products improve long-term physical performance among athletes or the general public.

I was invited on the Technical Expert Panel to review this report. Our reviews were recorded in the archives of the US National Institutes of Health, including my contribution.

“After reading the RAND report, my first impression is the following: What are we evaluating — ephedrine or herb ephedra? The latter is not a single-chemical entity and cannot be assumed to be ephedrine. Even assuming the herb ephedra in the literature is defined to contain specific dosage levels of ‘ephedrine,’ what efforts were made to ascertain that this ‘ephedrine’ is indeed ephedrine and not a mixture of ephedrine-type alkaloids, or, worse, different types of alkaloids that are also present in ephedra? Any study or report on a natural product (not just a single-chemical compound) must clearly define what the material under study or being reported is. I don’t see such a definition in this report. Despite the limited availability of useful data, this report’s conclusions regarding the efficacy of ephedrine (the single-chemical drug), in the presence and the absence of caffeine, in short-term weight loss and athletic performance, appears to be sound.“

This generated a reply from the authors that did not completely address the point.

“We agree that the lack of specificity is a problem. We have modified the conclusions to be more specific to only these herbal combinations studied. In the RCTs of herbal ephedra included in the efficacy analysis, the dose of ephedrine alkaloid was stated.“

On February 9, 2004, the US Food and Drug Administration (FDA) issued a final rule prohibiting the sale of dietary supplements containing ephedrine alkaloids (ephedra) because such supplements present an unreasonable risk of illness or injury.

Practitioners have continued to be grateful for the benefits of ephedra in the UK. However in recent years reliable supplies have been very hard to source.

Ephedra is included on a list of the Schedule 20 Part 2 herbs in the European Medicines Regulation 2012. These herbs may only be used by ‘qualified Medical Herbalists’ in their prescriptions and are not on General Sale. Other herbs on this list are:

• Adonis vernalis
• Aspidosperma quebracho-blanco
• Atropa belladonna (herba)
• Atropa belladonna (radix)
• Chelidonium majus
• Cinchona spp.
• Colchicum autumnale
• Convallaria majalis
• Datura stramonium
• Gelsemium sempervirens
• Hyoscyamus niger
• Lobelia inflata

Since the 2012 legislation there have been suggestions that the status of all Schedule 20 herbs will be reviewed.

The US experience of ephedra and ephedrine should provide us with a heads up … we should tell our story better.

1. J. Needham, L. Gwei-Djen, H. Hsing-Tsung (2013) Science & civilisation in China-Vol 6-1: biology and biological technology Cambridge University Press ed.
2. Yen Kun-Ying (1992) The Illustrated Chinese Materia Medica. SMC Publishing Taipei.
3. Mitchell C, Feng Y, Wiseman N. transl. (1999) Shang Han Lun on Cold Damage. Paradigm Publications, Brookline, Massachusetts.
4. Evans WC. (1989) Trease and Evans’ Pharmacognosy. 16th Ed. WB Saunders, London p 376
5. Hardman JG, Limbird LE, Gilman A. Eds (2001). Goodman and Gilman’s The Pharmacologic Basis of Disease. McGraw-Hill, New York.
6. Martin W R, Sloan J W, Sapira J D, Jasinski D R. (1971) Physiologic, subjective, and behavioral effects of amphetamine, methamphetamine, ephedrine, phenmetrazine, and methylphenidate in man. Clin Pharmacol Ther. 12(2): 245–58
7. Gheorghiev MD, Hosseini F, Moran J, Cooper CE. (2018) Effects of pseudoephedrine on parameters affecting exercise performance: a meta-analysis. Sports Med Open. 5;4(1): 44
8. Odaguchi H, Hyuga S, Sekine M, et al. (2019) [The Adverse Effects of Ephedra Herb and the Safety of Ephedrine Alkaloids-free Ephedra Herb Extract (EFE)]. Yakugaku Zasshi. 139(11): 1417-1425
9. Astrup A, Toubro S. (1993) Thermogenic, metabolic, and cardiovascular responses to ephedrine and caffeine in man. Int J Obes Relat Metab Disord. 17(Suppl 1):S41–3
10. Shekelle P, Morton SC, Maglione M, et al. (2003) Ephedra and Ephedrine for Weight Loss and Athletic Performance Enhancement: Clinical Efficacy and Side Effects. Rockville (MD): Agency for Healthcare Research and Quality (US); (Evidence Reports/Technology Assessments, No. 76.)

If we read all the safety threats in plants we might be too frightened to eat.  Wheat, rye, and barley contain a protein called gluten that is hydrolysed in the digestive system to a peptide alpha-gliadin, a well-established intestinal irritant, that has caused many thousands of deaths around the world through coeliac disease and sprue.

Apple seeds, and the kernels of apricots, plums and other stone fruits, as well as bitter almonds, contain glycosides that generate cyanide in the digestive system. Potatoes are members of the deadly nightshade family and produce the same poisonous alkaloids when they turn green under the influence of light.

Many common household pulses, like soya bean, red kidney bean, and haricot bean (used in “baked beans”), contain various toxins, notably types of lectins called phytohaemagglutinins, as well as trypsin-inhibitors, that can only reliably be neutralised by boiling for at least 30 minutes.

Of course the foods listed above are generally safe to eat. The real point is to show how difficult it is to predict the toxicity of a plant only from the presence of toxic constituents. The action of the whole plant, and the way in which it is normally consumed, counts for more than any individual constituent list. We will see here that for the most widely used plant remedies there are similar reassurances.

A key reason why people turn to herbs appears to be the assumption that they are free from side effects, “not like those drugs”.

On the other hand medical opinion is generally that any medicine that is effective must also be a risk, that it is impossible to have effects without side effects, that if herbs are claimed to be free from side effects they cannot then be effective at all.

Paradoxically, this aligns with the idea of the person being seen as a whole: the living body is so complex, so intricately interwoven that any intervention at one site may spark off reactions at other sites.

Yet we restate the principle that herbs are safer than conventional medicines. We refer to the uninterrupted use of the most established remedies by millions of people since prehistory. Even today the major herb formulations sold in health food shops sell in millions of units per year with remarkably few problems. There have also been extremely few cases of malpractice litigation brought against herbal practitioners (a fact reflected in the very low level of professional insurance premiums).

If we are right, how can we be both safe AND effective? These questions may be resolved if we look again at the nature of our remedies and the way they may work.

The remedies we use represent only a tiny proportion of available plant species around the world. It is certain that humans through history moved to using those plants that were quickly effective with minimum adverse effects. Short-term safety at least is built in to these millions of human experiences through the ages.

Further the benign qualities of these herbs arise from their complexity. The existence of tannins, mucilages, saponins, or other constituents in different ways buffer or modulate the effect of more active constituents, which are often in any case present in only low levels.

It is after all the essential feature of herbal pharmacology that the whole package has potential that no isolated principle can mimic.

Most importantly the whole thrust of treatment with plants is different from that of conventional medicine. The herbs are used ideally to nudge healing responses in the body rather than directly attack the symptoms or pathology.

A bitter stimulates digestive activity, a hot spice the digestion and circulation as well; laxatives provoke bile, bowel and urinary elimination; expectorants, diuretics, hepatics and lymphatics produce their own detoxifications, and so on. We trust the body to look after its affairs and seek only to help it on its way without disturbing it unduly.

If that is after all our claim, what is the evidence that our remedies are inherently safe to use?

There are two potential sources of safety information about any medicine:

• Toxicological research, usually from animal studies
• Reported adverse effects from actual human use:
  • Published clinical reports
  • Post-marketing surveillance of herbal medicines

Animal studies are still widely used to assess the safety of conventional medicines in spite of commitments to find reliable alternatives. In various parts of the world and over many decades herbal remedies have also been screened in this way and the evidence is available in the scientific literature. This generally shows that herbs are relatively safe, especially on oral consumption, with any adverse effects mostly tied to very high doses and injections.

Medicine manufacturers are generally required to pass on adverse effects reported to them and in some European countries doctors also have to report adverse drug reactions (ADRs) to the authorities. These post-marketing surveillance (pharmacovigilance) schemes also include herbs where they are categorised as medicines.

Most countries of the world pass their ADRs (as well as miscellaneous poisoning reports) to the WHO Uppsala Monitoring Centre in Sweden. In 2006 their director Ralph Edwards reported (2) that they had received 3.6 million ADR reports from around the world. Of these over 41,000 (1.1%) had listed a herb and just over 17,000 (0.5%) had listed one as ‘suspected’.

The reported ADRs most often associated with herbs were generally minor and transient symptoms: itching skin, urticaria and rash, nausea, vomiting, abdominal pain and diarrhoea and dyspnoea. “Very rare” serious symptoms included facial oedema, angioedema and anaphylactic shock, hepatitis, purpura, thrombocytopenia, Stevens Johnson syndrome, convulsions, erythema multiforme and circulatory failure.

Most herbal ADRs per head of population arise from France and Germany where herbal medicine is part of the mandatory reporting system and where the true level of herbal ADRs relative to those of synthetic drugs might be clearer; yet even here the levels of reports are very low.

Where local research has been conducted, including in Asian countries where herb use is more widespread, a proportion of 1% of all adverse medicine reports keeps recurring. Even allowing for the relative inefficiency of ADR schemes this figure is reassuring. Another way to see the relative hazard involved with herbal and other natural supplements is to look at overall deaths involved compared to other causes. The following chart compiles mortality data from all 27 European member states (view the full size chart here).

When we look more closely at the adverse effects that have been published we see that they can fit into five main categories.

Some plants medicines are dangerous when used incorrectly. A few were used as arrow poisons in days when much food was sourced by hunting. One of these, foxglove, is the origin of digoxin, a very widely prescribed medicine for a failing heart.

Others like mandrake, bryony, aconite have been used in carefully prepared dosages in traditional medicine as well. Opium has been the most widely used pain relief since antiquity but is well known to cause problems in long term use and high doses.

These are plants whose effects are more like conventional prescriptions: with both positive effects and negative side effects or adverse effects. These often contain strong phytochemicals called alkaloids which can have activity on the nerves, heart and other susceptible tissues.

Other examples include the alkaloids of tobacco, lobelia, nux vomica, henbane, belladonna and stramonium.

Powerful toxic or near toxic activity from plants include blocking parasympathetic (or cholinergic) activity (eg the nightshades), damaging the liver (eg. pyrrolizidines alkaloids found in ragworts, comfrey, borage and coltsfoot – see also section on long-term safety), the kidney (eg aristolochia, amaranthus, colchicine), and increasing sensitivity to light (eg. excessive doses of St Johns’ wort).

There are a few plants restricted for sale to the public that herbal practitioners are permitted to use with careful dosing and application. These include poke root, lobelia, mistletoe, greater celandine, lily-of-the-valley, and ephedra. There are no reported adverse reports following such professional use.

The main safety concern with toxic plants is accidental consumption through foraging or by children, of plants such as hemlock, hogweed, deadly nightshade, arum lily, oleander, delphinium, bryony, laburnum, mandrake, mistletoe and columbine. National poisons units hold information about treatment and antidotes if such exposure has occurred.

Inferior products are the most common causes of reported herbal adverse events.

Unfortunately there have always been perverse incentives for providers of medicinal products to doctor their wares. A classic and ancient example is ‘wetting’: a grower or gatherer paid by weight will be tempted not to dry the plant completely as even a couple of extra percentage points of water can substantially increase its weight.

Unfortunately any dampness in stored ‘drugs’ (from the old European word drogen meaning ‘dried plant’) can encourage mould and associated toxins. Finding creative ways to make up orders or prices were to be expected. Harsh penalties for providing poor quality medicines were recorded as far back as ancient Egypt and throughout the mediaeval world, and as Jacob Bell, the founder the Royal Pharmaceutical Society of Great Britain, noted in 1841: “In reviewing the history of pharmacy in all ages we find that fraud has always prevailed to a remarkable extent”.

In response to such experiences, the supply of conventional medicines around the world is tightly controlled by ‘pharmaceutical standards’ of manufacture, involving detailed quality control and associated paper trails, with independent inspections, sometimes unannounced, as the ultimate sanction. In a few jurisdictions the supply of herbal remedies is as tightly controlled (‘herbal medicinal products’ in Europe and ‘therapeutic goods’ in Australia). 

Medicinal standards are published in official national reference texts called ‘pharmacopoeia’. These set agreed definitions and analytical standards required to meet pharmaceutical standards. The early pharmacopoeia were largely devoted to plant drugs (Valeriana officinalis is one of many botanical plant names that reminds us that the plant was ‘official’ in the pharmacopoeia). Many herbs are still listed in pharmacopoeia (e.g. the European Pharmacopoeia, British Pharmacopoeia and those of China, India and elsewhere).

There are also specialist references, the British Herbal Pharmacopoeia and the American Herbal Pharmacopoeia that provide rigorous monographs not covered in the official texts. Manufacturers may choose to use these standards to assure the quality of their products. There are some voluntary assurance schemes aim to apply similar standards, eg, the British Herbal Medicine Association’s HerbMark, that is rolling out for herbal practitioner suppliers.

Most herbal remedies on the market are supplied as food supplements. These are required to meet local food hygiene laws, have accurate labelling, recommended consumption levels, and appropriate allergen and information regarding safe use (eg in children and pregnancy). In the UK enforcement is provided by local trading standards offices and inaccurate information relating to allergens and other known risks renders the supplier liable to other legal measures. These are safeguards when purchasing herbal supplements from responsible manufacturers.

However the buyer needs to beware of less reliable sources.

Compromised quality in herbal products can come about through contamination, adulteration or substitution:

• Contamination is the (often unintended) presence of other materials, including soil and related matter, soil-based heavy metals (some herbs, eg St John’s wort, bacopa, and gotu kola naturally accumulate these and need closer testing before entering the market), infective organisms or pesticides, all these most often due to loose quality controls. Testing for these is a key part of normal herb manufacturer quality control; of course sourcing herbs with organic certification is one way to reduce the pervasive contamination of all the food chain with pesticides.  Recently specific controls have been widely instituted to reduce contamination of herb crops with ragworts containing high levels of hepatoxic pyrrolizidine alkaloids.
• Adulteration is the intended addition of different materials to enhance appearance or intended effect: this can include pigments, isolated phytochemicals like polyphenols, or in modern times even synthetic drugs like steroids. In some early traditions heavy metals were added to plants to increase potency and this is still found occasionally.
• Substitution is when the plant is not what is labeled, either in error, due to linguistic confusion, or to reduce cost or when there is limited availability.

A notable example of the latter is the Chinese herb Aristolochia fangchi which has long been a commercial substitute for Stephania tetrandra (mandarin name: hang fang ji).

Unfortunately its constituent aristolochic acid has been associated with serious kidney damage in Europe, notably when the substituted ‘stephania’ was administered by doctors as part of a conventional intensive dieting regime in Belgium, with many suffering cancer and terminal kidney failure. This single episode in the early 1990s led to a major review of herbal quality in the UK and other countries. A similar occurrence followed widespread substitution of skullcap by a species of germander (Teucrium chamaedrys) and associated cases of liver toxicity reported in France.

Another substitution example relates to black cohosh, which has been identified as linked to a cluster of severe liver complications; however suspect products were found to contain a different species entirely. Unfortunately adulteration of this valuable plant is common.  In general the more expensive or in-demand the herb, the more likely it is that it will be substituted. Golden seal and ginseng are other classic examples.

Ginkgo leaf is often adulterated with added polyphenols and there are reports of adding pigments to sometimes substituted products marketed as elderberry and bilberry.

The best protection against consuming contaminated, adulterated or substituted herbs  (and where there is no external quality controls) is to buy only from reliable and well-established producers, with transparent quality control measures, and reputations to protect. Avoid buying from suppliers you do not recognise and particularly so if these are marketed over the internet. In general if the product is surprisingly cheap it should be avoided.

There are three types of adverse reactions that cannot be predicted, but which can occasionally have serious consequences.

Intolerance

Intolerance is the least severe and is an exaggeration of the activity of the substance in a few individuals. It is more likely to occur with foods than herbal remedies. With foods it is sometimes erroneously referred to as ‘food allergy’: however this is a much less common immunological reaction (see below).

Allergic/hypersensitivity reactions

Allergic or hypersensitivity reactions are dramatic over-responses of one part of the immune system associated with surface defences (perhaps originally targeted against parasites). They involve activation of a type of white blood cell (the mast cell) to release histamine and other inflammatory chemicals, and also the development of immunoglobulin (Ig) E antibodies.

Hayfever (in response to pollen) is the most common, but true allergies can be to almost anything. In the case of food substances such as gluten or lactoglobulin from milk they are often ‘masked’ so that the direct cause-effect connection can be difficult to make. Dangerous frank hypersensitivity reactions are increasingly recorded to peanuts, shrimps and other crustaceans.

Among conventional drugs such reactions are most likely with NSAIDs, angiotensin-converting enzyme (ACE) inhibitors and antibiotics. Very rarely these can include herbal remedies, with members of the daisy family (Compositae, including chamomile and echinacea) and mugworts among those most encountered. By definition the reaction once established is almost instantaneous.

Confusingly the term “allergic” is sometimes used to describe immune-related idiosyncratic reactions, when toxicity appears after several asymptomatic administrations of the compound (see below).

Idiosyncratic drug reactions (IDRs)

Idiosyncratic drug reactions (IDRs) are rare, unpredictable reactions to a substance that are not dose related and usually are delayed (although rapid on re-exposure). They include complex immune responses and are caused by the combination of a reactive metabolite of the substance with cellular proteins, and the production of DNA adducts. Symptoms can be severe and include anaphylaxis, fever, skin reactions, arthritis and lupus syndrome. Blood tests often show increased levels of eosinophil white blood cells. A notable type of IDR involves the liver and can closely mimic viral hepatitis.

IDRs account for most of the rare severe herbal adverse reactions. The observed liver problems that were associated with taking standardized kava-kava were probably idiosyncratic (Our safety book included a detailed case-by-case analysis of these reports and showed in forensic detail how misleading most were, concluding that the few clear cases were idiosyncratic rather than toxic, and incidentally giving a clean bill of health to traditional water extracts).

Some conventional drugs, eg antiepileptics and antidepressants, are more likely to induce IDRs and there seem some chemical types more likely to do the same in plants: kava contains one such group, lactones, and they occur also in the germander responsible for the French cluster of liver disease reported earlier.

IDRs are rare and unpredictable and generally do not suggest inherent toxicity. However, this has not stopped prohibition of kava across UK and Europe and risks to the availability of black cohosh (even with adverse effects linked to an adulterant – see above). If there is a cluster of IDRs (as can happen for several reasons) then the fate of any herb involved can be threatened.

There is always the possibility that two ingested substances will interact in their metabolism within the body. This is particularly likely in the liver: here there are many complex mechanisms for processing any molecules that are not core food materials.

Notable among these are cytochrome P-450 (CYP450) enzymes, a hierarchy of 14 enzyme families in the liver and most organs and tissues of the body. They are almost as adaptable as the body’s immune system and are designed to be able to metabolise an almost infinite range of molecules that might be taken in from the environment.

Such foreign molecules (sometimes referred to as xenobiotics) include medicines, and also most plant chemicals. Their metabolism includes engagement in complex dynamics with the hundreds of enzymes involved. Each CYP450 substrate can also inhibit the enzyme acting upon it, or by contrast can induce it, so that its effect on other molecules is changed.

One classic example is grapefruit. This is known to inhibit two enzymes: CYP2A6 and CYP3A4. The latter breaks down a wide range of medicines, including blood thinners, anti-cholesterol, heart and blood pressure medicines, anti-depressants, antihistamines, viagra and contraceptives, and notably anti-HIV and immunosuppressive drugs. In other words taking grapefruit at the same time as these medicines will reduce their breakdown rate and increase their activity in the body.

By contrast St John’s wort induces CYP3A4, so increasing the breakdown rate of the same medicines above. This means their effects may be reduced and St John’s wort remains the herb that doctors most worry about for its unintended potential for compromising the activity of sometimes critical medicines.

Low levels of interactions of these types are common between medicines and foods. Simple foods like garlic, brassicas, red wine and many common culinary spices can all interact with CYP450 enzymes and affect the availability of prescription medicines. However the key point is that most of these are:

1. Theoretical interactions (mostly observed in the test tube)
2. With very little reported evidence of impact in the real world

Additional scope for interactions lie with the physical properties of some plant constituents. Plant tannins, mucilages, saponins, and resins can theoretically slow absorption from the gut; hot spices may increase it. However again the real impact is doubtful and in any case food is more likely to be concern than herbal remedies.

Serious herb-drug interactions are probably rare. This is the view of all those in the regulatory field who have watched the surveillance data closely over many years. However many modern medicines are very strong and are used in critical situations. The challenge is that powerful prescription medicines may also have a ‘narrow therapeutic window’: problems can occur if they are either over- or under dosed. If one is on a such a regime it is important to be careful to monitor the effects of taking other medicines, herbs and foods.

Most reported reactions to herbs are not a threat to health, nor long term. Minor reactions to herbal treatment are quite common, especially at the beginning of a course of treatment.

There is an ancient precedent here. In the past herbal treatments were often robust and even unpleasant, to reflect the fact that they were often emergency medicine. Nowadays the emphasis is on supportive herbal treatments but in bringing about healthy changes in the body it is not surprising that there may be associated discomforts.

However the majority of such changes are transient and minor, including diuresis, changes in bowel performance, more productive coughing to clear an obstructed chest, or more sleepiness. It is also possible to see ‘healing crises’: short-term flare-ups in skin or headache symptoms, transitionary increases in menstrual symptoms.

Practitioners usually include calming components into their initial herbal blends to reduce the tendency of some conditions to exacerbate but a few people’s constitutions are trigger-happy.

The placebo effect is noted in controlled clinical research trials among subjects taking the sham treatment. Surprisingly, placebo benefits can occur in any proportion of a treatment group, from almost none to most, depending on the condition and circumstances. Distilling much debate on this, placebo can best be seen as a testament to the powerful healing forces that the body has, and how little it sometimes takes to mobilise them. It also suggests that providing support and reassurance can exert real physiological effects on the body.

However placebos can also generate significant levels of adverse effects. This is referred to as the nocebo phenomenon. In one review of placebo-controlled trials involving healthy volunteers, adverse responses were reported in almost a fifth taking placebo, increasing up to a third on repeated dosing. Overall the most frequent adverse reports were headache, drowsiness, and energy loss. In another review of studies of five different medications in the areas of cardiology, neurology/psychiatry, metabolism, and gastroenterology, it was shown that the placebo side effect profile was largely similar to the side effect profile of the active treatment.

It appears that having expectations of adverse effects from taking a medicine is more likely to lead to their happening (doctors should never say “there is nothing more we can do”). It also seems that people with anxieties can more easily generate physical symptoms. If nocebo effects can happen to dummy pills then they will feature after any remedy. Most practitioners will know patients who react badly to almost anything they are given.

Whereas we can be reasonably confident that short-term (‘acute’) side effects will have been well understood over thousands of years of human experience, we can not be so sure about the possibility of long-term (‘chronic’) consequences. Delayed effects of a substance can be hard to connect if they occur many years later, even with modern databases and record keeping. It is almost unimagineable that such connections would have been possible in the past.

The types of long term problems that might follow exposure to hidden ‘iceberg’ dangers include cancers, chronic inflammatory and auto-immune diseases, and chronic liver and kidney problems. However there is not much evidence that plant ingredients of any sort are linked to such conditions. Most evidence of connection comes from epidemiological observations of the effect of diet, lifestyle and environmental exposures.

For example the International Agency for Research on Cancer, part of the World Health Organization lists about 200 known or probable carcinogens, including coal tar, asbestos and processed meat. The only plants that make the list are Aristolochia (see above), betel nut and tobacco.

Some individual plant constituents have demonstrated mutagenic or carcinogenic activity in the laboratory or in animals (an example is the isolated compounds estragole and methyleugenol variously found in fennel, nutmeg, basil and tarragon, and coumarin found in Cassia cinnamon) but the case that these are dangerous to humans is contentious and  there are only limited measures to restrict access to the plants that contain them. Exposure to some dietary ingredients (like gluten, animal products) has been linked to inflammatory and immunological problems. However the case against dietary plants is very limited.

There is one part of the body relatively vulnerable to untoward impacts of some plants: the liver. As we have seen this is central to the metabolism of non-dietary constituents, including from plants. The very things that can be valuable as medicines can pose extra work for liver metabolism, this compounded by excess alcohol consumption, fatty diets and prescription or other medication.

Some of the most serious rare idiosyncratic adverse effects linked to plants, such as to germander, kava, and black cohosh (or substitute), also lead to chronic hepatic damage and consequent health problems in later years. This risk, even if rare, has led to such plants being widely restricted. However the rarity means that the risk of trouble to most plants is considered to be too small to present a public hazard.

However one case demonstrates the need for caution. Pyrrolizidine alkaloids (PAs) are a group of constituents in many plants, including ragworts, comfrey, borage and coltsfoot. Most of their toxicity data comes from animal studies and indicates that some PAs are hepatotoxic, genotoxic and carcinogenic. There are also human case reports of poisonings due to PA-containing plants, including deaths associated with grain crops contaminated with PA-containing weeds.

PA poisoning in humans is characterised by acute hepatic veno-occlusive disease. The acute disease is associated with high mortality, and a sub-acute or chronic onset may lead to liver cirrhosis. There is more information on PAs in our article “Pyrrolizidine alkaloids: What you need to know“.

Because some of the plants involved have been valuable remedies there has been resistance among the herbal community to restrictions as these particular plants have not yet been linked to harm and there is reasonable doubt about the dangers of all PAs. However others have taken the view that the risks and uncertainties do not adequately reassure the public that taking these plants is safe and have voluntarily stopped supplying them.

As far back as the early 1980’s the root of comfrey in internal remedies was withdrawn from trade catalogues for this reason (it remains an excellent external healing remedy). Most concluded that this was a case was not worth fighting, given a significant risk to the public, and a mode of action and delay that meant trouble could not be safely ruled out.

Be cautious with herbs during pregnancy and breastfeeding

There are always extra cautions in taking any remedies during pregnancy and a professional herbalist’s default position is to back off altogether during the first trimester (while the baby’s organs are forming) unless really necessary. Practitioners will not use strong herbs at all during pregnancy and any listed as risky elsewhere in this article should particularly be avoided. Many reference texts on herbs assume that if a herb has not been proved to be safe in pregnancy it should be avoided, without medical opinion at least.

On the other hand many herbs have a good combination of widespread use by pregnant women with reassuring research evidence: our textbook rates many western herbs by tight criteria and finds many a pregnant woman can choose from.

There is evidence that regular consumption of large amounts of licorice through pregnancy might interfere with the birth and even embryonic development. This effect is linked to the hormonal properties of licorice (inhibition of an enzyme that converts cortisol to cortisone). The available evidence is that a safe to take up to 6 g of (or up to 250mg of glycyrrhizin) per week during pregnancy. If there is associated high blood pressure (e.g. pre-eclampsia) liquorice should be avoided altogether.

Although precautionary statements have been made about the use of some herbal remedies during breastfeeding the evidence for risk is minimal. Plants with high levels of volatile oils will pass these easily through breastmilk so nursing mothers should be aware that these may affect their babies. This can actually be helpful, as in the case of reducing colic in infants by the mother consuming kitchen spices (although occasionally the reverse can happen). Some of these have additional reputations for enhancing breast milk production.

Don’t overdo it!

In traditional medicine herbs were often taken in ‘heroic’ doses for maximum short-term effect and at much higher levels than are usually applied today. Nowadays doses may range from 0.25g-100g/day, with most in the lower range consistent with their use as supportive and gently nudging remedies. This provides a good margin of safety.

There are some cases where higher doses can present problems. Obviously all the risky herbs mentioned above are very dose sensitive. If you have high blood pressure you should restrict your licorice consumption to a few grams or less a day.

You should avoid huge regular doses (more than 30g a day) of some of the spices like fennel with high estragole and methyleugenol content. Be particularly aware of dosing if you are also on prescription medicines with a narrow therapeutic window.

However common sense should prevail and the best advice is to observe recommended doses. Using herbs as part of our everyday diet, like chamomile, ginger and peppermint, or a sprinkle of a spice or herb on our food is, of course, completely safe.

When using herbs more  ‘medicinally’, in general one should always be looking for an exit plan in starting a herbal programme: the best herbal treatment is one that nudges the body to better performance. However there are some situations where long term use is needed, for example, adaptogenic herbs have incrementally benefit into the long term.

But, as we have seen, we cannot be absolutely sure what long term effects might build up and focused use of herbs is always the best option. Do review what your plan is if you are taking the same herbs for more than a year. It is always a good idea to have a break within this time to check that the herbs are still being useful.

Be sensible and all will be well.

1. Mills S & Bone K (2005) The Essential Guide to Herbal Safety. Elsevier/Churchill Livingstone, Edinburgh.
2. Ralph Edwards, Director, WHO Collaborating Centre, Uppsala. Reporting to Pharmacovigilance of herbal medicines: current state and future direction London 24-26 April 2006.

Doses for sweet

• Low: Restores homeostasis
• Medium: Nourishes vata nervous system, has a mild laxative action and cools pitta via its anti-inflammatory effect
• High: Calms the CNS, alleviates vata and relieves pain whilst also aggravating kapha

Doses for sour

• Low: Stimulates the appetite but may aggravate pitta acidity
• Medium: Moistens dryness and benefits undernourished vata but aggravates pitta inflammatory tendency
• High: Contracts the organs

Doses for salty

• Low: Stimulates digestion and can aggravate pitta acidity
• Medium: Moistens dryness but can aggravate kapha tendency to fluid retention and is a mild laxative thus benefiting vata‘s tendency to dryness and constipation
• High: Breaks accumulations, can cause vomiting and diarrhoea and aggravates all three doshas

Doses for pungent

• Low: Stimulates digestion and increases digestive fire agni
• Medium: Stimulates circulation, penetrates the tissues and can aggravate pitta acidity
• High: Causes sweating, dries sticky ama and dries fluids, therefore aggravating vata and pitta

Doses for bitter

• Low: Stimulates digestion, clears stagnant kapha and awakens the nervous system
• Medium: Detoxifies the liver and blood
• High: Drains downwards through the bowel and bladder, cools the system, clears pitta, slows digestion and aggravates sensitive vata

Doses for astringent

• Low: Cleans the mucus membranes and clears kapha and pitta
• Medium: Holds tissues and organs in place
• High: Binds and constricts the movement of blood, liquids and prana in the channels, thus aggravating vata

Adults (12-60 years old)

Medicinal tea hot infusion (Phantha): 30-60ml of a 1:8 infusion 3 x daily. This means 5g of herbs in 40ml hot water infused with a lid on for an hour. Another method is a 1:16 ratio; soak 30g dried herbs in 500ml freshly boiled water and leave to infuse for 4+ house. Very good for nutrient dense herbs such as Nettles, Red clover, Clovers etc. For a regular cup of supportive herbal tea the ratio is 1:100 (2g in 200ml).

Medicinal tea cold infusion (Hima): 30-60ml of a 1:6 infusion 3 x daily. This is useful for mucilagenous plants such as marshmallow root and some aromatics.

Medicinal tea hot decoction (Kvatha): 30ml of a 1:16 reduced to 4 parts 3x daily. This method is best for roots, resins – and generally ta good way to take herbs. Main method used in Traditional Chinese Medicine and Ayurveda.

Pills / tablets / gugguls: 250-500mg 2-3 x/day

Tincture: Average dose of 1-15ml of a 1:5 ratio 3x/day or 1-9ml of a 1:3 ratio 3x/day. A good method to extract a broad range of the polar and non-polar compounds from flavonoids to volatile oils to fatty-resins. Most common method used by Western herbalists and phytotherapists.

Children (5 – 12 years old)

There are some specific rules for determining dosages for children. Age is one consideration, weight is another, and physical constitution is another. Slight or frailer vata-like children require less. Heavy or robust more kapha-like children can use more. Use your intuition and their weight as guides. Dr. Clark’s Rule is very helpful:

To determine the appropriate fraction of an adult dose, divide the weight of the child in kilos by 75. Example: 25Kg child divided by 75 = 1/3. Therefore the child’s dose is 1/3 of the adult dosage.

Another method is Cowling’s dose: Divide the age at the next Birthday by 24 to determine the fraction of dose.

Rules of thumb doses for children:

• 12-year-olds get an adult dose
• 6-year-olds get ½ an adult dose
• 3-year-olds get a ¼ adult dose

While pharma engaged in intensive research and developments on new, patented drugs, and was forced to spend more and more money on both safety and efficacy trials required by licensing authorities, its earlier research on nutrients was largely abandoned.

The companies continued to manufacture and sell vitamins and minerals, and the one-a-day multi-vitamin and – mineral supplement became the norm on many a breakfast table.

These products, like their counterparts today, were seen largely as daily insurance for the prevention of deficiency diseases like scurvy, beriberi, pellagra and rickets.

But during the 1960s and ‘70s, an aspiring group of scientists, doctors, naturopaths, hippies and all-round natural health nuts—basking in the new-found freedom of the flower power generation—decided it was time to take this work out of mothballs and bring products to market. These individuals went on to establish some of the first US food/dietary supplement companies—or nutraceutical companies, as they are commonly referenced in the USA.

Many of these are still in existence today in the USA, some of which trade in Europe and beyond. Not only were these nutraceuticals marketed as a means of preventing deficiency diseases, they were also seen as an alternative to pharmaceuticals. The products were purportedly natural and were promoted as working with the body, hence few or no side effects.

As the nutraceutical industry developed, it took a greater interest in other healthcare traditions, such as Ayurveda and Unani from the Indian subcontinent, traditional Chinese medicine (TCM) and Kampo from Japan. These traditions were of course not reliant on synthetics, nature-identical or otherwise. They used a diverse range of naturally sourced ingredients, especially from plants, but also ones derived from microorganisms, fungi, minerals, animal organs, seaweeds and the like.

Increasingly, the US nutraceutical industry took on-board elements from both the East and the West. This represented the start of the East-West fusion phase of the natural products industry—one that is still very much alive and well today.

While the nutraceutical industry continued to grow in the USA during the 1970s and ‘80s, Europe quietly continued much as it had before. Pharmaceuticals became the primary choice of most when it came to treating diseases and infections, while simple multi-vitamins and -minerals, cod liver oil and other essential nutrients were available and widely used to maintain general health, and prevent deficiency diseases.

Where natural product traditions were existent prior to the pharmaceutical boom, these traditions continued and evolved, but were seen as appropriate only for minor ailments, the serious stuff being the sole domain of by-now Big Pharma, and its ‘miracle drugs’.