[Second Opinion] "Dahan-dahan sa dahon-dahon"

by Gideon Lasco
Philippine Daily Inquirer 

We Filipinos have a rich heritage of herbal medicines. Long before Dr. Nelia Maramba’s pioneering research and the Department of Health’s “Sampung Halamang Gamot,” Filipinos have been using herbs as remedies. In my own research, I encountered pine needles being used for contraception in the Cordilleras, kamangyan as treatment for asthma in Leyte, and the popular tawa-tawa for dengue all over the country.

In some way, this is good because many of our common ailments do not really require medication. Most cases of cough and cold, for instance, will get better even without any treatment, and patients end up attributing their recovery to whatever they were taking — be it an antibiotic, a vitamin, or an herbal medicine. Moreover, beyond a placebo effect, many herbs have very real benefits, as more and more scientific research is revealing.

But our soft spot for herbal medicines is being capitalized upon by various companies to sell all kinds of products. Some of these products actually have very little “herbs” in them: Dr. Bryan Lim, an infectious disease fellow at the Philippine General Hospital whose quip inspired the title of this piece, laments that some “herbal” powders promising to treat diabetes actually make it worse because they’re mostly sugar.

Others, while having actual herbs, are marketed as wonder drugs that can cure all kinds of diseases. Despite disclaimers of having “no approved therapeutic claims,” these products often come with implicit and explicit claims that even some radio newscasters attest to: a different way of being bayaran.

What’s more worrisome is when these herbal products are being presented as cures for serious conditions, particularly cancer. It is bad enough that patients are made to pay for unproven therapies, but what makes it worse is when these products take patients away from proven treatments that could have saved their lives. Any kind of therapy has an opportunity cost, which is often missed out in people’s decision-making processes.

Finally, there is also a chance they can cause actual harm. Contrary to the public’s perception that herbal medicines are largely harmless, they can be overdosed — and they do have side effects. Herbal supplements, considered technically as “food” but are often taken as medicine, remain a regulatory grey area, making it hard to ensure safety.

The appeal of herbs, of course, comes from the long-held idea that “nature heals.” To a certain extent, there is truth to this: A nutritious diet, coupled by a healthy lifestyle, can certainly make a big difference to our health. The industrialization of food and today’s sedentary lifestyles, on the other hand, have undeniably contributed to the rise of noncommunicable diseases.

But we must also bear in mind that the past was no Garden of Eden. Even when everything was “organic,” people had cancer, and it cannot be denied that modern medicine, with its vaccines, antibiotics, and novel technologies, has saved millions, if not billions, of lives.

On top of this discourse of “natural vs. artificial,” the appeal of herbs lies in the power of testimony. For scientists to be able to say something conclusive, they demand rigorous clinical trials—not just anecdotal evidence or animal studies. For many, however, a blog post can be more convincing—and celebrities more authoritative. Desperation, of course, can predispose people to cling to false hopes.

Having said all that, I have to stress that we should be open to the potential of herbal medicines, and thus support further research to validate their uses. But what we should be against is making false claims and raising expectations as to what they can do. Toward this end, government agencies and medical societies should be vigilant and critical in the way certain products are advertised. (This, by the way, also applies to pharmaceuticals — but that’s for another piece.)

Meanwhile, we must strive to create an environment of critical thinking: one that will empower the public to make informed health choices. When it comes to herbal medicines—as with all kinds of promised cures — a dose of healthy skepticism will go a long way.

Originally published in the Philippine Daily Inquirer: http://opinion.inquirer.net/105378/dahan-dahan-sa-dahon-dahon

Cancer and the merchants of hope

“Sayang ang mga buhay.”

Thus was the lament of my colleague, a medical oncologist, who confided to me her frustration over cancer patients who seek alternative treatments: “They would come in the early stages, and we would advise surgery and other treatments. But instead, they would resort to unproven kinds of alternative medicine, from cabbage leaves to mangosteen tablets. As expected, these treatments didn’t work and they would come back months or years later, at a higher stage. By then, the treatments are much more expensive. Had they opted for treatment early on, it would cost them much less - and their cancers could have been cured.” 

She concludes: “These ‘No approved therapeutic claims’ treatment modalities and their advertisements should really be regulated.”

***

My colleague, whose request to remain anonymous underscores the sensitivity of this matter even among oncologists, raises insights that are worth reflecting upon, in light of the growing incidence of cancer - the third leading cause of death in the Philippines. What is the role of alternative medicines in cancer treatment? What benefits and dangers do they have, and what factors lead patients to choose them over biomedicine? 

To be fair, we must note that there could be a “selection bias” at work here: Doctors are unlikely to encounter the "success stories” of alternative medicine: they will not come back for follow ups. Instead they will be blogging and telling people about how they recovered. Indeed, patients can be “cured” by other means. In fact, even without any form of active intervention, some cancers can just disappear: “spontaneous regression” is a rare but well-documented phenomenon in the scientific literature. In real life, however, cancer is rarely left alone; people attempt various kinds of treatments, and when they do experience some improvement, in the absence of a definitive explanation, they will attribute it to something specific: the religious to divine intervention, the healthy eater to diet, the MLM networker to the pill or a product that they could better sell.

Nonetheless, while testimonials can magnify these miracles, statistics show a dire picture: without biomedical treatment, most people progress through the stages of cancer. In one Canadian study for instance, the 5-year survival rate was 86% for breast cancer patients that accepted conventional cancer care and only 43% for those who didn’t.

The lack of evidence for their claims, however, has not stopped people from marketing all kinds of products as cancer treatments. Some manufacturers trumpet on the wonders of a single herb, while others claim to gather all kinds of curative herbs in one tablet. Many of them make use of scientific terms (i.e. “antioxidants”, “cytokines”) to sound authoritative, invoking laboratory and animal studies that are scientifically insufficient but are convincing enough for the general public. 

They will also be advertised as “FDA approved”, as if it were an endorsement, even though the FDA only registers supplements as a matter of procedure and makes no actual evaluation of the products themselves or their claims. 

Finally, many alternative medicines are promoted as harmless vis-a-vis the well-known side effects of chemotherapy. Left unsaid is the fact that supplements, too, can have side effects and more importantly there is a heavy opportunity cost of each day that goes by without getting proven treatments. 

It is worth mentioning that others go even further, offering not just unproven treatments, but unproven diagnostic tools, using dubious methods such as special urine and blood tests, oftentimes with “high-tech”-looking devices. By “diagnosing” someone as having “cancer”, these quacks can then offer a treatment that is sure to work, as there was no disease in the first place. 

 

***

Complementary and alternative medicine (CAM) must be taken seriously for a number of reasons. Firstly, biomedicine should never shut its door to new knowledge. Vincristine and vinblastine - derived from an periwinkle long used in India and China as an herbal medicine - are now important anti-cancer drugs. Immunotherapy - once set aside in favor of immunosuppression - is showing promising results and is now an exciting avenue for research. Indeed, CAM shouldn’t be generalized as ineffective. Moreover, while biomedicine’s paradigm is treatment, other forms of healing focus on prevention, and their view that modernity itself - our diets, lifestyles, and environments - has become carcinogenic is something that we must seriously consider.

Secondly, the health care system should see these alternatives as symptoms of its own problems and shortcomings. Perhaps it is not able to allay people’s fears and misconceptions about the causes of cancer and its treatment options (i.e. surgery, chemotherapy, radiotherapy). For people who fear cancer, taking supplements has “symbolic efficacy” in assuring themselves that they are doing “something” about their perceived risk. Perhaps, too, the cost of cancer treatment remains - or is perceived to be - prohibitively expensive to many Filipinos. Surely, better PhilHealth coverage will relieve patients of the hesitation brought about by the threat of financial ruin (On a positive note, the Z-benefit package is a step towards this direction). 

Finally, alternative medicines speak of the toothlessness of the Food and Drug Administration in controlling the ways in which supplements and other products are marketed. Disclaimers such as  “No approved therapeutic claims” and the newer “hindi ito gamot” (This is not a drug) are meaningless when drowned by imagery and language suggest otherwise. While the FDA has done a great job in issuing public advisories against false claims, the fact that these claims are even allowed in advertisements underscores the need to give the FDA more regulatory teeth - and inter-agency support.

Ultimately, however, the decisions will have to come from cancer patients and their families. While it is easy to dismiss them as gullible or irrational, we must understand that they are caught in desperate situations in which there is nothing more attractive than hope, something that Western medicine itself cannot offer in clear and reassuring terms. 

Until a cure for cancer is discovered - or unless we step up efforts towards information dissemination and regulation - the search for alternatives will go on, and “merchants of hope” will continue to profit from people’s desperation and hopelessness. 

(Originally published in Rappler on December 2, 2016)