Joanna Blythman
Saturday September 14, 2002
The Guardian
You feel shivery, your back aches, the glands in your throat resemble
golfballs; it's only a matter of time until your nose starts streaming. What
do you do? You could visit your doctor's surgery and brave a waiting room
full of people who are in as bad a state as you, or worse, and wait
patiently for a five-minute consultation with your pressured GP - only to be
told that it's probably viral and you should go home to bed, or be given
antibiotics that you most likely don't need. Alternatively, you used to be
able to head for your local healthfood shop where, at no cost to the
creaking, over-burdened NHS, you could get free, and often lengthy, advice
from a helpful member of staff who would recommend an affordable combination
of vitamin C, echinacea and zinc, a safe, over-the-counter supplement found
to be effective by millions of users.
If you're one of those who find such remedies useful, however, you'd
better start stockpiling now. A raft of EU legislation looks set to nip the
natural medicine market in the bud: soon, that popular vitamin C, echinacea
and zinc combination may not be allowed on the shelves. A shadow looms large
over the alternative health sector. Estimates of the impact of this new
legislation vary, but hundreds of vitamin and mineral supplements could be
banned outright, while an as yet incalculable number of common herbal
remedies will disappear unless consumers challenge it. The National
Association of Health Food Stores claims that as many as three-quarters of
its members could go out of business. The writing is on the wall for small
British supplement companies, which will be forced to reformulate entire
ranges and invest massively in applying for new product licences.
It's a scenario that is hard to take in. In recent years, so many more
consumers have been turning to the health store in preference to the
doctor's surgery that it had begun to seem a permanent fixture in modern
life. Though there may still be the odd simple soul who believes that eating
a clove of garlic can cure cancer, all sorts of perfectly sensible people
who want to take greater personal responsibility for their health are
finding solutions, or partial ones, at least, in natural remedies. Arthritis
sufferers tired of conventional anti-inflammatory drugs that upset the
stomach are looking to alternatives such as glucosamine sulphate and
chondroitin. People prone to anxiety are choosing kava kava over Valium.
Those who feel depressed are going for St John's wort in preference to
conventional anti-depressants such as Prozac. Menopausal women are seeing
black cohosh as an attractive alternative to hormone replacement therapy.
The hungover take high doses of vitamins B and C (eg, in the popular Berocca
tablets). This surge is reflected in the media. Conventional "doctor knows
best" columns have been eclipsed by alternative practitioners with a
proactive attitude to health and a range of natural, nonpharmaceutical
suggestions for the treatment of everything from cold sores to migraine.
All this interest is despite the fact that evidence of how - and, indeed,
if - these remedies work is open to interpretation and incomplete. Some
supplements are relatively well researched - two major epidemiological
studies have shown that vitamin E supplements, for example, can reduce the
incidence of heart disease by about 40%, while a substantial body of
research suggests that antioxidant vitamins protect against certain
diseases.
For other more obscure supplements, however, relatively little
conventional medical research has been carried out, so evidence of efficacy
relies more heavily on traditional usage. Much of the scientific work into
rhodiola rosa, for example - a herb that is thought to make the body more
resistant to stress - has been carried out in Russia, and a lot more
research is needed to confirm the benefits that are claimed for it. Even so,
it seems that growing sections of the public can live with this sort of
uncertainty. More people are voting with their feet and concluding that
alternative remedies work as well, or even better, than conventional drugs,
with fewer, if any, side effects. But that option could be taken away
altogether if the new EU legislation goes ahead unchecked.
The attack comes from four different pieces of legislation, one of which
is already in force, another approved in principle. All are couched in the
now familiar EU language of consumer safety and free trade. Currently, the
UK, the Netherlands and Ireland have a far more permissive attitude towards
supplements than other member states, and make available a wider range of
higher-dose remedies. This approach is in line with those in the US,
Australia, New Zealand and Canada. But those days are numbered. The idea
behind the new regulations is that, irrespective of whether you are a
healthy Cretan, living on fish, multiple fruit and vegetables and
monounsaturated olive oil, or a typically sun-starved Brit, existing on
nutritionally impoverished processed food, you should have the same range
and strength of supplements at your disposal.
Attack number one comes in the form of the Food Supplements Directive,
which will set maximum levels for vitamins and minerals. Currently,
consumers in the UK can buy high-strength vitamins in dosages that are way
above what's known as the recommended daily allowance (RDA). Far from being
a formula for good health, however, the RDA is simply the minimum dose you
need to prevent nutritional deficiency. RDAs were developed during the
second world war, to ensure that soldiers did not get sick. Now, modern
research into the positive health properties of vitamins and minerals is
focused on safe upper levels, or "suggested optimal nutrient allowances" (SONAs),
much larger doses that actively promote health, rather than simply prevent
disease. The difference between the two is vast. The RDA for vitamin B5, for
example, is just 6mg, but consumers in the UK can currently buy it in 550mg
doses; and arthritis sufferers take it in doses as high as 1g-2g, and find
it efficacious. Meanwhile, in most other European countries, a much more
restrictive range of vitamin and minerals, based on the RDA, is available. A
likely EU consensus might set limits at only two or three times the RDA,
representing a liberalisation for most European countries, but decimating
the choice available to the British consumer.
This "framework" directive has already been approved in principle by MEPs,
most of whom were effectively voting as if writing a blank cheque; now that
the full implications of the directive are emerging, however, many of those
same MEPS are reported to be "flabbergasted". The all-important detail - the
setting of new upper limits and an agreed "positive list" of nutrients -
will be decided next spring. So far, some 300 popular nutrient forms from
which thousands of supplements are derived are not listed. "This will wipe
the most popular and effective higher-dose vitamins and minerals off the
shelves," says Sue Croft of Consumers For Health Choice, the group that
successfully campaigned between 1997 and 1998 against the proposed ban on
higher-dose vitamin B6. "Millions of people will have their choices
restricted or taken away."
The second attack takes the form of the Traditional Herbal Medicinal
Products Directive, which says that herbal remedies can only be licensed if
they can be shown to be safe and produced to high standards. That sounds
reasonable enough - until you learn that herbal remedies will be licensed in
the same way as drugs. A company making garlic capsules, for example, will
have to go through many of the same regulatory hoops as a company producing
a new pharmaceutical drug. Estimates for the cost of getting these herbal
licences vary from £10,000 to several million pounds a product. This would
almost certainly deter all but the largest companies from producing remedies
such as St John's wort, kava kava, gingko biloba, red clover, rhodiola,
evening primrose oil and ginger. There is no prospect of several
manufacturers pooling resources to get an ingredient licensed, because each
company's formulation will be treated as individual.
Furthermore, to get a licence, a specific product must have been on the
market for 30 years, 15 of which must have been in Europe. The effects of
that time bar are dramatic. Black cohosh, for example, an oestrogenic herb
traditionally used by native Americans, has demonstrated results superior to
hormone replacement therapy in the treatment of menopausal symptoms, with
women who take the herb reporting fewer adverse events, even than those
taking a placebo.
But black cohosh has only been available here for around five years, so,
like any product introduced since 1973 - in other words, the most
cutting-edge herbal products - it will become illegal. As yet unknown herbal
remedies might never even see the light of day in Europe. "This is highly
restrictive and racist," says Patrick Holford, founder of the Institute for
Optimum Nutrition. "It could wipe out hundreds of really useful herbs, not
on the basis of consumer protection or science, but on the basis of
geography - herbs that have been used safely for hundreds of years in the
Americas, Africa, India and China." In addition, any combination of herbal
and vitamin/mineral products that natural medicine practitioners believe
work better in synergy than apart, such as vitamin B6 with evening primrose
oil, will be banned.
There's a third prong to the attack, in the form of the Novel Foods
Directive, which is already in force. This was originally designed to
control genetically modified foods and new, so-called "functional" foods,
such as fish oil-enriched bread, but is now being applied to absolutely
everything that is sold under food law. Any food product (which includes
supplements) that was not on the EU market before May 15 1997 can only be
granted approval after submission of a dossier containing huge amounts of
technical and safety data. So far, a herbal sweetener and an immune
system-boosting tonic have already been forced off the shelves as a result,
and next in the line of fire is MSM, an increasingly popular organic sulphur
that has been found to be effective in the treatment of joint problems. What
makes these developments even more worrying is that there is no appeals
process under this directive.
The final attack seems on the surface to be an innocuous tidying-up of
the EU Medicines Directive. But, in fact, it will mean that anything with a
physiological action can be reclassified as a medicine - and under EU
definitions, that means that any product sold in a health store, even herbal
tea, could be deemed to be medicines, while items such as coffee and
grapefruit juice (which also have proven physiological effects, but which
are sold in food shops), will not be affected. So much for Hippocrates, who
said, "Let food be your medicine." The new EU laws will say that a product
must be either one or the other.
The authority in the UK charged with drawing this line is the Medicines
Control Agency (MCA), yet it has a direct interest in classifying
supplements as medicines - it earns 95% of its budget from licensing the
latter. MCA committees are filled with doctors whose experience lies in
conventional medicine. Many of them are either employees of pharmaceutical
companies or are beholden to them for research grants. By contrast, the New
Zealand government recently decided that its equivalent of the MCA is not
qualified to consider natural reme-dies, while in Australia the Traditional
Medicines Evaluation Committee made up of natural medicine practitioners,
suppliers and scientists and applies different criteria to supplements than
those it applies to conventional drugs.
Faced with this onslaught of hos-tile legislation, the UK natural health
industry is smarting at what it sees as the breathtaking injustice of it
all. A key principle of natural medicine is the Hippocratic requirement
primum no nocere , or "first, do no harm". At the moment, supplements are
sold under food law, which means they have to be as safe as a loaf of bread.
The MCA already has the power to remove from the market any supplement it
considers to be dangerous. Conventional pharmaceutical drugs, on the other
hand, are sold on a costs versus benefits basis, the thinking being that the
beneficial effects of the drug should be balanced against its risks. Side
effects are simply an accepted part of the pharmaceutical package.
"There has never been a death due to vitamin and minerals in the UK,"
says Holford, "but thousands have been caused by conventional drugs. The
risks are completely different." Or, as John McKee, who runs Hanover Health
Foods in Edinburgh, puts it: "You can go to any petrol station and buy
enough paracetamol to kill yourself. It's very hard to commit suicide in a
healthfood store."
Yet EU commissioner David Byrne insists that the aim of the legislation
is to "assure consumers that these products are safe and that doses
available are not excessive and potentially dangerous". This echoes the
long-running demonisation by the orthodox medical establishment of natural
health practitioners as a bunch of cranks and charlatans, hawking useless
and potentially deadly products to a gullible public.
If you believed recent headlines, then fears over kava kava, the
traditional Polynesian remedy for anxiety, seem to lend weight to that
viewpoint. "Shyness remedy ruins your liver!" screamed the London free paper
Metro last December, and throughout the media reports appeared that kava
kava had been linked to 30 cases of liver failure and death in Germany. The
MCA put pressure on health stores not to stock it, and it was promptly
voluntarily withdrawn; it has been off the shelves ever since. Kava kava's
future is now in the hands of the MCA and the Food Standards Agency (which
has gone as far as issuing it with a health hazard warning), and a proposed
permanent ban is out for consultation. The MCA claims that there is
"significant existing evidence of hepatoxicity".
But delving into the details of those so-called casualties, the case
against kava kava is deeply unconvincing. Most of the victims were already
taking pharmaceutical drugs known to be toxic to the liver, and many were
elderly heavy drinkers who had already abused their livers. "The vast
majority of these cases involved hepatoxic drugs or alcohol," says Holford.
"Of the remaining nine, five have spurious relevance to a safety assessment
of kava kava for one reason or another, and four do not provide enough data
to know if it was kava kava causing the problem." Holford, along with Dr
Hyla Cass, associate professor at the University of California's school of
medicine, has carried out a detailed review, which is consistent with the
longest running study of kava kava to date, reported in 1997 in the journal
Pharmacopsychiatry, which concluded that, "in contrast to both
benzodiazepines and antidepressants, kava kava possesses an excellent
side-effect profile".
"The MCA's double standards are abhorrent," says Holford. "A large number
of published safety and toxicity studies clearly indicate that kava kava is
far safer than conventional pharmaceutical anti-anxiety and antidepressant
prescription drugs."
The MCA's cautious approach to kava kava contrasts with its attitude to
the commonly prescribed family of drugs called Selective Serotonin Reuptake
Inhibitors (SSRIs), of which Prozac is the best-known example. These have
been blamed for suicides, murders and even mass murders in the US, and are
the subject of ongoing litigation. In the UK, however, the MCA has resisted
putting a warning on them. "The MCA liaises with pharmaceutical companies to
decide what warnings might be appropriate," says Dr David Healy of the North
Wales department of psychological medicine, who has been petitioning the MCA
to issue some form of general warning. The drug firms, however, argue that
patients on SSRIs are already high suicide risks, and that the warnings that
accompany the medication are sufficient. "These are big players with
tremendous incentives to defend their product," says Healy. "Small companies
fighting off restrictions on herbs are at a disadvantage. They are small,
they don't have exclusive ownership of the herbs, so they have less reason
to do so, and they don't bite back."
Speculation is rife in the natural medicine world about the extent to
which pharmaceutical interests are orchestrating legislation. Back in 1987,
the Campaign Against Health Fraud (Healthwatch) waged an aggressive public
campaign against natural remedies, financed initially by medical insurance
and drug companies. Similar campaigns were waged in the US and Canada. And
in the 1990s, there was a series of well-publicised attacks on food
supplements. Now, there's a persistent rumour that PR agencies working for
drug firms are spinning stories to the media, casting doubt on the safety
and efficacy of natural alternatives.
Drug companies have a proven track record in trying to legislate the
natural health business out of existence. In 1996, for example, the
Ecologist magazine revealed that, when the Codex Alimentarius (the World
Trade Organisation body that sets international standards for drugs, food,
supplements, etc) met, the German delegation put forward a proposal,
sponsored by three German pharmaceutical firms, that no herb, vitamin or
mineral should be sold for preventive or therapeutic reasons, and that
supplements should be reclassified as drugs. The proposal was agreed, but
protests halted its implementation.
That same lobby now seems to be powering EU legislation. According to the
UK department of health, the impetus for the Traditional and Herbal
Medicinal Products Directive came from the European commission's
pharmaceutical committee. "No one is saying that the natural health industry
does not need regulation," says Holford. "It has grown from a small niche to
a major market sector. But this legislation is draconian. UK consumers now
have experience of many years of safe and effective usage. They don't want
supplements forced off the shelves or available only in ludicrously low
doses."
And if consumers can no longer buy that helpful supplement in the health
store, they may simply source them from unregulated internet suppliers. It
might lead, say, to a new variant on the clothes shopping trip to New York:
UK consumers who can afford it might go on supplements trips to stock up on
remedies that are freely available in the US, but banned or unavailable
here.
Surprisingly, in the 1980s the policy of the US Food and Drugs
Administration was to reclassify supplements as medicines. This even led to
a farcical situation in which armed FDA officers would raid clinics looking
for illegal caches of vitamins. But public protest forced a change, and
since 1994 the US has had a statute that guarantees both free availability
of supplements and information about how they work. Similarly, in Canada,
doctors in the 1990s were being struck off for prescribing vitamins and the
government reclassified hundreds of herbal remedies as medicines. Following
public outcry, however, they were all later declassified.
In the UK, when the government tried to withdraw higher-dose vitamin B6,
it met with a similar reaction. Many MPs were staggered by the sheer volume
of well-informed mail, and B6 was saved - at least until now. And the
natural health sector hopes that it can play the same card again, with the
same results: "There is still time to force changes to this ruinous
legislation," says Croft.
To that end, healthfood stores are tooling up with Save Our Supplements
petitions and leaflets, while celebrities such as Elton John, Cliff Richard
and Paul McCartney have weighed in with support. The ranks of regular health
store users are being mobilised. As consumers begin to realise the extent of
the attack on natural remedies, the hope is that they will simply not stand
for it. And heaven help any politicians who try to come between articulate
OAPs and their glucosamine sulphate or angry hormonal women deprived of
vitamin B6 and evening primrose oil
Consumers For Health Choice can be contacted by email at enquiries@healthchoice.org.uk
(www.healthchoice.org.uk).