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The Pharmaceutical Journal
Vol 269 No 7226 p778
30 November 2002

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Selling nature’s remedies — a challenge to professional credibility

By Terry Maguire

Terry Maguire a community pharmacist in Belfast

As I watched the early morning television news feature I felt saddened but, pulling myself together, I then thought I was just being too naive and unnecessarily cynical. "A new remedy is showing promise in the treatment of arthritis in dogs," said the slick anchor man. The "new" remedy ? New Zealand green lipped mussel ? was being endorsed as if it were a major medical breakthrough. Confusingly, it was being received with the excitement and prominence normally reserved for major advances in cancer chemotherapy. As the feature progressed I awaited the citation from a learned journal ? Nature, the BMJ or perhaps JAMA. None came, just endorsements by way of anecdotes from animal lovers sharing the joy of what this "natural" product did for their much loved pooch.

Some years ago in this journal, myself and Professor Alain Li Wan Po looked at the evidence for the efficacy of a range of "natural remedies", including the NZ green-lipped mussel (PJ, 26 May 1990, p640). For most there was little proof that they worked. For some there existed a few small, inconclusive, poorly designed studies and these amateurish offerings were used with unashamed deception to support clinical effectiveness. Since that time any available evidence has been reported and indeed the Pharmaceutical Press has published a useful book 'Nutraceuticals'. It documents that some good evidence has been amassed for a few agents in a small number of conditions. I must say I like the name "nutraceuticals". It is more wholesome and much less cynical and dismissive than the name that was used for them — "parapharmaceuticals".

But let us be honest, the majority of products have no supporting evidence at all. I found plenty of a type of endorsements from charming people, for example, Mrs Smith from Surrey, who claimed to have been bedridden for years but since trying "product X" now hoped to perform her own version of Riverdance at the local church hall. OK, this was only in some extreme cases.

Of course these products are registered as foods and whereas the product cannot be accompanied by any medical claims ? this would be illegal without a marketing authorisation from the Medicines Control Agency ? these claims appear elsewhere: in books, in magazine articles, on the radio and on television. This is not science; this is marketing, and skilful marketing by any standard. Students of marketing will easily recognise how well these products are sold to the public using the classical 4Ps ? the basis of the marketing concept.

P1 is for Promotion These natural remedies are promoted by a "champion". The champion may be a personality ? the more famous the better ? but above all he or she must be caring, charismatic and erudite, the sort of person you would trust your granny with.

P2 is for Product The product will be offered in a form — a tablet, capsule or tincture — that strongly suggests that it is a true medicine. The word "natural" will be stamped all over it. The public, of course, associate "natural" with "safe". The problems with Chinese herbals, kava and St John's wort have done nothing to alter this widely held opinion.

P3 is for Price These natural products must attract a premium price. If they are cheap as chips then how can they work? The price is usually around ?20 for a course. This is the oldest trick in the book. Someone foolish enough to spend ?20 on 20 capsules needs to ensure that they prove to others that they got some value for their money. In short the high price convinces them that the remedy worked ? it is a central component of the placebo effect.

P4 is for Place And it is here that my main problem exists. The place where any manufacturer of natural medicines wants to sell his or her product is in a community pharmacy. What better endorsement than that from one scientifically trained and professionally qualified!

So here is my problem. Could it be that through ignorance and complacency we are co-conspirators with these companies in a huge public deception, a deception that is being worked on some of the weakest members of our society?

Many sensible pharmacists will argue that this view is nothing short of nonsense. They will claim, and perhaps rightly so, that the natural movement in the UK and beyond is encouraging a more informed, patient-centred approach to personal health and the management of diseases. (And, anyway, the Prince of Wales himself endorses it.) They will also argue that, where such products are available in pharmacies, at least then there is a possibility that the patient, where a serious condition is suspected, can be referred for proper investigations. There is much merit in this latter argument. I allow the sale of a small range of these natural medicines in my pharmacies. I do not promote them or encourage their use and I and my staff are frank and honest when advising on their safety and efficacy. When selling we treat them as if they were over-the-counter medicines asking appropriate questions.

My concerns is, not so much that pharmacies are an increasingly the most common place for buying natural remedies, it is that pharmacists are getting too caught up in their promotion. This presents a huge challenge to our professional credibility. How can pharmacists argue for a more pivotal and responsible role at the heart of primary care when we are actively flogging remedies with the clinical efficacy of 19th century snake oil?

Recently I experienced great discomfort when attending a multiprofessional training event. Pharmacists mingled with general practitioners and practice nurses as we learned of current best practice in the management and treatment of raised blood pressure. Following an excellent lecture from an eminent cardiologist, the chairman asked the audience for questions. A GP asked a searching question about ACE inhibitors that was skilfully addressed by the speaker adding to everyone's understanding. Next a pharmacist asked if the speaker had any experience with use of garlic oil in the management of BP. The speaker was polite and claimed to have no experience or knowledge of its use in the manage of raised blood pressure but he had heard that it might have a positive effect on serum cholesterol. The pharmacist, not happy with the negative response, suggested he considered looking into it. The chairman, noting the speaker's irritation, moved on. GPs in the audience gave each other knowing glances and I and some other pharmacists wished we were somewhere else.

I have no doubt that there is a place for natural remedies (nutraceuticals) ? some have marketing authorisations and I applaud those manufacturers who have taken this route. However these are few and far between. In a health service committed to safety and efficacy and the use of evidence based medicines, we need to be better informed, more objective and less brainwashed by marketing gurus. If we want the respect that we deserve we need to work and act like scientists.

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