Germany

By Andy Eckardt
NBC NEWS

MAINZ, Germany - Herbal remedies are an integral part of mainstream medicine here, where they are reviewed as drugs and often prescribed by doctors. Many health advocates say it's a model that the United states can learn from.

UNLIKE in the United States, where dietary supplements are not systematically evaluated for safety or effectiveness, Germany has a government-appointed panel of experts known as the Commision E to evaluate herbal remedies for safety and "reasonable" efficacy - a standard that requires there be some evidence to support a therapeutic use even if large clinical trials haven't been conducted.
Producers of herbal remedies in Germany also must meet manufacturing standards to ensure the purity and quality of their products.
Safety reviews and quality controls have translated into public-health benefits. According to the German Drug Agency, headquartered in Bonn, there have been no reports of deaths caused by the use of herbal remedies, also known as phytomedicines, since the Commision E system was implemented.
"Since 1978, we have taken several thousand phytomedicines off the German market after studies found dangerous health risks with these products," says Konstantin Keller, a pharmacist with the German Drug Agency. "In 1981, for example, we excluded all products that contained aristolochia,a substance that is known to cause cancer."

Armed with the knowledge that approved botanical products are safe and may help patients who, like in the United States, are often eager to take them (about 65 percent of Germans use herbs), as many as 80 percent of German practitioners prescribe these remedies. Insurers reimburse for about 40 percent of herbal medicine prescriptions, which are dispensed by pharmacists.
Most doctors who prescribe herbal remedies do so for minor conditions such as colds, stomach upset and sleeping disorders. One of the most popular herbal remedies is St. John's wort, which is widely used to treat mild to moderate depression.
"Physicians rarely turn to these medicines for the treatment of serious organic diseases because they often lack the standards of commonly accepted evidence-based medicine," says Bruno Mueller-Oerlinghausen, chairman of the drug commission for the German Medical Association in Cologne.

While U.S.medical schools have only recently started offering courses in botanical medicine and American doctors typically know very little about these therapies, board exams for German doctors include questions on plant-based therapies.
Some herbal products are available over the counter, usually in weaker strengths than those that are prescribed.

LONG HISTORY WITH HERBS

German law has dealt with herbal medicine since the beginning of the 20th century. Starting in 1901, herbal products were registered but not evaluated for safety or effectiveness. In 1978, a medical law known as the Arzeneimittelgesetz required scientific testing of herbal remedies, and the government appointed a Commission E to evaluate the available data. The panel is composed or two dozen experts, including doctors, pharmacists, toxicologists and representatives of the pharmaceutical industry.
A German manufacturer processes St. John's wort.
By 1994, the Commission E had prepared a list of monographs, which detailed therapeutic uses, dosage, side effects and other information for 254 herbal remedies that it had approved. Data was gathered from various sources, such as clinical studies, patients records, epidemiological data, laboratory studies and reference works.
While these monographs are widely considered to be the most comprehensive information on herbs anywhere, some of the material is now out of date and needs to be revised to reflect the latest research.

Another criticism is that some herbal remedies sold in Germany still have not received Commission E approval because they were on the market prior to 1978 and the commission has not had the opportunity to review them yet. But Keller estimates that all old herbal remedies will receive proper evaluation by the end of 2004.

Despite it's flaws, many American experts believe the United States would benefit from such a panel to review herbs and other supplements for safety and effectiveness.
"We've been calling for years that there shoud be a Commission-E type system," says Mark Blumenthal, founder and executive director of the American Botanical Council, a nonprofit herbal research group in Austin, Texas.
In 1998, Blumenthal published " The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines," the first English translation of the commission's work. Last year, he released an updated version entitled "Herbal Medicine: Expanded Commission E Monographs."

Andy Eckardt is a producer for NBC news in Mainz, Germany. MSNBC'S Jacqueline Stenson contributed to this report.