A case for Herbal Medicine and herbalists!

Herbal medicine and herbalists seem to get a lot of bad press though deaths and incidences of adverse reactions are relatively few. Most of these incidents are due to people self medicating or to adulteration of herbal products. Death or adverse reactions caused by herbal medicine prescribed by a qualified practitioner are so few as to be non existent. This does not mean that all herbs are safe, but the proper herb taken at the proper dosage for the right length of time in general has only positive effects. Herbalists are trained professionals who are registered with professional registers, hold professional indemnity insurance and undergo constant training (CPD – continuous professional development). Herbalists support regulation and believe in quality and standards, but to date I believe we are living up to all of our responsibilities but do not seem to be getting any of the rights or recognition that should be within our scope. With the new regulations it seems that herbalists are not recognized as experts in their own field. St John’s wort may only be prescribed by medical doctors and making herbal medicinal products unless you can afford to hire a 6 year trained pharmacist is not an option. Throughout out all the regulations a pharmacist or medical doctor without any training in herbal medicine is recognised as a qualified person where a herbalist is not, herbalists have to be the only professionals who are not recognized as authorities in their own area of expertise. There is still debate as to whether a herbalist will be counted as qualified for a third party prescription service. A third party prescription service is where a prescription is made up specifically by a third party under the direction of a herbalist for their client. Taking into account that a herbalist is qualified to make remedies for their own clients I cannot see any reason why there is any debate as to whether they are qualified to make up a prescription on the request of another herbalist. It is issues like this that has compelled me to write this article. Herbalist are dedicated to their work, it is a vocation, an obsession with plants and their benefits. People do not turn to herbalism as a career for the good of their own health, there are no great holidays, bonuses, company cars, you are self employed wondering if you can pay the bills. Neither do you do it for respect nor recognition as ‘Quack’ still seems to be the prevailing attitude. At times I think the worst possible thing for your health is to be a self employed herbalists! So why do we do it, because we believe in the proven therapeutic power of plants and want to use this knowledge to restore our patients to health. Herbal medicine as a system of medicine, it is as old as the human race, since the beginning of time people have used herbs as medicines. Archaeological studies at Shanidar in Iraq have shown that Neanderthal man, living over 60,000 years ago had at least a basic pharmacopoeia. Studies

have shown that 7 of the 8 species of plant found at the burial site are still commonly used as folk medicine throughout the world. (yarrow, marshmallow, groundsel, centaury, ephedra, muscari). . In each country we have our own herbal tradition which is as individual to us and as much part of our culture as our language, dance and spiritual belief. Herbalism has survived to this day because it was the medicine of the people, the knowledge part of daily life. In fact, up until the 20 Th. Century, every village and rural community had a wealth of herbal folklore. Tried and tested local plants were picked for a range of common health problems, even as late as the 1930’s, around 90% of medicines prescribed by doctors or sold over the counter were herbal in origin. If we lose this information, we will lose a wealth of knowledge that could save lives and help maintain health. I believe we should be working towards a positive future that preserves this knowledge and which incorporates it into our modern medicinal system. It is estimated that around 70,000 plant species have been used for medicinal purposes. Biomedicine still relies on plants rather than the laboratory for at least 25% of all its medicines and many of these are amongst the most effective of all medications. In general the herbs provide for the synthesis of conventional drugs. Such as Digoxin, which is used for heart failure, which was isolated from common Foxglove and Quinine for Malaria. If we dismiss or try to suppress herbal medicine what other life saving medications will not be developed? I and most herbalists believe in integrative medicine and that both allopathic and herbal medicine can be used together with very positive benefits. We hear a lot about negative interactions but not a lot about positive interactions, herbs and medications can support each other and many herbs can be used in conjunction with medications to negate the side effects of the medication. If a particular medication damages the liver but is in itself lifesaving then a herb such as milk thistle known for its positive effects on the liver can be used to protect against liver damage. My own children are a perfect example of integrative medicine, my twin girls were born at 31 weeks, it was an emergency caesarean section, no amount of herbs could have saved their lives or kept them alive for the following weeks, this was due to medical intervention and the fantastic pediatricians and nurses in the hospital. However, one especially had weak lungs and without herbal intervention would have definitely ended up being asthmatic. To date they have never suffered any lung problems and are happy, healthy 4 year olds. I personally believe that allopathic and herbal medicine has a very positive future whereby we can combine the best of both worlds for our patients benefit. Modern Research or Traditional Use: Instead of OR, I would prefer AND! In recent years more modern research is being done, this has made for some interesting reading as the traditional use is described in modern scientific terms.

However (and correct me I have overlooked something) but I have been unable to find one new use for any of the herbs other than verification of their traditional uses. I have been playing with this for a while (but I have not researched everything) by looking at Culpepper 1645 and his description of the medicinal uses of plants, then looking up the same plants and research done on them on Pubmed a research site, I have as yet been unable to find anything new just confirmation of what Culpepper said. To illustrate the point, I have extracted some information on Dandelion. Nicholas Culpepper "It has an opening quality and, therefore, very effectual for removing obstructions of the liver, gall bladder and spleen and diseases arising from them, such as jaundice and hypochondriac. It openeth the passages of the urine both in young and old; powerfully cleanses imposthumes and inward ulcers in the urinary passage and by it’s drying and temperature doth afterward heal them. For this purpose the decoction of the roots or leaves in white wine, or the leaves used as pot herbs are very effectual. And whoever is drawing towards a consumption or an evil disposition of the whole body called cachexia shall find it a wonderful help. It also procures rest and sleep to bodies distempered by the heat of ague fits or otherwise. The distilled water can be drunk in pestilential fever and be used as a wash for sores. This common herb hath many virtues, which is why the French and Dutch eat them so often in the spring." Research from PubMed Taraxacum--a review on its phytochemical and pharmacological profile. Schütz K, Carle R, Schieber A. Institute of Food Technology, Section Plant Foodstuff Technology, Hohenheim University, August-von-Hartmann-Strasse 3, D-70599 Stuttgart, Germany. This contribution provides a comprehensive review of the pharmacologically relevant compounds of Taraxacum characterized so far and of the studies supporting its use as a medicinal plant. Particular attention has been given to diuretic (openeth the passages of urine), choleretic (It has an opening quality and, therefore, very effectual for removing obstructions of the liver, gall bladder and spleen and diseases arising from them, such as jaundice and hypochondriac), anti-inflammatory (as a wash for sores)., anti-oxidative, anticarcinogenic, analgesic (as a wash for sores), anti-hyperglycemic, anticoagulatory (as a wash for sores) and prebiotic effects Culpepper: ‘And whoever is drawing towards a consumption or an evil disposition of the whole body called cachexia shall find it a wonderful help.’

Research that supports Culpeppers use of dandelion for cancer and cachexia. Dandelion (Taraxacum officinale) flower extract suppresses both reactive oxygen species and nitric oxide and prevents lipid oxidation in vitro. Hu C, Kitts DD. Food, Nutrition and Health, Faculty of Agricultural Sciences, University of British Columbia, 6650 NW Marine Drive, Vancouver, BC, Canada V6T 1Z4. Lipolysis and lipid oxidation in weight-losing cancer patients and healthy subjects Sonja D. Zuijdgeest-van Leeuwena, J.Willem O. van den Berga, J.L.Darcos Wattimenaa, Ate van der Gaasta, G.Roelof Swarta, J.H.Paul Wilsona and Pieter C. Dagneliea a From the Departments of Internal Medicine II and Oncology, Erasmus University Medical Center Rotterdam, Rotterdam; and Department of Epidemiology, Maastricht University, Maastricht, The Netherlands. Anti-carcinogenic activity of Taraxacum plant. I. Takasaki M, Konoshima T, Tokuda H, Masuda K, Arai Y, Shiojima K, Ageta H. Kyoto Pharmaceutical University, Japan. Culpepper: "It has an opening quality and, therefore, very effectual for removing obstructions of the liver, gall bladder and spleen and diseases arising from them, such as jaundice and hypocondriac. Taraxacum officinale protects against cholecystokinin-induced acute pancreatitis in rats. Seo SW, Koo HN, An HJ, Kwon KB, Lim BC, Seo EA, Ryu DG, Moon G, Kim HY, Kim HM, Hong SH. Department of Pharmacology, College of Oriental Medicine, Kyung Hee University, Seoul, South Korea. Cholagogue: Dandelion has long been used to stimulate bile secretion. Animal data: In German studies, dandelion leaf extracts increased bile secretion by 40% in rats. In French studies, giving dogs a decoction of fresh dandelion root doubled their bile output. This is just an example as I believe that though the language is old the theories and medicinal applications still hold true. Scientific language, research and methodologies have always changed and adapted with time but it does not mean that all that came before should be rejected as nonsense. In years to come will scientists read the above scientific reports and reject them because the language is archaic?

I am an East West herbalist and this to me means I am privileged to be in a position to study both the old traditions and the western sciences, I am fascinated with both and see the integral benefit of all. I would never wish to portray a them or us scenario, however herbal medicine has been shown in such a bad light that I feel it should be put into context. With so much out there that is permitted in our food and cosmetics causing ill health and disease, it my sense of unjustness that has propelled me to try and redress this imbalance. How can ingredients such a parabens in our cosmetics and aspartame in our food be allowed, where so much scientific data exists which proves their hazards, and then effectively ban St. John’s Wort where a patient information leaflet would suffice. Yes, it is contraindicated with medications but surely in a society where we trust the public to take paractemal we could also trust them not to take St. John’s wort if taking medications. At this time St. John’s wort is only available by prescription from a medical doctor. St. John’s wort is a very useful herb not only used for its anti-depressant properties. Its other properties include alterative, antiviral, astringent, anodyne, antibacterial, cholagogue, nervine, vulnerary, anti-inflammatory, antispasmodic, expectorant, antiviral, sedative and vulnerary. Externally it is used for nerve pain, burns, hemorrhoids, herpes, neuralgia, sciatica, wounds and varicose veins. Besides depression, St. John’s wort is also used for anxiety, fatigue, jaundice, neuralgia, rheumatism, ulcers, dysmenorrhea, flu, herpes, viral infections, HIV and AIDS. A herb with so much to offer is now unavailable; don’t its benefits outweigh a concern that could be sensibly dealt with? In the case of drugs with numerous side effects, their benefit is deemed to outweigh any serious adverse reactions. Are the same principles applying to all? The proper herb taken at the right dosage for the right length of time with all contraindications adhered to has more chance of healing than hurting a person. Herbal medicine has at its essence the ability to heal people, and herbalists such as myself want herbalism to move forward in its entirety, keeping the traditional and incorporating the scientific, with a full range of herbs available to a practitioner so as to provide the best care to their patient. I would also like to see this available to the public who have for generations used herbal medicine as folk medicine. This can be done safely through a publically available safety database, patient information leaflets and trained personnel available for advice.

The Facts: Adverse Reactions Allopathic compared to Herbal medicine. To be fair the statistics are also relative as many more people use allopathic medicine than herbal medicine and a lot more statistics are available in relation to allopathic medicine. Nonetheless, a sizeable amount of people worldwide do use herbal medicine and according to the World Health Organisation, 60% worldwide use herbal medicine: In China, traditional medicine accounts for around 40% of all health care delivered. In Chile 71% of the population, and in Colombia 40% of the population, have used such medicine. In India, 65% of the population in rural areas use Ayurveda and medicinal plants to help meet their primary health care needs. In developed countries, traditional, complementary and alternative medicines are becoming more popular. For example, the percentage of the population that has used such medicines at least once is 48% in Australia, 31% in Belgium, 70% in Canada, 49% in France and 42% in the United States of America Adverse Reactions Herbal Medicine World Health Organisation • The WHO Monitoring Centre issued a summary of reports on adverse reactions of herbs worldwide over a 20 year period. The total number of adverse reactions reported worldwide was 8984. This figure works out at 449 incidences reported annually worldwide. They also observed that combinations of herbs seemed to cause fewer adverse reactions than single herbs. The reported adverse reactions for herbal combinations were only 368 this is only 4% of the total reports of adverse reactions and an incident rate of 18 cases worldwide annually. Medicines Control Agency UK • The results of a survey carried out by the UK National Poisons Unit from 1991 to 1995 on potentially serious adverse reactions associated with exposure to traditional medicines and food supplements have been published. Of 1297 inquiries, 785 cases were identified as possible or definitive cases of poisoning caused by traditional medicines or food supplements. The report concluded that the overall risk to public health was low; however, clusters of cases were identified that gave cause for concern. Twenty-one cases of liver toxicity, including two deaths were associated with the use of traditional Chinese medicines although no causative agent was identified. Adverse Reactions Allopathic Medicine America

According to a study done by the Journal of the American Medical Association 1998 • incidences of serious and fatal adverse drug (ADR’s) reactions in hospitalised patients are the fourth most common cause of death in the USA. This is over 100,000 deaths per year. • 2 million serious adverse drug reactions (defined as requiring hospitalisation or causing permanent disability) annually. • 46 people die every day from Aspirin alone in the USA. • Avoidable medical misadventure is the sixth most common cause of death according to the Centre for Disease Control (CDC). A study by the Harvard Medical practice published in 1991 in the New England Journal of Medicine estimated that 1 million people are injured by errors during hospital treatment each year and 120,000 die as a result of these injuries. “Death by Medicine”. Dr Carolyn Dean This fully referenced report shows the number of people: • having in-hospital, adverse reactions to prescribed drugs to be 2.2 million per year. • The number of unnecessary antibiotics prescribed annually for viral infections is 20 million per year. • The number of unnecessary medical and surgical procedures performed annually is 7.5 million per year. • The number of people exposed to unnecessary hospitalization annually is 8.9 million per year. • the total number of deaths caused by conventional medicine is an astounding 783,936 per year. It is now evident that the American medical system is the leading cause of death and injury in the US. (By contrast, the number of deaths attributable to heart disease in 2001 was 699,697, while the number of deaths attributable to cancer was 553,251.5) • the total number of deaths caused by conventional medicine is an astounding 783,936 per year. It is now evident that the American medical system is the leading cause of death and injury in the US. (By contrast, the number of deaths attributable to heart disease in 2001 was 699,697, while the number of deaths attributable to cancer was 553,251.5) • deaths induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures— in the US annually are 783,936. It is evident that the American medical system is itself the leading cause of death and injury in the US. By comparison, approximately 699,697 Americans died of heart in 2001, while 553,251 died of cancer. The Lazarou study: • analyzed records for prescribed medications for 33 million US hospital admissions in 1994. It discovered 2.2 million serious injuries due to prescribed drugs; 2.1% of inpatients experienced a serious adverse drug

reaction, 4.7% of all hospital admissions were due to a serious adverse drug reaction, and fatal adverse drug reactions occurred in 0.19% of inpatients and 0.13% of admissions. The authors estimated that 106,000 deaths occur annually due to adverse drug reactions. England A report by Professor Breckenridge of Liverpool University claims • that up to 20,000 deaths a year in Britain may be linked to ADR’s, that ADR’s may be implicated in 5% of all hospital admissions and that they may occur in as many as one in five hospital in-patients. Among patients taking five or more drugs, there is a 50% chance of an adverse reaction. • Results of the “Million Women Study” on HRT and breast cancer in the UK were published in medical journal The Lancet in August 2003. According to lead author Prof. Valerie Beral, director of the Cancer Research UK Epidemiology Unit: "We estimate that over the past decade, use of HRT by UK women aged 50-64 has resulted in an extra 20,000 breast cancers, estrogen-progestagen (combination) therapy accounting for 15,000 of these.”(151) We were unable to find statistics on breast cancer, stroke, uterine cancer, or heart disease caused by HRT used by American women. Because the US population is roughly six times that of the UK, it is possible that 120,000 cases of breast cancer have been caused by HRT in the past decade.

Australia The Australian Medical Journal claims • that 9,000 people die from avoidable medical misadventure and that 50,000 people are maimed by medical misadventure every year in Australia.

Similar statistics are reported in New Zealand and the UK. World Health Organisation (WHO) Report During the last decades it has been demonstrated by a number of studies that medicine morbidity and mortality is one of the major health problems which is beginning to be recognized by health professionals and the public. It has been estimated that such adverse drug reactions (ADR's) are the 4th to 6th largest cause for mortality in the USA. They result in the death of several thousands of patients each year, and many more suffer from ADR’s. The percentage of hospital admissions due to adverse drug reactions in some countries is about or more than 10%. Norway 11.5%, France 13.0%, UK 16.0%

Some points in favour of herbal medicine World Health Organisation • Access. Low-income countries need inexpensive and effective treatment for common diseases. The fact that traditional medicine practitioners live and work at community level makes such treatment available and affordable to most of the population. The role of traditional practitioners should be recognized and cooperation between them and community health-workers should be strengthened A recent study on cost-effectiveness of complementary and alternative medicine conducted for the Government of Peru and supported by WHO’s Regional Office for the Americas concluded that, of nine selected mild and chronic pathologies, the direct costs incurred in using such medicine were lower than those for conventional therapy, and that its efficacy was higher, with fewer side-effects. A key to ensuring access to traditional medicine is the protection of knowledge and sustainable use of medicinal plant resources. WHO provides support to Member States in recording and preserving knowledge of traditional medicine and in compiling a national inventory of medicinal plants to ensure that knowledge is correctly and continuously used over generations. For example, the Ministry of Health in Côte d’Ivoire has conducted a survey among traditional practitioners and recorded more than 2000 traditionally used plants. In India, a database of documented knowledge of Ayurveda and medicinal plants is already in the public domain. The Government of the Islamic Republic of Iran has recorded 2500 medicinal plants out of the 8000 used for medical purposes. The information generated in these inventories should be shared with national patent offices to ensure that the data will be duly considered when processing patent applications.

Medicines Control Agency UK • In general, most herbal medicinal products are unlikely to pose a significant threat to human health; nonetheless, the following report highlights issues that have arisen which have given rise to public health concerns.

Safety Issues within Herbal Medicine Considering that until recently there has been little quality control or regulation herbal medicine has had relatively few mishaps. With sensible control and regulation we can look forward I hope to an era of realization where the intrinsic

worth of herbs and herbalists are recognized and incorporated into the healthcare system. Many of the concerns relating to herbal medicine can be easily and sensibly dealt with and indeed many already are through existing legislations. Some of issues relating to herbal medicine are Hepatoxicity and Adverse Reactions Herbal Medicine: Many of the cases of liver toxicity etc have been due to adulteration of products or wrong dosaging. I have tried unsuccessfully to find statistics for the total number of cases of Hepatoxicity due to herbal ingestion; I can but presume they make up a certain percentage of cases of adverse reactions in the WHO statistics, so a certain percentage of 500 cases worldwide will be due to hepatoxicity. Allopathic Medicine: ‘Drugs are an important cause of liver injury. More than 900 drugs, toxins, and herbs have been reported to cause liver injury, and drugs account for 20-40% of all instances of fulminant hepatic failure. Approximately 75% of the idiosyncratic drug reactions result in liver transplantation or death. Drug-induced hepatic injury is the most common reason cited for withdrawal of an approved drug. In the United States, approximately 2000 cases of acute liver failure occur annually and drugs account for over 50% of them (39% are due to acetaminophen, 13% are idiosyncratic reactions due to other medications). Drugs account for 2-5% of cases of patients hospitalized with jaundice and approximately 10% of all cases of acute hepatitis. ‘ (From article: Drug-Induced Hepatoxicity Author: Nilesh Mehta, MD, Fellow, Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center and SUNY Upstate Medical Center. Coauthor(s): Lisa Ozick, MD, Chief, Division of Gastroenterology, Harlem Hospital Center; Emmanuel Gbadehan, MD, Instructor in Clinical Medicine, Columbia University College of Physicians and Surgeons; Consulting Staff, Department of Gastroenterology, Harlem Hospital Center, North General Hospital) This I hope puts hepatoxicity due to herbal medicine into perspective, it is not my intention to underestimate any case of hepatoxicity, however, I would like to see an overall statistic and the breakdown of each case so that we can address the real issues. From the cases I have read some of the reasons can be broke down into several categories which include adulteration and self medication. The area of self medication includes wrong dosaging, taking for an excessively long period and incompatibility due to history of liver/kidney insufficiency.

Steps to redress Adulteration All reputable herbal suppliers now perform tests on their products to ensure quality and safety. These include identification and tests for contaminants. This has now become the standard and incidents of adverse reactions due to adulteration should not happen. Some of these products have come from China but with western herbalists so restricted as not to be able to make these products, European made substitutes are unlikely. However reputable Chinese medicine suppliers do perform quality and safety tests and guarantee quality. Self medication Self medication as with all forms of self-treatment can cause problems; it may delay someone from seeking qualified advice or lead to herb- drug interactions, adverse reactions due to wrong dosaging, hepatoxicity through being unaware of liver/kidney function. Specific patient groups may also be at risk e.g. pregnant or nursing mothers, children, the elderly through taking inappropriate herbs or taking them at the wrong dose. This however can be sensibly dealt with patient information leaflets • Informing people on how to use the herb and detailing possible contraindications, warnings and potential interactions with other medicines. This would address many of the problems i.e. interactions with other medications and people taking herbs unsuitable for them or at the wrong dosage.

Toxic and potentially hazadorous herbs Legislation already exists which restricts toxic, potent and potentially hazardous to practitioner only status. Herbal Extracts: Another issue is that often it is an isolated constituent of the plant that is determined to be a risk factor, however scientific research is increasingly showing that the active constituents in many herb’s interact in complex way’s to produce the therapeutic effect the remedy as a whole e.g. Meadowsweet and White Willow .White Willow contains salicylic acid, the forerunner of aspirin, and like Meadowsweet does not irritate the stomach lining while still providing the anti-inflammatory and pain killing benefits, unlike Aspirin which can cause gastric ulceration. It is wise to be cautious but it is also prudent to not base research on any one isolated constituent but to research the benefits of the plant as a whole.

Herb Drug Interaction One rule of thumb is you do not treat like with like. If someone is taking steroids then you do not prescribe a herb with a steroidal action. This is well known to herbalists but may not be in the general public. People generally go looking for a herbal remedy for their presenting condition while taking medications, if there was more awareness and information provided especially via patient information leaflets it may decrease the likelihood of interaction. A ‘Yellow Card’ system is now in operation to report incidences of herb drug interaction which will help compile information and prevent further incidences. ‘Quacks’ To me this is should not be an issue, charlatans can appear in any profession and indeed a few have hit the headlines, however if you are visiting a practitioner or using any type of service whether it be a plumber, doctor or a herbalist it is advisable to check that they are qualified and belong to a professional register. This ensures that the person you are seeing is properly qualified and professional within their practice. Professional herbalists are qualified, belong to a register, hold indemnity insurance and are required to do CPD (Continuous Professional Development). The future should shine bright, an integrative system that has patient care at its integral core using the best of what’s available for its curative benefits. I would like to see the following aspects become a reality: Safety • • • Promote the proper and safe use of herbs by educating the public. Quality: properly identified, tested and quality assured raw herbs and products. Data: A working co operative between the medical and herbal establishment to identify and create a safety database including dosage, appropriate length of time for taking the herb, negative interactions and safety data. This information can then be publicly available and on patient information leaflets. Adverse Reactions: Where adverse reactions happen, a full breakdown of information as to the actual cause and statistics reflecting this. Patient Information Leaflet detailing medicinal applications, dosage, interactions/potential interactions and contraindications. Trained Personnel: where herbs are supplied.

• • •

Prescription Only: Some herbs should only be prescribed by a qualified practitioner, but to include herbalist not just doctors which would see many herbs fall out of use as many doctors do not herbal training. (and/or will not prescribe them as herbs do not have sponsoring drug salesmen)

Research • National Herbal Database: to compile information on the use of native plants and preserve the knowledge of traditional medicine for future generations. • Positive Interactions: Research into the positive interactions between herbs and drugs whereby the herb can help support the body while a person is taking a medication. Many side effects of medications can be negated in this way so that the person can have the best of both worlds. • Hepatoxicity: Identify herbs with potential for Hepatoxicity because of their constituents while researching them for this by individual constituent and the plant as a whole. • Traditional Use: where traditional use has been established, this may be taken as fact until further research proves otherwise. Integrative Medicine • As well as having positive interactions, herbal medicine in general works better for chronic conditions while allopathic medicine works better in acute cases. As in the case of my daughter both systems can work particularly well together. Quality Research and implementation could mean better patient care for all. • The communication between doctors and traditional practitioners should be strengthened and facilitated with appropriate training available for both. • A programme implemented which would allow integration into the national healthcare system, as well as treatments being available on the medical card ensuring access to all. Herbalists • Recognition of herbalists as qualified healthcare providers within their own field of expertise. • Herbal Medicinal products which are practitioner led rather than corporate.

.Still have to put togeher REFERENCES World Health Organisation. Traditional Medicine Strategy 2002- 2005 WHO 2002. Leape LL. Error in medicine. JAMA 1994;272:1851-57. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA 1995;274:35-43. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377-84. "Death by Modern Medicine" was written by Dr. Carolyn Dean MD, ND