The Surge of Complementary and Alternative Medicine in the United States

During the early 1990s, the use of complementary and alternative medicine (CAM), including herbal and dietary supplements, increased exponentially in the United States. The congressional passage of the Dietary Supplement Health and Education Act (DSHEA) in October of 1994 classified herbs and herbal supplements as foods, thereby facilitating their integration into the mainstream market and making them available to the general public.¹ (Note: Items classified as drugs or food additives require pre-market approval by the Food and Drug Administration.)

The results of a landmark national telephone survey conducted by David M. Eisenberg and collaborators in 1998 revealed that use of various CAM therapies in the United States increased from 33.8% in 1990 to 42.7% in 1997.² A 2002 study found that 62% of those surveyed used some form of CAM in the past 12 months.³ Among the diverse types of dietary supplements, herbal product use has shown a steady increase compared to other CAM modalities.^1,3,4 The sale of herbal dietary supplements rose from an estimated $4.6 billion in 2006 to $4.8 billion in 2007.⁵

Prevalence of Herbal Product Use Along the US-Mexico Border

Mexico and the United States share a 3000 km (1864 mile) border, and the border region has been defined as the distance of 100 kilometers (62.5 miles) in each direction of the dividing line between the 2 nations. This region includes a combined population of approximately 24 million people between the 2 countries.⁶ The cities of El Paso, Texas, and Ciudad Juarez, Mexico, (hereinafter referred to simply as Juarez) together comprise the largest border community in North America with a combined population of more than 2 million people.⁷ Every month, millions of people cross back and forth between the 2 countries,⁸ sometimes bringing with them diverse herbal products used as foodstuffs as well as therapeutic agents.

A survey by the University of Texas at El Paso and UT-Austin Cooperative Pharmacy Program was conducted by means of bilingual questionnaires sent to 1000 homes, 500 in El Paso and 500 in Juarez.⁹ The results of these questionnaires revealed that almost 70% of the combined population of both cities uses some sort of herbal product to treat various diseases and other physical ailments, a figure that is much higher compared to the rest of the United States (approximately 20%).¹⁰

The Therapeutic Use of Herbs as a Mexican and Mexican-American Tradition

Various herbal products have been used traditionally by many Mexicans and Mexican-Americans for the treatment of a multitude of ailments.^11,12 Mexico has a rich tradition of herbal use, predating the European conquest by many centuries. This country’s herbal pharmacopeia includes from 3,000 to 5,000 species of plants, which are commonly used by more than 60 different ethnic groups.¹³ The use of medicinal plants as a healing option is a commonly accepted practice among various natural health providers in Mexico.¹⁴

Some of the various reasons for higher herbal use within the border communities between the United States and Mexico may include Mexico’s rich diversity of medicinal plants, as well as the ancestral use of healing herbs by Mexicans and people of Mexican descent. Many people of Mexican descent living in the United States follow a traditional method of folk healing similar to that used in Mexico, using some herbs to treat diverse illnesses much in the same way their ancestors did.¹⁵

US Hispanics of various age groups seem to have a positive opinion of the use of medicinal herbs for the treatment of various ailments. The use of various alternative therapies, especially herbal medicine, seems to be equally prevalent among Hispanics regardless of origin. Hispanics living in the United States who may have come from the Caribbean, Central or South America, tend to have a cultural heritage of using herbs for various illnesses; however, some specific characteristics of users can vary widely, depending on the specific alternative therapeutic modal

Another factor that may explain the popularity of herbal medicine in both communities is that most herbal products are accessible to the border population without a prescription, as herbal products in both the United States and Mexico are classified by their respective health authorities as foods or dietary supplements, not as pharmaceutical drugs.¹ Many herbal products (especially the crude herbs sold to make teas) may also cost far less than conventional medications. However, the true efficacy of some herbs may be quite variable, and there is limited published clinical information regarding many plants commonly used in Mexican traditional medicine. In addition, certain herbal products may cause adverse reactions, either by direct toxicity or by interacting with prescription or over-the-counter (OTC) drugs.¹⁷

Types of Diseases or Ailments Treated by Herbs

One of the most important questions in the herbal product provider survey was related to the major disease states for which the providers recommended certain herbal products or treatments.¹⁸ In Juarez, the major ailments for which customers sought treatment were primarily diabetes and digestive problems. In El Paso, providers mentioned that clients sought herbal products to treat respiratory and digestive problems, as well as obesity.

Clients in Juarez purchased mostly crude herbs to be used as teas to treat specific diseases. In comparison, herbal products sold in El Paso were mainly processed herbal products sold as supplements, creams, tablets, capsules, or extracts used to treat conditions related to aesthetics (e.g., weight loss, baldness, and muscle mass augmentation), as well as to treat specific ailments.

Some of the commercial herbal products available in El Paso, especially those sold as extracts, tablets, and capsules, were manufactured in the United States, while the majority of those sold in Juarez were crude herbs originally from Mexico.¹⁸

Safety Concerns of Herbal Product Use

Some safety concerns have been associated with the use of herbal products in Juarez and El Paso. Nowadays, many people may be taking multiple prescription medications that could be inadvertently mixed with herbal or nutritional supplements. Aside from interactions potentially occurring between 2 or more prescription medications, there is the potential in some cases for an adverse interaction between the medications and certain herbal products (e.g., garlic [Allium sativum, Alliaceae] and St. John’s wort [Hypericum perforatum, Clusiaceae] with antiretroviral medications), which would not occur if these products were not taken concurrently.^17,21

Another problem is that the majority of people who use herbal products for therapeutic reasons do not disclose this or other CAM therapies to their physicians. According to the UT survey mentioned previously,⁹ the main reasons for this include the fact that some physicians do not routinely ask their patients about taking any CAM therapy concomitant to prescription or OTC medications, and also because most patients (67%) are wary of telling their physicians about their use of herbal products due to their fear of disapproval or ridicule. This situation is further complicated by what some have observed as a mostly negative attitude and lack of adequate knowledge about herbal products, as well as other CAM therapies, shown by some conventional healthcare providers on both sides of the border.

Additionally, the relatively limited regulatory oversight by the Mexican federal government allows manufacturers to produce and distribute herbal products that vary in quality and quantity of active ingredients. Quality control of herbal products in Mexico is essentially up to the individual or company that produces and markets them. There is currently no strict supervision or mandate for good manufacturing practices (GMPs) by either the state or federal governments. (Although there is more regulatory authority granted to the FDA in the United States, the degree to which the agency actually enforces such authority remains questionable.) Even though many plants have not been fully studied as to all of their potential bioactive ingredients, better supervision of GMPs involved in the processing of herbal supplements would make it easier for consumers to buy more trustworthy products. This is especially true in Mexico, where many herbal products are sold without adequate labeling of what they contain or only the mention of the common or regional name of the herb(s), which obviously can make the proper identification of the contents extremely difficult, at best.

The issue of improper use can also be a problem. Certain products such as gordolobo (Gnaphalium spp., Asteraceae) and matarique (Psacalium decompositum, Asteraceae), for example, should best be used under the guidance of a qualified health professional, especially if used over a long period of time, since these plants contain potentially hepatotoxic pyrrolizidine alkaloids. Additionally, these plants have not been studied in depth during pregnancy and lactation. Also worth noting is that few herbal products observed for sale in Juarez carried any warning or advisory information on the label or container.

When buying the “crude herb,” safety becomes all the more important, since no precautionary information is mentioned and some of the clerks who sell the herbs have little, if any, information pertinent to the safety and precautions of various plants. A common notion is that since herbal products are natural, they are always safe, and therefore free of any adverse reactions. Unfortunately, this is not always true, due to a variety of factors, such as the intrinsic potential toxicity of a given herb or the possible herb-drug interaction with various prescribed or OTC medications.^17,21-23

Common names of plants vary considerably from region to region, and this leads to confusion in trying to identify certain species of herbs. The herbal products provider survey indicated that some herbal products in Mexico were incorrectly classified; that is, the scientific name which appeared on the label was totally inconsistent with the photograph of the plant shown on the box or bottle.¹⁸ The survey also found that some of the scientific names written on the labels of certain herbal extracts or tablets were outdated, indicating a lack of knowledge regarding the changes in botanical nomenclature.

Serious intoxications have occurred around the globe due to mislabeling of herbal products or erroneous identification of some plant species. A simple mistake made in the identification of an herb or the incorrect use of a certain part of a plant can have serious repercussions on the health of the consumer.

The manner in which herbs are stored and packaged is also a crucial factor determining their safety and effectiveness, since incorrect storage of an herbal product can result in its deterioration due to environmental factors or contamination with chemicals or pests. The herbal product providers survey showed that points of sale in Juarez varied considerably with regard to organization and cleanliness.¹⁸ This was especially true regarding the crude herbs usually used for teas. While some stores sold packaged herbal teas, others placed them on open containers, thus exposing the herbs to fumes from passing vehicles or possibly to pests (e.g., rodents or insects) that might be present in the shops at night.