Europe gets tough on smoking.

News Intermittent drugs seen highly protective against malaria Malaria drugs given intermittently at the same time as routine childhood vaccinations could cut malaria episodes by nearly two- thirds, according to a randomised, placebo controlled trial reported in the 12 May issue of The Lancet. Dr David Schellenberg and colleagues from the Hospital Clinic in Barcelona, Spain, and the Ifakara Health Research and Development Centre, United Republic of Tanzania, randomly assigned either sulpha- doxine-pyrimethamine, a commonly used antimalarial drug combination, or placebo to 701 infants living in a rural area of the United Republic of Tanzania. The treatment was given at 2, 3 and 9 months of age alongside routine vaccinations delivered through WHO’s Expanded Programme on Immunization (EPI). All the children also received iron supplementation between 2 and 6 months of age. The Ifakara area where the trial was conducted has a high rate of malaria transmission and malaria is especially severe in under-1-year-old children. The treatment, the study found, reduced the rate of clinical malaria by 59%, the rate of severe anaemia by 50%, the number of hospital admissions by 30%, and the rate of all febrile episodes by 13%. The treatment was well tolerated and no drug-attributable side-effects were observed. Professor Pedro Alonso, head of epidemiology and international health at the Hospital Clinic Barcelona, and one of the study authors, told the Bulletin: ‘‘This drug costs less than 20 cents and our approach to using it makes use of existing contacts between the target population and health care workers. So this approach appears to be an extremely good buy.’’ One concern about using chemopro- phylaxis is that drug resistance may develop. However, Alonso argues that because the treatment is directly observed there can be no under-dosing, with its associated in- creased risk of inducing resistance. ‘‘And the drug is only given in three doses, so it is unlikely to constitute a major contribution to the problem of resistance when you consider the large quantities of malaria drugs consumed in countries with high rates of malaria.’’ During a previous trial in the same area, full chemoprophylaxis between 2 and 12 months was associated with a large increase in the rate of malaria once treatment stopped, suggesting that the development of malaria-specific immunity had been delayed. However, no such rebound effect was seen in this study. ‘‘Because the children received only intermittent treatment they developed their own immunity tomalaria just like those in the placebo group,’’ says Alonso. ‘‘Once the treatment stops the children will still go on to get malaria but they have been protected when they are most vulnerable.’’ Professor Brian Greenwood, head of the malaria centre at the London School of Hygiene and Tropical Medicine, comments: ‘‘This is a very important study. The difficulty in the past has been finding the right balance between protecting children from malaria at the most vulnerable time without impair- ing their natural immunity. This approach seems to have got it right.’’ Greenwood is currently participating withGhanaian colleagues in a similar study in the north of Ghana, which is due to be completed in 18 months’ time. ‘‘Hopefully our study, which has larger numbers, will provide independent confirmation about the value of intermittent drug treatment.’’ n Jacqui Wise, London, UK Drug-resistant HIV increasing, UK study finds Over a quarter of people newly infected with HIV in the UK and not yet receiving treatment may be carrying mutant virus strains already resistant to antiretroviral drugs, according to a study reported in the 5 May issue of the British Medical Journal. The study, which was conducted by the UK collaborative group on monitoring the transmission of HIV drug resistance, used genetic tests to measure viral drug resistance within 18 months of infection in 69 subjects who contracted the virus between 1994 and 2000. The researchers detected primary resistance to antiviral drugs — that is, in individuals not yet treated with drugs— in 14% of cases over the seven-year period. Of the 26 patients tested last year, seven, or 27%, had a resistant virus. A calculation of the risk of primary infection with drug-resistant virus suggested a steady increase since 1994, reaching a risk of about one in five by last year. Corresponding author of the study Dr Deenan Pillay, with the UK’s Public Health Laboratory Service and Birmingham University Medical School, notes that ‘‘the results are based on small numbers of patients and have therefore wide confidence intervals, so they should be taken as only indicative of what seems to be a disturbing trend’’. That trend, the researchers believe, is probably fuelled by the increasing use of antiretroviral drugs in the UK. Another contributing factor, they say, could be the W H O ,L .T ay lo r In Africa, where children are the main victims of malaria, delivery of antimalarial drugs through routine vaccination programmes is a promising new approach. 688 # World Health Organization 2001 Bulletin of the World Health Organization, 2001, 79 (7) growing number of people engaging in unprotected sex among groups at high risk of HIV infection, which increases the like- lihood of being infected by someonewho has already been treatedwith antiretroviral drugs. Commenting on the UK findings to the Bulletin, virologist and HIV-resistance expert Professor Mark Wainberg, director of the McGill University AIDS Centre in Montreal, Canada, said: ‘‘It is shocking. It’s higher than anything I’ve seen until now, and if it’s right, the UKwould appear to be leading the world in regard to transmission of drug-resistant virus.’’ Wainberg says that the figures are much greater than the 8–9% he reported from Canada last year. Reported figures from the US are between 15% and 20%. If widespread access to treatment in the UK is a reason for high resistance rates, what are the implications for developing countries where the epidemic is most prevalent? Dr Lynn Morris, head of the AIDS unit at South Africa’s National Institute for Virology in Johannesburg, has conducted genetic analysis of HIV in more than 70 recently infected ‘‘drug-naı¨ve’’ patients. ‘‘At this stage,’’ she told the Bulletin, ‘‘we haven’t found any resistant viruses.’’ Most patients in this part of the world, of course, still do not have access to antiretrovirals, so there is little pressure on the virus to mutate. But current efforts to lower the cost of these drugs and expand access to them in developing countries could increase the risk of resistance and its transmission. ‘‘The threat of resistance definitely doesn’t mean that we shouldn’t give drugs to developing countries,’’ says Morris. ‘‘If we use that argument then we shouldn’t be using TB drugs either. I think we need to make sure that people who get drugs are closely monitored and that they’re on the right therapies.’’ WHO, in collaboration with the Inter- national AIDS Society and Italy’s Istituto Superiore di Sanita`, is planning a global HIV resistance monitoring network that, among other things, will keep track of trends in the prevalence of HIV drug resistance in parts of the world where antiretroviral therapy is being introduced. n Karen Birmingham, London, UK Europe gets tough on smoking In a move coherent with WHO’s push for stringent legislation of tobacco products, the European Parliament, in a 15 May vote, approved of a package of far-reaching anti- smoking laws. The new rules — which now have to be adopted by the individual European Union (EU) member states—will lower the maximum levels allowed for tar from 12 mg to 10 mg. Nicotine levels above 1 mg and carbon monoxide levels above 10 mg will be banned. The new rules will also require manufacturers to display giant health warnings on about a third of the surface of cigarette packets, up from less than 5% today. Other measures of the EU directive, which will enter into force on 30 September 2002, include a ban on terms such as ‘low tar,’ ‘ultra light’ or ‘mild.’ Also, tobacco compa- nies will have to compile a list of all ingredients in their products, together with their quantities and the reasons for their use. What’s more, from the end of next year, EU member states will have the option to call for dissuasive colour photographs or other illustrations to be displayed on cigarette packs. Graphic pictures depicting the effects of smoking on the heart and lungs, on male sexual potency, or other smoking-related diseases are already in use on cigarette packs in Canada since the beginning of the year. Passed by a large majority, the legisla- tion received praise from all sides. Mr David Byrne, European Commissioner for Health and Consumer Protection, welcomed the new directive, saying that people needed to be made aware of the dangers of smoking. ‘‘Smoking is not cool — smoking kills,’’ he said. In the EU alone, more than 500 000 deaths each year are due to tobacco consumption, according to WHO estimates. Worldwide, the annual toll is close to 4 million. Byrne’s goal, he said, was to see ‘‘a reduction in the number of people smoking from one third of the European population to less than one fifth’’. Dr Douglas Bettcher of WHO’s Tobacco-Free Initiative called the new legislation ‘‘a very positive move. The EU is the first authority to ban such misleading descriptors as mild, low tar or light.’’ For Bettcher the mandatory submission of comprehensive lists covering all ingredients in tobacco products is long overdue. ‘‘Tobacco can contain up to 60 carcinogens and as many as 4000 ingredients. Which other product of that sort do you know, for which the content does not have to be disclosed? Tobacco was — and still is — a regulatory no man’s land. The EU legislation opens up a new pathway to reducing the harm caused by tobacco.’’ Some issues, such as the regulation of tobacco vending machines, fell by the wayside during ten weeks of a tedious ‘‘conciliation procedure’’ between Parlia- ment, which called for stark health warnings on the machines, and the EU Council, which refused such measures. Member of Parlia- ment Jules Maaten, who saw the directive through the legislative process, said in a press release: ‘‘Despite the terrible health conse- quences, I believe that people have the right to smoke, but the tobacco manufacturers spend huge sums of money trying to make their products appear glamorous, and this image needs to be countered.’’ More EU tobacco restrictions are on the way. On 30 May 2001 the Commission proposed rules on tobacco advertising and sponsorshipwhichwould harmonize existing regulations in the various member states. The rules would outlaw tobacco ads in print media, radio and on the Internet. (TV advertising of tobacco has been pro- hibited since 1989.) This is the EU’s second shot at trying to curb tobacco advertising; the first, dating from 1998, ended in defeat last October, when the European Court of Justice, following an appeal by tobacco companies and the German government, annulled the EU directive as there was no legal basis for prohibiting tobacco advertising which does not cross national frontiers. The new anti-smoking laws could be linked to the WHO Framework Conven- tion on Tobacco Control (FCTC), which is currently being negotiated by WHO’s Member States. ‘‘We would hope that the FCTC is a road to tobacco control on a global level. The EU decision can provide some impetus for international action,’’ Bettcher said. n Michael Hagmann, Zurich, Switzerland 689Bulletin of the World Health Organization, 2001, 79 (7) News WHO News Countries split over tobacco treaty Governmentnegotiators fromover150 coun- tries met in Geneva in May for a second round of talks on a global treaty on tobacco control and quickly found themselves at loggerheads over how vigorously the treaty should clamp down on tobacco advertising, sponsorship, and promotion. One striking development at these talks was the advent of a new, and highly vocal, coalition of about 50 developing countries led by South Africa, which acted as vice-chair of the meeting. The talks focused on a draft text of the proposed WHO framework convention on tobacco control drawn up by Mr Celso Amorim, theBrazilian ambassador inGeneva, who chairs the negotiating group. The draft, which was based on points made during the first negotiating session in October last year, included proposals for a global ban on all forms of tobacco advertising, promotion, and sponsorship which target young people under 18. But it stopped short of advocating an all- out ban, calling instead for ‘‘strict restric- tions’’ on tobacco advertising and promotion targeted to adults. The draft also proposed a gradual phase-out of tobacco sponsorship of sporting and cultural events and of cross- border advertising involving media, such as the Internet, and cable and satellite TV. The UK campaign group Action on Smoking and Health (ASH) described the proposals as ‘‘useless, unenforceable and misguided.’’ ASH says that tobacco advertis- ing is mainly targeted to older age-groups and that an ‘‘excessive’’ focus on youth would be counterproductive — making smoking more attractive to teenagers, not less, if it is seen as an adult activity. However, govern- ments remain split on the issue. Several countries, including China, Japan, Russia, the US, most Latin American countries and those of the EuropeanUnion, opposed a total ban on tobacco advertising, promotion, and sponsorship. Several countries, notably Brazil, Germany, and the US, argued that an outright ban is out of the question because it would be unconstitutional. Others, including Japan, whose government has a large stake in Japan Tobacco International, and China, which is currently negotiating with British American Tobacco (BAT) over company plans to build a tobacco factory in China, are believed by some observers to be opposing the measure on commercial grounds. Meanwhile, the developing countries— consisting primarily of the new African bloc of about 50 states, together with some Asian countries, New Zealand, and Australia — argued in support of an all-out ban. Even Malawi and Zimbabwe — both tobacco- exporting countries — aligned with other African countries in supporting a ban. Dr Yusuf Saloojee, of the South Africa- based International Nongovernmental Coalition against Tobacco (INGCAT), said that although Malawi and Zimbabwe were economically dependent on tobacco as a cash crop, they recognized that tobacco consumption was harmful and supported the African bloc countries in calling for an all-out ban on advertising. ‘‘Both countries will continue to grow tobacco but — unlike tobacco-manufacturing countries — they are not looking [so much] to expand their market,’’ he told theBulletin. ‘‘However, in the longer term, they will need help in switching to other crops and alternative livelihoods.’’ While some tobacco-manufacturing countries are expected to continue to oppose an advertising ban, Dr Saloojee believes that the majority of countries will strongly support the proposal when it comes up for discussion again at the next round of negotiations in November. Other proposals in the draft treaty included the prohibition of tax-free and duty- free sales of tobacco products, price and tax measures aimed at lowering consumption, and an end to subsidies for tobacco produc- tion. The draft also proposed measures to crack down on smuggling, limit people’s exposure to second-hand smoke, improve product labelling and health warnings, and encourage people to stop smoking. The positions and proposals being adopted by governments during the second round of talks on these and other issues are now being incorporated in a revised draft text which will include a wide range of amend- ments for discussion in November, when the ‘‘hard bargaining’’ is expected to begin. One of the most complex issues — for which there is still no draft text — is the proposal to include in the framework con- vention provisions for liability and compen- sation for tobacco-related illnesses. In April, a WHO technical meeting highlighted the difficulty of drawing up and enforcing this kind of international legal mechanism. One difficulty is a lack of national legislation. Another is the poor record of countries’ compliance with previous international liabi- lity regimes. In addition, the complex corpo- rate structure of the tobacco industry — in which tobacco products may be grown, produced, and marketed in different coun- tries— couldmake it difficult to knowwhom to sue and where. Governments have been invited to submit proposals for a draft text on these and other related issues for discus- sion at the next round of treaty negotiations in November. Dr Douglas Bettcher, WHO Coordi- nator for the framework convention team, told the Bulletin that the negotiations were ‘‘going quite smoothly andwell on schedule.’’ He said work on the convention, which will be the first global treaty on tobacco control, is expected to be completed, after an as yet unspecified number of negotiating rounds, in time for adoption by the World Health Assembly in May 2003. n Sheila Davey, Geneva, Switzerland In Brief Depleted uranium report says children face highest risk A WHO report published at the beginning of May recommends careful follow-up of children who may have been exposed to depleted uranium (DU) while playing in a conflict zone. Based on a review of the scientific literature on uranium and DU, the report, Depleted uranium: sources, exposure and health effects (available at http://www. who.int/environmental_information/radia- tion/depleted_uranium.htm), also details situations involving possible exposure of workers and members of the general public to DU and outlines the potential health risks posed by this heavy metal. (see WHO News story in the Bulletin, p. 274, vol. 79(3), March 2001). n Norplantt contraceptive safe and effective also in developing world A 5-year post-marketing study involving 16 000 women in eight developing countries has found the levonorgestrel contraceptive implant Norplantt as safe and effective as intrauterine devices (IUDs) and sterilization, WHO’s human reproduction research programme (HRP) has announced. No major adverse effects were observed. The annual pregnancy (or failure) rates for all three methods were less than 1 per 100 women. The full report of the study, which was conducted in collaboration with the Population Council and Family Health International, was published in Obstetrics & Gynecology, 97(4), April 2001. For more information contact Mr Jitendra Khanna, HRP (khannaj@who.int). n 690 Bulletin of the World Health Organization, 2001, 79 (7) News Features Herbs for health, but how safe are they? Herbal medicines are popular. They are extensively used in the developing world, where in many places they offer a more widely available and more affordable alter- native to pharmaceutical drugs. In Africa, for example, up to 80% of the population depends on them, according to WHO estimates. A recent study by the Roll Back Malaria Initiative found that in Ghana, Mali, Nigeria and Zambia, herbal medicine is the first choice for home treatment of nearly two thirds of children with high fever. In India, where the traditional Ayurvedic medicine employs over 1200 different herbs, herbal medicine is regularly used by about 65% of the population. Herbal medicines are also popular in developed countries — the same WHO estimates state that 50% of Canadians and 75% of people in France have tried com- plementary or alternative medicine, which often includes herbal remedies. And in Japan, 85% of doctors prescribe not only modern medicine but also the traditional herbal medicine (called Kampo), which is covered by health insurance. Herbal medicines are also profitable. Worldwide, they represent a market value of about US$ 43 billion a year, according to WHO. In the US, alone, over 1500 herbal medicines are sold annually for a total of nearly US$ 5 billion and now constitute the fastest growing sector of the US pharmaceutical market, according to the US president’s commission on dietary supplements. The growing popularity of these reme- dies is fuelling — and is to some extent fuelled — by increasing scientific interest in herbal medicine. WHO estimates that of the 35 000–70 000 species of plants that are used for medicinal purposes around the world, some 5000 have been submitted to biomedical scrutiny. Scientific evidence of efficacy is beginning to emerge from ran- domized controlled trials in which herbs compare favourably with placebo. Examples include St John’s wort for mild depression, ginkgo biloba for some forms of dementia, saw palmetto for benign prostatic hyperpla- sia, and horse chestnut seeds for chronic venous insufficiency, to mention only four. And, of course, a number of commonly used pharmaceutical products are of botanical origin — aspirin, digitoxin, and quinine are three well-known examples. Another reason for the growing popu- larity of herbal medicines is that many people believe they are safer, ‘‘more natural,’’ than pharmaceuticals. But as Dr Saul Green, a biochemist and board member of the nonprofit US National Council Against Health Fraud, notes: ‘‘Natural doesn’t mean safe. You can find a dozen or more poisons that are totally natural.’’ Herbal medicines, however natural, can cause serious illnesses, from allergy to liver or kidney malfunction, to cancer, and even death. In terms of carcinogenicity, for example, the toxicological potential of nat- ural plant chemicals is roughly the same as that of synthetic chemicals, according to US toxicologist Dr Lois Gold, head of the carcinogenic potency project at the Univer- sity of California at Berkeley. And the fact that herbal products tend to be taken for long periods at doses close to their toxic range doesn’t help, she notes. Blindness, too, has been attributed to the use of herbal medicines. A study published in the Journal of Tropical Medicine and Hygiene in 1994 reported that 25% of corneal ulcers in the United Republic of Tanzania were linked to the use of traditional eye medicines, of which many are based on herb extracts. Another study, published in the British Journal of Ophthalmology in 1976, found that they were associated with 26% of childhood blindness cases in Malawi. A lack of proper sterilization, along with inclusion of urine, saliva, or breast milk in some of Co ur te sy ,R es ea rc h Ce nt re fo rE th no m ed ic in es ,T oy am a M ed ic al an d Ph ar m ac eu tic al U ni ve rs ity ,J ap an . Japanese gentian (Gentiana scabra Bunge var. buergeri Maxim), whose roots and underground stems are used as an appetite stimulant, and to treat herpes zoster and inflammatory conditions of internal organs. 691Bulletin of the World Health Organization, 2001, 79 (7) these medicines, gives pathogens ample opportunity to thrive in eyes already hard hit by injury or infection. Perhaps the biggest problems with herbal medicines are a lack of standardization and of safety regulations. Standardization of a herbal medicine that may contain hundreds of chemical constituents, with little or no evidence indicating which might be respon- sible for the presumed or proven therapeutic effect, is a particularly thorny issue. Food or medicine Moreover, rules and regulations concerning herbal medicines vary greatly from country to country. ‘‘Some countries regulate them as food, others as medicines,’’ says Dr Alan Randell of the FAO/WHO Food Standards Programme in Rome. For the most part herbal medicines aren’t tightly regulated. ‘‘This is an industry that’s out of control and has been for a very long time. By and large, the people running the industry want it to stay that way,’’ says Randell. In 1997, the Codex Alimentarius Commission, an international body that regulates food standards, considered issuing rules for potentially harmful herbs and dietary sup- plements. But, according to Randell, the health food industry pressured the Codex against regulating herbs, and the Codex ultimately decided that herbal medicines didn’t fall under the category of food and thus weren’t subject to its regulations. Worldwide, only 64 of WHO’s 191 member states regulate herbal medicines. Dr Xiaorui Zhang, head ofWHO’s traditional medicine unit, agrees that the regulation and standardization of herbal medicines ‘‘clearly represent important problems’’ but she points out that considerable effort is being put into tackling the problems. In 1998, for example, WHO published a review of regulatory information from 50 countries. Last year, Zhang’s unit published guidelines on methods of evaluating tradi- tional medicine therapies, including herbal medicines. Over the past decade WHO’s work on herbal medicines has included the prepara- tion of a series of monographs on medicinal plants, based on input from an international panel of 170 experts. About 100monographs are planned, of which 28 appeared in 1999 in a first volume, a further 30 are in press in a second volume and work is well advanced on the remaining 40 or so, which will appear in a third volume. For each plant, the monographs give a definition, synonyms (including vernacular names), a description, identification of material of medicinal inter- est in the plant, and a wealth of scientific information about purity, chemical tests, pharmacology, warnings, precautions, ad- verse reactions, dosage, plus a copious scientific reference list. Zhang’s unit has also started a project to run clinical trials — being conducted in collaboration with the Roll Back Malaria initiative— of medicinal herbs. Trials of three herbs with antimalarial potential are under way in Africa. In Europe, the European Medicines Evaluation Agency (EMEA) set up a herbal medicinal products working party in May 1997 that, among other things, prepares guidelines for manufacturers seeking mar- keting authorization for their products. In the UK, the Medicines Control Agency (MCA) has launched an ethnic medicines forum to improve safety and quality standards of ‘‘unlicensed ethnic medicines’’. And Germany boasts a widely acclaimed regula- tory body, its ‘‘Commission E’’, that was set up in 1978 to assess the safety and efficacy of herbal medicines and has done so for about 400 of them, although, some critics complain, with insufficient information about scientific sources. FDA reports In the US, a 1994 law reportedly pushed through by herbal industry representatives prevents government officials from tightly regulating herbal supplements. The only safety measure in place is a system whereby consumers and health professionals can voluntarily report herb-related adverse events to the Food andDrugAdministration. The FDA makes these reports available publicly, and on a few occasions has issued recalls of products deemed especially dan- gerous. For instance, in February of 2000, the FDA recalled five Chinese herbal products after discovering that they contained poten- tially dangerous levels of two prescription diabetes drugs, glyburide and phenformin. And in August 2000, in a move to encourage better manufacturing practices in industry, the FDA issued a ‘‘guidance for industry’’ document that sets out the criteria it urges manufacturers to comply with when they wish to market a botanical drug product — ‘‘including those botanical products currently lawfully marketed as foods and dietary supplements’’. The US Pharmacopoeia, a non-govern- mental organization that establishes medi- cine quality standards recognized around the world, is launching a new programme to assess the quality of dietary supplements, including herbals. And the government sponsored National Toxicology Program is currently assessing about a dozen herbal medicines for safety, including goldenseal, comfrey, pulegone, gingko, Echinacea, aloe, ginseng, kava kava, milk thistle, and Thujone. Clearly, without strict safety regulations, dangerous herbal preparations are reaching consumers. In Belgium, 70 people who took a regimen ofChinese dietary herbs developed renal problems serious enough to require dialysis or a kidney transplant. A research team lead by Dr Joelle Nortier at the Universite´ Libre de Bruxelles discovered that among the herbs consumed by these people was Aristolochia fangchi, which contains high concentrations of the potent carcinogen and kidney toxin aristolochic acid, and which was mistakenly included in the regimen by the manufacturer. Contamination problems Pesticide residues present in or on herbs are another problem. In a study published this year in the Bulletin of Environmental Contam- ination and Toxicology, researchers at the Suez Canal University in Ismailia, Egypt, examined five spices — caraway, ginger, cumin seeds, cinnamon, and anise — they had purchased at a local market in Egypt. To their dismay, they discovered that the cumin seeds showed high levels of the organophosphate pesticide profenofos — 0.37g/kg, or nearly twice the residue the WHO and Codex Alimen- tarius Commission permit in vegetables. This pesticide is known to cause headaches, nausea, dizziness, intestinal cramps, and diarrhoea in high doses. The finding is especially troubling because Egyptian par- ents commonly give their children cumin to relieve coughs, aches, or itching, and chil- dren’s low body weights make them espe- cially vulnerable to the pesticides’ effects. In the US, Dr Richard Ko, a food and drug scientist at the California State Depart- ment of Health Services in Sacramento, says that of 260 Asian herbal products his department has tested, about one in three were found to contain heavy metals or undeclared ingredients, including prescrip- tion drugs. A US company, ConsumerLab. com, has tested hundreds of herbal products and posted the results on its website. ‘‘We’ve found ginseng products contaminated with pesticides and St John’swort with small levels of cadmium,’’ says Dr Tod Cooperman, the company’s president. ‘‘In our latest tests, we found one Echinacea product that had three times the WHO accepted level of microbial contamination.’’ All in all, herbal medicines inhabit a largely uncharted territory. Even the jungle of names for the different herbs is a regulator’s nightmare. Is Eupatorium perfoliatum ‘‘fever- wort’’, ‘‘thoroughwort’’, or ‘‘boneset’’? Take your pick. The same for Serenoa repens or Sabal serrulata or Corypha repens or Brahea serrulata. Clearly, though, when it comes to safety, what’s in a name is not what counts, but what’s in the herb itself. And that’s another nightmare. n Christie Aschwanden, Nederland, Colorado, USA 692 Bulletin of the World Health Organization, 2001, 79 (7) News Features