A mysterious, itchy rash appears on your skin. Where do you head for an explanation? In an age of instant gratification the answer is increasingly likely to be your computer keyboard, where you can find an instant (if unreliable) diagnosis and get a treatment delivered straight to your door. More than two million people in the UK are now thought to buy medications on the web; but in doing so, say experts, many are risking their health rather than finding a means to improve it.
Yesterday it was reported that researchers at Boston University school of medicine have found that one fifth of the Indian herbal medicines available online contain potentially toxic heavy metals, including lead, mercury and arsenic. Dr Robert Saper and his team found 25 websites through an internet search engine and randomly selected and purchased 193 products made by 37 different manufacturers. They then subjected them to laboratory analysis.
Their results, published in the Journal of the American Medical Association, showed that medicines used in a branch of ayurveda called rasa shastra, used to treat serious illnesses, including paralysis, contained the highest levels of toxic metals, and that 20.7% of all products tested exceeded "one or more standards for acceptable daily metal intake".
This is not the first time that ayurvedic medicine has come under scrutiny. Previous investigations have uncovered high levels of heavy metals in the remedies used in this ancient medical system, an approach that has been popularised in the west in recent years by the backing of celebrity fans including Madonna and Naomi Campbell. Worldwide, around 80 cases of lead poisoning have been reported in association with ayurvedic approaches, with some preparations containing the stimulant ephedrine, a substance linked to high blood pressure - and even to potentially fatal heart attacks and strokes in susceptible people.
In some ways the risks have always been there. What has changed so dramatically is the ease with which consumers can now obtain these dangerously toxic concoctions for their bathroom cabinets from bogus online suppliers. In 2006, a report by Envision, a web analysis company, suggested that there were around 2,500 websites selling medicines - prescription and alternative - to consumers worldwide. Since then that figure is thought to have risen. And many of those who purchase herbal medicines online do so without really knowing whether they are legitimate, effective or safe.
Like ayurveda, traditional Chinese medicine (or TCM), has become popular among those who want to try an alternative to Western medicine and prescription drugs. It has more than 1,000 clinics and 3,000 practitioners in the UK but is also a burgeoning online business. Through TCM's 3,000-year old healing system, ailments are corrected using a combination of herbal remedies that include a bewildering list of ingredients - more than 6,000 medicinal substances are used, 300 of them regularly. Proponents justify the safety of TCM by pointing to the 8,000 clinical studies that have confirmed it presents little risk. But critics argue that many of these investigations are not conducted to sufficiently rigorous standards and that some of the herbs, which are used in hundreds of different combinations, are known to be poisonous.
Random tests by the Committee on Safety of Medicines have identified banned substances such as the herb aristolochia, (which is linked to kidney failure), steroids, arsenic and mercury in many TCM preparations. In the wrong hands, these elements could be lethal, yet they are widely distributed in products available on the internet. According to the Medicines and Healthcare Products Regulatory Agency (MHRA), a government authority that oversees the licensing and supply of medicines in the UK, products found to be on sale in recent years include a TCM slimming preparation that contained a highly toxic derivative of a banned substance called fenluramine, which is poisonous to the liver and a cause of heart irregularities in some people. Another product they found on the shelves was a Chinese treatment for constipation, called fufang luhui jiaonang, which contains 13% mercury - 117,000 times more than is legal in UK foodstuffs.
Weeding out unscrupulous websites and suppliers is not easy, although efforts are being made to regulate UK suppliers of online medications. In February 2008, the Royal Pharmaceutical Society of Great Britain (RPSGB) launched an "internet pharmacy logo" designed to protect the public. Only credible UK e-pharmacies can carry the RPSGB logo which Priya Sejpal, head of professional ethics for the RPSGB, says is one step towards eliminating the use of risky sites. "Consumers just simply couldn't tell a good distributor from a bad one," says Sejpal. "A vast amount of products is available, but those sold from sites that offer to sell directly to the public or that offer unacceptable means of diagnosis do not meet our standards."
In a bid to crackdown on dangerous medication, the MHRA holds regular Internet Days of Action, the latest of which was in February. On these days, enforcement officers either visit the premises of UK websites to arrest those
selling medications illegally, or contact the internet service providers of offending websites to ensure they are closed down. More than 40 websites are currently under investigation. "We will not hesitate to take action against those who undermine public health," says Mick Deats, group manager of enforcement at the MHRA. But overseas suppliers are impossible to subject to any level of control. Often it is difficult to determine whether a site is UK-based or not - even websites ending in co.uk or org.uk can be based abroad. A survey of internet medicine suppliers by the Trading Standards Institute found that many of those based in places as far-flung as Canada, India and Peru were distributing powerful medications with no advice about dosage or associated risks.
In 2006, two consultant opthalmologists from Sunderland Eye Infirmary reported the risks of self-prescription in the Lancet medical journal, highlighting the case of a patient who went blind after using an obscure Thai medication she had bought online. Dr Philip Severn and Dr Scott Fraser explained how the woman had used information on the internet to self-diagnose chronic fatigue syndrome and then, on the recommendation of a neighbour, purchased a product from Thailand that contained steroids. She took the tablets for four years before arriving at Sunderland Eye infirmary,
complaining of loss of vision. Severn and Fraser discovered she had cataracts in both eyes and signs of glaucoma - both of which are indicative of long-term steroid use - which will require treatment for the rest of her life. Buying online treatments for any medical condition "is a gamble", Fraser noted.
Herbal products aren't just being bought and used to treat medical ailments. Dr Martin Schmidt, a specialist registrar in psychiatry at St George's Hospital in London, recently conducted a study into the rapid growth of what he calls the "worrying availability" of "herbal highs" - alternatives to recreational drugs - sold on the internet.
There is a commonly held belief, says Schmidt, that if something is labelled as "natural" it is safe, "but that is a dangerous assumption," he says. His findings, reported to the Royal College of Psychiatrists at their annual meeting, revealed that pills made from a cocktail of shamanic plants, synthetic stimulants and psychedelic cacti, were being sold as "legal highs" with unknown and potentially dangerous side effects.
"One product we found, called Original Herbal Ecstasy, contained nutmeg - which is hallucinogenic in sufficient quantities - hallucinogenic mushrooms and a lot of stimulants," he says. "Yet there is no way of telling how much of these substances is in there. Most packets contain no information about side effects or the potential of mixing these substances with things such as alcohol or other medications. They could cause a range of psychiatric disturbances from anxiety to panic attacks to psychosis."
In the course of his research, Schmidt stumbled across innocuous-looking herbal preparations intended for a range of uses, which contained ingredients as dangerous as fly agaric mushrooms (commonly regarded as poisonous), the San Pedro cacti (containing mescaline, a hallucinogenic drug) and salvia, a Mexican herb that has been linked to problems with motor coordination and balance with short-term use and, after long-term consumption, to schizophrenia.
"There is considerable risk to the public from obtaining medicines through unregulated websites," says Mick Deats of the MHRA. "There is no guarantee of safety, quality or effectiveness. It could be counterfeit or out of date. It may not contain the right amount of medicine. There is no ongoing treatment monitoring. At worst it may cause severe side effects. It's not worth it."
