The Wicked Problem of Lyme and Chronic Infections
Part 1 of a series on chronic infections and their treatment.
In systems thinking we have this thing called a wicked problem. It’s a problem that is difficult or impossible to solve because of incomplete, contradictory, and changing parameters that are often difficult to recognize. It’s characterized by complex interdependencies, and is not easily subjected to assortment into neat categories with tidy and quick solutions. Wicked problems change when you apply a solution to them. As a culture we tend to hate wicked problems because they defy mechanistic thinking and solutions.
Wicked problems can show up in our bodies, ecosystems, and societies. There are problems that involve all of these levels. Chronic infections like Lyme disease are an example. I am wholly fascinated by Lyme disease and related infections for several reasons:
- ecosystem disruption is a driver of zoonotic infectious disease epidemics
- they are challenging our current immunotherapies and are redefining medical practice
- I have skin in the game: I have contracted and overcome these illnesses, albeit with great effort and considerable expense
- microbes are cool
Herbalists have the potential to contribute to this area of great need. While this potential has yet to be actualized, we possess tools to sculpt a damaged immune system back into harmony and function by managing inflammatory reactions, increasing innate defenses, restoring GI tissue integrity, and the thoughtful use of complex antimicrobials. In this sense we’ve done some great work so far. We’re also at a fork in the road where we can decide if we want to continue with the “infection as invader” narrative, or broaden our understanding of chronic infection etiology and clarify our therapeutics.
Lyme herbs and protocols – convenient but limiting
I’ve been disenchanted by the current discourse on herbal medicine and chronic infections like Lyme disease. A few popular herbalists have designated several exotic and recently popularized herbs as the “Lyme herbs” with accompanying purveyors of Lyme-specific product lines. These popularized herbs have also organized themselves into Lyme protocols, which many people use for self treatment.
We have a problem of categorizing herbs as “Lyme herbs” and pioneering Lyme herb protocols. What’s the problem with this? The “Lyme herb” category is nearly useless. Lyme is too complex and variable as a condition, with too many contributing factors. It’s important to peel it back, get specific, and clarify the effects that we are hoping to achieve.
What we are really talking about are herbs that have known action against spirochetes, select viral infections, or support innate immunity, liver function, and adrenal health. When we’re more specific and clear with our terminology and intent with herbs, our therapeutic options expand. All of the sudden, instead of the 15 or so “Lyme herbs” that are regularly paraded, we have many options for hepatic herbs, adaptogens, alteratives, and specific antimicrobials.
All herbs can be Lyme herbs. Because Lyme disease and other chronic infections vary so much in their presentation among individuals, our approaches need to be dynamic and tailored to the patient.
This brings me to my next point- cookie-cutter Lyme protocols are not the answer. Don’t get me wrong- there is a valid place for “prescriber” approaches. “Take this for that” can be fine in specific situations, but is inappropriate for complex conditions. The issue is using Lyme protocols as cookie-cutter, one-size-fits-all protocols. These disease vary in their etiology (origin), symptom presentation, and therapeutic requirements. An individualized approach is called for. Focus on strategies, not protocols.
Furthermore, these protocols are based on choppy information and lots of test tube (in vitro) research. The Buhner protocol draws from Western herbal tradition but uses a lot of in vitro data. The Cowden protocol uses specialized extracts and claims to have an evidence base in the form an in vitro study that was published in the Townsend Letter and clinical trial (Horowitz R. Classical and integrative medical approaches in chronic Lyme disease: new paradigms in diagnosis and treatment. 8th Annual International Lyme and Associated Diseases Society (ILADS) Conference; 2007 October.) This one trial claims a 70% recovery rate but is marred with seriously flawed methodology (interventions weren’t isolated, to name one issue) and few conclusions can be drawn. The paper also appears to be no longer available but the powerpoint presentation is available for download.
These protocols are not useless by any stretch – we just need to recognize that they are limited.
There is some anecdotal evidence from clinicians and patients that have experienced success on some level with these protocols. The challenge is that it’s difficult to peel it back and understand what’s really happening. So many people say that teasel root, for example, “helped with their Lyme.” What does that mean? Did they do a Western blot test (standard for diagnosis) before and after treatment with that herb? Did it ease their symptoms? Did you use only one intervention (in this case teasel)? We rarely ask these clarifying questions when we discuss what works and what doesn’t. (To be fair, this issue of end point measurement is a general problem in herbal therapeutics.)
Further, diagnostic panels carry a very high margin of error. This renders diagnosis elusive, making it increasingly hard to determine progress and efficacy because we don’t have good metrics of measurement. In clinical practice, people can be easily under treated because they feel OK. The infection is knocked back enough for a remission of symptoms, only to creep back later. Similarly, over treatment occurs when symptoms like fatigue, joint pain, or brain fog persist and are attributed to ongoing infection rather than another disease process (autoimmunity, hypothyroidism, etc.).
The point is that we seldom know what we’re talking about when we say that “something works well for Lyme.” We need to peel back the layers more.
So, please don’t hang your hat on the available Lyme protocols without further consideration. And if you’re experiencing an acute Lyme infection, it’s wise to use antibiotics, as acute infections are very antibiotic-receptive (Source: Up to Date). I urge caution when foregoing a relatively straightforward remedy for a far-from-clinically-established herbal treatment. This herbalist recommends antibiotics when appropriate.
Herbal medicine has a long way to go to effectively meet chronic infections patient’s needs. And we’ve made some progress so far with developing treatment approaches and characterizing select herbs as helpful in these situations. But as my mentor would say, what got us here won’t get us there, and we need to move forward in a different way.
From reductionism to holism
Lyme and other chronic infections are challenging our notion of infectious disease. In the antibiotic era, infections were easily eradicated by antibiotics. In the post-antibiotic era, things are different. We know that there are myriad complex and chronic infections that linger in our body, evade immune detection, and grow slowly. Infections that escape immune detection are known as “stealth infections”. This is not to be confused with chronic infections, but they often overlap. Stealth infections tend to be chronic simply because our immune response is evaded. They are more difficult to diagnose and treat. Additionally, increasing numbers of bacteria and strains are becoming resistant to last-resort antibiotics.
There’s an enormous opportunity for herbal medicine here, should we accept the challenge. That challenge is a shift in our worldview. The opportunity is a chance to understand how the body’s ecology creates niches for infections, and clarify better strategies for their treatment.
One can look at infections from a reductionist approach. The narrative goes like this: evil bacteria infect good body, with antibiotics killing it and restoring justice.
Contrast that to a holistic approach that appreciates the complexity of the microbiome. Infections do not take place in a vacuum – our terrain creates ecological niches where beneficial or harmful bacteria can reside. When we approach infections in a conscious way, we ask: Who is here? Who is helpful and harmful? What in the terrain made this possible? What created this ecological niche? We do not necessarily engage in knee-jerk treatment for an infection simply because it shows up on a Western blot. (Sarah Carnes ND has a great blog post on this.) We support the body, and delve into antimicrobial therapy when it’s appropriate to do so.
The more we learn about the microbiome, we learn that treating infections is not just giving antimicrobials. Though far from conclusive, a case can be made that the Borrelia burgdorferi organism (which causes Lyme disease) has been residing in humans for quite some time – at least 5300 years. Is it possible that Borrelia was a commensal or mutualistic organism, and has recently become pathogenic due to our changes in our own terrain? Microbes work that way- they are indifferent or even beneficial partners in one context, but virulent or pathogenic in another. Our relationships with them are anything but black and white. Our dance with them is complex. (For a great book on the subject, see I Contain Multitudes by Ed Yong.)
Now we arrive at a provocative contemplation. What is the role of our ecological niches and infections? Does the bug exploits the niche, or does the niche enables the bug? Which way does causality flow? This chicken and egg problem will be addressed in a future post.
Our immune systems are less of a police force patrolling “self vs. non self” (a dichotomy that needs to end), and more of a harmonizer of our microbes and the ways in which they communicate.
Working with infections is mostly about harmony, not only killing. Yes, we’re working with antimicrobials, but we’re nurturing the body too and prioritizing nutrient absorption, stress load, HPA axis, liver/detox pathways. One can think of treatment more as gardening and pruning as opposed to the “nuke it to death“ approach.
Next, I’ll venture into greater depth on testing protocols and treatment approaches (herbal vs. antibiotic).
Thank you to Rosalee de la Foret, Traci Picard, and Jonathan Treasure for being a sounding board and friend.
Image credit: Center for Ecosystem Science and Society at NAU