Risk in Plant Medicine History

CONTENTS

Introduction page

Plant Medicine Risks

Stakeholders at Risk

Products at Risk

Risk Indicators

Causes of Risks

Risk Measurement and Assessment

Risk Characteristics

Intrinsic Risk Resistance

Managing Risks

Conclusions

References

Appendices
1. Modern Specialisms and Risk in Plant Medicine History
2. Risk Multiplication Chains
3. Non-medicinal Uses of Medicinal Flora
4. Written Information Transmission Risks
5. English Publications in Saturated Markets
6. Natural Factors Causing Plant Availability Risks
7. Simplistic Correlation of Symptoms and Plants
8. Gerard’s Imported Plants
9. Staffordshire Oral Information Transmission Risks
10. Risk Management Techniques
11. Writer and Treatment Consensus
12. Publication Topics and Locations
13. Substitution, Consensus and Differentiation
14. Treatment Differences

Figures
1/1. Early Records and Global Extent of Plant Medicine
1/ 2. Amerindian Users of Plant medicine: Canadian Section
1/3. Initial Evidence of Plant Medicine
2. Plant medicine System Network
3. Patient’s Influence
4. Demand-Supply-Price Mechanism
5. Environmental Risks to Supplies
6. Anthropic Risks to Supplies
7. Eighty Places in Sections of the Silk Road Network
8. Incorrect Medical Information Transmission Risks
9. Translation Activity Levels
10. Measurement of Elective and Unavoidable Risks
11. Early Resource and Research Gardens
12. Practitioners’ Information Acquisition
13. Logistical Influences
14. Utilisation of Plants in Culpeper

INTRODUCTION

Historically plant, or herbal, medicine, also known as medical botany and phytomedicine, was a complex, ubiquitous network of interacting variable elements and crossovers. Christopher p245. More popular than its present day successor, systems were driven by patients’ variable demands for treatment, and also entrepreneurial venturers. The Economist p80. Influencing treatment were risks of product availability, patient acceptability, provider attributes, financial considerations and external interference. Maddocks p148.

Plant medicine was practised by ancient civilisations in Mesopotamia, China, Greece and Rome, in the Arab world, then in medieval and early modern Europe as well as in the New World. In eighteenth century England, surgeon-apothecaries’ preparations were often herbal. Lane p46. Herbalism may have been the core of alternative medicine but, in nineteenth century Latin America, and possibly at other times, in other places, spiritism, magic and divination collectively constituted popular medicine. Birn p249. Bivins p580. Early Records and Extent of Plant Medicine, Figure 1, refers

The literature shows the complexity of plant medicine history, the scope for, and response to, its medical, logistic, financial and other risks. In many parts of the world, and throughout its long history, treating all social classes, age groups and genders, paid professionals, and unpaid amateurs, occasionally with parts of trees, but more routinely with preferred, and substitute, whole or parts of plants, wild and cultivated, raw or processed, singly, or in compounds, (sometimes with mineral, animal or vegetable supplements and using ancillary products), found locally, or imported, by entrepreneurial traders, probably distributed by intermediaries; used by practitioners, whose abilities varied, full-time specialists (possibly members of an association), or part-time jobbers, utilising written and oral, longstanding and contemporary information, case histories or their own on-the-spot diagnoses, as they recognised, or failed to recognise, foreseeable and unforeseeable risk-generating situations, varying in frequency, repeatability, duration, magnitude and causation.

Past events were portents of risks. Products and people were exposed to them. Responses to risks were not identical. Dissimilar responses showed circumstantial, local and personal differences. Similar responses occurred in geographically separate centres, and time periods. However similarity, and variability, co-existed wherever, and whenever, plant medicine was practised.

Practising plant medicine resulted in diverse organisations. Risk was an element in all of them. In markets with specialist segments, and niches, financial risks dominated. In Galen’s day, Marsi a small Italian tribe, famous for herbs and drugs, supplied them to the Roman market. Nutton 1992 p36. Folk medicine pockets were loosely organised, mutual associations. Families, and clans, were even more closely knit organisations based on blood relationships. In some universities, plant medicine was an organised discipline. In religious houses, plant medicine was an organised social service niche among their other activities. Doubt exists regarding the motivation of monarchs involved in it. Was their involvement vanity, philanthropy, protection of fighting men or recognition of business opportunities?

There was actual, and embryonic, commercial jargon. Although the words ‘restrictive practices’ are not, in the literature, they existed in Graeco-Roman medicine, in all but name. Medical clans kept drugs and therapies within the family. Nutton 1992 p 17. Thomson, 1769-1843, franchised, his 70 plant materia medica system. Porter 1997 p393. Informal self- treatment, in all historical periods, avoided practitioners’ prices. Schumaker p279. Illness led to loss of earnings by patients. Traders imported and exported.

Macro, and micro, economic forces were present. Supply and demand affected prices, shelf life products, inventory, substitution of products, profits and losses.

However non-financial elements were also present. Feminism was a cultural element. Herbalism, medical botany, and vegetarianism, empowered women in public, and private spheres. Marland 2011 p491. Religion, royalty and research interests were significant elements.

The word ‘ risk’ derived from the Greek word rhiza. It was the first word in European languages to denote uncertainty, the likelihood of something adverse happening and the consequences if its does. Kast p2, 5, Crozier p1. Risk, uncertainty, hazard and variability were also linked in New Testament times. 1 Corinthians 9v26 1 Corinthians 14v8, 1 Timothy 6v17, James 1v17 Acts 15v26. Porter 1997 (Ivy Press) p8, 9. Risks have causes, characteristics and outcomes affecting people and products.

Contributors to risk literature - Bernoulli, Calow, Crozier, Elshout & Vermeulen, Fuentes- Nieva & Seck, Glade, Knight F H, Kast & Lapied, Leiss & Chociolko, O’Riordan, Pidgeon & Beattie, Ricciardi, Schultz, Tapiero, Vose, Wisner and Zinn – join with applied, behavioural, management, and natural sciences authors, to assist historical analysis and appraisal of the risks.

‘Risk’, ‘uncertainty’ and ‘hazard’, were either dormant, active or lapsed, unavoidable or elective. Their levels of magnitude, and temporal measures, ranged from trivial to excessive. Dormant, latent, risks had delayed or lapsed outcomes.

‘Risk’ and ‘uncertainty’ were not always synonymous. Although by no means all, some items, in risk clusters, associated with stakeholders’ ventures, were known with certainty because financial commitments were in place. On the other hand ‘uncertainty’, for example in circumstances relating to supplies of wild flora, did not become synonymous with ‘risk’ and ‘hazards’, until quantities demanded exceeded assessments. Risk status then changed from dormant to active.

Uncertainty, was an adjunct of the several types of substantive and temporal variable risks. Knight. F H p313. Changing physical, and social, hazards compounded the uncertainty surrounding loss and damage risks. Some risks were neither recognised by stakeholders nor had precedents. Practising stakeholders, with sharp minds, and long experience, were better able to recognise risks than plant medicine dabblers.

Several sciences, not previously associated with studying risk in plant medicine history, are relevant. Natural sciences are relevant to plants and supplement doses, behavioural sciences to stakeholders as well as applied sciences, such as engineering to ancillary equipment. Logistics and economics, although relevant, are not always regarded as sciences. Management science techniques, pro-active and reactive, as well as changed circumstance boundaries, mollified and sometimes even annulled recognised risks. Vose 3rd edition p48, Zinn p4, Ricciardi p131. Modern Study Subjects and Risk in Plant Medicine History, Appendix 1 refers.

PLANT MEDICINE RISKS

Risks were medical, logistic, financial, fiscal, military, demographic, psychological and environmental. They had indicators, causes, characteristics, financial and temporal contexts, consequences and outcomes. Personnel exposed to risks, stakeholders, patients and providers, showed resourceful when applying management techniques.

Stakeholders were not equally exposed to risks. Uncertain knowledge about ailment incidence, its severity and duration, was a fundamental risk to patients. Yet, for providers of goods and services, to whom patients might have recourse, patients’ risks were a revenue generating opportunity, not without its own derived risks, especially medical and logistic ones. Ricciardi p131. Vose 2nd edition p19. Patient’s Influence, Figure 2, refers.

Similarly irrecoverable price increase risks, not only adversely affected patients, Apothecaries, buying from producers, physicians, buying from apothecaries, and fee-paying patients, were affected by these risks when increases had to be absorbed because they could not be passed on. Price, and order quantity risk increases, were often associated with customers’ illnesses increasing demands when competiting for limited supplies.

Some risks were recognised by stakeholders. Others, especially dormant ones, were unrecognised until actuated.

Unavoidable risks were caused by external factors, elective ones by stakeholder choice. Quantitive changes, to treatment demands and supplies of products and services, were unavoidable drivers. Some unavoidable, permanent risk initiators, such as volcanic eruptions affecting supplies, were dormant, inactive, for aeons.

Unavoidable risks were sickness, inadvertent medical mistakes, attributable to imperfect knowledge, political, military, discriminatory and fiscal intervention risks, introduced by authorities and fourthly logistical risks attributable to environmental and anthropic factors. Patients’ unavoidable sickness onset, severity and duration, the driver of all plant medicine, could neither be foreseen nor ascertained. Hacking. p47 Crozier & Glade p34. Consequent medical, logistical and financial risks, following ailment onset, were part of risk chains. The majority of patients’ ailments were unavoidable, and unpredictable, in magnitude and timing. Medical treatment risks could be unknown in incidence, intensity and unavoidable.

Externally caused difficult-to-predict, natural hazards, such as storms, were unavoidable risks. Their effects required management. Human-centred social risks, such as information ignorance and illegal practices, and change of land use might be preventible. Hardy p2, 3

Ventures were elective risks, often with quantified financial exposure. Stakeholders were free to decide whether to undertake, or reject, ventures based on their knowledge of upfront financial commitments, and their assessment of associated risks. Calow p297, Hamouda p74. Roman traders elected to make long voyages, to import products from India and China.

Vose 3rd edition p3. Some risk aversive adventurers were selective. They avoided some products, and destinations, because they were too risky. Risk seeking traders embarked on ventures because attractive potential gains outweighed perceived risks. Modern risk benefit analysis relates estimates of risk exposure to probable benefits. Crozier &Glade p35.

Speculative venture losses, and destruction of assets, by fire, flood and criminals, were three of several first order, variable magnitude financial risks. Premises, publications and products in inventory were tangible assets at risk. Intangible assets, were business goodwill and medical knowledge.

Stakeholders - patients and practitioners, businesses, producers, manufacturers, processors, merchants, distributors and traders - were often unprepared to manage active risks, and consequential adverse outcomes, especially those of which they had no prior knowledge. Tapiero p23. Preparation, for probable harmful risk outcomes, pro-action, was optional, strategic risk management. Reaction to changes, during the lifetime of risks, and actual short-term outcomes, was tactical risk management. Plant Medicine System Network, Figure 3, and other diagrams, show many potential risk network nodes and elements.

Sometimes local factors confined risks. Within the confines of a ship or neighbourhood, niche markets, pressing needs for treatment, such as sailors suffering from scurvy or impecunious peasants, resorted to whatever plants were readily available on board ship, in a port of call or growing wild in close proximity. For patients, in more stable settlements, affordability and acceptability augmented availability as local factors.

Depending on circumstances, and roles, all stakeholders, patients, and providers, were individually and severally exposed to risks, in pockets, niche markets, and networks . Logistic, information, medical, scientific, military, political, and fiscal, were primary risks, financial and reputation risks, consequential. Temporal, quantitive, variable, durable, repetitive, frequent, rare, unavoidable, avoidable and elective were risk descriptors.

Organisationally risks were embodied in pockets and their sub groups . Self-help pockets, treating minor ailments comprised mainly self-treating, often impecunious, patients, with few, if any providers. Self-treating involved several risks – diagnosis, prescription, plant acquisition, processing and administration. Another sub-group, in the self-help pocket, was more affluent patients who mistrusted providers. However patients, suffering from acute afflictions, forsook self-treating and resorted to a pocket, a niche market, serviced by remunerated, or altruistic, providers.

Pockets fluctuated in size, according to ailment severity, patient and provider numbers as well as their resources. Winter ailment, and epidemic, risks temporarily expanded pocketss in the short term. In the long term, providers servicing a pocket, and typical patient clientele, helped differentiate one pocket from another.

Networks connected and propagated risks in the pockets. Logistc risks were the common denominator. Unavoidable, environmental risks, such as volcanic eruptions, major and minor, initiated logistic risks before propagating economic and medical risk chains for providers and patients. Social risks propagated medical, scientific, information and reputation as well as economic risks. Physical and social risks combined to expose stakeholders - providers, and patients - to financial, health and mortality risks. In the twentieth century, Van Bertalanffy’s dynamic system theory supported connected risk networks. Any change in one part of a system affects all inter-related parts. Bothamley p163. Medical error risks connected with practitioners’ reputation risks, scientific risks with logistical and financial risks. A Risk Multiplication Chain, Appendix 2 refers.

Network connectivity meant that one risky treatment could generate long-remembered, consequential risks in scattered locations and circumstances. Quinine may have caused miscarriages for aristocrats. Furdell p234. In geographically scattered locations, in large and small organisations, inaccurate information risks, relating to flora identification, medicinal properties, and uses, circulated. Some information, and products, relating to herbal treatments, prepared by apothecaries, and administered by physicians, exposed patients to medical risks and providers of treatments to consequential reputation risks. Lesens p86, 136.

Stakeholders were not equally affected should consequential risks occur. For example should providers’ ingredient costs increase, in buyers’ markets, those without adequate working capital buffering were most harmed. Expected profits risked becoming losses. Sales, earnings, disposable income and cash flow reduced, insolvency and bad debt risks increased. Vendors’ opportunities to pass on price increases depended on the strength of buyers’ resistance to them, demand elasticity.

Deliberately incorrect diagnoses, communicated to patients, and inappropriate treatment, by avaricious healers, could accentuate inexcusable risks by prolonging patients’ exposure to costly medical risks. In addition products supplied by them, to patients, could be defective.

Inadvertently incorrect diagnoses, and treatments by conscientious practitioners, justified by information limitations and sickness complexity, were excusable medical risks to patients.

Should risks result in adverse outcomes, incomes, profits, investments and reputations could be totally lost, or partially impaired, fraud experienced, quality of life impoverished, supply variation consequences incurred and intervention by superior political and fiscal authorities encountered. Risk outcomes were, in varying degrees, harmful, beneficial or neutral. Lapsed risks did not have outcomes. Harmful risk outcomes required management reaction by local, national or international stakeholders should tolerances on risk thresholds be exceeded. Calow p3, Pidgeon p291. Beneficial, and neutral, outcomes indicated competent management.

However plant medicine, an established provider of medical services for many centuries, acquired some risk resistance in addition to that provided by the more resourceful stakeholders. For aeons, it was a first resort medical system for rich and poor, young and old, male and female, enslaved and free, inhabitants of all continents. Kelly p119, Pomata 1998 p233, Von Staden p17, Bynum p6.

STAKEHOLDERS AT RISK

All personnel with an interest in plant medicine were members of stakeholder risk networks. Stakeholders were members of groups with an interest, often an economic one, in the operation of plant medicine. First were patients, secondly providers of [1] vegetable, mineral, animal products i.e gatherers, root cutters, cultivators, processors, manufacturers, wholesale distributors, [2] finance i.e. insurers, investors, speculators, entrepreneurs, regulators, researchers, retailers [3] information i. e. authors, translators and thirdly practitioners, (occasionally physicians), supplying products and services to end-user patients. Spray p84.

In stable situations stakeholders dependended on one another in product and information supply chains. But, in shortage situations, they probably competed for supplies and business opportunities

Patients were consumer stakeholders, seeking healing, and income loss avoidance. Income generation, and altruism, motivated providers. Expected reward value is a modern, recognised, key decision variable, for economic choices. Schultz. Financial loss was a risk to both categories of stakeholders.

Both categories were knowingly, or unknowingly, exposed to substantive risks, varying in magnitude, duration and frequency. Their willingness to take elective financial risks is now known to be affected by neurological factors. Variations in the DR4 gene governing dopamine, as well as financial factors, are, and were, significant determinants in financial decision-making. Dreber, Kuhnen Online notes.

High magnitude risks were those whose probable adverse outcomes might exceed potential rewards. Crozier p341. However favourable outcomes produced attractive rewards.

Patients exposed to risks, differed. Some may be knowledgeable, self-treating, economically inactive rural dwellers familiar with local wild flora but were not exempt from exposure to logistical risks, even if financial risks were small. Contemporary medical risks were annulled when patients recovered without treatment. More exposed, were traders speculating on overseas ventures and aware of their financial liabilities and life threatening probabilities. Financially stretched providers, with limited skills, were also much exposed.

There were two groups of providers, first those primarily dedicated to plant medicine and secondly those with additional non-plant medicinal interests. Diversification into other markets, a strategic management measure, designed to reduce exposure to plant medicine risks, added exposure to risks associated with entry to non-medical markets. Client bases, and product ranges, logistic, medical and economic risks augmented their risk portfolios.

Functions of provider stakeholders were not always demarcated. Middlemen, apothecaries, distributors, and physicians sometimes doubled as product providers and practitioners. Products were supplied, ailments diagnosed and patients treated. Medieval chatelains had to be both apothecaries and herbalists. Rawcliffe p184. Multi role stakeholders were exposed to multiple risks associated with each type of activity. Feedback information to providers was an information inaccuracy risk

Economic forces, such as demand surges , and slumps, for products and services, compounded unavoidable, and elective, risks for both groups. For providers of products, and services, patients’ ailments were a dormant opportunity but with demand and supply fluctuation risks. Earning opportunities for providers at best reduced, or disappeared, when unwell patients recovered. Patients’ higher, or lower, than normal demands for treatment, compounded by population increase, and settlements expansion, determined market sizes for providers. Healthy patients, and treatment refuseniks, making few demands for their products and services, were an income risk to producers, distributors, merchants and practitioners.

A common denominator, for the majority of stakeholders, was financial loss risks. Profit- seeking providers, gatherers, producers, distributors, traders, investors, adventurers and physicians aimed to gain financially. Even altruistic stakeholders needed funds to maintain their work. Religious orders were an altruistic minority provider of treatment. Donation income loss was a risk if their treatment was below expectations, and patients, impecunious.

Additional risk complicating factors were stakeholder assets, market structure and changing circumstances. Risk exposure varied according to circumstances, financial resources and individual stakeholder choice. In expanding markets, providers least exposed to risks were adequately funded, highly regarded local stakeholders without competitors but with access to sufficient supplies of products for treating patients unencumbered by financial problems. However other entrepreneurs, practitioners, healers, apothecaries and physicians, attracted by new opportunities, entering expanded markets introduced market share shrinkage risks.

Insufficient funds exacerbated financial risks. Established practitioners risked erosion of their pre-expansion client base, inability to retain market share, and penetrate new markets. Later entrants to plant medicine markets risked being unable to penetrate markets by displacing established providers.

Market structures complicated risk exposure. All stakeholders were subject to them. In rural situations, one producer - root cutter, rhizotomist, gatherer of flora, or gardener - was exposed to financial risks when tied into a monopsony, supplying a single distributor, such as an apothecary. Groups of providers, competing with their peers, to supply that intermediary, risked exclusion from that market segment if the single intermediary suspended purchase orders.

Market size, and cash flow, risks existed for stakeholders providing products and services. Patients suffering from liquidity, and credit worthiness problems, accentuated risks to providers. Patients unable to pay reduced the market for providers by not seeking treatment, and self-treating.

Most risk exposed providers were time-poor, knowledge-deficient, working capital-restricted competing for scarce supplies, and opportunities, to treat patients, with negligible disposable income. Their earnings-related risks were further compounded, when patient numbers reduced, disaffected patients transferred to other practitioners and ailments subsided.

Surging markets for treatments, introduced competition risks for scarce products, although earning opportunities increased.

Perceptions of risks affected both categories of stakeholders. Psychological factors, predisposition, expectations, ignorance, cognitive bias, imprecision and vagueness, exacerbated or mollified perceptions of market forces risks - supply, demand and price. Calow p302, Hamouda p74, 107.

Financial risks were far reaching. In the first category were patients , classifiable by gender, age, wealth, employment, status and well being, the largest group of stakeholders in a disparate treatment market. Economically active patients risked inability to work, and avoid income loss. Better-off patients able-to-pay for products and services were less exposed.

Patients unable to work, to support their families, especially when sickness was prolonged, were exposed to risks of destitution. Pelling & Harrison p51. Inability to earn, or to fulfil feudal service obligations, or earn income, was caused by medical problems or accidents. Poor patients were economically insecure. Dercan p310

Folk medicine patients, a disparate group of amateurs, often self-treaters, had financial loss avoidance objectives. Avoiding paying practitioners, and enforced absence from gainful employment while undergoing treatment, were their risk response strategies. Quick recovery was important. Marland p249.

Payment systems made no allowance for sickness. In 604BC Nebuchadnezzar of Babylon paid weavers by piecework Peach p7. In the fourteenth and fifteenth centuries, piecework payment systems were widespread. Marriott p19. Some agricultural workers were on monthly or annual contracts. In Italy and Spain, winter rates of pay were lower then summer. In fifth and sixth century Eastern Europe, day labourers hired themselves. In medieval Europe, labourers were hired by daily, or piecework, rates. Boissonade p42, 257, 259. Urban residents were particularly vulnerable to income fluctuations. Pawning rates, to pay creditors, were high.

Irrespective of the extent of their role, all stakeholders were exposed to the financial consequences of the environmental, market mechanism, interventionist and erroneous information risks, appraised below but not all were equally vulnerable. Crozier p35. Temporal, quantititive and qualitive, logistic, medical, and reputational risks had financial overtones.

Self-treating, sometimes designated self-healing, was a response to residence and impecunity risks, with minimal involvement of other stakeholders. Self-healing is a misnomer because not all patients were healed. Patients living in villages had limited access to medical practitioners. Cantor p305, Vauchez. Moreover living in rural situations caused flora identification risks for less experienced self-treaters. Competition for supplies generated logistical risks.

Self-treaters were, at one and the same time, vertically integrated patients, gatherers and healers. Saxon peasants gathered their own healing herbs. Rohde p38. Some patients received treatment gratis from monastic orders, family and community stakeholders. The infirmary was an important part of medieval Dominican priories. Hinnebusch p191

Unethical behaviour, by lackadaisical, financially stretched providers, prolonging treatment and assessing patients’ financial means, in order to increase their fees, generated risks for patients without access to gratis, or self-treating, facilities.

Patients were also exposed to medical risks of incorrect diagnosis, incorrect treatment and defective products. Black p264.

Personal circumstances generated more risks for patients. Immobile patients, without benefactors, could not gather plants, whether or not in season, even if their ailments were correctly diagnosed and suitable treatments identified. Long distances between rural locations and the next nearest provider’s premises exposed patients to accessibility risks. For these patients, risks could increase due to worsening ailments because treatment was denied, or failed to improve a medical condition.

Oral information, supplied to patients unable to read whatever information was available, by family and community members, was another source or risks. Old wives were oral information providers, possibly altruistically motivated by care for their social groups, or seeking recognition from healers of higher social status.

Oral information was not always risky. The old woman, who introduced Wittering, a professional, to foxglove, digitalis, was one such person whose valid contribution is recorded in plant medicine literature. However recipients of information from folk sources were exposed to inaccurate onward information transmission with consequential medical risks to their patients. Moreover in newly independent United States of America, the public had inalienable right to practise medicine. Saks p29.

In the second category, producers were providers at the beginning of the supply chain. Their role was raw product provision, gathering from the local countryside, root cutting, cultivation and collection of basic ingredients for medicines, supplements and ancillaries. Producers were exposed to logistic shortage, and surplus, risks, ongoing price, and order quantity reduction risks. These deviations from the norm led to reduced earnings risks.

Degrees of risk exposure among providers varied. Roman herbalists, and root cutters, selling small quantities of plants from a market stall in a Roman town, were less exposed to economic downturn losses than apothecaries trading from buildings, a fixed asset. Cruse p56.

Competition for products, with medicinal as well as non-medicinal uses, exacerbated supply scarcity risks. From earliest times a significant number of plants, supplements and ancillary products, had other domestic and agricultural uses. Hedrick pp97 , 282 , 470 , 491. Root cutters, rhizotomists, such as Crateus, specialised in harvesting roots. Jones P M p58 Non- Medical Uses of Medicinal Plants, Appendix 3, refers.

When wild flora supply shortage risks coincided with anticipated high demand risks, from practitioners and other users, folk medicine healers were obliged to compete not only with one another but also with paid gatherers and root cutters.

Producers of supplementary products, and ancillaries, were stakeholders exposed to risks similar those to which flora providers were exposed. Bee keepers, produced honey and top quality candle wax. Farmers, grew barley for malt, beer and vinegar, fruit and vegetables for wine. Pig farmers reared pigs for lard, and bladders for storing formulations. Alum miners, malsters, brewers, renderers, producing lard, vinegar makers, potters and glass workers all had a stake in the phytomedicine market. They were not immune from its were logistic and consequential financial risks

Investors in gardens, to provide back-up flora supplies for producers, to counter shortage risks, needed to invest in maintenance to avoid them becoming unproductive. Reduced income, from sales, restricted their ability to maintain gardens in good order, ready to respond to increases in demand at a later date. Cultivated plants became compost, when not needed, because wild ones were freely available, in sufficient quantities, to satisfy demands for treatment. Pliny the Elder mentioned ‘compost’ in his writings. Similarly adventurers and traders were exposed to risks of inability to sell products purchased from overseas suppliers when patients were healthy.

Major merchants, were wholesale suppliers of imported exotic plant ingredients, and supplementary products. As elective risk seekers, they were exposed to buying, shipping, warehousing and distribution financial risks. Loans for these activities had to be repaid with interest. Overseas ventures exposed borrowers, and lenders, to loss of investment risks. In the nineteenth century drug suppliers bought in bulk, and sold to practitioners. Thomas Corbyn 1711-91, a Quaker, had a remarkable import-export trade in medicines. Bynum p164.

Entrepreneurs, trading plant medicine, and other products, were exposed to variable economic, fiscal, political and military intervention risks. They were importers, traders and carriers dealing in products and supplements not available from domestic sources. Product consignments could be lost. Increasing popularity of imported products heightened competition risks to pioneer importers, and merchants. Moreover, when demands for treatment reduced, these middlemen risked being unable to sell their stocks to practitioners. All providers of products, and services, to patients risked losing income when demand, from patients reduced. Potential earnings, from patients, motivated retailers and entrepreneurs to face the economic risks of including plant medicine products in their product portfolios.

Overseas trading ventures, to generate income for traders by selling products, purchased from producers, were elective, accepted risks. Hamouda p74. In the fifth century, a ship sailed from Alexandria to Smyrna with medicines. McCormick p97. Sailors on ships were exposed to life threatening risks, and their dependants to poverty. In the sixteenth century, Gerard was a threefold stakeholder. He imported plants, wrote a herbal and treated patients.

One risk, that of losing a ship, had ramifications for several stakeholder cohorts. Ship owners, investors, traders, merchants, insurers and apothecaries, practitioners, were all exposed to financial risks. Non-recoverable costs of losing the excess, charged in advance by marine insurers to cover for the ship and its cargo, were at risk.

For an entrepreneurial trader, the prime risk was losing purchased cargo and initial investment in a venture as well secondly opportunities to generate income by selling items from the cargo.

Coincidence of the several risks multiplied adversity for all stakeholders.

Manufacturers, and processors of the output from producers, were next in the product supply chain. Value was added to inventory, product life, and distribution, by also processing supplies, making formulations, and, sometimes additionally, treating patients, a form of vertical organisation. Drying, distillation, and adding, preservatives served two purposes – immediate response to demands and prolongation of shelf life. Inability to supply risks may have been avoided but there was another financial risk. Inventory, in which manufacturing and processing costs had been invested, yielded no revenue.

Practitioners, a larger provider group than producers and manufacturers, although smaller in number than patients, directly attended to patients’ needs. Paid physicians, apothecaries, and retailers, unpaid folk medicine practitioners, family, community and religious orders were exposed to medical, logistical and fluctuating demands for their services, risks. Medical mistakes affected their income. Cruse p35. Rohde p85. Merchants, wholesale traders and shippers of exotic flora, supported front line practitioners. A latent, underlying risk, to paid practitioners, was healthy patients having no need for treatment. Product prices fluctuated.

Physicians, healers, practitioners, combining product distribution with medical services, were exposed not only to logistic but also to competence, information and belief system risks, which could be transferred to patients. Product shortages, deficiencies in physicians’ medical skills and sub standard information were transferable risks to patients. External sources of aural, and written information, introduced inaccuracies leading to consequential medical risks. Written information, whether in the vernacular or Latin, when affordable, was accessed by practitioners whose reading abilities varied.

Apothecaries provided most official medical care, because they were cheaper than physicians. In isolated locations, one part-time practitioner ostensibly had a monopoly when charging for treatment. Bynum p6. Town dwellers were less at risk, of one apothecary being a monopoly supplier, than inhabitants of rural settlements served by a single part-time shopkeeper cum apothecary.

The first apothecary shop in London opened in 1345. Porter (Ivy Press) p9. The main job of apothecaries, and druggists, was not supplying physicians, but lay customers. Pelling p70. Apothecaries’ inventory could age, deteriorate and depreciate in value. When products became, unusable due to deterioration, apothecaries disposed of them.

A risk, to non-member apothecaries, came from professional associations. Objections to their non-members’ activities, was a continuous risk. Culpeper, a major player, an apothecary and author, fell foul of the College of Physicians. Plant medicine was not an open entry profession everywhere in Europe. At times established practitioners of different faiths, such as Jews, risked exclusion by religious zealots, backed by their governments.

Information providers authors and translators, amateurs, family and community members were a service to practitioners. The Leech Book 900-950 dealt with the virtues of herbs. Contracting markets, when mortality, and prevailing economic conditions reducing practitioners’ purchasing power, depressed earnings of information providers.

As this segment of plant medicine market attracted several authors and translators, for long historical periods in several countries, the financial rewards of success must have exceeded depressed sales risks. Written InformationTransmission Risks, Appendix 4 evidences the earnings opportunities provided by writing and translating.

Practitioners were exposed to information quality risks. Measures for preparing prescriptions were omitted. Rohde p1, p85, Rubin p108. By the ninth century, in England, the quality of illustrations had deteriorated. Rubin p46. Authors were not exclusively herbalists. In Essex John Ray 1627-1705, son of a blacksmith cum herbalist, published ‘Historia Generalis Plantarum’. Porter 1997 p565.

Plant medicine also featured in other medical books. ‘Science of Chirugie’ 1400, by Lanfrank mentioned oil of roses. Wort. Oxford English Dictionary Pharmacopeia.

Information providers, risked loss of preparation time, (“sweat equity”), and money investments if markets contracted, recovered slowly and stocks deteriorated. Self-financing writers, such as Culpeper, also an apothecary, Salmon and others, wrote speculatively in anticipation of being able to sell their writings. Publications in Saturated English Markets, Appendix 5 refers.

Commissioned writers were those employed by a person of high status, such as an emperor or monarch. Dismissal by their employer was their risk. Philanthropic writers, whose output was less than that of remunerated writers, were less exposed to financial risks because their motivation was altruistic, not economic.

Ancillary information providers were librarians, copyists, printers, bookbinders and booksellers dependent on the trading success of other stakeholders, especially physicians. They had a financial interest in the disposable income of potential buyers, literate healers. The large number of publication titles indicates attractive profit margins attracting entrants to these markets. Their risks were unsold, deteriorating badly stored books, and loss of sales income. Knight p125.

Scientists were numerically the smallest and least financially risk-exposed stakeholder group. Their risk exposure was importing small samples for unsuccessful innovation, propagation and experimentation. Innovatory products risked rejection, failure to reproduce and inconclusive experimentation.

At risk from other stakeholders, were dependent professional, governmental and religious authorities. Their interest in plant medicine products was for raising revenue through taxation. As well as being dependent on the fortunes of providers, governments were exposed to risk of financial loss when costly attempts at regulation, and collection of customs duties, failed. Religious authorities, providing medical care gratis risked losing donations from wealthier patients, when ailments were few and financial circumstances straitened.

PRODUCTS AT RISK

Stakeholders needed three groups of products, medicinal flora, supplements and ancillaries. Shortages, and surpluses, were quantitive risks, affecting prices. Medical mis-use, deterioration in storage, and sub standard quality, were qualitative risks.

Medicinal flora were parts of trees, whole plants, leaves, bark, roots, flowers and shoots. Flora were administered to patients, as processed simples, mixtures and compounds in various natural, wet and dry formulations, powders, lozenges, distillates, juices, decoctions, poultices, ointments. Hedrick p34. Compound recipes became more complex after Mithridates. Cruse p73.

Supplements were established everyday animal, vegetable and mineral products, used with flora. Wine, beer, ale, honey, vinegar, treacle and sugar were established, and ubiquitous, domestic consumables. Some were imported. Wine was used with morphine from the opium poppy, papaver somniferum, in 6000BC by Swiss Lake dwellers and in 4500BC by Sumerians. Lewington p145. Culpeper p289. Wright T p100. Romans used wine in medication. Cruse p74. Jews and Greeks also knew how to make wine. Vin. Grande Dictionnaire Encyclopedique Larousse. Additional supplements were added to wine. Spices were added to suppress vinegar taste in wine. Swahn p13. The Indian drug, citrgandha, was mixed with wine. Whitfield p181. Vinegar and salt prolonged shelf life.

Beer, made from malt in northern latitudes, was added to a variety of scurvy treatments. Carpenter p228. In later Medieval England, stewed mallow leaves, malva sylvestris, were used in ale. Rawcliffe1995 p61. According to William Salmon 1694, a prolific English author, malt was a medicine in its own right. An infusion, or decoction, of it was used to treat ulcers. Wort. Oxford English Dictionary. Some Saxon herbal recipes required ale. Cameron p100. Honey was used in an electuary, a conserve or paste, in 1398. Electuary: Oxford English Dictionary. Alum, hydrated double sulphate of aluminium and potassium, used in tanning and dyeing, was stocked by a grocer. Thrupp p283.

Acquiring re-usable ancillary products, the third product group, required capital investment risks. The two previous groups were consumables. Containers, for storing wet and dry formulations, were made from glass, pottery, and animal skin. Robert Pickering, in sixteenth century Cambridge, had earthenware gallipots for ointment, (2.5 litre pottle glasses). Gunther p246. Containers were at risk of breakage with consequences for losing money invested in them. A consequential risk of falling sales of consumables was under utilisation associated with lower than expected returns on investments. Animal products, used in ancillary products, aged. A bladder stopper, recommended by Culpeper, for distilled waters, was not re-usable. Culpeper p287.

RISK INDICATORS

For effective risk management, stakeholders needed reliable, timely indication of current, imminent, and first order, fundamental risks as well as derived, consequential ones. Indicators drew attention to needs for short term, reactive response and longer term risk avoidance and mitigation. Indicators were medical and logistical.

Risk recognition of pertubation away from norms, may be a modern indicator concept to alert the need for proaction, but it helps understanding of risk in plant medicine history. All available indicators should be treated equally seriously, not ranked or ignored on account of their age. ‘When a system is perturbed away from its existing norms, far from equilibrium, chaotic conditions operate’ is permanently applicable. Mitleton-Kelly p37.

In plant medicine history, norms were earlier events against which current happenings might be compared. Comparison indicated the presence, absence and magnitude of risks. However not all risks had precedents. The Eyam tailor, in the Peak District, had no indication that a bale of cloth, delivered in 1665 from London, contained yersinia pestis, an organism exposing the population of the village to a deadly plague medical risk.. Hill p42.

In early modern England, prices of aromatic herbs and flowers had soared in plague times without stakeholder manipulation. Aromatic herbs were used for insanitary conditions. Payne p10 . The normal price of dekkeron rosemary, rosmarinus officinalis, was 1 shilling (5p) per armful but soared to 6 shillings (30p) per handful. Dobson p529.

Indicator availability, and unreliability, affected their use. Some stakeholders probably ignored available indicators because they were imprecise for measuring risk magnitude and timing. Unreliability, combined with non-availability and indicator deficiencies, jeopardised risk management.

Historical, and contemporary, short, and long term risk indicators, ranged in scale from global to local. Major international conflicts and transport, brought exotic product availability, and widespread epidemics risks. Local practitioner competence and fluctuating flora supply availability prices brought medical and logistic risks to small communities.

Maritime insurance used indicators to calculate premiums. In Italian coastal cities, during the enlightenment, premiums varied widely between 5% and 19%. Daston p118. Patients’ Influence on Preferences, Figure 2, shows indicator datum points.

Quantities demanded, and supplies available, together with their resulting prices, were longstanding, widespread, far-reaching indicators of shortages, and surpluses not only of products, but also of healing services. Variable demands for products, and services, interacting with variable supply availability, eventually reacted causing variable price risks. Morley p31 , p85. Quantities demanded and prices were complimentary risk indicators. Demand-Supply- Price Mechanism, Figure 4 refers.

Rising demands, for products and services, indicated specific community health deterioration risks. Soaring demands, closely linked to numbers of patients becoming unwell, indicated risks associated with epidemics. Following an initial surge, subsequent falling demands indicated higher mortality rates. Gatherers, growers, distributors, apothecaries and physicians were able to use these demand changes as cost and revenue indicators.

Market prices, even in ancient Greece, were volatile, because supply, and demand, influenced economic behaviour. Halstead p68, Finch p24. In the ancient world, bad barley harvests caused the price of this supplement, an ingredient for malt vinegar and beer, plant medicine supplements, to increase. Osborne p120 . Centuries later, Culpeper prescribed its use with named plants to treat eleven ailments and injuries.

The demand-supply-price market mechanism, which also existed in Rome, was refined in 1776, by Adam Smith, and formalised in the nineteenth century as demand theory. Temin.p13, Bothamley p141.

Consequential financial indicators, changing costs, prices, profits, losses, bad debts, premiums, income and expenditure, indicators were all derivatives of this mechanism. Fluctuating quantity risks impacted on the majority of stakeholders. Lesens p131. Upward and downward quantity trends, over time, indicated increased risks. Collapsing prices for products indicated, to growers, sales income reductions from land under cultivation. Reduced profit risks increased.

The extent of demand surges, and supply scarcity changes, indicated forthcoming rising, or collapsing, price risks probabilities for buyers. Demand surges and price changes did not synchronise. Lag times, postponed the effect of surges on prices. Lead times anticipated changes and brought forward their effects. Knowledge of provider behaviour was useful for estimating the length of lag and lead times.

The consequential risks of combined high demand for treatment, and reduced product supply, were increased treatment costs and reduced availability. Variable shortages of plants, and supplements, logistical risks, resulting from treatment demands exacerbated natural and human activity causes.

Demand transfer, from a non-available, preferred product to a substitute, used two indicators. Initial high demand risks, for one preferred product, could initiate a second demand-supply-price indicator mechanism, for a substitute. Supply, and demand, data, for the substitute, was unlikely to be identical to that for the preferred product. For example, supplies may be more abundant or scarcer. Non-availability of a preferred product, because supplies were exhausted, meant that demand-supply-price interaction for that product no longer functioned.

Temporal characteristics of risk causes varied. In the short-term, demand, and supply, uncertainty caused consequential price-list compilation error, and obsolecence, risks for providers. Hanley p65. When prices were changing rapidly, product catalogues were out of date as soon as published. Suppliers risked financial losses when listed prices were lower than actual market prices. Risk probabilities fluctuated as circumstances changed and affected the different categories of risks.

In the medium and long term, there were medical, logistical, demographic, and financial, risk trends, causing long term risks for stakeholders. Industrialisation, and mechanisation heightened the probability of injury risks to patients and reduction is land available for products.

Information flow velocity affected use of past events, for potential risk recognition. Local information, obtained aurally, with minimal delay, probably from-fee paying patients, product, supplement and ancillary producers, distributors, traders, debtors and creditors, indicated risks to stakeholders. Roman Egypt was a free market where information circulated. Rathbone p712. Communications from further afield were slower.

Additional indicators were practitioners ceasing to practise. Depressed markets for products, and services, as well as cash flow problems, unaffordable prices and insolvency, under- employment of those continuing to practise indicated excess capacity and contracted market risks. Reduced demands for practitioner services led to them having insufficient disposable income for buying publications. Consequently authors, translators, printers, bookbinders and booksellers risked losing their investments of time and money expended in bringing publications to fruition.

Unreliability was however a problem. For traders, demand cannot be treated in isolation from price, income, payment and expenditure arrangements. Patterson p423. Deliberate manipulation of supply, and demand, sometimes undermined the demand-supply- price indicator. It was a foolproof indicator only when free from interference. Opportunistic providers, witholding products, decreased supplies in order to raise prices to consumers. A consequence of raised prices was depressed demand. Panic buying, and cautious practitioners, intent on acquiring inventory, inflated demands . Bothamley p115. Suppliers might withhold supplies to create artificial shortage risks in order to inflate prices. On the other hand, apothecaries and physicians might retalitate by delayed ordering, in order to artificially suppress the demand element of the mechanism.

Interpretation of legitimate demand, supply and price changes, irrespective of manipulation was another problem. Upward, and downward, changes could be either transitory blips or semi-permanent trends of uncertain duration. Distinguishing between blips, and trends, was difficult before statistical smoothing techniques were developed. If they could be isolated from blips, trends were more reliable risk indicators. Producers, at the beginning of the supply chain, experienced difficulty in finding reliable demand indicators because treatment demand time periods were shorter than plant growing ones. Demand-Supply-Price Mechanism, Figure 4 refers.

Non-availability of context data added to interpretation difficulties. Reduced demands for flora and supplements, without knowing mortality rates, were unreliable risk indicators because two interpretations were possible. Patients’ inability to afford treatment could either indicate disposable income deficiency, inflated prices, and depressed economies, or secondly healthy communities, not needing products, and services. Inventory surpluses, and reduced sales turnover, for practitioners, were risks. Refusal of practitioner-prescribed-treatments, when the price of the consultation was included in the product price, might be either an indicator of patient impecunity, or mistrust of practitioners.

Elasticity of demand was another factor affecting demand-supply-price indication. Demand elasticity varies according to the magnitude of changes, quantities demanded, their mutability and substitute availability. Lipsey p107. Some price change risks were annulled by ample demand elasticity. Demand from seriously ill wealthy patients, willing to pay high fees was inelastic, but those from impecunious members of poorer classes, prepared to forego paying for treatment, were elastic.

Human behaviour also weakened indicator interpretation. When demand was low, suppliers’ reluctance to pass on price reductions, prevented using low prices as an indicator of treatment costs and reduced income risks. If herb garden order intake was depressed, the return on growers’ financial investment, and running costs, was a risk indicator to investors. When rising demands were predicted, forward buying, to forestall anticipated shortages and avoid future price uplifts, artificially increased demands. But if rising demands, and predicted shortages did not happen, there were over-stocking risks. Therefore prices were not always a reliable risk indicator.

Historical records, of incidents, warnings and management responses, indicated sources of risks. Recollection of past causes of risks, and outcomes, international, national and local scenarios indicated several financial risks, to stakeholders.

Records of past events indicated potential risks to stakeholders. Some past events had human origins. Work related accidents, interference by government, religious and military authorities were ever-present risks. ‘The principles underpinning the effective flow of materials, and information, have altered little’. Christopher p3. Recurring floods were a natural event risk indicator. Wisner p205. Demands for variable supplies and services, costs and price fluctuations, were risks with both human and natural involvement. Demands from humans interacted with natural events affecting quantities and quality of supplies.

Historical records also indicated fire risks to information and premises. In AD192, many of Galen’s treatises were destroyed in the Temple of Peace fire in Rome. Lloyd p136. Shops, containing stored products, risked destruction by fire. Jenkins p13.

Book keeping records of traders, growers and stockists, such as apothecaries, indicated financial loss risks when compelled to dispose of and write-off unusable products – growing plants, seeds, dried leaves, roots, living plants or formulated concoctions, electuaries, lozenges, distillates and ointments, as well as unsold imports. Rathbone D p18

Records of skirmishes indicated risks to ships, and caravans, from brigands, marauders and pirates McCormick p74. A cluster of risks ensued. Plant medical and other supplies, lost in transit, were obviously not available for sale. Cockerell p22. Payments, made to purchase products from distant suppliers, were also lost. Some marine insurance underwriters exacerbated risks to traders by refusing cover in time of war. Cockerell p15. Uninsured traders were vulnerable. Hoddinott p78. Others adjusted premiums, in accordance with levels of risk. In 1801 a surcharge was applied but reduced after the Battle of Trafalgar in 1805. Trebilcock p558. Duty in 1660 was 5% but rose to 15% in 1713 following the war of Spanish Succession. It was increased yet again in 1746 during the War of Austrian Succession and the Napoleonic Wars in 1803. In the fifteenth century, apothecaries, and spicers, in Bristol, Dunstable, Gloucester and Leicester, ceased trading because they were unable to pay sums ranging from £2 to £20. Thrupp p176. Wars blocked preferred overland Silk Road routes across central Asia indicating forthcoming exotic product shortage logistic risks Wars indicated financial risks because costs would rise and losses be incurred. Increased taxes, and duties, were levied to fund wars. Glass and earthenware used for bottles, plant medicine containers, were also taxed in 1690 and again in 1746. Kennedy pp32, 33,97, 156 Dowell Volume 1 pp 75, 79, 165, Volume II pp58, 62, 171, 180.

History also indicated that discrimination risks, affecting practitioners, were liable to increase in severity, and reduce supplies of products and services. Religious discrimination reduced numbers of practitioners. In the fifteenth and sixteenth centuries, Jews, in Mediterranean countries, were not absolutely excluded from practising medicine, but excluded from pharmacy.

Records of disciplinary, and criminal proceedings, indicated risks, to individuals in addition to those affecting all stakeholders. In fifteenth century London, if an apothecary’s treatment failed, he would be condemned by a jury of physicians. Thrupp p250. In 1633 Alice Mays, an amateur herbalist, was accused of murder in King’s Lynn for prescribing medicine to be taken internally. Brooks p238. In eighteenth century England, courts dealt with only a small number of alleged medical malpractice cases. Practitioner-patient litigation was subject to the law of contract. Crawford C p409.

Fiscal history indicated financial risks. High prices risks were not only associated with the micro economic demand-supply-price mechanism and funding wars. Intervention, by government agencies, added tax surcharges. On the south and east English coasts, royal taxation, collected between 1291 and 1341, indicated disposable income reductions and product shortage risks. Communities were rendered unable to pay for maintenance of reclaimed coastal marshland. Flora habitats, on previously reclaimed land, but currently submerged by the ingress of the sea, were destroyed. Campbell B M p418.

Brewing, beer and malt, used for plant medicine supplements, were taxed as well as home produced, and imported, salt, a preservative for delaying biochemical processes. Black horehound, ballota nigra, with salt, wine, honey and carrot seed was a plant medicine recipe. Foreign vinegar and salt were taxed in 1649, with increases in 1798 and 1805. William III taxed brewing. In 1780 beer tax was increased, malt tax in 1697, and brewing tax, in 1802. Dowell Volume II p53.

Reputations were another quality based risk indicator, for providers of products and services. Roger Bacon ca 1265 wrote ‘On the Errors of Physicians’. Gourevitch p220. Richard Baxter 1615-1691, a dissenting minister, consulted 36 doctors before finding his own remedy for an eye problem. Porter 1997 p80. Gossip, hearsay and treatment failure reports, were local indicators. Patients were sometimes aware of tarnished reputation indicators before the allegedly incompetent producers and practitioners to which they referred. Alleged failed treatment information, circulating in communities by dissatisfied, surviving patients, indicated risks to producers and distributors of products. Demands for ineffective products, previously prescribed by allegedly incompetent practitioners, decreased. Competent providers, and practitioners, to whom dissatisfied personnel transferred, risked work overload.

Defection, as a reputation indicator, differed according to circumstances. Least statistically significant was one defecting patient, with negligible purchasing power, dissatisfied with one of several practitioners serving a sizeable community. Another weak indicator was one dissatisfied physician ceasing to trade with an established specialist apothecary supplying several physicians. However, a more significant risk indicator, with increased probability of reputation damage, was the aggregate risk to a whole professional body, should the reputation of one deficient member tarnish the reputation of all members. One risk could impact on several stakeholders.

In urban neighbourhoods, practitioners’ medical and behavioural shortcomings, together with exploitative practice, if known, indicated individual practitioners as sources of risks to patients. As it was not axiomatic that patients had the freedom to defect from unprofessional practitioners, these indicators did not always have any useful purpose.

In scattered rural communities, indicators of practitioner, real or imagined, deficiencies were less evident than in urban situations. Patients were unable to defect to another practitioner, when only one practised in the community. Patients had two options, continuing to use the services of the one practitioner or resorting to self-treating. Printed herbals facilitated self- medication for those able to read, and understand the content of publications. Saks p15.

Knowledge, an intangible asset, unless validated by successfully treating cohorts of patients, by academic examination or experimentation, was not a reliable medical risk indicator. Some sources of knowledge were themselves risks. Information from countrywomen was the source for many English Elizabethan herbalists’ information banks. Nagy p66. In the eighteenth century, preparations by surgeon-apothecaries, were often herb-based with folk origins. Lane p46.

Medical risk indicators were ailment severity and extent, sometimes untreatable, even by competent practitioners, defective and unsuitable products and incompetent healers. Minimal, if any, feedback information about practitioners’ inability to overcome untreatable ailments denied patients a competence risk indicator. Good practitioner-patient relations diverted attention away from this risk indicator.

Changing to another treatment, because an initial one had been ineffective, may have indicated risks of incorrect diagnosis.

Scientific discoveries, made after the use of plant medicine peaked, were rarely available as medical risk indicators. Herbals listed some plants, now known to be harmful, when safe doses are exceeded. Dermatitis, listed by Baker 1567, Lyte 1578, Culpeper 1650 and Salmon 1710 is caused by comfrey, (also known as bone set and knitbone) symphytum officinale and by horsetail, (also known as joint grass, scrub grass and pewterwort) equisetum arvense listed by Amerindians, and Culpeper. Hops, humulus lupulus, and common sorrel, rumex acetosa, both listed by Amerindians and Culpeper, are allergenic.

Reliable indicators, of product qualitity changes, were visible and odiferous senses . Pungent odours, and visible changes in appearance, indicated biochemical and microbiological deterioration of surplus, over stocked products. Shelf lives differed, and transit times, from producer to user, varied widely. Those carried on continent, and ocean- crossing routes, were most exposed to deterioration risks. If whole, or parts of plants, and supplements, remained in stock, or in transit, for periods in excess of their shelf life, deterioration would render them hazardous to patients, in need of disposal as valueless waste by honest practitioners.

Stacks of unsold publications were visible indicators to authors, translators, printers and customers, of depressed markets for information, inability to sell and practitioners’ disposable income shortage risks.

In rural situations, observation of products in the wild by gatherers, indicated current, and forthcoming, product availability risks.

CAUSES OF RISKS

There were many causes of interacting logistical, medical and financial risks mentioned above. Analysing records, and memories, of past occurrences alerted stakeholders to them. Causes, indicators, and management, were connected. Analysis of past causes indicated many possible, repeatable risks not confined to particular time periods.

Causes of risks were natural, and human. Complex networks, such as plant medicine, react to external causes. Cohen p5. Risks, caused by natural, environmental processes, and human actions, recurred at variable, random, stochastic, intervals with varying degrees of severity. May p82.

Relationships, linkages, between causes, and risks, were usually probabilistic in incidence, and extent. Vose 3rd edition p118. Wheat surpluses, a variable logistic risk, distilled into gin, a human action, might cause few, or many, medical risks. Wild flora shortages, depleted by natural abnormalities, such as weather extremes and over-harvesting by stakeholders, coinciding with times of high demand, caused instability in the demand-supply-price interactive mechanism. This mechanism operated in several risk scenarios appraised below.

Major risks could have minor causes. Some biological systems, such as plant medicine flora and vegetable supplements, are capable of displaying chaos. A minor disturbance can have extensive ramifications. Campbell & Mayer-Kress p23. A versinia pestis organism, in a bale of cloth, brought from London by an Eyam tailor, in Derbyshire, caused the 1665 plague and many deaths. Hill p42. Chaos implies the existence of unpredictable, or stochastic, aspects in dynamic systems. Cambel p15. Rising mortality rates, in times of plague, caused reductions in the number of potential patients and practitioners able to treat survivors. Change in one risk caused interaction, and multiplication, of related risks. Even rare events, such as the Eyam plague, serve to indicate causes of risks. Long before the Eyam Plague economic activity caused recurring medical risks. Trade routes facilitated the spread of the Plague of Justinian from Egypt. Wisner p181.

Risk multiplication caused more risks to stakeholders . Adverse price changes, consequent on demand-supply interaction, caused practitioner costs, profit and loss, liquidity, purchasing decision, cash flow and disposable income risks as well as influencing patients’ buy-in or self-treating decisions risks.

Affordability determined whether products, and services, would be purchased by patients, in the rare event of price being the sole purchasing criterion. This had risk ramifications. Practitioners, selling products at too low a price, caused business survival risks for suppliers, even if their product and service quality was superior. Conversely, increased prices deterred patients and could cause irreversible defection of patients to a competitor offering lower prices.

Temporary inability to supply products caused apothecaries to risk permanent loss of clients to competitors, especially in urban situations, where there were alternative, competing suppliers. In the absence of buffer stocks, strong inelastic demands by patients, allowed resulting price increases to be passed on. While stocks were available, financial benefits accrued until increased demands exhausted stocks, inflated prices for replacement stock, increased working hours to process supplies, and enforced recourse to substitute risks. Stock-out reduced incomes of providers and practitioners consequently causing shortage of funds risks for investment in inventory, and premises.

Out of phase lead times caused ancillary product logistic risks. Skin and glass containers, had manufacturing lead times too long to respond quickly to demand surges from distributors, when increased supplies were needed. Investment in buffer stocks, despite associated depreciation risks, was desirable, but not always affordable.

Highly elastic, flexible demands caused supplier profit margins to shrink because patients were able to resist price increases. Increasing unit prices to customers, to compensate for sales volume reductions, was not an option. Suppliers, vendors, were obliged to absorb price increases, suffer income reduction and even consider withdrawal from the market. Moreover ineffective treatments and inflated prices exacerbated reduced demand because patients were deterred. However inelastic demands caused financial risks to buyers but benefits to suppliers because price increases could not be resisted

Environmental changes caused unavoidable, unpredictable environmental risks to product supplies. Events in climatology, entomology, meteorology, geomorphology, glaciology, botany, entomology, vulcanology and zoology caused unpredictable logistic, medical and micro-economic risks. Christopher p234. Environmental Risks to Supplies, Figure 5 refers.

In seventeenth century England, long frosty winters, and cold wet summers, caused people to be without sufficient disposable income to buy products and services. Shortages of flora supplies inflated prices. Jones E L p30. Extreme weather conditions have been experienced in all countries where phytomedicine was practised.

Destructive tectonic activity, volcanoes and earthquakes, occurred in Asia, the Middle East, the Americas and southern Europe where phytomedicine was practised. In 1500BC, the Santori eruption devastated the Mediterranean coastline Earthquakes in Portugal, Japan, China, Greece, California and Italy caused major loss of life, thereby reducing the potential number of patients. The 1290 earthquake in Chihli, China caused 23, 000 deaths while the 1556 Shensi earthquake killed 830,000 people. Bolt p224

Memory and written records confirmed the relevance of environmental processes to supply and consequential earnings risks. Earthquakes, volcanic eruptions, tsunamis, landslides, avalanches, windstorms, sea level rises, droughts, floods and wildfire caused risks to product supply continuity and people. Salvadori pp58, 66, 68, 72, 77, 83, 86, 89, 94, 106, Christopher p247.

Unseasonable temperature, nivial, and pluvial precipitation, affected flora dieback and growth. In the ancient economy of Greece, bad barley harvests affected prices of this cereal from which the supplements vinegar and beer were brewed. Osborn p120 . The extent to which a plant is endangered, by frost depends, not only the magnitude of the drop in temperature, but also on the time of onset and the duration of the drop. Sakai p16. Time - independent, seemingly random, volcanic eruptions affected climate. Chester p163, 211. Natural Factors causing Plant availability Risks, Appendix 6, refers.

Temperature, precipitation, humidity, light intensity and duration and edaphic (soil) factors affected growing conditions. Turrill p68 , 77. In May 1740, there was no sign of verdure and it was still cold in July Jones E L p139. Not all plants mentioned in the literature were available in all places with similar environment. Nor were ostensibly similar plants identical in every respect. Wright E M p34.

Sand and rain storms disrupted transport of seeds, specimens and supplements from distant places. Sailings of packet boats from English ports were delayed by winds. Wright C & Fayle p5. In 1786, the French Academy of Sciences sent Jean-Francois de Galaup, Comte de la Perouse, to find innovative materia medicia in western North America. The ship was wrecked two years later, in 1788, by storms. Foster & Hobbs pv.

Vegetation removal occurs in a wide variety of environmental circumstances. Thornes p172, Crozier p156, Calow p1. Variations in product quality, as well as quantities were also caused by environmental phenomena. The chemical composition of plants was, and is, altered by the environment. Allen p26.

Some plants are almost cosmopolitan, but environmental causes confine many to local sites, where there is less competition for favourable growing conditions. Turrill pp59-67, 84. In the eighth century, Chinese plants could not be cultivated in Japan. Lock p51. Boniface, 680-755, complained about his inability to source ingredients found in European medical books, a logistic risk. Wright T p94.

Weather also caused shortages of supplements. Honey is dependent on fine weather. Jones E L p32. In 1171, in England, the cold dry spring affected the yield of ewes, the principal source of milk. Jones E L p145.

Until controlling methods were discovered, and implemented, many ailments of patients, which drove phytomedicine systems, were caused naturally. Avian, and mammal, faeces deposited on flora, were a cause of medical infection risks. Cinnabar moths strip ragwort senecio jacobea, whose juice was prescribed by Culpeper for ulcers, swellings, quinsy and sciatica. D(W) 1778/V/14B

Biochemical processes caused some logistic and treatment efficacy risks. Products stored, and in transit, deteriorated and became unusable so practitioners lost time and money.investments. Herbs boiled, or stored for too long, lost potency. Allen p26. Products were stored in imperfectly sealed containers, such as bottles and pigs’ bladders. Drying plants, to treat scurvy, caused loss of efficacy. Carpenter p228

Demographic changes, and trends, affected numbers of people, age and gender distribution, life expectancy, birth and death rates were caused by a combination of natural and human factors. Sometimes environmental phenomena, such as floods, made settlements uninhabitable. Economic activity caused settlements to expand, as well as contract.

Locations affected the magnitude and type of risk, to which practitioners were exposed. Permanent locations, where personnel practised, were either urban or sparsely populated rural ones. Place name suffixes of place names in England, ley, ton, dun, indicate small rural settlements, low population density and fewer services. Preferred medicinal plants might have been growing in close proximity to rural settlements. Income-generating risks were evidenced by depopulated, deserted villages. Allison.

When population centres increased in size, and the age structure changed, demand for services exceeding available competent practitioner capacity, and suitably formulated ingredients, caused additional logistic risks and medical ones if practitioners had insufficient time per patient, or lacked the skills, to diagnose correctly. In smaller communities, when an unsatisfactory practitioner was the only one available, patients had restricted choices, self- medication, continued use of the practitioner or foregoing treatment. Recourse to self- treating could cause additional medical risks for patients.

Human actions also caused logistic, economic, information and medical risks. Some causes were broadly based with far reaching effects. Anthropic Risks to Supplies, Figure 6 refers. Others were more narrowly focused on plant medicine risks. Human, and product deficiencies caused medical risks such as incorrect diagnosis, practitioner ignorance, ineffective treatment using inappropriate plants, sometimes involving toxins, incorrect doses and inflated price risks. Simplistic Correlation of Symptoms and Plants, Appendix 7 refers.

Profit seeking caused medical and logistic risks. Investment, in road and rail infrastructure, industrial expansion, and agricultural machinery, contributed to flora shortages. Deforestation, grazing and ploughing methods changed plant habitats. Hanley p212. Effluent from lead mining and smelting deposited toxic particles on plants. Mining waste heaps, factories and ugly rows of terraced house interfered, contaminated and destroyed plant habitats. Bell p18 Radical changes in vegetation resulted from accidental or intentional destruction by man. Crozier p156. Enclosures prevented lower classes gathering flora from common land. Campbell p414.

The practice of gathering herbs, for profitable city markets, exacerbated supply scarcity risks for rural populations. Allen p24. Some authors and translators risked making factual errors because their motives were primarily mercenary. Johnston I and Horsley pic

Injuries were a cause of manual labourers needing treatment, at the same time as being prevented from earning money to pay for it.

Competition was an endemic cause of sequential risks in the plant medicine market. Competition between practitioners, caused price increase risks, when supply reduction coincided with demand increases. Escalating prices caused practitioners to lose income, and cease trading, when only rich patients could afford higher prices for treatments. Practitioners risked losing trade because impecunious patients, who practised self- medication, competed with professionals. Consequential reductions, in practitioners’ disposable income, caused market shrinkage risks to authors, translators, printers and booksellers supplying the plant medicine information market

If there was not a protective cartel, individual members of clusters of apothecaries, in urban situations, risked being disadvantaged by price competition causing patients to patronise neighbouring apothecaries. In early modern Naples, there were one hundred and five shops selling plant medicine products, eighty-seven apothecaries and eighteen monasteries. Gentilcore 1998 p115

Other professions caused shortages of practitioners. More attractive careers attracted qualified personnel and consequently exposed patients to medical risks of non-availability, and sub standard, treatment.

On the other hand lucrative plant medicine markets attracted competition. Treatment successes, and earnings, caused additional entrepreneurs to enter the market, and compete with established practitioners. The entry of more practitioners, to finite markets, ultimately reduced market share per practitioner, and introduced more competition for supplies. Should higher costs exceed gross income, a practitioner would risk trading at a loss. Between 1750 and 1848, opportunist druggists began replacing apothecaries, and grocers, as sources of medication. Pelling p69.

A surfeit of publications caused excessive competion and market saturation risks. English Publications in Saturated Markets, Appendix 5, refers.

Major stakeholders caused serious risks to minor ones. In fourteenth century Europe, powerful cartels - Lombards, Tuscans, Caorsini, Riccardi, Bardi, Peruzzi, Scali - disadvantaged smaller traders by buying, and selling, medical drugs, arranging insurance, collecting bills of exchange and arranging loans. Boissonade p168.

In fifteenth century England, “ The Libelle of Englysche Polyce ” lamented the vogue for foreign medicines competing with English herbs. Thrupp p250.

Alternative, competitive, belief systems, magic and religion also caused the plant medicine market to contract

Liquidity problems, probably caused originally by competition, caused more risks for all stakeholders with financial interests. They caused business failure risks for practitioners, poverty and unemployment risks for patients. In seventeenth century England, real incomes were so low that everything that nature offered, even if contaminated, was used.

Poverty caused Ibn Ridwan, born 998 Giza in Egypt, to respond by teaching himself. Encyclopedia of Islam Volume III p21. Self-treating, to avoid paying providers, caused medical risks to patients who practised it. Marland p226, Jones E L p30.

Fiscal measures throughout history, caused financial, and psychological risks. Taxation, to finance wars, and maintain monarchs, was not only another cause of price increase risks, but a psychological cause of business uncertainty. Unwillingness to invest in premises and inventory together with inability to compile price lists was caused by uncertainty. Uncertainty, concerning import duties and taxes, affected flora, supplement and ancillary caused price and working capital risks. Traders required additional working capital to pay price increases. Imported plants and supplements, with other uses in England, accentuated economic consequences of shortages and surpluses. Gerard’s Imported Plants, Appendix 8 refers. Turrill p59ff

On Delos, a sales tax of 2% caused prices to increase. Morley p60. In Roman Egypt, there were 1% sales taxes. Rathbone D W 2002 p712.

In AD212, in Rome, debasement of coinage also caused price rises. Morley p101.

In 1203, the first customs houses in England, for collecting duties, were built at ports of entry. Dowell Volume 1 p75. The Long Parliament imposed customs duties on all manner of goods and merchandise. Customs duties on wine, a plant medicine supplement, were longstanding, and increased several times.

In 1782, the British government imposed a duty on fire insurance, which affected distributors’ premises. Jenkins p16. Patent medicines were taxed in 1783.

In 1302, butlerage was to be paid forty days after landing by foreign merchants. Prisage was payable on wine imported by denizens, permanent foreign residents. In 1782, tax on bills of exchange, negotiable instruments used for making commercial payments, increased liquidity and credit control risks for traders. Dowell Volume II p175.

Large quantity product suppliers needed increasing amounts of working capital to pay tax collectors, and to cope with delayed settlements by customers. Between 1291-1341, royal taxation caused coastal communities to be unable to pay for sea defences. Reclaimed marshland habitats of plants were submerged Campbell B M S p418 Working capital requirements increased because, in 1660 and 1802, retailers had to pay in advance for licences to sell wine, a plant medicine supplement. Dowell Volume II p253. Chandaman p117. Retailers’ profit margins were squeezed ca 1660. Wholesalers could collect tax from the retailers but it could not be passed on to consumers. In 1778, taxation increases caused merchants, and retailers, to quadruple prices. Chandaman p42 Dowell Volume II p173

Wine, a supplement, was taxed from eleventh century with increases in 14th 17th 18th 19th centuries. Dowell Volume 1 p75, Volume 2 p211, p231. Increases were also imposed in 1746 and in the period 1789-97 Kennedy p97, p156. Culpeper prescribed wine with clary seed, succory seed. Beer taxes were increased in 17th, 18th 19th centuries Dowell pp53, 137, 231. Beer was brewed with barley

In 1690, glass and stone earthenware, ancillary products used for storing products, was taxed but subsequently repealed by William III. Dowell Volume II p2.

Petty customs were additionally collected on wine imported through Southampton, in the eighteenth century. The practice of wine mixing in Guernsey, an entrepot for English trade with France, Spain and Portugal, caused risks to the suitability of imported wine for suppressing noxious plant medicine tastes.

Exemption in 1779, although welcome, caused more uncertainty. Kennedy p157. Repealing taxes caused a reputation risk for traders, apothecaries and practitioners. Should the reduction be passed on to patients or, in an uncertain business environment, current prices remain unchanged in order to create a reserve lest taxes were re-introduced at short notice. Reducing prices, and then increasing them after a short time, risked damaging practitioner-patient relations. Merchants and distributors, with stocks purchased before tax reductions, risked losing money if prices had to be marked down because prudent buyers were aware of the reductions.

Conflict caused risks to personnel, and financial loss. Patients, affected by conflict, may need products and services to treat them. Products transported by land, or sea, risked sequestration and loss. Pym’s chairs in the Derbyshire Peak were created as lookouts against bandits. Banditry, and the cost of protection, caused the decline of the central Asian caravan trade, between 960 and 1279. Rossabil p364

Marauders , bandits, thieves, pirates and dietary deficiencies caused life-threatening risks for personnel manning ships and caravan trains. McCormick p74. Individual traders were exposed to trans-central Asian banditry risks. Rossabil p355. 80 places in Silk Road Sections, Figure 7 refers. Herbal products were among the goods carried, in addition to silk. Gibb p460.

Intervention extended beyond fiscal measures and conflicts. King Sasanid of Persia [624- 651] blocked the northern arm of the Silk Route from China. Hornblower p255.

External intervention caused medical information risks to patients, as well as providers. In AD49, the School at Edessa was dissolved by Emperor Zeno. Budge p76. In 1194 Frederick II, reduced the University of Salerno to a state registered medical school, and ordered three years’ study of logic before the study of medicine at the University of Naples. Thompson p722. Avicenna was banished from his hometown. Gourevitch p168. In 1530 D’Orta , a Spanish Jew exiled to Portugal, devised a way to flee to India. Goodman D & Russel C A p124.

The dissolution of the English monasteries by Henry VIII denied treatment facilities to patients living in close proximity to religious houses and the supply of medicinal plants from their gardens.

Negative discrimination caused a number of risks. In plant medicine history, and in many places, negative discrimination caused businesses, and their owners, to be exposed to livelihood loss, knowledge deprivation and closure risks. Users of their services were obliged to find alternative suppliers, in markets distorted by reduced numbers of competent healers. Removal of distributors, from supply chains, caused cost-push inflation for patients in urban situations where they had previously benefitted from competition. At different times, and in different places, practitioners risked educational exclusion, access to information denial and removal of freedom to practise.

William Turner, the English author was exiled twice, once for embracing the Reformation, and subsequently during the Marian persecution. He used his periods in exile to study, in Bologna and Germany. Gunther p367

In 1250, Pope Pius IV succeeded Innocent IV. He placed apothecary services in the hands of Christians, not Jews, then in fifteenth century Spain Muslims were progressively excluded from the apothecary profession. Benezet pp70, 80 . In 1492 Jews and Muslims, amongst whom medical books had circulated for two centuries, were massacred in Castilian Spain. Hillgarth Volume II p162.

In 1135, with the rise of Montpelier as a plant medicine centre, monks were forbidden to practise medicine. Knowles p98. In 1237, Pope Gregory IX condemned the maritime insurance bottomry agreements, which originated in Roman times, as usury. Insurers lent merchants the cost of a voyage. If a ship was lost, the loan was annulled. If it did return safely, a bonus was paid. Daston p116.

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