THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION · JUNE 1983
Hanuman and the healing herb
Cover:
ln Hindu mythology, the monkey god Hanuman-sent to fetch a herb from the Himalayas to cure an injured warrior- brought the whole mountain instead.
Design by Peter Davies
IX ISSN 0043-8502
World Health is the official illustrated magazine of the World Health Organization.
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Contents
Which way for traditional medicine?
by Olayiwola Akerele . . . 3 The future is learning from the past by Xavier Lozoya . . . 5 Folk wisdom
by Alastair Anderson . . . 8 Traditional psychiatry in Mali
by Piero Coppo . . . 10 Unani Tibb in Pakistan
by Hakim Mohammed Said . . . 13 A treasure-house of herbs
by Norman R. Farnsworth . . . 16 Poisons of ancient Peru
by Fernando Cabieses. . . 18 Herbai medicine-fact or fiction 21 The TBAs of Senegal
by Pape Marcel Sène. . . 22 Essential drugs in Mozambique
by Joseph Hanlon . . . 26 News Page . . . 30
Which wav lor hditional medicine?
A "wind of change" is blowing in the field of traditional medicine, as in other fields of health care. lt is only by being visible and active that WHO will keep abreast of a develop-
ment which represents a re-birth of the medicine of the past-and will help to humanise the medicine of today
Traditional medicine responds directly to a given society's needs for psychosocial and physical health and well-being. lt also re- lates to man's whole desire for spiritual and artistic fulfilment. For an African, tradi- tional medicine represents the sum total of practices, measures, ingredients and procedures of all kinds, whether material or not, which from time immemorial have enabled him to guard against disease, to alleviate suffering and to cure himself.
The majority of Asians regard life itself as the union of body, senses, mind and soul;
in accordance with this conviction, they consider positive health as the blending of physical, mental, social, moral and spiri- tual welfare.
The realisation of the prospects inherent in the use of practitioners of traditional medicine as front-line workers in the development of national health systems is conditioned by two independent factors : the changed political power that accom- panied national independence, and the low levels of resources that are available to tackle issues of development. The first factor is related to national group pride, and is associated with past heritage and newly gained national independence. The second factor is linked to utilisation of all available resources. Since the practition- ers of traditional medicine are already well-patronised by members of the com- munities in which they live and work, the adoption of traditional medicine in the design and implementation of national health care systems obviously makes good sense.
A traditional healer in the Congo bottles one of her decoctions. Photo WHO/R. c. da Silva
by Olayiwola Akerele
In 1977, the 30th World Health Assem- bly adopted a resolution (WHA30.49) urging interested governments to give
"adequate importance to the utilisation of their traditional systems of medicine, with appropriate regulations as suited to their national health systems." Both developing and developed countries are showing greater interest in using traditional and indigenous health care resources in imple- menting their national health pro- grammes, particularly at the PHC level in developing countries. The vogue for using natural biological products rather than synthetic ones has been the prime motive behind renewed interest in folk medicine (including the use of medicinal herbs) in developed countries. In many instances, such trends have been backed by appro- priate legislation. Sorne developed coun- tries have already started to examine the possibility of introducing into their nat- ional curricula a number of alternative health systems not at present taught in their medical schools, a development which has already taken place in several developing countries.
Role of WHO
Immediately following resolution WHA30.49, WHO launched a world-wide promotion effort. The success of this promotion can be measured by the grow- ing interest in the subject. lt is also reflected in the large numbers of letters of enquiry and the numerous "internat- ional" conferences that have been held or are being planned, with or without WHO collaboration. There is, in addition, a growing volume of articles on related themes appearing in scientific journals and lay publications, while many institutes and agencies are seeking to associate themselves with WHO as collaborating
research and training centres, or in mak- ing films on different aspects of traditional medicine.
These recent positive developments are largely the consequence of WHO's leader- ship role in the health domain. Endorse- ment by WHO has also encouraged a re- examination of the value of traditional medicine in most developing countries, from which new cultural awareness of, and pride in, traditional values have emerged.
This newly-found national pride would be of little consequence unless it were trans- lated into a meaningful form of action.
WHO's role in this translation process is crucial. One of the most positive things that the Organization has is its credibility, its "non-partisan" involvement. In an area where developing countries are anx- ious to prevent a second wave of exploita- tion, the Organization can be trusted to look after their interests, and to prevent any over-exploitation of the potentials that are present in traditional medicine.
The large number of traditional health practices in specific countries need to be identified, gathered, sifted through and evaluated. The decision whether to make use of them rests ultimately with each country itself These practices, including herbal and home remedies, could consti- tute new tools for use by the health systems; a service-oriented mechanism is needed to make them readily available to suffering humanity. In any event, medical care in most rural as well as some urban areas is a mixture of both traditional and modern medicine. lt is often difficult to determine where one ends and the other be gins.
The field of traditional medicine is an area where various groups with different vested interests, including commercial in- terests, are vying to gain greater prestige and attention; some would like to have 3
WHO's backing for these purposes. WHO's
role must be to channel such initiatives towards the wider goal of equity and service, through careful assessments of the proposals that are submitted.
Critical analysis
What is imperative now is that WHO
should stand back and evaluate the tradi- tional medicine programme. Such a criti- cal analysis will serve to identify, classify and develop the different disciplines in- volved, and to map out clear grounds for further programme growth. Ideally, there should be a solid, steady expansion of concepts and experiences over the next five years.
The programme should continue to act in concert with the Organization's Re- gional Offices, encouraging and support- ing those countries that are ready to use practitioners of traditional medicine within their national health systems, as part of their strategy for "Health for all by the year 2000."
Closer links with other institutions working in this field will broaden WHO's
capacity to respond meaningfully to in- herent pressures and demands that may corne from various quarters.
Three major lines of action suggest themselves :
- Evaluation of traditional medicine and practices. It goes without saying that a kind of "power play" has often prevented the legitimisation of traditional medicine in different societies. lt is therefore all the more important to separate myths from reality. What is the possible value of traditional medicine systems in terms of diagnostic, therapeutic and rehabilitative application? Do we know enough? How can WHO bring the knowledge that is inherent in traditional medicine into the open? WHO could act as a facilitator and stimulator of the public interest that
Plant medicines on display in a Bolivian street. WHO collaborating centres are at work identifying patent herbai drugs for such purposes as fertility regulation and treatment of cardiovascular diseases, mental illnesses and diabetes. PhotoWHO/J. Bland
already exists in both developing and developed countries. Modern technology can be used to provide evidence of effi- cacy and safety, or to prove the placebo effect of some of the practices and re- medies that are currently in use in differ- ent countries. (The placebo effect is the positive therapeutic effect that some pa- tients derive from a medicament whose active properties cannot be shown ; this effect is frequently seen in disorders of a psychosomatic nature, and of course the placebo, or inactive drug, is as much used in modern medicine as in traditional medicine.)
The collaborating centres that have al- ready been designated in developing and developed countries will continue to carry out relevant research in ethnopharmacol- ogy, and in traditional systems of medical practice such as acupuncture, as well as undertaking epidemiological follow-up of their use. They will seek inter alia to identify potent herbal drugs for such pur- poses as fertility regulation and treatment of cardiovascular diseases, mental ill- nesses and diabetes, and test the best and safest ways of using them. These practices and remedies could then be made -readily available for wider application.
- Research into traditional medicine as part of a national health system. Apart from China, where a synthesis of tradi- tional and modern medicine is being pur- sued, and such countries as Burma, India, Mexico, Nigeria and Thailand, · where traditional medicine is being developed in parallel with allopathie medicine, not much is known about the possibilities that exist for making use of traditional
medicine technology in national health delivery systems. We need to find out how such proven technology could be incorpo- rated into those national health service systems that are willing to use it. On the basis of research results, WHO will promote the use, where appropriate, of effective traditional medicine and practices at all levels of the health system, but particu- larly through primary health care. WHO
will encourage programmes for setting up herbal gardens, particularly at the family and community level, to ensure that safe herbal remedies are available for self- care.
Certain fundamental problems of inte- gration were identified at a WHO meeting held in Geneva in 1977. For example,
"the impossibility of integrating certain aspects of traditional medicine based on spiritual, moral or other fundamental principles, e. g. exorcism and special heal- ing arts associated with spiritualism ". This and related problems make the issue of programme definition even more pressing. - Training. How do we train traditional practitioners? How do we introduce el- ements of traditional medicine of proven value into the curricula of health workers?
The important thing is to make practition- ers of traditional medicine our allies rather than our competitors; the training of traditional birth attendants in many countries is an excellent example of the possibilities that exist for this type of collaboration.
In order to have a clearer perspective of the social, political and · economic inter- play associated with the definition of a programme in traditional medicine, the opinions of national experts with widely differing backgrounds and experience will be crucial. A proposed Expert Committee meeting which is to examine "the role of traditional medicine in primary health
care" some time in late 1984 should fulfil
this requirement.
WHO's Traditional Medicine programme is at an historical crossroads. Having gen- erated international awareness of the rich- ness and importance of the subject, it can either sit back and become a passive observer and reporter of developments in different settings; or it can maintain its leadership role by actively defining more refined and widespread developments. Clearly the latter course of action is to be preferred. If WHO were to take a passive, low-profiled stance, it would risk being bypassed by events. A "wind of change"
is blowing in this as in other fields of health care. It is only by being visible and active that WHO will remain in the main- stream of this exciting development-a development which represents a re-birth of the medicine of the past, and one which will help to humanise the medicine of
~dey. •
llle lulure is leaming tom Ille past
Much of today's research into natural medicinal products is being done by the big pharmaceutical companies. So will the Third World countries in future have to spend scarce foreign currency on re-im- porting their own plants and plant extracts? Dr Lozoya of Mexico argues that drugs of the types now under study by modern science can be manufactured by the developing countries themselves
I
t used to be generally assumed that medicinal plants could now be safely relegated to no more than a footnote in medical history. But this assumption has turned out to be a premature one. lt is true that, where once the schools of chemistry obtained raw materials from plants in order to manufacture potent new drugs, now they preferred the industrial manufacture of synthetic products, at low- er cost and in huge quantities. This also ensured a reliable supply of safe drugs in developed societies. Medicinal plants, with their old-fashioned curative proper- ties, became a thing of the past once the secrets of their chemical composition had been wrested from them and their "active ingredients" had been identified.This epoch of the great phytochemical discoveries and the establishment of basic groups of natural compounds ushered in the era of drug taxonomy and industrial patents. The powerful pharmaceutical combines laid down standards and estab- lished procedures for the use of such compounds in modern medicine. They also stimulated the development of count- less chernical versions of natural and synthetic products, rivalling Nature itself in obtaining a wide variety of derivatives from a single substance. The use of med- icinal plants in the form of poultices, infusions, baths and aromatic oils now seemed to have been superseded by
"Western" science. Only in "primitive"
cultures in the "underdeveloped" coun- tries did bonesetters, traditional birth attendants and herbalists continue to use plants in age-old ways that have done so
by Xavier Lozoya
much to enrich the anthropological litera- ture of the twentieth century.
But at the start of the 1970s this picture began to change. The first manifestations of the post-industrial age began to gain ground within the affluent society. Vari-
Shen-Nung, of whom it is claimed that he founded Chinese medicine in 2838 B.C., holds a medicinal plant in his hands. His tunic is made from the leaves of healing
plants. Photo WHO/X. Lozoya
ous social movements questioned the de- finition of health and the prevailing medi- cal system, and broached the problems surrounding ecology, nutrition and the working environment in the cities.
These trends also affected drug con- sumption. The citizens of the indus- trialised countries began to condemn the excessive, almost daily, use of phar- maceutical products. The term "iatro- genic "-applied to disorders caused by medical treatment-be.came common cur- rency, and winds of change started to blow through the health care programmes. An increased awareness of Eastern cultures also developed at this period, and lent fresh impetus to the search for alternative ways of maintaining health and coping with disease.
Acupuncture and herbalism in particu- lar attracted the curiosity of the indus- trialized society. The study of medicinal plants was revived in the West under the influence of a "back to nature" move- ment which-although not without a cer- tain snob-value and some commercial undertones-has taken root within the middle classes of the indus trial society.
All this lent encouragement to the study and development of the traditional or folk medicines of Third World countries. Peo- ple are once again acknowledging the important social fonction fulfilled in de- veloping countries by bonesetters, herbal- ists, and other practitioners of traditional medicine which, it is claimed, restores cultural and human dignity in places where more modern forms of medicine seem to have lost it. The poorer countries themselves are realising the therapeutic value of indigenous medicines, and the need to assess their curative properties.
So we have a pharmaceutical paradox.
While the developing countries are 5
struggling to industrialise, including set- ting up their own pharmaceutical indus- tries and exploiting their own raw ma- terials (to manufacture drugs that are at present imported), the developed coun- tries are going back to natural substances that have not been chemically processed, in order to obtain the "natural" drugs demanded by a post-industrial society.
Scientific studies are beginning to ex- plain some of the curative phenomena associated with the traditional use of her- bai remedies. They have, for example, established the usefulness of the local application of salicylates such as aspirin
Headman of a whole tribe of healers in Ecuador, this wise old man explains the properties of his herbs. Photo WHO/D. Henrioud
( the original method of using the remedy based on powdered bark of the willow tree) to treat rheumatic complaints. This method is being compared with the oral administration of the same substances.
Percutaneous absorption-through thé skin-can achieve a therapeutic effect in the affected part of the body with much smaller quantities of a given drug, without any need for the drug to enter the blood-
stream. This calls into question the classic theories concerning the distribution of drugs in the blood ! Percutaneous absorp- tion also explains the therapeutic efficacy of a hot bath containing essential oils of aromatic and medicinal plants. The pres- ence in the body of terpenes, derived from essential oils, has been demonstrated up to 24 hours after taking a bath ; the efficacy of this procedure, which combines medicinal plants with hydrotherapy, is being investigated in several chronic dis- orders.
In the light of these studies, the applica- tion of poultices, massage with plant- based liniments, and the therapeutic use of essential oils are taking on a new dimension in the medicine of the future.
A similar development is taking place in the study of the pharmacological effects produced by plant-based infusions. lt used to be argued that pure chemico-phar- maceutical compounds must be superior to the complex mixtures of substances generally found in an infusion, because it was bard to standardise the latter and to administer them in accurate doses. But the advent of an effective technology of chemical analysis, using high-resolution chromatography, mass spectrometry and nuclear magnetic resonance, makes it easier to identify and quantify the chemi- cal ingredients of a mixture.
Is there then a place in scientific medicine for plant-based infusions? Most certainly there is. Nowadays such prepa- rations are described as "mild" remedies for treating minor aliments and general disorders of the body. Studies on the way in which camomile tea, for example, alters the hormonal balance or helps to reduce inflammatory processes appear to revolutionise some of the dogmas of
"orthodox" pharmacology. The treat- ment of diabetes mellitus with plant ex- tracts is becoming part of "Western"
medical practice, and investigations are under way into the combined action of the vegetable substances which make up the traditional potions used for this purpose.
In reproductive biology too, potions made from herbs have made an appear- ance. The development of new plant- based products which have the property of causing abortion- a fact known to the indigenous civilisations of Central Ameri- ca for more than 500 years-suggests the potential use of an infusion as a method of birth control.
Thus simple plants in their traditional forms of use-laxative decoctions of roots, antipyretic teas of leaves or flowers, oily poultices of analgesic or stimulating herbs, crude extracts to regulate menstruation, glycaemia-reducing plants taken orally in
combination with food, fomentations or massages using natural anti-influenzal substances, and sedatives of vegetable origin-are gaining acceptance from late twentieth-century science. There is high promise that in the future, in combination with other familiar natural rèsources such as antibiotics and hormones, they will become part of a new assortment of drugs suited to current health needs.
lt is ironie that medical circles in many developing countries, where a centuries- old knowledge of herbal remedies is part of popular lore, persist in believing that research on medicinal plants is out of date,
Dr Xavier Lozoya (right) discusses a medi- cinal plant which has already been system- atically analysed at the Biomedical Re- search Unit on Traditional and Herbai Medicine in Mexico City, of which he is the Director ! Photo WHO/J. Bland
and that their use is merely part of the folklore of under-privileged indigenous groups in those countries. They also main- tain that, once industrialisation and high technology bulldoze their way into the most remote rural areas and provide them with the benefits of the "modern world,"
herbal medicine will become a thing of the past.
Such thinking in the Third World coun- tries is out of step with that in the indus- trial and technological regions, where scientific research into traditional thera- pies is nowadays considered to be of undoubted importance for the future.
The new era of natural medicinal pro- ducts, of "biodrugs", has begun, and it is the pharmaceutical combines which are developing much of the relevant research technology. For those of us investigating this field in the developing countries, the question arises: will we in the future have to spend scarce foreign currency to re-
import our own plants and extracts? Are we going to lose the battle once again?
In the middle of the present century, when the great pharmaceutical industry was growing up, we lacked the technology and scientific knowledge to manufacture drugs. Our role was limited-at best-to providing raw plant materials. Today it is in the countries of the Third World that the tradition of using medicinal plants survives in its least adulterated form, and this makes it easier for us to identify the plants which need to be scientifically evaluated. Drugs of the types that are now being studied by modern science could be manufactured with the level of technology already attained in many developing countries. All the evidence shows that the gulf between traditional medicine and scientific medicine is at last beginning to close and need no longer be regarded as an obstacle in the path of scientific
progress. •
7
Folkwisdom
If the only reason for making use of tra- ditional healers within the health services were the chronic short- age of conventionally trained health work- ers, this would be jus- tification enough. lt has long been ap- parent that there can never be enough physicians to serve all the world's population-even if those physicians were neatly distributed around the countryside and not, as they are, concentrated in the main towns. The same is true of nurses, dentists, all branches of health personnel.
1t makes good sense, therefore, to take advantage of these experienced practition- ers of traditional healing who exist in most societies, whether they are called healers, shamans, curanderos, wise women, med- icine men, traditional birth attendants or even witch-doctors. lt is to these helpers that the great majority of people in developing countries ( and many people in industrialised countries) turn first in time of sickness. Too often, the health clinic or hospital seems remote, alarming, staffed by strangers. The healers may be the sons and grandsons-or daughters and grand- daughters-of healers; their skills and practices are familiar to the local people, who therefore have boundless . faith in them.
Certainly traditional healers have some- times to be weaned away from positively harmful practices-the casting of malign spells, female circumcision,, or applying cow-dung to the umbilicus of a new-born baby. But if they can subsequently be encouraged to learn some new habits, such as washing their hands before deliv- ering a baby or inspecting a wound, then here is a ready-made army of willing and valuable health workers.
But this is not the whole story. Medical science seems ever more ready to acknow- ledge that traditional medicine embodies a rich treasure-house of folk wisdom. Hand- ed down through the ages, from one generation to the next, this body of know- ledge ranges from the complex systems such as Ayurveda, Unani and traditional Chinese medicine to simple home rem- edies based on wild plants and herbs.
Today, determined efforts are under way to understand how certain ancient practices do succed where "modern"
medicine may not, and to analyse the active ingredients of decoctions and oint-
ments made from plants which have been proved to possess curative or preventive properties.
Just one example among many is the Biomedical Research Unit on Traditional and Herbal Medicine in Mexico City, which is now integrated with the Mexican Institute of Social Security, and is a recog- nised WHO Collaborating Centre. The unit is engaged in intensive pharmacological, chemical and botanical research into plants which were known to the Aztecs, the Mayans and other earlier civilisations.
lt makes use of liquid and gas chromato- graphy; magnetic resonance and even radio isotopes to separate and identify the active ingredients of healing herbs. The findings are stored in a computerised data ·
bank, which cross-refers botanical names,
popular names, the methods of use, the part of the plant used and the diseases treated.
There is yet another reason for taking the older forms of medicine "seriously ". Dr R. H. Bannerman wrote in World Health Forum (Vol. 3, No. 1) last year:
"lt seems paradoxical that, at a time when modern scientific medicine appears to be making such giant strictes and enjoying unparalleled prestige, so much interest should be taken in traditional medicine, in both developed and developing countries alike." And he suggested, among many motives underlying this interest, the fol- lowing: "Traditional practitioners in many parts of the world define life as the union of body, senses, mind and soul, and describe positive health as the blending of physical, mental, social, moral and spiritu- al welfare. The moral and spiritual aspects of life are here stressed, thus giving new dimensions to the system of health care by which man maintains his health."
Alastair Anderson
CD Herbai plants growing under controlled conditions at the pharmacognosy and horticulture field station of the University of Illinois, outside Chicago, USA. Photo WHO/J. Bland
® In Iran, a woman and a boy pick flowers for use in a "tea"
which is said to have healing properties. Photo L. Sirman c
® Technicians in a Chinese traditional pharmacy carefully weigh the herbai and plant ingredients before making them into prescrip-
tion medicines. PhotoWHO/D. Henrioud
© At a traditional medicine centre in Africa, patients fine up to receive decoctions for various ailments. Photo WHO/R. c. da Silva
@ Mass production methods at a processing plant for Ayurvedic drugs not far from Coimbatore, India. Photo WHO/A. s. Kochar
Traditional psychiatrv in Mali
A study of the traditional psychiatrie resources of the Dogon area in south- central Mali and of the Tuareg people of the north suggests how traditional and modern psychiatry can be integrated side-by-side within primary health care
by Piero Coppo
M
ental disorders are much rarer among the rural communities of the Dogon high plateau than elsewhere. Nevertheless, the problem is made more serious than the number of cases would suggest by the bard condi- tions in which sufferers have to live.They are shut up, isolated or sometimes even physically assaulted.
A system of "traditional psychiatrie centres"-there are 14 of them, or one for every 10,000 inhabitants-has spon- taneously grown up in this area and serves the whole district. They use un- usual and effective methods, but have features which "modern" psychiatry should try to understand and possibly adopt. At the same time, these methods do have limits which traditional psy- chiatry alone cannot overcome.
lt seems essential to have a psychia- trist with a modern training, who is first and foremost a physician, to diagnose cases requiring purely medical attention,
for instance, cases of dehydration or mental conditions caused by organic diseases. This person should also be able to build up mutual trust with the tradi- tional therapists so that the two ap- proaches to treatment can be almost spontaneously combined on the spot.
This idea deserves consideration be- cause the social, economic and cultural changes brought about inevitably by the process of modernisation and the growth of towns cannot fail to produce an increase in mental illness. New disor- ders such as neuroses, de pression and psychosomatic conditions are bound to appear, which the traditional psychia- trist would find bard to fit into his familiar framework.
So the information obtained from traditional communities needs to be tak- en into account when mental health care systems are being set up in rural areas where both modern and traditional methods can be deployed.
The Dogon communities tend to be in inaccessible areas; historically they were set up because their animist populations rejected Islam. Now their main occupa- tion, which involves everyone, is agricul- ture. They grow millet for food and onions for trade. The population is high- ly uniform and has not so far had any access to modern psychiatrie treatment.
Treatment of mental disorders, there- fore, is still wholly in the bands of the traditional healers.
What is the Dogon attitude to mental illness? The layman makes no differ- ence between the various forms of what he calls "qué-qué" or "madness". The traditional psychiatrist distinguishes be- tween several forms of madness, which he ascribes to various good and evil spirits living in the bush or in dwellings, some of them in human form, or to the malice of someone using sorcery to harm his enemy. The treatment of psychotic illnesses is often the same, but
This traditional medicine centre in Africa is in effect a hospital. Patients-some of them with mental ailments-may stay there for several days during their course of treatment.
Photo WHO/R. C. da Silva
the practitioner always makes an indi- vidual diagnosis.
Epilepsy is well known in the Dogon communities, where it is called "tibi sougo ", or "falling like a stone ". The healer observes the victim's fits, takes his pulse and examines the iris of the eye, and then suggests treatment. If, however, the patient has at any time fallen into the fire during a fit or if the disease is too far advanced, any treat- ment is considered to be useless.
During our studies in this area, we carried out an epidemiological survey in 16 villages with a total population of 6,448 and identified twelve cases of
psychosis (" qué'-qué "), affecting 1.85 per 1,000 of the population, and eight of epilepsy (" tibi sougo ") involving 1.24 per 1,000.
People from outside the study area also came to consult us. Several showed psychotic or epileptic symptoms, and the only cases of neurosis came either from urban areas or from environments which cannot be described as "traditional ru- ral communities ". In such rural com- munities, the types of "madness" are always similar. There is a striking ab- sence of depressive symptoms, neuroses and conditions which may be regarded as psychosomatic.
Sorne mental disorders, moreover, which are not regarded as "madness "
by local culture, do not seem to have been referred to us for observation. To avoid any entanglement in the insoluble problem of the borderline between what is "pathological" and what is "nor- mal", we preferred to leave the defini-
tion of "madness" to the local people whom we consider, for the purposes of our study, the only possible judges.
Traditional treatment
Traditional Dogon psychiatrists usu- ally apply therapies handed down from father to son, although sometimes they do develop their own. Sorne holy men from other, sometimes distant, cultural areas or local recent converts to Islam use Moslem methods based essentially on the reading of the Koran. There is a trend now for the animist and Moslem methods to be used side by side, but they do reflect the difference between the world's two approaches to insanity.
The animists believe that it is caused by spirits with which they must com- municate. To the Moslems, insanity is the result
of
action by a malevolent spirit, a" devil", which must be cast out.11
Each of these open-air cooking pots contains a different herbai preparation, being brewed under the supervision of a traditional healer in the Congo. Herbai recipes are just one form of treatment for mental illnesses.
Photo WHO/R. C. da Silva
Deeply embedded in the culture of the few Tuareg tribes, some nomadic, some settled, living in northem Mali is a well- ordered system of traditional psychiatry closely linked to Islam. lnsanity always has something to do with the Devil in Tuareg culture. A man goes mad be- cause he has met the Devil or is afraid of meeting him. Insanity can also be the result of poor hygiene because the Devil frequents dirty places.
lt is interesting to note that the origin of any illness, and thus also of mental conditions, is ascribed to an imbalance between hot and cold. ln the Tuareg culture, these two elements are as im- portant as the yin and the yang in oriental cultures, and must be taken into consideration in any treatment.
I The Tuareg holy men believe that mental problems are increasing because those with powers to stop the devils are becoming ever fewer, giving the devils new opportunities to spread insanity. lt is a sign of the "beginning of the end"
which, for some, must result in the
annihilation of the human race, while others believe that the time is coming when what was always hidden will be revealed, "as if a man who has always been clothed should walk around naked."
In prescribing treatment, the holy men rely on their own dreams, which may be good or bad, and also draw a great deal on the Koran. They read the texts, write verses on the patient's body and make up amulets containing the holy writ. They also give the patient water to drink in which pages bearing texts from the Koran have been soaked. lt is worth noting that the ink used is made {rom the ashes of a shrub used elsewhere in treating epilepsy and mental disorders.
The patient is also treated with medicines from various plants, is made to sweat and is spun round to make him lose his sense of direction. Rituals of the psycho-drama type are also used.
The importance of research into these various methods is obvious. First of all, the study of the development of the concept of mental illness in traditional rural communities makes it possible to stress the links which certainly exist between psycho-pathology and culture.
lt also makes it possible to discover what is universal and inherent in human na- ture, as distinct from that which arises from specific cultural, social, economic
or environmental factors. Finally, and most important, traditional psychiatry is still very much alive in many developing countries, where in some areas it is still the only way of helping the mentally ill and of defending the community from the disorder which anti-social behaviour could create.
If this contribution is properly under- stood and absorbed by the psychiatrie services which form part of primary health care, these countries will be bet- ter able to provide effective treatment for the mentally ill within their own
community. •
Examples of what is considered psy- cho-pathological behaviour in Mali's traditional rural communities:
- Anti-social behaviour, like making children afraid, hitting or injuring other people, theft,' or non-observ- ance of beliefs and social customs.
- An inability to maintain a place in society, to the point of having to look to others for sustenance.
- Strange behaviour, like undressing in public or taking to the bush.
- True psycho-pathological symp- toms, like verbal incoh~rence, visual or aurai hallucinations, ta/king to devils, negativism, fixations, agita- tion, confusion and insomnia.
Unani Tibb in Pakistan
The healer not only puts his trust in medication; he also derives support from his faith and from his close associations with his masque, temple or church. He recognises that the human body is not simply a chunk of flesh, but a combination of body and soul
by Hakim Mohammed Said
T
raditional systems of medicine have served Man through the ages to alleviate suffering and disease in various parts of the world. lt is mainly during the last 100 years, however, that some of the active ingredients present in herbal prescriptions have been iso- lated and introduced into "modern"medicine. This has been made possible by the development of sophisticated separation techniques which have great- ly simplified isolation procedures, and the availability of modern spectrometers which allow rapid identification of known ingredients in complex mixtures of organic compounds.
In spite of these rapid developments in scientific technology, and the better understanding of the chemistry of nat- ural products, it is fair to say that, of the 6,000 or so plants used in different traditional systems of medicine, only a few hundred have so far been examined in depth for their chemical constituents and physiological activity. The vast number and complexity of organic sub- stances found in various plants is re- flected by the fact that new natural products are still being isolated from plants which have been subjected to the closest of scrutinies over many decades.
"Western" medicine has largely con- fined itself to the isolation or synthesis of single active ingredients for the treat- ment of specific diseases. One reason for this is that the interaction of a single ingredient with the human body, and the metabolism of that ingredient by the human organism, can be studied scienti- fically and the fate of the metabolic
products determined by such methods as radioactive labelling techniques. Yet even though medical practitioners re-
Colchicum autumnale is known in English as the crocus or meadow saffron. Its name in Arabie signifies "the fingers of Hermes- messenger of the gods." It was used in Arabie medicine for treating gout at least as long ago as the tenth century A.D. Photo WHO
cognise that the act1v1ty present in a particular concoction need not be due to the presence of a single substance but may be caused by synergistic interaction of many different substances, attempts to utilise this understanding has not proceeded beyond lip service. This is primarily because science, in spite of its remarkable advancements, finds itself helpless to fully comprehend and ana- lyse the remedial factors present even in preparations made from a single herb. lt may contain several thousand organic constituents, peptides, proteins, enzy- mes and other factors.
Another barrier to the scientific study of traditional medicine is the stringent legislation in scientifically advanced countries which prohibits the necessary kind of clinical trials, and the lack of facilities for clinical pharmacological and toxicological studies in those Asian and African countries where traditional medicines are most widely used.
Pakistan's experience
In Pakistan, Unani Tibb (traditional medicine) is accepted by the govern- ment as a state system that exists along- side "modern" medicine. Unani medicine originated in Greece and travelled later to Arabia and Asia. ln Pakistan it has 36,000 practitioners, 2,000 of them women, who are gradu- ates of Tibbi colleges and cater to the entire rural population of Pakistan as well as many people in the cities.
The Unani system was recognised by the government of Pakistan through an 13
Act passed in 1965. There are nine Tibbia (medical colleges) in the coun- try; the one in Karachi is named Ham- dard Tibbia College (College of Eastern Medicine). About 350 hakims (tra- ditional doctors) qualify from these colleges each year.
The government has also approved the creation of a National Council for Tibb, similar to the Medical Council for allopathie medical systems. This Council regulates and maintains standards, con- ducts examinations and approves the four-year syllabus of education. The courses include· the history of medicine, pharmacognosy, ana tom y, physiology, psychology, community medicine, microbiology, minor surgery, infectious diseases, gynaecology and paediatrics.
Women students are routinely sent to the Maternity Hospital for six weeks' practical training in midwifery.
In the field of mental health, it is clear that our mental equilibrium can become disturbed if too many contradictory de- mands are made of us. Lack of creature comforts in the face of growing competi- tion for a livelihood, the impact of foreign cultures and the creation of false needs, loss of faith and a distorted view of the established norms and values-all these are among the factors which may disturb the mind. These causes can be grouped together under the general ru- bric of socio-economic imbalances, sin ce discontent with one's situation in life is the greatest single reason for mental torture.
But no man is an island in our pres- ent-day world society. One country's inventions and discoveries soon find their wa y to another. Values and needs become elastic. The voice from the pulpit be- comes ineff ectual in such a deafening
<lin of so many other and loud voices.
The result is a growing sense of dis- content, and there may well be many more people today suffering from one kind of mental ailment or another than ever before. "Modern" medicine be- lieves that the needed relaxation can only be provided by such chemical com- pounds as are found in tranquillizers and soporifics. But chemical compounds create their own actions and reactions, and the situation is aggravated further by the abuse of modern drugs. This problem is shared equally by the West~
ern and Eastern worlds. Its solution must therefore be found by their joint efforts.
In such a confusing world, the tra- ditional healer, with his traditional tools of cure, stands at a point of vantage. His materia medica is safe from side-effects since most of his medicines corne from the world of nature. They have been
Unani Tibb in Pakistan
Left : Street scene in Pakistan. "No man is an island in our present-day world society.
Values and needs become elastic. The voice from the pulpit becomes ineffectual in such a deafening din of contradictory voices. In such a confusing world, the traditional healer stands at a point of vantage."
Right: Sandalwood, Santalum album, has been valued throughout the ages for its strong, sweet perfume. A distillation made /rom this plant-which is in fact a parasitic tree-is used to treat infections of the urinary tract.
Photos WHO
traditionally tested on several genera- tions of his people. The healer not only puts his trust in medication ; he also derives support from his faith and reli- gion, having a close association with his mosque, temple or church.
In Pakistan, we are anxious to give recognition to the fact that the human body is not simply a chunk of flesh, but that it is a combination of body and soul.
We try to see that the physician, or the traditional healer, not only gives due importance to his faith or religion but also that he practises it and is worthy of trust.
The skill of the traditional dai ( or birth attendant) is very ancient and probably antedates that of the physician.
There are dais who have traditional obstetrics as a farnily profession. They have traditional methods for encourag- ing labour and traditional techniques for
normal and difficult births. They may not be well-versed in modern hygiene, pre-natal and post-natal care, but the fact that they are still respected for their skills by village communities speaks vol- umes. In villages wheré modern male doctors are few and modern female doctors none, these traditionally skilled dais have been serving the most primary need of societies for centuries on end, and many·of them are highly skilled.
Of course, village communities and poor people have a right to modern medical care. The old traditional mid- wife has to be initiated into hygienic practices so as to minimise suff ering and fatality through bacterial infection and so forth. But if Health for ail by the year 2000 is to be made possible, pro- grammes must be devised whereby even more use is made of the useful tradi- tional midwife.
About two-thirds of the population of Pakistan live in rural areas, where modern health facilities are not avail- able, and the traditional system of medicine is well accepted. Hakims who reside amongst the local community have wielded a considerable influence on individuals, thanks to the benevolent character of the services which they have offered to the community over the ages. Sorne of the research studies conducted locally have established that single ingredient and compound ingredient prescriptions have indeed contained anti-fertility properties.
Traditional medicine may yet pro- vide contraceptive technology with some new chemical substance. The Unani Tibb system includes many contraceptive prescriptions of differing kinds which have been and are still
being used. •
15
The fruits of Arn mi majus contain xanthotoxin, used in treating certain skin conditions.
Poisons ol ancienl Pem
A climbing plant, a fish, a frog-these natural sources of toxins long known to the early peoples of Peru have already contributed significantly to neurophysiology and the study of nerve impulses
E
ven before the structure of the tissues of the nervous system was discovered, many of the poisons present in nature were known to have a neurotoxic action. Sorne of these toxins were discovered and put to use by the ancient civilisations of Peru; they were used mainly on the arrows and spears used for hunting, fishing and warfare.Their continuous use down to the pre- sent day, references to them in the 16th century chronicles of the Spanish Con- quest, and their appearance in pre- Columbian art are not just a remarkable historical and archaeological curiosity;
they also represent an interesting cul- tural link between students of the past and present-day neurophysiologists.
Claude Bernard, the French scientist who is regarded as the creator of mod- ern physiology, deduced that there must be some connecting organ between nerve and muscle: a myoneurallink. He arrived at this conclusion through his investigations into curare, a hunting poison used by the natives of Amazonia.
In Bernard's experiments, both the nerve fibre and the muscle fibre were stimulated at two points, A or B, by an electrical current. Normally, stimulation at A produces a muscular response al- most identical to that obtained by stimu- lation at B. Over a century ago, in one of the earliest attempts to use poisons for the study of physiology, Bernard proved that under the effect of curare the stimulus at A could not reach the mus- cle, even though the muscle remained excitable; thus the discovery was made that the toxin does not cause muscular problems.
by Fernando Cabieses
Theo in 1907, using curare in inner- vated or denervated muscles, J. Langley established the basis for the physiology of the· motor end-plate, or myoneural junction. lt was not until 1936 that H.
Dale demonstrated that the production of acetylcholine, which had already been identified as the chemical intermediary in the end-plate, is not inhibited by
The puffer fish-Spheroides spengleri -origin of the lethal poison tetrodo- toxin.
Photo WHO/F. Cabieses
curare unless the latter acts after the myoneural junction, that is, in the mus- cle receptors themselves.
Three years la ter, A. Hodgkin and A.F. Huxley took a tremendous step forward by studying electrical potentials and ion exchange in the isolated axon of the squid. From that time onward, natural neurotoxins of different origins have been essential for advanced re- search on neurophysiology.
A great deal has been written about curare, and a hundred legends have been woven around the mystery of its
ongm. Even today, when the patient research of Dermot Taylor and the emi- nent botanist Ramon Ferreyra has pro- duced detailed information on its source and preparation, people still daim it is an unknown mixture of various sub- stances of obscure and unexplained ori- gin. This is simply not true. Basically, curare is an extract from a climbing plant of the Amazonian region, with the scientific name Chondodendron tomentosum.
The indigenous collectors of this plant, whose daily efforts are unfortu- nately contributing to its extinction, fetch from the forest small bundles of stems of varying thickness, which they boil in large pans. This extraction by boiling is not a simple process ; it lasts several days, until a smooth, sticky paste is obtained. The paste undergoes a number of tests that have been in use since time immemorial, and suggest the existence of sophisticated biological knowledge among the ancient peoples.
Quality, for example, is determined by the ability of a specified dosage of the paste to paralyse a toad in a given time.
From the two main types obtainable in the forest, "calabash curare" ( curare C) and "pipe curare", modern scientists have managed to purify C-curarine and tubocurarine, whose use in' modern medicine as a muscle relaxant is well known.
A hundred legends have been woven around curare-the poison used on the spears and arrows of native hunters and fishermen throughout the Amazonian region.
Photo WHO
Above : The coi-coi, a brightly coloured frog used in preparing the most patent non- proteinic poison existing in nature.
Below : The same frog figures on the pottery of the Nazcas, who knew its useful properties many centuries ago.
Photo WHO/F. Cabieses
Poisonous fish
From the earliest days of their explo- rations in Peru, as comments in contem- porary chronicles show, the Spaniards knew of the existence of an extremely poisonous fish which, on account of its ability to inflate itself rapidly to a much larger size, became known as the "puf- fer fish". Various eighteenth-century sources tell us that people in Japan and European sailors exploring the South Pacifie suffered from the highly taxie effects of this fish. The species most common in Peru, Spheroides spengleri, is found in the mangrove swamps of the Tumbes area. They are fish of the family Tetraodontidae, so called because they have four teeth. The family has given its name to the toxin which is the ac- tive principle for its lethal action:
tetrodotoxin.
As long ago as 1883, Yoshizumi, Tahara in Tokyo attempted to isolate the pure toxin from this fish, but it was not until 1950 that Akira Y okoo and Kyosuke Tsuda, working independently of each other, managed to obtain it in pure crystal form.
Anyone who eats the offal of the puffer fish, especially the liver or roe, feels a numbness and tingling of the lips, tangue and cheeks after a few minutes.
This presently becomes complicated by debility and progressive paralysis of all the muscles, vomiting, low blood pressure, tachycardia and respiratory paralysis ; death ensues within half an hour.
If a fraction of a milligram of the toxin is administered intravenously to a dog, within seconds it causes cardio-respirat- ory death and incapacity of all the muscles to respond to electrical stimuli.
An extensive series of neuro-phy- siological experiments initiated by Fusao Ishihara in 1918 and recently completed by Toshio Narahashi, showed that tetrodotoxin mainly and initially affects the axon of the motor nerve ; only at a later stage does it directly affect the muscle.
Today tetrodotoxin, the poison of the puffer fish which terrorised the Con- quistadors of Peru, has become a tool for the electro-chemical study of the conduction of nerve impulses. lt has made possible, for instance, the discov- ery that the channels for sodium inter- change in the nerve axon are selective and different from the channels for potassium.
Poison from a frog
lt has been claimed that the ancient Peruvians so often depicted batrachians on their finest pottery because, -accord- ing to their primitive polytheism, they looked upon the toad as the rain-god.
There is room for speculation here, but the truth is that little or no evidence of this was uncovered by the early Spanish missionaries bent on destroying pagan forms of worship. On the other hand, a number of records mention that the magicians and medicine men of the subjugated culture used frogs and toads for preparing various hallucinogenic or poisonous potions.
A frog painted in different colours appears very frequently on Nazca pot- tery. A study of the poisonous frogs still valued by Peruvian and Colombian In- dians in modern times has led to the identification of two genera of small brightly-coloured frogs, which are used for preparing very powerful hunting poisons by various tribal groups, par- ticularly in Colombia and the northern
· part of Peruvian Amazonia. These frogs
are the same as th ose shown on N azca pottery.
The genera Dendrobates and Phylo- bates contain a number of species whose skin produces a secretion regarded as the most patent non-proteinic poison existing in nature. A small frog two centimetres long can provide enough poison to kill 50' adults.
Of all the non-proteinic natural poisons, therefore, the two most effec- tive are those that were already used as arrow poisons by the ancient Peru- vians : one from the puffer fish and one from the frog popularly known as the coi-coi-tetrodotoxin and batracotoxin.
They are fatal in a dosage of one- millionth of a gram per kilo gram of body weight.
Batracotoxin is a steroid which has been exhaustively studied by Bernard Witkop and others. Unlike tetrodotoxin which is hydrophilic (moisture-absorb- ing), batracotoxin is lipophilic (having an affinity for body fats) and acts in the opposite way to the former within the sodium ion pathway in the axonal mem- brane. Whereas tetrodotoxin blacks the movement of the sodium ion, batracoto- xin selectively increases the membrane's permeability for sodium. The contrast- ing action of these two ancient Peruvian poisons has led to extremely important discoveries concerning the · molecular physiology of nerves and muscles.
Another small frog which also seems to have been familiar to the N azcas, Dendrobates histrionicus, also pro- duces highly taxie poison used on arrows by the Amazonian Indians : histrionicotoxin.
lt would be asking too much to take the reader into the arid wastes of mol- ecular biochemistry, and to describe all
· the neurophysiological conclusions to which we are being led by the experi- mental use of these poisons as we study the generation and transmission of nerve impulses. To the alkaloids of cu- rare, tetr-0dotoxin, batracotoxin and his- trionicotoxin, we can add other natural poisons from elsewhere in the world such as bungarotoxin ( derived from the krait snake), saxitoxin (from mussels), and holothurin (from sea cucumber).
Perhaps the most appropriate place for the motta displayed by the great Rudolf Virchow at the entrance to his dissecting room would be the neuro- physiology laboratory: Hic mors gaudet succurrere vitae-" Here death is pleased
to assist life. " •
Books, Publications and Films
'' Herbai Medicine-tact or fiction?''
S
ince time immemorial, man has made use of plants and herbs to cure disease and heal injuries. ln order to arouse public awareness of the existence and value of medicinal plants, a number of UN specialised agencies have joined together to co- produce a film on the subject.The film opens in Mexico where we see lndians gathering a plant called barbasco, used for many years as a heart medicine but which is now be- ing exploited for its contraceptive properties. For the vast majority of the rural world in developing countries, · the only form of medical care that is available and trusted is the traditional healer, who often uses a combination of religion and herbs. Where one ends and the other begins is sometimes difficult to determine.
From Mexico, we move to Egypt and see something of the wide variety of medicinal plants that are sold in the herbai pharmacies there. Medicines made from plants are also available in developed parts of the world and much research is going on to deter:
mine exactly which constituents are responsible for the pharmacological activity observed.
We see in Africa however, as in other parts of the world, that the .destruction of forests has caused the loss of many plant species which were used in herbai remedies. This can have a serious effect on the economy of countries who rely heav- ily on medicinal plants, since the cost of replacing them with chemical pharmaceuticals is htgh. ln Vietnam, eighty per cent of the medicine used cornes from plants and each village has its own green dispensary.
From Vietnam, the film moves on to lndia where the classic science of ayurvedic medicine is practised and
relies to a great extent on herbai medications. One often forgotten facet of these plants is that some of them are also very rich in natural vitamins. ln lndia, vitamin A capsules made from plants are used to prevent xerophthalmia.
The last country that we visit in the film is China, where herbai medicine
ln the Egyptian desert, a traditional healer seeks out the herbs that are valued for their healing properties. A sti/1 from the film "Herbai medicine- fact or fiction."
Photo WHO
has been used for more than 4,000 years and is today combined success- fully with modern medicine. We see a pharmaceutical factory that manufac- tures only herbally derived medicines and for many they are the medica- tions of choice. As we complete our herbai tour of the world, we are left wondering what riches still remain to be uncovered.
The film "Herbai Medicine: fact or fiction?" is in 16 mm, colour, 27 minutes. lt is available on sale in European countries from the World Health Organization, Geneva and, for the rest of the world, from UNICEF,
New York. •
21
De TBAs ol Senegal
Despite their numbers and their social and economic importance, the traditional birth attendants of the African continent may be extensively used in one place and illegal in another. ln general, no great effort has yet been made to givè them any legal status
by Pape Marcel Sène
T
he first time I visited her, so many people were there that I was unable to see her despite the late hour. The sun was sinking towards the sea and was already hidden behind the Cap Manuel lighthouse, at the southern tip of the Cap Vert peninsula. Thirty or so women sat quietly in the shade of gently rustling mahogany trees, awaiting their turn to enter the hut, a small building that was set apart from the other compounds and served both as bedroom and consulting room.lt was not until three days later that I finally pushed aside the curtain covering the entrance. Night had completely fallen when she received me, in between patients because women were still waiting. 1 con- fess to crossing her threshold with a great deal of apprehension: the isolated setting and the crowd outside heightened the air
of mystery which generally surrounds people who "possess knowledge," and particularly this one, Dame Ciré Coly. She came from faraway Casamance, a district renowned for its deep-rooted spiritualism and its worship of ancestral values. But I need not have worried. Indifferent at first, with a trace of tiredness, the features of this woman of indeterminate age became animated and impassive by turns through- out our conversation, which we conducted with the help of an interpreter.
Seated on the ground, she is surrounded by an impressive array of empty bottles which she will fill with decoctions and other medicinal preparations for her many clients, including some white women, who corne to her every day. Sorne will com- plain of stomach aches, others of high albumin or salt levels, sterility or lateness in giving birth.
How many clients does she see each day? Whether from mistrust or modesty, Dame Ciré Coly replies that although there are plenty of them-she cannot give any figures-the money she receives is immediately spent on feeding her large family. She left Casamance, she says, because her son asked her to. "Our know- ledge is handed down within the family,"
she explains. "When I feel my powers are leaving me, 1 shall go back to Casamance to pass this knowledge on to someone else."
Her secrets lie mainly in the properties contained in the plants, leaves and roots which she has sent from her home region.
On this point she complains of the many taxes she has to pay each time to the customs and to the Water Resources and Forestry Department. "Something has to be done to help me," she adds.
