Herbal Medicines in Hawaii From Tradition to Convention

Scott A. Norton MD, MPH, MSc*

The stories of kava and chaulmoogra demonstrate the importance through its geologic maturation, activity, dormancy, senescence, of herbal products in ancient and recent Hawaiian medicine. Kava extinction, and subsidence. The island chain has no land connec is a psychoactive beverage that has been used ceremonially for tions; therefore all forms of life arrived here as colonists. Wind, millennia throughout the Pacific. It is a nonfermented depressant water, and airlifts of seabirds brought the founding members of that causes tranquil intoxication in which thoughts and memory Hawaii’s flora and fauna. In Hawaii’s isolation, the ancestral plants remath clear. Its broad pharmacologic activity led to use in Hawaii to treat skin disorders and later h Germany to treat gonorrhea. Kava and animals evolved into unique species, often quite different from is now available outside the Pacific bash as a relaxant, emerging as their ancestors. Relatively few ancestral species acquired a foothold a popular, albeit deritualized, natural product. In the late 19th on Hawaii and from few, we now have many descendant species. century, the maThtreatment forleprosy was chaulmoogra, extracted Hawaii has the world’s most richly endemic flora; nevertheless it is from Hydnocarpus seeds. Chaulmoogra had been a traditional a depauperate flora. treatment for skh diseases ThAyurvedic and Chhese mediche. Many of the plants that outsiders most closely associated with Chaulmoogra fromAsian markets was expensive and usually adul Hawaii are introduced. There are few native orchids, for example, terated so the USDA decided to plant Hydnocarpus h HawaII. Joseph Rock, a botanist at University of Hawaii trekked through and coconut palms were introduced by the ancient Polynesian southeastAsia collecthg fresh seeds toplant on Qahu. Rocks trees voyagers who settled Hawaii. The Polynesian settlers brought with provided chaulmoogra for leprosy patients on Molokai and else them 30 or so plants that were eminently useful in the ancestral where until it was replaced by dapsone. Chaulmoogra, once the homeland.” These include the staples for consumption, construc treatment forleprosy worldwide, is now nearly forgotten; kava, once 2tion, clothing, art, and medicine, such as breadfruit, taro, sweet known Pacific, is alternative poorly outside the now a widely-used potato, coconut, banana, sugarcane, hala, and noni (Table 1).Many medicine. Hawaii willprobably conthue its role h the transition of of these have become naturalized and are now fully a part of the plants from traditional use to conventional use. Hawaiian landscape, such as coconut palms, wild ginger, and the Introduction state tree, the 2kukui. The Hawaiian Islands emerged from the Pacific seafloor over the past several million years. Each island arose as a volcano and passed Kava One of the thirty or so plants brought by the settlers, kava, has phannacological activity that led to its use in both traditional ceremonies and in traditional medicine. Kava refers to both the plant and the beverage that is3 made from the plant. The kava beverage has psychoactive effects that produce a calm, tranquil effect but thoughts and memory remain clear. The plant probably originated in Vanuatu (the former New Hebrides) but, as Pacific mailingaddress: peoples migrated, they carried their most useful products with ScottA.NortonMD,MPH,MSc them. Kava became widely used in rituals throughout the Pacific’s *ChiefofDermatology 4 RWBlissArmyHealthCenter three ethnogeographic regions: Polynesia, Micronesia, and FortHuachucaAZ85613 Melanesia. The plant has become naturalized on many high islands with rich soils but it is absent from coral atolls and from temperate ‘AssistantProfessorofMedicine JohnA.BumsSchoolofMedicine islands such as Aotearoa (New Zealand). UniversityofHawaii Western scientific attention to kava started with the Forsters, Honolulu,Hawaii96822 father and son, who served as the naturalists on Cook’s second

‘AssistantProfessorofMedicine voyage. They prepared the proper Linnean binomial, Piper UniversityofArizonaCollegeofMedicine methysticum,56 which means “intoxicating pepper.” Kava is in the Tucson,Arizona85724 ’ family Piperaceae, meaning it is a true pepper closely related to

Theopinionsexpressedinthis article black pepper and to the pepper leaf used in preparing betel quids. arethoseofthe authorandnotnecessarily Kava is a shrubby plant with jointed stems and heart-shaped thoseoftheDepartmentofDefense. Thisarticleis reprintedwithslightrevisions leaves. There are perhaps two-hundred varieties of the kava plant in fromtheProceedingsoftheInternational the Pacific, based mostly on differences in stem morphology. The SymposiumonHerbalMedicine1-4June 1997 Honolulu,Hawaiiwithpermission varieties also differ in their potency. The psychoactive components ofSanDiegoStateUniversity,1997. aremost concentrated in the lower stems and upper roots of the plant.

HAWA6 MEDICALJOURNAL, VOL57, JANUARY 1998 382 processors. reason, roots. deritualized. Federated third chewing in In beverage concentration ethnogeographic Traditional disinhibition setting; dozens and relatively islands, mortar prepared the strained strong Australian beverage sions. tanoa, society.3 kava mix, barefoot men, modern quent wish individual Because sensory men item.

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Hawaii, for greatest only

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JOURNAL, skin

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the the the

by by by

an an

of to

a 383

early gation practice, eruption Pharmacology interfere drink the psoriasis. of used narcotic, tions. keratinocyte a supported From he his Tonga, until American Germany’s to neither non-narcotic, all histopathology is sailed to Commoners, lung actions nonhallucinogenic, neuropharmacologic influence leprous islanders some head.8 many members a a German Kava the and islands western where VOL

photoeruption,

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century

a The Kava treat Kava In

other Western

of

instructed

beautiful

sacrifice

advent

form

Pohnpei 57,

disorders, for their

recent

which

noble

Western

traditional,

Pacific the

the

in

cause JANUARY

As

to as

kava skin

the was extractcontains

of

was

skin.39

where

skin

more

Pacific

physicians

reversed

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by the

of burial

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of

a

an beverage People

the the by skin

with

ago,

Samoa

which

of

explanation

arrival,

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disorders better

are recognized pellagra

first

decades, the

interest

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in but

other

once diseases, formation.’°

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scientific

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penicillin. dermopathy no the 1998

management than instead,

descriptions

became

Micronesia.

kava

kava

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of highest

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able

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with

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to island

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described

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daughter.

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to This

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urologic disorder

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fifteen

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began

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participated

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deficiency

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have kava

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of

would a

also

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cholesterol

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were

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kava

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world

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and and

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by

In

is seizures in laboratory animals and to attempt control of psychosis in written The Indigenous Trees of Hawaii in 1913.For months, Joseph humans. Trials with kava in people were stopped because kava Rock trekked through the rainforests of Siam and Burma in search dermopathy 12developed. of chaulmoogra trees. This was no simple task as the tree was Kava is, nevertheless, widely available in the West. In Germany scarcely known to Western botanists and it grew in just a few and France, it is a prescribed medicine. In the United States, it is relatively inaccessible mountainous regions. But after a year, Rock available at many health food stores and so-called nutrition centers. had gathered enough seeds to return to Hawaii.’ The USDA used Kava is available as tablets, alcohol tincture, powder, and unproc the seed to start a chaulmoogra plantation78 on 30 acres in the essed root. Most kava products are marketed towards non-tradi Waiahole Valley on Oahu. After a decade,’ the young chaulmoogra tional users. Pacific islanders living in the United States, may now trees were producing enough seeds to supply oil for American purchase boxes of instant kava in which root powder wrapped in a leprosaria, such as the ones at Carville and Molokai. muslin bag is steeped in water to prepare the beverage for ceremo The chaulmoogra tree is Hydnocarpus kurzii but the obsolete nial and deritualized use. name generic name, Taraktogenus, appears in much of the older A 1996 Newsweek cover story entitled “The Natural Drug Cul literature. There are about 40 species in Hydnocarpus, mostly in ture: From Herbal Ecstasy to Melatonin: What are The Risks?” southeast 9Asia.’ Medicinal oils were extracted from the seeds of quoted an herbal medicine entrepreneur, Shayan, who remarked three species. The tree stands about 40 feet tall and has shiny green that, “Kava is the next big thing. We think it can be as big as leaves. The fruits are about the size of an orange with a thick velvety- 13coffee.” There is considerable financial interest in the kava textured skin. Inside the fruits are dozens of hard, angular, marble- growing Pacific and among entrepreneurs to introduce kava widely sized seeds. To make the oil, the seeds are crushed and subjected to into western society. Marketing efforts, in most cases, accent the pressure extraction. The resulting amber-colored oil is a mixture of allure of tranquil life on a Pacific island because the scant amount of two fatty acids based on a cyclopentane ring that differ slightly in kavalactones in these preparations is unlikely to produce physi theirchemical composition. These acids were named chaulmoogric ologic effects. and hydnocarpic acids after the common and scientific names of the addition 2 In to its emergence in the botanicals industry, kava may plant. The best° method of extracting oils was developed by Dr make the leap from traditional Pacific medicine to conventional Arthur L. Dean, second president of University of Hawaii. Dean’s Western therapeutics. Conventional pharmacologists and physi derivative, as it was called, was the mainstay ’2of chaulmoogra cians continue to study kava for its neuropharmacologic andpsycho production around the world for many years. active effects. Kava’s effect on the skin also deserves further study asit isprobably due to subtle interference in cholesterol metabolism. Medical Uses of Chaulmoogra The chaulmoogra products were furthered refined into oral, Chaulmoogra topical, and parenteral forms. But all reports indicate that the best The history of modern medicine in Hawaii is closely associated treatment was with parenteral chaulmoogra, usually injected subcu with leprosy or Hansen’s disease (HD). The disease was introduced taneously. Treatment called for 15cc of oil to be injected, twice to the islands by Chinese peasants brought in to work in the weekly, for multiple 10-weekcourses until the disease was cured or canefields. The native Hawaiian population was vulnerable to the went into 22remission. It was a painful regimen and a survey of disease which then ravaged native populations. People with visible patients showed that many would prefer to have their disease left stigmata of leprosy were isolated for life in the Kalawao settlement untreated than to continue the mandatory therapy. on Molokai. The fear historically associated with HD comes from It was thought that chaulmoogra could indeed cure lepromatous the disfigurement caused by the disease and the notion that it was an disease and so for more than 50 years, chaulmoogra was hailed asthe incurable and highly contagious condition. There was little hope for only effective treatment for HD. Burroughs-Wellcome and Bayer effective treatment until the I850s when several promising reports were the largest commercial producers of chaulmoogra and made emerged from the British Medical Service in India. The reports several products (Alepol, Moogrol, and Antileprol) that were avail claimed that a local herbal medicine, chaulmoogra oil, could control able until the 1940s. the disease.’ This brought chaulmoogra out of the realm of tradi tional4 medicine and into the mainstream Western phannacopoeia.’ Pharmacology Chaulmoogra quickly became the treatment of choice for HD The mechanism of action of chaulmoogra is not known. A theory worldwide yet very little was known about it.All of5the chaulmoogra proposed in the I930s suggested that chaulmoogra activated host oil used in western medicine was purchased from native bazaars in lipases that subsequently destroyed all foreign lipids, including both Burma and Siam. The demand for chaulmoogra was enormous but the chaulmoogra oil and the lipophilic cell wall of the Hansen’s the supplies were insufficient, often adulterated, and always expen bacillus. The other theory invoked counter-irritation, a sort of sive. chemotaxis in which the irritation caused by the injections drew phagocytes toward the lepra 22bacilli. In truth, we simply don’t know University of Hawaii and Chaulmoogra Production whether chaulmoogra had any effect whatsoever on HD. No proper Chaulmoogra was considered so important that the United States therapeutic trial with chaulmoogra was ever conducted. Department of Agriculture (USDA) decided to break the Asian In the l940s, sulfones (such as dapsone) were developed and chaulmoogra cartel. In 1920, they hired Joseph Rock for the 6job.’ shown successful in the treatment of HD. Still, some proponents of Rock taught botany and Chinese languages at the University of chaulmoogra resisted change. In the 1940s, an article in Lancet Hawaii and was one of the premier botanists on the islands, having advocated combination therapy with sulfones and chaulmoogra

HAWAIIuCOICAL JOURNAL, VOL57, JANUARY 1998 384 sent botanists the jungles of South America to search for other Plants Mentionedintext Table1.—Hawaiian rubiaceous plants for the fight against malaria. The co-leader of the Warfare’s cinchona mission was Ray Common Hawaiian Linnean Family Department of Economic name name binomial Fosberg, a botanist trained at University of Hawaii and who later returned to the Pacific to become one of the premier botanists in breadfruit ulu Artocarpusaltills Moraceae Hawaii and Micronesia. laro kalo Colocasiaesculenta Araceae 25 Fortunately, quinine’s chemical structure had been known since sweet potato uala Ipomeabatatas Convolvulaceae the work of Pelletier and Caventou in the 1820s. When quinine was

coconut niu Cocosnucifera Arecaceae scarce, quinine-like products were synthesized and soon several of used in the prevention and treatment of malaria banana mai’a Musaparadisiaca Musaceae these were also (chloroquine, quinidine, atabrine, primaquine, and mefloquine). In sugarcane kd Saccharumoffinarum Poaceae much of the world today, malaria is resistant to chloroquine so many pandanus hala Pandanusspp. Pandananceae non-quinine products, such as doxycycline, are now used to manage noni non Monndacitafolia Rubiaceae malaria. wildginger awapuhi Zingiberzerumbet Zingiberacae Nevertheless, the Army is still interested in plant-derived treat

candlenut kukui Aleuritesmoluccana Euphorbiaceae ments for malaria. The Walter Reed Army Institute of Research Experimental Therapeutics, is interested in kava awa Pipermethysticum Piperaceae (WRAIR), Division of qinghaosu (or artemisinine), a medicine derived from Artemisia sea hibiscus hau Hibiscustiliaceus Malvaceae annua of the sagebrush genus. Several derivatives of qinghaosu are sedge abs awa Mariscusjavanicus Cyperaceae used widely in China (and experimentally elsewhere) to disrupt the wormwood ahinahina Artemisiaspp. Asteraceae life cycle of the malarial 26protozoan. Artemisia has many species in temperate regions of the northern hemisphere but only a few are known to have antimalarial activity. Three members of the genus are because their properties were viewed as complementary. Never native to Hawaii but their antimalarial activity has not been assessed. the U.S. Public Health Service declared23 in 1942that “the oil theless, has little or no curative value, and its unpleasant side effects Conclusion probably outweigh any advantage it could possibly 24offer.” The stories of two substances, kava and chaulmoogra, demon And so chaulmoogra, once the standard of care, has been dropped strate the importance of herbal products in both ancient and recent from our formularies and from our memories. In the 1930s, the Hawaiian medicine. When the USDA needed someone to obtain branch of Hydnocarpus was the symbol of the International Con chaulmoogra seeds, they turned to a University of Hawaii botanist, gress of Leprology but by the 1950s, better treatments allowed us to Joseph Rock, who could venture successfully in the Pacific Rim. abandon chaulmoogra therapy and, more importantly, to abandon The only place where soils and climate were suitable for chaul the concept of isolating patients in leprosaria.’ moogra plantations was also in Hawaii. And finally, another mem 6 ber of University of Hawaii, Arthur Dean, developed the extraction Current Military Interest in Plant-Derived technique to enable chaulmoogra to serve as the treatment of choice Medicines for leprosy for several decades. Remember that Dean was not simply The conveners of the conference asked me to include a brief a staff member at the university, but its president, providing testi discussion on current American military interest in plant-derived mony to the level of involvement at this institution. Kava, once medicines. During the Gulf War, considerable attention was given poorly known outside the Pacific, is emerging as a widely-used to plant-derived medications, such as atropine and physostigmine alternative medicine, in great part due to the interest generated in this (from Atropa belladonna and Physostigma venenosum, respec state. Hawaii, with its agricultural sophistication, salubrious cli tively), that can prevent or reverse the effects of nerve agents. mate, and heritage of accepting plant-derived medicines, will prob Historians and physicians, however, remind military leaders that the ably continue its role in the transition of plants from traditional use greatest threat to deployed soldiers is disease, not battle injury. The to conventional use. most abruptly debilitating diseases are acute infectious diseases, particularly those that are arthropod borne. Throughout much of the References 1. AbbottIA,ShimazuC. The geographicotiginof the plants mostcommonlyused formedicineby world, mosquito-borne diseases, such as dengue and malaria, ham Hawaiians.J Ethnopharmacol1985;14:213-22. per military operations. Consequently, the development of 2. WagnerWL,HerbstOR,SohmerSH.ManualofthefloweringplantsofHawaii.VolslandII.Honolulu: UniversityofHawaiiPress,1990. antimalarials for both prophylaxis and treatment greatly interests the 3. NortonSA,RuzePR.Kavadermopathy.JAmAcadDetmatol1994;31:89-97. Department of Defense. The customary therapy for malaria has 4. LebotV.Kava(PoermethysticumForst.f.):thePolynesiandispersalofanoceanianplant.In:CoxPA, BanackSA,eds.Islands,plants,andPotynesians:anintroductiontoPolynesianethnobotany.Portland, always been quinine or quinine derivatives, obtained from several OR:DioscoridesPress,1991:169-201. members of Cinchona in the coffee family, Rubiaceae. The early 5. Forster6. Avoyageroundthewotid.Berlin:Akademie-Vedag,1968:237-8. 6. BeagleholeJC.ThelifeofCaptainJamesCook.Stanford,CA:StanfordUniversityPress,1974:99-104. history of Peruvian bark as an antimalarial and febrifuge is well 7. MathewsJO,RileyMD,FejoLetal.Effectsoftheheanyusageofkavaonphysicalhealth:summary known. At the beginning of World War II, quinine supplies became ofa pilotsurveyinanAboriginalcommunity.MedJAust 1988;148:548-55. 8. CorneyP.VoyagesinthenorthernPacific.Honolulu:ThomasThrum,1896:104-5. a strategic military concern because of the Japanese occupation of 9. GiffordEW,ed.Tonganmythsandtales.BishopMuseumBull1924:8:71-2. the Dutch East Indies, now Indonesia, where much of the world’s 10. RuzePR.Kava-inducedderrnopathy:a niacindeficiency?Lancet1990;335:1442-5. 11. TitcombM.KavainHawaii.J PolynesianSoc1948;57:105-71. quinine was produced. During World War II, the War Department 12. ShulginAT.ThenarcoticpepperthechemistryandpharmacologyofPipermethysticumandrelated species.BullNarcotics1973;25:59-74.

HAWAIIMEDICALJOURNAL,VOL57, JANUARY1998 385 13. Newsweek.The NaturalDrugCulture:FromHerbalEcstasyto Melatonin:Whatare TheRisks?6 May1996. 14. MouatFJ. Notes on native remedies. IndianAnn Med Sd Military Medicine 1854;1:646-52. 15. KreigMB.Green medicine:the search for plants that heal. Continued from Page 372 Chicago:RandMcNally,1964;242-254. 16. NortonSA.Usefulplantsofdermatology.Ill.Hydnocarpusand chaulmoogra.JAmAcadDermatol1994:31:683-6. for full tuition and a stipend during medi logical casualty management, and Tropi 17. RockJF. Huntingthe chaulmoogratree. NationalGeographic 1922;16:243-276. cal school, and allows for up to 6 weeks of cal Medicine. Other specialized courses 18. RockJF. The chaulmoogratree and some relatedspecies:a training per year in a Military Medical in Aviation Medicine, Diving Medicine, surveyconductedinSiam,Burma,Assam,and Bengal.USDA BullNo1057.1922;1-29. facility during Medical school. Medical Environmental Medicine, andHyperbaric 19. SleumerH. Monographieder gatfungHydnocarpusGaertner, Students thus have the opportunity to Medicine are taught during residency, or BotanischeJahrbucher1939;69:1-93. 20. ColeHI,CardosoHT.Analysisofchaulmoograoils.In!JLeprosy visitMilitaryResidencytrainingprograms after primary residency training is com 1941;9:215-228. prior to application. Application for first pleted. Other topics which are of particu 21. DeanAL.WrenshatiR. Preparationof chaulmoograoilderiva tivesforthetreatmentofleprosy.Pub!HealthRep1922:37:1395- year graduate medical education (intern lar importance to all Military physicians 1399. ship) training is accomplished through include heat and cold injuries, post-op 22. CochraneRG.A practicaltextbookof leprosy.Oxford:Oxford Universitypress, 1947;117-132. the American Association of Medical erative care, closed head injury, altitude 23. RogersL.Combinedchaulmoograteand suiphonetreatmentof Colleges (AAMC) Electronic Residency relatedillness, disastermedicine, andvac leprosyandtuberculosis.Lance!1948;1:515-517. 24. McCoyGW.Chaulmoograoilinthe treatmentof leprosy.Pub! Application Service (ERAS). Positions cination strategies for deployment. HealthReports1942;57:1727-1733. are available only for those applicants The development of a specialized resi 25. HowardRA.TheroleofbotanistsduringWorldWarlIinthePacific

theatre.BotanicalReview1994;60:197-257. with a HPSP or USUHS obligation. The dency curriculum in Military Medicine is 26. HienTT,WhiteNJ.Qinghaosu.Lancef1993;341:603-8. Military “match” program takes place an ongoing project which includes field earlier than the civilian match. In early experiences in addition to the didactic Notes of Interest: December thepositions are matched with and clinically based experiences. The The firstWesternillustrationof kava was prepared by Sidney Parkinson,ship’sartistonJamesCook’sfirstvoyagetothePacific.On the applications, similarly to the Civilian important concepts of public health and thisvoyage,CookwassenttoTahititoobservethetransitofVenus, process. Announcements are made in late field hygiene are learned through didac aplanetaryeclipse,inanattemptbytheAstronomerRoyaltocalculate thedistancefromtheearthtothesun.Otherobservationsweremade December or January. Military bound tic sessions and opportunities to partici fromstationsinSouthAfricaandGreenwichto allowtriangulationof fourth year students have “matched” pate in training exercises, medical relief thedistance. OnRaiatea,near Tahiti,Parkinsonprepareda water color6 that,once backin England,was transferredto copperplates months earlier than their civilian class missions, and formal military field train whichwere then stored,nearlyforgottenfortwocenturies,in the mates. They generally have a much more ingcourses. Residents from Tripler Army archivesof the BnbshMuseum.Parkinson’s743 illustrationswere resurrectedinthemagnificentworkcalledtheBanksFlorilegium.Only relaxed spring semester! Medical Center have participated in field 50setsofthe34-volumeRori!egiumwereprinted.UniversityofHawaii While the curriculum in Military GME experiences in Micronesia, Mongolia, has a copyinthe SpecialCollectionsofthe HawaiiPacificReading Roomat the HamiltonLibrary. programs is based upon the standards and Japan, Samoa, and in the Mainland U.S. requirements of the ACGME, there are Residents routinely participate in the Rockdescribedseveralof hisAsianexpeditionsin articlespub lishedin NationalGeographic.PhotographsfromRock’sTibetan additional curricular topics which have Aeromedical Evacuation of patients to expeditionswere collectedin Lamas, Princes, and Brigandsby been termed a “Military Unique Curricu and from Hawaii. The combination of MichaelAds, husbandof AungSan Sc Kyi.Rock’schaulmoogra plantationwasinOahu’sWaiaholeValley(bestknownfortheWaiahole lum” These topics are topics which are of didactic training and operational experi PoiFactory).Theonlyremainingchaulmoogratrees (H.kurziandH. special importance to the Military Physi ence give the Military Resident an en anthelmentica)in the UnitedStates are at the Foster Botanical GardensinHonolulu. cian. Some such topics may be indeed hanced knowledge of Militarily relevant unique (e.g. management of radiation in medical issues, and a singular knowledge juries, and aerospace medicine), and oth of Militarily unique topics. The practice ers may be included in standard residency of medicine in the Military is geographi Tired of curriculums yet require special emphasis cally dispersed. The medical conditions (e.g. tropical medicine and wound man encountered may be particular to geogra throwing your agement). The curriculum development phy, occupation, orbattle. The training of process for Military residencies includes Military physicians must encompass the weight around? a number of common Military Medicine spectrum of diseases and management topics for all disciplines. Included are the strategies that are common to all practice Advanced Trauma Life Support (ATLS) environments, in addition to those as course and ACLS. Integrated into the pects of practice which are unique to the Exercise routine residency training are topics such Military practice. The U.S. Army GME as medical management of burns, infec system is in the process of defining and tious diarrhea, trauma surgery, transfu implementing a Military Unique Cur sion medicine, and sexually transmitted riculum, which will serve to assure that American Heart diseases. There isspecialemphasis placed Military Physicians are trained for the Association on some such subjects, and focused in practice environment that lies ahead. Fighting Hean Disease and Sftvke tensive training through specialized courses is provided in Chemical and Bio www.amhrt.org

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