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Home , Abhyanga, Agada, Agnivesh, Akash (missile), Allopathic medicine, Arya Vaidya Sala

Traditional in

Edited by Ranjit Roy Chaudhury Uton Muchtar Rafei

World Organization Regional Office for South-East Asia in Asia

SEARO Regional Publications No. 39

ISBN 92 9022 2247

© Health Organization 2001 This document is not issued to the general public, and all rights are reserved by the World Health Organization. The document may not be reviewed, abstracted, quoted, reproduced or translated, in whole or in part, without the written permission of WHO. No part of this document may be stored in a retrieval system or transmitted in any form by any means - electronic, mechanical or other without the prior written permission of WHO. The views expressed in this publication are those of the authors and do not necessarily reflect the decisions or stated policy of the World Health Organization; however they focus on issues that have been recognized by the Organization and Member States as being of high priority.

Photographs on cover page (clockwise) z is widely used in of western medicine (courtesy Prof. Chen Qui-Ting) z posture z A herbalist, preparing fresh z Crocus sativus - source of

Layout and Design by New Concept Information Systems Pvt. Ltd. New Delhi, ii Contents

Preface

All countries in the South-East Asia Region of the World Health Organization (WHO) have a heritage of traditional systems of medicine. There are large numbers of traditional medicine practitioners who provide help and service to the ill and the needy. Some of these practitioners are qualified doctors who have taken a five-year course in the system of medicine they practise; there are others who have learnt their system of medicine and the use of the different from their forbears, while there are still others who offer their services after working with practitioners and learning from them. It is important that this unique knowledge, often found in ancient texts, be utilized by countries to the maximum extent possible without endangering the environment and destroying the very plants which are the source of the medicine. Unfortunately, this too is happening. There are many ways in which the practitioners of these systems and the products and plants they use could be more effectively utilized for the benefit of the countries and their people. Greater use could be made of these at the primary level so that all persons could have recourse to –particularly those living in areas without any allopathic health care coverage. Further research directed at a few of the chronic against which more drugs are needed, such as diabetes, bronchial asthma and arthritis, could to the discovery of new drugs for these conditions. Regulated and selective export of some of these medicinal plants being eagerly sought after in other parts of the world could considerably enhance the foreign exchange earnings of countries with this biodiversity. Careful planning is needed so that such a programme could be launched without detriment to the environment and without reducing the availability of the medicinal plants in the countries. The very large numbers of trained and semi-trained practitioners of the traditional systems of medicine could become more involved in the national health care systems of the countries. Such involvement can come about only as a result of some regulation of the systems being followed, the products used for health care and the practitioners of such systems.

iii Traditional Medicine in Asia

It is important also to take steps to ensure that unethical and unjustified exploitation of these plants, which have been used for centuries, is prevented– particularly the patenting in western countries of these remedies. At the same time, it is necessary to protect the discoveries being made in the countries of the Region by scientists and research workers who are carrying out research and discovering and documenting the effectiveness of the plants used. The WHO Regional Office for South-East Asia has published this book in order to present to the governments, policy-makers, clinical investigators, regulatory authorities, doctors, practitioners of traditional systems of medicine and the public, the state of the art in these wide and many-faceted fields. It is felt that the information in this publication, presented by some of the most eminent international authorities, would help not only in our understanding of these systems of medicine but also in making better use of them. The book is divided into three sections. The first section describes broadly several of the systems of traditional medicine in the countries of the Region. The second discusses policy issues such as harmonization of traditional and modern medicine, the role of traditional systems of medicine in national health care, a framework for cost-benefit analysis of traditional and conventional medicines, and the development of training programmes. The third section discusses technical issues such as legislation and regulation, standardization, pre-clinical toxicology and clinical evaluation, including ethical considerations and protection of traditional systems of medicines and research, drug development and manufacture of herbal drugs. Finally, the last part of the third section contains a brief description of the current status of traditional medicine in each of the 10 countries of the Region. We are grateful to the contributors for not only accepting readily our invitation to contribute to this book but also for adhering to the time frame. We are also indebted to Dr Palitha Abeykoon of the Regional Office for his help in planning the book, and to Mr S. Khanna, Administrative Assistant at the Delhi Society for the Promotion of Rational Use of Drugs, for his contribution at all stages in the preparation of this book.

Professor Uton Muchtar Rafei, Professor Ranjit Roy Chaudhury, Regional Director, Emeritus Scientist, World Health Organization National Institute of , South-East Asia Region New Delhi New Delhi

iv Contents

Contents

SYSTEMS 3 Dr. P.N.V. Kurup An overview of traditional Chinese medicine 17 Dr. Hongguang Dong Dr. Xiaorui Zhang 3 1 Syed Khaleefathullah Traditional system of medicine in Indonesia 4 7 Dr. Lestari Handayani Dr. Haryadi Suparto Dr. Agus Suprapto Koryo system of medicine in DPR Korea 6 9 Dr. Choe Thae Sop Chinese Acupuncture- 7 5 Prof. Deng Liangyue Fundamentals of Yoga 9 3 Niranjanananda and Dr. Vivekananda Saraswati

v Traditional Medicine in Asia

POLICY ISSUES Harmonization of traditional and modern medicine 115 Prof. Zhu-fan Xie Role of traditional systems of medicine in national health care systems 135 Mrs. Shailaja A framework for cost-benefit analysis of traditional medicine 159 and conventional medicine Dr. G. Bodeker Development of training programmes for traditional medicine 183 Dr. Palitha Abeykoon Dr. O. Akerele

TECHNICAL ISSUES Legislation and regulation of traditional systems of medicine– 195 systems, practitioners and herbal products Dr. D.C. Jayasuriya Dr. Shanti Jayasuriya Standardization, pre-clinical toxicology and clinical evaluation of 209 medicinal plants, including ethical considerations Prof. Ranjit Roy Chaudhury Dr. Mandakini Roy Chaudhury Protection of traditional systems of medicine, patenting and promotion 227 of medicinal plants Prof. Carlos M. Correa Research, drug development and manufacture of herbal drugs 247 Dr. B.B. Gaitonde

vi Contents

CURRENT STATUS - COUNTRY SITUATION Traditional medicine in the WHO South-East Asia Region 273 Dr. Kin Shein Traditional medicine in Bangladesh 275 Dr. Md. Aftabuddin Khan & Dr. S.K. Chowdhury Traditional medicine system in Bhutan 279 Drungtsho Dr. Pema Dorji Koryo medicine of Korea 281 Dr. Choe Thae Sop Indian system of medicine and homoeopathy 283 Mr. L.V. Prasad Native traditional medicine in Indonesia 287 Dr. Ketut Ritiasa & Dr. Niniek Sudiani Dhivehibeys in 289 Dr. Abdulla Waheed Indigenous medicine in 291 Dr. U. Kyaw Myint Tun Traditional medicine in 295 Dr. Rishi Ram Koirala Indigenous system of medicine in 299 Dr. Lal Rupasinghe Thai traditional medicine as a holistic medicine 301 Dr. Pennapa Subcharoen

List of contributors 307

vii

Systems

Ayurveda Dr. P.N.V. Kurup An overview of traditional Chinese medicine Dr. Hongguang Dong Dr. Xiaorui Zhang Unani medicine Hakim Syed Khaleefathullah Traditional system of medicine in Indonesia Dr. Lestari Handayani Dr. Haryadi Suparto Dr. Agus Suprapto Koryo system of medicine in DPR Korea Dr. Choe Thae Sop Chinese Acupuncture-Moxibustion Prof. Deng Liangyue Fundamentals of Yoga Swami Niranjanananda Saraswati and Dr. Rishi Vivekananda Saraswati Traditional Medicine in Asia

2 Ayurveda

Ayurveda P.N.V. Kurup

yurveda, which means the Science of The Netherlands and Hungary have ALife, is the oldest medical science in recognized Ayurveda as an alternative the and has been medicine. A White House Commission for practised since the 12th Century BC. has been constituted Ayurveda is not merely a system of medicine; in the US to find ways and means of rather it is a way of life. Its objective is to recognizing alternative medicine, which accomplish physical, mental, social and includes Ayurveda also for the purpose of spiritual well-being by adopting preventive practice. and promotive approaches as well as treating diseases with the holistic approach.1 Four types of Ayurvedic practitioners exist The theory of Loka Samya2 – in various parts of the world: macrocosm, microcosm continuum, z Traditional Ayurvedic practitioners Panchamahabhuta, Tridosha, Dhatus, (about 300,000) who are not Prakriti and Vikriti, and Ama – is the institutionally trained, but have gained unique concept of Ayurveda. Ayurveda is knowledge through their family effective not only in common ailments but ; also in many incurable, chronic and z Tribal healers who practise in the tribal degenerative diseases as well as iatrogenic areas using various local medicinal conditions. It not only takes care of the ; health of human beings but also of animals z Institutionally qualified and plants, known as Pashu Ayurveda and (around 300,000 throughout the Vriksha Ayurveda, respectively. Ayurveda is world); prevalent not only in India but also in Nepal, z Graduates of modern medicine who Sri Lanka, , Bangladesh, , have faith in Ayurvedic practice. Indonesia, , Singapore, Maldives, etc. The traditional systems prevalent in System of Medicine Myanmar, Bhutan and a close resemblance to Ayurveda. It is also The Siddha system of medicine, more practised in Japan, , USA, Russia, prevalent in the Southern States of India UK, Germany, etc., as herbal medicine or as well as Sri Lanka, Singapore and alternative medicine. Recently Australia, Malaysia, traces its origin to Dravidian

3 Traditional Medicine in Asia

Divodas obtained knowledge of Ayurveda from Lord and taught it to , who authored the Sushrut Samhita4 (6th – 5th Century BC). Vagbhata (7th Century AD) was highly influenced by the teachings of Lord Buddha. He authored Ashtanga Sangraha and Ashtanga Hridaya texts. During the Medieval Period, Sharangadhara (14th Century AD) described the examination of the pulse for the first time,5 as a method of clinical examination and use of metals and minerals like gold, silver, iron, and copper for preparing Ayurvedic medicines. In the 16th Century, Rasa in Northern India and Siddha culture, which owes allegiance to the cult in the South dealt mostly with a large of and the worship of the Phallus number of metallic preparations as (linga). The Siddha system of medicine remedies. The most important metal used extensively describes the use of herbo- with success was mercury in many forms. mineral products like mercury, sulfur, iron, copper, gold and arsenic. The principles Fundamental Principles and doctrines of the Siddha system have a Ayurveda accepts the metaphysical concept close similarity to Ayurveda with specia- of creation as proclaimed in ancient Indian lization in . treatises.6 The Prakriti and Purush prelude gross creation. Mahat originates from the Historical Background absolute nature (the un-manifest) with all The history of Ayurveda can be traced to its qualities leading to , which is different periods, the earliest being the of three types – Vaikarika (Sattvika), Vedic period when the compiled the (Rajasa) and Bhutadi (Tamasa). The 11 four (1500–800 BC) with maximum Indriyas – five organs of perception (ear, references in and . skin, eye, tongue, nose), five effecter organs Ayurveda originated in Heaven from Lord (speech organ, hands, sex organs, rectum, , who passed on this knowledge feet) and the mind – are created out of the to Dakshaprajapati and then to the Vaikarika Ahamkara with the help of Taijasa Ashwinikumaras – the physicians of Ahamkara. The Panchatanmatras (five Devatas who transmitted it to Lord Indra.3 basic substances – sound, touch, vision, On earth, when diseases were at their taste, odour) are created out of Bhutadi peak, Maharshi Bharadwaj approached Ahamkara with the help of Taijasa Indra and got the knowledge of Ayurveda. Ahamkara. Later, Maharshi learnt Ayurveda The Panchamahabhuta (five basic from Bharadwaj and taught it to Agnivesh elements) are evolved from these and others. Agnivesh authored the Panchatanmatras, i.e., (ether), Agnivesh Tantra, known as Charak (air), Agni (fire), Jala (water) and Samhita (5th Century BC). Kashiraj (earth).

4 Ayurveda

Tridosha – Vata, Pitta and Kapha – are rise of body temperature, burning the psychobiological dimensions or sensation, , etc.; ii) Ranjaka Pitta, biological rhythms regulating the entire which has a role in formation with functioning of the . These the pathological manifestation of anaemia; are formed by the Panchama- iii) Sadhaka Pitta, which is responsible for habhutas. Vata is formed by the combi- intelligence and memory with pathological of Akash+Vayu and has the manifestation for lack of concentration, properties of cold, light, coarse and dry, loss of intelligence, loss of sleep, etc.; iv) Pitta by Teja having hot and liquid and Alochaka Pitta, which is responsible for Kapha by Jala+Prithvi with cold, heavy, vision with pathological manifestations solid, smooth and moist properties. Vata, pertaining to eye and vision; and v) Pitta and Kapha are of five types having Bhrajaka Pitta, which regulates body physiological functions and pathological complexion, body heat regulation, etc., with manifestations.7 pathological manifestations like vitiligo, The five types of Vata include, i) discolouration and skin diseases. Vayu, which strengthens the vital capacity, The five types of Kapha include, improves the intellectual power, respiration, i) Avalambaka Kapha, which is responsible deglutition, and the activities of the sense for the lubrication of joints, pericardium organs, etc., with pathological with pathological manifestations like manifestations like hiccough, flatulence, stiffness of the joints and chest pain; ii) breathing troubles, etc.; ii) Udana Vayu, Kledaka Kapha, which disintegrates food, which regulates strength, encouragement, maintains the fluid, lubrication, etc., with colour, knowledge, intelligence, memory, pathological manifestations like indigestion etc., with pathological manifestations of the and mucoid stool; iii) Bodhaka Kapha, eye, ear, nose and throat; iii) Samana Vayu, which is responsible for feeling the taste of which improves digestion and metabolism, various substances with pathological transformation of nutrients, circulation of manifestations like dryness of mouth and lymph and expulsion of urine, stool, etc., palate and loss of sensation of different with pathological manifestations like tastes; iv) Tarpaka Kapha, which provides anorexia, diarrhoea and abdominal nutrition to the sense organs with tumour; iv) Vyana Vayu, which regulates pathological manifestations like loss of the blood circulation, sweating, contraction, activities of the sense organs; and taste, ejaculation of sperm, development v) Shlesaka Kapha, which lubricates all of all the tissues, etc., with pathological body joints with pathological manifes- manifestations like fever and convulsion; tations of the bony joints. and v) Apana Vayu, which regulates The body and the mind are the two expulsion of urine, stool, sperm, complementary constituents of a living menstruation, etc., with pathological being, its dynamic normalcy being manifestations of urinary and the uterine responsible for health and its imbalance tract and ano-rectal diseases. for . The five types of Pitta include, i) Pachaka Pitta, which regulates digestion The mind exhibits three properties: of food, stimulates the digestive enzymes z (intelligence), which is signified and separates the waste products with by goodness, virtue, excellence, pathological manifestations of anorexia, wisdom and good sense;

5 Traditional Medicine in Asia

metabolism.9 Ama means unripe, Greater emphasis is given to uncooked and undigested and refers to the deformity or pathological events caused by impaired digestion and involvement of the related metabolism due to the hypo-functioning of 10 channels for the initiation of the Agni. The products arising out of this the disease process which impaired digestion and metabolism form toxic substances having excessive pastiness, results in susceptibility to the depriving the body of its nutrition and are disease due to lowered called Ama, which is the root cause of all resistance of the channels diseases. Any external factor, i.e., bacteria, virus or climatic conditions may increase or accumulate the leading to z , signified by passion, emotion disturbance in its equilibrium and causing and restlessness; its vitiation. These vitiated doshas, while z , signified by mental darkness, travelling through the macro- and micro- illusion, error, and inertia. channels of the body, are stuck due to deformity of the channels.11 They will lead At the biological level, Vata, Pitta and to blockage causing obstruction of the Kapha are stated to be predominantly normal flow of doshas and nutrient Rajasika, Sattvika and Tamasika, respec- material and stasis of waste products. tively, in their constitution, highlighting the Thus, doshas retained interact with psychosomatic approach of Ayurveda dushyas of the affected region, leading to towards disease. dosha dushya sammurchana resulting in disturbance of the body metabolism and Concept of Pathogenesis Ama formation, which corresponds to the The concept of health is based upon the phase of Sthansamshraya when prodromal equilibrium of Dosha (humour), Dhatu symptoms of the disease are said to (seven body tissues – lymph, blood, muscle, manifest.12 Greater emphasis is given to adipose tissue, bone, bone marrow, deformity or pathological involvement of semen) and Mala (faeces, urine and other the related channels for the initiation of the waste products), i.e., soil and seed theory.8 disease process which results in suscep- If this equilibrium of doshas is maintained tibility to the disease due to lowered (soil), then the disease process cannot take resistance of the channels. This organ place even if any causative organism/factor susceptibility is often due to genetic (seed) exists in the body. The disease predisposition, but is also dependent on process takes place whenever the environmental factors. Subsequently, full equilibrium of doshas is disturbed, causing manifestation of the disease occurs with its vitiation. The Kayagni or Pachakagni clear-cut symptomatology. comprehends various factors responsible for digestion and metabolism involving the Eight Clinical Disciplines of splitting of complex food substances into Ayurveda their simpler components for absorption. There are eight major clinical disciplines of It also contributes moieties of itself to the Ayurveda that help deal with various disease Dhatus as Dhatwagni dealing with tissue conditions effectively.13 These are:

6 Ayurveda z Tantra (); z Tongue; z Vajikarana (Reproductive health and z Voice and Speech; aphrodisiacs); z Skin; z Kayachikitsa (); z Eyes; z Shalya Tantra (); z Overall appearance. z Shalakya Tantra (Diseases of eye, ear, nose and throat); This eight-fold examination provides a z Bhootavidya (); comprehensive general survey of the body z Tantra (Toxicology); and its functions. z Kaumarabhritya (Paediatrics, Dushya (dhatu and mala), environ- and ). ment, vitality, time, digestion and metabo- lism, body constitution, age, psyche, Approach to the Diagnosis and acceptability, diet – all these should be Principles of Treatment minutely analysed and taken into Ayurveda stands for extensive and elaborate consideration before deciding the actual clinical examination to understand the line of treatment. If the principles are nature of the disease process. It identifies applied to all the disease conditions, the patient and the disease separately. perhaps a better management can be Thus, the Ayurvedic clinical method is evolved. To eliminate and correct the doshic broadly divided into two parts:14 disturbances, internal medicine, external i) Examination of the patient, and ii) medicine and surgical treatment have been Examination of the disease. The patient is mentioned.18 Under curative treatment, not examined as a diseased entity but also Dipan (which also includes appetizer) and as an individual human being with all its Pachan (helpful in digestion and metabo- usual attributes, including his constitution lism) drugs are indicated for dissolving the and lifestyle. The 10-fold examination of vitiated doshas by correcting the disturbed the patient evaluates:15 metabolism, provided the intensity of the z Psychosomatic constitution; disease is of a mild to moderate nature. If z Disease susceptibility; the pathological lesion is of a more severer z Quality of tissues; type than that which stimulates Agni to z Body build; improve hunger or appetite, these alone z Anthropometry; may not serve the purpose and the internal z Adaptability; purification measure or Panchakarma z Mental Health; should be applied. To deal with z Digestive power; psychosomatic problems, divine therapy, z Exercise endurance; objectively planned therapy and psycho- 19 z Age. therapy have been described. In Daivavyapashraya Chikitsa (Divine The examination of disease is carried out Therapy), Daiv refers to divinity and/or to by general examination, through the events of one’s past life. It is believed interrogation and physical examination.16 that many diseases are caused due to The eight-fold examination covers.17 actions or of an individual past life z Pulse; which can be treated by appropriate and z Urine; auspicious Karmas in this life. This z Stool; approach to therapy is called Daivavya-

7 Traditional Medicine in Asia pashraya Chiktisa. Divine karmas like tration of Rasayana drugs having an , chanting , ablutions, immunoprotective effect is helpful in yagya, wearing precious stones, etc., are improving the immunity and general well- the usual methods of Daivavyapashraya being of patients. Chikitsa. Panchakarma Special mode of treatment Panchakarma (Purification Therapy) deals mainly with the removal of toxins and waste Rasayana materials from the body to purify the Rasayana (Rejuvenation Therapy) is a biological system from gross channels to speciality of Ayurveda which mainly deals eradicate the disease completely. It is with the preservation and promotion of helpful in the prevention of disease and health. It promotes longevity and prevents preservation and promotion of health, as or delays the aging process. Rasayana well as the management of psychosomatic, promotes resistance against and neurological, gastrointestinal, cardiova- other causative factors for the disease by scular and many other chronic, degene- maintaining the equilibrium of Vata, Pitta rative diseases and iatrogenic conditions. and Kapha.20 The Rasayana, if administered Panchakarma plays a vital role in Ayurvedic at an early age, also helps the body therapeutics and occupies an important metabolism in such a way that the genetic place in the Ayurvedic system of medicine. predisposition for a particular disease is This five-fold purification therapy, a classical avoided and the intensity of the symptoms form of treatment in Ayurveda, includes of a particular disease is greatly reduced. (emesis), Virechana (Purgation), Rejuvenation therapy, in addition to Asthapana (Decoction enema), Anuvasana dealing with the preventive and promotive (Oily enema) and Nasya (Nasal Insuff- aspects of health rather than merely with lation).21 Under pre-operative manage- the disease condition, acts also by ment, the doshas are liquefied by external improving micro-circulation in the body and internal oleation by , oil, leading to better bio-availability of nutrients and fomentation followed by the to tissues. The use of Rasayana drugs and main purification processes, which also other measures produces longevity, include intra-vaginal and intra-urethral improves memory, intelligence and good enemas and blood letting, for the elimination health, promotes youthfulness, good of toxins from the body. Under post- lusture, complexion and voice, promotes operative management, various types of optimum strength of the body and the dietetics and disciplined living for a few days sense organs, efficiency in talk and humility, after the treatment have been indicated. In and makes the personality attractive. There Ayurveda many treatment methods are are many Rasayana preparations which are described, i.e., , , 13 used according to the psychosomatic types of fomentations, etc. In , constitution and disease condition of the physicians have developed specialized patient. The immunomodulatory effect of techniques of Panchakarma, which is Rasayana drugs like Withania somnifera, something more than the purification Asparagus racemosus and Tinospora therapy. The , , cordifolia is well-established through and the Arya Vaidyan Variar scientific parameters. Therefore, adminis- Educational Foundation of Ayurveda,

8 Ayurveda

Coimbatore, are the pioneer institutions in the field of Keraliya Panchakarma.

Pizhichil In this therapeutic measure, warm medicated oil is poured all over the body, followed by , in seven positions in a systematic manner for the treatment of diseases of the nervous system like paralysis, sciatica, osteoarthritis, musculo-skeletal, neuro-muscular and degenerative diseases.

Pizhichil is very useful as a health restora- Shirobasti treatment in Ayurveda tive measure for elderly persons when it is regularly used once a year or so. This treatment cleanses the minute channels in are prepared from plants like Arka and the body of morbid substances. Snuhi by using their or herbal alkaline material and tying it at the site. The 22 Shirobasti advantage of this therapy is that the This is an oil treatment applied to the head patients may remain mobile during the in which a leather belt is tied to the clean- treatment. It can also be carried out on shaven scalp. The junction of the scalp patients for whom modern surgery is and leather belt is sealed with paste contra-indicated. prepared from wheat flour or black gram. Medicated oil is then poured into it and Role of Ayurveda in Primary kept for the stipulated time. This is Health Care recommended for headaches, myopial conditions, insomnia, psychiatric illnesses, Ayurveda has laid due emphasis on the , hair fall, etc. It improves the preventive and promotive aspects of functioning of the sensory systems and health, in which dietetics and way of life, removes exhaustion. according to Prakriti (psychosomatic constitution), play an important role. The 23 Shirodhara balance of Vata, Pitta and Kapha to This therapeutic measure is carried out by a healthy state and disturbance in this pouring oil or medicated liquids on the equilibrium leads to diseases. If one forehead for treating headaches, vertigo, follows the daily routine and seasonal insomnia, anxiety, etc. It is also useful in routines as prescribed under personal many psychosomatic disorders and hygiene and socio-behavioural conduct, . then health can be preserved and diseases prevented by developing the capacity to 24 Ksharasutra adapt to the cosmic changes which have This Alkaline Thread Therapy is a an impact on the human biological popular herbal treatment for ano-rectal system. The violation of these principles diseases like fistula-in-Ano and disturbs the equilibrium of doshas haemorrhoids (piles) under the speciality increasing susceptibility to diseases. of Shalyatantra. The medicated threads

9 Traditional Medicine in Asia

The simple, effective, non-toxic locally medicinal plants is well-established on available medicinal herbs which cost very scientific lines for the promotion of health little – and are more acceptable to the and the treatment of common as well as people – are being used successfully to treat chronic diseases. common ailments by the practitioners of includes maternity and child health care, Ayurveda, who are playing an important role family planning, immuni-zation, control of in providing basic health services in remote communicable diseases, nutrition, clean areas where institutionally qualified doctors water supply, health education, treatment are not available. Traditionally, each village of common and chronic diseases. In had the traditional , who used to Ayurveda many methods are described to be a friend, philosopher and guide to the promote the health of the pregnant woman local people not only by taking care of in the antenatal period and later, in the health-related issues but also in regard to postnatal period, with due emphasis on other socio-cultural matters which play an breast-feeding of the baby for its optimal important role in the maintenance of health growth in the early period. Drugs like and precipitation of disease. Ayurveda is Asparagus racemosus promote lactation in used in various national health the postnatal period and the drugs Sida programmes. The thera-peutic efficacy of cordifolia and Abutilon indicum promote the

Therapeutic efficacy of medicinal plants For the Brain For the Alimentary Canal Sankhapushpi Convolvulus pluricaulis Bilva Mandukaparni Centella asiatica Haritaki Terminalia chebula Brahmi Bacopa monnieri Kutaja Holarrhena Vacha antidysenterica Jyotishmati Celastrus paniculatus For the Pancreas For the Tejpatra Cinnamomum tamala Arjuna Terminalia arjuna Jambu Syzygium cumini Guggulu Commiphora wightii Vijayasara Pterocarpus Pushkaramula Inula racemosa marsupium Kushta Saussurea lappa Karavella Momordica charantia Kiratatikta Swertia chirata For the Respiratory Tract Haridra Curcuma longa For the Urinary Tract Vasa Adhatoda vasica Punarnava Boerhaavia diffusa Yashtimadhu Glycyrrhiza glabra Gokshura Shirish Albizzia lebbeck Crataeva nurvala

For the Stomach For the Genital System Amalaki Emblica officinalis Men Bhringaraja Eclipta alba Kapikacchu Mucuna pruriens Satavari Asparagus racemosus Aswagandha Withania somnifera

For the Women Bhoomyamalaki Phyllanthus amarus Satavari Asparagus racemosus Pippali longum Ashok asoca Kalamegh Andrographis paniculata Japapushpam Hibiscus rosa-sinensis Katukarohini Picrorhiza kurroa

10 Ayurveda growth of the baby. The nutritional Tinospora cordifolia, etc., are good deficiency may cause anaemia, malnu- immunity-promoting drugs which can play trition and other vitamin deficiencies which an important role in primary health care can be corrected by available food articles from the preventive, promotive and curative in the rural areas such as carrot, , points of view. milk, leafy vegetables and pulses. With Extensive research has shown that regard to family planning, drugs like some of the medicinal plants exert specific Hibiscus rosa-sinensis and Piper longum action on various vital organs. They not only Linn have shown promising results after promote the normal functioning of the scientific investi-gations. Withania organ but also take care of the disease- somnifera, Asparagus racemosus, condition as well.

Treatment of Common Diseases

To deal with various common diseases at the primary health care level, many time-tested standard Ayurvedic formulations are highly effective.

Common Diseases Treatment Common Diseases Treatment Common Cold Laxmivilas rasa and Bacillary Sanjivani and Godanti Bhasma Dysentery Shankhodar

Fever Tribhuvankirti rasa, Piles Arshakuthar rasa Godanti Bhasma and Sudarshan Hepatitis Arogyavardhani rasa Ghanvati Liver Diseases

Hyper Acidity and Sutshekhar rasa, Dysfunctional Pushyanug Duodenal Ulcer Shankh Bhasma Uterine Bleeding

Cough Sitopaladi, Urinary Tract Chandraprabha vati Khadiradivati

Gastro-intestinal Shankhvati Arthritic Condition Yograj guggulu and problems Rasnadi kvath

Diarrhoea Jatiphaladi, Karpura Gout Kaishore guggulu rasa Bronchial Asthma Shvasa kuthar rasa Diarrhoea and Kutajghanavati Amoebic Dysentery Various Eye Saptamrata lauha Diseases and Mahatriphalaghrita

These are a few well-established like Bilva (Aegle marmelos), Haritaki Ayurvedic recipes frequently used by (Terminalia chebula), Nimba (Azadirachta Ayurvedic physicians throughout India for indica), Shirish (Albizzia lebbeck), Vasa the disease-conditions mentioned above. (Adhatoda vasica), Ghritkumari ( Many surgical cases, if treated during the vera) and Guduchi (Tinospora cordifolia) early stage, may be managed better by are very useful in treating common medicinal treatment. Medicinal plants diseases.

11 Traditional Medicine in Asia

Treatment of Chronic Diseases or guide the local villagers in collecting the The peculiarity of Ayurveda is that medicinal plants for preventive, promotive compound preparations are more powerful and curative purposes. The formulations and potentiate the therapeutic efficacy of were used as , vati, gutika, bhasma, medicinal herbs. Ayurveda not only treats extract, decoction, asava-arishta, the disease but, more importantly, takes care medicated oil and ghee. The pharma- of the patient as a whole with its holistic ceutical industry has played a revolutionary approach. Various Ayurvedic herbal and role in popularizing Ayurveda by providing herbo-mineral preparations are used for the modern technology for standard and treatment of chronic diseases, degenerative quality Ayurvedic drugs in the national and diseases and iatrogenic conditions without international market. At present 8800 any side-effect. The use of Rasayana and in India are producing these Panchakarma therapy is of immense value drugs worth Rs. 3000 crore ( one crore = for treating such conditions. Many people $ 200,000) for domestic use and living in rural areas often suffer from exporting drugs worth Rs. 300 crore. The common chronic ailments such as diabetes availability of required medicinal herbs is mellitus, hypertension, ischaemic heart gradually decreasing. It is necessary to disease and bronchial asthma. involve the local people by forming For the management of these cooperatives for medicinal plants. conditions, a large number of Ayurvedic Such village-level cooperatives will be highly drugs, based on established scientific useful in creating an awareness about the investigations, have shown excellent results. development of medicinal plants and the The therapeutic effect of Vijayasara need for their conservation to achieve the (Pterocarpus marsupium), Karavella objectives of producing and marketing (Momordica charantia), Tejpatra (Cinna- Ayurvedic drugs of quality. momum tamala), Kiratatikta (Swertia The , under the chirata) in diabetes mellitus, Sarpa- Ministry of Health and Family Welfare, has gandha (Rauwolfia serpentina) in Hyper- established a separate Department of tension, Arjuna (Terminalia arjuna) and Indian System of Medicine and Homoeo- Pushkaramula (Inula racemosa) in pathy to promote this ancient system of ischaemic heart disease, Shirish medicine. This department has published (Albizzia lebbeck), Haridra (Curcuma two volumes of a Pharma-copoeia longa) in bronchial asthma, Kalamegh containing 158 drugs. The Essential Drugs (Andrographis paniculata) and Bhoomya- list for dispensaries and hospitals has also malaki (Phyllanthus amarus) in infective been published. Ayurvedic drugs have been hepatitis, Kapikacchu (Mucuna pruriens) introduced in reproductive and child health in impotency and Varuna (Crataeva programmes. Agro- techniques have been nurvala), Gokshura (Tribulus terrestris) and developed for 100 medicinal plants. To Punarnava (Boerhaavia diffusa) in stone promote Good Manufacturing Practices, and urinary tract infection is well- laboratories have been identified for the established. standardization and quality control of ayurvedic drugs. Ayurvedic Pharmaceutics The prime foundation of pharma- Traditionally physicians used to - codynamics of ayurvedic drugs is based facture Ayurvedic medicine by themselves upon the theory of Pancha-mahabhuta,

12 Ayurveda which forms the physico-chemical basis of The Government of India has the body as well as diet and drugs. The established a National Academy of pharmaco-therapeutics is based on the Ayurveda to promote intensive training in theory of tridosha, which controls and different specialities for graduates and maintains the biological functions and are postgraduates of Ayurveda under the the cause of health in a state of equilibrium guidance of eminent scholars according and of disease in cases of disequilibrium. to the Shishya Parampara-. The composition, metabolism and action In this region, three Siddha colleges are of the drug are based on its Rasa (taste), functioning with the facility of postgraduate Guna (properties), Virya (potency), Vipaka education in one college, 107 hospitals (metabolism), Prabhava (specific potency) and 306 dispensaries. and (action). The Government of India, by an Act of Parliament, established the Central Council Education and Research of Indian Medicine (CCIM) in 1972 for regulating education and registration in College level education in Ayurveda started Ayurveda, Siddha and Unani medicine. about 100 years ago with royal petronage. Ayurvedic education and registration is Subsequently, modern knowledge was also regulated in the neighbouring countries as introduced in these colleges. At present, well. The Government of India also the number of Ayurvedic institutions in the established a research council, the Central Indian Subcontinent is 186 (which Council for Research in Indian Medicine, includes two graduate-level institutes in Sri Homoeopathy and Yoga (CCRIMH) in Lanka and 12 in Nepal). In addition, the 1971, which was subsequently developed National Institute of Traditional Medicines into four independent councils in 1978. at Nawinna in Sri Lanka conducts training The Central Council for Research in programmes for doctors, Ayurvedic Ayurveda and Siddha (CCRAS) promotes students, farmers and practitioners of research in Ayurveda. The CCRAS has 10 Medicine. Free Ayurvedic central research institutes of Ayurveda, 17 treatment facilities are available in about regional research institutes and nine 21,000 Ayurvedic dispensaries and regional research centres/research units, hospitals. Some 50 universities in the fully devoted to research in Ayurveda. The Subcontinent have facilities for Ayurvedic Bandaranayake Memorial Ayurvedic graduate (BAMS) and postgraduate Research Institute at Nawinna, Sri Lanka, (M.D.-Ayu) education. in Ayurveda is available in 31 colleges, which include three major Ayurveda takes care of the postgraduate centres: the Institute of patient as a whole with its Postgraduate Teaching and Research in holistic approach. Various Ayurveda at Gujarat Ayurved University, Ayurvedic herbal and herbo- Jamnagar; Banaras Hindu University, , and the National Institute of mineral preparations are used Ayurveda at Jaipur. The Faculty of for the treatment of chronic Ayurveda, Banaras Hindu University, has and degenerative diseases made significant contributions in the field without any side-effect. of research in Ayurveda.

13 Traditional Medicine in Asia is also making a significant contribution in jurisprudence and toxicology, Swastha the field of research in Ayurveda. The Vritta – hygiene, preventive, promotive and Central Research Institute, the Regional , Yoga and nature cure, Vikriti Research Institute and the Literary Research Vigyana – diagnostic methods and and Documentation Department are also , Samhita – classical devoted to research in the Siddha system textbook, Kayachikitsa – internal medicine, of medicine. Rasayana and Vajikarana – promotion of The Gujarat Ayurved University is the longevity, rejuvenation and reproductive only statutory university in the world health, Manas Roga – psychiatry, exclusively devoted to Ayurvedic studies Panchakarma – internal purification, and research. It has adequate facilities for massage and physiotherapy, extensive training in Ayurveda for foreign Kaumarabhritya, Prasuti Tantra, Striroga – students. The University has nine affiliated paediatrics, obstetrics and gynaecology, Ayurvedic colleges in Gujarat. Outside Shalya – surgery, Shalakya – Gujarat, the Ayurvedic institutions at , and . (Tamil Nadu) and Manipal (Karnataka) have also been granted of Medicine in Ayurveda recognition for postgraduate education in [M.D.(Ayu)] Ayurveda. Similarly, Ayurvedic institutions This postgraduate course of three years’ in Japan and South Australia have also duration is available in 13 specialities of been granted recognition. Ayurveda, i.e., Ayurveda Siddhanta and Darshan – fundamental principles of The details of the courses are as under: Ayurveda, Samhita – classical Ayurvedic texts, Dravyaguna – and Bachelor of Ayurveda Medicine , Rasa – science of and Surgery Degree Course mineral, herbal and aquatic drugs, (B.A.M.S.) Bhaishajya – and This five-and-a-half-year degree course pharmaceutics, ITSA – internal medicine, covers comprehensive and intensive Vikritivigyana and Roga Nidan – diagnostic practical and theoretical training in all the methods and pathology, Manas Roga and subjects of Ayurveda along with good Manovigyana – psychiatry and psychology, exposure to modern basic medical subjects Panchakarma – internal purification and like anatomy and , which makes massage therapy, Kaumarabhritya – these B.A.M.S. graduates competent paediatrics, Prasuti Tantra and Striroga – enough to practise Ayurveda. obstetrics and gynaecology, Shalya – The subjects under this degree course Surgery, Shalakya – ophthalmology and are taught utilizing the latest knowledge of otorhino-laryngology. the basic principles of Ayurveda and history of Ayurveda, Sharir Rachana – anatomy, Doctor of Philosophy (Ph.D.) Sharir Kriya – physiology, Guna – The facility for the award of Ph.D. degree pharmacology, pharmacognosy and is available in 13 specialities of Ayurveda. Materia Medica, and The M.D. (Ayu) or its equivalent degree in Bhaishajya Kalpana – science of mineral, the concerned subject/speciality is essential herbal and aquatic drugs, pharmacy and for registration in Ph.D. The minimum pharmaceutics, Agada Tantra – medical duration for this course is two years.

14 Ayurveda

Diploma Course in Ayurveda under this course are, basic principles of The objective of this one-year course Ayurveda, including Swasthavritta (hygiene (divided into three semesters of four months and positive health), the fundamentals of each) is to provide intensive theoretical and herbo-mineral Materia Medica and practical training in Ayurveda, covering pharmaceutics, the fundamentals of most of the five-year degree course in diagnosis and pathogenesis of diseases Ayurveda. This course is designed for the (Nidana), the fundamentals of treatment graduates of modern medicine or any other (Chikitsa) including Panchakarma traditional medicine to prepare them to (internal purification and massage become efficient Ayurvedic practitioners. ), Rasayana (geriatrics and The details of the subjects are, basic rejuvenation therapy), fundamentals of principles of Ayurveda, including hygiene surgery (Shalya) including Ksharasootra and public health, detailed study of (alkaline thread cauterization), Agnikarma medicinal plants, their properties and uses (cauterization), Jalaukavacharana ( (Dravyaguna), Ayurvedic mineral, herbal application), etc., management of common and aquatic drugs (Rasa Shastra), herbal clinical conditions through herbal pharmaceutical preparations (Bhaishajya preparation. Kalpana), intensive training in traditional Bachelor of Pharmacy in and classical preparation of Ayurvedic Ayurveda [B.Pharm (Ayu)] medicines; Ayurvedic diagnostic procedures, pathology and pathogenesis The main aim of this four-year Bachelor (Roga Nidana), Kayachikitsa – internal Degree Course is to produce high quality medicine, Rasayana – rejuvenation therapy technologists capable of producing quality in the promotion and preservation of health Ayurvedic drugs by employing traditional, and the treatment of various chronic modern or upgraded or modified illnesses, Vajikarana – promotion of traditional techniques as well as controlling reproductive health, Manas Roga – and maintaining their quality. The course psychiatry, Panchakarma, its role in the has been planned in such a manner that preservation and promotion of health and the personnel completing it should be treatment of chronic degenerative diseases, capable of meeting different requirements Yoga and nature cure; Kaumarabhritya, of both the manufacturing and consumer Prasuti and Striroga – paediatrics, obstetrics sectors for Ayurvedic drugs and other and gynaecology, Shalya – surgery, traditional systems of medicine. including Ksharasutra preparation and management of ano-rectal diseases, Master of Pharmacy in Ayurveda Shalakya – ophthalmology and otorhino- [M. Pharm (Ayu)] laryngology, Pathyapathya – Ayurvedic This two-year Master’s Degree course is dietetic preparations and management. designed to provide in-depth knowledge of Ayurvedic drugs, their method of Introductory Course in Ayurveda manufacturing and also their This three-month course is designed to standardization and quality control aspects impart basic knowledge of Ayurveda to with specialization in two subjects: scholars having a medical background or Pharmaceutics of Ayurvedic Drugs and graduation in bio-sciences or in fields allied Quality Control and Standardization of to medicine. The details of the subjects Ayurvedic Drugs.

15 Traditional Medicine in Asia

Diploma in Pharmacy in (M.Sc.) in Ayurveda [D.Pharm (Ayu)] Medicinal Plants This course of two years’ duration is The objective of this two-year course is to intended to train personnel, mainly for adopt a multi-disciplinary approach for meeting the requirements of the consumer comprehensive teaching of all aspects sector of Ayurvedic drugs and other related to medicinal plants, to generate traditional systems of medicine. They skilled manpower to meet the present and should be acquainted with the manu- future requirements of human resources facture of Ayurvedic drugs and should be in the field of medicinal resources qualified and competent to dispense development, and to provide distinctive Ayurvedic drugs in hospitals, dispensaries, education and training in all aspects of drug stores and related activities. They medicinal plants. This course is designed should also be trained to maintain the for graduates in botany, pharmacy, stores of Ayurvedic drugs (both raw agriculture or Ayurveda. materials and finished products) properly.

References

1. – Sutrasthana. 30th Chapter. Sloka 26. 2. Charaka Samhita – Sharirasthana. 5th Chapter. Sloka 3. 3. Charaka Samhita – Sutrasthana. 1st Chapter. Sloka 4–5. 4. – Sutrasthana. 1st Chapter. Sloka 3. 5. Sharangadhara Samhita – Purva Khanda. 3rd Chapter. Sloka 1. 6. Charaka Samhita – Sharirasthana. 1st Chapter. Sloka 16. Sushruta Samhita – Sharirasthana. 1st Chapter. Sloka 4. 7. Sushruta Samihta – Sutrasthana. 35th Chapter. Sloka 19. Ahstanga Hridaya – Sutrasthana. 12th Chapter. Sloka 4. 8. Charaka Samhita – Chikitsasthana. 3rd Chapter. Sloka 68. 9. Ashtanga Hridaya – Sutrasthana. 11th Chapter. Sloka 34. 10. Ashtanga Hridaya – Sutrasthana. 13th Chapter. Sloka 25. 11. Sushruta Samhita – Sutrasthana. 24th Chapter. Sloka 10. 12. Sushruta Samhita – Sutrasthana. 21st Chapter. Sloka 33. 13. Charaka Samhita – Sutrasthana. 30th Chapter. Sloka 28. Sushruta Samhita – Sutrasthana. 1st Chapter. Sloka 7. 14. Charaka Samhita – Vimanasthana. 8th Chapter. Sloka 83–84. Ashtanga Hridaya – Sutrasthana. 1st Chapter. Sloka 22. 15. Charaka Samhita – Vimanasthana. 8th Chapter. Sloka 84. 16. Sushruta Samhita – Sutrasthana. 10th Chapter. Sloka 4. 17. Yoga Ratnakara. Chowkhamba Samskrit Samsthana. 5th Edition. 1993. Page 5. Sloka 1. Chapter 1. 18. Charaka Samhita – Sutrasthana. 11th Chapter. Sloka 55. 19. Charaka Samhita – Sutrasthana. 1st Chapter. Sloka 58. 20. Charaka Samhita – Chikitsasthana. 1st Chapter. 1st Pada. Sloka 5. 21. Sharangadhara Samhita – Uttara Khanda. 8th Chapter. Sloka 1. 22. Ashtanga Hridaya – Sutrasthana. 22nd Chapter. Sloka 23. 23. Ashtanga Hridaya – Sutrasthana. 22nd Chapter. Sloka 29. 24. Sushruta Samhita – Chikitsasthana. 17th Chapter. Sloka 29.

16 An overview of traditional Chinese medicine

An overview of traditional Chinese medicine Hongguang Dong Xiaorui Zhang

Introduction prompted by a desire to present an overview of the Chinese system of uring the past decade, traditional medicine. Dsystems of medicine have received growing attention around the world. Fundamentals of TCM According to some estimates, a large number of people in many developing As an important part of the Chinese countries rely heavily on traditional culture, TCM has evolved into a unique and practices to meet their primary health care complete medical system during the long needs.1 In , although Western history of China. The Huang Di Nei medicine is available, the majority of the (The Yellow Emperor’s Classic of Medicine still rely on zhongyi (Chinese or Canon of Medicine) was the first medicine or traditional Chinese medicine, monumental classic which systematically or TCM) to solve their health problems. documented the etiology, physiology, Western medicine and Chinese medicine diagnosis, treatment and prevention of are practised side by side at every level of disease. This work was probably compiled the national health care system.2 over several centuries by various authors With a history of over 2000 years, the and consists of two parts: Su Wen (Plain TCM practice offers natural, safe and Questions) and Ling Shu (Miraculous Pivot, effective therapies and cures for many also known as Canon of Acupuncture). It diseases with much less side- effects. TCM takes the form of a dialogue between the takes a unique theoretical and practical legendary Yellow Emperor and his minister, approach to health. In treatment, it Bo, on the topic of medicine. Its includes the use of various intervention appearance between 300 BC and 100 BC modalities, such as Chinese , marked the establishment of TCM.4 One acupuncture and moxibustion, Tuina striking difference between TCM and (massotherapy), dietary, and .2, 3 Western medicine is in the way in which These modalities may be used separately the human body is observed, and hence or in combination to effect a treatment. the difference in the concept of health. TCM differs in fundamental ways from Chinese medicine holds a holistic view Western medicine. This paper is thus of the human body. It stresses the overall,

17 Traditional Medicine in Asia

human body and, on the other, the body Every modality of intervention is adapts to the variations in the natural aimed at regulating and environment. balancing . As stated The concept of yin and yang in The Yellow Emperor’s Classic The concept of yin and yang is fundamental of Medicine, yin is even and well to the understanding of Chinese medicine. while yang is firm, hence a The earliest reference of yin and yang is relative balance is maintained probably the one in the book “Yi Jing” (Book and health is guaranteed of Change, 700 BC). Originally, yin and yang were two topographic terms used to designate the shady and the sunny sides of a hill, or the north side and south side of delicate harmony and coordination among a mountain. The sunny side of mountain, different parts of the human body. in the sunlight, represents warm, bright, Therefore, it lays great emphasis on the and other active characteristics; and the careful readjustment and maintenance of shady side of the mountain represents cold, this natural balance in the body.5 It uses dark, and other passive properties. By zang fu (visceral organs) and the meridians extension, the theory of yin and yang holds as its theoretical basis and yin yang and that the universe consists of two opposing “five elements” as its theoretical tools. but mutually dependent forces that According to TCM, qi, ‘blood’ and ‘body complement and supplement each other, fluid’ are the fundamental substances resonate harmoniously, and maintain a which make up the human body and constant balance. As man is considered maintain its normal physiological as a microcosm in the universe, to achieve functioning.6 Health implies harmonious a healthy state a balance between the coordination among the various parts of forces of yin and yang in the human body the body and their adaptation to the should be maintained. physical environment. With respect to medicine, it could be The fundamental mechanism of said that the whole of the Chinese system disease is the breakdown of the relative of medicine, its physiology, pathology, equilibrium within the organism or between diagnosis, and treatment, can all be the organism and its environment.7 In TCM reduced to the basic and fundamental terms, this is known as an imbalance theory of yin and yang. Every physiological between yin and yang.8 In the diagnosis process and every pathological change and treatment of diseases, the basic can be analysed in the light of the yin yang characteristic of TCM, which sets itself theory. Ultimately, every modality of apart from modern Western medicine, is intervention is aimed at regulating yin and that of ‘syndromes differentiation(9) or yang, to balance yin and yang. As stated translated as diagnosis and treatment in The Yellow Emperor’s Classic of based on overall analysis of symptoms and Medicine, yin is even and well while yang signs’. Holism views not only the human is firm, hence a relative balance between body as an organic whole but also the unity yin and yang is maintained and health is of the human body and nature. On the guaranteed. one hand, nature constantly influences the

18 An overview of traditional Chinese medicine

The theory of Five Elements on the view of balance, holism, and Together with the theory of yin yang, the harmony in the human body. This theory theory of Five Elements constitutes the basis initially likened the organs in the human of Chinese medicine. Originally, the Five body to the Five Elements. The Elements referred to the five kinds of organ:element analogies are :metal; materials, which are wood, fire, earth, liver:wood; kidney:water; heart:fire; and metal and water with their characteristic spleen:earth (Tables 1a & 1b). This analogy properties—an ancient philosophical broadens out to encompass all concept to explain the composition and components of the body, since each and phenomena of the physical universe. The every part of the anatomy is controlled by primitive concept of Five Elements was a particular vital organ. For example, in further developed into a more complex TCM, liver stores blood, ensures the theory and was used to summarize the smooth flow of qi, controls the sinews; lung properties of things in nature into five governs qi and respiration, regulates water categories. Each matter in the universe has passages and controls skin; spleen a dominant character which transports and transforms water and food resemblance to the properties of one of five essence, keeping the blood flowing within elements. The theory of Five Elements is thus the vessels, controls muscles and the four used to group the things through their limbs, etc. different properties and to interpret the The Five Elements theory is extensively relationships among these different things applied in almost every aspect of Chinese through a generating sequence and a medicine. It is used in physiology to explain counteracting sequence among the Five the functions of different organs, tissues Elements. The generating sequence is in and their connections. In pathology, it is the following sequence: wood, fire, earth, applied to demonstrate the mutual metal and water, in which each Element is pathological influence and transmission conceived to promote or produce the among the viscera organs. It is used in subsequent one, namely, wood produces diagnosis to synthetize the data obtained fire, fire produces earth, etc. The through the four methods of diagnosis counteracting sequence is in the following (given in detail in the following chapter) and sequence: water, fire, metal, wood and deduce the evolution of disease. In earth, in which each Element is considered treatment, the theory of Five Elements is checking the subsequent one, namely, applied mainly under two headings: to water checks fire, fire checks metal, etc. It prevent the transmission of disease and to should be stressed that this is a symbolic guide the therapeutic method. recognition, an analogy. According to the When considering a certain dishar- Yellow Emperor’s Classic of Medicine, mony organ, one should keep in mind the “metal, wood, water, fire and earth various relationships between this organ encompass all natural phenomena. This and the others (the generating sequence symbolism also applies to man”. In other and counteracting sequence). This words, all parts of the human body have disharmony may be affected by another affinities in nature with particular elements. organ, and meanwhile it may be affecting The Five Elements view is important another organ. from the perspective of demonstrating the To prevent the transmission of disease: way in which Chinese medicine has built This was demonstrated by the “Classic on

19 Traditional Medicine in Asia

Table 1a Some of the main characteristics of the five elements Elements Human Body Five Zang Five Fu Five Sense Five Five Organs Tissues Emotions Wood Liver Gall Bladder Eyes Tendon Anger Fire Heart Small Intestine Tongue Vessel Joy Earth Spleen Stomach Mouth Muscle Anxiety Metal Lung Large Intestine Nose Skin Sorrow Water Kidney Bladder Ears Bone Terror

Table 1b Some of the main characteristics of the five elements Elements Nature Five Five Five Five Five Directions Seasons Climates Tastes Stages of Development Wood East Spring Wind Sours Birth Fire South Summer Heat Bitter Growth Earth Centre Late Summer Dampness Sweet Transformation Metal West Autumn Dryness Pungent Harvest Water North Winter Cold Salty Storage

Medical Problems” in chapter 77: “If Liver corresponding external manifestations. For is diseased, it can invade the Spleen, the this reason, TCM* does not emphasize the Spleen must therefore be tonified before it anatomy of the human body. Although TCM is affected” uses similar names for organs as those used To guide the therapeutic method: The in Western medicine, and many of these “Classic on Medical Problems” in chapter organs perform similar functions as 698 presents a classic interpretation: “If recognized in Western medicine, they in fact deficiency is found in the son organ, one do not reflect completely the same concepts. would tonify the mother organ; if excess is For example, in Chinese medicine, each found in the mother organ, one would visceral organ is a comprehensive system sedate the son organ”. and performs a set of physiological functions which often cover an area related to but The human body much larger than those in its anatomical In Chinese medicine, much stress is laid on sense. the observation of the outward physiological The visceral organs are divided into and pathological manifes-tations of the three categories according to their human body. It is believed that all internal morphological features and physiological organs and their activities will have their functions.

* Some terms in TCM are the same as those in Western medicine, but they may mean quite different things. In order to avoid confusing them with the notions of Western medicine, these terms are italicised to remind readers. Some terms applied directly from TCM are also italicised to remind readers.

20 An overview of traditional Chinese medicine

The five zang organs: these are body is formed; when qi dissipates, the substantial in morphology, and function to body “dies”.11 Qi has variously been store the “essence of life”. They include “liver, translated as “”, “vital energy”, or heart, spleen, lung, kidney”. “life force”; however, it is almost impossible The six fu organs: these are hollow in to capture the exact concept fully in one morphology, and their function is to English word or phrase; therefore we have transport and transform foodstuff. They decided to use its original Chinese word: consist of the “small intestine, large Qi. intestine, gall bladder, stomach, bladder The sources of qi can be divided into and sanjiao (triple energizer: a collective the inborn and the acquired. The inborn qi term for the three portions of the body is the innate vital essence stored in the cavity)” “kidney” which was inherited from the “Extraordinary organs”: these are parents at the moment of conception, and hollow in morphology, and their function augmented postnatally which is a is to store the “essence of life”. They are combination of the essence absorbed by the “brain, marrow, bone, vessels, gall the “spleen” from food and fresh air which bladder and uterus”. is inhaled by the “lung”. The two sources Each of the zang organs is linked to a of qi are gathered in the chest and form fu organ. The function of one organ in TCM zhengqi (genuine qi), which circulates may include the functional activities of through the body’s organs and tissues. several anatomically defined organs in Since qi is invisible, it can only be perceived Western medicine. For example, the through its actions. For instance, the “kidney” in Chinese medicine is not just the deficiency of the “kidney qi” means the organ that excretes urine; it stores the deficiency of energy required for the “essence of life”, controls reproduction, functioning of the “kidney” (namely, the growth and development and is closely hypofunction of the “kidney”). Generally related to the “brain, marrow and bones”. speaking, qi has five functions: it i) Serves Thus, in TCM the concept of “kidney” as the energy source of body activities, ii) includes most of the functions of the urinary Warms and nourishes the body, system, some functions of the endocrine iii) Defends the body surface against system, and something similar to those of invasion by any pathogenic factor, iv)Is the the pituitary-adenocortical-gonadal axis.10 vehicle of transportation inside the body, and v) Maintains the normal positions of Material basis of the vital body organs.12, 13 Blood: The concept of activities of the human body blood in TCM is not the same as it is in Qi: The major premise of TCM is that all Western medicine. In TCM, the blood is a living things, including human beings, have vital nutrient substance in the body. It is a life force within them. This essential vital formed from the combination of essence biological energy, which is invisible, is of food, which is derived via digestion and known in Chinese philosophy as qi absorption by the spleen and the stomach, (pronounced: chee; often also written as and fluids containing nutrients. The kidney ‘chi’). Qi circulates regularly along the also contributes to the formation of blood meridians in the body. Disruption in this as it is the kidney-stored essence that flow is believed to be responsible for produces bone marrow. After being diseases. When qi gathers, the physical formed, blood circulates in the vessels

21 Traditional Medicine in Asia

essence can be transformed into acquired essence and acquired essence replenishes congenital essence. Sexual over-indulgence is taken as an important cause of disease because it consumes the reproductive essence stored in the kidney, thus impairing the other organs. Jing Ye (Body fluids): Jing Ye is a general term for all normal liquids in the body. It is derived from the essence of food and drink, which is digested and absorbed by the spleen and the stomach. The difference in nature, form and location, and body fluid can be divided into two categories: Jing and Ye. Clear and thin fluids are referred to as jing, while thick and heavy fluids are known as ye. Body fluid moistens and nourishes various parts of the body. The formation, distribution and excretion of body fluid is a complicated process resulting from the coodinated activity of many Zang Fu organs, especially the lung, spleen and kidney.

Map of lung meridian Meridians–Pathways of the human body throughout the body, promoted by the Both Western and Chinese medicine agree heart with the help of the lung, controlled that the organs are physically connected. by the spleen which keeps blood flowing TCM believes that there exists in the human within the vessels, and regulated by the liver body a network of pathways called as a reserve. meridian (or channel) system, through Jing : Jing, which is defined as the vital which qi and “blood” circulate, and by essence of the body, consists of two parts: which internal organs are connected to and congenital essence and acquired essence. coordinated with superficial organs and Congenital essence, which is inherited from tissues, thus creating an integral whole. The the parents at conception, is responsible for meridian system consists of 12 pairs of reproduction, thus also known as regular meridians (six pairs of yin and six “reproductive essence”. It is stored in the pairs of yang meridians), eight extra kidney and serves as the origin of life. meridians, 12 collateral, and their Acquired essence is derived from the connective parts. The 12 regular meridians essential substance of food and is consist of the main parts of the meridian distributed to various organs and tissues. It systems and are symmetrically distributed serves as the material basis for life activities. on both sides of the body, and run The congenital and the acquired essence respectively through the medial or lateral rely on, and promote each other. Congenital side of each limb. Each regular meridian

22 An overview of traditional Chinese medicine pertains to a corresponding visceral organ Endogenous pathogenic factors and is named accordingly. To facilitate the include emotional factors (joy, anger, worry, learning and use of these meridians, the anxiety, sorrow, terror and fright, known names of the meridians have been as the Seven Emotions). translated into English. WHO has further There are also several other factors given standardized alphabetic codes to which do not belong to either of these two them.14 categories, such as pestilential pathogens, Acupuncture points are found along trauma, improper diet, exhaustion and the meridians under the skin. Each over-indulgence in sex. acupuncture point is anatomically located In essence, whether disease will occur and has its own specific therapeutic effects. depends on the outcome of the struggle Three hundred and sixty-one acupuncture between the vital energy and pathogenic points have been identified along the 14 factors. As stated in Su Wen (The Yellow meridians. WHO has also recommended Emperor’s Classic of Medicine): the standardized nomenclature of these “Pathogens cannot invade the body when points.15 The meridian system is used in vital energy is sufficient”; and, “only when TCM to explain the physiological functions the vital energy is in deficiency, can and pathological changes in the human pathogens invade the body”.16 body as well as to guide the diagnosis and TCM pays utmost attention to the treatment of diseases. Acupuncture and maintenance of the vital energy. Therefore, Moxibustion, Tuina, and Qigong are TCM gives a prominent place to prevention. therapeutic techniques based mainly on the It can be said that the traditional Chinese meridian theory. medicine is essentially a prevention-oriented medicine. This preventive philosophy of Causes of disease TCM is expressed at two levels: prevention According to TCM, health implies that the against the occurrence of disease, and body system is in a state of dynamic prevention against its further development equilibrium, not only between the various if disease has already occurred. parts of the body but also between the body and environmental conditions. Disease Principle of diagnosis results when the equilibrium is destroyed Diagnosis is an important component of (i.e., there is imbalance of yin and yang) the theoretical system of TCM. It includes by certain factors. The factors which cause two parts: diagnosis of disease and disturbance in the harmony and balance of the body are called pathogenic factors. In TCM, these are generally classified as TCM is essentially a prevention- exogenous and endogenous pathogenic oriented medicine. This factors. Exogenous pathogenic factors preventive philosophy is encompass atmospheric changes (“wind”, “cold”, “summer heat”, “dampness”, expressed as prevention against “dryness” and “fire” known as Six Excessive the occurrence of disease, and Atmospheric Influences). These are the six prevention against its further excessive climatic conditions to which the development if disease has individual concerned has lost his ability to already occurred. adapt.

23 Traditional Medicine in Asia differentiation of syndromes. Differentiation strength or weakness of qi and “blood” and of syndromes is often more important. predict the progress of the illness. Body TCM regards the human body as an palpation refers to systematic feeling of the organic entity. The component parts of the surface of the body, the meridians, body body are physically interconnected, so a temperature, and body moisture. Body local pathological change may influence palpation is applied especially when pain the whole body. Similarly, disorders of is concerned. The final diagnosis is based internal organs may be reflected on the on the information gathered from all the surface of the body. There are four major above-mentioned diagnostic methods. diagnostic methods used in TCM: These methods are not used in isolation, inspection, auscultation and olfaction, but as parts of a system. interrogation and palpation. Differentiation of syndromes is a Inspection is a method used to examine process in which the characteristics of the mental state, complexion, physical disease and syndrome are decided condition, behaviour, secretion and through interpretation and summing-up of excretion, as well as observation of the the phenomena collected from the four tongue. basic diagnostic methods. “Syndromes” in Auscultation and olfaction detects the TCM is not a simple summation of clinical status of a patient by listening to symptoms and sign; it reflects rather the his voice, his breathing, and his coughing, pathogenesis and pathophysiology of a and by smelling his body odours. given case, and provides a basis for the Interrogation is a way to interview the prevention and treatment of disease. patient, find out his or her family history to There are a number of methods in TCM determine the patient’s health state, major for syndromes diagnosis (differentiation of complaints, and progress of illness. Apart syndromes). It includes the differentiation from this, other specific conditions must be of pathological conditions in accordance inquired into while interrogating. This was with the eight principal differentiation called “Ten Questions” recommended by syndromes according to pathological Dr Zhang Jie-bin (1563–1640) and changes of zang fu organs, differentiation includes: chills and fever; perspiration; syndromes according to the condition of headache and general pains; urination body qi, blood and fluid, differentiation and defecation; appetite; feeling in the syndromes in accordance with the theory chest and abdomen; hearing; ; pulse of meridians, differentiation of epidemic taking and observation; auscultation and febrile disease in accordance with the smelling; characteristic of menstruation for theory of wei, qi, ying and xiue, and the women patients. differentiation syndromes in accordance Palpation is the most important with the theory of triple energizer. Of the diagnostic method unique to TCM. It several ways of syndrome differentiation, include two parts: pulse feeling and body differentiation of pathological conditions in palpation. Pulse feeling emphasizes the accordance with the eight principal quality of the pulse at the radial arteries of differentiation syndromes according to both wrists. It is recognized that there are pathological changes of zang fu organs 28 different pulse qualities which can be are the most useful. felt and each with its own subtle nuance of The eight principal syndromes serve as interpretation. It is used to examine the a guideline, namely, yin and yang, exterior

24 An overview of traditional Chinese medicine and interior, cold and heat, deficiency and Chinese materia medica developed excessiveness. Differentiation of patholo- continuously by the addition of new herbs, gical conditions in accordance with the together with a re-evaluation and addition eight principal syndromes is the foundation of new uses for existing herbs. Among for all the other methods of syndrome these, two pieces of work need to be noted: differentiation. It signifies the location and Xin Xiu Ben Cao (Newly Revised Materia nature of disease, the confrontation Medica, 659 AD) was considered to be the between the pathogenic factor and body first official in China, resistance, as well as establishes the compiled and issued by the Government. principle of treatment. Ben Cao Gang Mu (Compendium of Differentiation syndromes according to Materia Medica, 1596) is considered as a the pathological changes of zang fu organs world-renowned classic, written by Li Shi- are based on the symptoms and signs zhen (1518–1593 AD). obtained by four diagnostic methods when The concept of Chinese medicine qi and the blood of the internal organs are differs from that of the synthesized drugs out of balance. This method of syndrome in the ways their properties are determined. differentiation is applied to identify the Chinese medicines are determined mainly particular disharmony of a specific internal by the outcomes of their clinically observed organ. interaction within the human body. The terminology used in describing the Intervention in TCM pharmacology of Chinese medicine includes: property; taste or flavour; action Chinese medication of ascending, descending, floating and Chinese medication is the primary sinking; attributive of meridians, and toxicity. component of TCM and is used commonly Properties or four properties of herbs: in China. Chinese medication involves the Based on their therapeutic effects, there are use of herbal medicine, animal parts and four ways of describing property: cold, hot, minerals. The term “” used in Chinese warm, cool. For example, herbs effective medicine often goes beyond the traditional for the treatment of heat syndromes are concept of “plant”, since the 6000– 8000 endowed with cold or cool properties, substances used include, in addition to while those effective for cold syndromes are numerous plants, substance from animals herbs with warm or hot properties. and minerals. Taste: Sour, bitter, sweet, pungent, and According to Chinese history, Chinese salty taste of herbs. They are the expression medicine arose from mythical medicine to of the feature of the herb’s actions; thus become a system of herbal medicine. the taste does not necessarily mean the real Nong Ben Cao Jing (Divine Husbandman‘s taste of the herb. Classic of Materia Medica; or Shen Nong‘s Action of ascending, descending, Herbal) is the first work (25–220 AD) floating and sinking: Direction of a herb’s which prescribed the therapeutic effect of action. The ascending and floating herbs herbs and other materials. It contains 365 have an upward and outward effect, while entries. These are botanical (252 entries), descending and sinking herbs have a zoological (67 entries), and mineral (46 downward and inward effect. The action entries) substances. Beginning with Shen of a herb can be changed by processing Nong Ben Cao Jing, the literature of or by combined use with other herbs.

25 Traditional Medicine in Asia

Attributive of meridians: Classification milder in action but have sustained effects, of herbs according to the meridians on and are therefore used for chronic cases. which their therapeutic action is manifested. However, more convenient formulations in In addition, attributive of meridians also such forms as tablets and capsules are also refers to some herbs capable of guiding or available. leading other herbs included in the prescription to the targeted meridians or Acupuncture organs. For example, Radix bupleuri (Chai Acupuncture is defined as “puncturing with Hu) can relieve the pain in the hypocho- a sharp instrument”,12 but the original term ndriac region, which is believed in Chinese in Chinese includes both “needling” and medicine to be the result of stagnation of “moxibustion” (burning herbs, usually live qi. As the liver meridian crosses through , to stimulate acupuncture points). the hypochondriac region, it can be It is an important component of TCM for deduced that this herb acts on the liver the prevention and treatment of diseases. meridian. A herb can act on more than The theoretical basis of acupuncture is the one meridian. premise that there are patterns of qi that Toxicity: Refers to the harmful effects flow through the pathways-meridians of the produced by herbs on the human body. body, and any potential disruptions of this Toxic herbs are usually marked by “highly qi flow are believed to be responsible for toxic”, “moderatly toxic” or “slightly toxic” diseases. Acupuncture treatment can to indicate the different degrees of toxicity. correct imbalances in the flow of qi by The prescription in Chinese medicine inserting a needle at identified acupuncture must follow strict rules.11 A typical points. Other stimulating methods can also prescription is composed of principal be applied at the acupuncture points to herbs, associate herbs, adjuvant herbs and regulate the body’s qi, and help restore messenger herbs. The principal ingredient balance and harmony. The deqi (getting is a substance which provides the main the qi or needling sensation) is a crucial therapeutic thrust; associate herb is a factor in achieving acupuncture effects. It substance which enhances or assists the involves the feeling of “soreness, numbness, therapeutic action of the first; the adjuvant expansion, heaviness” by the patient; at the one treats the accompanying symptoms, same time, the operator should feel and moderately diminishes the harshness heaviness and tightness around the needle. or toxicity of the primary ones; the As stated in The Yellow Emperor’s Classic messenger herbs guide the medicine to the of Medicine: “the acupuncture effects can proper organs, or exert a harmonizing be achieved only when the deqi is effect. These herbs are often described in achieved”.(4) There exist many types of Chinese pharmacology as emperors, stimulating techniques which often ministers, assistants and envoys, produce different results. However, this respectively. crucial issue has often been ignored in The most common methods of applying clinical research on acupuncture.13 herbal therapy are decoction (the herb is Moxibustion is used to treat and prevent boiled with water) and -bound pills. diseases by applying ignited moxa at Decoction is generally regarded as fast and acupuncture points or certain parts of the strong in action, and is used for acute human body. The material used in cases; honey-bound pills are slower and moxibustion is mainly Artemisia Vulgaris

26 An overview of traditional Chinese medicine

(mugwort), a kind of herb in Chinese called translated as pressing and dragging, and Ai (moxa). Generally speaking, moxibustion Na as grasping. It belongs to external is applied in cold syndrome, deficient therapy and has evolved over thousands conditions and chronic diseases. of years. As a component of TCM inter- Moxibustion may be used in combination vention, tuina is based on a solid theoretical with acupuncture or separately to effect a background, and includes basic theories, treatment. diagnostic methods and syndrome differentiation of TCM, particularly the Qigong theory of meridians. In addition, tuina is The term qigong is composed of two also involved in a series of different kinds Chinese characters, qi and gong, where of specific manipulation techniques. qi can be translated roughly into English Tuina has its own specific benefits and as “vital energy”, and gong as “method” advantages in a wide range of applications. or “performance”. Qigong is a system of Tuina is used in both prevention and exercise performed by taking a proper treatment of diseases. It may be used in posture, adjusting breathing and the treatment of internal and external concentrating the mind and uniting vital conditions, traumatic injury, and muscu- essence and energy and mentality as a loskeletal, gynaecological, obstetric and whole for physical training, health paediatric diseases. preservation, prevention and treatment of Stringent and comprehensive practi- diseases.14 Since qi plays an important role tioner training is important. When in the vital processes of the human body, it performing tuina, the physician must first is natural that regulation of the flow of qi concentrate his mind, regulate his can be used as a method to preserve health breathing, and actuate the qi and power and prevent diseases. Qigong is different of his entire body towards his hands, elbow from physical exercises. The latter is aimed or other part of body with the requirement at building up health or at restoring the of treatment, then apply manipulation on body’s physical functioning by enhancing certain points or areas of the patient’s body strength, whereas the former is focused on to stimulate the flow of qi and blood in the mobilization of functional potentialities order to normalize the function of zang fu through regulating the mind and and balance yin and yang. breathing. In other words, physical exercise is purely somatic, whereas qigong therapy Proper use of TCM is generally psychosomatic. Another difference between physical exercise and In TCM, the conception of the organism qigong is that physical exercise expands as a whole and diagnosis and treatment energy by tensing up the muscle and based on overall analysis of symptoms and accelerating the heart beat and signs are two key elements. Diagnosis, respiration, while qigong works to relax, prevention and treatment of illness in TCM calm and regulate breathing so as to rely on a holistic approach towards the sick accumulate vital energy in the body. individual, and disturbances are treated at the physical, emotional, mental, spiritual Tuina and environmental levels simultaneously. The term Tuina is composed of two Chinese Safety issues are of paramount characters, Tui and Na. Tui can be concern. Since Chinese medicine is

27 Traditional Medicine in Asia

“natural” and has stood the test of history, minimal in the hands of a well-trained it is often automatically perceived as being practitioner.16 Reports show that one of harmless. It is true that Chinese medi- the more common problems of cations in general are less toxic and safer acupuncture is forgotten needles.17 Life- as compared to synthetic drugs or other threatening adverse reactions are possible forms of therapy, but they are by no means with acupuncture treatment;18, 19, 20 free from adverse effects. however, these are usually caused by The question of the toxic potentials of practitioners who have not received any or herbs has long been recognized in Chinese adequate training. Qualification in medical pharmacopoeia, and relevant theories practice is important. There should be no have been developed to avoid harmful uses exception in the case of Chinese medicine. or combinations of potentially toxic herbs, such as the theories of “Eighteen Prospects for TCM Incompatibilities”, “Nineteen Antagonism” and “Contraindication during ”, TCM is, by definition, traditional, but this “Pao Zhi” (herbal process). These theories in no way prevents it from evolving. Great continue to guide the Chinese pharma- progress has been made since the past copoeia to this day. decade in efforts to understand the Quality assurance procedures must be mechanisms of TCM, especially the strictly enforced in order to standardize physiological effects of acupuncture. In the herbal medicine. Chemical tests and assay meantime, efforts to combine TCM with procedures must be used to supplement in China have also accumu- the traditional standards of the Chinese lated a great amount of experience and pharmacopoeia. data. More concerted efforts are needed Concerns have also been expressed relating to theoretical studies which may regarding the safety of acupuncture. The elucidate the fundamentals of TCM through risks associated with acupuncture have acquired knowledge in Western medicine. been shown to be very small compared to Another challenge lies in how to clinically orthodox interventions.15 In November combine TCM and Western medicine more 1997, an Acupuncture Consensus effectively which may eventually contribute Statement made by the National Institute to the organic integration of these two of Health in the mentioned: schools of medicine. “One of the advantages of acupuncture is One frequent criticism regarding that the incidence of adverse effects is researches in TCM is the quality of such substantially lower than that of many drugs research. Improving the methodology or other accepted procedures for the same and devising an approach for the specific conditions.16” In general, side- effects from use of researches on TCM may be a acupuncture procedure itself have been worthwhile task.

28 An overview of traditional Chinese medicine

References

1. WHO monographs on selected medicinal plants (Volume 1). 1–4, 1999. (1) World Health Organization. Geneva. 2. Hesketh T., Zhu WX. Health in China. Traditional Chinese medicine: one country, two systems. BMJ 1997;315:115–17. 3. Diehl D.L. Acupuncture for gastrointestinal and hepatobiliary disorders. J.Altern. Complement Med. 1999;5:27–45. 4. Maoshing Ni. The Yellow emperor’s classic of medicine. A new translation of Neijing Suwen with Commentary. 1995. Massachusetts, Shambhala. 5. CHEN G.T. et al. Unbelievable cures and medicine from China. 1997; Beijing. China. New World Press. 6. Xie Z.F. Introduction to basic medical theories In: Best of traditional Chinese medicine. 16. 1995; Beijing. China, New World Press. 7. Lu Y.B. and Liu C.C. Concepts and theories of traditional Chinese medicine In: Advanced TCM Series 101. 1997; Beijing. China, Science Press. 8. Qin Y.R. Classic on Medical Problems. 1978; Beijing. China, People’s Health Publication House. 9. Williams T. The idea behind Chinese medicine In: The Complete Illustrated Guide to Chinese Medicine. 31–34. 1996. Great Britain, Element Books. 10. World Health Organization. Standard acupuncture nomenclature (second edition). 1993; World Health Organization. 11. Yuan R., Lin Y. Traditional Chinese medicine: an approach to scientific proof and clinical validation. Pharmacol.Ther. 2000;86:191–98. 12. NG LKY, Liao S.J. Acupuncture: Ancient Chinese and Modern Western. A Comparative Inquiry. J Altern. Complement Med. 1997;11–23. 13. Morey S.S. NIH issues consensus statement on acupuncture. Am.Fam.Physician. 1998;57:2545–46. 14. Xie Z.F. Qigong and Health Preservation In: Classified Dictionary of Traditional Chinese Medicine. 533–555. 1994. Beijing. China. New World Press. Beijing 100037. China. 15. MacPherson H. Fatal and adverse events from acupuncture: allegation, evidence, and the implications [see comments]. J Altern. Complement Med.1999;5:47–56. 16. Moyad M.A., Hathaway S., Ni H.S. Traditional Chinese medicine, acupuncture, and other alternative medicines for prostate : an introduction and the need for more research. Semin.Urol.Oncol. 1999;17:103–10. 17. Yamashita H., Tsukayama H., Tanno Y., Nishijo K. Adverse events in acupuncture and moxibustion treatment: a six-year survey at a national in Japan [see comments]. J Altern. Complement Med. 1999;5:229–36. 18. Ernst E., White A. Life-threatening adverse reactions after acupuncture? A systematic review [see comments]. Pain. 1997;71:123–26. 19. Norheim A.J., Fonnebo V. Adverse effects of acupuncture [letter] [see comments]. Lancet. 1995;345:1576. 20. Yamashita H., Tsukayama H., Tanno Y., Nishijo K. Adverse events related to acupuncture [letter]. JAMA 1998;280:1563–64.

29

Unani medicine

Unani medicine Syed Khaleefathullah

Origin and development Ali Ibn-E-Sina (980–1037AD) is the chief luminary of Unani Tibb. His brilliance he Horizon of Unani Tibb: Unani is shown in classifying and arranging all Tmedicine originated from Greece under the medical knowledge of his time, and in the patronage of Bukrat (460 presenting it in a logical form. His famous BC–377 BC) and from the fusion of diverse book of medicine is Al-Qanon-Fit-Tibb thoughts and experiences of with (Canon of Medicine). This book was written ancient cultural heritages, and advanced in five volumes. with the wealth of scientific thought of that refers to the uniqueness of age. Among the distinguished scholars and the human personality as a union of the translators of that period, Ibn-E- body with an immaterial soul. From the Masawayh, Hunain Bin Ishaque and scientific point of view, the strength and Qusha Bin Luqah deserve mention. When weakness of the Al-Qanon lie in its passion this rich material was made available, it for observation, classification and paved the way for further researchers, generalization. There is repeated physicians and like Rabban counselling to medical practitioners against Tabari, Zakaria Razi, Ali Bin Abbas, Abu indulgence in speculation. Sehl Masihi, Abu Ali Ibnsina and Abul Avicenna’s theory of interaction Hassan Tabari. between the four causes reveals that every Al Razi (850–923AD) is regarded as illness is a product of (i) heredity (ii) a distinguished physician in the history of environment (iii) constitutional strength and Unani Tibb. He devoted his life to literary the quality of temperament, and and clinical research. After his death, his (iv) nature’s own effort for the life and disciples edited the material collected by integrity of functions. him. His book, Al-Hawi, was translated into The concepts of Avicenna which in 1486 and published in Venice in require to be accepted as truth are the 1547AD. He was the first to describe elements – symbols of mass and energy; smallpox and measles in his valuable temperament – the energy pattern of the treatise, Al-Hasaba-Wa-Al-Judri, which is body as a whole; humours – the building considered as the best heritage of Unani material for the body and the source of Tibb. energy for work; the faculties – the power

31 Traditional Medicine in Asia or drive for organs and functions; and contaminated with these foul earthly finally vital force – the metabolic energy for bodies, no infection can occur. The Spanish the organization and differentiation of life. Arab physician, Ibn-E-Khatima knew that These are hypotheses imported from the man is surrounded by minute bodies, physics and biology of Avicenna’s time and which enter the human body and produce thus deserve not ridicule but serious disease. Dr Grunner, the translator of Al- consideration as helpful generalizations. Qanon of Avicenna, remarks in his preface Avicenna’s mode of presentation gives that the above two views considered the impression of concepts being true for together give us glimpses of modern germ all times. It is this impression which led his therapy. successors to regard the pursuit of other Unani Tibb was introduced in India by medical literature as superfluous and thus Arab and Persian settlers. The Unani acted as a deterrent to progress for several physicians paid special attention to the centuries. It was, however, not the fault of medicinal herbs found in India and wrote Avicenna that he presented it as such to books on the therapeutic qualities of these general practitioners and there is no herbs. reason for us to avoid the dispassionate India has produced eminent Unani examination of Al-Qanon for useful ideas. physicians. A few among them are Hakim The most frequently quoted Ajmal Khan and Hakim Abdul Hameed in during the middle ages was Abul Qasim northern India, and Hakim Zahoorul Huq, Al-Zahrawi. His book, Al-Tasrif, was used Hakim Mohammed Muqeem, Shifa Ul as a textbook until the beginning of the 17th Mulk and Hakim Syed Maqdoom Ashraf century. Hippocrates systemized the tibb in southern India. and gave it the status of ‘’Science’’. established its foundation on which the General Principles Arab physicians constructed an imposing edifice. Concepts The greatest name in botany is Ibn-Al- Unani Tibb is based on the humoral theory. Baytar (1248 AD). His book, Al-Jami-Li This theory supposes the presence of four Mufaradat Al-Adviya Wa Al-Aghziyah, humours in the body – blood, phlegm, contains all Greek and literature on yellow bile and black bile. The temperament botany and Materia Medica. of a person is accordingly expressed by the The Unani physicians were also words sanguine, phlegmatic, choloric and advanced in and performed the melancholic, according to the prepon- operation of “Cranio Clasty” for the derance in him/her, respectively, of the delivery of the dead foetus. Zahrawi’s book, above humours. The humours are assigned Al-Tasreef, is full of such examples. He was temperaments. Blood is hot and moist, the first to describe the Walcher’s position phlegm is cold and moist, yellow bile is hot in obstetrics. and dry, and black bile is cold and dry. The modern “Germ Therapy” is in fact Drugs are also assigned tempera-ments. a reflection of the views of the Unani Every person is supposed to have a unique physicians who realized the connection humoral constitution, which represents his between foul bodies and putrefaction. In healthy state. Any change in this brings this connection, Avicenna has discussed in about a change in the state of health. A detail that unless a bodily secretion is power of self-preservation or adjustment,

32 Unani medicine

“medicarix naturae”, is formulated, which consideration for arriving at a correct strives to restore any disturbance within the diagnosis and deciding the line of limits prescribed by the constitution of an treatment. individual. This corresponds to the defence mechanism, which is called to action in Arkan (Elements) case of insult to the body. The aim of the The human body consists of four elements, physician is to help and develop rather than viz., air, fire, water and earth. These supersede or impede the action of this elements actually symbolize the four states power. The consequence of this is that not of matter. They have their own tempera- only is the system enabled to overcome the ments. Air: hot and moist; water: cold and present disturbance by dint of its intrinsic moist; earth: cold and dry; and fire: hot power, but it also emerges, after recovery, and dry. with greater power of resistance to further disturbances. Mizaj (Temperament) In Unani Tibb, drugs of plant, mineral The interaction of the elements produces and animal origin are extensively used. The various states, which in their turn determine Unani physicians encouraged poly- the temperament of an individual, and it is pharmacy and devised a large number of of paramount importance to keep the poly-pharmaceutical recipes, which are still temperament of an individual in mind while in use in Unani Tibb. prescribing a course of treatment. A Gruner in a treatise on the Canon of temperament may be (i) real equitable – the Medicine of Avicenna published in 1930, temperaments of the four elements are in states: equal quantities – which do not exist, (ii) “Modern medicine is based on the equitable – just and required amount having conception of the universe as a conglo- compatible temperaments, and meration of dead matter out of which, by (iii) inequitable – an absence of a just some unexplained process, life may distribution according to their requirements. become evolved in forms. To Avicenna the whole of the universe is the manifestation Aklat (Humours) of a universal principle of life, acting These are the fluids which the human body through the instrumentality of forms. In obtains from food, and include various modern medicine, the forms are the source hormones and enzymes. These fluids are of life but to Avicenna, they are the product (i) primary fluids – four humours, and (ii) of life.” secondary fluids – these are also four in number and are called Rotubat E Arba Principles (four fluids). These are responsible for maintaining the moisture of the different The human body is considered to be made organs of the body and also provide up of the following seven components nutrition to the body. There are four types (Umore Tabaiya) each having a close of moisture: moisture of the small vessels; relation to and direct bearing on the state moisture in the small spaces of the body; of health of an individual and it is therefore moisture of the different parts of the necessary for a Unani physician to take all organ; and the moisture that holds the these factors of the human entity into body together.

33 Traditional Medicine in Asia

There are four stages of digestion (i) Arwah (Spirits) hazm e medi – gastric digestion followed These are considered to be the life force by and including hazm e mevi – intestinal and are therefore given importance in the digestion when food is turned into chyme diagnosis and treatment of diseases. They and chyle and carried to the liver by are defined as carriers of different powers. mesentric veins, (ii) hazm e kabid – hepatic digestion. In the course of this process chyle Quwa (Faculties) is converted into four humours in varying The faculties are of three kinds, quantities, that of blood being the largest, (a) Quvat e tabaiya: Natural power, (iii) hazm e urooqui – vessel digestion, and the power of metabolism and repro- (iv) hazm e uzuvi – tissue digestion. duction. The seat of this power is the While the humours are flowing in the liver but the process is carried on in blood vessels, every tissue absorbs its every tissue of the body. The process nutrition by its quvat e jaziba, (attractive of metabolism is completed by two power), and retains it by its quvat e masika factors, namely, (retentive power). Then the quvat e hazima z Nutritive power, which is served by (digestive power), in conjunction with quvat four powers. These are (i) Attractive e mushbah (assimilative power), converts power, (ii) Retentive power, (iii) it into tissues. The waste material at this Digestive power, and (iv) Expulsive stage is excreted by quvat e dafia (expulsive power. power). z Growing power is responsible for Aaza (Organs) the construction and growth of the human organism and is served by These are the various organs of the human three powers. These are (i) body. The health or disease of each Receptive power, (ii) Power to retain individual organ affects the state of health nutrition, and (iii) Assimilative of the whole body. power. There are four organs of primary As far as reproduction is importance in Unani medicine. These are concerned, the function is the brain, the heart, the liver, and the accompanied by two powers which testicles or the ovaries. Other organs are are (i) Generative power, and servers to the main organs. This shows that (ii) Forming power. the brain is served by the nerves, the heart (b) Psychic power: Nervous and psychic by the arteries, the liver by the veins, the power. Its seat is the brain and it is testicles by spermatic vessels and the constituted by two powers, ovaries by fallopian tubes. The heart is the z Perceptive power, which conveys source or starting point of the vital power impression or sensations; or innate heat of the body. The brain is the z Motive power, which brings about seat of the mental faculties, sensation and movement as a response to movement. The liver is the seat of the sensation. nutritive or the vegetative faculties. The generative organs (testes, ovaries) give the Perceptive power works in two masculine and feminine form and directions: External perceptive, when it temperament, and form the generative recognizes objects outside, and is served elements for propagation of the race. by the five senses and internal perceptive,

34 Unani medicine when perceptions are not from outside but z Health – The bodily functions are are inferences drawn from external carried on normally; impressions and recognition. This consists z Disease – The opposite of health, in of five powers: (i) Composite senses: Its which one or more functions or forms function is to collect in one place all the of the organs are at fault; external recognitions, (ii) Imagination: It z Neither health nor disease – There is retains all material collected by composite neither complete health nor disease. As senses, (iii) Conception: It co-relates all the in the case of old people or those who external recognitions and draws are convalescing. conclusions from them, (iv) Memory: It retains conclusion, and (v) Modifying Disease can be classified into two types: faculty: This power is possessed only by (1) Simple disease that completes its course human beings which gives us the capacity without complications. It involves simple to explain one thing in different ways and organs, compound organs, or both which interprets all internal and external and is differentiated as, recognitions. (a) Diseases of temperament: These Motive power is of two types, (i) Power affect only simple organs. When that is the cause of motions, and (ii) Power compound organs are involved it is that causes motions. through the affection of their (c) Vital power: Power that maintains life composing simple organs. Diseases and enables all the organs to accept of temperament are thus always the effect of psychic power. The seat of referred to as affecting simple organs this power is (i) Heart – the centre of and not compound organs; vital life, (ii) Brain – the centre of (b) Diseases of structure: These sensation and movement, and involve compound organs which (iii) Liver – the centre of nutrition. are composed of simple organs and are in reality the instruments Functions of body functions; This includes the movement and functions (c) Diseases of continuity and of the various organs of the body. Every dislocations: These affect both organ has a primary innate faculty (force simple as well as compound or drive) for nutrition by which it absorbs, organs. In the latter case, loss of retains, assimilates and integrates the food continuity involves compound material into tissues and excretes the organs directly and independently, wastes. Some organs are also capable of and not through the involvement influencing the activity of other organs while of simple organs which compose certain other organs have no such faculty. them. Dislocation is a loss of It is on account of such differences that continuity in a joint but without the various organs of the body are damage to any of its individual described as (i) receptors as well as components. effectors, (ii) receptors, (iii) effectors, and (2) Complex disease does not mean the (iv) neither receptors nor effectors. simultaneous occurrence of several States of the body: According to Unani diseases in one person, but the presence Tibb the states of the body are grouped of a number of abnormal conditions in under three heads. They are, the form of a single disease.

35 Traditional Medicine in Asia

Principles of Diagnosis perceptible. According to some it can be perceived occasionally in a strong pulse on In Unani Tibb, great reliance is placed on account of additional strength; in a large investigating the cause of the disease pulse on account of greater height; in a thoroughly for proper diagnosis. The pulse, hard pulse on account of greater urine and stool are employed as the general resistance, and in a slow pulse on account indications to diagnose the various states of increased length of the beat. of the body. Method of feeling the pulse Pulse The pulse is felt by palpating the radial Pulse is a movement of expansion and artery at the wrist for three distinct reasons. contraction in the receptacles of the First it is more accessible, second, it is in vital force (heart and arteries). The purpose direct continuity with the heart and third, of this movement is to condition the vital because it is quite close to it. force with light air (oxygen from lungs). The The forearm should be kept in mid- pulse can be discussed from the point of prone position, as in thin and weak persons view of: pronation increases the height and width z The general principles governing the of the pulse but decreases the length, while pulse; supination increases the height and length z The type of pulse in each disease. but decreases the width.

Each pulse-beat consists of two periods Features of the pulse of movement and two periods of rest. Unani physicians have laid down 10 Since each beat has one period of features for examining the pulse. In this way expansion and one of contraction, it is also the pulse varies in respect of its size, i.e., in important that between the two opposite the degree of expansion as estimated by types of movement, there should be a its height, length, and breath; strength of period of rest because it is impossible for the pulse-beat as felt by the fingers; velocity any movement to reach the end of its of the pulse-beat depending on the course and change into any type of duration of the movement; quality of the movement without intermission. This has vessel wall; fullness or emptiness of the been made clear in physics. It is, therefore, artery; quality of the pulse regarding its hot obvious that each pulse-beat before the or cold condition; frequency of pulse-beats next has two periods of movement and two based on the length of the rest period of rest, which are: (between two beats); constancy and z Expansion (systolic); inconstancy regarding the various features; z Rest between expansion and regularity or irregularity of the beats or contraction; rhythm of the pulse. z Contraction (diastolic); Size z Rest after the contraction (diastolic) of preceding beat and before the This is noted in the three spatial relations expansion of the next beat. of the pulse during expansion, i.e., height, length, breadth. The pulse thus has nine According to most physicians, the simple and a large number of compound phase of contraction in pulse is not varieties which are the long, short and

36 Unani medicine medium; the broad, narrow and medium pulse in this respect is the pulse of average and the high, low and medium. A pulse fullness between the two extremes. which is large in length, breath and height is called a pulse of large volume and the Temperature one which is small in these dimensions is The pulse may be hot, cold or moderate in called the pulse of small volume. The temperature. average pulse between these two is known as the pulse of medium volume. Similarly, Rate (Frequency) a pulse which is large in breadth and height The pulse is rapid when the period between is known as a bounding pulse and that the two beats is less than the normal. It is which is small in this respect is called a thin slow when this period is long. A medium pulse. A pulse which is average between pulse in this respect is of the average rate these two extremes is a medium pulse. between the two extremes.

Strength Constancy The pulse as felt by the fingers may be A pulse may remain constant or vary in strong, feeble or medium. A strong pulse respect of the features mentioned above. is the one which during expansion strikes The variation may extend over several beats forcibly against the physician’s palpating or involve a single beat, or part of a beat, fingers. A feeble pulse is the opposite of a e.g., the pulse may be rapid in one beat strong pulse and a medium pulse in this because of increased (metabolic) respect is midway between the two. requirement of the body and weak in another beat due to reduced vitality. The Speed (Velocity) five features of the pulse, which vary in a The velocity of pulse-beats may be quick, beat, are, size – as large or small; strength sluggish or medium in speed. A quick pulse – as strong or weak; velocity – as quick or is one in which the duration of individual sluggish; frequency – as rapid or slow, and beats is shorter. A sluggish pulse is the consistency – as hard or soft. The pulse opposite of a quick pulse and a medium may thus be constant or varied. A constant pulse, in this regard, is of the average speed pulse remains absolutely unaltered, i.e., it between the quick and the sluggish pulse. is smooth and even in respect of all the above-mentioned features. If the pulse Consistency (Elasticity) remains constant in any of the five features, The vessel wall may be soft, hard or it is known as being constant in that medium. A soft pulse is one which is easily particular feature, i.e., constant in strength compressed (with the fingers) while a hard or rate. Similarly, a pulse which is variable pulse is the opposite of a soft pulse. A may vary in only one or two features of the medium pulse in this respect is the average pulse. between the two. Regularity Fullness (Volume) An irregular pulse may be regularly The pulse may be full, empty or medium. A irregular or irregularly irregular. A regular full pulse is one which feels as if the artery is irregularity is the one which is repeated in full of blood. An empty pulse feels the a systematic manner. The irregularity is opposite of the full pulse and a medium simple when it pertains to a single feature

37 Traditional Medicine in Asia of the pulse. It is complex when more than concomitants of a healthy life, and (ii) one feature is involved, e.g., the pulse Subsidiary, which are not so necessary. shows two different types of irregularities but each one is so repeated that both Effects on the pulse of factors inimical to irregularities form a single cycle of a regular the body are: complex irregularity. An irregularly irregular z Temperament: The effects of various pulse is the converse of the above. abnormal temperaments have already been described. Rhythm z Compression of the vessel: This The rhythm of the pulse is the time relation changes the form of the pulse by between the two periods of movement and suppressing the strength and thus the two periods of rest. When these making it inconstant. When the relations are not perceived, the rhythm is pressure is overwhelming the pulse taken to be the relation between the period becomes irregular and arrhythmic. of rise and the period of rest in two The compression may or may not be consecutive pulse beats. In short, the from an inflammatory mass. period of movement should be compared z Strength: Dispersal of strength makes with the period of rest. The pulse may thus the pulse weak, as in severe pain, and be eurhythmic or dysrhythmic. psychological factors also cause severe dispersal. Dysrhythmic pulse is of three varieties: z Pararhythmic, in which the rhythm of Urine a child’s pulse is like that of the pulse of a young man; The following conditions have to be z Hetrorhythmic, in which the rhythm of observed so that the information derived a child’s pulse corresponds to that of out of it is reliable. The specimen should an old man’s pulse; be of overnight urine. Urine should be z Etrhythmic, in which the rhythm is so collected in a clear and colourless bottle in utterly abnormal that it does not the morning on empty stomach and not correspond to the rhythm of any age. retained for too long after collection. Marked deviations of rhythm indicate The individual should not have used gross derangement in the body. diuretics or any sustenances which colour the urine. Undue mental and physical The factors which govern the pulse are of exertions should be avoided as these too two types: colour the urine, e.g., fasting, lack of sleep, z Intrinsic factors: These are of a fatigue, hunger and outbursts of anger general type and are fundamentally make the urine red or yellow. Coitus gives responsible for the formation of pulse a marked oily appearance to the urine. and are thus known as the consti- Vomiting, diarrhoea and polyuria also tutional factors; change its colour and density. In infants z Extrinsic factors: Although these are and children, urine does not give any not directly concerned with the reliable indication because milk feeding formation of the pulse, they do produce hides the proper colour and consistency changes in it and are thus, (i) Absolute of urine. Also, their phlegmatic nature as those which are necessary tends to hold back the pigments and

38 Unani medicine excretes them in a smaller quantity. Since indicates jaundice, (ii) Quality – bubbles children are relatively weaker and more being large, coarse, fine or small. Coarse delicate and sleep longer than adults, their foam indicates that the eliminated matter urinary findings are apt to be misleading. is viscid, (iii) Quantity – excess of foam It is only when the examination is points to excess of reeh, (iv) Persistence of carried out with due observance of the froth shows that the eliminated matter is above-mentioned rules that it provides viscid. Increased viscosity of urine is a bad helpful indications. Let it be known that sign in kidney disease since it shows urine gives direct information only about abnormal phlegm or sauda is present in the functional condition of the liver, urinary the system, or this organ has become organs and the vascular system, and it is unduly cold in temperament. through these findings that the functional state of other organs is also learnt. Urine Odour examination is a particularly reliable test Urine of sick persons never has the same of the functional efficiency of the liver, odour as that of healthy persons. If the urine especially of its convex part. is odourless, it points to either a cold The points to be noted about urine are temperament or excessive immaturity of colour, density, turbidity or transparency, humours. sediment, quantity, odour and froth. Colour: The various shades of colour Quantity observed by the unaided eye, i.e., white, Scanty urine means impairment of vitality. black and the intermediate shade. If urine is scanty in spite of taking adequate Density: The thickness and thinness of fluids it is likely to be due to excessive urine. Density is different from the turbidity perspiration or diarrhoea. The passage of and transparency of urine. Thick urine may a large quantity of urine is a sign of early be clear like the white of an egg, fish glue recovery, especially if the urine is pale and or olive oil. Sometimes it is thin and yet looks is being passed freely. like turbid water. Urine becomes turbid from the suspension of dark-coloured particles. Mature urine (normal for health) Transparency: This is the opposite of Mature urine is of moderate density and turbidity. Turbidity differs from sediment. In pale yellow in colour. If there is sediment, it turbidity the particles are intimately mixed is of laudable type as described above, with urine while the sediment is quite namely, white, smooth, light and moderate distinct and separate from the liquid part smell, i.e., free from malodour but not of urine. Colour is the result of dissolved totally without smell. particles while turbidity is due to suspended particles. Urine at different age periods Sediment: Refers to the deposit and During infancy urine tends to be white also to the suspension of material denser because of milk feeding and moisture in than usual, i.e., it refers to the deposited the temperament. In childhood urine is as well as the suspended matter. thick, viscid and inclined to be excessively Froth: This is due to the admixture of frothy. At maturity it is yellowish and of reeh in the liquid urine during micturition. moderate density. In middle age it is pale The points to be noted about froth are and watery but may, at times, become thick (i) Colour – dark or orange-coloured froth from the elimination of waste matter. In old

39 Traditional Medicine in Asia

age urine is pale, watery and of low density. or irritating humour expelled by the liver If it becomes dense it points to stone into the neighbouring organs being hurried formation. out with the stools.

Stools Colour Stools are normally of faint yellow colour. Quantity When they are a darker shade of yellow then This is judged by taking into consideration there is excess of bile. Stools which are pale the amount of food consumed. Large stools indicate defective digestion and lack of indicate abundance of humours while scanty maturation. White stools denote obstruction stools their deficiency. Stools are retained in the bile duct and jaundice. If stools contain through obstruction in the caccum, colon offensive white pus, it is likely to be from or small intestine as a prelude to colic. rupture of an abscess. Stools resembling pus Sometimes the stools may be scanty due to are often passed by healthy persons of weakness of the expulsive faculty. sedentary habits and those who have given up exercise. These stools are not bad as they Consistency indicate purification and elimination of the Liquid stools point to indigestion or body rendered sluggish from lack of obstruction. Weakness and obstruction of exercise, as mentioned in the section on the messentric vessels produce liquid urine. Deep yellow stools passed at the stools by interfering with the absorption height of an illness are a sign of good of fluid into the portal vein. Sometimes maturation. However, these stools may be catarrh produces liquid stools. Laxatives a warning of the illness having got worse. also have a similar effect. Viscid stools are Black stools are generally due to excessive a sign of wasting but the stools then are combustion or maturation. Sometimes the foul smelling. When stools are not foul black colour is due to the intake of coloured smelling they indicate excessive quantity substances or wine having helped in of some abnormal and viscid humour. eliminating sauda. The worst type of black Sometimes viscid stools result from the stool is the one which has been excessively presence of some mucilaginous matter in burnt. This type of stool is, however, not only the food which, because of excessive heat, black but has acidity and putrefaction as has not been digested properly. Frothy revealed by the appearance of froth on its stools result from excessive heat or the contact with the ground. Such acidity is bad, excess of reeh. Stools become dry from whether in stools or vomit. These stools are exhausting illness or strenuous work also shiny. However, black stools which arise causing dispersion. Dry stools are also from destruction from moisture and passed during polyuria and in cases of excessive dispersion instead of ending in excessive heat in the body. Dry food and death have good prognosis. Green and also make the stools dry. bluish stools indicate failure of innate heat. Hard and dry stools with mucus Stools of unusual colours are unhealthy. indicate delay in the passage of stools or lack of irritable bile. When there is no Froth evidence of delay in bowels and no sign of Stools which, instead of being firm and excessive mucus, the cause is likely to be compact, are puffed up like cow dung are the presence of some thin purulent material a sign of reeh.

40 Unani medicine

Time The Unani system If stools are passed on quickly, there is likely to be some disturbance such as excess of considers that food and bile or weakness of the retentive faculty. drinks taken as nutrients When there is a delay in the passage of constitute the building stools there is either weak digestion, cold material of the body, temperament of the intestines or excess of including the humours. moisture.

Flatus Stools are passed noisily with the air is polluted, indoors should be preferred. elimination of wind. The best type of air is that which is pure, clean, and free of vapours from ponds, Other means of diagnoses ditches, bamboo fields, water-logged areas In addition to the above, other conventional and vegetable fields, especially of cabbage methods of diagnosis such as inspection, and herb-rockets. It should not be polluted palpation, percussion and auscultation with vapour arising from the dense have also been used by Unani physicians. overgrowth of , such as yew-trees, Regular case history of the patient is and figs. It is also essential that recorded and maintained as is evident from air should be free from pollution with foul the books of Rhazes and Avicenna. gases. Good air should be open to fresh breeze and it should come from the plains Preservation of Health and mountains. It should not be confined to pits and depressions where it warms up Definition of health quickly by the rising sun and cools down Health is a state in which the temperament immediately after sunset. Air which is and structure of the human body are such surrounded by recently painted or plastered that all its functions are carried out in a walls is not fresh. Air is not healthy if it correct and whole manner. produces choking or discomfort. The Unani Tibb recognizes the influence of surroundings and ecological conditions Food and Drink on the state of health. It has laid down six Avicenna was the first to observe that dirt essentials for the prevention of disease. and polluted water were carriers of disease These essentials are: and emphasized the need for keeping water free from all impurities. Food and drink after Air being taken by mouth affect the body by Avicenna, the famous Unani physician, their (i) Quality, (ii) Elementary constitution, says that the change of environment relieves and (iii) Essence. The Unani system the patient of many diseases. He has also considers that food and drinks taken as emphasized the need for open, airy houses nutrients constitute the building material of with proper ventilation, playgrounds and the body, including the humours. gardens. Air is deemed fresh when it is Therefore, the selection of foods for general free from pollution with smoke and vapour. nutrition and in correcting imbalances It should be free and open and not forms the core of the Unani system of enclosed by walls or under cover. If outside .

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Bodily Movement and Repose the excessive flow of excretions promoted To maintain perfect health and a trim body, by activity. Sleep takes up the digestion and exercise and rest are essential. All forms of maturation of food and converts it into activity – whether vigorous, prolonged, mild blood. Wakefulness has the opposite effect or slow – produce heat in varying degrees of sleep. When it is excessive it disturbs the but moderately vigorous activity differs from brain by producing dryness and weakness prolonged mild and slow activity in that it and thus causes confusion and also dulls produces more heat and less dispersion. the nervous and mental faculties and On the other hand, prolonged activity, even makes the head heavy. Wakefulness though mild, produces greater dispersion increases the desire for food and stimulates rather than heat. Prolonged activity of any appetite by dispersing the waste. It, kind leads to dispersion of the innate heat however, impairs digestion by dissipating and thus produces cold and dryness in the the strength of faculties. Sleep which is system. The presence of some additional restless and disturbed is harmful. factors may hinder or enhance the effect Evacuation and Retention of the activity. Rest is always cooling and moistening. It is cooling because there is Natural means of excretion are , no excitation of heat and there is an inward diaphoresis, vomiting, faeces, excretion collection and aggregation of matter which through uterus in the form of menstruation, suppresses the heat. It is moistening etc. Proper and normal functioning of the because it hinders the proper disposal of excretory process must be ensured in order wastes. to maintain perfect health.

Psychic Movement and Repose Curative Treatment

Unani physicians maintain that certain Definition of Disease diseases like hysteria and mental disorders are caused, in most cases, by emotional Disease is an abnormal state of the human strain and maladjustment and therefore, body which, primarily and independently while dealing with such cases, these factors but not secondarily, disturbs normal are taken into account. The curative effect functions. Disease may thus be a disorder of music, pleasant company and beautiful of temperament or of structure. scenery is also recognized by Unani Stages of Diseases physicians. A disease generally has four stages, viz., Sleep and Wakefulness onset, increment, acme and decline. Normal slumber and wakefulness are Stages of onset and acme are not just the essential for health. Sleep resembles rest beginning and the end of disease, but while wakefulness is akin to activity. Sleep definite periods of onset and acme, during directs the innate heat inwards and which special rules of management have strengthens the physical faculty. It weakens to be observed. the nervous faculty by relaxing and Onset moistening the passage of impulses and by making the vital force dense by stopping The stage when the disease has just dispersion produced by wake-fulness. appeared, remains stationary and does not Sleep removes all types of fatigue and stops advance to any appreciable extent.

42 Unani medicine

Increment diseases caused by sauda and painful The stage during which the disease goes disease of the kidneys and uterus. on increasing until it becomes quite severe. Unani medicine has the following modes of treating an ailment, depending Acme upon the nature of the ailment and its The stage during which the disease reaches cause: its height and remains stationary in all Regimental Therapy respects. The Unani physician attempts to use simple Decline physical means to cure a disease, but for The stage during which the disease begins certain specific and complicated diseases to subside and with the passage of time he applies special techniques, some of starts decreasing in intensity. which are as follows: (a) Venesection Transmission of Disease z To bring down hypertension. Disease can be transmitted from one z Stimulation of metabolism. person to another in the following manner: z Correction of hot material in Contagion occurs in leprosy, smallpox, temperament. epidemic fever and scabies. Contagion (b) Cupping: Cupping purifies the skin occurs more frequently in persons living in and underlying tissues better than congested areas or in the direction of the venesection. Since cupping removes wind from infected places. only thin blood, it is of little use in robust Heredity is found in baldness, gout, persons whose blood is generally leucoderma, consumption and leprosy. thicker and more difficult to draw. Racial transmission occurs particularly There are two types of cupping – dry in certain groups of persons. cupping and wet cupping. Regional transmission is endemic to (c) Sweating: Hot fomentation (dry and certain regions. wet) bath with warm water, massage and keeping the patient in a room and Prognosis of Diseases blowing hot air are some of the A disease is curable when there is nothing methods of diaphoresis. to hinder efficient treatment. A disease is (d) Diuresis: This method is used in cases easier to cure if the age, temperament and of diseases of the heart, lungs and liver. season are favourable. If these factors are (e) Turkish Bath: Hot bath is generally adverse, the case would be different applied for curing diseases like because, under certain conditions the paralysis and muscular wasting, after cause of disease must be extraordinarily massage. strong and thus more difficult to eradicate. (f) Massage: Soft massage is a sedative It must be remembered that some diseases and a relaxant. Dry and hard massage may change into new ones or disappear is a deodorant. Massage with oil completely. This is a good sign. Certain relaxes the muscles and softens the diseases cure some other disease, e.g., skin. quartan fever frequently cures epilepsy, (g) Counter Irritant: For providing relief arthritis, scabies and various spasmodic in pain, burning sensation and conditions. Bleeding from piles benefits irritation.

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(h) Cauterization: By this, the pathogenic and quantity of food. Many books are matters which are attached to some available on this subject in Unani Tibb. structures are removed or resolved. It is applied (i) To prevent the spread of Pharmacotherapy destructive lesions, (ii) To strengthen Natural drugs like plants, minerals and of organs which have become cold in animal origin are widely used when temperament, (iii) To remove putre- compared to synthetic ones used in modern factive matters which are firmly pharmacy. adherent to the tissues, and (iv) to arrest (a) State of drugs: Drugs having states haemorrhage. opposite to those present in the disease (i) Purgatives: Purgatives and laxatives are used. are widely used by Unani physicians. (b) Drugs Temperament: It is supposed that This method has a resolving, anti- drugs have their own tempera-ment spasmodic and detoxicating effect. due to their special constituents. Some (j) Vomiting: Emetics are used in certain drugs are composed of ingre-dients cases for relief. having the opposite qualities, one (k) Exercise: Physical exercise has great quality acting in a way contrary to the importance in the treatment of certain other, and these qualities are diseases as well as in the maintenance accommodated in two different parts of the healthy condition of an of the drugs. Ingredients possessing individual. Unani physicians have laid special actions are called active down rules regarding hard, moderate principles of the drugs. This theory of and light exercises and have also temperaments of the drugs is based on indicated the timings and conditions for analogy and careful experiments. various physical exercises. (c) Potency of drugs: Drugs are graded (l) Leeching: This is a unique method. into four degrees according to their Application of is better than potency. cupping in drawing the blood from (d) Mode of Action: The mechanism or deeper tissues. Certain conditions have mode of action of a drug can be been laid down for applying this explained only partially. Unani method. Leeches should be collected, physicians have tried to explain this as preferably a day earlier. They should be follows: held upside down to empty the z The direct action of a drug is the stomach and sponged clean of the result of its physical or acquired dirty viscid slime. Leeches with large characters; heads and black, grey or green colour z Drugs mainly act by heat, should be avoided. The application of coldness, moisture or dryness; leeches is most useful in the treatment z Some of the drugs have peculiar of skin diseases such as favus, characteristics, which influence the ringworm, freckles and mole. body when these drugs are administered. Dietotherapy (e) Division of drugs according to quality: Unani medicine lays great stress on treating z First group – This group contains certain ailments by the administration of drugs with a hot temperament such specific diets or by regulating the quality as heat-producing drugs.

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z Second group – This group are compounded for the following contains cold drugs like refrige- purposes: rants, repellants and anaesthetics. z To potentiate the drug’s effect z Third group – Comprises moist (synergism); drugs, lubricants, etc. z To decrease the harmful or z Fourth group – These are drugs excessive effect (Antagonism); like drying agents, astringents and z For sharp diffusion of the drug; obstruents, etc. z For slow diffusion of the drug; (f) Use of Coctive and Purgative: Coctives z For slow preservation of active are used to prepare the matter for principles; excretion through purging or other z To increase the quantity of a drug. means of excretion. This is used (k) Substitute of Drugs: Rhazes (920 AD) particularly for treating chronic or has compiled a treatise titled, Miquala obstinate diseases. This method has no Fil-Abdal- Il Adviyah-Fit-Tibb- Wal- Ilaj, parallel in any other system. on the subject of medicinal substitute (g) Dosage and Timings: While deter- wherein he has described the laws of mining the dosage of a drug, factors selection of substitutes of a drug and like temperament and potency of has mentioned substitutes of 122 single drugs, temperament and age of the drugs. patient, nature of disease, severity of disease and route of drug are kept in Unani physicians were pioneers in mind. High-potency drugs or strong surgery and had developed their own purgatives and emetics are avoided in instruments and techniques. Abul Qasim summer and severe winter. Different Zahravi wrote a book entitled ‘Al-Tasrif’ on types of treatment are prescribed for this subject. different stages of the same disease. The general principles of Al-Qanon Some drugs are used when the could equip medicine with the basic stomach is empty and some are used principles of science in the historical after meals. perspective, offer education to masses in (h) Route of drug use: In addition to oral the preservation of health and the cure of drugs, Unani physicians also diseases, serve as an introductory course administer drugs through huqna, in the bedside techniques of diagnosis and abzan, farzaja, shiaf, zimad and tila. treatment, and act as a key to the study of (i) Forms and shapes of drugs: Powders, Unani Tibb for research. tablets, decoctions, infusions distillates, The various systems, whether Eastern jawarish, majoon, sharbat, khamee- or Western, merely represent different rajat, lavooq and perfumes, etc., are approaches to medical science as used to achieve the desired effect. practised in different ages and in different (j) Compounding and correction of parts of the world. The aim of all systems is harmful-effect drugs: The harmful the maintenance of health and prevention effects are either corrected by simple of disease. Anything of value in them methods or by compounding with should be utilized for the benefit of other drugs, e.g., frying in oil decreases humanity as a whole without any the irritant effect of the drugs. Drugs reservation.

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References

1. Ghulam Jilani, Mukhzanul Jawaher (). 1923. Tibbi Kutubkhana. Lahore. 2. Ghulam Hussain Kantoori – Avicenna. Al Qanoon, Vol. I–V (Urdu). 1930. Neval Kishore Press. Lucknow. 3. Gruner O.C., Treatise on of Avicenna. 1930. Luzac and Company. London. 4. Kabiruddin Mohammed. Kulliyath I Qanoon (Urdu translation). Canon of Medicine Vol. I. 1930. Karol Bagh. Delhi. 5. Shah, M.H. Avicenna Kuliyath e Qanoon (English), The General Principles of Avicenna’s Canon of Medicine. 1966. Naveed Clinic. Karachi.

46 Traditional system of medicine in Indonesia

Traditional system of medicine in Indonesia Lestari Handayani, Haryadi Suparto and Agus Suprapto

Introduction very simple to sophisticated ones. Most of these are related to the local culture, which efore 1987, traditional medicine had makes it a little difficult for the outsider to Bno place in any formal health system in understand them. A plant, animal, mineral Indonesia. However, in 1988, in order to or an intangible like metaphysics, may be achieve greater equity in health used for healing. The tool/instrument used development, traditional medicine was may be very sophisticated like laser, or declared as an area for launching a potential simple, like a wooden rod. Alternatively, development programme. Traditional there may be no tool at all, and the healer herbal medicine and health care may simply use mental concentration. The practitioners, who have developed in line with process could involve chemistry, community needs, are to provide the mechanics, electricity and psychology/ alternative health services. Indigenous metaphysics. The route of administration knowledge and healing techniques, herbal could be the mouth, nostril, skin, vagina, medicines and traditional practitioners are rectum, etc. Usually, a traditional all very popular and familiar in the practitioner/healer uses different community, because they are easily usable combinations of categories, e.g., to treat and valuable, and have been proved safe a bone fracture, a bone healer uses a empirically. In 1995, a rule which regulates mechanical bandage, oil mixed with traditional medicine and healers who and inner power (concentration). There are contribute to health care, was laid down no strict, standard procedures of treatment by the Ministry of Health (MOH).(1) because of the many factors to be Acupuncture, adopted from China’s considered in the holistic approach. traditional medicine system, was integrated Subjectivity plays a major role in the into the national health system in November selection of the method of healing. The 1996. This rule has streng-thened the role methodology of testing traditional of traditional medicine and practitioners medicines should be adjusted to the within the country’s health system. philosophy on which they are based, such Indonesian traditional medicine uses as the holistic approach, the concept of many terms and categories, ranging from equilibrium or deep feeling. In such cases,

47 Traditional Medicine in Asia

promote safe and effective traditional Traditional medicines are health care, the Government will provide continuously being developed resources for research on traditional and used by the community. medicine. Government and private enterprises have made several Traditional Practices Using efforts to develop jamu as modern therapy (physiotherapy). In general, traditional medicine is called jamu (originating from the Javanese language) throughout Indonesia. Jamu, as indigenous Indonesian traditional scientific methods like statistical probability medicine, was practised in the country and multivariate analysis, the use of centuries ago and has been passed down sensitive instruments like Kirlian from generation to generation for purposes photography, the aura camera and other of health promotion, maintenance and electronic devices, are recommended. A treatment.(2) Jamu received a blow under methodology to evaluate traditional colonial rule, so that today the middle and medicines is yet to be developed. However, upper classes are no longer interested in the profitability or otherwise of traditional using traditional medicines. These people medicine can be judged by its impact on have greater faith in and use only modern the community. medicine; jamu is considered appropriate This paper will take up specific case only for poor people. This is evidenced by studies because the methods of different the fact that till recently, the national health local healers cannot be generalized. system was exclusively using modern Information was obtained through several medicines. means: observation, interviews, and However, though formally not secondary data from literature. This article acceptable, traditional medicines are will concentrate on traditional medicine continuously being developed and used by based on herbs, not because the other the community. Recently, with the call of systems are not important, but because “back to nature”, both Government and they have already been included in the private enterprises have made several formal health programme and therefore efforts to develop jamu so that it can be more information is available on them. The used as modern therapy (physiotherapy). regulations regarding traditional herbal Implicit in this is the assumption that medicine, especially for industries, are well phytopharmacology can be used in formal established—those dealing with standards health systems. The development of of production and the procedure for phytopharmacology would focus on acquiring a licence. These regulations were certain herbal medicines. Such traditional laid down by the MOH via the Directorate medicines are effective for specific diseases General of Food and Drug Control. The that are prevalent among the population, regulation pertaining to traditional healers and are the only alternative medicines for (alternative healing), however, concerns certain diseases. They are also predicted only the license for practice, which is given to have a therapeutic effect in certain by a district or a provincial attorney.(1) To diseases. For the purposes of phyto-

48 Traditional system of medicine in Indonesia pharmacology, priority is being given to consumes special jamu. Also, a teenage herbal medicines which can cure diseases; girl is not allowed to step on animal jamu focuses more on health maintenance, droppings, as this is believed to give the promotion and rehabilitation.(2,3) genitals a bad odour. The jamu that is Traditional medicine can thus be consumed every day is provided by the categorized into two groups, i.e., jamu and mother. This consists of water-extracted phytopharmacology. The next section deals kunci (Kaempferia pandurata), exclusively with jamu, which is part of (Curcuma domestica), and sirih (Piper indigenous Indonesian medicine. Phyto- betle). Jamu made in home industries is pharmacy is not discussed here as it bought for teenage girls, to be taken twice belongs to the realm of modern medicine. a week as a aid (i.e., for a slim body and good health, good skin, and to fight Jamu and Indonesian Culture body odour). The use of jamu is a part and parcel of The day of marriage is a special day Indonesian culture. It is said that jamu is for the bride. A month before the marriage akin to a daily need for a section of people, ceremony, the bride is given a both in urban and rural areas, where jamus comprehensive body care treatment are easily available. To understand the role consisting of lulur and cool powder made of jamu in the community’s daily life, we from rice and jasmine . The present an example of a custom of the treatment is meant to make the skin Maduranesea women in producing and smooth and shiny. A bride is not allowed using jamu.(4,5) to drink too much and is advised to have water-extracted jamu as a substitute so that Case 1 her body smells fresh and excessive It is culturally accepted that in daily living, perspiration is reduced. In addition, she women consume more jamus than men. must consume jamu rapat (vagina- Women are especially particular about constricting jamu), which is intended to using jamu, such behaviour being culturally constrict the vagina and reduce excessive institutionalized within the community. vaginal discharge, so that she can satisfy Maduranese women are fanatical about her husband on their first night. A consuming jamu as reflected in the motto: bridegroom should prepare himself by “Better to not have a meal than not consuming jamu that serves as a sexual consume jamu”. Madura’s tradition of stimulant, but his preparation is not as using jamu is intrinsically linked with the elaborate as that required for a bride. human life-cycle. Thus, the consumption Married women, too, follow the of jamu is adjusted according to the phases tradition of consuming jamu to keep their of life of a woman. bodies fit to serve their husbands. This is Mothers encourage their daughters to done voluntarily as proof of their use jamus for their health. Girls are started submission to their beloved husbands. For on jamu at the time of menarche. During body care, they routinely use jamu, either the menarche, a girl gets special treatment; made at home or bought from a kiosk she bathes with aroma and lulurb and then near the house. Every day, they prepare

a Madura is an island located north-east of Java. b Lulur is a compound paste, used for lubrication.

49 Traditional Medicine in Asia water-extracted jamu made from kemangi consumed sequentially, in accordance with ( basilicum), kunci and sirih to the post-pregnancy convalescence keep the body smelling fresh and to prevent process. For the first 20 days, jamu is taken leucorrhoea (excessive vaginal discharge). to remove blood residue and mucus from To prepare for sex, they take jamu sari the uterus. Subsequently, jamu is used for rapat, which is available at kiosks. It can restoring the uterus and abdomen to their contain from 10–40 jamu materials. former size, and for relieving fatigue. The Mondays and Thursdays are special days mother takes various kinds of food to for couples: there is a belief that having enhance the production of breast milk. sexual intercourse in these days is ibadah,c These include vegetables, katu (Sauropus and that the reward awaiting them is as androgynus) and different varieties glorious as that merited by a killer of 40 of beans. Spicy foods, ice and foods with a disbelievers and a thousand demons. To high water content are avoided. effectively constrict the vaginal opening and The child of a lactating mother using lubricate the vagina, jamu is applied jamu may suffer from constipation, and his externally or a jamu stick is inserted into stool may be dark and have a bad odour. the vagina just before intercourse to absorb This is believed to indicate good health, the the cervical mucus. In order to enhance assumption being that the baby is thus sexual potency and relieve fatigue, the getting rid of harmful abdominal wastes. husband takes jamu selokarang, This continues for around a month, till the supplemented with eggs and honey. To time the mother stops taking jamu. indicate that she is ready, the wife adorns Jamu is also used for the spacing of the bed with jasmines and lights some births. Most mothers in Sumenep take fragrant . jamu pills made at home. These contain a Special care is taken during pregnancy, small amount of lime encased in tamarind which can be categorized into early and (Tamarindus indica) flesh. About five to advanced. In the early stages of seven such pills are taken as a single dose pregnancy, the woman uses jamu anton after each menstruation. According to a muda. After six months, jamu cabe puyang herbalist, this method is quite effective. is used to relieve fatigue and pain. To Though they do not use modern hasten delivery, the woman should take contraceptive methods, each couple in oil supplemented with raw egg Sumenep has only one or two children. In yolk. Some also drink the water of green order to treat primary or secondary . Finally, they take jamu that serves amenorrhoea, while avoiding pregnancy at as a stimulant for lactation in order to the same time, women consume “hot jamu” prepare for breastfeeding. containing , pepper, cabe jamu (Piper Postnatally, the mother uses certain retrofractum), , tamarind flesh and postnatal jamus, packages of which can other substances. To overcome infertility, be ordered before delivery. Such jamu is women use “cool jamu”, which contains taken from the first day after delivery upto beluntas ( indica), sirih (Piper day 35 or 40. The package consists of betle), trawas (Litsea odorifera) leaves and many kinds of jamus, which should be 10–20 other substances.

c Ibadah signifies good deeds in the eyes of Allah

50 Traditional system of medicine in Indonesia

Provision of Jamu red sugar (traditional sugar) as well as The Maduranese customs, thus, consist of temulawak (Curcuma xanthorrhiza). the use of two types of jamu: (i) That which Apart from restoring health, jamu is is home-made, bought from the jamu also used for certain illnesses and health peddler (jamu gendong), or from problems, which are bound to afflict a industries, and (ii) That provided by family member at some time or the other. herbalists. As most of the Indonesian A mother is expected to provide at least population resides in the island of Java, the first aid in such situations. The disorders jamus discussed here are mostly those used that can be handled by mothers are mild by the people in Java. ailments. A common cold with symptoms of a running nose, mild cough and fever Home-made Jamu can be treated with jamu made of According to Javanese custom, it is materials taken from the kitchen. Fever traditionally the mother who is responsible resulting from infection is commonly for looking after the health of the family treated with jamu made from turmeric members, especially the children. This juice, or water extracted from practice is well-entrenched, especially leaves. Crushed onion mixed with among traditional folk, as is evident in the kajuputi (Leucodedron leacodendra) oil rural areas. A mother is expected to know or coconut oil is commonly applied to how to make simple jamu for the children with fever. Febrile convulsion is maintenance of the health of the family prevented by a compound containing members and for purposes of first aid. sangket (Moschosma poly-stachyum) These skills are generally acquired without leaves. Children with a poor appetite are any special training. Women learn and forcibly given temu ireng (Curcuma practise making jamu by observing others aeruginosa), which is very bitter. A paste who make it, as well as by gathering of heated castor leaves is applied on the information from neighbours. In addition, abdomen to relieve abdominal disorders they may hone their knowledge and skills (colic and dyspepsia), while chewing through a programme called TOGA (family young guava leaves is effective in treating 6, 7 herb garden). Due to the attention of the diarrhoea. Government in this matter, TOGA progra- A jamu drink like beras kencur, which mmes have spread over large areas of the is made from finely pounded rice and country. The programme recommends that kencur (Kaempferia galanga), tamarind families cultivate herbs in their gardens or flesh and red sugar, together with the d yards to have a source of fresh herbs which lubricating bobok beras kencur, helps in are ready for use.(6) reducing the oedema and pain caused by 7 Within a family, the tradition of using a sprain. Rheumatic pain can be treated jamu is introduced at a young age. Families by rubbing the painful area with finely commonly use a health drink (roborantia) pounded ginger. Rubbing castor sap or to promote good health and familiarize the papaya leaves, kamboja ( members with jamu. An example is sinom, acuminata) or patah tulang (Pedilanthus which is made from young leaves of the pringlai Robins) sap on a fresh cut/wound 6 tamarind, supplemented with turmeric and can provide immediate relief.

d Bobok beras kencur is a paste made from rice and kencur.

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minima), kudu (Morinda citrifolia), gempur batu (Ruellia naifera), and sembung (Blumea balsamifera).3, 6 To make jamu drinks or external medicines these herbs or spices are simply processed. The process of making jamu requires boiling, and kitchen utensils such as ceramic pots may be used. A traditional tool called lumpang or pipisan, made of stone, can be used for pounding. Jamu drinks can be made in the form of percolates (water-extracted) or concentrates of jamu materials. To obtain the essence of the raw materials, they are often cleaned and chewed. Home-made jamu is usually made when the need arises, so it is always fresh. The unused jamu is disposed of. A herbalist, preparing fresh herbal medicines in a traditional market Jamu gendong Jamu gendong is liquid jamu, which is The materials that mothers use to make stored in bottles. It is usually sold by jamu for the family members are not of many women, who carry the bottles in bamboo types. They can be obtained from the baskets slung on their backs. Jamu kitchen, and consist of spices used in gendong is cultivated extensively, and may traditional Indonesian cooking. These be seen growing in Java, Sumatra and include turmeric, ginger, kencur, kunci and Kalimantan island, in the cities, towns, or . Some fruits, like nipis lemon (Citrus remote areas. Most jamu gendong sellers aurantifolia) and onion are also used. Plants come from the Central Java province growing in the yard, garden, or rice fields— (especially Wonogiri) and make their living whether planted or growing wild—may also wandering about the country. They come be used. Fresh materials are extracted from from a low socio-economic stratum, and certain parts of plants (leaves, roots, flowers, have a low level of education, usually fruits, trunk, seeds), or from the entire plant. elementary school. Their consumers could A number of plants are deliberately cultivated be urban or rural people, who, too, are in the garden for their fruits, leaves or seeds. mostly from a similar background.7 These include papaya, guava, pares The following example from Surabaya (Momordica charantia), nipis lemon, daun city, East Java, illustrates how a jamu ungu (Pseuderthemum andersoniil), and gendong seller lives. 7, 8 pecut kuda (Stachytarpheta jamaicensis). Among the wild plants that are commonly Case 2 used are sambiloto (Andrographis Surti (a pseudonym) is a jamu gendong paniculata), tapak liman ( seller from Central Java. Twelve years ago, scaber), patikan kebo (Euphorbia hirta), she and her husband, together with their tapak dara (Vinca rosea), ciplukan (Physalis two daughters, moved to Surabaya to earn

52 Traditional system of medicine in Indonesia a living by selling jamu gendong. Surti, who tasted. The processed jamu is poured into is 40 years old, lives in a 3 m x 4 m rented several clean bottles. She uses the same room. She shares the room with her process to make other kinds of jamu. To husband, who works as a dawete seller, a make jamu pahitan,g in particular, the jamu 15-year-old daughter, and another materials are boiled in a special container daughter who is married with a three-year- but no sugar is added. In about an hour, old child. The small room has a single bed, eight kinds of jamu have been processed a simple wardrobe, a wooden rack and stored in 22 bottles. attached to the wall, a basket containing At around 6:00 a.m., Surti starts selling bottles, and a number of pockets and her jamu, covering her daily route on her plastic bags hanging on nails. In the corner bicycle. She places 14 bottles on a wooden is a small wooden table which is heaped rack at the rear of her bicycle, and another with various things, including a small radio. eight bottles in the bamboo basket, to be The room, which has a small fan, is small sold by her daughter. Her daughter, and rather dark even in the daytime, as it wearing a kabaya,h walks in another is lit only by a 25-watt bulb. A bicycle with direction, carrying the basket on her back. a wooden frame to carry bottles poised on It seems that Surti already has certain its back is also in the room. customers. Riding slowly into a lower socio- The entire family wakes up with economic dwelling complex, which she Shubuhf at about 4:30 a.m., after which visits routinely, she rings the bells as a they begin working. Surti immediately starts signal to her customers. A few mothers and preparing her cooking utensils, stove and young household attendants come out to pan to boil water. Next, she adds a quantity buy jamu. When she is sure that there are of red sugar and some white sugar to the no more buyers, she proceeds to a complex water. She then lays a mat on one side of where a group of men are busy with the room, where she prepares a number construction work. A number of workers of plastic jars, a funnel, liquid filter, dipper come forward to buy jamu and she greets and steel mortar with its pestle. them with a pleasant smile. The workers She takes jamu materials out of plastic relish the jamu. By 10:00 a.m., most of bags and jars, and places them on the floor. her bottles have been sold and she goes After the water has boiled, she prepares home. Her daughter is already there, certain materials for the jamu to be having sold all her jamu bottles as well. compounded. Sitting on a wooden Every day, Surti manages to sell 14 barstool, she processes jamu with great bottles of various kinds of jamus. Jamu skill. She adds jamu materials (there can kudu laos is believed to be good for be three to five kinds of materials), and then hypertension and for improving blood pounds them into a fine mixture. Next, she circulation; Jamu pahitan relieves the takes plastic jars and fills them with the itching caused by , parasitic sugar liquid and the pounded jamu infections and diabetes mellitus; Jamu mixture. The liquid is then stirred and cabe puyang is good for muscle stiffness

e Dawet is a kind of drink made of syrup containing small portions of boiled rice. f Shubuh is a Muslim morning prayer g Pahitan is a very bitter jamu. h Kabaya is a special traditional Javanese dress.

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from the provincial health office. Jamus Jamu industries are may be sold in the market provided that concentrated among those the seller has a registration licence from communities which have the Directorate General of Food and Drug acquired the skill of producing Control, MOH. One regulation states that jamu products must not be mixed with jamu from their ancestors and pharmaceutical chemical substances. The use it as a means of earning sale of jamus in the form of vaginal or anal their livelihood. suppositories is not allowed; and only a specified concentration of preservatives may be used in producing jamu. 1 These MOH regulations represent an effort to and fatigue; while jamu sinom refreshes promote and control the jamu industry in and cools the body; Jamu beras kencur the hope of improving the quality of jamus. improves the appetite and relieves fatigue; Big industries are capable of producing Jamu kunci suruh is helpful in cases of many forms of jamu to meet the people’s leucorrhoea or excessive vaginal discharge, requirements (e.g., extracts in the form of and jamu uyup-uyup stimulates lactation. capsules, effervescent or sugar-coated On the way home, Surti stops by a tablets and syrups). Their capital allows them jamu kiosk in the market to buy jamu to purchase modern machines for superior materials for the following day and for processing. With such resources, they can some foodstuff. Back at home, she rests provide jamu in the same form as modern for about one hour. After preparing the medicines. There is a lot of competition family lunch, she makes another jamu, to among the jamu industries, and jamu be sold at 3:00 p.m. products are advertised in the electronic (television, radio) and print media Industry-made Jamu (newspapers, magazines), and through the Both small and large-scale jamu industries distribution of leaflets. Given the large-scale are thriving in Indonesia. Many regulations production of these industries, their market pertaining to the jamu industry have been could extend to various places in the country. formulated by the Government (MOH). Small jamu industries are spread over These cover several aspects, such as the extensive areas of Indonesia. They are licence for establishing a jamu industry, concentrated among those communities recommended practices for the processing which have acquired the skill of producing of jamu, and compulsory registration of jamu from their ancestors and use it as a jamu. The industry can be categorized into means of earning their livelihood. As a big or small, depending on the amount of home industry, it contributes on the capital invested. There are just a few large economic front. Among the areas that jamu industries, mostly in Java, while small produce jamu are Madura, Wonogiri industries are scattered all over the (Central Java) and Cilacap (Central Java). country.1,4 These industries use only simple production Jamu industries must fulfil a number tools, and some have no special tools at of prerequisites so as to be able to sell their all. For the milling of raw materials, the products in the market. A person seeking producer has to hire the services of to start an industry must obtain a licence someone in the market with a milling

54 Traditional system of medicine in Indonesia machine. Some producers cannot even industrial jamu is varied, depending on the compound jamu, so they purchase the producer’s capacity to promote his compound powder, divide it into several products. Some big industries have even small packets and sell them. Often, they opened special outlets in supermarkets and also use kitchen utensils to process jamu.5 luxury malls, which cater to the middle- and Home industries produce jamu forms higher-income groups. But, as most jamu that can be readily served. The producers consumers belong to the lower economic compound jamu materials and then grind stratum, promoting techniques which are them to a fine powder. This is packed in friendly for lay people would be more plastic or paper packets and then re- popular. The same applies to the marketing packed in bigger paper packets that are system. Most industrial jamu sellers have labelled. Some are packaged very well, limited capital and vend their products in while others are simply packed. An small kiosks. Such businesses are beginning advanced method of jamu processing to thrive in dwelling complexes and comprises the production of pills, either markets. The jamu is sold at an affordable dried or moistened with honey. Some price and the products are sometimes producers pack jamu powder in capsules varied. The most popular variation is for consumers who do not like the taste of dissolved jamu mixed with egg yolk and jamu. Though very rare, some produce honey. Then there are the peripatetic jamu jamu in the form of tablets. Pills, capsules sellers like Surti, who visit residential and tablets are packed in labelled plastic complexes on carriages or bicycles, pots. Besides producing jamu to be taken complete with musical instruments. Their orally, producers also manufacture jamu products are suited to the consumer’s for external use like boboki (lubricants), needs, and have different brand names. pilisj and parem.k These three are sold in Jamu sellers serve the drink sinom, after the form of big pills or powders, which can the customer has had the jamu to be easily mixed with water. Godoganl , overcome its bitter taste. A simple way of which is compound jamu in the form of consuming jamu is by buying it at a kiosk, raw material, has to be boiled for extracting and then having it there. Jamu gendong its essence and is then taken orally. sellers also provide industrial jamu to Compound jamu godogan is packed in complement their product. labelled or unlabelled transparent plastic bags. 5 Jamu provided by herbalists The market for industrial jamu is very Herbalists include those who use local herbs large, as the culture of consuming jamu is grown in various areas of Indonesia, and already institutionalized in most of the those who use materials from outside the country. These days, industrial jamu seems country. The latter are mostly from China, to be more popular than traditionally made or Pakistan. They use jamu since it is more convenient to materials from their own countries, though consume and store. The market for some also add local materials.

i Bobok is a lubricant used on the arms and legs. j Pilis is a lubricant used on the face. k Parem is a lubricant used on the abdomen. l Godogan is jamu in the form of raw materials, the essence of which has to be extracted by boiling.

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Javanese herbalists stroking her hair, the jamu seller asks her a The Javanese community can easily buy few questions regarding her complaints, jamu from one of many traditional markets which the girl answers shyly. After skilfully almost anywhere on the island. The getting her answers, the herbalist takes a provinces of Yogyakarta and Central Java, pinch of jamu powder from the wooden which are well-known cultural centres, have boxes and jars. After completing the many traditional markets where jamu compound jamu, the herbalist hands it to peddlers sell the jamu racikan (blended the mother with some instructions on how jamu) made by them in accordance with to administer it. The mother pays her some the consumer’s needs. Basically, there are money. two types of Javanese herbalists: (i) Those Soon after, a young woman comes to who compound, prepare and sell fresh the kiosk. The two hug each other, and have jamu materials, and (ii) Those who a long, friendly chat occasionally compound and sell dried jamu materials. punctuated with laughter. They seem to be As the community has long been aware of aunt and niece. The niece also sells jamu these herbalists’ skills in compounding (jamu gendong) in other cities. She wants jamu, it uses their blended jamu for specific a stock of materials, including jamu illnesses. Yogyakarta’s case will provide an pahitan, for the next three months. She insight into their roles. notes these down on a piece of paper, and arranges to collect them the following day. Case 3 Not far from this kiosk, in a corner of A 60-year-old mother runs a small kiosk at the traditional market, many mothers in the roadside in front of Yogyakarta’s market. typical Javanese attire guard their Usually she sits calmly on a dilapidated merchandise, some of which is lying in m wooden chair and sometimes she stands in tampahs and some in bamboo baskets. her kiosk talking to prospective customers They sell fresh jamu materials and their in her warm and friendly voice. Various dried staple stock comprises various leaves, herbs lie in small containers inside radishes, varieties of lemon, something partitioned wooden boxes in the kiosk. The wrapped in banana leaves, and various materials include temulawak, mesoyi rhizomes. Some of the sellers are busy (Crytocarya massoy Kosterm), kayu legi serving their customers. A middle-aged (Glycyrrhiza glabra), adas (Foeniculum woman asks one of them for jamu for the vulgare) seeds, turmeric and temu ireng. postnatal care of her daughter. The jamu Some are stored in neatly arranged jars of seller asks when the delivery took place, various sizes on a rack attached to the wall. quickly fills a small plastic bag with certain On the floor may be seen several brown leaves, rhizomes and radishes. She also paper bags containing stocks of jamu picks up some lime and three lemons. She materials. A woman accompanied by her then explains how to clean and boil these 15-year-old daughter comes along and a materials, and tells her that their concentrate friendly conversation ensues. The woman should be given orally for postnatal care. wants to buy jamu to treat her daughter for She advises the woman not to throw away dysmenorrhoea (severe pain during the residues as they can be percolated again menstruation). Holding the girl’s hand and the following day. Lime and nipis lemon are

m Tampah is a circular and flat bamboo container.

56 Traditional system of medicine in Indonesia used as bobak perut n for postnatal care. For this, the patient has to lie down on a After the bobok has been applied, the bed in a manner that facilitates the process abdomen should be twisted with a of puncturing the abdomen, back, legs bengkung.o The mother pays and leaves. and hands. Shortly afterwards, a young mother in For the sale of compound jamu, a sin modern dress comes to buy jamu for body she charges a fee based on the price of odour. The jamu seller takes out beluntas the ingredients. This charge is higher than leaves, turmeric, tamarind leaves and some that of other traditional healers, as some red sugar and asks the lady to boil these at materials are imported from China. home. Many other buyers who purchase jamu materials without asking for Jamu based on Raw Material compounding can also be seen. Indonesia is a tropical country with forests containing thousands of small and large Chinese herbalist (sin she) plants, and several species of animals. The A sin she is a Chinese herbalist skilled in country’s natural resources, as well as its compounding jamu, as well as performing cultural and ethnic variety, have had an acupuncture and . Usually he influence on the way traditional medicines compounds his jamu on his own, or asks are prepared. Plants (herbal medicine), the patient to make the jamu according to animals and minerals are all used in the his recipes. A sin she does not always preparation of traditional medicines. provide the jamu himself; instead, he often jots down some in Chinese on a piece of Jamu from plants (herbal medicine) paper, like a medical prescription. The Nearly all kinds of jamu produced by big customer has to buy the material from a jamu industries, small-scale home Chinese drug store. The following is a industries and herbalists are made from detailed account of how a sin she practises. medicinal plants (herbs). There are about A sin she’s practice is relatively more 940 plant species that have therapeutic formal. His name and hours are written on effects, but the jamu industry uses only a board outside his clinic. Sin she‘s practise about 200 species. In general, the plant mostly in big cities. The room in which a species used as jamu in different parts of sin she practises is like a physician’s clinic, Indonesia are the same. However, some complete with a waiting room and an areas have their own specifications in this examination room. An attendant admits regard, e.g., kayu pasak bumi (earth patients and is in charge of the adminis- wooden pike) is used only in Kalimantan. trative procedures. Examination is The jamu made by both industries and conducted according to traditional herbalists usually utilizes a number of plant Chinese medicine methods, i.e., by species; rarely is just a single plant used. anamnesis (asking about the patient’s The number of plant species used for a complaints and symptoms), and checking particular kind of jamu usually ranges from the pulse at both wrists while continuing 5–10. Certain jamus contain 30–40 with the anamnesis. Many patients are species. Home-made jamu contains just treated with acupuncture or acupressure. two to three plant species.3, 4, 6

n Bobok perut consist of abdominal lubricants. o Bengkung is a long cloth, about five metres long and 15 cm wide.

57 Traditional Medicine in Asia

Jamu from animal materials vendors or in restaurants. It is also sold in Jamu made from animal materials is not a dried form. as popular as herbal jamu. These remedies Cobra remedies are sold in kiosks along use substances from the cobra, lizard, the streets of Surabaya. The vendors, who house lizard, molluscs, earthworm, gabus know how to prepare medicines out of the fish and other creatures.9 The animal can cobra blood, bile and spinal cord, get live be captured from its natural surroundings, cobras from East Java. The preparation or procured from the markets. The trade involves the use of arak (alcohol), other in animal remedies is not flourishing as well herbs and honey. There are many cobra as that in herbal medicines. Animal consumers, as can be seen from the fact medicines may be more easily obtained that, on an average, a cobra seller can sell from Chinese drug stores than the regular up to 20 cobras a day. markets. Molluscs Lizard and house lizard Molluscs are considered a plant pest by The house lizard can be easily found in farmers as they consume the leaves of dwellings or trees while other lizards may plants rapidly. However, they can be used be found in the bushes or grass near the for the treatment of certain illnesses. For house, in a garden, or in a field. example, they can be of use in clearing the Both are used as remedies for Tinea respiratory tract of mucus (mucolytic), versicolor, fungal skin infections, eczema treating oedema, pharyngitis and and other skin problems. The medicine may haemorrhoids and as a diuretic. The be taken orally or applied externally. For transparent liquid of a mollusc, obtained external use the animal’s flesh is crushed by cutting the small pole of its shell, can be and applied to the affected area for 10– used as first aid for fresh wounds. 15 minutes, after which the skin is cleaned. Earthworms For oral use, the lizard is baked until it is charred black, ground to a powder, mixed Earthworms loosen the soil and are found with some coffee and diluted with water. in the earth in pots, yards or gardens. They are used to treat several ailments. For Cobra example, the rural population drinks the The cobra is a poisonous snake whose bite blended, dried and fried oil of the worms can be fatal. Cobras are found near to treat fever due to typhoid. Chinese drug swamps, in paddy fields, or in the stores sell dried and processed worms underbrush. Cobra remedies are well- which they claim have a beneficial effect known in the big cities of Indonesia. All on patients with breast tumours, nose parts of the snake’s body are used for polyps, headaches and hypertension. medicines. Cobra blood is believed to Earthworms are also used as diuretics. enhance the sexual potency of men. The Jamu from minerals uncooked bile and spinal cord, mixed with special herbs, are considered beneficial for Minerals are not often used as jamu. Tawas diabetes, high levels of cholesterol or uric (hydrated alumni sulfas) help relieve acid, cancer, asthma, malaria, skin body odour, while sulphur powder is problems and general physical fitness. The commonly used for treating skin diseases. cobra’s flesh is cooked and served by food In certain areas, women consume ampo,

58 Traditional system of medicine in Indonesia i.e., soil that is water-blended, then dried education, most are in elementary school and cut into slices, as it contains iron. Lime or junior high school, and some have is used as bobok, i.e., to lubricate and received no formal education at all. warm the abdomen of postnatal women.6 According to traditional perspectives, diseases may be categorized as rational Other Traditional Practices and irrational. The former are believed to People opt for traditional healing be caused by the disturbance of techniques for a variety of reasons. The homeostasis, such as an imbalance in major reasons are that they are accessible nutrition. Irrational diseases are said to be and acceptable in social, cultural and caused by mystics. Supernatural/ economic terms. The other benefits are that healers, who believe in the existence of such traditional healers make home visits, ailments, often cure the latter, as well as without charging any fixed fee. Another certain strange problems, such as the reason is the inadequacy of modern removal of nails, stones, iron and other medicine in treating certain cases, such as objects embedded in the abdomen. at an advanced stage, or irrational Traditional healers usually do not have ailments like santet or tenung.p The a special room in which to examine their community learns of the existence of patients. In fact, they do not have a name traditional healers by word of mouth, board, fixed hours or fees. Most of them though these days magazines and practise on a part-time basis, though some newspapers also carry advertisements and who are well-known do work full-time as information on the subject. traditional healers. The latter have many Traditional practitioners in Indonesia patients, which can be seen from the long have acquired their knowledge and skills queues of patients awaiting consultation. not through formal education, but from Some have in-patient facilities to their parents. Some learn while assisting complement outpatient services. A established practitioners, some of whom traditional healer often combines a number teach their skills to just one or two trusted of traditional techniques, like massage and persons. A few healers claim to be graced jamu, magic treatment and jamu, and so by wangsit,q which comes to them either on. through dreams or after performing The following section focuses on “special deeds”, such as fasting, abiding traditional healing practices that are by certain , or living in seclusion. commonly used by the community, such Many traditional healing skills, as traditional methods of bone healing, however, are mass taught through an attending to deliveries, kerikan and informal process. These include circumcision. acupressure, urut massage,r acupuncture and the skill of compounding jamu either Traditional Bone Setting for males or females. The age of the pupils Almost all ethnic groups in Indonesia have ranges from 20 to over 60 years. While traditional (TBSs), who thrive some have acquired higher levels of both in urban and rural areas. These

p Santet or tenung is believed to be an ailment caused by black magic. q Wangsit is God’s revelation. r Urut massage is a type of traditional massage to relax the muscles.

59 Traditional Medicine in Asia healers honour certain ethnic concepts in betadine, rivanol, alcohol, sterile gauze and their practice. In Java, the TBS is commonly . Patients with open fractures are referred to as sangkal putung. These referred to the local health care centre. healers can help cure any kind of complaint Some healers even have informal related to bone fracture (e.g., complete, partnerships with nurses practising in the incomplete or multiple fracture), joint local institution. dislocation, as well as muscle sprains. The The pattern of treatment used by reason why people choose TBSs is because different healers is similar. The difference they are easily accessible, both in terms of lies only in the way they express their expense and distance, as well as to avoid supernatural or magical powers, e.g., in invasive surgical procedures.10 the kind of jimat (charm), special oil or Of the traditional bone-setting special water used. The processes of techniques, some are purely traditional treatment and diagnosis are simultaneous. while others attempt to incorporate certain For example, by uttering special modern techniques.3, 10, 11 The procedure (), the healer diagnoses as well as is as follows. A specific mantras is chanted fixes the fractured bone. Joint dislocation to a patient or he is given a drink which is is managed by pressing, pulling and treated by chanting mantras. Some healers massaging the affected area. The manner use charms, like a stone or a keris.t The of handling the problem depends on patient is asked to drink water into which individual cases. the charm has been dipped. It is believed To heal a fracture, the areas around that through the medium of drinking water, the site of fracture are first massaged in the prayer or charm would help relieve the order to relax the muscles. The bone is then ailment. A TBS does not ask many repositioned and aligned correctly. This is questions. By simply observing the fracture followed by continuously massaging the and touching it physically, he identifies the area with a special oil. During the process exact problem. Many healers say that their of treatment, the patient is asked to move feelings guide them in determining the the injured part, which is then pressed specific problem and the method of again. The materials used to secure the handling it.11 This faculty of feeling is said area are hardboard paper, the stem of to be acquired through special deeds. banana leaves, bamboo or wood, though To convince the patient and her/his modern TBSs use elastic bandages. family about his diagnosis, the healer often Whatever the material used, the dressing employs a symbol. For instance, to is opened every three to four days to assess demonstrate whether or not the bone is the alignment. The patient then receives fractured, the healer feels a banana and if another massage. In-patients are given a the flesh is found to be broken, it means daily massage.11 that the bone is fractured.11 Some, however, The effectiveness of the traditional utilize modern techniques such as X-rays. healing process is judged more by the Some healers, especially those living in extent to which it meets the expectations cities, treat a fracture with modern of the patient and his/her family. techniques, medicines and materials, like Psychological support is also considered

s A mantra is a special prayer based on traditional beliefs. t Keris is a traditional Javanese weapon.

60 Traditional system of medicine in Indonesia important. A patient is considered to have tools, like bamboo knives (welat) to cut the recovered if he is able to move the injured umbilical cord. Crushed pepper leaves or part or walk, even if movement is painful kunyit together with salt is applied to the or unsteady. However, some healers define pole of the umbilicus.13 Some of the more recovery as the ability to perform in a daring TBAs go a step further to facilitate normal way. The extent of recovery may be problematic deliveries. For instance, they assessed by asking the patient to lift may push the abdomen downward in weights; if no pain is experienced, it signifies difficult cases, or grope inside the uterus recovery. to disentangle the placenta. TBAs perform special ceremonies or chant prayers Traditional Birth Attendants (mantra) during the process of delivery. Many deliveries in Indonesia are still TBAs make daily visits to the mother’s assisted by traditional birth attendants house to take care of her and the baby, for (TBAs), who may be either trained or 35–40 days after delivery. They bathe the untrained. TBAs practise under the baby, massage both the baby and the supervision of health centre personnel, mother, and also help prepare for birth namely midwives. A programme to staff ceremonies. The placenta is bathed and villages all over the country with midwives several uborampeu are made to it. It is then was launched with the aim of providing buried in front of the house, and the spot mothers access to professional help for is lit by a lamp at night. A ceremony is deliveries.12 TBAs are expected to assist performed when the dried up umbilicus is these midwives. Though the Government severed from the baby’s stomach. Such is trying to prevent the proliferation of TBAs, ceremonies are performed at every step in this is not possible as the community still the baby’s growth. Apart from taking care seems to need them. of the baby and the mother, TBAs also help Some communities prefer TBAs to in household work, like washing the baby’s midwives. One reason for this is that the clothes, preparing jamu for the mother, and TBA is one of the local people, and thus so on.13 understands the local culture and is already familiar with members of the community. Traditional Circumcision (Khitan) TBAs not only assist with deliveries, but Since most Indonesians are Muslims, also render certain other services. For circumcision is obligatory for male children. example, they take care of women all Traditional circumcision is practised widely through pregnancy and advise them about in Indonesia, the demand for it arising from the norms to be followed during this period. the belief that the prayer performed during TBAs provide jamu as well as massages to the ceremony has a healing power. It is also relieve fatigue. A special massage is done believed to have certain other advantages, to fix the foetal presentation, if necessary.(13) e.g., the child is said to experience less pain As deliveries are natural events, the and fear, and the healing process is faster. techniques used by most TBAs are similar. The skill of performing traditional They simply wait through the process of circumcision is learnt from parents or delivery, until the baby is born naturally. family members who know how to do it. To Some untrained TBAs still use traditional be a khitan practitioner, one needs to

u Uborampe are offerings.

61 Traditional Medicine in Asia perform special deeds, in accordance with One in East Java, which certain Muslim norms. These deeds include believes in traditional circumcision, has a fasting for 40 days, and going without a different custom. The khitan practitioner meal for 24 hours on the last day. The is asked to cut off a small part of the person can only drink water at the time of prepuce before the doctor or the nurse is Maghrib.v For a traditional circumcision, asked to complete the procedure. This is either the practitioner goes to his patient’s perhaps explained by the belief that it is house, or the patient comes to him. only a khitan practitioner who can The techniques used for khitan do not perform the prayers properly, so he should vary much—basically, the practitioner cuts initiate the process. the prepuce of the penis. In the purely traditional technique, the prepuce is held The Practice of Kerikan in place by a clamp of wood, bamboo or The practice of kerikan is well-entrenched tusk, and then cut with a sharp knife. No in Indonesian society, especially among the local anaesthetic or medicine is used. The people of Java. The word kerikan, which patient is merely given water before the has its roots in the Javanese language, procedure. However, nowadays most means to peel off or remove a surface layer practitioners use modern medicines and that is unwanted. Thus, kerikan is a healing tools, like scissors and modern knives. technique which consists of scraping the Antiseptics like rivanol, betadine and affected area of the body. It could be the alcohol, and materials like cotton and chest, back, abdomen, neck, arms or legs. gauze are used. A few practitioners Usually, coins and spoon-holders are used prescribe to prevent infection for scraping, complemented by the use of and analgesics to relieve pain. The herbs like onions and kajuputi oil.14 Kerikan following is an account of a traditional is commonly used as a first-aid method circumcision: during illnesses. Generally, it is quite The boy who is to go through khitan is effective in providing relief from the given a new sarong, white shirt and cap symptoms of non-infectious diseases. by his parents. After the son is ready and Traditionally, it is believed to be very effective all the preparations have been made, the for masuk angin.w Kerikan may be used practitioner begins the process. After to treat almost all people, from a one-year- chanting a special prayer, he clamps the old child to an elderly person. Kerikan can prepuce of the penis and cuts it quickly with cure children of abdominal distension, a sharp knife. The wound is dressed with cough and laboured breathing, nausea gauze. The boy then wears the sarong, shirt and vomiting, diarrhoea, and fever. Adults and cap. To prevent the wound from use kerikan to obtain relief from toothache, touching the sarong, a supporting wooden intercostal ache, chest pain, backache, frame is used, in the ventral surface of the acute oedema, insomnia, fatigue, lower abdomen. Purely traditional headache, fever and other complaints. practitioners used only prayers or mantras A family member of the patient for pain relief and recovery. performs the procedure. The scraping is

v Magrib is Muslim evening prayer (done at sunset). w Masuk angin is an illness characterized by fatigue, nausea and vomiting, headache and muscle pain. It is sometimes accompanied with fever.

62 Traditional system of medicine in Indonesia done over the affected part of the body. some areas, like Lombok, Madura and East Frequent and continuous scraping makes Java. The tools used are varied and include the skin turn a specific colour and produces a buffalo/bull horn, coconut shell and erythematous stripes. It is believed that the rubber kop. degree of redness reflects the severity of To begin with, the inside of a coconut the illness. The redder the skin, the more shell or a buffalo horn is heated, for severe the ailment. Inexplicably, the patient example, by a candle. The concave surface feels more comfortable. During the process of the shell is then applied to the skin of of kerikan, the patient does uwat.x This the affected area. Due to the negative movement would stretch the muscles, pressure, the shell sucks in the skin. The which in turn would improve blood shell is removed once the negative pressure circulation and help the body reach ceases. The process results in a circular homeostasis. All these are ways of effecting erythematous protuberance. A more a recovery.14 modern technique consists of using a kind The patient could undergo kerikan in of pump that can suck in the skin without a sitting or supine position. To enhance the the use of heat. effect of the procedure, a number of oils like coconut or kajuputi oil, or analgesic The Practice of Traditional balm are commonly used. Kerikan should Massage be done as follows. The coin should be used Massage therapy is practised everywhere in with a strong but smooth pressure. On an urban and rural areas. The therapist could average, one stripe of kerikan is produced be a male or a female, usually above the after 20–30 of scraping. A good age of 40 years. Massages can be of two tool for scraping is one that is blunt but is types, urut massage and reflexive massage. able to produce deep pressure, so that it A masseuse learns the skill either from other can reach the deeper muscles. Kerikan masseuses, by attending a course, through should be done thoroughly and trial and error, or from books. sequentially in a proper order, over the skin Urut massage is beneficial for fatigue, surface. The sequential procedure is known myalgia, cough and muscle stiffness.14 The as tapis. The direction of scraping should whole body is massaged, with the focus follow the bundle of the muscle, called turut on the affected areas. Women and children (meaning to follow) so that the target points are given massages by females and men can be located. Warm oil is commonly used by males. Urut massage includes the after kerikan. massage given by TBAs to postnatal women and babies. Fussy babies are The Practice of KOP frequently taken to TBAs for this purpose,4 The method of kop is similar to kerikan, as it is believed that fever and fussing are but the tools used are different. In kop, the caused by muscular problems. A mother skin of the affected part of the body is can ask the TBA for walik dadah.y sucked upwards to produce an erythe- Reflexive massage focuses on matous effect. This method is employed in particular points in the palm of the hand

x Uwat means writhing, which occurs because of pain, ticklishness or the sensation of heat. y Walik dadah is a massage to change the position of the uterus into one of retroflexion with the aim of preventing pregnancy.

63 Traditional Medicine in Asia and the sole of the foot. This type of A person who wants traditional timung massage, believed to have originated in care is first undressed and seated on a and China, is very popular in chair, covered with mats made of pandan Indonesia. The technique used is similar to leaves. Under the chair is a pan on a lighted that of acupuncture. While some reflexive stove. The pan contains several herbs and masseuses use their hands to give the boiling water. The steam, which contains massage, others use a special tool, like a the essence of the herbs, warms the body. wooden or a metal stick. The steaming process lasts for about half Reflexive massages can be given to an hour. The technique is often combined people of all age groups. A person can with massage. learn the methods on his own, then attempt to try them out and practise them. Therapy of Gurah Malfunctioning organs can be identified by Gurah is a therapeutic technique that uses examining certain points in the palm or special extracts of herbs to clear the nasal sole, the assumption being that specific cavity and pharynx of mucus. It is claimed points are associated with different body that gurah benefits asthma, rhinitis, parts, like the intestines, spleen, pancreas, common cold, haemoptysis and pertussis.15 heart, and so on. It is believed that reflexive The technique is believed to have originated massage can help treat all diseases, from pesantren.z Its original aim was to including infectious diseases, because it improve the quality of the voice of those who improves the immunity status of the patient. read out the Koran. However, these days According to the doctors who practise people of all kinds use the technique in many reflexive massage, this kind of massage areas of Java. According to a gurah enhances general fitness, relieves practitioner in Central Java, anybody can depression and is of benefit in other learn the technique. emotional ailments.3, 4 The gurah method is very simple. The healer instils a special liquid into the The Practice of Timung patient’s nostrils. The liquid is prepared by The technique of timung used for therapy the healer and contains certain herbs, of or body care, employs steam enriched which the common ones are Srigunggu with various herbs. Traditional timung, (Clerodendron javanicum) or Awar-awar which originated in Kalimantan, focuses (Ficus septica) leaves and turmeric. Honey especially on body care, including skin is also used. The extracts of the herbs are care and preparing the bride for marriage. diluted to a weak concentration. The Timung can be practised for the same patient lies supine with the neck bent purposes by family members at home. The backwards. The liquid is then instilled into herbs required are available in the market. the nostrils for about three to five minutes Many fitness centres in the cities offer through a funnel made of banana leaves. timung. It is claimed that besides The composition of ingredients is adjusted improving fitness, the technique also according to the patient’s condition. The relieves a number of ailments, like process heats up the nasal cavity and the common cold, rheumatic complaints, mucus flows out automatically. When the fatigue, and so on. mucus is being discharged, the patient has

z Pesantren is a place where people learn how to read the Koran, the Muslim holy book.

64 Traditional system of medicine in Indonesia to either sit up or lie on his stomach. He of magic. Many magic healers have opined remains in that position until the mucus that certain diseases are caused by stops dripping. This therapy is often something that is rationally unacceptable. combined with jamu remedies, and An ailment can result from the curse of a sometimes with massage.15 rival who has hired a black magic practitioner ( santet) to harm the Therapy based on a Religious subject. It is quite common for magic Approach healers to remove strange objects like nails, As a majority of Indonesians are Muslims, stone and iron which may be embedded therapy based on the religion of Islam is in the patient’s abdomen or some other fairly common. This approach is commonly part of the body. mistaken to be similar to a supernatural A magic healer sometimes uses certain one, as the methods are similar. In the tools as a source of magic power. A number religious approach, based on Islamic of charms are believed to possess magic teachings, the healer advises patients to power that can help in the process of perform special prayers or deeds. healing. These include the eye of finger The clients need not fulfil any special rings, a special bark called pring temu rose prerequisites to avail themselves of such (meetingros of bamboo), keris, a piece of therapy. The prayer and ibadah (deeds to cloth with Arabic letters printed on it, and come closer to God) vary depending on soil wrapped in white cloth. Only magic individual needs, particularly the kind of healers possess such articles, though some ailment. Commonly, the patient is asked give the patient a portion of it to guard him. to drink water that has been sanctified by the chanting of special prayers. Some Therapy for removal of tumours healers write Arabic letters on a plate, then Cancer is one of the most dreaded fill it with water and ask the patient to drink diseases. People seek cures from magic/ it. Other healers give the patient a piece of supernatural healers because treatment paper or cloth with Arabic letters printed involves invasive procedures and they are on it, which the patient must keep in a suspicious of modern medicine or find certain part of his/her house to guard the modern treatment unaffordable. The family. following techniques are used by healers A religious healer is usually the leader to remove tumours. (chief person) of pesantren, or men who are learned in Muslim teachings (Kyai). Case 4 Usually, he requires no training to give A traditional practitioner called “Gus” (the therapy and his capacity to heal is seen as nickname for a son of Kyai, or a man whom God’s . Such healers often help people respect) is believed to heal patients people deal with family issues arising from with his supernatural powers. Not only can health problems. In fact, some pesantren he remove tumours, he can also cure many help drug abusers and treat psychological diseases, like paralysis and psychosis. In ailments. fact, he even helps in solving problems that are not related to health. His technique for Supernatural or Magic Therapy removing tumours is totally different from As mentioned earlier, irrational diseases those used in modern medicine. Gus first are believed to be caused by some source uses a knife to cut open the tumour but,

65 Traditional Medicine in Asia later, he uses only his fingernails. The traditional healer in Tuban, East Java, excised tumour is handed over to the claims to have the ability to displace the patient. The wound is dressed with gauze tumour into a goat. Either the patient or a or cotton. No antiseptic is used. member of his family visits the healer and Gus does not charge a fee, but patients tells him about the problem. After may contribute voluntarily, for which the understanding the disease, the healer asks healer provides a box. He has many pupils the family to buy a goat and bring it to him. who learn the Koran from him and, at He performs certain ceremonies and utters certain times, they chant prayers together a mantra, after which the goat is (isthighosah). However, Gus does not slaughtered. The goat’s organs are impart his therapeutic technique to his checked to ascertain whether the patient’s pupils, though they help him in curing his disease has been transferred to the goat. patients. For example, in a case of hepatoma, the Another kind of supernatural healer is liver of the slaughtered goat would show one who is able to remove tumours without signs of hepatoma, such as a lump or a touching the patient. After registration, the change in colour. The diseased portion of patient writes out his/her complaints on a the organ should be thrown away, while piece of paper, which is handed over to the the healthy portion may be cooked and healer. The healer sends the paper back to eaten. If the cancer is in too advanced a the patient after writing (in Javanese) about stage, the healer usually admits his inability the disease, the procedure to be followed to cure it. and the fee. If a patient agrees to these recommendations, he lies down in a supine Therapy of susuk position while the healer goes up to the Susuk is one or many small rod/s, second floor of his house. The healer later commonly made of copper or gold, though comes down and gives the patient a brief some healers use diamond. The susuk is glimpse of a lump of bloody flesh, said to implanted in a certain part of the body to be the removed tumour. If the patient keep it healthy. Before a susuk is implanted, desires, he can ask a doctor for an the patient is advised to fast for two nights ultrasonographic (USG) examination. and days. But some traditional implanters Besides removing tumours, the healer feel that they themselves can take over this prescribes jamu remedies or recipes which deed. Some others do not lay down any are available in drug stores. conditions. If the person implanting the Women healers in the rural areas of East susuk is not an expert, or if certain Java use a different technique. They remove prerequisites are not fulfilled, the procedure the tumour by sucking the area with the is believed to have unexpected mouth. If the tumour has been successfully consequences, such as death. Some believe removed, the healer brings out some bloody that the untoward consequences can be flesh (supposed to be the removed tumour) prevented by rubbing kelor (Cucumis from her mouth. Such healers also provide sativus) leaves on the body of the user. complementary jamu remedies. It is said that the skill of implanting Another technique consists of susuk is acquired by performing certain displacing the tumour from the patient’s deeds, like performing ngebleng.zz The body into another creature (animal). A kind of susuk to be implanted depends on

zz In Ngebleng fasting, a person must go without food or drink, for a number of days.

66 Traditional system of medicine in Indonesia the client’s demand. The fee varies, from the stomach. The nails would be depending on the kind of metal used. The expelled from the body automatically by more expensive the metal/material, the vomiting. more potent the effect of the procedure. In Indonesia, there are many groups of The technique of implantation seems inner power practitioners, such as the Satria fairly easy. The implanter inserts the susuk Nusantara group. In fact, some have into a specific part of the body after wiping branches overseas. The major focus of the the skin and then rubbing it with pepper members of these groups is on maintaining leaves. The susuk may become less potent and improving their health; only a few utilize or lose its potency altogether if the client their expertise to treat patients. The breaks certain taboos. The presence of the respiratory exercises can also produce susuk in the body can be ascertained by supernatural powers, which lighten the body an X-ray. and make one capable of accomplishing various feats. For example, an expert Therapy using inner power becomes so light that four persons can lift Therapy with inner power is a technique him if he stands on a newspaper. One can which utilizes energy emitted by the human even see or read with his eyes closed. body. Such energy is acquired by regulating respiration or doing respiratory exercises. Conclusion With regular exercise and by abiding by a number of basic principles, one can These traditional practices of medicine are accumulate inner power and use it to treat just a few of the many currently in use in others. Inner power is said to heal several Indonesia. Several methods or techniques, diseases like diabetes, hypertension and with their variations, have not been cancer. It is also used for non-therapeutic discussed in this paper. These traditional purposes, like protecting the body from real practices stand testimony to Indonesia’s or magic assault.(16) rich cultural heritage. This type of therapy can be of the active The safety and efficacy of the techniques or passive kind. In active healing, the healer used in the traditional system of medicine uses his own inner power to treat patients, are questionable. Most of the traditional while in passive healing the patient obtains practices have not yet been studied inner power from the healer. A healer treats systematically by modern science. However, a patient without touching him. The energy it is beyond doubt that they serve a large emitted from the healer’s hands enters the portion of the Indonesian population. Any area to be treated. An expert healer is said effort to do away with such practices would to be capable of curing patients who are be unsuccessful, as these forms of health far away, with or without a medium. The services have their own markets. The medium could be a photograph, or any Indonesian Government’s effort to promote possession of the patient. For example, a and develop traditional medicine into a safe healer in Indonesia can cure a patient in and effective option is a good policy, which the US. The technique is also used for could contribute towards achieving greater curing magic ailments, like removing nails equity in health services.

67 Traditional Medicine in Asia

References

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68 Koryo system of medicine in DPR Korea

Koryo system of medicine in DPR Korea Choe Thae Sop

lthough the Koryo system of medicine compatibility, dosages and administration. Ahas some similarities with the tradi- The action and efficacy of the drugs are tional system of Chinese medicine, it is quite explained on the basis of the peculiar different from the Ayurveda, Siddha and theories of KM, while the scale of use Unani systems prevalent in India. (indication) is determined by considering the The theoretical basis of Koryo medicine symptoms or syndromes as the main target (KM) is recorded in detail in the ancient of treatment.1 medical classics of Korea.1 Hyangyakjipsongbang (85 volumes), a classic materia medica published in DPR Materia medica Korea in 1443 AD,2 contains a description of 694 kinds of plants growing in the The materia medica, the main part of the country, as well as 10,706 prescriptions medical classics published in a wooden for the treatment of 955 symptoms.3 edition in the 15th century in Korea, In the preface to the book, the author described medicines as being divided into says: “Thanks to the limpid water and three types – those derived from vegetable, beautiful mountains, my country has animal and mineral sources. unlimited resources of medicinal plants. The classification according to the But there are those who disregard their own mode of action and use is similar to that of resources out of admiration for others’ and modern medicine, and includes anti- strive to get drugs from far-away, alien pyretics, antidotes, antitussives, digestives, lands, even though they are available in astringents, diuretics, and so on. However, any quantity in their own country.” it has some additional traditional Saddened at this lamentable situation, the categories, peculiar to KM, such as interior- author stresses that for treating diseases, warming drugs, drugs for eliminating one should use medicinal plants growing dampness and drugs for regulating Ki. in one’s own country.1, 2 The description of each drug includes the forms of the various medicinal plants, Acupuncture cultivation and picking period, the parts that are used, processing methods, properties According to the existing source materials, and flavours, efficacy, scale of use, toxicity, needles made of sharpened stone were

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of acupuncture and moxibustion, as well as the theory of meridians.1,5

Clinical aspects of Koryo medicine

The medical classics published in DPR Korea before the 17th century include manuals addressing the clinical aspects, as well as systematic and specialized books on internal medicine, surgery, gynaecology, etc.1 Uyebanryuchwi,6 a comprehensive medical classic published in the country in 1445, has the value of a great encyclopaedia. The book, consisting of as many as 365 volumes, contains a compilation of the material from 153 medical classics published before the 16th century at home and abroad, and a systematic presentation of the contents, A part of the preface of Hyangyakjipsongbang, which which are divided into different was written with a writing brush in block letters in 1, 6 1443 AD. categories. Tonguibogam is a well-known classic in the form of a manual which was used for the treatment of diseases for published in 25 volumes in 1610. One several centuries.4 From the specialized section of it describes the function book on acupuncture or the sections on (physiology) and shape (anatomy) of the acupuncture in various classics, it is evident five viscera and six entrails, manifestations that acupuncture had already been of the illness connected with them, and the established as a scientific system of pathological mechanisms involved. medicine.1 The clinical section contains a detailed The general introduction to the description of the causes of various acupuncture section of Tonguibogam,(5) a symptoms and syndromes, methods of typical medical classic, describes the differentiating these, prognosis, medication methods of making needles, seasonal (use of a single medicinal plant and herbal acupuncture, the selection of acu-points, prescriptions), the therapeutic methods of application of moxibustion, acu-moxa acupuncture and moxibustion, their combination and the stimulation intensity contraindications, etc. The section on of acupuncture and moxibustion, etc. This diarrhoea alone mentions 20 syndromes, section contains a systematic description classified according to the shape of the of the circulation course of the 14 stool, the different factors that induce meridians, the 365 acu-points on each diarrhoea, the correlationship between meridian, selection of acu-points, diarrhoea and the internal organs and the indications, contraindications, application severity and duration of the illness. It

70 Koryo system of medicine in DPR Korea explains the causes and describes the symptoms and methods of treatment in detail.5 Thus, the medical classics that we have inherited from our ancestors include almost all the clinical disciplines, such as internal medicine, surgery, paediatrics, , gynaecology and ENT. These classics are easy to consult because they contain systematic classifications1,4.

Teaching of Koryo medicine

Koryo medicine is taught at the KM faculties of the medical universities, which are found in each province. The duration of the course is seven years. Koryo Diarrhoea caused by chronica colitis suffered for over 10 years was medicine is practised mainly in the General cured by moxibustion of Koryo Medicine (GHKM). The KM faculties in the country train a number of Koryo doctors annually who are In the provinces and counties, this task also conversant with modern medicine. is performed by the health administrative The textbook in use teaches the basic departments of the respective local theories of KM, acupuncture, materia governments. medica, Koryo internal medicine, surgery, Under the aegis of MOPH, GHKM gynaecology, paediatrics, ophthalmology, provides the scientific and technical ENT, etc. Each KM faculty has separate guidance for various KM health departments for each subject and specific networks.1,4 lessons are given by the respective department teachers. Koryo medicine network In the training of KM doctors, the ratio of KM to modern medicine during the total The capital and all cities have specialized course is 70 per cent to 30 per cent. KM hospitals, and all large as well as small Therefore, a graduate from the Faculty is hospitals and have KM departments. able to diagnose and treat with modern The population can receive free KM methods and medicines as well.1,4 treatment through various KM medical networks which are evenly distributed all Implementation of the Koryo over the country. These networks are system national institutions under the MOPH and the local health administration. Their The Ministry of Public Health (MOPH) has working expenses are provided for in the an administrative department for KM. This national budget. department is in charge of implementing Not a single unit of the private KM the state policy to develop KM at all levels health sector is driven by the motive of of the KM health institutions. making money.1,4

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The combination of Koryo and modern Combination of Koryo and medicine is one of the mainstays of the modern medicine in the re- health policy, whereby the State helps in education system developing KM. A six-month re-education course is It is also a manifestation of the state’s conducted in the re-education colleges of concern for providing the inhabitants with the capital city and each province. Those 1 health care of high quality. attending are the KM doctors, as well as Combination of Koryo and other doctors who graduate from the KM modern medicine in the or medical faculty and have been working university’s regular education for more than five years. system These re-education courses are free of charge, and the doctors continue to receive in KM faculties is of a their usual monthly salary throughout the seven-year duration where KM takes up 70 six months. This course enables them to per cent of the time allotted and modern consolidate their knowledge, learn about medicine systems the remaining 30 per new developments, as well as advanced cent. This enables the graduates to attain methods of KM treatment. The course a certain level of knowledge of modern covers the latest therapeutic techniques medicine required for modern methods of developed both at home and abroad. diagnosis and treatment. Greater importance is attached to modern In the KM faculty, the lectures delivered medicine for KM doctors and to KM for on the theoretical aspects of KM are just other doctors.1,4 as detailed as the expositions in the medical classics. Combination of Koryo and The students are taught the clinical modern medicine at each level of aspects of KM, including internal medicine, medical care surgery, paediatrics and gynaecology, as At all levels in the hospitals, treatment by well as the auxiliary ones, such as the modern medicine and KM is combined in Materia Medica, herbal prescriptions and a ratio of 7:3. The larger the hospital, the acupuncture. As for modern medicine, KM higher the share of the former; the smaller faculties teach basic aspects like anatomy, the hospital, the higher the share of the physiology and pathology, as well as clinical latter. In specialized KM hospitals and each ones like internal medicine, surgery, of the KM departments in other hospitals, paediatrics and gynaecology. 70 per cent of the treatment is according Unlike the KM faculty, the seven-year to KM methods and 30 per cent according course of the medical faculty gives a to modern medicine. Generally, the utility weightage of 70 per cent to modern rate of chemical drugs is higher in the medicine and 30 per cent to KM. This larger hospitals, where conditions favour system aims to enable doctors to combine their use, rather than in the smaller their treatment methods with KM methods. hospitals, especially in clinics in the rural Though KM theories are taught with areas. extreme brevity, more detailed lessons are For purposes of diagnosis, KM doctors imparted on the methods of KM treatment, adopt modern methods. No KM doctor including acupuncture and herbal uses the conventional method of diagnosing 1,4 medication. diseases (i.e., by simply feeling the pulse).

72 Koryo system of medicine in DPR Korea

Almost all KM hospitals are equipped with z To decisively enhance the quality of clinical laboratories and various diagnostic health care in the country by combining equipment, enabling KM doctors to use Koryo and modern medicine; 1 modern methods of diagnosis. z To scientifically explain the real nature of the meridians and the therapeutic Collaboration between Koryo mechanism of acupuncture; and modern medicine in z To study the components and research activities pharmacological action of various Persons in charge of research projects for medicinal plants; the modernization and rationalization of z To use medicinal plants with knowledge KM are obliged to first study the KM of their components and their influence classics on the subject of research. In on the internal organs; summing up the project, the researcher first z To use the best possible methods of gives an overview of the description in the treatment. classic, and then states the findings of his research. The State has allocated sufficient funds Such research activities are undertaken for the translation of all ancient medical to either scientifically prove or invalidate the classics, including three well-known descriptions in the classics. The lectures classics which were published in modern delivered by Professor Ranjit Roy Korean from the seventh to the nineteenth Chaudhury on the clinico-pharmaco- centuries. Today, the translated versions are logical methodologies during his visit to used extensively as reference books in DPR Korea still serve as a programmatic educational, research and medical guide for our research activities.1 activities. In order to discover the best possible National policy for development methods of treatment, the State actively of Koryo medicine encourages health workers to gather The aims of the national policy are: information on folk cures popular among z To preserve, utilize and develop the the country’s inhabitants, and to carry out national medical heritage – a major research activities to scientifically establish objective to which the State attaches the efficacy of selected cures.1,4 great importance; Clinical and basic studies for the z To actively encourage medical workers to use KM, a target facilitated by the development of drugs fact that the country has no regulation Studies for the development of drugs are that can obstruct its development; carried out mainly by the GHKM, the z To do away with the unscientific and Korean Academy of Medical Science, superstitious elements contained in the Institute of Materia Medica and the national medical heritage, and pharmacological sections of medical assimilate and utilize only the superior universities. ones in public health services; The funds required for these research z To diagnose diseases through modern projects are provided for in the State methods, considering that the budget. conventional method of merely feeling A project is proposed at the Science the pulse lacks a scientific basis; Council of the institution concerned,

73 Traditional Medicine in Asia endorsed by MOPH, and then carried out. Newly developed drugs replace In the GHKM alone, 30– 40 projects are existing drugs with similar or inferior implemented each year. A clinical study is action. The latter are then weeded out, conducted under approved conditions, and their production and utilization is with a group to adjudge the discontinued.1,4 relative efficacy of the drugs to be developed by clinico-pharmacological Utility of Koryo Medicine observation. For basic studies, the GHKM puts in As a national medical heritage, KM enjoys considerable effort to identify the State protection and its utilization is actively components and the pharmacological encouraged.(3,4) In no other country is the action of medicinal plants. Studies to clarify State developing KM with such a high the therapeutic mechanism of acupuncture degree of commitment, nor is any other and the real nature of the meridians are country providing all its inhabitants high- also being carried out. quality KM health care, free of charge. The results of the study are reviewed In spite of the fact that KM is being by the Science Council of the institution promoted, it is not well-known all over the concerned. world. In the case of a drug, the approval of In Juche 78 (1989), WHO nominated the MOPH has to be obtained so that it the GHKM as its collaborating centre for can be used as a standardized formulation. traditional medicine. Since then, it has Newly developed drugs which have been annually been publishing technical standardized are manufactured in the information in English and has distributed pharmaceutical factories of hospitals as it widely to many countries. Especially in per the requirement of the hospital. If a recent years, the uniqueness of KM in DPR drug shows really marked benefits, it is Korea has become known in many included in the State production plan, and countries through these publication is manufactured in the central and local activities, with the financial support of pharmaceutical factories in large WHO, SEARO. quantities.

References

1. Choe Thae Sop (1999). Development history of traditional medicine in DPRK, Korea Today, 7:35–36, Juche 88 (1999). 2. Ro Jung Rye, Hyangyakjipsongbang, an ancient classic (85 Vols). 3. Choe Thae Sop (1995). Primary health care and herbal self-medication, Technical Information, WHO C.C. for TM, 7:5–11. 4. Choe Chang Sik (1995). Traditional medicine in DPRK, Technical Information, WHO C.C. for TM, 7:1–5. 5. Ho Jun (1610). Tonguibogam (25 Vols). 6. Ro Jung Rye, Yu Hyo Tong et al. (1445). Ulbanryuchwi (365 Vols).

74 Chinese acupuncture–moxibustion

Chinese acupuncture- moxibustion Deng Liangyue

he science of acupuncture–moxibustion ncture analgesia has revealed some sectors Tis an important component of traditional of the functional mechanism of acupu- Chinese medicine (TCM). It is the study of ncture. These achievements have been the meridians and collaterals, acupoints, internationally recognized in academic acupuncture techniques, and the laws of circles, and China thereby enjoys a pre- prevention and treatment of diseases by eminent position in this field. In the 1950s, acupuncture–moxibustion. Thousands of scientific research on acupuncture– years ago, ancient Chinese medicine used moxibustion concentrated on publishing bian stone (needle stone) as an instrument and popularizing the basic knowledge of for the treatment of diseases, and then this science and generally summarizing the discovered the points and invented special clinical practice of acupuncture– acupuncture instruments. Gradually, the moxibustion. In the 1960s, clinical “theory of meridians and collaterals”, a research on acupuncture–moxibustion and system of treatment rich both in practice and acupuncture anaesthesia was carried out. in theory, was founded, and has been In the 1970s, numerous organized studies applied worldwide. For thousands of years, were undertaken on the clinical acupuncture–moxibustion has contributed applications and principles of acupuncture immensely to the growth and health of the anaesthesia and on the mechanism of Chinese population. Today, even with the acupuncture analgesia. In the 1980s, rapid development of medical science, it is research on the clinical applications and regarded as an important part of the principles of acupuncture–moxibustion Chinese cultural heritage. and acupuncture anaesthesia as well as Since the foundation of new China, the research on meridians and collaterals, was science of acupuncture–moxibustion has brought together in an organized and developed rapidly due to the attention and planned manner. In November 1987, the support provided by the Government. World Foundation of Acupuncture– Numerous studies have been carried out, Moxibustion Societies (WFAS) was particularly in the functional mechanism of established in China, with its head office acupuncture–moxibustion, which has in Beijing. Professor Hu Ximin of China was given it a leading role in modernizing TCM. elected president of the First Conference Research on the mechanism of acupu- of WFAS. In the 1990s, the science of

75 Traditional Medicine in Asia acupuncture–moxibustion moved out of safety indications for the use of China into the outside world and combined acupuncture–moxibustion. WHO also with the modern sciences, thus becoming publicized the first group of 43 acupu- an inseparable component of world ncture–moxibustion-treated diseases, medical science. Since the 1980s, the which involved the , basic theory of acupuncture and moxi- digestive system and neuromuscular– bustion has included “Research on skeletal system, as well as areas such as Meridians and Collaterals ” in the special stomatology and the five sense organs. plan of all the major basic research Clinical practice shows that the indications projects of the State (State Climbing Plan). for acupuncture–moxibustion encompass As a result of research during the past half all clinical areas, and satisfactory clinical century, the science of acupuncture– results have been obtained, particularly in moxibustion has taken the lead in the treatment of painful diseases such as modernizing TCM. neuromuscular system diseases, sequelae of cardiocerebral and visceral functional Clinical application and disorders, dysfunctional diseases of the research on acupuncture– endocrine system, diseases due to moxibustion depressed immunity, and some allergic conditions. In addition, acupuncture– Clinical application and experimental moxibustion has certain clinical benefits in research has shown that acupuncture– the treatment of some difficult diseases such moxibustion could adjust the functions of as tumour and organic diseases in which all systems and organs of the human body the toxicity and sequelae are reduced. and so could effectively prevent and treat Combined with modern medicine, diseases. Chinese medical workers have acupuncture–moxibustion can treat some carried out extensive research programmes life-threatening diseases, such as chronic in the areas of clinical application of renal insufficiency, myocardial infarction, acupuncture–moxibustion, acupuncture haemorrhagic fever, and acute perforating anaesthesia and acupuncture analgesia, ulcers. Infectious and infective diseases and have accumulated rich experience and such as viral hepatitis, pulmonary documented significant advances. tuberculosis, epidemic parotitis, bacillary dysentery and acute mastitis can also be Expanding the scope of treated. Acupuncture–moxibustion also clinical application has an effect on the union of fractures, ovulation, and helps in easing labour pains According to an estimate, there were and in correcting abnormal foetal position. approximately 200 diseases that could be In 1996, a special issue—The Frontiers treated by acupuncture–moxibustion in the of Medicine—was published in the United 1950s. The number increased to 300 by States of America. This issue focused mainly the 1970s, of which effective treatment was on the Chinese acupuncture therapy, which available for about 100 diseases. In the was included as a special topic. In meantime, acupuncture anaesthesia was November 1997, the National Institutes of also being widely used.(1) In 1979, on the Health (NIH), USA, held a special meeting basis of research, the World Health with more than 1000 participants. The Organization (WHO) began to disseminate meeting discussed the effect of acupuncture

76 Chinese acupuncture–moxibustion therapy on nausea, vomiting, various painful medicines, and is used during operations diseases (including postoperative pain, while the patient remains conscious. dysmenorrhoea, tennis elbow, and myositis Acupuncture anaesthesia resulted from the fibrosa, etc.), or pain induced by combination of modern anaesthesiology, chemotherapy or operation. Other areas surgery and the neurosciences. Acupun- where acupuncture could be used were cture analgesia in China has a history of discussed. These included the after-effects more than 2000 years. It was introduced of stopping of smoking, management of as early as the Yellow Emperor’s Internal drug dependence, osteoarthritis, sequelae Classics. Acupuncture anaesthesia started of wind , and headache and asthma, in the late 1950s. On 30 August, 1958, and it was agreed that acupuncture therapy with the cooperation of the Departments in these cases was appropriate. A statement of Otorhinolaryngology and Acupuncture, was made after the meeting about the the First Shanghai Municipal People’s efficacy of acupuncture which further Hospital replaced allopathic anaesthesia by influenced the worldwide application of acupuncture analgesia, and successfully acupuncture–moxibustion. performed a tonsillectomy. A new chapter was thus started in the history of Meridian diagnosis acupuncture. During the past 40 years, Research on the pathological reaction of practitioners of acupuncture anaesthesia meridian points, for example, parae- have, on the one hand, been conducting sthesiae, tissue abnormality, change in the demonstration operations with acupun- volume of electric conduction and change cture anaesthesia, evaluating the treatment in thermal sensitivity, has boosted the effects and documenting experiences while, application of the diagnosis of differen- on the other hand, there have been efforts tiation according to the tenderness of to solve the problems of “incomplete meridians and points. Many scholars have analgesia and insufficient relaxation of the tried to diagnose meridians and collaterals abdominal muscles”. The “theory of with the aid of devices developed by the acupuncture–medicine composite anaes- modern technologies of physiology, thesia” was launched in the 1980s, under biochemistry, acoustics, optics, electricity, which the anaesthetic effect is achieved by thermal, magnetics and computers. These acupuncture along with a small dose of instruments not only increase the accuracy medicine which not only preserves the of diagnosis, but also have a good advantages of the operations by therapeutic effect. acupuncture anaesthesia, but also increases the effect of analgesia. Acupuncture anaesthesia Nowadays, some medical organizations in Acupuncture anaesthesia is a new method China and abroad are continuing further of administering anaesthesia that is based research on the method of acupuncture– on clinical acupuncture analgesia. This is medicine composite anaesthesia for those used in the treatment of complications special situations where medical anaes- following surgical operation. It has been thesia is unsuitable.2,3 developed according to the theory of Up till the late 1970s, more than 200 meridians and the principle of acupuncture acupuncture anaesthesia operations had functions. It functions mainly by needling been carried out. Acupuncture anaes- the points along with supplementation by thesia is now applicable for more than a

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the frequency and amplitude of respiratory Acupuncture–moxibustion has movement, the motor function of bronchial an adjusting effect with the smooth muscle, ventilation, vital capacity, heart rate, rhythm of the airway resistance, respiratory muscle heartbeat, blood pressure. It can strength, and the movement of the diaphragm. Hence, it can be used for the be used for the treatment of the treatment of acute and chronic bronchitis,4 blood vessels of the brain and bronchial asthma,5 and haemoptysis of rheumatic heart diseases. pulmonary origin.6 Central and peripheral respiratory failure can also be treated by electric acupuncture at the points of Su Liao (GV25), Nei Guan (PC6), and Tai Chong hundred types of diseases. Further research (LV3), etc. on points prescription, the degree of (2) Cardio-cerebral system:7 Acupu- acupuncture stimulation, supplementary ncture–moxibustion has an adjusting effect medication and surgical performance has with the heart rate, rhythm of the heartbeat, improved the effect of acupuncture blood pressure, function of the peripheral anaesthesia, which proved to be effective blood vessels, functional state of the left for about 30 kinds of operations. Of these, heart, coronary function and cerebro- the anterior basocranial, cervical vertebrae, vascular function. It can be used for the thyroid gland, tooth extraction, caesarean treatment of the blood vessels of the brain,8 section, pneumonectomy and abdominal rheumatic heart diseases and acute ligation of oviduct have received myocardial infarction.9 It was discovered approbation at the Chinese ministerial level. that the treatment of wind stroke and the Acupuncture anaesthesia is regarded as a absorption of blood following cerebral common practice with a success rate of haemorrhage can be promoted by 80 per cent. Some of the difficult acupuncture at Nei Guan (PC6). Following operations such as throat restoration, renal intensive research, Professor Shi Xuemin transplantation, and operation in the found an effective acupuncture method for functional area of the brain, have been the treatment of wind stroke. successfully carried out with acupuncture (3) : Acupuncture– anaesthesia. After years of exploration, the moxibustion adjusts the red-cell count in points for acupuncture anaesthesia the peripheral blood, haemoglobin content, operation have been streamlined, and the surface charge density of the red blood practice of acupuncture has become cells, and the content of oxygen and simpler and more effective. carbon dioxide. Therefore, there are occasional reports of acupuncture Indications of acupuncture treatment for primary thrombocytopenic treatment purpura10 or haemorrhage, thrombo- cytosis after splenectomy due to schisto- Visceral diseases somiasis, and hypoimmunity induced by Acupuncture–moxibustion has an adjusting radiotherapy and chemotherapy.11 function with all the organ systems. (4) Alimentary system: Acupuncture– (1) Respiratory system: Acupuncture– moxibustion can effectively adjust the moxibustion has an adjusting function with movement of the digestive canal, secretion

78 Chinese acupuncture–moxibustion of the digestive glands, flow of bile, and acupuncture–moxibustion has a good the peristaltic function of the gall bladder therapeutic effect in cases of malaria. and bile duct. (5) Urinary system: Acupuncture– Meridian, collateral and tendon moxibustion can affect the urinary function diseases of the kidneys, the movement of the ureter, Meridian, collateral and tendon diseases the movement of the bladder, and the refer to diseases of the tendon–muscle– function of the sphincter muscle of the joint system (motor system) and the urethra, and can therefore be used for the neurological system. These include, for treatment of stones in the urinary system.12 example, various types of headache, The rate of efficacy of treatment of trigeminal neuralgia, sciatica, lumbago, postpartum and postoperative retention of costalgia, cervical spondylopathy, scapulo- urine by acupuncture and moxibustion is as humeral periarthritis, fasciitis, sprain, stiff high as 97.5 per cent. neck, carpal tunnel syndrome, tenosy- (6) Endocrine system: Owing to its novitis arthritis, rheumatoid arthritis, as well dual-directional adjusting function to the as , hyperosteogeny, sympathetic–adrenomedullary system, hemiparalysis and numbness after wind acupuncture–moxibustion can also be stroke. Acupuncture–moxibustion has a applied for the treatment of thyroid diseases special effect on the treatment of these and diabetes, etc. diseases. The commonly used methods in (7) Genital system: Acupuncture and clinical practice are the various needling moxibustion have an obvious adjusting methods (including elongated needling, effect on the uterotonic function, so artificial opposing needling, short-thrust needling, or oxytocia can be successfully nape needling, tapping and penetrating carried out by electric needling at the points needling), point injection, moxibustion, of He Gu (LI 4), San Yin Jiao (SP 6), and scraping, cupping, electric needling, fire Zu San Li (ST 36), or supplemented by needling, collateral pricking and blood- auricular acupuncture. By giving letting, laser therapy, magnetic tape, and moxibustion at Zhi Yin (BL 67), abnormal conductor of meridians and collaterals. foetal position can also be successfully As regards the field of neurology, corrected.13 acupuncture–moxibustion has more Clinical research has also proved that advantages than in the acupuncture and moxibustion have an treatment of some diseases. One example adjusting function on the immune system; is a common ailment, facial paralysis, for example, the success rate for the which is normally caused by acute nonsu- treatment of allergic asthma is as high as ppurative inflammation of the facial nerve 96.8 per cent. Treatment for other allergic in the foramen of the styloid process, and diseases is also satisfactory, as is the is characterized by peripheral facial treatment of common inflammatory paralysis. Since the pathogenesis of this diseases such as parotitis, tonsillitis, disease is not clear, Western medicine has pharyngitis, laryngitis, mastitis, otitis media, no effective treatment other than gastroenteritis, cholecystitis and bronchitis. antipyretics, analgesics and corticosteroids. The rate of successful acupuncture According to TCM, the cause of this treatment for icterohepatitis has been disease is stagnation of qi and blood and reported to be 98.5 per cent. Besides, blockage of the meridians and hence it

79 Traditional Medicine in Asia should be diagnosed and treated on the of radiotherapy and chemotherapy, and basis of the overall analysis of symptoms prolong life. However, this function of and signs, the cause, nature, location of acupuncture and moxibustion cannot be the illness and the patient’s physical separated from its capability of improving condition. Acupuncture–moxibustion, the efficiency of the immune system. tuina and massage usually have a beneficial effect. In clinical practice, the Development of treating penetrating method is mainly applied at the methods nearby facial points, such as Jia Che (ST6) penetrating to Di Cang (ST4), Yang Bai Traditional acupuncture–moxibustion (GB14) penetrating to Yu Yao (EX.), and Si therapy warrants a good foundation for its Bai (ST2) penetrating to Ying Xiang (LI20). development. Based on the Nine-needles, The treatment of facial paralysis(14) with Nine-needling methods and Twelve- acupuncture is brief and satisfactory. needling methods in the Internal Classic, Basically, there are no sequelae. In China, various needling instruments were most patients who suffer from this disease developed, such as cutaneous needle, prefer acupuncture treatment, the intradermal needle, three-edged needle, superiority of which is widely recognized. point catgut embedding therapy, elongated needle, fire needle, and knife Management of weight-loss and needling. Different methods have been prevention of effects of stopping applied in clinical treatment with effective drugs, AIDS and tumour results, for example, superficial puncture, Clinical observation shows that needling tapping method, penetrating method, at Tian Mei (EX.) is effective in stopping multiple oblique needling, the three easing smoking, yet owing to psychological methods, and many more. factors, there are differing views on the Non-invasive treatment methods in effect of the treatment. Some Chinese combination with modern physical medical doctors have also tried acupu- techniques include point electric conduction ncture for drug de-addiction or for treating therapy, drug ion-introduction therapy, physical and psychological disorders point electrothermal moxibustion therapy, caused by drug addiction,15 such as point microwave radiation, laser radiation irregular menstruation and menopause. therapy, point ultrasonic input, point low- This research is still in progress. The frequency input, infrared radiation, practice of acupuncture for weight loss ultraviolet radiation, cryotherapy, drug continues, with some treatment effects. application on point, etc. However, a stricter comparative analysis is Traditional acupuncture therapy, in required because weight loss is affected by combination with modern , various factors. developed into electric acupuncture Treatment of AIDS16 with acupu- therapy, electrothermal acupuncture ncture–moxibustion is a subject which is therapy and magnetic acupuncture worth serious research. Research on therapy. In combination with drug injection malignant tumour17 shows that acupun- technique, point injection with small cture–moxibustion, as a supplementary dosage and point block therapy have been treatment method, could improve clinical developed. The knife needling method has symptoms of patients, minimize side-effects been developed in combination with

80 Chinese acupuncture–moxibustion dissection in the Departments of Parkinson’s disease, cerebral Orthopaedics and Traumatology. thrombosis, cerebral embolism, (1) Specific-area acupuncture therapy infantile chorea, Meniere’s (also called micro-acupuncture disease, enuresis, cervical therapy), which incorporates the spondylopathy, scapulohumeral Zangfu, meridian-collateral, and point periarthritis, acute lumbar sprain, theories of TCM with modern anatomy, ascariasis of the biliary duct, is different from traditional cholelithiasis, stiff neck, irregular acupuncture therapy, but reflects the menstruation, dysmenorrhoea, characteristic of Chinese functional endometrorrhagia, and acupuncture–moxibustion, and acne. possesses the dual functions of both (b) Scalp acupuncture therapy: After diagnosis and treatment. It covers nearly 30 years of clinical research, auricular acupuncture, as well as the methodology of locating the acupuncture of the scalp, face, eye, meridian according to the area and nose, tongue, abdomen, hand, foot, then locating the point on the and wrist- ankle, and the theory of meridian has been determined. holography. It is worth mentioning a Penetrating, twisting, lifting and little about auricular acupuncture and thrusting, electric stimulating scalp acupuncture. methods as well as reinforcing and (a) Auricular acupuncture therapy: In reducing by puncturing along and recent years, interest in research by against the direction of the doctors on auricular acupuncture meridian, respectively, have been and on treating methods is applied for the treatment of more growing. These include traditional than a hundred diseases. These needling methods, embedding and include hemiplegia, facial massage methods, drug paralysis, headache, trigeminal application on auricular points, neuralgia, paralysis agitans, herbal seeds pressing method, dizziness, tinnitus, sensory aphasia, magnetic ball pressing method, apraxia, enuresis, prolapse of the liquid nitrogen refrigeration uterus, functional endometro- treating method, as well as rrhagia, pelvic inflammation, instrumental detection and hypertension, coronary heart treatment on auricular points. disease, asthma, cataract, myopia Therefore, the indications for and cortical visual disturbance. auricular acupuncture have been (2) Conducting research and observing extended from a dozen to more the factors influencing the therapeutic than a hundred—common cold, effects of acupuncture and moxi- epidemic encephalitis, tracheitis, bustion, and analysing and comparing pneumonia, bronchitis, coronary these factors are the focus of present heart disease, myocarditis, and future clinical studies. The pulseless disease, shock, gastritis, therapeutic effects of acupuncture are ulcer, gastrointestinal neurosis, now being observed by objective testing phrenospasm, facial paralysis, methods, as modern technology is intercostal neuralgia, epilepsy, being introduced in clinics. Some

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scholars have observed that varying of some active substances in the body, stimulation and parameters produces changes the number of receptors and different clinical therapeutic effects. their reactions, alters the cell Han Jisheng observed that when membrane and the blood–cerebral electric stimulation is applied in barrier permeability, and influences the acupuncture treatment twice weekly, enzyme-inducing activity of the drug. the therapeutic effect may gradually Therefore, on the one hand, accumulate. Using relatively weak endogenous drug-like substances in stimulation (2 mA is better than 1 mA) the body are activated to perform a and a relatively longer duration therapeutic effect while, on the other between two treatments (treatment hand, the therapeutic effect of the applied once weekly) may achieve exogenous drug is enhanced. better relief for chronic pain. Thirty (4) Development and application of the cases of cerebral haemorrhage treated apparatus of acupuncture and by acupuncture with CT scan moxibustion, development in the areas guidance denote that the acupuncture of optics, electrothermal, magnetic and technique for promoting brain computer technologies has led to the functions and resuscitation obviously development of a variety of acupunc- accelerates the absorption of cerebral ture and moxibustion apparatus. These bleeding. In the application of have been designed and manufactured suppurative moxibustion for asthma, in keeping with optimal stimulating the relationship between the season parameters according to the findings and the pain present or absent during of acupuncture pain suppression the treatment has been analysed. research. The electro-acupoint (3) The clinical combination of stimulator, electrothermal needle acupuncture and moxibustion with instrument, laser needle apparatus, medicaments to raise the therapeutic low-frequency electric therapeutic effect has been common practice and apparatus, electrothermal moxibus- diseases are managed using this tioner, permanent magnetic needle, combination in various clinical etc., are examples of such apparatus departments. The medicaments and have been frequently used in applied are in the form of oral acupuncture clinics and for administration, acupoint injection, experimental research. Sterilized muscular injection, venous injection disposable needles and needles with and subcutaneous absorption. applicators (tubes) are examples of the Medicaments may enhance the modernization of acupuncture therapeutic effect of acupuncture,18 equipment. With regard to moxibu- depending on the type and dosage of stion, the moxibustioner and non- the drug used. The therapeutic effect smoke moxa stick promote the deve- produced by the combination of lopment of moxibustion. Application of acupuncture and medicaments is not these new technologies and new merely the addition of the original effect approaches enables traditional of the two, but is more than that. A Chinese acupuncture and moxibustion probable mechanism is that: practices based on experience, to be acupuncture, by inducing the release developed in modern scientific ways.

82 Chinese acupuncture–moxibustion

Theoretical study of activities, thereby raising the lymphocyte acupuncture and moxibustion transformation rate and rosette formation rate, activating the natural killer cells, and Study on the mechanism of also increasing the amount of lymphocytes. acupuncture and moxibustion Acupuncture and moxibustion also The various afferent nerve fibres to be increase the phagocytic power of the stimulated must be selected based on the non-specific immunocytes and the content intensity of hand manipulation and the of granulocytes. In humoral immunity, current of electric stimulation. Generally acupuncture and moxibustion may elevate speaking, moderate hand manipulation the amount of beta- and alpha-globulin, and low electro-current activate afferent as well as immunoglobulins IgG, IgA and fibres with a relatively large diameter, IgM. The proliferative reaction of splenic whereas strong hand manipulation and lymphocytes and the splenic lymphocyte electric stimulation of relatively strong transformation rate are also increased. intensity activate afferent fibres of various Acupuncture regulation of the diameters, particularly the fine fibres.(19) immunological function is related to the The effect of acupuncture takes place via intact functioning of the vegetative its action on the afferent fibre. Once the nervous system. Only under intact peripheral nerve is cut, most of the pain conditions of the nerves and the disappears. At some points near the adrenalin system can acupuncture evoke arteries, the afferent fibres of the immunoreaction. Endogenous opioid sympathetic nerve distributed in the vessels peptides (such as encephalin) have a also form a part of the acupuncture afferent close relationship with cellular and system, for even after the destruction of the humoral immunity; enhancement of the somatic nerves, when these points are immune system due to acupuncture may punctured, some effect of needling still be achieved via its action on the remains. However, when the autonomous endorphin. The benign regulation of the nerve supplying the vessel wall is damaged, endocrine and immune systems by acupuncture has no effect. acupuncture explains its therapeutic The effect of acupuncture on the effect in many diseases.20 human body is manifold. Its functions include regulating the endocrine and Research on meridians and immune systems. The activities of the collaterals various organs are under the control of the nervous system and the nerve–endocrine– Research on meridians and collaterals is immune system. The effect of acupuncture an important area of scientific research is also related to the participation of these in China. In 1956, it was listed among organ regulation systems. the projects for the first national natural The effect of acupuncture on the science developing plan. In 1986, it was immune system includes the regulation of again listed as one of the “Seventh Five- specific immunocytes, non-specific Year Plan” projects to be undertaken by immunocytes and the humoral immune the State Committee of Science. In 1989, system. Acupuncture and moxibustion the subject of research on meridians and increase T lymphocytes in the peripheral collaterals was considered one of the blood and enhance intracellular esterase “planned projects to be scaled”.

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and points may cause excitement of the In order to keep abreast of the skeletal muscle of the same meridian on latest on internationalization of another part through synaptic reflection acupuncture, in 1990 the State and synaptic transmission among the Technology Supervision Bureau motor neuron. Since such progressive excitement of the skeletal muscle fibre of the People’s Republic of China needs repeated time–space summation, issued the People’s Republic of there is a phenomenon of slow sensory China State Standardization of movement and release of myoelectricity. Acupoints’ Locations. This phenomenon observed in animals has been proved in humans who are sensitive to sensation transmission along the meridians. Researchers working hard for many years Systematic study of the relationship have yielded initial achievements. between the meridians and zang fu organs In China, a general study has been and their ways of connection: conducted on 200,000 people concer- Neuroscientific research by integrated ning the phenomenon of “sensation methods suggests that there is a relative transmission along the meridians”. The connection of specificity between the existence of the running course of the superficial meridians and the internal meridians put forward by the ancients has organs. On the one hand, such specific been approved and the fundamental connection is related to the anastomotic characteristics of sensation transmission level of the nerve segments and density along the meridians have been understood. dominated by the nerve segments. On the Literature and information from the ancient other hand, acupuncture stimulation on the to the present time have proved that meridians may cause changes in the sensation transmission along the meridians release of some neuropeptides of the is a kind of objective physiological relevant target organs specifically, and phenomenon that exists. Recent tests show affect the reactivity of the target organs to that when the skeletal muscles are in a state the corresponding neuropeptide. of excitement, sensation transmission along the meridians is in relation to the Existence of active energy nerve connected with the long axis and metabolism along the running induced by the summational current. The course of the meridians transneural segments and transjoint The system of meridians and collaterals is transmission mechanism are caused by a functional system. Previous tests suggest secondary excitement of the skeletal that energy metabolism is relatively active muscles. Yet, there is not enough evidence on the running course of the meridians. to prove the physiological significance of For instance, the index of skin temperature this phenomenon neurobiologically. The and the amount of carbon dioxide spinal cord is marked by the distribution of exhalation on the running course of the motor neurons according to the meridians. meridians is obviously higher than that on A mutual dendrodendritic synapse the other lines. This phenomenon shows relationship exists among the motor that the energy metabolism along the neurons. Local stimulation on the meridians running course of the meridians is active.

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Research on the morphology Standardization of location of of acupoints points

During 1960–1970, researchers in many In order to keep abreast of the latest on laboratories in China and elsewhere internationalization of acupuncture, in worked on the morphological charac- 1990 the State Technology Supervision teristics of tissue at the meridian points. As Bureau of the People’s Republic of China a result, besides the muscle spindle, issued the People’s Republic of China State Meissner corpuscle, Pacinian corpuscle, Standardization of Acupoints’ Locations. Kraus end-bulb and free nerve ending, a This was put forward by the State “special” receptor was found. A histoche- Administration of TCM and was imple- mical study shows that there is a network mented on 1 January, 1991. The standar- formed by the adrenergic nerve of the dization determined the methods of locating postganglionic fibres of the sympathetic points and the locations of 361 meridian nerve and the cholinergic nerve, which is points and 48 extra points, suiting the distributed over the small vascular wall of needs of acupuncture teaching, scientific some points of both human beings and research treatment, publications, and animals. Research on stereo-structures of academic exchange in China and abroad. points based on lamina, cross-section and In addition, based on the suggestion and study of CT scan anatomy has proved that demand by the Western Pacific Region of the points are stereo-space structures made WHO, China also formulated the Plan of up of various kinds of known tissues. The Standardization of Acupoints’ Names, A difference between points and non-points Draft Plan of International Standardization depends on the different distribution of of Auricular Points, and the Plan of known normal tissues. Standardization of Scalp Points’ Names, all of which were extensively used in clinical Research on the specificity of work. acupoints With the development of acupuncture, especially the expansion of its experimental Extensive research has shown that studies, animal experiments with significant differences exist in puncturing acupuncture are increasing day by day. On acupoints and non-acupoints. For the basis of massive achievements of instance, when points such as guanyuan contemporary traditional acupuncture, (CV4), qihai (CV6), zusanli (ST36) with veterinary acupuncture and experimental replenishing functions are punctured and acupuncture, the Academy of TCM of compared to weizhong (BL40), which has Jiangsu Province and some other units functions of reducing heat and cooling studied the nomenclature, location, blood, there is a remarkable difference in anatomical structures and indications of raising the transformation rate of acupoints from the viewpoint of lymphocytes. No obvious changes in the comparative anatomy, comparative immunological functions of the body have physiology and comparative acupuncture, been found when non-acupoints are with commonly used experimental animals. punctured. In pneumonectomy under Based on these findings, an atlas of animal acupuncture anaesthesia, sanyangluo acupoints was made, defining 71 points (TE8) has the best analgesic effect. of dog, 71 points of , 51 points of

85 Traditional Medicine in Asia rabbit, 51 points of guineapig, 42 points teaching of medium-level schools has been of rat, and 20 points of mouse. improved. Among these schools, the School of Chinese Medicine of Shandong Study on acupuncture literature Province was chosen as an important one Sifting through the literature on at the State level, and 19 of these schools acupuncture of past generations, the were named as standard ones by the State proof and annotation of some important Administration of TCM. ancient acupuncture books such as Miraculous Pivot, Systematic Classic of High-level professional Acupuncture and Moxibustion, the education revision of Huangdi’s Mingtang Classic, In 1956, TCM colleges of the first batch and the publication of the Four Mirrors of were established in Beijing, Shanghai, Chinese Acupuncture and Collective Nanjing and Chengdu. Till the end of Works of Chinese Acupuncture, laid a 1997, there were a total of 30 colleges of strong foundation for scientific research TCM and national medical colleges in and clinical practice. On the other hand, China, and all of them offered acupu- publication of the index of acupuncture ncture, or acupuncture and massage papers, establishment of the consulting courses. The school system included and analysing system of acupuncture undergraduate, postgraduate and literature, and exchange of literature , seven years’ undergraduate, amongst China and foreign countries and doctors of Western medicine learning facilitated the analysis of acupuncture Chinese medicine, and so on. Up till 1998, information and literature consulting and a total of 88,665 TCM students and 5000 promoted academic exchange on doctors of Western medicine had been acupuncture throughout the world. trained in acupuncture. There are 2056 personnel above the level of associate Acupuncture education medical professors in universities and 690 professors. The reforms in higher education Education in China stress on teaching content and courses are There are various forms of acupuncture continuing in full swing. education in China: high-level professional education, medium-level professional Adult education education, postgraduate education, Adult education is of two kinds–informal correspondence college, night college, and formal. In addition to education doctors training as apprentices, self-study through correspondence, night college, examination, and social strength running social college, self-study examination and schools. These have opened up avenues full-day courses, there are also continuing for training acupuncture personnel. education, postgraduate training, doctors’ training apprentices, and inheritance of Medium-level education famous TCM experts’ experiences, which At present, there are 51 medium-level form the system of adult education in TCM. schools of Chinese medicine, which have Some lectures and symposia are also part 51,260 students. Most of these schools of the activities of continuing education; offer acupuncture courses. Through the participants get credit for attending. teaching reforms and standardization, the

86 Chinese acupuncture–moxibustion

International training acupuncture standardization has WHO set up seven collaborating centres completed the standardization of names for traditional medicine in China. The and locations of the points. Yet the most Collaborating Centres in the Beijing China important and complicated task—the Academy of Traditional Chinese Medicine, standardization of indications of Nanjing and Shanghai are mainly engaged acupoints—has not yet started. Different in the study of acupuncture. In 1975, textbooks list different indications and international TCM training centres were there are no standards in prescribing established at Beijing, Guangzhou, Xiamen, points when treating patients. This etc., to train foreign doctors in acupuncture situation influences the therapeutic and Chinese medicine, thus promoting the effect of acupuncture. spread of acupuncture in the world. At the z Lack of a quantity index in acupun- Beijing centre itself, more than 5600 cture manipulation. Objective indices doctors from 104 countries and regions approved by academicians remain to have been trained in acupuncture in the be formed on many counts. There are last 25 years. Some high-level TCM no strict and systematic clinical universities recruit foreign students as well. observations and experimental studies Some of the students have received on defining terms such as reinforcing postgraduate degrees or . These and reducing acupuncture, the skilled acupuncture doctors will quicken intensity and quantity of stimulation, the process of internationalization of TCM. and the duration of retention of needles. Current problems in acupuncture z There is a lack of objective criteria in the evaluation of the therapeutic effects z Differences in the functions of acupuncture and moxibustion. Is there of acupuncture and moxibustion. any specific difference between the functions of acupuncture and Developing trends in moxibustion? For example, ancient acupuncture medicine acupuncture literature clearly recorded that, the point Shenting (GV 24), “if Elaborating the principles and treated by acupuncture, it is indicated scientific bases of the indications in manic mental disorders, and if by of acupoints moxibustion, indicated in depressive To a great extent, the therapeutic mental disorders”. Some points are effectiveness of acupuncture is determined suitable for puncture and some for by the scientific basis of the acupoints moxibustion, and some can be treated prescription. However, the scientific basis by both, but there are differences in of the acupoints prescription relies on the their functions. What is worth noting is scientific understanding of people that these experiences were mostly regarding the indications of the acupoints. recorded in the famous acupuncture In order to establish the scientific basis of doctor Zhenquan’s book during the the indications of the acupoints, studies Tang dynasty. However, further study is should be conducted on two aspects: (i) needed to ascertain these differences. By probing and analysing the acupuncture z Lack of objective and standardization literature of all generations; those in prescribing points. Research work on indications of the acupoints summarized

87 Traditional Medicine in Asia directly from practical experience should in treatment, the principle of cumulative be sorted out to ensure that the indications effectiveness of acupuncture treatment of traditional acupuncture points have a must be worked out. In other words, what solid practical basis, (ii) These indications needs to be explored should include the should be applied again in clinical time when the acupuncture effectiveness practice, and verified under strict scientific reaches its maximum; how long the experimental design so that the effectiveness would last upon reaching the indications can be re-sorted. The clinical maximum; whether there is a non- experience of modern acupuncturists responding period before the new should be summarized systematically and stimulation starts having an effect; and how generally so that acupuncture can be long the non-responding period lasts, if furbished with modern features. These there is one. Only after these basic experiences should then be used in clinical questions are clearly settled can the best practice for strict verification. Only by acupuncture treatment plan be worked undergoing the process of “panning the out. This would include the amount of each gold in the sand” can the real value of stimulation, the amount of total modern and traditional Chinese medicine stimulation, the interval between and acupuncture be guaranteed, and the stimulations and the treatment courses serious situation of poor integration of required by various diseases. acupuncture theory and practice be changed. Only then can acupuncture Peak value of therapeutic medicine take a great leap from the level effectiveness of acupuncture and of “empirical medicine” to the level of the best time to perform “evidence-based medicine”. Keeping this treatment in view, the foundation has been laid for Since the therapeutic actions of researching and working out acupuncture rely on the intrinsic functions “International Standard Acupuncture of self-regulation and self-recovery of the Points’ Indications”. human body, the intensity of its functions is limited. If clinical therapeutic effectiveness Quantifying the principles of needs to be advanced to its maximum, and acupuncture treatment if clinical indications of acupuncture are Ancient people practising acupuncture to be widened, future clinical research on observed that there are different principles acupuncture should be carried out in two in terms of various acupuncture points, directions. One is to further develop the different needling techniques, single potentiality: by conducting strictly acupuncture stimulation, total acupu- controlled research, by sorting out diseases, ncture stimulation and various treatment by establishing the best time and intervals. Also, depending on various opportunity to perform acupuncture disease conditions, during the same treatment, as well as by determining the treatment course, the amount of stimu- acupuncture stimulation parameters of lation increases gradually from low to high, different diseases, so that the effectiveness or decreases from high to low, or increases of acupuncture can be utilized to its in the beginning and decreases later. In optimum extent. The other is to blaze new order to improve the therapeutic trails, by integrating other supplementary effectiveness and to minimize ad hocism methods scientifically to enhance the

88 Chinese acupuncture–moxibustion effectiveness of acupuncture treatment and principles will be mastered only in due broaden its scope. Promising supple- course of time. mentary methods include the integration of acupuncture with Chinese herbal Expounding the or the integration of moxibustion mechanism of acupuncture with Chinese herbal medicine. This method According to deepened recognition of pain has been tried to increase the strength of physiology, acupuncture mechanisms to acupuncture functions and to reduce or stop pain will be gradually proved at the eliminate the side-effects of medication. level of molecular biology, especially the However, to enable this therapy to primary centre of afferent pain sensation. demonstrate its advantages we still have a Various methods of neuroscience research long way to go, because the human body’s will be applied to verify how the posterior physiological and biochemical functions horn of the spinal cord has a restraining are very complicated. Any functional activity effect on afferent harmful signals, and how is not a single biological change but rather the higher centre influences the process of a series of biological processes mutually stopping pain. These will provide theoretical linked and influenced. For example, while proof and a wide choice of clinical the afferent nerve conducts the applications to eliminate pain. physiological and biochemical regulations to the organs around it, apart from the Manufacture of safe and effective nerve impulse, there are such processes as acupuncture apparatus the synthesis, storage and release of the The clinical meaning of traditional neural transmitter, the combination of the acupuncture skills should be judged by strict transmitter and the receptor, and the experiments. For one kind of acupuncture inactivation of the transmitter. The skill, out of 10 experiments just one may regulative function of acupuncture is be of practical importance, while the rest probably realized through the induced may even trigger off reactions. The release of some active substances, through questions faced are: how to distinguish alternating the numbers and the reactivity meaningful composition, sum up of the receptor, changing the permeability regulation, simplify and standardize of the cell membrane and the blood– manipulation, reduce blindness of cerebral barrier, and influencing the activity acupuncture manipulation, diminish of the enzyme. Once medication is unnecessary (no clinical meaning) harmful involved, in which way does acupuncture stimulation, increase its scientific nature, affect the actions of the medication? Among the links that are important, are there any differences in various diseases In the last 10 years, the and for different ? If it is said relationship of stimulation that acupuncture and medication parameter of acupuncture coordinate in terms of function, would their with the ability to stop pain functions be merely combined or increased? To answer these questions, has been systematically Chinese scholars have already performed observed by research on preliminary clinical observations and acupuncture to stop pain. experimental research and the basic

89 Traditional Medicine in Asia effectively apply it in clinics, and gradually promulgated by the People’s Republic of increase curative effect. In the last 10 years, China, and “acupuncture points name with the relationship of stimulation parameter international standard”, “acupuncture of acupuncture with the ability to stop pain clinical research standard” promulgated by has been systematically observed by WHO. Following this, primary indications research on acupuncture to stop pain. On of points most related to acupuncture the basis of this research, the public should clinics will make great progress. be told of the interaction regulation of Traditional Chinese Medicine belongs acupuncture skill and of clinical curative to the category of natural medicine and effect. New models of acupuncture people today want to return to nature. They apparatus to further enhance acupuncture appreciate that TCM is a type of natural skills should be made available. With the medicine. WHO appreciates the traditional development of biological sensing medicines of countries all over the world, technologies, a sensor with needle style can especially TCM. It has founded seven be produced. Combined with the Collaborating Centres of Traditional development of biomembrane technology, Medicine, and is supporting nine biological material with activity can governments through the Federation of probably be added to the acupuncture World Acupuncture Association. With the apparatus. These techniques may urge guidance of WHO, China will gradually acupuncture medicine to develop into standardize research and clinical treatment needle medicine compound acupuncture of TCM. medicine. Besides, with progress in The Constitution of China explicitly techniques, no-wound acupuncture tools states “to develop modern medicine and combined with traditional acupuncture Traditional Chinese Medicine”, paying skills will be presented in the 21st century; equal attention to modern medicine, and trained persons have begun to try it. TCM is the primary law of medical and public health undertakings. It offers a very Standardization of acupuncture good opportunity for undertaking TCM, Research work on acupuncture and boosts its substantial healthy standardization has been completed in development. In the 21st century, Chinese certain areas. These include “location of medicine and acupuncture would occupy meridian points”, “name and location of a significant position in the world of auricular points”, which have been medicine.

References

1. Wang Xuetai. The present situation and the future development of acupuncture and moxibustion. Collection of Academic Articles for the 10th Anniversary of the Founding of the World Federation and Acupuncture Societies. 1997. 2. Zhang Ren. The history of the development of acupuncture anaesthesia in China (1st edition). Shanghai Science and Technology Literature Publishing House. March 1989. 3. Qian Xinzhong (chief editor). Acupuncture anaesthesia in China, Vol. 1 (1st edition). Shanxi Science and Education Publishing House. December 1987. 4. Liu Xinlian, Yixin, Jiang Shuying. Treatment of 97 cases of chronic bronchitis with seed- plaster auricular therapy. Shanghai Acupuncture and Moxibustion Journal. 1988. 7(1): 8–9.

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5. Sun Guixia, Chen Jingtao, Chuan Jianjun. Clinical observation on 141 cases of bronchial asthma treated with acupuncture and moxibustion. Journal of Acupuncture and Moxibustion Clinic. 1994. 10(2):13–15. 6. Yang Shufang. 224 cases of hemoptysis of TB treated by atropine and acupuncture at Yintang. Integration of Traditional Chinese Medicine and western medicine on Practical Clinical First Aid. 1995. 2(2):67. 7. Zhou Jiren, Fang Depei, You Haiqing. Impact of acupuncture on the left cardiac function and humoral endocrine of ectatic myocardosis patients with heart failure. Shanghai Acupuncture and Moxibustion Journal. 1992. 11(3):3–4. 8. Lu Hongxia, Zhang Zhenhui, Zhang Yunxiu. Observation of the therapeutic effect of the treatment for 200 cases of hemiplegia of wind stroke by acupuncture combined with immune functional regulation instrument. Chinese Acupuncture. 1996. 16(3):27–28. 9. Sun Jiqing, Wang Shaokai, Chen Jinglan. Observation on the therapeutic effect of 37 cases of acute myocardial infarction treated with integration of Traditional Chinese Medicine and western medicine. Journal of Chinese Medicine and Pharmacology. 1992. 1:34–36. 10. Cai Ligao. Observation on the short-term therapeutic effect of acupuncture treatment for 37 cases of chronic primary thrombocytopenic purpura. Acupuncture Research. 1988. 13(3):255–259. 11. Ouyang Qun, Jiang Yi, Ma Defeng. Impact of salt-insulted indirect moxibustion at Shenque (CV8) on the immune function of the organism–animal experiment and clinical evidence. New Chinese Medicine. 1992. 24(2):30–32. 12. Zhang Yongchen, Jia Hongling, Liu Yutan. Situation of the acupuncture treatment in the last 14 years for urinary stone. Chinese Acupuncture and Moxibustion. 1994. 14(5):273–276. 13. China Acupuncture and Moxibustion Society. Acupuncture and moxibustion in the new century. Chinese Science and Technology Publishing House. 1998:826. 14. Chen Daoqing, Wang Bingkun, Zhou Liya. Treatment of 102 cases of facial nerve inflammation by combination of acupuncture and herbal therapy. Chinese Folk Therapies. 1996. 3:23. 15. Qian Zhiyun. Some experience on the acupuncture treatment for drug addiction. Chinese Acupuncture and Moxibustion. 1997. 17(12):735–736. 16. Zhou Janwei. Progress of the research on prevention and treatment of AIDS by acupuncture and moxibustion both in China and the World. Chinese Acupuncture and Moxibustion. 1996. 16(9):54–56. 17. Bao Fei. Application of acupuncture and moxibustion to the treatment of malignant tumor. News Report of Medical Research. 1997. 26(3):36–38. 18. Xu Shaofen, Cao Xiaoding, Xu Zhenbang. Research on the enhancement of pain suppression effect of acupuncture by medicaments. Acupuncture Research. 1991. 61(3–4):240–242. 19. Tang Jingshi, et al. Research on the pain suppression of the afferent nerve by acupuncture. Acupuncture Research. 1989. 59(1–2):135. 20. Zhu . Scientific foundation of Acupuncture and Moxibustion. Qingdao Publishing House. 1998:87–109.

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Fundamentals of Yoga

Fundamentals of Yoga Niranjanananda Saraswati Rishi Vivekananda Saraswati

What is Yoga? knowledge of the mind and its processes was the beginning of self-awareness, and he word Yoga comes from the knowledge of the transcendental force/ T yuj, which means ‘yoke’ indicating a spirit was the beginning of self-realization. joining together, a unity, a harmony, These required a healthy and vital body, so balance between internal and external they developed the yoga postures, consciou-sness and manifestation. Thus, cleansing practices and breathing yoga means self-knowledge, understan- practices. They needed clarity of mind, so ding, awareness, and union with the they developed systems of concentration highest consciousness as the ultimate and clarity, which became the develop-ment. Yoga is a system of lifestyle, practices. As people started to live in more philosophy and practices, which evolve the concentrated communities, they evolved person’s potentials, including the physical, philosophies and behaviour that led to vital, mental, emotional, psychic and harmony between them. spiritual qualities. Vedic Era Early Beginnings The written history of yoga goes back The lie many thousands of thousands of years. The earliest writings years ago, but it is so relevant to our are known as the Vedas. The word veda present age that it is deservedly popular means ‘knowledge’; there are four Vedas, worldwide. Through the ages, it developed the Rig-Veda being the oldest book of from the experiences, and humanity. They discuss the spiritual and realizations of wise people, and it gradually scriptural laws of nature, thoughts on the built into the extensive body of knowledge meaning of life, inner and outer know- it is today. ledge, and recommend various rituals and As yoga is the result of personal inquiry meditations for human development. It is and experience, one might say that it began said that they contain eternal truths that when humans first became aware and have been discovered, not created (just as started asking questions on self-discovery. Newton discovered the law of gravity, which Knowledge of the body and its functions was there before him). At the end of the was the beginning of self-understanding, Vedic period, ritual went into the back-

93 Traditional Medicine in Asia ground, and the path of wisdom came to with in anatomy, physiology and physical the fore. This was the age of the medicine. . Pranamaya – The energy body (prana). Western science largely ignores Upanishadic Age this, yet it represents an area for real The greatest thinkers and sages are from improvement in therapy. The wise people that time. The culture was well-structured conceived that all creation is suffused with and secure. It was an agrarian economy, pranic energy and called it mahaprana. stable and fertile, giving opportunity for The localized collection, associated with the leisure and for delving into the depths of body, is the pranamaya kosha. human consciousness. Manomaya kosha – This consists of the mind and the functions of rationality, People went through the four recognized interaction, expression of emotion, belief, stages of life: the conscious, subconscious and uncon- z Brahmacharya: The students, who scious mind. This is the part dealt with in learnt the spiritual teachings, and the psychology and psychiatry. ways of controlling the mind, as well Vigyanamaya kosha – This is the as the vocational education to prepare dimension of our psychic abilities, wisdom them for their work to support their and understanding, which are higher than family in the next stage. the manomaya qualities. z : The householder stage, Anandamaya kosha – This is the when they married, had children and sheath of bliss, when the ego is merged fulfilled their social responsibilities. with super-consciousness. z : After fulfilling the This concept was fully incorporated householder responsibilities, they were into yoga and is the foundation of its great able to go into the solitude of the forest benefit as it attends to the whole person. for contemplation and meditation, Thus, yoga is ultimately a spiritual journey, which led to the next stage. but can easily be a science of health and z : Renunciation, and concen- therapy, and can be used when things go tration on spiritual realization. wrong in any or all five dimensions of the person. The results of the contemplation of the The indicates wise people came out in more than 10,000 the process to alter the states of Upanishads. Over time these have been consciousness. These are the wakeful state whittled down to approximately 108, of (jagriti), where consciousness operates which 10 are considered major Upani- through the senses, the dream state shads. Two of these are especially important (swapna), where the senses are withdrawn for yoga: and we experience the subconscious The classifies the mind, and deep sleep (nidra), where entire human entity into five dimensions of awareness of the individual self is lost. existence, the (sheaths) which inter- Above these is the state of turiya, which is penetrate each other, each being more transcendental consciousness that can subtle than the last: observe all three lower states. The first Annamaya kosha – Matter, the three have certainly been recognized by physical body. This is the part of us dealt Western psychology, though only in the

94 Fundamentals of Yoga last century, but turiya is not acknow- yoga. When people discuss the subject of ledged at all. health, they usually categorize their work in terms of the different forms of illness. In Puranic Age our opinion, this is not dealing with After the Upanishadic Age came the ‘health’, it is dealing with sickness and Puranic Age. This period was the time of abnormality. The subject of ‘health’ surely the writing of the two great epics, the deals with ways in which we can stay and the . The healthy in all dimensions of our being, and Ramayana describes the life of Sri Ram and yoga is pre-eminent in this area. It cares his wife . It includes the Yoga Vashistha, for our physical well-being, general vitality, which is in the form of instructions given to mental balance and tranquillity, emotional Ram about life, wisdom and knowledge by balance and direction, our higher mental, his Guru, Vashistha. psychic and intuitive abilities, and the The Mahabharata, another epic, awareness of our spiritual reality. Yoga is contains the , which is a a holistic and extensive system of attaining dialogue between a spiritual master, and maintaining health in its widest sense. , and his disciple, Arjuna. Krishna As well as the many useful practices clearly explains, among many other yoga teaches, the lifestyle improvements principles, the synthesis of action and that it recommends help us to live in a much meditation in life, a branch of yoga known more harmonious and useful way and as with which we will deal later. improve the quality of our relationships with is best illustrated by the Yoga other people. It has been said that the best of the great Sage . It is a way to have good friends is to be a good psychological approach to human friend. The person who absorbs the development, a science of mind control teachings of yoga certainly becomes a centring on meditation. This is also called good friend, because of their better Ashtanga Yoga, the yoga of eight limbs, personal discipline and more considerate and we will deal with it in detail later. attitude to other people and their needs. is described in In this way our life becomes less stressful Swatmarama’s and and this flows on to better health all round. the by Sage Gherand. Yoga philosophy teaches us to These texts contain a set of purification understand the real meaning of our lives. techniques known as the , In this age, in so many communities people which work on the vitality aspect, balancing have lost the sense of meaning in their lives. the energy with the mental force. These This is leading to a serious vacuum in their are important in yoga therapy and indeed self-esteem, their attitudes to their fellow in the prevention of illness, and will be dealt human beings and their world in general. with at length later. A ‘meaningless’ life is perceived as one that is worthless, and so suicide, murder, cruelty The Main and their and war atrocities are rife at this time. Contribution to Health The practices of yoga bestow many benefits. From the health point of view, We have defined yoga as a system of prevention of physical, mental and lifestyle, philosophy and practices. In this emotional illness is most important. section we will deal with different types of However, yoga can be used as a therapy

95 Traditional Medicine in Asia also, and there is a large body of research tell us that in order to achieve balance we which has demonstrated the effectiveness need to first purify the gross body. For this of the many yoga practices in curing or purpose, hatha yoga recommends the relieving illness. We will consider some of following cleansing techniques, known as these in this article. shatkarmas (please note that all practices in this paper are mentioned only for The forms of yoga we will discuss are: description and not for instruction. They z Hatha Yoga – The yoga of purification; should only be learnt under the guidance z Raja Yoga – The yoga of the mind, of of a qualified yoga instructor). introspection; Shatkarmas z Karma Yoga – The yoga of action with meditative awareness; (1) – The practice has been simplified z – The yoga of knowledge by Swami , and and wisdom; the technique can be found, with all z Mantra Yoga – Ehich deals with the the other practices in this section, in vibratory aspects of our nature. his book , , , .(1) Neti aims to clean out the Hatha Yoga nostrils and paranasal sinuses of the Originally, Hatha Yoga was designed to head, of stale and purulent mucous, balance the mental and vital functions of and to balance the flows of the breath the person, prior to meditation, in order to by decongesting the mucous attain higher states of consciousness. membranes of the nose. It is usually For thousands of years, the have practised by pouring warm salt water said that vital energy – prana – pervades through the individual nostrils, but if the whole universe, both manifest and un- the nasal passages are very much manifest, whether animate or not. Modern blocked, it can be done with a catheter. physicists now agree with this, and they call Neti is effective for treating chronic it ‘background energy’. They tell us that it sinusitis and asthma. also forms the substrate of matter. They (2) – The word means ‘cleansing’ say that matter is just organized energy, – there are six forms of dhauti: and can be converted back to it, albeit with z Danda dhauti – Cleaning teeth, the release of vast amounts of energy – ears and tongue; the atom bomb is an example. z Vatasara dhauti – Swallowing air When energy or prana is un-manifest, and burping it up again, which is it is known as mahaprana; when it is in said to ventilate the inside of the human existence, it is divided into chitta stomach, cleaning it with air; and prana shakti, the mental and z Vaman dhauti – (same as kunjal the vital forces. Hatha Yoga aims at kriya) – Quickly swallowing four creating a balance between mind and glasses of warm salty water and energy. The different amounts of air vomiting it back. Good for acidity flowing through the nostrils correspond to and clearing the lungs, it can be these forces and should alternate for fixed used to treat asthma. If used early periods of time during the day. If they are in an asthma attack it can actually not balanced, neither are we. The Hatha stop the attack. It dilates the Yoga Pradipika and the Gheranda Samhita bronchial tubes and causes the

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secretion of thin mucous, which (3) Basti – Yogic enema, cleans out the cleans out the respiratory tract. It lower intestine. It is not needed if one probably does this by either is doing shankhaprakshalana. stimulating the sympathetic (4) – Advanced practice that needs nervous system or retarding the excellent control of abdominal action of the parasympathetic muscles. nervous system; (5) Kapalbhati – (transl. ‘frontal lobes’ + z Varisara dhauti – Also called ‘to shine’). In this practice, there is shankhaprakshalana, this forced exhalation and passive technique cleans out the whole inhalation. It is said to stimulate the intestinal tract. The practitioner frontal lobes of the brain, and so clear quickly swallows two glasses of the mind of disturbance, and allow it warm salty water, then does a to become one pointed and series of five postures (), concentrated. It also increases the which open the valves of the vitality. stomach and intestines, eight times (6) Tratak – Visual concentration on one each. This technique of swallowing point, develops mental concentration, the water and practising the asanas mind control, clarity and calmness. It is repeated until clear fluid comes stimulates melatonin hormone out of the bowels. It is excellent secretion. for constipation, but it also forms Done in this sequence, the shatkarmas the mainstay of the yoga treatment are designed to clean and purify the gross for diabetes. There is a shortened body (neti, dhauti and basti), then version, laghoo shankhapraksha- stimulate the pranic energy (nauli), then lana, in which only three rounds stop mental dissipation (kapalbhati), and are done. People with high blood then concentrate the mind (tratak). After pressure, hernia, peptic ulcer or this preparation, the practices of cardiac illness should not do it, but meditation can progress smoothly. it is generally quite safe and easy; Nowadays, it is usual to include in z Vastra dhauti – Swallowing a long hatha yoga, the group of techniques called piece of cloth, and gently pulling it asanas, , and back up. This is also good for bandhas. asthma, and probably works the same way as vaman dhauti. It Asanas sounds difficult, and may be so for Asanas are the postures usually associated some people at first, but most with the name ‘yoga’. They vary in people can generally master it; complexity from simple stretching practices z Vahnisara dhauti is also called to difficult advanced postures. It should agnisar kriya; the muscles of the be noted, however, that even the simplest front of the abdomen are rapidly asanas can have a profoundly beneficial contracted and relaxed, with the effect. breath held out. It strengthens and Asanas affect all dimensions of the massages abdominal muscles and person, especially the body-mind organs, and stimulates the connection. Swami Satyananda states in digestive fire. Asana, Pranayama, Mudra, Bandha.1

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body. Through asana practice the dormant Pranayama is known potential energy is released and as the bellows breath, bhastrika experienced as increased confidence in all means ‘bellows’ in Sanskrit. areas of life.” Bhastrika rapidly increases the Pranayama vitality and warms the body, Pranayama is generally defined as ‘breath just as the bellows increases the control’. Although this interpretation may heat of the fire. seem correct in view of the practices involved, it does not convey the full meaning of the term. Pranayama should “The mind and body are not separate not be considered as mere breathing entities, although there is a tendency to practices to introduce more oxygen into the think and act as if they are. The gross form lungs. It is the utilization of breathing to of the mind is the body and the subtle form influence the vitality of the body, and the of the body is the mind. The practice of balance and calmness of the mind and asana integrates and harmonizes the two. emotions. Four pranayamas are worthy “Both the body and the mind harbour of mention in this respect. knots. Every mental knot has a corres- Pranayama is the ponding physical muscular knot and vice technique of blocking each nostril in turn versa. The aim of asana is to release these as the breathing goes on. The breath flows knots. Asanas release mental tensions by in through the left nostril and out through dealing with them on the physical level, the right, then in through the right nostril acting somato-psychically through the and out through the left, the eyes remaining body to the mind. For example, emotional closed throughout. This practice balances tensions and suppression can tighten up the emotions, and induces tranquillity of and block the smooth functioning of the the mind, clarity of thought, and improved lungs, diaphragm and breathing process, concentration. How does it create such contributing to a very debilitating form of balance? The most likely explanation is this: illness in the form of asthma. it has been clearly demonstrated that “Muscular knots can occur anywhere breathing only through the right nostril in the body: tightness of the neck leading to stimulates the left cerebral hemisphere and cervical spondylosis, or of the face as breathing only through the left nostril neuralgia, etc. A well chosen set of asanas, stimulates the right cerebral hemisphere. combined with pranayama, shatkarmas, Balancing the flows through both nostrils, meditation and , is most effective as in nadi shodhana, balances the two in eliminating these knots, tackling them sides of the brain, and with it, the thinking from both the physical and mental levels. and emotions. Nadi shodhana can become The result is the release of dormant energy; quite powerful with advanced additions the body becomes full of vitality and strength, such as breath holding and muscle locks. the mind becomes light, creative, joyful and Simple nadi shodhana can be done for balanced. 5–10 minutes. “Regular practice of asana maintains Bhramari Pranayama consists of the physical body in an optimum condition blocking the ears with the fingers, and, with and promotes health, even in an unhealthy the eyes closed, making a humming sound

98 Fundamentals of Yoga like a bee, as we breath out (bhramari Bandhas means ‘bumble bee’). A strong vibration Bandhas are a group of muscle locks, can be felt inside the head. Physically it is which aim to lock the pranic energy in excellent for tension headache, and to particular areas and redirect their flow for loosen thick mucus in the sinuses. Mentally the purpose of spiritual awakening. There it alleviates stress, tension, anger, and are four bandhas: jalandhara, uddiyana, anxiety and produces peace of mind. It is moola and maha. The last one is a usually done for a few minutes, but in cases combination of the first three. The three of extreme anxiety or panic, can be basic bandhas have therapeutic effects. practised for half an hour, a few times a Jalandhara bandha is done in the day. sitting position with the hands on the knees. Pranayama is done with the eyes With the breath in, the head is bent forward, closed. We remain aware of the natural and the chin is pressed into the upper chest breathing, while slightly contracting the as high as is comfortable – if possible into glottis to make a soft snoring sound. The the sternal notch. Physically, this practice breath should be slow and deep – first into helps to balance the secretions of the the abdomen, then into the lower chest, thyroid gland, and so regulate the then into the upper chest; then out in the metabolism. Psychologically, it produces reverse order. The practitioner notices mental relaxation, and relieves stress, increasing tranquillity of mind and anxiety and anger. relaxation of the body during the practice. Uddiyana bandha is done either Ujjayi can be used in combination with standing, bending over with the arms other yogic techniques for an even stronger straight and the hands on the knees, or effect. sitting with the arms the same way. The Bhastrika Pranayama is known as the stomach and bowels should be empty. bellows breath, bhastrika means ‘bellows’ With the breath fully out, we make a false in Sanskrit. In this practice, with the eyes inhalation with the glottis closed, as closed, we breathe in and out forcefully though breathing in but not actually taking through the nostrils, making sure the in any air. The anterior abdominal wall is breathing is abdominal, i.e., from the automatically drawn up towards the spine diaphragm. Bhastrika rapidly increases the and diaphragm to form uddiyana bandha. vitality and warms the body, just as the After a comfortable time it is released. bellows increases the heat of the fire. It is Uddiyana bandha is useful for consti- used for fatigue, tiredness, sluggish bowels, pation, indigestion and early diabetes. The asthma and the birth process. As it induces digestion is stimulated, and the abdominal tranquillity and one-pointedness of mind, it organs are all massaged and toned. It is is often used before meditation. said that the adrenal glands are balanced, which removes lethargy and soothes Mudras anxiety and tension. Mudras are a group of gestures or Moola bandha is the contraction of the attitudes which alter mood, attitude and muscles deep to the centre of the perineum. perception, and which deepen awareness It is held for the duration of a breath, then and concentration. They are introduced relaxed, and repeated 10 times. In a more after some proficiency has been attained advanced version it is combined with in asana, pranayama and bandha. jalandhara bandha. Moola bandha

99 Traditional Medicine in Asia stimulates the pelvic nerves and tones the z A person who has mastered yoga can urinary and genital systems. As a result, it teach the practices to other people raises low libido and helps erectile when the need arises. In some cases dysfunction in men, and vaginal dryness it can be used as a form of yogic first in women. It relieves the symptoms of aid. Many a time a yoga teacher has depression and can also immediately taught vaman dhauti to a person in neutralize other emotions. For example, if the early stages of an asthma attack a person wants to control crying, laughing, and stopped it. or even coughing, applying moola bandha will stop it. Raja Yoga The practices of hatha yoga combined with the techniques of meditation form the Until we can calm the disturbances of the foundation of Yoga Therapy. The blockages mind, we will always have problems with – mental, emotional, physical, psychic and our mental and emotional states, difficulties spiritual – that stop us from realizing our in our behaviour and relationships, and be fullest potential, are the same ones that unable to attain our true potential. Raja cause most illnesses. The yoga practices yoga, the yoga of meditation, shows us were developed for spiritual evolution, but how to calm the mind and realize who we they can be just as easily applied to relieving really are. illness. There are a number of advantages The principles of raja yoga are set out of yoga used in this way: in the Yoga Sutras written by Sage Patanjali z After we have learnt the practices, they about 2,500 years ago. As it is laid out in are free of charge. So if we benefit from eight consecutive steps, it is also known as them, we do not have to continue ashtanga Yoga (eight-fold path), which has paying for medicines. This can be sequential steps through: reflected at a national level where vast (1) amounts of money, which would have (2) been spent on pharmaceutical drugs, (3) Asanas can be saved by governments. (4) Pranayamas z The practitioner gains mastery over (5) whole areas of his/her life, becomes (6) Dharana independent of outside sources of (7) Dhyana treatment, and is able to apply the (8) . practices at any time they are needed. For instance, a person with asthma who The yamas and niyamas are recom- masters vaman dhauti has a means to mended moral codes, which the stop an early attack any time. The practitioner is to integrate into life more and person with anxiety that leads to panic more as time goes on: attacks, can settle the anxiety with many practices such as bhramari pranayama, Yamas ujjayi pranayama, and yoga nidra and The purpose of the yamas is to harmonize avoid the panic. Then by a virtuous the external environment and our circle effect, because they know they responses to it: have the practices, their anxiety about – Feeling of non-violence the possibility of panic also reduces. towards all things, from thoughts, words

100 Fundamentals of Yoga and deeds. As one develops ahimsa, one Ishwara pranidhana – Belief in higher detects one’s violence to be more and more reality. subtle, but also that there is less violence Why moral codes in a work on around one. meditation? Paramahamsa Satyananda – Truthfulness – this also involves says in Four Chapters on Freedom.(2) our thoughts, words and deeds. We must “The yamas are designed to harmonise be truthful at all these levels, sincere and one’s social interactions, and the niyamas true to ourselves as well. But truth should are intended to harmonise one’s inner not be used to intentionally hurt another. feelings. All the rules, yamas and niyamas, Asteya – Honesty – This means not are designed to reduce friction between stealing other peoples’ possessions, but it one’s outer actions and inner attitudes. also means internal honesty, simplicity and There is a two-way relationship: the mind sincerity. stimulates external actions and external Aparigraha – Non-possessiveness – actions stimulate the mind. If the external This is really the result of developing actions are not harmonious, then the mind detachment. We care for our possessions will be disturbed. Conversely, a disturbed or the people in our lives, but we are not mind will tend to produce disharmonious addicted to them. acts.” Brahmacharya – Being established in He goes on to state: “The rules are not the higher reality (nature of ). easy to apply, but even limited application Often equated with celibacy, but that is just will lead to greater peace of mind. Perfect a small part; in that state, carnality has no application can only arise with self- place. realisation”, but we can continue to improve as our life goes on. Niyamas Special codes of self-restraint aimed at Asanas internal discipline: These are the yoga postures. The Yoga Saucha – Cleanliness of the body, Sutras define asana as “that posture which external and internal, neatness and order is still and comfortable”; this refers to in our environment, and purification of the meditative postures. mind. The hatha yoga shatkarmas are Swami Niranjanananda in Yoga designed to help with this. Darshan3 says the human body is capable – Contentment, being of five movements and the yoga postures satisfied with what we have. This develops (dealt with in the hatha yoga section) as we do; our demands become fewer, our reproduce these: life becomes simpler and so we are more z Natural, like walking (stretching contented. postures such as pawanmuktasana); – Austerity – As we live simply z Dynamic, like running (dynamic we become better able to cope with postures such as salute to the sun); hardships. z Adaptable, like comfort in the folded Swadhyaya – Self-study – Analysis and positions (e.g., forward and backward knowledge of our own personality, becoming bends); aware of our strengths, weaknesses, z Balance, like standing still (balancing ambitions and needs. asanas);

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Stillness (meditative asanas) The state of pratyahara is deeply Asanas teach us to know our body through relaxing, but it is also the threshold of the these types of movements. They change subconscious and unconscious levels of the body chemistry, free energy flows and bring mind. These are then available for analysis balance to the mind and emotions. and inserting positive affirmations. This Therefore, they affect us on three levels, the state of mind is useful for many health physical, energy and mental levels. practices, and personal development techniques. Pranayama Some pratyahara techniques are: Patanjali states that “pranayama is the Yoga Nidra™ – In this practice we cessation of the movement of the breath”. use rotation of consciousness through all It sounds dangerous, but it really means parts of the body, and we easily reach a that if we can gradually widen the time sensitive state of mind to bring up and deal between each inhalation and exhalation, with deep mental impressions. the mind becomes calmer and calmer. This Ajapa – Internalized awareness is the meaning of pranayama according of breath with the mantra of the sound of to raja yoga, but in other yogas, as we have the breath ‘so hum’. It quickly calms the mentioned, there are many practices of mind and stops mental dissipation. pranayama which have different effects Tratak – Concentrating on an external such as calming the mind and emotions, form, often the flame of a candle – increasing the vitality and balancing the Develops one-pointed concentration and activities of the cerebral hemispheres. They calms the mind. It has been found to are very helpful in many different illnesses increase the secretion of melatonin, the such as anxiety, depression, emotional body’s natural tranquillizer, from the brain. instability and so forth. Antar Mouna – Works on observing, changing and stopping thoughts, and also Pratyahara tracing them to their source. Pratyahara means withdrawal of the mind When the state of pratyahara has been from the objects of sensory experience. The attained, we focus the mind and come to: mind then introverts and experiences its Dharana deeper nature. The aroused mind recognizes the parameters of name, form, The important thing here is to keep the mind object and time. Pratyahara cuts off fixed on one point only. Any point of awareness of the objects. As it is the concentration can be used, such as a sensory input that mainly keeps us fully mantra, symbol, thought or idea. At the conscious when we practise pratyahara, time of meditation, if there is oscillation of the rhythms of the brain slow down and the mind then concentration will not be we ‘descend’ from beta rhythms to alpha experienced. In the beginning it is difficult rhythms, down to the borderline of theta to concentrate the mind for a long time, (sometimes known as the alpha-theta but when the mind wanders we just gently state) – the threshold between waking and bring it back to the object of concentration. sleeping. At this level, we are mentally It is easier if we have done the preliminary relaxed and unaware of our external practices first. environment or sensations from the physical body.

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Dhyana The exhaustion phase that succeeds it leads Dhyana is the state of meditation. Note to many more, such as diabetes, and the that this is a state, not a practice. It is the results of exhaustion of the immune system result of perfecting dharana, when there such as chronic infections and cancer. It are no breaks in concentration. One also is little wonder, then, that the inner practices remains aware that one is practising are used to prevent and treat these dhyana. Thus, dhyana includes two things: conditions. one, an unbroken continuous flow of In the 1970s, Ainslie Meares, an consciousness of a single object, and two, Australian psychiatrist, published in the the awareness of dhyana; that is the Medical Journal of Australia, excellent awareness that one is practising unbroken results of his cancer patients using deep concentration. These two kinds of meditation. They only used the meditation awareness go hand in hand. practices and many cancers regressed. Carl Simonton, a radiotherapist from Fort Samadhi Worth, Texas, used meditation practices Dhyana leads to this final stage. In with visualizations, and his patients also meditation there are three active experienced good results. parameters: the meditator, the process of Positive influences on the unconscious meditation and the object being meditated mind – The evidence on using positive upon. In samadhi, only the object remains. affirmations and visualizations in the state of pratyahara and deeper, has been well- Benefits of Raja Yoga known and reported in innumerable books and articles over the years. It almost seems As discussed above, the lifestyle benefits that people use medications rather than of yamas and niyamas are many, and the meditations for many illnesses, only advantages of asanas and pranayamas because they do not know about the latter, have been mentioned. It is the inner prac- or they prefer the pills because they are tices, pratyahara, dharana, dhyana and easier and quicker. samadhi, that can bestow inner peace Eliminating negative content in the and reverse many health problems. There unconscious mind – The many yogic are at least four ways in which this can internal visualizations allow the negative happen. impressions in the deeper layers of the mind Deep mental and physical relaxation to come into consciousness, where they – Stress is rampant in our world, and most can be dealt with. When they are still of it comes from our own minds. Our repressed, they cause trouble on all levels expectations, which far exceed our needs, of the person, the physical, the energy, the cause us frustration, disappointment and mental, emotional and behavioural, and anxiety. Our sympathetic nervous systems at more subtle levels. They affect the are on full alert much of the time and our person’s attitudes, perceptions and bodies and minds get little rest, even when expectations of themselves, others and their we sleep. This state of arousal leads to world, so they are crucial in all areas of many illnesses such as hypertension, our lives. When we eliminate the effects of asthma, headaches, heart disease, arthritis, these deep mental impressions, we benefit bowel complaints and general deterioration our lives immeasurably. of all tissues by free radical damage, etc.

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Karma Yoga embodied beings to renounce action, but it is possible to renounce the results of the Karma Yoga is the ‘yoga of action’. We action”. People often answer this by saying, are always in action even when we are “but surely I can expect to be paid for my apparently doing nothing. At least our work”. Karma yoga says, “yes, but make minds are in action, and at some level we your contracts for payment, then get on still affect the objects or people about with doing the job for its own sake and with whom we are thinking. Even when asleep all your attention”. Many people who we dream, and even in deep sleep we are embark on the road of karma yoga find interacting at some level. The yogis say that they start to receive abundant payment that if we are always in action we had better because the people they work for do it the right way. The right way is karma appreciate their efforts. This is part of the yoga, in which we are functioning in the natural law of karma; we do indeed reap world but our inner attitude to that action what we sow. is of a special kind. It is the yoga of Lack of Ego – The Gita also says, “He dynamic action – interaction with the world who is free from the feeling of ego and who and normal daily situations, but with is not swayed by the feeling of good and meditative awareness and continuous flow bad, walks the path of righteousness and of energy. It aims to increase the level of righteous action”. Egolessness also implies our awareness of our internal reactions that one has to be simple (uncomplicated), such as our expectations. sincere and desireless. Our actions The word karma means ‘action’, but become unselfish with no ego motive, done in some respects also the results of our for others or the world. This lets us live in actions – we reap what we sow. The harmony with nature, to give and keep on actions can be physical ones, but they can giving. occur in all dimensions of our being, or at Renunciation of limiting desires – Most any level of consciousness. However, the desires limit us, such as the desire to important thing is to develop the ability to accumulate more and more possessions, act with the inner attitude which has the to soothe the insecurities caused by our following qualities: spiritual vacuum. These nagging desires Efficiency – This needs full concen- cause a vicious circle and take us even tration and awareness of the Self, of the further away from our spiritual goal. mind. It is necessary to be one pointed Other desires, such as the desire to help and not distracted. You must be able to others without expectation, take us towards observe the whole event to become it. The more we are able to limit our desires, efficient, to have the ‘big picture’. the less disappointed we will be and the Equanimity – The mind should remain more calm and balanced our mind. We balanced in success and in failure. In order also need to have the ability to discriminate to maintain mental balance, it is easiest if between our needs and our desires. one practises the other yogas as well, and No identification with the work – Have abandons the desire of attachment, the the attitude of only being the instrument, desire of result and the desire of not the doer, that you are not indispensable. achievement. When this is working properly, it is a Absence of Expectation – The wonderful feeling as the work flows along Bhagavad Gita says, “It is not possible for as if ‘guided by a higher force’. Everything

104 Fundamentals of Yoga we need for the job comes our way, and attitudes such as efficiency, renunciation, everyone we need to help us comes along equanimity, egolessness and duty in one at exactly the right time. It all happens so action is difficult. The thrust of karma yoga regularly that we realize these could not is to have these concepts combined in one possibly be coincidences. Then a higher thought, one action, in one moment. Once realization starts to dawn within us. When these different ideas are combined, then we are non-attached, it is possible to we can proudly say we are practising exhaust our karmas, which is another aim karma yoga.” of karma yoga. However, until then we can do the best Conversion of negative into positive – we can to have that attitude. In the Some people habitually see the positive side workplace, at home with the family, when of a thing (optimists), others the negative we are with other people, and indeed even side (pessimists). Karma yoga is a process when we are alone, relating to ourselves, of converting our negative attitudes into we can remember to apply the above positive ones. principles. Then over time, it will become Duty or – In Yoga Darshan by second nature in all our actions, bringing Swami Niranjanananda Saraswati,3 this a peace of mind that most people never point and karma yoga in general is attain. Karma yoga clears the mind of described thus: phobias, insecurities and complexes, and “The last attribute of karma Yoga is makes it steadier for further practices and consideration of every action as a duty. Do for life. The ultimate state is total serenity your duty, because action is superior to in the midst of intense action. inaction. Action when performed with the idea of duty produces a very deep Jnana Yoga experience of (devotion), surrender, belief, trust and faith in a higher nature, a Literally jnana means ‘wisdom’ or higher reality guiding us. This duty is to be ‘knowledge’. So jnana yoga means the understood in relation to one’s individual yoga of real knowledge. This knowledge dharma, social dharma, global dharma is not intellectual, acquired from books and and universal dharma. different sources of communication. It is “When one develops the awareness of an advanced yogic sadhana (spiritual dharma, as an inherent commitment of practice), a process of self-inquiry with a duty or obligation to other beings, then one concentrated mind. Jnana yoga is linked develops a giving or helping nature. Many with the of , times people talk about, and believe in which is a path of inquiry into Brahman, giving, a helping hand to others. Our the Absolute. actions, which outwardly may seem like In order to understand the Brahman helping, do not necessarily convey the same or the Absolute, the process of jnana yoga feeling to others. Often, even the desire to begins with self-analysis. The form of self- help others carries with it some kind of analysis is not high, abstract or abstruse; ulterior motive, whether for gain or profit. it is very definite. In fact, the practices of We should not be restricted to the idea of pratyahara and dharana may be classified some kind of personal gain. as part of jnana yoga also, because “Initially the practice of karma yoga is through these practices we analyse difficult, because to combine so many ourselves. What is happening at the level

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food, education, love and belongingness. The highest order of need A self-assessment on these dimensions structure has been named by provides the person a picture of their Maslow as self-actualization personality as perceived by them. This need. These needs include provides a basis for improving the quality of life by adopting yogic practices and pursuit of knowledge in a sadhanas. The practice of jnana yoga field of specialization that results in expanding one’s awareness to results in realizations of cover wider and wider areas of conscious- one’s unique potential. ness. This is called meditative awareness and it ultimately results in the power of discrimination and right understanding, and the ability to distinguish between the of our thoughts? How are the thoughts, real and the unreal. emotions and feelings swaying us? Do we In contemporary psychology, the have the ability to stop them or to recall humanistic approach is very close to jnana them at will? This kind of self-analysis, in yoga. The famous humanistic psychologist, terms of the physical, mental, emotional Abraham Maslow (1908–1970,) and intellectual aspects, can be considered proposed a hierarchical structure of human a part of jnana yoga. This kind of self- needs. According to him, all human needs knowledge helps a person mentally and can be arranged into seven categories, of emotionally. which five are distinctive and often cited. Swami Niranjanananda has proposed These categories of needs may be placed a technique of self-analysis known as in a sequential order of hierarchy. Most SWAN technique. The four letters of SWAN basic are the physiological needs that must stand for Strengths, Weaknesses, be satisfied for physical survival, for Ambitions and Needs. Anyone can analyse example, need for food, water, oxygen, etc. himself or herself by perceiving the extent Then come safety needs that are related to of these four dimensions in their personality. protection and security from potential ‘Strength’ refers to such qualities and dangers. The physiological and safety characteristics that contribute towards needs are obviously ‘biological needs’ advancement of spiritual evolution, related to physical survival and protection. resulting in mental quietness and inner The third group of needs are called needs happiness. Self-confidence, loving nature, for belongingness and love, i.e., the need concern for others, compassion for the to love or to be loved and the need of needy, contentment with one’s possessions, affiliations and associations with a group etc., may be cited as examples of one’s or groups. strengths. On the other hand, negative The fourth level in the hierarchy of needs thoughts, emotional instability, anxiety, is the category of esteem needs, i.e., the stress, hatred, egoism, etc., may be taken need to gain power, prestige and as one’s ‘Weaknesses’. ‘Ambitions’ refer recognition in society. Apparently, the to one’s aspirations for material achieve- second and third order needs in Maslow’s ment, social prestige, positions, etc., model consist of ‘psychological needs’. The ‘Needs’ include basic requirements for highest order of need structure has been survival and maintenance like need for named by Maslow as self-actualization

106 Fundamentals of Yoga need. These needs include pursuit of does not confuse it with the permanence knowledge in a field of specialization that of the ultimate. results in realizations of one’s unique Vairagya means ‘detachment’; it is potential. Although few people reach this freedom from raga (attraction) and level, everyone has a self-actualizing need. dwesha (repulsion), it is dispassion and In order to become self-actualized, the non-attachment to the fruits and benefits persons must be well-adjusted and self- of one’s activities. fulfilled. Maslow has given 15 characteri- Both and vairagya continue to stics of a self-actualized individual which grow and manifest in different behaviour include efficient perceptions of reality, and modes of adjustment, and with acceptance of self and others, spontaneity, expanding areas of consciousness through simplicity, task-oriented attitude, self- jnana yoga sadhana. Jnana yoga is a discipline and self-reliance, sense of higher order sadhana and not meant for appreciation, mystic experiences, every one. It has to be combined with other compassion and sympathy for humanity, practices of yoga as per the tendencies and creativeness, harmony with culture, need nature of the practitioner. Some who are for privacy and a life of detachment. Taken dynamically inclined can practise jnana together, these characteristics seem to refer yoga if they combine it with karma yoga. to the spiritual awakenings and are very People whose emotions are charged can similar to a self-realized as described practice jnana yoga by combining it with in jnana yoga. (the path of devotion, The different sequential needs as expression of the heart, of emotions). propounded by Maslow refer to the three Those who have potential psychic abilities interactive aspects of evolution of the human can practise jnana yoga combined with raja personality as conceived in yogic literature. yoga. Only those with indomitable will can They are from body awareness (annamaya practise jnana yoga by itself. So jnana yoga kosha) to spiritual enlightenment and is generally considered a supplement to experience of inner bliss (anandamaya meditation, dhyana. In dhyana there is kosha) through the psychological total identification and merger of the mind, awakening (manomaya kosha). and in jnana there is full experiential We find that Maslow’s need structure knowledge of that merger. So jnana and highly resembles the yogic theory of self- dhyana combined give the experience of realization. However, yogic literature is very samadhi. rich in terms of techniques or practices, called sadhana, to achieve the highest level Mantra Yoga of self. Jnana yoga practices develop two The word mantra is generally translated as distinctive qualities in the practitioner. They ‘sound vibration’, but the literal translation are viveka and vairagya. is ‘the force which liberates the mind from Viveka is the power of discrimination bondage’. However, mantras have effects between the real and the unreal, the eternal in all aspects of the person, not just the and the decaying. Viveka provides mind. The mantras used in yoga are understanding and knowledge of reality formed from combinations of the sounds and illusion. The person with viveka of the 50 Sanskrit alphabet characters, perceives the world as a changing play and which correspond to different energy

107 Traditional Medicine in Asia centres in the psychic body. Mantras which one’s own yoga instructor who is are composed of those sounds create experienced in the science of mantra. vibrations in specific areas of the psychic body. Their vibrations have effects on our Some research data on Yoga physical bodies and our mental functioning. Physical effects – Since the mantras, As we have seen, yoga covers a broad when sounded audibly, vibrate the range of techniques applicable to all appropriate parts of the physical body, any aspects of life. This needs to be taken into problems in those parts that respond to account when examining yoga research, vibration, improve when the appropriate since there are many articles that discuss mantras are repeated. For instance, the relaxation, hypometabolism, etc., which last letter of the often-used mantra, , are directly or indirectly related to yoga, produces a humming sound, which vibrates although this relationship may not be the head area. It is an excellent practice explicitly stated. for relieving tension, headache and chronic sinusitis. Similarly, other mantras especially Yoga and Cardiovascular Disease vibrate the chest area, and are good for Considerable research data have been relieving tension there. In this way, if one collected on yoga’s capacity to influence knows the area of action of mantras, one the cardiovascular system and improve can virtually prescribe an appropriate function. Research has focused on mantra for that area. hypertension and coronary artery disease Mental effects – If mantra is the force in particular. Yoga is seen to be a good that liberates the mind from bondage, what alternative to exercise, because of its is this bondage? It has two aspects, additional relaxation effect, and the fact impurities (mala) and oscillation (vikshepa). that it can be finely adjusted to the physical The impurities are the sum total of all the needs of the individual person. negative impressions deep in the mind. They The research on hypertension is now are the result of past problems in all areas conclusive as a result of more than 30 years of our mental being, and relate to such areas of data.4,5,6,7 In 1969, Datey successfully of our life as love, joy, security, power and treated 53 per cent of 47 patients suffering self-esteem. Mantras activate these parts from hypertension using the meditation of our mental apparatus and allow technique of . There have been memories to surface where they can be dealt several studies, which have compared with and eliminated. The other aspect of various meditative practices and their the mind, vikshepa, is the oscillation and effects on blood pressure. Bagga and distraction of the mind; the internal Gandhi compared shavasana with monologue goes on all day, the desires, the Transcendental Meditation© and found that fears, the plans, the disappointments, the both techniques lowered heart rate and mind is never at peace. By repeating the blood pressure, and increased skin mantras with one-pointed awareness, the resistance; however, a mantra-based oscillations can be quietened and the mind meditation practice was relatively more becomes tranquil and peaceful. significant.8 Psychic effects – Mantras can also be There have been a number of studies used to awaken our psychic potentials, but on the heart itself and it has been shown this subject is better left to be imparted by that yoga improves cardiovascular

108 Fundamentals of Yoga efficiency.9,10 Carson, et al., investigated (10 per cent fat in the diet, whole foods the effect of a relaxation technique on vegetarian diet, aerobic exercise, smoking coronary risk factors and found that cessation, and group psychosocial relaxation had a significantly beneficial support).15 Ornish showed that a group effect on plasma lipids, weight, blood who maintained lifestyle changes for one pressure and blood glucose.10 Carson year had a 4.5 per cent relative found that the use of a relaxation technique improvement in the decrease of their might be considered beneficial in reducing baseline stenosis, and 7.9 per cent after the risk factors. five years. These figures may seem small, Tulpule used yoga in the treatment of but they translate into a significant myocardial infarction.11 He found that improvement in the person’s functioning. simple yoga postures and pranayama L.Bernardi, et al., have shown that after (, shavasana, , one month of training in yoga pranayama, , etc.) were beneficial, when patients with chronic heart failure had a taught to 102 male patients with significant improvement in oxygen myocardial infarction who practised for one saturation and exercise perfor-mance.16 In year. The results indicated that yoga is easy chronic heart failure, impaired pulmonary to learn; it needs no medical supervision, function can itself contribute to oxygen de- and it can be practised at home as part of saturation and reduced physical activity. a rehabilitation programme. Yoga Bernardi found that by slowing the significantly reduced long-term mortality in breathing rate to 3–6 breaths per minute the yoga group compared to controls and using the ‘complete yogic breath’ the had a high rate of rehabilitation. Only three patients were able to reduce ventilation by out of the 102 subjects practising yoga died 40 per cent, but increase oxygen during one year, while 13 of the 103 saturation, with a substantial improvement controls died. Significantly, no patient in in ventilation to perfusion ratio. The the yoga group developed any evidence of method by which this is thought to work is cardiac decompensation or dysrhythmia that deeper and slower breathing makes during the one year while doing the yoga more efficient use of the diaphragm with practice. no increase in respiratory workload. Generally speaking, yoga is taught in Apart from its capacity to improve conjunction with other techniques in order physiology, yoga can be seen as an ideal to produce a synergistic effect. There have form of exercise for heart disease and blood been several studies showing that multi- pressure when it is practised with a relaxed factorial approaches have many benefits mind, and appropriate to the situation of and that one approach alone may not give the individual patient. All patients need to as good a result.12,13,14 engage in exercise programmes to Jurek, et al., showed that the addition rehabilitate their hearts and blood pressure. of a behavioural intervention (biofeedback- However, exercise programmes are assisted relaxation) produced a decrease recommended for a select group of in blood pressure beyond that associated patients, and there are definite contrain- with the diuretic alone.12 Ornish has dications to exercise testing in-patients. produced reversal in coronary artery This may be due to the fact that many occlusion using a combination of yoga people strain, because they have a fixed meditation and intensive lifestyle changes idea of how aerobic exercise should be.

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Tulpule, for example, said that yoga is, rate, blood pressure and skin resistance. “completely free of complications, whereas They showed that there is a strong link at every centre exercise has produced either between breath and autonomic control. death, arrhythmia, severe angina or Pratap, et al., showed that there is no precipitated myocardial infarction”.11,17 major change in blood gases after pranayama in normal subjects.26 However, Fitness L. Bernardi, et al., in 1998 showed that after Gharote, Ganguly, Bhole and Karambekar one month of training in yoga pranayama have shown that yoga increases fitness and there was a significant improvement in vital capacity. This is an essential part of oxygen saturation and exercise perfor- rehabilitation.18,19,20 mance in patients with chronic heart failure. Prakasamma and A. Bhaduri also showed Asana that patients with pleural effusion, who K. N. Udupa and R. H. Singh from Benares practised prana-, demonstrated a Hindu University have done much research quicker re-expansion of the lungs in most on the effect of yoga asana on of the measures of lung function.27 stress.21,22,23 Udupa has studied bioche- mical parameters such as catecholamines, Chronic Illness in General cholinesterase, mono-amine oxidase, Goyeche has reviewed research high- diamine oxidase, plasma cortisol, serum lighting the ability of yoga to be of great PBI, serum proteins, and blood sugar. He use in chronic illness as a method of measured students practising yoga versus rehabilitation.28 He cites studies on the use normal exercise and found that yoga of yoga and meditation in cancer, induces more vital effects than exercise, headache, migraine, asthma, emphysema, which works mainly on muscle. Different sinusitis, ulcers, diabetes, gastro-intestinal types of yogic practices produce different disorders, spondylosis, arthritis, and mental effects. disorders, including anxiety and Gopal, et al., studied the effects of depersonalization. asana and pranayama on pulse rate, Herbert Benson and Goodale have blood pressure and respiratory functions.6 shown that meditation and the relaxation He showed that yoga practitioners when response is an effective treatment for compared with controls had greater vital physical and emotional pre-menstrual capacity and tidal volume, and a relaxed symptoms and is most effective in women respiratory rate. Also, diastolic blood with severe symptoms.29 pressure was less in the yoga group Uma, et al., showed that yoga indicating decreased sympathetic tone. demonstrated a highly significant improve- M. S. Garfinkel, et al., showed that ment in IQ and social adaptation para- asanas improve grip strength and pain meters in a yogic group as compared to reduction in patients with carpal tunnel controls.30 syndrome.24 Preventive and Promotive Pranayama Measures Morse, et al., studied the effect of yoga Dr W. Selvamurthy reported the findings of and breath on the autonomic nervous a study conducted by the Defence Institute system.25 Such were measured for heart of Physiological and Allied Sciences of

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India. Over a period of six months, the A study conducted by Prof. L. I. yoga group sustained a low pulse rate Bhushan on 102 resident students of Bihar (about 50–60 per minute), decreased rate Yoga Bharati, Munger, indicated a decrease of breathing and quicker adjustment to in levels of anxiety, depression, somati- conditions of extreme cold on the zation, sensitivity, obsessive compulsive Himalayan border, perhaps due to better reaction, paranoid ideas, hostility, and heat conservation in the body. Yoga psychotism.35 practices were found helpful to tone up non-shivering thermo genesis.31 Unpublished Studies Singh and Madhu conducted a study In 1996, a study was carried out on 1150 on 20 male adults who underwent yoga prisoners during a yoga training training for six months. The results revealed programme in 24 Bihar (India) prisons. significant improvement in short-term Results included reductions in anxiety, memory and steadiness.32 Barnes and depression, hostility and feelings of Nagarkar studied 40 students of Standard revenge, together with relief of various VIII (between the ages of 12–14 years) who physical symptoms such as insomnia, were provided four months’ yoga training. arthritis and digestive problems. As a result Results indicated an improvement in of the programme, the State Government scholastic aptitude.33 Sridevi, Sitamma and of Bihar took a policy decision to introduce Rao found yoga promoted cognitive regular yoga training in all 82 state prisons. abilities.34

References

1. Satyananda Saraswati Swami. Asana Pranayama Mudra Bandha. . Munger. Bihar. India. 1999. 2. Satyananda Saraswati Swami. Four chapters on Freedom. Bihar School of Yoga. Munger. Bihar. India. 1989. 3. Niranjanananda Saraswati Swami. Yoga Darshan. Sri Panchdashnam Paramahamsa Alakh Bara. . Bihar. India. 1993. 4. Datey K.K., et al. Shavasana: a yogic exercise in the management of hypentension. . 1969; 20 : 333. 5. Benson H. and Wallace R.K. Decreased blood pressure in hypertensive subjects who practised meditation. Circulation. 1972; 46 & 45 (Suppl.II): 516. 6. Gopal K.S., et al. Effects of Yogasanas and pranayamas on blood pressure, pulse rate and some respiratory functions. Indian J. of physiology and pharmacology. 1973; 17(3): 276. 7. Patel C. and North W.R.S. Randomised controlled trial of Yoga and blood pressure in management of hypertension. Lancet. 1975; 2 (7925): 95. 8. Bagga O.P. and Gandhi A. A comparative study of the effect of Transcendental Meditation and Shavasana practice on the cardiovascular system. Indian Heart J. 1983; 35 (1): 39. 9. Tulpule T.H., et al. Yogic exercises in management of ischaemic heart disease. Indian Heart J. 1971; 23: 259. 10. Carson M.A., et al. The effect of a relaxation technique on coronary risk factors. Behavioral Medicine. 1988; Summer: 71. 11. Tulpule T.H. and Tulpule A.T. Yoga – a method of relaxation for rehabilitation and myocardial infarction. Indian Heart. 1980; 22 (1): 1.

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12. Jurek H.E., et al. Interaction of biofeedback-assisted relaxation and diuretic in treatment of essential hypertension. Biofeedback and diuretic treatment of essential hypertension. 1992; 17 (2): 125. 13. Ornish D.M., et al. Effects of a vegetarian diet and selected Yoga techniques in the treatment of coronary heart disease (abstract). Clinical Research.1979; 27: 720A. 14. Ornish D.M., et al. Can lifestyle changes reverse coronary atherosclerosis? The Lifestyle Heart Trial. Lancet. 1990; 336: 129. 15. Ornish D., et al. Intensive lifestyle changes for reversal of coronary artery disease. JAMA. 1998; 280: 23. 16. Bernardi L., et al. Effect of breathing rate on oxygen saturation and exercise performance in chronic heart failure. Lancet. 1998; 351: 1308. 17. Haskell W.L. Cardiovascular complications during exercise training of cardiac patients. Circulation. 1975; 57: 920. 18. Gharote M.L. Physical fitness in relation to the practice of selected yogic exercises. Yoga Mimamsa. 14 April 1976; DVIII 19. Bhole M. Effect of Yoga practices on vital capacity. Indian J. of Chest Disease. Jan– April 1970; XII (1 and 2). 20. Ganguly S. and Gharote M. Cardiovascular efficiency before and after Yoga training. Yoga Mimamsa. 1974; 17: 89. 21. Udupa K.N., et al. Studies on physiological, endocrine and metabolic response to the practice of Yoga in young normal volunteers. J. Research Indian J. Medicine. 1971; 6: 345. 22. Udupa K.N., et al. Certain studies on psychological and biochemical response of hatha Yoga in young normal volunteers. Indian J. Med Res. 1977; 61: 237. 23. Udupa K.N. and Singh R.H. Scientific Basis of Yoga. JAMA. 1972; 220: 1365. 24. Garfinkel, et al. Yoga-based intervention for carpal tunnel syndrome. JAMA 1998; 280:18. 25. Morse D.R., et al. A physiological evaluation of the Yoga concept of respiratory control of the autonomic nervous system activity. Int. J. Psychosomatics, 1984; 31 (1): 3. 26. Pratap V., et al. Arterial blood gases in pranayama practice. Perceptual and Motor Skills. 1978; 46: 171. 27. Prakasamma M. and Bhaduri M. A study of Yoga as a intervention in the care of patients with pleural effusion. J. of Advanced Nursing. 1984; 9: 127. 28. Goyeche J.R.M. in psychosomatic medicine. Proc. 4th Cong. Int. College Psychosomatic Med. Kyoto, 1977. Psychoth. Psychosom. 1979; 31: 373. 29. Goodale I., et al. Alleviation of premenstrual symptoms with the relaxation response. Obs & Gyn. 1990; 75 (4): 649. 30. Uma K., et al. The integrated approach of Yoga; a therapeutic tool for mentally retarded children: a one-year controlled study. J. Mental Deficiency Res: 1989; 33: 415. 31. Selvamurthy W. Yoga in the Army, Yoga. May 1998; Issue 3. (Journal published by Sivananda Math, Munger, India). 32. Singh V.A. and Madhu. A study of the effect of yogic practices on certain psychological parameters. Indian J. Clinical Psychology. 1987; 14: 80. 33. Barnes and Nagarkar S. Yoga education and scholastic achievement. Indian J. Clinical Psychology. 1989; 16: 96. 34. Sridevi K., Sitamma M. and Rao K.P.V. Perceptual organization and Yoga training. J. Indian Psychology.1995; 13: 21. 35. Bhushan L.I. Yogic lifestyle and psychological wellbeing. Yoga. May 1998; Issue 3. (Journal published by Sivananda Math, Munger, India).

112 Policy issues

Harmonization of traditional and modern medicine Prof. Zhu-fan Xie Role of traditional systems of medicine in national health care systems Mrs. Shailaja Chandra A framework for cost-benefit analysis of traditional medicine and conventional medicine Dr. G. Bodeker Development of training programmes for traditional medicine Dr. Palitha Abeykoon Dr. O. Akerele Traditional Medicine in Asia

114 Harmonization of traditional and modern medicine

Harmonization of traditional and modern medicine Zhu-fan Xie

he age-old wisdom of the people of Common features of T every country has been crystallized into traditional medicine systems different systems of traditional medicine, Basic theories of various each nation having its own system/s. Some traditional systems of these traditional systems are well- established, supported by theories and rich There are similarities in the basic theories experience and recorded in writing, such of various systems of traditional medicine. as the Indian system of Ayurveda, the Ayurveda considers human beings in their Muslim system of Unani, traditional totality, in their subtle relationship with the Chinese medicine, universe, and postulates the theory that a and the systems that evolved from it, and human being is a microcosm of the the humoral theory and therapy of Latin universe. Therefore, there is a close America. But traditional medicine in some relationship between the two. Ayurveda other parts of the world has merely been believes that the human body and all matter practised and handed down verbally from in the universe are made up of the five great generation to generation, without any elements: earth, water, fire, air and ether. written record. Whether sophisticated or All the physiological processes in the not, the systems of traditional medicine human body and the pathogenesis of served as the only means of health care various diseases can be explained by the for ages, till modern biomedicine came into three doshas: motion (vata), energy (pitta) being. and inertia (kapha).(1) In ancient Greece, In contrast to modern biomedicine, the authors of the Hippocratic Corpus all which was founded on the basis of presumed that bodily processes, health and modern natural sciences, most traditional disease could be explained in the same way systems of medicine originated in and as other natural phenomena. According developed according to the principles of to the Hippocratic humoral system, all ancient schools of philosophy. A things are composed of the four elements description of their characteristic features – fire, air, earth and water – and are formed follows. by the union of matter, as well as the four qualities of hot, cold, dry and moist. The

115 Traditional Medicine in Asia elements in the human body are Yin and yang refer to the two fundamental represented by yellow bile (fire), black bile principles, ever opposing and comple- (earth) and phlegm (water), while air is menting each other. Their ceaseless motion directly supplied by respiration.2 The Unani gives rise to all changes in the world, system postulates the presence in the including in the spheres of physiology, human body of four humours; blood, pathology, diagnosis and treatment. The phlegm, yellow bile and black bile. Arkan doctrine of the five elements further explains (elements) forms the universe as well as the the inter-relationship of yin and yang. human body.3 Traditional Chinese Therefore, the different systems of medicine regards qi as the basic traditional medicine are based on a constituent element of the universe. Qi common dialectic way of thinking, and produces everything, including human various parts or constituents of the body beings. Together with the five elements, are viewed as an organic whole, with an wood, fire, earth, metal and water, with their emphasis on a balanced relationship characteristic properties and inter- between them. relationships, qi explains the composition and phenomena of the universe, as well Correlation between the mind as the physiological and pathological and body processes of human beings. It is thus clear Ayurveda considers the body, mind and that the various systems of traditional soul as complementary to each other. All medicine view the human body and the imbalance and disease in the body begin universe as an integral whole. with an imbalance or stress in the awareness, or consciousness, of the Basic concepts of health and individual. Therefore, mental techniques disease such as meditation are considered In Ayurveda, the body remains healthy so essential to the promotion of healing and long as a balance is maintained between prevention.4 According to Hippocrates, the the three invisible forces of vata, pitta and mind and body profoundly affect each kapha, and disease results when they go other, and cannot be considered as out of balance.1 In ancient Greece, independent entities. Health consists of a Hippocrates believed that good health healthy mind in a healthy body, and it is resulted from an equilibrium between the always necessary to consider the “whole” four humours in the body, as well as from person while treating a patient. The basic harmony between the body and the philosophy of Unani medicine is that the environment. He regarded illness as some body, composed of matter and spirit, form of imbalance.2 In the Unani system, should be taken as a whole because disease is regarded as an expression of an harmonious life is possible only when there imbalance of the humours or a is a proper balance between the physical disturbance in their harmony.3 According and spiritual functions.3 In traditional to traditional Chinese medicine, good Chinese medicine, mental activities and health results from the maintenance of a emotions are taken as functions of the normal dynamic balance between yin and corresponding visceral organs: spirit is yang within the human body, and between attributed to the heart, while excessive joy the human being and circumstances. A injures the heart; soul is attributed to the yin–yang imbalance gives rise to disease. liver, while anger injures the liver, and so

116 Harmonization of traditional and modern medicine on. Thus, mind and body, emotions and The achievements of the natural viscera, are parts of an integral whole. sciences and the reductionistic No matter how diversified the various approaches, and the use of analytical systems of traditional medicine in the methodologies, brought about a medical spheres of diagnosis, treatment and revolution in the West – medieval medicine management of diseases and patients, they was transformed into scientific biomedicine. have a common viewpoint which may be The revolution started with anatomy, which summed up by the term holistic medical explored the precise structure of the human model or holism. body. The microscope not only became an essential aid for anatomists, but also Basic concepts of modern furthered pathological study from the biomedicine organic and histological levels to the cellular level. Progress in the physical In the Middle Ages in the West, the sciences inspired experimental investi- domination of religion and feudalistic gations in physiology. Breakthroughs in monarchy greatly hampered the develop- chemistry, such as the study of energy ment of the natural sciences, and conversion in the human body, also held obstructed the progress of medicine. Thus, great promise for medicine. In the latter medieval medicine was shrouded in the half of the 19th century, the “bacterio- mists of theology. logical revolution” clarified the true Modern western medicine was first pathogens of many communicable established in the 18th century, during the diseases. Along with the advance of “enlightenment” in Europe. The new natural anatomy, physiology, pathology and sciences created by Galileo, Descartes, bacteriology, clinical medicine also Newton, Boyle and others no longer progressed, particularly in respect of conceived of the world in terms of qualities diagnostics and surgical operations. A new and elements, but as consisting of particles system of medicine – modern biomedicine of measurable sizes, shapes and motion. – was thus formed and developed in the Descartes saw the body as he saw the world, West. This system is different from the in mechanical terms. This new and influential traditional systems, not only in terms of philosophy was one that reduced biological concrete knowledge and practice, but also processes to mechanical events.5 with respect to the underlying philosophical Closely related to mechanism is views. reductionism, which explains the properties of the whole entirely by the properties of Conflicts between traditional the parts that compose it. In medicine, medicine and modern reductionism offers explanations in terms biomedicine of physical, chemical and mechanical principles. The biomedicine which thus Owing to the fact that traditional medicine evolved “considers biological entities more and modern medicine evolved on the basis or less as equal to the sum of their of different philosophical assumptions and anatomical parts and endeavours to with different methodological approaches, elucidate molecular, physiological and conflicts are bound to arise when the two pathological mechanisms believed to form systems are used simultaneously in the the basis of biological processes”.6 same country or area. Different countries

117 Traditional Medicine in Asia have found different ways of solving this and acquaintances had experienced by problem, but since the People’s Republic using traditional methods of treatment. of China seems to be one of the countries Second, traditional remedies were simple, that has harmonized well the functioning convenient and affordable, and had fewer of the two systems of medicine, the side-effects. Modern biomedicine, on the developments which took place in China other hand, often necessitated surgical are described as an example. procedures, which could cause pain and Modern biomedicine was introduced result in complications. Third, the unique in China in the late 19th and early 20th philosophy underlying traditional medicine centuries. At this juncture, China felt the was well-received by the common people, urgent need to firmly establish and assert and had no satisfactory parallel in modern its national identity, and to gain biomedicine. Traditional medicine had a competence in various spheres. In addition unique theoretical system which was well- to the need for new political and received by the common people and could technological initiatives, the issue of health not be replaced by modern biomedicine. and medicine also came to the forefront. Some of the traditional medical expressions Particularly after the Revolution of 1911, and terminologies had already been many intellectuals who were frustrated by absorbed into the language of the common China’s failure to forge ahead began to people. Last but not the least, medical re-evaluate the country’s traditional culture professionals well-trained in modern in the light of what they perceived to be the Western biomedicine were to be found only key to the success of the West – modern in some big cities. With the ban on science. A Descartian faith in the potential traditional medicine, the vast majority of of science to solve mankind’s problems led the Chinese population had no access to them to embrace Western biomedicine. At health care of any kind. This scenario gave the same time, they denounced traditional rise to a bitter conflict between the practices as defunct remnants of the old traditional practitioner and the modern order. These, they felt, were impeding doctor, as well as between the common China’s modernization. They blasted people and the Government. traditional physicians for being ignorant It was only after the founding of the and irrational, and condemned their system People’s Republic of China in 1949 that of medicine as an amalgam of supersti- attempts began to be made to revive tions incompatible with scientific progress.7 traditional Chinese medicine, and to In 1929, the Central Government passed harmonize it with modern medicine. a Bill “to ban traditional medicine in order to clear the way for developing medical Policies to harmonize work”. traditional and modern However, in spite of the persecution it medicine suffered, traditional Chinese medicine has never been eliminated, nor replaced by To begin with, the Chinese Government modern biomedicine. First, most Chinese formulated official policies to protect and people continued to believe in traditional develop traditional medicine. In 1950, it medicine, not so much because of their stipulated “uniting the traditional Chinese cultural background, but more because of and modern western medical profe- the benefits that they, their family members ssionals” as one of the guiding principles

118 Harmonization of traditional and modern medicine of health work. A major reason for this was brilliant theorists would emerge through the that traditional medicine had been of great integration of both systems. In 1978, Deng benefit to the Chinese population, Xiaoping requested governments at all levels especially the common people, who loved to “provide good and favourable and endorsed the system. Also, according conditions for the development and to the statistics of 1949, the total improvement of Chinese medicine”. The population of mainland China was 5.4 present leader, Jiang Zemin, has empha- hundred million, while the number of sized that practitioners of traditional and doctors formally trained in modern Western medicine should strive for greater Western medicine was only 38,875, i.e., unity still, and learn from and complement the ratio between these doctors and the each other so as to promote integration of population was approximately 1:14,000.8 the two systems.9 The situation in rural areas was much The Government has adopted a series worse, with most of the trained modern of measures for the implementation of its doctors concentrated in the big cities. Of policies. These include the establishment all the practitioners of either system, the of administrative bodies at the central and majority (about 80 per cent) were trained local levels for the execution of policy, in traditional medicine. exploitation of human resources, The Constitution promulgated in 1982 development of related academic organi- and the present Constitution declared that zations and publications, gathering and the State should “develop both modern summarizing of the knowledge of medicine and traditional medicine”. Thus, experienced traditional medical doctors, the Chinese Government has clearly put and setting up of institutions for clinical both systems of medicine at par, and practice, education and research (both for “realizing modernization and globalization traditional and integrated medicine). One of traditional Chinese medicine” is seen as of the most powerful organizations for the a task of primary importance. The implementation of these policies is the Constitution advocates that “traditional relatively independent State Administration Chinese medicine and Western medicine of Traditional Chinese Medicine, which should unite and learn from each other, provides protection to traditional mutually complement each other and medicine.10 improve together, in order to promote the integration of traditional Chinese and Incorporation of traditional western medicine”.9 medicine in modern hospitals Besides the official policies, the remarks made by the leaders of China have had a The first step adopted by the Government great impact on the development of in the 1950s for the purpose of “uniting traditional medicine and its harmonization the traditional Chinese and modern with modern medicine. In 1958, Mao Western medical professionals” was the Zedong declared that “traditional Chinese incorporation of traditional medical doctors medicine is a great treasure-house, and into the staff of hospitals of modern efforts should be made to explore and raise medicine, as well as the establishment of it to a higher level”. He called upon hospitals of traditional Chinese medicine Western-trained doctors to learn traditional (TCM). Doctors in ancient China used to Chinese medicine and hoped that some see outpatients only in clinics or in the

119 Traditional Medicine in Asia patients’ homes. There were no institutions even though several hospitals devoted for in-patients. Hospitals began to be set exclusively to TCM have been set up. up in the early 20th century, once modern Western medicine was imported into Establishment of TCM China, but working in these hospitals was hospitals the privilege of Western-trained medical professionals. By 1950, the word Advantages aside, the inclusion of “hospital” had been defined in China as practitioners of traditional medicine in an institution providing modern Western hospitals had certain limitations. These medical and surgical treatment, and doctors were always in a minority, and the nursing care. To remedy this situation, TCM patients referred to them were often those departments were established in most whom modern methods of treatment had hospitals. This made matters easier for failed to help. Thus, their role became patients referred to traditional medicine largely limited to such cases and they were practitioners. In some hospitals or not in the mainstream of hospital services. specialized departments, TCM doctors In order to allow them greater initiative, were appointed directly as staff members and also to provide training bases for in the departments of Western medicine, students of traditional medicine, TCM thus creating improved opportunities for hospitals were established. The number of the exchange of ideas and cooperation TCM hospitals and beds has been growing between doctors of both systems. rapidly (Table 1). In 1997, there were This step seemed to facilitate 10,789 general hospitals of Western collaboration between doctors of the two medicine with 1,485,625 beds, and 2424 systems. Practitioners of modern medicine TCM hospitals with 223,696 beds. The became particularly interested in traditional ratios between the number of the two types methods of treatment when the latter of hospitals and the number of beds succeeded where modern methods had allotted to each were roughly 1:4.5 and failed. On the other hand, the TCM doctors 1:6.5, respectively.11 (It should be noted also required a modicum of knowledge of that at present, general hospitals of Western medicine, in order to function Western medicine in China are simply effectively in a set-up run on modern lines. called general hospitals because none of Many hospitals of Western medicine still them is exclusively devoted to Western have a department of traditional medicine, medicine.)

Table 1. Increase in number of TCM hospitals, beds and research institutions in China since the 1950s(11) 1952 1957 1963 1975 1980 1985 1990 1995 Number of 19 257 124 160 647 1414 2037 2371 TCM hospitals Number of 224 5684 9254 13 675 49 151 101 418 160 899 206 812 beds in TCM hospitals Number of – 16 33 29 47 54 55 65 TCM research institutions

120 Harmonization of traditional and modern medicine

The difference between the two types Moreover, in most cases the methods of of hospitals lies chiefly in the methods of treatment were highly individualized and treatment. Generally speaking, TCM varied from person to person. Therefore, hospitals are equipped with facilities for it is difficult to convince modern-trained modern laboratory diagnosis and medical doctors to believe in the emergency treatment. Therefore, the staff effectiveness of traditional medicines. After of these hospitals also includes a few the inclusion of traditional medical professionals trained in modern Western practitioners in hospitals of modern medicine. Some Western-trained doctors medicine and the establishment of TCM prefer to shift to TCM hospitals. hospitals, it became possible to carry out The establishment of TCM hospitals comparative clinical trials. At first, the has played an important role in the diseases studied were those that were harmonization of traditional and modern difficult to cure with modern Western medicine. The earlier conflict between the medicine, such as chronic nephritis, two systems had found expression not only chronic hepatitis and chronic gastritis. in the contempt in which the practitioners Traditional treatment for these diseases of modern medicine held the “unscientific” often achieved better results than practices of traditional medicine, but also contemporary Western treatment. The in the traditional medical practitioners’ most convincing evidence came from an exaggeration of the helplessness of epidemic of encephalitis B which broke out modern Western medicine in the treatment in the early 1950s in northern China. In of chronic diseases. While the TCM doctors those days, modern medicine could do were not as virulent as their rivals, they, too, little to help encephalitis patients, and needed to compromise. In TCM hospitals, could barely provide even symptomatic modern Western medical professionals relief from the high fever. Traditional proved the value of their work either by treatment, however, cured a large number carrying out laboratory tests for diagnosis of serious patients and reduced the fatality or by the emergency treatment of a chronic considerably. In the mid-1950s, case. Harmonization between the two traditional treatment of haemorrhoids medical systems is possible only if they made a strong impression on modern- begin to respect each other. trained surgeons. Traditional necrotizing therapy for haemorrhoids and ligation Confirmation of the efficacy therapy for anal fistulae succeeded in of traditional medicine curing more than 90 per cent of patients. Moreover, recovery was quicker and Traditional Chinese medicine has a there was less suffering than with modern brilliant history, but whether it is still of surgery. The treatments were well- practical value depends upon its received by the patients. By the end of advantages over modern biomedicine, the 1950s, the analgesic effect of particularly as far as its efficacy is acupuncture was acknowledged by all concerned. Traditional literature contains and acupuncture analgesia was numerous case reports of successful successfully used for tooth extraction and treatment of various diseases, but the tonsillectomy. In the 1960s, modern diseases were not diagnosed, observed or medical circles came to acknowledge the recorded in a modern, scientific way. benefits of herbal treatment for diphtheria

121 Traditional Medicine in Asia

practitioners learned through apprentice- ship. In most cases, knowledge was handed down from one generation to the next within the family. Although TCM could boast of the earliest teaching institutions, these institutions imparted training mainly to the court physicians of the imperial family and to high-ranking physicians in the service of feudal nobles and officials. As early as the fifth century, the Tang Dynasty set up a central institution called the “Imperial Medical Bureau”, which treatment is commonly used for curing infantile malnutrition (Courtesy Prof. Chen Gui-ting) served both as a and as a clinic. It had four departments: medicine, acupuncture, massage (including and conservative treatment for ectopic traumatology) and incantation. The pregnancy with herbal medication to department of medicine consisted of the remove stagnant blood. In addition, a specialities of internal medicine, paedia- herbal homeostatic formula that had trics, sores and ulcers, diseases of the ears, been developed, as well as couching in eyes, mouth and teeth, and cupping. The cataract operation were seen to achieve duration of training varied according to the very good results.12 Most of these clinical speciality. For example, the training period studies were carried out on large for general medicine was seven years, samples, at first jointly by traditional and paediatrics five years and cupping three modern medical practitioners and, later, years. Other than the Imperial Medical by traditional and integrated medical Bureau some prefectures had their own practitioners. Therefore, modern medical medical educational institutions. circles were convinced by the results. The succeeding dynasties developed There are many more diseases in which medical education further. For example, traditional treatment has been proved to during the reign of the Song Dynasty (960– be effective. In daily clinical practice, 1279), the Imperial Medical Bureau traditional medicine has been shown to became a purely educational institution, be effective in the treatment of many consisting of nine departments: internal common diseases, as assessed by medicine, stroke, paediatrics, sores and modern criteria of diagnosis and efficacy ulcers (including bone fractures), obstetrics, evaluation. eye diseases, diseases of the mouth, teeth and throat, acupuncture, and incised Reform of educational system wounds. A professor was appointed for of traditional medicine each department and the teachers were given the title of “”. The Historical review of TCM institution admitted 300 students annually education through an entrance examination. Besides Training of TCM professionals is of utmost the Imperial Medical Bureau, which was importance in the development of this the premier institution, medical schools system of medicine. In ancient China, most were set up by the local governments.13

122 Harmonization of traditional and modern medicine

After the early 20th century, once the Establishment of colleges and rule of the feudal dynasties came to an end, universities of traditional this education system stopped operating. medicine This had little impact on the health services After the founding of new China in 1949, available to the common people, as most in order to implement the new policy of of the practitioners they consulted were developing traditional medicine, it was trained in the master–apprentice style, or urgently felt that the educational system for had learnt from their family members or TCM should be promoted to a higher level. elders. The latter type of practitioner was In 1956, four TCM colleges were esta- held in high esteem by the people. There blished in Beijing, Shanghai, Guangzhou were other practitioners who studied and Chendu, four big cities situated in the medicine on their own. These included northern, southern, eastern and western literati who had failed the imperial regions of China. Since then, a regular examination for officialdom, or shifted their higher educational system has been interest from the management of state developed for the training of traditional affairs to the management of diseases. The medical personnel. The single-minded large volume of medical literature was of devotion of the Government resulted in the great use to those who wanted to teach rapid expansion of the number of TCM themselves. According to the catalogue colleges, which increased from five in 1957 compiled jointly by the China Academy of to 30 in 1995. The number of students Traditional Chinese Medicine and the enrolled increased from 1021 in 1957 to Peking National Library, the number of 39,786 in 1995 (Table 2). Furthermore, medical works collected before 1959 was since the late 1990s, some TCM colleges 14 7661. Most of them were written in the have been promoted to university level. The classical literary style, which ordinary duration of training has been extended to people could not follow easily, but the seven years for the specialty of general literati could. Since the Chinese literati were medicine, and five years each for Confucian scholars, those who practised acupuncture and traditional health medicine were also called Confucian protection and rehabilitation. It should be physicians. noted that China’s traditional medicine is In the 19th century, modern Western not limited to the traditional medicine of medicine was introduced into China, the Han ; it also includes the posing a serious challenge to TCM, traditional systems of medicine of minority including the TCM educational systems. , such as Tibetan medicine. Private medical schools of TCM, run by Among the traditional medical colleges, famous physicians, began to appear by the one is a college of minority medicine. end of the 19th century. The schools of Parallel to the growth of colleges and Western medicine – initially the missionary universities, secondary schools of TCM were medical schools, and later public and also established, and there has been a private medical schools – soon surpassed steady increase both in the number of the TCM schools, both in number and in schools and of students enrolled. Other scale. In the late 1940s, TCM schools were than the regular schools, correspondence on the verge of . schools have also been started for paramedical professionals to give them the opportunity of receiving practical training.

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Table 2. Increase in number of TCM colleges and universities and number of TCM students enrolled since the 1950s(11) Year Total number Number of TCM Percen- Total number Number of Percen- of medical colleges and tage of students TCM students tage colleges and universities enrolled enrolled universities 1957 37 5 13.5 49 107 1021* 2.1 1965 92 21 22.8 82 861 10 155* 12.3 1975 88 17 19.3 86 336 13 538* 15.7 1980 109 22 20.2 139 569 25 282* 18.1 1985 116 24 20.7 157 388 28 450* 18.1 1990 122 31 25.4 201 789 34 048* 16.9 1995 126 30 23.8 256 003 39 786* 15.5

* The number of TCM students enrolled includes those enrolled in TCM colleges and universities, and those enrolled in a TCM department or specialty in Western medical colleges and universities.

In 1978, a programme of post- passing the requisite examinations. In the graduate study was introduced in the 1990s, a special form of apprenticeship traditional medical colleges and univer- was adopted for training and grooming sities. A Master’s degree is granted to those successors to famous physicians and who have studied for three years after pharmacists. Licensed practitioners and graduation and passed the examinations pharmacists with formal college or and completed the required academic university qualifications were selected to paper. A doctorate (Ph.D.) is issued to those serve with famous traditional physicians who have studied for another two years and pharmacists for an effective period of after obtaining the Master’s degree and three years. This form of training has completed a high-level academic paper. proved to be particularly suitable for This postgraduate educational system is learning certain special skills and exactly the same as that being techniques that could hardly be described implemented for modern medicine. in words.

Modern apprenticeship Compilation of standard In the past, apprenticeship was a unique textbooks way of teaching Chinese medicine. It has Traditional Chinese medicine is certain advantages even now, as Chinese distinguished by the vast amount of medicine is not simply a branch of science, literature on it. Many books were used as but includes a large component of art and textbooks in different historical periods, but skill which are better learnt as an most of them could be used only as apprentice practising under the direct references. As they were no longer suitable guidance of, or together with, the master. for teaching in the 20th century and in Therefore, the system of apprenticeship was order to improve the quality of training, the encouraged for a few years after 1949. Ministry of Health had a set of standard Apprenticeship with experienced traditional textbooks compiled for TCM colleges. practitioners allowed one to practise after These were published in 1958 and have

124 Harmonization of traditional and modern medicine been revised five times since then. The last with the legal status of traditional medical (sixth) edition, which consisted of 32 practice and the licensing system for textbooks for various specialties of traditional medical professionals. In China, traditional medicine (general medicine, traditional medical practice is officially herbology, pharmaceutics, acupuncture recognized as being equivalent to modern and moxibustion, and orthopaedics and Western medicine. Since in traditional traumatology), was completed in 1994– practice the diagnosis is often made in a 1995. Besides the 32 TCM textbooks, the different way from that in modern Western standard textbooks for TCM colleges medicine, a national standard entitled include another six textbooks on modern “Classification and Coding of Diseases and Western medicine, one each for anatomy, Syndromes in TCM”, as well as criteria for physiology, pathology, biochemistry, the diagnosis and efficacy evaluation were fundamentals of diagnosis, and internal promulgated in the 1990s. This has further medicine. These courses are offered not only strengthened the legal basis of traditional to train the TCM graduates for their future medical practice. practice, but also to facilitate the exchange In order to guarantee the competence of ideas between them and medical of traditional medical professionals, a professionals trained in modern Western licensing and accreditation system similar medicine, thus facilitating the harmonization to the one that applies to Western medical of the two systems of medicine. professionals has been adopted. The A large number of traditional medical system of promotion for medical profe- practitioners have now been trained. ssionals of both schools is the same. There According to official statistics, the number are four ranks of medical doctors: resident, of qualified medical doctors in mainland physician/surgeon-in-charge, vice-chief China in 1998 was 2,724,670, 9.38 per physician/surgeon and / cent (255,641) of whom were traditional surgeon. The salary of each rank is the medical doctors and 0.41 per cent same in the case of both schools. Other (11,077) integrated medical doctors. The remuneration paid according to the quality number of practitioners with secondary and quantity of medical practice may vary medical education was 1,235,212, of from individual to individual, but these whom 5.67 per cent (70,085) were differences have nothing to do with the traditional practitioners.15 Thus, an particular system of medicine being appropriate and adequate number of practised. A hard-working, experienced traditional medical professionals have been physician of traditional medicine is usually trained to meet the people’s health care paid just as much, if not more, than his needs. Western medicine counterpart.

Establishment of the legal Getting Western-trained status of traditional medicine doctors to study traditional medicine In implementing the policy of placing both traditional and western medicine on an All the measures mentioned so far have equal footing, various issues need to be been of great help in harmonizing considered, particularly those of legitimacy traditional and modern medicine, but real and economics. The former deals chiefly harmonization involves two important

125 Traditional Medicine in Asia issues. These are the modernization of have not only contributed to the progress traditional medicine, and the integration of in many areas of medicine, but have also traditional and modern medicine. There is been playing a particularly important role a large overlap between the two, but they in encouraging cooperation and harmoni- are different theoretically. Modernization of zation between practitioners of the two traditional medicine refers to the appli- systems. Broadly speaking, their achieve- cation of modern scientific theories, ments have been in the following areas. knowledge and methodologies in the study of TCM, as well as the adoption of modern Proposal of modern scientific science and technology to develop TCM. In explanation for traditional this way, it would not only contain distinctive medical theories Chinese features, but also be relevant in It is mainly the unique theories underlying modern scientific terms. Integration of TCM that make it so difficult to understand. Chinese and Western medicine involves Some of these are actually ancient Chinese discovering the common points between philosophical ideas, which, though rather the theories of the two systems, a process quaint, are not disconsonant with modern of mutual learning so that each can benefit perspectives. Some other theories, however, the other, and combining the best elements such as the concept of visceral organs, are of the two systems so as to establish a new misleading. While the anatomical system of medicine. description and names of these organs Both for modernization of traditional correspond to those in modern Western medicine and integration of the two medicine, the physiological and patho- systems, it is essential for traditional medical physiological expositions on them are so practitioners to learn modern medicine, different from modern concepts that they and for Western-trained doctors to learn cast doubts on the correctness of TCM. traditional medicine. Measures to facilitate Extensive studies carried out by the both were taken in the 1950s, but it was “integrated” doctors have revealed that the latter that seemed to work more each visceral organ in TCM is actually efficiently. While summarizing this viewed as a comprehensive functional experience, the former Chairman of the system rather than an individual internal Chinese Government, Mao Zedong, organ. Also, greater emphasis is laid on lauded the efforts in this direction and the inter-relationships among the functional called on more Western-trained doctors to systems than on the consideration of devote themselves to the integration of the individual organs. For example, the word two systems. Since then, many types of kidney in TCM signifies far more than an courses have been started to help Western- organ of the urinary system; besides urine trained doctors learn traditional medicine. secretion, the kidneys are believed to be in Moreover, research institutes for integrating charge of the endocrine function the two systems, as well as integrated (particularly the function of the hypotha- hospitals and clinics, have been set up for lamic–pituitary–adrenocortical, Western-trained doctors who wish to carry hypothalamic–pituitary–gonad and out research and practices in integrated hypothalamic–pituitary–thyroid axes), medicine on completing the courses. At myeloid haemopoiesis, bone metabolism, present, there are about 12,000 high- and a few brain activities. That is why ranking “integrated” medical doctors. They kidney tonics are considered to be effective

126 Harmonization of traditional and modern medicine in the treatment of many disorders besides the treatment of various painful conditions, renal diseases, such as in aplastic anaemia, as long as it does not interfere with the osteoporosis, the menopausal syndrome, treatment of the primary lesions. anovulatory menstrual disorders, sexual Modern Western medicine still finds it disturbances and certain geriatric diseases. difficult to treat viral diseases, and interferon Why these seemingly unrelated is of limited clinical use in China due to its functional activities are lumped together in high cost and side-effects. However, one group is difficult to explain in terms of controlled clinical studies have shown modern physiology and pathology. many medicinal herbs and herbal formulae However, research using sophisticated to be effective in the treatment of viral techniques and knowledge of molecular diseases such as , viral hepatitis, biology and genetics has found a rational viral myocarditis and epidemic haemo- basis for these traditional Chinese rrhagic fever. Some herbal ingredients used concepts. Similarities have been found in for treatment have also been demonstrated the abnormal changes occurring in the to have antiviral effects in laboratory various diseases clubbed into one category, experiments. and the changes have been successfully remedied with the administration of herbal Combined treatment with formulae according to this theory. superior results Both modern and traditional medicine have Discovering advantages of their own strong points. It is but natural to traditional medicine through speculate that a combination of their strong comparison with modern points may lead to better results. Western medicine Comparing the traditional and modern While modern Western medicine has made treatment of bone fracture, Chinese rapid strides, particularly in the 20th orthopaedic surgeons found that while the century, TCM evolved many centuries ago. use of modern technology and methodo- Whether the latter still has advantages over logy had many advantages, traditional modern Western medicine is a question that treatment, too, had its own advantages: it is widely debated. It is the doctors proficient often achieved more rapid union. Further in both traditional and modern medicine studies revealed that the traditional who are best qualified to answer this. approach advised only relative fixation, with Comparative clinical and experimental appropriate compression and stress on the studies have revealed the advantages of site of fracture, following manipulative traditional treatment in many diseases or reduction and timely functional exercise. conditions. In many instances, traditional They, therefore, designed a new method treatment is more effective and has fewer of treatment based on the principle of side-effects. It is also more affordable than combining mobilization with immobili- modern Western treatment. Acupuncture zation, instead of extensive immobilization analgesia is a good example. The analgesic and complete rest. This method has resulted effect of acupuncture is comparable with in a marked reduction in the period for that of or meperidine and, at the clinical union and has minimized the same time, the process has minimal side- complications of fracture treatment. effects and no addiction-inducing The treatment of cancer poses a major properties. It is hence recommended for problem to modern medicine and the

127 Traditional Medicine in Asia possibility of recurrence is often not and produce qualified traditional medical eliminated even after resection of the doctors. Although the curriculum included tumour. As for traditional treatment, a some courses in modern Western medicine, number of medicinal herbs have been these merely served the purpose of found to be cytotoxic, but clinical trials have facilitating communication with Western- shown them to be either less potent than trained doctors, or for proper transfer of modern chemotherapeutic agents or to patients for receiving modern Western cause similar side-effects. However, the treatment. Even with an increase in teaching tonics used by traditional medical hours devoted to the modern sciences, the practitioners have the effect of improving graduates still faced difficulties in practising the patient’s general condition. Recent integrated medicine or in truly modernizing research has shown that most of these traditional medicine. After all, both tonics enhance the host’s immunity. They modernization of traditional medicine and cannot inhibit the growth of the cancer integration of the two systems required, and once the tumour has already become large still require, scientific research. Since the and the antigens from the cancer cells have setting up of the postgraduate educational crippled the host’s immune response. system in 1978, a conside-rable number However, they help prevent recurrence after of research fellows have been trained. removal of the tumour, and are also useful Many of them have been engaged in the in preventing the formation of tumours in modernization of traditional medicine, the precancerous stage. In addition, both which concerns mainly the following issues: acupuncture and herbal medication can (1) Technical innovation in the diagnostic give considerable relief from the toxic methods of the system, especially the effects and side-effects of modern formulation of objective criteria and chemotherapy. Therefore, a combined quantitative measurement of programme of traditional and modern symptoms and signs, for example, treatment is often adopted. Herbal objective recording and quantitative medication is used to aid convalescence analysis of pulse conditions (as after surgery. This is followed by acupun- assessed in the traditional system), and cture and/or herbal treatment to provide colorimetric assessment of the tongue relief from the toxic effects and side-effects and its coating. of chemotherapy, and the administration (2) Investigation of the pathophysiological of tonics and other measures to improve changes in the disease patterns general health and promote immunity so identified by traditional medicine, and as to prevent relapse. the systematization of traditional diagnosis and treatment by means of Education of TCM students in modern scientific methods, for modern sciences example, immunological studies in The harmonization of traditional and different types of deficiency and their modern medicine requires efforts on the treatment with the appropriate tonics. part of both medical systems. In the (3) Improvement of traditional therapeutic 1950s, however, the focus was on the need measures and techniques, particularly to promote traditional medicine by the emergency treatment of serious establishing formal educational institutions cases, to enhance their efficacy, for that would provide regular training in TCM example, the traditional treatment of

128 Harmonization of traditional and modern medicine

toxic shock in severe infections, and Chinese Medicine and Pharmacy, and the resuscitation of patients in coma. Chinese Association of the Integration of (4) Development of new preparations of Traditional and Western Medicine, were set traditional drugs to make their up in the late 1970s and early 1980s. The administration more convenient, former sponsors the Journal of Traditional acceptable and efficient, for example, Chinese Medicine, and the latter the the manufacture of some herbal Chinese Journal of Modern Developments formulae in the form of aerosols and in Traditional Medicine (later renamed injections. Chinese Journal of Integrated Traditional (5) Creating a database from the and Western Medicine). Both journals are experience of experts in traditional published in Chinese as well as English. diagnosis and treatment of certain Besides these two leading journals, there diseases, for example, pattern are dozens of other journals in the fields of identification and herbal medication in traditional as well as integrated medicine. patients with viral hepatitis. The work of researchers in these research institutions is no longer confined Development of research to determining the efficacy of traditional Traditional medicine, an age-old heritage medicine. They also study the following culled from years of experience, is bound to aspects: (i) The elucidation of the basic contain some valuable elements but theories of traditional medicine, such as the inevitably it also contains some aspects theory of yin–yang and qi, the unique which are no longer useful. It is therefore doctrine regarding the physiology and necessary to carry out scientific research in pathophysiology of the internal organs order to separate the grain from the chaff, (called “visceral manifestations” in TCM), and to develop and improve the useful and the theory of the meridian system, elements. (ii) the rationale behind the differentiation In the late 1950s, the Chinese of disease patterns and the identification Government began establishing research of syndromes, which are based on a institutes with a view to facilitating the unique, holistic approach, and (iii) the exploration of the real value of traditional mechanisms of traditional therapies, and medicine and developing it further. Over pharmaco-logical studies of individual the years, there has been an increase not medicinal herbs and compound formulae. only in the number of personnel trained in In brief, the research addresses not only traditional medicine, but also in that of the issue of whether traditional treatment research institutions (Table 1). In the works but also of how and why it works. 1950s, most of the results regarding the Since the late 1970s such research has efficacy of traditional medicine were progressed through the collaboration of obtained from hospitals, both of Western traditional, Western and “integrated” medicine (with the cooperation of traditional doctors, who may be working in hospitals, medical doctors) and TCM. Later, however, medical colleges, universities or research research began to be conducted mainly at institutions of either traditional or modern research institutions. Moreover, to facilitate medicine.16 The following examples the exchange of information among illustrate this. researchers, two national organizations, A concept unique to traditional the China Association of Traditional medicine is that of “”. This not

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Animal models of diseases related to blood New dosage forms have been stasis showed microcirculatory and/or produced, for intravenous haemodynamic disturbances and haema- administration in the treatment tological abnormalities, which were of ischaemic cardiovascular and ameliorated together. These animals were treated with blood-activating and stasis- cerebrovascular diseases, and removing herbs, which resulted in distinct compound danshen pills for oral improvements in their condition. Most of or sublingual administration to the herbs used for activating the circulation relieve angina pectoris. of blood and removing stasis have the effect of improving the micro-circulation, dilating the blood vessels and rectifying the only refers to venous congestion but also rheological characters of the blood. In includes all kinds of pathological conditions other animal experiments, a number of related to stagnant blood in the body. It these herbs have been shown to be may occur locally or generally, and within immunosuppressive and/or effective in or outside the vessels. Clinically, a series of normalizing connective tissue metabolism. diseases can be diagnosed as “blood These data not only explain the curative stasis” and successfully treated with mechanisms of blood-activating and stasis- “blood-activating stasis-removing” therapy. removing therapy but also expand the From the Western medical perspective, the clinical indications of this therapy. Besides diseases related to this concept would the diseases already mentioned, various include coronary heart disease, ischaemic autoimmune diseases (such as systemic cerebrovascular disease, thromboangiitis lupus erythematosus, rheumatoid arthritis, obliterans, chronic obstructive lung chronic glomerulonephritis), cicatricial disease, chronic hepatitis, liver cirrhosis, diseases (such as keloids, postoperative scleroderma, ectopic pregnancy, and other adhesion of the small intestine), and diseases and traumatic conditions gynaecological conditions (such as characterized by impeded blood endometriosis, inflammatory pelvic mass) circulation. Clinical observations demons- are presently often treated with herbs meant trated that most patients with these to activate the circulation and remove diseases had manifestations of “blood stasis. This therapy has also been reported stasis” as described by traditional medicine, to be useful in the treatment of dissemi- and that herbal formulae could be nated intravascular coagulation in serious successfully used to activate the circulation infections. Moreover, extensive studies have of blood and remove stasis. Further studies been conducted to identify the active revealed that patients with these diseases components of some of the most frequently did have common pathological features: used herbs of this category. New dosage haemodynamic and microcirculatory forms have been produced, e.g., disturbances, haematological abnorma- ligustrazine injection (derived from the lities, immunological changes, and rhizome of Ligustecum chuanxiong) for disorders of connective tissue metabolism. intravenous administration in the treatment Experimental research, including pharma- of ischaemic cardiovascular and cerebro- cological studies, has been able to explain vascular diseases, and compound the mechanism of the therapeutic effects. danshen pills (derived mainly from the root

130 Harmonization of traditional and modern medicine and rhizome of Salvia miltiorrhiza) for oral able to answer the basic question as to why or sublingual administration to relieve these pain-killing substances are produced angina pectoris. These can be easily used in the body. by Western-trained medical professionals, Acupuncture is effective in the and have become a part of the routine treatment of a number of disorders other treatment prescribed by them. As for the than pain, particularly functional disorders traditional practitioners, they were marked either by hyperfunction or unfamiliar with most of the diseases listed hypofunction. For example, it helps in above, at least in terms of the Western views lowering the blood pressure in hypertension on the pathogenesis and diagnostic and elevates it in hypotension. It is useful criteria. Research has inspired them to keep in relieving retention and helps in abreast of the relevant information incontinence of urine. Acupuncture is also uncovered by modern Western medicine. beneficial for patients with muscle spasm It is difficult to classify the intravenous and nerve paralysis. Clinical observations drip of ligustrazine for ischaemic cerebro- and experimental studies have revealed the and the sublingual regulatory mechanism of acupuncture administration of compound danshen pills treatment. In fact, its analgesic effect can for angina pectoris as either traditional be attributed to its regulatory mechanism. Chinese therapies or modern Western Yet another category of disease that can therapies. However, doctors of both be treated by acupuncture is infections. systems are now using these as routine Although acupuncture is seldom used for treatment. They are often called “integrated this purpose now, the results it can achieve therapies” since they have originated from are of great academic significance. Clinical traditional medicine and been modified by and experimental studies have confirmed the modern approach. the therapeutic effect of acupuncture in the The successful application of treatment of bacillary dysentery and acupuncture for anaesthetic purposes in malaria. Controlled clinical trials have surgery shook not only China but the entire repeatedly shown that the effect of world. Needless to say, it aroused the keen acupuncture in bacillary dysentery is interest of researchers everywhere. comparable to that of furazolidine, and that Research was carried out on two main the mechanism involved is the enhance- aspects: (i) The clinical aspect, including ment of the patients’ immune function. evaluation of the efficacy of the technique, Another example is the research on its improvement, and determination of the “tonification”. One of the characteristic indications, and (ii) The laboratory aspect, features of traditional diagnosis is to including the mechanisms by which determine the confrontation between the acupuncture provides relief from pain. The antipathogenic capability of the human latter stimulated the study of pain and pain- body and pathogenic factors. The former relief, particularly among the modern includes all kinds of functional activities and medical community of China, as well as in the substances required for fighting these some other countries. These studies pathogenic factors, as well as for resulted in the discovery of endorphins and maintaining good health. Whenever the related substances, the release of which antipathogenic capability is insufficient to during the process of acupuncture relieves overcome the pathogenic factor, illness pain. However, the studies have not been ensues. Therefore, all illnesses can be

131 Traditional Medicine in Asia classified into two main categories: Tonification, on the other hand, attempts (i) Those caused by lowered antipathogenic to stimulate the patient’s own capability. capability, called “deficiency” conditions, Even when used to replenish the required and (ii) Those caused by excessive substances, in most cases the aim of the pathogenic factors, called “excess” treatment is to stimulate the body to produce conditions. The former are treated by the these substances instead of directly principle of “tonification”, i.e., the adminis- substituting them. , the most tration of various tonics to strengthen the famous traditional tonic, is a good example. vital functions and/or replenish the It increases the anti-stress function, but required substances. contains no corticosteroid; by stimulating The purpose of treatment in traditional the hypothalamic–pituitary–adrenocortical and modern medicine is often the same, axis, it induces the body to synthesize and but the approach is different. According release corticosteroid. Also, though it to the approach of modern Western contains no estrogen or testosterone, by medicine, deficiency is made up mostly by stimulating the hypothalamic–pituitary– supplying the substance concerned, i.e., gonadotrophic axis, it acts like a sex replacement therapy. For example, thyroxin hormone in both males and females. It is administered for hypothyroidism, enhances thyroid function, but contains no adrenocorticosteroid for adrenocortical thyroxin. It promotes the release of insulin, deficiency, and gamma-globulins or but does not cause hypoglycaemia; on the specific antibodies for immunodeficiencies. contrary, it can be used for treating Indeed, replacement therapy is often of hypoglycaemia induced by insulin. Thus, the vital importance, such as for patients who advantages of traditional tonification are need blood transfusion for massive loss of that it seldom causes side-effects, and there blood. Its promptness in correcting the is usually no “withdrawal syndrome” when deficiency is incomparable. the treatment is discontinued. The major Replacement therapy, however, also disadvantage is that its therapeutic effect is has its disadvantages, especially if used usually not as prompt as that of modern over a long period. These include the need replacement therapy. Also, it is of limited to carefully determine the dosage and benefit once the related tissue has been frequently adjust it. Overdosage causes totally destroyed. severe side-effects or complications, while Both acupuncture and tonification underdosage does not relieve the therapy are guided by the principle of symptoms. Another important disadvan- stimulating the body’s natural healing tage is that of drug dependence in chronic power or functional potentiality. On the cases. Replacement therapy cannot other hand, modern biomedicine has made stimulate the recovery of the diseased rapid progress on the basis of the tissues or organs; on the contrary, it may replacement principle of treatment. Organ cause atrophy of the tissues or further transplantation, too, is based on the reduction of function due to disuse. That is principle of replacement, and has been why, for example, sudden discontinuation invaluable to many patients, with plenty of of prednisone therapy may cause an promise for the future. There is great scope adrenal crisis, and a rapid and over- for traditional medicine, with its rich whelming intensification of chronic adrenal experience in the mobilization and insufficiency. utilization of the body’s potentialities, and

132 Harmonization of traditional and modern medicine modern biomedicine to complement mechanistic and reductionistic approach each other. of modern medicine and the dialectic and holistic approach of traditional medicine; Future prospects of and between modern medicine’s analytical harmonization approach to arriving at conclusions and This brief review of the development of traditional medicine’s method of traditional medicine in the People’s comprehensive observation. However, the Republic of China clearly indicates the prospects of harmonization seem brighter possibility and benefits of the harmoni- now that biomedicine has proceeded from zation of traditional and modern medicine. the cellular to the molecular level. The Harmonization has progressed in China combined analytico–synthetic methodology mainly because of the Government’s is replacing the purely analytical efforts to formulate and implement methodology in the medical sciences, and appropriate policies, as well as the efforts the biomedical model is being transformed made by the Chinese medical community. into a bio–psycho–socio–medical model, In the quest for harmonization, one must developments which are bound to facilitate keep in mind that the breach between the harmonization.17 Research into traditional two systems is increasingly narrowing, with medicine at the molecular and genetic the rapid advance of modern medicine in levels is likely to throw greater light on the recent decades. Earlier, there were mechanisms of traditional therapies and irreconcilable conflicts between the their integration with modern medicine.

References

1. Svoboda R.E. (1993) Ayurveda : Life, Health and Longevity. Penguin Books. 2. Conrad L.I., Neve M. Nutton V., Porter R., Wear A. (1995). The Western Medical Tradition: 800 BC to AD 1800. Cambridge University Press. 3. Said H.M. (1983). The Unani system of health and medicare. In: Traditional Medicine and Health Care Coverage. World Health Organization, Geneva, Ed: Robert H. Bannerman, John Burton and Ch’en Wen Chieh. pp 61–67. 4. Alternative Medicine: Expanding Medical Horizons (1992). A Report to the National Institute of Health on Alternative Medical Systems and Practices in the United States, prepared under the auspices of the Workshop on Alternative Medicine. Chantilly. VA, p. 79. 5. Farquhar J (1994). Knowing Practice: The Clinical Encounter of Chinese Medicine. Westview Press. Boulder/San Francisco/Oxford. 6. Eskinaze D.P. (1998). Factors that shape alternative medicine. Journal of the American Medical Association. 1998, 280: 1621–1623. 7. Yip Ka-che (1995). Health and National Reconstruction in Nationalist China. Association for Asian Studies Inc. p. 27. 8. Huang Yongchang (1994). National Conditions of Health in China (in Chinese). Shanghai Medical University Press; pp 151–154. 9. Zhu Qingsheng (2000). Adhering to stress on both Chinese and Western medicine and promoting their integration, strive for the construction of Chinese socialistic health services (in Chinese) Zhongguo Zhongxiyi Jiehe Zazhi (Chinese Journal of Integrated Traditional and Western medicine). 2000; 6(2): 82–87.

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10. Zhu Qingsheng. Strive for the Adaptation of Traditional Medicine to the Demands of Health-Care. Chinese Journal of Integrated Traditional and Western Medicine. 6(2): 82–87. 11. Zhang Wenkang (Editor-in-Chief) Zhongguo Weisheng Nianjian (Year Book of Health of the People’s Republic of China) People’s Health Publishing House. 1999. p. 392 and 428. 12. Huang Shuze and Lin Shixiao. Dangdai Zhongguo de Weisheng Shiye (Health Services in Contemporary China) Vol. II. China Social Science Press. 1986, pp. 68–92. (in Chinese). 13. Zhen Zhiya and Fu Weikang, Zhongguo Yixueshi (Chinese Medical History. People’s Health Publishing House. 1991. p. 201–210 (in Chinese). 14. Ma Jixing (1990). Lore of Traditional Chinese Medical Literature (in Chinese). Shanghai Press Science and Technology. p.16. 15. Zhang Wenkang (Editor-in-chief). Zhongguo Zhongyiyao Nianjian (Year Book of Traditional Chinese Medicine of the People’s Republic of China). China Traditional Medicine Press. 1999. p. 492. (in Chinese). 16. Chen Ke-ji. Forty years of integrated medicine in China. Chinese Journal of Integrated Traditional and Western Medicine. 1997, 3(3): 162–166. 17. Deng Pingxiu. Zhongyi Xiandaihua he Zhongxiyi Jiehe Yanjiu Fangfa (Research Methodology on Modernization of Traditional Chinese Medicine and Integration of Chinese and Western Medicine). A chapter of the book Yixue Bianzhengfa (Medical Dialectics) edited by Peng Ruicong. People’s Health Publishing House. 1992; pp. 152–160. (in Chinese).

134 Role of traditional systems of medicine in national health care systems

Role of traditional systems of medicine in national health care systems Shailaja Chandra

Introduction fully understood or recognized by governments, including drug authorities. he world-wide interest in the use of Meanwhile, a strong consumer demand for Tnatural products and plant-based herbal products, plant-based remedies and remedies has led to different situations a growing interest in Ayurveda, developing in different countries. In Acupuncture, Chinese Medicine, and their countries with a strong foundation of concepts, applications and strengths, traditional medicine such as India and which are millennia old, is taking place. China, nationally recognized parallel Often this is happening without the traditional systems have run for long knowledge of the allopathic personal periods, along with Western medicine with physician who is seen to be ignorant or varying degrees of acceptance, integration incapable of understanding why patients and assimilation. In other countries like find relief in the use of alternative medicine. those in , there is now a move to give Added to that, the attainment of sensory legitimacy to the traditional healer whose control through self-restraint and self- medical practice has been the mainstay of realization through meditation has become the local people, even after Western the aspiration for a large number of people, medicine made its appearance and took propelled to some extent by the belief that firm roots. In Europe and USA, a new and the human body and the human mind have growing consumer interest in the use of the ability to prevent and cure disease and natural medicine and herbal products has achieve a state of well-being given the right opened burgeoning markets for health tools. That this approach has merit is promotion products aimed at the significant to some extent, by the fact that improvement of physical well-being. This Yoga is a nationally recognized system of is a comparatively new constituency of medicine in India. herbal medicine users for the prevention Countries today, the world over, are of disease rather than cures for illnesses. flooded with thousands of plant-based Their emphasis has been on the use of remedies which have entered the markets single herbs and therapies promoted by as food supplements. Such products, which consumer interest and demand and not yet are primarily plant based and may or may

135 Traditional Medicine in Asia not contain synthetic ingredients, are being In terms of priorities, the epidemio- freely manufactured and exported. Many of logical situation compels governments to the remedies have their roots in the use of confront basic public health problems, plants for their medicinal value. With the leaving little time, space or funds for growth of consumer demand on the one including traditional medicine approaches hand and the current socio-political which are necessarily individualistic, slow ideologies on the other, governments have and difficult to monitor and evaluate. On been trying to grapple with the task of yet another plane lies the clinical approach, approaching the traditional medicine extended through allopathic dispensaries practitioners and products in a way that can and hospitals designed to treat individual be simple and meaningful enough to make and specialized problems with modern a significant improvement to people’s daily diagnostics and drugs. lives while ensuring safety. In this pursuit, With such a wide difference in concepts the government has naturally to confer and approaches, is it at all possible to bring legitimacy only on such systems, practices, about any kind of integration which would therapies and drugs which have been be of significant benefit to the people? Are investigated and found to be efficacious and comparisons between the loss of where a process of standardization can be productivity on the one hand (which assured. This exercise, however, calls for the invariably calls for strong medication) and integration of several facets which go into the elimination of side-effects on the other the making and practice of traditional (albeit with gentler but slower traditional medicine, which requires an understanding drugs) at all possible? Can one weigh the of the sector, its strengths and weaknesses short-term benefits of getting back to work and what will work. over the long-term benefits of avoiding Traditional medicine in every country dependence on strong drugs and wherever it has a strong base, has emerged resistance patterns? Is there at all a case out of an individual physician’s approach for identifying which part of the traditional to the problems of an individual patient systems can be integrated into a health spreading to the family, and later the system? Where does traditional medicine community. Rooted in traditional medicine fall between the public health approach on is the belief that every person belongs to a the one hand and the specialist-driven broad stereotype and problems can be hospital-based approach on the other? treated by understanding the individual’s Where will the inclusion of traditional personal traits and specific factors which medicine work to the greatest advantage, have brought about disequilibrium. and can there be a policy on its integration Whereas Western allopathic medicine has into the health system? a reductionistic approach and looks upon These are some of the issues which the removal of the symptoms of disease as policy-makers administering the health the main objective, Traditional Medicine sector have to grapple with, and at the does not see only a single remedy or a back of every decision-making process lies single approach as being suitable for all the question of whether the alternative people. Symptoms are seen only as an offered by traditional medicine will lead to indication of a deeper malaise which is not a significant improvement over the current necessarily considered to be caused by situation, sufficient to call for a change of physiological factors alone. policy. Would governments like to introduce

136 Role of traditional systems of medicine in national health care systems strategies which may suit the individual but which may lead to delay in the diagnosis of a really serious illness? How can the expertise of the practitioner and the quality and safety of the drugs be assured? Would governments be in a position to introduce regulations and enforcement mechanisms that protect the patient against malpractice and spurious drugs, without curbing the individuality of the practitioner? Equally, should the consumer be denied access to simpler, gentler forms of treatment only Pupils practising surgical procedures on vegetables in because there is no one to inform him ancient India about such alternatives? If at all traditional medicine is to be used as a strategy to bolster the normal health care approach, singly or in combination mixed with other where will its inclusion make the greatest natural substances of mineral, animal or impact and how can such assimilation take marine origin having properties to improve place? physical well-being, remove disease and These are some of the questions that disability and prevent the onset of seasonal need to be answered. This paper is an problems. If the remedy has been attempt to respond to them based primarily documented and has been in use in a on the Indian experience, but also community for hundreds of years or, for documented elsewhere. that matter, even two or three decades, does it call for safety and toxicity studies to Giving Legitimacy to be conducted if there is a way of testing Traditional Medicine the absence of high microbial content and the absence of non-permissible Traditional medicine can play a far more substances?2 meaningful role in the health system of a Many traditional medicines are no country if it receives legitimacy from govern- different from food items like home-made ments. For this, several requirements need wines, jams, jellies, squashes and syrups. to be fulfilled. They contain only natural ingredients and, just as there are standards for food, National Recognition for formularies and have Traditional Medicine been evolved to set standards for the Governments need to recognize a system preparation of many such traditional or practice, therapies and drugs which medicines. For assimilation into a health have been studied by professional system, if the pharmacopoeial standards evaluators for safety and efficacy to give are adhered to, if a licensing mechanism legitimacy to what is considered appro- is in place and if there are ways of testing priate for public use. Thousands of the product for the presence of the main formulations in Ayurveda and, for that ingredients and the absence of non- matter, tribal and folk remedies the world permissible substances, the system is in over speak of the use of various herbs, place.

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In India there are thousands of led to a situation where common remedies Ayurvedic and Unani formulations licensed which had been administered without any as medicines and sold over the counter and doctors for years have now become included in the formularies of health questionable for a new generation of departments, both by the national and Western-educated urban public exposed state governments. These formulations can only to the allopathic system and allopathic be prescribed by practitioners of the drugs. The age-old practices of maintaining respective traditional stream who suggest kitchen gardens and visits to the village the use of classical (generic) or proprietary grocer who stocked all the dried herbs have drugs exactly as done in allopathy. All such gone into disuse in the cities. Knowledge items are sold as Ayurvedic, Unani or about which part of the plant is to be used, Siddha medicines and carry a licence namely, the root, stem, bark or leaves, has number, together with the list of ingredients been effaced. Yet, for centuries this had on the label. been the mainstay of entire , long before allopathy came on the scene, Role of Traditional Home and continues to be so for tribal and village Remedies in the Health System people in many developing countries Home remedies and licensed drugs fall into even today. two distinct categories. On the one hand Every government is in a position to there are what could be determined as identify such drugs, whether they are in use common remedies for common problems, in the country of origin or in another and almost every country in South-East country having a similar socio-cultural Asia, China and Korea have their own tried environment, to be used for self-care, and tested traditional remedies for primary health care and as preventive problems falling in the category of gastric medicine.1 Such remedies are used very problems, diseases of the respiratory frequently in countries like India, Sri Lanka, system, skin and muscular problems, Thailand, Nepal and Bhutan, and the same treatment of diseases of the reproductive or similar plants are used with little and urinary systems, digestive disorders, indigenous difference. Thailand is reported treatment for wound healing, and common to have identified about 150 selected paediatric problems. This list is not herbs, screened them and brought the list exhaustive, but countries like India, down to 61 items accepted as a cure for Thailand, China, Sri Lanka, Bhutan, Nepal, illnesses signified by 17 symptoms. The and Korea, to name but a few, herbs selected were mostly items used all have their own lists of herbs which are regularly in foods grown in domestic commonly used singly or in combination, gardens like ginger, garlic, banana and made into a fresh paste, decoctions, or . The idea is to provide an dried and powdered, having no side-effects alternative to promote good health, by and which have been in use in the attempting to solve health problems community for generations as the first through self-reliance at the personal, remedy when symptoms manifest. family and community level. These Urbanization and the advent of the remedies can take care of common nuclear family leading to the virtual maladies such as constipation, diarrhoea, disappearance of the grandmother, the nausea, joint pains, , cough and cold mother-in-law, and the village elders, have and sore throat.

138 Role of traditional systems of medicine in national health care systems

In India, the Department of Indian matically lead to their use. The calibre of Systems of Medicine and Homoeopathy of the practitioner and his skills decide whether the Ministry of Health has published Home patients place reliance on the system. In Remedies for Ayurvedic2 and Unani3 India, there is a vast infrastructure medicines and circulated them for use by comprising more than 2854 traditional community leaders, extension workers, medicine hospitals with 49,353 beds, nurse midwives and school teachers at the 400,000 institutionally trained practi- village level. tioners of Ayurveda, Unani, Siddha and Homoeopathy, more than 387 colleges of The Use of Traditional Drugs where indigenous medicine, and more than Therapeutic Claims are made 22,000 dispensaries mostly situated in the For the wider sale of processed drugs where rural areas of the country.4 The practi- therapeutic claims are made, licensing is tioners have attended a five-and-a-half- a prerequisite. Legislation to enforce year degree course after completing the licensing and registration is available in final year of school. They have been countries like India, Indonesia and Sri registered by a statutorily elected Lanka assisted by pharmacopoeias and professional Council called the Central texts which are recognized under the drugs Council of Indian Medicine. People come enforcement legislation of the country. India of their own volition to access traditional and Indonesia have also introduced care, particularly for certain chronic Good Manufacturing Practices (GMP) for ailments. In some states of India like traditional drugs which cover the and Tamil Nadu, the requirements relating to the qualification traditional medicine practitioner is very of employees, the responsibility of the much a part of the primary health care quality control managers, essential system and provides diagnosis and requirement of space, equipment, treatment in the same health facility along documentation of processing and with allopaths. In times of national disasters packaging methods and need for self- like cyclones, floods and earthquakes, regulation, coupled with enforcement by under Government orders traditional the licencing authorities. India, China, medicine practitioners provide their own Bhutan, Indonesia and Thailand have emergency medical relief, more specifically national drug lists for use in primary health to prevent diarrhoea, dysentery and skin care and in hospitals. These examples can ailments and to help people overcome be emulated with advantage as such lists shock and disorientation. They have been bring about confidence in the user and the used extensively during outbreaks of utilization patterns can be studied for Japanese encephalitis where homoeopathy modifications in stocking policy. was found to have particular efficacy. When the practitioner is part of the Use of Traditional Medicine in health system, his registration after More Complicated illnesses completion of a recognized educational In the case of complicated illnesses, simply course is absolutely necessary. The public stating that these drugs are recognized by have a right to receive standardized the Government and that they can be safely treatment and drugs and to hold practi- used for self-care and primary health care tioners responsible for the medication they for all kinds of diseases will not auto- administer.

139 Traditional Medicine in Asia

Role of Research in Traditional z Brahmi and Mandukaparni to promote Medicine Mental Health;12,13 Today, research is done mainly to establish z Ayurvedic drugs Aswagandha and evidence of the efficacy of the drug or Guduchi as rejuvenators and immuno- therapy that is being used. In the area of modulators; traditional medicine, unfortunately most z Panchakarma therapies for paralytic 14 people feel that it is mainly anecdotal disorders; evidence or at best confined to case studies z Ksharasootra ligation for anal fistulae 15,16 or observational studies. A few uncon- and haemorrhoids. trolled trials or small randomized clinical z Bio-enhancers like pippali and maricha trials do not inspire much confidence. to increase the bio-availability of drugs; 17 The Government of India set up four z Brahmyadi Yoga for Schizophrenia; research councils almost 30 years ago to z Oral contraceptives like pippaliyadi look at the efficacy of Ayurveda, Unani, yoga (CCRAS communication); 18 Siddha, Yoga and and z Spermicidal – Nimba Taila. subsequently that of Homoeopathy. Siddha Research conducted over the last 20 years has shown specific areas of strength where z A Siddha preparation 777 Oil for 19 traditional medicine is particularly useful, Psoriasis. often where western medicine has little to Unani offer. Areas where it can be used as a stand-alone therapy or as an adjunct The Council for Research in Unani therapy have also been identified. Some of Medicine prepared Unani formulations for the major outcomes of the clinical research the following areas: 20 undertaken in the field of Indian Systems z Bronchial Asthma, Filariasis, Infective 21 22 of Medicine include: Hepatitis and Vitiligo

Ayurveda Homoeopathy z Behavioural Disorders z An Ayurvedic Antimalarial Ayush-64 for P-vivax;5–7 Belladonna, Hyoscyamus, Ignatia amara, Stramonium; z An Ayurvedic Antiepileptic drug Ayush-56;8 z Diabetes Mellitus Cephalandra or Coccinia indica z An Ayurvedic drug Vijayasara for Diabetes Mellitus (ICMR Communi- (Bimbi); cations); z Filaria Apis mellifica, Bryonia alba, Rhus tox; z An Ayurvedic drug Guggulu and its extracts for hyperlipidaemia and z Gall stone atherosclerosis;9 Fel tauri 2X or 3X; z Malposition of human foetus z An Ayurvedic formulation Pushkara Guggulu for Coronary insufficiency for Pulsatilla nigra 200; stable angina;10 z HIV/AIDS Tuberculinum, Phosphorus, Arsenicum z An Ayurvedic drug Varuna for UTI, Urolithiasis and benign prostate album, , nux hypertrophy;11 vomica, syphilinum, sepin, mercurius solubitis.23,24 z Bhoomyamalaki for Hepatitis B;

140 Role of traditional systems of medicine in national health care systems

Presently, in India, operational research any country, particularly in the growing studies are about to start in the area of fields of non-communicable diseases and healthy aging, using Ayurvedic drugs for geriatric and mental care. In handling specific problems like benign prostrate difficult and intractable conditions, clinical hypertrophy, reduction in menopausal trials are necessary. The challenge for symptoms, preventive , arthritis health administrators lies in designing and the use of “Rasayana” for rejuvenation. studies and motivating allopathic hospitals Likewise, operational research studies have to undertake trials to establish the extent been designed and will commence shortly of benefits likely to be received by using the to cover nine specific areas affecting traditional approach, whether as a direct women and children’s health which include measure or as an adjunct therapy. menstrual disorders, reproductive tract However, research methodologies have to infections, antenatal care, postnatal care, be designed keeping in mind the indivi- complications of pregnancy (vomiting, dualistic nature of the traditional diagnosis oedema) galactogogue, health promotion and the holistic side of traditional drugs. of neonates and infants, and the WHO has recently finalized guidelines on management of common colds, etc. research methodologies for traditional Some of the important extra-mural medicine. The publication of the guidelines research projects which have been approved will create new and achievable parameters by the Department of Indian Systems of for research in this area, designed to foster Medicine and Homoeopathy of the greater enquiry, shorn of a restricted Government of India, and which are in approach not tenable for medical research progress, include examining the benefits of in the traditional area. the integrated Approach of Yoga Therapy on Schizophrenia, Clinical, Haematological, Why Raw Material and Biochemical and Immu-nological Studies on Standardization are of Patients of Chronic Arsenic Toxicity and its Paramount Importance in Homoeopathic Management, Role of Traditional Medicine Ayurvedic Drugs in the prevention and Traditional medicine relies almost 90 per Treatment of Occupational Health Problems cent on the use of medicinal plants (Pnemo-conicosis) in Industrial Workers, an supplemented by minerals and metals and objective Evaluation of the Efficacy of animal and marine products like corals and Panchavalkal, an Ayurvedic preparation, in shells. Health systems and health admini- treating Leucorhoea, a primary Study of strators have perforce to get involved with Cancer treated through the Ayurvedic the raw material aspect if traditional approach, a study on the treatment of medicine is to be taken seriously. Without Keloids in Homoeopathy and Allopathy, this the quality of medicine can suffer, Efficacy of Ayurvedic Treatment as an affecting the credibility of traditional Adjuvant Therapy for Fracture Treatment and remedies. Delayed Bone Healing, and a Comparative Medicinal plants comprising thousands Trial of Ayurvedic and Allopathic Therapy for of species of plants constitute a vast, Spasticity and Paralysis-A randomized undocumented and over-exploited resource. Controlled Study. The growth and cultivation of such plants, It will, thus, be seen that there are their collection, storage, distribution, areas of interest to the health systems of processing and marketing are now gaining

141 Traditional Medicine in Asia importance as they all have an impact on Biotechnology, Science & Technology and quality. For traditional medicine to get a Commerce have come together to evolve foothold on a sustained basis, the quality a coordinated approach to the develop- of the medicine has to be assured. There is ment of the medicinal plant sector. A a world of difference between the efficacy Medicinal Plant Board has been establi- of a medicine made from plants cultivated shed to coordinate all the activities under and harvested using good agricultural the Department of Indian Systems of practices and that derived from plants Medicine and Homoeopathy which also uprooted from the wild.25 has the responsibility to lay down standards In most countries, even in those where for traditional medicine drugs. Despite this the use of traditional medicine is strong, policy-level support, the role of traditional the cultivation of medicinal plants is at medicine in the health system will be present limited to a few items, most natural decided by only one factor, i.e., the curing products being collected by villagers and and health-giving ability of the practitioners tribal people from wastelands and forests. and the remedies on a sustained basis. For want of training, they may destroy the whole plant instead of collecting just the Standardization, a Pre-requisite part to be used. Re-plantation and for Quality Control of Traditional propagation is left to nature. Collection not Medicine Drugs done during the proper season often Standardization of plant-based drugs is detracts from the efficacy of the end extremely difficult because presently very few product. The networking of collection is quality control tests are available in most under the control of traders and the countries using traditional medicine. In their material collected is sold in the nearby absence, there are no methods to evaluate township from where it reaches regional the contents and the quantities as claimed centres for domestic use or export. Enligh- on the label. Quality control is required at tened industries do, however, cultivate three stages, namely, when the raw material plants so as to be assured of standard is used, for confirming the process quality and the presence of active undergone by the drug during manufacture, ingredients. They have invested in recruiting and at the finishing stage. The shelf-life or botanists and standardization experts in date of expiry needs to be indicated and the order to access quality raw material. Some possibility of mixing modern drugs has to of these industries have their own R&D be strictly eliminated and strong deterrents facilities where documentation is imposed to discourage such practices. maintained and quality assured through Measures to test the absence of pesticide finger printing, HPLC and TLC tests. residues, heavy metals and aflatoxin have However, small manufacturing industries to be taken through proper regulation and rely on market sources which have many testing.26, 27 At least a few important markers attendant problems which affect quality. have to be identified through TLC (finger In India, at the federal level the printing) and the process of making random Departments in charge of traditional checks has to be institutionalized and medicine (Indian Systems of Medicine and penalties imposed if non-permissible Homoeopathy under the Ministry of Health substances are found or the medicine does and Family Welfare), the Department of not conform to safety standards. For patent Environment and Forests, Agriculture, proprietary drugs, manufacturers must be

142 Role of traditional systems of medicine in national health care systems asked to provide the recipes. Consumers authorized to conduct quality control tests must be kept informed about how they can and issue certification is also contemplated. access quality products and where tests can Traditional medicine can play a role in be undertaken if doubts about quality are the health system of a country if the system experienced. and its medicaments have been prepared In India, pharmacopoeial standards in a manner that inspires confidence in the for 158 drugs are available and 634 quality and the Government supports the formulations have been published in the use of such systems with the needed Ayurvedic Formulary of India. Likewise, controls.36,37 Without this input, traditional for Unani medicine pharmacopoeial medicine can grow only in a haphazard standards are available for 45 drugs and way and public confidence may get eroded a Unani Formulary for 603 formulations over time. Issues of quality have to be is available. In respect of Homoeopathy, confronted squarely and national and pharmacopoeial standards are available provincial governments have to be made for 916 drugs.28-35 aware of what is acceptable across the In Ayurvedic and Unani formulations, world. Only then will traditional medicine sometimes a single medication has over 50 be able to achieve its due position in the ingredients and certainly even the simplest health system. medicines have 6–10 ingredients involving the use of different parts of several plants. Issues of Integration Standardization is not a simple task and it has to be undertaken and institutionalized Indian Government’s Policy on if the traditional medicine sector is to Traditional Medicine secure a niche for itself in the health system. The Central Council for Health and Family Scientists have given numerous Welfare, set up under Article 226 of the suggestions about the standardization and Constitution of India, is the highest policy- quality control of herbal drugs. In India, making body which lays down policy for the problems have been addressed all sectors covered under the health through a variety of measures, some of portfolio. It meets once a year and consists which have already been implemented and of the federal health ministers, state health some are still in the process of being ministers, eminent health experts, NGOs introduced. In order to give an impetus to with an interest in health, and officials of Quality Control and Standardization, the the central and state governments. Department of Indian Systems of Medicine The Council in its last meeting held in and Homoeopathy has initiated schemes 1999, inter alia, recommended that at to help strengthen the State Pharmacies and State Drug Testing Laboratories to become models for the proper formulation Traditional medicine can play of quality medicine for use in the public a role in the health system sector and Government-run hospitals and of a country if the system dispensaries. Side by side, recognition of and its medicaments have private laboratories which possess the been prepared in a manner equipment and the scientific and technical manpower as stipulated, and act as that inspires confidence Government-approved laboratories in the quality.

143 Traditional Medicine in Asia least one physician from the Indian Systems The Government of India has set up a of Medicine and Homoeopathy (ISM&H) Population Commission to address the should be available in every primary health whole issue of population stabilization. The centre in every state and that vacancies Commission has further set up a High caused by non-availability of allopathic Powered Advisory Group on Mainstrea- personnel should be filled by ISM&H ming of Indian Systems of Medicine and physicians. The Council also resolved that Homoeopathy (ISM&H) into the health specialist treatment centres for ISM&H system. The terms of reference seek to: should be introduced in rural hospitals and z Review the status of Reproductive and a wing should be created in the existing Child Health (RCH) services extended state and district-level Government by ISM&H practitioners, their infrastru- hospitals so that the benefits of these cture and personnel; systems are made available to the general z Identify areas where ISM&H practi- public, according to their choice. It has tioners can be used more effectively by also been resolved that expenses on upgrading their knowledge and skills; treatment received in traditional medicine z Select effective ISM&H practices which hospitals should be recognized for can augment the existing RCH approach; reimbursement as is already permitted in z Specify significant legislative, admini- the case of Central Government strative and schematic changes which employees. All these measures have been need to be introduced to achieve the recommended to all state governments and objective of utilizing ISM&H and their the action taken thereon is regularly practitioners to the best advantage. monitored at the central level. This is the first time that a separate high-powered group has been set up for Mainstreaming Indian Systems of using the strategies of ISM in population Medicine and Homoeopathy for stabilization, a major area of focus for the Population Stabilization Indian Government. The Government of India has adopted a ‘National Population Policy 2000’ and, for Integration of Traditional the first time, a Chapter has been Medicine into the Reproductive introduced on mainstreaming the Indian and Child Health Programme Systems of Medicine and Homoeopathy For the first time, drugs of the Ayurvedic (ISM&H). The Policy seeks to use the and Unani systems have been incorpo- institutionally qualified practitioners of rated into the kits of nurses and midwives ISM&H (who have completed a five-and- in the sub-centres of seven states and four a-half-year degree) and utilize their services cities, to be extended to the whole country to fill the gaps in manpower at appropriate later. The same drugs are also to be made levels in the health infrastructure. The Policy available in the kits of female extension also seeks to increase utilization of ISM workers in over 5,00,000 centres institutions, dispensaries and hospitals for providing supplementary nutrition to health and population-related progra- pregnant and lactating women and mmes. What is particularly noteworthy is children below six years. The traditional that the Policy advocates the use of tried drugs have been selected to take care of and tested ISM medicines at the village and common problems and are being centrally household level. procured and tested before being added

144 Role of traditional systems of medicine in national health care systems to the kits. This will further help the health developed a vaginal contraceptive systems to take care of a large number of (spermicidal agent) from Neem Oil women and children as a first line of care (Azadirachta indica) in the form of pessary, through traditional medicine. which has been approved for clinical trials. Meanwhile, but again for the first time, This product of DIPAS has overcome the the Ayurvedic concepts of the Healthy inconveniences of using the oil as such, Mother and Child are to be studied through being done by the CCRAS. an operational research project under the The work on Pipplyadi Yoga, a herbal joint aegis of the Indian Council of Medical contraceptive, is already undergoing Research and the Central Council for clinical trials in five allopathic centres with Research in Ayurveda and Siddha (CCRAS). allopathic clinical investigators. Both these Five states and 10 blocks have been initiatives will be a boon to rural women if identified for this study. The areas cover the highly effective cheap contraceptives are overall approach to reproductive and child developed. health, including menstruation, antenatal These examples show how the benefits care, preparation for delivery, vomiting in of Indian medicine are being brought into pregnancy, loss of appetite, constipation, the mainstream of health care where they gaseous distention, acidity and diarrhoea, are poised to play an increasingly important treatment of oedema, loss of sleep, piles and role. anaemia, delivery and its management, contraception and the management of the Does Traditional Medicine Have newborn. In regard to neonatal and child a Role in an Allopathic Set-up? health, the areas include care of the Different countries have made different newborn, precautions during the first week kinds of efforts to assimilate traditional after birth, supplementary food for the medicine into the normal health system. infant, general growth and development of This has met with varying degrees of the child, management of diarrhoea, success. Some examples of how India has constipation in children and eradication of given a role to traditional medicine in the worm infestation. The entire approach is health sector are described below. traditional and the applications are simple In a 900-bed general allopathic enough to be administered by Ayurvedic hospital in New Delhi (the R.M.L. Hospital), practitioners, nurse midwives, traditional services for Homoeopathy and Unani birth attendants or even at the household treatment are available under the same roof. level. This again is the first time that a joint In another 1500-bed allopathic hospital operational research study combining (Safdarjung Hospital), Ayurvedic and research talent from allopathy and Homoeopathic treatment is available. traditional medicine will be undertaken to Medicines are either given by the practi- determine the benefits of the Ayurvedic tioners or through the Central Government approach in this area. The objective is to Health Scheme (CGHS) to government identify areas of greater relevance and employees. significance, which could be introduced in The attendance pattern in the traditional the Reproductive and Child Health medicine clinics was analysed over a six- Programme. month period. The main findings were that The Defence Institute of Physiology and in Ayurveda, among the chronic diseases, Allied Sciences (DIPAS) has successfully arthritis (sandhi vata) accounted for 10.8

145 Traditional Medicine in Asia per cent of the attendance, abdominal In respect of Homoeopathy, it was diseases (udara ) for 10.1 per cent found that most people accessed the and nervous diseases (vata vyadhi) for 9.2 system for gout, arthritis and bronchial per cent. In the case of acute diseases, the asthma among chronic diseases. In the largest turnover was in respect of bronchitis case of acute diseases it was the upper (Kasa), weakness (dhatuksaya), disease of respiratory tract infections that had the mouth (mukha roga), etc. (Table 1). largest attendance (Table 2).

Table 1. Utilization of Ayurvedic Treatment over a six-month period in Safdarjung Hospital, New Delhi (A 1500-Bed Allopathic General Hospital) Chronic disease Attendance Ordinary disease Attendance %% Sandhi vata (Arthritis) 10.8 Kasa (Bronchitis) 12.8 Udara vikara (Abdominal disease) 10.1 Pratisyaya (Coryza) 8.4 Vata vyadhi (Nervous diseases) 9.2 Dhatuksaya (Weakness) 7.4 Amlapitta (Hyperacidity) 7.8 Mukha roga (Disease of mouth) 7.2 Sotha (Dropsy) 5.6 Mutra roga (U.T.I.) 6.1 Yakrta vikara () 5.2 Pandu (Anaemia) 5.6 Tvak-roga (Diseases of skin) 5.0 Pradara (Leucorrhoea) 5.6 Amvata (Rheumatism) 5.0 Rakta vikara (Blood impurities) 5.5 Svasa (Asthma) 4.7 Ajirna (Indigestion) 5.0 Grahanidosa (Sprue) 4.6 Kosthabaddhata (Constipation) 4.5 Other Diseases 32.0 Other Diseases 32.0 Total 100 100 (5593) (3989)

Table 2. Utilization of Homoeopathic Treatment over a six-month period in Dr. R.M.L. Hospital, New Delhi (A 900-Bed Allopathic General Hospital) Chronic disease Attendance Acute disease Attendance %% RA/Gout/Arthritis 9.9 U.R.I. (Upper Respiratory Tract Infections) 27.0 Dyspepsia 5.9 P.U.O. (Pyrexia/Fever of unknown origin ) 17.4 Sinusitis 4.8 Allergic Rhinitis/Rhinorrhoea 14.3 Dermatitis 4.4 Urticaria 5.9 Tonsillitis 3.5 Stomatitis 5.6 Bronchial Asthma 3.1 Abscess 3.9 Alopecia areata 2.8 Jaundice 3.4 NBA (Naso Bronchial Allergies) 2.7 Dysentery 3.3 Verruca 2.5 Gastro-enteritis 3.2 Headache 2.4 Dentition period/troubles 3.0 Other Diseases 58.0 Other Diseases 12.9 Total 100 100 (10006) (2613)

146 Role of traditional systems of medicine in national health care systems

Table 3. Utilization of Unani Treatment over a six-month period in Dr. R.M.L. Hospital, New Delhi (A 900-Bed Allopathic General Hospital) Chronic disease Attendance General disease Attendance %% Waja-ul-Mafasil (Rheumatoid Arthritis) 23.1 Su-e-Hazm (Dyspepsia) 10.5 Bars (Vitiligo) 7.9 Nazla-wa-Zukam (Common cold) 10.5 Sailan-ur-Rahem (Leucorrhoea) 6.1 Qabz (Constipation) 10.1 Saman-e-Mufrit (Obesity) 5.6 Faqruddam (Anaemia) 6.1 Zeequn Nafas (Bronchial Asthma) 5.4 Waja-ul-Batn (Abdominal pain) 6.1 Ziabetus Sukkari (Diabetes Mellitus) 5.2 Humma (Fever) 5.9 Humuzat-e-Meda (Hyperacidity) 4.0 Zaheer (Dysentery) 5.7 Warm-e-Qasbat-ur-Riya (Bronchitis) 3.3 Ishal (Diarrhoea) 4.7 Bawaseer (Piles) 3.2 Qula (Stomatitis) 4.1 Zof-e-Kabid (Liver dysfunction) 2.7 Suda (Headache) 3.9 Other Diseases 33.5 Other Diseases 32.4 Total 100 100 (18095) (10492) The Tables are indicative of the areas where patients visiting an allopathic hospital still prefer to use traditional medicine exclusively or as an adjunct therapy.

The Unani system appears to attract postgraduate level for teaching and the largest number of people for research and this approach is continuing rheumatoid arthritis (waja-ul-mafasil) and even today. The M.D. Ayurveda vitiligo among chronic diseases, common Programme of the Faculty of Ayurveda is cold (nazla-wa-zukam) and dyspepsia (su- also open to MBBS graduates. For such e-hazm) (Table 3). candidates, the first-year M.D. Course is a special preparatory course and there is Institute of Medical Sciences, a separate examination for the two Banaras Hindu University, streams. But the Final M.D. Ayurveda Varanasi – An example of examination and teaching is common for integration both the streams. They undergo the same Banaras Hindu University (BHU) is training in the 2nd and 3rd year, clear the probably the first institution which same examination and get the same conceived the idea of integrating the degree. ancient and modern systems of medicine The University has also passed an both at the level of education and Ordinance through which a candidate professional practice, 73 years ago, when holding an M.D. degree in Ayurveda may the first ever integrated Ayurvedic College be registered for a Ph.D. degree in the was established. Subsequently, this model respective speciality of modern medicine became controversial and was opposed and vice versa. by the mainstream of Ayurvedic organizations, and the Ayurvedic College Medical Research in BHU of BHU was closed in 1960 but an The M.D. Ayurveda and Ph.D. Ayurveda integrated education was started at the scholars adopt modern parameters of

147 Traditional Medicine in Asia study but they also adopt parallel Ayurvedic prescription of a practitioner) at other parameters such as determination of places. Whether traditional medicine can Prakriti, Ayurvedic Diagnosis, Status of Agni at all be used effectively both in the public and Ama. In all cases the main guide for health area and in clinical practice as an the thesis-level research is a teacher from adjunct or an adjuvant has no uniform the Faculty of Ayurveda but there are one answer. At the same time, there are a large or two co-guides from modern medicine number of approaches which may be used or the basic medical sciences. to advantage with a little effort, but that There are no formal rules or policy requires a policy backup and regulatory formed for this collaboration. The pattern systems to make such strategies work. has evolved spontaneously and mutually Since it is difficult to generalize, a few over the years. examples are given about how the public can be benefited. Cross-referrals in BHU The treatment and patient care in BHU like Yoga Hospital too is on an integrated pattern. Yoga is known to be effective in the The main morbidity areas in which the management of various disorders and patients are referred for Ayurvedic indexed research papers have shown treatment at BHU involve: improvement in cases of anxiety neurosis, Fistula in ano, chronic rheumatic depression, arthritis, bronchial asthma, diseases, residual psychosis and anxiety constipation, hypertension, respiratory disorders, chronic colitis and IBS, diseases diseases, back pain, insomnia and postural of the liver and jaundice, degenerative defects. The most important way that Yoga brain disease and neuropathy and can contribute in improving the state of terminally sick patients of all kinds declared well-being of a large number of individuals incurable and/or financially unable to is if governments were to introduce the afford modern treatment. Most cases are practice of yogic asanas in schools and referred to the Department of Kayachikitsa also if classes were to be held for the benefit or Internal Medicine. of the general public. In New Delhi, such classes are run in the mornings and Practical areas where evenings at a Central Institute for Yoga Traditional Medicine can be (MDNIY), separately for men and women used effectively in the Health and these can be accessed free of cost. System The general public can participate at will. During summer, when schools are closed, Traditional medicine falls into several the institute establishes 101 camps in different segments, from the highly different residential localities of Delhi for the researched and documented to that which benefit of residents by paying for the has been practised through , services of a Yoga teacher after prior from manual therapy and manipulation to screening for their capability, commu- . There are also important nication skills and knowledge of yogic systems like Homoeopathy which are postures. The yogic asanas with meditation routinely accessed over the counter in some have helped countless people to maintain countries but restrictions continue on the physical and mental equilibrium. use of the medicine (except on the The Defence Institute of Physiology

148 Role of traditional systems of medicine in national health care systems and Allied Sciences (DIPAS) has done licensed and sold with proper labelling and extensive work on looking at the effect of product information. In some countries like Yoga on soldiers working in extreme the United Kingdom, allopathic practi- climatic conditions as well as the effect of tioners undergo a one-year course in vegeta-rianism, yoga and meditation on Homoeopathy and can practise the system. persons having over 50 per cent blockage In India, students have to enrol after the of at least one artery with the results being school level and undergo a five-and-a-half- followed up after six months. Cardiologists year degree course to be allowed to from top allopathic institutions tested the practise. Homoeopathy is particularly results through angiography and the remarkable in being able to treat routine outcome has shown extremely promising problems, skin and other allergies, gastric results. In this way, patients have been problems and children’s ailments. It is enabled to overcome apparently possible to list at least 40 simple remedies intractable problems through simple and which could be sold through chemists over cheap strategies within their control and the counter without prescription, in 5 ml. devoid of side-effects. vials, so that there is no misuse. These 40 Several specialized institutions in the medicines are intended for common allopathic sector as well as those commi- ailments to relieve symptoms to aid early tted exclusively to Yoga are conducting restoration of normalcy. It is necessary to extensive research on the tremendous improve access to these simple medicines healing properties of Yoga and its strengths. and to sensitize people, who should be This is one of the cheapest ways of involving encouraged to use such remedies. Several the community in health promotion and in simple booklets are available which making it a community effort. The health describe the condition as well as the mode system only needs to screen the Yoga of administration of the drugs and the teacher, extend occasional supervision and dosage. Since Homoeopathy is a gentle to see that nominal payments are made and effective medicinal science, its use for the classes. The community can be left should be integrated into the health system to decide the teacher’s acceptability. In more effectively. order to make this a part of the health system, it is necessary to involve the local Traditional Therapies which can Government machinery in the rural and be integrated to advantage urban areas, community leaders, schools Research studies have also shown the teachers and doctors in-charge of PHCs. beneficial effects of Ksharasootra and Through this approach, a number of Panchakarma, two Ayurvedic therapies. problems can be taken care of without Ksharasootra comprises the use of medication. Ayurvedic medicated thread in the management of fistula-in-ano, and Homoeopathy multicentric trials have been conducted at Homoeopathy is recognized as a system the collaborating centres of the Indian of medicine in many countries and a large Council of Medical Research on 265 number of drugs are available over the patients where the approach was counter in the United States, as well as in compared with conventional surgery. The several European and other countries. It is finding showed that the long-term outcome extremely important that the drugs are of Ksharasootra is better than surgery,

149 Traditional Medicine in Asia

although the initial healing time is longer. cular and certain orthopaedic disorders. It is an effective, ambulatory and safe Ksharasootra has provided an alter- alternative treatment for patients with native for those patients who either do not fistula-in-ano, the main advantage being want surgery or who have encountered that general anaesthesia is avoided and the recurrence of the problem after conven- chance of recurrence of the problem is nil. tional surgery. In fact, it has been seen at Another highly acclaimed procedure in the KEM Hospital, a large allopathic Ayurveda refers to Panchakarma, which hospital in , that cases of fistula- constitutes a part of the therapeutic in-ano undertaking surgery have declined approach in the treatment of diseases as considerably ever since Kshar- has well as for the prevention and promotion been offered as an alternative. The cost of of health care. Panchakarma therapy these measures is nominal given the comprises five purificatory and therapeutic outstanding relief they have given patients. procedures consisting of oilation and There are applications similar to fomentation of the body followed by Panchakarma available throughout the medicated emesis, purgation, medicated traditional system of medicine in most enemata, nasal insufflation and blood countries of South-East Asia which would letting. Five modified procedures of oilation be worth incorporating in general hospital and fomentation of the body have come wards and other in-patient facilities. to be known as Keraliya Panchakarma. These include Sirodhara (dribbling of oil on Folk Medicine and Tribal forehead), Sarvangaseka (dribbling of oil Remedies on the whole body while massage is done) Every country has its own list of traditional sweda (fomentation with hot remedies and countries need to document medicated balls of cooked rice, etc.). these after observing local people and their Annalepa (besmearing of cooked and practices. This is important because this medicated rice on the whole body) and information is often the foundation of larger Sirolepa (application of thick medicated discoveries and inventions, and since this paste on the crown of the head). These are information is passed down by word of followed by specific dietary measures each mouth, it is likely to be lost forever. It is time. Panchakarma has been used in important to engage botanists, foresters treating many critical diseases like diabetes, and NGOs working in this area to prepare cardio-vascular diseases, hypertension, lists of such tribal, folk and village remedies. arthritis, rheumatoid arthritis, osteoporosis, In India, the Central Council for and degenerative disorders. Research in Ayurveda and Siddha Both these procedures have been (CCRAS),38 and the Central Council for advocated by the Department of Indian Research in Unani Medicine (CCRUM) Systems of Medicine and Homoeopathy for have observed and documented over being extended to allopathic hospitals 10,000 such remedies, although not all where large numbers of patients of them can be used and not all the plants congregate. Panchakarma has been found are readily available. Yet, these remedies to give significant relief well beyond what represent the knowledge of the people and drugs and physiotherapy can achieve, the intellectual property of the country. particularly for symptoms and ailments Unless these are documented, it will be caused by neurological and neuromus- difficult to give benefit to the country and

150 Role of traditional systems of medicine in national health care systems the community. Health departments must Government with a Secretary, who reports appoint the right blend of survey staff to to the Union Ministers for Health. Public document this knowledge, which will health is a State subject under the Indian otherwise disappear forever along with the Constitution and 18 state governments in disappearance of forests, tribal commu- the country have set up Directorates of nities and village doctors. Having Indian Systems of Medicine & Homoeo- documented it, the next step is to identify pathy. Some states have independent areas of current importance where the ministers in-charge of the non-allopathic remedy appears to offer a net advantage recognized systems. India has the following over available medicaments and to conduct capacity in the traditional medicine sector observational or animal studies (in the case (Table 4). of unknown plants) to test their efficacy.

Need for establishing an Drug Licensing for Traditional infrastructure for Traditional Medicine Medicine with supporting The drug-based systems, viz., Ayurveda, Legislation Unani, Siddha and Homoeopathy, are covered by the Drugs and Cosmetics Act Infrastructure for Indian Systems of the country and the rules made of Medicine & Homoeopathy thereunder. The licencing authorities for Six systems of traditional medicine are traditional medicine drugs are appointed nationally recognized by the Government by the state government, which implements of India and the state governments – the rules. However, the powers to modify Ayurveda, Siddha, Unani, Yoga Naturo- the Act and rules rest with the Union pathy and Homoeopathy. There is a full- Government, which is guided by the Drugs fledged, independent Department under Technical Advisory Board for Ayurveda, the Ministry of Health of the Union Siddha and Unani drugs and a Drugs

Table 4. Infrastructure for Indian systems of medicine and homoeopathy (1999) System Colleges Registered Licensed Under- Post- Traditional Pharmacies of graduate graduate Practitioners Traditional Medicine Ayurveda 196 49 3,66,812 8,405 Unani 40 03 40,748 549 Siddha 02 01 12,911 417 Homoeopathy 149 15 1,88,527 903 Naturopathy – – 402 –

Admission Capacity 14,255 700 Hospitals of ISM&H (in Govt. Sector) 2,854 Beds in hospitals of ISM&H 49,353 Dispensaries of ISM&H (in Govt. Sector) 22,735

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Consultative Committee, both of which are Kaumarabhritya (Maternity and Child statutory committees where the views of Health), etc., and laboratories for experts and state governments are biochemistry, pathology, pharmacology, discussed. All the rules have statutory modern pharmaceutical chemistry, nationwide application. pharmacognosy and experimental laboratories. These laboratories provide Medical Education and the support for research projects by utilizing registration of the Traditional the ancient knowledge of Ayurveda. Medicine practitioner Responding to the growing interest in Countries like India and China have Ayurveda, the University has broad based their own registration processes for its training programmes and also facilities traditional medicine practitioners. In India, for special diploma and certificate courses a student must pursue a five-and-a-half- in Ayurveda for foreign professionals and year degree course after the school level students. An International Centre for to be able to qualify as a registered Ayurvedic Studies has also been establi- practitioner of Ayurveda, Unani, Homoeo- shed. The courses run by the University are pathy or . The Indian indicative of the different approaches Parliament enacted an Act for the Central available for educating and training Council for Indian Medicine (CCIM) in students to equip them with varying 1970 and for the Central Council of degrees of competence to learn about and Homoeopathy (CCH) in 1973. These have practise Ayurveda. been set up on the lines of the Medical Presently, 18 students from 12 Council of India (MCI), patterned on the countries have completed different courses General Medical Council of UK. The at the University. Requests for affiliation educational standards for colleges have already been agreed to in the case of including the curriculum, are laid down by three foreign institutions and six more the Councils which grant recognition to requests are under consideration. This is educational institutes, which also have the indicative of the role that traditional powers to regulate the admission capacity, medicine is destined to play as more serious on an appraisal of the infrastructure. interest devolves on understanding the Affiliation is granted by the universities. philosophy and practice of Ayurveda.

Gujarat Ayurved University Issues of Registration and The Gujarat Ayurved University at Practice Jamnagar is the only statutory university For traditional medicine to be accepted on exclusively devoted to Ayurvedic studies a wider scale, it is necessary for the practi- and research. It has facilities for teaching tioners to be exposed to an educational Ayurveda up to graduation level as well system and to possess registration to as for the M.D. and Ph.D. courses in practise medicine. While there can always Ayurvedic Medicine. It has Departments be a case for the continuance of traditional of Basic Principles, Dravyaguna healers and their oral family tradition (Pharmacology), Rasashastra () passed on from generation to generation and Bhaishajya Kalpana (Pharmaceutics), in order to play an effective role in the Kayachikitsa (Internal Medicine), Shalya health system, practitioners need to go (Surgery), Shalkya (eye and ENT), through a course of educational training

152 Role of traditional systems of medicine in national health care systems and skills acquisition if they are to treat available. The list comprises some 315 patients at a level beyond that of home medicines falling under 19 categories of remedies for common ailments. diseases and problem areas. It has been Traditional medicine practitioners who calculated that health departments would have undergone a degree course are fully need to set aside about $950 per facility qualified to perform tasks like supervision per year if classical (generic) medicines are of TB drug intake, dispensation of malaria used for an OPD clinic visited by 50 drugs and screening of STI and RTI cases. patients a day. Such lists are available in They can facilitate referrals, undertake other countries too. Several of them are counselling and advocacy for the manufactured in Government-owned prevention of HIV/AIDS and help identify pharmacies or are purchased from cases of cataract blindness. Since most manufacturers. health system managers are doctors from There are over 9000 licensed the public health stream, they do not readily pharmacies manufacturing a vast array of accept this paradigm, which is why drugs catering to a wide range of human governments need to declare and as well as veterinary problems. Their implement a policy on the utilization of preparations conform to original classical these practitioners. The challenge is to texts or with some deviations, which put encourage traditional practitioners to them in the category of patent proprietary primarily use their own systems and to build medicines. These medicines are available awareness among the public that relying with allopathic chemists who stock Indian on traditional remedies for common medicines or with special grocers. The problems could be safer in the long run. public in India are well-acquainted with The practitioners can nevertheless be these remedies, which are aggressively assigned specific duties after being advertised and marketed throughout the screened for their knowledge and skills, and country. trained in fulfilling public health responsi- Ayurvedic medicines generally bilities besides practising their own systems. comprise several items.31–34 These include: In order to see that this does not lead to z Arka – Arkas are liquid preparations such practitioners practising allopathic obtained by condensation of vapours medicine, governments need to specify by the process of distillation. what can be done by such practitioners and z Pak – Avaleha – Avaleha or Leha is a should supervise and monitor their work. semi-solid preparation of drugs, prepared with the addition of sugar or Issues of access to Traditional candy and boiled with the prescribed Medicine drug juice or decoction, useful for For any traditional medical system to work chronic ailments. These preparations successfully, medicines of standard quality are usually tonics. must be available at reasonable prices. In z Chyawanprash – is an example of India, the problem has been addressed by Avaleha and is useful as a health tonic specifying an Essential Drug List to be used in any season. It is especially indicated at the dispensary and hospital levels for the for chronic respiratory problems and kind of ailments for which people generally general debility. Apart from being seek the services of traditional medicine particularly useful in warding off practitioners and where drugs are easily chronic coughs and respiratory

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problems, it revitalizes the metabolic Ayurvedic formula. These are useful in functions. the treatment of mild fever and in z Asavas and Arishtas – These are making the body healthy and strong. medicinal preparations made by They are useful in epilepsy and mental soaking the drugs, either in powder disorders, genito-urinary disorders, form or in the form of decoction, in a conjunctivitis and night blindness. solution of sugar or jaggery for a z Ayurveda also has a large number of specified period of time, during which medicated oils (Tailas) which are useful the mixture undergoes a process of for different kinds of pain in different fermentation generating alcohol, thus parts of the body. Medicated oils are facilitating the extraction of the active also available for hair problems, skin principles contained in the drugs. diseases and anorectic problems. There are several kinds of Arishtas and z All these items are prepared according Asavas but more than 30 such to Ayurvedic principles and the entire products are available commonly. recipe, its composition, the formula, z Vati-Gutikas – These are in the form the English and botanical names of the of tablets or pills made of one or more items, the parts in which the prepa- drugs of plant or mineral origin and ration is made, the indications and the these too comprise several items. Their doses, are all available in Pharmaco- uses range from the treatment of poeias and with the companies which jaundice, hyperacidity, intestinal colic, manufacture the products. Since all distention of the abdomen and loose these items have been in common use motions to chronic fevers. for centuries and the recipe has z Churna – Churnas comprise fine remained exactly the same as in the powders of single or multiple-plant case of classical medicines, the Indian drugs and are usually taken as public has confidence in their use. appetizers or digestives and still others as purgatives. Shatvaryadi Churnas Conclusion are widely used for abdominal colic, griping, constipation, worm infestation The entire spectrum of the role of traditional and acidity. Trifala Churna is used for medicine in the health system is much too chronic constipation and dropsical long and varied between and across conditions and is also used for countries and cannot, with due justice to improving eyesight. the subject, be encapsulated in a single z Guggulu – Guggulu is an exudate, chapter. Every country has its own health obtained from the plant Commiphora systems and, within the health system, mukul. It has excellent properties for resources have to be found to pay for the treating pain, nervine problems salaries of the providers, equipment, drugs and skin diseases. Combination of and consumables. All governments are Guggulu and herbal powders has been concerned about bringing down costs, given names like Triphla guggulu and improving access to health and health Yogsay guggulu. outcomes and, most important of all, z Ghritas – Ghritas are preparations in preventing ill-health. Many countries have which ghee/butter is boiled with the experienced acute problems in trying to do prescribed decoction according to the all that medical science and a public health

154 Role of traditional systems of medicine in national health care systems conscience require one to do. Debates a responsibility to ensure not only the about investment in tertiary health versus efficacy of the medicine but, more primary health, health insurance versus important, its safety. This can only be done voluntary safety nets for the poor, public by making available quality medicine and health versus preventive care, standard registering the practitioners who can be setting versus voluntary accreditation and held accountable. The experience of India self-regulation, and over-diagnostics versus clearly shows that it is possible to have the family physician approach, abound in traditional systems which can be used every country. Through all this runs an strongly and effectively to reinforce the important thread which essentially health system. However, what is essential determines whether health systems is strong policy support to give the system really work, and that refers to the public national stature, resources to conduct demand, consumer satisfaction and cost- evidence-based research and to include effectiveness. practical strategies for different traditional Consumer demand for improved medical practices to provide an alternative health outcomes, more choices, less side- or to complement the work of the normal effects, less resistance patterns, less intake health system. of chemicals and synthetic drugs, greater In this paper, an effort has been made reliance on natural and environmentally to place a few examples of what is possible, friendly products, all have pointed to the what can still be done and what is already burgeoning interest in natural plant-based being done before a public that wants to products and a desire to go back to nature understand how it can be done and where and investigate and re-package old it would be most relevant. Not all prescri- strategies, prescriptions and antidotes to ptions given in this paper can be applied meet the emerging problems of today. universally or emulated entirely. They Traditional medicine has much to offer and require investment in time and resources the sheer volume of empirical knowledge to understand where traditional medicine and the areas of application are so can contribute most meaningfully, resulting voluminous that it would be difficult to ever in better health outcome. But, most conclude which system, which drug and important of all, they require an open mind which application is superior to another. to the development of health systems which Traditional systems which are highly rise above the ordinary, an end to the hubris documented and which are backed by that surrounds traditional medicine today statute and by regulatory and enforcement and the strength to determine what can mechanisms, are bound to be taken more be offered to a hungry and curious public seriously than those which depend only on with a sense of legitimacy that the situation the faith of the consumer or the confidence demands. Now is the time to make better generated by word of mouth, howsoever use of the traditional system to augment convincing it may be. Since the medication access to health care, based on empirical of an individual can lead to all kinds of evidence, public demand and cost- effects years from now, governments have effectiveness studies.

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References

1. Essential Ayurvedic Drugs for Dispensaries & Hospitals. Department of Indian Systems of Medicine & Homoeopathy. Ministry of Health & Family Welfare. Government of India. New Delhi. 2000. 2. A Handbook of Domestic Medicine & Common Ayurvedic Remedies, Central Council for Research in Ayurveda & Siddha. Janakpuri. New Delhi. 1978. 3. A Handbook of Common Remedies in Unani System of Medicine. Central Council for Research in Unani Medicine. Janakpuri. New Delhi. 1977. 4. Indian Systems of Medicine & Homoeopathy in India. Ministry of Health. Government of India. New Delhi. 1998. 5. Ayush-64 A New Anti-Malarial Herbal Compound. Central Council for Research in Ayurveda & Siddha. Janakpuri. New Delhi. 1987. 6. Chari, M.V. et. al. Double-blind with Ayush-64 an Ayurvedic drug in P.Vivax Malaria, Jour. Res. Ay. Sid. Vol. VI. 1985. 7. Valecha, Neena. et. al. Comparative Efficacy of Ayush-64 Vs. Chloroquine in P. Vivax Malaria. Malaria Research Centre. Delhi. (under publication) 8. Ayush-56 An Ayurvedic Anti-Epileptic Drug. Central Council for Research in Ayurveda & Siddha, Janakpuri. New Delhi. 1997. 9. Clinical and Experimental Trial of Guggulu (Medo-Roga) Central Council for Research in Ayurveda & Siddha. Janakpuri. New Delhi. 1989. 10. Singh, Ramji et. al. Puskara-Guggulu, an Anti-anginal and Hypolipidemic Agent in Coronary Heart Diseases (CHD). Jour. Res. Ay. & Siddha. Vol. XII. 1991. 11. Effects of Varuna (Craetavia nurvala). In: Enlarged Prostate-associated Urinary Disorders Central Council for Research in Ayurveda & Siddha. Janakpuri. New Delhi. 1987. 12. Clinical and Experimental Studies on Rasayana Drugs and Panchakarma Therapy. Central Council for Research in Ayurveda & Siddha. Janakpuri. New Delhi. 1993. 13. Kuppurajan K. et.al. Anti-anxiety Effect of an Ayurvedic Compound Drug - A Crossover Trial. Jour. Res. Ay. & Siddha. Vol. XIII. 1992. 14. Management of Khanja and Pangu. Central Council for Research in Ayurveda & Siddha. Janakpuri. New Delhi. 1999. 15. Management of Bhagandara (Fistula in-Ano) with Ksharasootra. Central Council for Research in Ayurveda & Siddha. Janakpuri. New Delhi. 1989. 16. Shukla N.K., Narang R., Nair K., Radhakrishana S. and Satyavati G.V. Multicentric randomised controlled clinical trials of Ksharasootra (Ayurvedic medicated thread) in the management of fistula in Aro. Ind. Jour. Med. Res.(B) 94 June, 1991, p. 177–185. 17. Ayurvedic management of Unmada (Schizophrenia). Central Council for Research in Ayurveda & Siddha. Janakpuri. New Delhi. 1999. 18. Sehrawat, D. et.al. The Clinical Studies on Contraceptive Effect of Nimba Taila. Jour. Res. Ay. & Siddha Vol. XIX. 1999. 19. Clinical and Experimental Studies on the Efficacy of ‘777’ Oil, a Siddha Preparation in the Treatment of Kalanjagapadai (Psoriasis). Central Council for Research in Ayurveda & Siddha. Janakpuri. New Delhi. 1987. 20. Clinical Studies on Daul Feel (Filariasis). Central Council for Research in Unani Medicine. Janakpuri. New Delhi. 1992. 21. Report on Clinical Study of Iltechab-E-Kabid Had (Infective Hepatitis). Central Council for Research in Unani Medicine. Janakpuri. New Delhi. 1992. 22. Clinical Studies on Bars (Vitiligo). Central Council for Research in Unani Medicine. Janakpuri. New Delhi. 1986. 23. Rastogi, D.P. et.al. Homoeopathy in HIV Infections: a trial report of double blind placebo control study. British Homoeopathic Journal. Vol. 88. 1999.

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24. Rastogi, D.P. et.al. Evaluation of Homoeopathic Therapy in 129 asymptomatic HIV carriers. British Homoeopathic Journal. Vol. 82. 1993. 25. Report of the Task Force on Conservation & Sustainable Use of Medicinal Plants. Planning Commission. Government of India. New Delhi. 2000. 26. Handa, S.S. Indian Herbal Pharmacopoeia, Vol. I. Regional Research Laboratory. Jammu Tawi and Indian Drug Manufacturers Association. Mumbai. 1998. 27. Handa, S.S. Indian Herbal Pharmacopoeia. Vol. II. Regional Research Laboratory. Jammnu Tawi and Indian Drug Manufacturers Association. Mumbai. 1999. 28. Ayurvedic Formulary of India (Part–I). Ministry of Health. Government of India. New Delhi. 1978. 29. Ayurvedic Formulary of India (Part–II). Ministry of Health. Government of India. New Delhi. 1990. 30. Ayurvedic Pharmacopoeia of India (Part–I). Ministry of Health. Government of India. New Delhi. 1986. 31. Ayurvedic Pharmacopoeia of India (Part–II). Ministry of Health. Government of India. New Delhi. 2000. 32. National Formulary of Unani Medicine (Part-I). Ministry of Health. Government of India. New Delhi. 1981. 33. National Formulary of Unani Medicine (Part-II) Ministry of Health. Government of India. New Delhi. 1998. 34. Unani Pharmacopoeia of India (Part-I). Ministry of Health. Government of India. New Delhi. 1998. 35. Siddha Formulary of India (Part-I). Ministry of Health. Government of India. New Delhi. 1992. 36. Chaudhury, R.R., Herbal Medicine for Human Health. WHO. New Delhi. 1993. 37. General Guidelines on Methodologies on research and evaluation of Traditional Medicine. (In publication). WHO. Geneva. 38. An Appraisal of Tribal-Folk Medicines. Central Council for Research in Ayurveda & Siddha. Janakpuri. New Delhi. 1999.

157

A framework for cost-benefit analysis of traditional medicine and conventional medicine

A framework for cost- benefit analysis of traditional medicine and conventional medicine Gerard Bodeker

Introduction estimated that £1.6 billion is spent ‘out- of-pocket’ on CM annually – in addition uch of the discussion on research into to the £40 billion spent by the National M traditional medicine (TRM) has Health Service.3 focused around issues of safety, efficacy, As a result, the focus of policy has standar-dization and quality control. In the shifted beyond the necessary requirements absence of serious investment in the sector that products and services be at least safe over the past two decades that this and, ideally, effective. A new consideration discussion has been running, the issues in assessing CM is whether CM services and arguments have been reiterated time are economically competitive with conven- and again without any substantial impact tional health services. As governments and on policy or programmes. insurers increasingly focus on service Recent policy interest in this field has development in traditional and comple- added a new dimension to the discussion. mentary medicine, the challenge to This is an economic dimension and the address basic economic questions is emergence of economics into the TRM becoming one of central importance. policy discussion signals a new seriousness on the part of policy-makers. Potential Areas of Cost In the United States, Canada, Europe, Saving in Traditional Australia and New Zealand, health policy- Medicine makers and medical insurers have accepted that half or more of the public is White and Ernst (2000) have outlined five using some form of complementary broad areas in which there may be potential medicine (CM) on a regular basis and for cost savings from the use of CM3. largely paying for this ‘out-of-pocket’. In z Cost of drugs; the US, an estimated $27 billion was spent z Visits to a doctor; 1 in 1997. In Australia in 1996, the z Secondary referral; estimate was $AU621 million – more than z Adverse events arising from conven- the amount spent on pharmaceutical tional therapies; 2 drugs. And in the UK, it has been z Prevention of future disease.

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At present, the public in both developing can be as readily applied to the utilization and industrialized societies appear to be of traditional and complementary health using conventional medicine as well as TRM services as to mainstream medical services. or CM in an integrated way, wherever this The starting point for the choice of is possible.4,5 The question of cost savings methodology is the research question being presumes a different question: that of posed. This may be positioned from the substitution. In other words, while the public public sector perspective: namely, is combining health services in a pluralistic determining those health care interventions manner, integrating conventional and CM/ that maximize health gains in a society and TRM into their overall care programme, the to determine allocative efficiency, viz., the choice that is posed within an economic basis for deciding how best to choose on framework is: ‘Can traditional therapies allocating resources to one form of substitute for conventional treatments?’ If treatment over another. Other research not, the combination of traditional and questions may reflect the perspective of an modern medicine can be seen, from an insurer, where the issues are different. economic perspective, as simply adding to the cost of care. Cost descriptions Underlying the dichotomy between the This would entail collecting and collating all tendency of consumers to combine health costs involved in providing a particular care approaches from conventional and traditional health care service. This TRM, and the practice of medical insurers approach provides baseline data for further and health care providers to seek the single studies, but does permit other providers to least expensive care option, rests the deeper know what the costs of a particular policy issue of whose perspective and treatment programme may be. This type of priorities should determine the nature of research does not provide data on care that is offered – the consumer, the therapeutic outcomes. purchaser, or society in general. In applying or interpreting economic analyses of Cost-comparison research traditional health care services, it is first This entails a comparison of the costs of necessary to specify the perspective from two or more treatments which are designed which the analysis is being conducted. to achieve a common outcome. White and Thus, issues of economics can be weighed Ernst (2000) have noted that a limitation against questions of ethics, consumer of this approach is that treatments, choice, quality of life and the wider societal including drugs, rarely have directly impact of a particular intervention. With comparable outcomes.3 Thus the cost- this perspective as our starting point, it will comparison is at risk of being a comparison be useful to consider the various metho- of the proverbial ‘apples vs. oranges’ type. dologies used in assessing the economic merits of health care approaches. Cost-effectiveness analysis These studies are designed to measure the Methods of economic analysis costs of producing a change in a particular health outcome, e.g., life years, blood A range of methodologies exist for pressure. In their analysis of different examining the economic issues associated economic methodologies for assessing with the provision of health care.6 These health care strategies, White and Ernst

160 A framework for cost-benefit analysis of traditional medicine and conventional medicine point out that this approach overlooks other sort of framework for the analysis of TRM benefits that a therapy may generate as in light of conventional medical options. well as such negative effects as unpleasa- The first of these is a powerful social trend, ntness of the treatment or side-effects. namely, the growing public demand for TRM and CM worldwide. The second is the Cost-utility analysis move by governments towards integrating This is primarily oriented to assessing traditional health services into national patient satisfaction with a treatment. health care and the need for TRM progra- Instruments used may be a quality-of-life mmes and departments to justify the value instrument, such as the WHO Quality of of their sector in both therapeutic and Life Assessment Scale. While comparing economic terms. different treatments and their outcomes in In the following sections, we will review terms of patient satisfaction, this metho- the issues involved in each of these broad dology does not address the question of forces or emerging societal trends. Then whether the treatment is worth the financial we will move to a consideration of the cost outlay on it. issues entailed in traditional health care services. Finally, there will be a conside- Cost-benefit analysis ration of the policy implications of these At the centre of this approach is a trends and the beginnings of a framework methodology designed to assess patients’ for the economic analysis and comparison willingness to pay (WTP) for the benefits that of traditional and conventional health care the treatment provides. This is then services. compared with the actual cost of the treatment to determine if it provides value Utilization for money. A challenge of this approach is to define outcomes in monetary terms. This The widespread demand for TRM services challenge has meant that very few sound has been recognized as an enduring studies have been done to determine the phenomenon and early calls for TRM to cost-benefit issues associated with be replaced by modern medical services traditional therapeutic modalities. A further have now given way to recognition that limitation is that WTP does not necessarily some degree of formalization of these indicate ability to pay (ATP). health services might offer the public Households may persist in paying for increased standards of quality and safety. care, but to mobilize resources they may In both industrialized and developing sacrifice other basic needs such as food societies, use of CM and TRM is on the and education, with serious consequences rise. for the household and individuals within it. In 1993 research at Harvard University The opportunity costs of payment make the found that 30 per cent of Americans were payment “unaffordable” because other using some form of CM on a regular basis. basic needs are sacrificed.7 In 1998, the same research team reported that this number had increased to 40 per Backdrop to the Economic cent of the population.1 Research Analysis of Traditional Medicine published in The Lancet in 1996 reported There are at least two major forces at work that 40 per cent of Australians were using that drive the growing demand for some some form of CM.2 In April 1999,

161 Traditional Medicine in Asia legislation to establish an Australian Office The much-quoted figure that of 80 per of Complementary Medicines was annou- cent of the population of many countries nced in Australian Hansard as being utilize TRM for their everyday health needs warranted since 60 per cent of Australians is overdue to be questioned. regularly use some form of CM. Demand A survey of the literature reveals a is spiralling at rates that outstrip the diverse range of findings on utilization of capacity of national health policy to keep TRM services. The much-cited figure of 80 abreast. per cent becomes far less clear and it is In the US, higher educational level, evident that the needs of special higher income, and poor health have been populations – women, the elderly, children, found to be predictors of CM use.4 rural communities, immigrant groups, etc. Americans and Australians typically pay out – must all be taken into account when of pocket for CM services. Americans assessing who uses TRM care services, why spend more out of pocket on CM than on and in what relationship with the use of all US hospitalizations. Australians spend modern medical services. The value of more on CM than on all prescription considering these findings includes the drugs. Women have been found to be the following: majority of CM users in the US, the UK and z For planning purposes, research into Australia. health service utilization is a necessary prerequisite for establishing the need Use of traditional medicine in for, the nature of and the size of THC developing countries services; z Such studies illustrate the diversity of Traditional health care (THC) remains the models used for studying patterns of source of everyday health care for the utilization of THC services – including majority of the population of most non- ethnographic research, survey industrialized countries. The World Health research and, in the US, telephone Organization has consistently estimated surveys; that between 60–80 per cent of the z The data highlight the great diversity population of these countries rely on THC in patterns of use according to region, for their basic health care needs – age, education, gender, income, sometimes on its own and sometimes in availability of medical insurance, conjunction with modern medical care. perception of TRM, and distance to Studies show that demand is on the modern medical facilities. increase in many countries. In many countries, life begins with the support of TRM. An estimated 60–70 per cent of births in developing countries still take place with the sole help of traditional “In many countries, 80 per cent or more 8 of the population living in rural areas are birth attendants. cared for by traditional practitioners and birth attendants.” Africa (Bannerman, R.H.: Burton, J. & Ch’en, W-C. In Bannerman, R.H. Traditional There have been many general Medicine and Health Care Coverage. guesstimates of the extent of use in Africa. WHO. Geneva. 1993). Bannerman (1993) estimated that TRM

162 A framework for cost-benefit analysis of traditional medicine and conventional medicine caters for the health needs of 80 per cent to traditional healers in central Sudan of the African population.9 This figure indicated that children under 10 years did echoes an earlier estimate of 80 per cent not take part in visits. Most visitors were made by Koumare (1983).10 between 21 and 40 years (61%) and were However, some estimates of use are women (62%). They were less educated strikingly low. Shiferaw (1993), for example, compared to the general population in the reports on an interview-survey of perceived area. The main reasons given for attending morbidity in a rural community in South- traditional healers were treatment (60%) western Ethiopia, where 55.4 per cent of and blessing (26%).13 those reporting illness took no action at all; In Mali, men are more likely to prefer 30.3 per cent applied to health institutions, traditional treatments for malaria than 9.2 per cent reported self-care, and only women,14 and more boys than girls 5.2 per cent visited a traditional healer.(11) believed in herbal medicine in a survey in By contrast, research done at Mogopane the Sudan.15 It has been suggested that Hospital in North-eastern Transvaal, South women are less likely to be treated at Africa, showed that nine out of 10 patients modern facilities, and are more likely to who come to the out-patients department resort to traditional medicines.16 first consult traditional healers.12 People with a serious health condition Clearly, studies of community groups may seek THC before accepting modern and of hospital populations address the medical services. In Malawi, 37 per cent needs and choices of different populations of TB patients reported attending a with different health profiles. In planning traditional healer prior to attending the services such differences need to be health service. By the time a final diagnosis accounted for. of TB was made, most patients had visited Age and gender are factors in the several different care providers: private utilization of THC services. A study of visitors practitioner (69 visits), village clinic (64)

Table 1. Adult conditions taken to indigenous healers from Shai-Mahoko (1996) Condition No. of respondents Percentage [healers] Infertility 32 91 Septic sores 31 89 Impotence 30 86 STDs 28 80 Deliveries 28 80 Asthma 23 66 Mental illness 21 60 High blood pressure 20 57 Palpitations 15 43 TB 14 40 Alcoholism 12 34 Diabetes 9 26 Cancer 9 26

163 Traditional Medicine in Asia and traditional healer (40), and 32 patients to attend traditional healers, in Kenya 40 reported taking some form of traditional per cent of sick children were taken to the remedy at home.17 mganga [traditional healer] and 55 per Travel time can be a factor in the choice cent to the clinic; 26 per cent of the of traditional over modern medical services. mothers said that both sources of treat- Among comments made by traditional ment were consulted.19 midwives in South Africa, in a study by There are usually differences between Troskie (1997),18 was that “the nearest urban and rural populations in their use of hospital is 20 kilometres far”. Similar TRM and modern medicine. While 95 per responses were recorded from clients. In cent of urban women who attended Kwale district, Kenya, which has one health modern medical clinics in South Africa service facility for 12,000 people, it has strongly advocated mixing traditional and been estimated that 24 per cent of the western antenatal care, only 63 per cent population has a health facility within two of rural clinic attenders found this practice kilometres distance, 58 per cent within five acceptable. All groups favoured Western kilometres and 83 per cent within 10 over traditional care in cases of serious kilometres.(18) By contrast, THC services pregnancy complications.28 are readily available. Every village has a number of traditional healers and birth Asia attendants, each with their own specializations.19 In India, it has been found that the Similarly, in India, rural women in influence of family structure is significant. Gujarat were more likely to use services The presence of the mother-in-law is which were closer to home, other things associated with a greater use of traditional being equal. The “travel” variable (including healers.20 time and travel costs) is a more important Inadequacies in and scarcity of modern factor determining the use of modern and medical services can contribute to the use traditional services among women in the of traditional health services. Less than half study area than the actual direct costs of (44%) of Chinese immigrants studied in the the service.20 USA had used Western health services in In the case of malaria, selection of first- the US within the previous 12 months; 20 line treatment varies from area to area. per cent reported that they had never used Sometimes, herbal remedies are given at them. Chinese physicians stated that many home as the first-line treatment,21,22 Chinese patients are not satisfied with especially in mild cases of malaria.23,24 American doctors because of the inflexibility Sometimes, herbs are the second line after of appointments, short visit, long waiting, treatment with chemotherapy has distrust and miscommunication.29 failed.25,26 Munguti (1998) found that in In a study of health service utilization a rural area of Kenya, seven per cent used in four villages in India, the most common herbs as the first choice of treatment, 17 complaint by a majority of those surveyed per cent as the second choice, and 14 per was that “medicines are never available” cent as the third choice.27 at the primary health centre, followed by There can be contrasting patterns of discourteous behaviour of the staff and use across countries and regions. Whereas health personnel, “doctors never young children in Sudan were found not available”, “doctors demand money for

164 A framework for cost-benefit analysis of traditional medicine and conventional medicine better treatment”, and so on. Almost a quarter of the women initially tried homoeopathic treatment, followed by nine per cent who administered Western medicine at home, and two per cent opted for traditional home remedies for cure and treatment, before visiting and consulting a trained medical practitioner. Medical pluralism was found to be flourishing as people switched from one medical system to another depending on affordability and (30) time. Packaging herbal medicines in the Institute of Traditional Medicine, In Sri Lanka, two patterns of health Sri Lanka. care seeking which cut across modern and traditional medical systems were identified. per cent of persons with Medicaid only and The first involved patients who searched for 71 per cent of those with other types of a medicine which could cure or served as insurance including Medicare and a commodified fix for health. The second Medigap coverage. It is likely that the pattern involved the search for a practi- insured are those who also had more tioner who had the power of the hand to disposable income available to pay for cure one’s illness through an affinity to their traditional forms of health care. person.31 Medical pluralism is common world- Indigenous communities wide as consumers practise integrated Indigenous communities with a history of health care, irrespective of whether or not colonial conquest have patterns of use of it is present at the formal level. In Taiwan, TRM which may vary according to the 60 per cent of the public have been found degree of official support, the spiritual to be users of multiple healing systems, needs met by healers, and the strength and including modern Western medicine, intactness of their healing traditions. Chinese medicine, and religious healing.5 In Australia, The 1987 Review of Medical insurance coverage for TRM Rehabilitation Services in the Northern influences the utilization of traditional Territory found that traditional Aboriginal health services. Most Taiwanese (86%) medicine is widely practised in the Northern support the coverage of Chinese medicine Territory.32 In most regions of the Northern by the National Health Insurance and 79 Territory, more than 22 per cent of per cent indicated that they would use indigenous people had used Chinese medicine if that becomes the in the last six months when surveyed.32 case.5 In the USA, whereas older Chinese/ The decreased use of bush medicine seems Korean immigrants are more likely than to be because Western medicine is easier younger ones to use TRM, the most to access, not because of a lack of faith in significant difference in the use of its efficacy.32 Examples of bush medicine traditional practitioners appeared between include herbal preparations, diet, rest, insured and uninsured individuals. Only massage, restricted diet and external 24 per cent of the uninsured used remedies such as ochre, smoke, steam traditional practitioners, compared with 59 and heat.32

165 Traditional Medicine in Asia

Of native American patients attending Historically, the relationship between an urban Indian Health Service clinic in modern and traditional medicine has taken Wisconsin, the mean age of patients was four broad forms 40 years and the sex distribution was 68.7 z A Monopolistic situation, where per cent women and 31.3 per cent men; modern medical doctors have had the 38 per cent of patients see a healer, and sole right to practise medicine; of those who do not, 86 per cent would z A Tolerant situation, or one of consider seeing one in the future. Most Co-Existence where traditional medical patients report seeing a healer for spiritual practitioners, while not formally reasons. The most frequently visited healers recognized, are permitted to practise in were herbalists, spiritual healers and an unofficial capacity; medicine men. Sweat lodge ceremonies, z A Parallel or dual health care model, spiritual healing, and herbal remedies were as in India, where both modern and the most common treatments. More than traditional medicine are separate a third of the patients seeing healers components of the national health received different advice from their physi- systems; cians and healers. The patients rate their z An Integrated model where modern healer’s advice higher than their physician’s and traditional medicine are integrated advice 61.4 per cent of the time. Only 14.8 at the level of medical education and per cent of the patients seeing healers tell practice (e.g. China, ). their physician about their use.33 In this discussion, the term ‘formalization’ will be used to characterize Policy Points both the last two forms, given above. Asia has seen the most progress in (1) There is much variation in patterns of incorporating its traditional health systems use of THC services across communities, into national health policy. Most of this regions, age and gender groupings, development began 30–40 years ago and income levels, and according to access has accelerated in the past 15 or more to other health care services. years. In some Asian countries, the (2) Utilization studies are a sound starting development has been a matter of official point for traditional health service policy, e.g., China, while, in others, change development. Good studies can has come about as a result of a process of identify categories of need, target politicization of the TRM agenda, e.g., India groups, geographical priorities, and and South Korea. potential areas of partnership between In China, the process of integrating traditional and modern medicine. traditional Chinese medicine (TCM) into the national health care system began in the Formalization of Traditional late 1950s and was, in significant part, in Health Services response to national planning requirements to provide comprehensive health care The term ‘integration’ has come to be services. Prior to this, TCM had been viewed widely used to express the formalization as part of an imperial legacy to be replaced and official incorporation of TRM into by a secular health care system. national health services. However, the term The process of integration was guided has a more specific meaning. by health officials trained in modern

166 A framework for cost-benefit analysis of traditional medicine and conventional medicine medicine, and harmonization with modern storage, etc., it also administers medicine was the goal of integration from protection of wild medicinal resources the outset. This was accomplished by a (including medicinal resources in science-based approach to TCM education imminent danger); and an emphasis on research into TCM, z Department of Quality of Traditional both supported by a substantial organiza- Chinese Drugs. Formulates quality tional infrastructure. Integration and standards and technical standards for development of TCM was managed via a TCM products; supervises and inspects process of centralized national planning. production; More than 40 years on, the State z Scientific, Technical and Educational Administration of Traditional Chinese Department. Directs construction of Medicine in China now comprises eight scientific research institutes and functional departments. The departments laboratories; organizes research, are: development, appraisal and academic z Office. Responsible for overall exchanges, etc.; directs protection of coordination; intellectual property rights (IPR); z Department of Personnel, Labour, Laws administers proficiency examinations in and Regulation. Devises organizational TCM, etc.; structures; formulates technical z Foreign Affairs Department. Admini- standards for TCM professionals; sters and directs state technical and administers qualifications; studies and economic cooperation and academic formulates the guiding principles, exchange of TCM with foreign policies and development strategy of countries.34 TCM; drafts laws and statutes; organizes research; coordinates In 1995, the total production of herbal publications and media, etc.; medicines in China reached 17.57 billion z Planning and Financial Department. Chinese yuan in value, an increase of Formulation of development progra- 212.6 per cent since 1990. In that year, mme; administers the State’s special sales of herbal medicines accounted for funds and loans for TCM; import and 33.1 per cent of the drug market in China export activities; regulates overall (Source: WHO SE Asia). balance; In 1980, China was the first country z Medical Administration Department. to negotiate a component for TRM within Directs implementation of develop- a World Bank health sector loan. A more ment plan for TCM in urban and rural recent World Bank-financed expansion of areas. In charge of macroscopic hospital beds included provision that 20 administration and technical develop- per cent of these would be in hospitals of ment in all kinds of TCM institutions, TRM.35 including state, collective, private and In addition to formal integration of jointly owned hospitals of TCM; modern and traditional medicine in China, hospitals combining TCM and Western the public are pluralistic in their health care medicine, etc.; utilization, rendering integration a reality z Production and Circulation Depart- at the grassroots level. A survey carried out ment. In addition to directing/super- in two village health clinics in Zheijang vising production, trade, packaging, Province, China, showed that children with

167 Traditional Medicine in Asia upper respiratory tract infections were the lines of Western biomedicine and being prescribed an average of four oriental medicine (OM) is one of the separate drugs, always a combination of prominent aspects of the health care Western and Chinese.36 A challenge of service. This was established by law in integrated health care is the need to 1952. conduct research to determine which In 1996, there were 9299 licensed illnesses are best treated through one OM practitioners compared to 59,399 approach rather than the other. The Western practitioners. OM doctors operate Zheijang study reported that, in practice, in the health care services in the same way simultaneous use of both types of treatment as other medical care providers, with some is so commonplace that their individual notable differences. The private sector is contributions are hard to assess. dominant in OM, with almost all OM In South Korea, the parallel operation hospitals and primary clinics being privately of two independent medical systems along owned and operated. The great majority of OM doctors work in self-employed private settings at the primary care level. In 1995, the concentration in urban areas of OM clinics and hospitals (95.1%) was higher than that of Western medical clinics (90.6%) and hospitals (86.4%). Political conflict between the OM and modern medical sectors has been high during the 1990s over issues of fees, ability to sell and prescribe traditional herbal medicines and licensing of traditional practitioners. The level of coverage of OM in the National Medical Insurance is low and, as noted in the section on Finance, there is reluctance on the part of most OM practi- tioners to provide insurance cover for OM.37 A policy guideline on OM was adopted for the Seventh Project of the 5-year Economic and Social Development Plan in Korea (1992–1996). The guideline set a goal for full integration of Western and Oriental medicine by the year 2001. A number of short- to medium-term mea- sures were recommended to improve the quality of OM care: promotion of clinical cooperation, training of OM consultants and lifting the customary ban on OM doctors’ employment in the public hospital sector. An OM care unit was set up for the first time in the National Medical Center in 1991.37

168 A framework for cost-benefit analysis of traditional medicine and conventional medicine

In India, the Parallel Model of be for anaemia, oedema during formalization of indigenous medicine was pregnancy, post-partum problems such as adopted when the Central Council of pain, uterine and abdominal compli- Medicine Act was promulgated in 1970. cations, lactation-related problems, India’s formalization of its indigenous nutritional deficiencies and childhood systems of medicine came after a century diarrhoea. Also included are massage oils of committees had unsuccessfully for babies and mothers that are already attempted to create this outcome. The used routinely in Indian households. election to Parliament of the President of Concurrent evaluation and monitoring will the All-India Ayurveda Congress, Pandit be done to oversee acceptance levels and Shiv Sharma, and the election of a to ensure quality in drugs administration tradition-oriented Prime Minister, Morarji and storage and to monitor the sustaina- Desai, combined to create the conditions bility of the programme. for a political solution when policy reform Under Taiwan’s current health care had been unsuccessful. The Act set up a system, Chinese medicine is reported to Council to oversee the development of have a subordinate role to Western Indian Systems of Medicine and to ensure medicine,5 more characteristic of the that standards of training and practice Tolerant or Coexistence model described were developed according to both at the beginning of this section. This is traditional requirements and Government apparent in three ways: standards of good clinical practice. z Limited participation of Chinese Training would be in separate colleges, of medicine practitioners in any public which there are now well over one hundred. health policy-making and programmes; Current priorities of the Department of z Small proportion of Government ISM include education, standardization of medical resources allocated to the drugs, enhancement of availability of raw training, research and practice of materials, research and development, Chinese medicine; information, education and communi- z Loose licensure system for Chinese cation and larger involvement of ISM in the physicians. national health care delivery system including Reproductive and Child Health Two parallel licensure systems for Chinese (RCH). Due to the high cost and physicians exist in Taiwan: unavailability of modern medical services z The Chinese Medicine Physician in rural areas of India, the Indian License Exam (CMPLE) Government has undertaken to add 10 z The Chinese Medicine Physician medicines from the Ayurvedic and Unani Special License Qualifying Exam systems into its national family welfare (CMPSLQE).] programme. A pilot project, designed to last till 2003, is currently being The CMPLE is offered only to persons implemented in seven Indian states for with medical degrees in Chinese medicine. Ayurveda while Unani medicines are being One medical college in Taiwan offers introduced in four cities. The RCH project formal training and a in is co-funded by the World Bank and the Chinese medicine. The CMPSLQE has no Indian Government. The medicines, which educational or training prerequisites and are all traditional herbal formulations, will any citizen of Taiwan may apply for the first

169 Traditional Medicine in Asia level of the Qualifying Examination. After situation controlled by orthodox Western passing, they can proceed to the second medicine. In others, a more Tolerant level of Special License Examination. On situation exists, but in the absence of official passing the second level of examination, recognition or health sector investment in graduates can obtain the Chinese development. The same applies to indi- Medicine Physician (CMP) license. The two genous medical traditions in Australia. licenses, CMPLE and CMPSLQE, carry the same privileges and there is no way for Traditional Medicine and the patients to distinguish between the two.5 Formal Health sector in Africa Debate in Taiwan on improving There has been a long-reported willingness Chinese medicine focused on whether the on the part of traditional healers in Africa Government should begin with research or to collaborate with the formal sector and build a medical school. Characteristic of to establish joint training. Burnett, et al., many governments, research was given (1999) note that 37 of the 39 traditional priority and the Government established healers (94%) and 14 of the 27 formal the National Chinese Medicine and Drugs health workers (52%) interviewed in a Research Centre. Establishing a Chinese Zambian study were keen to collaborate medical school was left to the private sector. in training and patient care relating to The resultant China Medical College – HIV/AIDS.40 established in 1958 – is the only such However, this is not generally a college in Taiwan and has been considered reciprocal view. Although one per cent of to have been under-funded and inade- nurses in South Africa are reported to be quately equipped. traditional healers, rural nurses in Recommendations made by The Swaziland perceived themselves as being Commission on Health Research for teachers to healers, but not learning from Development,39 for strengthening essential healers. They saw themselves as a source national research, such as the support and of referral for healers, but not the reverse.41 cooperation from industrialized nations, One view is that it may be more should also extend to the area of research appropriate to work towards a system of in TRM and its integration. It has been cooperation between two independent argued that the global community should systems, with each recognizing and promote cooperation and information respecting the character of the other.(42) exchange centred on integration This has been the policy in Botswana, strategies.5 where parallel development has been In Africa and the Americas, traditional encouraged, since it is felt that one or other and indigenous medicine is informal, in of the two systems might suffer in the some cases operating under a Monopolistic process of integration.40 WHO policies of the late 1970s and 1980s have promoted the establishment “Healers have for long been treated like of associations of traditional healers in trees on savanna farms - not formally Africa. During the 1990s, NGOs of tradi- cultivated, yet valued and used, tional health practitioners – associations, particularly by women and children”. small groups, clinics, etc. – have grown Last & Chavanduka (1986) in The exponentially in Africa, playing a partnership Professionalisation of African Medicine. role in HIV/AIDS education and care,43 in

170 A framework for cost-benefit analysis of traditional medicine and conventional medicine delivering child survival messages and in and traditional healers, especially as TB managing endemic disease in partnership treatment supervisors, and examined what with modern health care workers. precedent and potential exists for traditional There is now an emerging momentum healers to act in this role.17 to begin a process of formalization of Before commencing collaborative traditional medicine in Africa. effort in health care between modern and In Uganda, new legislation is being traditional sectors, a careful assessment of developed to ensure a role for TRM in potential benefits and obstacles should be national health care, in part as a result of made. The medical services utilization the successful engagement of traditional patterns of the communities need to be healers in combating the AIDS epidemic in ascertained and the specific role of the country. traditional health practitioners considered. South Africa’s parliament, on 5 August, In such efforts the ideas of healers 1998, proposed that a statutory council themselves about possible collaboration be set up to regulate the 350,000 are crucial.19 traditional healers. A report by a parlia- Ghana has recently passed the mentary committee on social services Traditional Medicine Practice Act 2000, Act proposed that the council should present 595, to establish a Council to regulate and its recommendations within three years [by control the practice of TRM. The primary 2001] for the drafting of final legislation. draft of this act originated from the A Parliamentary Committee on Social traditional healers themselves. The Act Services in South Africa proposed that the defines TRM as “practice based on beliefs profession of traditional healing should be and ideas recognized by the community to divided into four categories: the inyanga provide health care by using herbs and (traditional doctors or herbalists); the other naturally occurring substances”, and sangoma (diviner); birth attendants or herbal medicine as “any finished labelled midwives; and traditional surgeons who medicinal products that contain as active mainly do circumcision. Spiritual healers ingredients aerial or underground parts of were not included because their training plants or other plant materials or the and accreditation was considered combination of them whether in crude “unclear” and “ill-defined”.44 state or plant preparation.” It is arranged In South Africa, many traditional into four sections, namely the establishment healers are members of well-organized and functions of the Traditional Medicine national organizations that are seeking Practice Council; registration of practi- formal recognition from the Government. tioners; licensing of practices; and In one instance of WHO-sponsored miscellaneous provisions. collaboration, it has been recognized that Ghana’s Ministry of Health has the rapid increase in TB caseload, especially incorporated a Traditional Medicine Unit in African countries heavily affected by the since 1991, and in 1999 this was HIV epidemic, requires a search for effective upgraded to the status of a Directorate. ways to treat patients outside hospital. As The Ministry, in collaboration with the a component of WHO’s Community Care Ghana Federation of Traditional Medicine for Tuberculosis in Africa Project, Wilkinson, Practitioners Associations (GHAFTRAM) et al. (1999), studied the potential role for and other stakeholders, has now developed collaboration between the health service a five-year strategic plan for TRM. This plan

171 Traditional Medicine in Asia outlines activities to be carried out from proposition for a mix of traditional and 2000–2004, and will be reviewed every modern medicine is an agenda of incorpo- two years. It proposes, among other rating the former into the political- aspects, the need to develop a compre- economic arena and cultural hegemony of hensive training in TRM from basic and biomedicine.46 Clearly, if TRM is to be given secondary to tertiary levels. a formal place in national health care, this A ‘Ghana Herbal Pharmacopoeia’, process needs to be done not only in close containing scientific information on 50 consultation with the traditional health medicinal plants, has been published. A sector, but taking direction from them as second volume is currently in preparation. to appropriate models of partnership, Efforts are being made to integrate TRM into formalization and training. the official public health system and it is One commentator has outlined six expected that by the year 2004, certified recommendations for effective integration and efficacious herbal medicines will be that cover many of the major salient issues: prescribed and dispensed in hospitals and z Promotion of communication and pharmacies. The Ghanaian Government mutual understanding among different has set aside the third week of March every medical systems that exist in a society; year as a Traditional Medicine Week, starting z Evaluation of TRM in its totality; from the year 2000. z Integration at the theoretical level and In Nigeria, the National Agency for the practical level; Food and Drug Administration and Control z Equitable distribution of resources (NAFDAC) has taken steps to regulate and between traditional and modern control TRM products with a view to Western medicine; ensuring their safety, efficacy and quality. z An integrated training and educational In consultation with traditional healers and programme for both traditional and researchers, NAFDAC has developed modern Western medicine; guidelines on regulating herbal medicines. z A national drug policy that includes Recently, the Government of Nigeria traditional drugs.5 approved a national policy on a Traditional Medicine Code of Ethics. Draft legislation Recognizing the need for a policy to has been prepared to establish national reflect public health care demands and and state Traditional Medicine Boards to patterns of use, the 12th Commonwealth enhance the regulation of TRM practice Health Ministers’ Meeting in November and promote cooperation and research in 1998 established a Working Group on TRM.45 Traditional and Complementary Health Clearly, planning for the formalization Systems47, 48 (Nelson, 1998; Bodeker, of traditional health services has many 1999). The Working Group was commi- dimensions that need to be addressed, ssioned to develop an action plan to depending on the state of current sectoral promote and integrate traditional systems development, level of political will, budget of health and CM within national health resources available, training infrastru- systems, giving consideration to: cture, the model of formalization suitable z Policy Framework, including: to and preferred by the country and by the ‹ provision of services traditional health care community. It has ‹ conservation of medicinal plants and been argued that, underlying the general related intellectual property rights;

172 A framework for cost-benefit analysis of traditional medicine and conventional medicine z Training of traditional and conventional modern medical services may be one practitioners; important reason for people turning to the z Development of standards of practice; services of TRM. In a rapid community z Mechanisms for enhanced sharing of survey in Boga, Zaire, 56 per cent of experiences in the Commonwealth; households reported that the price of z Regulation and safety, involving treatment was the greatest obstacle to their practitioners of TRM in the process; receiving medical care. Fees and other z Research – evidence-based research to factors will inevitably deter some people from promote mutual understanding and using the health services, and they may use confidence, and establish efficacy; traditional healers or drug sellers instead, 50 z Management of the integration of or alternatively receive no treatment at all. traditional and conventional medicine. This shift can be exacerbated by macro-economic factors such as devalua- Health Ministers representing most of tion of currencies. Structural adjustments, the 54 countries of the Commonwealth which have been accompanied by the noted that TRM should be seen as introduction of user fees for Government ‘complementary’ rather than ‘alternative’, health services, can result in a substantial indicating the need for collaboration and shift from modern to traditional medicine, partnerships with conventional medicine. even in urban populations. In an African Development Bank study of 800 Cost Considerations households in Abidjan, Cote D’Ivoire, devaluation of the Ivorian franc was In many Western countries, including the associated with a concurrent shift from US, debates on health-care reform are now modern to traditional medicine by 13.5 per dominated more by the language of cent of households. This was even higher efficiency and cost than the spirit of caring (16.7%) in women-headed households, and equity.49 where poverty is greater.51 Personal As governments begin to consider communications with medical personnel in developing formal health services in TRM, Tanzania suggest that the introduction of the question inevitably arises as to whether user fees for previously-free Government these will result in cost-savings and whether outpatient clinics resulted in a substantial consumers will be willing to pay for formal shift away from modern medical services services in TRM. These issues are similar to towards TRM. Simultaneously, traditional those underlying the justification of modern healers in the Kilimanjaro region reported medical services, and the debate on that they had experienced a substantial traditional health services is also shifting increase in demand for their services at the from a language of equity and quality of time that user fees were introduced for care to one of efficiency and cost. Government health services.52 In the industrialized countries, where The effect of user fees on health care almost half of the population regularly uses utilization and health outcomes has been CM, insurance coverage for this is still a subject of considerable debate in the relatively new.2 Major American medical 1990s. Much of this debate has centred insurers now routinely cover CM services– on the ability and willingness of households a trend which is emerging in Britain as well. to make larger out-of-pocket payments for In the developing world, the cost of health care.

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Many studies in developing countries TRM clinics – to the household. It is in indicate that health care utilization rates households that decisions are made on among both poor and non-poor individuals how to allocate limited resources to health, would not be significantly affected by small education and other essential commodities. increases in user fees.53 In addition, many In Vietnam there is a rural expression studies suggest that health care utilization that TRM can be paid for with one chicken, would actually increase if increased user modern medicine can cost one cow and fees are accompanied by improvements in hospitalization can cost a family its herd of service.53 cows. Translating this into immediate and However, other research indicates that downstream income benefits, such the price elasticity among the poor is sacrifices by poor families may be made at substantial, which suggests that user fee the expense of their future livelihood. schemes would have a regressive distri- Fees charged by traditional healers vary butional impact.53 greatly and can also be high. In South Africa, In many developing countries people for example, where payment is not exclusively are expected to contribute to the cost of monetary, the healer may receive a cow on health care from their own pockets. As a curing the patient. The treatment for a result, people’s ability to pay (ATP) for condition such as umtsebulo – presumed health care, or the affordability of health soul loss – can cost US$ 125.54 care, has become a critical policy issue in An approach to ATP, founded on basic developing countries. It is particularly needs and the opportunity costs of payment urgent where households face combined strategies (including non-utilization), has user fee burdens from various essential been proposed. Common household service sectors such as health, education responses to payment difficulties have been and water. Research and policy debates found to range from borrowing to more have focused on willingness to pay (WTP) serious “distress sales” of productive assets for essential services, and have tended to (e.g., land), delays to treatment and, assume that WTP is synonymous with ATP. ultimately, abandonment of treatment. However, this assumption has been Although these strategies may have a questioned and it has been suggested that devastating impact on livelihoods and WTP may not reflect ATP.7 As noted in the health, few studies have investigated them introductory section of this chapter, in any detail. In-depth longitudinal households may persist in paying for care, household studies would develop an but to do so may sacrifice other basic needs understanding of ATP and could inform such as food and education. This in turn policy initiatives which might contribute to can have serious consequences for the the development of affordable models of household and individuals within it. In terms THC services. of a social benefit analysis, the opportunity costs of payment make the payment Potential Conflicts Arising from “unaffordable” because other basic needs Allocation of Resources to are sacrificed. Traditional Health Care Services In this regard, research into the Resentment can arise from under-funded economics of health care utilization should sections of the modern medical sector shift the focus of attention from the health when resources are allocated to the facility – including Government and private development of traditional medicine. A

174 A framework for cost-benefit analysis of traditional medicine and conventional medicine traditional birth attendant (TBA) training in Nigeria attracted resentment from under- funded rural midwives as resources were given to birth attendants when maternity centres lacked equipment.56 Another potential conflict is that if THC services are made available under medical insurance schemes, those who can afford to pay for insurance will be the greatest beneficiaries of TRM. The poor may be relegated to purchasing unregulated drugs from unlicensed street vendors, as already happens in so many poor countries. This would stand in contrast to the customary role of TRM serving as the first and last resort for available health care for the poor. A further risk is that primary health care consultations differs by a ratio of 1:300 services in TRM may remain marginal and between the first and tenth deciles. The under-funded due to the tendency of spread is extreme (1:3000) in the case of national health budgets favouring tertiary expenditures on hospitalization. It has been care. In Cote D’Ivoire, the rich receive more argued that there is injustice in the high assistance than the poor, because the allocation of resources to tertiary care, when poorest patients rarely use anything but household expenditures on TRM and primary care, whereas the Government modern medicine indicate the demand and provides generous subsidies for the tertiary need at the primary care level (see Figure 3). level, which in practice serves the richest Differential allocation of resources to patients.57 Average per capita spending on areas of high priority might be one solution

An older woman I knew in Papua New Guinea did not perform any visible economic activity, being old and weak. On the surface she consumed rather than produced resources; thus there was little incentive to spend still more on maintaining her health. But what of the value of her knowledge and wisdom in the resolution of family conflicts? What of her value in the education of the children through myths, storytelling and personal history? What of her knowledge of herbal and household remedies for common illnesses? How to assess in monetary terms the fact that she can call upon the support of other community members in times of hardship, just as she has assisted them in times past? These are vital contributions to the continued health of her community, but we have a long way to go before we can cost them. Too often the economic spotlight is turned upon the more straightforward task of assessing the cost of her arthritis or her chronic obstructive lung disease: inevitably, she shows up as a negative item on the balance sheet.

(Hill, 1997)(55)

175 Traditional Medicine in Asia for building relevant and viable traditional ward’s profit, under the market model of health services. In Sri Lanka, Aluwihare health care provision that is in place, is the (1997) has examined sets of figures on 15–25 per cent mark-up for prescribed such indicators as infant mortality and medications, so the changed incentive women in the labour force. His finding is system has become associated with that national aggregate data do not help increased polypharmacy.59 in the appropriate targeting of resources. Under the market system, many TCM Rather, the best way would be to target hospitals in China operate at a deficit, as the parts of the country where the figures better equipped Western hospitals attract are the least satisfactory, as a dollar there more patients. As TCM is largely an would have produced a better effect than outpatient, low technology specialty, most 10 dollars in an area which had better of the income of traditional hospitals comes parameters.58 The use of data that are from the sale of drugs. Even with the 25 disaggregated by place and time is a more per cent mark-up allowed, it is hard to cover effective way of identifying “weak” points operational costs. While Government where specific action is needed. This subsidies currently ensure survival, there is would require that TRM utilization no surplus for improving services and studies be incorporated into national further market reforms may threaten this health service research as well as studies subsidy system.36 on the availability, quality and cost of The experience in Taiwan is that traditional health services on a region-by- insurance coverage for TRM would more region basis. than double the use of TCM. Whereas 35.4 per cent of Taiwanese reported using Health insurance for traditional TCM regularly, 86 per cent of the public medicine would support the coverage of Chinese As noted in the section on Utilization, health medicine by the new National Health insurance coverage can lead to a Insurance and 79 per cent would use substantial increase in the use of TRM Chinese medicine if it does.5 services. In a Korean immigrant population High profitability of TRM can lead to in Los Angeles, 24 per cent of the its custodians resisting moves to provide uninsured used traditional healers, insurance coverage for their services and compared with 59 per cent of persons with products. In Korea, where the profit margin Medicaid only and 71 per cent of those of herbal medicines is variously estimated with other types of insurance including to be 100–500 per cent compared to their Medicare and Medigap coverage. basic cost,37 the population utilize herbal In China, although traditional health medicines on a large scale.37 The amount services are covered by health insurance, of reimbursement for herbal medicine only about 12 per cent of the population under the National Medical Insurance has comprehensive medical insurance that (NMI) scheme was approximately 50 billion covers the cost of hospitalization, and the Korean won in 1993. This was estimated proportion of uninsured people may be as to be only a small portion of total expendi- high as 50 per cent.59, 49 In hospital ture on herbal medicines.37 The high settings, insured patients are more likely to returns on herbal medicine boosted the receive TCM.59 This is due to the fact that socio-economic status of TRM doctors to one of the primary sources of a hospital the extent that about two-thirds (64%) of

176 A framework for cost-benefit analysis of traditional medicine and conventional medicine them did not want herbal remedies to be Cost-Benefit Research included in the NMI scheme at all.37 Taking into account the bias towards higher In New Zealand, which has a long income groups among medical insurance tradition of universal insurance for medical enrollees, evaluating the health insurance and hospital services, a number of Maori records of TRM/CAM users can be an organizations signed contracts with effective way of estimating cost-savings of regional health authorities to provide using traditional or complementary health primary health care, resulting in an care for certain sectors of society. A increased number of Maori-controlled Canadian study provides an example. services throughout the country. New A retrospective study of Quebec health Zealand has allowed the registration of insurance enrollees compared a group of more than 600 Maori traditional healers Transcendental Meditation (TM) practi- and the Government reimburses their tioners with non-meditating controls.62 services under health insurance schemes. Earlier research had highlighted positive It has been argued that the New Zealand individual and group health effects of this experience showcases the importance of meditation, which derives from India’s a funder-purchaser-provider separation Vedic tradition. This study aimed to and shows that this can be beneficial to determine whether these health benefits indigenous health services.60 translate into savings to the Government In Australia, Easthope et al. (1998) in terms of possible reductions in payments show that since the introduction of a to physicians for the medi-tating group. Medicare rebate for acupuncture in 1984, The study involved a total of 2836 health use of acupuncture by medical practitioners insurance enrollees from Quebec. Of these, has increased greatly.61 By analysing Health 1418 were volunteers who had been Insurance Commission data on claims by practising the TM technique for an average all non-specialist medical practitioners for of six years, and 1418 were controls of the Medicare Benefits Schedule items for an same age, sex, and region who were attendance where acupuncture was randomly selected. Using data provided by performed by a medical practitioner, they RAMQ (Régie de l’Assurance-Maladie du showed that 15.1 per cent (about one in Quebec), Herron and associates first seven) of Australian GPs claimed for established a baseline by going back 14 acupuncture in 1996. Claims rose from years and gathering information on the total 655,000 in the financial year 1984–1985 amount of money paid to physicians for this to 960,000 in 1996–97, and Medicare group. Adjustments for inflation were made reimbursements to doctors for acupun- using the medical cost component of the cture rose during this period from $7.7 Canadian Government’s Consumer Price million to $17.7 million. Acupuncture was Index (CPI). The scientists were able to more likely to be performed by male determine a typical subject’s rate of change practitioners, by those aged 35–54 years, in expenditure over the period using robust and by practitioners with an overseas statistics. primary medical qualification. A survey of Researchers found that before starting general practices in Hobart showed that meditation, the yearly rate of increase in although only 15 per cent of the GPs payments between the TM group and the provided acupuncture, it was available in control group was not significant. However, 31 per cent of practices. after learning meditation, the TM group’s

177 Traditional Medicine in Asia mean payments declined one to two per Conclusion cent each year, while the control group’s mean payments increased up to 12 per Rising consumer demand for THC services, cent annually over six years. Thus, there the unavailability of conventional services was a mean annual difference between the in many areas of the developing world, and two groups of about 13 per cent. The the move by governments to integrate THC research team estimated that this could into national health services, all combine translate into savings of as much as $300 to create a new set of issues regarding TRM million per year for the Province’s health that extend beyond the long-established insurance company, the Régie de themes of safety, efficacy, standardization l’Assurance-Maladie du Quebec. of medicines and training of traditional A recent example of comparative health practitioners. While these issues are research of a traditionally used herbal at the core of quality control in traditional medicine and the main equivalent health services, planners are assuming that conventional medicine has cost-benefit if quality is indeed controlled, a new set of implications that are important. The study, questions arise. At the forefront of these on mild to moderate depression, are questions of the comparative cost of compared St. John’s Wort (Hypericum conventional and THC and treatments. perforatum), with the recommended dose In drawing together the basic five-point (150 mg) of imipramine, one of the most framework for economic analysis outlined commonly used tricyclic antidepressants. in the Introduction and the complex issues Hippocrates, Pliny and Galen had all that actually occur in real-life setting, a described the use of Hypericum for the number of policy issues can be identified treatment of mental disorders. An and distilled as providing the context for Randomized Clinical Trial (RCT) was the development of cost-effective THC conducted involving 324 outpatients with services. mild to moderate depression. The study With respect to the economic valuation found that Hypericum extract is thera- of TRM, it is necessary to recognize that in peutically equivalent to imipramine in the developing world, the cost of modern treating mild to moderate depression, but medical services can be a factor in people that patients tolerated Hypericum better.(63) choosing TRM. Programmes to develop Two years of treatment with Prozac (20 mg/ and formalize traditional health services day) will cost US$1,250 in China, about should not overlook this point. The risk in the annual income of an urban worker.(49) doing so is of depriving the poor of services A TCM equivalent of Hypericum would that have historically been their first and result in substantial cost savings and, if last resort for health care. Accordingly, similar to Hypericum, may be better economic policies on TRM should aim to tolerated by patients. Cost savings could keep any user fees affordable – including be calculated on an annual, national basis, those of THC practitioners in the as could economic and social costs arising community. from reductions in side-effects. Cost-benefit Significant investment is a prerequisite analysis of this type would assist countries for the development of effective THC in making informed choices about the services. Under-investment risks perpe- selection of treatments to be incorporated tuating poor standards of practice and in integrated health care services. products and also contributes to main-

178 A framework for cost-benefit analysis of traditional medicine and conventional medicine taining old stereotypes of inferior services at the theoretical and practical levels. and knowledge in TRM. If health insurance Governments and inter-national organi- coverage is provided for TRM, national zations, such as WHO, should work to schemes should be weighted in support of ensure that there is equitable distribution continued access by the poor to TRM. of resources between traditional and A necessary backdrop to economic modern Western medicine. analyses is a social analysis which examines An integrated training and educational the extent to which there is demand for programme is needed for both traditional traditional health services, who the clients and modern Western medicine. And finally, are, what the conditions are that they bring there is a need for a national drug policy for treatment, and how they rate the quality that includes traditional drugs. of both traditional and conventional health Economic analysis of TRM is necessary. care services. Political priorities can frame As we have seen, there are five broad and set the pace of formalization of THC. means of conducting such research: cost The traditional health sector is, can and descriptions; cost-comparison studies; should be part of this equation in the cost-effectiveness analysis and cost-utility interests of ensuring appropriate develop- analysis. The selection of methodology will ments in policy, regulation, accreditation, depend on who is asking the question – service development, standards of practice, Government, insurer, consumer advocate, training and research. etc. A necessary starting point is transpa- A comprehensive yet flexible infra- rency in stating the priorities lying behind structure is necessary to address the the research and the research question, diverse areas within the THC sector. These e.g., cost-savings, quality of life improve- include: legislation, regulation, financing, ment, etc., in order to enable a balanced research, product development, education interpretation of the outcomes of the and training , and sustainable medicinal research. plant production. Cost-benefit research is needed and, Priority areas for collaboration include increasingly will be done. While comparing diseases such as TB, malaria64 and HIV/ outcomes and costs of traditional and AIDS.(65) Here new sets of economic conventional interventions, care is needed questions present themselves and these to avoid the charge that is sometimes must include the ethics of not evaluating made that cheap medicines are being the medicines that the public uses for home- produced for poor people, with some treatment of serious diseases. disregard for quality and efficacy. A mechanism is needed for sharing As this is a nascent field, it would experience in policy and service benefit from the emergence of a specialized development both within and between group of researchers who are linked, countries. Communication and mutual potentially via the , to share understanding should be promoted among experience, models of research and different medical systems that exist in a findings. Such a group would work to society. In evaluating TRM, this should be develop priorities in an international done as a system in preference to selecting research agenda, refine evaluative single therapeutic modalities to be methodologies and articulate ethical and evaluated for a specific effect. Integration cultural perspectives to broaden the scope of health services should be coordinated of economic analyses.

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Clearly, for formalization of THC knowledge conduct cost-related research. services to be achieved in a climate of The potential is the development of a new competition for scarce resources, it will be basis for ensuring that traditional health vital that programme administrators and knowledge is put on sound footing custodians of traditional medical alongside conventional medicine.

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43. Kabatesi D. Use of traditional treatments for AIDS associated diseases in recourse-constrained setting. In: Health in the Commonwealth: challenges and solutions 1998/99 (ed. L. Robertson, K. Bell, L. Laypang & B. Blake). London: Kensington Publications. 1998. 44. Baleta A. South Africa to bring traditional healers into mainstream medicine (news). Lancet. 1998; 352: 554. 45. Osuide, G.E. Regulation of herbal medicines in Nigeria: The role of the National Agency for Food and Drug Administration and control (NAFDAC). Paper presented at the International Conference on Ethnomedicine and , Silver Spring MD. 1999; Nov 3–5. 46. Kagwanja P.M. Women and the political economy of traditional medicine in Kenya: a historical perspective. Curare Special Issue: Women and Health. 1997; 11 (97): 29–38. 47. Nelson T. Commonwealth Health Ministers and NGO’s seek health for all. Lancet. 1998; 352: 1766. 48. Bodeker G. Traditional (i.e. indigenous) and complementary medicine in the Commonwealth: new partnerships planned with the formal health sector. Journal of Alternative & Complementary Medicine. 1999; 5 (1): 97–101. 49. Lee S. Diagnosis postponed: shenjing shuairuo and the transformation of psychiatry in post-Mao China. Culture, Medicine and Psychiatry. 1999; 23 (3): 349–80. 50. Goodman H., Waddington C. Financing health care. Oxford: Oxfam. 1993. 51. African Development Bank/UNICEF. Les strategies d’adaptation socials des populations vulnerables d’abidjan face a la development et a ses effets. African Development Bank. 1995. 52. Tanzania, Lambheni Traditional Healers’ Association, personal communication. 1997. 53. Hotchkiss D.R., Rous J.J., Karmacharya K., Sangraula P. Household health expenditures in Nepal: implications for health care financing reform. Health Policy and planning. 1998; 13 (4): 371–83. 54. Kale R. Traditional healers in South Africa: a parallel health care system. British Medical Journal. 1995; 310: 1182–85. 55. Hill E. Over the edge: health care provision, development, and marginalisation. In: Development for Health, ed. Hill E. Oxford: Oxfam Publication. 1997: 6–13. 56. Matthews M.K., et al. Training traditional birth attendants in Nigeria – the pictorial method. World Health Forum. 1995; 16: 409–14. 57. Brunet-Jailly J. AIDS and health strategy options: the case of Cote d’Ivoire. AIDS Economics Online Conference 1998. http://www.worldbank.org/aids-econ/arv/index.htm. 58. Aluwihare A.P.R. Ethics and Practical decision-making. World Health Forum. 1997; 18: 120–24. 59. Phillips M.R., Lu S. and Wang R. Economics reform and the acute inpatient care of patients with schizophrenia: the Chinese experience. American Journal of Psychiatry. 1997; 154 (9): 1228–34. 60. Scrimgeour D. Funding for community control of indigenous health services. Australian and New Zealand. Journal of Public Health. 1996; 20 (1): 17–18. 61. Easthope G., et al. Acupuncture in Australian general practice: practitioner characteristics. Medical Journal of Australia. 1998; 169: 197–200. 62. Herron R.E., Hillis S.L. The impact of the Transcendental Meditation program on government payments to physicians in Quebec: an update. American Journal of Health Promotion 2000; 14(5): 284–91. 63. Woelk H. Comparison of St. John’s wort and imipramine for treating depression: randomized controlled trial. BMJ. 2000; 321 (2 Sept.): 536–39. 64. Bodeker G. & Willcox M.L. New research intitiative on plant-based antimalarials. The Lancet. 2000; Feb. 26: 355,761. 65. Bodeker G., et al. A regional task force on traditional medicine and AIDS in East and Southern Africa. The Lancet. 2000; April 8.

182 Development of training programmes for traditional medicine

Development of training programmes for traditional medicine Palitha Abeykoon O. Akerele

Introduction level, has been very erratic and non- productive, to say the least. This token he systems of traditional medicine in acquiescence of Member States of the TSouth-East Asia are amongst the most World Health Organization in galvanizing evolved of all the ancient systems of traditional medicine to achieve this medicine known to mankind. There is a collective goal has meant that the health rich tradition of recorded and unrecorded status of the poor, especially the rural poor, literature on their usefulness and use in has continued to be compromised. The most countries of South-East Asia. prevailing economic hardships facing most Practitioners of traditional medicine are developing countries of the Region have heirs to a rich heritage of knowledge and further complicated the picture for the skills, handed down from one generation urban poor. to the next with great dedication. The social Although reliable statistics are not goal of Health for All, with primary health available for some of the countries of the care as the key approach, was adopted by Region, there is a wide gap between the the Member States at the World Health health status of people in the urban areas Assembly in 1978. Traditional medicine and those in the rural areas of the Region. was identified as an essential component Life expectancy at birth and infant mortality, of the overall response for its achievement, and maternal mortality, another useful particularly in the developing world. It has index of the level of health, continue to be been clear to most health administrators, unacceptably high in many countries. for over two decades, that this exalted goal Infectious and parasitic diseases continue of “Health for All by the year 2000”1 would to sap the energies of the people. Some not be realized without the use of all children receive no preventive immunization available health resources, particularly for crippling diseases of childhood. Many traditional medicine and its practitioners. more suffer from severe malnutrition of one However, the actual experience has not deficiency or another. been totally encouraging in most countries In many countries, only a few city and the incorporation of traditional dwellers have access to organized health medicine into the organized public health and other social services at prices that they systems, especially at the district health could afford. The majority of the population

183 Traditional Medicine in Asia are left to their own devices which often Some lessons and questions means recognized traditional health from past experiences practitioners and/or . This situation highlights one facet of the social To place education and training as a sub- injustices that are being perpetrated, system in the health system in South-East knowingly or unknowingly, by policy- Asia, it is useful to examine some of the makers and administrators in most relevant experiences that have been developing countries. accumulated and which are of direct Most, if not all, traditional medicine relevance to these countries. A small practitioners are inadequately trained for number of these experiences have been the tasks that they perform in their extracted and summarized here as it would communities. In spite of this, licensed and help in the elaboration of national health unlicensed practitioners continue to be policy related to traditional medicine. readily available to the sick in rural and We have useful lessons from a number peri-urban settings, prescribing ethical and of African countries that have attempted non-ethical as well as rational or irrational to bring traditional medicine into the modern medical drugs to those they see in mainstream of the health services, often their daily practices. In the main, their without much success. For example, one activities are restricted to curative practices country, at independence, tried to correct only. the situation inherited by adopting policies The education and training of and promulgating legislation that were traditional practitioners becomes a crucial encouraging to traditional practitioners issue in this context. Of course, it is also a but, at the same time, alienated them from fact that education and training responses the formal health personnel.2 Conse- per se will not address, let alone solve, quently, the existing gap between the two many of the problems and issues related types of practitioners further widened. to the incorporation of traditional medicine Cooperation and collaboration should to complement the modern systems of be brought about as a purposeful part of medicine in our countries. This paper the overall development of the national outlines some of the contextual issues in health policy and not as a result of the integration of traditional medicine with injudicious or hasty adoption of policies to the general health care services, and promote traditional medicine which, in fact, suggests a rational framework and some have often tended to discredit it. The practical guidelines for the development of identification and categorization of the human resources in traditional medicine. various traditional practitioners should be Therefore, the list of issues and the a national undertaking with the intention suggestions offered in this paper do not of improving health benefits for the people, pretend to be exhaustive. However, taken as has been done in China, India, , together, they are key questions and issues Sri Lanka and Thailand. to be answered before designing any A good policy should be the ultimate meaningful education and training expression of a consensus and, therefore, programme for traditional medicine, the necessity of involving traditional medical including defining the role of traditional practitioners at all stages of this process health practitioners in the district health cannot be overemphasized. Such consul- system. tation is most easily achieved when there is

184 Development of training programmes for traditional medicine a national association of traditional tend to stay in their own communities. practitioners and when the representatives Successful attempts to utilize traditional of such an association can be brought into medicine are characterized by the ability direct relationship with the health authorities. of health personnel to understand local Sri Lanka is the only country where traditional practices. China and India are there is a separate ministry for indigenous examples of countries that have developed medicine. In India and China, there are their traditional systems of medicine to the Departments and Bureaus of traditional extent that they now command some medicine within the ministries of health. respect from practitioners trained in Regional and national associations exist in Western or modern medicine. They have these countries as well as in most African succeeded in making health personnel countries. All people value good health and aware of the place of traditional medicine traditional practitioners continue to exist in their culture, its strengths and weak- because people believe in them and their nesses, and the use that may be made of it practices, which have values that are in formal health care.3 derived from and are consistent with their Education in the classical systems of own culture. In most instances, these medicine such as Chinese traditional practitioners would be willing to participate medicine, Ayurveda and Unani, already in health-promoting activities, provided includes an appreciable amount of they were convinced that they could be instruction in Western medicine. In the effective and knew how. case of traditional systems, where remedies All too often, however, the opportunity are handed down from generation to to participate has not been afforded them generation by word of mouth, arrange- by the health services, and legislation in ments have to be made to provide some cases endorses this negative stance. practitioners with additional knowledge. Experience shows that restrictive legislation Examples include the ability to identify and remains unenforceable and people encourage existing beneficial practices continue to utilize their traditional systems (e.g., breastfeeding), as well as competence of medicine. For example, a restrictive law in certain modern methods of prevention forbidding traditional practitioners to issue and cure (e.g., the care of infants with certificates in respect of their patients was diarrhoea or acute respiratory infections). repealed in one country. However, it should The creation of a learning situation, where be noted that no enabling law has been health personnel actively work with introduced in its place, and people continue traditional practitioners and the commu- to patronize their practitioners. In many nities in identifying health needs, organizing instances, health services are influenced by health care activities, managing their technocrats bent on achieving and implementation and evaluating the results maintaining a set of “international medical achieved, would also promote a healthier standards”.2 These may not necessarily climate for all.4 reflect nationally acceptable training In an ideal situation, personnel of the curricula that meet local manpower needs, formal health system and traditional thus further accentuating the brain drain practitioners should be encouraged to work of qualified staff. together as teams in clinics and health Traditional medicine is to a large extent centres. Research in traditional medicine culture-specific and therefore practitioners and in the utilization of traditional

185 Traditional Medicine in Asia practitioners in district health care, with should be functionally integrated, and traditional health practitioners themselves these, in turn, should be integrated with as principal investigators, could greatly overall health systems development. In this enhance development in this field. To take scenario, ideally education and training another example, making available simple in traditional medicine should be multipurpose kits containing appropriate articulated within this system. But reality therapeutic agents and basic instruments is often otherwise. Many of the efforts in that could be handled by traditional the education and training of traditional practitioners in their own practices, as is medicine practitioners in the countries are done in some countries, could do much to made on an ad hoc basis outside the improve the quality of their work. mainstream of human resources for health Traditional medicine activities must, of development and do not constitute an course, be adequately funded and external integral part of the education and training and internal funding agencies and non- of health professionals. The reasons for governmental organizations should be this state of affairs are multiple, but they coopted into this endeavour. originate mainly from two generic problems that are inherent in our health Some guiding principles for systems. One is the place of traditional developing a training system medicine in the health system, the types in traditional medicine of issues that were identified in the earlier part of this paper. The other is an The above experiences and questions attitudinal and hierarchical problem provide the overall context for establishing wherein the practitioners of the modern and improving education and training allopathic system of medicine do not programmes in traditional medicine. The recognize the practitioners of traditional more immediate context for policy and medicine to be on par with them. The action will be the structure and the function years of dominance of the allopathic of the human resources development sub- system, and the technological advance- system in the particular country. ment it has achieved, supported by WHO advocates that each level of the public perception and demand, have health system should be the responsibility combined to create this situation and it of the most suitably trained health will be narve to expect it to change professionals, and not necessarily the “most overnight. But this is a fundamental highly” trained staff. The support such problem that needs to be recognized and “suitably trained” staff need must be addressed appropriately in many of our provided by the higher levels of staff. This countries. would be a critical requirement to None of the three processes in human “integrate” the traditional medicine resources development – planning, practitioners in the general health care education and management – can function system and place them in a position of independently of each other. They have their maximum use to the community. own cycles, though. WHO also believes that the three main z Human resources planners acting components of the human resources independently of production and development process – planning, produc- management become paper planners tion and management or utilization – only;

186 Development of training programmes for traditional medicine z Educators and trainers acting in z The roles have social and managerial ignorance of planning and manage- as well as technical aspects that require ment have abandoned the logic of an interdisciplinary approach to role purposeful education and the relevance definition and training; of their programmes to the needs of z The roles of each health worker include society; establishing and maintaining important z Health services managers who act relationships with others, and this independently of plans and education requires consideration of the overall and training have given away their most function of a team as well as training important management tools, for teamwork; including the influencing of the health z The roles involve close interaction with personnel they want to utilize. communities, which requires not only an understanding of the nature of that Defining the characteristics of interaction, but also calls for the graduates of educational and participation of communities in the training programmes process of role definition. It seems obvious that the roles to be fulfilled by graduates of educational and training Key questions/issues and some programmes should serve as a basis for answers determining the content and methods of (1) How can the formal health services learning, yet this process is seldom given work with traditional practitioners for careful attention. Most often, the roles are the benefit of the population? Why? taken for granted, based largely on Because so far, traditional practitioners outmoded recollections, or on the assum- have been excluded from exercising any ption that graduates can adapt to the responsibility in most national health situation in which they find themselves. services. Furthermore, the training institutions often (2) How can a traditional medicine do not even consider it necessary to train infrastructure be created? Why? students for well-defined roles and Because, without a clearly defined functions. When graduates complain infrastructure, through which tradi- that their preparation was not adequate, tional health practitioners themselves the programmes are only occasionally could be heard and which could be a modified. regulatory body in relation to ethical To ensure the relevance of health and professional matters, there is likely manpower preparation, it is necessary that to be chaos. there is a full understanding of the personal (3) How to sensitize, orient and use health and professional competencies, including professionals and others so that they the intellectual and practical skills, values, may support the national traditional and attitudes required if health workers are medicine programme? Why? to function effectively in the settings to which Because, if they are brought into a they are assigned.5 The development of such constructive relationship with the an understanding involves several problems: programme, they will continue with z The roles to be filled may not yet exist their biases and hamper Government but are planned; this is a common efforts to put traditional medicine on a occurrence in evolving health systems; sound footing.

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(4) How to review health legislation (6) How to develop a national drug policy concerning traditional medicine? that includes traditional medicine? Why? Why? Because, most of the present legislation Because, importing drugs is always very in this field is outdated or irrelevant and costly and consumes scarce foreign needs to be revised to conform with the currency. Developing traditional new policies adopted. In any case, a remedies of proven efficacy and quality reasonable and enforceable legislation will not only promote self-reliance but would greatly enhance the implemen- will also encourage research workers tation of traditional medicine activities. to investigate other traditional (5) How to define the role of bilateral and remedies more carefully. multilateral assistance? why? (7) How to formulate up-to-date research Because, any external support should and development policies in traditional be consistent with Government policies medicine? Why? and priorities; otherwise, it may lead Because, at present research policies to unnecessary and wasteful invest- in most countries do not reflect the role ment in esoteric projects which have of traditional medicine in health no direct relevance to the people’s services. New research and develop- health needs. ment policies could greatly assist

188 Development of training programmes for traditional medicine

institutions in addressing the critical (e) In parallel with the work outlined problems now being faced. above, it will be necessary to undertake (8) How to finance traditional medicine a survey of the national situation in activities? Why? respect of the practitioners, the Because, the introduction of traditional population’s preferences and needs, medicine activities will require adequate resources, special problems, etc., upon budgetary appropriations. A sound which a sound national health plan programme and budget that maximizes reflecting the role of traditional the effective use of all available resources medicine may be formulated. Practi- needs to be evolved. tioners of traditional medicine should (a) There is no single or simple approach be engaged in these activities and the to the problem of how to involve results should be made widely known traditional practitioners in national to the general public as well as to the health systems, especially at the health professions. primary health care level. Dedicated (f) The institution of practical, low-cost and sincere action on the part of all traditional medicine activities need not concerned will be required to foster a await the results of these surveys. One collective effort to generate and of the first activities should be the implement policies best suited to any generation of a public debate that given country. should include special educational (b) The first step could be the establishment efforts for the public (press, TV and of a National Council for Traditional radio), distribution of information on Medicine, that could be charged with traditional medicine, and short courses responsibility for preparing a national for traditional practitioners and strategy of laying down a broad plan conventional health personnel, as an of action to be followed by the initial step, to secure their involvement. Government. The Council should be multidisciplinary and multisectoral in There are three basic changes and nature, with appropriate represen- reorientations that are needed in the tation of the different types of traditional education and training programmes in practitioners involved. traditional medicine. Firstly, more attention (c) Major policy issues need to be must be paid to problem-solving skills as identified quickly, priorities determined the current curricula are overburdened with and mechanisms established to propose the pursuit of knowledge and information, the various options and courses of much of it is irrelevant to the priority tasks action open to the Government, with needed to meet the health problems of ad hoc groups being formed to tackle communities. The curricula also need to specific issues. be more problem-oriented and community- (d) Adequate finance should be assured oriented, if not community-based. In under the Government’s regular addition, appropriate teaching and budget for the support and promotion learning strategies need to be developed of traditional medicine activities. for traditional medicine practitioners to External finance should be considered work in teams. as only supplementary to the Secondly, the education and training Government’s main effort. programmes in traditional medicine need

189 Traditional Medicine in Asia to develop appropriate teaching and health and social needs of their learning materials and promote the wider communities. As promoters of learning, use of audiovisual, self-instructional and teachers need more than a sound grasp simulation techniques which have proven of their own health disciplines. They need value. The challenge is to adapt these to to know the needs and demands of their the specific requirements, especially to communities, and the intersectoral students and learners in rural areas, where activities that are most likely to contribute many of them are. Some of the knowledge to health development. It is by pursuing may not be documented and will need to such a wider agenda that the teachers of be elicited from the practitioners traditional medicine will develop the themselves. respect and the self-confidence to interact The third major change is in the with their counterparts in schools of evaluation of the education and training Western medicine. It is accepted in recent programmes. Evaluation should not only times that training in educational determine whether the students (and the principles and processes in teaching and teachers) have achieved their objectives learning methodology would be essential (often called student assessment), but also for teachers of all health personnel. By the quality of the whole teaching and this count there is a great dearth of learning process. It should determine teachers of traditional medicine with such whether the learners have achieved the knowledge and skills. It would therefore objectives, and if so, to what extent; take a considerably long time before a whether the objectives are relevant to majority (or even a sizeable number) of health care needs; whether the curriculum teachers are in these areas, but the and methods are relevant to the objectives process must begin now. and if the evaluation is valid and objective. In other words, this should be a self- Continuing Education controlling process. Education of traditional medicine practitioners should not be seen as a one- Training of teachers time event. Initial learning experiences The changes in education and training should be improved continuously, and envisaged in traditional medicine hold higher levels of competence achieved. important implications for the training of Improved work performance, enhanced their teachers. This, of course, is possible competencies, more positive work attitudes, in those instances where institutional cases and greater productivity should not be left are available. The traditional practitioner to chance. They should be pursued who works independently would not be through continuing education that seeks able to do these. Perhaps the most basic to enhance the performance of health aspect of teacher training is that they workers through a system of planned understand their role as teachers, i.e., to educational programmes relevant to promote the process of learning by service needs. Most of the countries in the guiding the students to achieve the Region still do not have any continuing learning objectives. The second would be activities, leave alone having in place well- for them to understand that the role of coordinated, systematic continuing their training institutions is to prepare education programmes. In the best sense, personnel for health systems that meet the modules or units of continuing education

190 Development of training programmes for traditional medicine should be sequential and progressive, and among them in this subject. It would be specific learning objectives should be easier when, and if, the two systems are derived from the competencies required for available to the community in some more effective and efficient performance.6 integrated or coordinated manner so that Here, there are greater opportunities than the practitioners communicate regularly with basic-level programmes to pursue with each other. multi-professional or team-and-problem- oriented approaches to education. Conclusion Since the purpose of continuing education is enhanced job performance in Many years have passed since the World the health services, it must be associated Health Assembly first urged interested with other factors that contribute to high governments to give adequate importance levels of staff morale and productivity. to the utilization of their traditional systems Continuing education is, therefore, not only of medicine with appropriate regulations a part of the training component of human as suited to their national health system resource development, but of human (Resolution WHA30.49). So far no clear resources management as well. In China picture as to how this was to be imple- these aspects are reasonably well- mented in many countries has evolved and articulated in the continuing education of many public health administrators look on traditional medicine practitioners. It traditional medicine with continued requires cooperation between the trainers cynicism. Without a proper understanding and the health service managers. at Government level of the issues involved and the creation of an informed body of Orientation of medical students opinion on the subject among the health and practitioners in traditional profession and the public, there will be no medicine significant move to utilize traditional In order to foster and generate an medicine in national health systems. atmosphere of cooperation between the One tends to speak as if the traditional practitioners of modern and traditional forms of medicine and their practitioners medicine, one requirement would be to are each homogeneous entities. It is, orientate the students and practitioners of however, important to distinguish between Western medicine in traditional medicine. the “formalized” traditional systems of This should therefore be taken up as a medicine, such as Ayurveda, Unani, and parallel activity. In India, for example, it is Chinese traditional medicine and the now compulsory for medical students to practice of those practitioners who are have a certain number of hours of recognized by their communities as being instruction dedicated to traditional competent to provide health care. These medicine. This is a good start and, later, it practitioners serve a long apprenticeship may be possible to incorporate some and their knowledge is handed down from assessments also into this. It would be generation to generation, mainly by word desirable to similarly orientate the of mouth. practitioners of Western medicine in There are also various types of healers traditional medicine, but this would be a whose practices are based on spiritual or much more difficult exercise as there would moral convictions and others more difficult be few available ways of generating interest to define but who, nevertheless, are

191 Traditional Medicine in Asia recognized healers within their communities, Countries’ primary concern should be such as exorcists and spirit media, who to encourage the utilization of those employ special healing arts associated with elements of traditional medicine which are the supernatural. Their methods and of value in their national health services. beliefs are so diverse as to preclude their In this modern age, the rich heritage of incorporation in any formal system. traditional medicine should not remain the Individual governments will have to decide exclusive or esoteric interest of only a few. on what place, if any, to accord them.

References

1. Primary Health Care. Report of the International Conference on Primary Health Care. Alma-Ata USSR. 6–12 September 1978. Geneva. World Health Organization. 1978 (“Health for All” Series, No. 1). 2. Stephan, J. “Legal Aspects: patterns of legislation concerning traditional medicine.” In: Bannerman, R. H. et al. ed. Traditional medicine and health care coverage: a reader for health administrators and practitioners. Geneva. World Health Organization. 1985. 3. Akerele, O. “Towards the utilization of traditional Medicine in National Health Services” In: American Journal of Chinese Medicine. Vol. XIV. Nos.1–2. 2–10. 4. Report of the Regional Consultation on Development of Traditional Medicine in South-East Asia region. World Health Organization. New Delhi. 14–17 September, 1999. Regional Office for South-East Asia. 1999. 5. Health Manpower Requirements for the Achievement of Health for All by the Year 2000, through Primary Health Care. Technical Report Series 717. Geneva. World Health Organization. 1985. 6. Guilbert, J.J. Educational Handbook for Health Personnel. World Health Organization. Geneva. 1981.

192 Technical issues

Legislation and regulation of traditional systems of medicine - systems, practitioners and herbal products Dr. D.C. Jayasuriya Dr. Shanti Jayasuriya Standardization, pre-clinical toxicology and clinical evaluation of medicinal plants, including ethical considerations Prof. Ranjit Roy Chaudhury Dr. Mandakini Roy Chaudhury Protection of traditional systems of medicine, patenting and promotion of medicinal plants Prof. Carlos M. Correa Research, drug development and manufacture of herbal drugs Dr. B.B. Gaitonde Traditional Medicine in Asia

194 Legislation and regulation of traditional systems of medicine – systems, practitioners and herbal products Legislation and regulation of traditional systems of medicine – systems, practitioners and herbal products D. C. Jayasuriya Shanti Jayasuriya

ust as much as we have “traditional In considering the role of regulating Jfoods” or “traditional dresses”, every traditional medicine, two areas need to be society has medicines and practitioners addressed: that have come to be labelled as z The regulation of traditional medicinal “traditional”. products; When does a type of medicine or z The regulation of traditional medical practitioner become “traditional”? Given practitioners. that “traditional” is a relative term, and that each country’s experience is unique, a Before these aspects are considered, it precise date cannot be easily determined. will be useful to examine what “traditional Generally, it is the date of recognition medicine” is. accorded, either by legislation or through “Traditional Medicine” has been defined practice or official patronage, to a certain in various ways; in most contexts, however, type of medicine and practitioner thereof, its content and parameters are understood that serves as the cut-off date for the even without a definition. A recent statutory demarcation of what we describe as definition is to be found in the Public Health “western” or “modern” or “allopathic” Code of Burkina Faso of 1994:a medicines and practitioners as against “Traditional medicine means the “traditional” medicines and practitioners. aggregate of all knowledge and practices In practice, it is through an evolutionary of a physical or non-physical nature, process that each system has emerged to, whether explicable or not, used in order or retained, its position of dominance. to diagnose, prevent, or eliminate Socio-historical and anthropological physical, mental, psychological, and social studies1 illustrate that this process disequilibrium, and based exclusively on continues notwithstanding the legal status past experience and knowledge passed because perceptions, beliefs and practices on from generation to generation, either of people are not easily amenable to orally or in writing.” change through the force of law.

a Law No. 23/94/ADP of 19 May 1994 promulgating the Public Health Code (IDHL, 1995, 46 (4), 452).

195 Traditional Medicine in Asia

This definition captures many salient Regulation of Traditional features of most non-Western systems of Medicinal Products medicine that look at the human body and the multifarious ailments from a holistic Before the advent of synthetic compounds perspective. In a few countries, including and preparations, medicinal plants several South-East Asian nations, provided the most diverse and potentially traditional medical education is organized most effective means of treating many on a well-structured basis; the definition illnesses, and the tradition of using plants does not specifically exclude this aspect was passed from one generation of but the way it is formulated may tend to traditional healers to the next.2 create the impression that instruction in While no precise figures are available, traditional medicine takes place in an estimates suggest that some 80 per cent informal context. Another possible of the world’s inhabitants remain limitation is contained in that part of the extensively reliant for their primary health definition which speaks of traditional care needs on traditional medicines, medicine being based exclusively on past including those manufactured from plant experience and knowledge. There is a extracts or purified active ingredients.3 growing, albeit relatively slowly, body of Such products are not by any means empirical evidence of the properties of confined to developing countries. Use of some herbal medicines looking especially herbal products and alternative systems of at inter alia long-term toxicity. medicine is widespread in many developed A broader definition is to be found in countries. In 1990, for instance, the sales the law of Guinea. “Traditional Guinean of over-the-counter (OTC) herbal medicine is the sum total of all technical medicines in Germany alone have been knowledge involving the preparation and claimed to be of the order of US$ 1.5 utilization of substances, measures, and billion.c practices in use, whether explicable or not Moreover, plant substances continue at the current state of the art, resulting to provide the basis for many modern from the sociocultural and religious medicines. In the United States, for foundations of Guinean communities, instance, a 1993 estimate indicates that which is based on practical experience and some 25 per cent of prescription drugs and on traditions handed down from genera- 60 per cent of non-prescription drugs tion to generation, whether verbally or in include one or more naturally-derived writing, and which is used in the diagnosis, substances and in 1990 the sales of such prevention or elimination of an imbalance products amounted to some US$ 15.5 of well-being of a physical, mental, social billion.4 or spiritual nature”.b This definition In addition to being the sources of includes within its scope the religious and active constituents for many therapeutic spiritual dimensions of traditional medicine. products, plants frequently provide the In some countries, traditional medical starting materials for potent synthesized practice is closely connected with both drugs, as well as providing models for the religious as well as spiritual practices. development of related, pharmacologically

b Law No. L/97/021/AN of 19 June 1997 (IDHL, 1999, 59 (2), 162). c Kuipers C.E. et al. Herbal medicines – a continuing world trend (draft manuscript available with the Programme).

196 Legislation and regulation of traditional systems of medicine – systems, practitioners and herbal products active compounds. Conservation of plant Several recently commissioned investi- species consequently operates to the gations of the potential toxicity of naturally advantage of populations in both occurring substances widely used in developed and developing countries. The herbal preparations have revealed “a imminent extinction of perhaps as many previously unsuspected potential for as 20,000 of the 40,000 to 75,000 plants systemic toxicity, carcinogenicity and potentially valuable to medicine,5 is a cause teratogenicity”.7 for concern worldwide and action has In recognition of the value of the already been broached in some countries world’s resources of medicinal plants and to regulate their harvesting and the need for discernment in their use, the exportation.6 The Fortieth World Health Assembly, in adopting Convention on Biological Diversity, states, resolution WHA40.33, called upon inter alia, that: “conservation and Member States: sustainable use of biological diversity is of z To initiate comprehensive programmes critical importance for meeting the food, for the identification, evaluation, health and other needs of the growing preparation, cultivation and conserva- world population, for which purpose tion of medicinal plants; access to and sharing of both genetic z To ensure quality control of drugs resources and technologies are essential.” derived from traditional plant remedies Species of medicinal value are specifi- by using modern techniques and cally cited in the Convention as being applying suitable standards and good among the categories of plants that need manufacturing practices. to be identified and scheduled as a prerequisite to assuring both conservation Similarly, the Forty-second World Health and sustainable use. Assembly, in resolution WHA 42.43, urged Member States: The policy context of regulation z To make a systematic inventory and It is estimated that only some 5000 plant assessment (pre-clinical and clinical) of species have so far been studied for the medicinal plants used by traditional biological activity and possible medical practitioners and by the population; application, and few of these – or their z To introduce measures for the component substances – have been regulation and control of medicinal comprehensively screened for toxicity and plant products and for the establish- specific pharmacological activity. ment and maintenance of suitable This holds importance, not least standards; because the aphorism is now z To identify those medicinal plants, or demonstrably fallacious that the safety of remedies derived from them, which herbal substances becomes apparent as have a satisfactory efficacy/side-effect a consequence of extensive use over many ratio and should be included in the generations. In general, this thesis is national formulary of pharmacopoeia. applicable only to dose-related, acute toxic effects. It is less reliable when applied to The WHO Secretariat has responded immunologically determined effects, and to those resolutions by formulating general largely irrelevant to the identification of guidelines for the assessment of herbal long-range consequences of exposure. medicines and research guidelines for

197 Traditional Medicine in Asia evaluating the safety and efficacy of herbal “a medicinal product consisting of a medicines. substance produced by subjecting a plant or plants of drying, crushing or any other Terminology and scope of process or of a mixture whose sole regulatory control ingredients are two or more substances Some national drug laws refer specifically so produced, or of a mixture whose sole to medicinal plants and/or herbal ingredients are one or more substances remedies, but there is no consistency in the so produced with water or some other terminology employed to identify or inert substance”. describe them for regulatory purposes. In The Australian Therapeutic Goods the international sphere, only the Single Regulations, 1990, has a broader Convention on Narcotic Drugs, 1961, as definition of herbal substance: amended by the Protocol of 1972, which “all or part of a plant or substance is concerned only with a limited number of (other than a pure chemical or a plant substances, and particularly those with substances of bacterial origin): (a) that is some therapeutic value and a high potential obtained only by drying, crushing, distilling, for abuse offers precise definitions. extracting, expressing, comminuting, In a more general context, the 1965 mixing with an inert diluent substance or EEC Directive on Medicinal Productsd lends another herbal substance or mixing with precision to general definitions. The word water, ethanol, glycerol or aqueous ethanol; “substance” is defined as applying to any and (b) that is not subjected to any other matter “irrespective of origin”. “Vegetable treatment or process other than a treatment substance” is established as a general or process that is necessary for its definition that comprises “plants” and presentation in a pharmaceutical form”. “parts of plants”. The WHO guidelines for the assess- Some national laws subsume medicinal ment of herbal medicines propose a plants into the definition of “substance” (e.g., definition which is subsidiary to the term the Netherlands); “medicament” (e.g., “plant preparation”: China); “traditional drug” (e.g., Indonesia), “Finished, labelled medicinal products “herb” (e.g., Rep. of Korea), “herbal remedy” that contain as active ingredients aerial (e.g., United Kingdom); “traditional medicine or underground parts of plants, or other (e.g., Singapore); or “herbal substance” plant material or combination thereof, (e.g., Australia). whether in the crude state or as plant In some countries, medicinal plants are preparations. Plant material includes embraced within national drug legislation juices, gums, fatty oils, essential oils, and by virtue of being listed in a pharmacopoeia any other substances of this nature. Herbal (e.g., France) or in a national formulary medicines may contain excipients in (e.g., the Philippines). addition to the active ingredients. The term “herbal remedy” is similarly Medicines containing plant material subjected to a variety of legal definitions. combined with chemically defined active In the Medicines Act, 1968, of the United substances, including chemically defined, Kingdom, “herbal remedy” has been isolated constituents of plants, are not defined as considered to be herbal medicines.” d Council Directive 65/65/EEC of 26th January 1965, as subsequently amended.

198 Legislation and regulation of traditional systems of medicine – systems, practitioners and herbal products

A different definition – similarly Different national laws apply various dependent upon the concept of prepared criteria to the scheduling of herbal or or processed ingredients – is preferred in traditional products for purposes of the recent WHO guidelines for evaluating registration. These criteria cover the the safety and efficacy of herbal medicines: following considerations: “A plant-derived material or z Whether or not the product is included preparation with therapeutic or other in an official pharmacopoeia or human health benefits which contains formulary; either raw or processed ingredients from z Whether or not the product is to be sold one or more plants. In some traditions, as a prescription product; materials of inorganic or animal origin z Whether or not a therapeutic effect is may also be present”. claimed; In formulating such a definition, two z Whether or not the product contains considerations are important: the ways in an ingredient or substance that is which related concepts and terms have either scheduled in an international been already defined, both within national convention or subjected to prescription statutes and international texts, and the control; particular aspects that it is intended to z Longevity of use (described as ‘well regulate.8 Thus, some definitions of herbal established’ or ‘long-term’ use) deter- remedies are drafted in terms that cover mined in relation to a stipulated date medicinal plants, while others specifically or classified as a ‘new drug within the exclude them. traditional system’; z Some countries draw a distinction Registration/Approval between ”officially approved” products Any attempt to apply broad generalizations and “officially recognized” products. to the wide variety of national approaches This is an important distinction in to the registration of plant-based medicinal practice since the intention is to enable products can be misleading.e National the latter to be legitimately marketed control systems have evolved in different and without formal assessment or unique ways, and these distinctive influences registration. continue to be reflected in the regulatory provisions currently in place. In many At the risk of oversimplification, it is possible instances, such products have been either to classify legislative approaches into three included or excluded for assessment and groups: registration purposes through exemptions z All medicinal products are subjected to inspired by any of a wide variety of factors. the same regulatory provisions; The piecemeal evolution of regulatory z All or some herbal and/or traditional requirements which in part is attributable to medicines are exempted from all difficulties in defining terms and validating regulatory provisions; claims regarding efficacy and safety is more z All or some herbal and/or traditional evident with regard to plant-based products medicines are exempted from specified than other medicinal products. regulatory provisions.

e WFPMM, Self medication: progress built on tradition (Swiss Pharma 11a/91), pp. 54–91; Drug Information Journal, Vol. 27, 1993, pp. 145-168; and Chaudhury, R.R. Herbal medicine for human health, New Delhi, WHO, 1992

199 Traditional Medicine in Asia

China features prominently among The extent to which countries that have issued regulations elements of Good specific to traditional herbal medicines. Manufacturing Practices are Detailed provisions have been promulgated applied to the manufacture on their preparation which specify standards and requirements to be of plant-based medicinal maintained in manufacturing facilities and products is varied. by personnel. In Indonesia, traditional medicines can be manufactured only under a licence granted by the Ministry of Health. Different national statutes require Hungary permits the marketing and different types of information and data to processing of only those medicinal plants be submitted with applications for that have been inspected by the Medicinal registration of herbal products. Some Plants Research Institute and for which a countries, including Turkey and the certificate of inspection has been granted. Philippines, require information on the In Singapore, the statutory requirements registration status of the product in other concerning manufacture do not apply to countries, and in case of the latter, infor- products prepared exclusively by drying, mation on the manufacturing operations crushing or comminuting plants or parts and facilities. of plants. The extent to which elements of Good Manufacture, Import, Export, Manufacturing Practices are applied to the Sale and Dispensing manufacture of plant-based medicinal In most countries, the manufacture, products is varied. Insofar as the European import, export, dispensing and sale of Community is concerned, guidelines for the medicinal plants are not specifically manufacture of herbal medicinal products regulated. Depending on the scope of the were drafted in 1990 under the aegis of law these may be governed by provisions the Committee for Proprietary Medicinal applicable to medicinal products in Products. general or, alternatively, this field of activity These guidelines are intended to may remain essentially laissez-faire. supplement the EC text of good manufac- Hence, it is not usual to establish by law turing practices. separate mechanisms to deal specifically Statutory provisions bearing specifically with certain aspects of medicinal plants. on the import of medicinal plants are Regulatory competence in nearly all uncommon. Countries that require countries is vested in the national drug registration of herbal medicinal products authority. France is among the few generally have the power to regulate their countries in which a separate authority import; any restrictions applied specifically has been established: the National to medicinal plants are usually set out only Interprofessional Office has certain in regulations. statutory powers and responsi-bilities with A number of countries have recently regard to plants, parts of plants, and the reported that some imported herbal products of initial processing of these products have been found to contain non- materials. labelled substances that are potentially harmful to health. Malaysia, for instance,

200 Legislation and regulation of traditional systems of medicine – systems, practitioners and herbal products reportedf the presence of several scheduled The dispensing and sale of medicinal poisons and controlled substances, products and medicinal plants are including betamethasone, dexamethasone, governed not only by the laws dealing chlorpheniramine, mefanamic acid, specifically with drug regulation but also phenylbutazone, and dexachlorphe- by those dealing with the health-related niramine, in both domestically produced professions. Statutory provisions relating to and imported herbal medicinal products. medicinal plants, where they exist, are This resulted in the confiscation of stocks based on a range of different approaches and the banning of these products from and modalities. In France, for instance, domestic markets. certain essential oils derived from plants may be sold or supplied to the public only Approaches to the export of by pharmacists. In the Republic of Korea, medicinal plants herbal practitioners – a category of health A few countries require all exports to be professionals who need to pass an regulated. In , for instance, the export examination to be granted this status – of medicinal plants is subject to the may sell herbs by preparing them in issuance of a certificate of guarantee by accordance with the specifications in the competent pharmaceutical inspectorate. oriental medical books or prescriptions of Other countries which cultivate oriental medical doctors. medicinal plants have sought to promote In the United Kingdom, herbal exports by specifying the competent remedies are sold on a retail basis by regulatory authority in the legal text. In Mali, shopkeepers (e.g., ‘health foods’ shops, for instance, one of the statutory responsi- supermarkets, grocers); herbalists (i.e., bilities of the Office of Pharmacy is to persons who make and sell herbal promote the export of products of its own remedies to persons who consult them); research and manufacture, particularly and pharmacists. In Bulgaria, only persons drugs based on medicinal plants. Similarly, in possession of medical qualifications may the National Pharmaceutical Office of receive authorization by the Ministry of Benin is required to promote the export of Health to prescribe medicinal plants. In medicinal products. , medicinal plants may be dispensed In some countries, however, specific only within pharmacies and herbalists’ restrictions are applied to the export of shops. Lesotho has a system – admini- protected plants. In Mali, prior authori- stered by the Universal Medicinemen and zation of the Director-General is required Herbalists Council – of licensing medicine- for any activity involving the collection of men and herbalists. In , there is a medicinal plants for export. In 1976, a statutory prohibition on the simultaneous WHO expert group on traditional practice of the profession of physician, medicines9 called upon countries to dental surgeon and midwife, on the one regulate the export of medicinal plants for hand, and that of a herbalist, on the other, commercial purposes – a call that remained even if the latter is otherwise qualified to largely unnoticed until the elaboration of practise any of the other professions. Those the United Nations Convention on licensed as a herbalist may sell any Biological Diversity. medicinal plant and parts of any such f Annon. Contaminated herbal medicines in Malaysia. SCRIP, No. 1892, 28 January 1994, p. 19.

201 Traditional Medicine in Asia plant, with the exception of those plants of Tanzania, the Institute of Medical included in the list of poisonous substances, Research and Medicinal Plants of and no herbalist may store or sell any other , and the National Institute for pharmaceutical preparation or speciality. Research on the Traditional Pharmaco- poeia and Traditional Medicine of Mali have Labelling, Advertising and a statutory responsibility to undertake Promotion research relating to medicinal plants. Few regulatory texts have specific provisions concerning the labelling, advertising and Conclusions promotion of medicinal plants. Those that Despite increasing pressures for the do address these issues tend to extend to introduction of controls, relatively few herbal medicines the general provisions countries have enacted specific legislative applied to other medicinal products. A few measures to control either the use of countries do have discrete and specific medicinal plants or of herbal preparations provisions derived from them in respect of which there Norway requires herbs and blended is only limited data concerning their quality, herbs available over-the-counter (OTC) to safety and efficacy. Legislative texts of those carry the following warnings countries that have developed systems for “The medicinal effect of this the scientific and technical assessment of preparation has not been assessed by the the quality, safety and efficacy of medicinal public authorities responsible for the plants, as well as guidelines formulated control of medicaments”. under the aegis of the World Health Brazil requires the botanical classi- Organization, define the criteria for fication of the medicinal plant to appear assessment and the procedures to be on labels and wrappers. No proprietary followed in undertaking such assessments. name is required in China either for As the assessment of medicinal plants medicinal plants or for decoctions cannot be guided by systematic or long prepared in accordance with Chinese experience, it is important that drug traditional medicine. Indonesia requires regulatory authorities wishing to regulate that traditional drugs intended for clinical medicinal plants as well as assess them trials must be labelled with the words make the maximum use of the accumulated “intended for Clinical Trials; Not for Sale”. wisdom of those authorities with more Gambia prohibits all advertising of experience in this relatively unchartered products derived from plants cultivated in territory. The new United Nations Convention the country and used as traditional on Biological Diversity offers a stimulus to medicines, unless specific approval has countries that wish to review the control of been obtained from the Medicines Board. medicinal plants within a framework that maintains a balance between reasonable Research and Institutional exploitation and conservation. Mechanisms Several African countries provide for further Traditional Medical research on medicinal plants. The National Practitioners Pharmaceutical Bureau of Burundi, the Central Laboratory at Mototo in Guinea, Traditional medical practitioners exist in the National Institute for Medical Research almost every society; not all prefer to be

202 Legislation and regulation of traditional systems of medicine – systems, practitioners and herbal products called as “traditional medical practitioners” part that they can play in the system of because with the advent of the Western comprehensive health care (health system of medicine, Western medical promotion, prevention of disease and practitioners have come to enjoy an almost disability, diagnosis and early treatment monopolistic position, with the attendant of disease and rehabilitation.”g status, privileges and concessions. In some countries, by law there are restrictions in A definition of a traditional health the use of the term “medical practitioner” practitioner is found in the Public Health or “doctor’, thus placing traditional Code of Guinea of 1997:h “A traditional medical practitioners at a disadvantage. It health practitioner is a person recognized has never been easy to establish the precise by the community in which he lives as role and status of traditional medical competent to carry out diagnoses with practitioners. Community acceptability, local sociocultural foundations and political patronage and perception as a contribute to the health and physical, source of last resort when practitioners of mental, social, and spiritual well-being of other systems have failed to provide relief the members of the locality concerned.” In are some of the factors that come into play addition to this definition, there are separate in determining the recognition to be definitions of traditional therapists; accorded to them. Attempts have been traditional midwives; herbalists; and, made by some countries to initiate a medico-druggists. These are reproduced process of dialogue and consultation with below: a view to arriving at some compromise. Mauritania, for instance, established a Traditional A person recognized by his working group on medicine and the therapist locality as being competent to pharmacopoeia: carry out diagnoses and “to determine the situation of dispense health care based on traditional medicine and the traditional the concepts of disease and pharmacopoeia in Mauritania and, in disability that prevail in that particular: locality; z to examine the most appropriate and Traditional A person recognized as realistic ways and means of establi- midwife competent to provide health shing an honest dialogue between the care to women and newborns official health services and traditional before, during and after practitioners in the spirit of the delivery, on the basis of the objectives of health for all by the year concepts prevailing in the 2000 through primary health care; locality concerned; z to propose the most appropriate Herbalist A person who has a know- mechanisms for identifying traditional ledge of the customs and sells medical practitioners who are medicinal plants; amenable to such a dialogue in order Medico- A person who has a know- to determine and acknowledge the druggist ledge of the customs and sells

g Decision No. 1831 of 9 December 1981 establishing a working group on medicine and the pharmacopoeia (IDHL, 1983, 34 (1), 122). h Law No. L/97/021/AN of 19 June 1997 (IDHL, 1999, 59 (2), 162).

203 Traditional Medicine in Asia

medical substances other than at minimal or no cost. Success stories of plants, of animal or mineral treating those who had found no relief after origin. taking Western medicaments and the belief that someone who is closer to one’s own The practice of traditional medicine is environment and religion is better placed defined as covering consultative, diagno- to provide treatment were additional stic, and care procedures that make factors. In other words, traditional medical exclusive use of traditional methods. practitioners have always been a force to What is significant about the above be reckoned with. In drafting legislation definitions is that they underline the governing health practitioners, a importance of community recognition and compromise had to be reached because it understanding of the local situation. was simply not politically or culturally Concepts of disease and treatment vary acceptable to overlook or dismiss the from system to system and from society to important role played by traditional medical society; the expected role of traditional practitioners. Legislative approaches practitioners is to provide treatment in relating to the regulation of traditional accordance with these concepts. The ability medical practitioners basically fall into four to adapt these concepts in accordance with categories:10 scientific advances will considerably z The exclusive (monopolistic) system; enhance their potential; they are best z The tolerant system; placed to gradually introduce into z The inclusive system; otherwise conservative cultures modern z The integrated system. methods and modern drugs. Each of the above systems are briefly A historical perspective described below: Legislative provisions relating to the status of health practitioners can be best The exclusive (monopolistic) understood only by considering the system evolution of such provisions in each Under this system, Western medical country. The reason for this is that each practitioners were the only ones to be country has approached the issue in a way legally recognized, at least at one point of that is unique and often dictated by time. Other practitioners were simply not considerations that are not readily mentioned in the legislation or the comprehensible or logical. Historically, with legislation clearly excluded them from the increasingly strong presence of those functioning as medical practitioners. trained in Western medicine, there was a Examples are available from European movement to entrench their role and countries, the most notable being France, position by providing for a virtual monopoly and the Americas of legislation conferring status. Every society has had persons – a monopolistic status on university- often without any formal education – with educated physicians and allied profe- the requisite knowledge and skills to treat ssionals such as dentists, pharmacists and the sick and the disabled. They were nurses. Some laws made it a specific popular because of their easy accessibility, offence to engage in medical acts contrary use of language that was simple to to the law. In certain instances, even when understand and the provision of treatment concessions were made, the provisions

204 Legislation and regulation of traditional systems of medicine – systems, practitioners and herbal products were specifically formulated to protect the z Issuing prescriptions in respect of monopoly. For example, Czechoslovakia certain drugs as provided for by the issued Ministerial Instructions in 1976 and Medicines Act 1968. 1981 to regulate the practice of acupun- cture but only physicians with special A few countries have moved towards training were permitted to use this method. the tolerant system by expressly mentioning in the legislation that non-modern scientific The Tolerant System systems are permissible. For instance, the A few countries with advanced health care Medical Act of 1971 of Malaysia states systems, such as the United Kingdom and that “…nothing in this Act shall be deemed Germany, do not prohibit healing by to affect the right of any person, not being persons without the necessary qualifi- a person taking or using any name, title, cations specified in the law for registration addition or description calculated to induce as a physician of what is commonly known any person to believe that he is qualified to as “western system” or “modern system” practise medicine or surgery according to of medicine. What the law often states is modern scientific methods, to practise that it is an offence for anyone who is not systems of therapeutics or surgery duly licensed as such to claim to be a according to purely Malay, Chinese, Indian physician or to use the title reserved for or other native methods, and to demand such a person. In the United Kingdom, for and recover reasonable charges in respect instance, under the Medical Act of 1956 of such practice.” Another example is to “any person who willfully and falsely be found in the Medical and Dental pretends to be or takes or uses the name Practitioners (Amendment) Act 1981 of the or title of physician, doctor of medicine… Republic of Kiribati. It states that “nothing surgeon, …or any in the Medical and Dental Practitioners name, title, addition or description implying Ordinance shall affect the right of any I- that he is registered…” is guilty of an Kiribati to practise in a responsible manner offence. Kiribati traditional healing by means of Under this system, while practising herbal therapy, bone setting and massage, medicine is not prohibited, traditional and to demand and recover reasonable medical practitioners nevertheless suffer charges in respect of such practice: from certain disabilities under the law. For provided that a person so practicing shall instance, in the United Kingdom, only not take or use any name, title, addition or registered practitioners enjoy, under the description likely to induce anyone to believe law, the following privileges: that he is qualified to practise medicine or z Entitlement to recover in the courts fees surgery according to modern scientific for treatment and advice; methods.” Systems of medicine exempted z Employment by and dispensing of from the application of the law are treatment under the National Health mentioned in the Medical Council Act of Service; 1988 of Mauritius which states that the z Holding appointments in public Act does not prohibit the practice of hospitals and other public systems of therapeutics according to establishments; homoeopathy, Ayurvedic and Chinese z Issuing such medical certificates as are traditional methods. required by law;

205 Traditional Medicine in Asia

The Inclusive System turning point in the country’s medical This system is found in countries such as history. Bangladesh, India, Pakistan and Sri Lanka where the law recognizes two parallel The Integrated System systems, the traditional and the modern. The integrated system represents a stage The law provides for the registration and where the inclusive system has evolved into recognition of traditional medical practi- a system that provides for the two tioners and regulates matters pertaining to professions – western or modern medical medical education, practice, and ethics. practitioners and traditional medical In most countries traditional medical practitioners – to work together as one practitioners originally came from families team. where they were taught by their elders. China provides the best known Knowledge was transmitted from one example of this integrated system. In South generation to another; secret remedies Asia, Nepal can be described as having remained a closely kept secret that was not adopted this system. The Chinese system, recorded in writing. Universities, schools with the well-known example of barefoot and colleges for training the different medical doctors, can be best understood categories of traditional medical practi- only within the country’s complex political tioners were set up much later. In the early context. Indeed, there are concerns as to stages, the laws governing medical practice whether the Chinese system can be easily recognized a category of practitioners tried out elsewhere with the same degree without formal educational qualifications of success. but who had been in active practice for a An integrated system offers an defined period of time. This was a legislative opportunity for each system to offer its best technique that is generally not found in for the welfare of the patient. In actual laws governing Western or modern practice, however, some problems can practitioners. Through this device, it was arise. For instance, drug interactions are possible to bring into the mainstream of not well-studied and in prescribing traditional medical practice thousands of medicines a choice would almost invariably practitioners who might otherwise have not have to be made between a Western drug been eligible for registration had formal and a herbal product, for instance. qualifications been a statutory requirement. In almost every society, traditional Conclusions medical practitioners gained recognition This review of traditional medical practi- through a struggle; each country has its tioners highlights that different countries own story of the battles that were fought. have approached the issue from different In many instances, traditional medical perspectives and that there is no single practitioners emerged as a strong and legislative model prevalent throughout the influential political force to be reckoned world or any particular geographical with – even though they were numerically region. Each country has a fairly complex not large, they had their supporters in large body of laws, regulations and codes of numbers. State patronage has always conduct applicable to traditional medical played an important role. The creation of practitioners. It is not possible to comment a separate Ministry of Indigenous Medicine on these laws unless they are examined in in Sri Lanka, for instance, was an important the light of the laws, regulations and codes

206 Legislation and regulation of traditional systems of medicine – systems, practitioners and herbal products of conduct applicable to modern or Principle 3: The determination of the Western medical practitioners. respective role to be assigned to each system must involve consultations with Towards the Future recognized practitioners of each system and consumer groups or community It cannot be gainsaid that for the vast leaders representative of users. Such majority of the population in most rural consultations must be based on the societies traditional medical practitioners premise that health-care products must will continue to provide the only source of conform to acceptable standards of quality, medicine that is easily available at a safety and efficacy, and that the numbers reasonable cost. While exclusion, through who use such products or the political experience and practice, of products on the patronage extended to such products or basis of evidence of short-term toxicity will the practitioners thereof are irrelevant to continue to operate as a safety valve, the the scientific process that must necessarily need for assessment based on appropriate take place to determine quality, safety and criteria has to be met sooner or later by all efficacy. Unsafe products or those of countries. Guidelines produced by WHO doubtful quality must be eliminated from exemplify that such assessments are not the market; the support of relevant groups unrealistic even in countries with limited must be mobilized to ensure that such resources. The challenge is to devise products are no longer marketed or used. “appropriate criteria” using cost-effective There must be an appropriate legislative methods. There must be a dialogue leading basis to mandate the process of evaluation to consensus and traditional medical and to authorize products to be marketed practitioners themselves must be in the or to be eliminated from the market. vanguard of the movement to rationalize Through a phased-in approach all the traditional medicine market. products can be assessed on a systematic It augurs well for the future that the basis. Even countries with limited WHO Regional Office for South-East Asia, manpower have been able to progress by in particular, has been promoting the making extensive use of the experience of integration of traditional medical practi- countries with more manpower. Unless tioners into the district health system (DHS). genetic and other factors dictate otherwise, From a regulatory perspective, the a product approved by many countries integration of traditional medical practi- must be assumed to be suitable for tioners and traditional medicine products inclusion in the list of essential medicines into the district health system (DHS) must for community use. be based on the following guiding principles: Principle 4: Products that are Principle 1: The DHS must recognize permitted to be used must be made that plural systems of health care exist and available through appropriate channels, that each system must be accorded not excluding those that have been devised recognition. for a particular type of product. Where an Principle 2: Recognition of plurality integrated approach to distribution is is not necessarily inconsistent with the feasible, such an approach must be obligation to ensure that those basic developed through a process of principles of public health and safety are consultation and collaboration. Practi- not compromised. tioners of each system must respect the

207 Traditional Medicine in Asia strengths and limitations of each system insurance or social reimbursement and the need to supplement delivery schemes exist, traditional medical products systems devised for each system. must be considered as eligible products. Managers of DHS must assume the In this first year of the new millennium responsibility for ensuring that the delivery we must have the modesty to recognize system can meet the demand. A that no single system can meet all our management committee must be in place health-care needs and the courage to to ensure that products are made available ensure that products that are not safe must to the extent possible. Where health not be permitted.

References

1. Wolffers I. Traditional practitioners and western pharmaceuticals in Sri Lanka. The Context of Medicines in Developing Countries. Amsterdam. Klluwer Academic Publishing. 1988: 47–56. 2. Nakajima H. Our earth and our health. Natural resources and human health-plants of medicinal and nutritional value. Amsterdam. Elsevier. 1992: 1. 3. Akerele O. Nature’s medicinal bounty: don’t throw it away. World Health Forum. 1993; 390. 4. Reid W.V., et al. A new lease on life. Biodiversity prospecting: using genetic Resources for sustainable development. Washington D.C. World Resource Institute. 1993: 7. 5. Kobe Conference. Plants of medicinal and nutritional value. Natural resources and human health. Amsterdam. Elsevier. 1992: xi. 6. De Klemm C. Medicinal plants and the law. Conservation of medicinal plants. Cambridge. Cambridge University Press. 1991: 265. 7. WHO. Guiding principles for small national drug regulatory authorities. In: WHO Expert Committee on Essential Drugs: Fifth report. WHO Technical Report Series. Geneva. World Health Organization. 1992; 825: Annexure. 8. Jayasuriya D.C. The regulation of pharmaceuticals in developing countries: legal issues and approaches. Geneva. World Health Organization. 1985. 9. WHO. African traditional medicine. Brazzaville. WHO. 1976; (TRS No. 1):20. 10. Stepan J. Legal aspects. Traditional Medicine and Health Care Coverage. Geneva. WHO. 1983: 290–313.

208 Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations Ranjit Roy Chaudhury Mandakini Roy Chaudhury

nadequate standardization of medicinal the unique heritage of abundant unlimited I plants, unacceptable preclinical toxico- biodiversity. Only if herbal medicines are logy studies and inappropriate uncon- well standardized will countries purchase trolled and badly designed clinical trials such medicines. Only if the allopathic form the triad of constraining factors which doctors are convinced that every sample have held back the use of medicinal plants of a herbal drug contains the same amount for health development and belied the of active constituents will they prescribe longstanding hopes that research on such medicines. medicinal plants would lead to a host of The need for proper standardization new drugs. has also been recognized by practitioners of the traditional systems of medicine. At Standardization the 3rd International Congress of Traditional Asian Medicine held at Mumbai When a medicine is administered to a from 4–9 January, 1990, this point was patient, the doctor who prescribes the repeatedly highlighted by a large number medicine needs to be certain that the of participants who did not belong to the medicine contains the correct amount of allopathic system.1 A group of Ayurvedic the right substance and does not contain research workers stressed the importance any impurities. Only then will the medicine of developing good methods for induce its therapeutic effect and not induce standardizing crude extracts, decoctions any toxic effect due perhaps to contami- and compound formulations which consist nants. This is only possible if the herbal of different ingredients. It was clearly stated medicine has undergone a process known that the technology available at that time, as standardization. It is this lack of 10 years ago, was not able to develop standardization of herbal remedies which suitable quality control criteria for mixtures acts as a constraint to the use of these and compound preparations. medicines in allopathic hospitals. It is also There are several factors which have one of the constraints preventing an acted as constraints in the development increase in the export of traditional of appropriate methods for standardizing medicines from third world countries with herbal medicines. Some of these have

209 Traditional Medicine in Asia been clearly brought out by Handa in his can be seen in many countries of South- contribution to the Regional Consultation East Asia. on Development of Traditional Medicine in The need for standardization has long South-East Asia Region held in New Delhi been recognized. The World Health from 14–17 September, 1999.2 Bottle- Organization organized an Inter-Regional necks in the standardization of herbal drugs Meeting on Standardization and Use of include dependence on wild sources for the Medicinal Plants at Tianjin in China in plants leading to variation in quality, November 1980.3 Participants clearly adulteration and substitution of the active pointed out the problems relating to plant material by inactive, cheaper varieties standardization of herbal medicines and of non-medicinal plants, and in many cases the tremendous need for immediate work incorrect identification of the plant itself. in this field. A second conference, also This is because the same plant may have organized by the Western Pacific Regional different local names at different locations Office of the World Health Organization while sometimes different plants have the at Tokyo in 1986, identified three areas of same local name. A good example of the priority research.4 Research on standardi- latter is that the plant which is commonly zation was one of these areas. Standardi- known as Punarnava, a quality-of-life zation, it was stressed, means standardi- enhancer, is collected under the botanical zation of the raw material, standardization name of Boerhaavia diffusa and also of the method of production and quality collected under the name Trianthema control of the final product. The Regional portulacastrum (Vishakarpara). This would Consultation at New Delhi held in 1999[2] certainly lead to problems in standardizing again highlighted the need for standardi- Boerhaavia diffusa if some Trianthema zation but added some new features to this portulacastrum is also contained in the issue. sample. Parikh2 in his presentation at the New The loss in medicinal plants due to Delhi meeting organized by the World ecological degradation has led to a Health Organization made a strong plea shortage of the actual plants and for cultivation of medicinal plants rather substitution by other non-medicinal plants. than collection from the wild. Standardi- One example is the preparation of a herbal zation of herbal preparations from plants drug from the bark of the plant Caesalpinia which are cultivated would be easier for sappan (Patranga). When this bark is the following reasons. The availability of the collected, the bark from other plants such plant material would be assured and the as Pterocarpus marsupium (Vijayasara), supplies could be controlled. The quality Gluta travancorica and Toona ciliata of such plants would be reliable, identi- (Nandivriksha) or Cedrela toona are fication totally accurate and adulteration substituted for Caesalpinia sappan. Other would not be an issue. Further, in this examples which have been found in India system the environment would be main- relate to the substitution of the bark of tained. Other possible advantages would (Ashok) by the bark of be the possibility, in these controlled Trema orientalis (Jivanti) and substitution conditions, of carrying out agronomic of the plant Holarrhena antidysenterica manipulation and genetic improvement. (Kutaja) by the plant tinctoria (Asita A reference was also made by Parikh2 kutaja). Similar instances of adulteration to the global market for medicinal plant

210 Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations products which had been estimated to be WHO Geneva, which followed the 1992 of the order of five trillion dollars in 2050. document “Quality control methods for Only those countries which invest imme- medicinal plant material”. Investigators diately and well in setting up standardi- interested in details of the methodology zation of herbal products could hope to proposed for use are requested to study exploit this worldwide growth in the need the publication brought out in 1998. for herbal products. Countries will, in the Another positive development has been years to come, not allow products which the publication of Herbal Pharmacopoeas are not standardized to be sold. which have laid down the standards for the Another major constraint in setting up different procedures. WHO has recently standardization procedures is the non- brought out its first Pharmacopoea availability of standards against which containing standards for plants. Other products could be assessed by chemical pharmacopoeas available include the or bioassay methodology. British Herbal Pharmacopoea (1990), Advances have been made in the last Japanese Standards for Herbal Medicines 10 years in the standardization of herbal (1993), Ayurveda Formulary and products. It is expected today that the Standards for Ayurvedic Formulations following macroscopic, microscopic, (1978), the Central Council for Research physicochemical and biological tests in Indian Medicine “Pharmacopeal should have been carried out before any Standard for Ayurvedic Formulations plant material is released for use. (1987), the Ayurvedic Pharmacopoea of z Macroscopic examination; India (1989), the Unani Pharmacopoea z Microscopic examination; (2000), National Formulary of Unani e.g. Anatomical structure Medicine – Part I (1984) and Part II (2000), Detailed study of fragments; the Pharmacopoea of the People’s Republic z Physiochemical testing of China and the Indian Herbal Pharma- e.g.Boiling point; copoea (1998), volumes one and two. Freezing point; In spite of these advances, standardi- Absorption coefficient; zation of herbal preparations needs to be Loss on drying; given a big boost by governments in the Ash value; Region if the tremendous potential of Refractory index; ancient heritage and biodiversity is to be Optical ratio; used for the people of the countries for Water/alcohol soluble solid; delivering improved health care. Herbal Spectroscopic analysis; medicines would be much more widely used Thin-layer chromatography – R.F. nationally and internationally, would be value; much more accepted and would tremen- Gas liquid chromatography. dously enhance health care if improved z Biological testing where appropriate standardization provides credibility to the e.g. Digitalis bioassay. quality of the medicines used. Unfortu- nately, there are very few centres for A big step forward towards improved standardization of herbal products in the standardization of plant medicines was the Region, too few qualified and trained publication in 1998 of the “Quality control experts in this area of expertise, and a lack methods for medicinal plant material”5 by of sustained funding for standardization

211 Traditional Medicine in Asia activities. These shortcomings need to be clinical evaluation, in a limited number of corrected. human subjects, of a plant Zaopatle – Montanoa tomentosa – for its luteolytic Preclinical Toxicology effect and possible use as a contraceptive. The animal toxicology tests carried out Preclinical toxicology studies in animals are before clinical evaluation were: carried out to determine the safety of z Thirty rats were administered the medicinal plants and herbal preparations decoction at three doses for four weeks; before administering these to humans z Four female monkeys were adminis- for the purpose of evaluating clinical tered the decoction once daily for 30 effectiveness. The quantum of toxicity tests days; to be carried out is defined in national laws, z Four adult dogs were given the and the drug regulatory agencies of the concoction for 12 weeks. The usual countries ensure that acute, subacute and toxicology profile after administration chronic studies in animals are carried out of the substance was studied in these and the results carefully assessed. These three species. requirements were, till recent years, the same for new synthetic molecules never The reason for the Swedish authorities before administered to man and for herbal putting zaopatle on the fast-track reduced medicines used for generations and, in toxicology profile was the great need for many instances, even being actually used early development of a contraceptive and at this time. the fact that zaopatle had been used for It was only in 1980 that the first author, its antiovulatory effect as a in in his keynote address at the First World Mexico. Such use was first described by Conference in Clinical Pharmacology in the Spanish monk Fray Bernadino de London, stated that extensive preclinical Sahagun in 1575.7 In recent years, drug animal toxicology studies for synthetic regulatory authorities of several countries drugs were not necessary for herbal have allowed clinical evaluation of plants medicines used for generations and even for the treatment of HIV/AIDS with very being used at the present time.6 He minimal toxicological studies. proposed a shorter, six-week toxicology The World Health Organization first model on two species of animals which accepted the fact that traditional medicines would be realistic, save time and resources may need shorter preclinical toxicological and prevent unnecessary animal sacrifice. evaluation 10 years after the Chandigarh Although there was considerable concern proposal at a WHO Consultation on as regards the ethical implications of this Traditional Medicine8 and AIDS in 1990 shortened toxicology testing model, it has when the report of the Consultation stated: been accepted by and large by the “The range of preclinical tests available for regulatory authorities of a large number evaluation of a synthetic drug, before of countries including India, and by the beginning clinical trials, is well known. World Health Organization. What is not known, however, is whether Another decision by the Swedish drug such preclinical tests need to be so regulatory agency helped in the accep- extensive for herbal remedies”. The group tance of reduced toxicology testing for suggested that herbal remedies were not medicinal plants. The authorities approved really new drugs and that these had been

212 Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations used for a long time and information regarding its use was available. They In recent years, drug regulatory concluded that a more limited range of authorities of several countries preclinical tests may be adequate for have allowed clinical evaluation traditional remedies and that this limited of plants for the treatment of testing would be justified by the remedy’s HIV/AIDS with very minimal previous use in human disease. They left it to individual countries to define their own toxicological studies. needs but even suggested that some herbal remedies could be directly approved for clinical evaluation without preclinical “prolonged and apparently uneventful use toxicological tests. of a substance usually offers testimony of It is interesting to note that, to a large its safety”. The document again stresses extent, this shortened toxicology profile was the importance of literature search and the accepted because of the urgent need to absence of side-effects after long-term use. discover a new contraceptive or an anti- It, however, for the first time, brings out the HIV herbal remedy. need for tests for systemic toxicity, carcino- WHO thinking on this subject was genicity and teratogenecity as it may not further consolidated when it published9 in be easy to document the absence of these 1991 the WHO Guidelines for Assessment from the long-term use of herbal remedies. of Herbal Medicines. The principle A few important points will be made at enunciated here was that “if a traditional this stage before delineating a toxicological medicine has been used without harm, no profile for herbal remedies. All the specific restrictions or regulatory action recommendations cited above are for should be undertaken” unless there is a herbal remedies used as such for reason for it. generations. If the method of preparation The WHO “Research Guidelines for is changed, or if a product – a chemical evaluating the Safety and Efficacy of Herbal entity – is being sought to be clinically Medicines”10 brought out in 1993 by the evaluated, or if two new mixtures or Western Pacific Regional Office in Manila products are combined, then it becomes a reiterates that not all tests are required for new drug – not a traditional medicine. All every herbal medicine. A list of tests to be the requirements for a new drug would carried out has been provided. apply and the drug regulatory authorities What generally comes out in a later would require the full range of toxicity WHO document published in 199611 is studies to be carried out. Thus, while only that if adequate study of the published very limited studies were needed for the use literature demonstrates lack of harmful of Picrorhiza kurroa as a hepatoprotective effects of a herbal remedy, then clinical substance, the full range of toxicology tests evaluation can be undertaken without had to be performed for Picroliv– the undertaking animal toxicology studies. If, compound obtained from Picrorhiza however, the literature survey does not kurroa. document long-term use without harm, Another point which needs discussion then animal toxicology studies should be is to examine the tenet that if no harm has undertaken before clinical evaluation. It been found after the use of a herbal makes the very interesting statement that medicine for generations and there is no

213 Traditional Medicine in Asia documentation of such an effect, then the no rigid framework, as has been prepared preparation can be used clinically. Lack of for synthetic drugs, will ever be possible. documentation of a side-effect or a harmful So much depends on the way the extract effect does not always mean that there is or plant is administered, the duration of no such effect. It may not have been use, the dose and so many other factors observed or, even if observed, it may not that the framework established by the have been documented. In fact, the WHO Chandigarh group in 1980 and broadly publication13 on “General Guidelines for accepted by the Indian Council of Medical methodologies on research and evaluation Research and the World Health Organi- of traditional medicine” makes this point zation can remain only a framework. The when it states clearly “Absence of reported actual requirements may have to be slightly or documented side-effect is not an absolute altered from plant to plant. The actual tests assurance of safety of herbal medicine. to be carried out in the Chandigarh model However, a full range of toxicology tests may and the duration have been described in not be necessary. Tests which examine Tables 1 and 2. The tests recommended effects that are difficult or even impossible by WHO are given in Table 3. This has to detect clinically should be encouraged. been given in detail in the 1996 Suggested tests include immunotoxicity, document of the Western Pacific Region genotoxicity, carcinogenicity and repro- of WHO.11 Another point which needs to ductive toxicity”. This latest WHO Guideline be made is that evaluation of literature (2000)[13] does not take a step backward does not mean only anecdotal information but takes a broader perspective on the need that a plant has been used for centuries for toxicological evaluation of herbal without inducing any side-effect. This sort remedies. It still reiterates that: “Only when of information has very limited value. there is no documentation of long historical However, if some clinical studies have been use of a herbal medicine or when doubts carried out then the value of absence of exist about its safety, should additional side-effects is enhanced. These clinical toxicity studies be performed”. There studies should, however, be looked at appears to be some anomaly between the carefully especially with regard to the study two quotations from the same document design, the number of patients, the specific but then this field is full of anomalies. It is diagnosis, the dose used, the duration of noteworthy that due to a resurgence of administration of the herbal medicine, and interest in traditional medicines much the criteria used for assessing the thinking is going on and will continue to go treatment. on in this area of herbal medicine preclinical Researchers, public health adminis- toxicology. The need for WHO to assist trators and drug regulatory agencies are countries in regulating the use of traditional interested in developing guidelines for medicines regarding their safety and efficacy toxicological assessment of herbal was one of the specific recommendations remedies which would, on the one hand, made by the Ministers of Health of the WHO ensure that patients are not subjected to South-East Asia Region at their meeting held the toxicity of the remedies and, on the in New Delhi in September 1998.12 other, not hamper the development and What comes out very clearly is that use of these medicines. The modified there has to be flexibility in the toxicological Chandigarh model14 being used in several requirements for herbal medicines and that countries could be a starting point. This

214 Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations

Table 1. Tests required for subacute toxicology studies

Liver function Serum Albumin/Globulin, Total proteins Alkaline phosphatase Bilirubin SGOT/SGPT Renal function Blood Urea Serum Creatinine Haematology Haemoglobin RBC, WBC – Total and Differential, ESR, PCV Others Cholesterol Glucose

Table 2. Duration of toxicity studies

Single administration or repeated 2 weeks to 1 month administration for less than one week Repeated administration from one 4 weeks to 3 months week to four weeks Repeated administration between 3 to 6 months one and six months Long-term repeated administration 9 to 12 months for more than six months

Table 3. Toxicity profile recommended by WHO for herbal medicines[10]

Acute toxicity Tests should be performed on two species – one rodent and one non-rodent. Males and females from one species at least. Five animals per group per sex in rodents and at least two animals per sex in non-rodents. Oral route orally or route of intended administration Different dose levels Observation studies Toxic signs, reversibility of signs. Animals to be observed for 7–14 days. Autopsy of any animal which dies with histopathology of organ showing macroscopic changes at autopsy. Long-term toxicity Two species – one rodent and one non-rodent. Both sexes to be used. Rodents – 10 male and 10 female. Non-Rodents – three males and three females. Route – expected route of clinical use. Administration period will vary with expected period of clinical use. Three different dose levels administered seven days a week. Observation studies General signs, body weight, food and water intake - Haematological examination - Renal and hepatic function tests. Other tests of E.C.G.; Visual and Auditory tests. appropriate period of administration recommended

215 Traditional Medicine in Asia consists of the usual acute toxicity studies requirements for specific plants depending complemented by six-week subacute on their earlier use, experimental results toxicology studies with three doses in two and the manner in which it is sought to be phylogenetically different species like the rat used. and the rabbit species and a control series. The following observations are made daily: Clinical Evaluation weight, food intake, water intake and general behaviour. The following tests for Clinical trials in the past have been carried looking at haematological, hepatic and out largely by clinicians and clinical renal effects specially need to be carried pharmacologists with experience in clinical out before and at the end of six weeks trial methodology of synthetic drugs but no before sacrificing the animal. background of herbal or traditional systems An autopsy has to be carried out on of medicine, or by traditional medicine every animal at the end of the study and on practitioners and experts who have very any animal which died during the course of little idea about the conduct of clinical trials the study. Histopathological studies need to according to modern concepts of clinical be carried out on every organ at the autopsy pharmacology. both for control and herbal remedy-treated The results of such trials are therefore animals on the high dose. If the animals on not acceptable to the larger scientific the high dose show histopathological community and the practitioners of the changes then the same histopathology modern system of medicine, allopathy, who should be carried out on animals need clear-cut evidence of efficacy and lack administered the intermediate dose. of side-effects of herbal remedies in well- Other tests could be added on if conducted clinical trials before they would thought necessary. These are tests for consider use of such medicines. immunotoxicity, carcinogenicity, genoto- An important challenge for clinical xicity and reproductive toxicity. Teratology researchers in the 21st century is to studies should also be carried out, as has conduct clinical evaluation of traditional recently been completed15 for a combi- medicines within the specific framework of nation of Embelia ribes (Vidanga), Piper rigorous clinical pharmacological principles longum and borax which is now being without ignoring or trampling on the evaluated in Phase II clinical trials as a concepts and practices of traditional contraceptive. Such an effort was described systems of medicine (Chaudhury, 1992).14 in ancient textbooks of Ayurveda 2500 Fortunately, more and more multidisci- year ago. plinary centres are being developed with Earlier studies have also shown that this objective in mind. It is also salutary that this model is effective in detecting toxicity. specialists and practitioners of the Chinese Semecarpus anacardium (Bhallatak) was Traditional System of Medicine in China and going to be clinically evaluated as a specialists in Ayurvedic and Unani contraceptive but the six-week toxicity study medicines in India have no objection to the demonstrated an effect on the white blood use of modern concepts of the metho- count which was not acceptable.16 The dology of clinical trials in evaluating the plant was therefore not investigated further. efficacy and side-effects of herbal It is hoped that this review would help preparations used in these traditional investigators to fashion the toxicology systems (Chaudhury, 2001).[17] Conside-

216 Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations rable effort has been made in the past two However, the preparation needs to be made decades to develop a herbal contraceptive and administered in exactly the same way keeping in perspective the concepts of as has been described in those books. A Ayurveda and the traditional systems of synthetic or traditional medicine cleared for medicine.18 Again, the Indian Council of use for a certain disease condition needs Medical Research has taken the plant fresh approval if it is to be used for a different Pterocarpus marsupium from its use in condition or if it is to be administered by a folklore and Ayurvedic medicine to Phase different route, or if it has excipients not III clinical evaluation for the treatment of stated in the ancient books referred to earlier. diabetes mellitus using well-accepted A product or a new combination of herbal clinical pharmacological principles.19 It is medicines will be treated as a new drug and now being handed over to industry for will have to be approved for clinical pharmaceutical development and evaluation. marketing. In addition to approval of the national The basic principles in the clinical drug regulatory agency, an investigator has evaluation of herbal remedies are, of to obtain the clearance of the Institutional course, the same irrespective of whether a Ethical Committee and, if necessary, synthetic compound or a herbal prepa- clearance of the National Ethical ration is being evaluated. However, there Committee or the Ethical Committee of the are also very important differences which agency supporting the clinical evaluation. need to be kept in mind. In the next few Thus, when Vicoa indica was clinically pages these basic concepts will be evaluated as a herbal contraceptive based delineated. The differences inherent in on observations made by public health clinical evaluation will then be described personnel on its use in a tribal community, with examples from the Indian programme, ethical approval was obtained from three which has taken note of these differences agencies – the local Institutional Ethical and modified the clinical trial methodology Committee at the Postgraduate Institute of accordingly. Finally, the grey areas still Medical Education and Research, awaiting clarification and elucidation will Chandigarh, where the trial was be discussed. conducted, the Ethical Committee of the Before any drug is administered to a Indian Council of Medical Research, New human subject or a patient for purposes of Delhi, and the Ethical Committee of the clinical evaluation, the approval of the Population Foundation of India, which national drug regulatory authority has to be supported the clinical trial. (Chaudhury, obtained. While this is mandatory and 1983).20 This is not the place to describe essential for all synthetic drugs, the national the composition and functioning of Government may, in some circumstances, Institutional Ethical Committees or the allow traditional medicines to be evaluated different nuances of obtaining informal without formal or informal approval of the consent of each person who enters the regulatory authority. This has to be clearly trial, although a little more will be spelt out. In India, for example, the Office mentioned about informed consent when of the Drugs Controller General allows, discussing some ethical aspects of clinical without further need of approval, plant evaluation of herbal products. preparations described for their therapeutic Once informed consent is obtained, effect in 27 ancient books and treatises. then clinical evaluation could begin. The

217 Traditional Medicine in Asia

chief investigator is solely responsible for The studies are usually limited to 3–4 the trial and can stop the trial any time he/ centres. The studies should be carried in a she feels that it is not in the interest of the randomized double-blind manner unless patients to further carry on the trial. This this is not possible. However, a well- could be due to serious adverse effects planned and well- conducted single-blind being observed or could even be because study in certain circumstances, particularly results at some other centre published with herbal medicines, could also yield recently had clearly shown the benefits of unequivocal and scientifically valid a particular treatment. In such circums- conclusions. tances, it may be difficult to continue a trial which would provide perhaps the same Phase III result two years later. The reader is referred The purpose of these trials is to obtain to the Ethical Guidelines for Biomedical adequate data about the efficacy and safety Research on Human Subjects published by of drugs in a larger number of patients of the Indian Council of Medical Research in both sexes in multiple centres, usually in 2000.21 comparison with a standard drug and/or Clinical evaluation of any synthetic or a placebo if a standard drug does not exist plant product is carried out in five phases. for the disease under study.

Phase I Phase IV The objective of Phase I of a clinical trial is After approval of the drug for marketing, to determine the safety of the maximum usually given after assessment of the results tolerated dose of the herbal product in of Phase III trials, the Phase IV studies or healthy adults of both sexes. At least two post-marketing surveillance is undertaken subjects should be administered each dose to obtain additional information about the to establish the safe dose range, pharma- drug’s risks, benefits and optimal use. A codynamic effects, and adverse reactions, rare side-effect or a side-effect not recorded if any, with their intensity and nature. An in strictly controlled trials could be investigator trained in clinical pharma- discovered in Phase IV studies. cology should carry out these studies and clinical emergency help and resuscitation Phase V facilities must be available at the centre These are studies in which the drug is used where the Phase I trials are being carried as it would be used in the community. The out. Such a Phase I study has recently been strict monitoring of Phase II and Phase III carried out with a herbal preparation being clinical trials and the follow-up inherent with evaluated for its contraceptive effect post-marketing surveillance would both be (Chaudhury, 2000).18 absent in these Phase V clinical trials. The efficacy and side-effects of the drugs would Phase II be seen in field conditions. These are controlled studies conducted in a limited number of patients of both sexes Multicentric trials to determine therapeutic effects, effective Reference has been made earlier to dose range and further evaluation of safety. multicentred studies. It is important to carry Normally, 20–25 patients should be out such studies and yet it is not easy to studied for assessment of each dosage. organize, coordinate and conduct these

218 Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations studies. The same protocol should be used and the trials should be conducted at the same time. All methods, whether laboratory methods or methods for the recruitment of subjects or methods even for asking questions to elucidate information, should be standardized. There should be centra- lized data management and analysis. There should be a Coordinator or a Clinical Trials Monitor who would visit each centre where the trial is being carried out to confirm that at each centre the trial is being conducted as it should be. Other- wise laxity in following inclusion and exclusion criteria during recruitment of subjects, different ways of dealing with drop-outs at different centres or using different reagents and kits at different centres would vitiate the trial and render months of hard work unacceptable.

Randomization Vijayasar - developed as an anti-diabetic drug in India. It is accepted today that all Phase II and Phase III trials should be randomized so – does not know which is the drug and as to rule out bias. As far as possible this which is the standard for comparison. should be followed. Randomization is Usually the doctor recording the condition possible in nearly every comparative clinical of the patient knows the drug group but trial and, while there may be problems in the patient does not know what he is carrying out double-blind studies, there receiving. However, it could be the reverse should be no problem in carrying out also – the doctor not knowing who has randomized Phase II and Phase III clinical received what drug while the patient is trials. aware of this. It needs to be clearly brought out that the gold standard of double-blind, Blind Studies randomized multicentred clinical trials is It is again generally accepted that well- not the only way to determine the planned and well-conducted clinical trials effectiveness, particularly of traditional should always be double-blind studies. medicine, and that very useful results can Such trials increase the confidence of the be obtained in single-blind and even, in scientific community and clinical fraternity preliminary investigations, in open studies. in accepting the results of these studies. A Thus, at one stage, an open trial of the double-blind study is one in which neither plant Pterocarpus marsupium had to be the doctor carrying out the trial nor the carried out and formed a vital link leading patient knows who is receiving what drug. to double- blind, flexible dose, randomized A single-blind study is a study where either clinical evaluation of the plant.19 Similarly, the investigator or the patient – one of these the therapeutic effect of a thread coated

219 Traditional Medicine in Asia with extracts of these plants was found as ment of research hypotheses, testing those effective as surgery in anal fistula in an hypotheses in daily clinical practice and open, randomized, multicentred trial.22 referring clinical techniques”. To be However, it is a challenge for the clinical meaningful, single-case designs should pharmacologist to plan, as far as possible, have a common protocol which could be double- blind randomized multicentred the basis of collaborative research between clinical trials even with traditional practitioners. medicines. The double-blind flexible dose, randomized, multicentred trial of Observational Studies Vijayasara, Pterocarpus marsupium, in Another approach which could be used is diabetes mellitus was one such study.19 to carry out Observational Studies. The Another ongoing study is a double- traditional medicine practitioner continues blind, randomized, multicentred trial of his treatment without modifying it in any Pipallyadi Vati as a herbal contraceptive.18 way and the clinical investigator observes whether clinical improvement takes place. Use of a placebo The data are recorded by the traditional The use of a placebo is decreasing in medicine practitioner and separately by the comparative clinical trials because in most investigator carrying out these studies. clinical conditions there already exists a More studies of this type should be carried treatment. The new drug should therefore out. It could provide a valuable model for be compared against that existing drug. It studying both the efficacy and the safety would be unethical to give a placebo, i.e., of herbal medicines. Such a study is in fact a similar looking, smelling tablet containing being coordinated by the first author in no medication to one group of patients for Mumbai where the allopathic doctors at a disease when a known remedy exists. A a well-known allopathic hospital are placebo still has a role in conditions where working together with traditional medicine no cure exists. In such conditions an open practitioners in a leading Ayurvedic hospital. trial with objective laboratory and clinical The protocols are prepared jointly but measurements to record the effects of a patients are being treated at an Ayurvedic new drug as compared to a placebo may hospital. The Ayurvedic physi-cians give the also be justified. treatment for bronchial asthma and arthritis according to an agreed protocol. The Single-Case Studies results of the treatment are assessed In addition to open, single-blind and separately by the physicians of the modern double-blind clinical trials, it is also possible system of medicine and by the Ayurvedic to obtain information from single-case physicians. These are then compared as studies for the evaluation of the efficacy of regards the effectiveness of the treatment a herbal medicine. This has been parti- and the side-effects seen. cularly pointed out in the WHO Document “General guidelines for methodologies on Indian Council of Medical research and evaluation of traditional Research Network medicine”, which was discussed at a WHO In the past 12 years, the Indian Council of meeting in Hong Kong in 2000.13 The Medical Research (ICMR) has set up a report states “Such studies, i.e., single-case unique network throughout the country for studies, are appropriate for the develop- carrying out controlled clinical trials of

220 Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations herbal medicines. The programme, first carrying out a single-blind study. No described by the author at a meeting on compromise is made on the quality of the Alternative Medicine organized by the scientific clinical trials. Although the trials National Institute of Health in Washington are planned by the multidisciplinary central in August 1977, is monitored by a Scientific group, they are carried out at the foremost Advisory Group consisting of persons from centres of allopathic medicine in the the Allopathic, Ayurveda and Unani systems country. This is the reverse of the Mumbai of medicine. This group also contains studies where the clinical evaluation is experts in pharmacognosy, toxicology, being carried out at the Ayurvedic hospital. pharmacology and clinical pharmacology The Chief Investigator of any one study is as well as clinicians and experts in always an outstanding clinical researcher standardization and quality control. in the field. The results obtained are The infrastructure consists of the core monitored by the whole group. Only group at the ICMR Headquarters at New standardized preparations with predeter- Delhi, three Advanced Centres in mined markers are used for these trials. Traditional Medicine and different expert Using this network, the Council has groups for every condition being studied. demonstrated that a medicated thread There are, for example, at this time special coated with Euphorbia neriifolia (Snuhi), expert groups for bronchial asthma, Achyranthes aspera (Apamarga) and arthritis, hepatitis, benign hypertrophy of Curcuma longa is as effective as surgery the prostate, filariasis and cancer. The three for the treatment of anal fistula.22 The Advanced Centres are at the Central Drug Council has also shown that Picrorhiza Research Institute, Lucknow (Pharma- kurroa is effective in hepatitis23 and that cology and Clinical Pharmacology), the Pterocarpus marsupium is again an National Institute of Epidemiology, effective anti-diabetic drug.19 Pterocarpus (Preparation of protocols, randomization marsupium will soon be handed over to and monitoring of results), and at the the industry for marketing. The results of Regional Research Institute, Jammu these clinical trials will be acceptable to (Standardization). There are specialized clinicians at allopathic hospitals because centres in the network such as the of the sophisticated clinical pharmaco- Institute of Himalayan Ecology at Palampur logical methodology used in these trials for the study of special features of medicinal with only well- standardized products. plants needing study, the National Institute of Education and Pharmaceutical Selection of patients Research, Chandigarh (Bioavailability In any clinical trial the right drug has to be Studies) and the Central Indian Medicinal given to the right patient. In allopathic Plants Organisation at Lucknow (growing medicine all cases of asthma, arthritis, medicinal plants). In addition, there are hepatitis or diabetes of a particular variety more than 25 clinical trial centres spread are considered as one entity and the cases throughout the country for carrying out are divided into two groups by randomi- multicentred studies. zation procedures. One group is given the The trials are planned and protocols standard drug and one the new drug. prepared by the whole group. All trials are While this concept and methodology is comparative, controlled, randomized and appropriate for synthetic drugs, it need not double-blind unless there is reason for always be appropriate for herbal medicines

221 Traditional Medicine in Asia used in traditional systems of medicine temperament. Kanaka is effective in such as Ayurveda and the Unani system of patients of bronchial asthma with a Kapha medicine. temperament but will cause congestion in This important issue was first patients with a Pitta temperament. The highlighted by the first author at the WHO fresh juice of Momordica charantia will be meeting on “General Guidelines for effective in diabetic patients with a Kapha methodologies on research and evaluation or Pitta temperament but should be of traditional medicine” held at Hong avoided in patients with a Vata tempera- Kong in April 2000, at the Global ment. Rasona is very effective in Conference on Research for Health arthritis patients with a Vata and a Kapha Development at Bangkok on 10 October, temperament but should be avoided in 2000, and subsequently in the British patients with a Pitta temperament. Medical Journal in 2001.17 A second issue is that in the traditional In many of these systems, the Prakriti systems of medicine, the medicine may be (Ayurveda) or Mijaj (Unani Medicine) different if the patient has another determines the effectiveness of a particular concomitant symptom. An asthma patient traditional medicine. This could be with gastrointestinal disturbances will described as a temperament or the respond to one medicine while another psychomotor character of the individual.24, patient without gastrointestinal distur- 25 A person could have predominantly any bances would need another medicine. The of the following temperaments: Vata, Pitta clinical pharmacologist should be wary of or Kapha. A hypertensive patient with Vata entering all cases of asthma into a clinical or Kapha temperament should be treated trial without taking these factors into with Samirpannaga rasa, but this will not consideration (Chaudhury, 1992).14 work in a patient with a Pitta temperament. The third issue is the importance given, He needs to be treated with Tagaradi unlike in allopathy, to the vehicle which Churna. Another simple example is the contains the active traditional medicine. treatment of fever of the malarial type The vehicle may accelerate or enhance the (Vishama jwara). A combination of the bark effect of the medicine or may counteract of Azadirachta indica, Zingiber officinale the side-effects induced by a particular (Sunti) and Piper nigrum (Maricham) would constituent in the combination of plants. be effective in the Kapha type of individual Some substances commonly used as but not in the Pitta or Vata type. There are vehicles are honey, molasses, butter, two preparations containing Commiphora buttermilk, ghee, juice of ginger and juice wightii (Gum Guggulu) for the treatment of betel (Piper betle). Finally it is very of arthritis. Mahayograj Guggulu is used common, in a combination of three plants, in Kapha patients while Yograj Guggulu is to have the second plant to enhance the used in Pitta patients. This perspective effect of the first plant while the third plant should therefore be kept in mind when would counteract the side-effects induced designing clinical trials with Ayurvedic or by the second plant. Attempting to Unani medicines. determine which of the many plants in Sometimes a traditional medicine combination is the effective one would be, useful for one type of patient is actually in the circumstances, an exercise in futility. harmful when administered to a patient These concepts have been kept in mind with the same disease but having a different and the protocols developed for the

222 Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations

Mumbai study, perhaps for the first time in Chinese Traditional Medicine, Ayurveda or modern clinical trial methodology, stratified the Unani System of Medicine are to be the subjects of asthma according to carried out at an allopathic hospital by whether gastrointestinal symptoms are a practitioner of the allopathic system of associated with the asthma and Ayurvedic medicine, then it is incumbent on him to drugs administered accordingly. In any have as a coinvestigator a physician from clinical trial of asthma, all patients would the traditional system in which that remedy have been included and then divided into is used. This principle would also hold good groups. The result of such a trial would not if an Ayurvedic physician wants to evaluate be accepted by the pratitioners of an allopathic drug. An allopathic physician traditional medicine. would have to be taken on as a Another important feature of medicinal coinvestigator. plants is that many of them induce an When a folklore medicine is ready for immunostimulant effect without exerting commercialization after it has been found any specific therapeutic effect. In ordinary effective, then, as stated in the Indian clinical trials this is difficult to measure. Council of Medical Research Ethical However, it would be well worth measuring Guidelines, the legitimate rights/share of when clinical trials of herbal remedies are the or community from whom the planned. In addition to studying the knowledge was gathered, should be taken efficacy of the plant and the side-effects care of appropriately while applying for the induced by it, the amount of Satisfaction Intellectual Property Rights and Patents for felt by the patient and the Quality-of-Life the product. Parameters could also be studied. This is The preclinical toxicological require- particularly important when a herbal ments before clinical trials have already remedy is being assessed alongside a been considered from a regulatory and synthetic compound. legal point of view. Ethically it may not be necessary to carry out such studies if much Ethical Considerations is known about the plant from ancient literature and if the plant is already in use Several of the ethical considerations which provided it is to be evaluated in the same need to be kept in mind when planning and form. When an extract of a plant or a conducting clinical evaluation of traditional compound from a plant is to be clinically medicines have already been discussed. evaluated for a new therapeutic effect, it These are aspects of clinical trials such as should be treated as a new entity and the the need for clearance from the Institute full range of acute, subacute and chronic Ethical Committee and Informed Consent. toxicity data will have to be generated as The responsibilities of the Chief Investigator required by the national drug regulatory apply equally to clinical evaluation of authority. synthetic drugs or herbal medicines. Is it ethical to add on a traditional There are, however, some special medicine to the standard allopathic features when traditional medicines are treatment to assess whether the dose of being evaluated. These will be discussed the allopathic drug could be reduced or below. whether the side-effects induced by the When clinical trials of herbal drugs used allopathic drug brought down? Normally in traditional systems of medicine such as it would not be justified to combine

223 Traditional Medicine in Asia treatment with medicines of different will therefore be ethically justifiable to systems and use these concurrently on a conduct Phase I clinical trials without patient. The effect of one of the medicines having this data till such time when it is could be reduced by the other or indeed possible to carry out bioavailability studies the side-effects of one could be increased on herbal remedies and medicinal plants. by the second drug. It is also possible that there could be a serious interaction Conclusion between the two. However, when a great It is hoped that the information provided deal of information is known about a plant in this chapter will help the reader to – its mechanism of action, lack of toxicity appreciate the complexities of studying in animal studies, lack of side-effects when medicinal plants and the difficulties used widely as a single drug – then it may inherent in this type of study. The advances be ethically acceptable to carry out a made in recent years have also been clinical trial of that plant drug with an described and should help investigators to allopathic drug. It would, however, be safer plan clinical trials of medicinal plants which if some limited animal studies are carried would respect both the concepts of the out administering both the allopathic drug traditional systems of medicine and those and the medicinal plant at the same time. of modern clinical trials methodology. Normally the pharmacokinetics of a synthetic drug and its breakdown Acknowledgement products are known before it is adminis- We are indebted to Vaidya S.K. Mishra for tered for Phase I studies to humans. This his invaluable help in the preparation of is not possible for herbal products as it is this paper. very difficult to obtain this information. It

References

1. Proceedings of Third International Congress of Asian Medicine. Mumbai. 1990. 2. Report of a Regional Consultation on development of Traditional Medicine in South- East Asia Region. WHO-SEARO. New Delhi. 1999. 3. Report of an Inter-Regional meeting on Standardization and Use of Medicinal Plants. WHO. WPRO. Manila. 1980. 4. Report of a consultation on medicinal plants. WHO. WPRO. Manila. 1986. 5. Quality control methods for medicinal plant material. WHO. Geneva. 1998. 6. Chaudhury, R.R. (1980), Controversies in clinical evaluation of antifertility plants. Clinical Pharmacology and Therapeutics. 474. P. Turner, (Ed.) Macmillan. New York. 7. Gallelos, A.J. (1983). The Zoapatle 1 – A traditional remedy from Mexico emerges to modern times. Contraception. 27, 211. 8. Report of a WHO Consultation on Traditional Medicine and AIDS : Clinical Evaluation of Traditional Medicine and Natural Products. WHO. Geneva. 1990. 9. WHO Guidelines for Assessment of Herbal Medicines. WHO. Geneva. 1991. 10. Research Guidelines for evaluating the safety and efficacy of herbal medicines. WHO. WPRO. Manila. 1993. 11. WHO Technical Report Series No. 863 on “Guidelines for assessment of herbal medicine”. WHO. 1996.

224 Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations

12. Report of Sixteenth Meeting of Ministers of Health. WHO South-East Asia Region. New Delhi. WHO. 1998. 13. General Guidelines for methodologies on research and evaluation of traditional medicine. WHO. Geneva. 2000. 14. Chaudhury, R.R. Herbal medicine for human health. WHO-SEARO. New Delhi. 1992. 15. Roy Chaudhury, M., Chandrasekharan and Mishra, S. (2001). Embryotoxicity and teratogenecity studies of an Ayurvedic Contraceptive. Pippalyadi Vati. J. Ethnopharmacology. 74, 189. 16. Vaishnav, R., Sankaranarayanan, A., Chaudhury, R.R., Mathur, V.S., and Chakravarti, R.N. (1983). Toxicity studies on proprietary preparation of Semecarpus anacardium. Indian Journal of Medical Research. 77, 902. 17. Chaudhury, R.R. (2001). Commentary: Challenges in using traditional systems of medicine. Brit.Med. J. 322, 164. 18. Chaudhury, R.R. (2000). Proceedings of Symposium on Current Status of Fertility Regulation. C.M. Gupta and Chaudhury S.R. (Ed.) Central Drug Research Institute. Lucknow. 11–21. 19. Chaudhury, R.R. (2001). Antidiabetic effect of Vijayasar – Pterocarpus marsupium. Pharmacology and Therapeutics in the New Millennium. S.K. Gupta (Ed.) Narosa. New Delhi. 355–356. 20. Chaudhury, R.R. (1983). Plant contraceptives: translating folklore into scientific application. 5: 58. Advances in Maternal and Child Health. Jelliffe, D.B. and Jelliffe, E.F.P. (Ed.) Oxford University Press. Oxford. 21. Ethical Guidelines for Biomedical Research on human subjects. Indian Council of Medical Research. New Delhi. 2000. 22. Shukla N.K. et al. Multicentric randomized controlled clinical trial of Ksharasootra (Ayurvedic medicated thread) in the management of fistula-in-ano. Indian Journal of Medical Research (B) 94. June 1991. 177–185. 23. Indian Council of Medical Research. Annual Report. New Delhi. 1994. 24. Verma, V. Ayurveda – a way of life. Samuel Weiser Inc. New York . 1995. 25. Majumdar, A. Bioregulating Principles: Tridoska in Ayurveda – The Ancient Indian Science of Healing. Wheeler Publishing House. New Delhi. 1998.

225

Protection of traditional systems of medicine, patenting and promotion of medicinal plants

Protection of traditional systems of medicine, patenting and promotion of medicinal plants Carlos M. Correa

Introduction compounds extracted from plants and algae as well as human proteins obtained raditional Medicine (TM) serves the by extraction or through genetic Thealth needs of a vast majority of engineering techniques (e.g., interferon, people in developing countries, where erythropoietin, growth hormone). Plants, in access to “modern” health care services particular, are an indispensable source of and medicine is limited by economic and medicines.iii cultural reasons. TM is broadly used in such The protection of TM under intellectual countries,i often being the only affordable property rights (IPRs) raises two types of treatment available to poor people and in issues. On the one hand, an important remote communities. The relevance of TM question is the extent to which TM may be in developing countries may increase in the protected under existing IPRs or new future in a context of growing poverty and modalities thereof. Certain aspects of TM marginalization and, particularly, in view may be covered by patents or other IPRs.iv of the high prices generally charged for There have also been many proposals to patented medicines.ii develop sui generis systems of protection. TM also plays an important role in Such proposals are often based on developed countries, where the demand for considerations of equity: if innovators in the “herbal medicines” has grown in recent “formal” system of innovation receive a years. Moreover, many pharmaceutical compensation through IPRs, holders of products are based on, or consist of, should be similarly biological materials. These include treated.

i For instance, the per capita consumption of TM products is, in Malaysia, more than double that of modern pharmaceuticals. TM is even significant in more advanced developing countries such as South Korea, where the per capita consumption of TM products is about 36% more than that of modern drugs (1, p. iii). ii The TRIPS Agreement has imposed the obligation to recognize product patents for pharmaceuticals. iii See, e.g., 2, p. 1. iv In particular, trade secrets protection, which relates to undisclosed information of a commercial and technical nature, may apply to different components of TM .

227 Traditional Medicine in Asia

On the other hand, the appropriation in diagnosis, prevention and elimination of of such knowledge and/or the related physical, mental or social imbalance and biological materials under IPRs by relying exclusively on practical experience unauthorized parties has raised significant and observation handed down from concerns, particularly in developing generation to generation, whether verbally countries where there is a long and or in writing”.v significant tradition in TM. Those concerns TM thus encompasses different types have been generated by several cases of of knowledge. Distinctions can be made patenting in developed countries, of plants, on the basis of its subject matter, the level their compounds or uses derived from TM, of codification, the individual or collective without fair compensation to those who form of possession, the usability and have preserved and made available such commercial value, and the degree of prior knowledge. disclosure of the relevant information. As This chapter examines the extent to discussed below, these factors may have which patents may be utilized to protect important implications with regard to the certain aspects of TM or the materials used extent to which patents can be applied in in traditional treatments. It considers, first, this area. the concept and components of TM. Second, the patentability of different Subject matter modalities of TM is examined, including The subject matter of TM may basically refer products, processes and uses. Third, the to different categories of knowledge: nature of alternative modes of protection a) The properties of certain biological is briefly described and some measures to materials used in isolation, in their wild promote the use of TM are discussed. form, or as part of a preparation or mixture. Such materials include phyto- The concept of “traditional medicines or “herbal medicines”, as medicine” well as animal parts and minerals. Though the concept of TM is often In order to examine the application of IPRs linked to plant-based medicines, to TM, a first essential step is to clarify the animal-based medicines have played meaning of this concept, and its different a significant role in the healing components. TM is a very broad term, practices, magic rituals, and religions comprising indigenous or “tribal” people’s of indigenous and Western societies. knowledge, farmers’ or “rural” traditional In fact, of the 252 essential medicines knowledge and regionally bound traditional selected by the World Health knowledge about the “healing”. Organization (1999), 11.1 per cent According to the definition provided by come from plants and 8.7 per cent are WHO’s Traditional Medicine Programme, derived from animals.4, p.6 A large TM is: number of medicinal plants are used “The sum total of all the knowledge and in the folk traditions as well as in other practices, whether explicable or not, used systems of TM.vi

v See 5. vi It has been estimated that around 7500 plant species are utilized in indigenous medicine, many of which (such as indigo) have multiple uses. see, e.g., 6, p. 170.

228 Protection of traditional systems of medicine, patenting and promotion of medicinal plants b) Methods of diagnosis and treatment, level. These are passed through oral including physical, mental and spiritual tradition and may be called, “people’s therapies, which are influenced by the health culture”, home remedies or folk culture and beliefs dominant in a remedies. They have a vital place in primary particular community.vii The traditional health care in developing countries.1 therapies may encompass the use of certain biological materials, including Individual/collective possession dosage and forms of administration TM may be possessed by individuals thereof, and rituals applied by healers (“individual knowledge”).viii In some cases, as part of their traditional healing for instance, healers use rituals as part of methods. their traditional healing methods, which often allow them to monopolize their Codification knowledge, despite disclosure of the The codification of TM varies significantly. phytochemical products or techniques A distinction can be made, particularly in used.8 Asia, between the codified systems of In other cases, knowledge is in the ‘traditional medicine’ and the non-codified possession of some but not all members medicinal knowledge, which includes of a group (“distributed knowledge”). There “folk”, “tribal” or “indigenous” medicine. is, hence, asymmetric information between Thus, in India, the system of medicine groups but not within a given group of consists of two major tendencies: the folk persons, even though the latter may not and the codified traditions. Folk traditions be aware that others share the same are handed down orally from generation knowledge.11 to generation. The codified tradition Finally, a certain kind of knowledge may consists of medical knowledge with be available to all the members of a group sophisticated theoretical foundations (“common knowledge”), such as in cases expressed in thousands of manuscripts of knowledge on herbal-home remedies covering all branches of medicine. which is held by millions of women and Examples are Ayurveda, Siddha, Unani and elders.ix the Tibetan tradition.7 The Ayurvedic system of medicine, in Commercial value particular, is codified in the 54 authoritative TM may encompass commercial value when books of this system. In contrast, the “folk” its application, and notably the delivery of TM medicine is based on traditional beliefs, products, can be made trough commercial norms and practices based on centuries- channels. While some TM can be used and old experiences of trials and errors, understood outside its local/traditional/ successes and failures at the household communal context, this is not always the

vii Physical methods of treatment involve muscle manipulation and massage. Mental methods of treatment involve self-discipline in the form, for instance, of a strict diet. Spiritual methods of treatment involve prayers and use of holy water (9, p. 167). viii Reviews of anthropological literature reveal that concepts close or equivalent to individual forms of IPRs are quite common in indigenous and traditional proprietary systems (see, e.g., 10, p. 69). ix For an alternative classification of modalities of knowledge possession based on the concept of “negative” and “positive” community, see 15, p. 185).

229 Traditional Medicine in Asia case. There are spiritual components in the Can TM be patented? TM peculiar to each community. Knowledge Patents protect inventions, that is, new, that cannot be utilized beyond its communal non-obvious technical solutions. Patents context has little or no commercial value, are granted by a Government authority despite the value that such knowledge may and confer the exclusive right to make, use 3 have for the communal life. or sell an invention generally for a period Herbal medicines and other TM of 20 years (counted from the date on products may be commercialized domesti- which the application for the patent was cally or internationally, subject to compli- filed). In order to be patentable, an ance with national sanitary laws. There is invention usually needs to meet the no limit, hence, to their commercial requirements of absolute novelty (previ- exploitation. A major issue, still unresolved, ously unknown to the public), inventive step is the sharing of benefits with the or non-obviousness, and industrial individuals/communities which provided applicability (or usefulness). Patents may 12 the relevant knowledge. be granted for all types of processes and Disclosure products, including those related to the primary sector of production, namely Most TM is of a non-contemporary nature. agriculture, fishing or mining. It has been used for generations and in Patents are conferred in many many cases collected and published by countries to protect inventions based on anthropologists, historians, botanists or or consisting of natural substances 3 other researchers and observers. Disclo- (including genetic materials), plants and sure erects an important barrier for the animals. Patents, as discussed below, can application of some forms of intellectual also be granted in respect of the use of a property protection, notably patents. product and of methods for diagnostics as However, there are cases in which TM well as for surgical and therapeutic is being kept secret. In specialized areas, treatment. Though there are important in particular, for example bone-setters, differences among national laws on the midwives or traditional birth attendants and subject matter of patent protection, at least herbalists, knowledge of different plants in principle patents may be applied to and healing techniques is restricted to different components of TM, provided that certain classes of persons, and the healing the above-mentioned patentability properties of particular plants are often requirements are met. 9 undisclosed. There are, however, several major Moreover, like other types of traditional obstacles to affording patent protection to knowledge, TM is not a static body of existing TM. One such obstacle stems from information; it continues to evolve with the the legal standards established by national practices of the individuals/communities laws to acquire patent rights. that held and use it.13 This evolution may give rise to new knowledge, which may Novelty meet, as described below, the requirements The universal novelty requirement, as for protection under intellectual property applied in most countries, prevents the rights. patentability of an information which belongs to the “prior art”, that is, which has been published in a written form or

230 Protection of traditional systems of medicine, patenting and promotion of medicinal plants has otherwise been made available to the TM knowledge has been previously used, public, for instance, through public use, in even for long periods. One example would any country before the date of filing of a be the case of a traditional knowledge used patent. in a small community, when the information “Prior art” generally includes any has not been diffused beyond the publication of the invention prior to the date community’s members. There are also cases of the patent application. This concept may in which the traditional healers have kept be defined so as to also include precedents confidentialxi certain aspects of their that have not been divulged before that treatment and associated medicines, a date, but which demonstrate that a third practice that may be more frequent than party had previously reached the same often believed. invention. This approach has been followed An important issue is whether the in some US decisions, based on Corona identification of the chemical srtucture of Cord Tire Co. vs. Dovan Chem. Corp. (US an active substance which is responsible Supreme Court, 1928), where a prior for the therapeutic effect of a known invention of another party, not publicly product, may lead to the granting of a known, was deemed as destructive of patent or whether it should be deemed that novelty for a second invention. Likewise, no novelty exists. In the case Merrill Dow novelty may be destroyed in certain cases Pharmaceuticals v. Norton & Co. (1996) by the information contained in previous the court held that it was not necessary for patent applications.x 14 an active substance to be identifiable or The novelty requirement will generally reproducible for it to have been made impede the patentability of TM knowledge available to the public.xii that has been openly used for many years, The novelty requirement may not be an and, in some cases, published in different obstacle to obtaining patents on TM in forms. This is likely to apply to a large part countries where a relative novelty standard of TM. is applied. In the United States, for instance, In order to destroy novelty, however, the according to article 102 of the Patent Law, prior use must generally be such that access to the information would have allowed a A person shall be entitled to a patent unless: third party to execute the invention, without (a) the invention was known or used by significant further research. There may be others in this country, or patented or situations in which novelty may not have described in a printed publication in been lost despite the fact that the relevant this or a foreign country, before the

x In Europe, however, the information contained in a prior, non-published, patent application is not considered for the purposes of considering the existence of “inventive step”. xi In the Mobil case, for instance, the Enlarged Board of Appeal of the European Patent Office decided that the word “available” carries with it the idea that, for lack of novelty to be found, all the technical features of the claimed invention in combination must have been communicated to the public, or laid open for inspection. Under the European Patent Convention, a hidden or secret use, because it has not been made available to the public, is not a ground for objection to validity of a European patent (Mobil/Friction-Reducing Additive (1990) O.J. E.P.O. 93; (1991)(see 9, p. 166). xii Lord Hoffmann exemplified this situation with the case of Amazonian Indians, who believed that the effect of the bark on malaria was due to “the spirit of the bark”. The Indians, however, should be said to have known about quinine even though they did not know its chemical structure (9, p. 166).

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invention thereof by the applicant for ceremonies, as part of their traditional patent, or religions. The US Patent and Trademark (b) the invention was patented or Office (PTO) issued a patent to a US citizen described in a printed publication in for the “” which was this or a foreign country or in public subsequently revoked by the same Office use or on sale in this country, more in November 1999. The PTO based its than one year prior to the date of the rejection of the patent on the fact that application for patent in the United publications describing Banisteriopsis States... (35 United States Code caapi were “known and available” prior to No.102). the filing of the patent application.xiii As discussed below, in order to prevent This means that TM knowledge which the appropriation by third parties under has been published in a written form in the patents of traditional knowledge, there United States or in any other country is not have been initiatives to develop proper patentable. But if such knowledge was publicly written documentation of such knowledge. used but not documented in a foreign country, It is assumed that if the material/knowledge novelty is not lost. is documented, it can be made available As a result of the relative novelty to patent examiners the world over, so that requirement of the US, several patents prior art in the case of inventions based on have been granted to researchers or firms such knowledge is readily available to them. from developed countries by the US Patent It should be noted, finally, that in some and Trademark Office relating to or countries (United States, , consisting of genetic materials or Mexico) the publication made by the traditional knowledge acquired in inventor within one year prior to the date developing countries.16, 17 of application for a patent does not destroy This appropriation (or “biopiracy”) has novelty. This “grace period” is particularly involved resources protected “as is”, that useful for the protection of research results is, without any further improvement (e.g., obtained in universities and other public US patent No. 5.304.718 on institutions, where researchers are usually granted to researchers of the Colorado under pressure to promptly publish their State University) and on products based on findings. A possible way to allow for the plant materials and knowledge developed patentability of TM may be to establish a and used by local/indigenous communities, special “grace period” for inventions such as the cases of the neem , , pertaining to this field whenever claimed barbasco, endod and turmeric (see below), by the communities or individuals that among others, etc.18 legitmately developed or possessed them.8 A telling example was the case of This would certainly expand the scope of ayahuasca,(Banisteriopsis caapi), a plant patentability in cases where it would have native to the Amazonian rainforest that been excluded by the application of the thousands of indigenous people of the novelty requirement standard. region use in sacred religious and healing

xiii The PTO’s decision came in response to a request for reexamination of the patent by the Coordinating Body for the Indigenous Organizations of the Amazon Basin (COICA), the Coalition for Amazonian Peoples and Their Environment, and lawyers at the Center for International Environmental Law (CIEL).

232 Protection of traditional systems of medicine, patenting and promotion of medicinal plants

Inventive step a relatively minor advancement in relation While in some cases, such as when a certain to previously available information. This is TM knowledge has been kept undisclosed, clearly undesirable from the point of view the novelty of the information may have of public policy and the preservation of the been preserved, an additional standard of freedom to use knowledge in the public patentability must be met in order to acquire domain. patent rights. The “inventive-step” or “non- obviousness” requires that the claimed What can be protected? invention be non-obvious for a person with Natural products average skills in a given technical field. This means that, even if novel, a piece of TM include plants, animal and mineral knowledge will not be patentable if it is materials, extracts, mixtures, condiments proven obvious or lacking inventive step. and herbal preparations. Obstacles for the Obviousness is judged in the United patentability of such medicines may arise States on the basis of the determination of when they consist of or are based on i) The scope and content of the “prior art”, natural materials which have not been ii) The differences between the claimed processed or modified. invention versus the prior art, and iii) The One of the basic problems is the extent level of ordinary skill in the art.19 In Europe to which a substance which exists in nature, and other countries, emphasis is given to but for which a certain use has been the extent that the invention solves a identified, may be deemed to be an technical problem. This “problem-and- “invention” or a mere “discovery”. Such use solution” approach makes the inquiry on may have been identified with regard to a inventive step more objective than in the product the properties of which were not United States.14 known, or in respect of products of known The fact is, however, that thousands of properties and for which the “invention” patents are granted each year in the major would be the determination of its chemical countries for minor, sometimes purely trivial or genetic structure. developments.20 In 1999, for instance, the Patent protection of biological United States Patent Office granted over materials, including cells and genes, has 160,000 patents, twice the number been accepted in many countries. This granted 10 years ago. This is partially the remains, however, a controversial issue, fruit of an excessive flexibility of the Patent particularly with regard to the patentability Office in assessing the inventive step and of materials that pre-exist in nature and of shortcomings in the examination are just isolated, purified, or slightly altered, procedures.xiv in order to be claimed as an “invention”. The flexibility with which the inventive In some jurisdictions (e.g., the United step/non-obviousness is judged allows for States) an isolated or purified form of a the patentability of technical solutions of , including genes, is an incremental nature or which represent patentable.22, 23, xv The European Directive xiv For example, less than 50 per cent of the examinations conducted by said Office refer to relevant background bibliography; the examination is by and large limited to analysing previous patents. See, 21. xv The extent of patentability of biological materials in the USA has not been addressed yet, however, by the Supreme Court.

233 Traditional Medicine in Asia

344 (1993) do not allow, in principle, the patentability of materials existing in nature. The Brazilian patent law (1996) stipulates that no patents shall be granted with respect to living beings or “biological materials found in nature”, even if isolated, including the “genome or germplasm” of any living being. Despite the exclusion of certain biotechnology-based products from the patent domain, patents may still be granted

Example of a United States Patent for the process used to obtain them. This may be the preferred option for countries prioritizing medicine affordability and on Biotechnological Inventions (No. 96/9/ access, or where the patentability of such EC of March 11, 1996)xvi adopts a similar substances is deemed contrary to basic approach. The Directive, essentially cultural and ethical values.xviii The ability declaratory of long-standing law to do so may be limited, however, by the throughout much of Europe,xvii establishes provision of the Agreement on Trade that “biological material” and substances Related Aspects of Intellectual Property isolated from nature (such as new Rights (“TRIPS Agreement”) which requires antibiotics) will be considered patentable.23 the patentability of micro-organism (Article In some countries, however, the 27.3.(b)). patentability of existing biological materials, Some developing countries may, unless they are genetically altered, has however, worry that excluding substances been contested or excluded. Thus, in the found in nature from patentability could United Kingdom the High Court of Appeal conceivably hinder investment in some held that the isolation of gene sequences local activities, including activities that constituted a mere discovery and, hence, might otherwise lead to patents on products was not itself patentable. The Court held derived from traditional knowledge or that although the amino acid sequence of specific local skills or know-how. For those t-PA had not previously been determined, that seek intellectual property protection for one cannot patent a known substance just TM, limiting the patentability of natural by being the first to determine its materials may convey negative conse- structure.(24) quences. It must be borne in mind, however, The Mexican law (1991/1994) that the developing countries that possess excludes the patentability of all genetic TM knowledge often lack the financial materials. The Argentine patent law resources and the research and industrial (1995) and the Andean Group Decision capabilities to scientifically identify and

xvi “Biological material which is isolated from its natural environment or processed by means of a technical process may be the subject of an invention even if it already occurred in nature” (article 3.2). xvii See, e.g., 23, p. 213. xviii See, the proposal for review of article 27.3. (b) of the TRIPS Agreement submitted by Kenya on behalf of the African countries (WT/GC/W/302, of 6 August, 1999).

234 Protection of traditional systems of medicine, patenting and promotion of medicinal plants isolate the compounds that explain the cases where a composition is a simple therapeutic effects of certain traditional mixture of diverse components and where medicines. In addition, traditional healers there is some chemical reaction between and communities generally lack the skills them.23 and resources necessary to follow the Many examples of patents granted on complex procedures of patents systems combinations of plants for therapeutic and, in particular, to face the costs of regis- purposes can be mentioned, for instance, tration both locally and abroad.xix EP 0519777 relating to formulations It should also be noted that since the made out of a variety of fresh plants; and granting of patents is dependent on each WO 93/11780 on a skin therapeutic national law, the non-patentability in one mixture containing cold-processed Aloe country does not mean that “pieces” of TM vera extract (with yellow sap and aloin could not be patented in another country. removed). If protection were obtained without the authorization of the healers/communities Production and extraction that developed or possessed them, it would processes be possible to request the nullification of Many TM products are obtained through the patent in the foreign country.xx fractionation, purification or concentration. The processes for obtaining such products, Extracts and formulations if novel and non-obvious, may also be While, as mentioned, the patentability of patented. natural products may be limited by patent There are numerous examples of rules, it is possible to obtain protection (if patents relating to extraction and other the patentability requirements are met) for processes for the preparation of medicines extracts or formulations of natural based on natural products, such as ES products. 475.812 on a process for the extraction Examples of patents of this type of organic compounds with therapeutic include US 4178372 on hypoallergenic activity from plants; ES 2010127 for the stabilized Aloe vera gel: US 4725438 on preparation of a medicine for skin an Aloe vera ointment; US 4696819 on reparation; EP 0530833 on a process to anorexic material extracted from coca prepare hard gelatine capsules containing leaves; and EP 0513671 on “Commipho- Chinese herbal extracts; ES 8801986 for ra mukul” extracts. preparation of a jus or gel of aloe; ES 393347 on a process for the extraction of Combinations an active ingredient from anacardium Patents may be obtained, if the patentability occidentale; and US 4956429 on a requirements are met, for combinations method of making a coca leaf flavour and preparations. This is normally the case extract. with modern pharmaceuticals, both in

xix The costs for the international protection of an invention are somewhere in the range of $ 40,000–$ 50,000, including registration and maintenance fees.(25) xx Examples were the actions initiated by the Government of India in relation to a patent on turmeric granted in the United States, and the already referred action against the ayahusaca patent. In both cases, the USPTO finally revoked the patents.

235 Traditional Medicine in Asia

Methods for Treatment and the patentability of such methods, if Diagnostics possible, would restrict the use of TM rather than promote it. Most national patent laws exclude the patentability of diagnostic, therapeutic and Patentability of uses surgical methods for the treatment of An important issue in relation to the humans or animals. Patents on such protection of TM is the extent to which the methods are not granted due to ethical “use” of a known product can be subject reasons or to difficulties with actually to patent protection. This may occur, for enforcing those patents. In addition, a instance, when the therapeutic properties method that is applied to the human body of a natural product are identified and is not considered industrially applicable claimed. Patent applications on the thera- and, hence, does not comply with one of peutic use of a known product are usually the key patentability requirements of most written as instructions to the physician on patent laws. However, in the United States how to employ a certain substance to treat patent practice increasingly favours the a particular disease, and may be deemed patenting of medical methods if they satisfy as non-patentable either as a “discovery” the definition of process and the other or as a therapeutic treatment, whenever conditions of eligibility.xxi the latter is not eligible for protection under Article 27.3.(a) of the TRIPS Agreement the domestic law. explicitly allows Members not to grant In countries which admit the protection patents for methods for therapeutic and of inventions, claims may be either a product surgical treatment and for diagnostics. claim or a process claim, depending on the TM includes a large variety of methods context.xxii Some national laws treat the new of treatment. Traditional methods of use as a process patent claim of one of two treatment are usually specific to a particular kinds: “use” claims (such as “the use of X country or to a particular community in that as an antihista-minic”) or claims on one or country, although some of them, such as more actual process steps (e.g., “a method acupuncture, are used worldwide. The of preventing .…”).xxiii The patenting of use protection of such methods under patents inventions depends on whether the purpose would be possible if allowed by national of the use is novel and non-obvious. Method law and viable under the patentability inventions may be judged independently of requirements. However, it may be quite the purpose. Even if intended for a novel difficult to enforce patent rights obtained, purpose, the key consideration in determi- since it may be extremely costly and ning the patentability of a method invention complex to identify and prosecute a large is whether it could be anticipated by other number of possible infringers. In addition, methods.xxiv

xxi A bill enacted in 1996 (amending US patent law, 35 USC 287.c) determined, however, that the use of patented surgical procedures cannot be subjected to infringement suits. See, e.g., 23, p. 220. xxii Thus, in Europe, first medical indications have been dealt with as a product claim, whereas the second medical indication (that is, when a new use is discovered for a product that already had pharmaceutical use) as a process claim. xxiii See, e.g., 23, p. 208. xxiv See, e.g., 26, p. 120.

236 Protection of traditional systems of medicine, patenting and promotion of medicinal plants

One example of a patent on a the use of natural and other known therapeutic use of a natural product is products.xxvii Many patent laws recently afforded by the patent granted in March adopted in developing countries make no 1995 by the US Patent and Trademark specific reference to the availability of Office on “Use of Turmeric (Curcuma patents for uses, leaving unclear whether longa) in Wound Healing”. It was awarded the protection for processes covers “uses” to the University of Mississippi Medical and “methods of use.” Center. The claim covered “a method of Countries concerned about “biopiracy” promoting healing of a wound by adminis- may wish to exclude the patentability of the tering turmeric to a patient afflicted with use of known products in order to prevent the wound”, such wounds including the appropriation under patent rights of surgical wounds and body ulcers. biological materials. It would seem logical, The powder of the turmeric plant was in particular, that a country that broadly a classic “grandmother’s remedy” in India. excludes methods of medical treatment It had been applied to the scrapes and cuts also broadly excludes new therapeutic uses of children for generations.10 On 14 for known products. Nevertheless, given the August 1997, the US Patent and territoriality of the patent system, a country Trademark Office invalidated the patent that prevents the patenting of uses under upon request of India’s Council for its national law cannot force other countries Scientific and Industrial Research, in the to follow the same approach. In the context of a growing protest by many absence of international rules on the developing countries against “biopiracy”.xxv matter, nothing will prevent other countries In Europe, a legal provision allows the from declaring as patentable (if the legal patentability of a known product for a new requirements are met) what is not deemed specific indication.(27) Under article 54(5) protectable in a particular country. of the European Patent Convention, the identification of the first medical indication Policy options: Protecting or of a known product may suffice to get a promoting TM patent on the product.xxvi The United States, The previous sections have indicated the by contrast, has adopted a more restrictive scope available for the patenting of different approach, confining patents on uses to a components of TM. However, there are particular “method-of-use.” Such method- divergent opinions on the desirability of of-use patents do not encompass extending IPRs protection to such protection of the product as such.14 knowledge, as well as on the modalities to Under the TRIPS Agreement, WTO be applied therefor. These different views Member Countries seem free to decide arise from different philosophical and whether or not to allow the patentability of ethical perceptions, as well as from

xxv SUNS, No, 4050, 8.9.97 xxvi The Technical Board of Appeal of the EPO has ruled that such claims should be deemed as covering all therapeutical uses of the product like in the case of claims on a pharmaceutical composition. Infringement of such claims would only take place when the product is commercialized for direct therapeutic use, and not in bulk. xxvii Because patents protect inventions but not discoveries, the discovery of a new purpose for a product cannot render a known product patentable as such under general principles of patent law. Unless in connection with the new purpose the product is forced to be present in an amended new form.

237 Traditional Medicine in Asia diverging considerations on the socio- to be compensated by means of intellectual economic implications of IPRs protection, property rights or other measures. At the including the danger of distortion to international level, the Council of TRIPS has indigenous systems.28 under its consideration the possible review of article 27.3(b) of the TRIPS Agreement. Developing a sui generis regime Such review is regarded by some develo- Many proposals have been elaborated, by ping countries as an opportunity to harmo- scholars and NGOs, to protect traditional nize the TRIPS Agreement with the CBD,xxxi knowledge (including medicinal use) and to develop rules for the protection of through a sui generis regime.xxviii This is traditional knowledge.xxxii The proposed the case, for instance, in respect of approaches differ, however. proposals relating to “tribal”, “communal” Thus, for the African Group the review or “community intellectual rights”,xxix and of article 27.3(b) should preserve the room “traditional resource rights”, among existing to develop specific modalities of others.xxx Some proposals aim to develop protection for traditional knowledge new forms of protection as an independent (including TM) at the national level.xxxiii category of intellectual property,9 or as a Venezuelaxxxiv has gone a step further. component of the broader body of It has proposed the development of binding “traditional knowledge”. In many cases, international rules on the matter. It has however, the rationale for the proposed suggested protection is unclear.13 “to establish on a mandatory basis A few countries have started to address within the TRIPS Agreement a system for the complex conceptual and operational the protection of intellectual property, with problems involved in the recognition of an ethical and economic content, communities’ rights on traditional know- applicable to the traditional knowledge of ledge. For instance, “collective” intellectual local and indigenous communities, property rights have been recognized by together with recognition of the need to the Constitution of Ecuador (1998). The define the rights of collective holders” Biodiversity law of Costa Rica (1998) (WT/GC/W/282). protects “sui generis community rights” Though the viability of this latter (article 82), and a draft law in Brazil (Bill proposal in the framework of the TRIPS No. 306, 1995) recognizes the rights of Agreement is still uncertain, it addresses local communities to collectively benefit one of the problems that countries that opt from their traditions and knowledge and for protecting traditional knowledge may

xxviii For a review of literature on the matter, see x. xxix See, e.g., 29, p. 38. xxx See, e.g., 30. xxxi See, e.g., the submission by Egypt, WT/GC/W/136. xxxii See, in particular, the submissions by India (WT/GC/W/147)and by the African Group (WT/GC/W/302 of 6 August, 1999). xxxiii The OAU has developed a “Model law on Community Rights and Control of Access to Biological Resources” (1999). xxxiv Under Decision 391 of the Andean Pact, the Member Countries thereof are bound to develop legal regimes for the protection of communities’ knowledge. A constitutional provision to that effect has been adopted in Ecuador. None of the Andean countries, however, have so far developed such regimes.

238 Protection of traditional systems of medicine, patenting and promotion of medicinal plants face. Due to the principle of territoriality, prevent grant of such patents and protection at home would not prevent the biopiracy”.12 misappropriation of the protected know- Among the projects initiated in India ledge in other countries or that such know- to impede the consideration of such ledge would continue to be considered as knowledge as “new” and, therefore, paten- belonging to the public domain. table in some jurisdictions, “Gene Developing countries (notably Latin Campaign” has undertaken work on American and Caribbean) have also documentation of biodiversity and actively promoted the increased involve- knowledge relating thereto aimed at three ment of the World Intellectual Property tribal populations: the Munnars in South Organization (WIPO) in the discussion Bihar (in the Chotanagpur region); the Bhils and development of a “sui generis” regime of Madhya Pradesh, and the Tharus of the for traditional knowledge.xxxv Terai region. Medicinal plants and knowledge related thereto was sought to Curbing “biopiracy” be documented with the help of educated Despite the general agreement in the tribal youth. Elders in the village, medical developing world about the importance of practitioners and traditional healers were obtaining a recognition for traditional consulted in the collection and under- knowledge, the main concern of some standing of the information.12 countries has been to avoid the “biopiracy” The documentation of traditional of traditional knowledge and to ensure knowledge, in the Indian Government’s benefit sharing (as provided for under views, permits not only the prevention of articles 15 and 16 of the CBD), rather than “biopiracy”; it may also provide a basis for the establishment of a system of positive the sharing of benefits arising out of the appropriation. Thus, the Government of use of such knowledge, though documen- India has stated that tation per se will not facilitate benefit “In the recent past, there have been sharing with the holders of such several cases of biopiracy of traditional knowledge.12 knowledge (TK) from India. For preventing In addition, Section 36 (iv) of the Indian such instances in the future there is a need Biodiversity Bill provides for the protection for developing digital databases of prior of knowledge of local people relating to art related to herbs already in the public biodiversity through measures such as domain. Following patents on brinjal, etc., registration of such knowledge, and in India, an exercise has been initiated to development of a sui generis system. For prepare easily navigable computerized ensuring equitable sharing of benefits arising database of documented TK relating to from the use of biological resources and use of medicinal and other plants (which associated knowledge, Sections 19 and 21 is already under public domain) known as stipulate prior approval of the National TK Digital Library (TKDL). Such digital Biodiversity Authority (NBA) before their databases would enable Patent Offices all access. While granting approval, NBA will over the world to search and examine any impose terms and conditions, which secure prevalent use/prior art, and thereby equitable sharing of benefits. Section 6

xxxv A proposal for the establishment of a Committee to deal with these issues was submitted to the WIPO Governing Bodies in September 2000.

239 Traditional Medicine in Asia provides that anybody seeking any kind of to TM treatments that the exercise of such IPR on a research based upon biological rights would entail. resource or knowledge obtained from India While an option to deal with TM is to needs to obtain prior approval of the NBA, work within the sphere of IPRs, which will impose benefit-sharing conditions. governments should aim to promote the Section 18 (iv) stipulates that one of the use of TM for preventive and curative health functions of NBA is to take measures to care rather than to protect it under rights oppose the grant of IPRs in any country that may restrict its diffusion. An example outside India on any biological resource is provided by Act No. 8423 (1997) of the obtained from India or knowledge Philippines, which aims “to accelerate the associated with such biological resource. development of traditional and alternative In the Patent (Second Amendment) Bill health care” by improving the manu- 1999, the grounds for rejection of the facture, quality control and marketing of patent application, as well as revocation traditional health care materials of the patent, include non-disclosure or (Section 3.d). wrongful disclosure of the source of origin This promotional approach may be of biological resource. It has also been combined with a misappropriation regime made incumbent upon patent applications aimed at avoiding the monopolization of to disclose the source of origin of the TM and related biological materials. Such biological material used in the invention in a regime – just as in the case of trade their patent applications. secrets – would not be based on the The Andean Group Decision 391 has granting of exclusive rights (i.e, on a ius already established that any IPR or other prohibendi) but only on the right to prevent claims to resources shall not be considered or require a compensation for the use of valid, if they were obtained or used in traditional knowledge when it has been violation of the terms of a permit for access acquired, for instance, in a manner contrary to biological resources residing in any of to legitimate rules and practices on such countries, as regulated under that access.13 Decision. The promotion of TM requires much more than defining the appropriate Improving access to TM framework for IPRs protection. Attention A possible negative impact on the access should be paid to research and develop- to health care of the strengthening of IPRs ment (R&D) and to the condition for the in developing countries has been stressed use of such knowledge. in recent analyses, including some studies Developing countries only account for by the World Health Organization.(31) The a minor part (around 4 per cent) of world recognition or establishment of new types R&D,32 and a significant part of the scarce of IPRs on TM may reduce, rather than resources devoted thereto are applied to enhance, access to medicines and health issues that have been defined by and are treatment, particularly by the poor. In of primary interest to developed dealing with TM, developing countries countries.33 Though the technical capacity should, therefore, very carefully balance the to undertake clinical trials in order to expected benefits from a possible IPRs-like establish the safety and efficacy of TM protection of TM, with the costs that are products exists in many developing likely to arise from the limitations on access countries, this is a costly endeavour for

240 Protection of traditional systems of medicine, patenting and promotion of medicinal plants which considerable financing is necessary Herbal medicines are currently traded and generally unavailable, even to test TM internationally, in many cases without the used locally to treat common diseases in strict conditions that apply to other drugs. those countries, such as malaria. The export of such products may, Pharmaceutical companies have however, face many regulatory and shown considerable interest in acquiring commercial barriers. Pharmaceutical and developing TM, as illustrated by the products are subject to health regulations Program of the Instituto in order to establish their safety, efficacy Nacional de Biodiversidad (INBio) of Costa and quality. The tests required to prove Rica and the recent agreement between those conditions are, as indicated above, Extracta (a Brazilian company) and Glaxo- time consuming and very costly. Though, Wellcome to investigate on natural in general, prolonged use of a TM offers compounds that may be used as antibiotics testimony of its safety, in a few instances and tropical diseases, such as dengue.xxxvi WHO has warned: In some cases, pharmaceutical companies “investigation of the potential toxicity have obtained considerable benefits from of naturally occurring substances widely the exploitation of TM.xxxvii There are, used as ingredients in these preparations however, signs that the interest of such has revealed previously unsuspected companies may be fading out, due in part potential for systematic toxicity, to the prospects of newer methods of drug carcinogenicity and teratogenicity”.34 development and genetic engineering.xxxviii In some cases, herbs, which are in fact The promotion of TM should also drugs, are sold in several countries as consider the need for an assessment of dietary supplements and, therefore, they herbal medicines,xxxix as well as the training, fall outside the regulations on medicines, certification and registration, where which are generally stricter than those appropriate, of traditional healers and related to such supplements. In other practitioners.1 cases, there is no control or monitoring over the advertising and promotion of Exports of TM products herbal medicines.1 As mentioned, TM plays an important role The granting of patents on herbal in health care in developing as well as medicines or natural compounds may also developed countries. Though TM methods create trade obstacles. Besides any and products have been originally consideration on the unfairness of developed to satisfy local demands within “biopiracy”, the patenting of TM products a given community, trade in TM products or substances can be used to prevent the may be important and provide a new import of such products, even – source of income to developing countries. paradoxically – where supplied from their

xxxvi Jornal do Brasil, 30 July, 1999. xxxvii An often cited case is the use of the rosy periwinkle plant by Eli Lilly for the treatment of Hodgkin’s disease (a type of lymph cancer) and childhood leukaemia. xxxviii Health 24 News, Volume 1, Issue 49, 7 July, 2000. This article reports that one of the most active firms in exploring the use of TM, Shaman Pharmaceuticals, abandoned its multimillion-dollar effort to bring new drugs from the rainforest. xxxix WHO has developed Guidelines for this purpose (see 34).

241 Traditional Medicine in Asia country of origin. Patent owners enjoy, in the norm to cover other products (‘yacun’ effect, the right to prevent any commercia- and ‘para-para’). lization, including imports, of a patented product.xl Conclusions A similar problem may be faced if the plant varieties used to produce a TM TM plays an important role in the health product were protected under breeders’ care systems of developing countries. The rights in the country of import. Breeders’ diffusion of TM products is also significant rights are a type of intellectual property in developed countries. The commercial rights that are exercised in respect of value of TM has raised divergent views on propagating materials of plant varieties. the need and scope for protection of TM The UPOV (Union for the Protection of Plant under IPRs. Some governments, scholars Varieties) Convention provides an inter- and NGOs have voiced the need to protect national framework for the protection of TM under existing or new forms of IPRs such varieties. The TRIPS Agreement has protection, as a means to recognize and obliged all WTO Member Countries to compensate the creators and possessors provide a patent or an effective “sui of such knowledge. Others object to that generis” protection (or a combination of possibility for ethical, economic or other both). reasons. However, there is, in general, If breeders’ rights were obtained by agreement on condemning “biopiracy”, unauthorized parties on plants used for TM, that is, the unauthorized appropriation the countries of origin thereof would also under Western IPRs systems of traditional find a serious barrier, since breeders’ right- knowledge and biological materials. holders enjoy a similar set of exclusive rights The concept of TM embraces different with regard to imported products. categories of knowledge that may be Finally, it should be borne in mind that subject to various types of IPRs, if the many medicinal plants face extinction or conditions for protection are met. Several severe genetic loss. Overexploitation of components of TM, including products and such plants in order to satisfy export processes and, in some countries, uses and demands can aggravate these risks. methods of treatment, can be covered by Hence, governments should control trade patent rights. In fact, a large number of in medicinal plants in the framework of patents have been granted in relation to broader policies for the conservation and natural products, combinations, extracts sustainable use of such plants. , for and preparations thereof, as well as instance, passed a law in July 1999 which processes of production. The application bans the non value-added export of some of patents to TM, however, faces important botanical species with known healing obstacles, in particular due to the novelty properties, which had become the target requirement and to the costs and of massive extraction by foreign labora- complexity of procedures before patent tories. The law covers the two best-known offices. medicinal plants in Peru’s indigenous While designing national policies on pharmacopoeia: ‘cat’s claw’ and ‘maca’; TM, a careful assessment of the possible and legislators are considering expanding objectives and implications of IPRs xl See article 28 of the TRIPS Agreement.

242 Protection of traditional systems of medicine, patenting and promotion of medicinal plants protection of TM should be made. Their knowledge, including TM, particularly in establishment may provide a basis for the order to curb “biopiracy”. Given, however, recognition of traditional and indigenous the considerable conceptual divergences healers and communities. Nevertheless, still existing on these issues, it does not seem due to the very nature of IPRs, they may likely that an international consensus on limit rather than increase access to the objectives, scope and content of medicines that are essential to millions of possible rights to be recognized in relation people in developing countries. A balanced to such knowledge will be reached soon. policy may be based on a restrictive This is a difficult task at the national level approach towards the patentability of itself, as evidenced by the small number of naturally occurring products and uses of countries that have just started, but not yet existing products, as well as in the accomplished, the establishment of a application of strict patentability require- system of protection in this area. ments, particularly with regard to novelty. In a scenario in which developing Governments may also adopt countries will have to pay more for needed measures to promote the use of TM for the medicines after the full implementation of affordable treatment of national and the TRIPS Agreement, what part TM will play regional priority diseases, and may also as a component of a public health strategy seek to preserve and expand export has become an urgent and crucial issue. opportunities for TM products. IPRs Governments and the World Health granted in foreign countries may pose Organization should be encouraged to obstacles to such exports, particularly in clarify the implications of different policy countries where patents are granted on the options, including the protection under basis of a criterion on relative novelty. IPRs, and to define the role that TM is called Some developing countries have upon to play in the health systems of such proposed development of international countries. rules on the IPRs protection of traditional

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1. Balasubramanian, K. (1997). Herbal Remedies: Consumer Protection Concerns. Consumers International. Penang. 2. Lambert, John; Srivastava, Jitendra and Vietmeyer, Noel. (1997). Medicinal Plants. Recuing a Global Heritage. World Bank Technical Paper No. 355. Washington D.C. 3. Koning, Martine. (1998). “Biodiversity prospecting and the equitable remuneration of ethnobiological knowledge: reconciling industry and indigenous interests”. Intellectual Property Journal. No.12. 4. Medeiros Costa Neto, Eraldo. (1999). “Traditional use and sale of animals as medicines in Feira de Santana City, Bahia, Brazil”. Indigenous Knowledge and Development Monitor. Vol.7. Issue 2. 5. Zhang, Xiaorui. (1998). “Significance of Traditional Medicine in Human Health Care”. Paper presented at WIPO Asian Regional Seminar on Intellectual Property Issues in the Field of Traditional Medicine. New Delhi. India. October 7–9. 6. Shankar, Darshan. (1996). “Tribal and rural farmer-conservers”. In: Agrobiodiversity and Farmers’ Rights. Swaminathan Research Foundation. No.14. Chennai.

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7. Shankar, Darshan; Hafeel, Abdul and Suma, T. (1999). “Cultural Richness of Green Pharmacy”. Compas Newsletter. No. 2. 8. Bhatti, Shakeel. (2000). “Intellectual property rights and traditional medicines”. Prepared for WHO-ASEAN Meeting on the TRIPS Agreement and its Impact on Drug Supply. Jakarta. 9. Koon, Ong Chui. (1999). “Intellectual property protection of traditional medicine and treatments in Malaysia”. Blakeney, Michael (Ed.). Perspectives on Intellectual Property. Intellectual property aspects of . Vol.6. Sweet & Maxwell. London. 10. Dutfield, Graham. (2000). Intellectual property rights, trade and biodiversity. IUCN. London. 11. Bonabeau, Eric and Theraulaz, Guy. (Ed.) (1994). Intelligence collective. Hermes. Paris. 12. Government of India (2000). “Protection of biodiversity and traditional knowledge. The Indian experience”. WT/CTE/W/156. 14 July. 13. Correa, Carlos. (2000). “In situ conservation and intellectual property rights”. in Brush, Stephen (Ed.). Genes in the field. On-farm conservation of crop diversity. IPGRI/IDRC/Lewis Publishers (p. 242). 14. Merges, Robert P. (1992). Patent law and policy. Cases and materials. Contemporary Legal Educational Series. Boston. 15. Drahos, . (1997). “Indigenous knowledge and the duties of intellectual property owners”. Intellectual Property Journal. No.11. 16. Correa, Carlos. (1999). Access to plant genetic resources and intellectual property rights. Background Study Paper No. 8. FAO. Rome. 17. The Croucible Group. (2000). Seeding Solutions. Vol. 1. IDRC-IPGRI. Rome. 18. Mooney, Pat. (1998). “The parts of life. Agricultural biodiversity, indigenous knowledge and the role of the third system”. Development Dialogue. Special Issue. Uppsala (pp 152-154). 19. Wegner, Harold. (1994). Patent law in biotechnology, chemicals & pharmaceuticals. Stockton. Chippenham (p. 224). 20. Barton, John. (2000). “Reforming the patent system”. SCIENCE. Vol. 287. 17 March. 21. Aharonian, Greg. (2000). “Patent examination system is intellectually corrupt”. Patnews. 1 May. 22. Bent, S., Schwab, R., Conlin, D., and Jeffrey, D. (1991). Intellectual property rights in biotechnology worldwide. Stockton Press. New York. 23. Grubb, Philip. (1999). Patents for chemicals, pharmaceuticals and biotechnology. Fundamentals of global law, practice and strategy. Clarendon Press. Oxford. 24. Thurston, J. and Burnett, Hall. (1988). “Genentech Inc. vs. The Wellcome Foundation Ltd. How important is the decision for the biotechnology industry”. European Intellectual Property Review. No. 2. 25. Hofinger, S. (1996). “Determinants of an Active Patent Policy – An Empirical Study”. European Patent Convention. No. 3. 26. Hansen, Bernd and Hirsch, Fritjoff. (1997). Protecting inventions in chemistry. Commentary on chemical case law under the European Patent Convention and the German Patent Law. WILEY-VCH. Weinheim. 27. Stieger, Werner. (1982). “Article 54 (5) of the Munich Patent Convention: An Exception for Pharmaceuticals”. International Review of Industrial Property and Copyright Law. Vol. 13. No.2. 28. Blakeney, Michael. (2000). “Protection for indigenous or traditional works (e.g. folklore): Has the Time Come?”. Fordham University School of Law. International Property Law & Policy. Annual Conference. April.

244 Protection of traditional systems of medicine, patenting and promotion of medicinal plants

29. Berhan, Tewolde and Egziabher. (1996). «A case of community rights». In: Tilahun, S. and Sue, E. (Ed.). The movement for collective intellectual rights. The Institute for Sustainable Foundation/The Gaia Foundation. Addis Ababa. 30. Posey, Darrell and Dutfield, Graham. (1996). Beyond Intellectual Property. Toward Traditional Resource Rights for and Local Communities. International Development Research Centre. Ottawa. 31. Velásquez, Germán and Boulet, Pascale. (1999). Globalization and access to drugs. Perspectives on the WTO/TRIPS Agreement. WHO. WHO/DAP/98.9. Geneva. 32. UNDP. (1999). Human Development Report 1999. New York. 33. Arunachalam, Subbiah. (1995). “Science on the periphery: can it contribute to mainstream science?”. Knowledge and Policy. Vol. 8. No. 2. 34. WHO. (1996). “Guidelines for the assessment of herbal medicines”. WHO Technical Report Series. No. 863 (p. 180).

245 Research, drug development and manufacture of herbal drugs

Research, drug development and manufacture of herbal drugs B. B. Gaitonde

Introduction systems of medicine like the Chinese system, Ayurveda, Unani and Siddha. Concept of Diseases and Drugs in Ebers Papyrus of ancient Egyptians, or the Traditional Medicines of Ayurveda were veritable wo-thirds of the world’s population treasurehouses of human knowledge on T depend upon herbal resources for their herbal remedies and ethno-therapeutics. primary health care needs. Furthermore, The origin of Ayurveda, the ancient a large number of modern drugs are either system of medicine of the Indian subcon- derived from plant material or conceived, tinent, can be traced to the Vedic period, modelled and discovered based on the i.e., about 1500 B.C. The Atharv-veda of practice of traditional medicine. Most the Aryans, composed during their people, particularly from rural areas in migration to the Indian Subcontinent, developing countries, have their access first described medicinal plant remedies for ill- to traditional herbal medicines to relieve or health as well as for rejuvenation of the cure their ailments. body and mind. The use of medicinal plants Traditional health practices are based progressed into the period of the Samhitas, on many years of experience acquired by notably Charak and Sushruta Samhitas, humans in their journey in evolution. wherein one finds the “healing science” Primitive man sought remedies for illnesses emerging from the “magico-religious” state from his surrounding animal, vegetable, to a truly empirico-rational medicine. The and mineral kingdoms. Some of these Samhitas have elaborate treatises on remedies were based on mistaken beliefs recognition of plants based on their or mysticism. However, as civilization botanical characteristics, description of the progressed, particularly in Asia and notably parts of the plants, appropriate agronomic in China, Egypt, India and the , conditions for their cultivation (soil, the rich treasure of knowledge on herbal manure, etc.), classification based on remedies was systematically preserved, medicinal use (Charaka mentions more collated and written about, based on the than 50 plant groups); collection, prevailing concepts of health and disease. conditions for preservation, and the use of This resulted in the development of different different parts of plants such as bark, stem,

247 Traditional Medicine in Asia leaves, flowers, fruits, seeds and roots. organ leads to disease. Acupuncture is said There are also elaborate descriptions of the to stimulate Yin or Yang and restore the methodology for the preparation of normal flow of Qi. medicines (dosage forms) and methods of Numerous herbs or medicaments detoxification of mineral products. made from animal parts are thought to Most fascinating are the descriptions help in restoring the balance of Yin and of the pathogenesis of diseases based on Yang when disturbance manifests as the concept of Tridosha: Vata, Pitta, Kapha. disease. It describes measures to remain It is postulated that the human body is healthy and prevent or treat disease. composed of five elements (Panchmaha- Traditional Chinese medicine has produced bhutas) and is in perfect health when the over 10,000 medical books, and described “Three Doshas” are in a state of equili- over 5000 herbal drugs. Most countries brium. Disease produces imbalance of in the Western Pacific Region have been Doshas and, depending upon the nature influenced by traditional Chinese medicine. and extent of imbalance, an appropriate These medicines are complex mixtures management strategy is employed to bring of plants, animal parts or products, back the body to its original equilibrium.(1) minerals and metals. However, plants and Ayurveda describes very methodically plant products form the dominant part of the pharmacology of “Drugs and Diet”, the materia medica of traditional medicine both being accorded equal importance in practised in different parts of the world and the management of a patient. Charaka’s in particular in Asia, especially China, classification of plants was based on their India, Korea, Philippines, Indonesia and therapeutic uses and properties. Each Tibet. In India, for example, the Charaka medicine and also dietetic article have in Samhita (treatise), dating back to 900 BC, them what Ayurveda describes as Rasa lists 341 plants and plant products for (taste) Vipaka (alteration or metabolism in medicinal use. Susruta, who practised the body), Virya (potency) and Prabhava surgery about 600 BC, described 395 (specific action/potential which is beyond medicinal plants. Vagbhatta practised the rasadi attributes of the drug). Thus, in Ayurveda in Sindh (now in Pakistan) around Ayurveda drugs are prescribed to treat an the 7th century AD and wrote an unrivalled individual and not just his disease, depen- treatise on the principles and practices of ding upon the predominant property of the medicines called Ashtangahridaya which medicament and the Prakriti (Vata, Pitta or provides systematic descriptions of Kapha) of the patient. medicinal plants and mixtures of plant In the Chinese system of traditional products, minerals or metals. Bhava- medicine, the human body is considered prakash, written by Bhavamishra in about as a single entity. Normal body functions 1550 AD, describes 470 medicinal plants. are a result of the harmonious, balanced It is thus evident that traditional medicines behaviour of elemental forces called Yin- offer a wide range of herbal medicines, yang and Wuxing. Other concepts are often classified therapeutically. Zang fu (internal organs) and Jing luo (channels and collaterals), and Qi, a vital Research Policy force circulating in the body. Continuous circulation of Qi is believed to promote Most countries in the South-East Asia health, while interruption of Qi in any Region (SEAR) have a political commitment

248 Research, drug development and manufacture of herbal drugs to give priority to research and develop- extensively by traditional practitioners in the ment of traditional medicines. The health treatment of inflammation of joints, obesity, policy of China aims at integrating modern lipid disorders, etc., on the basis of the medicine with the traditional Chinese description of Medorog (Lipid disorder) by medicines and conducting research in Susruta. Chemical investigation has yielded traditional practices in a rational way. India two active compounds, namely z- has set up the Central Council for Research Guggulsterone and e-Guggulsterone.5 It in Ayurveda and Siddha (CCRAS) and is evident that such a composite approach Unani systems to investigate a number of in the investigation of medicinal plants is herbal medicines to establish the scientific likely to be more rewarding in establishing basis of their use. The Indian Council of the therapeutic claims of traditional Medical Research has established a remedies and obtaining novel chemical programme of Composite Drug Research entities. (CDR) whereby herbal drugs are investi- Thailand, Indonesia, Vietnam, Sri Lanka gated by a team of traditional and modern and Nepal, have all given priority to medicine practitioners, a botanist, a research in traditional medicines in their phytochemist and a pharmacologist in a health and drug policies. Several countries coordinated manner. have established pharmacopoeias of More than a hundred medicinal plants traditional medicines and established used in Ayurveda have been investigated institutes to undertake research in all in the CDR scheme and have provided aspects, including standardization and some promising leads for further quality control of herbal medicines. investigation. In some cases, the thera- peutic claims made by Ayurveda practi- Objectives of Research in tioners have been justified by pharmaco- Herbal Medicines logical studies. The plants selected in CDR have been botanically identified and their The hallmark of modern medicine is the pharmacognostic data have been scientific approach in promoting health, reported. Phytochemical studies have preventing diseases and curing ailments. yielded some novel chemical structures.2 Scientific methodology consists of the Thus, the Satavari (Asparagus racemosus) following approaches: root used in Ayurveda as a galactogogue z Astute observation; was studied in experimental animals and z Formation of hypothesis; reported to possess galactogogue and z Experimentation to prove or reject the anti-oxytosic activities.(3,4) The plant is hypothesis; reported to contain Shatavarin having a z Acceptance and incorporation of the specific pharmacological action. Picrorhiza results of research in modern medicine. kurroa has been reported to posses hepatoprotective activity and its active Since most herbal medicines used in principles have been identified as traditional practices are based on Picrocytes. Butea frondosa, which is used empiricism, there is a need to separate in Ayurvedic preparations as an anthelmi- chaff from the grain and prove, beyond ntic, has yielded an active principle called reasonable doubt, the efficacy, safety and palasonin. Guggulisterone from guggul cost-effectiveness of herbal medicines. Such resin has been isolated.2 The resin is used an approach not only enriches modern

249 Traditional Medicine in Asia medicine but the empiricism, if any, of Drug Research traditional medicine also gives way to rationality. Research on herbal drugs as conceived in In the context of primary health care, modern parlance consists of observations, the major objective of such research would discussions and literature review/search, be the utilization of local resources in a animal experimentation, chemical fractio- more rational manner in meeting the health nation and clinical evaluation. Opinions care needs of the vast majority of the differ on whether it is appropriate to employ population who are beyond the reach of such a scheme for “Plant to Drug” in case modern medicine. of traditional medicines. Most traditional systems aim at a holistic approach for the Policy and Organization cure of diseases and therefore most of their medicines are mixtures of plants, metals Several countries in SEAR have formulated and minerals rather than a single drug as national policies and strategies for research in modern medicine. and development of traditional medicines. Furthermore, such a drug combination The overall developmental objective is the is conceived by taking into account the utilization of indigenous resources for the pathogenesis based on the concepts of health and well-being of the populations. health and disease in traditional medicine. Specific objectives are: Several drugs are combined with a view to z To evaluate, on a scientific basis, the enhancing the potency of each other or to prevailing health practices and adopt mitigate or obligate the adverse effects of those in primary health care; others. Most traditional practitioners have z To complement and enrich modern scant interest in research in herbal health practices by the experiences of medicines since they firmly believe that such traditional practitioners. type of research is not necessary or because it will perhaps serve to enrich modern In order to implement the national medicine rather than traditional medicine. policy on herbal medicines, there has to In spite of such views, there is a be a multidisciplinary organization. In such constant search for medicines from herbal an organization, the key role of traditional sources. In the last two centuries, several practitioners must be emphasized. The drugs having a high therapeutic value have organizational structure for such an been derived from plants, for example, integrated approach would involve a digoxin from digitalis, eserine from calabar national committee for policy decision or beans, reserpine from the roots of a high-power board, consisting of bota- R.serpentina, etc. Such drugs have not nists, pharmacologists, pharmacists and only entered the therapeutic armamen- physicians of modern medicine along with tarium of modern physicians but also have an enlightened practitioner of traditional served as tools to understand the physiology medicine, drug manufacturers and repre- and pathogenesis of diseases. sentatives of the drug regulatory agency. “Plant to drug” research has often Having verified the therapeutic claim of proceeded according to the following herbal medicines, the next step would be to scheme: develop methods of standardization, quality control and appropriate dosage forms.6,7

250 Research, drug development and manufacture of herbal drugs

Composite Drug Research for establishing the botanical authenticity of the sample, a clinician of modern India and other countries in Asia, notably medicine, a phytochemist and a Thailand, Nepal, Myanmar and China, pharmacologist. Each unit has been have adopted national policies aimed at allocated medicinal plants for investigation. research and development of national As mentioned earlier, the major obstacle herbal resources and traditional medicines. in such a study is that the traditional One of the strategies adopted in India for practitioners do not believe in using a single research in the Ayurvedic, Unani and plant but a combination of plants with or Siddha systems of medicine was the without mineral or animal products. establishment of “composite drug research Elaborate methods of preparation of such units”. Each unit consists of a traditional a medicament are described. For example, practitioner, a crude medicinal plant Celastrus paniculatus, which has been collection centre with a pharmacognosist prescribed in Ayurveda for improving

251 Traditional Medicine in Asia memory and intellectual performance, has seeds, or roots, etc.). It would also be an elaborate method of preparation of the necessary to study the method of prepa- oil from the plant. ration of dosage forms used in traditional Another problem encountered in practices, treatment formulae, dose and research on herbal medicine relates to mode of administration to patients. seasonal variations in the activities of In this connection, a rational model plants. It has been reported that some developed in China is the use of retros- plants, when collected only in a particular pective data on plants or animals to season, show activity. Samples collected in analyse the rationale of their use in Chinese other seasons are devoid of active medicine. Thus, 248 plants and animal principles and therefore biological activity. drugs used in over 700 polypharmacy prescriptions were studied for their Ethno-Pharmacognostic rationale, if any, based on the published Research reports of their pharmacological actions, complete with any available folklore claims. Although there are elaborate descriptions If there was any correlation between of medicinal plants using various reported pharmacological effects with use synonyms, in the ancient treatises there are in Chinese medicine, it was presumed that hardly any botanical descriptions as in there is a rational basis for its use. modern pharmacognosy. The usual Another important consideration given practice in ancient times seemed to be for by the Chinese is what is described as a practising physician to collect plants from “Conversant evolution”. If a particular his surroundings and prepare the drugs traditional medicine is used for the same himself for use in his practice. It is not purpose by peoples widely separated by unusual to find that a herbal medicine used geographical distances or belonging to in different parts of a country for a different religious, ethnic or cultural particular ailment contains plants widely backgrounds, a strong possibility of its varying in botanical characterizations. For being “really effective” was accepted and example, it has been reported that samples further research was undertaken. of Pushpi (Convolvulus Ethno-botanical studies involve pluricalis), used by traditional practitioners macroscopic and microscopic descrip- in different parts of India, contain widely tions, preparation of plant specimens for varying plant species. It is therefore a herbarium and also a preliminary necessary to study the ethno-practices in chemical analysis to identify chemicals such different parts of SEAR countries, collect as , glycoside, terpenes, sesqui- samples of medicinal plants, and subject terpenes, etc. them to pharmacognostic studies employing modern methodology. In such Napralert Database a study it would be important to collect information not only on the plant itself but A computerized database on the chemistry on the time of collection, cultivation, and pharmacology of natural products is harvesting, the mode of preservation, now available at the University of Illinois, conditions in which it is used (fresh or USA. This department is now headed by dried), parts of the plant in use (whole plant, Dr Fong. The database covers over 4595 leaves, stems, bark, flowers, shoots, fruits, genera of plants, animals and micro-

252 Research, drug development and manufacture of herbal drugs organisms. It provides useful information From the early days, when pharmaco- on plants used in traditional medicines and dynamic studies were done to determine can be used for literature search before the effects of drugs on systems and tissues, planning an elaborate research i.e., on circulatory or nervous systems, etc., programme.8 the scientists working in this field are now It is possible to obtain from the involved in identifying the molecular basis database names of plants of a specific of drug action, interactions with receptors country or area: plants with pharmaco- (both extra and intracellular) effects on logical data on specific activity, i.e., transmission mechanisms or interaction hypoglycaemic, antitumour, antifertility, etc. with cytokines. With the cloning of receptors through recombinant DNA Agrobotanical Research technology, research methodology has been further refined.2 Such research is necessary for the Classical pharmacological studies on identification and evaluation of the natural experimental animals, using crude or distribution of the plant species. Research refined plant extracts, have yielded some on conditions of soil, weather, or type of fruitful data. On a global basis, about 130 manure used for cultivation of the plant drugs, all single entities extracted from and the effect on seasonal variations in the higher plants or modified chemicals, are growth and properties of the plant would currently used in modern medicine.2 also form a part of such agrobotanical However, such a classical “phyto studies. Such studies are important for pharmacological” approach has not been undertaking the cultivation of medicinal cost-effective. In fact, out of 200 new plants and making herb gardens. chemical entities (NCE) introduced in medicinal chemistry globally, only about 2 Pharmacological Studies per cent were based on higher plants.(2) The National Cancer Institute (USA), Modern pharmacology has made remar- beginning in 1959, screened over the next kable progress in the last four decades. 25 years, 180,000 plant extracts covering

Table 1. Drugs from ethnotherapeutic field Drugs Ethnotherapeutic information Morphine Opium used by ancient Egyptians and Sumarians Atropine Used by Babylonians Ephedrine Used by the Chinese for respiratory ailment (2700 BC) Quinine Used by Peruvians for fever Emetine Used by Brazilians and South Americans for dysentery and to induce vomiting Digoxin Used in England in the 17th century for heart illness Tubocurarine Used as arrow poison by Red Indians Reserpine Rauwolfia serpentina used as ‘folklore’ remedy for mental diseases in Bihar (North India) Artemisin Used in ancient Chinese medicine for fever

* Modified for Table 1 in reference: Sukh Deo

253 Traditional Medicine in Asia

3500 plant genera but this tremendous 1997)2 gives examples of some important effort did not yield a single marketable remedies which are the result of such drug.2 This has weaned major pharma- investigative approach. ceutical companies away from plant From the Table, it is evident that research and instead made them go in for traditional medicines offer investigative synthetic drugs. In synthetic drug research, leads to undertake further studies to assess once any innovative breakthrough and establish their therapeutic utility in a occurred, several “me-too” drugs flood the number of clinical conditions, especially market. Several examples can be given those diseases in which modern medicine about the success of this approach, such offers very limited therapy. In Ayurveda, for as NSAID, ACE, inhibitor, B-lactamase example, there is a group of drugs called inhibitors, quinolones and B-blockers. This “Rasayana” or life promoters or rejuve- has no doubt proved cost-effective. nators, which can be investigated in terms In spite of what has been said above, it of modern physiological parlance, as anti- must be emphasized that the ethnothe- inflammatory, antioxidants, immunomo- rapeutic use of traditional medicines dulators, antiaging, etc.8 provides clues for searching for plant drugs, identifying their active principles, Specific Screening Models synthesizing their analogues, and leading to their introduction in modern therapeutics. Experimental pharmacology offers several The following Table (adapted from Sukh Deo, screening models to screen crude or semi-

Table 2. Some plants with notable therapeutic activity(2) Botanical name Probable therapeutic activity Acorus calamus Tranquillizer Asparagus racemosus Galactogogue: uterine sedative Bacopa monnieri Improves memory Boerhaavia diffusa Diuretic Curcuma longa Anti-inflammatory Phyllanthus niruri Hepatoprotective Picrorrhiza kurroa Hepatoprotective Celastrus paniculatus Immunomodulator, antioxidant Ocimum sanctum Antistress Gymnema sylvestre Hypoglycaemic Momordica charantia Hypoglycaemic Hibiscus rosa-sinensis Hypoglycaemic Plumbago zeylanica Antifertility Commiphora mukul Hypolipidemic Withania somnifera Tranquillizer, immunomodulator Terminalia chebula Antiaging Convolvulus microphyllus Neural regeneration and synaptic plasticity Panax ginseng Antifatigue, adaptogenic, antistress

254 Research, drug development and manufacture of herbal drugs purified herbal drugs for therapeutic from Cyperus rotundus possesses anti- activities based on traditional usage.9,10 inflammatory activity comparable to Some of the models used in the screening hydrocortisone.12 Tinospora cordifolia was programme are discussed. reported by Pendse, et al (1981), as The criteria for selection of plants possessing anti-inflammatory activity mentioned under each of the activities can against both acute and chronic inflamma- be summarized as follows: tion comparable to non-steroidal anti- 13 z Plants are in use by traditional practiti- inflammatory agents. oners in a particular clinical condition; Potassium embelete, a quinone obtai- z Preliminary pharmacological studies ned from Embelia ribes, was reported by have yielded promising leads; Atal, et al (1984), as a potent, centrally z Plants are mentioned in the ancient acting analgesic. It was reported to possess texts as useful in certain diseases, a highly therapeutic index and lack absti- particularly those for which there are nence syndrome.14 Similarly, no effective or safe drugs in modern melangena was reported by Vohra, et al medicine, e.g., diabetes, arthritis; (1984 a), as possessing non-narcotic 15 z Ancient texts providing leads for analgesic activity. Petroleum ether extract selection of plants for screening for of Abutilon indicum was shown to possess such conditions as cancer, stress, analgesic activity against acetic acid- rejuvenation. induced writhing in mice and has a good margin of safety.16

Anti-inflammatory, Analgesic- Antiallergic Activity Antipyretic Activities Several plants are used in traditional Several herbal remedies have been medicines for treating allergic conditions screened for anti-inflammatory, analgesic such as bronchial asthma, urticaria, and antipyretic activities using appropriate eczema and allergic rhinitis. These are screening models. A simple and commonly usually screened in animal models on the used method to study anti-inflammatory basis of their antihistaminic or antiserotonin activities, though not ideal, is carageenin- activities in isolated tissue systems such as induced oedema of rat paws. Analgesic isolated intestine and isolated lung activities have been studied in animal perfusion. Other models used are passive models to assess pain relief in acid-induced cutaneous anaphylaxix in rats (PCA), writhing in mice or by tail clip method in histamine contents, or release by antigens. rats. Antipyretic activity has been studied in animals with induced fever. Plants showing some antiallergic activities Several plants have shown anti- are: inflammatory activities in a number of z Piper longum; screening models and would need further z Tylophora indica. studies. Thus, Randia dumetorum contains orionic acid 3 B-glucoside, which was Dry fruits of Piper longum reduced PCA reported by Ghosh, et al (1983), as in rats and also prevented histamine- possessing anti-inflammatory activities in induced bronchospasm in guineapigs.17 the exudative and proliferative phases of Similarly, Tylophora indica alkaloids were inflammation in rats.11 B-sitosterol isolated found to posses activity comparable with

255 Traditional Medicine in Asia

disodium cromoglycate.18 Because of their primed with saline and measuring urine extensive use in Ayurvedic preparations and output in a fixed time period. A dose supportive experimental evidence, both the response study is planned, and the effect plants would need further evaluation. on sodium or potassium excretion can also be assessed. Hypoglycaemic Activity Diabetes mellitus has been described in Plants showing diuretic activity are: ancient texts on traditional medicine both z Milingtonia hortensis; in China and India. In Ayurveda, Charaka z Toddalia asiatica; has given an elaborate description of the z Cucumis trigonus. disease and has prescribed the dietetic regime and drug treatment. Millingtonia hortensis showed a Following are some of the herbal significant natruratic effect without remedies screened for diabetes. The most affecting potassium excretion to any great often used screening model is alloxan- extent.21 Toddalia asiatica was reported to induced hyperglycaemia in rats and contain coumarins which possess diuretic rabbits. Some plants screened for the activity though less potent than hydrochlo- hypoglycaemic activity are: rothiazide.22 Similarly, Cucumis trigonus z Acacia catechu; was also reported to possess some degree 23 z Gymnema sylvestre; of diuretic activity. z Momordica charantia; Spasmolytic Activity z Leucaena leucocephala; z Hamiltonia suaveolans; These drugs are used to relieve spasm of z Pterecarpus marsupium. smooth muscles as in bronchial asthma, renal colic or colicky pain in abdomen. Gymnema sylvestre is used in Several test systems have been used to combination for the control of diabetes and assess the spasmolytic activity of the plant was reported to regulate blood sugar in extracts. Commonly used ones are experimental animals by affecting insulin- isolated guineapig ileum, spasm induced dependent enzymes.19 Momordica chara- by acetyl chloline or histamine and ntia contains a polypeptide posse-ssing tracheo-bronchial tree of guineapigs. hypoglycaemic activity(20) and the plant was Since histamine has been implicated in shown to be effective in both juvenile and bronchial asthma, its release or that of maturity onset diabetes, probably due to other cytokines, induced by histamine increased insulin release from pancreas. releasers or stabilization of mast cell Diabetes is a complex metabolic granules, has been studied to assess the disorder which, according to the traditional effects of plant extracts on various local medicine concept, needs management of hormones. diet, physical activity, emotional problems and appropriate drug combinations. Some of the plants screened for spasmolytic activity are: Diuretics z Clausena pentaphyla; Drugs of this class are used in several clinical z Corydalis meifolia; conditions, such as dropsy, hypertension z Symplocos spicata; and acute left ventricular failure. Diuretic z Corchorus tridens; activity has often been studied in rats z Selaginella rupestris.

256 Research, drug development and manufacture of herbal drugs

Patnaik and Dhawan (1982) have reported extensively on several species of Clausena24 Clausmerin-produced relaxa- tion of smooth muscles. This compound seems to possess a high safety margin. Bhakuni and Chaturvedi (1983) reported on the spasmolytic activity of Corydalis meifolia.25 The active compound was not as potent as papaverine. Symplocos spicata26 Corchorus tridens,27 and Selagi- nella rupestris28 show varying degrees of

spasmolytic activity in experi-mental models. Ocimum Sanctum - antistress, adaptogenic plant used in India Central Nervous System Activity A large number of herbal remedies are Amongst these, Bacopa monnieri has used in traditional medicine to influence the been investigated extensively by Singh and functions of the nervous system. While Dhawan (1982, 1985) who have con- some enhance or depress CNS non- firmed the claims made in Ayurvedic texts specifically, others are used to influence on memory and performance in experi- behaviour abnormalities, sleep pattern, mental models.29,30 Melia azadirach was improvement of memory or in the treat- shown by Srivastava, et al (1981), as an ment of mental disorders like depression, anorexogenic.(31) Agrawal (1981) reported schizophrenia or dementia. on the neuroleptic activity of Hydrocotyle Most studies are conducted in rats or asiatica, showing promising results.32 mice for exploring the effects of plant extracts on motor activity, exploratory behaviour, Adaptogenic Activity amphetamine-induced agitation, condi- tioned reflexes, drug-induced convulsions, Ayurveda has described a group of phenobarbitone-induced sleeping time, complex remedies called or life behavioural responses, natural or acquired, promoters. Some of these can be described etc. Several investi-gators have studied a as antistress, immunomodulators, preven- number of plants mentioned in traditional tives of memory loss or cognitive functions, medicines for their effects on different etc. They provide a challenge to modern functions of the nervous system using very pharmacologists to devise screening sophisticated techniques like stereotaxic models for establishing an appropriate stimulation, estimating neurohormones in activity as described in ancient texts. different parts of the brain, etc. The effects of drugs have been studied on stress-induced pathological changes in The following are a few plants screened for mice or rats, such as increased endurance their activities on the CNS: of swimming mice, stress-induced gastric z Melia azadirach; ulcers in rats, milk-induced leucocytosis in z Hydrocotyle asiatica; mice, stress-induced increase in the weight z Salvia haematodes; of adrenal glands in mice, and isoprena- z Calophyllum inophyllum; line-induced myocardial damage in rats. z Taxus baccata. More recently, with the advances in

257 Traditional Medicine in Asia molecular pharmacology, investigators in lines or in Vivo tumors. Alkaloids from Vinca this field have looked afresh at some of the rosea have already been used in the plants utilizing receptor-binding or/and treatment of human cancers for over a enzyme-inhibition techniques. These have decade. The following herbal products provided encouraging clues and would have shown some anticancer activity: need further probing. z Centella asiatica; z Salacia oblonga; Plants described in traditional medicines as z Janakia arayalpathra; possessing antistress activity are: z Podophyllum hexandrum. z Allium sativum; z Acorus calamus; The plants mentioned above have been z Celastrus paniculatus; reported to posses either direct anticancer z Centella asiatica; activity in experimental models or have z Convolvulus microphyllus; radiosensitizing or immunostimulant z Nardostachys jatamansi; effects. These have been reviewed by 35 z Ocimum gratissimum or sanctum; Dahanukar, et al (2000). z Pluchea lanceolata; Nutraceutics z Terminalia chebula; z Withania somnifera; There is an emerging trend to use dietary z Emblica officinalis. substances for the prevention or cure of diseases. People are becoming more and Dahanukar, et al (1997), in a series of more health conscious and wish to pick experiments, have reported the beneficial and choose “diets” which promote health effects of aqueous extracts of several of the and avoid “those” which cause harm. above-mentioned plants in experimental Scientists all over the world are studying animals in doses comparable to those used the scientific basis of such a line of thinking in humans.33 All of these were found to or dietary practices. Some of the “dietetic produce immuno-stimulation. Emblica substances” studied are the following: officinalis seems to strengthen defence z Edible oils; mechanisms against free radical damage z Spinacia oleracea (Spinach); induced by stress. Sambulingum, et al z Momordica charantia (a vegetable); (1997), have shown the antistress effects z Curcuma longa (condiment); of Ocimum sanctum especially in noise z Trigonella foenum graecum (seeds); 34 pollution-induced stress. z Murraya koenigii (curry leaf); Such leads provided by traditional z Brassica juncea (mustard seeds/ medicines call for further studies in this leaves); important area, particularly with a view to z spicata (mint leaf); elucidating the mechanism of action of the z Allium cepa (Onions); drugs vis-à-vis the pathogenesis of stress. z Allium sativum (Garlic); z Myristica fragrans (); Anticancer Activity z Piper nigrum (). Several plants and plant extracts have been studied as anticancer agents, chemo- In traditional medicine, diet plays a preventive, radio sensitizers, or immunity major role in health and disease. In enhancers. Test systems are cancer cell Ayurveda, dietetic articles are described as

258 Research, drug development and manufacture of herbal drugs ushna (hot) or sita (cold) and the patients, commonly used include hepatic damage depending on their Prakriti, are advised to induced by carbon tetrachloride in rats, take or avoid one or the other. Sarkar, et al both as acute and chronic hepatic injury. (1996), have reported on the clastogenic Alcohol, isoniazide, pyrazinamide or and non-clastogenic effects of Indian paracetamol-induced hepatic injury in rats spinach.36 Momordica charantia,36 edible has also been used to produce hepatic oils,37,38 Curcuma longa,39 ,40,41 injury. However, there is no animal model and Mentha spicata.42 to simulate chronic progressive hepatitis or cirrhosis. Anti-peptic Ulcer Activity Acid peptic disease is treated with remedies The following are commonly used herbal which restore equilibrium of humors in the medicines as hepatoprotectives: body. There is, therefore, no appropriate z Tinospora cordifolia; test model to assess the activity of herbal z Acacia catechu; medicines in this disease complex. z Piper longum; However, commonly used models to test z Phyllanthus niruri; antipeptic ulcer activity are experimentally z Eclipta alba; produced ulcers in rats by pyloric ligation, z Picrorhiza kurroa. or immobilization, and prednisolone or histamine-induced ulcers in guineapigs. Rege, et al (1984b), have reported that Herbal drugs proposed for this condition chronic liver damage was prevented by are: Tinospora cordifolia.45 Similarly, Acacia z Tectona grandis; catechu prevented chronic damage of liver z Andrographis paniculata. but not the acute variety. Piper longum is a drug most commonly advocated in Ayurveda Ethanol extract of the bark of Tectona for the treatment of liver disorders. However, grandis was studied by Pandey, et al (1982), in studies by Rege, et al (1984c), it only and showed anti-ulcer activity in rats and seems to restrict fibrosis.45 Picrorhiza kurroa guineapigs.43 Vishwanathan, et al (1981), and Eclipta alba have been extensively reported a similar activity of a flavone investigated for hepatoprotective activities isolated from Andrographis paniculata.44 (Pilankar, Ph.D thesis submitted to Mumbai Several such plants used in combination by University).46 These drugs form important traditional practitioners in gastric disorders ingredients of Ayurvedic preparations such should provide leads from animal experi- as Liv 52 or Liv 100 marketed in India for mental studies for clinical evaluation. liver disorders. Vaidya, et al (1996), have reviewed experimental and clinical research Hepatoprotective relating to the hepatoprotective effects of Modern medicine does not offer any Ayurvedic formulations.47 Saraswathi, et al specific hepatoprotective drugs. Viral (1998), have reported on the hepato- hepatitis or liver cirrhosis is treated sympto- protective activities of Liv 52 and Liv 100, matically and by diet rather than drugs. which are mixtures of herbal drugs Traditional medicine, in particular extensively used in liver disorders such as Ayurveda, offers several medicinal plants progressive hepatitis, and cirrhosis.48 It was with possible hepatoprotective activity. shown that hepatic enzyme activity was Experimental test models which are protected by these preparations.

259 Traditional Medicine in Asia

Antifertility Activity degree of activity. Lygodium flexuosum was The serious problem of population studied by Gaitonde, et al, on the basis of explosion and the limitations of modern its use in folklore practices among Adivasis drugs used in the control of conceptions in Maharashtra, India. The plant extracts have attracted the attention of several showed significant anti-implantation scientists sufficiently for them to investigate activities in three species of animals and medicinal plants for antiinfertility activity in the effect was reversible. both females and males. Chemotheapeutic Agents The test models usually employed are anti-implantation study in rats, litre size, The chemotherapeutic era started with estrogenic or anti-estrogenic or aborti- penicillins isolated from molds. Thereafter, facient activity in rats, study of the response several compounds possessing antimi- of isolated rat uterus induced contracture, crobial, antifungal, antiviral and antipa- in vitro spermicidal activity, etc. In males, rasitic activities have been studied and the test models are the effects on testes in introduced as chemotherapeutic agents. male dogs, the effect on spermatogenesis The test system is to note the effect of the in dogs, mating behavioural study, etc. plant product on the in vitro culture of micro-organisms or to study the effect in Some of the plants screened for antifertility experimental animals infected with the activities are: organisms. Some of the plant products showing such chemotherapeutic activities z Bupleurum marginata; are: z Embelia ribes; z Clausena anisata; z Thespesia populnea; z Cassia alata; z Hibiscus rosa-sinensis; z Semecarpus anacardium; z Plumbago zeylanica; z Cinnamomum zeylanicum; z Xeromphis spinosa; z Azadirachta indica. z Annona squamosa; z Lygodium flexuosum; Antiviral Activity z Adhatoda vasica; This is shown by the following plants: z Azadirachta indica; z Phyllanthus amarus; z Trichopus zeylanicum. z Glycyrrhiza glabra.

Kamboj and Dhawan (1982) have Antimalarials presented a review of medicinal plants screened for antifertility activity in z Artemisia japanica; experimental animals.(49) Embelin isolated z Artemisia maritima; from berries of Embelia ribes was reported z Azadirachta indica. by Prakash (1981) as possessing signi- ficant anti-implantation activities.50 Most investigators in this field have Hibiscus rosa sinensis flowers have been used standard in vitro assays. Clausena used in traditional medicine as antifertility anisata was active against both gram- 52 agents. They have shown both anti-fertility positive and gram-negative bacteria. and aborticacient activities in rats.51 Annona glabra was reported to possess a Plumbago zeylanica was studied by substantial anti-microbial, anti-fungal and Chowdhary, and reported to possess some moderate degree of insecticidal activities.

260 Research, drug development and manufacture of herbal drugs

Semecarpus anacardium was shown to be Phytochemical Research bactericidal in vitro against gram-negative organisms such as S.typhi and Proteus Chemical processing of the plant or its vulgaris. The growth of Vibrio cholerae was parts involves the following steps inhibited by the acetone extracts of Cassia z Crude Plants/parts; alata. Agnihotri and Vaidya (1996) have z Dried – sometimes fresh; studied a number of plants for their z Solvent extraction. antibacterial properties and found Thymus vulgaris to posses substantial antibacterial Step I activity.53 Identification of active chemical Azadirachta indica was shown to be constituents: very active against clinical isolates of z alkaloids, glycosides, terpenes, dermatophytes. Similarly, essential oils sesquiterpenes (terpenoids) obtained from Santolina chamaecyparissus z oleoresins, steroids, coumarins, etc.; showed a significant activity in vitro against Candida albicans. Rai screened 17 Step II medicinal plants (1996) for anti-mytotic Further purification using: activity and reported that maximum activity z Thin-layer chromatography or ion was present in Eucalyptus globulus and exchange, or gas, Catharanthus roseus.54 Ocimum sanctum z Chromatography, was also found to be effective as an z Coupled with mass spectrometry, antimytotic. z High-performance liquid chromato- Phyllanthus amarus was reported to be graphy (HPLC); effective against Hepatitis-B virus at cellular level.55 Glycyrrhiza glabra has been tested Step III against both DNA and RNA viruses in vitro, z Determination of chemical structure. particularly on DNA viruses. Premnathan, et al, have also carried out in vitro screening Chromatography is a powerful tool used against HIV-infected MT-4cells. Some plant primarily for separating the components of extracts were found to inhibit the adsorption a sample. The components are distributed of HIV virus into the cells.56 between two phases, one of which is With the resurgence of malaria, several stationary and the other mobile. The sample, plants have been studied for antimalarial when introduced into the mobile phase, activity on the basis of leads provided by undergoes a series of partition or adsorption either folklore use or ancient texts of tradi- interactions as it moves through the tional medicines. Both in vivo and in vitro chromatographic system. screening models have been used and It is expected that the differences in the several species of Artemisia were reported physical and chemical properties of the to possess varying degrees of antimalarial individual components determine their activities. relative affinity for the stationary phase and From the above discussion it becomes therefore the components would migrate evident that further research, in particular through the system at differing rates. This clinical studies based on specific pharma- permits separation, isolation, identification cological properties, would prove and also quantification of the chemical rewarding. constituents in a mixture. Each of the

261 Traditional Medicine in Asia

purified components can, after elution, be compounds satisfy the appropriate stereo- tested for biological activity in an appro- structure. Computer modelling has already priate test system. Thus, by such highly yielded a number of compounds of herbal sophisticated methodology it is possible to origin with therapeutic possibilities. proceed from “plant to drug”.2 Drugs derived from plants as pure Molecular Approach to Drug chemicals have been in therapeutic use for Development almost a century. Some of the plant consti- tuents have yielded novel chemical entities, In recent years there have been tremen- leading to their synthesis and the prepa- dous advances in understanding how drug ration of their analogues or derivatives. molecules modify cell functions. After Paul Some examples of such drugs derived from Ehrlich postulated that drug molecules plants are given in the following Table. interact with specific areas on cell mem- brane or inside the cell called “receptors”, Table 3. Drugs derived from plants such receptors have now been identified Source Plant Active Constituent and their stereo-chemistry studied. With Digitals lauata Digoxin advances in genetic engineering the vulgaris Ephedrine receptors have even been cloned. It is now serpentina Reserpine possible to study drug receptor interactions and their kinetics and therefore it is possible Cinchona bark Quinine to evaluate the therapeutic potential of Artemesia annua Artemisinin several naturally occurring phytochemicals Commiphora mukul Guggulusterones derived from higher plants. Asparagus racemosus Shatavarin While most investigators in this area of Picrorhiza kurroa Picroside drug development would prefer to work on Adhatoda zeylanica Vasicine synthetic drugs, the potentials of herbal Atropa belladona Atropine medicines offering interesting chemical Morphine entities are enormous. This type of develop- ment can only be undertaken by the . Considering that Plant Culture their annual turnover exceeds US$ 200 This is a recent addition to bio-technology billion globally and the R&D inputs of some in plant research. In vitro plant cultures dominant pharmaceutical companies is in under varying experimental conditions result the vicinity of 10–15 per cent of their in bioproducts with novel chemical turnover, it is possible for such frontline structures and biological activities. industrial houses to invest in R&D on the basis of leads provided by materia medica Structure-based Designs and practices of traditional medicine.

Having identified a chemical structure, Research on Quality Control organic chemists are engaged in intensive Methodology and computerized drug design exercises. This Standardization requires computer graphics, software for molecular visualization, and docking Quality control and standardization are programmes to screen and find out which essential to ensure safety and efficacy. Most

262 Research, drug development and manufacture of herbal drugs herbal drugs are complex combinations uniform and high quality raw materials and are often prepared by a variety of which are fundamental for quality assu- methods described in the ancient texts. rance, the trend is towards domestication Very often these methods are not well- of plants (herbal gardens), genetic impro- standardized and therefore the end- vement or use of plant-culture techniques. product may not yield consistent results. The tests on the final product or dosage Safety of Herbal Medicines forms are not often available in the old treatises. It is therefore essential to under- Any medicinal preparation, whatever its take extensive research and development origin, has to be safe for human or animal for quality control and standardization. use. Since traditional medicines, parti- Herbal preparations contain active cularly of herbal origin, have been in use ingredients of plant parts or materials in a over several centuries, these are presumed crude or processed form. India, China, to be free from toxic effects. These presum- Thailand and Indonesia have prepared ptions do not seem to be valid in all cases pharmacopoeias of herbal medicines considering that medicinal plants contain which describe the botanical characteristics highly toxic chemicals such as glycosides, or pharmacognosy of individual plant alkaloids, or and cytotoxic agents. materials, their chemical characterizations, There is a likelihood that herbal medicines including the spectrum of active ingre- in general have overall less toxicity than dients, both quantitative and qualitative, synthetic compounds. Furthermore, the methods of preparation, and some tests traditional methods of preparation of on the final product. However, much more dosage forms and combinations of several research is needed in this field, particularly plants are supposed to reduce or eliminate for developing methods for quality control toxicity and make the final product safe for to be used by the authorities for regulatory therapeutic use. control and for their harmonization and Elaborate toxicity studies prescribed by improvement by different countries in the regulatory authorities for “New Drugs” are South-East Asia Region. not required for those herbal medicines The combination of scientific studies which are either described in ancient and traditional knowledge should be the treatises or are in use as folklore for several hallmark of such research. Scientific centuries. However, most regulatory methods presently used include studies on authorities would require some toxicity data botanical characteristics and chemical in two or more species of animals before studies using instrumentation analysis such allowing such drugs to be adopted in as neutron activation techniques. Since this national pharmacopoeia or in therapeutic type of research would require adequate practice. resources, both human and financial, it can Once the active principles from a best be undertaken either by commercial herbal drug are isolated in chemically pure companies or through international form and their analogues are prepared, collaboration. such “New Drugs” would require elaborate Variations of plant material harvested toxicity studies. from different geographical areas in There are a few reports on adverse different seasons pose a serious problem reactions to herbal medicines. Very often in standardization. In order to obtain there is a lack of proper observation in

263 Traditional Medicine in Asia patients and of documentation. In order, are critical observations, hypothesis, therefore, to assess the extent of adverse carefully designed experimentations and reactions, it is desirable to undertake valid conclusions. Through this process multicentric studies on the adverse effects alone can rational therapeutics progress. of some commonly used herbal medicinal Application of the science of statistics preparations in the field situation, in to clinical experimentation is now particular at primary health care, level recognized as essential for valid conclusions through a judicially devised open-ended from experimentations. In most instances, questionnaire. Such a study would throw patients vary in their responses to the same more light on the problems of safety of medication. The disease process itself may herbal medicines. have such wide variation. Prof. Bradford Hill therefore put forward the concept of Efficacy: Clinical Research controlled clinical trials which demands, i) Two or more groups of patients observed Since herbal medicines have been in use at the same time and differing in the over several centuries, they are regarded as treatments, ii) Constructing the groups by useful and efficacious in the treatment of random selection (randomization), iii) Use ailments. While the original herbal remedy of placebo or inert medication, and iv) may often have been found by chance, Comparison of two or more types of several substances of doubtful merit have treatment or treatment regimens by no doubt entered traditional practices. Some applying appropriate statistical methods. of the ancient recipes contain such amazing The objectives of the clinical evaluation and often preposterous substances like of herbal medicines are, i) Establishing pearls, musk, crocodile’s dung, horns of scientific validity for herbal medicines used antelopes, extracts of ants and so forth. It is by traditional practitioners, ii) Studying therefore necessary to separate the grain plants considered medicinal and available from the chaff. locally in abundance, and iii) Searching Most physicians in the past millenium for drugs from medicinal plants for chronic, have relied upon traditional materia refractory or specific diseases for which medica based on empiricism. There is a there is no satisfactory treatment presently possibility that for every therapeutic regimen available in modern medicine. Some of some significance, there would be examples of such diseases are athero- several others, acceptable to the practising sclerosis and hyperlipidaemia, bronchial physicians of those times which may asthma, immunological disorders, appear incredible to the present-day rheumatoid arthritis, urolithiasis, metabolic scientific community. The modern scientific disorders like diabetes mellitus, acid peptic community may raise such questions as disease, , liver diseases, how to differentiate the good from the bad fertility control, malignant malaria, mental and how to differentiate a truly effective diseases, rejuvenation of the elderly therapeutic remedy from misguided (cognitive disease), including Alzheimer’s enthusiasm. disease, etc.8 Applying modern concepts and In the case of the first objective, clinical methodology, the basis of all treatment evaluation using conventional scientific regimes should be experimentation. The methods is all that is necessary to prove essential elements of all scientific evaluation the claims of herbal medicines. There is no

264 Research, drug development and manufacture of herbal drugs

need for elaborate preclinical studies. The Plants considered medicinal and modern-medicine clinician should work available locally in abundance will fall into with a traditional practitioner for evaluating two groups: i) Those described in either the clinical efficacy of the drug therapy, traditional or modern literature, either singly using dosage forms used by the traditional or in combination, and ii) Those which are practitioners. This is important because “folklore”. In the case of the first group, there are examples where dosage forms based on the literature survey, a protocol is of herbal drugs prepared by modern prepared for clinical evaluation taking into pharmaceutical methods may not yield the consideration all the available information expected results. such as agro-botanical and ethno-pharma- Having established efficacy and cognostic data, phytochemical data, “Clinical Safety”, the next step would be to pharmacodynamic studies and acute and evaluate dosage forms and the appropriate subacute toxicity data. dose of the medicine, with the objective of In the case of “folklore” medicines, adopting these in modern pharmaco- careful observations and study of “folklore poeias. At that stage, drug regulatory practices”, the traditional method of authorities should be consulted to find out preparation and rituals accompanying the if it is possible to lay down standard quality administration of the medicine are prere- control methods and establish large-scale quisites for planning clinical evaluation. At production facilities. this stage, the objective is simply to assess

265 Traditional Medicine in Asia the efficacy of the herbal medicine. Having inflammation and degeneration. Phyllan- validated the claim, it would be necessary thus niruri, or Picrorhiza kurroa are to plan an elaborate research programme examples of herbal medicines investigated in order to adopt the drug in modern for their effectiveness in liver disorders clinical practice. based on Ayurvedic concepts, and this has Research and development of herbal led to the isolation of a novel chemical drugs for specific chronic diseases should structure. Asparagus racemosus is follow more or less the same approaches described as galactogogue and used in as in the case of “folklore” medicines. In lactating mothers. Its investigation has this type of research, a careful study of resulted in the isolation of Shatavarin, a traditional literature, the concepts of health chemical with a novel structure. As and diseases, descriptions of the pathoge- mentioned earlier, Artemesin and Arete- nesis of the specific condition, and the mesinine isolated from Artemisia annua in mechanisms of drug action as described China has proved a very valuable drug in in ancient treatises, are all important and the treatment of falciparum malaria. This necessary before embarking on such type is based on the use of the plant in fevers of research. mentioned in ancient Chinese medicines. It is also necessary to try to correlate modern concepts of the pathogenesis of Pharmaceutical Technology disease with the traditional concept. For example, the Rasayana drugs mentioned Herbal medicines, used by traditional in Ayurveda as health promoters can be practitioners, are administered to patients conceived to act as “antioxidants” or in several dosage forms. These are immunomodulators, and Celastrus prepared according to methods prescribed paniculatus (jyotishmati) described in in ancient traditional treatises. For Ayurveda as a promoter of memory could example, Ayurvedic classics mention act through receptor activation or regene- elaborate pharmaceutical methods for the ration. Sushruta has described treatment preparation of a medicament. Usually the of obesity and lipid disorders (medoroga) dosage forms prepared according to with the use of a gum resin from Ayurvedic texts are distillates (Arka) Commiphora mukul called “Guggulu” in fermented products (Asavas and Aristas), Sanskrit. Sushruta gives an elaborate Linctuses, (Avaleha), powders (Churna), description of the etiology and pathoge- incinerated material (Bhasma), pills or nesis of the disease, which has a conside- tablets (Vati/gutika), and decoction rable resemblance to the modern concepts (kwatha). of atherosclerosis. Dr C. Dwaraknath, the As mentioned earlier, it is important then advisor to the Government of India that traditional pharmaceutical technology on traditional medicines (1969), proposed is investigated thoroughly before changing a collaborative study on this plant for its over to modern technology. It is possible use in atherosclerosis or hyperlipidaemia. that the therapeutic properties of the This study has led to the isolation, dosage forms are preserved only when identification, and characterization of a these are prepared according to traditional new structural type, Guggulusterone. A pharmaceutical methods, and this aspect similar approach has been adopted for therefore needs investigation. herbal drugs in the treatment of liver

266 Research, drug development and manufacture of herbal drugs

Standardization and Herbal and private manufacturing units have come Pharmacopoeias up in India, China, Indonesia and Nepal Several countries in SEAR have developed to produce herbal drugs in large quantities methods for the quality control and for sale in the country and for export. standardization of herbal medicines. This Modern pharmaceutical technology activity is often undertaken in close has been used to prepare herbal dosage collaboration with traditional practitioners forms such as tablets, pills, sachets and utilizing the expertise in , mixtures. Partial or total automation has , pharmacology and cell been employed. In China, Korea and biology. Investigation of this nature has Thailand, governments have established led to the development of monographs on herbal gardens and the plants are simple or complex herbal medicines. harvested in appropriate seasons. These These have been compiled into a National are then processed according to the Pharmacopoeia of Herbal Medicines. For directions provided by the ancient texts but, example, the 1990 edition of Chinese wherever possible, the process is automated Pharmacoepoeia enlists more than 784 using mixers, granulators, fluid bed dryers, traditional Chinese drugs. tableting machines, coating pans, China, India, the Philippines and automatic bottling, labelling and strip Indonesia have published National packaging, etc. Pharmacopoeias of herbal medicines Several pharmaceutical manufacturers listing several local drugs. This is a have introduced in their manufacturing continuing process and has been going on activities Good Manufacturing Practices in order to make additions, deletions, and (GMP) as recommended by WHO, refinement of methodology. Such pharma- wherever possible. copoeias are yet to gain recognition by Quality Control is usually done by drug regulatory authorities in some subjecting the raw materials as well as countries. finished products to i) Physical tests such as colour, taste and disintegration rate, if warranted, and ii) Chemical tests: tests for Manufacture alkaloids, or glycosides, etc., including Globally, the pharmaceutical industry has chromatographic tests. grown enormously. In Asia, excluding All this needs substantial developmental Japan, China and India have registered a resources which are usually provided by the phenomenal growth in the pharmaceutical modern pharmaceutical industry. sector, producing both formulations and Epilogue bulk drugs. However, in all these efforts, the share of medicinal plants is rather low. Research is the hallmark of progress and According to Kurup, there are over rationality. Herbal medicines have been 4500 pharmacies in SEAR producing used for centuries and are still patronized herbal medicines.1 In India, herbal drug by large sections of the people, particularly production is over Rs. 7000 million in the rural areas in developing countries. annually. While the large majority of These remedies have to be evaluated for traditional practitioners all over the Region their efficacy and safety so that their use continue to prepare their own recipes for becomes more rational and they can then use in their practice, several public sector be adopted in modern therapeutics

267 Traditional Medicine in Asia globally. Some higher plants which are of technical human resources. Technology medicinal interest should be carefully missions and policy commitment at the investigated in all aspects57,58 because they highest political level, and international offer great possibility for achieving a collaboration at national and regional breakthrough in respect of several diseases levels, would serve to speed up research for which there is no satisfactory therapy and development in the field of herbal in modern medicine. Countries should drugs. therefore provide both financial as well as

References

1. Kurup P.N.V. Traditional medicines and health care coverage. Robert H. Bannerman, John Barton and Chen-Wen-Chien (Ed.). WHO publication. Ayurveda. 1983; 50. 2. Sukh Deo. Ethnotherapeutic and modern drug development: potential of Ayurveda. Current Sciences. 1997; 75 (11): 909. 3. Sabnis P.B., Gaitonde B.B. and Jethmalani M.H. Effect of alcohol extract of Asparagus racemosus (wild) on mammary glands of rats. Ind.J.Exp. Biology. 1968; 6: 55. 4. Gaitonde B.B. and Jethmalani M.H. Anti-oxytocic action of isolated from Asparagus racemosus (wild) (Shatawari) on uterine muscle. Ind. J.Pharmacol. 1969; 31: 175. 5. Attiso M.A. Phytopharmacology and phytotherapy. Robert Bannerman (Ed.) et al. WHO publication. Geneva. 1983; 194. 6. World Health Organization. Quality control methods for plant material. WHO publication. Geneva. 1998. 7. Fransworth Norman R. The Napralert database as an information source for application to traditional medicine. In: Traditional medicine and health coverage. Robert H Bannerman (Ed.) et al. WHO publications. 1983; 184. 8. Lele R.D. New interface between Ayurveda and modern medicine. The Indian Journal of Clinical Pharmacology and therapeutics. 2000; 20:1. 9. Patnaik G.K. and Dhawan B.N. Current research on medicinal plants in India. B.N. Dhavan (Ed.). Indian National Sciences Academy. New Delhi. 1986; 47. 10. Dahanukar S, Kulkarni R.A and Rege N.N. Pharmacology of medicinal plants and natural products. 2000; 32: 581. 11. Ghosh D. Thejomoorthy P. and Veluchamy. Anti-inflammtaory and analgesic activity of oleonolic acid 3-3 glucoside (RDG-1) from Randia dumetorum. Ind.J.Parmacol. 1983; 15: 33. 12. Gupta N.B., Naik R., Srivastava N., Shankar K., Kishore K. and Bhargava K.P. Antiinflammatory and antipyretic activities of B-sitosterols. Planta Medica. 1980; 39: 157. 13. Pendse V.K., Mahawar M.M., Khanna N.K., Somani K.C. and Gautam S.K. Anti- inflammatory and related activity of watery extract of Tinospora cordifolia. Indian drugs. 1981; 19: 19. 14. Atal C.K., Siddiqui M.A., Zutshi U., Amla V., Johri R.K., Rao P.G. and Kaur S. Non- narcotic orally, effective, centrally acting analgesic from ayurvedic drugs. J.Ethnopharmacol. 1984; 11: 309. 15. Vohra S.B., Kumar J. and Khan M.S.Y. Effects of alkaloids of Solanum melongena on the central nervous system. J.Ethnopharmacol. 1984A; 11: 331. 16. Bagi M.K., Kalyani G.A., Denmo T.J., Kumar K.A. A preliminary pharmacological screening of abutilon medicine, analgesic activity. Indian Drugs. 1984; 22: 69.

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17. Dahanukar S.A. and Karandikar S.M. Evaluation of antiallergic activity of Piper longum. Indian drugs. 1984; 21: 377. 18. Geetha V.S., Vishwanathan S. and Kameshwaran L. Comparison of total alkaloids of Tylophora indica and disodium chromaglycate on mast cells stablization. Ind.J.Pharmacol. 1981; 13: 199. 19. Shanmugsundaram K.R., Panneevselvum G., Samudram P. and Panneeselvim E.R.B. Enzyme changes and utilization in diabetic rabbits: effect of Gymnema Sylvestre R, Br.J.Ethnopharmacol. 1983; 7: 205. 20. Kedar P and E.H. Effect of bitter gourd, Momordica charantia seeds and glybenclamide in streptozoticin-induced diabetes mellitus. Ind. J.Exp. Biol. 1982; 20: 232. 21. Agrawal V.K. Some pharmacological studies on the stem bark of Millingtonia hortensis. J.Res.Ayur. Siddha. 1982; 2: 50. 22. Rastogi R.P. and Dhawan B.N. Research on medicinal plants at Central Drug Research Institute, Lucknow (India). Ind.J.Med.Res. 1982; 26: 27. 23. Naik V.K., Agshikar N.V. and Abraham G.J.S. Cucumis trigonus Rox B. II diuretic activity. J.Ethnopharmacol. 1981; 3: 15. 24. Patnaik G.K. and Dhawan B.N. Evaluation of spasmolytic activity of clausmarin. A novel coumarin from Clausena pentaphylla. J.Ethnopharmacol. 1982; 5: 127. 25. Bhakuni D.S. and Chaturvedi R. Alkaloids of Corydalis meifolia. J.Nat.Prod. 1983; 46: 466. 26. Rao Y.V., Dasgupta G., S.B., Pathak N.K.R. and Biswas M. Preliminary pharmacological studies on glycosides of Symplocos spicata Rox B. Indian J.Pharmacol. 1983; 5: 349. 27. Vohra S.B., Khan M.S.Y. and Naqvi S.A.H. Pharmacological and antimicrobial studies on Corchorus tridens. India J.Crude Drug Res. 1983; 21: 81. 28. Chakravarthy B.K., Rao Y.V., Gambhir S.S. and Gode K.D. Isolation of a mentoflavone from Selaginella rupestris and its pharmacological activity on central nervous system, smooth muscle and isolated from heart preparation. Planta Medica 1981; 43: 64. 29. Singh H.K. and Dhawan B.N. Effect of Bacopa monnieri Linn (Brahmi) extract on avoidance of response in rats. J.Ethnopharmacol. 1982; 5: 205. 30. Singh H.K. and Dhawan B.N. Effects of a mixture for Bacosides A and B on mental retention capacity in rats. Ind.J.Pharmacol. 1985; 17(Sappl.): 1. 31. Srivastava A.K., Srivastava R. and Dixit V. Pharmacological studies on fruits of Melia azadirach. J.Res.Ayur. Siddha. 1981; 2: 260. 32. Agarwal S.S. Some CNS effects of Hydrocotyl asiatica Linn. J.Res.Ayur. Siddha. 1981; 2: 144. 33. Dahanukar S.A., Rege N.N., Thatte U.M. “Adaptogenes”. In: Ed. Medicinal plants their bioactivity, screening and evaluation: proceedings of international workshop, CDRI, Lucknow (India). 1997; 143. 34. Sembulingam K., Sembulingam P., Namasivayam A. Effects of Ocimum sanctum Linn. on noise-induced changes in plasma corticosterone levels. Indian J.Physiology & Pharmacol. 1997; 41: 139. 35. Dahanukar S.A., Kulkarni R.A. and Rege N.N. Pharmacology of Medicinal Plants & Natural Products, 2000; 32: S81. 36. Sarkar D., Sharma A. and Talukdar G. Clastogenic activity of pure chlorophyll & anticlostogenic effects of equivalent amounts of crude extract of Indian spinach leaf and chlorophyllin following dietary supplementation to mice. Environ, Mol. Mutagen. 1996; 28: 121. 37. Ghafoorunnisa, Reddy V., Sesikaran B. Palmolein & groundnut oil have comparable effects of blood lipids and platelet aggregation in healthy Indian subjects Lipids. 1995; 30: 1163.

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38. Kumar P.D. The role of coconut and coconut oil in coronary heart disease in Kerala, . Trop. Diet. 1997; 27: 215. 39. Deshpande U.R., Gadre S.G., Raste A.S., et al. Effects of Turmeric (Curcuma longa L.) extract on carbon tetrachloride-induced liver damage in rats. Indian J.Exp. Biol. 1998; 36: 573. 40. Khosla P., Gupta D.O., Nagpal R.K. Effects of Trigonella Foenum graecum (Fenugreek) on serum lipids in normal and diabetic rats. Indian J.Pharmacology. 1995; 27: 89. 41. Khan B.A., Abraham A., Leelama S. Haematological and histological studies after curry leaf (Murraya koenigii) and mustard (Brassica juncea) feeding in rats. Indian J.Med.Research. 1995; 102:84. 42. Sharathchandra J.N., Patel K., Srinivasan K. Digestive enzymes of rat pancreas and small intestine in response to orally administered mint (Mentha spicata) leaf and garlic (Allium sativum) oil. Indian J.Pharmacol. 1995; 27: 156. 43. Pandey B.L., Goel R.K., Pathak N.K.R., Biswas M. and Das P.K. Effect of Tectona grandis Linn, on experimental ulcers and gastric secretion. Indian J. Med Res. 1982; 76: S.89. 44. Vishwanathan S., Kulanthiavel P., Nazimudeen S.K., et al. The effect of apeigenni 7,4 diomethyl ether, a flavone from Andrographis paniculata on experimentally induced ulcers. Indian. Pharm. Sc. 1981; 43: 159. 45. Rege N., Dahanukar S. and Karandikar S.M. Hepatoprotective effects of Tinospora cordifolia against carbon tetrachloride-induced liver damage. Indian Drugs. 1984a; 21: 544. 46. Pilankar P.PhD. thesis on Piccorhiza kurruoa and Eclipta alba as epatoprotectives. 1981. 47. Vaidya A.B., Sirsat S.M. Doshi J.C. and Antarkar D.S. Selected medicinal plants and formulations as Hepato-biliary drugs: an overview. J.Clinical Pharmacol. Ther. 1996; 7: 11. 48. Saraswathi D.S., Suja R. Gurumurthy P., Shymala C.S. Effects of liv.100. against antitubercular drug-induced hepato-toxicity in rats. Indian J.Pharmacol. 1998; 30: 233. 49. Kamboj V.P. and Dhawan B.N. Research in plants for fertility regulation. In: India.J.Ethnopharmacol. 1982; 6: 191. 50. Prakash A.O. Antifertility investigations on Embelin as oral contraceptive of plant origin: part 1-biological properties. Planta Medica 1981; 41: 259. 51. Singh M.P., Singh R.H. and Udupa K.N. Antifertility activity of a benzene extract of Hibiscus rosa-sinensis. Planta Medica. 1982; 44: 171. 52. Chakraborty A., Chowdhary B.K. and Bhattacharya P. Clausenol and clausenine the carbon alkaloids form Clausena anisata. Phytochemistry. 1995; 40: 295. 53. Agnihotri S. and Vaidya A.D. A novel approach to study antibacterial properties of volatile components of selected Indian medicinal herbs. Indian J.Exp. Biol. 1996; 34: 712. 54. Rai M.K. In vitro evaluation of medicinal plant extracts against Pestalotiopsis mangiferae. Hindustan Bulletin. 1996; 38: 53. 55. Jairam S. and Thygarajan S.P. Inhibition of HbsAg secretion from Alexander cell line by Phyllanthus amarus. Indian J.Path.Microbiol. 1996; 39: 211. 56. Premnathan M., Nakashima H., Kathirasan et al (1996): In vitro anti-human immuno- deficiency virus activity of mangrove plants, Indian J. Med. Res. 103, 278. 57. Valiathan M.S. Healing plants. Current Sciences. 1998; 75: 1122. 58. Chaudhury, R.R. Herbal medicine for human health. WHO-SEARO New Delhi. 1992.

270

Current status – Country situation

Traditional medicine in the WHO South-East Asia Region Dr. Kin Shein Traditional medicine in Bangladesh Dr. Md. Aftabuddin Khan & Dr. S.K. Chowdhury Traditional medicine system in Bhutan Drungtsho Dr. Pema Dorji Koryo medicine of Korea Dr. Choe Thae Sop Indian system of medicine and homoeopathy Mr. L.V. Prasad Native traditional medicine in Indonesia Dr. Ketut Ritiasa & Dr. Niniek Sudiani Dhivehibeys in Maldives Dr. Abdulla Waheed Indigenous medicine in Myanmar Dr. U. Kyaw Myint Tun Traditional medicine in Nepal Dr. Rishi Ram Koirala Indigenous system of medicine in Sri Lanka Dr. Lal Rupasinghe Thai traditional medicine as a holistic medicine Dr. Pennapa Subcharoen Traditional Medicine in Asia

272 Traditional medicine in the WHO South-East Asia Region

Traditional medicine in the WHO South-East Asia Region Kin Shein

General introduction health care (PHC). However, the potential of services that can be provided by the n many countries of the world and TMP is far from being fully utilized. TM I especially in the developing countries, and TMP have significant potential for traditional medicine (TM) is an important contributing to the national health services part of health care. In countries of the and for the attainment of the goal of South-East Asia Region, although Health for All. modern medicines are now increasingly available throughout different levels of Traditional systems of medicine health care, TM has maintained its in South-East Asia Region popularity since it has been used for Countries of SEAR have a rich heritage of generations in the past. In recent years, various systems of traditional medicine. many developed countries have also Bangladesh, India, Nepal and Sri Lanka begun to take interest in herbal medicine, have people practising Ayurveda, Unani acupuncture and alternative systems of and /or Siddha Medicine(s). TM known as medicine. Consequently, there is Jamu has flourished in Indonesia. The increasing trade among countries in traditional medicine of DPR Korea is Koryo medicinal plants and, to a certain extent, medicine while the TM of Maldives is called traditional remedies as well. It is therefore Dhjivehi Beys. Bhutan, Myanmar and Thai becoming important that the safety, traditional medicines are practised in the efficacy and proper use of TM are taken respective countries. Thus, systems of up as among the important areas for traditional medicine in various countries of development or strengthening in the the Region have a significant role to play countries of the Region. in the provision of health care as they are All Member Countries of the South- being used by those living in the cities as East Asia Region (SEAR) have been well as by the majority of the population developing and strengthening their TM who live in the rural areas. Apart from these programmes. Many countries are in the systems, homoeopathy, nature cure and process of introducing TM and traditional yoga are also practised in a number of medical practitioners (TMP) in primary countries of the Region.

273 Traditional Medicine in Asia

WHO has been assisting the Member of human resources and exchange of Countries in the following areas: National information. programme development in the various The development of various systems of aspects of TM; traditional health systems traditional medicine in countries of the and operational research; standardization, South-East Asia Region are described by quality control and proper utilization of the national authorities in the ensuing traditional and herbal medicines; training chapters.

274 Koryo medicine in Korea

Koryo medicine of Korea Choe Thae Sop

oryo Medicine, the nation’s tradi- not found anywhere else. K tional medicine and precious medical Although various kinds of theories and heritage, has contributed to the health therapies of Koryo Medicine such as drug promotion of the people and treatment of prescription, acupuncture and moxibustion diseases for thousands of years. have many advantages, (some legendary Existing historical works record that in and non-scientific) scientifically planned the 5–7th century BC famous Korean clinical trials have been carried out to doctors were sent for treating the elite on validate the claim of Koryo medicine. Koryo the invitation of the neighbouring kings. medicine products can be combined with Korean acupuncture specialists crossed allopathic medicine treatment. over to Japan and taught acupuncture DPRK has a well-knit Koryo medical skills and trained expatriate trainees in our service system. In the Ministry of Public country. This makes it clear that in those Health, Koryo Medicine Guiding Section days our Koryo Medicine was of a very high gives guidance on traditional medical quality. services. At the Central level there is a Theories of Koryo Medicine were General Hospital of Koryo Medicine; all of systematized through clinical practices and the 12 provinces have Koryo medicine experiences and, whether big or small, were hospitals, and each city and county hospital integrated and published by contemporary has a Koryo treatment department. medical scientists. These have been preser- All the Koryo Medicine institutions in ved and handed down from generation to DPRK are State-owned. generation and are even now considered Basic research is also being carried out as valuable references in the field of Koryo on Koryo medicine – these include Medicine. identification of the components of herbal For example, “Uibangryuchui’’ (Medical medicine, pharmacology of herbs, the Encyclopaedia), a world-famous work principles of meridian practices and published in 1443, is an unparalleled acupuncture, and clinical trials with herbal masterpiece and consisted of 366 volumes. drugs – in combination as well as singly. A prominent Japanese medical historian, The following table gives an idea of the Mikisake, highly praised Uibangryuchui as extent of services under Koryo medicine in the foremost world medical encyclopaedia the country.

281 Traditional Medicine in Asia

282 Traditional medicine system in Bhutan

Traditional medicine system in Bhutan Pema Dorji

he traditional system of medicine in regular training is being given. After the TBhutan is known as gSo-ba-rig-pa and completion of the five-year course, in line it came into existence in the country during with the national health policy, the students the 16th century. During the reign of are given practical training in modern Shabdrung Ngawang Namgyel and first medicine (allopathic system) for three Hereditary Monarch, there were some months, and thereafter undergo a further physicians who served as personal three-month attachment course with senior physicians and some were private traditional physicians at the Institute of practitioners. Among the physicians, some Traditional Medicine Services. had been trained in Tibet and the rest obtained knowledge from their forefathers. Medicine Until 1966, this system was not regularized and there existed only private Seventy per cent of the raw materials are practitioners, but since 1967 it has been obtained within Bhutan and these are regularized and recognized by the further categorized as follows Government of Bhutan and is considered z Snogo-smen - High-altitude as one of the important national health medicinal plants; systems under the Health Division. This was z Throg-smen - Low-altitude medicinal done in order to preserve our own tradition plants; as well as to give the general public a choice z Sa-smen/Do-smen - Mineral origin; between the two systems. z Sog-smen - Animal origin; z Tsha-chu - Hot spring; Training z Sman-chu - Stone-heated bath with herbal medicated water. As mentioned above, till 1970 there was In the preparation of Bhutanese no regular training for Dungtsho traditional medicine no chemicals are used (traditional doctor). A training foundation or mixed; the method is purely natural. started in 1971 and in 1978 it was In the past, all the medicines were institutionalized and a training curriculum prepared manually; small-scale mecha- (five years) was developed. Since then nized production started only in 1982 with

279 Traditional Medicine in Asia assistance from the World Health In children, in whom it is difficult to find Organization. Now all the products are the radial pulse, diagnosis is made by produced mechanically but strictly in looking at the blood vessels of the ear lobes. accordance with GMP (Good Manufa- cturing Practices) regulations, emphasizing Treatment quality control. Our products are formulated in different dosage forms like Besides treatment with medicine, patients z Ril-bu - Pills; are also treated with surgical procedures, z Gor-lab - Tablets; which are never as invasive as modern z Byugs-smen - Medicated surgery practice. These include: ointments; z gSer- - Acupressure with z Tung-smen - Syrup; khab golden needle; z Shub-lden - Capsule. z Me-rtsa - Moxibustion by herbal compound; Hospital z Me- - Cupping; z Tshug - Cauterization, which Until 1979, it was functioning as a consists of eight types; dispensary and became a hospital only in z Dugs - Applying heat and that year after shifting from cold to parts of the Dechenchholing to Kawang Jangsa. It is body without burning our plan to establish indigenous units in or cauterizing; it all 20 districts, and we have now already consists of two established 15 units in 15 districts around methods: the country, attached with modern district z Grang- - similar hospitals. The target is to cover all the 20 dugs to cold sponging districts with indigenous units by the year z Tsha-dugs - applying warm 2002. poultices; The objective of attaching indigenous z Byugs-pa - Medicated oil units with the modern hospitals is mainly massages; to give a choice to the patients and to z Lum - Vapour treatment cross-check as to which system is more consists of two effective for what kind of diseases. methods; z Chu-lum - herbal bath Diagnosis z Rlang-lum- steam bath;

One of the important aspects of treatment A nationwide survey is being made to is correct diagnosis. This is done in the identify the medicinal plants available as following ways: well as the hot and cold springs which are z Pulse reading; used for treatment. z Urine analysis; The quality control laboratory is being z Eye and tongue examination; strengthened for the standardization of z Discussion with the patients, mainly on medicinal plants. their medical history.

280 Traditional medicine in Bangladesh

Traditional medicine in Bangladesh Md. Aftabuddin Khan S.K. Chowdhury

Introduction areas of the country on the use of traditional medicine revealed that among raditional medicines have existed in the sick family members, one month T Bangladesh as an important basis of preceding the day of interview, 37.6 per health care since olden times. Because of cent had been treated by village their potentialities and close association practitioners. Allopathic (MBBS) doctors, with the culture and tradition of the people, hakims, kabiraj, health assistants (HA) and traditional systems of medicine have homoeopathic practitioners provided assumed a unique position in the health treatment to 16.7 per cent, 16.2 per cent, care of the people living in even the 9.5 per cent, 8.6 per cent and 6.8 per cent remotest areas of the country. There are of cases, respectively. The study also reveals several types of traditional medical that, of 57 deaths, initial treatment was practitioners in the country and their provided by MBBS doctors in 29.8 per cent spectrum ranges from Unani and Ayurvedic cases, homoeopathic in 5.3 per cent practitioners qualified institutionally or cases, Unani 1.7 per cent cases, Ayurvedic through some years of apprenticeship, to 17.5 per cent cases, and village persons who are born into a family of practitioners in 28.1 per cent of the cases traditional healers and learn traditional before death. A significant proportion of medicine from the family. the community members (39 per cent) have knowledge about medicinal plants and 13 Present Status: Status of per cent of cases with simple ailment were Utilization – by Category treated by them with herbs. It was also found that community members use In spite of the development of an extensive various metals, salts, minerals and animal network of a modern health care delivery products for self-treatment. This finding system all over the country, traditional reveals the level of confidence of the village systems still play a significant role in community in traditional medicine in the delivering health care at the community country. level. A recent study conducted in the rural

275 Traditional Medicine in Asia

Government Policy on This college offers two degrees in the Traditional Medicine and its relevant areas – Bachelor of Unani Development medicine and Surgery and Bachelor of Ayurvedic medicine and Surgery; The Unani and Ayurvedic systems have z Status of trained manpower (Diploma been recognized by the Government since and Graduate practitioners of Unani British rule and, after the liberation of and Ayurvedic Medicine) – At present Bangladesh, the Government intensified its there are more than 1000 registered efforts for their continuous development diploma practitioners of Unani and and to raise the quality of services. Ayurvedic Medicine. Nearly 150 Unani Professional bodies of Unani, Ayurvedic and Ayurvedic physicians have and Homoeopathic medicines have been graduated till end of July 2000. In included in the planning process of national addition, more than 3000 Hakims and services. A few of the steps taken are Kabiraj have attended certificate described below: courses organized by the Board. z Administrative set-up for National Programming – The post of Director, Case Management Facilities Homoeopathy and Traditional with Traditional Medicine – Medicines has been created under the Public and Private Sector Director- General of Health Services to assist him to deal with all matters There is only one 100-bed hospital (50 for relating to traditional medicine to plan, Unani and 50 for Ayurvedic Systems) implement, monitor and control working as a teaching hospital for the programmes in traditional medicine. Government Unani and Ayurvedic Degree The Director is assisted by a Deputy College. The hospital can accommodate Director, an Assistant Director and a maximum of 50 male and 50 female necessary supporting staff at central patients. It also provides outdoor medical level; services. z Educational facilities and Training of The Government diploma institution Traditional Practitioners – There are and some of the non-governmental several educational institutes of diploma institutions also provide outdoor Traditional Medicine offering diploma medical services in Unani and Ayurvedic courses of four years’ duration Medicine. established in different areas. Five Currently, 30 Unani and Ayurvedic Ayurvedic and 10 Unani Institutes are medical graduates are posted at 30 recognized by the Bangladesh Board Government district hospitals. These of Unani and Ayurvedic system of physicians are providing outdoor services Medicine. These institutes receive at these hospitals. financial and technical support from Most of the practitioners having a the Board; diploma are practising all over the country z Establishment of Unani and Ayurvedic both in the urban and rural areas. A large Degree College – The Government number of them are also working in established a Unani and Ayurvedic commercial organizations and production Degree College at Mirpur in 1989. units.

276 Traditional medicine in Bangladesh

Legislation and Regulation Medicines. These two medical systems have formularies for commercial z Control of practices of Unani and production. Approximately 50 per cent Ayurvedic Practitioners – Since the of these formulae are manufactured in beginning, the Government of the traditional medicine factories. These Bangladesh has been keen to develop, traditional preparations are controlled promote, protect and control the by the Drug Administration Directorate. practice of Unani and Ayurvedic Registered practitioners can, by virtue Medicine. The Homoeopathic, of their registration, manufacture on a Ayurvedic and Unani Practitioners Act small-scale the medicines they need for of 1965 was revised in 1983 and two their own patients. Acts were enacted in 1983 – the Homoeopathic Practitioners Act and Medicinal Plants the Unani and Ayurvedic Practitioners Act. The Unani and Ayurvedic Board Medicinal plants are the major ingredients was formed under these Acts. The of Unani and Ayurvedic medicines. The Board is responsible for the implemen- geographical location, climate and tation of Government objectives for the topographic conditions of Bangladesh development, promotion and prote- helps the growth of most of these plants ction of traditional medicine besides locally in different areas of the country. supporting research in this field; However, due to continuous massive z Unani and Ayurvedic Drug and Acts – deforestation, destruction of homestead The Unani and Ayurvedic drug industry trees/plantations, frequent natural had been outside the purview of the disasters, commercial mono-culture Drugs Act of 1940. On 12 June plantations, etc., the availability of most of 1982, the Government of Bangladesh these precious medicinal plants will be promulgated the “Drugs (control) reduced, and these plants may even be in Ordinance, 1982” to control the danger of extinction. If such a trend manufacture, import, distribution and continues, these plants will scarcely be sale of drugs. Section 3(d) of the available locally to meet the needs of the ordinance reads: “Drug” shall have the manufacturing plants in the near future. same meaning as in the Act and shall In Bangladesh there are approximately also include any substance exclusively 5000 plants, of which 1500 to 2000 used or prepared for use in accor- plants are covered through different dance with the Ayurvedic, Unani and ethnobotanical and ethnomedicinal Homoeopathic or Biochemist systems surveys. Conservatively, a minimum of of medicine; 1000 plants have medicinal value. z National Formularies for Unani and Ayurvedic Medicines – The Bangladesh Integration into the National Unani and Ayurvedic Board, under the Health Care System authority vested in it by the Bangladesh Unani and Ayurvedic Ordinance (Act.) The Government of Bangladesh has 83, has compiled two formularies, viz., created facilities to provide alternative National Formulary for Unani Medicine medical care in the existing Government and National Formulary for Ayurvedic hospitals at the district level along with

277 Traditional Medicine in Asia modern medicine, facilitating integration of The Bangladesh Institute of Research traditional medicine in the national health and Rehabilitation in Diabetes, Endocri- delivery system. The operational activities nological and Metabolic Disorders have been processed under the close (BIRDEM) is carrying out research on anti- supervision of the district health authorities diabetes plants. The International Centre for quality and effective output. for Diarrhoeal Diseases Research, Bangladesh (ICDDR,B) is carrying out Research and Studies research on anti-dysenteric medicinal plants. In the Department of Pharmacy of It has been observed that considerable Jahangirnagar University in-depth work is research has been carried out in underway on different aspects of the Bangladesh during the last few decades. pharmacology of Ayurvedic medicines.

278 Koryo medicine in Korea

Koryo medicine of Korea Choe Thae Sop

oryo Medicine, the nation’s tradi- not found anywhere else. K tional medicine and precious medical Although various kinds of theories and heritage, has contributed to the health therapies of Koryo Medicine such as drug promotion of the people and treatment of prescription, acupuncture and moxibustion diseases for thousands of years. have many advantages, (some legendary Existing historical works record that in and non-scientific) scientifically planned the 5–7th century BC famous Korean clinical trials have been carried out to doctors were sent for treating the elite on validate the claim of Koryo medicine. Koryo the invitation of the neighbouring kings. medicine products can be combined with Korean acupuncture specialists crossed allopathic medicine treatment. over to Japan and taught acupuncture DPRK has a well-knit Koryo medical skills and trained expatriate trainees in our service system. In the Ministry of Public country. This makes it clear that in those Health, Koryo Medicine Guiding Section days our Koryo Medicine was of a very high gives guidance on traditional medical quality. services. At the Central level there is a Theories of Koryo Medicine were General Hospital of Koryo Medicine; all of systematized through clinical practices and the 12 provinces have Koryo medicine experiences and, whether big or small, were hospitals, and each city and county hospital integrated and published by contemporary has a Koryo treatment department. medical scientists. These have been preser- All the Koryo Medicine institutions in ved and handed down from generation to DPRK are State-owned. generation and are even now considered Basic research is also being carried out as valuable references in the field of Koryo on Koryo medicine – these include Medicine. identification of the components of herbal For example, “Uibangryuchui’’ (Medical medicine, pharmacology of herbs, the Encyclopaedia), a world-famous work principles of meridian practices and published in 1443, is an unparalleled acupuncture, and clinical trials with herbal masterpiece and consisted of 366 volumes. drugs – in combination as well as singly. A prominent Japanese medical historian, The following table gives an idea of the Mikisake, highly praised Uibangryuchui as extent of services under Koryo medicine in the foremost world medical encyclopaedia the country.

281 Traditional Medicine in Asia

282 Indian system of medicine and homoeopathy

Indian system of medicine and homoeopathy L. V. Prasad

ndia has a rich, centuries-old heritage complete philosophy of health. It is well- I of medical and health sciences. Some documented. The most exhaustive classic of these systems date back to 5000 years on medicine is Charaka Samhita; Sushruta BC. These systems have taken care of the Samhita is an exhaustive treatise on surgical health needs of the people and have principles and procedures. Ksyapa Samhita survived due to their strengths, efficacy of exclusively deals with matters of maternity treatment and drugs. India has the unique and child health. The four key concepts of distinction of having six recognized systems Ayurveda which guide the preventive, of medicine under Indian Systems of promotive and curative aspects of the Medicine and Homoeopathy (ISM&H). The practice of Ayurveda are : Panch Indian systems are Ayurveda, Siddha, Mahabhutas, Tridoshas, Sapta Dhatus and Unani, Yoga & Naturopathy. Within the Three . Though it is ancient in origin, ambit, however, of Indian Systems of the system is modern in approach. Medicine and Homoeopathy is covered the Undergraduate education in Ayurveda has Homoeopathy system, though it originated a course curriculum and training schedule in Germany and came to India in the early for five-and-a-half years, including clinical 18th century. This system has got exposure. It has eight distinct branches of completely assimilated, accepted and teaching disciplines corresponding to enriched like any other Indian system of modern systems. Postgraduate courses are medicine. of three years’ duration. The training in The Ayurveda system of medicine is Ayurvedic medicines and surgery is of great antiquity and dates back to about regulated by a statutory body, namely, the 5000 BC Ayurveda is a branch of Atharva Central Council of Indian Medicine Veda, which is the repository of and treatise (CCIM). The registration of physicians, on the knowledge and wisdom of great practice and ethics are governed by the sages and seers, acquired, tried and handed regulations made by the Council. The drugs down to succeeding generations. Ayurveda are manufactured according to formularies; is not only a system of medicine, but also pharmacopoeial standards have been laid represents a way of healthy living. It is down. Drug manufacture is licensed and holistic in approach and enshrines the regulated under the Drugs & Cosmetics Act,

283 Traditional Medicine in Asia

1940. It uses materials of plant origin for are governed by the regulations framed by most of its products, which are natural, safe, the Statutory Council. Drug standar- cost-effective and efficacious. Therapeutics dization, official formularies, licensing and under the Ayurveda system include manufacture of drugs are governed by the Shamana Therapy, Shodhana Therapy, Drugs and Cosmetics Act, 1940. There Satyavajaya Therapy, Panchakarma are dispensaries, hospitals, pharmacies treatment and Rasayana Therapy. Its wide and research units under the Siddha network of physicians and infrastructure of system. Two undergraduate colleges and medical institutions, hospitals, dispensaries one postgraduate college are imparting and manufacturing units make Ayurveda the education in the Siddha system. most widespread Indian system providing The Unani System of medicine health care to the people of India. Some 196 originated in Greece and came to India undergraduate and 49 postgraduate through the Arabs. It flourished in the colleges are imparting education, and country for centuries under the patronage 3,66,812 registered practitioners are of successive rulers. Today, it is one of the engaged in health care. About 8400 recognized systems of medicine. This pharmacies are manufacturing drugs, both system is also holistic in approach and classical and proprietary. Intramural and bases its philosophy on the humoral theory. extramural research and clinical trials, The human body is made up of seven separately and in collaboration with modern components, such as the Elements, institutions with proper protocols adopting Temperament, Human organs, Spirits, scientific parameters, are being conducted Faculties and Functions. Unani is popular extensively to enrich and develop this system. with the masses and is extremely efficacious The Siddha System of medicine is in certain chronic indications. Under- also one of the oldest systems being graduate and postgraduate education, practised in India for centuries. The registration of physicians, practice and principles and doctrines of the Siddha ethics are regulated by the same Council system, fundamental and applied, are as for Ayurveda and Siddha. Most of the similar to Ayurveda. It is also holistic in Unani classical texts are in Arabic, Persian approach. This system emphasizes that and Urdu, but are being translated into medical treatment should be oriented not English. The diagnosis takes into conside- merely to disease but should also take into ration the temperament, structure, strength account the patient, his environment, sex, of facilities, the type of factors operating age, habits, mental frame, habitat, diet and on the patient from outside, etc. Unani physical condition. The human body is a treatment uses regimental therapy, diet conglomeration of three humours, seven therapy, pharmaco therapy and surgery. basic tissues and waste products of the In this system, although the general body. Their equilibrium is good health, and preference is for single drugs, compound any disturbance or imbalance leads to formulations are also used in the treatment disease or sickness. In the Siddha system, of various complex and chronic diseases. the drug preparation is largely based on The drug licensing, manufacture and plants, but minerals and metals are also quality of products are regulated under the used for drug preparation. The educational Drugs and Cosmetics Act, 1940. There are pattern, regulation of education, regis- practitioners, hospitals, dispensaries and tration of practitioners, practice and ethics pharmacies under the Unani system, in

284 Indian system of medicine and homoeopathy addition to 40 undergraduate and three postgraduate teaching institutions. A total Homoeopathy’s popularity is of 40,478 practitioners of Unani are greatly enhanced by its cost- registered with the Council and 549 effectiveness and the absence manufacturing units are engaged in drug of adverse effects if the drugs manufacture. Official formularies for are administered in Unani drug manufacture have been published and pharmacopoeial standards prescribed doses. have been laid down. Extensive and intensive extramural and intramural research, clinical trials, etc., have developed and enriched this system. education. It has a wide network of Homoeopathy originated in Germany educational institutions imparting U.G. and and came to India in the early 18th century. P.G. education. Registered physicians, It has been practised in India for about two dispensaries and hospitals are providing centuries and has become a popular health care. About 1,89,000 practitioners system of medicine. This system is based are registered with the Council. It has 149 on four demonstrable principles: the law undergraduate and 15 postgraduate of similars, the law of direction of cure, the colleges. Homoeopathy’s popularity is law of single remedy and the law of greatly enhanced by its cost-effectiveness minimum dose. Disequilibrium in the and the absence of adverse effects if the functioning of the organs of the body drugs are administered in prescribed implies sickness. Cure of disease involves doses. It has evolved pharmacopoeial restoring the equilibrium. Symptoms are standards, of which several volumes have treated as a reaction of the defence been published. Drugs standardization and mechanism of the body. Treatment through the quality of drugs manufactured by drugs is given to further strengthen the pharmacies are regulated by the Drugs & defence mechanism and help it in Cosmetics Act, 1940. overcoming the disease. In diagnosis, every Yoga and Naturopathy are basically case is treated on a uniquely individual drugless therapies. The concept and basis and patients with the same disease practice of yoga originated in India several may be prescribed different medicines. The thousand years ago. It is one of the six physician has to consider every individual’s systems of Vedic philosophy. It is also mental, emotional and physical pathology holistic and seeks complete harmony in order to understand the peculiar ways among the body, mind and the thinking in which the patient’s defence mechanism process. Yoga has been found useful in the is reacting. Thus, a very comprehensive prevention of diseases, mitigation and cure and unique individualizing process is of diseases and promotion of health. Yoga involved in making a proper diagnosis. The advocates an eight-fold path known as educational curricula for U.G. and P.G. “Ashtanga Yoga” for the all-around courses, registration of practitioners, development of the human personality. practice and ethics and related matters are These are: Yama, , Asana, governed by the Central Council of Pranayama, Pratyahara, Dharma, Homoeopathy, a statutory council. It Dhyana, and Samadhi. These components follows the same pattern of U.G. and P.G. advocate restraint, observance of austerity,

285 Traditional Medicine in Asia physical postures, breathing exercises, There are five degree colleges restraining the sense organs, contem- conducting bachelor courses in Naturo- plation, meditation and Samadhi. pathy and Yogic practices of five-and-a-half Researches are fortifying and validating the years’ duration. These are affiliated to preventive, promotive and curative aspects various universities. A large number of of Yoga. institutions are conducting diploma and Naturopathy is a recognized system of certificate courses. There are a number of medicine. Its philosophy is fully based on good Yoga and Naturopathy treatment the holistic approach. Naturopathy believes centres. There is the National Institute of that health is the normal and harmonious Naturopathy, , and the Morarji Desai vibration of the elements and forces National Institute of Yoga, New Delhi, under comprising the human entity and disease is the Central Government, as well as a abnormal or non-harmonious vibration of research council, namely, the Central the elements and forces. The primary cause Council for Research in Yoga and of disease is violation of the laws of nature. Naturopathy, New Delhi. It advocates a natural way of living, and the All drug-based systems under ISM&H, treatment covers regulation of eating, namely, Ayurveda, Siddha, Unani and drinking, breathing, etc., elementary Homoeopathy, largely use medicinal plants remedies, biochemical remedies, as raw materials for the preparation of mechanical remedies and mental remedies. drugs. To develop the medicinal plant Naturopathy advocates diet therapy, sector, this department has set up a hydrotherapy, mud therapy, fasting therapy, Medicinal Plants Board to coordinate all massage therapy, etc. Naturopathy efforts to conserve, cultivate, process and treatment has no side or after-effects. These market raw materials with a view to making are simple, scientific, easy, cost-effective available standard products relevant to methods and can be practised by everyone. each medical system.

286 Dhivehibeys in Maldives

Dhivehibeys in Maldives Abdullah Waheed

iterally, dhivehibeys means Maldivian therapies and ingredients are also based Lmedicine. It is a unique system of on the Unani system. Thus, cupping, medicine that Maldivians have been cauterization and massage find a place in practising since time immemorial. the local system. Despite these similarities Though the origin of dhivehibeys is lost most scholars agree that dhivehibeys is in the dark recesses of history, there are distinct from Unani medicine. indications that a well-developed medicinal The old masters of dhivehibeys were system existed in the country throughout experts at feeling the radial pulse and the 800-year known history. Indeed, this making observations. They, however, lacked would have been a survival necessity in an a sound basis for analysing them further to isolated archipelago nation. identify the underlying conditions. Like The original dhivehibeys depended on many other alternative systems of locally available ingredients, mostly fresh medicine, dhivehibeys had only a vague herbs. Often the practitioners used what understanding of diseases and their they called ‘fassangu’, a term that referred classification. Therefore, the diagnoses it to the five main parts of a plant. Things made were also vague, often equating changed when communication with the symptoms with disease. When dealing with outside world improved, bringing in fresh external injuries this may not have been a ideas and new ingredients. The fresh ideas major a drawback, but with internal mostly came from Unani textbooks in diseases it definitely would have. Interestingly, Arabic and Urdu. The new ingredients ruggalubeys, the branch of dhivehibeys came from Ceylon and India in the form dealing with bone injury, continued to be of dry herbs and compounds. popular long after other branches declined. Today dhivehibeys reveals strong The modern period of dhivehibeys may Unani influences. Thus, the system be said to have begun with Dhon Beyya of attributes many diseases to changes in Addu Atoll. He wrote a treatise on body constitution and associates them with dhivehibeys, which he passed on through elements such as air, heat (corresponding his illustrious pupil, Hussein Salahuddeen to fire in Unani) and water that are to Addu Hussein Manikfan. Manikfan, who supposed to flow in the body. Many of the went on to become a leprosy expert, was

289 Traditional Medicine in Asia the founder of a family of practitioners, who At various times many distinct branches still continue to be active. of dhivehibeys flourished to cater to the During the first half of the 20th century, varying needs of the society. In earlier times dhivehibeys flourished and produced a priority need was the treatment of battle many notable practitioners such as wounds resulting from recurrent skirmishes Ibrahim Faamuladheyri Kilegefaanu, with the ubiquitous pirates. Historical Naifaru Dhonkaleyfaanu, Ahmed Kaamil anecdotes indicate that the branch of and Badeegey Mohammed Didi. They were dhivehibeys called kandifaarubeys (literally, instrumental in popularizing new concepts treatment of sword wounds) was highly learnt from Unani medicine throughout the developed in those days. Another branch country and ushering in what can be of dhivehibeys was lolubeys, or the described as the golden era of treatment of eye diseases. Ruggalubeys dhivehibeys. The era ended when modern specialized in treating bone disorders. There medicine came during the ’50s and were also practitioners who specialized in gradually weaned patients away from the circumcision. traditional system. Dhivehibeys was never far from Along with the decline in dhivehibeys, spiritual healing or fanditha as the natives its practitioners also largely disappeared, called it. Some of the most successful since not many new entrants came forward practitioners were those who could get the to replace the aging masters. Heera Yousuf right mix of the two. One of the last expo- Fulhu was perhaps the last survivor from nents of this technique was Ihavandhoo the golden era. Hajee, who successfully combined his Tragically, many aging practitioners with charms and prayers. died without having an opportunity to pass With the advent of effective Western on their knowledge to the next generation. alternatives some branches such as Centuries of accumulated knowledge in kandifaarubeys and lolubeys have virtually their collective memory was thus irrevo- disappeared. But some others continue to cably lost. A monograph on individual be popular. A large part of the population ingredients and a few handwritten manu- still depend on ruggalubeys to heal their scripts are the only records that survive. fractures and the overwhelming majority go Despite the absence of written texts to dhivehibeys practitioners for circumcision. and the lack of a formal system for sharing In recent years the Government has information, existing sources of knowledge taken several steps to develop dhivehibeys. agree remarkably on the general principles This includes the appointment of a high- of dhivehibeys. However, when it comes level committee and a chair for to details, different schools of thought dhivehibeys at the Faculty of Health represented by traditional families have Sciences of the Maldives College of Higher disagreements. For example, for treating Education. The committee has recognized bone injuries all schools agree on the that improving access to herbs is the key ingredients of the dressing. But for to preserving dhivehibeys. Otherwise, tempering it the Gaddaduge school more and more patients are going to find believes in applying strong heat, whereas it not only easier but also cheaper to buy some others believe in applying only an aspirin at the neighbourhood store than moderate heat with sunlight. to go searching all over the island for impossible ingredients.

290 Indigenous medicine in Myanmar

Indigenous medicine in Myanmar U Kyaw Myint Tun

The regulatory situation defect in character or infamous conduct is yanmar’s indigenous medicine is established. Section 24 of the Act prescribes M based on Ayurvedic concepts and has that, subject to the provisions of section 23 been influenced by . of the Myanmar Medical Act, in order to Prior to the Second World War, certain sign a medical certificate required by the law committees recommended that this system to be signed by a medical practitioner, an be recognized by the Government, but no indigenous medical practitioner must be action resulted. Four years after Myanmar registered. Similarly, unless he or she has attained its independence in 1948, the obtained the prior sanction of the Head of Myanmar Indigenous Medical Committee State, an indigenous medical practitioner was formed. It drafted the Indigenous who is not registered may not hold certain Myanmar Medical Practitioners Board Act, specified appointments in publicly supported which was promulgated in 1953, with hospitals and other health facilities. amendments in 1955, 1962, and 1987. Section 7 of the Indigenous Myanmar It established an Indigenous Myanmar Medical Practitioners Board Rules, 1955, Medical Practitioners Board, whose provides for the registration of such functions are to advise the Government on, practitioners in six classes. The system of inter alia, the revival and development of classification is essentially based on the Indigenous Myanmar Medicine, related division of Myanmar medicine into four research and the promotion of public branches (Desana, Ayurveda, , health; Section 11 specifies as a particular and Vizzadara). In section 9 of the Rules, function of the Board “suppression of details are given of the knowledge required charlatans or quacks who are earning their for registration in the particular classes. living by means of indigenous Myanmar Provision is also made, in section 10, for medicine”. The Board is also empowered authors of works on indigenous medicine (subject to the prior sanction of the Head of to be registered in one of three classes; it State) to prescribe the subjects for is indicated in this section that monks may examination in indigenous Myanmar not be registered as medical practitioners. Medicine, to register practitioners, or to Under Section 12 of the Rules, the remove their names from the register if a Board is to seek ways and means of

291 Traditional Medicine in Asia consolidating into a single system the four the aforementioned Act and has updated branches of medicine currently practised; and revised it as the Traditional Medical the Board is likewise to undertake studies Council Law, which was enacted on 14 and research and advise the competent January, 2000, by the Government. At authorities on standardizing the methods present there are over 8000 traditional of treatment provided in dispensaries medicine practitioners registered under the operated by the Government. said law. The Indigenous Burmese Medical In 1996, the Government promu- Practitioners Board Amendment Act of 1962 lgated the Traditional Medicine Law in order introduced new sections 22-A and 28-A to control the production and sales of empowering the Chairman of the traditional medicine drugs systematically. Revolutionary Council of Burma to, (i) Cancel This was followed by a series of notifica- the registration of indigenous medical tions concerning registration and licensing, practitioners, (ii) Prescribe qualifications for labelling and advertising. registration, and (iii) Terminate the services of any or all of the members of the Board Education and Training in and appoint new members in their place. Traditional Medicine Under these powers, a new Board was There is one Institute conferring diploma appointed to initiate the re-registration of in Traditional Medicine, situated in practitioners. The Department of Indigenous Mandalay, the second capital of Myanmar. Medicine was established on the 3rd of This institute was opened in 1976 and is August 1989. attached to the 50-bed teaching hospital with the aim of eradicating bogus medical Education and training practitioners by producing full-fledged An educational institution known as the practitioners, to update traditional Institute of Indigenous Medicine was medicine to modern standards, to carry out established by the Ministry of Health in 1976, research work in traditional medicine, to offering a three-year training programme. produce skilled researchers, and to give citizens effective treatment by traditional Organization medicine. The second-grade department was formed It is a three-year diploma course, in mid-1989 by upgrading the branch of followed by a one-year . Till the indigenous medicine under the Department 1997–98 academic year, the number of of Health. The staff strength at that time students awarded diploma totalled 890. was about 700. In late 1997, the Depart- The yearly intake of candidates is 100 at ment was again upgraded into a first-grade present. The Institute has its own one, expanding the manpower up to 1796 medicinal plant garden for teaching consisting of four main divisions, viz., demonstrations. The Department is now administration, medical care, research and planning to upgrade the Institute to development, and herbal garden and drug become a degree-conferring one in the production. near future. In addition, the Institute also conducts Law and Regulation a one-year course for outside Traditional To keep abreast with the changing Medicine Practitioners who have no circumstances, the Department reviewed certificates or licences to treat patients.

292 Indigenous medicine in Myanmar

Those who are successful in the course will Cultivation of medicinal herbs have the licence to practise as Traditional and maintenance of herbal Medicine practitioners. gardens With the main aim of producing enough Medical Care Service raw materials for the Department-owned There are two 50-bed traditional medicine drug manufacturing factories, the hospitals, one each in Yangon and Department has been establishing one Mandalay, and three 16-bed hospitals in garden after another for the cultivation of other parts of the country. medicinal herbs. Thus, there are now For rural and township communities, altogether nine gardens with a total area the Department has established 194 of over 120 acres. Since herbal gardening township traditional medicine depart- is still in its infancy, only 20 per cent of the ments attached with their own outpatient area has been utilized at the moment. They clinics. If necessary, the patients are are situated in different parts of the country referred to both Western medical hospitals with different weather and soil conditions, and the nearest traditional medicine so that different kinds of species can be hospitals. cultivated, depending on their climate and Since 1999 was designated by WHO the nature of the soil. as the International Year for Older People, primary health care and medical services Traditional medicine by traditional means serve the elderly manufacturing factories population more by paying greater The traditional drugs used in township attention to the diseases prevalent among traditional medicine clinics and hospitals elderly people such as metabolic diseases, are provided by two traditional medicine e.g., diabetes. manufacturing factories situated one each in Upper and Lower Myanmar. The yearly Registration and Legislation production of each factory is 10,000 kgs of Traditional Medicine and the drugs are produced according to Drugs the national formulary. In addition, these According to the Traditional Medicine Law, factories also manufacture 12 kinds of drugs all the traditional medicine drugs produced in tablet form for commercial purposes. in the country have to be registered and the manufacturer must have a licence to Research and Development produce them. This has been done since The main tasks in this sector are to carry 1996 after the promulgation of this law. out basic analysis for traditional drugs for There are altogether 3962 registered items registration purposes and standardization of drugs and 632 manufacturers have of commonly used medicinal plants and already got the licences for production. quality control analysis for Department- Good Manufacturing Practices are owned drug production factories. considered before giving the licence. In Promotion of the systematic utilization addition, the Department is also involved of TM among the people is done by in the control of advertisements of these disseminating information through the commodities. mass media and by conserving old palm- leaf manuscripts regarding TM which are translated into Burmese for publication.

293

Traditional medicine in Nepal

Traditional medicine in Nepal Rishi Ram Koirala

epal is one of the richest countries in Institutions and Networks of Nculture, tradition, knowledge of Ayurveda in Nepal Ayurveda and other traditional medical practices. Ayurveda is a cultural and The main Governmental organizations for scientific heritage of this country. Nepal Ayurveda are as follows. has been free from major foreign invasions in its history and has unique socio-cultural Department of Ayurveda and traditional practices. Both culturally This is the highest institution under the and traditionally, the country has been a Ministry of Health for Ayurveda in the bridge between India, Tibet and China. country. The Department is responsible for Since pre-historical times, there have been Ayurveda Health Policy, implementation, many ethnic groups in Nepal possessing planning, monitoring and provision of unique cultural and healing practices. services throughout the country. This These unbroken traditions of healing department was established in 1981 and practices play a big role in Nepal’s health consists of the following network: care systems. Ayurvedic Hospitals Traditional Medical Systems There are two Ayurvedic hospitals: a 100- in Nepal bed hospital located in Kathmandu and a 15-bed hospital in Dang district in the The traditional medical systems in Nepal Middle-west region. are as follows: District Ayurveda Health Centres Ayurveda There are 50 district Ayurvedic health This is the oldest authentically recorded life- centres, one in each district, and it is science in existence today. This is a part of proposed to open five every year till all the National Health System and has a districts (75) are covered. These institutions Government-run network throughout the are based on the New Ayurveda Health country. Policy.

295 Traditional Medicine in Asia

Zonal Ayurveda Dispensaries (Ayurveda Auxiliary Course – 15 months There are 14 zonal Ayurvedic dispensaries – and Ayurveda Certificate-level course – in each zone. It is planned to merge these 36 months). dispensaries into the district Ayurveda Mahendra Sanskrit University- Health Centres. Affiliated Institutions Peripheral Ayurvedic Of recent origin are private Ayurveda Dispensaries institutions, affiliated to Mahendra Sanskrit There are 211 Ayurvedic dispensaries University, that provide Ayurveda certificate- spread over different parts of the country. level training courses (30 months). These are the only units in the health sector Council of Technical Education that utilize the local resources of medicinal and Vocational Training (CTEVT) herbs abundantly available in the country. This council has given affiliation to the Rural Ayurvedic Pharmacies private sector providing 15 months’ There are three rural Ayurvedic training to Ayurveda auxiliary workers for pharmacies, and an additional pharmacy the past four years. is planned to be established this year. These Council of Ayurvedic Medicine pharmacies are managed by and located within zonal and district Ayurvedic This council has recently been formed by dispensaries. the Ministry of Health. This is a regulatory and legislative body for Ayurvedic courses, Singha Durbar Vaidhyakhana manpower, institutions, practitioners and Vikasa Samiti (SDVKVS) traditional healers in Nepal. Ayurvedic The SDVKVS was established during the graduates are registered with this council. Malla dynasty (355 years ago). This is the Similarly, certificate-level trainees (30 only Governmental unit manufacturing months), other trainees (15 months) and Ayurvedic medicines in Nepal. Since traditional healers are also enrolled in this 1994, SDVKVS is being run by a council, which is also responsible for Development Board under the Ministry of developing a data bank of traditional Health. healers, practitioners and their recipes.

Ayurveda Training and Academic Quality Control of GMP of Institutions Ayurvedic Products The following are the academic and Up to now GMP of Ayurvedic products has training institutions in the country: to be based on Ayurvedic principles. In Nepal, there is no proper unit for quality Ayurveda Campus assessment for Ayurvedic or traditional This is the only campus that trains Ayurveda herbal products. graduates (BAMS, a 5½-year course) in the country. It is a constituent campus of the Traditional Herbal/Spiritual Institute of Medicine, which is one of the Therapies technical institutes of Tribhuvan University. A large number of the population is still Nearly a decade ago, this campus was dependent on these practitioners. Basically, conducting pre-university training courses they follow some ethno-traditional, tantrik,

296 Traditional medicine in Nepal spiritual and Ayurvedic knowledge. The Amchi estimated number of these practitioners in Amchi is a Tibetan medicine or healing Nepal is 400,000. Though they are not practice existing in the upper-Himalayan included in the official system of health regions. Though this is not an official system care, they are wellknown by different of medicine, there are two types of names in different communities. practitioners in this field. Some of them are Homoeopathy institutionally trained and others follow the tradition. This system has recently been recognized as a national health system and a homoeo- Main Constraints pathy hospital is run by the Government. The Unani system of medicine is also Qualified, competent and trained incorporated in this hospital. manpower is a primary prerequisite for any institutional development. Ayurveda and Naturopathy other traditional systems are facing a severe This is not an official system of medicine, crisis of manpower development, mobi- but it has been well-practised by the lization and leadership. There is no proper community. Training in naturopathy is training programme for traditional healers. provided by the private sector. There are Academic and other institutions are being private hospitals, training centres, clinics run with poor budgetary support, planning, and dispensaries in the country. infrastructure and leadership.

297

Indigenous system of medicine in Sri Lanka

Indigenous system of medicine in Sri Lanka Lal Rupasinghe

ri Lanka is a country of rich heritage, of medicine were institutionalized. The Sone of which is its indigenous system syllabi and subject matter of both consisted of medicine, which has been practised by of Ayurveda and Traditional Medicine. the people since time immemorial. The Thus, at present the country has two sets Ayurvedic system of medicine from North of Ayurvedic physicians, one set trained by India, the Siddha system of medicine from their ancestral teachers, physicians, and South India and the Unani system of the other institutionally trained cadres, both medicine of the Arabs enriched with commanding the respect and veneration contributions from the traditional system of the public. Although the modes of of medicine called Desheeya Chikithsa is practice followed by these two groups are popularly known as the “Indigenous system very similar with respect to the systems and of Medicine in Sri Lanka”. principles, there exists considerable The Government of Sri Lanka recog- difference as to the actual medications nized this system as an alternative system of used. Institutionally trained practitioners health care by establishing a Department use more of Indian-based medicaments, of Ayurveda under the Ministry of Health whereas traditional physicians use more of and Indigenous Medicine. Presently the traditional therapies taught and trained to Ministry of Indigenous Medicine and the practise by their ancestral teachers. Department of Ayurveda are responsible for They evolved the following highly the development of the Indigenous System, developed divisions of traditional medicine including training, registration, research, and these services are still available to the hospital care and production of Ayurvedic people. drugs. z Fractures and dislocations; A well-amalgamated health care z Snake-bite poisoning and operating system, made up of the endemic hydrophobia; traditional system and the Ayurvedic z Eye diseases, sinusitis; system, is in operation to suit the z Neurological diseases; requirements of the people of this land. z Mental diseases; In 1929, two training institutes for z Diarrhoeal diseases; producing doctors in the Ayurvedic system z Kamala (Hepatitis).

299 Traditional Medicine in Asia

This country enjoys the services of surveys conducted revealed that well over 15,000 traditional and Ayurvedic 45 per cent of the entire population seeks practitioners, 70 per cent being traditional Ayurvedic and traditional medical physicians, trained by their and who assistance in spite of the mere 1.4 per cent had acquired knowledge through years of of the entire health budget it is receiving experience as well. The remaining 30 per annually. cent are institutionally trained, obtaining a The Department of Ayurveda manages Diploma or Degree after undergoing a six- an intricately woven network of health care year curriculum course, as a part of which delivery outlets throughout the country. The they are taught the basics and essentials details are as follows: of traditional medicine on the above- mentioned specialities. In addition to the Table Ayurved delivery outlets above-mentioned course, a three-year z Teaching Hospitals 2 diploma course is available in the country z Central Dispensaries 122 to train, as physicians, youngsters z Provisional Hospitals 46 descended from families whose forefathers z Local Dispensaries 231 z Research Institute 1 were traditional physicians. z National Institute of The traditional and Ayurvedic system Traditional Medicine of medicine by Government Policy is (Teaching and Training only) 1 recognized as a component of the national z Herbal Gardens 5 health service. Indigenous medical practitioners who fan out throughout the Sri Lanka is the only country where the country, especially to the remote rural areas traditional medical fraternity together with where the Western medical and health care the Ayurvedic component enjoys the status delivery system does not reach, offer of a cabinet portfolio in the whole of the invaluable service to the people. Recent South-East Asia Region.

300 Thai traditional medicine as a holistic medicine

Thai traditional medicine as a holistic medicine Pennapa Subcharoen

hai traditional medicine, which has Variation in the elements Tlooked after the health of the people for thousands of years, is part of the cultural The body consists of four body elements heritage and wisdom of the country. Our or Dhatus. It is believed that imbalance and ancestors had accumulated precious disharmony between the four body experience of holistic health in the fight elements cause disease. The four body against disease. The different elements of elements are: Thai traditional medicine have been derived z The earth body element, which refers from wisdom handed down from gene- to any entity that is non-liquid, tangible ration to generation, from observations, old and visible; manuscripts and instructions provided at z The water body element, which means institutes of Thai traditional medicine. Thai the fluid composition of the human traditional medicine is closely linked to body, e.g., blood, tears, nasal mucous . Diagnosis in Thai traditional secretion and urine; medicine does not only concentrate on z The wind body element, which diagnosis of disease but goes into the circulates throughout the body; different theories and hypotheses of z The fire body element, which burns disease. the food which is consumed and Thai traditional medicine believes that transforms it into body waste material. the following six causes are the main source of disease: Human disease can be traced back to z Variation in the elements; irregularity and abnormality in these four z Seasonal variation; body elements. z Age variation; Seasonal variation z Place variation; z Time variation; The different seasons could cause z Behavioural variation. imbalance of the four body elements. In the rainy season, for example, the wind

301 Traditional Medicine in Asia body element could be responsible for a z Salt water, mud and the beach are fever. Humans should adjust themselves to related to diseases of the earth element. the diseases which occur in the different seasons. These are given below: Time variation z Summer - Diseases of fire The time of the day or night has an element; influence on the different body elements or z Rainy season - Diseases of wind Dhatus. These are described below: element; z 06.00–10.00 a.m. and z Winter - Diseases of water z 18.00–22.00 p.m. element. Nasal secretion problems or indigestion; Age variation z 10.00 a.m.–14.00 p.m. and Age can be related to the propensity of a z 22.00 p.m.–02.00 a.m. particular disease to occur in a particular Fever caused by the fire element, person. Different age-groups are corre- stomach ache or hunger pains; lated with the diseases of a particular z 14.00 p.m.–18.00 p.m. and element. This relationship is shown below: z 02.00 a.m.–06.00 a.m. z Primary age (0–16 years) The wind element causes giddiness, Water element diseases; feeling of being worn out, exhaustion z Middle age (17–32 years) and fainting in the afternoon. Fire element diseases; Behavioural variation z Old age (over 32 years) Wind element diseases. Certain behavioural patterns are asso- ciated with disease. Some of these are: Place variation z Having too much or too little food and The environment has a relationship with the eating spoilt food; imbalance in occurrence of a particular disease. Illness activities such as standing, sitting, can be caused by a different geographical walking or lying down; location, extremes of temperature or a z Exposure to hot or cold weather; new water supply. It is suggested that such z Going without food, water and sleep; an influence could be mediated through z Delayed defecation or urination; the immune system. Information as regards z Overwork; the birthplace of the patient or the actual z Excessive sorrow; place of residence may give the physician z Excessive anger. clues as regards the diseases which are likely to afflict the patient. The correlation Diagnosis between geography and diseases is given below: A correct diagnosis is extremely important z High mountains are associated with as a wrong diagnosis would lead to diseases of the fire element; inappropriate treatment, which could be z Rain, water and mud are associated fatal. The method of arriving at the correct with diseases of the wind element; diagnosis in Thai traditional medicine z Rainwater, soil and groundwater are consists of two factors – history-taking and related to diseases of the water physical examination. element;

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History-taking altering lifestyle so that the four Attention is paid to the birth date of the elements and the external environ- patient because it shows the essential ment are in balance. elements or Dhatu of the patient. The z Use of herbal food or medicine for history would also indicate illnesses which adjusting the elements of the body to occurred during childhood, seasonal achieve balance. This consists of using illnesses, lifestyle and behaviour which herbal food for adjusting the Dhatu, could have related to the illness. using herbal food according to the season and administering such food Physical examination for adjusting the Dhatu according to The physical examination consists of the taste of the herbal medicine. These confirming the characteristics of the tastes are cool taste (to adjust the fire essential elements, palpation of the wrist element), hot food (to adjust the wind pulse, checking the body temperature, element), delicate taste (to adjust the checking the disordered organ, exami- water element) and nine other tastes nation of the blood, using meditation for to adjust the body elements such as checking the cause of illness and checking astringent, sweet, intoxicating, bitter, the astrological configuration. creamy, aromatic and sour, spicy and salty; Curative methods z The herbal food should be adminis- tered according to the body element Thai traditional medicine is holistic or Dhatu. Examples are given below: medicine and takes into consideration several factors which could be associated Body element of earth with the illness. Some of these are given These persons should have food with below: astringent, sweet, creamy and salty flavours z Factors created by nature, such as the such as raw guava, mangostein, pumpkin, basic elements of the human body, the rambutan, taro, bean, milk and molasses. season and the need for taking herbal food and medicine and altering Body element of water behaviour; These persons should eat food with sour z Behavioural factors have to be taken and bitter flavours such as lemon, orange, into account. The need for exercise and pineapple, tomato, cavilla fruit, magosa physical stretching (Ruesee dat Tone) and kiffer lime. have to be kept in mind. Thai traditional massage and meditation, which is a Body element of wind principle of the Dharma treatment, These persons should eat spicy food such need to be kept in mind. The treatment as ginger, galingale, lemongrass, pepper, could be: sweet and holy basil. z Physical treatment such as exercise and body exercises, including body Body element of fire twisting; These persons should eat food with bitter z Moral treatment such as medi- or tasteless flavours such as morning glory, tation and merit making; watermelon, cassia, ivy gonro and tiger z Treatment which consists of herbal.

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Healing is carried out by using a single- Unofficial herb preparation or a mixed medicinal This massage is given by persons to each plants prescription. Mixed herb prepara- other in a family or in the village. This type tions are used for chronic diseases. of massage is carried out not only by hand but also by standing on the patient, pushing, Advantages and pulling and kneeling him by using also the characteristics of holistic elbow, knee, forehand and edge of the foot. medicine This type of massage relieves tiredness and pain and also develops warm and good z Holistic medicine places emphasis on relationship among the family members. lifestyle, health promotion and disease prevention; Royal Thai massage z Holistic medicine creates a warm and This massage is given to the King and the empathic relationship between the Royal family. In this type of polite massage, practitioner and the patient. Proper only the hand is used. The person carrying mental health of the patient is essential out the massage does not come close to for treatment; the member of the Royal family, does not z Treatment by holistic medicine lays breathe into the person undergoing the emphasis on the patients’ Dhatu or massage and does not turn up his face, as Element; it is disrespectful. z Holistic medicine can cure chronic The characteristics of the Royal Thai diseases which are induced by stress. massage and folk massage are given below:

Traditional Thai massage Royal Thai massage

Thai traditional massage is based on the z Give a massage in a polite manner by indigenous wisdom which the Thai people walking on knees towards the patient have adopted from their ancestors and by not breathing directly on him; centuries ago. Massaging is a way of z Start massage from the back of the treating sickness; it starts by relieving feet; tiredness or pain by the patient pressing z Give the massage only by using the on the pain himself. When he cannot hands, thumbs and fingers. The arms massage himself he should ask somebody should be straight; to massage him. This pattern has deve- z Give the massage to the patient when loped from massage by the family to he is sitting, lying on the back, lying in massage at the village-level and later on a side position but not when he is lying to massage on a commercial scale. on his stomach; z The person doing the massage does Two patterns of Thai Traditional Massage: not bend part of the body of the patient z Unofficial Thai Massage (Folk being massaged with force by using his Massage); knees or elbows; z Royal Thai Massage. z The massage has an effect on the organs and tissues by enhancing the

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circulating system and the nervous body systems necessary for maintaining system. The person who carries out the good health. For example, it strengthens massage should, therefore, have a the circulatory system, removes wastes, acts knowledge of anatomy and should as a diuretic, relaxes the nervous system possess the skill of massaging the and relieves pain. Some of the types of pain blood vessels and nerves. for which it is effective are headache, displaced shoulder joint, neck pain, Folk massage sprained ankle, backache and kneecap z Start the massage from the feet; pain. It is effective also in diseases of the z Give the massage to the patient while elderly such as paralysis, limpness, he is sitting, lying on the back, lying in flatulence, constipation and reduced sexual a side position but not when he lies on efficiency. the stomach; The benefits of Thai massage and the z Bend the joints and parts of the body safety while carrying it out depend on the with force using the knees and elbows; expertise of the Thai practitioner. He should z The massage has an effect on the know the body and the condition of health organs and tissues. of the patient. He should know the principle of massage and know what not to do and Thai traditional massage is a valuable he should know how much weight he aspect of Thai traditional medicine; it is should apply to make it suitable for the able to relieve disease and assuage pain. patients. The massage has a beneficial effect on the

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List of contributors

List of contributors

1. Dr. Palitha Abeykoon, Former Director, Health Technology & Pharmaceuticals, WHO-SEARO, New Delhi, India. 2. Dr. O. Akerele, former Advisor, Traditional Medicine, WHO HQs., Geneva, Switzerland. 3. Dr. Gerard Bodeker, Chair, Global Initiative For Traditional Systems (GIFTS) of Health, Green College, University of Oxford, Oxford, U.K. 4. Mrs. Shailaja Chandra, Secretary, Department of Indian Systems of Medicine & Homoeopathy, Ministry of Health & Family Welfare, New Delhi, India. 5. Mr. S.K. Chowdhury, Associate Professor, Department of Pharmacy, Jahangirnagar University, Bangladesh. 6. Professor Carlos M. Correa, Director, Master Program on Science & Technology Policy and Management, University of Buenos Aires, Buenos Aires, Argentina. 7. Dr. Hongguang Dong, Clinic of Infertility and Gynaecological , Department of Obstetrics and Gynaecology, Geneva University Hospital, Geneva, Switzerland. 8. Dungtsho Pema Dorji, Director, Institute of Traditional Medicine Services, Bhutan. 9. Dr. B. B. Gaitonde, Former Director, Haffkine Institute, Bombay, Banda Sindhudurg, India. 10. Dr. Lestari Handayani, Health Services Research and Development Centre, National Institute of Health Research and Development, Ministry of Health, Surabaya, Indonesia. 11. Dr. D.C. Jayasuriya, Attorney-at-Law, DCJAY Law Associates, Nawala, Sri Lanka.

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12. Mrs. Shanti Jayasuriya, Attorney-at-Law, DCJAY Law Associates, Nawala, Sri Lanka. 13. Professor Hakim Syed Khaleefathullah, President, Niamath Science Academy, Chennai, India. 14. Dr. Md. Aftabuddin Khan, Ministry of Health, Dhaka, Bangladesh. 15. Dr. Kin Shein, Former Regional Advisor, Essential Drugs & Medicines Policy, WHO-SEARO, New Delhi, India. 16. Dr. Rishi Ram Koirala, Registrar – Council of Ayurvedic Medicine Nepal, Kathmandu, Nepal. 17. Dr. P.N.V. Kurup, Vice Chancellor, Gujarat Ayurved University, Jamnagar, Gujarat, India. 18. Professor Deng Liangyue, Director, Professor of Acupuncture, Institute of China Academy of Traditional Chinese Medicine, Beijing, China. 19. Mr. L.V. Prasad, Joint Secretary, Department of Indian Systems of Medicine & Homoeopathy, Ministry of Health & Family Welfare, New Delhi, India. 20. Dr. Ketut Ritiasa, Director of Traditional Medicine and Cosmetics Control, Ministry of Health, Jakarta, Indonesia. 21. Dr. (Mrs.) M. Roy Chaudhury, Former Toxicologist, National Institute of Immunology, New Delhi, India. 22. Professor Ranjit Roy Chaudhury, Emeritus Scientist, National Institute of Immunology, New Delhi, India. 23. Dr. Lal Rupasinghe, Commissioner of Ayurveda, Department of Ayurveda, Ministry of Health & Indigenous Medicine, Maharagama, Sri Lanka. 24. Swami Niranjanananda Saraswati, Chancellor, Bihar Yoga Bharati, Yoga (Yoga University), Munger, Bihar, India. 25. Dr. Rishi Vivekananda Saraswati, Patron, Satyananda Yoga Academy, Mangrove Mt., NSW, Australia. 26. Dr. Choe Thae Sop, General Hospital of Koryo Medicine, WHO Collaborating Centre for Research and Standardization in Traditional Medicine, Pyongyang, DPR Korea. 27. Dr. Pennapa Subcharoen, Director, National Institute of Thai Traditional Medicine, Department of Medical Services, Ministry of Public Health, Nonthaburi, Thailand. 28. Dr. Niniek Sudiani, Head, Sub-Directorate of Traditional Medicine Registration, Ministry of Health, Jakarta, Indonesia. 29. Dr. Haryadi Suparto, Health Services Research and Development Centre, National Institute of Health Research and Development, Ministry of Health, Surabaya, Indonesia.

308 List of contributors

30. Dr. Agus Suprapto, Health Services Research and Development Centre, National Institute of Health Research and Development, Ministry of Health, Surabaya, Indonesia. 31. Dr. U. Kyaw Myint Tun, Director-General, Department of Traditional Medicine, Ministry of Health, Yangon, Union of Myanmar. 32. Dr. Abdulla Waheed, former Director-General Health Services, Ministry of Health, Republic of Maldives, Male. 33. Professor Zhu-fan Xie, Honorary Director, Institute of Integrated Chinese & Western Medicine, The First Clinical Medical College, Peking University, Beijing, P.R. China. 34. Dr. Xiaorui Zhang, Acting Coordinator, Traditional Medicine (TRM), Department of Essential Drugs and Medicines Policy (EDM), World Health Organization, Geneva, Switzerland.

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