MAGAZINE Cover: Aesculapius, God of Medicine. Design by Peter Davies from a wood- carving in Chur, Switzerland. Contents The staff of Aesculapius by H. Mahler Malaysia's bomohs by J. Dauth Balance between man and nature by X. Lozoya The Science of Life by P N. V Kurup Ayurvedic training by K. N. Udupa WHO's Programme by R. H. Bannerman New status for the hilot by A Mangay-Angara Study Tour in China Plants that heal by 0 Am pofo News Page 3 4 8 12 15 16 18 22 26 31 World Health appears in Arabic . English. French. German. Italian. Persian. Portu - guese. Ru ssia n and Spanish . Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization . Signed articles do not necessarily reflect WHO's views . World Health . W HO. Av. Appia. 1211 Geneva 27 , Switzerland . 2 The staff of Aesculapius BY DR HALFDAN MAHLER Director-General of the World Health Organization I If we had to justify the inclusion of traditional medicine within the compass of the World Health Organization, we need look no further than the oppo- site page. The emblem of WHO superim- poses on the globe the staff of Aescula- pius, ancient god of medicine, entwined by a snake. The god's serpents were said to lick the wounds and lesions of the sick in their sleep and thus to heal them. For far too long, traditional systems of medicine and "modern" medicine have gone their separate ways in mutual anti- pathy. Yet are not their goals identical- to improve the health of mankind and thereby the quality of life? Only the blinkered mind would assume that each has nothing to learn from the other. Unfortunately that divergence be- tween the two systems of medicine has almost exactly paralleled the division of the world between the rich and the poor. Too often the privileged and well-to-do, living in large towns and cities, enjoy access to all the complex technology and lifesaving apparatus of modern medi- cine. Tens of millions of people have no such access; for them the traditional healer, the herbalist and the traditional birth attendant are the only agents of health care to whom they can turn. Not only are most of the rural areas of deve- loping countries without a single quali- fied physician, but on the average they do not have more than one auxiliary health worker for 10,000 persons. In some parts of the world, even when modern medical care is available, the majority actually prefer the traditional healer, whom they know and trust. But the political winds of change that have been sweeping the world in recent decades have been matched by winds of change in community health: a newly awakened global social conscience requires that the health gap between rich and poor within countries and between countries should be narrowed and ulti- <JA traditional herbalist sells his wares in a Sudanese market. (Photo WHO/D. Henrioud) mately eliminated. The neglected 80 per cent of the world's population have their rights too; they too have an equal claim to health care, to protection from the killer diseases of childhood, to primary health care for mothers and children, to treatment for those ills that mankind has long ago learnt to control if not to cure. Two years ago we in WHO pledged ourselves to an ambitious target: to pro- vide health for all by the year 2000. This ambitious goal is, quite simply, beyond the scope of the present health care sys- tems and personnel trained in modern medicine. With but 23 years to go, and since it is unlikely that the least devel- oped countries can even dream of having enough of the orthodox type of person- nel, it is clear that unorthodox solutions must be sought. The training of health auxiliaries, traditional midwives and healers may seem very disagreeable to some policy makers, but if the solution is the right one to help people, we should have the courage to insist that this is the best policy in the long run, and is by no means an expedient acceptance of an inferior solution. This is why WHO has proposed that the great numbers of traditional healers who practise today in virtually every country of the world should not be overlooked. For the most part they are already living in those remote communities, intimately involved with the life there, conscious of their neighbours' needs and trusted by them. Many such healers have already undergone elaborate training in ancient systems of medicine that had evolved reliable methods of treatment and pat- terns of medication long before modern medicine came along. Other healers have had their skills handed down through the generations-the distillation of a surpris- ing degree of practical knowledge, skills and wisdom about the physical, mental and psychological ills of mankind. Provided they are willing, such tradi- tional healers and local midwives can, at a very moderate expense, be trained to the level where they can provide ade- quate and acceptable health care under suitable supervision. Such training might include personal hygiene, mother and child care (including family planning), nutritional guidance, immunization against the major infectious diseases, ele- mentary treatment of all age groups for the common diseases and injury, and a basic understanding of sanitation and environmental hygiene. They can at the same time be weaned away from any practices that might pose possible risks for their patients. The age-old arts of the herbalists too must be tapped. Many of the plants familiar to the "wise-woman" or the "witch-doctor" really do have the heal- ing powers that tradition attaches to them; the pharmacopoeia of modern medicine would be poorer if one removed from it all the preparations, chemicals and compounds whose origins lie in herbs, funguses, flowers, fruits and roots. Let us not be in any doubt: modern medicine has a great deal still to learn from the collector of herbs. And already a number of Ministries of Health, in the developing countries especially, are care- fully analysing the potions and decoc- tions used by traditional healers to deter- mine whether their active ingredients have healing powers that "science" has overlooked. Whatever the outcome of such scientific testing, there is no doubt that the judicious use of such herbs, flow- ers and other plants for palliative purpo- ses in primary health care can make a major contribution towards reducing a developing country's drug bill. The present issue of World Health illustrates just a few of the aspects of traditional medicine in different parts of the world, and indicates the contribution that its practitioners could make towards better health care, and primary health care in particular-an aspect to be high- lighted at the WHO conference on pri- mary health care scheduled for 1978 at Alma Ata in the Soviet Union. Given goodwill on both sides, such an army of healers, traditional birth atten- dants and herbalists can help to make our goal of health care for all by the year 2000 attainable. Malaysias bon1ohs "To treat a mentally-ill young woman, the healer staged a kind of theatrical performance ln which her closest relatives and fellow-villagers each had a role to play" "The sky suddenly went dark and the jungle fell silent", a Por- ,.. .. ,...,"'"'...,. tuguese seaman wrote nearly 200 years ago, describing his first en- counter with a Malayan bomoh. The magic of these spiritual healers may not run to such extremes but, all the same, the people of the Malacca peninsu- la ascribe supernatural powers to the bomohs which are still being demon- strated to this day, according to popular belief. Didn't a bomoh cause the hitherto incessant monsoon rains to stop for a day at the request of the Ruler of Sara- wak? Didn't another invoke blazing sun- shine for the open-air boxing match of Mohammed Ali (formerly Cassius Clay) some three years ago, while rain poured down in torrents all round the stadium? The Malaysians are convinced that these things happened. However, Professor Paul Chen of the Medical Faculty of the University of Malaya foresees a more important sphere of influence for the traditional medicine men. In his view the bomohs have always ha<;l an essential role to play in the nation's health care, and he is con- vinced that magic ritual and the psycho- therapeutic understanding derived from it by the Malaysian medicine man, as well as his subtle knowledge of the healing powers of Nature, represent im- portant contributions to medical science. Certainly Malaysia will need its bomohs for some time to come, since at present only 2,350 modern physicians supply health care to the 12 million Malaysians while there are 20,000 practising bomohs offering their services. 4 BY JURGEN DAUTH Whether they are Malays, Indians or Chinese, whether Moslems, Hindus, Buddhists or Christians, all of them remain to this day firmly rooted in the belief in spirits, their influence on the ~ ' ·~ t ' Above: A M .... . . prepares a herbaloffering to ward off evil spirits. ght: A basis of practical knowledge un- derlies the spiritual healer!srulings on w to .eat certain fruits wh!?n tfz~y '"ar. forbidden-taboo . . '"·"i (P 1f0j£. , ~~ soul and their lifegiving power known as semanganat. They have not the least doubt that illness is caused by evil spirits. And only the bomoh has mastered their tongue, can overcome them or can con- jure up guardian spirits to take their place. The medical treatment undertaken by the bomoh invariably revolves around a ritual exorcism. The bomoh hands out amulets against the "evil eye" or pre- scribes magic spells which are based on astrological lines and may be written on paper, the leaf of a plant or on leather hide. Texts and magic symbols may be taken from the Koran in the case of Moslems, while the Chinese Buddhists and Taoists swear by the traditions of their homelands, and the Christians con- tent themselves with reciting the Lord's Prayer backwards. The bomoh may put a medium into a trance in order to arrive at a diagnosis or he lets the illness declare itself from the mouth of a hypnotised patient. Incanta- tory music on an instrument called a game/an, dances and burnt offerings- in which the hair or finger-nails of the patient play a major role-complete the ritual. The enlightened student of medicine may loftily dismiss all this ceremonial as so much charlatanry, but that would be too hasty a judgment. Because on closer study black magic is seen as only a superficial framework to prepare the patient for the real medical treatment. It is precisely in this that Professor Chen sees the special advantage that the bomohs have over the modern doctor.
In Malaysia- as in most countries of the world- the doctor hardly has the time to concern himself about the psych- ic origins of many illnesses, and the top- heavy doctor-patient relationship, gener- ally speaking, permits only a scientific approach. Yet for a long time scientific medicine has acknowledged that on its own it is incapable of getting to the root of sickness. The bomoh, on the other hand , says Professor Chen, lives in the village where he has inherited his skills from his fore- fathers, and where he is a respected and trusted person . He is personally ac- quainted with every one of his fellow- villagers and knows what goes on behind the scenes. He can make use of the knowledge that a healthy body needs a healthy spirit in a way that few doctors can. So long as belief in spirits is a fact of life, it is useless to inveigh against magic ritual. In any case, superstition is far from being confined only to developing countries- it maintains a clandestine hold even among the crews of moon- bound spaceships. On the East coast of Malaysia I watch- ed an exorcism of evil spirits carried out on a well-born but mentally disturbed young woman. The bomoh had staged a kind of theatrical production in which the woman's closest relatives and her fellow-villagers each had roles to play . It was noteworthy that the actors in this little play had to demonstrate warm af- fection for the patient. Embraces, friend- ly gestures and tender caresses were much in evidence . The play took on an increasingly frenetic character with dance-like movements, until those taking part fell into a trance and finally reached total physical exhaustion. The coaxing of the evil spirit which had caused the ill- ness with an offering of food until it . could be caught in a container and packed off on a "journey without return" down the river was merely a ritual appendage. The young woman was now considered to be cured. I heard that the bomoh had passed the whole of the previous day before the ceremony in the house of her family so as to "get in touch with the spirit". Only in its outward appearance does this treatment differ from what is accepted in the industria- lized world as group therapy under ex- pensive psychiatrists. The bomoh also works extensively with taboos which are invested with magic powers. Certain foods are forbid- den, the physical stresses on the patient are limited or specific rituals are used to soothe his nerves. This too is a very practical means- among simple people who know little of modern hygiene, ap- 6 propriate diets or physiology- for exert- ing a favourable influence on the course of an illness. The modern practice of medicine in Malaysia makes use of the bomoh as an assistant at childbirth, for instance, often in collaboration with a state-trained mid- wife. And nobody would wish to deny that the psychological attitude of the mother-to-be has great influence on the course of a " natural" childbirth. Individ- ual bomohs are also entrusted with carry- ing out mass immunization and help the doctors with such tasks as smallpox vaccination. As regards operations, the bomoh limits himself to ritual bleeding. Accord- ing to local belief, blood is the bearer of the life force and must not be overbur- dened. Thus opening an artery may be prescribed for headaches and vertigo; either the skin is pierced or leeches are . applied. The bomoh obtains antiseptic preparations from extracts of plants or from the poison sacs of certain sea-fish. Painkilling potions can be distilled from the areka-n ut, better known as the betel- nut. The right dose of poison taken from one particular fish can sufficiently lower Above: Before applying the healing power of his hands, the bomoh tells his patients to breathe deeply and then puts them into a trance. Right: A healer shows off his totem- the source of his magic powers. So long as belief in spirits is a fact of life, it is useless to inveigh against magic ritual. After all, superstition is far from being confined only to developing countries; it is to be met with even among the crews of spaceships heading for the moon! (Photos WHO/I. Dauth) the blood.-pressure to make "bleeding" unnecessary. The tropical vegetation and tropical fauna , with their rich variety of forms, are the sources of the bomoh's pharma- copoeia, and stocking it is based upon the knowledge handed down over the centuries that for every poison in nature there is a natural antidote. The sap of the mangrove trees serves as a remedy for bowel and stomach disorders, causing vomiting which purges the intestines . The betel-nut is prescribed for parasitic worms, and the dried roots of the pomegranate can strengthen this action. Pineapple juice is a remedy for indigestion and overeating. Skin eruptions, often originating from poisonous plants or insect bites, can be cleared up by the application of tea-oil. In rural areas, sexually transmitted diseases are very rare, yet even for these the bomoh has a cure. Against syphilis he may use the root of a certain legumi- nous plant which he calls " hantu" or spirit. The remedy for gonorrhoea sounds rather more drastic ; a certain green beetle is made into a powder and added to the patient's food . Even more surprising for the scientist is the cure for toothache in children: a hair from the tail of an elephant. Against rheumatism, the Dayaks of Malaysian Borneo insist, the best remedy is tiger-fat. For sure, religious motives are in- volved for declaring certain plants taboo and forbidding the combination of cer- tain foods , but there can be no doubt that here too there is a basis of practical knowledge. Thus mangoes are not eaten with sugar , nor water-melons with honey nor heart of coconut-palm with shellfish or oysters. Such combinations are viewed as poisonous or at least highly indigestible. Beef, mutton, mangoes and pumpkins are to be avoided in cases of fever , eye diseases or gonorrhoea, while eggs and milk are recommended . On the other hand , eggs, dried fish and brown sugar are stricken from the menu in the case of bronchial troubles. And "the worm of night blindness" rises to the eyes if one eats only sweet potatoes or bananas. Vitamin A deficiency can be avoided by a special diet of fish , mutton or liver. Many more examples could be given of the bomoh 's pharmacopoeia. In Pro- fessor Chen's opinion it contains many hidden virtues which amount to the stored-up knowledge of an entire chemis- try laboratory . Closer study of this could be of value to modern medicine, once one discounts the special links with the supernatural; yet this too may have its psychological advantages. •
Balance between man and nature I Among the countries forming that part of the American con-tinent known as Mesoamerica, Mexico enjoys a special position thanks to the pre-Colombian cultures which once flourished on its territory. The wide variety of climates and soils found here meant that its in- habitants acquired a profound know- ledge of medicinal plants and hence of medical science itself. The ancient Mex- icans collected, catalogued and used these plants, integrating them into a vision of the universe whose basis was as much practical as religious. Although no precise documentation remains to us about the experimentation that must have been undertaken at that time, the information that has been handed down testifies to a broad understanding of the curative properties of Mexico's flora. The chronicles and manuscripts of that bygone age contain descriptions of flou- rishing botanical gardens and parks with rich collections of plants, as well as quite precise information about their use. Ever since the fusion of cultures that followed the Spanish Conquest in the 16th century, Western medicine has tried to analyse the ancient medical wisdom, hoping to find among such cultural relics as remain a correct interpretation of the vision left by those early explorers. In the course of time a wide spectrum of evi- dence has emerged from a variety of cultural sources, all of it tending to con- firm the balance that exists between man and nature. As the centuries have unfolded, the rich grain of native knowledge has stead- ily evolved among the mixed-blooded population of Mexico. Rooted in past civilizations and nourished by fresh in- sights into the art of medicine, that grain has ripened into methods of treatment which are quite distinct from those based on modern science, and flourishes today as what we call "traditional medicine". Unequal development, which in con- 8 BY XAVIER LOZOYA temporary society mainly takes the form of an unequal distribution of resources, means that not all the population is able to benefit from health care. The result is that 40 per cent of Mexico's population today still has recourse to traditional medicine- the medicine of the poor- which is enshrouded in magic and mys- tery. On the world scene, the study of her- bal medicine in Mexico is of special interest because of three factors: its rich heritage of curative plants, the continued use of such plants among a large propor- tion of the population , and the wealth of available information- whether historic, archaeological, botanical or traditional. Moreover Mexico, as a developing coun- try, is grappling with the reality of vast public health problems. The efforts made so far to introduce "Western" forms of Above: Traditional medicine in Mexico is rooted in the rich soil of folk-wisdom hand- ed down from earlier civilizations. Right: This old man in the marketplace of Oaxaca, south-central Mexico, is the prod- uct of the fusion of cultures that followed the Spanish Conquest in the 16th century. Today, 40 per cent of the country's popula- tion still has recourse to traditional medi- cine, enshrouded in magic and mystery but still based on a very practicalfrarnework. (Photos WHO ) medical care are still far from meeting the demands of a fast-growing popula- tion. In the framework of such social, economic and historic realities , Mexican traditional medicine and the medicinal plants themselves are crucially important to the future development of national public health policies. If we are to elevate the various combi- nations of treatments and drugs to the point where traditional medicine occu- pies the position it deserves, we have to re-examine and re-value popular medi- cine so as to bring it level with the mod- ern scientific knowledge which now serves the health of many people. In order to undertake this laborious task, a complete analysis is needed of all infor- mation relating to medicinal plants, the way they are used and their characteris- tics. These studies will enable us to prove the advantages and benefits of the practi- cal, empirical knowledge which has sur- vived the passage of time. When submit- ted to rigorous scientific analysis , the results could give rise to a new type of research going far beyond the limits of chemical and pharmacological analysis, but not dissociating itself from the anth- ropological reality in which traditional medicine is so deeply rooted. Starting from this multidisciplinary standpoint and with the object of pro- moting and justifying the usefulness of Mexican medicine, the Mexican Institute of Medicinal Plants (IMEPLAM) has incor- porated its activities within the research programme of Appropriate Technology at the Third World Centre for Economic and Social Studies ( CEESTEM). We have plenty of information about Mexican medical plants and will confine ourselves here to those with special im- portance for public health, which have been given priority in IMEPLAM's research programme. Our Institute' s systematic study of medicinal plants first of all entailed an interdisciplinary effort to collect a
bibliography of everything published in Mexico from the 16th century until mod- ern times, and to subject it to different levels of interpretation , classification and analysis. This also enabled us to start creating a bank of information on medic- inal plants, already in full swing and illustrating in part what we know about plants with cardiovascular, anti-diabetic and anti-parasitic properties. This infor- mation is being compared with modern botanical studies with the object of iden- tifying a group of medicinal plants which may then be submitted to a global study. Examining the existing data in Mexico reveals that, although medicinal plants have been the object of research under- taken at various times and according to the different trends of scientific thought that have influenced Mexican science, the vast majority of studies made have been undertaken unilaterally, aiming at isolating the active ingredients but without ever succeeding in creating a national pharmaceutical industry . That is why most studies , while providing useful preliminary information , ought rather to be combined with a social objective- that of upgrading the status of popular knowledge, so as to lend 10 scientific support to the practice of tradi- tional medicine . Here are some of the most popular Mexican plants, representing the three groups to which priority was given . Plants with cardiovascular properties: Talauma mexicana (D.C.) Don. Mag- noliaceae. This large tree with beautiful flowers has been known and used since pre-Hispanic times ; its name in Nahuatl (the language of the Aztecs) is Yolox- ochitl or Heart Flower, and was given because of the properties attributed to its flower , bark and leaves as cardiac stimu- lants. A decoction made from the leaves and flowers is still used to treat various car- diac ailments. Scientific research into this plant dates from the last century when chemical and pharmacological studies confirmed its tonic effect on the heart- increasing the heartbeat, and regularis- ing cardiac contractions. The chemical composition of the Talauma was at least partially discovered around the 1950s, when it was found to include certain alkaloids such as talau- mine and aztequine. But the relationship Balance between man and nature Left: A symbol of M exico, the maguey cactus flourishes everywhere. Its fleshy leaves y ield a juice which is f ermented into pulque, the national drink. (Photo WHO ) Right : This housewife in the Yucatan peninsu- la takes for granted the fact that the plants growing around her home have medicinal uses. The study of such plants should serve to upgrade the status of popular knowledge, and thus lend scientific support to the practice of traditional medicine. (Photo WHO/P. Almasy) between these substances and the cura- tive effects attributed to the plant remained obscure. Its very extensive use puts it among the most important plants in Mexican traditional medicine. Casimiroa edulis, Rutaceae. Among the sweet edible fruits described by the Aztecs figure those of the Casimiroa edulis, a tree mentioned in the descrip- tions of the period by the name of " Cochitzapotl" - the fruit that brings sleep. Today, its use is very widespread almost everywhere in Mexico for the beneficial effects on the blood pressure which are attributed to its leaves and its seeds. Certainly this is the most favoured traditional prescription for producing a slight but long-lasting regularisation of the blood pressure. Although this fruit has been repeated- ly studied over the years, the experimen- tal proof of its action on the blood pressure has only recently come to light in our laboratories . We have determined how the active ingredient present in the aqueous extracts used as popular reme- dies actually functions. The property at- tributed to the fruit of " soothing one to sleep" has been confirmed as resulting from reduced blood pressure sustained by dilation of the blood vessels; acting on the autonomic nervous system, this facilitates the spontaneous onset of sleep. The decoction made from the Casimiroa also contains another substance possess- ing powerful properties as a constrictor of the womb, which explains why this plant is not prescribed for pregnant women. Plants with anti-parasitic properties: Chenopodium ambrosioides, L. Chenopodiaceae. Known in Mexico by the name "Yapotzotl" , its Spanish name is Epazote and its US name American wormseed. It figures in the recipe of many Mexican dishes and is widely used as a parasite-expellent. A herbaceous plant with a strong odour reminiscent of camphor and a sharp spicy flavour, it owes its anti-parasitic activity to the volatile oil with a concentration of 0.35 per cent contained in its leaves. It also contains such alkaloids as que- nodopine, colina and tannin , as well as ascaridole. Its effects are powerful and 20 grammes of the plant administered in the form of a decoction suffices to pro- duce a rapid parasite-~xpellent effect without apparent side-effects. Toxicolog- ical considerations will require further study. Traditional medicine also uses two other kinds of Chenopodium- foeti- dium and graveolens for the same pur- pose. Cucurbita maxima, D. Cucurbitaceae. The seeds of pumpkins cultivated in the hot lowlands of Mexico are used by local people in the form of an aqueous emul- sion , or as a refreshing drink mixed with sugar, for treating various intestinal parasites. These remedies have proved effective against tapeworm. They are also used to treat different forms of intestinal parasites since they are often , though incorrectly , substituted for the seeds of Cucurbita pepo L. , which has similar but much less specific properties. Plants with anti-diabetic properties: Tecoma mollis, H .B.K. Begoniaceae. Under a great variety of popular names, depending on the region of origin, the "nixtalaxochitl" refers as much to T . Mollis as to T. Stans, all well-known in traditional medicine for their anti- diabetic action . It is often associated with Leucophyllum tenaxum, which is similarly employed . Pharmacological studies have shown that aqueous extracts of Tecoma admini stered orally cause an increase in the level of glucose in the blood and thus help to palliate the types of diabetes for which this treatment is particularly indicated . Coutarea Latiflora, D.C. Rubiaceae. Commonly called " Copalchi", the bark of this shrub is traditionally known for its anti-diabetic effect. Its diuretic prop- erties in particular are valid for diabetics, and the increased volume of urine elimi- nated is accompanied within 24 hours by a diminution in the amount of glucose secreted , and results in a general im- provement in the patient's condition. Traditionally the bark is used in powder form decocted in alcohol and adminis- tered orally . There are many such representative examples of traditional medicinal plants. The more they are investigated and stud- ied in the light of a science which once more reverts to serving the public good, the more they will contribute to the development of a system of medicine adapted to the needs, the cultural demands and the overall health of our country. • 11 The science of life I Human nature instinctively seeks relief from pain and dis-ease. This basic instinct prompted man, through the ages, to analyse the phenomenon of nature and obtain clues to help him ameliorate pain and disease. His ex- periences led to empirical methods of healing which in due course crystallized into distinct systems of medical practice. Although modern or " western" medi- cine is generally accepted throughout the world, yet it has not been able to reach the remote rural areas of the world for various reasons. The developing coun- tries, with their meagre financial resources, cannot avail themselves of the services of modern medicine in view of the huge investment involved in estab- lishing and maintaining modern clinics and hospitals. The traditional systems of medicine, however, still tend the health needs of most rural populations of the world , and find patronage also in urban areas. The traditional healers, herbalists, spi- ritualists , and birth attendants constitute a vast resource of practitioners outside the official health services. Their methods of diagnosis and treatment vary from region to region, and some of their practices are similar to modern medicine. For example, in certain tribal communi- ties the traditional healer applies his ear close to the patient' s chest to listen to the heart beats and diagnose disease . Such practices as cupping, cauteriza- tion or showering mineral water over the head (for curing headaches), when admi- nistered by the practitioners, are said to be effective in curing metabolic and psychic disorders . In South-East Asia the chanting of mantras (mystic incanta- tions) to cure jaundice and even snake bites is still a prevalent practice. Such traditional methods, grounded in some kind of rudimentary medical prac- tice, have mellowed in the course of time into well-defined and distinct systems 12 BY P. N. V. KURUP influenced by local civilization, religion and tradition, and have evolved through trial and error , keen observation , intui- tion , accumulated experience, folk cus- toms and ancestral beliefs. With the development of civilization these systems a ttained some scientific status . The concepts regarding the nature of di sease and its underlying causes are based on the fundamental doctrines of each sys- tem . Whereas the early founders of mod- ern medicine initiated the pattern of ob- serving the sequence of symptoms for diagnosis and prognosis, traditional medicine had a highly developed science not only for diagnosis and prognosis but also for determining the cause and treat- ment of diseases . Urine, stool and spu- tum tests were conducted by traditional practitioners many centuries before these techniques were known to modern medi- cme. A number of well-defined and well- developed traditional systems are pre- valent in various parts of the world . Among them, Ayurveda, Unani and Chinese medicine occupy the foremost place as the most ancient and best devel- oped of these systems. Nature cure and Yoga also have followers in many parts of the world for their therapeutic value and in general as a means to maintain positive health and well-being. Ayurveda literally means the Science of Life. The doctrine of Ayurveda postu- lates life as the union of body, the senses, mind and the soul ; the living man or the man of action is said to be a well- balanced combination of three humours, seven basic tissues and three excretions. Everything in the universe including the physical body is composed of five ele- ments or substances (panchabhutas) , namely prithvi , ap, tejas, vayu and aka- sha. These elements combine in different proportions to suit the specific needs of different structures and functions of the body, whose growth and develop- ment depend on its nutrition, that is, on food which again is composed of these very elements that replenish or nourish the body. Man is therefore a micro- cosm within the macrocosm, the universe, since all the basic constituents of the universe are also present in him. When there is an imbalance in any or all of these essential attributes of the body, the individual falls prey to sick- ness. The mind of a person is classified broadly into three categories- satva , rajas and thamas. This science also clas- sifies the person according to his consti- tution and natural disposition into seven distinct types based on the three humours. The identification of these characteristics in a person gives impor- tant clues to the physicians as to how to treat the disease and bring the body back to its original harmony and health. Thus Ayurveda looks at the whole body and mind, and not merely at external or inter- nal factors as the contributing causes of the disease, in deciding the appropriate remedy . It is a fully developed science, with eight different branches covering the whole of medical science. A wide range of books written by scholars and special- ists have enriched the classical and con- temporary literature of Ayurveda . Its materia medica is stupendous and con- tains as many as 8,000 published recipes. This may be an under-estimate if unpub- lished recipes held as " family secrets" by traditional practitioners are also taken into account. Some 1,200 drugs are in frequent use either in the form of single drugs or as compound formulations. In the South-East Asia Region, as many as 800 pharmacies are active in the private and public sectors, and many employ A patient undergoing Thirummal treatment , in which his body is covered with medicated oil and massaged delicately by hand or foot: one of the accepted techniques of Ayurveda- the "science of life ". ( Photo WHO jP. Kurup )
Cauterization , the application of heat , is a recognized form of treatment for certain mental disorders under the Tibetan sy stem of medicine, which draws on both Ayurveda and Chinese traditional healing. (Photo WHO/P. Kurup ) modern techniques for the manufacture of medicines . Traditional methods of preparing such drugs are so simple that they could be easily adopted anywhere in the world. A broad spectrum of therapeutic methods and techniques available to this science ensures that it commands im- mense popularity. The Panchakarma treatment, involving five special techni- ques, is considered the most important for metabolic management and for pro- viding detoxicating and purifying effects while conferring other therapeutic bene- fits. This is especially beneficial in the case of neurological disorders, metabolic diseases, digestive disorders and respira- tory ailments . Rasayana chikitsa is another techni- que which not only rejuvenates the body and enables the patient to live longer, but also builds up resistance against various diseases. A few other techniques which are of comparatively later origin deserve men- tion. Ayurveda recognizes certain vital 14 centres in the human body which are termed marma. To treat diseases in or originating from these marmas, certain highly effective techniques are practised in South India. The process, called Thirummal, consists of applying medi- cated oil all over the body followed by various types of delicate massage not only by hand but by foot as well. Pizhichal and Navarakizhi are other ways of treating various diseases of the nervous system or of musculo-skeletal origin and other chronic conditions. Piz- hichal is a process in which the physician drips medicated oil in a thin continuous stream at constant temperature and pres- sure on to the body and immediately applies massage. In Navarakizhi, a cer- tain variety of rice is cooked in a mixture of herbal decoction and milk, and the jelly-like semi-solid mass is then tied up in a small cloth sac. The practitioner massages the patient with this sac, mois- tening in from time to time by dipping it into the same hot herbal decoction . The Unani System owes its origin to Greece but has absorbed a great deal from native medical systems during its long journey through the Arabian coun- tries. This is again based on the theory of the humours . The temperament of each individual is expressed according to the preponderance of these humours, and drugs are determined according to the temperaments. As in Ayurveda , Unani physicians attach great importance to diet as well as medication. The Siddha System of medicine prac- tised in Tamil-speaking parts of South- East Asia also has a long and rich tradi- tion. Its unique feature is that it makes extensive use of minerals and metals, especially mercurial preparations, and has made notable advances in developing organic compound s for treating various di seases . The Tibetan system of medicine has drawn considerable knowledge from Ayurveda and has been influenced by the Chinese system. It also makes use of drugs of plant, mineral and animal ori- gin. Cauterization at special points in the head is carried out by Tibetan practition- ers in treating mental disorders. Pulse examination has attained a high degree of perfection especially in the Ayurvedic, Unani and Tibetan systems, which have established a correlation be- tween pulse behaviour and humoral im- balance. The institutionally trained tra- ditional practitioners now take advan- tage of modern diagnostic aids in their day-to-day practice. Within many of these traditional sys- tems, facilities are available for impart- ing systematic and comprehensive train- ing at graduate and postgraduate levels. In fact institutional training is almost a century old in this region. In India alone there are about 500,000 practitioners, a quarter of whom have received regular training in recognized institutions, which number about 115. Of these, 98 colleges exclusively offer training in Ayurveda, and most are affiliated to the universities. The curriculum and the period of train- ing in most of these institutions in India have now been made uniform . The degree course in these systems is spread over a period of five and a half years, including an internship of one year. The students are also instructed in modern practice in some of these institu- tions, though most of the time is devoted to teaching subjects within the medical system concerned . Other practitioners have acquired professional knowledge and skill through their forefathers or by working as apprentices under hereditary practitioners; 239 hospitals and 15 ,000 dispensaries offering treatment in these systems also exist in India. In integrating these systems within a national health care programme, the first task should be to make a proper ap- praisal of the manpower available to traditional systems of medicine, its com- petence and its capacity. Appropriate training in the shape of refresher or reorientation courses should then be of- fered to the different categories of tradi- tional practitioners . For example in the training programme for birth attendants, emphasis should be on basic education regarding pregnancy and child birth , hygiene, gynaecological complications and the basic principles of infant and child care . After providing appropriate training, all this medical expertise can be absorbed into the main stream of general health services for the rural population , so that the largest number of people can benefit from an effective and person- alized service. These traditional practitioners com- mand the implicit faith and confidence of their rural clientele, as they form an integral part of the village life. They can treat most of the common ailments which constitute almost 80 per cent of diseases. Treatment in these systems is much cheaper, and is especially effective in dealing with chronic ailments, allergic conditions and psychosomatic diseases. They make use of locally available herbs and other ingredients in their day-to-day practice, and often write out prescrip- tions with detailed instructions for pre- paring the decoction to be taken by the patient. The services of traditional heal- ers and practitioners could therefore be utilized with advantage at primary health centres in remote rural areas. If the health care delivery system is to reach the maximum number of people in the shortest possible time , and is to become a real instrument in alleviating human suffering, an open-minded ap- proach devoid of rigid dogmas is called for. No single system can thrive or be useful to all irrespective of its origin , location or merit. Anything that is good in all these systems should be made available, while false claims or ineffective practices and faulty approaches that may be currently in vogue should be eliminat- ed through intensive and systematic research . In our anxiety to make an effective, comprehensive community health service available as soon as possible to the max- imum number of people, the available material , financial and manpower resources that are rooted in traditional medical practices should not be over- looked. In order to reach the masses in the developing countries, there must be proper planning as well as a building up of health care facilities with all the lim- ited resources available . Against this background the traditional systems of medicine and their rich heritage can play a vital role as an additional or alternative approach in a country's Health Delivery Programme. • Ayurvedic tra · • BY 1(. N. UDUPA I India is one of th e few As ian cou ntri es w here Ayurveda has bee n given due recog -niti on as a system of medi -c in e for prov iding hea lth care to th e people Alth oug h there are refe rences to Ayurvedi c prin ci - pl es in Vedic li terature w ritten about 2000 B C. th e prese nt available li - terature on Ayurveda starts with Sushruta Samhita and Charaka Sam - hita . co mpiled some t ime dur ing th e fifth Century B.C From these ancient documents it appea rs th at edu cat ion in th is sc ience wa s initiall y imparted to highly se lected groups of stu - dents. In more recent ti mes it has taken more th an a ce ntury fo r a stand ard - ized and acceptabl e trai nin g pro - gramme to be introd uced in most of th e Ayurvedi c coll eges in Ind ia . Th e admi ss ion standard . and th e durati on of th e course and intern ship training . are quite simila r to th e trai ning in modern med ica l co lleges Thus afte r 1 2 yea rs of educat ion in scie nce and humanities. five years of train ing in vari ous Ay urvedi c subjects are en- visaged Peculiar to thi s training is a tho roug h grou nding in bas ic princi - pl es- the phil osophica l as pects of life. th e body -mind re lati onship. th e " humours" of th e body and th eir fun ct ion. inc luding the best meth ods for leading a healthy life accord ing to the body's constitut io n and the tem - perament Th e technical meth odology of c li - ni cal exa minati on is similar to mo - dern med ic in e. th e primary meth ods being th e c lini ca l history and a fi ve - fo ld phys ica l exa minatio n usi ng th e fi ve senses. However. greater em- phasis is given to th e constituti onal as pects of patients. their nutriti onal statu s and th ei r psychoso matic in - tegrity The pulse exa minat ion forms an impo rtant part of th e c lin ical methodo logy. The pati ent is exa mi - ned and treated as a w ho le. unlike the modern medical approach w here a larg e number of speciali sts may be invo lved simultaneously in such an examinati on. Th e undergrad uate curri culum compn ses radi o logy, path ology, parasito logy, microbio logy and prac- tical laboratory instruction . Th e Ayurvedic principl es of surgery. gy- naeco logy, child health and oth er allied su bj ects are also taught Th e train ing in surg ery in c ludes th e prin - c ipl es of management of different types of fracture. and various opera- tive and palliative procedures for such conditions as urinary stones. piles. f istula e. go itre. lymphad eniti s and hern ia Stud ents w ant ing to und ertake furth er studi es are admitted to post - gradu ate co urses leading to the award of a Doctorate of Ayurved ic Medic in e. These co nsist of three years of postgraduate train ing In the f irst yea r. th e postgraduates recei ve advan ced training in applied basic med ica l sc iences. both Ayurvedi c and modern . In th e seco nd and thi rd years they are all owed to spec ial ize in on e of th e f ive majo r disci plines- intern al medicine. Ayurvedi c surgery. obstetri cs and gyn aecol ogy, materi a med ica or the bas ic principl es of Ayurveda Doctor of Philosophy degrees in va rious specia li t ies ca n also be ob - tained at so me uni versi ties. Th is has led to co nsiderable output of re- sea rch materi al w hich co uld prove very useful in moderni zing Ayurved ic investi gati on and treatment Thu s train ing in Ayurveda . both at the und ergraduate and postgraduate level . has underg one a rap id change in recent yea rs M oderniza t ion co nti - nues and in due co urse th e d iffer- ence between the pattern of modern medi ca l training and Ayurvedi c trai n - ing w ill be minimal. to th e point w here trained Ayurvedic and modern doctors shou ld prove co mplementary to each other . Their services co uld then be utili zed fo r health care at variou s levels. and a better coopera - tive attitude between the two types of practitioners should contribute to - w ards improving th e health care of Ind ia 's vast populatio n both in urban and rural area s. • 15 -----O's Progrannne on the psychosocial and aspects of traditional medicine, on acupuncture and other healing methods, and on the claims made for herbs and medicinal plants The approach will focus anthropological BY R. H. BANNERMAN I Traditional and indigenous sys-tems of medicine have persisted for many centuries, even in parts of the world where modern health care is readily available. The idea of mobilizing the manpower component of traditional medicine for purposes of primary health care, particu- larly in rural areas, has been gaining ground in many countries in recent years. An initial beginning was made with traditional birth attendants, because of the acute shortage of trained midwives. A meeting on the training and utiliza- tion of traditional birth attendants was held in 1972 at WHO headquarters in order to develop the kind of training programmes, research and studies that could improve the services of these work- ers in their respective communities. In 1974 a joint UNICEF/WHO study on alternative approaches to meeting basic health needs in developing countries recommended the mobilization and training of practitioners of traditional medicine, including traditional birth at- 16 tendants, for primary health care services. This was endorsed the following year by an Executive Board resolution and the idea was given support at the World Health Assembly in 1977, when a resolu- tion sponsored by several Third World Member States was passed by acclama- tion for the promotion and development of training and research in traditional medicine. Several Member States have already initiated training programmes for the traditional birth attendants, and orienta- tion courses and seminars for other health professionals. In 1976, WHO's Regional Committee for Africa had " Traditional Medicine and its Role in the Development of Health Services in Africa" as the topic for technical discussion . The Regional Committee for South-East Asia also adopted a resolution in the same year calling for the promotion of traditional and indigenous systems of medicine in the Region. This was followed by a semi- nar in Colombo, Sri Lanka, that made pragmatic recommendations about how to implement trammg, service and research programmes. June 1976 saw the foundation at WHO headquarters of a working group for the promotion and development of tradi- tional medicine. Its aim was to coordi- nate the various activities relating to the subject, and it prepared a programme with the following objectives: - to foster a realistic approach to tradi- tional medicine so as to promote and further contribute to health care; - to explore the merits of traditional medicine in the light of modern science so as to maximize useful and effective practices and discourage harmful ones ; - to promote the integration of proven valuable knowledge and skills in tradi- tional and modern medicine. High priority will be given to the devel- oping countries particularly with regard to primary health care within the context of the country's political structure, eco- nomic resources and development plans. Execution of the programme will be effected in close collaboration with the regional offices and, primarily, at the Dr. R. H. Bannerman (right ) , Secretary of WHO's Working Group on Traditional Medi- cine, is greeted by Chinese Vice-Premier Chi Teng-Kuei during the recent Study Tour on Traditional Medicine in Community Health Services in China (see page 23) (Photo WHO ) country level and with active community participation . The suggested approaches include the formulation of national health policies so as to contain provisions concerning traditional medicine and mechanisms of coordination, and better utilization of the useful elements of traditional medi- cine in the country's health care sys- tem. The administrative machinery needed to ensure effective planning, uti- lization and supervision of practitioners of traditional medicine will be reviewed within the context of the national health care delivery system. A questionnaire has already been designed for the collection of all avail- able information concerning practition- ers of traditional medicine, their training and services to the community. The ana- lysis of information collected, together with the results of surveys and research findings , will no doubt assist us all in the development of meaningful training pro- grammes for the various categories of practitioners of traditional medicine. Doctors, nurse/midwives, other health workers and students of health sciences will all be encouraged to undergo orien- tation in traditional medicine where ap- propriate. Multidisciplinary investigations into systems of traditional medicine will be encouraged, and special attention will be given to laboratory and clinical investi- gations for identifying effective remedies, comprising medicinal, plants, animal products and mineral substances. Inves- tigations will also be conducted into the psychosocial and anthropological as- pects of traditional medicine, as well as the mechanisms of acupuncture and other healing methods. Wherever possible, priority will be given to the promotion and development of useful local resources such as herbs for the production of medicinal substances; such action should effectively reduce the drug bills of many developing countries. Traditional healers and some modern physicians depend to a large extent on herbs and medicinal plants for treat- ment. The story of herbal medicines is a fascinating one- quinine, until recently, was the only cure for malaria ; morphia remains a most effective pain-reliever ; rauwolfia is still widely used for the control of hypertension and certain forms of psychiatric disorder, and herbal pre- parations have been used for many decades to treat rheumatoid arthritis . Recently, we have received serious claims that herbs are being used in China, tropical Africa and Central America for the control of diabetes mel- litus. All these claims have to be invest- igated scientifically and authenticated. There are clear indications of a major breakthrough in therapeutics and health care delivery, and those of us involved in the traditional medicine programme share fully the goal of our Director- General, that we should achieve total health care coverage for all people by the year 2000. • 17
New status for the hilot When 75 per cent of births turned out still to be handled by hilots-traditional birth attendants- the Philippines' Department of Health decided to re-train them and bring them into the health team BY AMANSIA MANGAY-ANGARA Traditional birth attendants- hi/ots- have probably been practising their skills in the Phil- ippines since the earliest history ... ..,.... of the country's predominantly Malay population. This is suggested by the similarity of hilot practices with those of the bidan of Malaysia and the dukun of Indonesia . Such practices pro- bably emerged out of the necessity for mutual help among womenfolk in the small villages many centuries before modern medicine was introduced to the country . ln the traditional village society there have always been such categories of indi- genous healers as the herbalist, the bone setter, the faith healer and the hilot. The latter usually confines her activities to attendance at birth and to the care of the newborn child. Her services vary but often include offering such assistance with household chores as is traditionally demanded by good neighbourly practice in the village. It is largely through main- taining this combination of services to the mother, the child and the household that the hilot has survived and continues to be accepted by the local community to the present day even though modern health care has since become available to the rural population . Unfortunately, the hi lot's practices have time and again contributed to maternal and infant morbidity and mar- Mrs Rosa Raymundo , a traditional birth at- tendant , dons a plastic apron before bathing a newborn child, as she has been taught during special training. (Photo WHO fl . Abcede ) Traditional Birth Attendants Still the greatest barrier to < ~e.alizing the proper potential of traditional birth attendants (TBAs) today is the resistance of some professional health workers. · Bu.t TBAs still deliver two - thirds of the babies in the world . In Asia. Africa and Latin America they are accorded, for the most part very , high prestige in theif villages. Several countries have already started on-going training programmes for th,~~~ women. to e..nsure that they offer safe midwife'ry practices where they will be most eff~ctive. Other countries are beginning to encourage them and g,ive them additioqal training so as to >gain for them increasing involvement in primary health care activities. Several countries have also tried to explore thei{ full potential in family planning programmes. They have proved capable of making useful con- tributions to family planning com- munication activities in Indonesia (where they are known as dukuns). Malaysia ·(as bidans) , Mexico (as parteras) and India (as dais). There is probably no reasonable alternative for government maternal health and family planning programmes but to join hands with TBAs. The findings and . recommer)dations of various studies have repeatedly shown that thei ,enjoy a relatively high' degree of cr edibil'ity in ,the eyes of villagers and the urban poor. while their potential for incorporation as partners in public Health vyork is a very practical reatity. · tality. She performs very few manipula- tions during childbirth; the newborn is passively received under cover of a cloth to conceal the mother's private parts. Although some complications in the mother may result from errors of omis- sion by the birth attendant, such as fai - lure to protect the perineum, others may follow acts of commission such as apply- ing manual pressure on the fundus of the uterus to facilitate expulsion of the fetus, causing a subsequent rupture. In the case of the newborn child , errors of commis- sion are frequent ; it is common for the umbilical cord to be cut with a non- sterilized knife or bamboo blade and the application of some powder, chopped tobacco leaves or even dried horse manure on the cord dressing. Practices of this nature are responsible for the high incidence of tetanus of the newborn in the Philippines. Until around the early 1950s the Government' s general attitude had been to discourage hilot practice and to pro- mote their replacement by trained licensed midwives . In 1954, the Depart- ment of Health reviewed the prevailing status of midwifery services and found that a large proportion of births (about 75 per cent) were attended by traditional midwives. While infant and mortality rates were high, available trained health manpower was grossly insufficient to meet the demands for midwifery services, particularly in the rural areas. Largely as a consequence of these find- ings, and of the realization that while the country's population was rapidly on the increase its health resources were insuffi- cient, a revised strategy was evolved. 19 This included some concessions to hilot practice in localities where the services of practising physicians or registered mid- wives were not available. Within this new policy frame, traditional birth attendants would receive such training and orienta- tion on hygienic procedures and routine midwifery practices as would promote the safety of the mother and the newborn child; they would also be given health staff supervision and guidance in the course of their work. In 1954, with WHO and UNICEF assis- tance, the Department of Health initiat- ed the training of hilots as part of the country's midwifery training pro- gramme. Priority was given first to staff involved in teaching and supervision such as nurse-midwife supervisors at the central level, then at the regional and later at the provincial and local levels. This was followed by a teaching pro- 20 gramme to make hilot practice safer for mothers and to encourage the birth ·at- tendants to seek guidance and assistance from the trained health personnel. This training was first conducted by a provincial nurse supervisor who had herself undergone training under the midwifery training programme. Her un- derstudy was a nurse or midwife of the rural health unit or puericulture (mother and child health) centre, who took over as instructor of subsequent hilot classes. The classes are usually organized in groups of ten, and the course consists of 12 weekly or bi-weekly meetings each lasting three hours. Instruction is given in the local dialect. A hilot who satisfac- torily completes a course is given a UNICEF midwifery kit and issued with a record book to insert the necessary infor- mation needed to register the birth of the child she has delivered or report any New status for the hilot Left : Hilot Asuncion Sag ins in pays a pre- natal visit to a patient. The Philippines' Government has introduced a teaching pro- gramme to make hilot practice safer for moth- ers and to encourage the traditional birth attendants , to seek guidance from trained health personnel when needed. Right: Nurse Felicitas Bautista graphically explains to a class of hilots-in-training the basic steps to be taken when · attending deliv- eries. (Photos WHO fJ. Abeede) ~ ', ..... birth which has not yet been registered. After training, the birth attendants orga- nize themselves into a local association which holds monthly follow-up meet- ings. At these meetings, the nurse or midwife of the rural health unit inspects their kits and evaluates reports of their activities. Now that official recognition has been given to the trained hilots, and with the increasing acceptance of the health aux- iliary or aide in providing health care, the hilot is being encouraged to get herself involved in a wider variety of community health activities. These in- clude helping to notify communicable diseases, organizing mothers' classes, registering births, helping to arrange mother and child referrals to the health centre or hospital, participating in the housekeeping at the health centre, assist- ing in community immunization round- ups and collaborating in the family plan- ning programme by motivating mothers and following up those who accept the services. On the whole, hilot training and the broadening of her participation in community health work have forged stronger links between the traditional birth attendant and the local health staff. She has thus become an important resource in the local health service even though she is still not a member of the health team. She receives neither com- pensation , honorarium nor daily wages for her services. The remuneration she receives from the mother may be in the form of a gift or sometimes in cash, but more often her services amount to simple acts of goodwill and good neighbour- liness. The Government's goal of ultimately replacing the hilots with licensed mid- wives remains unchanged. But consider- ing the limited resources and the magni- tude of existing health problems, it will take some considerable time before the Government's goal can be achieved. Therefore the stop-gap arrangements for training the hilot and involving her in health services are proceeding with more active Government support as well as the endorsement of various sectors of the local community. Increasing attention is being given to the hilot as a potential health manpower resource capable of being trained and guided to respond to local community health demands, partic- ularly for mother and child care. With a view to obtaining more accu- rate information about the hilot man- power resources in the country, the Department of Health carried out a nationwide survey in 1974 with the help of a WHO grant. The objective was to obtain information on the number of traditional birth attendants in practice, where they live and other useful data which would enable central and local hilot registries to be drawn up. More than 31,000 hilots- both men and wom- en- were identified . On the basis of the findings it was calculated that the total number who were in practice was be- tween 38,000 and 40,000, or roughly a ratio of one hilot for every barangay- the smallest local administrative unit with an average population of 1,000 to 2,000. The registries that have since come into existence will help in identifying those birth attendants who need training and in locating their homes, and will thereby facilitate their supervision by the local health personnel. The registries will be kept constantly up-to-date and will furnish other useful information which will help in designing the hilot training courses in the coming years. • 21
Study ToliT in China Community health specialists and senior health administrators from 29 developing countries con- verged on Peking in August to begin a Study Tour on traditional Chinese medicine arranged under the auspices of WHO and UNDP. Dr Bannerman of Ghana acted as Team Leader to the group, and is also the Secretary of the Working Group on Traditional Medicine at WHO head- quarters. On his return to Geneva he was interviewed for this special issue of World Health. WH : Dr Bannerman, what was the objec- tive of' this Study Tour involving so many senior health officialsfrom the developing countries ? BA NNERMAN : The main purpose was to give participants the opportunity to st ud y how China has harnessed its pre- cious legacy of traditional medicine to the needs of its vast rural populations, and has combined the traditional Chinese sys tem with " Western " medi- cine. The group had the opportunity to study the training of health personnel including practitioners of traditional Chinese medicine and the barefoot doc- tors. We also learnt something about the use of medicinal herbs, the preparation and production of pharmaceuticals and the use of special methods such as acu- puncture for treating various disorders and for anaesthesia. The study was in fact multisectoral, and we were exposed to agricultural and irrigation projects, housing schemes, rural development and so forth. WH : One gets the impression that the division which is very noticeable in the rest of the world between "orthodox" and "traditional" medicine is much less pro- nounced in China. Is this the case, and to what degree has the older system been integrated with more modern aspects of medicine ? <l A veteran herb grower shows a team of medical workers how to distinguish medicinal herbs during a plant-gathering session on the slopes of Mount Huangshan , China. ( Photo WHO/Chinese Ministry of Health ) BANNERMAN: As was emphasized by the late Chairman Mao, traditional C hinese medicine has a great storehouse of knowledge . C hinese pharmacology is therefore being integrated and various in st itutes and hospitals for the practice of Chi nese medicine have been established. At the first national health conference held in 1950, three principles were adopted : firstly , to serve the wod·kers, peasants and soldiers; secondly , the pre- vention of disease ; and thirdly , integra- tion of traditional Chinese and " West- ern" medicine. In 1953 , Premier Chou En-Lai endorsed the fourth principle: " to combine health work with mass movement". The people are educated to combat disease by themselves and not to rely exclusively on health workers. The difference between "orthodox" and " traditional" medicine is therefore much less pronounced in China. Many of the orthodox-trained doctors receive orientation in traditional Chinese medi- cine and practise both systems. It has therefore become difficult to draw a defi- nite line between the two. Their attempts a t integration have evolved into what they now call the 'New' traditional Chinese medicine, which can be de- scribed as the application of modern scientific principles to the traditional Chinese system. The integration of tradi- tional Chinese and modern medicine is now an established policy and is by no means an expedient. Veteran practition- ers are involved in shaping the ' New' traditional Chinese medicine. Some teach in medical colleges and are often consulted in matters relating to medici- nal herbs and plants. In 1965, priority in health work was given to the rural areas where 80 per cent of the population live. The doctors are now community oriented and 70 per cent of the graduate doctors work in rural areas. The "mass-movement" has been responsible for the virtual extinction of the four pests- rats , flies , mosquitos and bed-bugs. WH : What did you see which might be regarded as the kind of simple medical technology that might well be transferred to and adapted by other countries? BANNERMAN: Offhand, I would say the use of acupuncture for the treatment of disease, the relief of pain and for pur- poses of anaesthesia. About 70 diseases can be treated with acupuncture alone and some 200 when used in combination with herbal medicines. Training in the use of acupuncture is essential, if the transfer of this technique is to be truly beneficial. The equipment is relatively simple and, in essence , all that one needs is the acupuncture needle which can be inserted into the appropriate point and rotated to and fro with the index finger and thumb. But recently an electrical machine has been developed which intro- duces regular electrical pulsations to the needle and thus produces the desired effect. The application of acupuncture for purposes of local and regional anaesthe- sia is well developed . Many procedures on the head and neck, such as dental extractions, and eye, ear, nose and throat operations were demonstrated . We also saw major abdominal operations like total hysterectomy and prostatectomy- all under acupuncture anaesthesia. 23 We saw the highly successful treat- ment of extensive burns in the general wards by the application of only one set of surgical dressings medicated with medicinal herbs and without resort to specially equipped intensive care units ; the management of fractures by employ- ing small padded splints ; and the care of patients with acute abdominal condi- tions such as perforated peptic ulcer , appendicitis and extra-uterine pregnan- cy- all of these by combined traditional Chinese and " Western" methods. All these could be readily replicated in many developing countries . The techniques for preparing medicinal herbs and plants as powders, tablets and liquid extracts us- ing relatively simple locally manufac- tured equipment proved of great interest to us. What might perhaps be more difficult to emulate is the capacity for hard work, resourcefulness, motivation 24 and discipline we encountered m every community we visited . WH: Is the famous barefoot doctor part of the traditional system or is he regarded as a totally modern phenomenon of Chinese public health ? BANNERMAN: The well-known barefoot doctor is very much part of the tradi- tional Chinese system. They used to be called "peasant doctors", but acquired the title " barefoot doctor" not because they walk barefoot but as a reminder of the fact that many of them spent a greater part of their time with other members of the community in the rice- paddy fields . Barefoot doctors are trained in the first instance for six months, and those who show keen interest in health work and Study Tour in China Left: The simplest of equipment suffices to prepare traditional herbal medicaments and roll them into pellets. The pharmacopoeia of traditional Chinese medicine has long proved to be a great storehouse of knowledge. (Photo WHO/R. Bannerman) Right : Health students practising acupuncture techniques on each other. An acupuncture needle carefully planted above this girl's nose will act as a local anaesthetic. The application of acupuncture for local and general anaesthesia is well developed in China, and is used even for major abdominal operations. (Photo WHO/L. Ambrose) wish to follow it as a profession can become fully qualified doctors through further training in colleges . Work as a barefoot doctor has now become an im- portant entry point to medical college and university . On the average, they spend about two-thirds of their time each year in agricultural work and industry and the rest in health work. They are very much a part of their community and are selected initially for health work by members of the community. WH: Your colleagues during the Study Tour came from all parts of the world. Do you feel that they had ideas to offer which China might find worthwhile taking up and adapting ? BANNERMAN: We were asked this ques- tion in various forms during the tour. None of us could really make any con- crete suggestions. We have to remind ourselves that China has a population of an estimated 850 million. The basic necessities such as electricity, water sup- ply, adequate sewerage and refuse dis- posal were available equally in both ur- ban and rural areas. The people ap- peared well nourished and adequately housed; everybody was well clothed and nobody wore rags or went barefoot. We were told that there was total employ- ment with generous pension schemes for women at 55 years and men at 60, ade- quate educational facilities and , of course, total health care for all. There was no evidence whatsoever of the infla- tionary trends that have recently gripped the rest of the world . In a situation like this one could only marvel and wish a friendly people greater success. There could, however, be greater mechanization especially m agricul- ture- provided that did not cause unem- ployment in any way. I personally con- sidered the absence of private motor cars from the roads a great boon, and the use of bicycles contributory to good health . WH: It will no doubt take some time for the ideas exchanged during the Study Tour to be evaluated. What use is WHO going to make of its new view on tradi- tional Chinese medicine? BANNERMAN: We prepared a question- naire for the participants before the tour started and happily there was 100 per cent response . Every participant stated that the tour was truly worthwhile and should be repeated for other, smaller groups on a yearly or even twice-yearly basis. Many took the opportunity to re- examine their own priorities and decided that national priorities in several coun- tries required urgent review. Health problems were never presented in isola- tion and the part played by agriculture, housing, jobs, water supply, and educa- tion (academic, technical and political) were all very obvious to the discerning eye. The developing countries certainly have a great deal to learn from China, and WHO could well make an in-depth study of the 'New' traditional Chinese system, particularly in terms of cost benefits and technical cooperation, with a view to adapting the system for use in various developing countries that might be interested. The most attractive feature to us from the developing countries is the extent to which China has improved the quality of life of her people and achieved total health coverage within one generation. There is no such parallel in ancient or modern history . China is unique! • 25 Plants that heal Plant screenLng has often yielded poor results because traditional healers were not involved; but the advice of good healers ensures at least a 50/50 chance of success I When, some years ago, I started showing interest in African tra-ditional medicine, like many other investigators in this field I doubted the efficacy of ahy of the claims made by our local healers . Time soon proved me wrong, and luck too came to my aid. It was not difficult to establish contact with two well-known herbalists in my district and they were most willing to pass on their age-long knowledge. They were both octoge- narians with long years of practice behind them and were trusted and re- spected by their patients . I also learned to respect them for their wide knowledge of plants and diseases , their frankness and wealth of human experience. Every other week I would go with one of them into the bush, collect plants and learn about their uses. These old herbalists were great botanists and knew something about every plant we saw in the bush. They each identified at least 200 plants with healing properties. These traditional herbalists treated a wide variety of diseases and injuries, apart from offering maternal and child care. One day, one of our modern-trained district midwives was faced with a case of severe post-partum haemorrhage, and she later told me that she actually ran to 26 BY OI(U AMPOFO find a taxi to carry the patient to my clinic. On her return she was surprised to see the patient washing her baby. Her bleed- ing had been arrested by one of the old herbalists who lived a few yards away. It was this incident which first put me in touch with this herbalist. I later learnt of some interesting cures from other local herbalists, found out about their methods and tried them out in my practice . As Director of the new Centre for Scientific Research into Plant Medi- cine in Ghana, I now have greater oppor- tunity for doing clinical trials with tradi- tional methods. It is my contention that to achieve any success in the field of research into tradi- tional medicine, we have first to acquire our knowledge from the traditional heal- er himself, try out his methods clinically and then, if successful, subject them to scientific analysis. Many plant screening programmes have not yielded any fruit- ful results because traditional healers have not been involved in these trials; but experience shows that with the ad- vice of the good healers there is at least a 50/50 chance of success. In our clinical trials with medicinal plants, our aim has not only been to find cures for diseases in which "Western" medicine is ineffective but also more particularly to find substitutes for im- ported drugs. Here are two examples. The Public Health Department of our Medical School recently asked us to help them to fight an epidemic of guinea- worm in three nearby villages. In pre- vious years, attempts had been made to treat the yearly epidemic with a combi- nation of procaine penicillin and dif- ferent proprietary drugs. The 88 people involved in this trial included 18 chil- dren , 20 bed-ridden adults and 50 ambu- lant adults . These were divided into two groups of 44 people each. The first group was put on a decoction of pieces of root of Combretum mucronatum, a known worm-expeller, at a calculated dose of .03 gmjkilo. The second group was given a decoction of Mitragyna stipulosa which looks like Combretum mucronatum ; the calculated dose was .06 gm/kilo. Patients were examined twice weekly . After one week , examination revealed that there was complete extrusion of the worms in 43 out of 44 in the first group (i.e . 97.7 per cent) and there was marked reduction in the inflammation around Herbalists at a centre for African traditional t> medicine learn how to prepare and process roots so as to make the best of their healing properties . ( Photo WHO/R . da Silva )
Hille ria latifolia - Phyto- laccaceae Myrianthus arboreus - Moraceae the lesions. The wounds healed com- pletely after two weeks with local appli- cation of sterile palm oil. In the second group, there was complete extrusion of worms in 23 out of the 44 cases (i.e. 52.2 per cent), with healing of the wounds after local application of palm oil in two weeks. Thus, it was proved that Combre- tum mucronatum-as the traditional her- balists claim- is indeed a true expellent of guinea-worm. We were also able to prove that the leaves of Elaeophorbia drupifera and Hil- leria latifolia, taken in combination in a palm soup preparation, act as a filaricide in guinea-worm infestation. Skin diseases have particularly en- gaged our attention and we have had success in the treatment of coccal infec- tions, epidermophytons, allergy and herpes zoster. Four traditional treat- ments of herpes zoster are particularly interesting. The local application of the flowers of Hoslundia opposita and red cola nut, chewed together and sprayed on the lesion twice a day, often heals it within a fortnight. The local application of guava leaves, ground into paste with 28 Securidaca longipedunculata - Polygalaceae Picralima nitida- Apo- cynaceae kaolin or white clay and Piper guineense twice a day, heals the infection in about ten days. Alternatively, the root of Picra- lima nitida is charred with Piper guineense and ground into fine powder, mixed with kernel oil and applied to the infected area with cotton wool twice daily; for internal application, the black powder is mixed in alcohol and taken, one dessertspoonful thrice daily, to allay pains; this treatment is very effective and healing takes place in 10-14 days. But perhaps the most dramatic form of treat- ment is the use of the root bark of Bala- nites aegyptiaca, ground into fine pow- der, then made into a paste with water and applied to the infected area morning and night; healing occurs from five to seven days. A similar result is obtained with Securidaetl- longipedunculata root bark, which is also useful in treating psoriasis and possesses anti-convulsive properties. Guinea-worm and herpes zoster are some of the diseases for which modern medicine has so far no effective remedy. Traditional African medicine appears to be more effective. Plants that heal Left: Hille ria latifolia has been proved to act as a filaricide in cases of guinea-worm infesta- tion. The bark of Securidaca longipedunculata is useful in treating psoriasis and also has anti- convulsive properties. Myrianthus arboreus ; a decoction made from its bark appears effective against diabetes. When suitably prepared, the root of Picralima nitida can heal the sk in disease herpes zoster in the space of two weeks. Right: This woman has come to consult a healer at a centre for traditional medicine. Such healers are respected in their local com- munities for their wide knowledge of plants and diseases as well as for their understanding and wealth of human experience. (Photo WHO JR . da Silva) Two other diseases for which tradi- tional African medicine appears to be more effective and less risky than mod- ern medicine are diabetes mellitus and bronchial asthma. For some years now, we have been studying the work of her- balists who treat diabetes mellitus, some of whose remedies come mainly from herbal preparations. In particular, the anti-diabetic activity of herbs of the Loganiaceae family has been confirmed by our University of Science and Tech- nology. One teacher herbalist claims as high as 75 per cent of "cures" among his diabetic patients treated with the Loga- niaceae family. He has successfully treat- ed a patient who developed gangrene and ketosis even though he was on insulin injections. A thorough investigation into the anti-diabetic property of the Loga- niaceae seems to be called for. The combination of Canthium and Myrianthus bark as decoction or alcohol- ic "bitters" also appears effective. One patient had his diabetes mellitus arrested when he was treated with this extract for two months. His fasting blood sugar has been normal since. Another colleague who practises dentistry in England per- suaded a physician friend to try the alcoholic extract on two English patients with juvenile diabetes five years ago. After two months treatment, it made no impression on one case but the second improved considerably and her fasting blood sugar has remained normal ever since. They were both on insulin. Costus schlechteri is another plant claimed by some herbalists to be effective against diabetes mellitus, and our observation is that this plant is effective in some early cases. It is in the use of Bridelia ferruginea for controlling diabetes mellitus that I have acquired more experience and hope for the treatment of diabetes. Of the 12 cases under treatment, I have selected three as showing typical reactions to the plant. Patient M.A. , a woman aged 49 years, reported in May 1976 and had been receiving insulin injections, 44 units daily for the last two years. Her fasting blood sugar was 242 mgm/ 100 ml. The patient looked worried , did not want any more insulin and preferred herbal treatment. She was put on one dessertspoonful of powdered Sclerocarya birrea leaves twice daily but at the end of the third week, her fasting blood sugar had risen to 340 mgm/ 1 00 ml. Treatment was discon- tinued and the patient was put on a chlor- propamide preparation, 250 mg twice daily for ten weeks. There was mild im- provement but the patient wanted to try another herbal treatment. In August 1976, she was put on Costus schlechteri as recommended by a herbalist. Her fast- ing blood sugar rose to 250 mgm% and it was decided to try Bridelia ferruginea- ten leaves boiled with one pint of water, one teacupful to be taken three times daily as recommended by a herbalist. There was a steady lowering of the fast- ing blood sugar till it became normal after 12 weeks, and it has since remained normal. Patient L.B., a woman aged 45 years, reported for treatment of her hyperten- sion. Routine examination revealed that she had diabetes mellitus with fasting blood sugar of 370 mgm% . We decided not to give her any "Western" drugs and put her straight on Bridelia ferruginea- 20 leaves boiled in a pint of water, one teacupful being taken three times daily. After one week the fasting blood sugar came down by 120 mgm% and conti- nued to fall till it became normal after 11 weeks. It has since remained normal. Incidentally, no treatment was given for her hypertension which also automati- cally fell from 180/90 to 140/90. Mrs T. 0. , aged 59 years, is another typical case. She has been a diabetic since 1969, and first reported to us in April 1975 for a prescription for more of the proprietary tablets which she had been taking daily . Her fasting blood sugar was 252 mgm% and it ranged between 190 mg and 285 mg for 16 months until October 1976 when we decided to put her on Bridelia leaves. There was no signifi- cant change for three months and the dosage was increased by 50 per cent. After another two months, the dose was doubled as the fasting blood sugar conti- nued to rise. There was still no significant change for two months and the patient was put back on her tablets. It was then discovered that the patient had been secretly taking both Bridelia and the tablets together and we concluded that 29 Watched by two village women, a herbalist explains the contents of a pot of mixed herbs and roots to a visiting official (in white suit ) . (Photo WHO/R . da Silva ) this may have accounted for the ineffec- tiveness of the former. It would appear that the traditional drug and the modern one acted as antagonists here. This is true of other patients who are over- anxious to get well and take both drugs, while patients who take alcohol during Bridelia treatment also show no im- provement. My own experience in the prophylactic use of plants for bronchial asthma will be supported by Professor Marian Addy, who has used the same materials in ex- perimental animals. Drugs used for bronchial asthma in modern medicine are mainly applied during attacks whereas medicinal plants can be used prophylactically until attacks are well reduced or completely eliminated. Of the 30 many plants available for bronchial asth- ma the following have been most widely used at our Centre: Desmodium adscen- dens- Papilionaceae, Thonningia san- guinea- Balanophoraceae, and Deinbol- lia pinnata- Sapindaceae. The leaves of Desmodium adscendens can be given in the form of dry powder, one to two teaspoonfuls, according to age, in warm water in three divided doses per day, or it can be made into alcoholic extract. Thonningia sanguinea root is pul- verized and dried . Two dessertspoonfuls of the powder are mixed thoroughly in ten ounces of honey and given in doses of one teaspoonful to one tablespoonful thrice daily. This too can also be pre- pared in the form of alcoholic extract. Dry, powdered Deinbollia pinnata root bark is used differently : one to two teas- poonfuls of the powder may be taken according to age in palm soup every other day for two to three weeks, and it can also be taken in soda water. Each of these preparations is capable of deferring bronchial asthma attacks or even stopping them, especially in chil- dren. But the best result we have ob- tained at our Centre is the administra- tion of a combination of Desmodium adscendens and either Thonningia or Deinbollia. We undertook a "double blind" clini- cal trial during which 12 randomly selected patients were treated with place- bo herbs, that is, drugs having no therapeutic value, for three months and then for a second period of three months with combinations of Desmodium, Dein- bollia and Thonningia. The results were quite clear. All the patients continued to have asthmatic attacks during placebo treatment, but eight of them had no attacks during the herbal therapy . Some of the remaining four had decreased attacks, but the response to the com- bined herbs was judged less than satis- factory . From our point of view there is no question that Desmodium and the other herbal preparation produced a satisfactory response in 75 per cent of the patients . • PORTUGAl AND WHO WORK TOGETHER Portugal's health authorities first in- vited environmental health experts from WHO to visit the country in 1974. following a sudden outbreak of cho lera . In October 1976, at the Government's request. a joint WHO / World Bank team carried out an extens ive country-wide sector study of the water supp ly and waste disposa l cond itions. This study pro- vided Portugal w ith an overa ll pic - ture of the ex ist ing situation. indi - cated the constraints that were then limiting the development of this vital sector. and suggested an acti on programme for immediate and long - term improvements. One result of the activities that fol - lowed was the convening of a semi- nar on " project preparation and evaluation" organized by WHO and held in Lisbon last July Thirty-five Portuguese engineers participated in the seminar. which gave them an opportunity to acquaint themselves with new trends in planning , design, and econom ic and financial evalua- tion. Now a project of assistance to the basic sanitat ion sector. with backing from WHO and the UN Develop - ment Programme (UNDP) . has just started. at an estimated cost of US $250.000. The project w ill last for two and a half years and WHO has been designated as Executing Agency . A furth er result of the 1976 sector study was the ident ification of such investment projects as water supply and sewerage for Lisbon and Oporto. the second - largest c ity . The World Bank is expected to assist in financing these schemes. and in the first instan ce a loan is being consid- ered for the improve ment of Li s- bon's water supply. GREETING CARDS WHO' s new programme of Appro - priate Techno log y for Health was g iven the task of designing this sea- son's greetings cards for the Organi - zation. In fu ll co lour and w ith the theme "Through to a better w orld ". the cards may be ordered from : The WH 0 Staff Assoc iat ion. WHO. 1 211 Geneva 27 . Switzerland. or from any of WHO' s Regional Offices in Alex - andria . Brazzaville. Copenhagen. Manila. New Delhi and Washington. The price is US $3 or 8 Swiss francs per packet of ten . and each card is within the airmail limit Any profits from the sale of the cards wil l go to WHO's Voluntary Fund for Hea lth Promotion. In the next issue The December issue of World Health will be concerned with Mental Health. and wi ll show how certain countries are dealing wi th this problem within the framework of their health services . Authors of the month Dr H. MAHLER is Director-General of the World Health Organization. Mr J. DAUTH, formerly Press Offi- cer at the Embassy of the Federal Republic·clfGermany in Malaysia, is now working as a journalist in Malaysia. Dr X. Lozov A is the Co-ordinator of the Mexican Institute for the Study of Medicinal Plants (IMEPLAM) in Mexico City. Dr P.N.V. KuRUP is Adviser to the Government of India for Indi- genous Systems of Medicine. Dr K. N. UoUPA is Professor of Surgery and Director of the Insti- tuteofMedical Sciences at Banaras Hindu University, Varanasi, India. Dr R. H. BANNERMAN is Secretary of the Working Group on Tradi- tional Medicine at WHO head~ quarters in Geneva. Dr A. MANGAY-ANGARAisChief of the Division of Maternal and Child Health, · Department of Health, Philippines. Dr 0 . AMPOFO is Director of the · Centre for Scientific Research into ' Plant. Medicine at Mampong- Akwapim, Gha.na. 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