alternative medicine

Traditional Medicinein Asia

Edited by

Ranjit Roy Chaudhury

Uton Muchtar Rafei

World Health OrganizationRegional Office for South-East Asia

New Delhi

Traditional Medicine in Asia

ii

This document is not issued to the general public, and all rights are reserved by the World HealthOrganization. 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 bestored in a retrieval system or transmitted in any form by any means - electronic, mechanical orother without the prior written permission of WHO.

The views expressed in this publication are those of the authors and do not necessarily reflectthe decisions or stated policy of the World Health Organization; however they focus on issues thathave been recognized by the Organization and Member States as being of high priority.

Layout and Design by

New Concept Information Systems Pvt. Ltd. New Delhi, India

SEARO Regional Publications No. 39

© World Health Organization 2001

Photographs on cover page (clockwise)Acupuncture is widely used in hospitals of western medicine (courtesy Prof. Chen Qui-Ting)Yoga postureA herbalist, preparing fresh herbal medicinesCrocus sativus - source of saffron

ISBN 92 9022 2247

Contents

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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 oftraditional medicine practitioners who provide help and service to the ill and theneedy. Some of these practitioners are qualified doctors who have taken a five-yearcourse in the system of medicine they practise; there are others who have learnttheir system of medicine and the use of the different plants from their forbears,while there are still others who offer their services after working with practitionersand learning from them.

It is important that this unique knowledge, often found in ancient texts, be utilizedby countries to the maximum extent possible without endangering the environmentand 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 thesesystems and the products and plants they use could be more effectively utilized forthe benefit of the countries and their people. Greater use could be made of thesemedicinal plants at the primary health care level so that all persons could have recourseto herbal medicine–particularly those living in areas without any allopathic healthcare coverage. Further research directed at a few of the chronic diseases againstwhich more drugs are needed, such as diabetes, bronchial asthma and arthritis,could lead to the discovery of new drugs for these conditions. Regulated and selectiveexport of some of these medicinal plants being eagerly sought after in other parts ofthe world could considerably enhance the foreign exchange earnings of countrieswith this biodiversity. Careful planning is needed so that such a programme could belaunched without detriment to the environment and without reducing the availabilityof the medicinal plants in the countries. The very large numbers of trained andsemi-trained practitioners of the traditional systems of medicine could become moreinvolved in the national health care systems of the countries. Such involvement cancome about only as a result of some regulation of the systems being followed, theproducts used for health care and the practitioners of such systems.

Preface


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

It is important also to take steps to ensure that unethical and unjustifiedexploitation 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 Regionby scientists and research workers who are carrying out research and discoveringand documenting the effectiveness of the plants used.

The WHO Regional Office for South-East Asia has published this book in orderto present to the governments, policy-makers, clinical investigators, regulatoryauthorities, 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 informationin 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 inmaking better use of them.

The book is divided into three sections. The first section describes broadlyseveral of the systems of traditional medicine in the countries of the Region. Thesecond discusses policy issues such as harmonization of traditional and modernmedicine, the role of traditional systems of medicine in national health care, aframework for cost-benefit analysis of traditional and conventional medicines, andthe development of training programmes. The third section discusses technical issuessuch as legislation and regulation, standardization, pre-clinical toxicology and clinicalevaluation, including ethical considerations and protection of traditional systems ofmedicines 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 oftraditional medicine in each of the 10 countries of the Region.

We are grateful to the contributors for not only accepting readily our invitationto contribute to this book but also for adhering to the time frame. We are alsoindebted to Dr Palitha Abeykoon of the Regional Office for his help in planning thebook, and to Mr S. Khanna, Administrative Assistant at the Delhi Society for thePromotion of Rational Use of Drugs, for his contribution at all stages in the preparationof this book.

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SYSTEMSAyurveda 3

Dr. P.N.V. Kurup

An overview of traditional Chinese medicine 17Dr. Hongguang Dong

Dr. Xiaorui Zhang

Unani medicine 31Hakim Syed Khaleefathullah

Traditional system of medicine in Indonesia 47Dr. Lestari Handayani

Dr. Haryadi Suparto

Dr. Agus Suprapto

Koryo system of medicine in DPR Korea 69Dr. Choe Thae Sop

Chinese Acupuncture-Moxibustion 75Prof. Deng Liangyue

Fundamentals of Yoga 93Swami Niranjanananda Saraswati

and Dr. Rishi Vivekananda Saraswati

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POLICY ISSUESHarmonization of traditional and modern medicine 115

Prof. Zhu-fan Xie

Role of traditional systems of medicine in national health care systems 135Mrs. Shailaja Chandra

A framework for cost-benefit analysis of traditional medicine 159and conventional medicine

Dr. G. Bodeker

Development of training programmes for traditional medicine 183Dr. Palitha Abeykoon

Dr. O. Akerele

TECHNICAL ISSUESLegislation and regulation of traditional systems of medicine– 195systems, practitioners and herbal products

Dr. D.C. Jayasuriya

Dr. Shanti Jayasuriya

Standardization, pre-clinical toxicology and clinical evaluation of 209medicinal plants, including ethical considerations

Prof. Ranjit Roy Chaudhury

Dr. Mandakini Roy Chaudhury

Protection of traditional systems of medicine, patenting and promotion 227of medicinal plants

Prof. Carlos M. Correa

Research, drug development and manufacture of herbal drugs 247Dr. B.B. Gaitonde

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CURRENT STATUS - COUNTRY SITUATIONTraditional medicine in the WHO South-East Asia Region 273

Dr. Kin Shein

Traditional medicine in Bangladesh 275Dr. Md. Aftabuddin Khan &

Dr. S.K. Chowdhury

Traditional medicine system in Bhutan 279Drungtsho Dr. Pema Dorji

Koryo medicine of Korea 281Dr. Choe Thae Sop

Indian system of medicine and homoeopathy 283Mr. L.V. Prasad

Native traditional medicine in Indonesia 287Dr. Ketut Ritiasa &

Dr. Niniek Sudiani

Dhivehibeys in Maldives 289Dr. Abdulla Waheed

Indigenous medicine in Myanmar 291Dr. U. Kyaw Myint Tun

Traditional medicine in Nepal 295Dr. Rishi Ram Koirala

Indigenous system of medicine in Sri Lanka 299Dr. Lal Rupasinghe

Thai traditional medicine as a holistic medicine 301Dr. Pennapa Subcharoen

List of contributors 307

SystemsAyurveda

Dr. P.N.V. Kurup

An overview of traditional Chinese medicineDr. Hongguang DongDr. Xiaorui Zhang

Unani medicineHakim Syed Khaleefathullah

Traditional system of medicine in IndonesiaDr. Lestari HandayaniDr. Haryadi SupartoDr. Agus Suprapto

Koryo system of medicine in DPR KoreaDr. Choe Thae Sop

Chinese Acupuncture-MoxibustionProf. Deng Liangyue

Fundamentals of YogaSwami Niranjanananda Saraswatiand Dr. Rishi Vivekananda Saraswati


2

Ayurveda

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Athe Indian subcontinent and has beenpractised since the 12th Century BC.Ayurveda is not merely a system of medicine;rather it is a way of life. Its objective is toaccomplish physical, mental, social andspiritual well-being by adopting preventiveand promotive approaches as well astreating diseases with the holistic approach.1The theory of Loka Purusha Samya2 –macrocosm, microcosm continuum,Panchamahabhuta, Tridosha, Dhatus,Prakriti and Vikriti, Agni and Ama – is theunique concept of Ayurveda. Ayurveda iseffective not only in common ailments butalso in many incurable, chronic anddegenerative diseases as well as iatrogenicconditions. It not only takes care of thehealth of human beings but also of animalsand plants, known as Pashu Ayurveda andVriksha Ayurveda, respectively. Ayurveda isprevalent not only in India but also in Nepal,Sri Lanka, Mauritius, Bangladesh, Pakistan,Indonesia, Malaysia, Singapore, Maldives,etc. The traditional systems prevalent inMyanmar, Bhutan and Thailand bear aclose resemblance to Ayurveda. It is alsopractised in Japan, Australia, USA, Russia,UK, Germany, etc., as herbal medicine oralternative medicine. Recently Australia,

Ayurveda

The Netherlands and Hungary haverecognized Ayurveda as an alternativemedicine. A White House Commission forAlternative Medicine has been constitutedin the US to find ways and means ofrecognizing alternative medicine, whichincludes Ayurveda also for the purpose ofpractice.

Four types of Ayurvedic practitioners existin various parts of the world:

Traditional Ayurvedic practitioners(about 300,000) who are notinstitutionally trained, but have gainedknowledge through their familytraditions;Tribal healers who practise in the tribalareas using various local medicinalherbs;Institutionally qualified physicians(around 300,000 throughout theworld);Graduates of modern medicine whohave faith in Ayurvedic practice.

Siddha System of Medicine

The Siddha system of medicine, moreprevalent in the Southern States of Indiaas well as Sri Lanka, Singapore andMalaysia, traces its origin to Dravidian

P.N.V. Kurup

yurveda, which means the Science ofLife, is the oldest medical science in


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culture, which owes allegiance to the cultof Shiva and the worship of the Phallus(linga). The Siddha system of medicineextensively describes the use of herbo-mineral products like mercury, sulfur, iron,copper, gold and arsenic. The principlesand doctrines of the Siddha system have aclose similarity to Ayurveda with specia-lization in iatrochemistry.

Historical BackgroundThe history of Ayurveda can be traced todifferent periods, the earliest being theVedic period when the Aryans compiled thefour Vedas (1500–800 BC) with maximumreferences in Rigveda and Atharvaveda.Ayurveda originated in Heaven from LordBrahma, who passed on this knowledgeto Dakshaprajapati and then to theAshwinikumaras – the physicians ofDevatas who transmitted it to Lord Indra.3On earth, when diseases were at theirpeak, Maharshi Bharadwaj approachedIndra and got the knowledge of Ayurveda.Later, Maharshi Atreya learnt Ayurvedafrom Bharadwaj and taught it to Agniveshand others. Agnivesh authored theAgnivesh Tantra, known as CharakSamhita (5th Century BC). Kashiraj

Divodas Dhanvantari obtained knowledgeof Ayurveda from Lord Indra and taught itto Sushruta, who authored the SushrutSamhita4 (6th – 5th Century BC).Vagbhata (7th Century AD) was highlyinfluenced by the teachings of LordBuddha. He authored Ashtanga Sangrahaand Ashtanga Hridaya texts. During theMedieval Period, Sharangadhara Samhita(14th Century AD) described theexamination of the pulse for the first time,5as a method of clinical examination anduse of metals and minerals like gold, silver,iron, mercury and copper for preparingAyurvedic medicines. In the 16th Century,Rasa Tantra in Northern India and Siddhain the South dealt mostly with a largenumber of metallic preparations asremedies. The most important metal usedwith success was mercury in many forms.

Fundamental PrinciplesAyurveda accepts the metaphysical conceptof creation as proclaimed in ancient Indiantreatises.6 The Prakriti and Purush preludegross creation. Mahat originates from theabsolute nature (the un-manifest) with allits qualities leading to Ahamkara, which isof three types – Vaikarika (Sattvika), Taijasa(Rajasa) and Bhutadi (Tamasa). The 11Indriyas – five organs of perception (ear,skin, eye, tongue, nose), five effecter organs(speech organ, hands, sex organs, rectum,feet) and the mind – are created out of theVaikarika Ahamkara with the help of TaijasaAhamkara. The Panchatanmatras (fivebasic substances – sound, touch, vision,taste, odour) are created out of BhutadiAhamkara with the help of TaijasaAhamkara.

The Panchamahabhuta (five basicelements) are evolved from thesePanchatanmatras, i.e., Akash (ether), Vayu(air), Agni (fire), Jala (water) and Prithvi(earth).

Ayurveda

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Tridosha – Vata, Pitta and Kapha – arethe psychobiological dimensions orbiological rhythms regulating the entirefunctioning of the human body. Thesedoshas are formed by the Panchama-habhutas. Vata is formed by the combi-nation of Akash+Vayu and has theproperties of cold, light, coarse and dry,Pitta by Teja having hot and liquid andKapha by Jala+Prithvi with cold, heavy,solid, smooth and moist properties. Vata,Pitta and Kapha are of five types havingphysiological functions and pathologicalmanifestations.7

The five types of Vata include, i) PranaVayu, which strengthens the vital capacity,improves the intellectual power, respiration,deglutition, and the activities of the senseorgans, etc., with pathologicalmanifestations like hiccough, flatulence,breathing troubles, etc.; ii) Udana Vayu,which regulates strength, encouragement,colour, knowledge, intelligence, memory,etc., with pathological manifestations of theeye, ear, nose and throat; iii) Samana Vayu,which improves digestion and metabolism,transformation of nutrients, circulation oflymph and expulsion of urine, stool, etc.,with pathological manifestations likeanorexia, diarrhoea and abdominaltumour; iv) Vyana Vayu, which regulatesblood circulation, sweating, contraction,taste, ejaculation of sperm, developmentof all the tissues, etc., with pathologicalmanifestations like fever and convulsion;and v) Apana Vayu, which regulatesexpulsion of urine, stool, sperm,menstruation, etc., with pathologicalmanifestations of urinary and the uterinetract and ano-rectal diseases.

The five types of Pitta include, i)Pachaka Pitta, which regulates digestionof food, stimulates the digestive enzymesand separates the waste products withpathological manifestations of anorexia,

rise of body temperature, burningsensation, indigestion, etc.; ii) Ranjaka Pitta,which has a role in blood formation withthe pathological manifestation of anaemia;iii) Sadhaka Pitta, which is responsible forintelligence and memory with pathologicalmanifestation for lack of concentration,loss of intelligence, loss of sleep, etc.; iv)Alochaka Pitta, which is responsible forvision with pathological manifestationspertaining to eye and vision; and v)Bhrajaka Pitta, which regulates bodycomplexion, body heat regulation, etc., withpathological manifestations like vitiligo,discolouration and skin diseases.

The five types of Kapha include,i) Avalambaka Kapha, which is responsiblefor the lubrication of joints, pericardiumwith pathological manifestations likestiffness of the joints and chest pain; ii)Kledaka Kapha, which disintegrates food,maintains the fluid, lubrication, etc., withpathological manifestations like indigestionand mucoid stool; iii) Bodhaka Kapha,which is responsible for feeling the taste ofvarious substances with pathologicalmanifestations like dryness of mouth andpalate and loss of sensation of differenttastes; iv) Tarpaka Kapha, which providesnutrition to the sense organs withpathological manifestations like loss of theactivities of the sense organs; andv) Shlesaka Kapha, which lubricates allbody joints with pathological manifes-tations of the bony joints.

The body and the mind are the twocomplementary constituents of a livingbeing, its dynamic normalcy beingresponsible for health and its imbalancefor disease.

The mind exhibits three properties:Sattva (intelligence), which is signifiedby goodness, virtue, excellence,wisdom and good sense;


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Rajas, signified by passion, emotionand restlessness;Tamas, signified by mental darkness,illusion, error, and inertia.

At the biological level, Vata, Pitta andKapha are stated to be predominantlyRajasika, Sattvika and Tamasika, respec-tively, in their constitution, highlighting thepsychosomatic approach of Ayurvedatowards disease.

Concept of PathogenesisThe concept of health is based upon theequilibrium of Dosha (humour), Dhatu(seven body tissues – lymph, blood, muscle,adipose tissue, bone, bone marrow,semen) and Mala (faeces, urine and otherwaste products), i.e., soil and seed theory.8If this equilibrium of doshas is maintained(soil), then the disease process cannot takeplace even if any causative organism/factor(seed) exists in the body. The diseaseprocess takes place whenever theequilibrium of doshas is disturbed, causingits vitiation. The Kayagni or Pachakagnicomprehends various factors responsiblefor digestion and metabolism involving thesplitting of complex food substances intotheir simpler components for absorption.It also contributes moieties of itself to theDhatus as Dhatwagni dealing with tissue

metabolism.9 Ama means unripe,uncooked and undigested and refers to theevents caused by impaired digestion andmetabolism due to the hypo-functioning ofthe Agni.10 The products arising out of thisimpaired digestion and metabolism formtoxic substances having excessive pastiness,depriving the body of its nutrition and arecalled Ama, which is the root cause of alldiseases.

Any external factor, i.e., bacteria, virusor climatic conditions may increase oraccumulate the dosha leading todisturbance in its equilibrium and causingits vitiation. These vitiated doshas, whiletravelling through the macro- and micro-channels of the body, are stuck due todeformity of the channels.11 They will leadto blockage causing obstruction of thenormal flow of doshas and nutrientmaterial and stasis of waste products.Thus, doshas retained interact withdushyas of the affected region, leading todosha dushya sammurchana resulting indisturbance of the body metabolism andAma formation, which corresponds to thephase of Sthansamshraya when prodromalsymptoms of the disease are said tomanifest.12 Greater emphasis is given todeformity or pathological involvement ofthe related channels for the initiation of thedisease process which results in suscep-tibility to the disease due to loweredresistance of the channels. This organsusceptibility is often due to geneticpredisposition, but is also dependent onenvironmental factors. Subsequently, fullmanifestation of the disease occurs withclear-cut symptomatology.

Eight Clinical Disciplines ofAyurvedaThere are eight major clinical disciplines ofAyurveda that help deal with various diseaseconditions effectively.13 These are:

Greater emphasis is given todeformity or pathologicalinvolvement of the related

channels for the initiation ofthe disease process which

results in susceptibility to thedisease due to lowered

resistance of the channels

Ayurveda

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Rasayana Tantra (Geriatrics);Vajikarana (Reproductive health andaphrodisiacs);Kayachikitsa (Internal medicine);Shalya Tantra (Surgery);Shalakya Tantra (Diseases of eye, ear,nose and throat);Bhootavidya (Psychiatry);Agada Tantra (Toxicology);Kaumarabhritya (Paediatrics, obstetricsand gynaecology).

Approach to the Diagnosis andPrinciples of TreatmentAyurveda stands for extensive and elaborateclinical examination to understand thenature of the disease process. It identifiesthe patient and the disease separately.Thus, the Ayurvedic clinical method isbroadly divided into two parts:14

i) Examination of the patient, and ii)Examination of the disease. The patient isnot examined as a diseased entity but alsoas an individual human being with all itsusual attributes, including his constitutionand lifestyle. The 10-fold examination ofthe patient evaluates:15

Psychosomatic constitution;Disease susceptibility;Quality of tissues;Body build;Anthropometry;Adaptability;Mental Health;Digestive power;Exercise endurance;Age.

The examination of disease is carried outby general examination, throughinterrogation and physical examination.16

The eight-fold examination covers.17

Pulse;Urine;Stool;

Tongue;Voice and Speech;Skin;Eyes;Overall appearance.

This eight-fold examination provides acomprehensive general survey of the bodyand its functions.

Dushya (dhatu and mala), environ-ment, vitality, time, digestion and metabo-lism, body constitution, age, psyche,acceptability, diet – all these should beminutely analysed and taken intoconsideration before deciding the actualline of treatment. If the principles areapplied to all the disease conditions,perhaps a better management can beevolved. To eliminate and correct the doshicdisturbances, internal medicine, externalmedicine and surgical treatment have beenmentioned.18 Under curative treatment,Dipan (which also includes appetizer) andPachan (helpful in digestion and metabo-lism) drugs are indicated for dissolving thevitiated doshas by correcting the disturbedmetabolism, provided the intensity of thedisease is of a mild to moderate nature. Ifthe pathological lesion is of a more severertype than that which stimulates Agni toimprove hunger or appetite, these alonemay not serve the purpose and the internalpurification measure or Panchakarmatherapy should be applied. To deal withpsychosomatic problems, divine therapy,objectively planned therapy and psycho-therapy have been described.19

In Daivavyapashraya Chikitsa (DivineTherapy), Daiv refers to divinity and/or tothe events of one’s past life. It is believedthat many diseases are caused due toactions or Karmas of an individual past lifewhich can be treated by appropriate andauspicious Karmas in this life. Thisapproach to therapy is called Daivavya-


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pashraya Chiktisa. Divine karmas likeprayer, chanting mantras, ablutions,yagya, wearing precious stones, etc., arethe usual methods of DaivavyapashrayaChikitsa.

Special mode of treatment

RasayanaRasayana (Rejuvenation Therapy) is aspeciality of Ayurveda which mainly dealswith the preservation and promotion ofhealth. It promotes longevity and preventsor delays the aging process. Rasayanapromotes resistance against infections andother causative factors for the disease bymaintaining the equilibrium of Vata, Pittaand Kapha.20 The Rasayana, if administeredat an early age, also helps the bodymetabolism in such a way that the geneticpredisposition for a particular disease isavoided and the intensity of the symptomsof a particular disease is greatly reduced.

Rejuvenation therapy, in addition todealing with the preventive and promotiveaspects of health rather than merely withthe disease condition, acts also byimproving micro-circulation in the bodyleading to better bio-availability of nutrientsto tissues. The use of Rasayana drugs andother measures produces longevity,improves memory, intelligence and goodhealth, promotes youthfulness, goodlusture, complexion and voice, promotesoptimum strength of the body and thesense organs, efficiency in talk and humility,and makes the personality attractive. Thereare many Rasayana preparations which areused according to the psychosomaticconstitution and disease condition of thepatient. The immunomodulatory effect ofRasayana drugs like Withania somnifera,Asparagus racemosus and Tinosporacordifolia is well-established throughscientific parameters. Therefore, adminis-

tration of Rasayana drugs having animmunoprotective effect is helpful inimproving the immunity and general well-being of patients.

PanchakarmaPanchakarma (Purification Therapy) dealsmainly with the removal of toxins and wastematerials from the body to purify thebiological system from gross channels toeradicate the disease completely. It ishelpful in the prevention of disease andpreservation and promotion of health, aswell as the management of psychosomatic,neurological, gastrointestinal, cardiova-scular and many other chronic, degene-rative diseases and iatrogenic conditions.Panchakarma plays a vital role in Ayurvedictherapeutics and occupies an importantplace in the Ayurvedic system of medicine.This five-fold purification therapy, a classicalform of treatment in Ayurveda, includesVamana (emesis), Virechana (Purgation),Asthapana (Decoction enema), Anuvasana(Oily enema) and Nasya (Nasal Insuff-lation).21 Under pre-operative manage-ment, the doshas are liquefied by externaland internal oleation by ghee, oil,massages and fomentation followed by themain purification processes, which alsoinclude intra-vaginal and intra-urethralenemas and blood letting, for the eliminationof toxins from the body. Under post-operative management, various types ofdietetics and disciplined living for a few daysafter the treatment have been indicated. InAyurveda many treatment methods aredescribed, i.e., Abhyanga, Tarpana, 13types of fomentations, etc. In Kerala,physicians have developed specializedtechniques of Panchakarma, which issomething more than the purificationtherapy. The Arya Vaidya Sala, Kottakkal,and the Arya Vaidyan Rama VariarEducational Foundation of Ayurveda,

Ayurveda

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

Pizhichi lIn this therapeutic measure, warmmedicated oil is poured all over the body,followed by massage, in seven positionsin a systematic manner for the treatment ofdiseases of the nervous system like paralysis,sciatica, osteoarthritis, musculo-skeletal,neuro-muscular and degenerative diseases.Pizhichil is very useful as a health restora-tive measure for elderly persons when it isregularly used once a year or so. Thistreatment cleanses the minute channels inthe body of morbid substances.

Shirobasti22

This is an oil treatment applied to the headin which a leather belt is tied to the clean-shaven scalp. The junction of the scalpand leather belt is sealed with pasteprepared from wheat flour or black gram.Medicated oil is then poured into it andkept for the stipulated time. This isrecommended for headaches, myopialconditions, insomnia, psychiatric illnesses,epilepsy, hair fall, etc. It improves thefunctioning of the sensory systems andremoves exhaustion.

Shirodhara23

This therapeutic measure is carried out bypouring oil or medicated liquids on theforehead for treating headaches, vertigo,insomnia, anxiety, etc. It is also useful inmany psychosomatic disorders andhypertension.

Ksharasutra24

This Alkaline Thread Therapy is apopular herbal treatment for ano-rectaldiseases like fistula-in-Ano andhaemorrhoids (piles) under the specialityof Shalyatantra. The medicated threads

are prepared from plants like Arka andSnuhi by using their milk or herbal alkalinematerial and tying it at the site. Theadvantage of this therapy is that thepatients may remain mobile during thetreatment. It can also be carried out onpatients for whom modern surgery iscontra-indicated.

Role of Ayurveda in PrimaryHealth Care

Ayurveda has laid due emphasis on thepreventive and promotive aspects ofhealth, in which dietetics and way of life,according to Prakriti (psychosomaticconstitution), play an important role. Thebalance of Vata, Pitta and Kapha leads toa healthy state and disturbance in thisequilibrium leads to diseases. If onefollows the daily routine and seasonalroutines as prescribed under personalhygiene and socio-behavioural conduct,then health can be preserved and diseasesprevented by developing the capacity toadapt to the cosmic changes which havean impact on the human biologicalsystem. The violation of these principlesdisturbs the equilibrium of doshasincreasing susceptibility to diseases.

Shirobasti treatment in Ayurveda

Ayurveda


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The simple, effective, non-toxic locallyavailable medicinal herbs which cost verylittle – and are more acceptable to thepeople – are being used successfully to treatcommon ailments by the practitioners ofAyurveda, who are playing an important rolein providing basic health services in remoteareas where institutionally qualified doctorsare not available. Traditionally, each villagehad the traditional physician, who used tobe a friend, philosopher and guide to thelocal people not only by taking care ofhealth-related issues but also in regard toother socio-cultural matters which play animportant role in the maintenance of healthand precipitation of disease. Ayurveda isused in various national healthprogrammes. The thera-peutic efficacy of

medicinal plants is well-established onscientific lines for the promotion of healthand the treatment of common as well aschronic diseases. Primary health careincludes maternity and child health care,family planning, immuni-zation, control ofcommunicable diseases, nutrition, cleanwater supply, health education, treatmentof common and chronic diseases. InAyurveda many methods are described topromote the health of the pregnant womanin the antenatal period and later, in thepostnatal period, with due emphasis onbreast-feeding of the baby for its optimalgrowth in the early period. Drugs likeAsparagus racemosus promote lactation inthe postnatal period and the drugs Sidacordifolia and Abutilon indicum promote the

For the BrainSankhapushpi Convolvulus pluricaulisMandukaparni Centella asiaticaBrahmi Bacopa monnieriVacha Acorus calamusJyotishmati Celastrus paniculatus

For the HeartArjuna Terminalia arjunaGuggulu Commiphora wightiiPushkaramula Inula racemosaKushta Saussurea lappa

For the Respiratory TractHaridra Curcuma longaVasa Adhatoda vasicaYashtimadhu Glycyrrhiza glabraShirish Albizzia lebbeck

For the StomachAmalaki Emblica officinalisBhringaraja Eclipta albaSatavari Asparagus racemosus

For the LiverBhoomyamalaki Phyllanthus amarusPippali Piper longumKalamegh Andrographis paniculataKatukarohini Picrorhiza kurroa

For the Alimentary CanalBilva Aegle marmelosHaritaki Terminalia chebulaKutaja Holarrhena

antidysenterica

For the PancreasTejpatra Cinnamomum tamalaJambu Syzygium cuminiVijayasara Pterocarpus

marsupiumKaravella Momordica charantiaKiratatikta Swertia chirata

For the Urinary TractPunarnava Boerhaavia diffusaGokshura Tribulus terrestrisVaruna Crataeva nurvala

For the Genital SystemMenKapikacchu Mucuna pruriensAswagandha Withania somnifera

WomenSatavari Asparagus racemosusAshok Saraca asocaJapapushpam Hibiscus rosa-sinensis

Therapeutic efficacy of medicinal plants

Ayurveda

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growth of the baby. The nutritionaldeficiency may cause anaemia, malnu-trition and other vitamin deficiencies whichcan be corrected by available food articlesin the rural areas such as carrot, cabbage,milk, leafy vegetables and pulses. Withregard to family planning, drugs likeHibiscus rosa-sinensis and Piper longumLinn have shown promising results afterscientific investi-gations. Withaniasomnifera, Asparagus racemosus,

Tinospora cordifolia, etc., are goodimmunity-promoting drugs which can playan important role in primary health carefrom the preventive, promotive and curativepoints of view.

Extensive research has shown thatsome of the medicinal plants exert specificaction on various vital organs. They not onlypromote the normal functioning of theorgan but also take care of the disease-condition as well.

Common Cold Laxmivilas rasa andGodanti Bhasma

Fever Tribhuvankirti rasa,Godanti Bhasmaand SudarshanGhanvati

Hyper Acidity and Sutshekhar rasa,Duodenal Ulcer Shankh Bhasma

Cough Sitopaladi,Khadiradivati

Gastro-intestinal Shankhvatiproblems

Diarrhoea Jatiphaladi, Karpurarasa

Diarrhoea and KutajghanavatiAmoebic Dysentery

Bacillary Sanjivani andDysentery Shankhodar

Piles Arshakuthar rasa

Hepatitis Arogyavardhani rasaLiver Diseases

Dysfunctional PushyanugUterine Bleeding

Urinary Tract Chandraprabha vatiInfection

Arthritic Condition Yograj guggulu andRasnadi kvath

Gout Kaishore guggulu

Bronchial Asthma Shvasa kuthar rasa

Various Eye Saptamrata lauhaDiseases and

Mahatriphalaghrita

Common Diseases Treatment Common Diseases Treatment

Treatment of Common DiseasesTo deal with various common diseases at the primary health care level, many time-testedstandard Ayurvedic formulations are highly effective.

These are a few well-establishedAyurvedic recipes frequently used byAyurvedic physicians throughout India forthe disease-conditions mentioned above.Many surgical cases, if treated during theearly stage, may be managed better bymedicinal treatment. Medicinal plants

like Bilva (Aegle marmelos), Haritaki(Terminalia chebula), Nimba (Azadirachtaindica), Shirish (Albizzia lebbeck), Vasa(Adhatoda vasica), Ghritkumari (Aloevera) and Guduchi (Tinospora cordifolia)are very useful in treating commondiseases.


12

Treatment of Chronic DiseasesThe peculiarity of Ayurveda is thatcompound preparations are more powerfuland potentiate the therapeutic efficacy ofmedicinal herbs. Ayurveda not only treatsthe disease but, more importantly, takes careof the patient as a whole with its holisticapproach. Various Ayurvedic herbal andherbo-mineral preparations are used for thetreatment of chronic diseases, degenerativediseases and iatrogenic conditions withoutany side-effect. The use of Rasayana andPanchakarma therapy is of immense valuefor treating such conditions. Many peopleliving in rural areas often suffer fromcommon chronic ailments such as diabetesmellitus, hypertension, ischaemic heartdisease and bronchial asthma.

For the management of theseconditions, a large number of Ayurvedicdrugs, based on established scientificinvestigations, have shown excellent results.The therapeutic effect of Vijayasara(Pterocarpus marsupium), Karavella(Momordica charantia), Tejpatra (Cinna-momum tamala), Kiratatikta (Swertiachirata) in diabetes mellitus, Sarpa-gandha (Rauwolfia serpentina) in Hyper-tension, Arjuna (Terminalia arjuna) andPushkaramula (Inula racemosa) inischaemic heart disease, Shirish(Albizzia lebbeck), Haridra (Curcumalonga) in bronchial asthma, Kalamegh(Andrographis paniculata) and Bhoomya-malaki (Phyllanthus amarus) in infectivehepatitis, Kapikacchu (Mucuna pruriens)in impotency and Varuna (Crataevanurvala), Gokshura (Tribulus terrestris) andPunarnava (Boerhaavia diffusa) in stoneand urinary tract infection is well-established.

Ayurvedic PharmaceuticsTraditionally physicians used to manu-facture Ayurvedic medicine by themselves

or guide the local villagers in collecting themedicinal plants for preventive, promotiveand curative purposes. The formulationswere used as churna, vati, gutika, bhasma,sindoor extract, decoction, asava-arishta,medicated oil and ghee. The pharma-ceutical industry has played a revolutionaryrole in popularizing Ayurveda by providingmodern technology for standard andquality Ayurvedic drugs in the national andinternational market. At present 8800pharmacies in India are producing thesedrugs worth Rs. 3000 crore ( one crore =$ 200,000) for domestic use andexporting drugs worth Rs. 300 crore. Theavailability of required medicinal herbs isgradually decreasing. It is necessary toinvolve the local people by formingcooperatives for medicinal plants.Such village-level cooperatives will be highlyuseful in creating an awareness about thedevelopment of medicinal plants and theneed for their conservation to achieve theobjectives of producing and marketingAyurvedic drugs of quality.

The Government of India, under theMinistry of Health and Family Welfare, hasestablished a separate Department ofIndian System of Medicine and Homoeo-pathy to promote this ancient system ofmedicine. This department has publishedtwo volumes of a Pharma-copoeiacontaining 158 drugs. The Essential Drugslist for dispensaries and hospitals has alsobeen published. Ayurvedic drugs have beenintroduced in reproductive and child healthprogrammes. Agro- techniques have beendeveloped for 100 medicinal plants. Topromote Good Manufacturing Practices,laboratories have been identified for thestandardization and quality control ofayurvedic drugs.

The prime foundation of pharma-codynamics of ayurvedic drugs is basedupon the theory of Pancha-mahabhuta,

Ayurveda

13

which forms the physico-chemical basis ofthe body as well as diet and drugs. Thepharmaco-therapeutics is based on thetheory of tridosha, which controls andmaintains the biological functions and arethe cause of health in a state of equilibriumand of disease in cases of disequilibrium.The composition, metabolism and actionof the drug are based on its Rasa (taste),Guna (properties), Virya (potency), Vipaka(metabolism), Prabhava (specific potency)and Karma (action).

Education and Research

College level education in Ayurveda startedabout 100 years ago with royal petronage.Subsequently, modern knowledge was alsointroduced in these colleges. At present,the number of Ayurvedic institutions in theIndian Subcontinent is 186 (whichincludes two graduate-level institutes in SriLanka and 12 in Nepal). In addition, theNational Institute of Traditional Medicinesat Nawinna in Sri Lanka conducts trainingprogrammes for doctors, Ayurvedicstudents, farmers and practitioners ofFolklore Medicine. Free Ayurvedictreatment facilities are available in about21,000 Ayurvedic dispensaries andhospitals. Some 50 universities in theSubcontinent have facilities for Ayurvedicgraduate (BAMS) and postgraduate(M.D.-Ayu) education. Postgraduateeducation in Ayurveda is available in 31colleges, which include three majorpostgraduate centres: the Institute ofPostgraduate Teaching and Research inAyurveda at Gujarat Ayurved University,Jamnagar; Banaras Hindu University,Varanasi, and the National Institute ofAyurveda at Jaipur. The Faculty ofAyurveda, Banaras Hindu University, hasmade significant contributions in the fieldof research in Ayurveda.

The Government of India hasestablished a National Academy ofAyurveda to promote intensive training indifferent specialities for graduates andpostgraduates of Ayurveda under theguidance of eminent scholars accordingto the Guru Shishya Parampara-tradition.In this region, three Siddha colleges arefunctioning with the facility of postgraduateeducation in one college, 107 hospitalsand 306 dispensaries.

The Government of India, by an Act ofParliament, established the Central Councilof Indian Medicine (CCIM) in 1972 forregulating education and registration inAyurveda, Siddha and Unani medicine.Ayurvedic education and registration isregulated in the neighbouring countries aswell. The Government of India alsoestablished a research council, the CentralCouncil for Research in Indian Medicine,Homoeopathy and Yoga (CCRIMH) in1971, which was subsequently developedinto four independent councils in 1978.

The Central Council for Research inAyurveda and Siddha (CCRAS) promotesresearch in Ayurveda. The CCRAS has 10central research institutes of Ayurveda, 17regional research institutes and nineregional research centres/research units,fully devoted to research in Ayurveda. TheBandaranayake Memorial AyurvedicResearch Institute at Nawinna, Sri Lanka,

Ayurveda takes care of thepatient as a whole with itsholistic approach. Various

Ayurvedic herbal and herbo-mineral preparations are usedfor the treatment of chronicand degenerative diseaseswithout any side-effect.


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is also making a significant contribution inthe field of research in Ayurveda. TheCentral Research Institute, the RegionalResearch Institute and the Literary Researchand Documentation Department are alsodevoted to research in the Siddha systemof medicine.

The Gujarat Ayurved University is theonly statutory university in the worldexclusively devoted to Ayurvedic studiesand research. It has adequate facilities forextensive training in Ayurveda for foreignstudents. The University has nine affiliatedAyurvedic colleges in Gujarat. OutsideGujarat, the Ayurvedic institutions atCoimbatore (Tamil Nadu) and Manipal(Karnataka) have also been grantedrecognition for postgraduate education inAyurveda. Similarly, Ayurvedic institutionsin Japan and South Australia have alsobeen granted recognition.

The details of the courses are as under:

Bachelor of Ayurveda Medicineand Surgery Degree Course(B.A.M.S.)This five-and-a-half-year degree coursecovers comprehensive and intensivepractical and theoretical training in all thesubjects of Ayurveda along with goodexposure to modern basic medical subjectslike anatomy and physiology, which makesthese B.A.M.S. graduates competentenough to practise Ayurveda.

The subjects under this degree courseare taught utilizing the latest knowledge ofthe basic principles of Ayurveda and historyof Ayurveda, Sharir Rachana – anatomy,Sharir Kriya – physiology, Dravya Guna –pharmacology, pharmacognosy andMateria Medica, Rasa Shastra andBhaishajya Kalpana – science of mineral,herbal and aquatic drugs, pharmacy andpharmaceutics, Agada Tantra – medical

jurisprudence and toxicology, SwasthaVritta – hygiene, preventive, promotive andpublic health, Yoga and nature cure, VikritiVigyana – diagnostic methods andpathology, Charaka Samhita – classicaltextbook, Kayachikitsa – internal medicine,Rasayana and Vajikarana – promotion oflongevity, rejuvenation and reproductivehealth, Manas Roga – psychiatry,Panchakarma – internal purification,massage and physiotherapy,Kaumarabhritya, Prasuti Tantra, Striroga –paediatrics, obstetrics and gynaecology,Shalya – surgery, Shalakya –ophthalmology, and otorhinolaryngology.

Doctor of Medicine in Ayurveda[M.D.(Ayu)]This postgraduate course of three years’duration is available in 13 specialities ofAyurveda, i.e., Ayurveda Siddhanta andDarshan – fundamental principles ofAyurveda, Samhita – classical Ayurvedictexts, Dravyaguna – pharmacognosy andpharmacology, Rasa Shastra – science ofmineral, herbal and aquatic drugs,Bhaishajya Kalpana – pharmacy andpharmaceutics, ITSA – internal medicine,Vikritivigyana and Roga Nidan – diagnosticmethods and pathology, Manas Roga andManovigyana – psychiatry and psychology,Panchakarma – internal purification andmassage therapy, Kaumarabhritya –paediatrics, Prasuti Tantra and Striroga –obstetrics and gynaecology, Shalya –Surgery, Shalakya – ophthalmology andotorhino-laryngology.

Doctor of Philosophy (Ph.D.)The facility for the award of Ph.D. degreeis available in 13 specialities of Ayurveda.The M.D. (Ayu) or its equivalent degree inthe concerned subject/speciality is essentialfor registration in Ph.D. The minimumduration for this course is two years.

Ayurveda

15

Diploma Course in AyurvedaThe objective of this one-year course(divided into three semesters of four monthseach) is to provide intensive theoretical andpractical training in Ayurveda, coveringmost of the five-year degree course inAyurveda. This course is designed for thegraduates of modern medicine or any othertraditional medicine to prepare them tobecome efficient Ayurvedic practitioners.

The details of the subjects are, basicprinciples of Ayurveda, including hygieneand public health, detailed study ofmedicinal plants, their properties and uses(Dravyaguna), Ayurvedic mineral, herbaland aquatic drugs (Rasa Shastra), herbalpharmaceutical preparations (BhaishajyaKalpana), intensive training in traditionaland classical preparation of Ayurvedicmedicines; Ayurvedic diagnosticprocedures, pathology and pathogenesis(Roga Nidana), Kayachikitsa – internalmedicine, Rasayana – rejuvenation therapyin the promotion and preservation of healthand the treatment of various chronicillnesses, Vajikarana – promotion ofreproductive health, Manas Roga –psychiatry, Panchakarma, its role in thepreservation and promotion of health andtreatment of chronic degenerative diseases,Yoga and nature cure; Kaumarabhritya,Prasuti and Striroga – paediatrics, obstetricsand gynaecology, Shalya – surgery,including Ksharasutra preparation andmanagement of ano-rectal diseases,Shalakya – ophthalmology and otorhino-laryngology, Pathyapathya – Ayurvedicdietetic preparations and management.

Introductory Course in AyurvedaThis three-month course is designed toimpart basic knowledge of Ayurveda toscholars having a medical background orgraduation in bio-sciences or in fields alliedto medicine. The details of the subjects

under this course are, basic principles ofAyurveda, including Swasthavritta (hygieneand positive health), the fundamentals ofherbo-mineral Materia Medica andpharmaceutics, the fundamentals ofdiagnosis and pathogenesis of diseases(Nidana), the fundamentals of treatment(Chikitsa) including Panchakarma(internal purification and massagetherapies), Rasayana (geriatrics andrejuvenation therapy), fundamentals ofsurgery (Shalya) including Ksharasootra(alkaline thread cauterization), Agnikarma(cauterization), Jalaukavacharana (leechapplication), etc., management of commonclinical conditions through herbalpreparation.

Bachelor of Pharmacy inAyurveda [B.Pharm (Ayu)]The main aim of this four-year BachelorDegree Course is to produce high qualitytechnologists capable of producing qualityAyurvedic drugs by employing traditional,modern or upgraded or modifiedtraditional techniques as well as controllingand maintaining their quality. The coursehas been planned in such a manner thatthe personnel completing it should becapable of meeting different requirementsof both the manufacturing and consumersectors for Ayurvedic drugs and othertraditional systems of medicine.

Master of Pharmacy in Ayurveda[M. Pharm (Ayu)]

This two-year Master’s Degree course isdesigned to provide in-depth knowledge ofAyurvedic drugs, their method ofmanufacturing and also theirstandardization and quality control aspectswith specialization in two subjects:Pharmaceutics of Ayurvedic Drugs andQuality Control and Standardization ofAyurvedic Drugs.


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Diploma in Pharmacy inAyurveda [D.Pharm (Ayu)]This course of two years’ duration isintended to train personnel, mainly formeeting the requirements of the consumersector of Ayurvedic drugs and othertraditional systems of medicine. Theyshould be acquainted with the manu-facture of Ayurvedic drugs and should bequalified and competent to dispenseAyurvedic drugs in hospitals, dispensaries,drug stores and related activities. Theyshould also be trained to maintain thestores of Ayurvedic drugs (both rawmaterials and finished products) properly.

Master of Science (M.Sc.) inMedicinal PlantsThe objective of this two-year course is toadopt a multi-disciplinary approach forcomprehensive teaching of all aspectsrelated to medicinal plants, to generateskilled manpower to meet the present andfuture requirements of human resourcesin the field of medicinal plant resourcesdevelopment, and to provide distinctiveeducation and training in all aspects ofmedicinal plants. This course is designedfor graduates in botany, pharmacy,agriculture or Ayurveda.

References

1. Charaka Samhita – Sutrasthana. 30th Chapter. Sloka 26.2. Charaka Samhita – Sharirasthana. 5th Chapter. Sloka 3.3. Charaka Samhita – Sutrasthana. 1st Chapter. Sloka 4–5.4. Sushruta Samhita – 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.

An overview of traditional Chinese medicine

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growing attention around the world.According to some estimates, a largenumber of people in many developingcountries rely heavily on traditionalpractices to meet their primary health careneeds.1 In China, although Westernmedicine is available, the majority of thepopulation still rely on zhongyi (Chinesemedicine or traditional Chinese medicine,or TCM) to solve their health problems.Western medicine and Chinese medicineare practised side by side at every level ofthe national health care system.2

With a history of over 2000 years, theTCM practice offers natural, safe andeffective therapies and cures for manydiseases with much less side- effects. TCMtakes a unique theoretical and practicalapproach to health. In treatment, itincludes the use of various interventionmodalities, such as Chinese medication,acupuncture and moxibustion, Tuina(massotherapy), dietary, and Qigong.2, 3

These modalities may be used separatelyor in combination to effect a treatment.TCM differs in fundamental ways fromWestern medicine. This paper is thus

An overview of traditionalChinese medicine

prompted by a desire to present anoverview of the Chinese system ofmedicine.

Fundamentals of TCM

As an important part of the Chineseculture, TCM has evolved into a unique andcomplete medical system during the longhistory of China. The Huang Di Nei Jing(The Yellow Emperor’s Classic of Medicineor Canon of Medicine) was the firstmonumental classic which systematicallydocumented the etiology, physiology,diagnosis, treatment and prevention ofdisease. This work was probably compiledover several centuries by various authorsand consists of two parts: Su Wen (PlainQuestions) and Ling Shu (Miraculous Pivot,also known as Canon of Acupuncture). Ittakes the form of a dialogue between thelegendary Yellow Emperor and his minister,Qi Bo, on the topic of medicine. Itsappearance between 300 BC and 100 BCmarked the establishment of TCM.4 Onestriking difference between TCM andWestern medicine is in the way in whichthe human body is observed, and hencethe difference in the concept of health.

Chinese medicine holds a holistic viewof the human body. It stresses the overall,

Hongguang DongXiaorui Zhang

DIntroduction

uring the past decade, traditionalsystems of medicine have received


18

delicate harmony and coordination amongdifferent parts of the human body.Therefore, it lays great emphasis on thecareful readjustment and maintenance ofthis natural balance in the body.5 It useszang fu (visceral organs) and the meridiansas its theoretical basis and yin yang and“five elements” as its theoretical tools.According to TCM, qi, ‘blood’ and ‘bodyfluid’ are the fundamental substanceswhich make up the human body andmaintain its normal physiologicalfunctioning.6 Health implies harmoniouscoordination among the various parts ofthe body and their adaptation to thephysical environment.

The fundamental mechanism ofdisease is the breakdown of the relativeequilibrium within the organism or betweenthe organism and its environment.7 In TCMterms, this is known as an imbalancebetween yin and yang.8 In the diagnosisand treatment of diseases, the basiccharacteristic of TCM, which sets itselfapart from modern Western medicine, isthat of ‘syndromes differentiation(9) ortranslated as diagnosis and treatmentbased on overall analysis of symptoms andsigns’. Holism views not only the humanbody as an organic whole but also the unityof the human body and nature. On theone hand, nature constantly influences the

human body and, on the other, the bodyadapts to the variations in the naturalenvironment.

The concept of yin and yangThe concept of yin and yang is fundamentalto the understanding of Chinese medicine.The earliest reference of yin and yang isprobably the one in the book “Yi Jing” (Bookof Change, 700 BC). Originally, yin andyang were two topographic terms used todesignate the shady and the sunny sidesof a hill, or the north side and south side ofa mountain. The sunny side of mountain,in the sunlight, represents warm, bright,and other active characteristics; and theshady side of the mountain represents cold,dark, and other passive properties. Byextension, the theory of yin and yang holdsthat the universe consists of two opposingbut mutually dependent forces thatcomplement and supplement each other,resonate harmoniously, and maintain aconstant balance. As man is consideredas a microcosm in the universe, to achievea healthy state a balance between theforces of yin and yang in the human bodyshould be maintained.

With respect to medicine, it could besaid that the whole of the Chinese systemof medicine, its physiology, pathology,diagnosis, and treatment, can all bereduced to the basic and fundamentaltheory of yin and yang. Every physiologicalprocess and every pathological changecan be analysed in the light of the yin yangtheory. Ultimately, every modality ofintervention is aimed at regulating yin andyang, to balance yin and yang. As statedin The Yellow Emperor’s Classic ofMedicine, yin is even and well while yangis firm, hence a relative balance betweenyin and yang is maintained and health isguaranteed.

Every modality of intervention isaimed at regulating and

balancing yin and yang. As statedin The Yellow Emperor’s Classicof Medicine, yin is even and well

while yang is firm, hence arelative balance is maintained

and health is guaranteed


19

The theory of Five ElementsTogether with the theory of yin yang, thetheory of Five Elements constitutes the basisof Chinese medicine. Originally, the FiveElements referred to the five kinds ofmaterials, which are wood, fire, earth,metal and water with their characteristicproperties—an ancient philosophicalconcept to explain the composition andphenomena of the physical universe. Theprimitive concept of Five Elements wasfurther developed into a more complextheory and was used to summarize theproperties of things in nature into fivecategories. Each matter in the universe hasa dominant character which bearsresemblance to the properties of one of fiveelements. The theory of Five Elements is thusused to group the things through theirdifferent properties and to interpret therelationships among these different thingsthrough a generating sequence and acounteracting sequence among the FiveElements. The generating sequence is inthe following sequence: wood, fire, earth,metal and water, in which each Element isconceived to promote or produce thesubsequent one, namely, wood producesfire, fire produces earth, etc. Thecounteracting sequence is in the followingsequence: water, fire, metal, wood andearth, in which each Element is consideredchecking the subsequent one, namely,water checks fire, fire checks metal, etc. Itshould be stressed that this is a symbolicrecognition, an analogy. According to theYellow Emperor’s Classic of Medicine,“metal, wood, water, fire and earthencompass all natural phenomena. Thissymbolism also applies to man”. In otherwords, all parts of the human body haveaffinities in nature with particular elements.

The Five Elements view is importantfrom the perspective of demonstrating theway in which Chinese medicine has built

on the view of balance, holism, andharmony in the human body. This theoryinitially likened the organs in the humanbody to the Five Elements. Theorgan:element analogies are lung:metal;liver:wood; kidney:water; heart:fire; andspleen:earth (Tables 1a & 1b). This analogybroadens out to encompass allcomponents of the body, since each andevery part of the anatomy is controlled bya particular vital organ. For example, inTCM, liver stores blood, ensures thesmooth flow of qi, controls the sinews; lunggoverns qi and respiration, regulates waterpassages and controls skin; spleentransports and transforms water and foodessence, keeping the blood flowing withinthe vessels, controls muscles and the fourlimbs, etc.

The Five Elements theory is extensivelyapplied in almost every aspect of Chinesemedicine. It is used in physiology to explainthe functions of different organs, tissuesand their connections. In pathology, it isapplied to demonstrate the mutualpathological influence and transmissionamong the viscera organs. It is used indiagnosis to synthetize the data obtainedthrough the four methods of diagnosis(given in detail in the following chapter) anddeduce the evolution of disease. Intreatment, the theory of Five Elements isapplied mainly under two headings: toprevent the transmission of disease and toguide the therapeutic method.

When considering a certain dishar-mony organ, one should keep in mind thevarious relationships between this organand the others (the generating sequenceand counteracting sequence). Thisdisharmony may be affected by anotherorgan, and meanwhile it may be affectinganother organ.

To prevent the transmission of disease:This was demonstrated by the “Classic on


20

Medical Problems” in chapter 77: “If Liveris diseased, it can invade the Spleen, theSpleen must therefore be tonified before itis affected”

To guide the therapeutic method: The“Classic on Medical Problems” in chapter698 presents a classic interpretation: “Ifdeficiency is found in the son organ, onewould tonify the mother organ; if excess isfound in the mother organ, one wouldsedate the son organ”.

The human bodyIn Chinese medicine, much stress is laid onthe observation of the outward physiologicaland pathological manifes-tations of thehuman body. It is believed that all internalorgans and their activities will have their

corresponding external manifestations. Forthis reason, TCM* does not emphasize theanatomy of the human body. Although TCMuses similar names for organs as those usedin Western medicine, and many of theseorgans perform similar functions asrecognized in Western medicine, they in factdo not reflect completely the same concepts.For example, in Chinese medicine, eachvisceral organ is a comprehensive systemand performs a set of physiological functionswhich often cover an area related to butmuch larger than those in its anatomicalsense.

The visceral organs are divided intothree categories according to theirmorphological features and physiologicalfunctions.

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

Table 1b Some of the main characteristics of the five elementsElements Nature

Five Five Five Five FiveDirections Seasons Climates Tastes Stages of

Development

Wood East Spring Wind Sours BirthFire South Summer Heat Bitter GrowthEarth Centre Late Summer Dampness Sweet TransformationMetal West Autumn Dryness Pungent HarvestWater North Winter Cold Salty Storage

Table 1a Some of the main characteristics of the five elementsElements Human Body

Five Zang Five Fu Five Sense Five FiveOrgans Tissues Emotions

Wood Liver Gall Bladder Eyes Tendon AngerFire Heart Small Intestine Tongue Vessel JoyEarth Spleen Stomach Mouth Muscle AnxietyMetal Lung Large Intestine Nose Skin SorrowWater Kidney Bladder Ears Bone Terror


21

The five zang organs: these aresubstantial in morphology, and function tostore the “essence of life”. They include “liver,heart, spleen, lung, kidney”.

The six fu organs: these are hollow inmorphology, and their function is totransport and transform foodstuff. Theyconsist of the “small intestine, largeintestine, gall bladder, stomach, bladderand sanjiao (triple energizer: a collectiveterm for the three portions of the bodycavity)”

“Extraordinary organs”: these arehollow in morphology, and their functionis to store the “essence of life”. They arethe “brain, marrow, bone, vessels, gallbladder and uterus”.

Each of the zang organs is linked to afu organ. The function of one organ in TCMmay include the functional activities ofseveral anatomically defined organs inWestern medicine. For example, the“kidney” in Chinese medicine is not just theorgan that excretes urine; it stores the“essence of life”, controls reproduction,growth and development and is closelyrelated to the “brain, marrow and bones”.Thus, in TCM the concept of “kidney”includes most of the functions of the urinarysystem, some functions of the endocrinesystem, and something similar to those ofthe pituitary-adenocortical-gonadal axis.10

Material basis of the vitalactivities of the human bodyQi: The major premise of TCM is that allliving things, including human beings, havea life force within them. This essential vitalbiological energy, which is invisible, isknown in Chinese philosophy as qi(pronounced: chee; often also written as‘chi’). Qi circulates regularly along themeridians in the body. Disruption in thisflow is believed to be responsible fordiseases. When qi gathers, the physical

body is formed; when qi dissipates, thebody “dies”.11 Qi has variously beentranslated as “energy”, “vital energy”, or“life force”; however, it is almost impossibleto capture the exact concept fully in oneEnglish word or phrase; therefore we havedecided to use its original Chinese word:Qi.

The sources of qi can be divided intothe inborn and the acquired. The inborn qiis the innate vital essence stored in the“kidney” which was inherited from theparents at the moment of conception, andaugmented postnatally which is acombination of the essence absorbed bythe “spleen” from food and fresh air whichis inhaled by the “lung”. The two sourcesof qi are gathered in the chest and formzhengqi (genuine qi), which circulatesthrough the body’s organs and tissues.Since qi is invisible, it can only be perceivedthrough its actions. For instance, thedeficiency of the “kidney qi” means thedeficiency of energy required for thefunctioning of the “kidney” (namely, thehypofunction of the “kidney”). Generallyspeaking, qi has five functions: it i) Servesas the energy source of body activities, ii)Warms and nourishes the body,iii) Defends the body surface againstinvasion by any pathogenic factor, iv)Is thevehicle of transportation inside the body,and v) Maintains the normal positions ofbody organs.12, 13 Blood: The concept ofblood in TCM is not the same as it is inWestern medicine. In TCM, the blood is avital nutrient substance in the body. It isformed from the combination of essenceof food, which is derived via digestion andabsorption by the spleen and the stomach,and fluids containing nutrients. The kidneyalso contributes to the formation of bloodas it is the kidney-stored essence thatproduces bone marrow. After beingformed, blood circulates in the vessels


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throughout the body, promoted by theheart with the help of the lung, controlledby the spleen which keeps blood flowingwithin the vessels, and regulated by the liveras a reserve.

Jing : Jing, which is defined as the vitalessence of the body, consists of two parts:congenital essence and acquired essence.Congenital essence, which is inherited fromthe parents at conception, is responsible forreproduction, thus also known as“reproductive essence”. It is stored in thekidney and serves as the origin of life.Acquired essence is derived from theessential substance of food and isdistributed to various organs and tissues. Itserves as the material basis for life activities.The congenital and the acquired essencerely on, and promote each other. Congenital

essence can be transformed into acquiredessence and acquired essence replenishescongenital essence. Sexual over-indulgenceis taken as an important cause of diseasebecause it consumes the reproductiveessence stored in the kidney, thus impairingthe other organs.

Jing Ye (Body fluids): Jing Ye is ageneral term for all normal liquids in thebody. It is derived from the essence of foodand drink, which is digested and absorbedby the spleen and the stomach. Thedifference in nature, form and location, andbody fluid can be divided into twocategories: Jing and Ye. Clear and thinfluids are referred to as jing, while thick andheavy fluids are known as ye. Body fluidmoistens and nourishes various parts of thebody. The formation, distribution andexcretion of body fluid is a complicatedprocess resulting from the coodinatedactivity of many Zang Fu organs, especiallythe lung, spleen and kidney.

Meridians–Pathways of thehuman bodyBoth Western and Chinese medicine agreethat the organs are physically connected.TCM believes that there exists in the humanbody a network of pathways calledmeridian (or channel) system, throughwhich qi and “blood” circulate, and bywhich internal organs are connected to andcoordinated with superficial organs andtissues, thus creating an integral whole. Themeridian system consists of 12 pairs ofregular meridians (six pairs of yin and sixpairs of yang meridians), eight extrameridians, 12 collateral, and theirconnective parts. The 12 regular meridiansconsist of the main parts of the meridiansystems and are symmetrically distributedon both sides of the body, and runrespectively through the medial or lateralside of each limb. Each regular meridian

Map of lung meridian



23

pertains to a corresponding visceral organand is named accordingly. To facilitate thelearning and use of these meridians, thenames of the meridians have beentranslated into English. WHO has furthergiven standardized alphabetic codes tothem.14

Acupuncture points are found alongthe meridians under the skin. Eachacupuncture point is anatomically locatedand has its own specific therapeutic effects.Three hundred and sixty-one acupuncturepoints have been identified along the 14meridians. WHO has also recommendedthe standardized nomenclature of thesepoints.15 The meridian system is used inTCM to explain the physiological functionsand pathological changes in the humanbody as well as to guide the diagnosis andtreatment of diseases. Acupuncture andMoxibustion, Tuina, and Qigong aretherapeutic techniques based mainly on themeridian theory.

Causes of diseaseAccording to TCM, health implies that thebody system is in a state of dynamicequilibrium, not only between the variousparts of the body but also between the bodyand environmental conditions. Diseaseresults when the equilibrium is destroyed(i.e., there is imbalance of yin and yang)by certain factors. The factors which causedisturbance in the harmony and balanceof the body are called pathogenic factors.In TCM, these are generally classified asexogenous and endogenous pathogenicfactors. Exogenous pathogenic factorsencompass atmospheric changes (“wind”,“cold”, “summer heat”, “dampness”,“dryness” and “fire” known as Six ExcessiveAtmospheric Influences). These are the sixexcessive climatic conditions to which theindividual concerned has lost his ability toadapt.

Endogenous pathogenic factorsinclude emotional factors (joy, anger, worry,anxiety, sorrow, terror and fright, knownas the Seven Emotions).

There are also several other factorswhich do not belong to either of these twocategories, such as pestilential pathogens,trauma, improper diet, exhaustion andover-indulgence in sex.

In essence, whether disease will occurdepends on the outcome of the strugglebetween the vital energy and pathogenicfactors. As stated in Su Wen (The YellowEmperor ’s Classic of Medicine):“Pathogens cannot invade the body whenvital energy is sufficient”; and, “only whenthe vital energy is in deficiency, canpathogens invade the body”.16

TCM pays utmost attention to themaintenance of the vital energy. Therefore,TCM gives a prominent place to prevention.It can be said that the traditional Chinesemedicine is essentially a prevention-orientedmedicine. This preventive philosophy ofTCM is expressed at two levels: preventionagainst the occurrence of disease, andprevention against its further developmentif disease has already occurred.

Principle of diagnosisDiagnosis is an important component ofthe theoretical system of TCM. It includestwo parts: diagnosis of disease and

TCM is essentially a prevention-oriented medicine. Thispreventive philosophy is

expressed as prevention againstthe occurrence of disease, andprevention against its furtherdevelopment if disease has

already occurred.


24

differentiation of syndromes. Differentiationof syndromes is often more important.

TCM regards the human body as anorganic entity. The component parts of thebody are physically interconnected, so alocal pathological change may influencethe whole body. Similarly, disorders ofinternal organs may be reflected on thesurface of the body. There are four majordiagnostic methods used in TCM:inspection, auscultation and olfaction,interrogation and palpation.

Inspection is a method used to examinethe mental state, complexion, physicalcondition, behaviour, secretion andexcretion, as well as observation of thetongue.

Auscultation and olfaction detects theclinical status of a patient by listening tohis voice, his breathing, and his coughing,and by smelling his body odours.

Interrogation is a way to interview thepatient, find out his or her family history todetermine the patient’s health state, majorcomplaints, and progress of illness. Apartfrom this, other specific conditions must beinquired into while interrogating. This wascalled “Ten Questions” recommended byDr Zhang Jie-bin (1563–1640) andincludes: chills and fever; perspiration;headache and general pains; urinationand defecation; appetite; feeling in thechest and abdomen; hearing; thirst; pulsetaking and observation; auscultation andsmelling; characteristic of menstruation forwomen patients.

Palpation is the most importantdiagnostic method unique to TCM. Itinclude two parts: pulse feeling and bodypalpation. Pulse feeling emphasizes thequality of the pulse at the radial arteries ofboth wrists. It is recognized that there are28 different pulse qualities which can befelt and each with its own subtle nuance ofinterpretation. It is used to examine the

strength or weakness of qi and “blood” andpredict the progress of the illness. Bodypalpation refers to systematic feeling of thesurface of the body, the meridians, bodytemperature, and body moisture. Bodypalpation is applied especially when painis concerned. The final diagnosis is basedon the information gathered from all theabove-mentioned diagnostic methods.These methods are not used in isolation,but as parts of a system.

Differentiation of syndromes is aprocess in which the characteristics ofdisease and syndrome are decidedthrough interpretation and summing-up ofthe phenomena collected from the fourbasic diagnostic methods. “Syndromes” inTCM is not a simple summation ofsymptoms and sign; it reflects rather thepathogenesis and pathophysiology of agiven case, and provides a basis for theprevention and treatment of disease.

There are a number of methods in TCMfor syndromes diagnosis (differentiation ofsyndromes). It includes the differentiationof pathological conditions in accordancewith the eight principal differentiationsyndromes according to pathologicalchanges of zang fu organs, differentiationsyndromes according to the condition ofbody qi, blood and fluid, differentiationsyndromes in accordance with the theoryof meridians, differentiation of epidemicfebrile disease in accordance with thetheory of wei, qi, ying and xiue, and thedifferentiation syndromes in accordancewith the theory of triple energizer. Of theseveral ways of syndrome differentiation,differentiation of pathological conditions inaccordance with the eight principaldifferentiation syndromes according topathological changes of zang fu organsare the most useful.

The eight principal syndromes serve asa guideline, namely, yin and yang, exterior


25

and interior, cold and heat, deficiency andexcessiveness. Differentiation of patholo-gical conditions in accordance with theeight principal syndromes is the foundationfor all the other methods of syndromedifferentiation. It signifies the location andnature of disease, the confrontationbetween the pathogenic factor and bodyresistance, as well as establishes theprinciple of treatment.

Differentiation syndromes according tothe pathological changes of zang fu organsare based on the symptoms and signsobtained by four diagnostic methods whenqi and the blood of the internal organs areout of balance. This method of syndromedifferentiation is applied to identify theparticular disharmony of a specific internalorgan.

Intervention in TCM

Chinese medicationChinese medication is the primarycomponent of TCM and is used commonlyin China. Chinese medication involves theuse of herbal medicine, animal parts andminerals. The term “herb” used in Chinesemedicine often goes beyond the traditionalconcept of “plant”, since the 6000– 8000substances used include, in addition tonumerous plants, substance from animalsand minerals.

According to Chinese history, Chinesemedicine arose from mythical medicine tobecome a system of herbal medicine. ShenNong Ben Cao Jing (Divine Husbandman‘sClassic of Materia Medica; or Shen Nong‘sHerbal) is the first work (25–220 AD)which prescribed the therapeutic effect ofherbs and other materials. It contains 365entries. These are botanical (252 entries),zoological (67 entries), and mineral (46entries) substances. Beginning with ShenNong Ben Cao Jing, the literature of

Chinese materia medica developedcontinuously by the addition of new herbs,together with a re-evaluation and additionof new uses for existing herbs. Amongthese, two pieces of work need to be noted:Xin Xiu Ben Cao (Newly Revised MateriaMedica, 659 AD) was considered to be thefirst official pharmacopoeia in China,compiled and issued by the Government.Ben Cao Gang Mu (Compendium ofMateria Medica, 1596) is considered as aworld-renowned classic, written by Li Shi-zhen (1518–1593 AD).

The concept of Chinese medicinediffers from that of the synthesized drugsin the ways their properties are determined.Chinese medicines are determined mainlyby the outcomes of their clinically observedinteraction within the human body.

The terminology used in describing thepharmacology of Chinese medicineincludes: property; taste or flavour; actionof ascending, descending, floating andsinking; attributive of meridians, and toxicity.

Properties or four properties of herbs:Based on their therapeutic effects, there arefour ways of describing property: cold, hot,warm, cool. For example, herbs effectivefor the treatment of heat syndromes areendowed with cold or cool properties,while those effective for cold syndromes areherbs with warm or hot properties.

Taste: Sour, bitter, sweet, pungent, andsalty taste of herbs. They are the expressionof the feature of the herb’s actions; thusthe taste does not necessarily mean the realtaste of the herb.

Action of ascending, descending,floating and sinking: Direction of a herb’saction. The ascending and floating herbshave an upward and outward effect, whiledescending and sinking herbs have adownward and inward effect. The actionof a herb can be changed by processingor by combined use with other herbs.


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Attributive of meridians: Classificationof herbs according to the meridians onwhich their therapeutic action is manifested.In addition, attributive of meridians alsorefers to some herbs capable of guiding orleading other herbs included in theprescription to the targeted meridians ororgans. For example, Radix bupleuri (ChaiHu) can relieve the pain in the hypocho-ndriac region, which is believed in Chinesemedicine to be the result of stagnation oflive qi. As the liver meridian crosses throughthe hypochondriac region, it can bededuced that this herb acts on the livermeridian. A herb can act on more thanone meridian.

Toxicity: Refers to the harmful effectsproduced by herbs on the human body.Toxic herbs are usually marked by “highlytoxic”, “moderatly toxic” or “slightly toxic”to indicate the different degrees of toxicity.

The prescription in Chinese medicinemust follow strict rules.11 A typicalprescription is composed of principalherbs, associate herbs, adjuvant herbs andmessenger herbs. The principal ingredientis a substance which provides the maintherapeutic thrust; associate herb is asubstance which enhances or assists thetherapeutic action of the first; the adjuvantone treats the accompanying symptoms,and moderately diminishes the harshnessor toxicity of the primary ones; themessenger herbs guide the medicine to theproper organs, or exert a harmonizingeffect. These herbs are often described inChinese pharmacology as emperors,ministers, assistants and envoys,respectively.

The most common methods of applyingherbal therapy are decoction (the herb isboiled with water) and honey-bound pills.Decoction is generally regarded as fast andstrong in action, and is used for acutecases; honey-bound pills are slower and

milder in action but have sustained effects,and are therefore used for chronic cases.However, more convenient formulations insuch forms as tablets and capsules are alsoavailable.

AcupunctureAcupuncture is defined as “puncturing witha sharp instrument”,12 but the original termin Chinese includes both “needling” and“moxibustion” (burning herbs, usuallymugwort, to stimulate acupuncture points).It is an important component of TCM forthe prevention and treatment of diseases.The theoretical basis of acupuncture is thepremise that there are patterns of qi thatflow through the pathways-meridians of thebody, and any potential disruptions of thisqi flow are believed to be responsible fordiseases. Acupuncture treatment cancorrect imbalances in the flow of qi byinserting a needle at identified acupuncturepoints. Other stimulating methods can alsobe applied at the acupuncture points toregulate the body’s qi, and help restorebalance and harmony. The deqi (gettingthe qi or needling sensation) is a crucialfactor in achieving acupuncture effects. Itinvolves the feeling of “soreness, numbness,expansion, heaviness” by the patient; at thesame time, the operator should feelheaviness and tightness around the needle.As stated in The Yellow Emperor’s Classicof Medicine: “the acupuncture effects canbe achieved only when the deqi isachieved”.(4) There exist many types ofstimulating techniques which oftenproduce different results. However, thiscrucial issue has often been ignored inclinical research on acupuncture.13

Moxibustion is used to treat and preventdiseases by applying ignited moxa atacupuncture points or certain parts of thehuman body. The material used inmoxibustion is mainly Artemisia Vulgaris


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(mugwort), a kind of herb in Chinese calledAi (moxa). Generally speaking, moxibustionis applied in cold syndrome, deficientconditions and chronic diseases.Moxibustion may be used in combinationwith acupuncture or separately to effect atreatment.

Q igongThe term qigong is composed of twoChinese characters, qi and gong, whereqi can be translated roughly into Englishas “vital energy”, and gong as “method”or “performance”. Qigong is a system ofexercise performed by taking a properposture, adjusting breathing andconcentrating the mind and uniting vitalessence and energy and mentality as awhole for physical training, healthpreservation, prevention and treatment ofdiseases.14 Since qi plays an important rolein the vital processes of the human body, itis natural that regulation of the flow of qican be used as a method to preserve healthand prevent diseases. Qigong is differentfrom physical exercises. The latter is aimedat building up health or at restoring thebody’s physical functioning by enhancingstrength, whereas the former is focused onthe mobilization of functional potentialitiesthrough regulating the mind andbreathing. In other words, physical exerciseis purely somatic, whereas qigong therapyis generally psychosomatic. Anotherdifference between physical exercise andqigong is that physical exercise expandsenergy by tensing up the muscle andaccelerating the heart beat andrespiration, while qigong works to relax,calm and regulate breathing so as toaccumulate vital energy in the body.

TuinaThe term Tuina is composed of two Chinesecharacters, Tui and Na. Tui can be

translated as pressing and dragging, andNa as grasping. It belongs to externaltherapy and has evolved over thousandsof years. As a component of TCM inter-vention, tuina is based on a solid theoreticalbackground, and includes basic theories,diagnostic methods and syndromedifferentiation of TCM, particularly thetheory of meridians. In addition, tuina isalso involved in a series of different kindsof specific manipulation techniques.

Tuina has its own specific benefits andadvantages in a wide range of applications.Tuina is used in both prevention andtreatment of diseases. It may be used inthe treatment of internal and externalconditions, traumatic injury, and muscu-loskeletal, gynaecological, obstetric andpaediatric diseases.

Stringent and comprehensive practi-tioner training is important. Whenperforming tuina, the physician must firstconcentrate his mind, regulate hisbreathing, and actuate the qi and powerof his entire body towards his hands, elbowor other part of body with the requirementof treatment, then apply manipulation oncertain points or areas of the patient’s bodyto stimulate the flow of qi and blood inorder to normalize the function of zang fuand balance yin and yang.

Proper use of TCM

In TCM, the conception of the organismas a whole and diagnosis and treatmentbased on overall analysis of symptoms andsigns are two key elements. Diagnosis,prevention and treatment of illness in TCMrely on a holistic approach towards the sickindividual, and disturbances are treated atthe physical, emotional, mental, spiritualand environmental levels simultaneously.

Safety issues are of paramountconcern. Since Chinese medicine is


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“natural” and has stood the test of history,it is often automatically perceived as beingharmless. It is true that Chinese medi-cations in general are less toxic and saferas compared to synthetic drugs or otherforms of therapy, but they are by no meansfree from adverse effects.

The question of the toxic potentials ofherbs has long been recognized in Chinesepharmacopoeia, and relevant theorieshave been developed to avoid harmful usesor combinations of potentially toxic herbs,such as the theories of “EighteenIncompatibilities”, “Nineteen Antagonism”and “Contraindication during pregnancy”,“Pao Zhi” (herbal process). These theoriescontinue to guide the Chinese pharma-copoeia to this day.

Quality assurance procedures must bestrictly enforced in order to standardizeherbal medicine. Chemical tests and assayprocedures must be used to supplementthe traditional standards of the Chinesepharmacopoeia.

Concerns have also been expressedregarding the safety of acupuncture. Therisks associated with acupuncture havebeen shown to be very small compared toorthodox interventions.15 In November1997, an Acupuncture ConsensusStatement made by the National Instituteof Health in the United States mentioned:“One of the advantages of acupuncture isthat the incidence of adverse effects issubstantially lower than that of many drugsor other accepted procedures for the sameconditions.16” In general, side- effects fromacupuncture procedure itself have been

minimal in the hands of a well-trainedpractitioner.16 Reports show that one ofthe more common problems ofacupuncture is forgotten needles.17 Life-threatening adverse reactions are possiblewith acupuncture treatment;18, 19, 20

however, these are usually caused bypractitioners who have not received any oradequate training. Qualification in medicalpractice is important. There should be noexception in the case of Chinese medicine.

Prospects for TCM

TCM is, by definition, traditional, but thisin no way prevents it from evolving. Greatprogress has been made since the pastdecade in efforts to understand themechanisms of TCM, especially thephysiological effects of acupuncture. In themeantime, efforts to combine TCM withbiomedicine in China have also accumu-lated a great amount of experience anddata. More concerted efforts are neededrelating to theoretical studies which mayelucidate the fundamentals of TCM throughacquired knowledge in Western medicine.Another challenge lies in how to clinicallycombine TCM and Western medicine moreeffectively which may eventually contributeto the organic integration of these twoschools of medicine.

One frequent criticism regardingresearches in TCM is the quality of suchresearch. Improving the methodologyand devising an approach for the specificuse of researches on TCM may be aworthwhile task.


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References

1. WHO monographs on selected medicinal plants (Volume 1). 1–4, 1999. (1) WorldHealth Organization. Geneva.

2. Hesketh T., Zhu WX. Health in China. Traditional Chinese medicine: one country, twosystems. 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 NeijingSuwen with Commentary. 1995. Boston 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 HealthPublication House.

9. Williams T. The idea behind Chinese medicine In: The Complete Illustrated Guide toChinese 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 andclinical validation. Pharmacol.Ther. 2000;86:191–98.

12. NG LKY, Liao S.J. Acupuncture: Ancient Chinese and Modern Western. A ComparativeInquiry. 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 ChineseMedicine. 533–555. 1994. Beijing. China. New World Press. Beijing 100037.China.

15. MacPherson H. Fatal and adverse events from acupuncture: allegation, evidence, andthe implications [see comments]. J Altern. Complement Med.1999;5:47–56.

16. Moyad M.A., Hathaway S., Ni H.S. Traditional Chinese medicine, acupuncture, andother alternative medicines for prostate cancer: an introduction and the need for moreresearch. Semin.Urol.Oncol. 1999;17:103–10.

17. Yamashita H., Tsukayama H., Tanno Y., Nishijo K. Adverse events in acupuncture andmoxibustion treatment: a six-year survey at a national clinic in Japan [see comments].J Altern. Complement Med. 1999;5:229–36.

18. Ernst E., White A. Life-threatening adverse reactions after acupuncture? A systematicreview [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.

Unani medicine

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he Horizon of Unani Tibb: Unanimedicine originated from Greece under

the patronage of Bukrat Hippocrates (460BC–377 BC) and from the fusion of diversethoughts and experiences of nations withancient cultural heritages, and advancedwith the wealth of scientific thought of thatage. Among the distinguished scholars andtranslators of that period, Ibn-E-Masawayh, Hunain Bin Ishaque andQusha Bin Luqah deserve mention. Whenthis rich material was made available, itpaved the way for further researchers,physicians and surgeons like RabbanTabari, Zakaria Razi, Ali Bin Abbas, AbuSehl Masihi, Abu Ali Ibnsina and AbulHassan Tabari.

Al Razi (850–923AD) is regarded asa distinguished physician in the history ofUnani Tibb. He devoted his life to literaryand clinical research. After his death, hisdisciples edited the material collected byhim. His book, Al-Hawi, was translated intoLatin in 1486 and published in Venice in1547AD. He was the first to describesmallpox and measles in his valuabletreatise, Al-Hasaba-Wa-Al-Judri, which isconsidered as the best heritage of UnaniTibb.

Unani medicine

Ali Ibn-E-Sina (980–1037AD) is thechief luminary of Unani Tibb. His brillianceis shown in classifying and arranging allthe medical knowledge of his time, and inpresenting it in a logical form. His famousbook of medicine is Al-Qanon-Fit-Tibb(Canon of Medicine). This book was writtenin five volumes.

Avicenna refers to the uniqueness ofthe human personality as a union of thebody with an immaterial soul. From thescientific point of view, the strength andweakness of the Al-Qanon lie in its passionfor observation, classification andgeneralization. There is repeatedcounselling to medical practitioners againstindulgence in speculation.

Avicenna’s theory of interactionbetween the four causes reveals that everyillness is a product of (i) heredity (ii)environment (iii) constitutional strength andthe quality of temperament, and(iv) nature’s own effort for the life andintegrity of functions.

The concepts of Avicenna whichrequire to be accepted as truth are theelements – symbols of mass and energy;temperament – the energy pattern of thebody as a whole; humours – the buildingmaterial for the body and the source ofenergy for work; the faculties – the power

Syed Khaleefathullah

TOrigin and development


32

or drive for organs and functions; andfinally vital force – the metabolic energy forthe organization and differentiation of life.These are hypotheses imported from thephysics and biology of Avicenna’s time andthus deserve not ridicule but seriousconsideration as helpful generalizations.

Avicenna’s mode of presentation givesthe impression of concepts being true forall times. It is this impression which led hissuccessors to regard the pursuit of othermedical literature as superfluous and thusacted as a deterrent to progress for severalcenturies. It was, however, not the fault ofAvicenna that he presented it as such togeneral practitioners and there is noreason for us to avoid the dispassionateexamination of Al-Qanon for useful ideas.

The most frequently quoted surgeonduring the middle ages was Abul QasimAl-Zahrawi. His book, Al-Tasrif, was usedas a textbook until the beginning of the 17thcentury. Hippocrates systemized the tibband gave it the status of ‘’Science’’. Galenestablished its foundation on which theArab physicians constructed an imposingedifice.

The greatest name in botany is Ibn-Al-Baytar (1248 AD). His book, Al-Jami-LiMufaradat Al-Adviya Wa Al-Aghziyah,contains all Greek and Arabic literature onbotany and Materia Medica.

The Unani physicians were alsoadvanced in midwifery and performed theoperation of “Cranio Clasty” for thedelivery of the dead foetus. Zahrawi’s book,Al-Tasreef, is full of such examples. He wasthe first to describe the Walcher’s positionin obstetrics.

The modern “Germ Therapy” is in facta reflection of the views of the Unaniphysicians who realized the connectionbetween foul bodies and putrefaction. Inthis connection, Avicenna has discussed indetail that unless a bodily secretion is

contaminated with these foul earthlybodies, no infection can occur. The SpanishArab physician, Ibn-E-Khatima knew thatman is surrounded by minute bodies,which enter the human body and producedisease. Dr Grunner, the translator of Al-Qanon of Avicenna, remarks in his prefacethat the above two views consideredtogether give us glimpses of modern germtherapy.

Unani Tibb was introduced in India byArab and Persian settlers. The Unaniphysicians paid special attention to themedicinal herbs found in India and wrotebooks on the therapeutic qualities of theseherbs.

India has produced eminent Unaniphysicians. A few among them are HakimAjmal Khan and Hakim Abdul Hameed innorthern India, and Hakim Zahoorul Huq,Hakim Mohammed Muqeem, Shifa UlMulk and Hakim Syed Maqdoom Ashrafin southern India.

General Principles

ConceptsUnani Tibb is based on the humoral theory.This theory supposes the presence of fourhumours in the body – blood, phlegm,yellow bile and black bile. The temperamentof a person is accordingly expressed by thewords sanguine, phlegmatic, choloric andmelancholic, according to the prepon-derance in him/her, respectively, of theabove humours. The humours are assignedtemperaments. Blood is hot and moist,phlegm is cold and moist, yellow bile is hotand dry, and black bile is cold and dry.Drugs are also assigned tempera-ments.Every person is supposed to have a uniquehumoral constitution, which represents hishealthy state. Any change in this bringsabout a change in the state of health. Apower of self-preservation or adjustment,

Unani medicine

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“medicarix naturae”, is formulated, whichstrives to restore any disturbance within thelimits prescribed by the constitution of anindividual. This corresponds to the defencemechanism, which is called to action incase of insult to the body. The aim of thephysician is to help and develop rather thansupersede or impede the action of thispower. The consequence of this is that notonly is the system enabled to overcome thepresent disturbance by dint of its intrinsicpower, but it also emerges, after recovery,with greater power of resistance to furtherdisturbances.

In Unani Tibb, drugs of plant, mineraland animal origin are extensively used. TheUnani physicians encouraged poly-pharmacy and devised a large number ofpoly-pharmaceutical recipes, which are stillin use in Unani Tibb.

Gruner in a treatise on the Canon ofMedicine of Avicenna published in 1930,states:

“Modern medicine is based on theconception of the universe as a conglo-meration of dead matter out of which, bysome unexplained process, life maybecome evolved in forms. To Avicenna thewhole of the universe is the manifestationof a universal principle of life, actingthrough the instrumentality of forms. Inmodern medicine, the forms are the sourceof life but to Avicenna, they are the productof life.”

Principles

The human body is considered to be madeup of the following seven components(Umore Tabaiya) each having a closerelation to and direct bearing on the stateof health of an individual and it is thereforenecessary for a Unani physician to take allthese factors of the human entity into

consideration for arriving at a correctdiagnosis and deciding the line oftreatment.

Arkan (Elements)The human body consists of four elements,viz., air, fire, water and earth. Theseelements actually symbolize the four statesof matter. They have their own tempera-ments. Air: hot and moist; water: cold andmoist; earth: cold and dry; and fire: hotand dry.

Mizaj (Temperament)The interaction of the elements producesvarious states, which in their turn determinethe temperament of an individual, and it isof paramount importance to keep thetemperament of an individual in mind whileprescribing a course of treatment. Atemperament may be (i) real equitable – thetemperaments of the four elements are inequal quantities – which do not exist, (ii)equitable – just and required amount havingcompatible temperaments, and(iii) inequitable – an absence of a justdistribution according to their requirements.

Aklat (Humours)These are the fluids which the human bodyobtains from food, and include varioushormones and enzymes. These fluids are(i) primary fluids – four humours, and (ii)secondary fluids – these are also four innumber and are called Rotubat E Arba(four fluids). These are responsible formaintaining the moisture of the differentorgans of the body and also providenutrition to the body. There are four typesof moisture: moisture of the small vessels;moisture in the small spaces of the body;moisture of the different parts of theorgan; and the moisture that holds thebody together.


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There are four stages of digestion (i)hazm e medi – gastric digestion followedby and including hazm e mevi – intestinaldigestion when food is turned into chymeand chyle and carried to the liver bymesentric veins, (ii) hazm e kabid – hepaticdigestion. In the course of this process chyleis converted into four humours in varyingquantities, that of blood being the largest,(iii) hazm e urooqui – vessel digestion, and(iv) hazm e uzuvi – tissue digestion.

While the humours are flowing in theblood vessels, every tissue absorbs itsnutrition by its quvat e jaziba, (attractivepower), and retains it by its quvat e masika(retentive power). Then the quvat e hazima(digestive power), in conjunction with quvate mushbah (assimilative power), convertsit into tissues. The waste material at thisstage is excreted by quvat e dafia (expulsivepower).

Aaza (Organs)These are the various organs of the humanbody. The health or disease of eachindividual organ affects the state of healthof the whole body.

There are four organs of primaryimportance in Unani medicine. These arethe brain, the heart, the liver, and thetesticles or the ovaries. Other organs areservers to the main organs. This shows thatthe brain is served by the nerves, the heartby the arteries, the liver by the veins, thetesticles by spermatic vessels and theovaries by fallopian tubes. The heart is thesource or starting point of the vital poweror innate heat of the body. The brain is theseat of the mental faculties, sensation andmovement. The liver is the seat of thenutritive or the vegetative faculties. Thegenerative organs (testes, ovaries) give themasculine and feminine form andtemperament, and form the generativeelements for propagation of the race.

Arwah (Spirits)These are considered to be the life forceand are therefore given importance in thediagnosis and treatment of diseases. Theyare defined as carriers of different powers.

Quwa (Faculties)The faculties are of three kinds,(a) Quvat e tabaiya: Natural power,

the power of metabolism and repro-duction. The seat of this power is theliver but the process is carried on inevery tissue of the body. The processof metabolism is completed by twofactors, namely,

Nutritive power, which is served byfour powers. These are (i) Attractivepower, (ii) Retentive power, (iii)Digestive power, and (iv) Expulsivepower.Growing power is responsible forthe construction and growth of thehuman organism and is served bythree powers. These are (i)Receptive power, (ii) Power to retainnutrition, and (iii) Assimilativepower.As far as reproduction isconcerned, the function isaccompanied by two powers whichare (i) Generative power, and(ii) Forming power.

(b) Psychic power: Nervous and psychicpower. Its seat is the brain and it isconstituted by two powers,

Perceptive power, which conveysimpression or sensations;Motive power, which brings aboutmovement as a response tosensation.

Perceptive power works in twodirections: External perceptive, when itrecognizes objects outside, and is servedby the five senses and internal perceptive,

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when perceptions are not from outside butare inferences drawn from externalimpressions and recognition. This consistsof five powers: (i) Composite senses: Itsfunction is to collect in one place all theexternal recognitions, (ii) Imagination: Itretains all material collected by compositesenses, (iii) Conception: It co-relates all theexternal recognitions and drawsconclusions from them, (iv) Memory: Itretains conclusion, and (v) Modifyingfaculty: This power is possessed only byhuman beings which gives us the capacityto explain one thing in different ways andwhich interprets all internal and externalrecognitions.

Motive power is of two types, (i) Powerthat is the cause of motions, and (ii) Powerthat causes motions.(c) Vital power: Power that maintains life

and enables all the organs to acceptthe effect of psychic power. The seat ofthis power is (i) Heart – the centre ofvital life, (ii) Brain – the centre ofsensation and movement, and(iii) Liver – the centre of nutrition.

FunctionsThis includes the movement and functionsof the various organs of the body. Everyorgan has a primary innate faculty (forceor drive) for nutrition by which it absorbs,retains, assimilates and integrates the foodmaterial into tissues and excretes thewastes. Some organs are also capable ofinfluencing the activity of other organs whilecertain other organs have no such faculty.It is on account of such differences thatthe various organs of the body aredescribed as (i) receptors as well aseffectors, (ii) receptors, (iii) effectors, and(iv) neither receptors nor effectors.

States of the body: According to UnaniTibb the states of the body are groupedunder three heads. They are,

Health – The bodily functions arecarried on normally;Disease – The opposite of health, inwhich one or more functions or formsof the organs are at fault;Neither health nor disease – There isneither complete health nor disease. Asin the case of old people or those whoare convalescing.

Disease can be classified into two types:(1) Simple disease that completes its course

without complications. It involves simpleorgans, compound organs, or bothand is differentiated as,(a) Diseases of temperament: These

affect only simple organs. Whencompound organs are involved it isthrough the affection of theircomposing simple organs. Diseasesof temperament are thus alwaysreferred to as affecting simple organsand not compound organs;

(b) Diseases of structure: Theseinvolve compound organs whichare composed of simple organsand are in reality the instrumentsof body functions;

(c) Diseases of continuity anddislocations: These affect bothsimple as well as compoundorgans. In the latter case, loss ofcontinuity involves compoundorgans directly and independently,and not through the involvementof simple organs which composethem. Dislocation is a loss ofcontinuity in a joint but withoutdamage to any of its individualcomponents.

(2) Complex disease does not mean thesimultaneous occurrence of severaldiseases in one person, but the presenceof a number of abnormal conditions inthe form of a single disease.


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Principles of Diagnosis

In Unani Tibb, great reliance is placed oninvestigating the cause of the diseasethoroughly for proper diagnosis. The pulse,urine and stool are employed as the generalindications to diagnose the various statesof the body.

PulsePulse is a movement of expansion andcontraction in the receptacles of thevital force (heart and arteries). The purposeof this movement is to condition the vitalforce with light air (oxygen from lungs). Thepulse can be discussed from the point ofview of:

The general principles governing thepulse;The type of pulse in each disease.

Each pulse-beat consists of two periodsof movement and two periods of rest.Since each beat has one period ofexpansion and one of contraction, it is alsoimportant that between the two oppositetypes of movement, there should be aperiod of rest because it is impossible forany movement to reach the end of itscourse and change into any type ofmovement without intermission. This hasbeen made clear in physics. It is, therefore,obvious that each pulse-beat before thenext has two periods of movement and twoof rest, which are:

Expansion (systolic);Rest between expansion andcontraction;Contraction (diastolic);Rest after the contraction (diastolic) ofpreceding beat and before theexpansion of the next beat.

According to most physicians, thephase of contraction in pulse is not

perceptible. According to some it can beperceived occasionally in a strong pulse onaccount of additional strength; in a largepulse on account of greater height; in ahard pulse on account of greaterresistance, and in a slow pulse on accountof increased length of the beat.

Method of feeling the pulseThe pulse is felt by palpating the radialartery at the wrist for three distinct reasons.First it is more accessible, second, it is indirect continuity with the heart and third,because it is quite close to it.

The forearm should be kept in mid-prone position, as in thin and weak personspronation increases the height and widthof the pulse but decreases the length, whilesupination increases the height and lengthbut decreases the width.

Features of the pulseUnani physicians have laid down 10features for examining the pulse. In this waythe pulse varies in respect of its size, i.e., inthe degree of expansion as estimated byits height, length, and breath; strength ofthe pulse-beat as felt by the fingers; velocityof the pulse-beat depending on theduration of the movement; quality of thevessel wall; fullness or emptiness of theartery; quality of the pulse regarding its hotor cold condition; frequency of pulse-beatsbased on the length of the rest period(between two beats); constancy andinconstancy regarding the various features;regularity or irregularity of the beats orrhythm of the pulse.

SizeThis is noted in the three spatial relationsof the pulse during expansion, i.e., height,length, breadth. The pulse thus has ninesimple and a large number of compoundvarieties which are the long, short and

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medium; the broad, narrow and mediumand the high, low and medium. A pulsewhich is large in length, breath and heightis called a pulse of large volume and theone which is small in these dimensions iscalled the pulse of small volume. Theaverage pulse between these two is knownas the pulse of medium volume. Similarly,a pulse which is large in breadth and heightis known as a bounding pulse and thatwhich is small in this respect is called a thinpulse. A pulse which is average betweenthese two extremes is a medium pulse.

StrengthThe pulse as felt by the fingers may bestrong, feeble or medium. A strong pulseis the one which during expansion strikesforcibly against the physician’s palpatingfingers. A feeble pulse is the opposite of astrong pulse and a medium pulse in thisrespect is midway between the two.

Speed (Velocity)The velocity of pulse-beats may be quick,sluggish or medium in speed. A quick pulseis one in which the duration of individualbeats is shorter. A sluggish pulse is theopposite of a quick pulse and a mediumpulse, in this regard, is of the average speedbetween the quick and the sluggish pulse.

Consistency (Elasticity)The vessel wall may be soft, hard ormedium. A soft pulse is one which is easilycompressed (with the fingers) while a hardpulse is the opposite of a soft pulse. Amedium pulse in this respect is the averagebetween the two.

Fullness (Volume)The pulse may be full, empty or medium. Afull pulse is one which feels as if the artery isfull of blood. An empty pulse feels theopposite of the full pulse and a medium

pulse in this respect is the pulse of averagefullness between the two extremes.

TemperatureThe pulse may be hot, cold or moderate intemperature.

Rate (Frequency)The pulse is rapid when the period betweenthe two beats is less than the normal. It isslow when this period is long. A mediumpulse in this respect is of the average ratebetween the two extremes.

ConstancyA pulse may remain constant or vary inrespect of the features mentioned above.The variation may extend over several beatsor involve a single beat, or part of a beat,e.g., the pulse may be rapid in one beatbecause of increased (metabolic)requirement of the body and weak inanother beat due to reduced vitality. Thefive features of the pulse, which vary in abeat, are, size – as large or small; strength– as strong or weak; velocity – as quick orsluggish; frequency – as rapid or slow, andconsistency – as hard or soft. The pulsemay thus be constant or varied. A constantpulse remains absolutely unaltered, i.e., itis smooth and even in respect of all theabove-mentioned features. If the pulseremains constant in any of the five features,it is known as being constant in thatparticular feature, i.e., constant in strengthor rate. Similarly, a pulse which is variablemay vary in only one or two features of thepulse.

RegularityAn irregular pulse may be regularlyirregular or irregularly irregular. A regularirregularity is the one which is repeated ina systematic manner. The irregularity issimple when it pertains to a single feature


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of the pulse. It is complex when more thanone feature is involved, e.g., the pulseshows two different types of irregularitiesbut each one is so repeated that bothirregularities form a single cycle of a regularcomplex irregularity. An irregularly irregularpulse is the converse of the above.

RhythmThe rhythm of the pulse is the time relationbetween the two periods of movement andthe two periods of rest. When theserelations are not perceived, the rhythm istaken to be the relation between the periodof rise and the period of rest in twoconsecutive pulse beats. In short, theperiod of movement should be comparedwith the period of rest. The pulse may thusbe eurhythmic or dysrhythmic.

Dysrhythmic pulse is of three varieties:Pararhythmic, in which the rhythm ofa child’s pulse is like that of the pulseof a young man;Hetrorhythmic, in which the rhythm ofa child’s pulse corresponds to that ofan old man’s pulse;Etrhythmic, in which the rhythm is soutterly abnormal that it does notcorrespond to the rhythm of any age.Marked deviations of rhythm indicategross derangement in the body.

The factors which govern the pulse are oftwo types:

Intrinsic factors: These are of ageneral type and are fundamentallyresponsible for the formation of pulseand are thus known as the consti-tutional factors;Extrinsic factors: Although these arenot directly concerned with theformation of the pulse, they do producechanges in it and are thus, (i) Absoluteas those which are necessary

concomitants of a healthy life, and (ii)Subsidiary, which are not so necessary.

Effects on the pulse of factors inimical tothe body are:

Temperament: The effects of variousabnormal temperaments have alreadybeen described.Compression of the vessel: Thischanges the form of the pulse bysuppressing the strength and thusmaking it inconstant. When thepressure is overwhelming the pulsebecomes irregular and arrhythmic.The compression may or may not befrom an inflammatory mass.Strength: Dispersal of strength makesthe pulse weak, as in severe pain, andpsychological factors also cause severedispersal.

Urine

The following conditions have to beobserved so that the information derivedout of it is reliable. The specimen shouldbe of overnight urine. Urine should becollected in a clear and colourless bottle inthe morning on empty stomach and notretained for too long after collection.

The individual should not have useddiuretics or any sustenances which colourthe urine. Undue mental and physicalexertions should be avoided as these toocolour the urine, e.g., fasting, lack of sleep,fatigue, hunger and outbursts of angermake the urine red or yellow. Coitus givesa marked oily appearance to the urine.Vomiting, diarrhoea and polyuria alsochange its colour and density. In infantsand children, urine does not give anyreliable indication because milk feedinghides the proper colour and consistencyof urine. Also, their phlegmatic naturetends to hold back the pigments and

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excretes them in a smaller quantity. Sincechildren are relatively weaker and moredelicate and sleep longer than adults, theirurinary findings are apt to be misleading.

It is only when the examination iscarried out with due observance of theabove-mentioned rules that it provideshelpful indications. Let it be known thaturine gives direct information only aboutthe functional condition of the liver, urinaryorgans and the vascular system, and it isthrough these findings that the functionalstate of other organs is also learnt. Urineexamination is a particularly reliable testof the functional efficiency of the liver,especially of its convex part.

The points to be noted about urine arecolour, density, turbidity or transparency,sediment, quantity, odour and froth.

Colour: The various shades of colourobserved by the unaided eye, i.e., white,black and the intermediate shade.

Density: The thickness and thinness ofurine. Density is different from the turbidityand transparency of urine. Thick urine maybe clear like the white of an egg, fish glueor olive oil. Sometimes it is thin and yet lookslike turbid water. Urine becomes turbid fromthe suspension of dark-coloured particles.

Transparency: This is the opposite ofturbidity. Turbidity differs from sediment. Inturbidity the particles are intimately mixedwith urine while the sediment is quitedistinct and separate from the liquid partof urine. Colour is the result of dissolvedparticles while turbidity is due to suspendedparticles.

Sediment: Refers to the deposit andalso to the suspension of material denserthan usual, i.e., it refers to the depositedas well as the suspended matter.

Froth: This is due to the admixture ofreeh in the liquid urine during micturition.The points to be noted about froth are(i) Colour – dark or orange-coloured froth

indicates jaundice, (ii) Quality – bubblesbeing large, coarse, fine or small. Coarsefoam indicates that the eliminated matteris viscid, (iii) Quantity – excess of foampoints to excess of reeh, (iv) Persistence offroth shows that the eliminated matter isviscid. Increased viscosity of urine is a badsign in kidney disease since it showsabnormal phlegm or sauda is present inthe system, or this organ has becomeunduly cold in temperament.

OdourUrine of sick persons never has the sameodour as that of healthy persons. If the urineis odourless, it points to either a coldtemperament or excessive immaturity ofhumours.

QuantityScanty urine means impairment of vitality.If urine is scanty in spite of taking adequatefluids it is likely to be due to excessiveperspiration or diarrhoea. The passage ofa large quantity of urine is a sign of earlyrecovery, especially if the urine is pale andis being passed freely.

Mature urine (normal for health)Mature urine is of moderate density andpale yellow in colour. If there is sediment, itis of laudable type as described above,namely, white, smooth, light and moderatesmell, i.e., free from malodour but nottotally without smell.

Urine at different age periodsDuring infancy urine tends to be whitebecause of milk feeding and moisture inthe temperament. In childhood urine isthick, viscid and inclined to be excessivelyfrothy. At maturity it is yellowish and ofmoderate density. In middle age it is paleand watery but may, at times, become thickfrom the elimination of waste matter. In old


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or irritating humour expelled by the liverinto the neighbouring organs being hurriedout with the stools.

ColourStools are normally of faint yellow colour.When they are a darker shade of yellow thenthere is excess of bile. Stools which are paleindicate defective digestion and lack ofmaturation. White stools denote obstructionin the bile duct and jaundice. If stools containoffensive white pus, it is likely to be fromrupture of an abscess. Stools resembling pusare often passed by healthy persons ofsedentary habits and those who have givenup exercise. These stools are not bad as theyindicate purification and elimination of thebody rendered sluggish from lack ofexercise, as mentioned in the section onurine. Deep yellow stools passed at theheight of an illness are a sign of goodmaturation. However, these stools may bea warning of the illness having got worse.Black stools are generally due to excessivecombustion or maturation. Sometimes theblack colour is due to the intake of colouredsubstances or wine having helped ineliminating sauda. The worst type of blackstool is the one which has been excessivelyburnt. This type of stool is, however, not onlyblack but has acidity and putrefaction asrevealed by the appearance of froth on itscontact with the ground. Such acidity is bad,whether in stools or vomit. These stools arealso shiny. However, black stools which arisefrom destruction from moisture andexcessive dispersion instead of ending indeath have good prognosis. Green andbluish stools indicate failure of innate heat.Stools of unusual colours are unhealthy.

FrothStools which, instead of being firm andcompact, are puffed up like cow dung area sign of reeh.

age urine is pale, watery and of low density.If it becomes dense it points to stoneformation.

Stools

QuantityThis is judged by taking into considerationthe amount of food consumed. Large stoolsindicate abundance of humours while scantystools their deficiency. Stools are retainedthrough obstruction in the caccum, colonor small intestine as a prelude to colic.Sometimes the stools may be scanty due toweakness of the expulsive faculty.

ConsistencyLiquid stools point to indigestion orobstruction. Weakness and obstruction ofthe messentric vessels produce liquidstools by interfering with the absorptionof fluid into the portal vein. Sometimescatarrh produces liquid stools. Laxativesalso have a similar effect. Viscid stools area sign of wasting but the stools then arefoul smelling. When stools are not foulsmelling they indicate excessive quantityof some abnormal and viscid humour.Sometimes viscid stools result from thepresence of some mucilaginous matter inthe food which, because of excessive heat,has not been digested properly. Frothystools result from excessive heat or theexcess of reeh. Stools become dry fromexhausting illness or strenuous workcausing dispersion. Dry stools are alsopassed during polyuria and in cases ofexcessive heat in the body. Dry food andconstipation also make the stools dry.

Hard and dry stools with mucusindicate delay in the passage of stools orlack of irritable bile. When there is noevidence of delay in bowels and no sign ofexcessive mucus, the cause is likely to bethe presence of some thin purulent material

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TimeIf stools are passed on quickly, there is likelyto be some disturbance such as excess ofbile or weakness of the retentive faculty.When there is a delay in the passage ofstools there is either weak digestion, coldtemperament of the intestines or excess ofmoisture.

FlatusStools are passed noisily with theelimination of wind.

Other means of diagnosesIn addition to the above, other conventionalmethods of diagnosis such as inspection,palpation, percussion and auscultationhave also been used by Unani physicians.Regular case history of the patient isrecorded and maintained as is evident fromthe books of Rhazes and Avicenna.

Preservation of Health

Definition of healthHealth is a state in which the temperamentand structure of the human body are suchthat all its functions are carried out in acorrect and whole manner.

The Unani Tibb recognizes the influenceof surroundings and ecological conditionson the state of health. It has laid down sixessentials for the prevention of disease.These essentials are:

AirAvicenna, the famous Unani physician,says that the change of environment relievesthe patient of many diseases. He has alsoemphasized the need for open, airy houseswith proper ventilation, playgrounds andgardens. Air is deemed fresh when it isfree from pollution with smoke and vapour.It should be free and open and notenclosed by walls or under cover. If outside

air is polluted, indoors should be preferred.The best type of air is that which is pure,clean, and free of vapours from ponds,ditches, bamboo fields, water-logged areasand vegetable fields, especially of cabbageand herb-rockets. It should not be pollutedwith vapour arising from the denseovergrowth of trees, such as yew-trees,walnuts and figs. It is also essential thatair should be free from pollution with foulgases. Good air should be open to freshbreeze and it should come from the plainsand mountains. It should not be confinedto pits and depressions where it warms upquickly by the rising sun and cools downimmediately after sunset. Air which issurrounded by recently painted or plasteredwalls is not fresh. Air is not healthy if itproduces choking or discomfort.

Food and DrinkAvicenna was the first to observe that dirtand polluted water were carriers of diseaseand emphasized the need for keeping waterfree from all impurities. Food and drink afterbeing taken by mouth affect the body bytheir (i) Quality, (ii) Elementary constitution,and (iii) Essence. The Unani systemconsiders that food and drinks taken asnutrients constitute the building material ofthe body, including the humours.Therefore, the selection of foods for generalnutrition and in correcting imbalancesforms the core of the Unani system ofhealing.

The Unani systemconsiders that food anddrinks taken as nutrientsconstitute the buildingmaterial of the body,

including the humours.


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Bodily Movement and ReposeTo maintain perfect health and a trim body,exercise and rest are essential. All forms ofactivity – whether vigorous, prolonged, mildor slow – produce heat in varying degreesbut moderately vigorous activity differs fromprolonged mild and slow activity in that itproduces more heat and less dispersion.On the other hand, prolonged activity, eventhough mild, produces greater dispersionrather than heat. Prolonged activity of anykind leads to dispersion of the innate heatand thus produces cold and dryness in thesystem. The presence of some additionalfactors may hinder or enhance the effectof the activity. Rest is always cooling andmoistening. It is cooling because there isno excitation of heat and there is an inwardcollection and aggregation of matter whichsuppresses the heat. It is moisteningbecause it hinders the proper disposal ofwastes.

Psychic Movement and ReposeUnani physicians maintain that certaindiseases like hysteria and mental disordersare caused, in most cases, by emotionalstrain and maladjustment and therefore,while dealing with such cases, these factorsare taken into account. The curative effectof music, pleasant company and beautifulscenery is also recognized by Unaniphysicians.

Sleep and WakefulnessNormal slumber and wakefulness areessential for health. Sleep resembles restwhile wakefulness is akin to activity. Sleepdirects the innate heat inwards andstrengthens the physical faculty. It weakensthe nervous faculty by relaxing andmoistening the passage of impulses andby making the vital force dense by stoppingdispersion produced by wake-fulness.Sleep removes all types of fatigue and stops

the excessive flow of excretions promotedby activity. Sleep takes up the digestion andmaturation of food and converts it intoblood. Wakefulness has the opposite effectof sleep. When it is excessive it disturbs thebrain by producing dryness and weaknessand thus causes confusion and also dullsthe nervous and mental faculties andmakes the head heavy. Wakefulnessincreases the desire for food and stimulatesappetite by dispersing the waste. It,however, impairs digestion by dissipatingthe strength of faculties. Sleep which isrestless and disturbed is harmful.

Evacuation and RetentionNatural means of excretion are diuresis,diaphoresis, vomiting, faeces, excretionthrough uterus in the form of menstruation,etc. Proper and normal functioning of theexcretory process must be ensured in orderto maintain perfect health.

Curative Treatment

Definition of DiseaseDisease is an abnormal state of the humanbody which, primarily and independentlybut not secondarily, disturbs normalfunctions. Disease may thus be a disorderof temperament or of structure.

Stages of DiseasesA disease generally has four stages, viz.,onset, increment, acme and decline.Stages of onset and acme are not just thebeginning and the end of disease, butdefinite periods of onset and acme, duringwhich special rules of management haveto be observed.

OnsetThe stage when the disease has justappeared, remains stationary and does notadvance to any appreciable extent.

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IncrementThe stage during which the disease goeson increasing until it becomes quite severe.

AcmeThe stage during which the disease reachesits height and remains stationary in allrespects.

DeclineThe stage during which the disease beginsto subside and with the passage of timestarts decreasing in intensity.

Transmission of DiseaseDisease can be transmitted from oneperson to another in the following manner:

Contagion occurs in leprosy, smallpox,epidemic fever and scabies. Contagionoccurs more frequently in persons living incongested areas or in the direction of thewind from infected places.

Heredity is found in baldness, gout,leucoderma, consumption and leprosy.

Racial transmission occurs particularlyin certain groups of persons.

Regional transmission is endemic tocertain regions.

Prognosis of DiseasesA disease is curable when there is nothingto hinder efficient treatment. A disease iseasier to cure if the age, temperament andseason are favourable. If these factors areadverse, the case would be differentbecause, under certain conditions thecause of disease must be extraordinarilystrong and thus more difficult to eradicate.It must be remembered that some diseasesmay change into new ones or disappearcompletely. This is a good sign. Certaindiseases cure some other disease, e.g.,quartan fever frequently cures epilepsy,arthritis, scabies and various spasmodicconditions. Bleeding from piles benefits

diseases caused by sauda and painfuldisease of the kidneys and uterus.

Unani medicine has the followingmodes of treating an ailment, dependingupon the nature of the ailment and itscause:

Regimental TherapyThe Unani physician attempts to use simplephysical means to cure a disease, but forcertain specific and complicated diseaseshe applies special techniques, some ofwhich are as follows:(a) Venesection

To bring down hypertension.Stimulation of metabolism.Correction of hot material intemperament.

(b) Cupping: Cupping purifies the skinand underlying tissues better thanvenesection. Since cupping removesonly thin blood, it is of little use in robustpersons whose blood is generallythicker and more difficult to draw.There are two types of cupping – drycupping and wet cupping.

(c) Sweating: Hot fomentation (dry andwet) bath with warm water, massageand keeping the patient in a room andblowing hot air are some of themethods of diaphoresis.

(d) Diuresis: This method is used in casesof diseases of the heart, lungs and liver.

(e) Turkish Bath: Hot bath is generallyapplied for curing diseases likeparalysis and muscular wasting, aftermassage.

(f) Massage: Soft massage is a sedativeand a relaxant. Dry and hard massageis a deodorant. Massage with oilrelaxes the muscles and softens theskin.

(g) Counter Irritant: For providing reliefin pain, burning sensation andirritation.


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(h) Cauterization: By this, the pathogenicmatters which are attached to somestructures are removed or resolved. Itis applied (i) To prevent the spread ofdestructive lesions, (ii) To strengthenorgans which have become cold intemperament, (iii) To remove putre-factive matters which are firmlyadherent to the tissues, and (iv) to arresthaemorrhage.

(i) Purgatives: Purgatives and laxativesare widely used by Unani physicians.This method has a resolving, anti-spasmodic and detoxicating effect.

(j) Vomiting: Emetics are used in certaincases for relief.

(k) Exercise: Physical exercise has greatimportance in the treatment of certaindiseases as well as in the maintenanceof the healthy condition of anindividual. Unani physicians have laiddown rules regarding hard, moderateand light exercises and have alsoindicated the timings and conditions forvarious physical exercises.

(l) Leeching: This is a unique method.Application of leeches is better thancupping in drawing the blood fromdeeper tissues. Certain conditions havebeen laid down for applying thismethod. Leeches should be collected,preferably a day earlier. They should beheld upside down to empty thestomach and sponged clean of thedirty viscid slime. Leeches with largeheads and black, grey or green colourshould be avoided. The application ofleeches is most useful in the treatmentof skin diseases such as favus,ringworm, freckles and mole.

DietotherapyUnani medicine lays great stress on treatingcertain ailments by the administration ofspecific diets or by regulating the quality

and quantity of food. Many books areavailable on this subject in Unani Tibb.

PharmacotherapyNatural drugs like plants, minerals and ofanimal origin are widely used whencompared to synthetic ones used in modernpharmacy.(a) State of drugs: Drugs having states

opposite to those present in the diseaseare used.

(b) Drugs Temperament: It is supposed thatdrugs have their own tempera-mentdue to their special constituents. Somedrugs are composed of ingre-dientshaving the opposite qualities, onequality acting in a way contrary to theother, and these qualities areaccommodated in two different partsof the drugs. Ingredients possessingspecial actions are called activeprinciples of the drugs. This theory oftemperaments of the drugs is based onanalogy and careful experiments.

(c) Potency of drugs: Drugs are gradedinto four degrees according to theirpotency.

(d) Mode of Action: The mechanism ormode of action of a drug can beexplained only partially. Unaniphysicians have tried to explain this asfollows:

The direct action of a drug is theresult of its physical or acquiredcharacters;Drugs mainly act by heat,coldness, moisture or dryness;Some of the drugs have peculiarcharacteristics, which influence thebody when these drugs areadministered.

(e) Division of drugs according to quality:First group – This group containsdrugs with a hot temperament suchas heat-producing drugs.

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Second group – This groupcontains cold drugs like refrige-rants, repellants and anaesthetics.Third group – Comprises moistdrugs, lubricants, etc.Fourth group – These are drugslike drying agents, astringents andobstruents, etc.

(f) Use of Coctive and Purgative: Coctivesare used to prepare the matter forexcretion through purging or othermeans of excretion. This is usedparticularly for treating chronic orobstinate diseases. This method has noparallel in any other system.

(g) Dosage and Timings: While deter-mining the dosage of a drug, factorslike temperament and potency ofdrugs, temperament and age of thepatient, nature of disease, severity ofdisease and route of drug are kept inmind. High-potency drugs or strongpurgatives and emetics are avoided insummer and severe winter. Differenttypes of treatment are prescribed fordifferent stages of the same disease.Some drugs are used when thestomach is empty and some are usedafter meals.

(h) Route of drug use: In addition to oraldrugs, Unani physicians alsoadminister drugs through huqna,abzan, farzaja, shiaf, zimad and tila.

(i) Forms and shapes of drugs: Powders,tablets, decoctions, infusions distillates,jawarish, majoon, sharbat, khamee-rajat, lavooq and perfumes, etc., areused to achieve the desired effect.

(j) Compounding and correction ofharmful-effect drugs: The harmfuleffects are either corrected by simplemethods or by compounding withother drugs, e.g., frying in oil decreasesthe irritant effect of the drugs. Drugs

are compounded for the followingpurposes:

To potentiate the drug’s effect(synergism);To decrease the harmful orexcessive effect (Antagonism);For sharp diffusion of the drug;For slow diffusion of the drug;For slow preservation of activeprinciples;To increase the quantity of a drug.

(k) Substitute of Drugs: Rhazes (920 AD)has compiled a treatise titled, MiqualaFil-Abdal- Il Adviyah-Fit-Tibb- Wal- Ilaj,on the subject of medicinal substitutewherein he has described the laws ofselection of substitutes of a drug andhas mentioned substitutes of 122 singledrugs.

Unani physicians were pioneers insurgery and had developed their owninstruments and techniques. Abul QasimZahravi wrote a book entitled ‘Al-Tasrif’ onthis subject.

The general principles of Al-Qanoncould equip medicine with the basicprinciples of science in the historicalperspective, offer education to masses inthe preservation of health and the cure ofdiseases, serve as an introductory coursein the bedside techniques of diagnosis andtreatment, and act as a key to the study ofUnani Tibb for research.

The various systems, whether Easternor Western, merely represent differentapproaches to medical science aspractised in different ages and in differentparts of the world. The aim of all systems isthe maintenance of health and preventionof disease. Anything of value in themshould be utilized for the benefit ofhumanity as a whole without anyreservation.


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References

1. Ghulam Jilani, Mukhzanul Jawaher (Urdu). 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 the Canon of Medicine 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.

Traditional system of medicine in Indonesia

47

efore 1987, traditional medicine hadno place in any formal health system in

Indonesia. However, in 1988, in order toachieve greater equity in healthdevelopment, traditional medicine wasdeclared as an area for launching a potentialdevelopment programme. Traditionalherbal medicine and health carepractitioners, who have developed in line withcommunity needs, are to provide thealternative health services. Indigenousknowledge and healing techniques, herbalmedicines and traditional practitioners areall very popular and familiar in thecommunity, because they are easily usableand valuable, and have been proved safeempirically. In 1995, a rule which regulatestraditional medicine and healers whocontribute to health care, was laid downby the Ministry of Health (MOH).(1)

Acupuncture, adopted from China’straditional medicine system, was integratedinto the national health system in November1996. This rule has streng-thened the roleof traditional medicine and practitionerswithin the country’s health system.

Indonesian traditional medicine usesmany terms and categories, ranging from

Traditional system ofmedicine in Indonesia

very simple to sophisticated ones. Most ofthese are related to the local culture, whichmakes it a little difficult for the outsider tounderstand them. A plant, animal, mineralor an intangible like metaphysics, may beused for healing. The tool/instrument usedmay be very sophisticated like laser, orsimple, like a wooden rod. Alternatively,there may be no tool at all, and the healermay simply use mental concentration. Theprocess could involve chemistry,mechanics, electricity and psychology/metaphysics. The route of administrationcould be the mouth, nostril, skin, vagina,rectum, etc. Usually, a traditionalpractitioner/healer uses differentcombinations of categories, e.g., to treata bone fracture, a bone healer uses amechanical bandage, oil mixed with flowerand inner power (concentration). There areno strict, standard procedures of treatmentbecause of the many factors to beconsidered in the holistic approach.

Subjectivity plays a major role in theselection of the method of healing. Themethodology of testing traditionalmedicines should be adjusted to thephilosophy on which they are based, suchas the holistic approach, the concept ofequilibrium or deep feeling. In such cases,

Lestari Handayani, Haryadi Supartoand Agus Suprapto

BIntroduction


48

scientific methods like statistical probabilityand multivariate analysis, the use ofsensitive instruments like Kirlianphotography, the aura camera and otherelectronic devices, are recommended. Amethodology to evaluate traditionalmedicines is yet to be developed. However,the profitability or otherwise of traditionalmedicine can be judged by its impact onthe community.

This paper will take up specific casestudies because the methods of differentlocal healers cannot be generalized.Information was obtained through severalmeans: observation, interviews, andsecondary data from literature. This articlewill concentrate on traditional medicinebased on herbs, not because the othersystems are not important, but becausethey have already been included in theformal health programme and thereforemore information is available on them. Theregulations regarding traditional herbalmedicine, especially for industries, are wellestablished—those dealing with standardsof production and the procedure foracquiring a licence. These regulations werelaid down by the MOH via the DirectorateGeneral of Food and Drug Control. Theregulation pertaining to traditional healers(alternative healing), however, concernsonly the license for practice, which is givenby a district or a provincial attorney.(1) To

promote safe and effective traditionalhealth care, the Government will provideresources for research on traditionalmedicine.

Traditional Practices UsingJamu

In general, traditional medicine is calledjamu (originating from the Javaneselanguage) throughout Indonesia. Jamu, asindigenous Indonesian traditionalmedicine, was practised in the countrycenturies ago and has been passed downfrom generation to generation for purposesof health promotion, maintenance andtreatment.(2) Jamu received a blow undercolonial rule, so that today the middle andupper classes are no longer interested inusing traditional medicines. These peoplehave greater faith in and use only modernmedicine; jamu is considered appropriateonly for poor people. This is evidenced bythe fact that till recently, the national healthsystem was exclusively using modernmedicines.

However, though formally notacceptable, traditional medicines arecontinuously being developed and used bythe community. Recently, with the call of“back to nature”, both Government andprivate enterprises have made severalefforts to develop jamu so that it can beused as modern therapy (physiotherapy).Implicit in this is the assumption thatphytopharmacology can be used in formalhealth systems. The development ofphytopharmacology would focus oncertain herbal medicines. Such traditionalmedicines are effective for specific diseasesthat are prevalent among the population,and are the only alternative medicines forcertain diseases. They are also predictedto have a therapeutic effect in certaindiseases. For the purposes of phyto-

Traditional medicines arecontinuously being developedand used by the community.

Government and privateenterprises have made several

efforts to develop jamu asmodern therapy (physiotherapy).


49

pharmacology, priority is being given toherbal medicines which can cure diseases;jamu focuses more on health maintenance,promotion and rehabilitation.(2,3)

Traditional medicine can thus becategorized into two groups, i.e., jamu andphytopharmacology. The next section dealsexclusively with jamu, which is part ofindigenous Indonesian medicine. Phyto-pharmacy is not discussed here as itbelongs to the realm of modern medicine.

Jamu and Indonesian CultureThe use of jamu is a part and parcel ofIndonesian culture. It is said that jamu isakin to a daily need for a section of people,both in urban and rural areas, where jamusare easily available. To understand the roleof jamu in the community’s daily life, wepresent an example of a custom of theMaduranesea women in producing andusing jamu.(4,5)

Case 1It is culturally accepted that in daily living,women consume more jamus than men.Women are especially particular aboutusing jamu, such behaviour being culturallyinstitutionalized within the community.Maduranese women are fanatical aboutconsuming jamu as reflected in the motto:“Better to not have a meal than notconsume jamu”. Madura’s tradition ofusing jamu is intrinsically linked with thehuman life-cycle. Thus, the consumptionof jamu is adjusted according to the phasesof life of a woman.

Mothers encourage their daughters touse jamus for their health. Girls are startedon jamu at the time of menarche. Duringthe menarche, a girl gets special treatment;she bathes with aroma and lulurb and then

consumes special jamu. Also, a teenagegirl is not allowed to step on animaldroppings, as this is believed to give thegenitals a bad odour. The jamu that isconsumed every day is provided by themother. This consists of water-extractedkunci (Kaempferia pandurata), turmeric(Curcuma domestica), and sirih (Piperbetle). Jamu made in home industries isbought for teenage girls, to be taken twicea week as a beauty aid (i.e., for a slim bodyand good health, good skin, and to fightbody odour).

The day of marriage is a special dayfor the bride. A month before the marriageceremony, the bride is given acomprehensive body care treatmentconsisting of lulur and cool powder madefrom rice and jasmine flowers. Thetreatment is meant to make the skinsmooth and shiny. A bride is not allowedto drink too much and is advised to havewater-extracted jamu as a substitute so thather body smells fresh and excessiveperspiration is reduced. In addition, shemust consume jamu rapat (vagina-constricting jamu), which is intended toconstrict the vagina and reduce excessivevaginal discharge, so that she can satisfyher husband on their first night. Abridegroom should prepare himself byconsuming jamu that serves as a sexualstimulant, but his preparation is not aselaborate as that required for a bride.

Married women, too, follow thetradition of consuming jamu to keep theirbodies fit to serve their husbands. This isdone voluntarily as proof of theirsubmission to their beloved husbands. Forbody care, they routinely use jamu, eithermade at home or bought from a kiosknear 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.


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water-extracted jamu made from kemangi(Ocimum basilicum), kunci and sirih tokeep the body smelling fresh and to preventleucorrhoea (excessive vaginal discharge).To prepare for sex, they take jamu sarirapat, which is available at kiosks. It cancontain from 10–40 jamu materials.Mondays and Thursdays are special daysfor couples: there is a belief that havingsexual intercourse in these days is ibadah,cand that the reward awaiting them is asglorious as that merited by a killer of 40disbelievers and a thousand demons. Toeffectively constrict the vaginal opening andlubricate the vagina, jamu is appliedexternally or a jamu stick is inserted intothe vagina just before intercourse to absorbthe cervical mucus. In order to enhancesexual potency and relieve fatigue, thehusband takes jamu selokarang,supplemented with eggs and honey. Toindicate that she is ready, the wife adornsthe bed with jasmines and lights somefragrant incense.

Special care is taken during pregnancy,which can be categorized into early andadvanced. In the early stages ofpregnancy, the woman uses jamu antonmuda. After six months, jamu cabe puyangis used to relieve fatigue and pain. Tohasten delivery, the woman should takecoconut oil supplemented with raw eggyolk. Some also drink the water of greencoconuts. Finally, they take jamu that servesas a stimulant for lactation in order toprepare for breastfeeding.

Postnatally, the mother uses certainpostnatal jamus, packages of which canbe ordered before delivery. Such jamu istaken from the first day after delivery uptoday 35 or 40. The package consists ofmany kinds of jamus, which should be

consumed sequentially, in accordance withthe post-pregnancy convalescenceprocess. For the first 20 days, jamu is takento remove blood residue and mucus fromthe uterus. Subsequently, jamu is used forrestoring the uterus and abdomen to theirformer size, and for relieving fatigue. Themother takes various kinds of food toenhance the production of breast milk.These include vegetables, katu (Sauropusandrogynus) leaves and different varietiesof beans. Spicy foods, ice and foods with ahigh water content are avoided.

The child of a lactating mother usingjamu may suffer from constipation, and hisstool may be dark and have a bad odour.This is believed to indicate good health, theassumption being that the baby is thusgetting rid of harmful abdominal wastes.This continues for around a month, till thetime the mother stops taking jamu.

Jamu is also used for the spacing ofbirths. Most mothers in Sumenep takejamu pills made at home. These contain asmall amount of lime encased in tamarind(Tamarindus indica) flesh. About five toseven such pills are taken as a single doseafter each menstruation. According to aherbalist, this method is quite effective.Though they do not use moderncontraceptive methods, each couple inSumenep has only one or two children. Inorder to treat primary or secondaryamenorrhoea, while avoiding pregnancy atthe same time, women consume “hot jamu”containing clove, pepper, cabe jamu (Piperretrofractum), ginger, tamarind flesh andother substances. To overcome infertility,women use “cool jamu”, which containsbeluntas (Pluchea indica), sirih (Piperbetle), trawas (Litsea odorifera) leaves and10–20 other substances.

c Ibadah signifies good deeds in the eyes of Allah


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Provision of JamuThe Maduranese customs, thus, consist ofthe use of two types of jamu: (i) That whichis home-made, bought from the jamupeddler (jamu gendong), or fromindustries, and (ii) That provided byherbalists. As most of the Indonesianpopulation resides in the island of Java, thejamus discussed here are mostly those usedby the people in Java.

Home-made JamuAccording to Javanese custom, it istraditionally the mother who is responsiblefor looking after the health of the familymembers, especially the children. Thispractice is well-entrenched, especiallyamong traditional folk, as is evident in therural areas. A mother is expected to knowhow to make simple jamu for themaintenance of the health of the familymembers and for purposes of first aid.These skills are generally acquired withoutany special training. Women learn andpractise making jamu by observing otherswho make it, as well as by gatheringinformation from neighbours. In addition,they may hone their knowledge and skillsthrough a programme called TOGA (familyherb garden). Due to the attention of theGovernment in this matter, TOGA progra-mmes have spread over large areas of thecountry. The programme recommends thatfamilies cultivate herbs in their gardens oryards to have a source of fresh herbs whichare ready for use.(6)

Within a family, the tradition of usingjamu is introduced at a young age. Familiescommonly use a health drink (roborantia)to promote good health and familiarize themembers with jamu. An example is sinom,which is made from young leaves of thetamarind, supplemented with turmeric and

red sugar (traditional sugar) as well astemulawak (Curcuma xanthorrhiza).

Apart from restoring health, jamu isalso used for certain illnesses and healthproblems, which are bound to afflict afamily member at some time or the other.A mother is expected to provide at leastfirst aid in such situations. The disordersthat can be handled by mothers are mildailments. A common cold with symptomsof a running nose, mild cough and fevercan be treated with jamu made ofmaterials taken from the kitchen. Feverresulting from infection is commonlytreated with jamu made from turmericjuice, or water extracted from papayaleaves. Crushed onion mixed withkajuputi (Leucodedron leacodendra) oilor coconut oil is commonly applied tochildren with fever. Febrile convulsion isprevented by a compound containingsangket (Moschosma poly-stachyum)leaves. Children with a poor appetite areforcibly given temu ireng (Curcumaaeruginosa), which is very bitter. A pasteof heated castor leaves is applied on theabdomen to relieve abdominal disorders(colic and dyspepsia), while chewingyoung guava leaves is effective in treatingdiarrhoea.6, 7

A jamu drink like beras kencur, whichis made from finely pounded rice andkencur (Kaempferia galanga), tamarindflesh and red sugar, together with thelubricating bobok beras kencur,d helps inreducing the oedema and pain caused bya sprain.7 Rheumatic pain can be treatedby rubbing the painful area with finelypounded ginger. Rubbing castor sap orpapaya leaves, kamboja (Plumeriaacuminata) or patah tulang (Pedilanthuspringlai Robins) sap on a fresh cut/woundcan provide immediate relief.6

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


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The materials that mothers use to makejamu for the family members are not of manytypes. They can be obtained from thekitchen, and consist of spices used intraditional Indonesian cooking. Theseinclude turmeric, ginger, kencur, kunci andgarlic. Some fruits, like nipis lemon (Citrusaurantifolia) and onion are also used. Plantsgrowing in the yard, garden, or rice fields—whether planted or growing wild—may alsobe used. Fresh materials are extracted fromcertain parts of plants (leaves, roots, flowers,fruits, trunk, seeds), or from the entire plant.A number of plants are deliberately cultivatedin the garden for their fruits, leaves or seeds.These include papaya, guava, pares(Momordica charantia), nipis lemon, daunungu (Pseuderthemum andersoniil), andpecut kuda (Stachytarpheta jamaicensis).Among the wild plants that are commonlyused are sambiloto (Andrographispaniculata), tapak liman (Elephantopusscaber), patikan kebo (Euphorbia hirta),tapak dara (Vinca rosea), ciplukan (Physalis

minima), kudu (Morinda citrifolia), gempurbatu (Ruellia naifera), and sembung(Blumea balsamifera).3, 6

To make jamu drinks or externalmedicines these herbs or spices are simplyprocessed. The process of making jamurequires boiling, and kitchen utensils suchas ceramic pots may be used. A traditionaltool called lumpang or pipisan, made ofstone, can be used for pounding.

Jamu drinks can be made in the formof percolates (water-extracted) orconcentrates of jamu materials. To obtainthe essence of the raw materials, they areoften cleaned and chewed. Home-madejamu is usually made when the need arises,so it is always fresh. The unused jamu isdisposed of.

Jamu gendongJamu gendong is liquid jamu, which isstored in bottles. It is usually sold bywomen, who carry the bottles in bamboobaskets slung on their backs. Jamugendong is cultivated extensively, and maybe seen growing in Java, Sumatra andKalimantan island, in the cities, towns, orremote areas. Most jamu gendong sellerscome from the Central Java province(especially Wonogiri) and make their livingwandering about the country. They comefrom a low socio-economic stratum, andhave a low level of education, usuallyelementary school. Their consumers couldbe urban or rural people, who, too, aremostly from a similar background.7

The following example from Surabayacity, East Java, illustrates how a jamugendong seller lives. 7, 8

Case 2Surti (a pseudonym) is a jamu gendongseller from Central Java. Twelve years ago,she and her husband, together with theirtwo daughters, moved to Surabaya to earn

A herbalist, preparing fresh herbal medicines in atraditional market



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a living by selling jamu gendong. Surti, whois 40 years old, lives in a 3 m x 4 m rentedroom. She shares the room with herhusband, who works as a dawete seller, a15-year-old daughter, and anotherdaughter who is married with a three-year-old child. The small room has a single bed,a simple wardrobe, a wooden rackattached to the wall, a basket containingbottles, and a number of pockets andplastic bags hanging on nails. In the corneris a small wooden table which is heapedwith various things, including a small radio.The room, which has a small fan, is smalland rather dark even in the daytime, as itis lit only by a 25-watt bulb. A bicycle witha wooden frame to carry bottles poised onits back is also in the room.

The entire family wakes up withShubuhf at about 4:30 a.m., after whichthey begin working. Surti immediately startspreparing her cooking utensils, stove andpan to boil water. Next, she adds a quantityof red sugar and some white sugar to thewater. She then lays a mat on one side ofthe room, where she prepares a numberof plastic jars, a funnel, liquid filter, dipperand steel mortar with its pestle.

She takes jamu materials out of plasticbags and jars, and places them on the floor.After the water has boiled, she preparescertain materials for the jamu to becompounded. Sitting on a woodenbarstool, she processes jamu with greatskill. She adds jamu materials (there canbe three to five kinds of materials), and thenpounds them into a fine mixture. Next, shetakes plastic jars and fills them with thesugar liquid and the pounded jamumixture. The liquid is then stirred and

tasted. The processed jamu is poured intoseveral clean bottles. She uses the sameprocess to make other kinds of jamu. Tomake jamu pahitan,g in particular, the jamumaterials are boiled in a special containerbut no sugar is added. In about an hour,eight kinds of jamu have been processedand stored in 22 bottles.

At around 6:00 a.m., Surti starts sellingher jamu, covering her daily route on herbicycle. She places 14 bottles on a woodenrack at the rear of her bicycle, and anothereight bottles in the bamboo basket, to besold by her daughter. Her daughter,wearing a kabaya,h walks in anotherdirection, carrying the basket on her back.

It seems that Surti already has certaincustomers. Riding slowly into a lower socio-economic dwelling complex, which shevisits routinely, she rings the bells as asignal to her customers. A few mothers andyoung household attendants come out tobuy jamu. When she is sure that there areno more buyers, she proceeds to a complexwhere a group of men are busy withconstruction work. A number of workerscome forward to buy jamu and she greetsthem with a pleasant smile. The workersrelish the jamu. By 10:00 a.m., most ofher bottles have been sold and she goeshome. Her daughter is already there,having sold all her jamu bottles as well.

Every day, Surti manages to sell 14bottles of various kinds of jamus. Jamukudu laos is believed to be good forhypertension and for improving bloodcirculation; Jamu pahitan relieves theitching caused by allergies, parasiticinfections and diabetes mellitus; Jamucabe 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 prayerg Pahitan is a very bitter jamu.h Kabaya is a special traditional Javanese dress.


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and fatigue; while jamu sinom refreshesand cools the body; Jamu beras kencurimproves the appetite and relieves fatigue;Jamu kunci suruh is helpful in cases ofleucorrhoea or excessive vaginal discharge,and jamu uyup-uyup stimulates lactation.

On the way home, Surti stops by ajamu kiosk in the market to buy jamumaterials for the following day and forsome foodstuff. Back at home, she restsfor about one hour. After preparing thefamily lunch, she makes another jamu, tobe sold at 3:00 p.m.

Industry-made JamuBoth small and large-scale jamu industriesare thriving in Indonesia. Many regulationspertaining to the jamu industry have beenformulated by the Government (MOH).These cover several aspects, such as thelicence for establishing a jamu industry,recommended practices for the processingof jamu, and compulsory registration ofjamu. The industry can be categorized intobig or small, depending on the amount ofcapital invested. There are just a few largejamu industries, mostly in Java, while smallindustries are scattered all over thecountry.1,4

Jamu industries must fulfil a numberof prerequisites so as to be able to sell theirproducts in the market. A person seekingto start an industry must obtain a licence

from the provincial health office. Jamusmay be sold in the market provided thatthe seller has a registration licence fromthe Directorate General of Food and DrugControl, MOH. One regulation states thatjamu products must not be mixed withpharmaceutical chemical substances. Thesale of jamus in the form of vaginal or analsuppositories is not allowed; and only aspecified concentration of preservativesmay be used in producing jamu. 1 TheseMOH regulations represent an effort topromote and control the jamu industry inthe hope of improving the quality of jamus.

Big industries are capable of producingmany forms of jamu to meet the people’srequirements (e.g., extracts in the form ofcapsules, effervescent or sugar-coatedtablets and syrups). Their capital allows themto purchase modern machines for superiorprocessing. With such resources, they canprovide jamu in the same form as modernmedicines. There is a lot of competitionamong the jamu industries, and jamuproducts are advertised in the electronic(television, radio) and print media(newspapers, magazines), and through thedistribution of leaflets. Given the large-scaleproduction of these industries, their marketcould extend to various places in the country.

Small jamu industries are spread overextensive areas of Indonesia. They areconcentrated among those communitieswhich have acquired the skill of producingjamu from their ancestors and use it as ameans of earning their livelihood. As ahome industry, it contributes on theeconomic front. Among the areas thatproduce jamu are Madura, Wonogiri(Central Java) and Cilacap (Central Java).These industries use only simple productiontools, and some have no special tools atall. For the milling of raw materials, theproducer has to hire the services ofsomeone in the market with a milling

Jamu industries areconcentrated among thosecommunities which have

acquired the skill of producingjamu from their ancestors and

use it as a means of earningtheir livelihood.


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machine. Some producers cannot evencompound jamu, so they purchase thecompound powder, divide it into severalsmall packets and sell them. Often, theyalso use kitchen utensils to process jamu.5

Home industries produce jamu formsthat can be readily served. The producerscompound jamu materials and then grindthem to a fine powder. This is packed inplastic or paper packets and then re-packed in bigger paper packets that arelabelled. Some are packaged very well,while others are simply packed. Anadvanced method of jamu processingcomprises the production of pills, eitherdried or moistened with honey. Someproducers pack jamu powder in capsulesfor consumers who do not like the taste ofjamu. Though very rare, some producejamu in the form of tablets. Pills, capsulesand tablets are packed in labelled plasticpots. Besides producing jamu to be takenorally, producers also manufacture jamufor external use like boboki (lubricants),pilisj and parem.k These three are sold inthe form of big pills or powders, which canbe easily mixed with water. Godoganl ,which is compound jamu in the form ofraw material, has to be boiled for extractingits essence and is then taken orally.Compound jamu godogan is packed inlabelled or unlabelled transparent plasticbags. 5

The market for industrial jamu is verylarge, as the culture of consuming jamu isalready institutionalized in most of thecountry. These days, industrial jamu seemsto be more popular than traditionally madejamu since it is more convenient toconsume and store. The market for

industrial jamu is varied, depending on theproducer’s capacity to promote hisproducts. Some big industries have evenopened special outlets in supermarkets andluxury malls, which cater to the middle- andhigher-income groups. But, as most jamuconsumers belong to the lower economicstratum, promoting techniques which arefriendly for lay people would be morepopular. The same applies to the marketingsystem. Most industrial jamu sellers havelimited capital and vend their products insmall kiosks. Such businesses are beginningto thrive in dwelling complexes andmarkets. The jamu is sold at an affordableprice and the products are sometimesvaried. The most popular variation isdissolved jamu mixed with egg yolk andhoney. Then there are the peripatetic jamusellers like Surti, who visit residentialcomplexes on carriages or bicycles,complete with musical instruments. Theirproducts are suited to the consumer’sneeds, and have different brand names.Jamu sellers serve the drink sinom, afterthe customer has had the jamu toovercome its bitter taste. A simple way ofconsuming jamu is by buying it at a kiosk,and then having it there. Jamu gendongsellers also provide industrial jamu tocomplement their product.

Jamu provided by herbalistsHerbalists include those who use local herbsgrown in various areas of Indonesia, andthose who use materials from outside thecountry. The latter are mostly from China,Saudi Arabia or Pakistan. They usematerials from their own countries, thoughsome 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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stroking her hair, the jamu seller asks her afew questions regarding her complaints,which the girl answers shyly. After skilfullygetting her answers, the herbalist takes apinch of jamu powder from the woodenboxes and jars. After completing thecompound jamu, the herbalist hands it tothe mother with some instructions on howto administer it. The mother pays her somemoney.

Soon after, a young woman comes tothe kiosk. The two hug each other, and havea long, friendly chat occasionallypunctuated with laughter. They seem to beaunt and niece. The niece also sells jamu(jamu gendong) in other cities. She wantsa stock of materials, including jamupahitan, for the next three months. Shenotes these down on a piece of paper, andarranges to collect them the following day.

Not far from this kiosk, in a corner ofthe traditional market, many mothers intypical Javanese attire guard theirmerchandise, some of which is lying intampahsm and some in bamboo baskets.They sell fresh jamu materials and theirstaple stock comprises various leaves,radishes, varieties of lemon, somethingwrapped in banana leaves, and variousrhizomes. Some of the sellers are busyserving their customers. A middle-agedwoman asks one of them for jamu for thepostnatal care of her daughter. The jamuseller asks when the delivery took place,quickly fills a small plastic bag with certainleaves, rhizomes and radishes. She alsopicks up some lime and three lemons. Shethen explains how to clean and boil thesematerials, and tells her that their concentrateshould be given orally for postnatal care.She advises the woman not to throw awaythe residues as they can be percolated againthe following day. Lime and nipis lemon are

Javanese herbalistsThe Javanese community can easily buyjamu from one of many traditional marketsalmost anywhere on the island. Theprovinces of Yogyakarta and Central Java,which are well-known cultural centres, havemany traditional markets where jamupeddlers sell the jamu racikan (blendedjamu) made by them in accordance withthe consumer’s needs. Basically, there aretwo types of Javanese herbalists: (i) Thosewho compound, prepare and sell freshjamu materials, and (ii) Those whocompound and sell dried jamu materials.As the community has long been aware ofthese herbalists’ skills in compoundingjamu, it uses their blended jamu for specificillnesses. Yogyakarta’s case will provide aninsight into their roles.

Case 3A 60-year-old mother runs a small kiosk atthe roadside in front of Yogyakarta’s market.Usually she sits calmly on a dilapidatedwooden chair and sometimes she stands inher kiosk talking to prospective customersin her warm and friendly voice. Various driedherbs lie in small containers insidepartitioned wooden boxes in the kiosk. Thematerials include temulawak, mesoyi(Crytocarya massoy Kosterm), kayu legi(Glycyrrhiza glabra), adas (Foeniculumvulgare) seeds, turmeric and temu ireng.Some are stored in neatly arranged jars ofvarious sizes on a rack attached to the wall.On the floor may be seen several brownpaper bags containing stocks of jamumaterials. A woman accompanied by her15-year-old daughter comes along and afriendly conversation ensues. The womanwants to buy jamu to treat her daughter fordysmenorrhoea (severe pain duringmenstruation). Holding the girl’s hand and

m Tampah is a circular and flat bamboo container.


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used as bobak perut n for postnatal care.After the bobok has been applied, theabdomen should be twisted with abengkung.o The mother pays and leaves.Shortly afterwards, a young mother inmodern dress comes to buy jamu for bodyodour. The jamu seller takes out beluntasleaves, turmeric, tamarind leaves and somered sugar and asks the lady to boil these athome. Many other buyers who purchasejamu materials without asking forcompounding can also be seen.

Chinese herbalist (sin she)A sin she is a Chinese herbalist skilled incompounding jamu, as well as performingacupuncture and acupressure. Usually hecompounds his jamu on his own, or asksthe patient to make the jamu according tohis recipes. A sin she does not alwaysprovide the jamu himself; instead, he oftenjots down some in Chinese on a piece ofpaper, like a medical prescription. Thecustomer has to buy the material from aChinese drug store. The following is adetailed account of how a sin she practises.

A sin she’s practice is relatively moreformal. His name and hours are written ona board outside his clinic. Sin she‘s practisemostly in big cities. The room in which asin she practises is like a physician’s clinic,complete with a waiting room and anexamination room. An attendant admitspatients and is in charge of the adminis-trative procedures. Examination isconducted according to traditionalChinese medicine methods, i.e., byanamnesis (asking about the patient’scomplaints and symptoms), and checkingthe pulse at both wrists while continuingwith the anamnesis. Many patients aretreated with acupuncture or acupressure.

For this, the patient has to lie down on abed in a manner that facilitates the processof puncturing the abdomen, back, legsand hands.

For the sale of compound jamu, a sinshe charges a fee based on the price ofthe ingredients. This charge is higher thanthat of other traditional healers, as somematerials are imported from China.

Jamu based on Raw MaterialIndonesia is a tropical country with forestscontaining thousands of small and largeplants, and several species of animals. Thecountry’s natural resources, as well as itscultural and ethnic variety, have had aninfluence on the way traditional medicinesare prepared. Plants (herbal medicine),animals and minerals are all used in thepreparation of traditional medicines.

Jamu from plants (herbal medicine)Nearly all kinds of jamu produced by bigjamu industries, small-scale homeindustries and herbalists are made frommedicinal plants (herbs). There are about940 plant species that have therapeuticeffects, but the jamu industry uses onlyabout 200 species. In general, the plantspecies used as jamu in different parts ofIndonesia are the same. However, someareas have their own specifications in thisregard, e.g., kayu pasak bumi (earthwooden pike) is used only in Kalimantan.

The jamu made by both industries andherbalists usually utilizes a number of plantspecies; rarely is just a single plant used.The number of plant species used for aparticular kind of jamu usually ranges from5–10. Certain jamus contain 30–40species. Home-made jamu contains justtwo 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.


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Jamu from animal materialsJamu made from animal materials is notas popular as herbal jamu. These remediesuse substances from the cobra, lizard,house lizard, molluscs, earthworm, gabusfish and other creatures.9 The animal canbe captured from its natural surroundings,or procured from the markets. The tradein animal remedies is not flourishing as wellas that in herbal medicines. Animalmedicines may be more easily obtainedfrom Chinese drug stores than the regularmarkets.

Lizard and house lizardThe house lizard can be easily found indwellings or trees while other lizards maybe found in the bushes or grass near thehouse, in a garden, or in a paddy field.Both are used as remedies for Tineaversicolor, fungal skin infections, eczemaand other skin problems. The medicine maybe taken orally or applied externally. Forexternal use the animal’s flesh is crushedand applied to the affected area for 10–15 minutes, after which the skin is cleaned.For oral use, the lizard is baked until it ischarred black, ground to a powder, mixedwith some coffee and diluted with water.

CobraThe cobra is a poisonous snake whose bitecan be fatal. Cobras are found nearswamps, in paddy fields, or in theunderbrush. Cobra remedies are well-known in the big cities of Indonesia. Allparts of the snake’s body are used formedicines. Cobra blood is believed toenhance the sexual potency of men. Theuncooked bile and spinal cord, mixed withspecial herbs, are considered beneficial fordiabetes, high levels of cholesterol or uricacid, cancer, asthma, malaria, skinproblems and general physical fitness. Thecobra’s flesh is cooked and served by food

vendors or in restaurants. It is also sold ina dried form.

Cobra remedies are sold in kiosks alongthe streets of Surabaya. The vendors, whoknow how to prepare medicines out of thecobra blood, bile and spinal cord, get livecobras from East Java. The preparationinvolves the use of arak (alcohol), otherherbs and honey. There are many cobraconsumers, as can be seen from the factthat, on an average, a cobra seller can sellup to 20 cobras a day.

MolluscsMolluscs are considered a plant pest byfarmers as they consume the leaves ofplants rapidly. However, they can be usedfor the treatment of certain illnesses. Forexample, they can be of use in clearing therespiratory tract of mucus (mucolytic),treating oedema, pharyngitis andhaemorrhoids and as a diuretic. Thetransparent liquid of a mollusc, obtainedby cutting the small pole of its shell, can beused as first aid for fresh wounds.

EarthwormsEarthworms loosen the soil and are foundin the earth in pots, yards or gardens. Theyare used to treat several ailments. Forexample, the rural population drinks theblended, dried and fried oil of the wormsto treat fever due to typhoid. Chinese drugstores sell dried and processed wormswhich they claim have a beneficial effecton patients with breast tumours, nosepolyps, headaches and hypertension.Earthworms are also used as diuretics.

Jamu from mineralsMinerals are not often used as jamu. Tawas(hydrated alumni kali sulfas) help relievebody odour, while sulphur powder iscommonly used for treating skin diseases.In certain areas, women consume ampo,


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i.e., soil that is water-blended, then driedand cut into slices, as it contains iron. Limeis used as bobok, i.e., to lubricate andwarm the abdomen of postnatal women.6

Other Traditional PracticesPeople opt for traditional healingtechniques for a variety of reasons. Themajor reasons are that they are accessibleand acceptable in social, cultural andeconomic terms. The other benefits are thattraditional healers make home visits,without charging any fixed fee. Anotherreason is the inadequacy of modernmedicine in treating certain cases, such ascancers at an advanced stage, or irrationalailments like santet or tenung.p Thecommunity learns of the existence oftraditional healers by word of mouth,though these days magazines andnewspapers also carry advertisements andinformation on the subject.

Traditional practitioners in Indonesiahave acquired their knowledge and skillsnot through formal education, but fromtheir parents. Some learn while assistingestablished practitioners, some of whomteach their skills to just one or two trustedpersons. A few healers claim to be gracedby wangsit,q which comes to them eitherthrough dreams or after performing“special deeds”, such as fasting, abidingby certain taboos, or living in seclusion.

Many traditional healing skills,however, are mass taught through aninformal process. These includeacupressure, urut massage,r acupunctureand the skill of compounding jamu eitherfor males or females. The age of the pupilsranges from 20 to over 60 years. Whilesome have acquired higher levels of

education, most are in elementary schoolor junior high school, and some havereceived no formal education at all.

According to traditional perspectives,diseases may be categorized as rationaland irrational. The former are believed tobe caused by the disturbance ofhomeostasis, such as an imbalance innutrition. Irrational diseases are said to becaused by mystics. Supernatural/magichealers, who believe in the existence of suchailments, often cure the latter, as well ascertain strange problems, such as theremoval of nails, stones, iron and otherobjects embedded in the abdomen.

Traditional healers usually do not havea special room in which to examine theirpatients. In fact, they do not have a nameboard, fixed hours or fees. Most of thempractise on a part-time basis, though somewho are well-known do work full-time astraditional healers. The latter have manypatients, which can be seen from the longqueues of patients awaiting consultation.Some have in-patient facilities tocomplement outpatient services. Atraditional healer often combines a numberof traditional techniques, like massage andjamu, magic treatment and jamu, and soon.

The following section focuses ontraditional healing practices that arecommonly used by the community, suchas traditional methods of bone healing,attending to deliveries, kerikan andcircumcision.

Traditional Bone SettingAlmost all ethnic groups in Indonesia havetraditional bonesetters (TBSs), who thriveboth 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.


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healers honour certain ethnic concepts intheir practice. In Java, the TBS is commonlyreferred to as sangkal putung. Thesehealers can help cure any kind of complaintrelated to bone fracture (e.g., complete,incomplete or multiple fracture), jointdislocation, as well as muscle sprains. Thereason why people choose TBSs is becausethey are easily accessible, both in terms ofexpense and distance, as well as to avoidinvasive surgical procedures.10

Of the traditional bone-settingtechniques, some are purely traditionalwhile others attempt to incorporate certainmodern techniques.3, 10, 11 The procedureis as follows. A specific mantras is chantedto a patient or he is given a drink which istreated by chanting mantras. Some healersuse charms, like a stone or a keris.t Thepatient is asked to drink water into whichthe charm has been dipped. It is believedthat through the medium of drinking water,the prayer or charm would help relieve theailment. A TBS does not ask manyquestions. By simply observing the fractureand touching it physically, he identifies theexact problem. Many healers say that theirfeelings guide them in determining thespecific problem and the method ofhandling it.11 This faculty of feeling is saidto be acquired through special deeds.

To convince the patient and her/hisfamily about his diagnosis, the healer oftenemploys a symbol. For instance, todemonstrate whether or not the bone isfractured, the healer feels a banana and ifthe flesh is found to be broken, it meansthat the bone is fractured.11 Some, however,utilize modern techniques such as X-rays.

Some healers, especially those living incities, treat a fracture with moderntechniques, medicines and materials, like

betadine, rivanol, alcohol, sterile gauze andcotton. Patients with open fractures arereferred to the local health care centre.Some healers even have informalpartnerships with nurses practising in thelocal institution.

The pattern of treatment used bydifferent healers is similar. The differencelies only in the way they express theirsupernatural or magical powers, e.g., inthe kind of jimat (charm), special oil orspecial water used. The processes oftreatment and diagnosis are simultaneous.For example, by uttering special prayers(mantra), the healer diagnoses as well asfixes the fractured bone. Joint dislocationis managed by pressing, pulling andmassaging the affected area. The mannerof handling the problem depends onindividual cases.

To heal a fracture, the areas aroundthe site of fracture are first massaged inorder to relax the muscles. The bone is thenrepositioned and aligned correctly. This isfollowed by continuously massaging thearea with a special oil. During the processof treatment, the patient is asked to movethe injured part, which is then pressedagain. The materials used to secure thearea are hardboard paper, the stem ofbanana leaves, bamboo or wood, thoughmodern TBSs use elastic bandages.Whatever the material used, the dressingis opened every three to four days to assessthe alignment. The patient then receivesanother massage. In-patients are given adaily massage.11

The effectiveness of the traditionalhealing process is judged more by theextent to which it meets the expectationsof the patient and his/her family.Psychological support is also considered

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


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important. A patient is considered to haverecovered if he is able to move the injuredpart or walk, even if movement is painfulor unsteady. However, some healers definerecovery as the ability to perform in anormal way. The extent of recovery may beassessed by asking the patient to liftweights; if no pain is experienced, it signifiesrecovery.

Traditional Birth AttendantsMany deliveries in Indonesia are stillassisted by traditional birth attendants(TBAs), who may be either trained oruntrained. TBAs practise under thesupervision of health centre personnel,namely midwives. A programme to staffvillages all over the country with midwiveswas launched with the aim of providingmothers access to professional help fordeliveries.12 TBAs are expected to assistthese midwives. Though the Governmentis trying to prevent the proliferation of TBAs,this is not possible as the community stillseems to need them.

Some communities prefer TBAs tomidwives. One reason for this is that theTBA is one of the local people, and thusunderstands the local culture and is alreadyfamiliar with members of the community.

TBAs not only assist with deliveries, butalso render certain other services. Forexample, they take care of women allthrough pregnancy and advise them aboutthe norms to be followed during this period.TBAs provide jamu as well as massages torelieve fatigue. A special massage is doneto fix the foetal presentation, if necessary.(13)

As deliveries are natural events, thetechniques used by most TBAs are similar.They simply wait through the process ofdelivery, until the baby is born naturally.Some untrained TBAs still use traditional

tools, like bamboo knives (welat) to cut theumbilical cord. Crushed pepper leaves orkunyit together with salt is applied to thepole of the umbilicus.13 Some of the moredaring TBAs go a step further to facilitateproblematic deliveries. For instance, theymay push the abdomen downward indifficult cases, or grope inside the uterusto disentangle the placenta. TBAs performspecial ceremonies or chant prayers(mantra) during the process of delivery.

TBAs make daily visits to the mother’shouse to take care of her and the baby, for35–40 days after delivery. They bathe thebaby, massage both the baby and themother, and also help prepare for birthceremonies. The placenta is bathed andseveral uborampeu are made to it. It is thenburied in front of the house, and the spotis lit by a lamp at night. A ceremony isperformed when the dried up umbilicus issevered from the baby’s stomach. Suchceremonies are performed at every step inthe baby’s growth. Apart from taking careof the baby and the mother, TBAs also helpin household work, like washing the baby’sclothes, preparing jamu for the mother, andso on.13

Traditional Circumcision (Khitan)Since most Indonesians are Muslims,circumcision is obligatory for male children.Traditional circumcision is practised widelyin Indonesia, the demand for it arising fromthe belief that the prayer performed duringthe ceremony has a healing power. It is alsobelieved to have certain other advantages,e.g., the child is said to experience less painand fear, and the healing process is faster.

The skill of performing traditionalcircumcision is learnt from parents orfamily members who know how to do it. Tobe a khitan practitioner, one needs to

u Uborampe are offerings.


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perform special deeds, in accordance withcertain Muslim norms. These deeds includefasting for 40 days, and going without ameal for 24 hours on the last day. Theperson can only drink water at the time ofMaghrib.v For a traditional circumcision,either the practitioner goes to his patient’shouse, or the patient comes to him.

The techniques used for khitan do notvary much—basically, the practitioner cutsthe prepuce of the penis. In the purelytraditional technique, the prepuce is heldin place by a clamp of wood, bamboo ortusk, and then cut with a sharp knife. Nolocal anaesthetic or medicine is used. Thepatient is merely given water before theprocedure. However, nowadays mostpractitioners use modern medicines andtools, like scissors and modern knives.

Antiseptics like rivanol, betadine andalcohol, and materials like cotton andgauze are used. A few practitionersprescribe antibiotics to prevent infectionand analgesics to relieve pain. Thefollowing is an account of a traditionalcircumcision:

The boy who is to go through khitan isgiven a new sarong, white shirt and capby his parents. After the son is ready andall the preparations have been made, thepractitioner begins the process. Afterchanting a special prayer, he clamps theprepuce of the penis and cuts it quickly witha sharp knife. The wound is dressed withgauze. The boy then wears the sarong, shirtand cap. To prevent the wound fromtouching the sarong, a supporting woodenframe is used, in the ventral surface of thelower abdomen. Purely traditionalpractitioners used only prayers or mantrasfor pain relief and recovery.

One ethnic group in East Java, whichbelieves in traditional circumcision, has adifferent custom. The khitan practitioneris asked to cut off a small part of theprepuce before the doctor or the nurse isasked to complete the procedure. This isperhaps explained by the belief that it isonly a khitan practitioner who canperform the prayers properly, so he shouldinitiate the process.

The Practice of KerikanThe practice of kerikan is well-entrenchedin Indonesian society, especially among thepeople of Java. The word kerikan, whichhas its roots in the Javanese language,means to peel off or remove a surface layerthat is unwanted. Thus, kerikan is a healingtechnique which consists of scraping theaffected area of the body. It could be thechest, back, abdomen, neck, arms or legs.Usually, coins and spoon-holders are usedfor scraping, complemented by the use ofherbs like onions and kajuputi oil.14 Kerikanis commonly used as a first-aid methodduring illnesses. Generally, it is quiteeffective in providing relief from thesymptoms of non-infectious diseases.Traditionally, it is believed to be very effectivefor masuk angin.w Kerikan may be usedto treat almost all people, from a one-year-old child to an elderly person. Kerikan cancure children of abdominal distension,cough and laboured breathing, nauseaand vomiting, diarrhoea, and fever. Adultsuse kerikan to obtain relief from toothache,intercostal ache, chest pain, backache,acute oedema, insomnia, fatigue,headache, fever and other complaints.

A family member of the patientperforms 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.


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done over the affected part of the body.Frequent and continuous scraping makesthe skin turn a specific colour and produceserythematous stripes. It is believed that thedegree of redness reflects the severity ofthe illness. The redder the skin, the moresevere the ailment. Inexplicably, the patientfeels more comfortable. During the processof kerikan, the patient does uwat.x Thismovement would stretch the muscles,which in turn would improve bloodcirculation and help the body reachhomeostasis. All these are ways of effectinga recovery.14

The patient could undergo kerikan ina sitting or supine position. To enhance theeffect of the procedure, a number of oilslike coconut or kajuputi oil, or analgesicbalm are commonly used. Kerikan shouldbe done as follows. The coin should be usedwith a strong but smooth pressure. On anaverage, one stripe of kerikan is producedafter 20–30 strokes of scraping. A goodtool for scraping is one that is blunt but isable to produce deep pressure, so that itcan reach the deeper muscles. Kerikanshould be done thoroughly andsequentially in a proper order, over the skinsurface. The sequential procedure is knownas tapis. The direction of scraping shouldfollow the bundle of the muscle, called turut(meaning to follow) so that the target pointscan be located. Warm oil is commonly usedafter kerikan.

The Practice of KOPThe method of kop is similar to kerikan,but the tools used are different. In kop, theskin of the affected part of the body issucked upwards to produce an erythe-matous effect. This method is employed in

some areas, like Lombok, Madura and EastJava. The tools used are varied and includea buffalo/bull horn, coconut shell andrubber kop.

To begin with, the inside of a coconutshell or a buffalo horn is heated, forexample, by a candle. The concave surfaceof the shell is then applied to the skin ofthe affected area. Due to the negativepressure, the shell sucks in the skin. Theshell is removed once the negative pressureceases. The process results in a circularerythematous protuberance. A moremodern technique consists of using a kindof pump that can suck in the skin withoutthe use of heat.

The Practice of TraditionalMassageMassage therapy is practised everywhere inurban and rural areas. The therapist couldbe a male or a female, usually above theage of 40 years. Massages can be of twotypes, urut massage and reflexive massage.A masseuse learns the skill either from othermasseuses, by attending a course, throughtrial and error, or from books.

Urut massage is beneficial for fatigue,myalgia, cough and muscle stiffness.14 Thewhole body is massaged, with the focuson the affected areas. Women and childrenare given massages by females and menby males. Urut massage includes themassage given by TBAs to postnatalwomen and babies. Fussy babies arefrequently taken to TBAs for this purpose,4as it is believed that fever and fussing arecaused by muscular problems. A mothercan ask the TBA for walik dadah.y

Reflexive massage focuses onparticular 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.


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and the sole of the foot. This type ofmassage, believed to have originated inEgypt and China, is very popular inIndonesia. The technique used is similar tothat of acupuncture. While some reflexivemasseuses use their hands to give themassage, others use a special tool, like awooden or a metal stick.

Reflexive massages can be given topeople of all age groups. A person canlearn the methods on his own, then attemptto try them out and practise them.Malfunctioning organs can be identified byexamining certain points in the palm orsole, the assumption being that specificpoints are associated with different bodyparts, like the intestines, spleen, pancreas,heart, and so on. It is believed that reflexivemassage can help treat all diseases,including infectious diseases, because itimproves the immunity status of the patient.According to the doctors who practisereflexive massage, this kind of massageenhances general fitness, relievesdepression and is of benefit in otheremotional ailments.3, 4

The Practice of TimungThe technique of timung used for therapyor body care, employs steam enrichedwith various herbs. Traditional timung,which originated in Kalimantan, focusesespecially on body care, including skincare and preparing the bride for marriage.Timung can be practised for the samepurposes by family members at home. Theherbs required are available in the market.Many fitness centres in the cities offertimung. It is claimed that besidesimproving fitness, the technique alsorelieves a number of ailments, likecommon cold, rheumatic complaints,fatigue, and so on.

A person who wants traditional timungcare is first undressed and seated on achair, covered with mats made of pandanleaves. Under the chair is a pan on a lightedstove. The pan contains several herbs andboiling water. The steam, which containsthe essence of the herbs, warms the body.The steaming process lasts for about halfan hour. The technique is often combinedwith massage.

Therapy of GurahGurah is a therapeutic technique that usesspecial extracts of herbs to clear the nasalcavity and pharynx of mucus. It is claimedthat gurah benefits asthma, rhinitis,common cold, haemoptysis and pertussis.15

The technique is believed to have originatedfrom pesantren.z Its original aim was toimprove the quality of the voice of those whoread out the Koran. However, these dayspeople of all kinds use the technique in manyareas of Java. According to a gurahpractitioner in Central Java, anybody canlearn the technique.

The gurah method is very simple. Thehealer instils a special liquid into thepatient’s nostrils. The liquid is prepared bythe healer and contains certain herbs, ofwhich the common ones are Srigunggu(Clerodendron javanicum) or Awar-awar(Ficus septica) leaves and turmeric. Honeyis also used. The extracts of the herbs arediluted to a weak concentration. Thepatient lies supine with the neck bentbackwards. The liquid is then instilled intothe nostrils for about three to five minutesthrough a funnel made of banana leaves.The composition of ingredients is adjustedaccording to the patient’s condition. Theprocess heats up the nasal cavity and themucus flows out automatically. When themucus is being discharged, the patient has

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


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to either sit up or lie on his stomach. Heremains in that position until the mucusstops dripping. This therapy is oftencombined with jamu remedies, andsometimes with massage.15

Therapy based on a ReligiousApproachAs a majority of Indonesians are Muslims,therapy based on the religion of Islam isfairly common. This approach is commonlymistaken to be similar to a supernaturalone, as the methods are similar. In thereligious approach, based on Islamicteachings, the healer advises patients toperform special prayers or deeds.

The clients need not fulfil any specialprerequisites to avail themselves of suchtherapy. The prayer and ibadah (deeds tocome closer to God) vary depending onindividual needs, particularly the kind ofailment. Commonly, the patient is askedto drink water that has been sanctified bythe chanting of special prayers. Somehealers write Arabic letters on a plate, thenfill it with water and ask the patient to drinkit. Other healers give the patient a piece ofpaper or cloth with Arabic letters printedon it, which the patient must keep in acertain part of his/her house to guard thefamily.

A religious healer is usually the leader(chief person) of pesantren, or men whoare learned in Muslim teachings (Kyai).Usually, he requires no training to givetherapy and his capacity to heal is seen asGod’s blessing. Such healers often helppeople deal with family issues arising fromhealth problems. In fact, some pesantrenhelp drug abusers and treat psychologicalailments.

Supernatural or Magic TherapyAs mentioned earlier, irrational diseasesare believed to be caused by some source

of magic. Many magic healers have opinedthat certain diseases are caused bysomething that is rationally unacceptable.An ailment can result from the curse of arival who has hired a black magicpractitioner (dukun santet) to harm thesubject. It is quite common for magichealers to remove strange objects like nails,stone and iron which may be embeddedin the patient’s abdomen or some otherpart of the body.

A magic healer sometimes uses certaintools as a source of magic power. A numberof charms are believed to possess magicpower that can help in the process ofhealing. These include the eye of fingerrings, a special bark called pring temu rose(meetingros of bamboo), keris, a piece ofcloth with Arabic letters printed on it, andsoil wrapped in white cloth. Only magichealers possess such articles, though somegive the patient a portion of it to guard him.

Therapy for removal of tumoursCancer is one of the most dreadeddiseases. People seek cures from magic/supernatural healers because treatmentinvolves invasive procedures and they aresuspicious of modern medicine or findmodern treatment unaffordable. Thefollowing techniques are used by healersto remove tumours.

Case 4A traditional practitioner called “Gus” (thenickname for a son of Kyai, or a man whompeople respect) is believed to heal patientswith his supernatural powers. Not only canhe remove tumours, he can also cure manydiseases, like paralysis and psychosis. Infact, he even helps in solving problems thatare not related to health. His technique forremoving tumours is totally different fromthose used in modern medicine. Gus firstuses a knife to cut open the tumour but,


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later, he uses only his fingernails. Theexcised tumour is handed over to thepatient. The wound is dressed with gauzeor cotton. No antiseptic is used.

Gus does not charge a fee, but patientsmay contribute voluntarily, for which thehealer provides a box. He has many pupilswho learn the Koran from him and, atcertain times, they chant prayers together(isthighosah). However, Gus does notimpart his therapeutic technique to hispupils, though they help him in curing hispatients.

Another kind of supernatural healer isone who is able to remove tumours withouttouching the patient. After registration, thepatient writes out his/her complaints on apiece of paper, which is handed over to thehealer. The healer sends the paper back tothe patient after writing (in Javanese) aboutthe disease, the procedure to be followedand the fee. If a patient agrees to theserecommendations, he lies down in a supineposition while the healer goes up to thesecond floor of his house. The healer latercomes down and gives the patient a briefglimpse of a lump of bloody flesh, said tobe the removed tumour. If the patientdesires, he can ask a doctor for anultrasonographic (USG) examination.Besides removing tumours, the healerprescribes jamu remedies or recipes whichare available in drug stores.

Women healers in the rural areas of EastJava use a different technique. They removethe tumour by sucking the area with themouth. If the tumour has been successfullyremoved, the healer brings out some bloodyflesh (supposed to be the removed tumour)from her mouth. Such healers also providecomplementary jamu remedies.

Another technique consists ofdisplacing the tumour from the patient’sbody into another creature (animal). A

traditional healer in Tuban, East Java,claims to have the ability to displace thetumour into a goat. Either the patient or amember of his family visits the healer andtells him about the problem. Afterunderstanding the disease, the healer asksthe family to buy a goat and bring it to him.He performs certain ceremonies and uttersa mantra, after which the goat isslaughtered. The goat’s organs arechecked to ascertain whether the patient’sdisease has been transferred to the goat.For example, in a case of hepatoma, theliver of the slaughtered goat would showsigns of hepatoma, such as a lump or achange in colour. The diseased portion ofthe organ should be thrown away, whilethe healthy portion may be cooked andeaten. If the cancer is in too advanced astage, the healer usually admits his inabilityto cure it.

Therapy of susukSusuk is one or many small rod/s,commonly made of copper or gold, thoughsome healers use diamond. The susuk isimplanted in a certain part of the body tokeep it healthy. Before a susuk is implanted,the patient is advised to fast for two nightsand days. But some traditional implantersfeel that they themselves can take over thisdeed. Some others do not lay down anyconditions. If the person implanting thesusuk is not an expert, or if certainprerequisites are not fulfilled, the procedureis believed to have unexpectedconsequences, such as death. Some believethat the untoward consequences can beprevented by rubbing kelor (Cucumissativus) leaves on the body of the user.

It is said that the skill of implantingsusuk is acquired by performing certaindeeds, like performing ngebleng.z z Thekind of susuk to be implanted depends on

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


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the client’s demand. The fee varies,depending on the kind of metal used. Themore expensive the metal/material, themore potent the effect of the procedure.

The technique of implantation seemsfairly easy. The implanter inserts the susukinto a specific part of the body after wipingthe skin and then rubbing it with pepperleaves. The susuk may become less potentor lose its potency altogether if the clientbreaks certain taboos. The presence of thesusuk in the body can be ascertained byan X-ray.

Therapy using inner powerTherapy with inner power is a techniquewhich utilizes energy emitted by the humanbody. Such energy is acquired by regulatingrespiration or doing respiratory exercises.With regular exercise and by abiding by anumber of basic principles, one canaccumulate inner power and use it to treatothers. Inner power is said to heal severaldiseases like diabetes, hypertension andcancer. It is also used for non-therapeuticpurposes, like protecting the body from realor magic assault.(16)

This type of therapy can be of the activeor passive kind. In active healing, the healeruses his own inner power to treat patients,while in passive healing the patient obtainsinner power from the healer. A healer treatsa patient without touching him. The energyemitted from the healer’s hands enters thearea to be treated. An expert healer is saidto be capable of curing patients who arefar away, with or without a medium. Themedium could be a photograph, or anypossession of the patient. For example, ahealer in Indonesia can cure a patient inthe US. The technique is also used forcuring magic ailments, like removing nails

from the stomach. The nails would beexpelled from the body automatically byvomiting.

In Indonesia, there are many groups ofinner power practitioners, such as the SatriaNusantara group. In fact, some havebranches overseas. The major focus of themembers of these groups is on maintainingand improving their health; only a few utilizetheir expertise to treat patients. Therespiratory exercises can also producesupernatural powers, which lighten the bodyand make one capable of accomplishingvarious feats. For example, an expertbecomes so light that four persons can lifthim if he stands on a newspaper. One caneven see or read with his eyes closed.

Conclusion

These traditional practices of medicine arejust a few of the many currently in use inIndonesia. Several methods or techniques,with their variations, have not beendiscussed in this paper. These traditionalpractices stand testimony to Indonesia’srich cultural heritage.

The safety and efficacy of the techniquesused in the traditional system of medicineare questionable. Most of the traditionalpractices have not yet been studiedsystematically by modern science. However,it is beyond doubt that they serve a largeportion of the Indonesian population. Anyeffort to do away with such practices wouldbe unsuccessful, as these forms of healthservices have their own markets. TheIndonesian Government’s effort to promoteand develop traditional medicine into a safeand effective option is a good policy, whichcould contribute towards achieving greaterequity in health services.


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References

1. Ministry of Health, Republic of Indonesia. The rule codification of traditional medicine.Part I. Jakarta: Directorate General of Food and Drug Control. 1994.

2. Suparto H. Jamu, an inherent traditional medicine. TOGA. 2000. 2:27.3. Salan R. et al. A study on traditional medicine practices (workshop). Jakarta: National

Institute of Health Research and Development. MOH. Republic of Indonesia. 1989.4. Handayani L., et al. Madura herbal medicine inventory of women’s reproductive

remedies. Bulletin of Health System Research. 1998. 2(1):40–45.5. Handayani L., Suharti S. Traditional medicine small-scale industry in Madura. Medika

No.5.1999. XX:290–295.6. Suharmiati. et al. Guidance for health cadres. Introducing and the usage of medicinal

plants for family health care. Surabaya: Health Services and Technology Research andDevelopment Center. 1996.

7. Suharmiati, Handayani L. Study on quality of handling jamu gendong (research report).Surabaya: Health Services and Technology Research and Development Center. 1998.

8. Handayani L. Suharmiati. The microbiology test of jamu gendong. Medika No.7.2000. XXVI:424–428.

9. Maryani H. Raw material from animals. TOGA. 2000. 4:30.10. Notosiswoyo M. Research on traditional bone healing in Cimande. Jakarta: Center of

Noninfectious Research and Development, National Institute of Health Research andDevelopment, MOH, Republic of Indonesia. 1992.

11. Suprapto A., et al. Study on traditional bone healing (research report). Surabaya:Health Services and Technology Research and Development Center. 1996.

12. Ministry of Health. Republic of Indonesia. Guidance of midwives in rural area, Parts Iand II. Jakarta: Ministry of Health. 1989.

13. Handayani L. et al. Leading to comprehensive delivery services. Yogyakarta: GajahmadaUniversity. Report series 70. 1997.

14. Krido Wiyoto S.S.K. Traditional medicine practices using massage, kerikan/kerokanand jamu. Pekalongan: Bahagia. 1982.

15. Masruri. The secret of gurah therapy. Solo: CV Aneka Solo. 2000.16. Safriyanur. Treatment of Satria Nusantara inner power guidance. Surabaya: Health

Services and Technology Research and Development Center. 2000.

Koryo system of medicine in DPR Korea

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tional system of Chinese medicine, it is quitedifferent from the Ayurveda, Siddha andUnani systems prevalent in India.

The theoretical basis of Koryo medicine(KM) is recorded in detail in the ancientmedical classics of Korea.1

Materia medica

The materia medica, the main part of themedical classics published in a woodenedition in the 15th century in Korea,described medicines as being divided intothree types – those derived from vegetable,animal and mineral sources.

The classification according to themode of action and use is similar to that ofmodern medicine, and includes anti-pyretics, antidotes, antitussives, digestives,astringents, diuretics, and so on. However,it has some additional traditionalcategories, peculiar to KM, such as interior-warming drugs, drugs for eliminatingdampness and drugs for regulating Ki.

The description of each drug includesthe forms of the various medicinal plants,cultivation and picking period, the parts thatare used, processing methods, propertiesand flavours, efficacy, scale of use, toxicity,

Koryo system ofmedicine in DPR Korea

compatibility, dosages and administration.The action and efficacy of the drugs areexplained on the basis of the peculiartheories of KM, while the scale of use(indication) is determined by considering thesymptoms or syndromes as the main targetof treatment.1

Hyangyakjipsongbang (85 volumes),a classic materia medica published in DPRKorea in 1443 AD,2 contains a descriptionof 694 kinds of plants growing in thecountry, as well as 10,706 prescriptionsfor the treatment of 955 symptoms.3

In the preface to the book, the authorsays: “Thanks to the limpid water andbeautiful mountains, my country hasunlimited resources of medicinal plants.But there are those who disregard their ownresources out of admiration for others’ andstrive to get drugs from far-away, alienlands, even though they are available inany quantity in their own country.”Saddened at this lamentable situation, theauthor stresses that for treating diseases,one should use medicinal plants growingin one’s own country.1, 2

Acupuncture

According to the existing source materials,needles made of sharpened stone were

Choe Thae Sop

Although the Koryo system of medicinehas some similarities with the tradi-


70

used for the treatment of diseases forseveral centuries.4 From the specializedbook on acupuncture or the sections onacupuncture in various classics, it is evidentthat acupuncture had already beenestablished as a scientific system ofmedicine.1

The general introduction to theacupuncture section of Tonguibogam,(5) atypical medical classic, describes themethods of making needles, seasonalacupuncture, the selection of acu-points,application of moxibustion, acu-moxacombination and the stimulation intensityof acupuncture and moxibustion, etc. Thissection contains a systematic descriptionof the circulation course of the 14meridians, the 365 acu-points on eachmeridian, selection of acu-points,indications, contraindications, application

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

Clinical aspects of Koryomedicine

The medical classics published in DPRKorea before the 17th century includemanuals addressing the clinical aspects,as well as systematic and specialized bookson internal medicine, surgery, gynaecology,etc.1

Uyebanryuchwi,6 a comprehensivemedical classic published in the country in1445, has the value of a greatencyclopaedia. The book, consisting of asmany as 365 volumes, contains acompilation of the material from 153medical classics published before the 16thcentury at home and abroad, and asystematic presentation of the contents,which are divided into differentcategories.1, 6

Tonguibogam is a well-known classicin the form of a manual which waspublished in 25 volumes in 1610. Onesection of it describes the function(physiology) and shape (anatomy) of thefive viscera and six entrails, manifestationsof the illness connected with them, and thepathological mechanisms involved.

The clinical section contains a detaileddescription of the causes of varioussymptoms and syndromes, methods ofdifferentiating these, prognosis, medication(use of a single medicinal plant and herbalprescriptions), the therapeutic methods ofacupuncture and moxibustion, theircontraindications, etc. The section ondiarrhoea alone mentions 20 syndromes,classified according to the shape of thestool, the different factors that inducediarrhoea, the correlationship betweendiarrhoea and the internal organs and theseverity and duration of the illness. It

A part of the preface of Hyangyakjipsongbang, whichwas written with a writing brush in block letters in1443 AD.


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explains the causes and describes thesymptoms and methods of treatment indetail.5

Thus, the medical classics that we haveinherited from our ancestors include almostall the clinical disciplines, such as internalmedicine, surgery, paediatrics, neurology,gynaecology and ENT. These classics areeasy to consult because they containsystematic classifications1,4.

Teaching of Koryo medicine

Koryo medicine is taught at the KMfaculties of the medical universities, whichare found in each province. The durationof the course is seven years. Koryomedicine is practised mainly in the GeneralHospital of Koryo Medicine (GHKM).

The KM faculties in the country train anumber of Koryo doctors annually who arealso conversant with modern medicine.The textbook in use teaches the basictheories of KM, acupuncture, materiamedica, Koryo internal medicine, surgery,gynaecology, paediatrics, ophthalmology,ENT, etc. Each KM faculty has separatedepartments for each subject and specificlessons are given by the respectivedepartment teachers.

In the training of KM doctors, the ratioof KM to modern medicine during the totalcourse is 70 per cent to 30 per cent.Therefore, a graduate from the Faculty isable to diagnose and treat with modernmethods and medicines as well.1,4

Implementation of the Koryosystem

The Ministry of Public Health (MOPH) hasan administrative department for KM. Thisdepartment is in charge of implementingthe state policy to develop KM at all levelsof the KM health institutions.

In the provinces and counties, this taskis performed by the health administrativedepartments of the respective localgovernments.

Under the aegis of MOPH, GHKMprovides the scientific and technicalguidance for various KM healthnetworks.1,4

Koryo medicine network

The capital and all cities have specializedKM hospitals, and all large as well as smallhospitals and clinics have KM departments.The population can receive free KMtreatment through various KM medicalnetworks which are evenly distributed allover the country. These networks arenational institutions under the MOPH andthe local health administration. Theirworking expenses are provided for in thenational budget.

Not a single unit of the private KMhealth sector is driven by the motive ofmaking money.1,4

Diarrhoea caused by chronica colitis suffered for over 10 years wascured by moxibustion



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The combination of Koryo and modernmedicine is one of the mainstays of thehealth policy, whereby the State helps indeveloping KM.

It is also a manifestation of the state’sconcern for providing the inhabitants withhealth care of high quality.1

Combination of Koryo andmodern medicine in theuniversity’s regular educationsystemMedical education in KM faculties is of aseven-year duration where KM takes up 70per cent of the time allotted and modernmedicine systems the remaining 30 percent. This enables the graduates to attaina certain level of knowledge of modernmedicine required for modern methods ofdiagnosis and treatment.

In the KM faculty, the lectures deliveredon the theoretical aspects of KM are justas detailed as the expositions in the medicalclassics.

The students are taught the clinicalaspects of KM, including internal medicine,surgery, paediatrics and gynaecology, aswell as the auxiliary ones, such as theMateria Medica, herbal prescriptions andacupuncture. As for modern medicine, KMfaculties teach basic aspects like anatomy,physiology and pathology, as well as clinicalones like internal medicine, surgery,paediatrics and gynaecology.

Unlike the KM faculty, the seven-yearcourse of the medical faculty gives aweightage of 70 per cent to modernmedicine and 30 per cent to KM. Thissystem aims to enable doctors to combinetheir treatment methods with KM methods.Though KM theories are taught withextreme brevity, more detailed lessons areimparted on the methods of KM treatment,including acupuncture and herbalmedication.1,4

Combination of Koryo andmodern medicine in the re-education systemA six-month re-education course isconducted in the re-education colleges ofthe capital city and each province. Thoseattending are the KM doctors, as well asother doctors who graduate from the KMor medical faculty and have been workingfor more than five years.

These re-education courses are free ofcharge, and the doctors continue to receivetheir usual monthly salary throughout thesix months. This course enables them toconsolidate their knowledge, learn aboutnew developments, as well as advancedmethods of KM treatment. The coursecovers the latest therapeutic techniquesdeveloped both at home and abroad.Greater importance is attached to modernmedicine for KM doctors and to KM forother doctors.1,4

Combination of Koryo andmodern medicine at each level ofmedical careAt all levels in the hospitals, treatment bymodern medicine and KM is combined ina ratio of 7:3. The larger the hospital, thehigher the share of the former; the smallerthe hospital, the higher the share of thelatter. In specialized KM hospitals and eachof the KM departments in other hospitals,70 per cent of the treatment is accordingto KM methods and 30 per cent accordingto modern medicine. Generally, the utilityrate of chemical drugs is higher in thelarger hospitals, where conditions favourtheir use, rather than in the smallerhospitals, especially in clinics in the ruralareas.

For purposes of diagnosis, KM doctorsadopt modern methods. No KM doctoruses the conventional method of diagnosingdiseases (i.e., by simply feeling the pulse).


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Almost all KM hospitals are equipped withclinical laboratories and various diagnosticequipment, enabling KM doctors to usemodern methods of diagnosis.1

Collaboration between Koryoand modern medicine inresearch activitiesPersons in charge of research projects forthe modernization and rationalization ofKM are obliged to first study the KMclassics on the subject of research. Insumming up the project, the researcher firstgives an overview of the description in theclassic, and then states the findings of hisresearch.

Such research activities are undertakento either scientifically prove or invalidate thedescriptions in the classics. The lecturesdelivered by Professor Ranjit RoyChaudhury on the clinico-pharmaco-logical methodologies during his visit toDPR Korea still serve as a programmaticguide for our research activities.1

National policy for developmentof Koryo medicineThe aims of the national policy are:

To preserve, utilize and develop thenational medical heritage – a majorobjective to which the State attachesgreat importance;To actively encourage medical workersto use KM, a target facilitated by thefact that the country has no regulationthat can obstruct its development;To do away with the unscientific andsuperstitious elements contained in thenational medical heritage, andassimilate and utilize only the superiorones in public health services;To diagnose diseases through modernmethods, considering that theconventional method of merely feelingthe pulse lacks a scientific basis;

To decisively enhance the quality ofhealth care in the country by combiningKoryo and modern medicine;To scientifically explain the real natureof the meridians and the therapeuticmechanism of acupuncture;To study the components andpharmacological action of variousmedicinal plants;To use medicinal plants with knowledgeof their components and their influenceon the internal organs;To use the best possible methods oftreatment.

The State has allocated sufficient fundsfor the translation of all ancient medicalclassics, including three well-knownclassics which were published in modernKorean from the seventh to the nineteenthcenturies. Today, the translated versions areused extensively as reference books ineducational, research and medicalactivities.

In order to discover the best possiblemethods of treatment, the State activelyencourages health workers to gatherinformation on folk cures popular amongthe country’s inhabitants, and to carry outresearch activities to scientifically establishthe efficacy of selected cures.1,4

Clinical and basic studies for thedevelopment of drugsStudies for the development of drugs arecarried out mainly by the GHKM, theKorean Academy of Medical Science,Institute of Materia Medica and thepharmacological sections of medicaluniversities.

The funds required for these researchprojects are provided for in the Statebudget.

A project is proposed at the ScienceCouncil of the institution concerned,


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References

1. Choe Thae Sop (1999). Development history of traditional medicine in DPRK, KoreaToday, 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).

endorsed by MOPH, and then carried out.In the GHKM alone, 30– 40 projects areimplemented each year. A clinical study isconducted under approved conditions,with a placebo group to adjudge therelative efficacy of the drugs to bedeveloped by clinico-pharmacologicalobservation.

For basic studies, the GHKM puts inconsiderable effort to identify thecomponents and the pharmacologicalaction of medicinal plants. Studies to clarifythe therapeutic mechanism of acupunctureand the real nature of the meridians arealso being carried out.

The results of the study are reviewedby the Science Council of the institutionconcerned.

In the case of a drug, the approval ofthe MOPH has to be obtained so that itcan be used as a standardized formulation.Newly developed drugs which have beenstandardized are manufactured in thepharmaceutical factories of hospitals asper the requirement of the hospital. If adrug shows really marked benefits, it isincluded in the State production plan, andis manufactured in the central and localpharmaceutical factories in largequantities.

Newly developed drugs replaceexisting drugs with similar or inferioraction. The latter are then weeded out,and their production and utilization isdiscontinued.1,4

Utility of Koryo Medicine

As a national medical heritage, KM enjoysState protection and its utilization is activelyencouraged.(3,4) In no other country is theState developing KM with such a highdegree of commitment, nor is any othercountry providing all its inhabitants high-quality KM health care, free of charge.

In spite of the fact that KM is beingpromoted, it is not well-known all over theworld.

In Juche 78 (1989), WHO nominatedthe GHKM as its collaborating centre fortraditional medicine. Since then, it hasannually been publishing technicalinformation in English and has distributedit widely to many countries. Especially inrecent years, the uniqueness of KM in DPRKorea has become known in manycountries through these publicationactivities, with the financial support ofWHO, SEARO.

Chinese acupuncture–moxibustion

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Chinese medicine (TCM). It is the study ofthe meridians and collaterals, acupoints,acupuncture techniques, and the laws ofprevention and treatment of diseases byacupuncture–moxibustion. Thousands ofyears ago, ancient Chinese medicine usedbian stone (needle stone) as an instrumentfor the treatment of diseases, and thendiscovered the points and invented specialacupuncture instruments. Gradually, the“theory of meridians and collaterals”, asystem of treatment rich both in practice andin theory, was founded, and has beenapplied worldwide. For thousands of years,acupuncture–moxibustion has contributedimmensely to the growth and health of theChinese population. Today, even with therapid development of medical science, it isregarded as an important part of theChinese cultural heritage.

Since the foundation of new China, thescience of acupuncture–moxibustion hasdeveloped rapidly due to the attention andsupport provided by the Government.Numerous studies have been carried out,particularly in the functional mechanism ofacupuncture–moxibustion, which hasgiven it a leading role in modernizing TCM.Research on the mechanism of acupu-

Chinese acupuncture-moxibustion

ncture analgesia has revealed some sectorsof the functional mechanism of acupu-ncture. These achievements have beeninternationally recognized in academiccircles, and China thereby enjoys a pre-eminent position in this field. In the 1950s,scientific research on acupuncture–moxibustion concentrated on publishingand popularizing the basic knowledge ofthis science and generally summarizing theclinical practice of acupuncture–moxibustion. In the 1960s, clinicalresearch on acupuncture–moxibustion andacupuncture anaesthesia was carried out.In the 1970s, numerous organized studieswere undertaken on the clinicalapplications and principles of acupunctureanaesthesia and on the mechanism ofacupuncture analgesia. In the 1980s,research on the clinical applications andprinciples of acupuncture–moxibustionand acupuncture anaesthesia as well asresearch on meridians and collaterals, wasbrought together in an organized andplanned manner. In November 1987, theWorld Foundation of Acupuncture–Moxibustion Societies (WFAS) wasestablished in China, with its head officein Beijing. Professor Hu Ximin of China waselected president of the First Conferenceof WFAS. In the 1990s, the science of

Deng Liangyue

The science of acupuncture–moxibustionis an important component of traditional


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acupuncture–moxibustion moved out ofChina into the outside world and combinedwith the modern sciences, thus becomingan inseparable component of worldmedical science. Since the 1980s, thebasic theory of acupuncture and moxi-bustion has included “Research onMeridians and Collaterals ” in the specialplan of all the major basic researchprojects of the State (State Climbing Plan).As a result of research during the past halfcentury, the science of acupuncture–moxibustion has taken the lead inmodernizing TCM.

Clinical application andresearch on acupuncture–moxibustion

Clinical application and experimentalresearch has shown that acupuncture–moxibustion could adjust the functions ofall systems and organs of the human bodyand so could effectively prevent and treatdiseases. Chinese medical workers havecarried out extensive research programmesin the areas of clinical application ofacupuncture–moxibustion, acupunctureanaesthesia and acupuncture analgesia,and have accumulated rich experience anddocumented significant advances.

Expanding the scope ofclinical application

According to an estimate, there wereapproximately 200 diseases that could betreated by acupuncture–moxibustion in the1950s. The number increased to 300 bythe 1970s, of which effective treatment wasavailable for about 100 diseases. In themeantime, acupuncture anaesthesia wasalso being widely used.(1) In 1979, on thebasis of research, the World HealthOrganization (WHO) began to disseminate

safety indications for the use ofacupuncture–moxibustion. WHO alsopublicized the first group of 43 acupu-ncture–moxibustion-treated diseases,which involved the respiratory system,digestive system and neuromuscular–skeletal system, as well as areas such asstomatology and the five sense organs.Clinical practice shows that the indicationsfor acupuncture–moxibustion encompassall clinical areas, and satisfactory clinicalresults have been obtained, particularly inthe treatment of painful diseases such asneuromuscular system diseases, sequelaeof cardiocerebral and visceral functionaldisorders, dysfunctional diseases of theendocrine system, diseases due todepressed immunity, and some allergicconditions. In addition, acupuncture–moxibustion has certain clinical benefits inthe treatment of some difficult diseases suchas tumour and organic diseases in whichthe toxicity and sequelae are reduced.Combined with modern medicine,acupuncture–moxibustion can treat somelife-threatening diseases, such as chronicrenal insufficiency, myocardial infarction,haemorrhagic fever, and acute perforatingulcers. Infectious and infective diseasessuch as viral hepatitis, pulmonarytuberculosis, epidemic parotitis, bacillarydysentery and acute mastitis can also betreated. Acupuncture–moxibustion alsohas an effect on the union of fractures,ovulation, and helps in easing labour painsand in correcting abnormal foetal position.

In 1996, a special issue—The Frontiersof Medicine—was published in the UnitedStates of America. This issue focused mainlyon the Chinese acupuncture therapy, whichwas included as a special topic. InNovember 1997, the National Institutes ofHealth (NIH), USA, held a special meetingwith more than 1000 participants. Themeeting discussed the effect of acupuncture


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therapy on nausea, vomiting, various painfuldiseases (including postoperative pain,dysmenorrhoea, tennis elbow, and myositisfibrosa, etc.), or pain induced bychemotherapy or operation. Other areaswhere acupuncture could be used werediscussed. These included the after-effectsof stopping of smoking, management ofdrug dependence, osteoarthritis, sequelaeof wind stroke, and headache and asthma,and it was agreed that acupuncture therapyin these cases was appropriate. A statementwas made after the meeting about theefficacy of acupuncture which furtherinfluenced the worldwide application ofacupuncture–moxibustion.

Meridian diagnosisResearch on the pathological reaction ofmeridian points, for example, parae-sthesiae, tissue abnormality, change in thevolume of electric conduction and changein thermal sensitivity, has boosted theapplication of the diagnosis of differen-tiation according to the tenderness ofmeridians and points. Many scholars havetried to diagnose meridians and collateralswith the aid of devices developed by themodern technologies of physiology,biochemistry, acoustics, optics, electricity,thermal, magnetics and computers. Theseinstruments not only increase the accuracyof diagnosis, but also have a goodtherapeutic effect.

Acupuncture anaesthesiaAcupuncture anaesthesia is a new methodof administering anaesthesia that is basedon clinical acupuncture analgesia. This isused in the treatment of complicationsfollowing surgical operation. It has beendeveloped according to the theory ofmeridians and the principle of acupuncturefunctions. It functions mainly by needlingthe points along with supplementation by

medicines, and is used during operationswhile the patient remains conscious.Acupuncture anaesthesia resulted from thecombination of modern anaesthesiology,surgery and the neurosciences. Acupun-cture analgesia in China has a history ofmore than 2000 years. It was introducedas early as the Yellow Emperor’s InternalClassics. Acupuncture anaesthesia startedin the late 1950s. On 30 August, 1958,with the cooperation of the Departmentsof Otorhinolaryngology and Acupuncture,the First Shanghai Municipal People’sHospital replaced allopathic anaesthesia byacupuncture analgesia, and successfullyperformed a tonsillectomy. A new chapterwas thus started in the history ofacupuncture. During the past 40 years,practitioners of acupuncture anaesthesiahave, on the one hand, been conductingdemonstration operations with acupun-cture anaesthesia, evaluating the treatmenteffects and documenting experiences while,on the other hand, there have been effortsto solve the problems of “incompleteanalgesia and insufficient relaxation of theabdominal muscles”. The “theory ofacupuncture–medicine composite anaes-thesia” was launched in the 1980s, underwhich the anaesthetic effect is achieved byacupuncture along with a small dose ofmedicine which not only preserves theadvantages of the operations byacupuncture anaesthesia, but alsoincreases the effect of analgesia.Nowadays, some medical organizations inChina and abroad are continuing furtherresearch on the method of acupuncture–medicine composite anaesthesia for thosespecial situations where medical anaes-thesia is unsuitable.2,3

Up till the late 1970s, more than 200acupuncture anaesthesia operations hadbeen carried out. Acupuncture anaes-thesia is now applicable for more than a


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hundred types of diseases. Further researchon points prescription, the degree ofacupuncture stimulation, supplementarymedication and surgical performance hasimproved the effect of acupunctureanaesthesia, which proved to be effectivefor about 30 kinds of operations. Of these,the anterior basocranial, cervical vertebrae,thyroid gland, tooth extraction, caesareansection, pneumonectomy and abdominalligation of oviduct have receivedapprobation at the Chinese ministerial level.Acupuncture anaesthesia is regarded as acommon practice with a success rate of80 per cent. Some of the difficultoperations such as throat restoration, renaltransplantation, and operation in thefunctional area of the brain, have beensuccessfully carried out with acupunctureanaesthesia. After years of exploration, thepoints for acupuncture anaesthesiaoperation have been streamlined, and thepractice of acupuncture has becomesimpler and more effective.

Indications of acupuncturetreatment

Visceral diseasesAcupuncture–moxibustion has an adjustingfunction with all the organ systems.

(1) Respiratory system: Acupuncture–moxibustion has an adjusting function with

the frequency and amplitude of respiratorymovement, the motor function of bronchialsmooth muscle, ventilation, vital capacity,airway resistance, respiratory musclestrength, and the movement of thediaphragm. Hence, it can be used for thetreatment of acute and chronic bronchitis,4bronchial asthma,5 and haemoptysis ofpulmonary origin.6 Central and peripheralrespiratory failure can also be treated byelectric acupuncture at the points of Su Liao(GV25), Nei Guan (PC6), and Tai Chong(LV3), etc.

(2) Cardio-cerebral system:7 Acupu-ncture–moxibustion has an adjusting effectwith the heart rate, rhythm of the heartbeat,blood pressure, function of the peripheralblood vessels, functional state of the leftheart, coronary function and cerebro-vascular function. It can be used for thetreatment of the blood vessels of the brain,8rheumatic heart diseases and acutemyocardial infarction.9 It was discoveredthat the treatment of wind stroke and theabsorption of blood following cerebralhaemorrhage can be promoted byacupuncture at Nei Guan (PC6). Followingintensive research, Professor Shi Xueminfound an effective acupuncture method forthe treatment of wind stroke.

(3) Circulatory system: Acupuncture–moxibustion adjusts the red-cell count inthe peripheral blood, haemoglobin content,surface charge density of the red bloodcells, and the content of oxygen andcarbon dioxide. Therefore, there areoccasional reports of acupuncturetreatment for primary thrombocytopenicpurpura10 or haemorrhage, thrombo-cytosis after splenectomy due to schisto-somiasis, and hypoimmunity induced byradiotherapy and chemotherapy.11

(4) Alimentary system: Acupuncture–moxibustion can effectively adjust themovement of the digestive canal, secretion

Acupuncture–moxibustion hasan adjusting effect with theheart rate, rhythm of the

heartbeat, blood pressure. It canbe used for the treatment of theblood vessels of the brain and

rheumatic heart diseases.


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of the digestive glands, flow of bile, andthe peristaltic function of the gall bladderand bile duct.

(5) Urinary system: Acupuncture–moxibustion can affect the urinary functionof the kidneys, the movement of the ureter,the movement of the bladder, and thefunction of the sphincter muscle of theurethra, and can therefore be used for thetreatment of stones in the urinary system.12

The rate of efficacy of treatment ofpostpartum and postoperative retention ofurine by acupuncture and moxibustion is ashigh as 97.5 per cent.

(6) Endocrine system: Owing to itsdual-directional adjusting function to thesympathetic–adrenomedullary system,acupuncture–moxibustion can also beapplied for the treatment of thyroid diseasesand diabetes, etc.

(7) Genital system: Acupuncture andmoxibustion have an obvious adjustingeffect on the uterotonic function, so artificialabortion or oxytocia can be successfullycarried out by electric needling at the pointsof He Gu (LI 4), San Yin Jiao (SP 6), andZu San Li (ST 36), or supplemented byauricular acupuncture. By givingmoxibustion at Zhi Yin (BL 67), abnormalfoetal position can also be successfullycorrected.13

Clinical research has also proved thatacupuncture and moxibustion have anadjusting function on the immune system;for example, the success rate for thetreatment of allergic asthma is as high as96.8 per cent. Treatment for other allergicdiseases is also satisfactory, as is thetreatment of common inflammatorydiseases such as parotitis, tonsillitis,pharyngitis, laryngitis, mastitis, otitis media,gastroenteritis, cholecystitis and bronchitis.The rate of successful acupuncturetreatment for icterohepatitis has beenreported to be 98.5 per cent. Besides,

acupuncture–moxibustion has a goodtherapeutic effect in cases of malaria.

Meridian, collateral and tendondiseasesMeridian, collateral and tendon diseasesrefer to diseases of the tendon–muscle–joint system (motor system) and theneurological system. These include, forexample, various types of headache,trigeminal neuralgia, sciatica, lumbago,costalgia, cervical spondylopathy, scapulo-humeral periarthritis, fasciitis, sprain, stiffneck, carpal tunnel syndrome, tenosy-novitis arthritis, rheumatoid arthritis, as wellas ankylosing spondylitis, hyperosteogeny,hemiparalysis and numbness after windstroke. Acupuncture–moxibustion has aspecial effect on the treatment of thesediseases. The commonly used methods inclinical practice are the various needlingmethods (including elongated needling,opposing needling, short-thrust needling,nape needling, tapping and penetratingneedling), point injection, moxibustion,scraping, cupping, electric needling, fireneedling, collateral pricking and blood-letting, laser therapy, magnetic tape, andconductor of meridians and collaterals.

As regards the field of neurology,acupuncture–moxibustion has moreadvantages than allopathic medicine in thetreatment of some diseases. One exampleis a common ailment, facial paralysis,which is normally caused by acute nonsu-ppurative inflammation of the facial nervein the foramen of the styloid process, andis characterized by peripheral facialparalysis. Since the pathogenesis of thisdisease is not clear, Western medicine hasno effective treatment other thanantipyretics, analgesics and corticosteroids.According to TCM, the cause of thisdisease is stagnation of qi and blood andblockage of the meridians and hence it


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should be diagnosed and treated on thebasis of the overall analysis of symptomsand signs, the cause, nature, location ofthe illness and the patient’s physicalcondition. Acupuncture–moxibustion,tuina and massage usually have abeneficial effect. In clinical practice, thepenetrating method is mainly applied at thenearby facial points, such as Jia Che (ST6)penetrating to Di Cang (ST4), Yang Bai(GB14) penetrating to Yu Yao (EX.), and SiBai (ST2) penetrating to Ying Xiang (LI20).The treatment of facial paralysis(14) withacupuncture is brief and satisfactory.Basically, there are no sequelae. In China,most patients who suffer from this diseaseprefer acupuncture treatment, thesuperiority of which is widely recognized.

Management of weight-loss andprevention of effects of stoppingdrugs, AIDS and tumourClinical observation shows that needlingat Tian Mei (EX.) is effective in stoppingsmoking, yet owing to psychologicalfactors, there are differing views on theeffect of the treatment. Some Chinesemedical doctors have also tried acupu-ncture for drug de-addiction or for treatingphysical and psychological disorderscaused by drug addiction,15 such asirregular menstruation and menopause.This research is still in progress. Thepractice of acupuncture for weight losscontinues, with some treatment effects.However, a stricter comparative analysis isrequired because weight loss is affected byvarious factors.

Treatment of AIDS16 with acupu-ncture–moxibustion is a subject which isworth serious research. Research onmalignant tumour17 shows that acupun-cture–moxibustion, as a supplementarytreatment method, could improve clinicalsymptoms of patients, minimize side-effects

of radiotherapy and chemotherapy, andprolong life. However, this function ofacupuncture and moxibustion cannot beseparated from its capability of improvingthe efficiency of the immune system.

Development of treatingmethods

Traditional acupuncture–moxibustiontherapy warrants a good foundation for itsdevelopment. Based on the Nine-needles,Nine-needling methods and Twelve-needling methods in the Internal Classic,various needling instruments weredeveloped, such as cutaneous needle,intradermal needle, three-edged needle,point catgut embedding therapy,elongated needle, fire needle, and knifeneedling. Different methods have beenapplied in clinical treatment with effectiveresults, for example, superficial puncture,tapping method, penetrating method,multiple oblique needling, the three easingmethods, and many more.

Non-invasive treatment methods incombination with modern physicaltechniques include point electric conductiontherapy, drug ion-introduction therapy,point electrothermal moxibustion therapy,point microwave radiation, laser radiationtherapy, point ultrasonic input, point low-frequency input, infrared radiation,ultraviolet radiation, cryotherapy, drugapplication on point, etc.

Traditional acupuncture therapy, incombination with modern physical therapy,developed into electric acupuncturetherapy, electrothermal acupuncturetherapy and magnetic acupuncturetherapy. In combination with drug injectiontechnique, point injection with smalldosage and point block therapy have beendeveloped. The knife needling method hasbeen developed in combination with


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dissection in the Departments ofOrthopaedics and Traumatology.(1) Specific-area acupuncture therapy

(also called micro-acupuncturetherapy), which incorporates theZangfu, meridian-collateral, and pointtheories of TCM with modern anatomy,is different from traditionalacupuncture therapy, but reflects thecharacteristic of Chineseacupuncture–moxibustion, andpossesses the dual functions of bothdiagnosis and treatment. It coversauricular acupuncture, as well asacupuncture of the scalp, face, eye,nose, tongue, abdomen, hand, foot,and wrist- ankle, and the theory ofholography. It is worth mentioning alittle about auricular acupuncture andscalp acupuncture.(a) Auricular acupuncture therapy: In

recent years, interest in research bydoctors on auricular acupunctureand on treating methods isgrowing. These include traditionalneedling methods, embedding andmassage methods, drugapplication on auricular points,herbal seeds pressing method,magnetic ball pressing method,liquid nitrogen refrigerationtreating method, as well asinstrumental detection andtreatment on auricular points.Therefore, the indications forauricular acupuncture have beenextended from a dozen to morethan a hundred—common cold,epidemic encephalitis, tracheitis,pneumonia, bronchitis, coronaryheart disease, myocarditis,pulseless disease, shock, gastritis,ulcer, gastrointestinal neurosis,phrenospasm, facial paralysis,intercostal neuralgia, epilepsy,

Parkinson’s disease, cerebralthrombosis, cerebral embolism,infantile chorea, Meniere’sdisease, enuresis, cervicalspondylopathy, scapulohumeralperiarthritis, acute lumbar sprain,ascariasis of the biliary duct,cholelithiasis, stiff neck, irregularmenstruation, dysmenorrhoea,functional endometrorrhagia, andacne.

(b) Scalp acupuncture therapy: Afternearly 30 years of clinical research,the methodology of locating themeridian according to the area andthen locating the point on themeridian has been determined.Penetrating, twisting, lifting andthrusting, electric stimulatingmethods as well as reinforcing andreducing by puncturing along andagainst the direction of themeridian, respectively, have beenapplied for the treatment of morethan a hundred diseases. Theseinclude hemiplegia, facialparalysis, headache, trigeminalneuralgia, paralysis agitans,dizziness, tinnitus, sensory aphasia,apraxia, enuresis, prolapse of theuterus, functional endometro-rrhagia, pelvic inflammation,hypertension, coronary heartdisease, asthma, cataract, myopiaand cortical visual disturbance.

(2) Conducting research and observingthe factors influencing the therapeuticeffects of acupuncture and moxi-bustion, and analysing and comparingthese factors are the focus of presentand future clinical studies. Thetherapeutic effects of acupuncture arenow being observed by objective testingmethods, as modern technology isbeing introduced in clinics. Some


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scholars have observed that varyingstimulation and parameters producesdifferent clinical therapeutic effects.Han Jisheng observed that whenelectric stimulation is applied inacupuncture treatment twice weekly,the therapeutic effect may graduallyaccumulate. Using relatively weakstimulation (2 mA is better than 1 mA)and a relatively longer durationbetween two treatments (treatmentapplied once weekly) may achievebetter relief for chronic pain. Thirtycases of cerebral haemorrhage treatedby acupuncture with CT scanguidance denote that the acupuncturetechnique for promoting brainfunctions and resuscitation obviouslyaccelerates the absorption of cerebralbleeding. In the application ofsuppurative moxibustion for asthma,the relationship between the seasonand the pain present or absent duringthe treatment has been analysed.

(3) The clinical combination ofacupuncture and moxibustion withmedicaments to raise the therapeuticeffect has been common practice anddiseases are managed using thiscombination in various clinicaldepartments. The medicamentsapplied are in the form of oraladministration, acupoint injection,muscular injection, venous injectionand subcutaneous absorption.Medicaments may enhance thetherapeutic effect of acupuncture,18

depending on the type and dosage ofthe drug used. The therapeutic effectproduced by the combination ofacupuncture and medicaments is notmerely the addition of the original effectof the two, but is more than that. Aprobable mechanism is that:acupuncture, by inducing the release

of some active substances in the body,changes the number of receptors andtheir reactions, alters the cellmembrane and the blood–cerebralbarrier permeability, and influences theenzyme-inducing activity of the drug.Therefore, on the one hand,endogenous drug-like substances inthe body are activated to perform atherapeutic effect while, on the otherhand, the therapeutic effect of theexogenous drug is enhanced.

(4) Development and application of theapparatus of acupuncture andmoxibustion, development in the areasof optics, electrothermal, magnetic andcomputer technologies has led to thedevelopment of a variety of acupunc-ture and moxibustion apparatus. Thesehave been designed and manufacturedin keeping with optimal stimulatingparameters according to the findingsof acupuncture pain suppressionresearch. The electro-acupointstimulator, electrothermal needleinstrument, laser needle apparatus,low-frequency electric therapeuticapparatus, electrothermal moxibus-tioner, permanent magnetic needle,etc., are examples of such apparatusand have been frequently used inacupuncture clinics and forexperimental research. Sterilizeddisposable needles and needles withapplicators (tubes) are examples of themodernization of acupunctureequipment. With regard to moxibu-stion, the moxibustioner and non-smoke moxa stick promote the deve-lopment of moxibustion. Application ofthese new technologies and newapproaches enables traditionalChinese acupuncture and moxibustionpractices based on experience, to bedeveloped in modern scientific ways.


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Theoretical study ofacupuncture and moxibustion

Study on the mechanism ofacupuncture and moxibustionThe various afferent nerve fibres to bestimulated must be selected based on theintensity of hand manipulation and thecurrent of electric stimulation. Generallyspeaking, moderate hand manipulationand low electro-current activate afferentfibres with a relatively large diameter,whereas strong hand manipulation andelectric stimulation of relatively strongintensity activate afferent fibres of variousdiameters, particularly the fine fibres.(19)

The effect of acupuncture takes place viaits action on the afferent fibre. Once theperipheral nerve is cut, most of the paindisappears. At some points near thearteries, the afferent fibres of thesympathetic nerve distributed in the vesselsalso form a part of the acupuncture afferentsystem, for even after the destruction of thesomatic nerves, when these points arepunctured, some effect of needling stillremains. However, when the autonomousnerve supplying the vessel wall is damaged,acupuncture has no effect.

The effect of acupuncture on thehuman body is manifold. Its functionsinclude regulating the endocrine andimmune systems. The activities of thevarious organs are under the control of thenervous system and the nerve–endocrine–immune system. The effect of acupunctureis also related to the participation of theseorgan regulation systems.

The effect of acupuncture on theimmune system includes the regulation ofspecific immunocytes, non-specificimmunocytes and the humoral immunesystem. Acupuncture and moxibustionincrease T lymphocytes in the peripheralblood and enhance intracellular esterase

activities, thereby raising the lymphocytetransformation rate and rosette formationrate, activating the natural killer cells, andalso increasing the amount of lymphocytes.Acupuncture and moxibustion alsoincrease the phagocytic power of thenon-specific immunocytes and the contentof granulocytes. In humoral immunity,acupuncture and moxibustion may elevatethe amount of beta- and alpha-globulin,as well as immunoglobulins IgG, IgA andIgM. The proliferative reaction of spleniclymphocytes and the splenic lymphocytetransformation rate are also increased.

Acupuncture regulation of theimmunological function is related to theintact functioning of the vegetativenervous system. Only under intactconditions of the nerves and theadrenalin system can acupuncture evokeimmunoreaction. Endogenous opioidpeptides (such as encephalin) have aclose relationship with cellular andhumoral immunity; enhancement of theimmune system due to acupuncture maybe achieved via its action on theendorphin. The benign regulation of theendocrine and immune systems byacupuncture explains its therapeuticeffect in many diseases.20

Research on meridians andcollaterals

Research on meridians and collaterals isan important area of scientific researchin China. In 1956, it was listed amongthe projects for the first national naturalscience developing plan. In 1986, it wasagain listed as one of the “Seventh Five-Year Plan” projects to be undertaken bythe State Committee of Science. In 1989,the subject of research on meridians andcollaterals was considered one of the“planned projects to be scaled”.


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and points may cause excitement of theskeletal muscle of the same meridian onanother part through synaptic reflectionand synaptic transmission among themotor neuron. Since such progressiveexcitement of the skeletal muscle fibreneeds repeated time–space summation,there is a phenomenon of slow sensorymovement and release of myoelectricity.This phenomenon observed in animals hasbeen proved in humans who are sensitiveto sensation transmission along themeridians.

Systematic study of the relationshipbetween the meridians and zang fu organsand their ways of connection:

Neuroscientific research by integratedmethods suggests that there is a relativeconnection of specificity between thesuperficial meridians and the internalorgans. On the one hand, such specificconnection is related to the anastomoticlevel of the nerve segments and densitydominated by the nerve segments. On theother hand, acupuncture stimulation on themeridians may cause changes in therelease of some neuropeptides of therelevant target organs specifically, andaffect the reactivity of the target organs tothe corresponding neuropeptide.

Existence of active energymetabolism along the runningcourse of the meridiansThe system of meridians and collaterals isa functional system. Previous tests suggestthat energy metabolism is relatively activeon the running course of the meridians.For instance, the index of skin temperatureand the amount of carbon dioxideexhalation on the running course of themeridians is obviously higher than that onthe other lines. This phenomenon showsthat the energy metabolism along therunning course of the meridians is active.

Researchers working hard for many yearshave yielded initial achievements.

In China, a general study has beenconducted on 200,000 people concer-ning the phenomenon of “sensationtransmission along the meridians”. Theexistence of the running course of themeridians put forward by the ancients hasbeen approved and the fundamentalcharacteristics of sensation transmissionalong the meridians have been understood.Literature and information from the ancientto the present time have proved thatsensation transmission along the meridiansis a kind of objective physiologicalphenomenon that exists. Recent tests showthat when the skeletal muscles are in a stateof excitement, sensation transmissionalong the meridians is in relation to thenerve connected with the long axis andinduced by the summational current. Thetransneural segments and transjointtransmission mechanism are caused bysecondary excitement of the skeletalmuscles. Yet, there is not enough evidenceto prove the physiological significance ofthis phenomenon neurobiologically. Thespinal cord is marked by the distribution ofmotor neurons according to the meridians.A mutual dendrodendritic synapserelationship exists among the motorneurons. Local stimulation on the meridians

In order to keep abreast of thelatest on internationalization ofacupuncture, in 1990 the StateTechnology Supervision Bureau

of the People’s Republic of Chinaissued the People’s Republic ofChina State Standardization of

Acupoints’ Locations.


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Research on the morphologyof acupoints

During 1960–1970, researchers in manylaboratories in China and elsewhereworked on the morphological charac-teristics of tissue at the meridian points. Asa result, besides the muscle spindle,Meissner corpuscle, Pacinian corpuscle,Kraus end-bulb and free nerve ending, a“special” receptor was found. A histoche-mical study shows that there is a networkformed by the adrenergic nerve of thepostganglionic fibres of the sympatheticnerve and the cholinergic nerve, which isdistributed over the small vascular wall ofsome points of both human beings andanimals. Research on stereo-structures ofpoints based on lamina, cross-section andstudy of CT scan anatomy has proved thatthe points are stereo-space structures madeup of various kinds of known tissues. Thedifference between points and non-pointsdepends on the different distribution ofknown normal tissues.

Research on the specificity ofacupoints

Extensive research has shown thatsignificant differences exist in puncturingacupoints and non-acupoints. Forinstance, when points such as guanyuan(CV4), qihai (CV6), zusanli (ST36) withreplenishing functions are punctured andcompared to weizhong (BL40), which hasfunctions of reducing heat and coolingblood, there is a remarkable difference inraising the transformation rate oflymphocytes. No obvious changes in theimmunological functions of the body havebeen found when non-acupoints arepunctured. In pneumonectomy underacupuncture anaesthesia, sanyangluo(TE8) has the best analgesic effect.

Standardization of location ofpoints

In order to keep abreast of the latest oninternationalization of acupuncture, in1990 the State Technology SupervisionBureau of the People’s Republic of Chinaissued the People’s Republic of China StateStandardization of Acupoints’ Locations.This was put forward by the StateAdministration of TCM and was imple-mented on 1 January, 1991. The standar-dization determined the methods of locatingpoints and the locations of 361 meridianpoints and 48 extra points, suiting theneeds of acupuncture teaching, scientificresearch treatment, publications, andacademic exchange in China and abroad.In addition, based on the suggestion anddemand by the Western Pacific Region ofWHO, China also formulated the Plan ofStandardization of Acupoints’ Names, ADraft Plan of International Standardizationof Auricular Points, and the Plan ofStandardization of Scalp Points’ Names, allof which were extensively used in clinicalwork.

With the development of acupuncture,especially the expansion of its experimentalstudies, animal experiments withacupuncture are increasing day by day. Onthe basis of massive achievements ofcontemporary traditional acupuncture,veterinary acupuncture and experimentalacupuncture, the Academy of TCM ofJiangsu Province and some other unitsstudied the nomenclature, location,anatomical structures and indications ofacupoints from the viewpoint ofcomparative anatomy, comparativephysiology and comparative acupuncture,with commonly used experimental animals.Based on these findings, an atlas of animalacupoints was made, defining 71 pointsof dog, 71 points of cat, 51 points of


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rabbit, 51 points of guineapig, 42 pointsof rat, and 20 points of mouse.

Study on acupuncture literatureSifting through the literature onacupuncture of past generations, theproof and annotation of some importantancient acupuncture books such asMiraculous Pivot, Systematic Classic ofAcupuncture and Moxibustion, therevision of Huangdi’s Mingtang Classic,and the publication of the Four Mirrors ofChinese Acupuncture and CollectiveWorks of Chinese Acupuncture, laid astrong foundation for scientific researchand clinical practice. On the other hand,publication of the index of acupuncturepapers, establishment of the consultingand analysing system of acupunctureliterature, and exchange of literatureamongst China and foreign countriesfacilitated the analysis of acupunctureinformation and literature consulting andpromoted academic exchange onacupuncture throughout the world.

Acupuncture education

Education in ChinaThere are various forms of acupunctureeducation in China: high-level professionaleducation, medium-level professionaleducation, postgraduate education,correspondence college, night college,doctors training as apprentices, self-studyexamination, and social strength runningschools. These have opened up avenuesfor training acupuncture personnel.

Medium-level educationAt present, there are 51 medium-levelschools of Chinese medicine, which have51,260 students. Most of these schoolsoffer acupuncture courses. Throughteaching reforms and standardization, the

teaching of medium-level schools has beenimproved. Among these schools, theSchool of Chinese Medicine of ShandongProvince was chosen as an important oneat the State level, and 19 of these schoolswere named as standard ones by the StateAdministration of TCM.

High-level professionaleducationIn 1956, TCM colleges of the first batchwere established in Beijing, Shanghai,Nanjing and Chengdu. Till the end of1997, there were a total of 30 colleges ofTCM and national medical colleges inChina, and all of them offered acupu-ncture, or acupuncture and massagecourses. The school system includedundergraduate, postgraduate anddoctorate, seven years’ undergraduate,and doctors of Western medicine learningChinese medicine, and so on. Up till 1998,a total of 88,665 TCM students and 5000doctors of Western medicine had beentrained in acupuncture. There are 2056personnel above the level of associatemedical professors in universities and 690professors. The reforms in higher educationstress on teaching content and courses arecontinuing in full swing.

Adult educationAdult education is of two kinds–informaland formal. In addition to educationthrough correspondence, night college,social college, self-study examination andfull-day courses, there are also continuingeducation, postgraduate training, doctors’training apprentices, and inheritance offamous TCM experts’ experiences, whichform the system of adult education in TCM.Some lectures and symposia are also partof the activities of continuing education;the participants get credit for attending.


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International trainingWHO set up seven collaborating centresfor traditional medicine in China. TheCollaborating Centres in the Beijing ChinaAcademy of Traditional Chinese Medicine,Nanjing and Shanghai are mainly engagedin the study of acupuncture. In 1975,international TCM training centres wereestablished at Beijing, Guangzhou, Xiamen,etc., to train foreign doctors in acupunctureand Chinese medicine, thus promoting thespread of acupuncture in the world. At theBeijing centre itself, more than 5600doctors from 104 countries and regionshave been trained in acupuncture in thelast 25 years. Some high-level TCMuniversities recruit foreign students as well.Some of the students have receivedpostgraduate degrees or doctorates. Theseskilled acupuncture doctors will quickenthe process of internationalization of TCM.

Current problems in acupunctureDifferences in the functions ofacupuncture and moxibustion. Is thereany specific difference between thefunctions of acupuncture andmoxibustion? For example, ancientacupuncture literature clearly recordedthat, the point Shenting (GV 24), “iftreated by acupuncture, it is indicatedin manic mental disorders, and if bymoxibustion, indicated in depressivemental disorders”. Some points aresuitable for puncture and some formoxibustion, and some can be treatedby both, but there are differences intheir functions. What is worth noting isthat these experiences were mostlyrecorded in the famous acupuncturedoctor Zhenquan’s book during theTang dynasty. However, further study isneeded to ascertain these differences.Lack of objective and standardizationin prescribing points. Research work on

acupuncture standardization hascompleted the standardization of namesand locations of the points. Yet the mostimportant and complicated task—thestandardization of indications ofacupoints—has not yet started. Differenttextbooks list different indications andthere are no standards in prescribingpoints when treating patients. Thissituation influences the therapeuticeffect of acupuncture.Lack of a quantity index in acupun-cture manipulation. Objective indicesapproved by academicians remain tobe formed on many counts. There areno strict and systematic clinicalobservations and experimental studieson defining terms such as reinforcingand reducing acupuncture, theintensity and quantity of stimulation,and the duration of retention ofneedles.There is a lack of objective criteria inthe evaluation of the therapeutic effectsof acupuncture and moxibustion.

Developing trends inacupuncture medicine

Elaborating the principles andscientific bases of the indicationsof acupointsTo a great extent, the therapeuticeffectiveness of acupuncture is determinedby the scientific basis of the acupointsprescription. However, the scientific basisof the acupoints prescription relies on thescientific understanding of peopleregarding the indications of the acupoints.In order to establish the scientific basis ofthe indications of the acupoints, studiesshould be conducted on two aspects: (i)By probing and analysing the acupunctureliterature of all generations; thoseindications of the acupoints summarized


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directly from practical experience shouldbe sorted out to ensure that the indicationsof traditional acupuncture points have asolid practical basis, (ii) These indicationsshould be applied again in clinicalpractice, and verified under strict scientificexperimental design so that theindications can be re-sorted. The clinicalexperience of modern acupuncturistsshould be summarized systematically andgenerally so that acupuncture can befurbished with modern features. Theseexperiences should then be used in clinicalpractice for strict verification. Only byundergoing the process of “panning thegold in the sand” can the real value ofmodern and traditional Chinese medicineand acupuncture be guaranteed, and theserious situation of poor integration ofacupuncture theory and practice bechanged. Only then can acupuncturemedicine take a great leap from the levelof “empirical medicine” to the level of“evidence-based medicine”. Keeping thisin view, the foundation has been laid forresearching and working out“International Standard AcupuncturePoints’ Indications”.

Quantifying the principles ofacupuncture treatmentAncient people practising acupunctureobserved that there are different principlesin terms of various acupuncture points,different needling techniques, singleacupuncture stimulation, total acupu-ncture stimulation and various treatmentintervals. Also, depending on variousdisease conditions, during the sametreatment course, the amount of stimu-lation increases gradually from low to high,or decreases from high to low, or increasesin the beginning and decreases later. Inorder to improve the therapeuticeffectiveness and to minimize ad hocism

in treatment, the principle of cumulativeeffectiveness of acupuncture treatmentmust be worked out. In other words, whatneeds to be explored should include thetime when the acupuncture effectivenessreaches its maximum; how long theeffectiveness would last upon reaching themaximum; whether there is a non-responding period before the newstimulation starts having an effect; and howlong the non-responding period lasts, ifthere is one. Only after these basicquestions are clearly settled can the bestacupuncture treatment plan be workedout. This would include the amount of eachstimulation, the amount of totalstimulation, the interval betweenstimulations and the treatment coursesrequired by various diseases.

Peak value of therapeuticeffectiveness of acupuncture andthe best time to performtreatmentSince the therapeutic actions ofacupuncture rely on the intrinsic functionsof self-regulation and self-recovery of thehuman body, the intensity of its functionsis limited. If clinical therapeutic effectivenessneeds to be advanced to its maximum, andif clinical indications of acupuncture areto be widened, future clinical research onacupuncture should be carried out in twodirections. One is to further develop thepotentiality: by conducting strictlycontrolled research, by sorting out diseases,by establishing the best time andopportunity to perform acupuncturetreatment, as well as by determining theacupuncture stimulation parameters ofdifferent diseases, so that the effectivenessof acupuncture can be utilized to itsoptimum extent. The other is to blaze newtrails, by integrating other supplementarymethods scientifically to enhance the


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effectiveness of acupuncture treatment andbroaden its scope. Promising supple-mentary methods include the integrationof acupuncture with Chinese herbalmedicine or the integration of moxibustionwith Chinese herbal medicine. This methodhas been tried to increase the strength ofacupuncture functions and to reduce oreliminate the side-effects of medication.However, to enable this therapy todemonstrate its advantages we still have along way to go, because the human body’sphysiological and biochemical functionsare very complicated. Any functional activityis not a single biological change but rathera series of biological processes mutuallylinked and influenced. For example, whilethe afferent nerve conducts thephysiological and biochemical regulationsto the organs around it, apart from thenerve impulse, there are such processes asthe synthesis, storage and release of theneural transmitter, the combination of thetransmitter and the receptor, and theinactivation of the transmitter. Theregulative function of acupuncture isprobably realized through the inducedrelease of some active substances, throughalternating the numbers and the reactivityof the receptor, changing the permeabilityof the cell membrane and the blood–cerebral barrier, and influencing the activityof the enzyme. Once medication isinvolved, in which way does acupunctureaffect the actions of the medication?Among the links that are important, arethere any differences in various diseasesand for different medications? If it is saidthat acupuncture and medicationcoordinate in terms of function, would theirfunctions be merely combined orincreased? To answer these questions,Chinese scholars have already performedpreliminary clinical observations andexperimental research and the basic

principles will be mastered only in duecourse of time.

Expounding the functionalmechanism of acupunctureAccording to deepened recognition of painphysiology, acupuncture mechanisms tostop pain will be gradually proved at thelevel of molecular biology, especially theprimary centre of afferent pain sensation.Various methods of neuroscience researchwill be applied to verify how the posteriorhorn of the spinal cord has a restrainingeffect on afferent harmful signals, and howthe higher centre influences the process ofstopping pain. These will provide theoreticalproof and a wide choice of clinicalapplications to eliminate pain.

Manufacture of safe and effectiveacupuncture apparatusThe clinical meaning of traditionalacupuncture skills should be judged by strictexperiments. For one kind of acupunctureskill, out of 10 experiments just one maybe of practical importance, while the restmay even trigger off reactions. Thequestions faced are: how to distinguishmeaningful composition, sum upregulation, simplify and standardizemanipulation, reduce blindness ofacupuncture manipulation, diminishunnecessary (no clinical meaning) harmfulstimulation, increase its scientific nature,

In the last 10 years, therelationship of stimulationparameter of acupuncture

with the ability to stop painhas been systematicallyobserved by research onacupuncture to stop pain.


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effectively apply it in clinics, and graduallyincrease curative effect. In the last 10 years,the relationship of stimulation parameterof acupuncture with the ability to stop painhas been systematically observed byresearch on acupuncture to stop pain. Onthe basis of this research, the public shouldbe told of the interaction regulation ofacupuncture skill and of clinical curativeeffect. New models of acupunctureapparatus to further enhance acupunctureskills should be made available. With thedevelopment of biological sensingtechnologies, a sensor with needle style canbe produced. Combined with thedevelopment of biomembrane technology,biological material with activity canprobably be added to the acupunctureapparatus. These techniques may urgeacupuncture medicine to develop intoneedle medicine compound acupuncturemedicine. Besides, with progress intechniques, no-wound acupuncture toolscombined with traditional acupunctureskills will be presented in the 21st century;trained persons have begun to try it.

Standardization of acupunctureResearch work on acupuncturestandardization has been completed incertain areas. These include “location ofmeridian points”, “name and location ofauricular points”, which have been

promulgated by the People’s Republic ofChina, and “acupuncture points name withinternational standard”, “acupunctureclinical research standard” promulgated byWHO. Following this, primary indicationsof points most related to acupunctureclinics will make great progress.

Traditional Chinese Medicine belongsto the category of natural medicine andpeople today want to return to nature. Theyappreciate that TCM is a type of naturalmedicine. WHO appreciates the traditionalmedicines of countries all over the world,especially TCM. It has founded sevenCollaborating Centres of TraditionalMedicine, and is supporting ninegovernments through the Federation ofWorld Acupuncture Association. With theguidance of WHO, China will graduallystandardize research and clinical treatmentof TCM.

The Constitution of China explicitlystates “to develop modern medicine andTraditional Chinese Medicine”, payingequal attention to modern medicine, andTCM is the primary law of medical andpublic health undertakings. It offers a verygood opportunity for undertaking TCM,and boosts its substantial healthydevelopment. In the 21st century, Chinesemedicine and acupuncture would occupya significant position in the world ofmedicine.

References

1. Wang Xuetai. The present situation and the future development of acupuncture andmoxibustion. Collection of Academic Articles for the 10th Anniversary of the Founding ofthe World Federation and Acupuncture Societies. 1997.

2. Zhang Ren. The history of the development of acupuncture anaesthesia in China (1stedition). Shanghai Science and Technology Literature Publishing House. March 1989.

3. Qian Xinzhong (chief editor). Acupuncture anaesthesia in China, Vol. 1 (1st edition). ShanxiScience and Education Publishing House. December 1987.

4. Liu Xinlian, Wu 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 bronchialasthma treated with acupuncture and moxibustion. Journal of Acupuncture and MoxibustionClinic. 1994. 10(2):13–15.

6. Yang Shufang. 224 cases of hemoptysis of TB treated by atropine and acupuncture atYintang. Integration of Traditional Chinese Medicine and western medicine on PracticalClinical First Aid. 1995. 2(2):67.

7. Zhou Jiren, Fang Depei, You Haiqing. Impact of acupuncture on the left cardiac function andhumoral endocrine of ectatic myocardosis patients with heart failure. Shanghai Acupunctureand Moxibustion Journal. 1992. 11(3):3–4.

8. Lu Hongxia, Zhang Zhenhui, Zhang Yunxiu. Observation of the therapeutic effect of thetreatment for 200 cases of hemiplegia of wind stroke by acupuncture combined with immunefunctional regulation instrument. Chinese Acupuncture. 1996. 16(3):27–28.

9. Sun Jiqing, Wang Shaokai, Chen Jinglan. Observation on the therapeutic effect of 37 casesof acute myocardial infarction treated with integration of Traditional Chinese Medicine andwestern medicine. Journal of Chinese Medicine and Pharmacology. 1992. 1:34–36.

10. Cai Ligao. Observation on the short-term therapeutic effect of acupuncture treatment for37 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 14years for urinary stone. Chinese Acupuncture and Moxibustion. 1994. 14(5):273–276.

13. China Acupuncture and Moxibustion Society. Acupuncture and moxibustion in the newcentury. Chinese Science and Technology Publishing House. 1998:826.

14. Chen Daoqing, Wang Bingkun, Zhou Liya. Treatment of 102 cases of facial nerve inflammationby combination of acupuncture and herbal therapy. Chinese Folk Therapies. 1996. 3:23.

15. Qian Zhiyun. Some experience on the acupuncture treatment for drug addiction. ChineseAcupuncture and Moxibustion. 1997. 17(12):735–736.

16. Zhou Janwei. Progress of the research on prevention and treatment of AIDS by acupunctureand 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 suppressioneffect 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 Bing. Scientific foundation of Acupuncture and Moxibustion. Qingdao PublishingHouse. 1998:87–109.

Fundamentals of Yoga

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joining together, a unity, a harmony,balance between internal and externalconsciou-sness and manifestation. Thus,yoga means self-knowledge, understan-ding, awareness, and union with thehighest consciousness as the ultimatedevelop-ment. Yoga is a system of lifestyle,philosophy and practices, which evolve theperson’s potentials, including the physical,vital, mental, emotional, psychic andspiritual qualities.

Early BeginningsThe roots of Yoga lie many thousands ofyears ago, but it is so relevant to ourpresent age that it is deservedly popularworldwide. Through the ages, it developedfrom the experiences, meditations andrealizations of wise people, and it graduallybuilt into the extensive body of knowledgeit is today.

As yoga is the result of personal inquiryand experience, one might say that it beganwhen humans first became aware andstarted asking questions on self-discovery.Knowledge of the body and its functionswas the beginning of self-understanding,


knowledge of the mind and its processeswas the beginning of self-awareness, andknowledge of the transcendental force/spirit was the beginning of self-realization.These required a healthy and vital body, sothey developed the yoga postures,cleansing practices and breathingpractices. They needed clarity of mind, sothey developed systems of concentrationand clarity, which became the meditationpractices. As people started to live in moreconcentrated communities, they evolvedphilosophies and behaviour that led toharmony between them.

Vedic EraThe written history of yoga goes backthousands of years. The earliest writingsare known as the Vedas. The word vedameans ‘knowledge’; there are four Vedas,the Rig-Veda being the oldest book ofhumanity. They discuss the spiritual andscriptural laws of nature, thoughts on themeaning of life, inner and outer know-ledge, and recommend various rituals andmeditations for human development. It issaid that they contain eternal truths thathave been discovered, not created (just asNewton discovered the law of gravity, whichwas there before him). At the end of theVedic period, ritual went into the back-

Niranjanananda SaraswatiRishi Vivekananda Saraswati

TWhat is Yoga?

he word Yoga comes from the Sanskrityuj, which means ‘yoke’ indicating a


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ground, and the path of wisdom came tothe fore. This was the age of theUpanishads.

Upanishadic AgeThe greatest thinkers and sages are fromthat time. The culture was well-structuredand secure. It was an agrarian economy,stable and fertile, giving opportunity forleisure and for delving into the depths ofhuman consciousness.

People went through the four recognizedstages of life:

Brahmacharya: The students, wholearnt the spiritual teachings, and theways of controlling the mind, as wellas the vocational education to preparethem for their work to support theirfamily in the next stage.Grihastha: The householder stage,when they married, had children andfulfilled their social responsibilities.Vanaprastha: After fulfilling thehouseholder responsibilities, they wereable to go into the solitude of the forestfor contemplation and meditation,which led to the next stage.Sannyasa: Renunciation, and concen-tration on spiritual realization.

The results of the contemplation of thewise people came out in more than 10,000Upanishads. Over time these have beenwhittled down to approximately 108, ofwhich 10 are considered major Upani-shads. Two of these are especially importantfor yoga:

The Taittiriya Upanishad classifies theentire human entity into five dimensions ofexistence, the koshas (sheaths) which inter-penetrate each other, each being moresubtle than the last:

Annamaya kosha – Matter, thephysical body. This is the part of us dealt

with in anatomy, physiology and physicalmedicine.

Pranamaya Kosha – The energy body(prana). Western science largely ignoresthis, yet it represents an area for realimprovement in therapy. The wise peopleconceived that all creation is suffused withpranic energy and called it mahaprana.The localized collection, associated with thebody, is the pranamaya kosha.

Manomaya kosha – This consists of themind and the functions of rationality,interaction, expression of emotion, belief,the conscious, subconscious and uncon-scious mind. This is the part dealt with inpsychology and psychiatry.

Vigyanamaya kosha – This is thedimension of our psychic abilities, wisdomand understanding, which are higher thanthe manomaya qualities.

Anandamaya kosha – This is thesheath of bliss, when the ego is mergedwith super-consciousness.

This concept was fully incorporatedinto yoga and is the foundation of its greatbenefit as it attends to the whole person.Thus, yoga is ultimately a spiritual journey,but can easily be a science of health andtherapy, and can be used when things gowrong in any or all five dimensions of theperson.

The Mandukya Upanishad indicatesthe process to alter the states ofconsciousness. These are the wakeful state(jagriti), where consciousness operatesthrough the senses, the dream state(swapna), where the senses are withdrawnand we experience the subconsciousmind, and deep sleep (nidra), whereawareness of the individual self is lost.Above these is the state of turiya, which istranscendental consciousness that canobserve all three lower states. The firstthree have certainly been recognized byWestern psychology, though only in the


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last century, but turiya is not acknow-ledged at all.

Puranic AgeAfter the Upanishadic Age came thePuranic Age. This period was the time ofthe writing of the two great epics, theRamayana and the Mahabharata. TheRamayana describes the life of Sri Ram andhis wife Sita. It includes the Yoga Vashistha,which is in the form of instructions given toRam about life, wisdom and knowledge byhis Guru, Vashistha.

The Mahabharata, another epic,contains the Bhagavad Gita, which is adialogue between a spiritual master,Krishna, and his disciple, Arjuna. Krishnaclearly explains, among many otherprinciples, the synthesis of action andmeditation in life, a branch of yoga knownas Karma Yoga with which we will deal later.

Raja Yoga is best illustrated by the YogaSutras of the great Sage Patanjali. It is apsychological approach to humandevelopment, a science of mind controlcentring on meditation. This is also calledAshtanga Yoga, the yoga of eight limbs,and we will deal with it in detail later.

Hatha Yoga is described inSwatmarama’s Hatha Yoga Pradipika andthe Gheranda Samhita by Sage Gherand.These texts contain a set of purificationtechniques known as the shatkarmas,which work on the vitality aspect, balancingthe energy with the mental force. Theseare important in yoga therapy and indeedin the prevention of illness, and will be dealtwith at length later.

The Main Yogas and theirContribution to Health

We have defined yoga as a system oflifestyle, philosophy and practices. In thissection we will deal with different types of

yoga. When people discuss the subject ofhealth, they usually categorize their workin terms of the different forms of illness. Inour opinion, this is not dealing with‘health’, it is dealing with sickness andabnormality. The subject of ‘health’ surelydeals with ways in which we can stayhealthy in all dimensions of our being, andyoga is pre-eminent in this area. It caresfor our physical well-being, general vitality,mental balance and tranquillity, emotionalbalance and direction, our higher mental,psychic and intuitive abilities, and theawareness of our spiritual reality. Yoga isa holistic and extensive system of attainingand maintaining health in its widest sense.

As well as the many useful practicesyoga teaches, the lifestyle improvementsthat it recommends help us to live in a muchmore harmonious and useful way andimprove the quality of our relationships withother people. It has been said that the bestway to have good friends is to be a goodfriend. The person who absorbs theteachings of yoga certainly becomes agood friend, because of their betterpersonal discipline and more considerateattitude to other people and their needs.In this way our life becomes less stressfuland this flows on to better health all round.

Yoga philosophy teaches us tounderstand the real meaning of our lives.In this age, in so many communities peoplehave lost the sense of meaning in their lives.This is leading to a serious vacuum in theirself-esteem, their attitudes to their fellowhuman beings and their world in general.A ‘meaningless’ life is perceived as one thatis worthless, and so suicide, murder, crueltyand war atrocities are rife at this time.

The practices of yoga bestow manybenefits. From the health point of view,prevention of physical, mental andemotional illness is most important.However, yoga can be used as a therapy


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also, and there is a large body of researchwhich has demonstrated the effectivenessof the many yoga practices in curing orrelieving illness. We will consider some ofthese in this article.

The forms of yoga we will discuss are:Hatha Yoga – The yoga of purification;Raja Yoga – The yoga of the mind, ofintrospection;Karma Yoga – The yoga of action withmeditative awareness;Jnana Yoga – The yoga of knowledgeand wisdom;Mantra Yoga – Ehich deals with thevibratory aspects of our nature.

Hatha YogaOriginally, Hatha Yoga was designed tobalance the mental and vital functions ofthe person, prior to meditation, in order toattain higher states of consciousness.

For thousands of years, the yogis havesaid that vital energy – prana – pervadesthe whole universe, both manifest and un-manifest, whether animate or not. Modernphysicists now agree with this, and they callit ‘background energy’. They tell us that italso forms the substrate of matter. Theysay that matter is just organized energy,and can be converted back to it, albeit withthe release of vast amounts of energy –the atom bomb is an example.

When energy or prana is un-manifest,it is known as mahaprana; when it is inhuman existence, it is divided into chittashakti and prana shakti, the mental andthe vital forces. Hatha Yoga aims atcreating a balance between mind andenergy. The different amounts of airflowing through the nostrils correspond tothese forces and should alternate for fixedperiods of time during the day. If they arenot balanced, neither are we. The HathaYoga Pradipika and the Gheranda Samhita

tell us that in order to achieve balance weneed to first purify the gross body. For thispurpose, hatha yoga recommends thefollowing cleansing techniques, known asshatkarmas (please note that all practicesin this paper are mentioned only fordescription and not for instruction. Theyshould only be learnt under the guidanceof a qualified yoga instructor).

Shatkarmas(1) Neti – The practice has been simplified

by Swami Satyananda Saraswati, andthe technique can be found, with allthe other practices in this section, inhis book Asana, Pranayama, Mudra,Bandha.(1) Neti aims to clean out thenostrils and paranasal sinuses of thehead, of stale and purulent mucous,and to balance the flows of the breathby decongesting the mucousmembranes of the nose. It is usuallypractised by pouring warm salt waterthrough the individual nostrils, but ifthe nasal passages are very muchblocked, it can be done with a catheter.Neti is effective for treating chronicsinusitis and asthma.

(2) Dhauti – The word means ‘cleansing’– there are six forms of dhauti:

Danda dhauti – Cleaning teeth,ears and tongue;Vatasara dhauti – Swallowing airand burping it up again, which issaid to ventilate the inside of thestomach, cleaning it with air;Vaman dhauti – (same as kunjalkriya) – Quickly swallowing fourglasses of warm salty water andvomiting it back. Good for acidityand clearing the lungs, it can beused to treat asthma. If used earlyin an asthma attack it can actuallystop the attack. It dilates thebronchial tubes and causes the


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secretion of thin mucous, whichcleans out the respiratory tract. Itprobably does this by eitherstimulating the sympatheticnervous system or retarding theaction of the parasympatheticnervous system;Varisara dhauti – Also calledshankhaprakshalana, thistechnique cleans out the wholeintestinal tract. The practitionerquickly swallows two glasses ofwarm salty water, then does aseries of five postures (asanas),which open the valves of thestomach and intestines, eight timeseach. This technique of swallowingthe water and practising the asanasis repeated until clear fluid comesout of the bowels. It is excellentfor constipation, but it also formsthe mainstay of the yoga treatmentfor diabetes. There is a shortenedversion, laghoo shankhapraksha-lana, in which only three roundsare done. People with high bloodpressure, hernia, peptic ulcer orcardiac illness should not do it, butit is generally quite safe and easy;Vastra dhauti – Swallowing a longpiece of cloth, and gently pulling itback up. This is also good forasthma, and probably works thesame way as vaman dhauti. Itsounds difficult, and may be so forsome people at first, but mostpeople can generally master it;Vahnisara dhauti is also calledagnisar kriya; the muscles of thefront of the abdomen are rapidlycontracted and relaxed, with thebreath held out. It strengthens andmassages abdominal muscles andorgans, and stimulates thedigestive fire.

(3) Basti – Yogic enema, cleans out thelower intestine. It is not needed if oneis doing shankhaprakshalana.

(4) Nauli – Advanced practice that needsexcellent control of abdominalmuscles.

(5) Kapalbhati – (transl. ‘frontal lobes’ +‘to shine’). In this practice, there isforced exhalation and passiveinhalation. It is said to stimulate thefrontal lobes of the brain, and so clearthe mind of disturbance, and allow itto become one pointed andconcentrated. It also increases thevitality.

(6) Tratak – Visual concentration on onepoint, develops mental concentration,mind control, clarity and calmness. Itstimulates melatonin hormonesecretion.Done in this sequence, the shatkarmas

are designed to clean and purify the grossbody (neti, dhauti and basti), thenstimulate the pranic energy (nauli), thenstop mental dissipation (kapalbhati), andthen concentrate the mind (tratak). Afterthis preparation, the practices ofmeditation can progress smoothly.

Nowadays, it is usual to include inhatha yoga, the group of techniques calledasanas, pranayamas, mudras andbandhas.

AsanasAsanas are the postures usually associatedwith the name ‘yoga’. They vary incomplexity from simple stretching practicesto difficult advanced postures. It shouldbe noted, however, that even the simplestasanas can have a profoundly beneficialeffect.

Asanas affect all dimensions of theperson, especially the body-mindconnection. Swami Satyananda states inAsana, Pranayama, Mudra, Bandha.1


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“The mind and body are not separateentities, although there is a tendency tothink and act as if they are. The gross formof the mind is the body and the subtle formof the body is the mind. The practice ofasana integrates and harmonizes the two.

“Both the body and the mind harbourknots. Every mental knot has a corres-ponding physical muscular knot and viceversa. The aim of asana is to release theseknots. Asanas release mental tensions bydealing with them on the physical level,acting somato-psychically through thebody to the mind. For example, emotionaltensions and suppression can tighten upand block the smooth functioning of thelungs, diaphragm and breathing process,contributing to a very debilitating form ofillness in the form of asthma.

“Muscular knots can occur anywherein the body: tightness of the neck leading tocervical spondylosis, or of the face asneuralgia, etc. A well chosen set of asanas,combined with pranayama, shatkarmas,meditation and Yoga nidra, is most effectivein eliminating these knots, tackling themfrom both the physical and mental levels.The result is the release of dormant energy;the body becomes full of vitality and strength,the mind becomes light, creative, joyful andbalanced.

“Regular practice of asana maintainsthe physical body in an optimum conditionand promotes health, even in an unhealthy

body. Through asana practice the dormantpotential energy is released andexperienced as increased confidence in allareas of life.”

PranayamaPranayama is generally defined as ‘breathcontrol’. Although this interpretation mayseem correct in view of the practicesinvolved, it does not convey the fullmeaning of the term. Pranayama shouldnot be considered as mere breathingpractices to introduce more oxygen into thelungs. It is the utilization of breathing toinfluence the vitality of the body, and thebalance and calmness of the mind andemotions. Four pranayamas are worthyof mention in this respect.

Nadi Shodhana Pranayama is thetechnique of blocking each nostril in turnas the breathing goes on. The breath flowsin through the left nostril and out throughthe right, then in through the right nostriland out through the left, the eyes remainingclosed throughout. This practice balancesthe emotions, and induces tranquillity ofthe mind, clarity of thought, and improvedconcentration. How does it create suchbalance? The most likely explanation is this:it has been clearly demonstrated thatbreathing only through the right nostrilstimulates the left cerebral hemisphere andbreathing only through the left nostrilstimulates the right cerebral hemisphere.Balancing the flows through both nostrils,as in nadi shodhana, balances the twosides of the brain, and with it, the thinkingand emotions. Nadi shodhana can becomequite powerful with advanced additionssuch as breath holding and muscle locks.Simple nadi shodhana can be done for5–10 minutes.

Bhramari Pranayama consists ofblocking the ears with the fingers, and, withthe eyes closed, making a humming sound

Bhastrika Pranayama is knownas the bellows breath, bhastrika

means ‘bellows’ in Sanskrit.Bhastrika rapidly increases thevitality and warms the body,

just as the bellows increases theheat of the fire.


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like a bee, as we breath out (bhramarimeans ‘bumble bee’). A strong vibrationcan be felt inside the head. Physically it isexcellent for tension headache, and toloosen thick mucus in the sinuses. Mentallyit alleviates stress, tension, anger, andanxiety and produces peace of mind. It isusually done for a few minutes, but in casesof extreme anxiety or panic, can bepractised for half an hour, a few times aday.

Ujjayi Pranayama is done with the eyesclosed. We remain aware of the naturalbreathing, while slightly contracting theglottis to make a soft snoring sound. Thebreath should be slow and deep – first intothe abdomen, then into the lower chest,then into the upper chest; then out in thereverse order. The practitioner noticesincreasing tranquillity of mind andrelaxation of the body during the practice.Ujjayi can be used in combination withother yogic techniques for an even strongereffect.

Bhastrika Pranayama is known as thebellows breath, bhastrika means ‘bellows’in Sanskrit. In this practice, with the eyesclosed, we breathe in and out forcefullythrough the nostrils, making sure thebreathing is abdominal, i.e., from thediaphragm. Bhastrika rapidly increases thevitality and warms the body, just as thebellows increases the heat of the fire. It isused for fatigue, tiredness, sluggish bowels,asthma and the birth process. As it inducestranquillity and one-pointedness of mind, itis often used before meditation.

MudrasMudras are a group of gestures orattitudes which alter mood, attitude andperception, and which deepen awarenessand concentration. They are introducedafter some proficiency has been attainedin asana, pranayama and bandha.

BandhasBandhas are a group of muscle locks,which aim to lock the pranic energy inparticular areas and redirect their flow forthe purpose of spiritual awakening. Thereare four bandhas: jalandhara, uddiyana,moola and maha. The last one is acombination of the first three. The threebasic bandhas have therapeutic effects.

Jalandhara bandha is done in thesitting position with the hands on the knees.With the breath in, the head is bent forward,and the chin is pressed into the upper chestas high as is comfortable – if possible intothe sternal notch. Physically, this practicehelps to balance the secretions of thethyroid gland, and so regulate themetabolism. Psychologically, it producesmental relaxation, and relieves stress,anxiety and anger.

Uddiyana bandha is done eitherstanding, bending over with the armsstraight and the hands on the knees, orsitting with the arms the same way. Thestomach and bowels should be empty.With the breath fully out, we make a falseinhalation with the glottis closed, asthough breathing in but not actually takingin any air. The anterior abdominal wall isautomatically drawn up towards the spineand diaphragm to form uddiyana bandha.After a comfortable time it is released.Uddiyana bandha is useful for consti-pation, indigestion and early diabetes. Thedigestion is stimulated, and the abdominalorgans are all massaged and toned. It issaid that the adrenal glands are balanced,which removes lethargy and soothesanxiety and tension.

Moola bandha is the contraction of themuscles deep to the centre of the perineum.It is held for the duration of a breath, thenrelaxed, and repeated 10 times. In a moreadvanced version it is combined withjalandhara bandha. Moola bandha


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stimulates the pelvic nerves and tones theurinary and genital systems. As a result, itraises low libido and helps erectiledysfunction in men, and vaginal drynessin women. It relieves the symptoms ofdepression and can also immediatelyneutralize other emotions. For example, ifa person wants to control crying, laughing,or even coughing, applying moola bandhawill stop it.

The practices of hatha yoga combinedwith the techniques of meditation form thefoundation of Yoga Therapy. The blockages– mental, emotional, physical, psychic andspiritual – that stop us from realizing ourfullest potential, are the same ones thatcause most illnesses. The yoga practiceswere developed for spiritual evolution, butthey can be just as easily applied to relievingillness. There are a number of advantagesof yoga used in this way:

After we have learnt the practices, theyare free of charge. So if we benefit fromthem, we do not have to continuepaying for medicines. This can bereflected at a national level where vastamounts of money, which would havebeen spent on pharmaceutical drugs,can be saved by governments.The practitioner gains mastery overwhole areas of his/her life, becomesindependent of outside sources oftreatment, and is able to apply thepractices at any time they are needed.For instance, a person with asthma whomasters vaman dhauti has a means tostop an early attack any time. Theperson with anxiety that leads to panicattacks, can settle the anxiety with manypractices such as bhramari pranayama,ujjayi pranayama, and yoga nidra andavoid the panic. Then by a virtuouscircle effect, because they know theyhave the practices, their anxiety aboutthe possibility of panic also reduces.

A person who has mastered yoga canteach the practices to other peoplewhen the need arises. In some casesit can be used as a form of yogic firstaid. Many a time a yoga teacher hastaught vaman dhauti to a person inthe early stages of an asthma attackand stopped it.

Raja Yoga

Until we can calm the disturbances of themind, we will always have problems withour mental and emotional states, difficultiesin our behaviour and relationships, and beunable to attain our true potential. Rajayoga, the yoga of meditation, shows ushow to calm the mind and realize who wereally are.

The principles of raja yoga are set outin the Yoga Sutras written by Sage Patanjaliabout 2,500 years ago. As it is laid out ineight consecutive steps, it is also known asashtanga Yoga (eight-fold path), which hassequential steps through:

(1) Yamas(2) Niyamas(3) Asanas(4) Pranayamas(5) Pratyahara(6) Dharana(7) Dhyana(8) Samadhi.

The yamas and niyamas are recom-mended moral codes, which thepractitioner is to integrate into life more andmore as time goes on:

YamasThe purpose of the yamas is to harmonizethe external environment and ourresponses to it:

Ahimsa – Feeling of non-violencetowards all things, from thoughts, words


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and deeds. As one develops ahimsa, onedetects one’s violence to be more and moresubtle, but also that there is less violencearound one.

Satya – Truthfulness – this also involvesour thoughts, words and deeds. We mustbe truthful at all these levels, sincere andtrue to ourselves as well. But truth shouldnot be used to intentionally hurt another.

Asteya – Honesty – This means notstealing other peoples’ possessions, but italso means internal honesty, simplicity andsincerity.

Aparigraha – Non-possessiveness –This is really the result of developingdetachment. We care for our possessionsor the people in our lives, but we are notaddicted to them.

Brahmacharya – Being established inthe higher reality (nature of Brahman).Often equated with celibacy, but that is justa small part; in that state, carnality has noplace.

NiyamasSpecial codes of self-restraint aimed atinternal discipline:

Saucha – Cleanliness of the body,external and internal, neatness and orderin our environment, and purification of themind. The hatha yoga shatkarmas aredesigned to help with this.

Santosha – Contentment, beingsatisfied with what we have. This developsas we do; our demands become fewer, ourlife becomes simpler and so we are morecontented.

Tapas – Austerity – As we live simplywe become better able to cope withhardships.

Swadhyaya – Self-study – Analysis andknowledge of our own personality, becomingaware of our strengths, weaknesses,ambitions and needs.

Ishwara pranidhana – Belief in higherreality.

Why moral codes in a work onmeditation? Paramahamsa Satyanandasays in Four Chapters on Freedom.(2)

“The yamas are designed to harmoniseone’s social interactions, and the niyamasare intended to harmonise one’s innerfeelings. All the rules, yamas and niyamas,are designed to reduce friction betweenone’s outer actions and inner attitudes.There is a two-way relationship: the mindstimulates external actions and externalactions stimulate the mind. If the externalactions are not harmonious, then the mindwill be disturbed. Conversely, a disturbedmind will tend to produce disharmoniousacts.”

He goes on to state: “The rules are noteasy to apply, but even limited applicationwill lead to greater peace of mind. Perfectapplication can only arise with self-realisation”, but we can continue to improveas our life goes on.

AsanasThese are the yoga postures. The YogaSutras define asana as “that posture whichis still and comfortable”; this refers tomeditative postures.

Swami Niranjanananda in YogaDarshan3 says the human body is capableof five movements and the yoga postures(dealt with in the hatha yoga section)reproduce these:

Natural, like walking (stretchingpostures such as pawanmuktasana);Dynamic, like running (dynamicpostures such as salute to the sun);Adaptable, like comfort in the foldedpositions (e.g., forward and backwardbends);Balance, like standing still (balancingasanas);


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The state of pratyahara is deeplyrelaxing, but it is also the threshold of thesubconscious and unconscious levels of themind. These are then available for analysisand inserting positive affirmations. Thisstate of mind is useful for many healthpractices, and personal developmenttechniques.

Some pratyahara techniques are:Yoga Nidra™ – In this practice we

use rotation of consciousness through allparts of the body, and we easily reach asensitive state of mind to bring up and dealwith deep mental impressions.

Ajapa Japa – Internalized awarenessof breath with the mantra of the sound ofthe breath ‘so hum’. It quickly calms themind and stops mental dissipation.

Tratak – Concentrating on an externalform, often the flame of a candle –Develops one-pointed concentration andcalms the mind. It has been found toincrease the secretion of melatonin, thebody’s natural tranquillizer, from the brain.

Antar Mouna – Works on observing,changing and stopping thoughts, and alsotracing them to their source.

When the state of pratyahara has beenattained, we focus the mind and come to:

DharanaThe important thing here is to keep the mindfixed on one point only. Any point ofconcentration can be used, such as amantra, symbol, thought or idea. At thetime of meditation, if there is oscillation ofthe mind then concentration will not beexperienced. In the beginning it is difficultto concentrate the mind for a long time,but when the mind wanders we just gentlybring it back to the object of concentration.It is easier if we have done the preliminarypractices first.

Stillness (meditative asanas)Asanas teach us to know our body throughthese types of movements. They changebody chemistry, free energy flows and bringbalance to the mind and emotions.Therefore, they affect us on three levels, thephysical, energy and mental levels.

PranayamaPatanjali states that “pranayama is thecessation of the movement of the breath”.It sounds dangerous, but it really meansthat if we can gradually widen the timebetween each inhalation and exhalation,the mind becomes calmer and calmer. Thisis the meaning of pranayama accordingto raja yoga, but in other yogas, as we havementioned, there are many practices ofpranayama which have different effectssuch as calming the mind and emotions,increasing the vitality and balancing theactivities of the cerebral hemispheres. Theyare very helpful in many different illnessessuch as anxiety, depression, emotionalinstability and so forth.

PratyaharaPratyahara means withdrawal of the mindfrom the objects of sensory experience. Themind then introverts and experiences itsdeeper nature. The aroused mindrecognizes the parameters of name, form,object and time. Pratyahara cuts offawareness of the objects. As it is thesensory input that mainly keeps us fullyconscious when we practise pratyahara,the rhythms of the brain slow down andwe ‘descend’ from beta rhythms to alpharhythms, down to the borderline of theta(sometimes known as the alpha-thetastate) – the threshold between waking andsleeping. At this level, we are mentallyrelaxed and unaware of our externalenvironment or sensations from thephysical body.


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DhyanaDhyana is the state of meditation. Notethat this is a state, not a practice. It is theresult of perfecting dharana, when thereare no breaks in concentration. One alsoremains aware that one is practisingdhyana. Thus, dhyana includes two things:one, an unbroken continuous flow ofconsciousness of a single object, and two,the awareness of dhyana; that is theawareness that one is practising unbrokenconcentration. These two kinds ofawareness go hand in hand.

SamadhiDhyana leads to this final stage. Inmeditation there are three activeparameters: the meditator, the process ofmeditation and the object being meditatedupon. In samadhi, only the object remains.

Benefits of Raja YogaAs discussed above, the lifestyle benefitsof yamas and niyamas are many, and theadvantages of asanas and pranayamashave been mentioned. It is the inner prac-tices, pratyahara, dharana, dhyana andsamadhi, that can bestow inner peaceand reverse many health problems. Thereare at least four ways in which this canhappen.

Deep mental and physical relaxation– Stress is rampant in our world, and mostof it comes from our own minds. Ourexpectations, which far exceed our needs,cause us frustration, disappointment andanxiety. Our sympathetic nervous systemsare on full alert much of the time and ourbodies and minds get little rest, even whenwe sleep. This state of arousal leads tomany illnesses such as hypertension,asthma, headaches, heart disease, arthritis,bowel complaints and general deteriorationof all tissues by free radical damage, etc.

The exhaustion phase that succeeds it leadsto many more, such as diabetes, and theresults of exhaustion of the immune systemsuch as chronic infections and cancer. Itis little wonder, then, that the inner practicesare used to prevent and treat theseconditions.

In the 1970s, Ainslie Meares, anAustralian psychiatrist, published in theMedical Journal of Australia, excellentresults of his cancer patients using deepmeditation. They only used the meditationpractices and many cancers regressed.Carl Simonton, a radiotherapist from FortWorth, Texas, used meditation practiceswith visualizations, and his patients alsoexperienced good results.

Positive influences on the unconsciousmind – The evidence on using positiveaffirmations and visualizations in the stateof pratyahara and deeper, has been well-known and reported in innumerable booksand articles over the years. It almost seemsthat people use medications rather thanmeditations for many illnesses, onlybecause they do not know about the latter,or they prefer the pills because they areeasier and quicker.

Eliminating negative content in theunconscious mind – The many yogicinternal visualizations allow the negativeimpressions in the deeper layers of the mindto come into consciousness, where theycan be dealt with. When they are stillrepressed, they cause trouble on all levelsof the person, the physical, the energy, themental, emotional and behavioural, andat more subtle levels. They affect theperson’s attitudes, perceptions andexpectations of themselves, others and theirworld, so they are crucial in all areas ofour lives. When we eliminate the effects ofthese deep mental impressions, we benefitour lives immeasurably.


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Karma Yoga

Karma Yoga is the ‘yoga of action’. Weare always in action even when we areapparently doing nothing. At least ourminds are in action, and at some level westill affect the objects or people aboutwhom we are thinking. Even when asleepwe dream, and even in deep sleep we areinteracting at some level. The yogis saythat if we are always in action we had betterdo it the right way. The right way is karmayoga, in which we are functioning in theworld but our inner attitude to that actionis of a special kind. It is the yoga ofdynamic action – interaction with the worldand normal daily situations, but withmeditative awareness and continuous flowof energy. It aims to increase the level ofour awareness of our internal reactionssuch as our expectations.

The word karma means ‘action’, butin some respects also the results of ouractions – we reap what we sow. Theactions can be physical ones, but they canoccur in all dimensions of our being, or atany level of consciousness. However, theimportant thing is to develop the ability toact with the inner attitude which has thefollowing qualities:

Efficiency – This needs full concen-tration and awareness of the Self, of themind. It is necessary to be one pointedand not distracted. You must be able toobserve the whole event to becomeefficient, to have the ‘big picture’.

Equanimity – The mind should remainbalanced in success and in failure. In orderto maintain mental balance, it is easiest ifone practises the other yogas as well, andabandons the desire of attachment, thedesire of result and the desire ofachievement.

Absence of Expectation – TheBhagavad Gita says, “It is not possible for

embodied beings to renounce action, butit is possible to renounce the results of theaction”. People often answer this by saying,“but surely I can expect to be paid for mywork”. Karma yoga says, “yes, but makeyour contracts for payment, then get onwith doing the job for its own sake and withall your attention”. Many people whoembark on the road of karma yoga findthat they start to receive abundant paymentbecause the people they work forappreciate their efforts. This is part of thenatural law of karma; we do indeed reapwhat we sow.

Lack of Ego – The Gita also says, “Hewho is free from the feeling of ego and whois not swayed by the feeling of good andbad, walks the path of righteousness andrighteous action”. Egolessness also impliesthat one has to be simple (uncomplicated),sincere and desireless. Our actionsbecome unselfish with no ego motive, donefor others or the world. This lets us live inharmony with nature, to give and keep ongiving.

Renunciation of limiting desires – Mostdesires limit us, such as the desire toaccumulate more and more possessions,to soothe the insecurities caused by ourspiritual vacuum. These nagging desirescause a vicious circle and take us evenfurther away from our spiritual goal.Other desires, such as the desire to helpothers without expectation, take us towardsit. The more we are able to limit our desires,the less disappointed we will be and themore calm and balanced our mind. Wealso need to have the ability to discriminatebetween our needs and our desires.

No identification with the work – Havethe attitude of only being the instrument,not the doer, that you are not indispensable.When this is working properly, it is awonderful feeling as the work flows alongas if ‘guided by a higher force’. Everything


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we need for the job comes our way, andeveryone we need to help us comes alongat exactly the right time. It all happens soregularly that we realize these could notpossibly be coincidences. Then a higherrealization starts to dawn within us. Whenwe are non-attached, it is possible toexhaust our karmas, which is another aimof karma yoga.

Conversion of negative into positive –Some people habitually see the positive sideof a thing (optimists), others the negativeside (pessimists). Karma yoga is a processof converting our negative attitudes intopositive ones.

Duty or dharma – In Yoga Darshan bySwami Niranjanananda Saraswati,3 thispoint and karma yoga in general isdescribed thus:

“The last attribute of karma Yoga isconsideration of every action as a duty. Doyour duty, because action is superior toinaction. Action when performed with theidea of duty produces a very deepexperience of bhakti (devotion), surrender,belief, trust and faith in a higher nature, ahigher reality guiding us. This duty is to beunderstood in relation to one’s individualdharma, social dharma, global dharmaand universal dharma.

“When one develops the awareness ofdharma, as an inherent commitment ofduty or obligation to other beings, then onedevelops a giving or helping nature. Manytimes people talk about, and believe ingiving, a helping hand to others. Ouractions, which outwardly may seem likehelping, do not necessarily convey the samefeeling to others. Often, even the desire tohelp others carries with it some kind ofulterior motive, whether for gain or profit.We should not be restricted to the idea ofsome kind of personal gain.

“Initially the practice of karma yoga isdifficult, because to combine so many

attitudes such as efficiency, renunciation,equanimity, egolessness and duty in oneaction is difficult. The thrust of karma yogais to have these concepts combined in onethought, one action, in one moment. Oncethese different ideas are combined, thenwe can proudly say we are practisingkarma yoga.”

However, until then we can do the bestwe can to have that attitude. In theworkplace, at home with the family, whenwe are with other people, and indeed evenwhen we are alone, relating to ourselves,we can remember to apply the aboveprinciples. Then over time, it will becomesecond nature in all our actions, bringinga peace of mind that most people neverattain. Karma yoga clears the mind ofphobias, insecurities and complexes, andmakes it steadier for further practices andfor life. The ultimate state is total serenityin the midst of intense action.

Jnana Yoga

Literally jnana means ‘wisdom’ or‘knowledge’. So jnana yoga means theyoga of real knowledge. This knowledgeis not intellectual, acquired from books anddifferent sources of communication. It isan advanced yogic sadhana (spiritualpractice), a process of self-inquiry with aconcentrated mind. Jnana yoga is linkedwith the Vedanta of Indian philosophy,which is a path of inquiry into Brahman,the Absolute.

In order to understand the Brahmanor the Absolute, the process of jnana yogabegins with self-analysis. The form of self-analysis is not high, abstract or abstruse;it is very definite. In fact, the practices ofpratyahara and dharana may be classifiedas part of jnana yoga also, becausethrough these practices we analyseourselves. What is happening at the level


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of our thoughts? How are the thoughts,emotions and feelings swaying us? Do wehave the ability to stop them or to recallthem at will? This kind of self-analysis, interms of the physical, mental, emotionaland intellectual aspects, can be considereda part of jnana yoga. This kind of self-knowledge helps a person mentally andemotionally.

Swami Niranjanananda has proposeda technique of self-analysis known asSWAN technique. The four letters of SWANstand for Strengths, Weaknesses,Ambitions and Needs. Anyone can analysehimself or herself by perceiving the extentof these four dimensions in their personality.‘Strength’ refers to such qualities andcharacteristics that contribute towardsadvancement of spiritual evolution,resulting in mental quietness and innerhappiness. Self-confidence, loving nature,concern for others, compassion for theneedy, contentment with one’s possessions,etc., may be cited as examples of one’sstrengths. On the other hand, negativethoughts, emotional instability, anxiety,stress, hatred, egoism, etc., may be takenas one’s ‘Weaknesses’. ‘Ambitions’ referto one’s aspirations for material achieve-ment, social prestige, positions, etc.,‘Needs’ include basic requirements forsurvival and maintenance like need for

food, education, love and belongingness.A self-assessment on these dimensionsprovides the person a picture of theirpersonality as perceived by them. Thisprovides a basis for improving the qualityof life by adopting yogic practices andsadhanas. The practice of jnana yogaresults in expanding one’s awareness tocover wider and wider areas of conscious-ness. This is called meditative awarenessand it ultimately results in the power ofdiscrimination and right understanding,and the ability to distinguish between thereal and the unreal.

In contemporary psychology, thehumanistic approach is very close to jnanayoga. The famous humanistic psychologist,Abraham Maslow (1908–1970,)proposed a hierarchical structure of humanneeds. According to him, all human needscan be arranged into seven categories, ofwhich five are distinctive and often cited.These categories of needs may be placedin a sequential order of hierarchy. Mostbasic are the physiological needs that mustbe satisfied for physical survival, forexample, need for food, water, oxygen, etc.Then come safety needs that are related toprotection and security from potentialdangers. The physiological and safetyneeds are obviously ‘biological needs’related to physical survival and protection.The third group of needs are called needsfor belongingness and love, i.e., the needto love or to be loved and the need ofaffiliations and associations with a groupor groups.

The fourth level in the hierarchy of needsis the category of esteem needs, i.e., theneed to gain power, prestige andrecognition in society. Apparently, thesecond and third order needs in Maslow’smodel consist of ‘psychological needs’. Thehighest order of need structure has beennamed by Maslow as self-actualization

The highest order of needstructure has been named byMaslow as self-actualizationneed. These needs includepursuit of knowledge in afield of specialization thatresults in realizations ofone’s unique potential.


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need. These needs include pursuit ofknowledge in a field of specialization thatresults in realizations of one’s uniquepotential. Although few people reach thislevel, everyone has a self-actualizing need.In order to become self-actualized, thepersons must be well-adjusted and self-fulfilled. Maslow has given 15 characteri-stics of a self-actualized individual whichinclude efficient perceptions of reality,acceptance of self and others, spontaneity,simplicity, task-oriented attitude, self-discipline and self-reliance, sense ofappreciation, mystic experiences,compassion and sympathy for humanity,creativeness, harmony with culture, needfor privacy and a life of detachment. Takentogether, these characteristics seem to referto the spiritual awakenings and are verysimilar to a self-realized yogi as describedin jnana yoga.

The different sequential needs aspropounded by Maslow refer to the threeinteractive aspects of evolution of the humanpersonality as conceived in yogic literature.They are from body awareness (annamayakosha) to spiritual enlightenment andexperience of inner bliss (anandamayakosha) through the psychologicalawakening (manomaya kosha).

We find that Maslow’s need structurehighly resembles the yogic theory of self-realization. However, yogic literature is veryrich in terms of techniques or practices,called sadhana, to achieve the highest levelof self.

Jnana yoga practices develop twodistinctive qualities in the practitioner. Theyare viveka and vairagya.

Viveka is the power of discriminationbetween the real and the unreal, the eternaland the decaying. Viveka providesunderstanding and knowledge of realityand illusion. The person with vivekaperceives the world as a changing play and

does not confuse it with the permanenceof the ultimate.

Vairagya means ‘detachment’; it isfreedom from raga (attraction) anddwesha (repulsion), it is dispassion andnon-attachment to the fruits and benefitsof one’s activities.

Both viveka and vairagya continue togrow and manifest in different behaviourand modes of adjustment, and withexpanding areas of consciousness throughjnana yoga sadhana. Jnana yoga is ahigher order sadhana and not meant forevery one. It has to be combined with otherpractices of yoga as per the tendencies andnature of the practitioner. Some who aredynamically inclined can practise jnanayoga if they combine it with karma yoga.People whose emotions are charged canpractice jnana yoga by combining it withbhakti yoga (the path of devotion,expression of the heart, of emotions).Those who have potential psychic abilitiescan practise jnana yoga combined with rajayoga. Only those with indomitable will canpractise jnana yoga by itself. So jnana yogais generally considered a supplement tomeditation, dhyana. In dhyana there istotal identification and merger of the mind,and in jnana there is full experientialknowledge of that merger. So jnana anddhyana combined give the experience ofsamadhi.

Mantra Yoga

The word mantra is generally translated as‘sound vibration’, but the literal translationis ‘the force which liberates the mind frombondage’. However, mantras have effectsin all aspects of the person, not just themind. The mantras used in yoga areformed from combinations of the soundsof the 50 Sanskrit alphabet characters,which correspond to different energy


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centres in the psychic body. Mantras whichare composed of those sounds createvibrations in specific areas of the psychicbody. Their vibrations have effects on ourphysical bodies and our mental functioning.

Physical effects – Since the mantras,when sounded audibly, vibrate theappropriate parts of the physical body, anyproblems in those parts that respond tovibration, improve when the appropriatemantras are repeated. For instance, thelast letter of the often-used mantra, OM,produces a humming sound, which vibratesthe head area. It is an excellent practicefor relieving tension, headache and chronicsinusitis. Similarly, other mantras especiallyvibrate the chest area, and are good forrelieving tension there. In this way, if oneknows the area of action of mantras, onecan virtually prescribe an appropriatemantra for that area.

Mental effects – If mantra is the forcethat liberates the mind from bondage, whatis this bondage? It has two aspects,impurities (mala) and oscillation (vikshepa).The impurities are the sum total of all thenegative impressions deep in the mind. Theyare the result of past problems in all areasof our mental being, and relate to such areasof our life as love, joy, security, power andself-esteem. Mantras activate these partsof our mental apparatus and allowmemories to surface where they can be dealtwith and eliminated. The other aspect ofthe mind, vikshepa, is the oscillation anddistraction of the mind; the internalmonologue goes on all day, the desires, thefears, the plans, the disappointments, themind is never at peace. By repeating themantras with one-pointed awareness, theoscillations can be quietened and the mindbecomes tranquil and peaceful.

Psychic effects – Mantras can also beused to awaken our psychic potentials, butthis subject is better left to be imparted by

one’s own yoga instructor who isexperienced in the science of mantra.

Some research data on Yoga

As we have seen, yoga covers a broadrange of techniques applicable to allaspects of life. This needs to be taken intoaccount when examining yoga research,since there are many articles that discussrelaxation, hypometabolism, etc., whichare directly or indirectly related to yoga,although this relationship may not beexplicitly stated.

Yoga and Cardiovascular DiseaseConsiderable research data have beencollected on yoga’s capacity to influencethe cardiovascular system and improvefunction. Research has focused onhypertension and coronary artery diseasein particular. Yoga is seen to be a goodalternative to exercise, because of itsadditional relaxation effect, and the factthat it can be finely adjusted to the physicalneeds of the individual person.

The research on hypertension is nowconclusive as a result of more than 30 yearsof data.4,5,6,7 In 1969, Datey successfullytreated 53 per cent of 47 patients sufferingfrom hypertension using the meditationtechnique of shavasana. There have beenseveral studies, which have comparedvarious meditative practices and theireffects on blood pressure. Bagga andGandhi compared shavasana withTranscendental Meditation© and found thatboth techniques lowered heart rate andblood pressure, and increased skinresistance; however, a mantra-basedmeditation practice was relatively moresignificant.8

There have been a number of studieson the heart itself and it has been shownthat yoga improves cardiovascular


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efficiency.9,10 Carson, et al., investigatedthe effect of a relaxation technique oncoronary risk factors and found thatrelaxation had a significantly beneficialeffect on plasma lipids, weight, bloodpressure and blood glucose.10 Carsonfound that the use of a relaxation techniquemight be considered beneficial in reducingthe risk factors.

Tulpule used yoga in the treatment ofmyocardial infarction.11 He found thatsimple yoga postures and pranayama(sukhasana, shavasana, bhujangasana,matsyasana, etc.) were beneficial, whentaught to 102 male patients withmyocardial infarction who practised for oneyear. The results indicated that yoga is easyto learn; it needs no medical supervision,and it can be practised at home as part ofa rehabilitation programme. Yogasignificantly reduced long-term mortality inthe yoga group compared to controls andhad a high rate of rehabilitation. Only threeout of the 102 subjects practising yoga diedduring one year, while 13 of the 103controls died. Significantly, no patient inthe yoga group developed any evidence ofcardiac decompensation or dysrhythmiaduring the one year while doing the yogapractice.

Generally speaking, yoga is taught inconjunction with other techniques in orderto produce a synergistic effect. There havebeen several studies showing that multi-factorial approaches have many benefitsand that one approach alone may not giveas good a result.12,13,14

Jurek, et al., showed that the additionof a behavioural intervention (biofeedback-assisted relaxation) produced a decreasein blood pressure beyond that associatedwith the diuretic alone.12 Ornish hasproduced reversal in coronary arteryocclusion using a combination of yogameditation and intensive lifestyle changes

(10 per cent fat in the diet, whole foodsvegetarian diet, aerobic exercise, smokingcessation, and group psychosocialsupport).15 Ornish showed that a groupwho maintained lifestyle changes for oneyear had a 4.5 per cent relativeimprovement in the decrease of theirbaseline stenosis, and 7.9 per cent afterfive years. These figures may seem small,but they translate into a significantimprovement in the person’s functioning.

L.Bernardi, et al., have shown that afterone month of training in yoga pranayama,patients with chronic heart failure had asignificant improvement in oxygensaturation and exercise perfor-mance.16 Inchronic heart failure, impaired pulmonaryfunction can itself contribute to oxygen de-saturation and reduced physical activity.Bernardi found that by slowing thebreathing rate to 3–6 breaths per minuteusing the ‘complete yogic breath’ thepatients were able to reduce ventilation by40 per cent, but increase oxygensaturation, with a substantial improvementin ventilation to perfusion ratio. Themethod by which this is thought to work isthat deeper and slower breathing makesmore efficient use of the diaphragm withno increase in respiratory workload.

Apart from its capacity to improvephysiology, yoga can be seen as an idealform of exercise for heart disease and bloodpressure when it is practised with a relaxedmind, and appropriate to the situation ofthe individual patient. All patients need toengage in exercise programmes torehabilitate their hearts and blood pressure.However, exercise programmes arerecommended for a select group ofpatients, and there are definite contrain-dications to exercise testing in-patients.This may be due to the fact that manypeople strain, because they have a fixedidea of how aerobic exercise should be.


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Tulpule, for example, said that yoga is,“completely free of complications, whereasat every centre exercise has produced eitherdeath, arrhythmia, severe angina orprecipitated myocardial infarction”.11,17

FitnessGharote, Ganguly, Bhole and Karambekarhave shown that yoga increases fitness andvital capacity. This is an essential part ofrehabilitation.18,19,20

AsanaK. N. Udupa and R. H. Singh from BenaresHindu University have done much researchon the effect of yoga asana onstress.21,22,23 Udupa has studied bioche-mical parameters such as catecholamines,cholinesterase, mono-amine oxidase,diamine oxidase, plasma cortisol, serumPBI, serum proteins, and blood sugar. Hemeasured students practising yoga versusnormal exercise and found that yogainduces more vital effects than exercise,which works mainly on muscle. Differenttypes of yogic practices produce differenteffects.

Gopal, et al., studied the effects ofasana and pranayama on pulse rate,blood pressure and respiratory functions.6He showed that yoga practitioners whencompared with controls had greater vitalcapacity and tidal volume, and a relaxedrespiratory rate. Also, diastolic bloodpressure was less in the yoga groupindicating decreased sympathetic tone.

M. S. Garfinkel, et al., showed thatasanas improve grip strength and painreduction in patients with carpal tunnelsyndrome.24

PranayamaMorse, et al., studied the effect of yogaand breath on the autonomic nervoussystem.25 Such were measured for heart

rate, blood pressure and skin resistance.They showed that there is a strong linkbetween breath and autonomic control.

Pratap, et al., showed that there is nomajor change in blood gases afterpranayama in normal subjects.26 However,L. Bernardi, et al., in 1998 showed that afterone month of training in yoga pranayamathere was a significant improvement inoxygen saturation and exercise perfor-mance in patients with chronic heart failure.Prakasamma and A. Bhaduri also showedthat patients with pleural effusion, whopractised prana-yama, demonstrated aquicker re-expansion of the lungs in mostof the measures of lung function.27

Chronic Illness in GeneralGoyeche has reviewed research high-lighting the ability of yoga to be of greatuse in chronic illness as a method ofrehabilitation.28 He cites studies on the useof yoga and meditation in cancer,headache, migraine, asthma, emphysema,sinusitis, ulcers, diabetes, gastro-intestinaldisorders, spondylosis, arthritis, and mentaldisorders, including anxiety anddepersonalization.

Herbert Benson and Goodale haveshown that meditation and the relaxationresponse is an effective treatment forphysical and emotional pre-menstrualsymptoms and is most effective in womenwith severe symptoms.29

Uma, et al., showed that yogademonstrated a highly significant improve-ment in IQ and social adaptation para-meters in a yogic group as compared tocontrols.30

Preventive and PromotiveMeasuresDr W. Selvamurthy reported the findings ofa study conducted by the Defence Instituteof Physiological and Allied Sciences of


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References

1. Satyananda Saraswati Swami. Asana Pranayama Mudra Bandha. Bihar School ofYoga. 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 ParamahamsaAlakh Bara. Deoghar. Bihar. India. 1993.

4. Datey K.K., et al. Shavasana: a yogic exercise in the management of hypentension.Angiology. 1969; 20 : 333.

5. Benson H. and Wallace R.K. Decreased blood pressure in hypertensive subjects whopractised meditation. Circulation. 1972; 46 & 45 (Suppl.II): 516.

6. Gopal K.S., et al. Effects of Yogasanas and pranayamas on blood pressure, pulse rateand 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 inmanagement of hypertension. Lancet. 1975; 2 (7925): 95.

8. Bagga O.P. and Gandhi A. A comparative study of the effect of Transcendental Meditationand 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. IndianHeart 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 andmyocardial infarction. Indian Heart. 1980; 22 (1): 1.

India. Over a period of six months, theyoga group sustained a low pulse rate(about 50–60 per minute), decreased rateof breathing and quicker adjustment toconditions of extreme cold on theHimalayan border, perhaps due to betterheat conservation in the body. Yogapractices were found helpful to tone upnon-shivering thermo genesis.31

Singh and Madhu conducted a studyon 20 male adults who underwent yogatraining for six months. The results revealedsignificant improvement in short-termmemory and steadiness.32 Barnes andNagarkar studied 40 students of StandardVIII (between the ages of 12–14 years) whowere provided four months’ yoga training.Results indicated an improvement inscholastic aptitude.33 Sridevi, Sitamma andRao found yoga promoted cognitiveabilities.34

A study conducted by Prof. L. I.Bhushan on 102 resident students of BiharYoga Bharati, Munger, indicated a decreasein levels of anxiety, depression, somati-zation, sensitivity, obsessive compulsivereaction, paranoid ideas, hostility, andpsychotism.35

Unpublished StudiesIn 1996, a study was carried out on 1150prisoners during a yoga trainingprogramme in 24 Bihar (India) prisons.Results included reductions in anxiety,depression, hostility and feelings ofrevenge, together with relief of variousphysical symptoms such as insomnia,arthritis and digestive problems. As a resultof the programme, the State Governmentof Bihar took a policy decision to introduceregular yoga training in all 82 state prisons.


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12. Jurek H.E., et al. Interaction of biofeedback-assisted relaxation and diuretic in treatmentof 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 thetreatment of coronary heart disease (abstract). Clinical Research.1979; 27: 720A.

14. Ornish D.M., et al. Can lifestyle changes reverse coronary atherosclerosis? TheLifestyle 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 performancein 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 thepractice 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 ofhatha 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 MotorSkills. 1978; 46: 171.

27. Prakasamma M. and Bhaduri M. A study of Yoga as a nursing intervention in the careof patients with pleural effusion. J. of Advanced Nursing. 1984; 9: 127.

28. Goyeche J.R.M. Yoga as therapy 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 mentallyretarded 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 bySivananda Math, Munger, India).

32. Singh V.A. and Madhu. A study of the effect of yogic practices on certain psychologicalparameters. Indian J. Clinical Psychology. 1987; 14: 80.

33. Barnes and Nagarkar S. Yoga education and scholastic achievement. Indian J. ClinicalPsychology. 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).

Policy issuesHarmonization of traditional and modernmedicine

Prof. Zhu-fan Xie

Role of traditional systems of medicine innational health care systems

Mrs. Shailaja Chandra

A framework for cost-benefit analysis oftraditional medicine and conventionalmedicine

Dr. G. Bodeker

Development of training programmes fortraditional medicine

Dr. Palitha AbeykoonDr. O. Akerele


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Harmonization of traditional and modern medicine

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different systems of traditional medicine,each nation having its own system/s. Someof these traditional systems are well-established, supported by theories and richexperience and recorded in writing, suchas the Indian system of Ayurveda, theMuslim system of Unani, traditionalChinese medicine, ancient Greek medicineand the systems that evolved from it, andthe humoral theory and therapy of LatinAmerica. But traditional medicine in someother parts of the world has merely beenpractised and handed down verbally fromgeneration to generation, without anywritten record. Whether sophisticated ornot, the systems of traditional medicineserved as the only means of health carefor ages, till modern biomedicine came intobeing.

In contrast to modern biomedicine,which was founded on the basis ofmodern natural sciences, most traditionalsystems of medicine originated in anddeveloped according to the principles ofancient schools of philosophy. Adescription of their characteristic featuresfollows.

Harmonization oftraditional and modernmedicine

Common features oftraditional medicine systems

Basic theories of varioustraditional systemsThere are similarities in the basic theoriesof various systems of traditional medicine.Ayurveda considers human beings in theirtotality, in their subtle relationship with theuniverse, and postulates the theory that ahuman being is a microcosm of theuniverse. Therefore, there is a closerelationship between the two. Ayurvedabelieves that the human body and all matterin the universe are made up of the five greatelements: earth, water, fire, air and ether.All the physiological processes in thehuman body and the pathogenesis ofvarious diseases can be explained by thethree doshas: motion (vata), energy (pitta)and inertia (kapha).(1) In ancient Greece,the authors of the Hippocratic Corpus allpresumed that bodily processes, health anddisease could be explained in the same wayas other natural phenomena. Accordingto the Hippocratic humoral system, allthings are composed of the four elements– fire, air, earth and water – and are formedby the union of matter, as well as the fourqualities of hot, cold, dry and moist. The

Zhu-fan Xie

The age-old wisdom of the people ofevery country has been crystallized into


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elements in the human body arerepresented by yellow bile (fire), black bile(earth) and phlegm (water), while air isdirectly supplied by respiration.2 The Unanisystem postulates the presence in thehuman body of four humours; blood,phlegm, yellow bile and black bile. Arkan(elements) forms the universe as well as thehuman body.3 Traditional Chinesemedicine regards qi as the basicconstituent element of the universe. Qiproduces everything, including humanbeings. Together with the five elements,wood, fire, earth, metal and water, with theircharacteristic properties and inter-relationships, qi explains the compositionand phenomena of the universe, as wellas the physiological and pathologicalprocesses of human beings. It is thus clearthat the various systems of traditionalmedicine view the human body and theuniverse as an integral whole.

Basic concepts of health anddiseaseIn Ayurveda, the body remains healthy solong as a balance is maintained betweenthe three invisible forces of vata, pitta andkapha, and disease results when they goout of balance.1 In ancient Greece,Hippocrates believed that good healthresulted from an equilibrium between thefour humours in the body, as well as fromharmony between the body and theenvironment. He regarded illness as someform of imbalance.2 In the Unani system,disease is regarded as an expression of animbalance of the humours or adisturbance in their harmony.3 Accordingto traditional Chinese medicine, goodhealth results from the maintenance of anormal dynamic balance between yin andyang within the human body, and betweenthe human being and circumstances. Ayin–yang imbalance gives rise to disease.

Yin and yang refer to the two fundamentalprinciples, ever opposing and comple-menting each other. Their ceaseless motiongives rise to all changes in the world,including in the spheres of physiology,pathology, diagnosis and treatment. Thedoctrine of the five elements further explainsthe inter-relationship of yin and yang.Therefore, the different systems oftraditional medicine are based on acommon dialectic way of thinking, andvarious parts or constituents of the bodyare viewed as an organic whole, with anemphasis on a balanced relationshipbetween them.

Correlation between the mindand bodyAyurveda considers the body, mind andsoul as complementary to each other. Allimbalance and disease in the body beginwith an imbalance or stress in theawareness, or consciousness, of theindividual. Therefore, mental techniquessuch as meditation are consideredessential to the promotion of healing andprevention.4 According to Hippocrates, themind and body profoundly affect eachother, and cannot be considered asindependent entities. Health consists of ahealthy mind in a healthy body, and it isalways necessary to consider the “whole”person while treating a patient. The basicphilosophy of Unani medicine is that thebody, composed of matter and spirit,should be taken as a whole becauseharmonious life is possible only when thereis a proper balance between the physicaland spiritual functions.3 In traditionalChinese medicine, mental activities andemotions are taken as functions of thecorresponding visceral organs: spirit isattributed to the heart, while excessive joyinjures the heart; soul is attributed to theliver, while anger injures the liver, and so


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on. Thus, mind and body, emotions andviscera, are parts of an integral whole.

No matter how diversified the varioussystems of traditional medicine in thespheres of diagnosis, treatment andmanagement of diseases and patients, theyhave a common viewpoint which may besummed up by the term holistic medicalmodel or holism.

Basic concepts of modernbiomedicine

In the Middle Ages in the West, thedomination of religion and feudalisticmonarchy greatly hampered the develop-ment of the natural sciences, andobstructed the progress of medicine. Thus,medieval medicine was shrouded in themists of theology.

Modern western medicine was firstestablished in the 18th century, during the“enlightenment” in Europe. The new naturalsciences created by Galileo, Descartes,Newton, Boyle and others no longerconceived of the world in terms of qualitiesand elements, but as consisting of particlesof measurable sizes, shapes and motion.Descartes saw the body as he saw the world,in mechanical terms. This new and influentialphilosophy was one that reduced biologicalprocesses to mechanical events.5

Closely related to mechanism isreductionism, which explains the propertiesof the whole entirely by the properties ofthe parts that compose it. In medicine,reductionism offers explanations in termsof physical, chemical and mechanicalprinciples. The biomedicine which thusevolved “considers biological entities moreor less as equal to the sum of theiranatomical parts and endeavours toelucidate molecular, physiological andpathological mechanisms believed to formthe basis of biological processes”.6

The achievements of the naturalsciences and the reductionisticapproaches, and the use of analyticalmethodologies, brought about a medicalrevolution in the West – medieval medicinewas transformed into scientific biomedicine.The revolution started with anatomy, whichexplored the precise structure of the humanbody. The microscope not only became anessential aid for anatomists, but alsofurthered pathological study from theorganic and histological levels to thecellular level. Progress in the physicalsciences inspired experimental investi-gations in physiology. Breakthroughs inchemistry, such as the study of energyconversion in the human body, also heldgreat promise for medicine. In the latterhalf of the 19th century, the “bacterio-logical revolution” clarified the truepathogens of many communicablediseases. Along with the advance ofanatomy, physiology, pathology andbacteriology, clinical medicine alsoprogressed, particularly in respect ofdiagnostics and surgical operations. A newsystem of medicine – modern biomedicine– was thus formed and developed in theWest. This system is different from thetraditional systems, not only in terms ofconcrete knowledge and practice, but alsowith respect to the underlying philosophicalviews.

Conflicts between traditionalmedicine and modernbiomedicine

Owing to the fact that traditional medicineand modern medicine evolved on the basisof different philosophical assumptions andwith different methodological approaches,conflicts are bound to arise when the twosystems are used simultaneously in thesame country or area. Different countries


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have found different ways of solving thisproblem, but since the People’s Republicof China seems to be one of the countriesthat has harmonized well the functioningof the two systems of medicine, thedevelopments which took place in Chinaare described as an example.

Modern biomedicine was introducedin China in the late 19th and early 20thcenturies. At this juncture, China felt theurgent need to firmly establish and assertits national identity, and to gaincompetence in various spheres. In additionto the need for new political andtechnological initiatives, the issue of healthand medicine also came to the forefront.Particularly after the Revolution of 1911,many intellectuals who were frustrated byChina’s failure to forge ahead began tore-evaluate the country’s traditional culturein the light of what they perceived to be thekey to the success of the West – modernscience. A Descartian faith in the potentialof science to solve mankind’s problems ledthem to embrace Western biomedicine. Atthe same time, they denounced traditionalpractices as defunct remnants of the oldorder. These, they felt, were impedingChina’s modernization. They blastedtraditional physicians for being ignorantand irrational, and condemned their systemof medicine as an amalgam of supersti-tions incompatible with scientific progress.7In 1929, the Central Government passeda Bill “to ban traditional medicine in orderto clear the way for developing medicalwork”.

However, in spite of the persecution itsuffered, traditional Chinese medicine hasnever been eliminated, nor replaced bymodern biomedicine. First, most Chinesepeople continued to believe in traditionalmedicine, not so much because of theircultural background, but more because ofthe benefits that they, their family members

and acquaintances had experienced byusing traditional methods of treatment.Second, traditional remedies were simple,convenient and affordable, and had fewerside-effects. Modern biomedicine, on theother hand, often necessitated surgicalprocedures, which could cause pain andresult in complications. Third, the uniquephilosophy underlying traditional medicinewas well-received by the common people,and had no satisfactory parallel in modernbiomedicine. Traditional medicine had aunique theoretical system which was well-received by the common people and couldnot be replaced by modern biomedicine.Some of the traditional medical expressionsand terminologies had already beenabsorbed into the language of the commonpeople. Last but not the least, medicalprofessionals well-trained in modernWestern biomedicine were to be found onlyin some big cities. With the ban ontraditional medicine, the vast majority ofthe Chinese population had no access tohealth care of any kind. This scenario gaverise to a bitter conflict between thetraditional practitioner and the moderndoctor, as well as between the commonpeople and the Government.

It was only after the founding of thePeople’s Republic of China in 1949 thatattempts began to be made to revivetraditional Chinese medicine, and toharmonize it with modern medicine.

Policies to harmonizetraditional and modernmedicine

To begin with, the Chinese Governmentformulated official policies to protect anddevelop traditional medicine. In 1950, itstipulated “uniting the traditional Chineseand modern western medical profe-ssionals” as one of the guiding principles


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of health work. A major reason for this wasthat traditional medicine had been of greatbenefit to the Chinese population,especially the common people, who lovedand endorsed the system. Also, accordingto the statistics of 1949, the totalpopulation of mainland China was 5.4hundred million, while the number ofdoctors formally trained in modernWestern medicine was only 38,875, i.e.,the ratio between these doctors and thepopulation was approximately 1:14,000.8The situation in rural areas was muchworse, with most of the trained moderndoctors concentrated in the big cities. Ofall the practitioners of either system, themajority (about 80 per cent) were trainedin traditional medicine.

The Constitution promulgated in 1982and the present Constitution declared thatthe State should “develop both modernmedicine and traditional medicine”. Thus,the Chinese Government has clearly putboth systems of medicine at par, and“realizing modernization and globalizationof traditional Chinese medicine” is seen asa task of primary importance. TheConstitution advocates that “traditionalChinese medicine and Western medicineshould unite and learn from each other,mutually complement each other andimprove together, in order to promote theintegration of traditional Chinese andwestern medicine”.9

Besides the official policies, the remarksmade by the leaders of China have had agreat impact on the development oftraditional medicine and its harmonizationwith modern medicine. In 1958, MaoZedong declared that “traditional Chinesemedicine is a great treasure-house, andefforts should be made to explore and raiseit to a higher level”. He called uponWestern-trained doctors to learn traditionalChinese medicine and hoped that some

brilliant theorists would emerge through theintegration of both systems. In 1978, DengXiaoping requested governments at all levelsto “provide good and favourableconditions for the development andimprovement of Chinese medicine”. Thepresent leader, Jiang Zemin, has empha-sized that practitioners of traditional andWestern medicine should strive for greaterunity still, and learn from and complementeach other so as to promote integration ofthe two systems.9

The Government has adopted a seriesof measures for the implementation of itspolicies. These include the establishmentof administrative bodies at the central andlocal levels for the execution of policy,exploitation of human resources,development of related academic organi-zations and publications, gathering andsummarizing of the knowledge ofexperienced traditional medical doctors,and setting up of institutions for clinicalpractice, education and research (both fortraditional and integrated medicine). Oneof the most powerful organizations for theimplementation of these policies is therelatively independent State Administrationof Traditional Chinese Medicine, whichprovides protection to traditionalmedicine.10

Incorporation of traditionalmedicine in modern hospitals

The first step adopted by the Governmentin the 1950s for the purpose of “unitingthe traditional Chinese and modernWestern medical professionals” was theincorporation of traditional medical doctorsinto the staff of hospitals of modernmedicine, as well as the establishment ofhospitals of traditional Chinese medicine(TCM). Doctors in ancient China used tosee outpatients only in clinics or in the


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patients’ homes. There were no institutionsfor in-patients. Hospitals began to be setup in the early 20th century, once modernWestern medicine was imported intoChina, but working in these hospitals wasthe privilege of Western-trained medicalprofessionals. By 1950, the word“hospital” had been defined in China asan institution providing modern Westernmedical and surgical treatment, andnursing care. To remedy this situation, TCMdepartments were established in mosthospitals. This made matters easier forpatients referred to traditional medicinepractitioners. In some hospitals orspecialized departments, TCM doctorswere appointed directly as staff membersin the departments of Western medicine,thus creating improved opportunities forthe exchange of ideas and cooperationbetween doctors of both systems.

This step seemed to facilitatecollaboration between doctors of the twosystems. Practitioners of modern medicinebecame particularly interested in traditionalmethods of treatment when the lattersucceeded where modern methods hadfailed. On the other hand, the TCM doctorsalso required a modicum of knowledge ofWestern medicine, in order to functioneffectively in a set-up run on modern lines.Many hospitals of Western medicine stillhave a department of traditional medicine,

Table 1. Increase in number of TCM hospitals, beds and researchinstitutions in China since the 1950s(11)

1952 1957 1963 1975 1980 1985 1990 1995

Number of 19 257 124 160 647 1414 2037 2371TCM hospitalsNumber of 224 5684 9254 13 675 49 151 101 418 160 899 206 812beds in TCMhospitalsNumber of – 16 33 29 47 54 55 65TCM researchinstitutions

even though several hospitals devotedexclusively to TCM have been set up.

Establishment of TCMhospitals

Advantages aside, the inclusion ofpractitioners of traditional medicine inhospitals had certain limitations. Thesedoctors were always in a minority, and thepatients referred to them were often thosewhom modern methods of treatment hadfailed to help. Thus, their role becamelargely limited to such cases and they werenot in the mainstream of hospital services.In order to allow them greater initiative,and also to provide training bases forstudents of traditional medicine, TCMhospitals were established. The number ofTCM hospitals and beds has been growingrapidly (Table 1). In 1997, there were10,789 general hospitals of Westernmedicine with 1,485,625 beds, and 2424TCM hospitals with 223,696 beds. Theratios between the number of the two typesof hospitals and the number of bedsallotted to each were roughly 1:4.5 and1:6.5, respectively.11 (It should be notedthat at present, general hospitals ofWestern medicine in China are simplycalled general hospitals because none ofthem is exclusively devoted to Westernmedicine.)


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The difference between the two typesof hospitals lies chiefly in the methods oftreatment. Generally speaking, TCMhospitals are equipped with facilities formodern laboratory diagnosis andemergency treatment. Therefore, the staffof these hospitals also includes a fewprofessionals trained in modern Westernmedicine. Some Western-trained doctorsprefer to shift to TCM hospitals.

The establishment of TCM hospitalshas played an important role in theharmonization of traditional and modernmedicine. The earlier conflict between thetwo systems had found expression not onlyin the contempt in which the practitionersof modern medicine held the “unscientific”practices of traditional medicine, but alsoin the traditional medical practitioners’exaggeration of the helplessness ofmodern Western medicine in the treatmentof chronic diseases. While the TCM doctorswere not as virulent as their rivals, they, too,needed to compromise. In TCM hospitals,modern Western medical professionalsproved the value of their work either bycarrying out laboratory tests for diagnosisor by the emergency treatment of a chroniccase. Harmonization between the twomedical systems is possible only if theybegin to respect each other.

Confirmation of the efficacyof traditional medicine

Traditional Chinese medicine has abrilliant history, but whether it is still ofpractical value depends upon itsadvantages over modern biomedicine,particularly as far as its efficacy isconcerned. Traditional literature containsnumerous case reports of successfultreatment of various diseases, but thediseases were not diagnosed, observed orrecorded in a modern, scientific way.

Moreover, in most cases the methods oftreatment were highly individualized andvaried from person to person. Therefore,it is difficult to convince modern-trainedmedical doctors to believe in theeffectiveness of traditional medicines. Afterthe inclusion of traditional medicalpractitioners in hospitals of modernmedicine and the establishment of TCMhospitals, it became possible to carry outcomparative clinical trials. At first, thediseases studied were those that weredifficult to cure with modern Westernmedicine, such as chronic nephritis,chronic hepatitis and chronic gastritis.Traditional treatment for these diseasesoften achieved better results thancontemporary Western treatment. Themost convincing evidence came from anepidemic of encephalitis B which broke outin the early 1950s in northern China. Inthose days, modern medicine could dolittle to help encephalitis patients, andcould barely provide even symptomaticrelief from the high fever. Traditionaltreatment, however, cured a large numberof serious patients and reduced the fatalityconsiderably. In the mid-1950s,traditional treatment of haemorrhoidsmade a strong impression on modern-trained surgeons. Traditional necrotizingtherapy for haemorrhoids and ligationtherapy for anal fistulae succeeded incuring more than 90 per cent of patients.Moreover, recovery was quicker andthere was less suffering than with modernsurgery. The treatments were well-received by the patients. By the end ofthe 1950s, the analgesic effect ofacupuncture was acknowledged by alland acupuncture analgesia wassuccessfully used for tooth extraction andtonsillectomy. In the 1960s, modernmedical circles came to acknowledge thebenefits of herbal treatment for diphtheria


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and conservative treatment for ectopicpregnancy with herbal medication toremove stagnant blood. In addition, aherbal homeostatic formula that hadbeen developed, as well as couching incataract operation were seen to achievevery good results.12 Most of these clinicalstudies were carried out on largesamples, at first jointly by traditional andmodern medical practitioners and, later,by traditional and integrated medicalpractitioners. Therefore, modern medicalcircles were convinced by the results.There are many more diseases in whichtraditional treatment has been proved tobe effective. In daily clinical practice,traditional medicine has been shown tobe effective in the treatment of manycommon diseases, as assessed bymodern criteria of diagnosis and efficacyevaluation.

Reform of educational systemof traditional medicine

Historical review of TCMeducationTraining of TCM professionals is of utmostimportance in the development of thissystem of medicine. In ancient China, most

practitioners learned through apprentice-ship. In most cases, knowledge was handeddown from one generation to the nextwithin the family. Although TCM couldboast of the earliest teaching institutions,these institutions imparted training mainlyto the court physicians of the imperialfamily and to high-ranking physicians inthe service of feudal nobles and officials.

As early as the fifth century, the TangDynasty set up a central institution calledthe “Imperial Medical Bureau”, whichserved both as a medical school and as aclinic. It had four departments: medicine,acupuncture, massage (includingtraumatology) and incantation. Thedepartment of medicine consisted of thespecialities of internal medicine, paedia-trics, sores and ulcers, diseases of the ears,eyes, mouth and teeth, and cupping. Theduration of training varied according to thespeciality. For example, the training periodfor general medicine was seven years,paediatrics five years and cupping threeyears. Other than the Imperial MedicalBureau some prefectures had their ownmedical educational institutions.

The succeeding dynasties developedmedical education further. For example,during the reign of the Song Dynasty (960–1279), the Imperial Medical Bureaubecame a purely educational institution,consisting of nine departments: internalmedicine, stroke, paediatrics, sores andulcers (including bone fractures), obstetrics,eye diseases, diseases of the mouth, teethand throat, acupuncture, and incisedwounds. A professor was appointed foreach department and the teachers weregiven the title of “doctor of medicine”. Theinstitution admitted 300 students annuallythrough an entrance examination. Besidesthe Imperial Medical Bureau, which wasthe premier institution, medical schoolswere set up by the local governments.13

Chiropractic treatment is commonly used for curing infantilemalnutrition (Courtesy Prof. Chen Gui-ting)



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After the early 20th century, once therule of the feudal dynasties came to an end,this education system stopped operating.This had little impact on the health servicesavailable to the common people, as mostof the practitioners they consulted weretrained in the master–apprentice style, orhad learnt from their family members orelders. The latter type of practitioner washeld in high esteem by the people. Therewere other practitioners who studiedmedicine on their own. These includedliterati who had failed the imperialexamination for officialdom, or shifted theirinterest from the management of stateaffairs to the management of diseases. Thelarge volume of medical literature was ofgreat use to those who wanted to teachthemselves. According to the cataloguecompiled jointly by the China Academy ofTraditional Chinese Medicine and thePeking National Library, the number ofmedical works collected before 1959 was7661.14 Most of them were written in theclassical literary style, which ordinarypeople could not follow easily, but theliterati could. Since the Chinese literati wereConfucian scholars, those who practisedmedicine were also called Confucianphysicians.

In the 19th century, modern Westernmedicine was introduced into China,posing a serious challenge to TCM,including the TCM educational systems.Private medical schools of TCM, run byfamous physicians, began to appear by theend of the 19th century. The schools ofWestern medicine – initially the missionarymedical schools, and later public andprivate medical schools – soon surpassedthe TCM schools, both in number and inscale. In the late 1940s, TCM schools wereon the verge of extinction.

Establishment of colleges anduniversities of traditionalmedicineAfter the founding of new China in 1949,in order to implement the new policy ofdeveloping traditional medicine, it wasurgently felt that the educational system forTCM should be promoted to a higher level.In 1956, four TCM colleges were esta-blished in Beijing, Shanghai, Guangzhouand Chendu, four big cities situated in thenorthern, southern, eastern and westernregions of China. Since then, a regularhigher educational system has beendeveloped for the training of traditionalmedical personnel. The single-mindeddevotion of the Government resulted in therapid expansion of the number of TCMcolleges, which increased from five in 1957to 30 in 1995. The number of studentsenrolled increased from 1021 in 1957 to39,786 in 1995 (Table 2). Furthermore,since the late 1990s, some TCM collegeshave been promoted to university level. Theduration of training has been extended toseven years for the specialty of generalmedicine, and five years each foracupuncture and traditional healthprotection and rehabilitation. It should benoted that China’s traditional medicine isnot limited to the traditional medicine ofthe Han nationality; it also includes thetraditional systems of medicine of minoritynationalities, such as Tibetan medicine.Among the traditional medical colleges,one is a college of minority medicine.Parallel to the growth of colleges anduniversities, secondary schools of TCM werealso established, and there has been asteady increase both in the number ofschools and of students enrolled. Otherthan the regular schools, correspondenceschools have also been started forparamedical professionals to give them theopportunity of receiving practical training.


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In 1978, a programme of post-graduate study was introduced in thetraditional medical colleges and univer-sities. A Master’s degree is granted to thosewho have studied for three years aftergraduation and passed the examinationsand completed the required academicpaper. A doctorate (Ph.D.) is issued to thosewho have studied for another two yearsafter obtaining the Master’s degree andcompleted a high-level academic paper.This postgraduate educational system isexactly the same as that beingimplemented for modern medicine.

Modern apprenticeshipIn the past, apprenticeship was a uniqueway of teaching Chinese medicine. It hascertain advantages even now, as Chinesemedicine is not simply a branch of science,but includes a large component of art andskill which are better learnt as anapprentice practising under the directguidance of, or together with, the master.Therefore, the system of apprenticeship wasencouraged for a few years after 1949.Apprenticeship with experienced traditionalpractitioners allowed one to practise after

passing the requisite examinations. In the1990s, a special form of apprenticeshipwas adopted for training and groomingsuccessors to famous physicians andpharmacists. Licensed practitioners andpharmacists with formal college oruniversity qualifications were selected toserve with famous traditional physiciansand pharmacists for an effective period ofthree years. This form of training hasproved to be particularly suitable forlearning certain special skills andtechniques that could hardly be describedin words.

Compilation of standardtextbooksTraditional Chinese medicine isdistinguished by the vast amount ofliterature on it. Many books were used astextbooks in different historical periods, butmost of them could be used only asreferences. As they were no longer suitablefor teaching in the 20th century and inorder to improve the quality of training, theMinistry of Health had a set of standardtextbooks compiled for TCM colleges.These were published in 1958 and have

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

Table 2. Increase in number of TCM colleges and universities andnumber 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 enrolleduniversities

1957 37 5 13.5 49 107 1021* 2.11965 92 21 22.8 82 861 10 155* 12.31975 88 17 19.3 86 336 13 538* 15.71980 109 22 20.2 139 569 25 282* 18.11985 116 24 20.7 157 388 28 450* 18.11990 122 31 25.4 201 789 34 048* 16.91995 126 30 23.8 256 003 39 786* 15.5


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been revised five times since then. The last(sixth) edition, which consisted of 32textbooks for various specialties oftraditional medicine (general medicine,herbology, pharmaceutics, acupunctureand moxibustion, and orthopaedics andtraumatology), was completed in 1994–1995. Besides the 32 TCM textbooks, thestandard textbooks for TCM collegesinclude another six textbooks on modernWestern medicine, one each for anatomy,physiology, pathology, biochemistry, thefundamentals of diagnosis, and internalmedicine. These courses are offered not onlyto train the TCM graduates for their futurepractice, but also to facilitate the exchangeof ideas between them and medicalprofessionals trained in modern Westernmedicine, thus facilitating the harmonizationof the two systems of medicine.

A large number of traditional medicalpractitioners have now been trained.According to official statistics, the numberof qualified medical doctors in mainlandChina in 1998 was 2,724,670, 9.38 percent (255,641) of whom were traditionalmedical doctors and 0.41 per cent(11,077) integrated medical doctors. Thenumber of practitioners with secondarymedical education was 1,235,212, ofwhom 5.67 per cent (70,085) weretraditional practitioners.15 Thus, anappropriate and adequate number oftraditional medical professionals have beentrained to meet the people’s health careneeds.

Establishment of the legalstatus of traditional medicine

In implementing the policy of placing bothtraditional and western medicine on anequal footing, various issues need to beconsidered, particularly those of legitimacyand economics. The former deals chiefly

with the legal status of traditional medicalpractice and the licensing system fortraditional medical professionals. In China,traditional medical practice is officiallyrecognized as being equivalent to modernWestern medicine. Since in traditionalpractice the diagnosis is often made in adifferent way from that in modern Westernmedicine, a national standard entitled“Classification and Coding of Diseases andSyndromes in TCM”, as well as criteria fordiagnosis and efficacy evaluation werepromulgated in the 1990s. This has furtherstrengthened the legal basis of traditionalmedical practice.

In order to guarantee the competenceof traditional medical professionals, alicensing and accreditation system similarto the one that applies to Western medicalprofessionals has been adopted. Thesystem of promotion for medical profe-ssionals of both schools is the same. Thereare four ranks of medical doctors: resident,physician/surgeon-in-charge, vice-chiefphysician/surgeon and chief physician/surgeon. The salary of each rank is thesame in the case of both schools. Otherremuneration paid according to the qualityand quantity of medical practice may varyfrom individual to individual, but thesedifferences have nothing to do with theparticular system of medicine beingpractised. A hard-working, experiencedphysician of traditional medicine is usuallypaid just as much, if not more, than hisWestern medicine counterpart.

Getting Western-traineddoctors to study traditionalmedicine

All the measures mentioned so far havebeen of great help in harmonizingtraditional and modern medicine, but realharmonization involves two important


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issues. These are the modernization oftraditional medicine, and the integration oftraditional and modern medicine. There isa large overlap between the two, but theyare different theoretically. Modernization oftraditional medicine refers to the appli-cation of modern scientific theories,knowledge and methodologies in the studyof TCM, as well as the adoption of modernscience and technology to develop TCM. Inthis way, it would not only contain distinctiveChinese features, but also be relevant inmodern scientific terms. Integration ofChinese and Western medicine involvesdiscovering the common points betweenthe theories of the two systems, a processof mutual learning so that each can benefitthe other, and combining the best elementsof the two systems so as to establish a newsystem of medicine.

Both for modernization of traditionalmedicine and integration of the twosystems, it is essential for traditional medicalpractitioners to learn modern medicine,and for Western-trained doctors to learntraditional medicine. Measures to facilitateboth were taken in the 1950s, but it wasthe latter that seemed to work moreefficiently. While summarizing thisexperience, the former Chairman of theChinese Government, Mao Zedong,lauded the efforts in this direction andcalled on more Western-trained doctors todevote themselves to the integration of thetwo systems. Since then, many types ofcourses have been started to help Western-trained doctors learn traditional medicine.Moreover, research institutes for integratingthe two systems, as well as integratedhospitals and clinics, have been set up forWestern-trained doctors who wish to carryout research and practices in integratedmedicine on completing the courses. Atpresent, there are about 12,000 high-ranking “integrated” medical doctors. They

have not only contributed to the progressin many areas of medicine, but have alsobeen playing a particularly important rolein encouraging cooperation and harmoni-zation between practitioners of the twosystems. Broadly speaking, their achieve-ments have been in the following areas.

Proposal of modern scientificexplanation for traditionalmedical theoriesIt is mainly the unique theories underlyingTCM that make it so difficult to understand.Some of these are actually ancient Chinesephilosophical ideas, which, though ratherquaint, are not disconsonant with modernperspectives. Some other theories, however,such as the concept of visceral organs, aremisleading. While the anatomicaldescription and names of these organscorrespond to those in modern Westernmedicine, the physiological and patho-physiological expositions on them are sodifferent from modern concepts that theycast doubts on the correctness of TCM.Extensive studies carried out by the“integrated” doctors have revealed thateach visceral organ in TCM is actuallyviewed as a comprehensive functionalsystem rather than an individual internalorgan. Also, greater emphasis is laid onthe inter-relationships among the functionalsystems than on the consideration ofindividual organs. For example, the wordkidney in TCM signifies far more than anorgan of the urinary system; besides urinesecretion, the kidneys are believed to be incharge of the endocrine function(particularly the function of the hypotha-lamic–p i tu i ta ry–adrenocor t i ca l ,hypothalamic–pituitary–gonad andhypothalamic–pituitary–thyroid axes),myeloid haemopoiesis, bone metabolism,and a few brain activities. That is whykidney tonics are considered to be effective


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in the treatment of many disorders besidesrenal diseases, such as in aplastic anaemia,osteoporosis, the menopausal syndrome,anovulatory menstrual disorders, sexualdisturbances and certain geriatric diseases.

Why these seemingly unrelatedfunctional activities are lumped together inone group is difficult to explain in terms ofmodern physiology and pathology.However, research using sophisticatedtechniques and knowledge of molecularbiology and genetics has found a rationalbasis for these traditional Chineseconcepts. Similarities have been found inthe abnormal changes occurring in thevarious diseases clubbed into one category,and the changes have been successfullyremedied with the administration of herbalformulae according to this theory.

Discovering advantages oftraditional medicine throughcomparison with modernWestern medicineWhile modern Western medicine has maderapid strides, particularly in the 20thcentury, TCM evolved many centuries ago.Whether the latter still has advantages overmodern Western medicine is a question thatis widely debated. It is the doctors proficientin both traditional and modern medicinewho are best qualified to answer this.Comparative clinical and experimentalstudies have revealed the advantages oftraditional treatment in many diseases orconditions. In many instances, traditionaltreatment is more effective and has fewerside-effects. It is also more affordable thanmodern Western treatment. Acupunctureanalgesia is a good example. The analgesiceffect of acupuncture is comparable withthat of morphine or meperidine and, at thesame time, the process has minimal side-effects and no addiction-inducingproperties. It is hence recommended for

the treatment of various painful conditions,as long as it does not interfere with thetreatment of the primary lesions.

Modern Western medicine still finds itdifficult to treat viral diseases, and interferonis of limited clinical use in China due to itshigh cost and side-effects. However,controlled clinical studies have shownmany medicinal herbs and herbal formulaeto be effective in the treatment of viraldiseases such as influenza, viral hepatitis,viral myocarditis and epidemic haemo-rrhagic fever. Some herbal ingredients usedfor treatment have also been demonstratedto have antiviral effects in laboratoryexperiments.

Combined treatment withsuperior resultsBoth modern and traditional medicine havetheir own strong points. It is but natural tospeculate that a combination of their strongpoints may lead to better results.Comparing the traditional and moderntreatment of bone fracture, Chineseorthopaedic surgeons found that while theuse of modern technology and methodo-logy had many advantages, traditionaltreatment, too, had its own advantages: itoften achieved more rapid union. Furtherstudies revealed that the traditionalapproach advised only relative fixation, withappropriate compression and stress on thesite of fracture, following manipulativereduction and timely functional exercise.They, therefore, designed a new methodof treatment based on the principle ofcombining mobilization with immobili-zation, instead of extensive immobilizationand complete rest. This method has resultedin a marked reduction in the period forclinical union and has minimized thecomplications of fracture treatment.

The treatment of cancer poses a majorproblem to modern medicine and the


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possibility of recurrence is often noteliminated even after resection of thetumour. As for traditional treatment, anumber of medicinal herbs have beenfound to be cytotoxic, but clinical trials haveshown them to be either less potent thanmodern chemotherapeutic agents or tocause similar side-effects. However, thetonics used by traditional medicalpractitioners have the effect of improvingthe patient’s general condition. Recentresearch has shown that most of thesetonics enhance the host’s immunity. Theycannot inhibit the growth of the canceronce the tumour has already become largeand the antigens from the cancer cells havecrippled the host’s immune response.However, they help prevent recurrence afterremoval of the tumour, and are also usefulin preventing the formation of tumours inthe precancerous stage. In addition, bothacupuncture and herbal medication cangive considerable relief from the toxiceffects and side-effects of modernchemotherapy. Therefore, a combinedprogramme of traditional and moderntreatment is often adopted. Herbalmedication is used to aid convalescenceafter surgery. This is followed by acupun-cture and/or herbal treatment to providerelief from the toxic effects and side-effectsof chemotherapy, and the administrationof tonics and other measures to improvegeneral health and promote immunity soas to prevent relapse.

Education of TCM students inmodern sciencesThe harmonization of traditional andmodern medicine requires efforts on thepart of both medical systems. In the1950s, however, the focus was on the needto promote traditional medicine byestablishing formal educational institutionsthat would provide regular training in TCM

and produce qualified traditional medicaldoctors. Although the curriculum includedsome courses in modern Western medicine,these merely served the purpose offacilitating communication with Western-trained doctors, or for proper transfer ofpatients for receiving modern Westerntreatment. Even with an increase in teachinghours devoted to the modern sciences, thegraduates still faced difficulties in practisingintegrated medicine or in truly modernizingtraditional medicine. After all, bothmodernization of traditional medicine andintegration of the two systems required, andstill require, scientific research. Since thesetting up of the postgraduate educationalsystem in 1978, a conside-rable numberof research fellows have been trained.Many of them have been engaged in themodernization of traditional medicine,which concerns mainly the following issues:(1) Technical innovation in the diagnostic

methods of the system, especially theformulation of objective criteria andquantitative measurement ofsymptoms and signs, for example,objective recording and quantitativeanalysis of pulse conditions (asassessed in the traditional system), andcolorimetric assessment of the tongueand its coating.

(2) Investigation of the pathophysiologicalchanges in the disease patternsidentified by traditional medicine, andthe systematization of traditionaldiagnosis and treatment by means ofmodern scientific methods, forexample, immunological studies indifferent types of deficiency and theirtreatment with the appropriate tonics.

(3) Improvement of traditional therapeuticmeasures and techniques, particularlythe emergency treatment of seriouscases, to enhance their efficacy, forexample, the traditional treatment of


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toxic shock in severe infections, andresuscitation of patients in coma.

(4) Development of new preparations oftraditional drugs to make theiradministration more convenient,acceptable and efficient, for example,the manufacture of some herbalformulae in the form of aerosols andinjections.

(5) Creating a database from theexperience of experts in traditionaldiagnosis and treatment of certaindiseases, for example, patternidentification and herbal medication inpatients with viral hepatitis.

Development of researchTraditional medicine, an age-old heritageculled from years of experience, is bound tocontain some valuable elements butinevitably it also contains some aspectswhich are no longer useful. It is thereforenecessary to carry out scientific research inorder to separate the grain from the chaff,and to develop and improve the usefulelements.

In the late 1950s, the ChineseGovernment began establishing researchinstitutes with a view to facilitating theexploration of the real value of traditionalmedicine and developing it further. Overthe years, there has been an increase notonly in the number of personnel trained intraditional medicine, but also in that ofresearch institutions (Table 1). In the1950s, most of the results regarding theefficacy of traditional medicine wereobtained from hospitals, both of Westernmedicine (with the cooperation of traditionalmedical doctors) and TCM. Later, however,research began to be conducted mainly atresearch institutions. Moreover, to facilitatethe exchange of information amongresearchers, two national organizations,the China Association of Traditional

Chinese Medicine and Pharmacy, and theChinese Association of the Integration ofTraditional and Western Medicine, were setup in the late 1970s and early 1980s. Theformer sponsors the Journal of TraditionalChinese Medicine, and the latter theChinese Journal of Modern Developmentsin Traditional Medicine (later renamedChinese Journal of Integrated Traditionaland Western Medicine). Both journals arepublished in Chinese as well as English.Besides these two leading journals, thereare dozens of other journals in the fields oftraditional as well as integrated medicine.

The work of researchers in theseresearch institutions is no longer confinedto determining the efficacy of traditionalmedicine. They also study the followingaspects: (i) The elucidation of the basictheories of traditional medicine, such as thetheory of yin–yang and qi, the uniquedoctrine regarding the physiology andpathophysiology of the internal organs(called “visceral manifestations” in TCM),and the theory of the meridian system,(ii) the rationale behind the differentiationof disease patterns and the identificationof syndromes, which are based on aunique, holistic approach, and (iii) themechanisms of traditional therapies, andpharmaco-logical studies of individualmedicinal herbs and compound formulae.In brief, the research addresses not onlythe issue of whether traditional treatmentworks but also of how and why it works.

Since the late 1970s such research hasprogressed through the collaboration oftraditional, Western and “integrated”doctors, who may be working in hospitals,medical colleges, universities or researchinstitutions of either traditional or modernmedicine.16 The following examplesillustrate this.

A concept unique to traditionalmedicine is that of “blood stasis”. This not


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only refers to venous congestion but alsoincludes all kinds of pathological conditionsrelated to stagnant blood in the body. Itmay occur locally or generally, and withinor outside the vessels. Clinically, a series ofdiseases can be diagnosed as “bloodstasis” and successfully treated with“blood-activating stasis-removing” therapy.From the Western medical perspective, thediseases related to this concept wouldinclude coronary heart disease, ischaemiccerebrovascular disease, thromboangiitisobliterans, chronic obstructive lungdisease, chronic hepatitis, liver cirrhosis,scleroderma, ectopic pregnancy, and otherdiseases and traumatic conditionscharacterized by impeded bloodcirculation. Clinical observations demons-trated that most patients with thesediseases had manifestations of “bloodstasis” as described by traditional medicine,and that herbal formulae could besuccessfully used to activate the circulationof blood and remove stasis. Further studiesrevealed that patients with these diseasesdid have common pathological features:haemodynamic and microcirculatorydisturbances, haematological abnorma-lities, immunological changes, anddisorders of connective tissue metabolism.Experimental research, including pharma-cological studies, has been able to explainthe mechanism of the therapeutic effects.

Animal models of diseases related to bloodstasis showed microcirculatory and/orhaemodynamic disturbances and haema-tological abnormalities, which wereameliorated together. These animals weretreated with blood-activating and stasis-removing herbs, which resulted in distinctimprovements in their condition. Most ofthe herbs used for activating the circulationof blood and removing stasis have the effectof improving the micro-circulation, dilatingthe blood vessels and rectifying therheological characters of the blood. Inother animal experiments, a number ofthese herbs have been shown to beimmunosuppressive and/or effective innormalizing connective tissue metabolism.These data not only explain the curativemechanisms of blood-activating and stasis-removing therapy but also expand theclinical indications of this therapy. Besidesthe diseases already mentioned, variousautoimmune diseases (such as systemiclupus erythematosus, rheumatoid arthritis,chronic glomerulonephritis), cicatricialdiseases (such as keloids, postoperativeadhesion of the small intestine), andgynaecological conditions (such asendometriosis, inflammatory pelvic mass)are presently often treated with herbs meantto activate the circulation and removestasis. This therapy has also been reportedto be useful in the treatment of dissemi-nated intravascular coagulation in seriousinfections. Moreover, extensive studies havebeen conducted to identify the activecomponents of some of the most frequentlyused herbs of this category. New dosageforms have been produced, e.g.,ligustrazine injection (derived from therhizome of Ligustecum chuanxiong) forintravenous administration in the treatmentof ischaemic cardiovascular and cerebro-vascular diseases, and compounddanshen pills (derived mainly from the root

New dosage forms have beenproduced, for intravenous

administration in the treatmentof ischaemic cardiovascular andcerebrovascular diseases, and

compound danshen pills for oralor sublingual administration to

relieve angina pectoris.


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and rhizome of Salvia miltiorrhiza) for oralor sublingual administration to relieveangina pectoris. These can be easily usedby Western-trained medical professionals,and have become a part of the routinetreatment prescribed by them. As for thetraditional practitioners, they wereunfamiliar with most of the diseases listedabove, at least in terms of the Western viewson the pathogenesis and diagnosticcriteria. Research has inspired them to keepabreast of the relevant informationuncovered by modern Western medicine.

It is difficult to classify the intravenousdrip of ligustrazine for ischaemic cerebro-vascular disease and the sublingualadministration of compound danshen pillsfor angina pectoris as either traditionalChinese therapies or modern Westerntherapies. However, doctors of bothsystems are now using these as routinetreatment. They are often called “integratedtherapies” since they have originated fromtraditional medicine and been modified bythe modern approach.

The successful application ofacupuncture for anaesthetic purposes insurgery shook not only China but the entireworld. Needless to say, it aroused the keeninterest of researchers everywhere.Research was carried out on two mainaspects: (i) The clinical aspect, includingevaluation of the efficacy of the technique,its improvement, and determination of theindications, and (ii) The laboratory aspect,including the mechanisms by whichacupuncture provides relief from pain. Thelatter stimulated the study of pain and pain-relief, particularly among the modernmedical community of China, as well as insome other countries. These studiesresulted in the discovery of endorphins andrelated substances, the release of whichduring the process of acupuncture relievespain. However, the studies have not been

able to answer the basic question as to whythese pain-killing substances are producedin the body.

Acupuncture is effective in thetreatment of a number of disorders otherthan pain, particularly functional disordersmarked either by hyperfunction orhypofunction. For example, it helps inlowering the blood pressure in hypertensionand elevates it in hypotension. It is usefulin relieving retention and helps inincontinence of urine. Acupuncture is alsobeneficial for patients with muscle spasmand nerve paralysis. Clinical observationsand experimental studies have revealed theregulatory mechanism of acupuncturetreatment. In fact, its analgesic effect canbe attributed to its regulatory mechanism.Yet another category of disease that canbe treated by acupuncture is infections.Although acupuncture is seldom used forthis purpose now, the results it can achieveare of great academic significance. Clinicaland experimental studies have confirmedthe therapeutic effect of acupuncture in thetreatment of bacillary dysentery andmalaria. Controlled clinical trials haverepeatedly shown that the effect ofacupuncture in bacillary dysentery iscomparable to that of furazolidine, and thatthe mechanism involved is the enhance-ment of the patients’ immune function.

Another example is the research on“tonification”. One of the characteristicfeatures of traditional diagnosis is todetermine the confrontation between theantipathogenic capability of the humanbody and pathogenic factors. The formerincludes all kinds of functional activities andthe substances required for fighting thesepathogenic factors, as well as formaintaining good health. Whenever theantipathogenic capability is insufficient toovercome the pathogenic factor, illnessensues. Therefore, all illnesses can be


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classified into two main categories:(i) Those caused by lowered antipathogeniccapability, called “deficiency” conditions,and (ii) Those caused by excessivepathogenic factors, called “excess”conditions. The former are treated by theprinciple of “tonification”, i.e., the adminis-tration of various tonics to strengthen thevital functions and/or replenish therequired substances.

The purpose of treatment in traditionaland modern medicine is often the same,but the approach is different. Accordingto the approach of modern Westernmedicine, deficiency is made up mostly bysupplying the substance concerned, i.e.,replacement therapy. For example, thyroxinis administered for hypothyroidism,adrenocorticosteroid for adrenocorticaldeficiency, and gamma-globulins orspecific antibodies for immunodeficiencies.Indeed, replacement therapy is often ofvital importance, such as for patients whoneed blood transfusion for massive loss ofblood. Its promptness in correcting thedeficiency is incomparable.

Replacement therapy, however, alsohas its disadvantages, especially if usedover a long period. These include the needto carefully determine the dosage andfrequently adjust it. Overdosage causessevere side-effects or complications, whileunderdosage does not relieve thesymptoms. Another important disadvan-tage is that of drug dependence in chroniccases. Replacement therapy cannotstimulate the recovery of the diseasedtissues or organs; on the contrary, it maycause atrophy of the tissues or furtherreduction of function due to disuse. That iswhy, for example, sudden discontinuationof prednisone therapy may cause anadrenal crisis, and a rapid and over-whelming intensification of chronic adrenalinsufficiency.

Tonification, on the other hand, attemptsto stimulate the patient’s own capability.Even when used to replenish the requiredsubstances, in most cases the aim of thetreatment is to stimulate the body to producethese substances instead of directlysubstituting them. Ginseng, the mostfamous traditional tonic, is a good example.It increases the anti-stress function, butcontains no corticosteroid; by stimulatingthe hypothalamic–pituitary–adrenocorticalaxis, it induces the body to synthesize andrelease corticosteroid. Also, though itcontains no estrogen or testosterone, bystimulating the hypothalamic–pituitary–gonadotrophic axis, it acts like a sexhormone in both males and females. Itenhances thyroid function, but contains nothyroxin. It promotes the release of insulin,but does not cause hypoglycaemia; on thecontrary, it can be used for treatinghypoglycaemia induced by insulin. Thus, theadvantages of traditional tonification arethat it seldom causes side-effects, and thereis usually no “withdrawal syndrome” whenthe treatment is discontinued. The majordisadvantage is that its therapeutic effect isusually not as prompt as that of modernreplacement therapy. Also, it is of limitedbenefit once the related tissue has beentotally destroyed.

Both acupuncture and tonificationtherapy are guided by the principle ofstimulating the body’s natural healingpower or functional potentiality. On theother hand, modern biomedicine has maderapid progress on the basis of thereplacement principle of treatment. Organtransplantation, too, is based on theprinciple of replacement, and has beeninvaluable to many patients, with plenty ofpromise for the future. There is great scopefor traditional medicine, with its richexperience in the mobilization andutilization of the body’s potentialities, and


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modern biomedicine to complementeach other.

Future prospects ofharmonizationThis brief review of the development oftraditional medicine in the People’sRepublic of China clearly indicates thepossibility and benefits of the harmoni-zation of traditional and modern medicine.Harmonization has progressed in Chinamainly because of the Government’sefforts to formulate and implementappropriate policies, as well as the effortsmade by the Chinese medical community.In the quest for harmonization, one mustkeep in mind that the breach between thetwo systems is increasingly narrowing, withthe rapid advance of modern medicine inrecent decades. Earlier, there wereirreconcilable conflicts between the

mechanistic and reductionistic approachof modern medicine and the dialectic andholistic approach of traditional medicine;and between modern medicine’s analyticalapproach to arriving at conclusions andtraditional medicine’s method ofcomprehensive observation. However, theprospects of harmonization seem brighternow that biomedicine has proceeded fromthe cellular to the molecular level. Thecombined analytico–synthetic methodologyis replacing the purely analyticalmethodology in the medical sciences, andthe biomedical model is being transformedinto a bio–psycho–socio–medical model,developments which are bound to facilitateharmonization.17 Research into traditionalmedicine at the molecular and geneticlevels is likely to throw greater light on themechanisms of traditional therapies andtheir 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 NationalInstitute 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 AmericanMedical 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 medicineand promoting their integration, strive for the construction of Chinese socialistichealth services (in Chinese) Zhongguo Zhongxiyi Jiehe Zazhi (Chinese Journal ofIntegrated 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 ofHealth-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 Healthof the People’s Republic of China) People’s Health Publishing House. 1999. p. 392and 428.

12. Huang Shuze and Lin Shixiao. Dangdai Zhongguo de Weisheng Shiye (Health Servicesin Contemporary China) Vol. II. China Social Science Press. 1986, pp. 68–92. (inChinese).

13. Zhen Zhiya and Fu Weikang, Zhongguo Yixueshi (Chinese Medical History. People’sHealth Publishing House. 1991. p. 201–210 (in Chinese).

14. Ma Jixing (1990). Lore of Traditional Chinese Medical Literature (in Chinese). ShanghaiPress Science and Technology. p.16.

15. Zhang Wenkang (Editor-in-chief). Zhongguo Zhongyiyao Nianjian (Year Book ofTraditional Chinese Medicine of the People’s Republic of China). China TraditionalMedicine Press. 1999. p. 492. (in Chinese).

16. Chen Ke-ji. Forty years of integrated medicine in China. Chinese Journal of IntegratedTraditional and Western Medicine. 1997, 3(3): 162–166.

17. Deng Pingxiu. Zhongyi Xiandaihua he Zhongxiyi Jiehe Yanjiu Fangfa (ResearchMethodology on Modernization of Traditional Chinese Medicine and Integration ofChinese and Western Medicine). A chapter of the book Yixue Bianzhengfa (MedicalDialectics) edited by Peng Ruicong. People’s Health Publishing House. 1992; pp.152–160. (in Chinese).

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remedies has led to different situationsdeveloping in different countries. Incountries with a strong foundation oftraditional medicine such as India andChina, nationally recognized paralleltraditional systems have run for longperiods, along with Western medicine withvarying degrees of acceptance, integrationand assimilation. In other countries likethose in Africa, there is now a move to givelegitimacy to the traditional healer whosemedical practice has been the mainstay ofthe local people, even after Westernmedicine made its appearance and tookfirm roots. In Europe and USA, a new andgrowing consumer interest in the use ofnatural medicine and herbal products hasopened burgeoning markets for healthpromotion products aimed at theimprovement of physical well-being. Thisis a comparatively new constituency ofherbal medicine users for the preventionof disease rather than cures for illnesses.Their emphasis has been on the use ofsingle herbs and therapies promoted byconsumer interest and demand and not yet

Role of traditionalsystems of medicine innational health caresystems

fully understood or recognized bygovernments, including drug authorities.Meanwhile, a strong consumer demand forherbal products, plant-based remedies anda growing interest in Ayurveda,Acupuncture, Chinese Medicine, and theirconcepts, applications and strengths,which are millennia old, is taking place.Often this is happening without theknowledge of the allopathic personalphysician who is seen to be ignorant orincapable of understanding why patientsfind relief in the use of alternative medicine.Added to that, the attainment of sensorycontrol through self-restraint and self-realization through meditation has becomethe aspiration for a large number of people,propelled to some extent by the belief thatthe human body and the human mind havethe ability to prevent and cure disease andachieve a state of well-being given the righttools. That this approach has merit issignificant to some extent, by the fact thatYoga is a nationally recognized system ofmedicine in India.

Countries today, the world over, areflooded with thousands of plant-basedremedies which have entered the marketsas food supplements. Such products, whichare primarily plant based and may or may

Shailaja Chandra

TIntroduction

he world-wide interest in the use ofnatural products and plant-based


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not contain synthetic ingredients, are beingfreely manufactured and exported. Many ofthe remedies have their roots in the use ofplants for their medicinal value. With thegrowth of consumer demand on the onehand and the current socio-politicalideologies on the other, governments havebeen trying to grapple with the task ofapproaching the traditional medicinepractitioners and products in a way that canbe simple and meaningful enough to makea significant improvement to people’s dailylives while ensuring safety. In this pursuit,the government has naturally to conferlegitimacy only on such systems, practices,therapies and drugs which have beeninvestigated and found to be efficacious andwhere a process of standardization can beassured. This exercise, however, calls for theintegration of several facets which go intothe making and practice of traditionalmedicine, which requires an understandingof the sector, its strengths and weaknessesand what will work.

Traditional medicine in every countrywherever it has a strong base, has emergedout of an individual physician’s approachto the problems of an individual patientspreading to the family, and later thecommunity. Rooted in traditional medicineis the belief that every person belongs to abroad stereotype and problems can betreated by understanding the individual’spersonal traits and specific factors whichhave brought about disequilibrium.Whereas Western allopathic medicine hasa reductionistic approach and looks uponthe removal of the symptoms of disease asthe main objective, Traditional Medicinedoes not see only a single remedy or asingle approach as being suitable for allpeople. Symptoms are seen only as anindication of a deeper malaise which is notnecessarily considered to be caused byphysiological factors alone.

In terms of priorities, the epidemio-logical situation compels governments toconfront basic public health problems,leaving little time, space or funds forincluding traditional medicine approacheswhich are necessarily individualistic, slowand difficult to monitor and evaluate. Onyet another plane lies the clinical approach,extended through allopathic dispensariesand hospitals designed to treat individualand specialized problems with moderndiagnostics and drugs.

With such a wide difference in conceptsand approaches, is it at all possible to bringabout any kind of integration which wouldbe of significant benefit to the people? Arecomparisons between the loss ofproductivity on the one hand (whichinvariably calls for strong medication) andthe elimination of side-effects on the other(albeit with gentler but slower traditionaldrugs) at all possible? Can one weigh theshort-term benefits of getting back to workover the long-term benefits of avoidingdependence on strong drugs andresistance patterns? Is there at all a casefor identifying which part of the traditionalsystems can be integrated into a healthsystem? Where does traditional medicinefall between the public health approach onthe one hand and the specialist-drivenhospital-based approach on the other?Where will the inclusion of traditionalmedicine work to the greatest advantage,and can there be a policy on its integrationinto the health system?

These are some of the issues whichpolicy-makers administering the healthsector have to grapple with, and at theback of every decision-making process liesthe question of whether the alternativeoffered by traditional medicine will lead toa significant improvement over the currentsituation, sufficient to call for a change ofpolicy. Would governments like to introduce


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strategies which may suit the individual butwhich may lead to delay in the diagnosisof a really serious illness? How can theexpertise of the practitioner and the qualityand safety of the drugs be assured? Wouldgovernments be in a position to introduceregulations and enforcement mechanismsthat protect the patient against malpracticeand spurious drugs, without curbing theindividuality of the practitioner? Equally,should the consumer be denied access tosimpler, gentler forms of treatment onlybecause there is no one to inform himabout such alternatives? If at all traditionalmedicine is to be used as a strategy tobolster the normal health care approach,where will its inclusion make the greatestimpact and how can such assimilation takeplace?

These are some of the questions thatneed to be answered. This paper is anattempt to respond to them based primarilyon the Indian experience, but alsodocumented elsewhere.

Giving Legitimacy toTraditional Medicine

Traditional medicine can play a far moremeaningful role in the health system of acountry if it receives legitimacy from govern-ments. For this, several requirements needto be fulfilled.

National Recognition forTraditional MedicineGovernments need to recognize a systemor practice, therapies and drugs whichhave been studied by professionalevaluators for safety and efficacy to givelegitimacy to what is considered appro-priate for public use. Thousands offormulations in Ayurveda and, for thatmatter, tribal and folk remedies the worldover speak of the use of various herbs,

singly or in combination mixed with othernatural substances of mineral, animal ormarine origin having properties to improvephysical well-being, remove disease anddisability and prevent the onset of seasonalproblems. If the remedy has beendocumented and has been in use in acommunity for hundreds of years or, forthat matter, even two or three decades,does it call for safety and toxicity studies tobe conducted if there is a way of testingthe absence of high microbial content andthe absence of non-permissiblesubstances?2

Many traditional medicines are nodifferent from food items like home-madewines, jams, jellies, squashes and syrups.They contain only natural ingredients and,just as there are standards for food,formularies and pharmacopoeias havebeen evolved to set standards for thepreparation of many such traditionalmedicines. For assimilation into a healthsystem, if the pharmacopoeial standardsare adhered to, if a licensing mechanismis in place and if there are ways of testingthe product for the presence of the mainingredients and the absence of non-permissible substances, the system is inplace.

Pupils practising surgical procedures on vegetables inancient India



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In India there are thousands ofAyurvedic and Unani formulations licensedas medicines and sold over the counter andincluded in the formularies of healthdepartments, both by the national andstate governments. These formulations canbe prescribed by practitioners of therespective traditional stream who suggestthe use of classical (generic) or proprietarydrugs exactly as done in allopathy. All suchitems are sold as Ayurvedic, Unani orSiddha medicines and carry a licencenumber, together with the list of ingredientson the label.

Role of Traditional HomeRemedies in the Health SystemHome remedies and licensed drugs fall intotwo distinct categories. On the one handthere are what could be determined ascommon remedies for common problems,and almost every country in South-EastAsia, China and Korea have their own triedand tested traditional remedies forproblems falling in the category of gastricproblems, diseases of the respiratorysystem, skin and muscular problems,treatment of diseases of the reproductiveand urinary systems, digestive disorders,treatment for wound healing, and commonpaediatric problems. This list is notexhaustive, but countries like India,Thailand, China, Sri Lanka, Bhutan, Nepal,South Africa and Korea, to name but a few,all have their own lists of herbs which arecommonly used singly or in combination,made into a fresh paste, decoctions, ordried and powdered, having no side-effectsand which have been in use in thecommunity for generations as the firstremedy when symptoms manifest.

Urbanization and the advent of thenuclear family leading to the virtualdisappearance of the grandmother, themother-in-law, and the village elders, have

led to a situation where common remedieswhich had been administered without anydoctors for years have now becomequestionable for a new generation ofWestern-educated urban public exposedonly to the allopathic system and allopathicdrugs. The age-old practices of maintainingkitchen gardens and visits to the villagegrocer who stocked all the dried herbs havegone into disuse in the cities. Knowledgeabout which part of the plant is to be used,namely, the root, stem, bark or leaves, hasbeen effaced. Yet, for centuries this hadbeen the mainstay of entire populations,long before allopathy came on the scene,and continues to be so for tribal and villagepeople in many developing countrieseven today.

Every government is in a position toidentify such drugs, whether they are in usein the country of origin or in anothercountry having a similar socio-culturalenvironment, to be used for self-care,primary health care and as preventivemedicine.1 Such remedies are used veryfrequently in countries like India, Sri Lanka,Thailand, Nepal and Bhutan, and the sameor similar plants are used with littleindigenous difference. Thailand is reportedto have identified about 150 selectedherbs, screened them and brought the listdown to 61 items accepted as a cure forillnesses signified by 17 symptoms. Theherbs selected were mostly items usedregularly in foods grown in domesticgardens like ginger, garlic, banana andaloe vera. The idea is to provide analternative to promote good health, byattempting to solve health problemsthrough self-reliance at the personal,family and community level. Theseremedies can take care of commonmaladies such as constipation, diarrhoea,nausea, joint pains, burns, cough and coldand sore throat.


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In India, the Department of IndianSystems of Medicine and Homoeopathy ofthe Ministry of Health has published HomeRemedies for Ayurvedic2 and Unani3medicines and circulated them for use bycommunity leaders, extension workers,nurse midwives and school teachers at thevillage level.

The Use of Traditional Drugs whereTherapeutic Claims are madeFor the wider sale of processed drugs wheretherapeutic claims are made, licensing isa prerequisite. Legislation to enforcelicensing and registration is available incountries like India, Indonesia and SriLanka assisted by pharmacopoeias andtexts which are recognized under the drugsenforcement legislation of the country. Indiaand Indonesia have also introducedGood Manufacturing Practices (GMP) fortraditional drugs which cover therequirements relating to the qualificationof employees, the responsibility of thequality control managers, essentialrequirement of space, equipment,documentation of processing andpackaging methods and need for self-regulation, coupled with enforcement bythe licencing authorities. India, China,Bhutan, Indonesia and Thailand havenational drug lists for use in primary healthcare and in hospitals. These examples canbe emulated with advantage as such listsbring about confidence in the user and theutilization patterns can be studied formodifications in stocking policy.

Use of Traditional Medicine inMore Complicated illnessesIn the case of complicated illnesses, simplystating that these drugs are recognized bythe Government and that they can be safelyused for self-care and primary health carefor all kinds of diseases will not auto-

matically lead to their use. The calibre ofthe practitioner and his skills decide whetherpatients place reliance on the system. InIndia, there is a vast infrastructurecomprising more than 2854 traditionalmedicine hospitals with 49,353 beds,400,000 institutionally trained practi-tioners of Ayurveda, Unani, Siddha andHomoeopathy, more than 387 colleges ofindigenous medicine, and more than22,000 dispensaries mostly situated in therural areas of the country.4 The practi-tioners have attended a five-and-a-half-year degree course after completing thefinal year of school. They have beenregistered by a statutorily electedprofessional Council called the CentralCouncil of Indian Medicine. People comeof their own volition to access traditionalcare, particularly for certain chronicailments. In some states of India likeMaharashtra and Tamil Nadu, thetraditional medicine practitioner is verymuch a part of the primary health caresystem and provides diagnosis andtreatment in the same health facility alongwith allopaths. In times of national disasterslike cyclones, floods and earthquakes,under Government orders traditionalmedicine practitioners provide their ownemergency medical relief, more specificallyto prevent diarrhoea, dysentery and skinailments and to help people overcomeshock and disorientation. They have beenused extensively during outbreaks ofJapanese encephalitis where homoeopathywas found to have particular efficacy.

When the practitioner is part of thehealth system, his registration aftercompletion of a recognized educationalcourse is absolutely necessary. The publichave a right to receive standardizedtreatment and drugs and to hold practi-tioners responsible for the medication theyadminister.


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Role of Research in TraditionalMedicineToday, research is done mainly to establishevidence of the efficacy of the drug ortherapy that is being used. In the area oftraditional medicine, unfortunately mostpeople feel that it is mainly anecdotalevidence or at best confined to case studiesor observational studies. A few uncon-trolled trials or small randomized clinicaltrials do not inspire much confidence.

The Government of India set up fourresearch councils almost 30 years ago tolook at the efficacy of Ayurveda, Unani,Siddha, Yoga and Naturopathy andsubsequently that of Homoeopathy.Research conducted over the last 20 yearshas shown specific areas of strength wheretraditional medicine is particularly useful,often where western medicine has little tooffer. Areas where it can be used as astand-alone therapy or as an adjuncttherapy have also been identified. Some ofthe major outcomes of the clinical researchundertaken in the field of Indian Systemsof Medicine include:

AyurvedaAn Ayurvedic Antimalarial Ayush-64for P-vivax;5–7

An Ayurvedic Antiepileptic drugAyush-56;8An Ayurvedic drug Vijayasara forDiabetes Mellitus (ICMR Communi-cations);An Ayurvedic drug Guggulu and itsextracts for hyperlipidaemia andatherosclerosis;9An Ayurvedic formulation PushkaraGuggulu for Coronary insufficiency forstable angina;10

An Ayurvedic drug Varuna for UTI,Urolithiasis and benign prostatehypertrophy;11

Bhoomyamalaki for Hepatitis B;

Brahmi and Mandukaparni to promoteMental Health;12,13

Ayurvedic drugs Aswagandha andGuduchi as rejuvenators and immuno-modulators;Panchakarma therapies for paralyticdisorders;14

Ksharasootra ligation for anal fistulaeand haemorrhoids.15,16

Bio-enhancers like pippali and marichato increase the bio-availability of drugs;Brahmyadi Yoga for Schizophrenia;17

Oral contraceptives like pippaliyadiyoga (CCRAS communication);Spermicidal – Nimba Taila.18

SiddhaA Siddha preparation 777 Oil forPsoriasis.19

UnaniThe Council for Research in UnaniMedicine prepared Unani formulations forthe following areas:

Bronchial Asthma, Filariasis,20 InfectiveHepatitis21 and Vitiligo 22

HomoeopathyBehavioural DisordersBelladonna, Hyoscyamus, Ignatiaamara, Stramonium;Diabetes MellitusCephalandra or Coccinia indica(Bimbi);FilariaApis mellifica, Bryonia alba, Rhus tox;Gall stoneFel tauri 2X or 3X;Malposition of human foetusPulsatilla nigra 200;HIV/AIDSTuberculinum, Phosphorus, Arsenicumalbum, Azadirachta indica, nuxvomica, syphilinum, sepin, mercuriussolubitis.23,24


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Presently, in India, operational researchstudies are about to start in the area ofhealthy aging, using Ayurvedic drugs forspecific problems like benign prostratehypertrophy, reduction in menopausalsymptoms, preventive cardiology, arthritisand the use of “Rasayana” for rejuvenation.Likewise, operational research studies havebeen designed and will commence shortlyto cover nine specific areas affectingwomen and children’s health which includemenstrual disorders, reproductive tractinfections, antenatal care, postnatal care,complications of pregnancy (vomiting,oedema) galactogogue, health promotionof neonates and infants, and themanagement of common colds, etc.

Some of the important extra-muralresearch projects which have been approvedby the Department of Indian Systems ofMedicine and Homoeopathy of theGovernment of India, and which are inprogress, include examining the benefits ofthe integrated Approach of Yoga Therapyon Schizophrenia, Clinical, Haematological,Biochemical and Immu-nological Studies onPatients of Chronic Arsenic Toxicity and itsHomoeopathic Management, Role ofAyurvedic Drugs in the prevention andTreatment of Occupational Health Problems(Pnemo-conicosis) in Industrial Workers, anobjective Evaluation of the Efficacy ofPanchavalkal, an Ayurvedic preparation, intreating Leucorhoea, a primary Study ofCancer treated through the Ayurvedicapproach, a study on the treatment ofKeloids in Homoeopathy and Allopathy,Efficacy of Ayurvedic Treatment as anAdjuvant Therapy for Fracture Treatment andDelayed Bone Healing, and a ComparativeTrial of Ayurvedic and Allopathic Therapy forSpasticity and Paralysis-A randomizedControlled Study.

It will, thus, be seen that there areareas of interest to the health systems of

any country, particularly in the growingfields of non-communicable diseases andgeriatric and mental care. In handlingdifficult and intractable conditions, clinicaltrials are necessary. The challenge forhealth administrators lies in designingstudies and motivating allopathic hospitalsto undertake trials to establish the extentof benefits likely to be received by using thetraditional approach, whether as a directmeasure or as an adjunct therapy.However, research methodologies have tobe designed keeping in mind the indivi-dualistic nature of the traditional diagnosisand the holistic side of traditional drugs.WHO has recently finalized guidelines onresearch methodologies for traditionalmedicine. The publication of the guidelineswill create new and achievable parametersfor research in this area, designed to fostergreater enquiry, shorn of a restrictedapproach not tenable for medical researchin the traditional area.

Why Raw Material andStandardization are ofParamount Importance inTraditional MedicineTraditional medicine relies almost 90 percent on the use of medicinal plantssupplemented by minerals and metals andanimal and marine products like corals andshells. Health systems and health admini-strators have perforce to get involved withthe raw material aspect if traditionalmedicine is to be taken seriously. Withoutthis the quality of medicine can suffer,affecting the credibility of traditionalremedies.

Medicinal plants comprising thousandsof species of plants constitute a vast,undocumented and over-exploited resource.The growth and cultivation of such plants,their collection, storage, distribution,processing and marketing are now gaining


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importance as they all have an impact onquality. For traditional medicine to get afoothold on a sustained basis, the qualityof the medicine has to be assured. There isa world of difference between the efficacyof a medicine made from plants cultivatedand harvested using good agriculturalpractices and that derived from plantsuprooted from the wild.25

In most countries, even in those wherethe use of traditional medicine is strong,the cultivation of medicinal plants is atpresent limited to a few items, most naturalproducts being collected by villagers andtribal people from wastelands and forests.For want of training, they may destroy thewhole plant instead of collecting just thepart to be used. Re-plantation andpropagation is left to nature. Collection notdone during the proper season oftendetracts from the efficacy of the endproduct. The networking of collection isunder the control of traders and thematerial collected is sold in the nearbytownship from where it reaches regionalcentres for domestic use or export. Enligh-tened industries do, however, cultivateplants so as to be assured of standardquality and the presence of activeingredients. They have invested in recruitingbotanists and standardization experts inorder to access quality raw material. Someof these industries have their own R&Dfacilities where documentation ismaintained and quality assured throughfinger printing, HPLC and TLC tests.However, small manufacturing industriesrely on market sources which have manyattendant problems which affect quality.

In India, at the federal level theDepartments in charge of traditionalmedicine (Indian Systems of Medicine andHomoeopathy under the Ministry of Healthand Family Welfare), the Department ofEnvironment and Forests, Agriculture,

Biotechnology, Science & Technology andCommerce have come together to evolvea coordinated approach to the develop-ment of the medicinal plant sector. AMedicinal Plant Board has been establi-shed to coordinate all the activities underthe Department of Indian Systems ofMedicine and Homoeopathy which alsohas the responsibility to lay down standardsfor traditional medicine drugs. Despite thispolicy-level support, the role of traditionalmedicine in the health system will bedecided by only one factor, i.e., the curingand health-giving ability of the practitionersand the remedies on a sustained basis.

Standardization, a Pre-requisitefor Quality Control of TraditionalMedicine DrugsStandardization of plant-based drugs isextremely difficult because presently very fewquality control tests are available in mostcountries using traditional medicine. In theirabsence, there are no methods to evaluatethe contents and the quantities as claimedon the label. Quality control is required atthree stages, namely, when the raw materialis used, for confirming the processundergone by the drug during manufacture,and at the finishing stage. The shelf-life ordate of expiry needs to be indicated and thepossibility of mixing modern drugs has tobe strictly eliminated and strong deterrentsimposed to discourage such practices.Measures to test the absence of pesticideresidues, heavy metals and aflatoxin haveto be taken through proper regulation andtesting.26, 27 At least a few important markershave to be identified through TLC (fingerprinting) and the process of making randomchecks has to be institutionalized andpenalties imposed if non-permissiblesubstances are found or the medicine doesnot conform to safety standards. For patentproprietary drugs, manufacturers must be


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asked to provide the recipes. Consumersmust be kept informed about how they canaccess quality products and where tests canbe undertaken if doubts about quality areexperienced.

In India, pharmacopoeial standardsfor 158 drugs are available and 634formulations have been published in theAyurvedic Formulary of India. Likewise,for Unani medicine pharmacopoeialstandards are available for 45 drugs anda Unani Formulary for 603 formulationsis available. In respect of Homoeopathy,pharmacopoeial standards are availablefor 916 drugs.28-35

In Ayurvedic and Unani formulations,sometimes a single medication has over 50ingredients and certainly even the simplestmedicines have 6–10 ingredients involvingthe use of different parts of several plants.Standardization is not a simple task and ithas to be undertaken and institutionalizedif the traditional medicine sector is tosecure a niche for itself in the health system.

Scientists have given numeroussuggestions about the standardization andquality control of herbal drugs. In India,the problems have been addressedthrough a variety of measures, some ofwhich have already been implemented andsome are still in the process of beingintroduced. In order to give an impetus toQuality Control and Standardization, theDepartment of Indian Systems of Medicineand Homoeopathy has initiated schemesto help strengthen the State Pharmaciesand State Drug Testing Laboratories tobecome models for the proper formulationof quality medicine for use in the publicsector and Government-run hospitals anddispensaries. Side by side, recognition ofprivate laboratories which possess theequipment and the scientific and technicalmanpower as stipulated, and act asGovernment-approved laboratories

authorized to conduct quality control testsand issue certification is also contemplated.

Traditional medicine can play a role inthe health system of a country if the systemand its medicaments have been preparedin a manner that inspires confidence in thequality and the Government supports theuse of such systems with the neededcontrols.36,37 Without this input, traditionalmedicine can grow only in a haphazardway and public confidence may get erodedover time. Issues of quality have to beconfronted squarely and national andprovincial governments have to be madeaware of what is acceptable across theworld. Only then will traditional medicinebe able to achieve its due position in thehealth system.

Issues of Integration

Indian Government’s Policy onTraditional MedicineThe Central Council for Health and FamilyWelfare, set up under Article 226 of theConstitution of India, is the highest policy-making body which lays down policy forall sectors covered under the healthportfolio. It meets once a year and consistsof the federal health ministers, state healthministers, eminent health experts, NGOswith an interest in health, and officials ofthe central and state governments.

The Council in its last meeting held in1999, inter alia, recommended that at

Traditional medicine can playa role in the health systemof a country if the systemand its medicaments havebeen prepared in a manner

that inspires confidencein the quality.


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least one physician from the Indian Systemsof Medicine and Homoeopathy (ISM&H)should be available in every primary healthcentre in every state and that vacanciescaused by non-availability of allopathicpersonnel should be filled by ISM&Hphysicians. The Council also resolved thatspecialist treatment centres for ISM&Hshould be introduced in rural hospitals anda wing should be created in the existingstate and district-level Governmenthospitals so that the benefits of thesesystems are made available to the generalpublic, according to their choice. It hasalso been resolved that expenses ontreatment received in traditional medicinehospitals should be recognized forreimbursement as is already permitted inthe case of Central Governmentemployees. All these measures have beenrecommended to all state governments andthe action taken thereon is regularlymonitored at the central level.

Mainstreaming Indian Systems ofMedicine and Homoeopathy forPopulation StabilizationThe Government of India has adopted a‘National Population Policy 2000’ and, forthe first time, a Chapter has beenintroduced on mainstreaming the IndianSystems of Medicine and Homoeopathy(ISM&H). The Policy seeks to use theinstitutionally qualified practitioners ofISM&H (who have completed a five-and-a-half-year degree) and utilize their servicesto fill the gaps in manpower at appropriatelevels in the health infrastructure. The Policyalso seeks to increase utilization of ISMinstitutions, dispensaries and hospitals forhealth and population-related progra-mmes. What is particularly noteworthy isthat the Policy advocates the use of triedand tested ISM medicines at the village andhousehold level.

The Government of India has set up aPopulation Commission to address thewhole issue of population stabilization. TheCommission has further set up a HighPowered Advisory Group on Mainstrea-ming of Indian Systems of Medicine andHomoeopathy (ISM&H) into the healthsystem. The terms of reference seek to:

Review the status of Reproductive andChild Health (RCH) services extendedby ISM&H practitioners, their infrastru-cture and personnel;Identify areas where ISM&H practi-tioners can be used more effectively byupgrading their knowledge and skills;Select effective ISM&H practices whichcan augment the existing RCH approach;Specify significant legislative, admini-strative and schematic changes whichneed to be introduced to achieve theobjective of utilizing ISM&H and theirpractitioners to the best advantage.This is the first time that a separate

high-powered group has been set up forusing the strategies of ISM in populationstabilization, a major area of focus for theIndian Government.

Integration of TraditionalMedicine into the Reproductiveand Child Health ProgrammeFor the first time, drugs of the Ayurvedicand Unani systems have been incorpo-rated into the kits of nurses and midwivesin the sub-centres of seven states and fourcities, to be extended to the whole countrylater. The same drugs are also to be madeavailable in the kits of female extensionworkers in over 5,00,000 centresproviding supplementary nutrition topregnant and lactating women andchildren below six years. The traditionaldrugs have been selected to take care ofcommon problems and are being centrallyprocured and tested before being added


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to the kits. This will further help the healthsystems to take care of a large number ofwomen and children as a first line of carethrough traditional medicine.

Meanwhile, but again for the first time,the Ayurvedic concepts of the HealthyMother and Child are to be studied throughan operational research project under thejoint aegis of the Indian Council of MedicalResearch and the Central Council forResearch in Ayurveda and Siddha (CCRAS).Five states and 10 blocks have beenidentified for this study. The areas cover theoverall approach to reproductive and childhealth, including menstruation, antenatalcare, preparation for delivery, vomiting inpregnancy, loss of appetite, constipation,gaseous distention, acidity and diarrhoea,treatment of oedema, loss of sleep, piles andanaemia, delivery and its management,contraception and the management of thenewborn. In regard to neonatal and childhealth, the areas include care of thenewborn, precautions during the first weekafter birth, supplementary food for theinfant, general growth and development ofthe child, management of diarrhoea,constipation in children and eradication ofworm infestation. The entire approach istraditional and the applications are simpleenough to be administered by Ayurvedicpractitioners, nurse midwives, traditionalbirth attendants or even at the householdlevel. This again is the first time that a jointoperational research study combiningresearch talent from allopathy andtraditional medicine will be undertaken todetermine the benefits of the Ayurvedicapproach in this area. The objective is toidentify areas of greater relevance andsignificance, which could be introduced inthe Reproductive and Child HealthProgramme.

The Defence Institute of Physiology andAllied Sciences (DIPAS) has successfully

developed a vaginal contraceptive(spermicidal agent) from Neem Oil(Azadirachta indica) in the form of pessary,which has been approved for clinical trials.This product of DIPAS has overcome theinconveniences of using the oil as such,being done by the CCRAS.

The work on Pipplyadi Yoga, a herbalcontraceptive, is already undergoingclinical trials in five allopathic centres withallopathic clinical investigators. Both theseinitiatives will be a boon to rural women ifhighly effective cheap contraceptives aredeveloped.

These examples show how the benefitsof Indian medicine are being brought intothe mainstream of health care where theyare poised to play an increasingly importantrole.

Does Traditional Medicine Havea Role in an Allopathic Set-up?Different countries have made differentkinds of efforts to assimilate traditionalmedicine into the normal health system.This has met with varying degrees ofsuccess. Some examples of how India hasgiven a role to traditional medicine in thehealth sector are described below.

In a 900-bed general allopathichospital in New Delhi (the R.M.L. Hospital),services for Homoeopathy and Unanitreatment are available under the same roof.In another 1500-bed allopathic hospital(Safdarjung Hospital), Ayurvedic andHomoeopathic treatment is available.Medicines are either given by the practi-tioners or through the Central GovernmentHealth Scheme (CGHS) to governmentemployees.

The attendance pattern in the traditionalmedicine clinics was analysed over a six-month period. The main findings were thatin Ayurveda, among the chronic diseases,arthritis (sandhi vata) accounted for 10.8


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per cent of the attendance, abdominaldiseases (udara vikara) for 10.1 per centand nervous diseases (vata vyadhi) for 9.2per cent. In the case of acute diseases, thelargest turnover was in respect of bronchitis(Kasa), weakness (dhatuksaya), disease ofmouth (mukha roga), etc. (Table 1).

In respect of Homoeopathy, it wasfound that most people accessed thesystem for gout, arthritis and bronchialasthma among chronic diseases. In thecase of acute diseases it was the upperrespiratory tract infections that had thelargest attendance (Table 2).

Table 1. Utilization of Ayurvedic Treatment over a six-month period inSafdarjung Hospital, New Delhi (A 1500-Bed Allopathic GeneralHospital)

Chronic disease Attendance Ordinary disease Attendance% %

Sandhi vata (Arthritis) 10.8 Kasa (Bronchitis) 12.8Udara vikara (Abdominal disease) 10.1 Pratisyaya (Coryza) 8.4Vata vyadhi (Nervous diseases) 9.2 Dhatuksaya (Weakness) 7.4Amlapitta (Hyperacidity) 7.8 Mukha roga (Disease of mouth) 7.2Sotha (Dropsy) 5.6 Mutra roga (U.T.I.) 6.1Yakrta vikara (Liver disease) 5.2 Pandu (Anaemia) 5.6Tvak-roga (Diseases of skin) 5.0 Pradara (Leucorrhoea) 5.6Amvata (Rheumatism) 5.0 Rakta vikara (Blood impurities) 5.5Svasa (Asthma) 4.7 Ajirna (Indigestion) 5.0Grahanidosa (Sprue) 4.6 Kosthabaddhata (Constipation) 4.5Other Diseases 32.0 Other Diseases 32.0Total 100 100

(5593) (3989)

Table 2. Utilization of Homoeopathic Treatment over a six-month period inDr. R.M.L. Hospital, New Delhi (A 900-Bed Allopathic GeneralHospital)

Chronic disease Attendance Acute disease Attendance% %

RA/Gout/Arthritis 9.9 U.R.I. (Upper Respiratory Tract Infections) 27.0Dyspepsia 5.9 P.U.O. (Pyrexia/Fever of unknown origin ) 17.4Sinusitis 4.8 Allergic Rhinitis/Rhinorrhoea 14.3Dermatitis 4.4 Urticaria 5.9Tonsillitis 3.5 Stomatitis 5.6Bronchial Asthma 3.1 Abscess 3.9Alopecia areata 2.8 Jaundice 3.4NBA (Naso Bronchial Allergies) 2.7 Dysentery 3.3Verruca 2.5 Gastro-enteritis 3.2Headache 2.4 Dentition period/troubles 3.0Other Diseases 58.0 Other Diseases 12.9Total 100 100

(10006) (2613)


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The Unani system appears to attractthe largest number of people forrheumatoid arthritis (waja-ul-mafasil) andvitiligo among chronic diseases, commoncold (nazla-wa-zukam) and dyspepsia (su-e-hazm) (Table 3).

Institute of Medical Sciences,Banaras Hindu University,Varanasi – An example ofintegrationBanaras Hindu University (BHU) isprobably the first institution whichconceived the idea of integrating theancient and modern systems of medicineboth at the level of education andprofessional practice, 73 years ago, whenthe first ever integrated Ayurvedic Collegewas established. Subsequently, this modelbecame controversial and was opposedby the mainstream of Ayurvedicorganizations, and the Ayurvedic Collegeof BHU was closed in 1960 but anintegrated education was started at the

postgraduate level for teaching andresearch and this approach is continuingeven today. The M.D. AyurvedaProgramme of the Faculty of Ayurveda isalso open to MBBS graduates. For suchcandidates, the first-year M.D. Course isa special preparatory course and there isa separate examination for the twostreams. But the Final M.D. Ayurvedaexamination and teaching is common forboth the streams. They undergo the sametraining in the 2nd and 3rd year, clear thesame examination and get the samedegree.

The University has also passed anOrdinance through which a candidateholding an M.D. degree in Ayurveda maybe registered for a Ph.D. degree in therespective speciality of modern medicineand vice versa.

Medical Research in BHUThe M.D. Ayurveda and Ph.D. Ayurvedascholars adopt modern parameters of

The Tables are indicative of the areas where patients visiting an allopathic hospital still prefer to use traditionalmedicine exclusively or as an adjunct therapy.

Table 3. Utilization of Unani Treatment over a six-month period inDr. R.M.L. Hospital, New Delhi (A 900-Bed Allopathic GeneralHospital)

Chronic disease Attendance General disease Attendance% %

Waja-ul-Mafasil (Rheumatoid Arthritis) 23.1 Su-e-Hazm (Dyspepsia) 10.5Bars (Vitiligo) 7.9 Nazla-wa-Zukam (Common cold) 10.5Sailan-ur-Rahem (Leucorrhoea) 6.1 Qabz (Constipation) 10.1Saman-e-Mufrit (Obesity) 5.6 Faqruddam (Anaemia) 6.1Zeequn Nafas (Bronchial Asthma) 5.4 Waja-ul-Batn (Abdominal pain) 6.1Ziabetus Sukkari (Diabetes Mellitus) 5.2 Humma (Fever) 5.9Humuzat-e-Meda (Hyperacidity) 4.0 Zaheer (Dysentery) 5.7Warm-e-Qasbat-ur-Riya (Bronchitis) 3.3 Ishal (Diarrhoea) 4.7Bawaseer (Piles) 3.2 Qula (Stomatitis) 4.1Zof-e-Kabid (Liver dysfunction) 2.7 Suda (Headache) 3.9Other Diseases 33.5 Other Diseases 32.4Total 100 100

(18095) (10492)


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study but they also adopt parallel Ayurvedicparameters such as determination ofPrakriti, Ayurvedic Diagnosis, Status of Agniand Ama. In all cases the main guide forthe thesis-level research is a teacher fromthe Faculty of Ayurveda but there are oneor two co-guides from modern medicineor the basic medical sciences.

There are no formal rules or policyformed for this collaboration. The patternhas evolved spontaneously and mutuallyover the years.

Cross-referrals in BHUThe treatment and patient care in BHUHospital too is on an integrated pattern.

The main morbidity areas in which thepatients are referred for Ayurvedictreatment at BHU involve:

Fistula in ano, chronic rheumaticdiseases, residual psychosis and anxietydisorders, chronic colitis and IBS, diseasesof the liver and jaundice, degenerativebrain disease and neuropathy andterminally sick patients of all kinds declaredincurable and/or financially unable toafford modern treatment. Most cases arereferred to the Department of Kayachikitsaor Internal Medicine.

Practical areas whereTraditional Medicine can beused effectively in the HealthSystem

Traditional medicine falls into severaldifferent segments, from the highlyresearched and documented to that whichhas been practised through oral tradition,from manual therapy and manipulation tofaith healing. There are also importantsystems like Homoeopathy which areroutinely accessed over the counter in somecountries but restrictions continue on theuse of the medicine (except on the

prescription of a practitioner) at otherplaces. Whether traditional medicine canat all be used effectively both in the publichealth area and in clinical practice as anadjunct or an adjuvant has no uniformanswer. At the same time, there are a largenumber of approaches which may be usedto advantage with a little effort, but thatrequires a policy backup and regulatorysystems to make such strategies work.Since it is difficult to generalize, a fewexamples are given about how the publiccan be benefited.

Manual Therapy like YogaYoga is known to be effective in themanagement of various disorders andindexed research papers have shownimprovement in cases of anxiety neurosis,depression, arthritis, bronchial asthma,constipation, hypertension, respiratorydiseases, back pain, insomnia and posturaldefects. The most important way that Yogacan contribute in improving the state ofwell-being of a large number of individualsis if governments were to introduce thepractice of yogic asanas in schools andalso if classes were to be held for the benefitof the general public. In New Delhi, suchclasses are run in the mornings andevenings at a Central Institute for Yoga(MDNIY), separately for men and womenand these can be accessed free of cost.The general public can participate at will.During summer, when schools are closed,the institute establishes 101 camps indifferent residential localities of Delhi for thebenefit of residents by paying for theservices of a Yoga teacher after priorscreening for their capability, commu-nication skills and knowledge of yogicpostures. The yogic asanas with meditationhave helped countless people to maintainphysical and mental equilibrium.

The Defence Institute of Physiology


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and Allied Sciences (DIPAS) has doneextensive work on looking at the effect ofYoga on soldiers working in extremeclimatic conditions as well as the effect ofvegeta-rianism, yoga and meditation onpersons having over 50 per cent blockageof at least one artery with the results beingfollowed up after six months. Cardiologistsfrom top allopathic institutions tested theresults through angiography and theoutcome has shown extremely promisingresults. In this way, patients have beenenabled to overcome apparentlyintractable problems through simple andcheap strategies within their control anddevoid of side-effects.

Several specialized institutions in theallopathic sector as well as those commi-tted exclusively to Yoga are conductingextensive research on the tremendoushealing properties of Yoga and its strengths.This is one of the cheapest ways of involvingthe community in health promotion and inmaking it a community effort. The healthsystem only needs to screen the Yogateacher, extend occasional supervision andto see that nominal payments are madefor the classes. The community can be leftto decide the teacher’s acceptability. Inorder to make this a part of the healthsystem, it is necessary to involve the localGovernment machinery in the rural andurban areas, community leaders, schoolsteachers and doctors in-charge of PHCs.Through this approach, a number ofproblems can be taken care of withoutmedication.

HomoeopathyHomoeopathy is recognized as a systemof medicine in many countries and a largenumber of drugs are available over thecounter in the United States, as well as inseveral European and other countries. It isextremely important that the drugs are

licensed and sold with proper labelling andproduct information. In some countries likethe United Kingdom, allopathic practi-tioners undergo a one-year course inHomoeopathy and can practise the system.In India, students have to enrol after theschool level and undergo a five-and-a-half-year degree course to be allowed topractise. Homoeopathy is particularlyremarkable in being able to treat routineproblems, skin and other allergies, gastricproblems and children’s ailments. It ispossible to list at least 40 simple remedieswhich could be sold through chemists overthe counter without prescription, in 5 ml.vials, so that there is no misuse. These 40medicines are intended for commonailments to relieve symptoms to aid earlyrestoration of normalcy. It is necessary toimprove access to these simple medicinesand to sensitize people, who should beencouraged to use such remedies. Severalsimple booklets are available whichdescribe the condition as well as the modeof administration of the drugs and thedosage. Since Homoeopathy is a gentleand effective medicinal science, its useshould be integrated into the health systemmore effectively.

Traditional Therapies which canbe integrated to advantageResearch studies have also shown thebeneficial effects of Ksharasootra andPanchakarma, two Ayurvedic therapies.Ksharasootra comprises the use ofAyurvedic medicated thread in themanagement of fistula-in-ano, andmulticentric trials have been conducted atthe collaborating centres of the IndianCouncil of Medical Research on 265patients where the approach wascompared with conventional surgery. Thefinding showed that the long-term outcomeof Ksharasootra is better than surgery,


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cular and certain orthopaedic disorders.Ksharasootra has provided an alter-

native for those patients who either do notwant surgery or who have encounteredrecurrence of the problem after conven-tional surgery. In fact, it has been seen atthe KEM Hospital, a large allopathichospital in Mumbai, that cases of fistula-in-ano undertaking surgery have declinedconsiderably ever since Kshar-Sutra hasbeen offered as an alternative. The cost ofthese measures is nominal given theoutstanding relief they have given patients.

There are applications similar toPanchakarma available throughout thetraditional system of medicine in mostcountries of South-East Asia which wouldbe worth incorporating in general hospitalwards and other in-patient facilities.

Folk Medicine and TribalRemediesEvery country has its own list of traditionalremedies and countries need to documentthese after observing local people and theirpractices. This is important because thisinformation is often the foundation of largerdiscoveries and inventions, and since thisinformation is passed down by word ofmouth, it is likely to be lost forever. It isimportant to engage botanists, forestersand NGOs working in this area to preparelists of such tribal, folk and village remedies.

In India, the Central Council forResearch in Ayurveda and Siddha(CCRAS),38 and the Central Council forResearch in Unani Medicine (CCRUM)have observed and documented over10,000 such remedies, although not allof them can be used and not all the plantsare readily available. Yet, these remediesrepresent the knowledge of the people andthe intellectual property of the country.Unless these are documented, it will bedifficult to give benefit to the country and

although the initial healing time is longer.It is an effective, ambulatory and safealternative treatment for patients withfistula-in-ano, the main advantage beingthat general anaesthesia is avoided and thechance of recurrence of the problem is nil.

Another highly acclaimed procedure inAyurveda refers to Panchakarma, whichconstitutes a part of the therapeuticapproach in the treatment of diseases aswell as for the prevention and promotionof health care. Panchakarma therapycomprises five purificatory and therapeuticprocedures consisting of oilation andfomentation of the body followed bymedicated emesis, purgation, medicatedenemata, nasal insufflation and bloodletting. Five modified procedures of oilationand fomentation of the body have cometo be known as Keraliya Panchakarma.These include Sirodhara (dribbling of oil onforehead), Sarvangaseka (dribbling of oilon the whole body while massage is done)Pinda sweda (fomentation with hotmedicated balls of cooked rice, etc.).Annalepa (besmearing of cooked andmedicated rice on the whole body) andSirolepa (application of thick medicatedpaste on the crown of the head). These arefollowed by specific dietary measures eachtime. Panchakarma has been used intreating many critical diseases like diabetes,cardio-vascular diseases, hypertension,arthritis, rheumatoid arthritis, osteoporosis,and degenerative disorders.

Both these procedures have beenadvocated by the Department of IndianSystems of Medicine and Homoeopathy forbeing extended to allopathic hospitalswhere large numbers of patientscongregate. Panchakarma has been foundto give significant relief well beyond whatdrugs and physiotherapy can achieve,particularly for symptoms and ailmentscaused by neurological and neuromus-


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the community. Health departments mustappoint the right blend of survey staff todocument this knowledge, which willotherwise disappear forever along with thedisappearance of forests, tribal commu-nities and village doctors. Havingdocumented it, the next step is to identifyareas of current importance where theremedy appears to offer a net advantageover available medicaments and to conductobservational or animal studies (in the caseof unknown plants) to test their efficacy.

Need for establishing aninfrastructure for TraditionalMedicine with supportingLegislation

Infrastructure for Indian Systemsof Medicine & HomoeopathySix systems of traditional medicine arenationally recognized by the Governmentof India and the state governments –Ayurveda, Siddha, Unani, Yoga Naturo-pathy and Homoeopathy. There is a full-fledged, independent Department underthe Ministry of Health of the Union

Government with a Secretary, who reportsto the Union Ministers for Health. Publichealth is a State subject under the IndianConstitution and 18 state governments inthe country have set up Directorates ofIndian Systems of Medicine & Homoeo-pathy. Some states have independentministers in-charge of the non-allopathicrecognized systems. India has the followingcapacity in the traditional medicine sector(Table 4).

Drug Licensing for TraditionalMedicineThe drug-based systems, viz., Ayurveda,Unani, Siddha and Homoeopathy, arecovered by the Drugs and Cosmetics Actof the country and the rules madethereunder. The licencing authorities fortraditional medicine drugs are appointedby the state government, which implementsthe rules. However, the powers to modifythe Act and rules rest with the UnionGovernment, which is guided by the DrugsTechnical Advisory Board for Ayurveda,Siddha and Unani drugs and a Drugs

Table 4. Infrastructure for Indian systems of medicine andhomoeopathy (1999)

System Colleges Registered Licensed Under- Post- Traditional Pharmacies of

graduate graduate Practitioners Traditional MedicineAyurveda 196 49 3,66,812 8,405Unani 40 03 40,748 549Siddha 02 01 12,911 417Homoeopathy 149 15 1,88,527 903Naturopathy – – 402 –

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


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Consultative Committee, both of which arestatutory committees where the views ofexperts and state governments arediscussed. All the rules have statutorynationwide application.

Medical Education and theregistration of the TraditionalMedicine practitionerCountries like India and China havetheir own registration processes fortraditional medicine practitioners. In India,a student must pursue a five-and-a-half-year degree course after the school levelto be able to qualify as a registeredpractitioner of Ayurveda, Unani, Homoeo-pathy or Siddha Medicine. The IndianParliament enacted an Act for the CentralCouncil for Indian Medicine (CCIM) in1970 and for the Central Council ofHomoeopathy (CCH) in 1973. These havebeen set up on the lines of the MedicalCouncil of India (MCI), patterned on theGeneral Medical Council of UK. Theeducational standards for collegesincluding the curriculum, are laid down bythe Councils which grant recognition toeducational institutes, which also have thepowers to regulate the admission capacity,on an appraisal of the infrastructure.Affiliation is granted by the universities.

Gujarat Ayurved UniversityThe Gujarat Ayurved University atJamnagar is the only statutory universityexclusively devoted to Ayurvedic studiesand research. It has facilities for teachingAyurveda up to graduation level as wellas for the M.D. and Ph.D. courses inAyurvedic Medicine. It has Departmentsof Basic Principles, Dravyaguna(Pharmacology), Rasashastra (Alchemy)and Bhaishajya Kalpana (Pharmaceutics),Kayachikitsa (Internal Medicine), Shalya(Surgery), Shalkya (eye and ENT),

Kaumarabhritya (Maternity and ChildHealth), etc., and laboratories forbiochemistry, pathology, pharmacology,modern pharmaceutical chemistry,pharmacognosy and experimentallaboratories. These laboratories providesupport for research projects by utilizingthe ancient knowledge of Ayurveda.

Responding to the growing interest inAyurveda, the University has broad basedits training programmes and also facilitiesfor special diploma and certificate coursesin Ayurveda for foreign professionals andstudents. An International Centre forAyurvedic Studies has also been establi-shed. The courses run by the University areindicative of the different approachesavailable for educating and trainingstudents to equip them with varyingdegrees of competence to learn about andpractise Ayurveda.

Presently, 18 students from 12countries have completed different coursesat the University. Requests for affiliationhave already been agreed to in the case ofthree foreign institutions and six morerequests are under consideration. This isindicative of the role that traditionalmedicine is destined to play as more seriousinterest devolves on understanding thephilosophy and practice of Ayurveda.

Issues of Registration andPracticeFor traditional medicine to be accepted ona wider scale, it is necessary for the practi-tioners to be exposed to an educationalsystem and to possess registration topractise medicine. While there can alwaysbe a case for the continuance of traditionalhealers and their oral family traditionpassed on from generation to generationin order to play an effective role in thehealth system, practitioners need to gothrough a course of educational training


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and skills acquisition if they are to treatpatients at a level beyond that of homeremedies for common ailments.

Traditional medicine practitioners whohave undergone a degree course are fullyqualified to perform tasks like supervisionof TB drug intake, dispensation of malariadrugs and screening of STI and RTI cases.They can facilitate referrals, undertakecounselling and advocacy for theprevention of HIV/AIDS and help identifycases of cataract blindness. Since mosthealth system managers are doctors fromthe public health stream, they do not readilyaccept this paradigm, which is whygovernments need to declare andimplement a policy on the utilization ofthese practitioners. The challenge is toencourage traditional practitioners toprimarily use their own systems and to buildawareness among the public that relyingon traditional remedies for commonproblems could be safer in the long run.The practitioners can nevertheless beassigned specific duties after beingscreened for their knowledge and skills, andtrained in fulfilling public health responsi-bilities besides practising their own systems.In order to see that this does not lead tosuch practitioners practising allopathicmedicine, governments need to specifywhat can be done by such practitioners andshould supervise and monitor their work.

Issues of access to TraditionalMedicineFor any traditional medical system to worksuccessfully, medicines of standard qualitymust be available at reasonable prices. InIndia, the problem has been addressed byspecifying an Essential Drug List to be usedat the dispensary and hospital levels for thekind of ailments for which people generallyseek the services of traditional medicinepractitioners and where drugs are easily

available. The list comprises some 315medicines falling under 19 categories ofdiseases and problem areas. It has beencalculated that health departments wouldneed to set aside about $950 per facilityper year if classical (generic) medicines areused for an OPD clinic visited by 50patients a day. Such lists are available inother countries too. Several of them aremanufactured in Government-ownedpharmacies or are purchased frommanufacturers.

There are over 9000 licensedpharmacies manufacturing a vast array ofdrugs catering to a wide range of humanas well as veterinary problems. Theirpreparations conform to original classicaltexts or with some deviations, which putthem in the category of patent proprietarymedicines. These medicines are availablewith allopathic chemists who stock Indianmedicines or with special grocers. Thepublic in India are well-acquainted withthese remedies, which are aggressivelyadvertised and marketed throughout thecountry.

Ayurvedic medicines generallycomprise several items.31–34 These include:

Arka – Arkas are liquid preparationsobtained by condensation of vapoursby the process of distillation.Pak – Avaleha – Avaleha or Leha is asemi-solid preparation of drugs,prepared with the addition of sugar orcandy and boiled with the prescribeddrug juice or decoction, useful forchronic ailments. These preparationsare usually tonics.Chyawanprash – is an example ofAvaleha and is useful as a health tonicin any season. It is especially indicatedfor chronic respiratory problems andgeneral debility. Apart from beingparticularly useful in warding offchronic coughs and respiratory


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problems, it revitalizes the metabolicfunctions.Asavas and Arishtas – These aremedicinal preparations made bysoaking the drugs, either in powderform or in the form of decoction, in asolution of sugar or jaggery for aspecified period of time, during whichthe mixture undergoes a process offermentation generating alcohol, thusfacilitating the extraction of the activeprinciples contained in the drugs.There are several kinds of Arishtas andAsavas but more than 30 suchproducts are available commonly.Vati-Gutikas – These are in the formof tablets or pills made of one or moredrugs of plant or mineral origin andthese too comprise several items. Theiruses range from the treatment ofjaundice, hyperacidity, intestinal colic,distention of the abdomen and loosemotions to chronic fevers.Churna – Churnas comprise finepowders of single or multiple-plantdrugs and are usually taken asappetizers or digestives and still othersas purgatives. Shatvaryadi Churnasare widely used for abdominal colic,griping, constipation, worm infestationand acidity. Trifala Churna is used forchronic constipation and dropsicalconditions and is also used forimproving eyesight.Guggulu – Guggulu is an exudate,obtained from the plant Commiphoramukul. It has excellent properties fortreating pain, nervine problemsand skin diseases. Combination ofGuggulu and herbal powders has beengiven names like Triphla guggulu andYogsay guggulu.Ghritas – Ghritas are preparations inwhich ghee/butter is boiled with theprescribed decoction according to the

Ayurvedic formula. These are useful inthe treatment of mild fever and inmaking the body healthy and strong.They are useful in epilepsy and mentaldisorders, genito-urinary disorders,conjunctivitis and night blindness.Ayurveda also has a large number ofmedicated oils (Tailas) which are usefulfor different kinds of pain in differentparts of the body. Medicated oils arealso available for hair problems, skindiseases and anorectic problems.All these items are prepared accordingto Ayurvedic principles and the entirerecipe, its composition, the formula,the English and botanical names of theitems, the parts in which the prepa-ration is made, the indications and thedoses, are all available in Pharmaco-poeias and with the companies whichmanufacture the products. Since allthese items have been in common usefor centuries and the recipe hasremained exactly the same as in thecase of classical medicines, the Indianpublic has confidence in their use.

Conclusion

The entire spectrum of the role of traditionalmedicine in the health system is much toolong and varied between and acrosscountries and cannot, with due justice tothe subject, be encapsulated in a singlechapter. Every country has its own healthsystems and, within the health system,resources have to be found to pay for thesalaries of the providers, equipment, drugsand consumables. All governments areconcerned about bringing down costs,improving access to health and healthoutcomes and, most important of all,preventing ill-health. Many countries haveexperienced acute problems in trying to doall that medical science and a public health


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conscience require one to do. Debatesabout investment in tertiary health versusprimary health, health insurance versusvoluntary safety nets for the poor, publichealth versus preventive care, standardsetting versus voluntary accreditation andself-regulation, and over-diagnostics versusthe family physician approach, abound inevery country. Through all this runs animportant thread which essentiallydetermines whether health systemsreally work, and that refers to the publicdemand, consumer satisfaction and cost-effectiveness.

Consumer demand for improvedhealth outcomes, more choices, less side-effects, less resistance patterns, less intakeof chemicals and synthetic drugs, greaterreliance on natural and environmentallyfriendly products, all have pointed to theburgeoning interest in natural plant-basedproducts and a desire to go back to natureand investigate and re-package oldstrategies, prescriptions and antidotes tomeet the emerging problems of today.Traditional medicine has much to offer andthe sheer volume of empirical knowledgeand the areas of application are sovoluminous that it would be difficult to everconclude which system, which drug andwhich application is superior to another.

Traditional systems which are highlydocumented and which are backed bystatute and by regulatory and enforcementmechanisms, are bound to be taken moreseriously than those which depend only onthe faith of the consumer or the confidencegenerated by word of mouth, howsoeverconvincing it may be. Since the medicationof an individual can lead to all kinds ofeffects years from now, governments have

a responsibility to ensure not only theefficacy of the medicine but, moreimportant, its safety. This can only be doneby making available quality medicine andregistering the practitioners who can beheld accountable. The experience of Indiaclearly shows that it is possible to havetraditional systems which can be usedstrongly and effectively to reinforce thehealth system. However, what is essentialis strong policy support to give the systemnational stature, resources to conductevidence-based research and to includepractical strategies for different traditionalmedical practices to provide an alternativeor to complement the work of the normalhealth system.

In this paper, an effort has been madeto place a few examples of what is possible,what can still be done and what is alreadybeing done before a public that wants tounderstand how it can be done and whereit would be most relevant. Not all prescri-ptions given in this paper can be applieduniversally or emulated entirely. Theyrequire investment in time and resourcesto understand where traditional medicinecan contribute most meaningfully, resultingin better health outcome. But, mostimportant of all, they require an open mindto the development of health systems whichrise above the ordinary, an end to the hubristhat surrounds traditional medicine todayand the strength to determine what canbe offered to a hungry and curious publicwith a sense of legitimacy that the situationdemands. Now is the time to make betteruse of the traditional system to augmentaccess to health care, based on empiricalevidence, public demand and cost-effectiveness studies.


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References

1. Essential Ayurvedic Drugs for Dispensaries & Hospitals. Department of Indian Systemsof Medicine & Homoeopathy. Ministry of Health & Family Welfare. Government ofIndia. New Delhi. 2000.

2. A Handbook of Domestic Medicine & Common Ayurvedic Remedies, Central Councilfor Research in Ayurveda & Siddha. Janakpuri. New Delhi. 1978.

3. A Handbook of Common Remedies in Unani System of Medicine. Central Council forResearch in Unani Medicine. Janakpuri. New Delhi. 1977.

4. Indian Systems of Medicine & Homoeopathy in India. Ministry of Health. Governmentof India. New Delhi. 1998.

5. Ayush-64 A New Anti-Malarial Herbal Compound. Central Council for Research inAyurveda & Siddha. Janakpuri. New Delhi. 1987.

6. Chari, M.V. et. al. Double-blind Clinical Trial with Ayush-64 an Ayurvedic drug inP.Vivax Malaria, Jour. Res. Ay. Sid. Vol. VI. 1985.

7. Valecha, Neena. et. al. Comparative Efficacy of Ayush-64 Vs. Chloroquine in P. VivaxMalaria. 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 Researchin Ayurveda & Siddha. Janakpuri. New Delhi. 1989.

10. Singh, Ramji et. al. Puskara-Guggulu, an Anti-anginal and Hypolipidemic Agent inCoronary Heart Diseases (CHD). Jour. Res. Ay. & Siddha. Vol. XII. 1991.

11. Effects of Varuna (Craetavia nurvala). In: Enlarged Prostate-associated Urinary DisordersCentral 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 CrossoverTrial. 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 forResearch in Ayurveda & Siddha. Janakpuri. New Delhi. 1989.

16. Shukla N.K., Narang R., Nair K., Radhakrishana S. and Satyavati G.V. Multicentricrandomised controlled clinical trials of Ksharasootra (Ayurvedic medicated thread) inthe 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 inAyurveda & 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 inthe 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 UnaniMedicine. Janakpuri. New Delhi. 1992.

21. Report on Clinical Study of Iltechab-E-Kabid Had (Infective Hepatitis). Central Councilfor 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 blindplacebo 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 HIVcarriers. 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. NewDelhi. 1978.

29. Ayurvedic Formulary of India (Part–II). Ministry of Health. Government of India. NewDelhi. 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 ofIndia. New Delhi. 1981.

33. National Formulary of Unani Medicine (Part-II) Ministry of Health. Government ofIndia. New Delhi. 1998.

34. Unani Pharmacopoeia of India (Part-I). Ministry of Health. Government of India. NewDelhi. 1998.

35. Siddha Formulary of India (Part-I). Ministry of Health. Government of India. NewDelhi. 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.

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focused around issues of safety, efficacy,standar-dization and quality control. In theabsence of serious investment in the sectorover the past two decades that thisdiscussion has been running, the issuesand arguments have been reiterated timeand again without any substantial impacton policy or programmes.

Recent policy interest in this field hasadded a new dimension to the discussion.This is an economic dimension and theemergence of economics into the TRMpolicy discussion signals a new seriousnesson the part of policy-makers.

In the United States, Canada, Europe,Australia and New Zealand, health policy-makers and medical insurers haveaccepted that half or more of the public isusing some form of complementarymedicine (CM) on a regular basis andlargely paying for this ‘out-of-pocket’. Inthe US, an estimated $27 billion was spentin 1997.1 In Australia in 1996, theestimate was $AU621 million – more thanthe amount spent on pharmaceuticaldrugs.2 And in the UK, it has been

A framework for cost-benefit analysis oftraditional medicine andconventional medicine

estimated that £1.6 billion is spent ‘out-of-pocket’ on CM annually – in additionto the £40 billion spent by the NationalHealth Service.3

As a result, the focus of policy hasshifted beyond the necessary requirementsthat products and services be at least safeand, ideally, effective. A new considerationin assessing CM is whether CM servicesare economically competitive with conven-tional health services. As governments andinsurers increasingly focus on servicedevelopment in traditional and comple-mentary medicine, the challenge toaddress basic economic questions isbecoming one of central importance.

Potential Areas of CostSaving in TraditionalMedicine

White and Ernst (2000) have outlined fivebroad areas in which there may be potentialfor cost savings from the use of CM3.

Cost of drugs;Visits to a doctor;Secondary referral;Adverse events arising from conven-tional therapies;Prevention of future disease.

Gerard Bodeker

MIntroduction

uch of the discussion on research intotraditional medicine (TRM) has


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At present, the public in both developingand industrialized societies appear to beusing conventional medicine as well as TRMor CM in an integrated way, wherever thisis possible.4,5 The question of cost savingspresumes a different question: that ofsubstitution. In other words, while the publicis combining health services in a pluralisticmanner, integrating conventional and CM/TRM into their overall care programme, thechoice that is posed within an economicframework is: ‘Can traditional therapiessubstitute for conventional treatments?’ Ifnot, the combination of traditional andmodern medicine can be seen, from aneconomic perspective, as simply adding tothe cost of care.

Underlying the dichotomy between thetendency of consumers to combine healthcare approaches from conventional andTRM, and the practice of medical insurersand health care providers to seek the singleleast expensive care option, rests the deeperpolicy issue of whose perspective andpriorities should determine the nature ofcare that is offered – the consumer, thepurchaser, or society in general. In applyingor interpreting economic analyses oftraditional health care services, it is firstnecessary to specify the perspective fromwhich the analysis is being conducted.Thus, issues of economics can be weighedagainst questions of ethics, consumerchoice, quality of life and the wider societalimpact of a particular intervention. Withthis perspective as our starting point, it willbe useful to consider the various metho-dologies used in assessing the economicmerits of health care approaches.

Methods of economic analysis

A range of methodologies exist forexamining the economic issues associatedwith the provision of health care.6 These

can be as readily applied to the utilizationof traditional and complementary healthservices as to mainstream medical services.The starting point for the choice ofmethodology is the research question beingposed. This may be positioned from thepublic sector perspective: namely,determining those health care interventionsthat maximize health gains in a society andto determine allocative efficiency, viz., thebasis for deciding how best to choose onallocating resources to one form oftreatment over another. Other researchquestions may reflect the perspective of aninsurer, where the issues are different.

Cost descriptionsThis would entail collecting and collating allcosts involved in providing a particulartraditional health care service. Thisapproach provides baseline data for furtherstudies, but does permit other providers toknow what the costs of a particulartreatment programme may be. This type ofresearch does not provide data ontherapeutic outcomes.

Cost-comparison researchThis entails a comparison of the costs oftwo or more treatments which are designedto achieve a common outcome. White andErnst (2000) have noted that a limitationof this approach is that treatments,including drugs, rarely have directlycomparable outcomes.3 Thus the cost-comparison is at risk of being a comparisonof the proverbial ‘apples vs. oranges’ type.

Cost-effectiveness analysisThese studies are designed to measure thecosts of producing a change in a particularhealth outcome, e.g., life years, bloodpressure. In their analysis of differenteconomic methodologies for assessinghealth care strategies, White and Ernst


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point out that this approach overlooks otherbenefits that a therapy may generate aswell as such negative effects as unpleasa-ntness of the treatment or side-effects.

Cost-utility analysisThis is primarily oriented to assessingpatient satisfaction with a treatment.Instruments used may be a quality-of-lifeinstrument, such as the WHO Quality ofLife Assessment Scale. While comparingdifferent treatments and their outcomes interms of patient satisfaction, this metho-dology does not address the question ofwhether the treatment is worth the financialoutlay on it.

Cost-benefit analysisAt the centre of this approach is amethodology designed to assess patients’willingness to pay (WTP) for the benefits thatthe treatment provides. This is thencompared with the actual cost of thetreatment to determine if it provides valuefor money. A challenge of this approach isto define outcomes in monetary terms. Thischallenge has meant that very few soundstudies have been done to determine thecost-benefit issues associated withtraditional therapeutic modalities. A furtherlimitation is that WTP does not necessarilyindicate ability to pay (ATP).

Households may persist in paying forcare, but to mobilize resources they maysacrifice other basic needs such as foodand education, with serious consequencesfor the household and individuals within it.The opportunity costs of payment make thepayment “unaffordable” because otherbasic needs are sacrificed.7

Backdrop to the EconomicAnalysis of Traditional MedicineThere are at least two major forces at workthat drive the growing demand for some

sort of framework for the analysis of TRMin light of conventional medical options.The first of these is a powerful social trend,namely, the growing public demand forTRM and CM worldwide. The second is themove by governments towards integratingtraditional health services into nationalhealth care and the need for TRM progra-mmes and departments to justify the valueof their sector in both therapeutic andeconomic terms.

In the following sections, we will reviewthe issues involved in each of these broadforces or emerging societal trends. Thenwe will move to a consideration of the costissues entailed in traditional health careservices. Finally, there will be a conside-ration of the policy implications of thesetrends and the beginnings of a frameworkfor the economic analysis and comparisonof traditional and conventional health careservices.

Utilization

The widespread demand for TRM serviceshas been recognized as an enduringphenomenon and early calls for TRM tobe replaced by modern medical serviceshave now given way to recognition thatsome degree of formalization of thesehealth services might offer the publicincreased standards of quality and safety.

In both industrialized and developingsocieties, use of CM and TRM is on therise.

In 1993 research at Harvard Universityfound that 30 per cent of Americans wereusing some form of CM on a regular basis.In 1998, the same research team reportedthat this number had increased to 40 percent of the population.1 Researchpublished in The Lancet in 1996 reportedthat 40 per cent of Australians were usingsome form of CM.2 In April 1999,


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legislation to establish an Australian Officeof Complementary Medicines was annou-nced in Australian Hansard as beingwarranted since 60 per cent of Australiansregularly use some form of CM. Demandis spiralling at rates that outstrip thecapacity of national health policy to keepabreast.

In the US, higher educational level,higher income, and poor health have beenfound to be predictors of CM use.4

Americans and Australians typically pay outof pocket for CM services. Americansspend more out of pocket on CM than onall US hospitalizations. Australians spendmore on CM than on all prescriptiondrugs. Women have been found to be themajority of CM users in the US, the UK andAustralia.

Use of traditional medicine indeveloping countries

Traditional health care (THC) remains thesource of everyday health care for themajority of the population of most non-industrialized countries. The World HealthOrganization has consistently estimatedthat between 60–80 per cent of thepopulation of these countries rely on THCfor their basic health care needs –sometimes on its own and sometimes inconjunction with modern medical care.Studies show that demand is on theincrease in many countries.

The much-quoted figure that of 80 percent of the population of many countriesutilize TRM for their everyday health needsis overdue to be questioned.

A survey of the literature reveals adiverse range of findings on utilization ofTRM services. The much-cited figure of 80per cent becomes far less clear and it isevident that the needs of specialpopulations – women, the elderly, children,rural communities, immigrant groups, etc.– must all be taken into account whenassessing who uses TRM care services, whyand in what relationship with the use ofmodern medical services. The value ofconsidering these findings includes thefollowing:

For planning purposes, research intohealth service utilization is a necessaryprerequisite for establishing the needfor, the nature of and the size of THCservices;Such studies illustrate the diversity ofmodels used for studying patterns ofutilization of THC services – includingethnographic research, surveyresearch and, in the US, telephonesurveys;The data highlight the great diversityin patterns of use according to region,age, education, gender, income,availability of medical insurance,perception of TRM, and distance tomodern medical facilities.In many countries, life begins with the

support of TRM. An estimated 60–70 percent of births in developing countries stilltake place with the sole help of traditionalbirth attendants.8

Africa

There have been many generalguesstimates of the extent of use in Africa.Bannerman (1993) estimated that TRM

“In many countries, 80 per cent or moreof the population living in rural areas arecared for by traditional practitioners andbirth attendants.”

(Bannerman, R.H.: Burton, J. & Ch’en,W-C. In Bannerman, R.H. TraditionalMedicine and Health Care Coverage.

WHO. Geneva. 1993).


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caters for the health needs of 80 per centof the African population.9 This figureechoes an earlier estimate of 80 per centmade by Koumare (1983).10

However, some estimates of use arestrikingly low. Shiferaw (1993), for example,reports on an interview-survey of perceivedmorbidity in a rural community in South-western Ethiopia, where 55.4 per cent ofthose reporting illness took no action at all;30.3 per cent applied to health institutions,9.2 per cent reported self-care, and only5.2 per cent visited a traditional healer.(11)

By contrast, research done at MogopaneHospital in North-eastern Transvaal, SouthAfrica, showed that nine out of 10 patientswho come to the out-patients departmentfirst consult traditional healers.12

Clearly, studies of community groupsand of hospital populations address theneeds and choices of different populationswith different health profiles. In planningservices such differences need to beaccounted for.

Age and gender are factors in theutilization of THC services. A study of visitors

to traditional healers in central Sudanindicated that children under 10 years didnot take part in visits. Most visitors werebetween 21 and 40 years (61%) and werewomen (62%). They were less educatedcompared to the general population in thearea. The main reasons given for attendingtraditional healers were treatment (60%)and blessing (26%).13

In Mali, men are more likely to prefertraditional treatments for malaria thanwomen,14 and more boys than girlsbelieved in herbal medicine in a survey inthe Sudan.15 It has been suggested thatwomen are less likely to be treated atmodern facilities, and are more likely toresort to traditional medicines.16

People with a serious health conditionmay seek THC before accepting modernmedical services. In Malawi, 37 per centof TB patients reported attending atraditional healer prior to attending thehealth service. By the time a final diagnosisof TB was made, most patients had visitedseveral different care providers: privatepractitioner (69 visits), village clinic (64)

Table 1. Adult conditions taken to indigenous healersfrom Shai-Mahoko (1996)

Condition No. of respondents Percentage[healers]

Infertility 32 91Septic sores 31 89Impotence 30 86STDs 28 80Deliveries 28 80Asthma 23 66Mental illness 21 60High blood pressure 20 57Palpitations 15 43TB 14 40Alcoholism 12 34Diabetes 9 26Cancer 9 26


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and traditional healer (40), and 32 patientsreported taking some form of traditionalremedy at home.17

Travel time can be a factor in the choiceof traditional over modern medical services.

Among comments made by traditionalmidwives in South Africa, in a study byTroskie (1997),18 was that “the nearesthospital is 20 kilometres far”. Similarresponses were recorded from clients. InKwale district, Kenya, which has one healthservice facility for 12,000 people, it hasbeen estimated that 24 per cent of thepopulation has a health facility within twokilometres distance, 58 per cent within fivekilometres and 83 per cent within 10kilometres.(18) By contrast, THC servicesare readily available. Every village has anumber of traditional healers and birthattendants, each with their ownspecializations.19

Similarly, in India, rural women inGujarat were more likely to use serviceswhich were closer to home, other thingsbeing equal. The “travel” variable (includingtime and travel costs) is a more importantfactor determining the use of modern andtraditional services among women in thestudy area than the actual direct costs ofthe service.20

In the case of malaria, selection of first-line treatment varies from area to area.Sometimes, herbal remedies are given athome as the first-line treatment,21,22

especially in mild cases of malaria.23,24

Sometimes, herbs are the second line aftertreatment with chemotherapy hasfailed.25,26 Munguti (1998) found that ina rural area of Kenya, seven per cent usedherbs as the first choice of treatment, 17per cent as the second choice, and 14 percent as the third choice.27

There can be contrasting patterns ofuse across countries and regions. Whereasyoung children in Sudan were found not

to attend traditional healers, in Kenya 40per cent of sick children were taken to themganga [traditional healer] and 55 percent to the clinic; 26 per cent of themothers said that both sources of treat-ment were consulted.19

There are usually differences betweenurban and rural populations in their use ofTRM and modern medicine. While 95 percent of urban women who attendedmodern medical clinics in South Africastrongly advocated mixing traditional andwestern antenatal care, only 63 per centof rural clinic attenders found this practiceacceptable. All groups favoured Westernover traditional care in cases of seriouspregnancy complications.28

Asia

In India, it has been found that theinfluence of family structure is significant.The presence of the mother-in-law isassociated with a greater use of traditionalhealers.20

Inadequacies in and scarcity of modernmedical services can contribute to the useof traditional health services. Less than half(44%) of Chinese immigrants studied in theUSA had used Western health services inthe US within the previous 12 months; 20per cent reported that they had never usedthem. Chinese physicians stated that manyChinese patients are not satisfied withAmerican doctors because of the inflexibilityof appointments, short visit, long waiting,distrust and miscommunication.29

In a study of health service utilizationin four villages in India, the most commoncomplaint by a majority of those surveyedwas that “medicines are never available”at the primary health centre, followed bydiscourteous behaviour of the staff andhealth personnel, “doctors neveravailable”, “doctors demand money for


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better treatment”, and so on. Almost aquarter of the women initially triedhomoeopathic treatment, followed by nineper cent who administered Westernmedicine at home, and two per cent optedfor traditional home remedies for cure andtreatment, before visiting and consulting atrained medical practitioner. Medicalpluralism was found to be flourishing aspeople switched from one medical systemto another depending on affordability andtime.(30)

In Sri Lanka, two patterns of healthcare seeking which cut across modern andtraditional medical systems were identified.The first involved patients who searched fora medicine which could cure or served asa commodified fix for health. The secondpattern involved the search for a practi-tioner who had the power of the hand tocure one’s illness through an affinity to theirperson.31

Medical pluralism is common world-wide as consumers practise integratedhealth care, irrespective of whether or notit is present at the formal level. In Taiwan,60 per cent of the public have been foundto be users of multiple healing systems,including modern Western medicine,Chinese medicine, and religious healing.5

Medical insurance coverage for TRMinfluences the utilization of traditionalhealth services. Most Taiwanese (86%)support the coverage of Chinese medicineby the National Health Insurance and 79per cent indicated that they would useChinese medicine if that becomes thecase.5 In the USA, whereas older Chinese/Korean immigrants are more likely thanyounger ones to use TRM, the mostsignificant difference in the use oftraditional practitioners appeared betweeninsured and uninsured individuals. Only24 per cent of the uninsured usedtraditional practitioners, compared with 59

per cent of persons with Medicaid only and71 per cent of those with other types ofinsurance including Medicare andMedigap coverage. It is likely that theinsured are those who also had moredisposable income available to pay fortraditional forms of health care.

Indigenous communitiesIndigenous communities with a history ofcolonial conquest have patterns of use ofTRM which may vary according to thedegree of official support, the spiritualneeds met by healers, and the strength andintactness of their healing traditions.

In Australia, The 1987 Review ofRehabilitation Services in the NorthernTerritory found that traditional Aboriginalmedicine is widely practised in the NorthernTerritory.32 In most regions of the NorthernTerritory, more than 22 per cent ofindigenous people had used bush medicinein the last six months when surveyed.32

The decreased use of bush medicine seemsto be because Western medicine is easierto access, not because of a lack of faith inits efficacy.32 Examples of bush medicineinclude herbal preparations, diet, rest,massage, restricted diet and externalremedies such as ochre, smoke, steamand heat.32

Packaging herbal medicines in the Institute of Traditional Medicine,Sri Lanka.



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Of native American patients attendingan urban Indian Health Service clinic inWisconsin, the mean age of patients was40 years and the sex distribution was 68.7per cent women and 31.3 per cent men;38 per cent of patients see a healer, andof those who do not, 86 per cent wouldconsider seeing one in the future. Mostpatients report seeing a healer for spiritualreasons. The most frequently visited healerswere herbalists, spiritual healers andmedicine men. Sweat lodge ceremonies,spiritual healing, and herbal remedies werethe most common treatments. More thana third of the patients seeing healersreceived different advice from their physi-cians and healers. The patients rate theirhealer’s advice higher than their physician’sadvice 61.4 per cent of the time. Only 14.8per cent of the patients seeing healers telltheir physician about their use.33

Policy Points

(1) There is much variation in patterns ofuse of THC services across communities,regions, age and gender groupings,income levels, and according to accessto other health care services.

(2) Utilization studies are a sound startingpoint for traditional health servicedevelopment. Good studies canidentify categories of need, targetgroups, geographical priorities, andpotential areas of partnership betweentraditional and modern medicine.

Formalization of TraditionalHealth Services

The term ‘integration’ has come to bewidely used to express the formalizationand official incorporation of TRM intonational health services. However, the termhas a more specific meaning.

Historically, the relationship betweenmodern and traditional medicine has takenfour broad forms

A Monopolistic situation, wheremodern medical doctors have had thesole right to practise medicine;A Tolerant situation, or one ofCo-Existence where traditional medicalpractitioners, while not formallyrecognized, are permitted to practise inan unofficial capacity;A Parallel or dual health care model,as in India, where both modern andtraditional medicine are separatecomponents of the national healthsystems;An Integrated model where modernand traditional medicine are integratedat the level of medical education andpractice (e.g. China, Vietnam).In this discussion, the term

‘formalization’ will be used to characterizeboth the last two forms, given above.

Asia has seen the most progress inincorporating its traditional health systemsinto national health policy. Most of thisdevelopment began 30–40 years ago andhas accelerated in the past 15 or moreyears. In some Asian countries, thedevelopment has been a matter of officialpolicy, e.g., China, while, in others, changehas come about as a result of a process ofpoliticization of the TRM agenda, e.g., Indiaand South Korea.

In China, the process of integratingtraditional Chinese medicine (TCM) into thenational health care system began in thelate 1950s and was, in significant part, inresponse to national planning requirementsto provide comprehensive health careservices. Prior to this, TCM had been viewedas part of an imperial legacy to be replacedby a secular health care system.

The process of integration was guidedby health officials trained in modern


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medicine, and harmonization with modernmedicine was the goal of integration fromthe outset. This was accomplished by ascience-based approach to TCM educationand an emphasis on research into TCM,both supported by a substantial organiza-tional infrastructure. Integration anddevelopment of TCM was managed via aprocess of centralized national planning.

More than 40 years on, the StateAdministration of Traditional ChineseMedicine in China now comprises eightfunctional departments. The departmentsare:

Office. Responsible for overallcoordination;Department of Personnel, Labour, Lawsand Regulation. Devises organizationalstructures; formulates technicalstandards for TCM professionals;administers qualifications; studies andformulates the guiding principles,policies and development strategy ofTCM; drafts laws and statutes;organizes research; coordinatespublications and media, etc.;Planning and Financial Department.Formulation of development progra-mme; administers the State’s specialfunds and loans for TCM; import andexport activities; regulates overallbalance; Medical Administration Department.Directs implementation of develop-ment plan for TCM in urban and ruralareas. In charge of macroscopicadministration and technical develop-ment in all kinds of TCM institutions,including state, collective, private andjointly owned hospitals of TCM;hospitals combining TCM and Westernmedicine, etc.;Production and Circulation Depart-ment. In addition to directing/super-vising production, trade, packaging,

storage, etc., it also administersprotection of wild medicinal resources(including medicinal resources inimminent danger);Department of Quality of TraditionalChinese Drugs. Formulates qualitystandards and technical standards forTCM products; supervises and inspectsproduction;Scientific, Technical and EducationalDepartment. Directs construction ofscientific research institutes andlaboratories; organizes research,development, appraisal and academicexchanges, etc.; directs protection ofintellectual property rights (IPR);administers proficiency examinations inTCM, etc.;Foreign Affairs Department. Admini-sters and directs state technical andeconomic cooperation and academicexchange of TCM with foreigncountries.34

In 1995, the total production of herbalmedicines in China reached 17.57 billionChinese yuan in value, an increase of212.6 per cent since 1990. In that year,sales of herbal medicines accounted for33.1 per cent of the drug market in China(Source: WHO SE Asia).

In 1980, China was the first countryto negotiate a component for TRM withina World Bank health sector loan. A morerecent World Bank-financed expansion ofhospital beds included provision that 20per cent of these would be in hospitals ofTRM.35

In addition to formal integration ofmodern and traditional medicine in China,the public are pluralistic in their health careutilization, rendering integration a realityat the grassroots level. A survey carried outin two village health clinics in ZheijangProvince, China, showed that children with


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the lines of Western biomedicine andoriental medicine (OM) is one of theprominent aspects of the health careservice. This was established by law in1952.

In 1996, there were 9299 licensedOM practitioners compared to 59,399Western practitioners. OM doctors operatein the health care services in the same wayas other medical care providers, with somenotable differences. The private sector isdominant in OM, with almost all OMhospitals and primary clinics being privatelyowned and operated. The great majorityof OM doctors work in self-employedprivate settings at the primary care level.In 1995, the concentration in urban areasof OM clinics and hospitals (95.1%) washigher than that of Western medical clinics(90.6%) and hospitals (86.4%). Politicalconflict between the OM and modernmedical sectors has been high during the1990s over issues of fees, ability to sell andprescribe traditional herbal medicines andlicensing of traditional practitioners.

The level of coverage of OM in theNational Medical Insurance is low and, asnoted in the section on Finance, there isreluctance on the part of most OM practi-tioners to provide insurance cover for OM.37

A policy guideline on OM was adoptedfor the Seventh Project of the 5-yearEconomic and Social Development Planin Korea (1992–1996). The guideline set agoal for full integration of Western andOriental medicine by the year 2001. Anumber of short- to medium-term mea-sures were recommended to improve thequality of OM care: promotion of clinicalcooperation, training of OM consultantsand lifting the customary ban on OMdoctors’ employment in the public hospitalsector. An OM care unit was set up forthe first time in the National Medical Centerin 1991.37

upper respiratory tract infections werebeing prescribed an average of fourseparate drugs, always a combination ofWestern and Chinese.36 A challenge ofintegrated health care is the need toconduct research to determine whichillnesses are best treated through oneapproach rather than the other. TheZheijang study reported that, in practice,simultaneous use of both types of treatmentis so commonplace that their individualcontributions are hard to assess.

In South Korea, the parallel operationof two independent medical systems along


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In India, the Parallel Model offormalization of indigenous medicine wasadopted when the Central Council ofMedicine Act was promulgated in 1970.India’s formalization of its indigenoussystems of medicine came after a centuryof committees had unsuccessfullyattempted to create this outcome. Theelection to Parliament of the President ofthe All-India Ayurveda Congress, PanditShiv Sharma, and the election of atradition-oriented Prime Minister, MorarjiDesai, combined to create the conditionsfor a political solution when policy reformhad been unsuccessful. The Act set up aCouncil to oversee the development ofIndian Systems of Medicine and to ensurethat standards of training and practicewere developed according to bothtraditional requirements and Governmentstandards of good clinical practice.Training would be in separate colleges, ofwhich there are now well over one hundred.

Current priorities of the Department ofISM include education, standardization ofdrugs, enhancement of availability of rawmaterials, research and development,information, education and communi-cation and larger involvement of ISM in thenational health care delivery systemincluding Reproductive and Child Health(RCH). Due to the high cost andunavailability of modern medical servicesin rural areas of India, the IndianGovernment has undertaken to add 10medicines from the Ayurvedic and Unanisystems into its national family welfareprogramme. A pilot project, designed tolast till 2003, is currently beingimplemented in seven Indian states forAyurveda while Unani medicines are beingintroduced in four cities. The RCH projectis co-funded by the World Bank and theIndian Government. The medicines, whichare all traditional herbal formulations, will

be for anaemia, oedema duringpregnancy, post-partum problems such aspain, uterine and abdominal compli-cations, lactation-related problems,nutritional deficiencies and childhooddiarrhoea. Also included are massage oilsfor babies and mothers that are alreadyused routinely in Indian households.Concurrent evaluation and monitoring willbe done to oversee acceptance levels andto ensure quality in drugs administrationand storage and to monitor the sustaina-bility of the programme.

Under Taiwan’s current health caresystem, Chinese medicine is reported tohave a subordinate role to Westernmedicine,5 more characteristic of theTolerant or Coexistence model describedat the beginning of this section. This isapparent in three ways:

Limited participation of Chinesemedicine practitioners in any publichealth policy-making and programmes;Small proportion of Governmentmedical resources allocated to thetraining, research and practice ofChinese medicine;Loose licensure system for Chinesephysicians.

Two parallel licensure systems for Chinesephysicians exist in Taiwan:

The Chinese Medicine PhysicianLicense Exam (CMPLE)The Chinese Medicine PhysicianSpecial License Qualifying Exam(CMPSLQE).]

The CMPLE is offered only to personswith medical degrees in Chinese medicine.One medical college in Taiwan offersformal training and a medical degree inChinese medicine. The CMPSLQE has noeducational or training prerequisites andany citizen of Taiwan may apply for the first


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level of the Qualifying Examination. Afterpassing, they can proceed to the secondlevel of Special License Examination. Onpassing the second level of examination,graduates can obtain the ChineseMedicine Physician (CMP) license. The twolicenses, CMPLE and CMPSLQE, carry thesame privileges and there is no way forpatients to distinguish between the two.5

Debate in Taiwan on improvingChinese medicine focused on whether theGovernment should begin with research orbuild a medical school. Characteristic ofmany governments, research was givenpriority and the Government establishedthe National Chinese Medicine and DrugsResearch Centre. Establishing a Chinesemedical school was left to the private sector.The resultant China Medical College –established in 1958 – is the only suchcollege in Taiwan and has been consideredto have been under-funded and inade-quately equipped.

Recommendations made by TheCommission on Health Research forDevelopment,39 for strengthening essentialnational research, such as the support andcooperation from industrialized nations,should also extend to the area of researchin TRM and its integration. It has beenargued that the global community shouldpromote cooperation and informationexchange centred on integrationstrategies.5

In Africa and the Americas, traditionaland indigenous medicine is informal, insome cases operating under a Monopolistic

situation controlled by orthodox Westernmedicine. In others, a more Tolerantsituation exists, but in the absence of officialrecognition or health sector investment indevelopment. The same applies to indi-genous medical traditions in Australia.

Traditional Medicine and theFormal Health sector in AfricaThere has been a long-reported willingnesson the part of traditional healers in Africato collaborate with the formal sector andto establish joint training. Burnett, et al.,(1999) note that 37 of the 39 traditionalhealers (94%) and 14 of the 27 formalhealth workers (52%) interviewed in aZambian study were keen to collaboratein training and patient care relating toHIV/AIDS.40

However, this is not generally areciprocal view. Although one per cent ofnurses in South Africa are reported to betraditional healers, rural nurses inSwaziland perceived themselves as beingteachers to healers, but not learning fromhealers. They saw themselves as a sourceof referral for healers, but not the reverse.41

One view is that it may be moreappropriate to work towards a system ofcooperation between two independentsystems, with each recognizing andrespecting the character of the other.(42)

This has been the policy in Botswana,where parallel development has beenencouraged, since it is felt that one or otherof the two systems might suffer in theprocess of integration.40

WHO policies of the late 1970s and1980s have promoted the establishmentof associations of traditional healers inAfrica. During the 1990s, NGOs of tradi-tional health practitioners – associations,small groups, clinics, etc. – have grownexponentially in Africa, playing a partnershiprole in HIV/AIDS education and care,43 in

“Healers have for long been treated liketrees on savanna farms - not formallycultivated, yet valued and used,particularly by women and children”.

Last & Chavanduka (1986) in TheProfessionalisation of African Medicine.


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delivering child survival messages and inmanaging endemic disease in partnershipwith modern health care workers.

There is now an emerging momentumto begin a process of formalization oftraditional medicine in Africa.

In Uganda, new legislation is beingdeveloped to ensure a role for TRM innational health care, in part as a result ofthe successful engagement of traditionalhealers in combating the AIDS epidemic inthe country.

South Africa’s parliament, on 5 August,1998, proposed that a statutory councilbe set up to regulate the 350,000traditional healers. A report by a parlia-mentary committee on social servicesproposed that the council should presentits recommendations within three years [by2001] for the drafting of final legislation.

A Parliamentary Committee on SocialServices in South Africa proposed that theprofession of traditional healing should bedivided into four categories: the inyanga(traditional doctors or herbalists); thesangoma (diviner); birth attendants ormidwives; and traditional surgeons whomainly do circumcision. Spiritual healerswere not included because their trainingand accreditation was considered“unclear” and “ill-defined”.44

In South Africa, many traditionalhealers are members of well-organizednational organizations that are seekingformal recognition from the Government.In one instance of WHO-sponsoredcollaboration, it has been recognized thatthe rapid increase in TB caseload, especiallyin African countries heavily affected by theHIV epidemic, requires a search for effectiveways to treat patients outside hospital. Asa component of WHO’s Community Carefor Tuberculosis in Africa Project, Wilkinson,et al. (1999), studied the potential role forcollaboration between the health service

and traditional healers, especially as TBtreatment supervisors, and examined whatprecedent and potential exists for traditionalhealers to act in this role.17

Before commencing collaborativeeffort in health care between modern andtraditional sectors, a careful assessment ofpotential benefits and obstacles should bemade. The medical services utilizationpatterns of the communities need to beascertained and the specific role oftraditional health practitioners considered.In such efforts the ideas of healersthemselves about possible collaborationare crucial.19

Ghana has recently passed theTraditional Medicine Practice Act 2000, Act595, to establish a Council to regulate andcontrol the practice of TRM. The primarydraft of this act originated from thetraditional healers themselves. The Actdefines TRM as “practice based on beliefsand ideas recognized by the community toprovide health care by using herbs andother naturally occurring substances”, andherbal medicine as “any finished labelledmedicinal products that contain as activeingredients aerial or underground parts ofplants or other plant materials or thecombination of them whether in crudestate or plant preparation.” It is arrangedinto four sections, namely the establishmentand functions of the Traditional MedicinePractice Council; registration of practi-tioners; licensing of practices; andmiscellaneous provisions.

Ghana’s Ministry of Health hasincorporated a Traditional Medicine Unitsince 1991, and in 1999 this wasupgraded to the status of a Directorate.The Ministry, in collaboration with theGhana Federation of Traditional MedicinePractitioners Associations (GHAFTRAM)and other stakeholders, has now developeda five-year strategic plan for TRM. This plan


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outlines activities to be carried out from2000–2004, and will be reviewed everytwo years. It proposes, among otheraspects, the need to develop a compre-hensive training in TRM from basic andsecondary to tertiary levels.

A ‘Ghana Herbal Pharmacopoeia’,containing scientific information on 50medicinal plants, has been published. Asecond volume is currently in preparation.Efforts are being made to integrate TRM intothe official public health system and it isexpected that by the year 2004, certifiedand efficacious herbal medicines will beprescribed and dispensed in hospitals andpharmacies. The Ghanaian Governmenthas set aside the third week of March everyyear as a Traditional Medicine Week, startingfrom the year 2000.

In Nigeria, the National Agency forFood and Drug Administration and Control(NAFDAC) has taken steps to regulate andcontrol TRM products with a view toensuring their safety, efficacy and quality.In consultation with traditional healers andresearchers, NAFDAC has developedguidelines on regulating herbal medicines.Recently, the Government of Nigeriaapproved a national policy on a TraditionalMedicine Code of Ethics. Draft legislationhas been prepared to establish nationaland state Traditional Medicine Boards toenhance the regulation of TRM practiceand promote cooperation and research inTRM.45

Clearly, planning for the formalizationof traditional health services has manydimensions that need to be addressed,depending on the state of current sectoraldevelopment, level of political will, budgetresources available, training infrastru-cture, the model of formalization suitableto and preferred by the country and by thetraditional health care community. It hasbeen argued that, underlying the general

proposition for a mix of traditional andmodern medicine is an agenda of incorpo-rating the former into the political-economic arena and cultural hegemony ofbiomedicine.46 Clearly, if TRM is to be givena formal place in national health care, thisprocess needs to be done not only in closeconsultation with the traditional healthsector, but taking direction from them asto appropriate models of partnership,formalization and training.

One commentator has outlined sixrecommendations for effective integrationthat cover many of the major salient issues:

Promotion of communication andmutual understanding among differentmedical systems that exist in a society;Evaluation of TRM in its totality;Integration at the theoretical level andthe practical level;Equitable distribution of resourcesbetween traditional and modernWestern medicine;An integrated training and educationalprogramme for both traditional andmodern Western medicine;A national drug policy that includestraditional drugs.5

Recognizing the need for a policy toreflect public health care demands andpatterns of use, the 12th CommonwealthHealth Ministers’ Meeting in November1998 established a Working Group onTraditional and Complementary HealthSystems47, 48 (Nelson, 1998; Bodeker,1999). The Working Group was commi-ssioned to develop an action plan topromote and integrate traditional systemsof health and CM within national healthsystems, giving consideration to:

Policy Framework, including:provision of servicesconservation of medicinal plants andrelated intellectual property rights;


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Training of traditional and conventionalpractitioners;Development of standards of practice;Mechanisms for enhanced sharing ofexperiences in the Commonwealth;Regulation and safety, involvingpractitioners of TRM in the process;Research – evidence-based research topromote mutual understanding andconfidence, and establish efficacy;Management of the integration oftraditional and conventional medicine.

Health Ministers representing most ofthe 54 countries of the Commonwealthnoted that TRM should be seen as‘complementary’ rather than ‘alternative’,indicating the need for collaboration andpartnerships with conventional medicine.

Cost Considerations

In many Western countries, including theUS, debates on health-care reform are nowdominated more by the language ofefficiency and cost than the spirit of caringand equity.49

As governments begin to considerdeveloping formal health services in TRM,the question inevitably arises as to whetherthese will result in cost-savings and whetherconsumers will be willing to pay for formalservices in TRM. These issues are similar tothose underlying the justification of modernmedical services, and the debate ontraditional health services is also shiftingfrom a language of equity and quality ofcare to one of efficiency and cost.

In the industrialized countries, wherealmost half of the population regularly usesCM, insurance coverage for this is stillrelatively new.2 Major American medicalinsurers now routinely cover CM services–a trend which is emerging in Britain as well.

In the developing world, the cost of

modern medical services may be oneimportant reason for people turning to theservices of TRM. In a rapid communitysurvey in Boga, Zaire, 56 per cent ofhouseholds reported that the price oftreatment was the greatest obstacle to theirreceiving medical care. Fees and otherfactors will inevitably deter some people fromusing the health services, and they may usetraditional healers or drug sellers instead,or alternatively receive no treatment at all.50

This shift can be exacerbated bymacro-economic factors such as devalua-tion of currencies. Structural adjustments,which have been accompanied by theintroduction of user fees for Governmenthealth services, can result in a substantialshift from modern to traditional medicine,even in urban populations. In an AfricanDevelopment Bank study of 800households in Abidjan, Cote D’Ivoire,devaluation of the Ivorian franc wasassociated with a concurrent shift frommodern to traditional medicine by 13.5 percent of households. This was even higher(16.7%) in women-headed households,where poverty is greater.51 Personalcommunications with medical personnel inTanzania suggest that the introduction ofuser fees for previously-free Governmentoutpatient clinics resulted in a substantialshift away from modern medical servicestowards TRM. Simultaneously, traditionalhealers in the Kilimanjaro region reportedthat they had experienced a substantialincrease in demand for their services at thetime that user fees were introduced forGovernment health services.52

The effect of user fees on health careutilization and health outcomes has beena subject of considerable debate in the1990s. Much of this debate has centredon the ability and willingness of householdsto make larger out-of-pocket payments forhealth care.


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Many studies in developing countriesindicate that health care utilization ratesamong both poor and non-poor individualswould not be significantly affected by smallincreases in user fees.53 In addition, manystudies suggest that health care utilizationwould actually increase if increased userfees are accompanied by improvements inservice.53

However, other research indicates thatthe price elasticity among the poor issubstantial, which suggests that user feeschemes would have a regressive distri-butional impact.53

In many developing countries peopleare expected to contribute to the cost ofhealth care from their own pockets. As aresult, people’s ability to pay (ATP) forhealth care, or the affordability of healthcare, has become a critical policy issue indeveloping countries. It is particularlyurgent where households face combineduser fee burdens from various essentialservice sectors such as health, educationand water. Research and policy debateshave focused on willingness to pay (WTP)for essential services, and have tended toassume that WTP is synonymous with ATP.However, this assumption has beenquestioned and it has been suggested thatWTP may not reflect ATP.7 As noted in theintroductory section of this chapter,households may persist in paying for care,but to do so may sacrifice other basic needssuch as food and education. This in turncan have serious consequences for thehousehold and individuals within it. In termsof a social benefit analysis, the opportunitycosts of payment make the payment“unaffordable” because other basic needsare sacrificed.

In this regard, research into theeconomics of health care utilization shouldshift the focus of attention from the healthfacility – including Government and private

TRM clinics – to the household. It is inhouseholds that decisions are made onhow to allocate limited resources to health,education and other essential commodities.

In Vietnam there is a rural expressionthat TRM can be paid for with one chicken,modern medicine can cost one cow andhospitalization can cost a family its herd ofcows. Translating this into immediate anddownstream income benefits, suchsacrifices by poor families may be made atthe expense of their future livelihood.

Fees charged by traditional healers varygreatly and can also be high. In South Africa,for example, where payment is not exclusivelymonetary, the healer may receive a cow oncuring the patient. The treatment for acondition such as umtsebulo – presumedsoul loss – can cost US$ 125.54

An approach to ATP, founded on basicneeds and the opportunity costs of paymentstrategies (including non-utilization), hasbeen proposed. Common householdresponses to payment difficulties have beenfound to range from borrowing to moreserious “distress sales” of productive assets(e.g., land), delays to treatment and,ultimately, abandonment of treatment.Although these strategies may have adevastating impact on livelihoods andhealth, few studies have investigated themin any detail. In-depth longitudinalhousehold studies would develop anunderstanding of ATP and could informpolicy initiatives which might contribute tothe development of affordable models ofTHC services.

Potential Conflicts Arising fromAllocation of Resources toTraditional Health Care ServicesResentment can arise from under-fundedsections of the modern medical sectorwhen resources are allocated to thedevelopment of traditional medicine. A


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traditional birth attendant (TBA) training inNigeria attracted resentment from under-funded rural midwives as resources weregiven to birth attendants when maternitycentres lacked equipment.56

Another potential conflict is that if THCservices are made available under medicalinsurance schemes, those who can affordto pay for insurance will be the greatestbeneficiaries of TRM. The poor may berelegated to purchasing unregulated drugsfrom unlicensed street vendors, as alreadyhappens in so many poor countries. Thiswould stand in contrast to the customaryrole of TRM serving as the first and lastresort for available health care for the poor.

A further risk is that primary health careservices in TRM may remain marginal andunder-funded due to the tendency ofnational health budgets favouring tertiarycare. In Cote D’Ivoire, the rich receive moreassistance than the poor, because thepoorest patients rarely use anything butprimary care, whereas the Governmentprovides generous subsidies for the tertiarylevel, which in practice serves the richestpatients.57 Average per capita spending on

consultations differs by a ratio of 1:300between the first and tenth deciles. Thespread is extreme (1:3000) in the case ofexpenditures on hospitalization. It has beenargued that there is injustice in the highallocation of resources to tertiary care, whenhousehold expenditures on TRM andmodern medicine indicate the demand andneed at the primary care level (see Figure 3).

Differential allocation of resources toareas of high priority might be one solution

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

(Hill, 1997)(55)


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for building relevant and viable traditionalhealth services. In Sri Lanka, Aluwihare(1997) has examined sets of figures onsuch indicators as infant mortality andwomen in the labour force. His finding isthat national aggregate data do not helpin the appropriate targeting of resources.Rather, the best way would be to targetthe parts of the country where the figuresare the least satisfactory, as a dollar therewould have produced a better effect than10 dollars in an area which had betterparameters.58 The use of data that aredisaggregated by place and time is a moreeffective way of identifying “weak” pointswhere specific action is needed. Thiswould require that TRM utilizationstudies be incorporated into nationalhealth service research as well as studieson the availability, quality and cost oftraditional health services on a region-by-region basis.

Health insurance for traditionalmedicineAs noted in the section on Utilization, healthinsurance coverage can lead to asubstantial increase in the use of TRMservices. In a Korean immigrant populationin Los Angeles, 24 per cent of theuninsured used traditional healers,compared with 59 per cent of persons withMedicaid only and 71 per cent of thosewith other types of insurance includingMedicare and Medigap coverage.

In China, although traditional healthservices are covered by health insurance,only about 12 per cent of the populationhas comprehensive medical insurance thatcovers the cost of hospitalization, and theproportion of uninsured people may be ashigh as 50 per cent.59, 49 In hospitalsettings, insured patients are more likely toreceive TCM.59 This is due to the fact thatone of the primary sources of a hospital

ward’s profit, under the market model ofhealth care provision that is in place, is the15–25 per cent mark-up for prescribedmedications, so the changed incentivesystem has become associated withincreased polypharmacy.59

Under the market system, many TCMhospitals in China operate at a deficit, asbetter equipped Western hospitals attractmore patients. As TCM is largely anoutpatient, low technology specialty, mostof the income of traditional hospitals comesfrom the sale of drugs. Even with the 25per cent mark-up allowed, it is hard to coveroperational costs. While Governmentsubsidies currently ensure survival, there isno surplus for improving services andfurther market reforms may threaten thissubsidy system.36

The experience in Taiwan is thatinsurance coverage for TRM would morethan double the use of TCM. Whereas35.4 per cent of Taiwanese reported usingTCM regularly, 86 per cent of the publicwould support the coverage of Chinesemedicine by the new National HealthInsurance and 79 per cent would useChinese medicine if it does.5

High profitability of TRM can lead toits custodians resisting moves to provideinsurance coverage for their services andproducts. In Korea, where the profit marginof herbal medicines is variously estimatedto be 100–500 per cent compared to theirbasic cost,37 the population utilize herbalmedicines on a large scale.37 The amountof reimbursement for herbal medicineunder the National Medical Insurance(NMI) scheme was approximately 50 billionKorean won in 1993. This was estimatedto be only a small portion of total expendi-ture on herbal medicines.37 The highreturns on herbal medicine boosted thesocio-economic status of TRM doctors tothe extent that about two-thirds (64%) of


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them did not want herbal remedies to beincluded in the NMI scheme at all.37

In New Zealand, which has a longtradition of universal insurance for medicaland hospital services, a number of Maoriorganizations signed contracts withregional health authorities to provideprimary health care, resulting in anincreased number of Maori-controlledservices throughout the country. NewZealand has allowed the registration ofmore than 600 Maori traditional healersand the Government reimburses theirservices under health insurance schemes.It has been argued that the New Zealandexperience showcases the importance ofa funder-purchaser-provider separationand shows that this can be beneficial toindigenous health services.60

In Australia, Easthope et al. (1998)show that since the introduction of aMedicare rebate for acupuncture in 1984,use of acupuncture by medical practitionershas increased greatly.61 By analysing HealthInsurance Commission data on claims byall non-specialist medical practitioners forMedicare Benefits Schedule items for anattendance where acupuncture wasperformed by a medical practitioner, theyshowed that 15.1 per cent (about one inseven) of Australian GPs claimed foracupuncture in 1996. Claims rose from655,000 in the financial year 1984–1985to 960,000 in 1996–97, and Medicarereimbursements to doctors for acupun-cture rose during this period from $7.7million to $17.7 million. Acupuncture wasmore likely to be performed by malepractitioners, by those aged 35–54 years,and by practitioners with an overseasprimary medical qualification. A survey ofgeneral practices in Hobart showed thatalthough only 15 per cent of the GPsprovided acupuncture, it was available in31 per cent of practices.

Cost-Benefit ResearchTaking into account the bias towards higherincome groups among medical insuranceenrollees, evaluating the health insurancerecords of TRM/CAM users can be aneffective way of estimating cost-savings ofusing traditional or complementary healthcare for certain sectors of society. ACanadian study provides an example.

A retrospective study of Quebec healthinsurance enrollees compared a group ofTranscendental Meditation (TM) practi-tioners with non-meditating controls.62

Earlier research had highlighted positiveindividual and group health effects of thismeditation, which derives from India’sVedic tradition. This study aimed todetermine whether these health benefitstranslate into savings to the Governmentin terms of possible reductions in paymentsto physicians for the medi-tating group.

The study involved a total of 2836 healthinsurance enrollees from Quebec. Of these,1418 were volunteers who had beenpractising the TM technique for an averageof six years, and 1418 were controls of thesame age, sex, and region who wererandomly selected. Using data provided byRAMQ (Régie de l’Assurance-Maladie duQuebec), Herron and associates firstestablished a baseline by going back 14years and gathering information on the totalamount of money paid to physicians for thisgroup. Adjustments for inflation were madeusing the medical cost component of theCanadian Government’s Consumer PriceIndex (CPI). The scientists were able todetermine a typical subject’s rate of changein expenditure over the period using robuststatistics.

Researchers found that before startingmeditation, the yearly rate of increase inpayments between the TM group and thecontrol group was not significant. However,after learning meditation, the TM group’s


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mean payments declined one to two percent each year, while the control group’smean payments increased up to 12 percent annually over six years. Thus, therewas a mean annual difference between thetwo groups of about 13 per cent. Theresearch team estimated that this couldtranslate into savings of as much as $300million per year for the Province’s healthinsurance company, the Régie del’Assurance-Maladie du Quebec.

A recent example of comparativeresearch of a traditionally used herbalmedicine and the main equivalentconventional medicine has cost-benefitimplications that are important. The study,on mild to moderate depression,compared St. John’s Wort (Hypericumperforatum), with the recommended dose(150 mg) of imipramine, one of the mostcommonly used tricyclic antidepressants.Hippocrates, Pliny and Galen had alldescribed the use of Hypericum for thetreatment of mental disorders. AnRandomized Clinical Trial (RCT) wasconducted involving 324 outpatients withmild to moderate depression. The studyfound that Hypericum extract is thera-peutically equivalent to imipramine intreating mild to moderate depression, butthat patients tolerated Hypericum better.(63)

Two years of treatment with Prozac (20 mg/day) will cost US$1,250 in China, aboutthe annual income of an urban worker.(49)

A TCM equivalent of Hypericum wouldresult in substantial cost savings and, ifsimilar to Hypericum, may be bettertolerated by patients. Cost savings couldbe calculated on an annual, national basis,as could economic and social costs arisingfrom reductions in side-effects. Cost-benefitanalysis of this type would assist countriesin making informed choices about theselection of treatments to be incorporatedin integrated health care services.

Conclusion

Rising consumer demand for THC services,the unavailability of conventional servicesin many areas of the developing world, andthe move by governments to integrate THCinto national health services, all combineto create a new set of issues regarding TRMthat extend beyond the long-establishedthemes of safety, efficacy, standardizationof medicines and training of traditionalhealth practitioners. While these issues areat the core of quality control in traditionalhealth services, planners are assuming thatif quality is indeed controlled, a new set ofquestions arise. At the forefront of theseare questions of the comparative cost ofconventional and THC and treatments.

In drawing together the basic five-pointframework for economic analysis outlinedin the Introduction and the complex issuesthat actually occur in real-life setting, anumber of policy issues can be identifiedand distilled as providing the context forthe development of cost-effective THCservices.

With respect to the economic valuationof TRM, it is necessary to recognize that inthe developing world, the cost of modernmedical services can be a factor in peoplechoosing TRM. Programmes to developand formalize traditional health servicesshould not overlook this point. The risk indoing so is of depriving the poor of servicesthat have historically been their first andlast resort for health care. Accordingly,economic policies on TRM should aim tokeep any user fees affordable – includingthose of THC practitioners in thecommunity.

Significant investment is a prerequisitefor the development of effective THCservices. Under-investment risks perpe-tuating poor standards of practice andproducts and also contributes to main-


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taining old stereotypes of inferior servicesand knowledge in TRM. If health insurancecoverage is provided for TRM, nationalschemes should be weighted in support ofcontinued access by the poor to TRM.

A necessary backdrop to economicanalyses is a social analysis which examinesthe extent to which there is demand fortraditional health services, who the clientsare, what the conditions are that they bringfor treatment, and how they rate the qualityof both traditional and conventional healthcare services. Political priorities can frameand set the pace of formalization of THC.The traditional health sector is, can andshould be part of this equation in theinterests of ensuring appropriate develop-ments in policy, regulation, accreditation,service development, standards of practice,training and research.

A comprehensive yet flexible infra-structure is necessary to address thediverse areas within the THC sector. Theseinclude: legislation, regulation, financing,research, product development, educationand training , and sustainable medicinalplant production.

Priority areas for collaboration includediseases such as TB, malaria64 and HIV/AIDS.(65) Here new sets of economicquestions present themselves and thesemust include the ethics of not evaluatingthe medicines that the public uses for home-treatment of serious diseases.

A mechanism is needed for sharingexperience in policy and servicedevelopment both within and betweencountries. Communication and mutualunderstanding should be promoted amongdifferent medical systems that exist in asociety. In evaluating TRM, this should bedone as a system in preference to selectingsingle therapeutic modalities to beevaluated for a specific effect. Integrationof health services should be coordinated

at the theoretical and practical levels.Governments and inter-national organi-zations, such as WHO, should work toensure that there is equitable distributionof resources between traditional andmodern Western medicine.

An integrated training and educationalprogramme is needed for both traditionaland modern Western medicine. And finally,there is a need for a national drug policythat includes traditional drugs.

Economic analysis of TRM is necessary.As we have seen, there are five broadmeans of conducting such research: costdescriptions; cost-comparison studies;cost-effectiveness analysis and cost-utilityanalysis. The selection of methodology willdepend on who is asking the question –Government, insurer, consumer advocate,etc. A necessary starting point is transpa-rency in stating the priorities lying behindthe research and the research question,e.g., cost-savings, quality of life improve-ment, etc., in order to enable a balancedinterpretation of the outcomes of theresearch.

Cost-benefit research is needed and,increasingly will be done. While comparingoutcomes and costs of traditional andconventional interventions, care is neededto avoid the charge that is sometimesmade that cheap medicines are beingproduced for poor people, with somedisregard for quality and efficacy.

As this is a nascent field, it wouldbenefit from the emergence of a specializedgroup of researchers who are linked,potentially via the internet, to shareexperience, models of research andfindings. Such a group would work todevelop priorities in an internationalresearch agenda, refine evaluativemethodologies and articulate ethical andcultural perspectives to broaden the scopeof economic analyses.


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References

1. Eisenberg D.M., et al. Trends in alternative medicine use in the United States. Results of afollow-up National Survey. JAMA.1998; 280 (18): 1569–75.

2. MacLennan A.H., Wilson D.W. and Taylor A.W. Prevalence and cost of alternative medicinein Australia. Lancet. 1996; 347:569–72.

3. White A. and Ernst E. Economic analysis of complementary medicine: a systematic review.Complementary Therapies in Medicine. 2000; 8:111–18.

4. Astin J.A. Why patients use alternative medicine: results of a national study. JAMA. 1998;279 (19): 1548–53.

5. Chi C. Integrating traditional medicine into health care systems: examining the role ofChinese medicine in Taiwan. Social Science and Medicine. 1994; 39 (3): 307–21.

6. Robinson R. Economic evaluation and healthcare: what does it mean? BMJ. 1993; 307:670–73.

7. Russell S. Ability to pay for health care: concept and evidence. Health Policy and planning.1996; 11(3): 219–37.

8. Stephens C. Training urban traditional birth attendants: balancing international policy andlocal reality. Preliminary evidence from the slums of India on the attitudes and practice ofclients and practitioners. Social Science and Medicine. 1992; 35 (6): 811–17.

9. Bannerman R.H. Traditional Medicine and Healthcare Coverage. WHO, Geneva.1993.10. Shai-Mahoko S.N. Indigenous healers in the North West Province: a survey of their clinical

activities in healthcare in the rural areas. Curationis. 1996; 19(4): 31–34.11. Shiferaw T. Illness burden and use of health services in a rural community. South-western

Ethiopia. East African Medical Journal. 1993; 70 (11): 717–20.12. Oskowitz B. Bridging the communication gap between traditional healers and nurses.

Nursing RSA. 1991; 6 (7): 20–2.13. Ahmed I.M., et al. Characteristics of visitors to traditional healers in central Sudan. Eastern

Mediterranean Health Journal. 1999; 5 (1): 79–85.14. Traore S., Coulibaly S.O., Sidibe M. Comportements et couts lies au Paludisme chez les

femmes des campements de pecheurs dans la zone Selingue au Mali, Institute National deRecherche en Sante Publique. Bamako, Mali. WHO: TDR/SER/PRS/12.1993.

15. Elzubier A.G., et al. Knowledge and misconceptions about malaria among secondaryschool students and teachers in Kassala, Eastern Sudan. Journal of the Royal Society ofHealth. 1997; 117 (6): 381–5.

16. Tanner M., Vlassoff C. Treatment-seeking behaviour for malaria: a typology based onendemicity and gender. Social Science and Medicine. 1998; 46: 523–32.

17. Wilkinson D., Gcabashe L. and Lurie M. Traditional healers as tuberculosis treatmentsupervisors: precedent and potential. International Journal of Tuberculosis and LungDiseases. 1999; 3 (9): 838–42.

18. Troskie T.R. The importance of traditional midwives in the delivery of health care in theRepublic of South Africa. Curationis. 1997; 20 (1): 15–20.

19. Boerma J.T., Baya M.S. Maternal and child health in an ethnomedical perspective: traditionaland modern medicine in coastal Kenya. Health Policy and Planning. 1990; 5 (4): 347–57.

Clearly, for formalization of THCservices to be achieved in a climate ofcompetition for scarce resources, it will bevital that programme administrators andcustodians of traditional medical

knowledge conduct cost-related research.The potential is the development of a newbasis for ensuring that traditional healthknowledge is put on sound footingalongside conventional medicine.


181

20. Vissandjee B., Barlow R. and Fraser D.W. Utilization of health services among rural womenin Gujarat, India. Public Health. 1997; 111 (3): 135–48.

21. Agyepong I.A., Manderson L. The diagnosis and management of fever at household level inthe Greater Accra Region, Ghana. Acta Tropica. 1994; 58: 317–30.

22. Ruebush T.K., Kern M.K., Campbell C.C., Oloo Aj. Self-treatment of malaria in a rural ofwestern Kenya. Bulletin of the World Health Organization. 1995; 73: 229–36.

23. Miguel C.A., Manderson L., Lansang M.A. Patterns of treatment for malaria in Tayabas. ThePhilippines: Implications for control. Trop. Med. Int. Health. 1998; 3 (5): 413–21.

24. Miguel C.A., Tallo V.L., Manderson L., Lansang M.A. Local knowledge and treatment ofmalaria in Agusan del Sur, The Philippines. Soc. Sci. Med. 1999; 48: 607–18.

25. Muela H.S., Ribera J.M., Tammer M. Fake malaria and hidden parasites – the ambiguity ofmalaria. Anthropology and Medicine. 1998; 5 (1): 43–61.

26. Bitahwa N., Tumwesigye O., Kabariime P., Tayebwa A.K.M., Tumwesigye S., Ogwal-OkengJ.W. Herbal treatment of malaria – four case reports from the Rukarawe Partnership Workshopfor Rural Development (Uganda). Tropical Doctor.1997; (Suppl1): 17–9.

27. Munguti K.J. Community perceptions and treatment seeking for malaria in Baringo District,Kenya: implications for disease control. East African Med J. 1998; 75 (12): 687–91.

28. Varga C.A., Veale D.J.H. Isihlambezo: utilization patterns and potential health effects ofpregnancy-related traditional herbal medicine. Social Science and Medicine. 1997; 44 (7):911–24.

29. Ma G.X. Between two worlds: the use of traditional and Western health services by Chineseimmigrants. Journal of Community Health. 1999; 24 (6): 421–37.

30. Bandyopadhyay M., MacPherson S. Women and health: tradition and culture in ruralIndia.1998.

31. Nichter M. Ethnomedicine: diverse trends, common linkages. Commentary MedicalAnthropology. 1991; 13:137–71.

32. Maher P. A review of “traditional” aboriginal health beliefs. Australian Journal of RuralHealth. 1999; 7 (4): 229–36.

33. Marbella A.M., Harris M.C., Diehr S. Use of Native American healers among NativeAmerican patients in an urban Native American health center. Archives of Family Medicine.1998; 7: 182–95.

34. State Administration of Traditional Chinese Medicine of the People’s Republic of China.Anthology of policies, laws and regulations of the People’s Republic of China on TraditionalChinese Medicine. Shangdong: Shangdong University. 1997.

35. Hesketh T., Zhu W.X. Health in China. Traditional Chinese medicine: one country, twosystems. British Medical Journal.1997; 315: 115–17.

36. Hesketh T.M., Zhu W.X. Excessive expenditure of income on treatments in developingcountries. British Medical Journal. 1994; 309: 1441.

37. Cho H.J. Traditional medicine, professional monopoly and structural interests: a Koreancase. Social Science and Medicine. 1999; 50 (1): 123–35.

38. India. Ministry of Health and Family Welfare. Indian systems of medicines and homoeopathy:annual report. 1999–2000. (http://mohfw.nic.in/ismh/).

39. COHRED. Proceedings of the International Conference on Health Research for Development.1990.

40. Burnett A., et al. Caring for people with HIV in Zambia: are traditional healers and formalhealth workers willing to work together? AIDS care. 1999; 11 (4): 481–91.

41. Upvall M.J. Nursing perceptions of collaboration with indigenous healers in Swaziland.International Journal of Nursing Studies. 1992; 29 (1): 27–36.

42. Last M., Chavanduka G. The professionalisation of African medicine. 1986.


182

43. Kabatesi D. Use of traditional treatments for AIDS associated diseases in recourse-constrainedsetting. 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 Agencyfor Food and Drug Administration and control (NAFDAC). Paper presented at the InternationalConference on Ethnomedicine and Drug Discovery, Silver Spring MD. 1999; Nov 3–5.

46. Kagwanja P.M. Women and the political economy of traditional medicine in Kenya: a historicalperspective. 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 inpost-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 MedicalJournal. 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 EconomicsOnline 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 patientswith 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 andNew 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 governmentpayments to physicians in Quebec: an update. American Journal of Health Promotion2000; 14(5): 284–91.

63. Woelk H. Comparison of St. John’s wort and imipramine for treating depression: randomizedcontrolled trial. BMJ. 2000; 321 (2 Sept.): 536–39.

64. Bodeker G. & Willcox M.L. New research intitiative on plant-based antimalarials. TheLancet. 2000; Feb. 26: 355,761.

65. Bodeker G., et al. A regional task force on traditional medicine and AIDS in East andSouthern Africa. The Lancet. 2000; April 8.

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evolved of all the ancient systems ofmedicine known to mankind. There is arich tradition of recorded and unrecordedliterature on their usefulness and use inmost countries of South-East Asia.Practitioners of traditional medicine areheirs to a rich heritage of knowledge andskills, handed down from one generationto the next with great dedication. The socialgoal of Health for All, with primary healthcare as the key approach, was adopted bythe Member States at the World HealthAssembly in 1978. Traditional medicinewas identified as an essential componentof the overall response for its achievement,particularly in the developing world. It hasbeen clear to most health administrators,for over two decades, that this exalted goalof “Health for All by the year 2000”1 wouldnot be realized without the use of allavailable health resources, particularlytraditional medicine and its practitioners.

However, the actual experience has notbeen totally encouraging in most countriesand the incorporation of traditionalmedicine into the organized public healthsystems, especially at the district health

Development of trainingprogrammes fortraditional medicine

level, has been very erratic and non-productive, to say the least. This tokenacquiescence of Member States of theWorld Health Organization in galvanizingtraditional medicine to achieve thiscollective goal has meant that the healthstatus of the poor, especially the rural poor,has continued to be compromised. Theprevailing economic hardships facing mostdeveloping countries of the Region havefurther complicated the picture for theurban poor.

Although reliable statistics are notavailable for some of the countries of theRegion, there is a wide gap between thehealth status of people in the urban areasand those in the rural areas of the Region.Life expectancy at birth and infant mortality,and maternal mortality, another usefulindex of the level of health, continue to beunacceptably high in many countries.Infectious and parasitic diseases continueto sap the energies of the people. Somechildren receive no preventive immunizationfor crippling diseases of childhood. Manymore suffer from severe malnutrition of onedeficiency or another.

In many countries, only a few citydwellers have access to organized healthand other social services at prices that theycould afford. The majority of the population

Palitha AbeykoonO. Akerele

TIntroduction

he systems of traditional medicine inSouth-East Asia are amongst the most


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are left to their own devices which oftenmeans recognized traditional healthpractitioners and/or charlatans. Thissituation highlights one facet of the socialinjustices that are being perpetrated,knowingly or unknowingly, by policy-makers and administrators in mostdeveloping countries.

Most, if not all, traditional medicinepractitioners are inadequately trained forthe tasks that they perform in theircommunities. In spite of this, licensed andunlicensed practitioners continue to bereadily available to the sick in rural andperi-urban settings, prescribing ethical andnon-ethical as well as rational or irrationalmodern medical drugs to those they see intheir daily practices. In the main, theiractivities are restricted to curative practicesonly.

The education and training oftraditional practitioners becomes a crucialissue in this context. Of course, it is also afact that education and training responsesper se will not address, let alone solve,many of the problems and issues relatedto the incorporation of traditional medicineto complement the modern systems ofmedicine in our countries. This paperoutlines some of the contextual issues inthe integration of traditional medicine withthe general health care services, andsuggests a rational framework and somepractical guidelines for the development ofhuman resources in traditional medicine.Therefore, the list of issues and thesuggestions offered in this paper do notpretend to be exhaustive. However, takentogether, they are key questions and issuesto be answered before designing anymeaningful education and trainingprogramme for traditional medicine,including defining the role of traditionalhealth practitioners in the district healthsystem.

Some lessons and questionsfrom past experiences

To place education and training as a sub-system in the health system in South-EastAsia, it is useful to examine some of therelevant experiences that have beenaccumulated and which are of directrelevance to these countries. A smallnumber of these experiences have beenextracted and summarized here as it wouldhelp in the elaboration of national healthpolicy related to traditional medicine.

We have useful lessons from a numberof African countries that have attemptedto bring traditional medicine into themainstream of the health services, oftenwithout much success. For example, onecountry, at independence, tried to correctthe situation inherited by adopting policiesand promulgating legislation that wereencouraging to traditional practitionersbut, at the same time, alienated them fromthe formal health personnel.2 Conse-quently, the existing gap between the twotypes of practitioners further widened.

Cooperation and collaboration shouldbe brought about as a purposeful part ofthe overall development of the nationalhealth policy and not as a result ofinjudicious or hasty adoption of policies topromote traditional medicine which, in fact,have often tended to discredit it. Theidentification and categorization of thevarious traditional practitioners should bea national undertaking with the intentionof improving health benefits for the people,as has been done in China, India, Mexico,Sri Lanka and Thailand.

A good policy should be the ultimateexpression of a consensus and, therefore,the necessity of involving traditional medicalpractitioners at all stages of this processcannot be overemphasized. Such consul-tation is most easily achieved when there is


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a national association of traditionalpractitioners and when the representativesof such an association can be brought intodirect relationship with the health authorities.

Sri Lanka is the only country wherethere is a separate ministry for indigenousmedicine. In India and China, there areDepartments and Bureaus of traditionalmedicine within the ministries of health.Regional and national associations exist inthese countries as well as in most Africancountries. All people value good health andtraditional practitioners continue to existbecause people believe in them and theirpractices, which have values that arederived from and are consistent with theirown culture. In most instances, thesepractitioners would be willing to participatein health-promoting activities, providedthey were convinced that they could beeffective and knew how.

All too often, however, the opportunityto participate has not been afforded themby the health services, and legislation insome cases endorses this negative stance.Experience shows that restrictive legislationremains unenforceable and peoplecontinue to utilize their traditional systemsof medicine. For example, a restrictive lawforbidding traditional practitioners to issuecertificates in respect of their patients wasrepealed in one country. However, it shouldbe noted that no enabling law has beenintroduced in its place, and people continueto patronize their practitioners. In manyinstances, health services are influenced bytechnocrats bent on achieving andmaintaining a set of “international medicalstandards”.2 These may not necessarilyreflect nationally acceptable trainingcurricula that meet local manpower needs,thus further accentuating the brain drainof qualified staff.

Traditional medicine is to a large extentculture-specific and therefore practitioners

tend to stay in their own communities.Successful attempts to utilize traditionalmedicine are characterized by the abilityof health personnel to understand localtraditional practices. China and India areexamples of countries that have developedtheir traditional systems of medicine to theextent that they now command somerespect from practitioners trained inWestern or modern medicine. They havesucceeded in making health personnelaware of the place of traditional medicinein their culture, its strengths and weak-nesses, and the use that may be made of itin formal health care.3

Education in the classical systems ofmedicine such as Chinese traditionalmedicine, Ayurveda and Unani, alreadyincludes an appreciable amount ofinstruction in Western medicine. In thecase of traditional systems, where remediesare handed down from generation togeneration by word of mouth, arrange-ments have to be made to providepractitioners with additional knowledge.Examples include the ability to identify andencourage existing beneficial practices(e.g., breastfeeding), as well as competencein certain modern methods of preventionand cure (e.g., the care of infants withdiarrhoea or acute respiratory infections).The creation of a learning situation, wherehealth personnel actively work withtraditional practitioners and the commu-nities in identifying health needs, organizinghealth care activities, managing theirimplementation and evaluating the resultsachieved, would also promote a healthierclimate for all.4

In an ideal situation, personnel of theformal health system and traditionalpractitioners should be encouraged to worktogether as teams in clinics and healthcentres. Research in traditional medicineand in the utilization of traditional


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practitioners in district health care, withtraditional health practitioners themselvesas principal investigators, could greatlyenhance development in this field. To takeanother example, making available simplemultipurpose kits containing appropriatetherapeutic agents and basic instrumentsthat could be handled by traditionalpractitioners in their own practices, as isdone in some countries, could do much toimprove the quality of their work.Traditional medicine activities must, ofcourse, be adequately funded and externaland internal funding agencies and non-governmental organizations should becoopted into this endeavour.

Some guiding principles fordeveloping a training systemin traditional medicine

The above experiences and questionsprovide the overall context for establishingand improving education and trainingprogrammes in traditional medicine. Themore immediate context for policy andaction will be the structure and the functionof the human resources development sub-system in the particular country.

WHO advocates that each level of thehealth system should be the responsibilityof the most suitably trained healthprofessionals, and not necessarily the “mosthighly” trained staff. The support such“suitably trained” staff need must beprovided by the higher levels of staff. Thiswould be a critical requirement to“integrate” the traditional medicinepractitioners in the general health caresystem and place them in a position ofmaximum use to the community.

WHO also believes that the three maincomponents of the human resourcesdevelopment process – planning, produc-tion and management or utilization –

should be functionally integrated, andthese, in turn, should be integrated withoverall health systems development. In thisscenario, ideally education and trainingin traditional medicine should bearticulated within this system. But realityis often otherwise. Many of the efforts inthe education and training of traditionalmedicine practitioners in the countries aremade on an ad hoc basis outside themainstream of human resources for healthdevelopment and do not constitute anintegral part of the education and trainingof health professionals. The reasons forthis state of affairs are multiple, but theyoriginate mainly from two genericproblems that are inherent in our healthsystems. One is the place of traditionalmedicine in the health system, the typesof issues that were identified in the earlierpart of this paper. The other is anattitudinal and hierarchical problemwherein the practitioners of the modernallopathic system of medicine do notrecognize the practitioners of traditionalmedicine to be on par with them. Theyears of dominance of the allopathicsystem, and the technological advance-ment it has achieved, supported bypublic perception and demand, havecombined to create this situation and itwill be narve to expect it to changeovernight. But this is a fundamentalproblem that needs to be recognized andaddressed appropriately in many of ourcountries.

None of the three processes in humanresources development – planning,education and management – can functionindependently of each other. They have theirown cycles, though.

Human resources planners actingindependently of production andmanagement become paper plannersonly;


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Educators and trainers acting inignorance of planning and manage-ment have abandoned the logic ofpurposeful education and the relevanceof their programmes to the needs ofsociety;Health services managers who actindependently of plans and educationand training have given away their mostimportant management tools,including the influencing of the healthpersonnel they want to utilize.

Defining the characteristics ofgraduates of educational andtraining programmesIt seems obvious that the roles to be fulfilledby graduates of educational and trainingprogrammes should serve as a basis fordetermining the content and methods oflearning, yet this process is seldom givencareful attention. Most often, the roles aretaken for granted, based largely onoutmoded recollections, or on the assum-ption that graduates can adapt to thesituation in which they find themselves.Furthermore, the training institutions oftendo not even consider it necessary to trainstudents for well-defined roles andfunctions. When graduates complainthat their preparation was not adequate,the programmes are only occasionallymodified.

To ensure the relevance of healthmanpower preparation, it is necessary thatthere is a full understanding of the personaland professional competencies, includingthe intellectual and practical skills, values,and attitudes required if health workers areto function effectively in the settings to whichthey are assigned.5 The development of suchan understanding involves several problems:

The roles to be filled may not yet existbut are planned; this is a commonoccurrence in evolving health systems;

The roles have social and managerialas well as technical aspects that requirean interdisciplinary approach to roledefinition and training;The roles of each health worker includeestablishing and maintaining importantrelationships with others, and thisrequires consideration of the overallfunction of a team as well as trainingfor teamwork;The roles involve close interaction withcommunities, which requires not onlyan understanding of the nature of thatinteraction, but also calls for theparticipation of communities in theprocess of role definition.

Key questions/issues and someanswers(1) How can the formal health services

work with traditional practitioners forthe benefit of the population? Why?Because so far, traditional practitionershave been excluded from exercising anyresponsibility in most national healthservices.

(2) How can a traditional medicineinfrastructure be created? Why?Because, without a clearly definedinfrastructure, through which tradi-tional health practitioners themselvescould be heard and which could be aregulatory body in relation to ethicaland professional matters, there is likelyto be chaos.

(3) How to sensitize, orient and use healthprofessionals and others so that theymay support the national traditionalmedicine programme? Why?Because, if they are brought into aconstructive relationship with theprogramme, they will continue withtheir biases and hamper Governmentefforts to put traditional medicine on asound footing.


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(4) How to review health legislationconcerning traditional medicine?Why?Because, most of the present legislationin this field is outdated or irrelevant andneeds to be revised to conform with thenew policies adopted. In any case, areasonable and enforceable legislationwould greatly enhance the implemen-tation of traditional medicine activities.

(5) How to define the role of bilateral andmultilateral assistance? why?Because, any external support shouldbe consistent with Government policiesand priorities; otherwise, it may leadto unnecessary and wasteful invest-ment in esoteric projects which haveno direct relevance to the people’shealth needs.

(6) How to develop a national drug policythat includes traditional medicine?Why?Because, importing drugs is always verycostly and consumes scarce foreigncurrency. Developing traditionalremedies of proven efficacy and qualitywill not only promote self-reliance butwill also encourage research workersto investigate other traditionalremedies more carefully.

(7) How to formulate up-to-date researchand development policies in traditionalmedicine? Why?Because, at present research policiesin most countries do not reflect the roleof traditional medicine in healthservices. New research and develop-ment policies could greatly assist


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institutions in addressing the criticalproblems now being faced.

(8) How to finance traditional medicineactivities? Why?Because, the introduction of traditionalmedicine activities will require adequatebudgetary appropriations. A soundprogramme and budget that maximizesthe effective use of all available resourcesneeds to be evolved.

(a) There is no single or simple approachto the problem of how to involvetraditional practitioners in nationalhealth systems, especially at theprimary health care level. Dedicatedand sincere action on the part of allconcerned will be required to foster acollective effort to generate andimplement policies best suited to anygiven country.

(b) The first step could be the establishmentof a National Council for TraditionalMedicine, that could be charged withresponsibility for preparing a nationalstrategy of laying down a broad planof action to be followed by theGovernment. The Council should bemultidisciplinary and multisectoral innature, with appropriate represen-tation of the different types of traditionalpractitioners involved.

(c) Major policy issues need to beidentified quickly, priorities determinedand mechanisms established to proposethe various options and courses ofaction open to the Government, withad hoc groups being formed to tacklespecific issues.

(d) Adequate finance should be assuredunder the Government’s regularbudget for the support and promotionof traditional medicine activities.External finance should be consideredas only supplementary to theGovernment’s main effort.

(e) In parallel with the work outlinedabove, it will be necessary to undertakea survey of the national situation inrespect of the practitioners, thepopulation’s preferences and needs,resources, special problems, etc., uponwhich a sound national health planreflecting the role of traditionalmedicine may be formulated. Practi-tioners of traditional medicine shouldbe engaged in these activities and theresults should be made widely knownto the general public as well as to thehealth professions.

(f) The institution of practical, low-costtraditional medicine activities need notawait the results of these surveys. Oneof the first activities should be thegeneration of a public debate thatshould include special educationalefforts for the public (press, TV andradio), distribution of information ontraditional medicine, and short coursesfor traditional practitioners andconventional health personnel, as aninitial step, to secure their involvement.

There are three basic changes andreorientations that are needed in theeducation and training programmes intraditional medicine. Firstly, more attentionmust be paid to problem-solving skills asthe current curricula are overburdened withthe pursuit of knowledge and information,much of it is irrelevant to the priority tasksneeded to meet the health problems ofcommunities. The curricula also need tobe more problem-oriented and community-oriented, if not community-based. Inaddition, appropriate teaching andlearning strategies need to be developedfor traditional medicine practitioners towork in teams.

Secondly, the education and trainingprogrammes in traditional medicine need


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to develop appropriate teaching andlearning materials and promote the wideruse of audiovisual, self-instructional andsimulation techniques which have provenvalue. The challenge is to adapt these tothe specific requirements, especially tostudents and learners in rural areas, wheremany of them are. Some of the knowledgemay not be documented and will need tobe elicited from the practitionersthemselves.

The third major change is in theevaluation of the education and trainingprogrammes. Evaluation should not onlydetermine whether the students (and theteachers) have achieved their objectives(often called student assessment), but alsothe quality of the whole teaching andlearning process. It should determinewhether the learners have achieved theobjectives, and if so, to what extent;whether the objectives are relevant tohealth care needs; whether the curriculumand methods are relevant to the objectivesand if the evaluation is valid and objective.In other words, this should be a self-controlling process.

Training of teachersThe changes in education and trainingenvisaged in traditional medicine holdimportant implications for the training oftheir teachers. This, of course, is possiblein those instances where institutional casesare available. The traditional practitionerwho works independently would not beable to do these. Perhaps the most basicaspect of teacher training is that theyunderstand their role as teachers, i.e., topromote the process of learning byguiding the students to achieve thelearning objectives. The second would befor them to understand that the role oftheir training institutions is to preparepersonnel for health systems that meet the

health and social needs of theircommunities. As promoters of learning,teachers need more than a sound graspof their own health disciplines. They needto know the needs and demands of theircommunities, and the intersectoralactivities that are most likely to contributeto health development. It is by pursuingsuch a wider agenda that the teachers oftraditional medicine will develop therespect and the self-confidence to interactwith their counterparts in schools ofWestern medicine. It is accepted in recenttimes that training in educationalprinciples and processes in teaching andlearning methodology would be essentialfor teachers of all health personnel. Bythis count there is a great dearth ofteachers of traditional medicine with suchknowledge and skills. It would thereforetake a considerably long time before amajority (or even a sizeable number) ofteachers are in these areas, but theprocess must begin now.

Continuing EducationEducation of traditional medicinepractitioners should not be seen as a one-time event. Initial learning experiencesshould be improved continuously, andhigher levels of competence achieved.Improved work performance, enhancedcompetencies, more positive work attitudes,and greater productivity should not be leftto chance. They should be pursuedthrough continuing education that seeksto enhance the performance of healthworkers through a system of plannededucational programmes relevant toservice needs. Most of the countries in theRegion still do not have any continuingactivities, leave alone having in place well-coordinated, systematic continuingeducation programmes. In the best sense,modules or units of continuing education


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should be sequential and progressive, andspecific learning objectives should bederived from the competencies required formore effective and efficient performance.6Here, there are greater opportunities thanwith basic-level programmes to pursuemulti-professional or team-and-problem-oriented approaches to education.

Since the purpose of continuingeducation is enhanced job performance inthe health services, it must be associatedwith other factors that contribute to highlevels of staff morale and productivity.Continuing education is, therefore, not onlya part of the training component of humanresource development, but of humanresources management as well. In Chinathese aspects are reasonably well-articulated in the continuing education oftraditional medicine practitioners. Itrequires cooperation between the trainersand the health service managers.

Orientation of medical studentsand practitioners in traditionalmedicineIn order to foster and generate anatmosphere of cooperation between thepractitioners of modern and traditionalmedicine, one requirement would be toorientate the students and practitioners ofWestern medicine in traditional medicine.This should therefore be taken up as aparallel activity. In India, for example, it isnow compulsory for medical students tohave a certain number of hours ofinstruction dedicated to traditionalmedicine. This is a good start and, later, itmay be possible to incorporate someassessments also into this. It would bedesirable to similarly orientate thepractitioners of Western medicine intraditional medicine, but this would be amuch more difficult exercise as there wouldbe few available ways of generating interest

among them in this subject. It would beeasier when, and if, the two systems areavailable to the community in someintegrated or coordinated manner so thatthe practitioners communicate regularlywith each other.

Conclusion

Many years have passed since the WorldHealth Assembly first urged interestedgovernments to give adequate importanceto the utilization of their traditional systemsof medicine with appropriate regulationsas suited to their national health system(Resolution WHA30.49). So far no clearpicture as to how this was to be imple-mented in many countries has evolved andmany public health administrators look ontraditional medicine with continuedcynicism. Without a proper understandingat Government level of the issues involvedand the creation of an informed body ofopinion on the subject among the healthprofession and the public, there will be nosignificant move to utilize traditionalmedicine in national health systems.

One tends to speak as if the traditionalforms of medicine and their practitionersare each homogeneous entities. It is,however, important to distinguish betweenthe “formalized” traditional systems ofmedicine, such as Ayurveda, Unani, andChinese traditional medicine and thepractice of those practitioners who arerecognized by their communities as beingcompetent to provide health care. Thesepractitioners serve a long apprenticeshipand their knowledge is handed down fromgeneration to generation, mainly by wordof mouth.

There are also various types of healerswhose practices are based on spiritual ormoral convictions and others more difficultto define but who, nevertheless, are


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recognized healers within their communities,such as exorcists and spirit media, whoemploy special healing arts associated withthe supernatural. Their methods andbeliefs are so diverse as to preclude theirincorporation in any formal system.Individual governments will have to decideon 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: areader 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 inSouth-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 Year2000, through Primary Health Care. Technical Report Series 717. Geneva. WorldHealth Organization. 1985.

6. Guilbert, J.J. Educational Handbook for Health Personnel. World Health Organization.Geneva. 1981.

Countries’ primary concern should beto encourage the utilization of thoseelements of traditional medicine which areof value in their national health services.In this modern age, the rich heritage oftraditional medicine should not remain theexclusive or esoteric interest of only a few.

Technical issuesLegislation and regulation of traditionalsystems of medicine - systems, practitionersand herbal products

Dr. D.C. JayasuriyaDr. Shanti Jayasuriya

Standardization, pre-clinical toxicologyand clinical evaluation of medicinal plants,including ethical considerations

Prof. Ranjit Roy ChaudhuryDr. Mandakini Roy Chaudhury

Protection of traditional systems ofmedicine, patenting and promotion ofmedicinal plants

Prof. Carlos M. Correa

Research, drug development andmanufacture of herbal drugs

Dr. B.B. Gaitonde


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

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society has medicines and practitionersthat have come to be labelled as“traditional”.

When does a type of medicine orpractitioner become “traditional”? Giventhat “traditional” is a relative term, and thateach country’s experience is unique, aprecise date cannot be easily determined.Generally, it is the date of recognitionaccorded, either by legislation or throughpractice or official patronage, to a certaintype of medicine and practitioner thereof,that serves as the cut-off date for thedemarcation of what we describe as“western” or “modern” or “allopathic”medicines and practitioners as against“traditional” medicines and practitioners.In practice, it is through an evolutionaryprocess that each system has emerged to,or retained, its position of dominance.Socio-historical and anthropologicalstudies1 illustrate that this processcontinues notwithstanding the legal statusbecause perceptions, beliefs and practicesof people are not easily amenable tochange through the force of law.

Legislation andregulation of traditionalsystems of medicine –systems, practitionersand herbal products

In considering the role of regulatingtraditional medicine, two areas need to beaddressed:

The regulation of traditional medicinalproducts;The regulation of traditional medicalpractitioners.

Before these aspects are considered, itwill be useful to examine what “traditionalmedicine” is.

“Traditional Medicine” has been definedin various ways; in most contexts, however,its content and parameters are understoodeven without a definition. A recent statutorydefinition is to be found in the Public HealthCode of Burkina Faso of 1994:a

“Traditional medicine means theaggregate of all knowledge and practicesof a physical or non-physical nature,whether explicable or not, used in orderto diagnose, prevent, or eliminatephysical, mental, psychological, and socialdisequilibrium, and based exclusively onpast experience and knowledge passedon from generation to generation, eitherorally or in writing.”

D. C. JayasuriyaShanti Jayasuriya

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

Just as much as we have “traditionalfoods” or “traditional dresses”, every


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This definition captures many salientfeatures of most non-Western systems ofmedicine that look at the human body andthe multifarious ailments from a holisticperspective. In a few countries, includingseveral South-East Asian nations,traditional medical education is organizedon a well-structured basis; the definitiondoes not specifically exclude this aspectbut the way it is formulated may tend tocreate the impression that instruction intraditional medicine takes place in aninformal context. Another possiblelimitation is contained in that part of thedefinition which speaks of traditionalmedicine being based exclusively on pastexperience and knowledge. There is agrowing, albeit relatively slowly, body ofempirical evidence of the properties ofsome herbal medicines looking especiallyat inter alia long-term toxicity.

A broader definition is to be found inthe law of Guinea. “Traditional Guineanmedicine is the sum total of all technicalknowledge involving the preparation andutilization of substances, measures, andpractices in use, whether explicable or notat the current state of the art, resultingfrom the sociocultural and religiousfoundations of Guinean communities,which is based on practical experience andon traditions handed down from genera-tion to generation, whether verbally or inwriting, and which is used in the diagnosis,prevention or elimination of an imbalanceof well-being of a physical, mental, socialor spiritual nature”.b This definitionincludes within its scope the religious andspiritual dimensions of traditional medicine.In some countries, traditional medicalpractice is closely connected with bothreligious as well as spiritual practices.

Regulation of TraditionalMedicinal Products

Before the advent of synthetic compoundsand preparations, medicinal plantsprovided the most diverse and potentiallymost effective means of treating manyillnesses, and the tradition of using plantswas passed from one generation oftraditional healers to the next.2

While no precise figures are available,estimates suggest that some 80 per centof the world’s inhabitants remainextensively reliant for their primary healthcare needs on traditional medicines,including those manufactured from plantextracts or purified active ingredients.3Such products are not by any meansconfined to developing countries. Use ofherbal products and alternative systems ofmedicine is widespread in many developedcountries. In 1990, for instance, the salesof over-the-counter (OTC) herbalmedicines in Germany alone have beenclaimed to be of the order of US$ 1.5billion.c

Moreover, plant substances continueto provide the basis for many modernmedicines. In the United States, forinstance, a 1993 estimate indicates thatsome 25 per cent of prescription drugs and60 per cent of non-prescription drugsinclude one or more naturally-derivedsubstances and in 1990 the sales of suchproducts amounted to some US$ 15.5billion.4

In addition to being the sources ofactive constituents for many therapeuticproducts, plants frequently provide thestarting materials for potent synthesizeddrugs, as well as providing models for thedevelopment 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).


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active compounds. Conservation of plantspecies consequently operates to theadvantage of populations in bothdeveloped and developing countries. Theimminent extinction of perhaps as manyas 20,000 of the 40,000 to 75,000 plantspotentially valuable to medicine,5 is a causefor concern worldwide and action hasalready been broached in some countriesto regulate their harvesting andexportation.6 The United NationsConvention on Biological Diversity, states,inter alia, that: “conservation andsustainable use of biological diversity is ofcritical importance for meeting the food,health and other needs of the growingworld population, for which purposeaccess to and sharing of both geneticresources and technologies are essential.”

Species of medicinal value are specifi-cally cited in the Convention as beingamong the categories of plants that needto be identified and scheduled as aprerequisite to assuring both conservationand sustainable use.

The policy context of regulationIt is estimated that only some 5000 plantspecies have so far been studied forbiological activity and possible medicalapplication, and few of these – or theircomponent substances – have beencomprehensively screened for toxicity andspecific pharmacological activity.

This holds importance, not leastbecause the aphorism is nowdemonstrably fallacious that the safety ofherbal substances becomes apparent asa consequence of extensive use over manygenerations. In general, this thesis isapplicable only to dose-related, acute toxiceffects. It is less reliable when applied toimmunologically determined effects, andlargely irrelevant to the identification oflong-range consequences of exposure.

Several recently commissioned investi-gations of the potential toxicity of naturallyoccurring substances widely used inherbal preparations have revealed “apreviously unsuspected potential forsystemic toxicity, carcinogenicity andteratogenicity”.7

In recognition of the value of theworld’s resources of medicinal plants andthe need for discernment in their use, theFortieth World Health Assembly, in adoptingresolution WHA40.33, called uponMember States:

To initiate comprehensive programmesfor the identification, evaluation,preparation, cultivation and conserva-tion of medicinal plants;To ensure quality control of drugsderived from traditional plant remediesby using modern techniques andapplying suitable standards and goodmanufacturing practices.

Similarly, the Forty-second World HealthAssembly, in resolution WHA 42.43, urgedMember States:

To make a systematic inventory andassessment (pre-clinical and clinical) ofthe medicinal plants used by traditionalpractitioners and by the population;To introduce measures for theregulation and control of medicinalplant products and for the establish-ment and maintenance of suitablestandards;To identify those medicinal plants, orremedies derived from them, whichhave a satisfactory efficacy/side-effectratio and should be included in thenational formulary of pharmacopoeia.

The WHO Secretariat has respondedto those resolutions by formulating generalguidelines for the assessment of herbalmedicines and research guidelines for


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evaluating the safety and efficacy of herbalmedicines.

Terminology and scope ofregulatory controlSome national drug laws refer specificallyto medicinal plants and/or herbalremedies, but there is no consistency in theterminology employed to identify ordescribe them for regulatory purposes. Inthe international sphere, only the SingleConvention on Narcotic Drugs, 1961, asamended by the Protocol of 1972, whichis concerned only with a limited number ofplant substances, and particularly those withsome therapeutic value and a high potentialfor abuse offers precise definitions.

In a more general context, the 1965EEC Directive on Medicinal Productsd lendsprecision to general definitions. The word“substance” is defined as applying to anymatter “irrespective of origin”. “Vegetablesubstance” is established as a generaldefinition that comprises “plants” and“parts of plants”.

Some national laws subsume medicinalplants into the definition of “substance” (e.g.,the Netherlands); “medicament” (e.g.,China); “traditional drug” (e.g., Indonesia),“herb” (e.g., Rep. of Korea), “herbal remedy”(e.g., United Kingdom); “traditional medicine(e.g., Singapore); or “herbal substance”(e.g., Australia).

In some countries, medicinal plants areembraced within national drug legislationby virtue of being listed in a pharmacopoeia(e.g., France) or in a national formulary(e.g., the Philippines).

The term “herbal remedy” is similarlysubjected to a variety of legal definitions.In the Medicines Act, 1968, of the UnitedKingdom, “herbal remedy” has beendefined as

“a medicinal product consisting of asubstance produced by subjecting a plantor plants of drying, crushing or any otherprocess or of a mixture whose soleingredients are two or more substancesso produced, or of a mixture whose soleingredients are one or more substancesso produced with water or some otherinert substance”.

The Australian Therapeutic GoodsRegulations, 1990, has a broaderdefinition of herbal substance:

“all or part of a plant or substance(other than a pure chemical or asubstances of bacterial origin): (a) that isobtained only by drying, crushing, distilling,extracting, expressing, comminuting,mixing with an inert diluent substance oranother herbal substance or mixing withwater, ethanol, glycerol or aqueous ethanol;and (b) that is not subjected to any othertreatment or process other than a treatmentor process that is necessary for itspresentation in a pharmaceutical form”.

The WHO guidelines for the assess-ment of herbal medicines propose adefinition which is subsidiary to the term“plant preparation”:

“Finished, labelled medicinal productsthat contain as active ingredients aerialor underground parts of plants, or otherplant material or combination thereof,whether in the crude state or as plantpreparations. Plant material includesjuices, gums, fatty oils, essential oils, andany other substances of this nature. Herbalmedicines may contain excipients inaddition to the active ingredients.Medicines containing plant materialcombined with chemically defined activesubstances, including chemically defined,isolated constituents of plants, are notconsidered to be herbal medicines.”

d Council Directive 65/65/EEC of 26th January 1965, as subsequently amended.


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A different definition – similarlydependent upon the concept of preparedor processed ingredients – is preferred inthe recent WHO guidelines for evaluatingthe safety and efficacy of herbal medicines:

“A plant-derived material orpreparation with therapeutic or otherhuman health benefits which containseither raw or processed ingredients fromone or more plants. In some traditions,materials of inorganic or animal originmay also be present”.

In formulating such a definition, twoconsiderations are important: the ways inwhich related concepts and terms havebeen already defined, both within nationalstatutes and international texts, and theparticular aspects that it is intended toregulate.8 Thus, some definitions of herbalremedies are drafted in terms that covermedicinal plants, while others specificallyexclude them.

Registration/ApprovalAny attempt to apply broad generalizationsto the wide variety of national approachesto the registration of plant-based medicinalproducts can be misleading.e Nationalcontrol systems have evolved in different andunique ways, and these distinctive influencescontinue to be reflected in the regulatoryprovisions currently in place. In manyinstances, such products have been eitherincluded or excluded for assessment andregistration purposes through exemptionsinspired by any of a wide variety of factors.The piecemeal evolution of regulatoryrequirements which in part is attributable todifficulties in defining terms and validatingclaims regarding efficacy and safety is moreevident with regard to plant-based productsthan other medicinal products.

Different national laws apply variouscriteria to the scheduling of herbal ortraditional products for purposes ofregistration. These criteria cover thefollowing considerations:

Whether or not the product is includedin an official pharmacopoeia orformulary;Whether or not the product is to be soldas a prescription product;Whether or not a therapeutic effect isclaimed;Whether or not the product containsan ingredient or substance that iseither scheduled in an internationalconvention or subjected to prescriptioncontrol;Longevity of use (described as ‘wellestablished’ or ‘long-term’ use) deter-mined in relation to a stipulated dateor classified as a ‘new drug within thetraditional system’;Some countries draw a distinctionbetween ”officially approved” productsand “officially recognized” products.This is an important distinction inpractice since the intention is to enablethe latter to be legitimately marketedwithout formal assessment orregistration.

At the risk of oversimplification, it is possibleto classify legislative approaches into threegroups:

All medicinal products are subjected tothe same regulatory provisions;All or some herbal and/or traditionalmedicines are exempted from allregulatory provisions;All or some herbal and/or traditionalmedicines are exempted from specifiedregulatory 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


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Different national statutes requiredifferent types of information and data tobe submitted with applications forregistration of herbal products. Somecountries, including Turkey and thePhilippines, require information on theregistration status of the product in othercountries, and in case of the latter, infor-mation on the manufacturing operationsand facilities.

Manufacture, Import, Export,Sale and DispensingIn most countries, the manufacture,import, export, dispensing and sale ofmedicinal plants are not specificallyregulated. Depending on the scope of thelaw these may be governed by provisionsapplicable to medicinal products ingeneral or, alternatively, this field of activitymay remain essentially laissez-faire.Hence, it is not usual to establish by lawseparate mechanisms to deal specificallywith certain aspects of medicinal plants.Regulatory competence in nearly allcountries is vested in the national drugauthority. France is among the fewcountries in which a separate authorityhas been established: the NationalInterprofessional Office has certainstatutory powers and responsi-bilities withregard to plants, parts of plants, and theproducts of initial processing of thesematerials.

China features prominently amongcountries that have issued regulationsspecific to traditional herbal medicines.Detailed provisions have been promulgatedon their preparation which specifystandards and requirements to bemaintained in manufacturing facilities andby personnel. In Indonesia, traditionalmedicines can be manufactured only undera licence granted by the Ministry of Health.Hungary permits the marketing andprocessing of only those medicinal plantsthat have been inspected by the MedicinalPlants Research Institute and for which acertificate of inspection has been granted.In Singapore, the statutory requirementsconcerning manufacture do not apply toproducts prepared exclusively by drying,crushing or comminuting plants or partsof plants.

The extent to which elements of GoodManufacturing Practices are applied to themanufacture of plant-based medicinalproducts is varied. Insofar as the EuropeanCommunity is concerned, guidelines for themanufacture of herbal medicinal productswere drafted in 1990 under the aegis ofthe Committee for Proprietary MedicinalProducts.

These guidelines are intended tosupplement the EC text of good manufac-turing practices.

Statutory provisions bearing specificallyon the import of medicinal plants areuncommon. Countries that requireregistration of herbal medicinal productsgenerally have the power to regulate theirimport; any restrictions applied specificallyto medicinal plants are usually set out onlyin regulations.

A number of countries have recentlyreported that some imported herbalproducts have been found to contain non-labelled substances that are potentiallyharmful to health. Malaysia, for instance,

The extent to whichelements of Good

Manufacturing Practices areapplied to the manufacture

of plant-based medicinalproducts is varied.


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reportedf the presence of several scheduledpoisons and controlled substances,including betamethasone, dexamethasone,chlorpheniramine, mefanamic acid,phenylbutazone, and dexachlorphe-niramine, in both domestically producedand imported herbal medicinal products.This resulted in the confiscation of stocksand the banning of these products fromdomestic markets.

Approaches to the export ofmedicinal plantsA few countries require all exports to beregulated. In Spain, for instance, the exportof medicinal plants is subject to theissuance of a certificate of guarantee bythe competent pharmaceutical inspectorate.

Other countries which cultivatemedicinal plants have sought to promoteexports by specifying the competentregulatory authority in the legal text. In Mali,for instance, one of the statutory responsi-bilities of the Office of Pharmacy is topromote the export of products of its ownresearch and manufacture, particularlydrugs based on medicinal plants. Similarly,the National Pharmaceutical Office ofBenin is required to promote the export ofmedicinal products.

In some countries, however, specificrestrictions are applied to the export ofprotected plants. In Mali, prior authori-zation of the Director-General is requiredfor any activity involving the collection ofmedicinal plants for export. In 1976, aWHO expert group on traditionalmedicines9 called upon countries toregulate the export of medicinal plants forcommercial purposes – a call that remainedlargely unnoticed until the elaboration ofthe United Nations Convention onBiological Diversity.

The dispensing and sale of medicinalproducts and medicinal plants aregoverned not only by the laws dealingspecifically with drug regulation but alsoby those dealing with the health-relatedprofessions. Statutory provisions relating tomedicinal plants, where they exist, arebased on a range of different approachesand modalities. In France, for instance,certain essential oils derived from plantsmay be sold or supplied to the public onlyby pharmacists. In the Republic of Korea,herbal practitioners – a category of healthprofessionals who need to pass anexamination to be granted this status –may sell herbs by preparing them inaccordance with the specifications inoriental medical books or prescriptions oforiental medical doctors.

In the United Kingdom, herbalremedies are sold on a retail basis byshopkeepers (e.g., ‘health foods’ shops,supermarkets, grocers); herbalists (i.e.,persons who make and sell herbalremedies to persons who consult them);and pharmacists. In Bulgaria, only personsin possession of medical qualifications mayreceive authorization by the Ministry ofHealth to prescribe medicinal plants. InBrazil, medicinal plants may be dispensedonly within pharmacies and herbalists’shops. Lesotho has a system – admini-stered by the Universal Medicinemen andHerbalists Council – of licensing medicine-men and herbalists. In Morocco, there is astatutory prohibition on the simultaneouspractice of the profession of physician,dental surgeon and midwife, on the onehand, and that of a herbalist, on the other,even if the latter is otherwise qualified topractise any of the other professions. Thoselicensed as a herbalist may sell anymedicinal plant and parts of any such

f Annon. Contaminated herbal medicines in Malaysia. SCRIP, No. 1892, 28 January 1994, p. 19.


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plant, with the exception of those plantsincluded in the list of poisonous substances,and no herbalist may store or sell any otherpharmaceutical preparation or speciality.

Labelling, Advertising andPromotionFew regulatory texts have specific provisionsconcerning the labelling, advertising andpromotion of medicinal plants. Those thatdo address these issues tend to extend toherbal medicines the general provisionsapplied to other medicinal products. A fewcountries do have discrete and specificprovisions

Norway requires herbs and blendedherbs available over-the-counter (OTC) tocarry the following warnings

“The medicinal effect of thispreparation has not been assessed by thepublic authorities responsible for thecontrol of medicaments”.

Brazil requires the botanical classi-fication of the medicinal plant to appearon labels and wrappers. No proprietaryname is required in China either formedicinal plants or for decoctionsprepared in accordance with Chinesetraditional medicine. Indonesia requiresthat traditional drugs intended for clinicaltrials must be labelled with the words“intended for Clinical Trials; Not for Sale”.

Gambia prohibits all advertising ofproducts derived from plants cultivated inthe country and used as traditionalmedicines, unless specific approval hasbeen obtained from the Medicines Board.

Research and InstitutionalMechanismsSeveral African countries provide for furtherresearch on medicinal plants. The NationalPharmaceutical Bureau of Burundi, theCentral Laboratory at Mototo in Guinea,the National Institute for Medical Research

of Tanzania, the Institute of MedicalResearch and Medicinal Plants ofCameroon, and the National Institute forResearch on the Traditional Pharmaco-poeia and Traditional Medicine of Mali havea statutory responsibility to undertakeresearch relating to medicinal plants.

ConclusionsDespite increasing pressures for theintroduction of controls, relatively fewcountries have enacted specific legislativemeasures to control either the use ofmedicinal plants or of herbal preparationsderived from them in respect of which thereis only limited data concerning their quality,safety and efficacy. Legislative texts of thosecountries that have developed systems forthe scientific and technical assessment ofthe quality, safety and efficacy of medicinalplants, as well as guidelines formulatedunder the aegis of the World HealthOrganization, define the criteria forassessment and the procedures to befollowed in undertaking such assessments.

As the assessment of medicinal plantscannot be guided by systematic or longexperience, it is important that drugregulatory authorities wishing to regulatemedicinal plants as well as assess themmake the maximum use of the accumulatedwisdom of those authorities with moreexperience in this relatively uncharteredterritory. The new United Nations Conventionon Biological Diversity offers a stimulus tocountries that wish to review the control ofmedicinal plants within a framework thatmaintains a balance between reasonableexploitation and conservation.

Traditional MedicalPractitioners

Traditional medical practitioners exist inalmost every society; not all prefer to be


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called as “traditional medical practitioners”because with the advent of the Westernsystem of medicine, Western medicalpractitioners have come to enjoy an almostmonopolistic position, with the attendantstatus, privileges and concessions. In somecountries, by law there are restrictions inthe use of the term “medical practitioner”or “doctor’, thus placing traditionalmedical practitioners at a disadvantage. Ithas never been easy to establish the preciserole and status of traditional medicalpractitioners. Community acceptability,political patronage and perception as asource of last resort when practitioners ofother systems have failed to provide reliefare some of the factors that come into playin determining the recognition to beaccorded to them. Attempts have beenmade by some countries to initiate aprocess of dialogue and consultation witha view to arriving at some compromise.Mauritania, for instance, established aworking group on medicine and thepharmacopoeia:

“to determine the situation oftraditional medicine and the traditionalpharmacopoeia in Mauritania and, inparticular:

to examine the most appropriate andrealistic ways and means of establi-shing an honest dialogue between theofficial health services and traditionalpractitioners in the spirit of theobjectives of health for all by the year2000 through primary health care;to propose the most appropriatemechanisms for identifying traditionalmedical practitioners who areamenable to such a dialogue in orderto determine and acknowledge the

part that they can play in the system ofcomprehensive health care (healthpromotion, prevention of disease anddisability, diagnosis and early treatmentof disease and rehabilitation.”g

A definition of a traditional healthpractitioner is found in the Public HealthCode of Guinea of 1997:h “A traditionalhealth practitioner is a person recognizedby the community in which he lives ascompetent to carry out diagnoses withlocal sociocultural foundations andcontribute to the health and physical,mental, social, and spiritual well-being ofthe members of the locality concerned.” Inaddition to this definition, there are separatedefinitions of traditional therapists;traditional midwives; herbalists; and,medico-druggists. These are reproducedbelow:

Traditional A person recognized by histherapist locality as being competent to

carry out diagnoses anddispense health care based onthe concepts of disease anddisability that prevail in thatlocality;

Traditional A person recognized asmidwife competent to provide health

care to women and newbornsbefore, during and afterdelivery, on the basis of theconcepts prevailing in thelocality concerned;

Herbalist A person who has a know-ledge of the customs and sellsmedicinal plants;

Medico- A person who has a know-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).


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at minimal or no cost. Success stories oftreating those who had found no relief aftertaking Western medicaments and the beliefthat someone who is closer to one’s ownenvironment and religion is better placedto provide treatment were additionalfactors. In other words, traditional medicalpractitioners have always been a force tobe reckoned with. In drafting legislationgoverning health practitioners, acompromise had to be reached because itwas simply not politically or culturallyacceptable to overlook or dismiss theimportant role played by traditional medicalpractitioners. Legislative approachesrelating to the regulation of traditionalmedical practitioners basically fall into fourcategories:10

The exclusive (monopolistic) system;The tolerant system;The inclusive system;The integrated system.

Each of the above systems are brieflydescribed below:

The exclusive (monopolistic)systemUnder this system, Western medicalpractitioners were the only ones to belegally recognized, at least at one point oftime. Other practitioners were simply notmentioned in the legislation or thelegislation clearly excluded them fromfunctioning as medical practitioners.Examples are available from Europeancountries, the most notable being France,and the Americas of legislation conferringa monopolistic status on university-educated physicians and allied profe-ssionals such as dentists, pharmacists andnurses. Some laws made it a specificoffence to engage in medical acts contraryto the law. In certain instances, even whenconcessions were made, the provisions

medical substances other thanplants, of animal or mineralorigin.

The practice of traditional medicine isdefined as covering consultative, diagno-stic, and care procedures that makeexclusive use of traditional methods.

What is significant about the abovedefinitions is that they underline theimportance of community recognition andunderstanding of the local situation.Concepts of disease and treatment varyfrom system to system and from society tosociety; the expected role of traditionalpractitioners is to provide treatment inaccordance with these concepts. The abilityto adapt these concepts in accordance withscientific advances will considerablyenhance their potential; they are bestplaced to gradually introduce intootherwise conservative cultures modernmethods and modern drugs.

A historical perspectiveLegislative provisions relating to the statusof health practitioners can be bestunderstood only by considering theevolution of such provisions in eachcountry. The reason for this is that eachcountry has approached the issue in a waythat is unique and often dictated byconsiderations that are not readilycomprehensible or logical. Historically, withthe increasingly strong presence of thosetrained in Western medicine, there was amovement to entrench their role andposition by providing for a virtual monopolystatus. Every society has had persons –often without any formal education – withthe requisite knowledge and skills to treatthe sick and the disabled. They werepopular because of their easy accessibility,use of language that was simple tounderstand and the provision of treatment


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were specifically formulated to protect themonopoly. For example, Czechoslovakiaissued Ministerial Instructions in 1976 and1981 to regulate the practice of acupun-cture but only physicians with specialtraining were permitted to use this method.

The Tolerant SystemA few countries with advanced health caresystems, such as the United Kingdom andGermany, do not prohibit healing bypersons without the necessary qualifi-cations specified in the law for registrationas a physician of what is commonly knownas “western system” or “modern system”of medicine. What the law often states isthat it is an offence for anyone who is notduly licensed as such to claim to be aphysician or to use the title reserved forsuch a person. In the United Kingdom, forinstance, under the Medical Act of 1956“any person who willfully and falselypretends to be or takes or uses the nameor title of physician, doctor of medicine…surgeon, general practitioner…or anyname, title, addition or description implyingthat he is registered…” is guilty of anoffence.

Under this system, while practisingmedicine is not prohibited, traditionalmedical practitioners nevertheless sufferfrom certain disabilities under the law. Forinstance, in the United Kingdom, onlyregistered practitioners enjoy, under thelaw, the following privileges:

Entitlement to recover in the courts feesfor treatment and advice;Employment by and dispensing oftreatment under the National HealthService;Holding appointments in publichospitals and other publicestablishments;Issuing such medical certificates as arerequired by law;

Issuing prescriptions in respect ofcertain drugs as provided for by theMedicines Act 1968.

A few countries have moved towardsthe tolerant system by expressly mentioningin the legislation that non-modern scientificsystems are permissible. For instance, theMedical Act of 1971 of Malaysia statesthat “…nothing in this Act shall be deemedto affect the right of any person, not beinga person taking or using any name, title,addition or description calculated to induceany person to believe that he is qualified topractise medicine or surgery according tomodern scientific methods, to practisesystems of therapeutics or surgeryaccording to purely Malay, Chinese, Indianor other native methods, and to demandand recover reasonable charges in respectof such practice.” Another example is tobe found in the Medical and DentalPractitioners (Amendment) Act 1981 of theRepublic of Kiribati. It states that “nothingin the Medical and Dental PractitionersOrdinance shall affect the right of any I-Kiribati to practise in a responsible mannerKiribati traditional healing by means ofherbal therapy, bone setting and massage,and to demand and recover reasonablecharges in respect of such practice:provided that a person so practicing shallnot take or use any name, title, addition ordescription likely to induce anyone to believethat he is qualified to practise medicine orsurgery according to modern scientificmethods.” Systems of medicine exemptedfrom the application of the law arementioned in the Medical Council Act of1988 of Mauritius which states that theAct does not prohibit the practice ofsystems of therapeutics according tohomoeopathy, Ayurvedic and Chinesetraditional methods.


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The Inclusive SystemThis system is found in countries such asBangladesh, India, Pakistan and Sri Lankawhere the law recognizes two parallelsystems, the traditional and the modern.The law provides for the registration andrecognition of traditional medical practi-tioners and regulates matters pertaining tomedical education, practice, and ethics.

In most countries traditional medicalpractitioners originally came from familieswhere they were taught by their elders.Knowledge was transmitted from onegeneration to another; secret remediesremained a closely kept secret that was notrecorded in writing. Universities, schoolsand colleges for training the differentcategories of traditional medical practi-tioners were set up much later. In the earlystages, the laws governing medical practicerecognized a category of practitionerswithout formal educational qualificationsbut who had been in active practice for adefined period of time. This was a legislativetechnique that is generally not found inlaws governing Western or modernpractitioners. Through this device, it waspossible to bring into the mainstream oftraditional medical practice thousands ofpractitioners who might otherwise have notbeen eligible for registration had formalqualifications been a statutory requirement.

In almost every society, traditionalmedical practitioners gained recognitionthrough a struggle; each country has itsown story of the battles that were fought.In many instances, traditional medicalpractitioners emerged as a strong andinfluential political force to be reckonedwith – even though they were numericallynot large, they had their supporters in largenumbers. State patronage has alwaysplayed an important role. The creation ofa separate Ministry of Indigenous Medicinein Sri Lanka, for instance, was an important

turning point in the country’s medicalhistory.

The Integrated SystemThe integrated system represents a stagewhere the inclusive system has evolved intoa system that provides for the twoprofessions – western or modern medicalpractitioners and traditional medicalpractitioners – to work together as oneteam.

China provides the best knownexample of this integrated system. In SouthAsia, Nepal can be described as havingadopted this system. The Chinese system,with the well-known example of barefootmedical doctors, can be best understoodonly within the country’s complex politicalcontext. Indeed, there are concerns as towhether the Chinese system can be easilytried out elsewhere with the same degreeof success.

An integrated system offers anopportunity for each system to offer its bestfor the welfare of the patient. In actualpractice, however, some problems canarise. For instance, drug interactions arenot well-studied and in prescribingmedicines a choice would almost invariablyhave to be made between a Western drugand a herbal product, for instance.

ConclusionsThis review of traditional medical practi-tioners highlights that different countrieshave approached the issue from differentperspectives and that there is no singlelegislative model prevalent throughout theworld or any particular geographicalregion. Each country has a fairly complexbody of laws, regulations and codes ofconduct applicable to traditional medicalpractitioners. It is not possible to commenton these laws unless they are examined inthe light of the laws, regulations and codes


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of conduct applicable to modern orWestern medical practitioners.

Towards the Future

It cannot be gainsaid that for the vastmajority of the population in most ruralsocieties traditional medical practitionerswill continue to provide the only source ofmedicine that is easily available at areasonable cost. While exclusion, throughexperience and practice, of products on thebasis of evidence of short-term toxicity willcontinue to operate as a safety valve, theneed for assessment based on appropriatecriteria has to be met sooner or later by allcountries. Guidelines produced by WHOexemplify that such assessments are notunrealistic even in countries with limitedresources. The challenge is to devise“appropriate criteria” using cost-effectivemethods. There must be a dialogue leadingto consensus and traditional medicalpractitioners themselves must be in thevanguard of the movement to rationalizethe traditional medicine market.

It augurs well for the future that theWHO Regional Office for South-East Asia,in particular, has been promoting theintegration of traditional medical practi-tioners into the district health system (DHS).From a regulatory perspective, theintegration of traditional medical practi-tioners and traditional medicine productsinto the district health system (DHS) mustbe based on the following guiding principles:

Principle 1: The DHS must recognizethat plural systems of health care exist andthat each system must be accordedrecognition.

Principle 2: Recognition of pluralityis not necessarily inconsistent with theobligation to ensure that those basicprinciples of public health and safety arenot compromised.

Principle 3: The determination of therespective role to be assigned to eachsystem must involve consultations withrecognized practitioners of each systemand consumer groups or communityleaders representative of users. Suchconsultations must be based on thepremise that health-care products mustconform to acceptable standards of quality,safety and efficacy, and that the numberswho use such products or the politicalpatronage extended to such products orthe practitioners thereof are irrelevant tothe scientific process that must necessarilytake place to determine quality, safety andefficacy. Unsafe products or those ofdoubtful quality must be eliminated fromthe market; the support of relevant groupsmust be mobilized to ensure that suchproducts are no longer marketed or used.There must be an appropriate legislativebasis to mandate the process of evaluationand to authorize products to be marketedor to be eliminated from the market.Through a phased-in approach allproducts can be assessed on a systematicbasis. Even countries with limitedmanpower have been able to progress bymaking extensive use of the experience ofcountries with more manpower. Unlessgenetic and other factors dictate otherwise,a product approved by many countriesmust be assumed to be suitable forinclusion in the list of essential medicinesfor community use.

Principle 4: Products that arepermitted to be used must be madeavailable through appropriate channels,not excluding those that have been devisedfor a particular type of product. Where anintegrated approach to distribution isfeasible, such an approach must bedeveloped through a process ofconsultation and collaboration. Practi-tioners of each system must respect the


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strengths and limitations of each systemand the need to supplement deliverysystems devised for each system.Managers of DHS must assume theresponsibility for ensuring that the deliverysystem can meet the demand. Amanagement committee must be in placeto ensure that products are made availableto the extent possible. Where health

insurance or social reimbursementschemes exist, traditional medical productsmust be considered as eligible products.

In this first year of the new millenniumwe must have the modesty to recognizethat no single system can meet all ourhealth-care needs and the courage toensure that products that are not safe mustnot be permitted.

References

1. Wolffers I. Traditional practitioners and western pharmaceuticals in Sri Lanka. TheContext of Medicines in Developing Countries. Amsterdam. Klluwer AcademicPublishing. 1988: 47–56.

2. Nakajima H. Our earth and our health. Natural resources and human health-plants ofmedicinal 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 Resourcesfor sustainable development. Washington D.C. World Resource Institute. 1993: 7.

5. Kobe Conference. Plants of medicinal and nutritional value. Natural resources andhuman 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: WHOExpert 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: legalissues 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.

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logy studies and inappropriate uncon-trolled and badly designed clinical trialsform the triad of constraining factors whichhave held back the use of medicinal plantsfor health development and belied thelongstanding hopes that research onmedicinal plants would lead to a host ofnew drugs.

Standardization

When a medicine is administered to apatient, the doctor who prescribes themedicine needs to be certain that themedicine contains the correct amount ofthe right substance and does not containany impurities. Only then will the medicineinduce its therapeutic effect and not induceany toxic effect due perhaps to contami-nants. This is only possible if the herbalmedicine has undergone a process knownas standardization. It is this lack ofstandardization of herbal remedies whichacts as a constraint to the use of thesemedicines in allopathic hospitals. It is alsoone of the constraints preventing anincrease in the export of traditionalmedicines from third world countries with

the unique heritage of abundant unlimitedbiodiversity. Only if herbal medicines arewell standardized will countries purchasesuch medicines. Only if the allopathicdoctors are convinced that every sampleof a herbal drug contains the same amountof active constituents will they prescribesuch medicines.

The need for proper standardizationhas also been recognized by practitionersof the traditional systems of medicine. Atthe 3rd International Congress ofTraditional Asian Medicine held at Mumbaifrom 4–9 January, 1990, this point wasrepeatedly highlighted by a large numberof participants who did not belong to theallopathic system.1 A group of Ayurvedicresearch workers stressed the importanceof developing good methods forstandardizing crude extracts, decoctionsand compound formulations which consistof different ingredients. It was clearly statedthat the technology available at that time,10 years ago, was not able to developsuitable quality control criteria for mixturesand compound preparations.

There are several factors which haveacted as constraints in the developmentof appropriate methods for standardizingherbal medicines. Some of these have

Ranjit Roy ChaudhuryMandakini Roy Chaudhury

Inadequate standardization of medicinalplants, unacceptable preclinical toxico-

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been clearly brought out by Handa in hiscontribution to the Regional Consultationon Development of Traditional Medicine inSouth-East Asia Region held in New Delhifrom 14–17 September, 1999.2 Bottle-necks in the standardization of herbal drugsinclude dependence on wild sources for theplants leading to variation in quality,adulteration and substitution of the activeplant material by inactive, cheaper varietiesof non-medicinal plants, and in many casesincorrect identification of the plant itself.This is because the same plant may havedifferent local names at different locationswhile sometimes different plants have thesame local name. A good example of thelatter is that the plant which is commonlyknown as Punarnava, a quality-of-lifeenhancer, is collected under the botanicalname of Boerhaavia diffusa and alsocollected under the name Trianthemaportulacastrum (Vishakarpara). This wouldcertainly lead to problems in standardizingBoerhaavia diffusa if some Trianthemaportulacastrum is also contained in thesample.

The loss in medicinal plants due toecological degradation has led to ashortage of the actual plants andsubstitution by other non-medicinal plants.One example is the preparation of a herbaldrug from the bark of the plant Caesalpiniasappan (Patranga). When this bark iscollected, the bark from other plants suchas Pterocarpus marsupium (Vijayasara),Gluta travancorica and Toona ciliata(Nandivriksha) or Cedrela toona aresubstituted for Caesalpinia sappan. Otherexamples which have been found in Indiarelate to the substitution of the bark ofSaraca indica (Ashok) by the bark ofTrema orientalis (Jivanti) and substitutionof the plant Holarrhena antidysenterica(Kutaja) by the plant Wrightia tinctoria (Asitakutaja). Similar instances of adulteration

can be seen in many countries of South-East Asia.

The need for standardization has longbeen recognized. The World HealthOrganization organized an Inter-RegionalMeeting on Standardization and Use ofMedicinal Plants at Tianjin in China inNovember 1980.3 Participants clearlypointed out the problems relating tostandardization of herbal medicines andthe tremendous need for immediate workin this field. A second conference, alsoorganized by the Western Pacific RegionalOffice of the World Health Organizationat Tokyo in 1986, identified three areas ofpriority research.4 Research on standardi-zation was one of these areas. Standardi-zation, it was stressed, means standardi-zation of the raw material, standardizationof the method of production and qualitycontrol of the final product. The RegionalConsultation at New Delhi held in 1999[2]

again highlighted the need for standardi-zation but added some new features to thisissue.

Parikh2 in his presentation at the NewDelhi meeting organized by the WorldHealth Organization made a strong pleafor cultivation of medicinal plants ratherthan collection from the wild. Standardi-zation of herbal preparations from plantswhich are cultivated would be easier forthe following reasons. The availability of theplant material would be assured and thesupplies could be controlled. The qualityof such plants would be reliable, identi-fication totally accurate and adulterationwould not be an issue. Further, in thissystem the environment would be main-tained. Other possible advantages wouldbe the possibility, in these controlledconditions, of carrying out agronomicmanipulation and genetic improvement.

A reference was also made by Parikh2

to the global market for medicinal plant


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products which had been estimated to beof the order of five trillion dollars in 2050.Only those countries which invest imme-diately and well in setting up standardi-zation of herbal products could hope toexploit this worldwide growth in the needfor herbal products. Countries will, in theyears to come, not allow products whichare not standardized to be sold.

Another major constraint in setting upstandardization procedures is the non-availability of standards against whichproducts could be assessed by chemicalor bioassay methodology.

Advances have been made in the last10 years in the standardization of herbalproducts. It is expected today that thefollowing macroscopic, microscopic,physicochemical and biological testsshould have been carried out before anyplant material is released for use.

Macroscopic examination;Microscopic examination;e.g. Anatomical structure

Detailed study of fragments;Physiochemical testinge.g.Boiling point;

Freezing point;Absorption coefficient;Loss on drying;Ash value;Refractory index;Optical ratio;Water/alcohol soluble solid;Spectroscopic analysis;Thin-layer chromatography – R.F.value;Gas liquid chromatography.

Biological testing where appropriatee.g. Digitalis bioassay.

A big step forward towards improvedstandardization of plant medicines was thepublication in 1998 of the “Quality controlmethods for medicinal plant material”5 by

WHO Geneva, which followed the 1992document “Quality control methods formedicinal plant material”. Investigatorsinterested in details of the methodologyproposed for use are requested to studythe publication brought out in 1998.

Another positive development has beenthe publication of Herbal Pharmacopoeaswhich have laid down the standards for thedifferent procedures. WHO has recentlybrought out its first Pharmacopoeacontaining standards for plants. Otherpharmacopoeas available include theBritish Herbal Pharmacopoea (1990),Japanese Standards for Herbal Medicines(1993), Ayurveda Formulary andStandards for Ayurvedic Formulations(1978), the Central Council for Researchin Indian Medicine “PharmacopealStandard for Ayurvedic Formulations(1987), the Ayurvedic Pharmacopoea ofIndia (1989), the Unani Pharmacopoea(2000), National Formulary of UnaniMedicine – Part I (1984) and Part II (2000),the Pharmacopoea of the People’s Republicof China and the Indian Herbal Pharma-copoea (1998), volumes one and two.

In spite of these advances, standardi-zation of herbal preparations needs to begiven a big boost by governments in theRegion if the tremendous potential ofancient heritage and biodiversity is to beused for the people of the countries fordelivering improved health care. Herbalmedicines would be much more widely usednationally and internationally, would bemuch more accepted and would tremen-dously enhance health care if improvedstandardization provides credibility to thequality of the medicines used. Unfortu-nately, there are very few centres forstandardization of herbal products in theRegion, too few qualified and trainedexperts in this area of expertise, and a lackof sustained funding for standardization


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activities. These shortcomings need to becorrected.

Preclinical Toxicology

Preclinical toxicology studies in animals arecarried out to determine the safety ofmedicinal plants and herbal preparationsbefore administering these to humansfor the purpose of evaluating clinicaleffectiveness. The quantum of toxicity teststo be carried out is defined in national laws,and the drug regulatory agencies of thecountries ensure that acute, subacute andchronic studies in animals are carried outand the results carefully assessed. Theserequirements were, till recent years, thesame for new synthetic molecules neverbefore administered to man and for herbalmedicines used for generations and, inmany instances, even being actually usedat this time.

It was only in 1980 that the first author,in his keynote address at the First WorldConference in Clinical Pharmacology inLondon, stated that extensive preclinicalanimal toxicology studies for syntheticdrugs were not necessary for herbalmedicines used for generations and evenbeing used at the present time.6 Heproposed a shorter, six-week toxicologymodel on two species of animals whichwould be realistic, save time and resourcesand prevent unnecessary animal sacrifice.Although there was considerable concernas regards the ethical implications of thisshortened toxicology testing model, it hasbeen accepted by and large by theregulatory authorities of a large numberof countries including India, and by theWorld Health Organization.

Another decision by the Swedish drugregulatory agency helped in the accep-tance of reduced toxicology testing formedicinal plants. The authorities approved

clinical evaluation, in a limited number ofhuman subjects, of a plant Zaopatle –Montanoa tomentosa – for its luteolyticeffect and possible use as a contraceptive.The animal toxicology tests carried outbefore clinical evaluation were:

Thirty rats were administered thedecoction at three doses for four weeks;Four female monkeys were adminis-tered the decoction once daily for 30days;Four adult dogs were given theconcoction for 12 weeks. The usualtoxicology profile after administrationof the substance was studied in thesethree species.

The reason for the Swedish authoritiesputting zaopatle on the fast-track reducedtoxicology profile was the great need forearly development of a contraceptive andthe fact that zaopatle had been used forits antiovulatory effect as a herbal tea inMexico. Such use was first described bythe Spanish monk Fray Bernadino deSahagun in 1575.7 In recent years, drugregulatory authorities of several countrieshave allowed clinical evaluation of plantsfor the treatment of HIV/AIDS with veryminimal toxicological studies.

The World Health Organization firstaccepted the fact that traditional medicinesmay need shorter preclinical toxicologicalevaluation 10 years after the Chandigarhproposal at a WHO Consultation onTraditional Medicine8 and AIDS in 1990when the report of the Consultation stated:“The range of preclinical tests available forevaluation of a synthetic drug, beforebeginning clinical trials, is well known.What is not known, however, is whethersuch preclinical tests need to be soextensive for herbal remedies”. The groupsuggested that herbal remedies were notreally new drugs and that these had been


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used for a long time and informationregarding its use was available. Theyconcluded that a more limited range ofpreclinical tests may be adequate fortraditional remedies and that this limitedtesting would be justified by the remedy’sprevious use in human disease. They left itto individual countries to define their ownneeds but even suggested that some herbalremedies could be directly approved forclinical evaluation without preclinicaltoxicological tests.

It is interesting to note that, to a largeextent, this shortened toxicology profile wasaccepted because of the urgent need todiscover a new contraceptive or an anti-HIV herbal remedy.

WHO thinking on this subject wasfurther consolidated when it published9 in1991 the WHO Guidelines for Assessmentof Herbal Medicines. The principleenunciated here was that “if a traditionalmedicine has been used without harm, nospecific restrictions or regulatory actionshould be undertaken” unless there is areason for it.

The WHO “Research Guidelines forevaluating the Safety and Efficacy of HerbalMedicines”10 brought out in 1993 by theWestern Pacific Regional Office in Manilareiterates that not all tests are required forevery herbal medicine. A list of tests to becarried out has been provided.

What generally comes out in a laterWHO document published in 199611 isthat if adequate study of the publishedliterature demonstrates lack of harmfuleffects of a herbal remedy, then clinicalevaluation can be undertaken withoutundertaking animal toxicology studies. If,however, the literature survey does notdocument long-term use without harm,then animal toxicology studies should beundertaken before clinical evaluation. Itmakes the very interesting statement that

“prolonged and apparently uneventful useof a substance usually offers testimony ofits safety”. The document again stressesthe importance of literature search and theabsence of side-effects after long-term use.It, however, for the first time, brings out theneed for tests for systemic toxicity, carcino-genicity and teratogenecity as it may notbe easy to document the absence of thesefrom the long-term use of herbal remedies.

A few important points will be made atthis stage before delineating a toxicologicalprofile for herbal remedies. All therecommendations cited above are forherbal remedies used as such forgenerations. If the method of preparationis changed, or if a product – a chemicalentity – is being sought to be clinicallyevaluated, or if two new mixtures orproducts are combined, then it becomes anew drug – not a traditional medicine. Allthe requirements for a new drug wouldapply and the drug regulatory authoritieswould require the full range of toxicitystudies to be carried out. Thus, while onlyvery limited studies were needed for the useof Picrorhiza kurroa as a hepatoprotectivesubstance, the full range of toxicology testshad to be performed for Picroliv– thecompound obtained from Picrorhizakurroa.

Another point which needs discussionis to examine the tenet that if no harm hasbeen found after the use of a herbalmedicine for generations and there is no

In recent years, drug regulatoryauthorities of several countrieshave allowed clinical evaluationof plants for the treatment ofHIV/AIDS with very minimal

toxicological studies.


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documentation of such an effect, then thepreparation can be used clinically. Lack ofdocumentation of a side-effect or a harmfuleffect does not always mean that there isno such effect. It may not have beenobserved or, even if observed, it may nothave been documented. In fact, the WHOpublication13 on “General Guidelines formethodologies on research and evaluationof traditional medicine” makes this pointwhen it states clearly “Absence of reportedor documented side-effect is not an absoluteassurance of safety of herbal medicine.However, a full range of toxicology tests maynot be necessary. Tests which examineeffects that are difficult or even impossibleto detect clinically should be encouraged.Suggested tests include immunotoxicity,genotoxicity, carcinogenicity and repro-ductive toxicity”. This latest WHO Guideline(2000)[13] does not take a step backwardbut takes a broader perspective on the needfor toxicological evaluation of herbalremedies. It still reiterates that: “Only whenthere is no documentation of long historicaluse of a herbal medicine or when doubtsexist about its safety, should additionaltoxicity studies be performed”. Thereappears to be some anomaly between thetwo quotations from the same documentbut then this field is full of anomalies. It isnoteworthy that due to a resurgence ofinterest in traditional medicines muchthinking is going on and will continue to goon in this area of herbal medicine preclinicaltoxicology. The need for WHO to assistcountries in regulating the use of traditionalmedicines regarding their safety and efficacywas one of the specific recommendationsmade by the Ministers of Health of the WHOSouth-East Asia Region at their meeting heldin New Delhi in September 1998.12

What comes out very clearly is thatthere has to be flexibility in the toxicologicalrequirements for herbal medicines and that

no rigid framework, as has been preparedfor synthetic drugs, will ever be possible.So much depends on the way the extractor plant is administered, the duration ofuse, the dose and so many other factorsthat the framework established by theChandigarh group in 1980 and broadlyaccepted by the Indian Council of MedicalResearch and the World Health Organi-zation can remain only a framework. Theactual requirements may have to be slightlyaltered from plant to plant. The actual teststo be carried out in the Chandigarh modeland the duration have been described inTables 1 and 2. The tests recommendedby WHO are given in Table 3. This hasbeen given in detail in the 1996document of the Western Pacific Regionof WHO.11 Another point which needs tobe made is that evaluation of literaturedoes not mean only anecdotal informationthat a plant has been used for centurieswithout inducing any side-effect. This sortof information has very limited value.However, if some clinical studies have beencarried out then the value of absence ofside-effects is enhanced. These clinicalstudies should, however, be looked atcarefully especially with regard to the studydesign, the number of patients, the specificdiagnosis, the dose used, the duration ofadministration of the herbal medicine, andthe criteria used for assessing thetreatment.

Researchers, public health adminis-trators and drug regulatory agencies areinterested in developing guidelines fortoxicological assessment of herbalremedies which would, on the one hand,ensure that patients are not subjected tothe toxicity of the remedies and, on theother, not hamper the development anduse of these medicines. The modifiedChandigarh model14 being used in severalcountries could be a starting point. This


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

Acute toxicity Tests should be performed on two species – one rodent and onenon-rodent. Males and females from one species at least.Five animals per group per sex in rodents and at least two animalsper sex in non-rodents.Oral route orally or route of intended administrationDifferent dose levels

Observation studies Toxic signs, reversibility of signs. Animals to be observed for 7–14days. Autopsy of any animal which dies with histopathology oforgan 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 malesand 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 ofadministrationrecommended

Table 2. Duration of toxicity studiesSingle administration or repeated 2 weeks to 1 monthadministration for less than one weekRepeated administration from one 4 weeks to 3 monthsweek to four weeksRepeated administration between 3 to 6 monthsone and six monthsLong-term repeated administration 9 to 12 monthsfor more than six months

Table 1. Tests required for subacute toxicology studiesLiver function Serum Albumin/Globulin, Total proteins

Alkaline phosphatase BilirubinSGOT/SGPT

Renal function Blood UreaSerum Creatinine

Haematology HaemoglobinRBC, WBC – Total and Differential,ESR, PCV

Others CholesterolGlucose


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consists of the usual acute toxicity studiescomplemented by six-week subacutetoxicology studies with three doses in twophylogenetically different species like the ratand the rabbit species and a control series.The following observations are made daily:weight, food intake, water intake andgeneral behaviour. The following tests forlooking at haematological, hepatic andrenal effects specially need to be carriedout before and at the end of six weeksbefore sacrificing the animal.

An autopsy has to be carried out onevery animal at the end of the study and onany animal which died during the course ofthe study. Histopathological studies need tobe carried out on every organ at the autopsyboth for control and herbal remedy-treatedanimals on the high dose. If the animals onthe high dose show histopathologicalchanges then the same histopathologyshould be carried out on animalsadministered the intermediate dose.

Other tests could be added on ifthought necessary. These are tests forimmunotoxicity, carcinogenicity, genoto-xicity and reproductive toxicity. Teratologystudies should also be carried out, as hasrecently been completed15 for a combi-nation of Embelia ribes (Vidanga), Piperlongum and borax which is now beingevaluated in Phase II clinical trials as acontraceptive. Such an effort was describedin ancient textbooks of Ayurveda 2500year ago.

Earlier studies have also shown thatthis model is effective in detecting toxicity.Semecarpus anacardium (Bhallatak) wasgoing to be clinically evaluated as acontraceptive but the six-week toxicity studydemonstrated an effect on the white bloodcount which was not acceptable.16 Theplant was therefore not investigated further.

It is hoped that this review would helpinvestigators to fashion the toxicology

requirements for specific plants dependingon their earlier use, experimental resultsand the manner in which it is sought to beused.

Clinical Evaluation

Clinical trials in the past have been carriedout largely by clinicians and clinicalpharmacologists with experience in clinicaltrial methodology of synthetic drugs but nobackground of herbal or traditional systemsof medicine, or by traditional medicinepractitioners and experts who have verylittle idea about the conduct of clinical trialsaccording to modern concepts of clinicalpharmacology.

The results of such trials are thereforenot acceptable to the larger scientificcommunity and the practitioners of themodern system of medicine, allopathy, whoneed clear-cut evidence of efficacy and lackof side-effects of herbal remedies in well-conducted clinical trials before they wouldconsider use of such medicines.

An important challenge for clinicalresearchers in the 21st century is toconduct clinical evaluation of traditionalmedicines within the specific framework ofrigorous clinical pharmacological principleswithout ignoring or trampling on theconcepts and practices of traditionalsystems of medicine (Chaudhury, 1992).14

Fortunately, more and more multidisci-plinary centres are being developed withthis objective in mind. It is also salutary thatspecialists and practitioners of the ChineseTraditional System of Medicine in China andspecialists in Ayurvedic and Unanimedicines in India have no objection to theuse of modern concepts of the metho-dology of clinical trials in evaluating theefficacy and side-effects of herbalpreparations used in these traditionalsystems (Chaudhury, 2001).[17] Conside-


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rable effort has been made in the past twodecades to develop a herbal contraceptivekeeping in perspective the concepts ofAyurveda and the traditional systems ofmedicine.18 Again, the Indian Council ofMedical Research has taken the plantPterocarpus marsupium from its use infolklore and Ayurvedic medicine to PhaseIII clinical evaluation for the treatment ofdiabetes mellitus using well-acceptedclinical pharmacological principles.19 It isnow being handed over to industry forpharmaceutical development andmarketing.

The basic principles in the clinicalevaluation of herbal remedies are, ofcourse, the same irrespective of whether asynthetic compound or a herbal prepa-ration is being evaluated. However, thereare also very important differences whichneed to be kept in mind. In the next fewpages these basic concepts will bedelineated. The differences inherent inclinical evaluation will then be describedwith examples from the Indian programme,which has taken note of these differencesand modified the clinical trial methodologyaccordingly. Finally, the grey areas stillawaiting clarification and elucidation willbe discussed.

Before any drug is administered to ahuman subject or a patient for purposes ofclinical evaluation, the approval of thenational drug regulatory authority has to beobtained. While this is mandatory andessential for all synthetic drugs, the nationalGovernment may, in some circumstances,allow traditional medicines to be evaluatedwithout formal or informal approval of theregulatory authority. This has to be clearlyspelt out. In India, for example, the Officeof the Drugs Controller General allows,without further need of approval, plantpreparations described for their therapeuticeffect in 27 ancient books and treatises.

However, the preparation needs to be madeand administered in exactly the same wayas has been described in those books. Asynthetic or traditional medicine cleared foruse for a certain disease condition needsfresh approval if it is to be used for a differentcondition or if it is to be administered by adifferent route, or if it has excipients notstated in the ancient books referred to earlier.A product or a new combination of herbalmedicines will be treated as a new drug andwill have to be approved for clinicalevaluation.

In addition to approval of the nationaldrug regulatory agency, an investigator hasto obtain the clearance of the InstitutionalEthical Committee and, if necessary,clearance of the National EthicalCommittee or the Ethical Committee of theagency supporting the clinical evaluation.Thus, when Vicoa indica was clinicallyevaluated as a herbal contraceptive basedon observations made by public healthpersonnel on its use in a tribal community,ethical approval was obtained from threeagencies – the local Institutional EthicalCommittee at the Postgraduate Institute ofMedical Education and Research,Chandigarh, where the trial wasconducted, the Ethical Committee of theIndian Council of Medical Research, NewDelhi, and the Ethical Committee of thePopulation Foundation of India, whichsupported the clinical trial. (Chaudhury,1983).20 This is not the place to describethe composition and functioning ofInstitutional Ethical Committees or thedifferent nuances of obtaining informalconsent of each person who enters thetrial, although a little more will bementioned about informed consent whendiscussing some ethical aspects of clinicalevaluation of herbal products.

Once informed consent is obtained,then clinical evaluation could begin. The


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The studies are usually limited to 3–4centres. The studies should be carried in arandomized double-blind manner unlessthis is not possible. However, a well-planned and well- conducted single-blindstudy in certain circumstances, particularlywith herbal medicines, could also yieldunequivocal and scientifically validconclusions.

Phase IIIThe purpose of these trials is to obtainadequate data about the efficacy and safetyof drugs in a larger number of patients ofboth sexes in multiple centres, usually incomparison with a standard drug and/ora placebo if a standard drug does not existfor the disease under study.

Phase IVAfter approval of the drug for marketing,usually given after assessment of the resultsof Phase III trials, the Phase IV studies orpost-marketing surveillance is undertakento obtain additional information about thedrug’s risks, benefits and optimal use. Arare side-effect or a side-effect not recordedin strictly controlled trials could bediscovered in Phase IV studies.

Phase VThese are studies in which the drug is usedas it would be used in the community. Thestrict monitoring of Phase II and Phase IIIclinical trials and the follow-up inherent withpost-marketing surveillance would both beabsent in these Phase V clinical trials. Theefficacy and side-effects of the drugs wouldbe seen in field conditions.

Multicentric trialsReference has been made earlier tomulticentred studies. It is important to carryout such studies and yet it is not easy toorganize, coordinate and conduct these

chief investigator is solely responsible forthe trial and can stop the trial any time he/she feels that it is not in the interest of thepatients to further carry on the trial. Thiscould be due to serious adverse effectsbeing observed or could even be becauseresults at some other centre publishedrecently had clearly shown the benefits ofa particular treatment. In such circums-tances, it may be difficult to continue a trialwhich would provide perhaps the sameresult two years later. The reader is referredto the Ethical Guidelines for BiomedicalResearch on Human Subjects published bythe Indian Council of Medical Research in2000.21

Clinical evaluation of any synthetic orplant product is carried out in five phases.

Phase IThe objective of Phase I of a clinical trial isto determine the safety of the maximumtolerated dose of the herbal product inhealthy adults of both sexes. At least twosubjects should be administered each doseto establish the safe dose range, pharma-codynamic effects, and adverse reactions,if any, with their intensity and nature. Aninvestigator trained in clinical pharma-cology should carry out these studies andclinical emergency help and resuscitationfacilities must be available at the centrewhere the Phase I trials are being carriedout. Such a Phase I study has recently beencarried out with a herbal preparation beingevaluated for its contraceptive effect(Chaudhury, 2000).18

Phase IIThese are controlled studies conducted ina limited number of patients of both sexesto determine therapeutic effects, effectivedose range and further evaluation of safety.Normally, 20–25 patients should bestudied for assessment of each dosage.


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studies. The same protocol should be usedand the trials should be conducted at thesame time. All methods, whether laboratorymethods or methods for the recruitmentof subjects or methods even for askingquestions to elucidate information, shouldbe standardized. There should be centra-lized data management and analysis.There should be a Coordinator or aClinical Trials Monitor who would visit eachcentre where the trial is being carried outto confirm that at each centre the trial isbeing conducted as it should be. Other-wise laxity in following inclusion andexclusion criteria during recruitment ofsubjects, different ways of dealing withdrop-outs at different centres or usingdifferent reagents and kits at differentcentres would vitiate the trial and rendermonths of hard work unacceptable.

RandomizationIt is accepted today that all Phase II andPhase III trials should be randomized soas to rule out bias. As far as possible thisshould be followed. Randomization ispossible in nearly every comparative clinicaltrial and, while there may be problems incarrying out double-blind studies, thereshould be no problem in carrying outrandomized Phase II and Phase III clinicaltrials.

Blind StudiesIt is again generally accepted that well-planned and well-conducted clinical trialsshould always be double-blind studies.Such trials increase the confidence of thescientific community and clinical fraternityin accepting the results of these studies. Adouble-blind study is one in which neitherthe doctor carrying out the trial nor thepatient knows who is receiving what drug.A single-blind study is a study where eitherthe investigator or the patient – one of these

– does not know which is the drug andwhich is the standard for comparison.Usually the doctor recording the conditionof the patient knows the drug group butthe patient does not know what he isreceiving. However, it could be the reversealso – the doctor not knowing who hasreceived what drug while the patient isaware of this. It needs to be clearly broughtout that the gold standard of double-blind,randomized multicentred clinical trials isnot the only way to determine theeffectiveness, particularly of traditionalmedicine, and that very useful results canbe obtained in single-blind and even, inpreliminary investigations, in open studies.Thus, at one stage, an open trial of theplant Pterocarpus marsupium had to becarried out and formed a vital link leadingto double- blind, flexible dose, randomizedclinical evaluation of the plant.19 Similarly,the therapeutic effect of a thread coated

Vijayasar - developed as an anti-diabetic drug in India.



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with extracts of these plants was found aseffective as surgery in anal fistula in anopen, randomized, multicentred trial.22

However, it is a challenge for the clinicalpharmacologist to plan, as far as possible,double- blind randomized multicentredclinical trials even with traditionalmedicines. The double-blind flexible dose,randomized, multicentred trial ofVijayasara, Pterocarpus marsupium, indiabetes mellitus was one such study.19

Another ongoing study is a double-blind, randomized, multicentred trial ofPipallyadi Vati as a herbal contraceptive.18

Use of a placeboThe use of a placebo is decreasing incomparative clinical trials because in mostclinical conditions there already exists atreatment. The new drug should thereforebe compared against that existing drug. Itwould be unethical to give a placebo, i.e.,a similar looking, smelling tablet containingno medication to one group of patients fora disease when a known remedy exists. Aplacebo still has a role in conditions whereno cure exists. In such conditions an opentrial with objective laboratory and clinicalmeasurements to record the effects of anew drug as compared to a placebo mayalso be justified.

Single-Case StudiesIn addition to open, single-blind anddouble-blind clinical trials, it is also possibleto obtain information from single-casestudies for the evaluation of the efficacy ofa herbal medicine. This has been parti-cularly pointed out in the WHO Document“General guidelines for methodologies onresearch and evaluation of traditionalmedicine”, which was discussed at a WHOmeeting in Hong Kong in 2000.13 Thereport states “Such studies, i.e., single-casestudies, are appropriate for the develop-

ment of research hypotheses, testing thosehypotheses in daily clinical practice andreferring clinical techniques”. To bemeaningful, single-case designs shouldhave a common protocol which could bethe basis of collaborative research betweenpractitioners.

Observational StudiesAnother approach which could be used isto carry out Observational Studies. Thetraditional medicine practitioner continueshis treatment without modifying it in anyway and the clinical investigator observeswhether clinical improvement takes place.The data are recorded by the traditionalmedicine practitioner and separately by theinvestigator carrying out these studies.More studies of this type should be carriedout. It could provide a valuable model forstudying both the efficacy and the safetyof herbal medicines. Such a study is in factbeing coordinated by the first author inMumbai where the allopathic doctors ata well-known allopathic hospital areworking together with traditional medicinepractitioners in a leading Ayurvedic hospital.The protocols are prepared jointly butpatients are being treated at an Ayurvedichospital. The Ayurvedic physi-cians give thetreatment for bronchial asthma and arthritisaccording to an agreed protocol. Theresults of the treatment are assessedseparately by the physicians of the modernsystem of medicine and by the Ayurvedicphysicians. These are then compared asregards the effectiveness of the treatmentand the side-effects seen.

Indian Council of MedicalResearch NetworkIn the past 12 years, the Indian Council ofMedical Research (ICMR) has set up aunique network throughout the country forcarrying out controlled clinical trials of


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herbal medicines. The programme, firstdescribed by the author at a meeting onAlternative Medicine organized by theNational Institute of Health in Washingtonin August 1977, is monitored by a ScientificAdvisory Group consisting of persons fromthe Allopathic, Ayurveda and Unani systemsof medicine. This group also containsexperts in pharmacognosy, toxicology,pharmacology and clinical pharmacologyas well as clinicians and experts instandardization and quality control.

The infrastructure consists of the coregroup at the ICMR Headquarters at NewDelhi, three Advanced Centres inTraditional Medicine and different expertgroups for every condition being studied.There are, for example, at this time specialexpert groups for bronchial asthma,arthritis, hepatitis, benign hypertrophy ofthe prostate, filariasis and cancer. The threeAdvanced Centres are at the Central DrugResearch Institute, Lucknow (Pharma-cology and Clinical Pharmacology), theNational Institute of Epidemiology, Chennai(Preparation of protocols, randomizationand monitoring of results), and at theRegional Research Institute, Jammu(Standardization). There are specializedcentres in the network such as theInstitute of Himalayan Ecology at Palampurfor the study of special features of medicinalplants needing study, the National Instituteof Education and PharmaceuticalResearch, Chandigarh (BioavailabilityStudies) and the Central Indian MedicinalPlants Organisation at Lucknow (growingmedicinal plants). In addition, there aremore than 25 clinical trial centres spreadthroughout the country for carrying outmulticentred studies.

The trials are planned and protocolsprepared by the whole group. All trials arecomparative, controlled, randomized anddouble-blind unless there is reason for

carrying out a single-blind study. Nocompromise is made on the quality of thescientific clinical trials. Although the trialsare planned by the multidisciplinary centralgroup, they are carried out at the foremostcentres of allopathic medicine in thecountry. This is the reverse of the Mumbaistudies where the clinical evaluation isbeing carried out at the Ayurvedic hospital.The Chief Investigator of any one study isalways an outstanding clinical researcherin the field. The results obtained aremonitored by the whole group. Onlystandardized preparations with predeter-mined markers are used for these trials.

Using this network, the Council hasdemonstrated that a medicated threadcoated with Euphorbia neriifolia (Snuhi),Achyranthes aspera (Apamarga) andCurcuma longa is as effective as surgeryfor the treatment of anal fistula.22 TheCouncil has also shown that Picrorhizakurroa is effective in hepatitis23 and thatPterocarpus marsupium is again aneffective anti-diabetic drug.19 Pterocarpusmarsupium will soon be handed over tothe industry for marketing. The results ofthese clinical trials will be acceptable toclinicians at allopathic hospitals becauseof the sophisticated clinical pharmaco-logical methodology used in these trialswith only well- standardized products.

Selection of patientsIn any clinical trial the right drug has to begiven to the right patient. In allopathicmedicine all cases of asthma, arthritis,hepatitis or diabetes of a particular varietyare considered as one entity and the casesare divided into two groups by randomi-zation procedures. One group is given thestandard drug and one the new drug.While this concept and methodology isappropriate for synthetic drugs, it need notalways be appropriate for herbal medicines


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used in traditional systems of medicinesuch as Ayurveda and the Unani system ofmedicine.

This important issue was firsthighlighted by the first author at the WHOmeeting on “General Guidelines formethodologies on research and evaluationof traditional medicine” held at HongKong in April 2000, at the GlobalConference on Research for HealthDevelopment at Bangkok on 10 October,2000, and subsequently in the BritishMedical Journal in 2001.17

In many of these systems, the Prakriti(Ayurveda) or Mijaj (Unani Medicine)determines the effectiveness of a particulartraditional medicine. This could bedescribed as a temperament or thepsychomotor character of the individual.24,

25 A person could have predominantly anyof the following temperaments: Vata, Pittaor Kapha. A hypertensive patient with Vataor Kapha temperament should be treatedwith Samirpannaga rasa, but this will notwork in a patient with a Pitta temperament.He needs to be treated with TagaradiChurna. Another simple example is thetreatment of fever of the malarial type(Vishama jwara). A combination of the barkof Azadirachta indica, Zingiber officinale(Sunti) and Piper nigrum (Maricham) wouldbe effective in the Kapha type of individualbut not in the Pitta or Vata type. There aretwo preparations containing Commiphorawightii (Gum Guggulu) for the treatmentof arthritis. Mahayograj Guggulu is usedin Kapha patients while Yograj Guggulu isused in Pitta patients. This perspectiveshould therefore be kept in mind whendesigning clinical trials with Ayurvedic orUnani medicines.

Sometimes a traditional medicineuseful for one type of patient is actuallyharmful when administered to a patientwith the same disease but having a different

temperament. Kanaka is effective inpatients of bronchial asthma with a Kaphatemperament but will cause congestion inpatients with a Pitta temperament. Thefresh juice of Momordica charantia will beeffective in diabetic patients with a Kaphaor Pitta temperament but should beavoided in patients with a Vata tempera-ment. Rasona Kalpa is very effective inarthritis patients with a Vata and a Kaphatemperament but should be avoided inpatients with a Pitta temperament.

A second issue is that in the traditionalsystems of medicine, the medicine may bedifferent if the patient has anotherconcomitant symptom. An asthma patientwith gastrointestinal disturbances willrespond to one medicine while anotherpatient without gastrointestinal distur-bances would need another medicine. Theclinical pharmacologist should be wary ofentering all cases of asthma into a clinicaltrial without taking these factors intoconsideration (Chaudhury, 1992).14

The third issue is the importance given,unlike in allopathy, to the vehicle whichcontains the active traditional medicine.The vehicle may accelerate or enhance theeffect of the medicine or may counteractthe side-effects induced by a particularconstituent in the combination of plants.Some substances commonly used asvehicles are honey, molasses, butter,buttermilk, ghee, juice of ginger and juiceof betel leaf (Piper betle). Finally it is verycommon, in a combination of three plants,to have the second plant to enhance theeffect of the first plant while the third plantwould counteract the side-effects inducedby the second plant. Attempting todetermine which of the many plants incombination is the effective one would be,in the circumstances, an exercise in futility.

These concepts have been kept in mindand the protocols developed for the


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Mumbai study, perhaps for the first time inmodern clinical trial methodology, stratifiedthe subjects of asthma according towhether gastrointestinal symptoms areassociated with the asthma and Ayurvedicdrugs administered accordingly. In anyclinical trial of asthma, all patients wouldhave been included and then divided intogroups. The result of such a trial would notbe accepted by the pratitioners oftraditional medicine.

Another important feature of medicinalplants is that many of them induce animmunostimulant effect without exertingany specific therapeutic effect. In ordinaryclinical trials this is difficult to measure.However, it would be well worth measuringwhen clinical trials of herbal remedies areplanned. In addition to studying theefficacy of the plant and the side-effectsinduced by it, the amount of Satisfactionfelt by the patient and the Quality-of-LifeParameters could also be studied. This isparticularly important when a herbalremedy is being assessed alongside asynthetic compound.

Ethical Considerations

Several of the ethical considerations whichneed to be kept in mind when planning andconducting clinical evaluation of traditionalmedicines have already been discussed.These are aspects of clinical trials such asthe need for clearance from the InstituteEthical Committee and Informed Consent.The responsibilities of the Chief Investigatorapply equally to clinical evaluation ofsynthetic drugs or herbal medicines.

There are, however, some specialfeatures when traditional medicines arebeing evaluated. These will be discussedbelow.

When clinical trials of herbal drugs usedin traditional systems of medicine such as

Chinese Traditional Medicine, Ayurveda orthe Unani System of Medicine are to becarried out at an allopathic hospital bya practitioner of the allopathic system ofmedicine, then it is incumbent on him tohave as a coinvestigator a physician fromthe traditional system in which that remedyis used. This principle would also hold goodif an Ayurvedic physician wants to evaluatean allopathic drug. An allopathic physicianwould have to be taken on as acoinvestigator.

When a folklore medicine is ready forcommercialization after it has been foundeffective, then, as stated in the IndianCouncil of Medical Research EthicalGuidelines, the legitimate rights/share ofthe tribe or community from whom theknowledge was gathered, should be takencare of appropriately while applying for theIntellectual Property Rights and Patents forthe product.

The preclinical toxicological require-ments before clinical trials have alreadybeen considered from a regulatory andlegal point of view. Ethically it may not benecessary to carry out such studies if muchis known about the plant from ancientliterature and if the plant is already in useprovided it is to be evaluated in the sameform. When an extract of a plant or acompound from a plant is to be clinicallyevaluated for a new therapeutic effect, itshould be treated as a new entity and thefull range of acute, subacute and chronictoxicity data will have to be generated asrequired by the national drug regulatoryauthority.

Is it ethical to add on a traditionalmedicine to the standard allopathictreatment to assess whether the dose ofthe allopathic drug could be reduced orwhether the side-effects induced by theallopathic drug brought down? Normallyit would not be justified to combine


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treatment with medicines of differentsystems and use these concurrently on apatient. The effect of one of the medicinescould be reduced by the other or indeedthe side-effects of one could be increasedby the second drug. It is also possible thatthere could be a serious interactionbetween the two. However, when a greatdeal of information is known about a plant– its mechanism of action, lack of toxicityin animal studies, lack of side-effects whenused widely as a single drug – then it maybe ethically acceptable to carry out aclinical trial of that plant drug with anallopathic drug. It would, however, be saferif some limited animal studies are carriedout administering both the allopathic drugand the medicinal plant at the same time.

Normally the pharmacokinetics of asynthetic drug and its breakdownproducts are known before it is adminis-tered for Phase I studies to humans. Thisis not possible for herbal products as it isvery difficult to obtain this information. It

will therefore be ethically justifiable toconduct Phase I clinical trials withouthaving this data till such time when it ispossible to carry out bioavailability studieson herbal remedies and medicinal plants.

ConclusionIt is hoped that the information providedin this chapter will help the reader toappreciate the complexities of studyingmedicinal plants and the difficultiesinherent in this type of study. The advancesmade in recent years have also beendescribed and should help investigators toplan clinical trials of medicinal plants whichwould respect both the concepts of thetraditional systems of medicine and thoseof modern clinical trials methodology.

AcknowledgementWe are indebted to Vaidya S.K. Mishra forhis invaluable help in the preparation ofthis paper.

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.


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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 traditionalmedicine. 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 ofmedicine. Brit.Med. J. 322, 164.

18. Chaudhury, R.R. (2000). Proceedings of Symposium on Current Status of FertilityRegulation. 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 scientificapplication. 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 ofMedical 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 ofMedical 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.

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people in developing countries, whereaccess to “modern” health care servicesand medicine is limited by economic andcultural reasons. TM is broadly used in suchcountries,i often being the only affordabletreatment available to poor people and inremote communities. The relevance of TMin developing countries may increase in thefuture in a context of growing poverty andmarginalization and, particularly, in viewof the high prices generally charged forpatented medicines.ii

TM also plays an important role indeveloped countries, where the demand for“herbal medicines” has grown in recentyears. Moreover, many pharmaceuticalproducts are based on, or consist of,biological materials. These include

Protection of traditionalsystems of medicine,patenting and promotionof medicinal plants

compounds extracted from plants andalgae as well as human proteins obtainedby extraction or through geneticengineering techniques (e.g., interferon,erythropoietin, growth hormone). Plants, inparticular, are an indispensable source ofmedicines.iii

The protection of TM under intellectualproperty rights (IPRs) raises two types ofissues. On the one hand, an importantquestion is the extent to which TM may beprotected under existing IPRs or newmodalities thereof. Certain aspects of TMmay be covered by patents or other IPRs.i v

There have also been many proposals todevelop sui generis systems of protection.Such proposals are often based onconsiderations of equity: if innovators in the“formal” system of innovation receive acompensation through IPRs, holders oftraditional knowledge should be similarlytreated.

Carlos M. Correa

i For instance, the per capita consumption of TM products is, in Malaysia, more than double that of modernpharmaceuticals. TM is even significant in more advanced developing countries such as South Korea, where theper 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 .

TIntroduction

raditional Medicine (TM) serves thehealth needs of a vast majority of


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On the other hand, the appropriationof such knowledge and/or the relatedbiological materials under IPRs byunauthorized parties has raised significantconcerns, particularly in developingcountries where there is a long andsignificant tradition in TM. Those concernshave been generated by several cases ofpatenting in developed countries, of plants,their compounds or uses derived from TM,without fair compensation to those whohave preserved and made available suchknowledge.

This chapter examines the extent towhich patents may be utilized to protectcertain aspects of TM or the materials usedin traditional treatments. It considers, first,the concept and components of TM.Second, the patentability of differentmodalities of TM is examined, includingproducts, processes and uses. Third, thenature of alternative modes of protectionis briefly described and some measures topromote the use of TM are discussed.

The concept of “traditionalmedicine”

In order to examine the application of IPRsto TM, a first essential step is to clarify themeaning of this concept, and its differentcomponents. TM is a very broad term,comprising indigenous or “tribal” people’sknowledge, farmers’ or “rural” traditionalknowledge and regionally bound traditionalknowledge about the “healing”.

According to the definition provided byWHO’s Traditional Medicine Programme,TM is:

“The sum total of all the knowledge andpractices, whether explicable or not, used

in diagnosis, prevention and elimination ofphysical, mental or social imbalance andrelying exclusively on practical experienceand observation handed down fromgeneration to generation, whether verballyor in writing”.v

TM thus encompasses different typesof knowledge. Distinctions can be madeon the basis of its subject matter, the levelof codification, the individual or collectiveform of possession, the usability andcommercial value, and the degree of priordisclosure of the relevant information. Asdiscussed below, these factors may haveimportant implications with regard to theextent to which patents can be applied inthis area.

Subject matterThe subject matter of TM may basically referto different categories of knowledge:a) The properties of certain biological

materials used in isolation, in their wildform, or as part of a preparation ormixture. Such materials include phyto-medicines or “herbal medicines”, aswell as animal parts and minerals.Though the concept of TM is oftenlinked to plant-based medicines,animal-based medicines have playeda significant role in the healingpractices, magic rituals, and religionsof indigenous and Western societies.In fact, of the 252 essential medicinesselected by the World HealthOrganization (1999), 11.1 per centcome from plants and 8.7 per cent arederived from animals.4, p.6 A largenumber of medicinal plants are usedin the folk traditions as well as in othersystems 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.


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b) Methods of diagnosis and treatment,including physical, mental and spiritualtherapies, which are influenced by theculture and beliefs dominant in aparticular community.vii The traditionaltherapies may encompass the use ofcertain biological materials, includingdosage and forms of administrationthereof, and rituals applied by healersas part of their traditional healingmethods.

CodificationThe codification of TM varies significantly.A distinction can be made, particularly inAsia, between the codified systems of‘traditional medicine’ and the non-codifiedmedicinal knowledge, which includes“folk”, “tribal” or “indigenous” medicine.Thus, in India, the system of medicineconsists of two major tendencies: the folkand the codified traditions. Folk traditionsare handed down orally from generationto generation. The codified traditionconsists of medical knowledge withsophisticated theoretical foundationsexpressed in thousands of manuscriptscovering all branches of medicine.Examples are Ayurveda, Siddha, Unani andthe Tibetan tradition.7

The Ayurvedic system of medicine, inparticular, is codified in the 54 authoritativebooks of this system. In contrast, the “folk”medicine is based on traditional beliefs,norms and practices based on centuries-old experiences of trials and errors,successes and failures at the household

level. These are passed through oraltradition and may be called, “people’shealth culture”, home remedies or folkremedies. They have a vital place in primaryhealth care in developing countries.1

Individual/collective possessionTM may be possessed by individuals(“individual knowledge”).viii In some cases,for instance, healers use rituals as part oftheir traditional healing methods, whichoften allow them to monopolize theirknowledge, despite disclosure of thephytochemical products or techniquesused.8

In other cases, knowledge is in thepossession of some but not all membersof a group (“distributed knowledge”). Thereis, hence, asymmetric information betweengroups but not within a given group ofpersons, even though the latter may notbe aware that others share the sameknowledge.11

Finally, a certain kind of knowledge maybe available to all the members of a group(“common knowledge”), such as in casesof knowledge on herbal-home remedieswhich is held by millions of women andelders.ix

Commercial valueTM may encompass commercial value whenits application, and notably the delivery of TMproducts, can be made trough commercialchannels. While some TM can be used andunderstood outside its local/traditional/communal context, this is not always the

vii Physical methods of treatment involve muscle manipulation and massage. Mental methods of treatment involveself-discipline in the form, for instance, of a strict diet. Spiritual methods of treatment involve prayers and use ofholy water (9, p. 167).

viii Reviews of anthropological literature reveal that concepts close or equivalent to individual forms of IPRs are quitecommon 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).


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case. There are spiritual components in theTM peculiar to each community. Knowledgethat cannot be utilized beyond its communalcontext has little or no commercial value,despite the value that such knowledge mayhave for the communal life.3

Herbal medicines and other TMproducts may be commercialized domesti-cally or internationally, subject to compli-ance with national sanitary laws. There isno limit, hence, to their commercialexploitation. A major issue, still unresolved,is the sharing of benefits with theindividuals/communities which providedthe relevant knowledge.12

DisclosureMost TM is of a non-contemporary nature.It has been used for generations and inmany cases collected and published byanthropologists, historians, botanists orother researchers and observers.3 Disclo-sure erects an important barrier for theapplication of some forms of intellectualproperty protection, notably patents.

However, there are cases in which TMis being kept secret. In specialized areas,in particular, for example bone-setters,midwives or traditional birth attendants andherbalists, knowledge of different plantsand healing techniques is restricted tocertain classes of persons, and the healingproperties of particular plants are oftenundisclosed.9

Moreover, like other types of traditionalknowledge, TM is not a static body ofinformation; it continues to evolve with thepractices of the individuals/communitiesthat held and use it.13 This evolution maygive rise to new knowledge, which maymeet, as described below, the requirementsfor protection under intellectual propertyrights.

Can TM be patented?Patents protect inventions, that is, new,non-obvious technical solutions. Patentsare granted by a Government authorityand confer the exclusive right to make, useor sell an invention generally for a periodof 20 years (counted from the date onwhich the application for the patent wasfiled). In order to be patentable, aninvention usually needs to meet therequirements of absolute novelty (previ-ously unknown to the public), inventive stepor non-obviousness, and industrialapplicability (or usefulness). Patents maybe granted for all types of processes andproducts, including those related to theprimary sector of production, namelyagriculture, fishing or mining.

Patents are conferred in manycountries to protect inventions based onor consisting of natural substances(including genetic materials), plants andanimals. Patents, as discussed below, canalso be granted in respect of the use of aproduct and of methods for diagnostics aswell as for surgical and therapeutictreatment. Though there are importantdifferences among national laws on thesubject matter of patent protection, at leastin principle patents may be applied todifferent components of TM, provided thatthe above-mentioned patentabilityrequirements are met.

There are, however, several majorobstacles to affording patent protection toexisting TM. One such obstacle stems fromthe legal standards established by nationallaws to acquire patent rights.

NoveltyThe universal novelty requirement, asapplied in most countries, prevents thepatentability of an information whichbelongs to the “prior art”, that is, whichhas been published in a written form or


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has otherwise been made available to thepublic, for instance, through public use, inany country before the date of filing of apatent.

“Prior art” generally includes anypublication of the invention prior to the dateof the patent application. This concept maybe defined so as to also include precedentsthat have not been divulged before thatdate, but which demonstrate that a thirdparty had previously reached the sameinvention. This approach has been followedin some US decisions, based on CoronaCord Tire Co. vs. Dovan Chem. Corp. (USSupreme Court, 1928), where a priorinvention of another party, not publiclyknown, was deemed as destructive ofnovelty for a second invention. Likewise,novelty may be destroyed in certain casesby the information contained in previouspatent applications.x 14

The novelty requirement will generallyimpede the patentability of TM knowledgethat has been openly used for many years,and, in some cases, published in differentforms. This is likely to apply to a large partof TM.

In order to destroy novelty, however, theprior use must generally be such that accessto the information would have allowed athird party to execute the invention, withoutsignificant further research. There may besituations in which novelty may not havebeen lost despite the fact that the relevant

TM knowledge has been previously used,even for long periods. One example wouldbe the case of a traditional knowledge usedin a small community, when the informationhas not been diffused beyond thecommunity’s members. There are also casesin which the traditional healers have keptconfidentialxi certain aspects of theirtreatment and associated medicines, apractice that may be more frequent thanoften believed.

An important issue is whether theidentification of the chemical srtucture ofan active substance which is responsiblefor the therapeutic effect of a knownproduct, may lead to the granting of apatent or whether it should be deemed thatno novelty exists. In the case Merrill DowPharmaceuticals v. Norton & Co. (1996)the court held that it was not necessary foran active substance to be identifiable orreproducible for it to have been madeavailable to the public.xii

The novelty requirement may not be anobstacle to obtaining patents on TM incountries where a relative novelty standardis applied. In the United States, for instance,according to article 102 of the Patent Law,

A person shall be entitled to a patent unless:(a) the invention was known or used by

others in this country, or patented ordescribed in a printed publication inthis or a foreign country, before the

x In Europe, however, the information contained in a prior, non-published, patent application is not considered forthe 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 claimedinvention in combination must have been communicated to the public, or laid open for inspection. Under theEuropean Patent Convention, a hidden or secret use, because it has not been made available to the public, is nota 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 thecinchona bark on malaria was due to “the spirit of the bark”. The Indians, however, should be said to have knownabout quinine even though they did not know its chemical structure (9, p. 166).


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invention thereof by the applicant forpatent, or

(b) the invention was patented ordescribed in a printed publication inthis or a foreign country or in publicuse or on sale in this country, morethan one year prior to the date of theapplication for patent in the UnitedStates... (35 United States CodeNo.102).

This means that TM knowledge whichhas been published in a written form in theUnited States or in any other country is notpatentable. But if such knowledge was publiclyused but not documented in a foreign country,novelty is not lost.

As a result of the relative noveltyrequirement of the US, several patentshave been granted to researchers or firmsfrom developed countries by the US Patentand Trademark Office relating to orconsisting of genetic materials ortraditional knowledge acquired indeveloping countries.16, 17

This appropriation (or “biopiracy”) hasinvolved resources protected “as is”, thatis, without any further improvement (e.g.,US patent No. 5.304.718 on quinoagranted to researchers of the ColoradoState University) and on products based onplant materials and knowledge developedand used by local/indigenous communities,such as the cases of the neem tree, kava,barbasco, endod and turmeric (see below),among others, etc.18

A telling example was the case ofayahuasca,(Banisteriopsis caapi), a plantnative to the Amazonian rainforest thatthousands of indigenous people of theregion use in sacred religious and healing

ceremonies, as part of their traditionalreligions. The US Patent and TrademarkOffice (PTO) issued a patent to a US citizenfor the “ayahuasca” which wassubsequently revoked by the same Officein November 1999. The PTO based itsrejection of the patent on the fact thatpublications describing Banisteriopsiscaapi were “known and available” prior tothe filing of the patent application.xiii

As discussed below, in order to preventthe appropriation by third parties underpatents of traditional knowledge, therehave been initiatives to develop properwritten documentation of such knowledge.It is assumed that if the material/knowledgeis documented, it can be made availableto patent examiners the world over, so thatprior art in the case of inventions based onsuch knowledge is readily available to them.

It should be noted, finally, that in somecountries (United States, Argentina,Mexico) the publication made by theinventor within one year prior to the dateof application for a patent does not destroynovelty. This “grace period” is particularlyuseful for the protection of research resultsobtained in universities and other publicinstitutions, where researchers are usuallyunder pressure to promptly publish theirfindings. A possible way to allow for thepatentability of TM may be to establish aspecial “grace period” for inventionspertaining to this field whenever claimedby the communities or individuals thatlegitmately developed or possessed them.8This would certainly expand the scope ofpatentability in cases where it would havebeen excluded by the application of thenovelty requirement standard.

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


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Inventive stepWhile in some cases, such as when a certainTM knowledge has been kept undisclosed,the novelty of the information may havebeen preserved, an additional standard ofpatentability must be met in order to acquirepatent rights. The “inventive-step” or “non-obviousness” requires that the claimedinvention be non-obvious for a person withaverage skills in a given technical field. Thismeans that, even if novel, a piece ofknowledge will not be patentable if it isproven obvious or lacking inventive step.

Obviousness is judged in the UnitedStates on the basis of the determination ofi) The scope and content of the “prior art”,ii) The differences between the claimedinvention versus the prior art, and iii) Thelevel of ordinary skill in the art.19 In Europeand other countries, emphasis is given tothe extent that the invention solves atechnical problem. This “problem-and-solution” approach makes the inquiry oninventive step more objective than in theUnited States.14

The fact is, however, that thousands ofpatents are granted each year in the majorcountries for minor, sometimes purely trivialdevelopments.20 In 1999, for instance, theUnited States Patent Office granted over160,000 patents, twice the numbergranted 10 years ago. This is partially thefruit of an excessive flexibility of the PatentOffice in assessing the inventive step andof shortcomings in the examinationprocedures.xiv

The flexibility with which the inventivestep/non-obviousness is judged allows forthe patentability of technical solutions ofan incremental nature or which represent

a relatively minor advancement in relationto previously available information. This isclearly undesirable from the point of viewof public policy and the preservation of thefreedom to use knowledge in the publicdomain.

What can be protected?

Natural productsTM include plants, animal and mineralmaterials, extracts, mixtures, condimentsand herbal preparations. Obstacles for thepatentability of such medicines may arisewhen they consist of or are based onnatural materials which have not beenprocessed or modified.

One of the basic problems is the extentto which a substance which exists in nature,but for which a certain use has beenidentified, may be deemed to be an“invention” or a mere “discovery”. Such usemay have been identified with regard to aproduct the properties of which were notknown, or in respect of products of knownproperties and for which the “invention”would be the determination of its chemicalor genetic structure.

Patent protection of biologicalmaterials, including cells and genes, hasbeen accepted in many countries. Thisremains, however, a controversial issue,particularly with regard to the patentabilityof materials that pre-exist in nature andare just isolated, purified, or slightly altered,in order to be claimed as an “invention”.In some jurisdictions (e.g., the UnitedStates) an isolated or purified form of anatural product, including genes, ispatentable.22, 23, xv The European Directive

xiv For example, less than 50 per cent of the examinations conducted by said Office refer to relevant backgroundbibliography; 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 SupremeCourt.


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on Biotechnological Inventions (No. 96/9/EC of March 11, 1996)xvi adopts a similarapproach. The Directive, essentiallydeclaratory of long-standing lawthroughout much of Europe,xvii establishesthat “biological material” and substancesisolated from nature (such as newantibiotics) will be considered patentable.23

In some countries, however, thepatentability of existing biological materials,unless they are genetically altered, hasbeen contested or excluded. Thus, in theUnited Kingdom the High Court of Appealheld that the isolation of gene sequencesconstituted a mere discovery and, hence,was not itself patentable. The Court heldthat although the amino acid sequence oft-PA had not previously been determined,one cannot patent a known substance justby being the first to determine itsstructure.(24)

The Mexican law (1991/1994)excludes the patentability of all geneticmaterials. The Argentine patent law(1995) and the Andean Group Decision

344 (1993) do not allow, in principle,the patentability of materials existing innature. The Brazilian patent law (1996)stipulates that no patents shall begranted with respect to living beings or“biological materials found in nature”,even if isolated, including the “genomeor germplasm” of any living being.

Despite the exclusion of certainbiotechnology-based products from thepatent domain, patents may still be grantedfor the process used to obtain them. Thismay be the preferred option for countriesprioritizing medicine affordability andaccess, or where the patentability of suchsubstances is deemed contrary to basiccultural and ethical values.xviii The abilityto do so may be limited, however, by theprovision of the Agreement on TradeRelated Aspects of Intellectual PropertyRights (“TRIPS Agreement”) which requiresthe patentability of micro-organism (Article27.3.(b)).

Some developing countries may,however, worry that excluding substancesfound in nature from patentability couldconceivably hinder investment in somelocal activities, including activities thatmight otherwise lead to patents on productsderived from traditional knowledge orspecific local skills or know-how. For thosethat seek intellectual property protection forTM, limiting the patentability of naturalmaterials may convey negative conse-quences. It must be borne in mind, however,that the developing countries that possessTM knowledge often lack the financialresources and the research and industrialcapabilities to scientifically identify and

Example of a United States Patent

xvi “Biological material which is isolated from its natural environment or processed by means of a technical processmay 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).


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isolate the compounds that explain thetherapeutic effects of certain traditionalmedicines. In addition, traditional healersand communities generally lack the skillsand resources necessary to follow thecomplex procedures of patents systemsand, in particular, to face the costs of regis-tration both locally and abroad.xix

It should also be noted that since thegranting of patents is dependent on eachnational law, the non-patentability in onecountry does not mean that “pieces” of TMcould not be patented in another country.If protection were obtained without theauthorization of the healers/communitiesthat developed or possessed them, it wouldbe possible to request the nullification ofthe patent in the foreign country.xx

Extracts and formulationsWhile, as mentioned, the patentability ofnatural products may be limited by patentrules, it is possible to obtain protection (ifthe patentability requirements are met) forextracts or formulations of naturalproducts.

Examples of patents of this typeinclude US 4178372 on hypoallergenicstabilized Aloe vera gel: US 4725438 onan Aloe vera ointment; US 4696819 onanorexic material extracted from cocaleaves; and EP 0513671 on “Commipho-ra mukul” extracts.

CombinationsPatents may be obtained, if the patentabilityrequirements are met, for combinationsand preparations. This is normally the casewith modern pharmaceuticals, both in

cases where a composition is a simplemixture of diverse components and wherethere is some chemical reaction betweenthem.23

Many examples of patents granted oncombinations of plants for therapeuticpurposes can be mentioned, for instance,EP 0519777 relating to formulationsmade out of a variety of fresh plants; andWO 93/11780 on a skin therapeuticmixture containing cold-processed Aloevera extract (with yellow sap and aloinremoved).

Production and extractionprocessesMany TM products are obtained throughfractionation, purification or concentration.The processes for obtaining such products,if novel and non-obvious, may also bepatented.

There are numerous examples ofpatents relating to extraction and otherprocesses for the preparation of medicinesbased on natural products, such as ES475.812 on a process for the extractionof organic compounds with therapeuticactivity from plants; ES 2010127 for thepreparation of a medicine for skinreparation; EP 0530833 on a process toprepare hard gelatine capsules containingChinese herbal extracts; ES 8801986 forpreparation of a jus or gel of aloe; ES393347 on a process for the extraction ofan active ingredient from anacardiumoccidentale; and US 4956429 on amethod of making a coca leaf flavourextract.

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 theUnited States, and the already referred action against the ayahusaca patent. In both cases, the USPTO finallyrevoked the patents.


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the patentability of such methods, ifpossible, would restrict the use of TM ratherthan promote it.

Patentability of usesAn important issue in relation to theprotection of TM is the extent to which the“use” of a known product can be subjectto patent protection. This may occur, forinstance, when the therapeutic propertiesof a natural product are identified andclaimed. Patent applications on the thera-peutic use of a known product are usuallywritten as instructions to the physician onhow to employ a certain substance to treata particular disease, and may be deemedas non-patentable either as a “discovery”or as a therapeutic treatment, wheneverthe latter is not eligible for protection underthe domestic law.

In countries which admit the protectionof inventions, claims may be either a productclaim or a process claim, depending on thecontext.xxii Some national laws treat the newuse as a process patent claim of one of twokinds: “use” claims (such as “the use of Xas an antihista-minic”) or claims on one ormore actual process steps (e.g., “a methodof preventing .…”).xxiii The patenting of useinventions depends on whether the purposeof the use is novel and non-obvious. Methodinventions may be judged independently ofthe purpose. Even if intended for a novelpurpose, the key consideration in determi-ning the patentability of a method inventionis whether it could be anticipated by othermethods.xxiv

Methods for Treatment andDiagnostics

Most national patent laws exclude thepatentability of diagnostic, therapeutic andsurgical methods for the treatment ofhumans or animals. Patents on suchmethods are not granted due to ethicalreasons or to difficulties with actuallyenforcing those patents. In addition, amethod that is applied to the human bodyis not considered industrially applicableand, hence, does not comply with one ofthe key patentability requirements of mostpatent laws. However, in the United Statespatent practice increasingly favours thepatenting of medical methods if they satisfythe definition of process and the otherconditions of eligibility.xxi

Article 27.3.(a) of the TRIPS Agreementexplicitly allows Members not to grantpatents for methods for therapeutic andsurgical treatment and for diagnostics.

TM includes a large variety of methodsof treatment. Traditional methods oftreatment are usually specific to a particularcountry or to a particular community in thatcountry, although some of them, such asacupuncture, are used worldwide. Theprotection of such methods under patentswould be possible if allowed by nationallaw and viable under the patentabilityrequirements. However, it may be quitedifficult to enforce patent rights obtained,since it may be extremely costly andcomplex to identify and prosecute a largenumber of possible infringers. In addition,

xxi A bill enacted in 1996 (amending US patent law, 35 USC 287.c) determined, however, that the use of patentedsurgical 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 medicalindication (that is, when a new use is discovered for a product that already had pharmaceutical use) as a processclaim.

xxiii See, e.g., 23, p. 208.xxiv See, e.g., 26, p. 120.


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One example of a patent on atherapeutic use of a natural product isafforded by the patent granted in March1995 by the US Patent and TrademarkOffice on “Use of Turmeric (Curcumalonga) in Wound Healing”. It was awardedto the University of Mississippi MedicalCenter. The claim covered “a method ofpromoting healing of a wound by adminis-tering turmeric to a patient afflicted withthe wound”, such wounds includingsurgical wounds and body ulcers.

The powder of the turmeric plant wasa classic “grandmother’s remedy” in India.It had been applied to the scrapes and cutsof children for generations.10 On 14August 1997, the US Patent andTrademark Office invalidated the patentupon request of India’s Council forScientific and Industrial Research, in thecontext of a growing protest by manydeveloping countries against “biopiracy”.xxv

In Europe, a legal provision allows thepatentability of a known product for a newspecific indication.(27) Under article 54(5)of the European Patent Convention, theidentification of the first medical indicationof a known product may suffice to get apatent on the product.xxvi The United States,by contrast, has adopted a more restrictiveapproach, confining patents on uses to aparticular “method-of-use.” Such method-of-use patents do not encompassprotection of the product as such.14

Under the TRIPS Agreement, WTOMember Countries seem free to decidewhether or not to allow the patentability of

the use of natural and other knownproducts.xxvii Many patent laws recentlyadopted in developing countries make nospecific reference to the availability ofpatents for uses, leaving unclear whetherthe protection for processes covers “uses”and “methods of use.”

Countries concerned about “biopiracy”may wish to exclude the patentability of theuse of known products in order to preventthe appropriation under patent rights ofbiological materials. It would seem logical,in particular, that a country that broadlyexcludes methods of medical treatmentalso broadly excludes new therapeutic usesfor known products. Nevertheless, given theterritoriality of the patent system, a countrythat prevents the patenting of uses underits national law cannot force other countriesto follow the same approach. In theabsence of international rules on thematter, nothing will prevent other countriesfrom declaring as patentable (if the legalrequirements are met) what is not deemedprotectable in a particular country.

Policy options: Protecting orpromoting TMThe previous sections have indicated thescope available for the patenting of differentcomponents of TM. However, there aredivergent opinions on the desirability ofextending IPRs protection to suchknowledge, as well as on the modalities tobe applied therefor. These different viewsarise from different philosophical andethical perceptions, as well as from

xxv SUNS, No, 4050, 8.9.97xxvi 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 ofsuch 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 rendera known product patentable as such under general principles of patent law. Unless in connection with the newpurpose the product is forced to be present in an amended new form.


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diverging considerations on the socio-economic implications of IPRs protection,including the danger of distortion toindigenous systems.28

Developing a sui generis regimeMany proposals have been elaborated, byscholars and NGOs, to protect traditionalknowledge (including medicinal use)through a sui generis regime.xxviii This isthe case, for instance, in respect ofproposals relating to “tribal”, “communal”or “community intellectual rights”,xxix and“traditional resource rights”, amongothers.xxx Some proposals aim to developnew forms of protection as an independentcategory of intellectual property,9 or as acomponent of the broader body of“traditional knowledge”. In many cases,however, the rationale for the proposedprotection is unclear.13

A few countries have started to addressthe complex conceptual and operationalproblems involved in the recognition ofcommunities’ rights on traditional know-ledge. For instance, “collective” intellectualproperty rights have been recognized bythe Constitution of Ecuador (1998). TheBiodiversity law of Costa Rica (1998)protects “sui generis community rights”(article 82), and a draft law in Brazil (BillNo. 306, 1995) recognizes the rights oflocal communities to collectively benefitfrom their traditions and knowledge and

to be compensated by means of intellectualproperty rights or other measures. At theinternational level, the Council of TRIPS hasunder its consideration the possible reviewof article 27.3(b) of the TRIPS Agreement.Such review is regarded by some develo-ping countries as an opportunity to harmo-nize the TRIPS Agreement with the CBD,xxxi

and to develop rules for the protection oftraditional knowledge.xxxii The proposedapproaches differ, however.

Thus, for the African Group the reviewof article 27.3(b) should preserve the roomexisting to develop specific modalities ofprotection for traditional knowledge(including TM) at the national level.xxxiii

Venezuelaxxxiv has gone a step further.It has proposed the development of bindinginternational rules on the matter. It hassuggested

“to establish on a mandatory basiswithin the TRIPS Agreement a system forthe protection of intellectual property, withan ethical and economic content,applicable to the traditional knowledge oflocal and indigenous communities,together with recognition of the need todefine the rights of collective holders”(WT/GC/W/282).

Though the viability of this latterproposal in the framework of the TRIPSAgreement is still uncertain, it addressesone of the problems that countries that optfor 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.


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face. Due to the principle of territoriality,protection at home would not prevent themisappropriation of the protected know-ledge in other countries or that such know-ledge would continue to be considered asbelonging to the public domain.

Developing countries (notably LatinAmerican and Caribbean) have alsoactively promoted the increased involve-ment of the World Intellectual PropertyOrganization (WIPO) in the discussionand development of a “sui generis” regimefor traditional knowledge.xxxv

Curbing “biopiracy”Despite the general agreement in thedeveloping world about the importance ofobtaining a recognition for traditionalknowledge, the main concern of somecountries has been to avoid the “biopiracy”of traditional knowledge and to ensurebenefit sharing (as provided for underarticles 15 and 16 of the CBD), rather thanthe establishment of a system of positiveappropriation. Thus, the Government ofIndia has stated that

“In the recent past, there have beenseveral cases of biopiracy of traditionalknowledge (TK) from India. For preventingsuch instances in the future there is a needfor developing digital databases of priorart related to herbs already in the publicdomain. Following patents on brinjal, etc.,in India, an exercise has been initiated toprepare easily navigable computerizeddatabase of documented TK relating touse of medicinal and other plants (whichis already under public domain) known asTK Digital Library (TKDL). Such digitaldatabases would enable Patent Offices allover the world to search and examine anyprevalent use/prior art, and thereby

prevent grant of such patents andbiopiracy”.12

Among the projects initiated in Indiato impede the consideration of suchknowledge as “new” and, therefore, paten-table in some jurisdictions, “GeneCampaign” has undertaken work ondocumentation of biodiversity andknowledge relating thereto aimed at threetribal populations: the Munnars in SouthBihar (in the Chotanagpur region); the Bhilsof Madhya Pradesh, and the Tharus of theTerai region. Medicinal plants andknowledge related thereto was sought tobe documented with the help of educatedtribal youth. Elders in the village, medicalpractitioners and traditional healers wereconsulted in the collection and under-standing of the information.12

The documentation of traditionalknowledge, in the Indian Government’sviews, permits not only the prevention of“biopiracy”; it may also provide a basis forthe sharing of benefits arising out of theuse of such knowledge, though documen-tation per se will not facilitate benefitsharing with the holders of suchknowledge.12

In addition, Section 36 (iv) of the IndianBiodiversity Bill provides for the protectionof knowledge of local people relating tobiodiversity through measures such asregistration of such knowledge, anddevelopment of a sui generis system. Forensuring equitable sharing of benefits arisingfrom the use of biological resources andassociated knowledge, Sections 19 and 21stipulate prior approval of the NationalBiodiversity Authority (NBA) before theiraccess. While granting approval, NBA willimpose terms and conditions, which secureequitable sharing of benefits. Section 6

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


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provides that anybody seeking any kind ofIPR on a research based upon biologicalresource or knowledge obtained from Indianeeds to obtain prior approval of the NBA,which will impose benefit-sharing conditions.Section 18 (iv) stipulates that one of thefunctions of NBA is to take measures tooppose the grant of IPRs in any countryoutside India on any biological resourceobtained from India or knowledgeassociated with such biological resource.

In the Patent (Second Amendment) Bill1999, the grounds for rejection of thepatent application, as well as revocationof the patent, include non-disclosure orwrongful disclosure of the source of originof biological resource. It has also beenmade incumbent upon patent applicationsto disclose the source of origin of thebiological material used in the invention intheir patent applications.

The Andean Group Decision 391 hasalready established that any IPR or otherclaims to resources shall not be consideredvalid, if they were obtained or used inviolation of the terms of a permit for accessto biological resources residing in any ofsuch countries, as regulated under thatDecision.

Improving access to TMA possible negative impact on the accessto health care of the strengthening of IPRsin developing countries has been stressedin recent analyses, including some studiesby the World Health Organization.(31) Therecognition or establishment of new typesof IPRs on TM may reduce, rather thanenhance, access to medicines and healthtreatment, particularly by the poor. Indealing with TM, developing countriesshould, therefore, very carefully balance theexpected benefits from a possible IPRs-likeprotection of TM, with the costs that arelikely to arise from the limitations on access

to TM treatments that the exercise of suchrights would entail.

While an option to deal with TM is towork within the sphere of IPRs,governments should aim to promote theuse of TM for preventive and curative healthcare rather than to protect it under rightsthat may restrict its diffusion. An exampleis provided by Act No. 8423 (1997) of thePhilippines, which aims “to accelerate thedevelopment of traditional and alternativehealth care” by improving the manu-facture, quality control and marketing oftraditional health care materials(Section 3.d).

This promotional approach may becombined with a misappropriation regimeaimed at avoiding the monopolization ofTM and related biological materials. Sucha regime – just as in the case of tradesecrets – would not be based on thegranting of exclusive rights (i.e, on a iusprohibendi) but only on the right to preventor require a compensation for the use oftraditional knowledge when it has beenacquired, for instance, in a manner contraryto legitimate rules and practices onaccess.13

The promotion of TM requires muchmore than defining the appropriateframework for IPRs protection. Attentionshould be paid to research and develop-ment (R&D) and to the condition for theuse of such knowledge.

Developing countries only account fora minor part (around 4 per cent) of worldR&D,32 and a significant part of the scarceresources devoted thereto are applied toissues that have been defined by and areof primary interest to developedcountries.33 Though the technical capacityto undertake clinical trials in order toestablish the safety and efficacy of TMproducts exists in many developingcountries, this is a costly endeavour for


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which considerable financing is necessaryand generally unavailable, even to test TMused locally to treat common diseases inthose countries, such as malaria.

Pharmaceutical companies haveshown considerable interest in acquiringand developing TM, as illustrated by theBioprospecting Program of the InstitutoNacional de Biodiversidad (INBio) of CostaRica and the recent agreement betweenExtracta (a Brazilian company) and Glaxo-Wellcome to investigate on naturalcompounds that may be used as antibioticsand tropical diseases, such as dengue.xxxvi

In some cases, pharmaceutical companieshave obtained considerable benefits fromthe exploitation of TM.xxxvii There are,however, signs that the interest of suchcompanies may be fading out, due in partto the prospects of newer methods of drugdevelopment and genetic engineering.xxxviii

The promotion of TM should alsoconsider the need for an assessment ofherbal medicines,xxxix as well as the training,certification and registration, whereappropriate, of traditional healers andpractitioners.1

Exports of TM productsAs mentioned, TM plays an important rolein health care in developing as well asdeveloped countries. Though TM methodsand products have been originallydeveloped to satisfy local demands withina given community, trade in TM productsmay be important and provide a newsource of income to developing countries.

Herbal medicines are currently tradedinternationally, in many cases without thestrict conditions that apply to other drugs.

The export of such products may,however, face many regulatory andcommercial barriers. Pharmaceuticalproducts are subject to health regulationsin order to establish their safety, efficacyand quality. The tests required to provethose conditions are, as indicated above,time consuming and very costly. Though,in general, prolonged use of a TM offerstestimony of its safety, in a few instancesWHO has warned:

“investigation of the potential toxicityof naturally occurring substances widelyused as ingredients in these preparationshas revealed previously unsuspectedpotential for systematic toxicity,carcinogenicity and teratogenicity”.34

In some cases, herbs, which are in factdrugs, are sold in several countries asdietary supplements and, therefore, theyfall outside the regulations on medicines,which are generally stricter than thoserelated to such supplements. In othercases, there is no control or monitoringover the advertising and promotion ofherbal medicines.1

The granting of patents on herbalmedicines or natural compounds may alsocreate trade obstacles. Besides anyconsideration on the unfairness of“biopiracy”, the patenting of TM productsor substances can be used to prevent theimport of such products, even –paradoxically – where supplied from their

xxxvi Jornal do Brasil, 30 July, 1999.xxxvii An often cited case is the use of the Madagascar 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 therainforest.

xxxix WHO has developed Guidelines for this purpose (see 34).


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xl See article 28 of the TRIPS Agreement.

country of origin. Patent owners enjoy, ineffect, the right to prevent any commercia-lization, including imports, of a patentedproduct.xl

A similar problem may be faced if theplant varieties used to produce a TMproduct were protected under breeders’rights in the country of import. Breeders’rights are a type of intellectual propertyrights that are exercised in respect ofpropagating materials of plant varieties.The UPOV (Union for the Protection of PlantVarieties) Convention provides an inter-national framework for the protection ofsuch varieties. The TRIPS Agreement hasobliged all WTO Member Countries toprovide a patent or an effective “suigeneris” protection (or a combination ofboth).

If breeders’ rights were obtained byunauthorized parties on plants used for TM,the countries of origin thereof would alsofind a serious barrier, since breeders’ right-holders enjoy a similar set of exclusive rightswith regard to imported products.

Finally, it should be borne in mind thatmany medicinal plants face extinction orsevere genetic loss. Overexploitation ofsuch plants in order to satisfy exportdemands can aggravate these risks.Hence, governments should control tradein medicinal plants in the framework ofbroader policies for the conservation andsustainable use of such plants. Peru, forinstance, passed a law in July 1999 whichbans the non value-added export of somebotanical species with known healingproperties, which had become the targetof massive extraction by foreign labora-tories. The law covers the two best-knownmedicinal plants in Peru’s indigenouspharmacopoeia: ‘cat’s claw’ and ‘maca’;and legislators are considering expanding

the norm to cover other products (‘yacun’and ‘para-para’).

Conclusions

TM plays an important role in the healthcare systems of developing countries. Thediffusion of TM products is also significantin developed countries. The commercialvalue of TM has raised divergent views onthe need and scope for protection of TMunder IPRs. Some governments, scholarsand NGOs have voiced the need to protectTM under existing or new forms of IPRsprotection, as a means to recognize andcompensate the creators and possessorsof such knowledge. Others object to thatpossibility for ethical, economic or otherreasons. However, there is, in general,agreement on condemning “biopiracy”,that is, the unauthorized appropriationunder Western IPRs systems of traditionalknowledge and biological materials.

The concept of TM embraces differentcategories of knowledge that may besubject to various types of IPRs, if theconditions for protection are met. Severalcomponents of TM, including products andprocesses and, in some countries, uses andmethods of treatment, can be covered bypatent rights. In fact, a large number ofpatents have been granted in relation tonatural products, combinations, extractsand preparations thereof, as well asprocesses of production. The applicationof patents to TM, however, faces importantobstacles, in particular due to the noveltyrequirement and to the costs andcomplexity of procedures before patentoffices.

While designing national policies onTM, a careful assessment of the possibleobjectives and implications of IPRs


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protection of TM should be made. Theirestablishment may provide a basis for therecognition of traditional and indigenoushealers and communities. Nevertheless,due to the very nature of IPRs, they maylimit rather than increase access tomedicines that are essential to millions ofpeople in developing countries. A balancedpolicy may be based on a restrictiveapproach towards the patentability ofnaturally occurring products and uses ofexisting products, as well as in theapplication of strict patentability require-ments, particularly with regard to novelty.

Governments may also adoptmeasures to promote the use of TM for theaffordable treatment of national andregional priority diseases, and may alsoseek to preserve and expand exportopportunities for TM products. IPRsgranted in foreign countries may poseobstacles to such exports, particularly incountries where patents are granted on thebasis of a criterion on relative novelty.

Some developing countries haveproposed development of internationalrules on the IPRs protection of traditional

knowledge, including TM, particularly inorder to curb “biopiracy”. Given, however,the considerable conceptual divergencesstill existing on these issues, it does not seemlikely that an international consensus onthe objectives, scope and content ofpossible rights to be recognized in relationto such knowledge will be reached soon.This is a difficult task at the national levelitself, as evidenced by the small number ofcountries that have just started, but not yetaccomplished, the establishment of asystem of protection in this area.

In a scenario in which developingcountries will have to pay more for neededmedicines after the full implementation ofthe TRIPS Agreement, what part TM will playas a component of a public health strategyhas become an urgent and crucial issue.Governments and the World HealthOrganization should be encouraged toclarify the implications of different policyoptions, including the protection underIPRs, and to define the role that TM is calledupon to play in the health systems of suchcountries.

References

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 ofethnobiological knowledge: reconciling industry and indigenous interests”. IntellectualProperty Journal. No.12.

4. Medeiros Costa Neto, Eraldo. (1999). “Traditional use and sale of animals asmedicines in Feira de Santana City, Bahia, Brazil”. Indigenous Knowledge andDevelopment 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 inthe Field of Traditional Medicine. New Delhi. India. October 7–9.

6. Shankar, Darshan. (1996). “Tribal and rural farmer-conservers”. In: Agrobiodiversityand Farmers’ Rights. Swaminathan Research Foundation. No.14. Chennai.


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7. Shankar, Darshan; Hafeel, Abdul and Suma, T. (1999). “Cultural Richness of GreenPharmacy”. Compas Newsletter. No. 2.

8. Bhatti, Shakeel. (2000). “Intellectual property rights and traditional medicines”. Preparedfor WHO-ASEAN Meeting on the TRIPS Agreement and its Impact on Drug Supply.Jakarta.

9. Koon, Ong Chui. (1999). “Intellectual property protection of traditional medicineand treatments in Malaysia”. Blakeney, Michael (Ed.). Perspectives on IntellectualProperty. Intellectual property aspects of ethnobiology. 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”. inBrush, 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. ContemporaryLegal Educational Series. Boston.

15. Drahos, Peter. (1997). “Indigenous knowledge and the duties of intellectual propertyowners”. Intellectual Property Journal. No.11.

16. Correa, Carlos. (1999). Access to plant genetic resources and intellectual propertyrights. 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 IntellectualProperty 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 theGerman Patent Law. WILEY-VCH. Weinheim.

27. Stieger, Werner. (1982). “Article 54 (5) of the Munich Patent Convention: An Exceptionfor 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. InternationalProperty Law & Policy. Annual Conference. April.


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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 forSustainable Foundation/The Gaia Foundation. Addis Ababa.

30. Posey, Darrell and Dutfield, Graham. (1996). Beyond Intellectual Property. TowardTraditional Resource Rights for Indigenous Peoples 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).

Research, drug development and manufacture of herbal drugs

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primary health care needs. Furthermore,a large number of modern drugs are eitherderived from plant material or conceived,modelled and discovered based on thepractice of traditional medicine. Mostpeople, particularly from rural areas indeveloping countries, have their access firstto traditional herbal medicines to relieve orcure their ailments.

Traditional health practices are basedon many years of experience acquired byhumans in their journey in evolution.Primitive man sought remedies for illnessesfrom his surrounding animal, vegetable,and mineral kingdoms. Some of theseremedies were based on mistaken beliefsor mysticism. However, as civilizationprogressed, particularly in Asia and notablyin China, Egypt, India and the Middle East,the rich treasure of knowledge on herbalremedies was systematically preserved,collated and written about, based on theprevailing concepts of health and disease.This resulted in the development of different

Research, drugdevelopment andmanufacture of herbaldrugs

systems of medicine like the Chinesesystem, Ayurveda, Unani and Siddha.Ebers Papyrus of ancient Egyptians, or theSamhitas of Ayurveda were veritabletreasurehouses of human knowledge onherbal remedies and ethno-therapeutics.

The origin of Ayurveda, the ancientsystem of medicine of the Indian subcon-tinent, can be traced to the Vedic period,i.e., about 1500 B.C. The Atharv-veda ofthe Aryans, composed during theirmigration to the Indian Subcontinent,described medicinal plant remedies for ill-health as well as for rejuvenation of thebody and mind. The use of medicinal plantsprogressed into the period of the Samhitas,notably Charak and Sushruta Samhitas,wherein one finds the “healing science”emerging from the “magico-religious” stateto a truly empirico-rational medicine. TheSamhitas have elaborate treatises onrecognition of plants based on theirbotanical characteristics, description of theparts of the plants, appropriate agronomicconditions for their cultivation (soil,manure, etc.), classification based onmedicinal use (Charaka mentions morethan 50 plant groups); collection,conditions for preservation, and the use ofdifferent parts of plants such as bark, stem,

B. B. Gaitonde

T

Introduction

Concept of Diseases and Drugs inTraditional Medicines

wo-thirds of the world’s populationdepend upon herbal resources for their


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leaves, flowers, fruits, seeds and roots.There are also elaborate descriptions of themethodology for the preparation ofmedicines (dosage forms) and methods ofdetoxification of mineral products.

Most fascinating are the descriptionsof the pathogenesis of diseases based onthe concept of Tridosha: Vata, Pitta, Kapha.It is postulated that the human body iscomposed of five elements (Panchmaha-bhutas) and is in perfect health when the“Three Doshas” are in a state of equili-brium. Disease produces imbalance ofDoshas and, depending upon the natureand extent of imbalance, an appropriatemanagement strategy is employed to bringback the body to its original equilibrium.(1)

Ayurveda describes very methodicallythe pharmacology of “Drugs and Diet”,both being accorded equal importance inthe management of a patient. Charaka’sclassification of plants was based on theirtherapeutic uses and properties. Eachmedicine and also dietetic article have inthem what Ayurveda describes as Rasa(taste) Vipaka (alteration or metabolism inthe body), Virya (potency) and Prabhava(specific action/potential which is beyondthe rasadi attributes of the drug). Thus, inAyurveda drugs are prescribed to treat anindividual and not just his disease, depen-ding upon the predominant property of themedicament and the Prakriti (Vata, Pitta orKapha) of the patient.

In the Chinese system of traditionalmedicine, the human body is consideredas a single entity. Normal body functionsare a result of the harmonious, balancedbehaviour of elemental forces called Yin-yang and Wuxing. Other concepts areZang fu (internal organs) and Jing luo(channels and collaterals), and Qi, a vitalforce circulating in the body. Continuouscirculation of Qi is believed to promotehealth, while interruption of Qi in any

organ leads to disease. Acupuncture is saidto stimulate Yin or Yang and restore thenormal flow of Qi.

Numerous herbs or medicamentsmade from animal parts are thought tohelp in restoring the balance of Yin andYang when disturbance manifests asdisease. It describes measures to remainhealthy and prevent or treat disease.Traditional Chinese medicine has producedover 10,000 medical books, and describedover 5000 herbal drugs. Most countriesin the Western Pacific Region have beeninfluenced by traditional Chinese medicine.

These medicines are complex mixturesof plants, animal parts or products,minerals and metals. However, plants andplant products form the dominant part ofthe materia medica of traditional medicinepractised in different parts of the world andin particular in Asia, especially China,India, Korea, Philippines, Indonesia andTibet. In India, for example, the CharakaSamhita (treatise), dating back to 900 BC,lists 341 plants and plant products formedicinal use. Susruta, who practisedsurgery about 600 BC, described 395medicinal plants. Vagbhatta practisedAyurveda in Sindh (now in Pakistan) aroundthe 7th century AD and wrote an unrivalledtreatise on the principles and practices ofmedicines called Ashtangahridaya whichprovides systematic descriptions ofmedicinal plants and mixtures of plantproducts, minerals or metals. Bhava-prakash, written by Bhavamishra in about1550 AD, describes 470 medicinal plants.It is thus evident that traditional medicinesoffer a wide range of herbal medicines,often classified therapeutically.

Research Policy

Most countries in the South-East AsiaRegion (SEAR) have a political commitment


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to give priority to research and develop-ment of traditional medicines. The healthpolicy of China aims at integrating modernmedicine with the traditional Chinesemedicines and conducting research intraditional practices in a rational way. Indiahas set up the Central Council for Researchin Ayurveda and Siddha (CCRAS) andUnani systems to investigate a number ofherbal medicines to establish the scientificbasis of their use. The Indian Council ofMedical Research has established aprogramme of Composite Drug Research(CDR) whereby herbal drugs are investi-gated by a team of traditional and modernmedicine practitioners, a botanist, aphytochemist and a pharmacologist in acoordinated manner.

More than a hundred medicinal plantsused in Ayurveda have been investigatedin the CDR scheme and have providedsome promising leads for furtherinvestigation. In some cases, the thera-peutic claims made by Ayurveda practi-tioners have been justified by pharmaco-logical studies. The plants selected in CDRhave been botanically identified and theirpharmacognostic data have beenreported. Phytochemical studies haveyielded some novel chemical structures.2Thus, the Satavari (Asparagus racemosus)root used in Ayurveda as a galactogoguewas studied in experimental animals andreported to possess galactogogue andanti-oxytosic activities.(3,4) The plant isreported to contain Shatavarin having aspecific pharmacological action. Picrorhizakurroa has been reported to posseshepatoprotective activity and its activeprinciples have been identified asPicrocytes. Butea frondosa, which is usedin Ayurvedic preparations as an anthelmi-ntic, has yielded an active principle calledpalasonin. Guggulisterone from guggulresin has been isolated.2 The resin is used

extensively by traditional practitioners in thetreatment of inflammation of joints, obesity,lipid disorders, etc., on the basis of thedescription of Medorog (Lipid disorder) bySusruta. Chemical investigation has yieldedtwo active compounds, namely z-Guggulsterone and e-Guggulsterone.5 Itis evident that such a composite approachin the investigation of medicinal plants islikely to be more rewarding in establishingthe therapeutic claims of traditionalremedies and obtaining novel chemicalentities.

Thailand, Indonesia, Vietnam, Sri Lankaand Nepal, have all given priority toresearch in traditional medicines in theirhealth and drug policies. Several countrieshave established pharmacopoeias oftraditional medicines and establishedinstitutes to undertake research in allaspects, including standardization andquality control of herbal medicines.

Objectives of Research inHerbal Medicines

The hallmark of modern medicine is thescientific approach in promoting health,preventing diseases and curing ailments.Scientific methodology consists of thefollowing approaches:

Astute observation;Formation of hypothesis;Experimentation to prove or reject thehypothesis;Acceptance and incorporation of theresults of research in modern medicine.

Since most herbal medicines used intraditional practices are based onempiricism, there is a need to separatechaff from the grain and prove, beyondreasonable doubt, the efficacy, safety andcost-effectiveness of herbal medicines. Suchan approach not only enriches modern


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medicine but the empiricism, if any, oftraditional medicine also gives way torationality.

In the context of primary health care,the major objective of such research wouldbe the utilization of local resources in amore rational manner in meeting the healthcare needs of the vast majority of thepopulation who are beyond the reach ofmodern medicine.

Policy and Organization

Several countries in SEAR have formulatednational policies and strategies for researchand development of traditional medicines.The overall developmental objective is theutilization of indigenous resources for thehealth and well-being of the populations.Specific objectives are:

To evaluate, on a scientific basis, theprevailing health practices and adoptthose in primary health care;To complement and enrich modernhealth practices by the experiences oftraditional practitioners.

In order to implement the nationalpolicy on herbal medicines, there has tobe a multidisciplinary organization. In suchan organization, the key role of traditionalpractitioners must be emphasized. Theorganizational structure for such anintegrated approach would involve anational committee for policy decision ora high-power board, consisting of bota-nists, pharmacologists, pharmacists andphysicians of modern medicine along withan enlightened practitioner of traditionalmedicine, drug manufacturers and repre-sentatives of the drug regulatory agency.

Having verified the therapeutic claim ofherbal medicines, the next step would be todevelop methods of standardization, qualitycontrol and appropriate dosage forms.6,7

Drug Research

Research on herbal drugs as conceived inmodern parlance consists of observations,discussions and literature review/search,animal experimentation, chemical fractio-nation and clinical evaluation. Opinionsdiffer on whether it is appropriate to employsuch a scheme for “Plant to Drug” in caseof traditional medicines. Most traditionalsystems aim at a holistic approach for thecure of diseases and therefore most of theirmedicines are mixtures of plants, metalsand minerals rather than a single drug asin modern medicine.

Furthermore, such a drug combinationis conceived by taking into account thepathogenesis based on the concepts ofhealth and disease in traditional medicine.Several drugs are combined with a view toenhancing the potency of each other or tomitigate or obligate the adverse effects ofothers. Most traditional practitioners havescant interest in research in herbalmedicines since they firmly believe that suchtype of research is not necessary or becauseit will perhaps serve to enrich modernmedicine rather than traditional medicine.

In spite of such views, there is aconstant search for medicines from herbalsources. In the last two centuries, severaldrugs having a high therapeutic value havebeen derived from plants, for example,digoxin from digitalis, eserine from calabarbeans, reserpine from the roots ofR.serpentina, etc. Such drugs have notonly entered the therapeutic armamen-tarium of modern physicians but also haveserved as tools to understand the physiologyand pathogenesis of diseases.

“Plant to drug” research has oftenproceeded according to the followingscheme:


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Composite Drug Research

India and other countries in Asia, notablyThailand, Nepal, Myanmar and China,have adopted national policies aimed atresearch and development of nationalherbal resources and traditional medicines.One of the strategies adopted in India forresearch in the Ayurvedic, Unani andSiddha systems of medicine was theestablishment of “composite drug researchunits”. Each unit consists of a traditionalpractitioner, a crude medicinal plantcollection centre with a pharmacognosist

for establishing the botanical authenticityof the sample, a clinician of modernmedicine, a phytochemist and apharmacologist. Each unit has beenallocated medicinal plants for investigation.As mentioned earlier, the major obstaclein such a study is that the traditionalpractitioners do not believe in using a singleplant but a combination of plants with orwithout mineral or animal products.Elaborate methods of preparation of sucha medicament are described. For example,Celastrus paniculatus, which has beenprescribed in Ayurveda for improving


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memory and intellectual performance, hasan elaborate method of preparation of theoil from the plant.

Another problem encountered inresearch on herbal medicine relates toseasonal variations in the activities ofplants. It has been reported that someplants, when collected only in a particularseason, show activity. Samples collected inother seasons are devoid of activeprinciples and therefore biological activity.

Ethno-PharmacognosticResearch

Although there are elaborate descriptionsof medicinal plants using varioussynonyms, in the ancient treatises there arehardly any botanical descriptions as inmodern pharmacognosy. The usualpractice in ancient times seemed to be fora practising physician to collect plants fromhis surroundings and prepare the drugshimself for use in his practice. It is notunusual to find that a herbal medicine usedin different parts of a country for aparticular ailment contains plants widelyvarying in botanical characterizations. Forexample, it has been reported that samplesof Shankha Pushpi (Convolvuluspluricalis), used by traditional practitionersin different parts of India, contain widelyvarying plant species. It is thereforenecessary to study the ethno-practices indifferent parts of SEAR countries, collectsamples of medicinal plants, and subjectthem to pharmacognostic studiesemploying modern methodology. In sucha study it would be important to collectinformation not only on the plant itself buton the time of collection, cultivation,harvesting, the mode of preservation,conditions in which it is used (fresh ordried), parts of the plant in use (whole plant,leaves, stems, bark, flowers, shoots, fruits,

seeds, or roots, etc.). It would also benecessary to study the method of prepa-ration of dosage forms used in traditionalpractices, treatment formulae, dose andmode of administration to patients.

In this connection, a rational modeldeveloped in China is the use of retros-pective data on plants or animals toanalyse the rationale of their use in Chinesemedicine. Thus, 248 plants and animaldrugs used in over 700 polypharmacyprescriptions were studied for theirrationale, if any, based on the publishedreports of their pharmacological actions,complete with any available folklore claims.If there was any correlation betweenreported pharmacological effects with usein Chinese medicine, it was presumed thatthere is a rational basis for its use.

Another important consideration givenby the Chinese is what is described as“Conversant evolution”. If a particulartraditional medicine is used for the samepurpose by peoples widely separated bygeographical distances or belonging todifferent religious, ethnic or culturalbackgrounds, a strong possibility of itsbeing “really effective” was accepted andfurther research was undertaken.

Ethno-botanical studies involvemacroscopic and microscopic descrip-tions, preparation of plant specimens fora herbarium and also a preliminarychemical analysis to identify chemicals suchas alkaloids, glycoside, terpenes, sesqui-terpenes, etc.

Napralert Database

A computerized database on the chemistryand pharmacology of natural products isnow available at the University of Illinois,USA. This department is now headed byDr Fong. The database covers over 4595genera of plants, animals and micro-


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organisms. It provides useful informationon plants used in traditional medicines andcan be used for literature search beforeplanning an elaborate researchprogramme.8

It is possible to obtain from thedatabase names of plants of a specificcountry or area: plants with pharmaco-logical data on specific activity, i.e.,hypoglycaemic, antitumour, antifertility, etc.

Agrobotanical Research

Such research is necessary for theidentification and evaluation of the naturaldistribution of the plant species. Researchon conditions of soil, weather, or type ofmanure used for cultivation of the plantand the effect on seasonal variations in thegrowth and properties of the plant wouldalso form a part of such agrobotanicalstudies. Such studies are important forundertaking the cultivation of medicinalplants and making herb gardens.

Pharmacological Studies

Modern pharmacology has made remar-kable progress in the last four decades.

From the early days, when pharmaco-dynamic studies were done to determinethe effects of drugs on systems and tissues,i.e., on circulatory or nervous systems, etc.,the scientists working in this field are nowinvolved in identifying the molecular basisof drug action, interactions with receptors(both extra and intracellular) effects ontransmission mechanisms or interactionwith cytokines. With the cloning ofreceptors through recombinant DNAtechnology, research methodology hasbeen further refined.2

Classical pharmacological studies onexperimental animals, using crude orrefined plant extracts, have yielded somefruitful data. On a global basis, about 130drugs, all single entities extracted fromhigher plants or modified chemicals, arecurrently used in modern medicine.2

However, such a classical “phytopharmacological” approach has not beencost-effective. In fact, out of 200 newchemical entities (NCE) introduced inmedicinal chemistry globally, only about 2per cent were based on higher plants.(2)

The National Cancer Institute (USA),beginning in 1959, screened over the next25 years, 180,000 plant extracts covering

Table 1. Drugs from ethnotherapeutic fieldDrugs Ethnotherapeutic informationMorphine Opium used by ancient Egyptians and SumariansAtropine Used by BabyloniansEphedrine Used by the Chinese for respiratory ailment (2700 BC)Quinine Used by Peruvians for feverEmetine Used by Brazilians and South Americans for dysentery

and to induce vomitingDigoxin Used in England in the 17th century for heart illnessTubocurarine Used as arrow poison by Red IndiansReserpine 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


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3500 plant genera but this tremendouseffort did not yield a single marketabledrug.2 This has weaned major pharma-ceutical companies away from plantresearch and instead made them go in forsynthetic drugs. In synthetic drug research,once any innovative breakthroughoccurred, several “me-too” drugs flood themarket. Several examples can be givenabout the success of this approach, suchas NSAID, ACE, inhibitor, B-lactamaseinhibitors, quinolones and B-blockers. Thishas no doubt proved cost-effective.

In spite of what has been said above, itmust be emphasized that the ethnothe-rapeutic use of traditional medicinesprovides clues for searching for plant drugs,identifying their active principles,synthesizing their analogues, and leadingto their introduction in modern therapeutics.The following Table (adapted from Sukh Deo,

1997)2 gives examples of some importantremedies which are the result of suchinvestigative approach.

From the Table, it is evident thattraditional medicines offer investigativeleads to undertake further studies to assessand establish their therapeutic utility in anumber of clinical conditions, especiallythose diseases in which modern medicineoffers very limited therapy. In Ayurveda, forexample, there is a group of drugs called“Rasayana” or life promoters or rejuve-nators, which can be investigated in termsof modern physiological parlance, as anti-inflammatory, antioxidants, immunomo-dulators, antiaging, etc.8

Specific Screening Models

Experimental pharmacology offers severalscreening models to screen crude or semi-

Table 2. Some plants with notable therapeutic activity(2)

Botanical name Probable therapeutic activityAcorus calamus TranquillizerAsparagus racemosus Galactogogue: uterine sedativeBacopa monnieri Improves memoryBoerhaavia diffusa DiureticCurcuma longa Anti-inflammatoryPhyllanthus niruri HepatoprotectivePicrorrhiza kurroa HepatoprotectiveCelastrus paniculatus Immunomodulator, antioxidantOcimum sanctum AntistressGymnema sylvestre HypoglycaemicMomordica charantia HypoglycaemicHibiscus rosa-sinensis HypoglycaemicPlumbago zeylanica AntifertilityCommiphora mukul HypolipidemicWithania somnifera Tranquillizer, immunomodulatorTerminalia chebula AntiagingConvolvulus microphyllus Neural regeneration and

synaptic plasticityPanax ginseng Antifatigue, adaptogenic, antistress


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purified herbal drugs for therapeuticactivities based on traditional usage.9,10

Some of the models used in the screeningprogramme are discussed.

The criteria for selection of plantsmentioned under each of the activities canbe summarized as follows:

Plants are in use by traditional practiti-oners in a particular clinical condition;Preliminary pharmacological studieshave yielded promising leads;Plants are mentioned in the ancienttexts as useful in certain diseases,particularly those for which there areno effective or safe drugs in modernmedicine, e.g., diabetes, arthritis;Ancient texts providing leads forselection of plants for screening forsuch conditions as cancer, stress,rejuvenation.

Anti-inflammatory, Analgesic-Antipyretic Activities

Several herbal remedies have beenscreened for anti-inflammatory, analgesicand antipyretic activities using appropriatescreening models. A simple and commonlyused method to study anti-inflammatoryactivities, though not ideal, is carageenin-induced oedema of rat paws. Analgesicactivities have been studied in animalmodels to assess pain relief in acid-inducedwrithing in mice or by tail clip method inrats. Antipyretic activity has been studiedin animals with induced fever.

Several plants have shown anti-inflammatory activities in a number ofscreening models and would need furtherstudies. Thus, Randia dumetorum containsorionic acid 3 B-glucoside, which wasreported by Ghosh, et al (1983), aspossessing anti-inflammatory activities inthe exudative and proliferative phases ofinflammation in rats.11 B-sitosterol isolated

from Cyperus rotundus possesses anti-inflammatory activity comparable tohydrocortisone.12 Tinospora cordifolia wasreported by Pendse, et al (1981), aspossessing anti-inflammatory activityagainst both acute and chronic inflamma-tion comparable to non-steroidal anti-inflammatory agents.13

Potassium embelete, a quinone obtai-ned from Embelia ribes, was reported byAtal, et al (1984), as a potent, centrallyacting analgesic. It was reported to possessa highly therapeutic index and lack absti-nence syndrome.14 Similarly, Solanummelangena was reported by Vohra, et al(1984 a), as possessing non-narcoticanalgesic activity.15 Petroleum ether extractof Abutilon indicum was shown to possessanalgesic activity against acetic acid-induced writhing in mice and has a goodmargin of safety.16

Antiallergic ActivitySeveral plants are used in traditionalmedicines for treating allergic conditionssuch as bronchial asthma, urticaria,eczema and allergic rhinitis. These areusually screened in animal models on thebasis of their antihistaminic or antiserotoninactivities in isolated tissue systems such asisolated intestine and isolated lungperfusion. Other models used are passivecutaneous anaphylaxix in rats (PCA),histamine contents, or release by antigens.

Plants showing some antiallergic activitiesare:

Piper longum;Tylophora indica.

Dry fruits of Piper longum reduced PCAin rats and also prevented histamine-induced bronchospasm in guineapigs.17

Similarly, Tylophora indica alkaloids werefound to posses activity comparable with


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primed with saline and measuring urineoutput in a fixed time period. A doseresponse study is planned, and the effecton sodium or potassium excretion can alsobe assessed.

Plants showing diuretic activity are:Milingtonia hortensis;Toddalia asiatica;Cucumis trigonus.

Millingtonia hortensis showed asignificant natruratic effect withoutaffecting potassium excretion to any greatextent.21 Toddalia asiatica was reported tocontain coumarins which possess diureticactivity though less potent than hydrochlo-rothiazide.22 Similarly, Cucumis trigonuswas also reported to possess some degreeof diuretic activity.23

Spasmolytic ActivityThese drugs are used to relieve spasm ofsmooth muscles as in bronchial asthma,renal colic or colicky pain in abdomen.Several test systems have been used toassess the spasmolytic activity of the plantextracts. Commonly used ones areisolated guineapig ileum, spasm inducedby acetyl chloline or histamine andtracheo-bronchial tree of guineapigs.Since histamine has been implicated inbronchial asthma, its release or that ofother cytokines, induced by histaminereleasers or stabilization of mast cellgranules, has been studied to assess theeffects of plant extracts on various localhormones.

Some of the plants screened forspasmolytic activity are:

Clausena pentaphyla;Corydalis meifolia;Symplocos spicata;Corchorus tridens;Selaginella rupestris.

disodium cromoglycate.18 Because of theirextensive use in Ayurvedic preparations andsupportive experimental evidence, both theplants would need further evaluation.

Hypoglycaemic ActivityDiabetes mellitus has been described inancient texts on traditional medicine bothin China and India. In Ayurveda, Charakahas given an elaborate description of thedisease and has prescribed the dieteticregime and drug treatment.

Following are some of the herbalremedies screened for diabetes. The mostoften used screening model is alloxan-induced hyperglycaemia in rats andrabbits. Some plants screened for thehypoglycaemic activity are:

Acacia catechu;Gymnema sylvestre;Momordica charantia;Leucaena leucocephala;Hamiltonia suaveolans;Pterecarpus marsupium.

Gymnema sylvestre is used incombination for the control of diabetes andwas reported to regulate blood sugar inexperimental animals by affecting insulin-dependent enzymes.19 Momordica chara-ntia contains a polypeptide posse-ssinghypoglycaemic activity(20) and the plant wasshown to be effective in both juvenile andmaturity onset diabetes, probably due toincreased insulin release from pancreas.

Diabetes is a complex metabolicdisorder which, according to the traditionalmedicine concept, needs management ofdiet, physical activity, emotional problemsand appropriate drug combinations.

DiureticsDrugs of this class are used in several clinicalconditions, such as dropsy, hypertensionand acute left ventricular failure. Diureticactivity has often been studied in rats


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Patnaik and Dhawan (1982) havereported extensively on several species ofClausena24 Clausmerin-produced relaxa-tion of smooth muscles. This compoundseems to possess a high safety margin.Bhakuni and Chaturvedi (1983) reportedon the spasmolytic activity of Corydalismeifolia.25 The active compound was notas potent as papaverine. Symplocosspicata26 Corchorus tridens,27 and Selagi-nella rupestris28 show varying degrees ofspasmolytic activity in experi-mental models.

Central Nervous System ActivityA large number of herbal remedies areused in traditional medicine to influence thefunctions of the nervous system. Whilesome enhance or depress CNS non-specifically, others are used to influencebehaviour abnormalities, sleep pattern,improvement of memory or in the treat-ment of mental disorders like depression,schizophrenia or dementia.

Most studies are conducted in rats ormice for exploring the effects of plant extractson motor activity, exploratory behaviour,amphetamine-induced agitation, condi-tioned reflexes, drug-induced convulsions,phenobarbitone-induced sleeping time,behavioural responses, natural or acquired,etc. Several investi-gators have studied anumber of plants mentioned in traditionalmedicines for their effects on differentfunctions of the nervous system using verysophisticated techniques like stereotaxicstimulation, estimating neurohormones indifferent parts of the brain, etc.

The following are a few plants screened fortheir activities on the CNS:

Melia azadirach;Hydrocotyle asiatica;Salvia haematodes;Calophyllum inophyllum;Taxus baccata.

Amongst these, Bacopa monnieri hasbeen investigated extensively by Singh andDhawan (1982, 1985) who have con-firmed the claims made in Ayurvedic textson memory and performance in experi-mental models.29,30 Melia azadirach wasshown by Srivastava, et al (1981), as ananorexogenic.(31) Agrawal (1981) reportedon the neuroleptic activity of Hydrocotyleasiatica, showing promising results.32

Adaptogenic Activity

Ayurveda has described a group ofcomplex remedies called Rasayanas or lifepromoters. Some of these can be describedas antistress, immunomodulators, preven-tives of memory loss or cognitive functions,etc. They provide a challenge to modernpharmacologists to devise screeningmodels for establishing an appropriateactivity as described in ancient texts.

The effects of drugs have been studiedon stress-induced pathological changes inmice or rats, such as increased enduranceof swimming mice, stress-induced gastriculcers in rats, milk-induced leucocytosis inmice, stress-induced increase in the weightof adrenal glands in mice, and isoprena-line-induced myocardial damage in rats.More recently, with the advances in

Ocimum Sanctum - antistress, adaptogenic plant used in India



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molecular pharmacology, investigators inthis field have looked afresh at some of theplants utilizing receptor-binding or/andenzyme-inhibition techniques. These haveprovided encouraging clues and wouldneed further probing.

Plants described in traditional medicines aspossessing antistress activity are:

Allium sativum;Acorus calamus;Celastrus paniculatus;Centella asiatica;Convolvulus microphyllus;Nardostachys jatamansi;Ocimum gratissimum or sanctum;Pluchea lanceolata;Terminalia chebula;Withania somnifera;Emblica officinalis.

Dahanukar, et al (1997), in a series ofexperiments, have reported the beneficialeffects of aqueous extracts of several of theabove-mentioned plants in experimentalanimals in doses comparable to those usedin humans.33 All of these were found toproduce immuno-stimulation. Emblicaofficinalis seems to strengthen defencemechanisms against free radical damageinduced by stress. Sambulingum, et al(1997), have shown the antistress effectsof Ocimum sanctum especially in noisepollution-induced stress.34

Such leads provided by traditionalmedicines call for further studies in thisimportant area, particularly with a view toelucidating the mechanism of action of thedrugs vis-à-vis the pathogenesis of stress.

Anticancer ActivitySeveral plants and plant extracts have beenstudied as anticancer agents, chemo-preventive, radio sensitizers, or immunityenhancers. Test systems are cancer cell

lines or in Vivo tumors. Alkaloids from Vincarosea have already been used in thetreatment of human cancers for over adecade. The following herbal productshave shown some anticancer activity:

Centella asiatica;Salacia oblonga;Janakia arayalpathra;Podophyllum hexandrum.

The plants mentioned above have beenreported to posses either direct anticanceractivity in experimental models or haveradiosensitizing or immunostimulanteffects. These have been reviewed byDahanukar, et al (2000).35

NutraceuticsThere is an emerging trend to use dietarysubstances for the prevention or cure ofdiseases. People are becoming more andmore health conscious and wish to pickand choose “diets” which promote healthand avoid “those” which cause harm.Scientists all over the world are studyingthe scientific basis of such a line of thinkingor dietary practices. Some of the “dieteticsubstances” studied are the following:

Edible oils;Spinacia oleracea (Spinach);Momordica charantia (a vegetable);Curcuma longa (condiment);Trigonella foenum graecum (seeds);Murraya koenigii (curry leaf);Brassica juncea (mustard seeds/leaves);Mentha spicata (mint leaf);Allium cepa (Onions);Allium sativum (Garlic);Myristica fragrans (Nutmeg);Piper nigrum (Black pepper).

In traditional medicine, diet plays amajor role in health and disease. InAyurveda, dietetic articles are described as


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ushna (hot) or sita (cold) and the patients,depending on their Prakriti, are advised totake or avoid one or the other. Sarkar, et al(1996), have reported on the clastogenicand non-clastogenic effects of Indianspinach.36 Momordica charantia,36 edibleoils,37,38 Curcuma longa,39 Fenugreek,40,41

and Mentha spicata.42

Anti-peptic Ulcer ActivityAcid peptic disease is treated with remedieswhich restore equilibrium of humors in thebody. There is, therefore, no appropriatetest model to assess the activity of herbalmedicines in this disease complex.However, commonly used models to testantipeptic ulcer activity are experimentallyproduced ulcers in rats by pyloric ligation,or immobilization, and prednisolone orhistamine-induced ulcers in guineapigs.Herbal drugs proposed for this conditionare:

Tectona grandis;Andrographis paniculata.

Ethanol extract of the bark of Tectonagrandis was studied by Pandey, et al (1982),and showed anti-ulcer activity in rats andguineapigs.43 Vishwanathan, et al (1981),reported a similar activity of a flavoneisolated from Andrographis paniculata.44

Several such plants used in combination bytraditional practitioners in gastric disordersshould provide leads from animal experi-mental studies for clinical evaluation.

HepatoprotectiveModern medicine does not offer anyspecific hepatoprotective drugs. Viralhepatitis or liver cirrhosis is treated sympto-matically and by diet rather than drugs.

Traditional medicine, in particularAyurveda, offers several medicinal plantswith possible hepatoprotective activity.Experimental test models which are

commonly used include hepatic damageinduced by carbon tetrachloride in rats,both as acute and chronic hepatic injury.

Alcohol, isoniazide, pyrazinamide orparacetamol-induced hepatic injury in ratshas also been used to produce hepaticinjury. However, there is no animal modelto simulate chronic progressive hepatitis orcirrhosis.

The following are commonly used herbalmedicines as hepatoprotectives:

Tinospora cordifolia;Acacia catechu;Piper longum;Phyllanthus niruri;Eclipta alba;Picrorhiza kurroa.

Rege, et al (1984b), have reported thatchronic liver damage was prevented byTinospora cordifolia.45 Similarly, Acaciacatechu prevented chronic damage of liverbut not the acute variety. Piper longum is adrug most commonly advocated in Ayurvedafor the treatment of liver disorders. However,in studies by Rege, et al (1984c), it onlyseems to restrict fibrosis.45 Picrorhiza kurroaand Eclipta alba have been extensivelyinvestigated for hepatoprotective activities(Pilankar, Ph.D thesis submitted to MumbaiUniversity).46 These drugs form importantingredients of Ayurvedic preparations suchas Liv 52 or Liv 100 marketed in India forliver disorders. Vaidya, et al (1996), havereviewed experimental and clinical researchrelating to the hepatoprotective effects ofAyurvedic formulations.47 Saraswathi, et al(1998), have reported on the hepato-protective activities of Liv 52 and Liv 100,which are mixtures of herbal drugsextensively used in liver disorders such asprogressive hepatitis, and cirrhosis.48 It wasshown that hepatic enzyme activity wasprotected by these preparations.


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Antifertility ActivityThe serious problem of populationexplosion and the limitations of moderndrugs used in the control of conceptionshave attracted the attention of severalscientists sufficiently for them to investigatemedicinal plants for antiinfertility activity inboth females and males.

The test models usually employed areanti-implantation study in rats, litre size,estrogenic or anti-estrogenic or aborti-facient activity in rats, study of the responseof isolated rat uterus induced contracture,in vitro spermicidal activity, etc. In males,the test models are the effects on testes inmale dogs, the effect on spermatogenesisin dogs, mating behavioural study, etc.

Some of the plants screened for antifertilityactivities are:

Bupleurum marginata;Embelia ribes;Thespesia populnea;Hibiscus rosa-sinensis;Plumbago zeylanica;Xeromphis spinosa;Annona squamosa;Lygodium flexuosum;Adhatoda vasica;Azadirachta indica;Trichopus zeylanicum.

Kamboj and Dhawan (1982) havepresented a review of medicinal plantsscreened for antifertility activity inexperimental animals.(49) Embelin isolatedfrom berries of Embelia ribes was reportedby Prakash (1981) as possessing signi-ficant anti-implantation activities.50

Hibiscus rosa sinensis flowers have beenused in traditional medicine as antifertilityagents. They have shown both anti-fertilityand aborticacient activities in rats.51

Plumbago zeylanica was studied byChowdhary, and reported to possess some

degree of activity. Lygodium flexuosum wasstudied by Gaitonde, et al, on the basis ofits use in folklore practices among Adivasisin Maharashtra, India. The plant extractsshowed significant anti-implantationactivities in three species of animals andthe effect was reversible.

Chemotheapeutic AgentsThe chemotherapeutic era started withpenicillins isolated from molds. Thereafter,several compounds possessing antimi-crobial, antifungal, antiviral and antipa-rasitic activities have been studied andintroduced as chemotherapeutic agents.The test system is to note the effect of theplant product on the in vitro culture ofmicro-organisms or to study the effect inexperimental animals infected with theorganisms. Some of the plant productsshowing such chemotherapeutic activitiesare:

Clausena anisata;Cassia alata;Semecarpus anacardium;Cinnamomum zeylanicum;Azadirachta indica.

Antiviral ActivityThis is shown by the following plants:

Phyllanthus amarus;Glycyrrhiza glabra.

AntimalarialsArtemisia japanica;Artemisia maritima;Azadirachta indica.

Most investigators in this field haveused standard in vitro assays. Clausenaanisata was active against both gram-positive and gram-negative bacteria.52

Annona glabra was reported to possess asubstantial anti-microbial, anti-fungal andmoderate degree of insecticidal activities.


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Semecarpus anacardium was shown to bebactericidal in vitro against gram-negativeorganisms such as S.typhi and Proteusvulgaris. The growth of Vibrio cholerae wasinhibited by the acetone extracts of Cassiaalata. Agnihotri and Vaidya (1996) havestudied a number of plants for theirantibacterial properties and found Thymusvulgaris to posses substantial antibacterialactivity.53

Azadirachta indica was shown to bevery active against clinical isolates ofdermatophytes. Similarly, essential oilsobtained from Santolina chamaecyparissusshowed a significant activity in vitro againstCandida albicans. Rai screened 17medicinal plants (1996) for anti-mytoticactivity and reported that maximum activitywas present in Eucalyptus globulus andCatharanthus roseus.54 Ocimum sanctumwas also found to be effective as anantimytotic.

Phyllanthus amarus was reported to beeffective against Hepatitis-B virus at cellularlevel.55 Glycyrrhiza glabra has been testedagainst both DNA and RNA viruses in vitro,particularly on DNA viruses. Premnathan,et al, have also carried out in vitro screeningagainst HIV-infected MT-4cells. Some plantextracts were found to inhibit the adsorptionof HIV virus into the cells.56

With the resurgence of malaria, severalplants have been studied for antimalarialactivity on the basis of leads provided byeither folklore use or ancient texts of tradi-tional medicines. Both in vivo and in vitroscreening models have been used andseveral species of Artemisia were reportedto possess varying degrees of antimalarialactivities.

From the above discussion it becomesevident that further research, in particularclinical studies based on specific pharma-cological properties, would proverewarding.

Phytochemical Research

Chemical processing of the plant or itsparts involves the following steps

Crude Plants/parts;Dried – sometimes fresh;Solvent extraction.

Step IIdentification of active chemicalconstituents:

alkaloids, glycosides, terpenes,sesquiterpenes (terpenoids)oleoresins, steroids, coumarins, etc.;

Step IIFurther purification using:

Thin-layer chromatography or ionexchange, or gas,Chromatography,Coupled with mass spectrometry,High-performance liquid chromato-graphy (HPLC);

Step IIIDetermination of chemical structure.

Chromatography is a powerful tool usedprimarily for separating the components ofa sample. The components are distributedbetween two phases, one of which isstationary and the other mobile. The sample,when introduced into the mobile phase,undergoes a series of partition or adsorptioninteractions as it moves through thechromatographic system.

It is expected that the differences in thephysical and chemical properties of theindividual components determine theirrelative affinity for the stationary phase andtherefore the components would migratethrough the system at differing rates. Thispermits separation, isolation, identificationand also quantification of the chemicalconstituents in a mixture. Each of the


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purified components can, after elution, betested for biological activity in an appro-priate test system. Thus, by such highlysophisticated methodology it is possible toproceed from “plant to drug”.2

Drugs derived from plants as purechemicals have been in therapeutic use foralmost a century. Some of the plant consti-tuents have yielded novel chemical entities,leading to their synthesis and the prepa-ration of their analogues or derivatives.Some examples of such drugs derived fromplants are given in the following Table.

Plant CultureThis is a recent addition to bio-technologyin plant research. In vitro plant culturesunder varying experimental conditions resultin bioproducts with novel chemicalstructures and biological activities.

Structure-based Designs

Having identified a chemical structure,organic chemists are engaged in intensivecomputerized drug design exercises. Thisrequires computer graphics, software formolecular visualization, and dockingprogrammes to screen and find out which

compounds satisfy the appropriate stereo-structure. Computer modelling has alreadyyielded a number of compounds of herbalorigin with therapeutic possibilities.

Molecular Approach to DrugDevelopment

In recent years there have been tremen-dous advances in understanding how drugmolecules modify cell functions. After PaulEhrlich postulated that drug moleculesinteract with specific areas on cell mem-brane or inside the cell called “receptors”,such receptors have now been identifiedand their stereo-chemistry studied. Withadvances in genetic engineering thereceptors have even been cloned. It is nowpossible to study drug receptor interactionsand their kinetics and therefore it is possibleto evaluate the therapeutic potential ofseveral naturally occurring phytochemicalsderived from higher plants.

While most investigators in this area ofdrug development would prefer to work onsynthetic drugs, the potentials of herbalmedicines offering interesting chemicalentities are enormous. This type of develop-ment can only be undertaken by thepharmaceutical industry. Considering thattheir annual turnover exceeds US$ 200billion globally and the R&D inputs of somedominant pharmaceutical companies is inthe vicinity of 10–15 per cent of theirturnover, it is possible for such frontlineindustrial houses to invest in R&D on thebasis of leads provided by materia medicaand practices of traditional medicine.

Research on Quality ControlMethodology andStandardization

Quality control and standardization areessential to ensure safety and efficacy. Most

Table 3. Drugs derived from plantsSource Plant Active ConstituentDigitals lauata DigoxinEphedra vulgaris EphedrineRauvolfia serpentina ReserpineCinchona bark QuinineArtemesia annua ArtemisininCommiphora mukul GuggulusteronesAsparagus racemosus ShatavarinPicrorhiza kurroa PicrosideAdhatoda zeylanica VasicineAtropa belladona AtropinePapaver somniferum Morphine


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herbal drugs are complex combinationsand are often prepared by a variety ofmethods described in the ancient texts.Very often these methods are not well-standardized and therefore the end-product may not yield consistent results.The tests on the final product or dosageforms are not often available in the oldtreatises. It is therefore essential to under-take extensive research and developmentfor quality control and standardization.

Herbal preparations contain activeingredients of plant parts or materials in acrude or processed form. India, China,Thailand and Indonesia have preparedpharmacopoeias of herbal medicineswhich describe the botanical characteristicsor pharmacognosy of individual plantmaterials, their chemical characterizations,including the spectrum of active ingre-dients, both quantitative and qualitative,methods of preparation, and some testson the final product. However, much moreresearch is needed in this field, particularlyfor developing methods for quality controlto be used by the authorities for regulatorycontrol and for their harmonization andimprovement by different countries in theSouth-East Asia Region.

The combination of scientific studiesand traditional knowledge should be thehallmark of such research. Scientificmethods presently used include studies onbotanical characteristics and chemicalstudies using instrumentation analysis suchas neutron activation techniques. Since thistype of research would require adequateresources, both human and financial, it canbest be undertaken either by commercialcompanies or through internationalcollaboration.

Variations of plant material harvestedfrom different geographical areas indifferent seasons pose a serious problemin standardization. In order to obtain

uniform and high quality raw materialswhich are fundamental for quality assu-rance, the trend is towards domesticationof plants (herbal gardens), genetic impro-vement or use of plant-culture techniques.

Safety of Herbal Medicines

Any medicinal preparation, whatever itsorigin, has to be safe for human or animaluse. Since traditional medicines, parti-cularly of herbal origin, have been in useover several centuries, these are presumedto be free from toxic effects. These presum-ptions do not seem to be valid in all casesconsidering that medicinal plants containhighly toxic chemicals such as glycosides,alkaloids, or saponins and cytotoxic agents.There is a likelihood that herbal medicinesin general have overall less toxicity thansynthetic compounds. Furthermore, thetraditional methods of preparation ofdosage forms and combinations of severalplants are supposed to reduce or eliminatetoxicity and make the final product safe fortherapeutic use.

Elaborate toxicity studies prescribed byregulatory authorities for “New Drugs” arenot required for those herbal medicineswhich are either described in ancienttreatises or are in use as folklore for severalcenturies. However, most regulatoryauthorities would require some toxicity datain two or more species of animals beforeallowing such drugs to be adopted innational pharmacopoeia or in therapeuticpractice.

Once the active principles from aherbal drug are isolated in chemically pureform and their analogues are prepared,such “New Drugs” would require elaboratetoxicity studies.

There are a few reports on adversereactions to herbal medicines. Very oftenthere is a lack of proper observation in


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patients and of documentation. In order,therefore, to assess the extent of adversereactions, it is desirable to undertakemulticentric studies on the adverse effectsof some commonly used herbal medicinalpreparations in the field situation, inparticular at primary health care, levelthrough a judicially devised open-endedquestionnaire. Such a study would throwmore light on the problems of safety ofherbal medicines.

Efficacy: Clinical Research

Since herbal medicines have been in useover several centuries, they are regarded asuseful and efficacious in the treatment ofailments. While the original herbal remedymay often have been found by chance,several substances of doubtful merit haveno doubt entered traditional practices. Someof the ancient recipes contain such amazingand often preposterous substances likepearls, musk, crocodile’s dung, horns ofantelopes, extracts of ants and so forth. It istherefore necessary to separate the grainfrom the chaff.

Most physicians in the past milleniumhave relied upon traditional materiamedica based on empiricism. There is apossibility that for every therapeutic regimenof some significance, there would beseveral others, acceptable to the practisingphysicians of those times which mayappear incredible to the present-dayscientific community. The modern scientificcommunity may raise such questions ashow to differentiate the good from the badand how to differentiate a truly effectivetherapeutic remedy from misguidedenthusiasm.

Applying modern concepts andmethodology, the basis of all treatmentregimes should be experimentation. Theessential elements of all scientific evaluation

are critical observations, hypothesis,carefully designed experimentations andvalid conclusions. Through this processalone can rational therapeutics progress.

Application of the science of statisticsto clinical experimentation is nowrecognized as essential for valid conclusionsfrom experimentations. In most instances,patients vary in their responses to the samemedication. The disease process itself mayhave such wide variation. Prof. Bradford Hilltherefore put forward the concept ofcontrolled clinical trials which demands, i)Two or more groups of patients observedat the same time and differing in thetreatments, ii) Constructing the groups byrandom selection (randomization), iii) Useof placebo or inert medication, and iv)Comparison of two or more types oftreatment or treatment regimens byapplying appropriate statistical methods.

The objectives of the clinical evaluationof herbal medicines are, i) Establishingscientific validity for herbal medicines usedby traditional practitioners, ii) Studyingplants considered medicinal and availablelocally in abundance, and iii) Searchingfor drugs from medicinal plants for chronic,refractory or specific diseases for whichthere is no satisfactory treatment presentlyavailable in modern medicine. Someexamples of such diseases are athero-sclerosis and hyperlipidaemia, bronchialasthma, immunological disorders,rheumatoid arthritis, urolithiasis, metabolicdisorders like diabetes mellitus, acid pepticdisease, ulcerative colitis, liver diseases,fertility control, malignant malaria, mentaldiseases, rejuvenation of the elderly(cognitive disease), including Alzheimer’sdisease, etc.8

In the case of the first objective, clinicalevaluation using conventional scientificmethods is all that is necessary to provethe claims of herbal medicines. There is no


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need for elaborate preclinical studies. Themodern-medicine clinician should workwith a traditional practitioner for evaluatingthe clinical efficacy of the drug therapy,using dosage forms used by the traditionalpractitioners. This is important becausethere are examples where dosage formsof herbal drugs prepared by modernpharmaceutical methods may not yield theexpected results.

Having established efficacy and“Clinical Safety”, the next step would be toevaluate dosage forms and the appropriatedose of the medicine, with the objective ofadopting these in modern pharmaco-poeias. At that stage, drug regulatoryauthorities should be consulted to find outif it is possible to lay down standard qualitycontrol methods and establish large-scaleproduction facilities.

Plants considered medicinal andavailable locally in abundance will fall intotwo groups: i) Those described in eithertraditional or modern literature, either singlyor in combination, and ii) Those which are“folklore”. In the case of the first group,based on the literature survey, a protocol isprepared for clinical evaluation taking intoconsideration all the available informationsuch as agro-botanical and ethno-pharma-cognostic data, phytochemical data,pharmacodynamic studies and acute andsubacute toxicity data.

In the case of “folklore” medicines,careful observations and study of “folklorepractices”, the traditional method ofpreparation and rituals accompanying theadministration of the medicine are prere-quisites for planning clinical evaluation. Atthis stage, the objective is simply to assess


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the efficacy of the herbal medicine. Havingvalidated the claim, it would be necessaryto plan an elaborate research programmein order to adopt the drug in modernclinical practice.

Research and development of herbaldrugs for specific chronic diseases shouldfollow more or less the same approachesas in the case of “folklore” medicines. Inthis type of research, a careful study oftraditional literature, the concepts of healthand diseases, descriptions of the pathoge-nesis of the specific condition, and themechanisms of drug action as describedin ancient treatises, are all important andnecessary before embarking on such typeof research.

It is also necessary to try to correlatemodern concepts of the pathogenesis ofdisease with the traditional concept. Forexample, the Rasayana drugs mentionedin Ayurveda as health promoters can beconceived to act as “antioxidants” orimmunomodulators, and Celastruspaniculatus (jyotishmati) described inAyurveda as a promoter of memory couldact through receptor activation or regene-ration. Sushruta has described treatmentof obesity and lipid disorders (medoroga)with the use of a gum resin fromCommiphora mukul called “Guggulu” inSanskrit. Sushruta gives an elaboratedescription of the etiology and pathoge-nesis of the disease, which has a conside-rable resemblance to the modern conceptsof atherosclerosis. Dr C. Dwaraknath, thethen advisor to the Government of Indiaon traditional medicines (1969), proposeda collaborative study on this plant for itsuse in atherosclerosis or hyperlipidaemia.This study has led to the isolation,identification, and characterization of anew structural type, Guggulusterone. Asimilar approach has been adopted forherbal drugs in the treatment of liver

inflammation and degeneration. Phyllan-thus niruri, or Picrorhiza kurroa areexamples of herbal medicines investigatedfor their effectiveness in liver disordersbased on Ayurvedic concepts, and this hasled to the isolation of a novel chemicalstructure. Asparagus racemosus isdescribed as galactogogue and used inlactating mothers. Its investigation hasresulted in the isolation of Shatavarin, achemical with a novel structure. Asmentioned earlier, Artemesin and Arete-mesinine isolated from Artemisia annua inChina has proved a very valuable drug inthe treatment of falciparum malaria. Thisis based on the use of the plant in feversmentioned in ancient Chinese medicines.

Pharmaceutical Technology

Herbal medicines, used by traditionalpractitioners, are administered to patientsin several dosage forms. These areprepared according to methods prescribedin ancient traditional treatises. Forexample, Ayurvedic classics mentionelaborate pharmaceutical methods for thepreparation of a medicament. Usually thedosage forms prepared according toAyurvedic texts are distillates (Arka)fermented products (Asavas and Aristas),Linctuses, (Avaleha), powders (Churna),incinerated material (Bhasma), pills ortablets (Vati/gutika), and decoction(kwatha).

As mentioned earlier, it is importantthat traditional pharmaceutical technologyis investigated thoroughly before changingover to modern technology. It is possiblethat the therapeutic properties of thedosage forms are preserved only whenthese are prepared according to traditionalpharmaceutical methods, and this aspecttherefore needs investigation.


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Standardization and HerbalPharmacopoeiasSeveral countries in SEAR have developedmethods for the quality control andstandardization of herbal medicines. Thisactivity is often undertaken in closecollaboration with traditional practitionersutilizing the expertise in ethnobotany,phytochemistry, pharmacology and cellbiology. Investigation of this nature hasled to the development of monographs onsimple or complex herbal medicines.These have been compiled into a NationalPharmacopoeia of Herbal Medicines. Forexample, the 1990 edition of ChinesePharmacoepoeia enlists more than 784traditional Chinese drugs.

China, India, the Philippines andIndonesia have published NationalPharmacopoeias of herbal medicineslisting several local drugs. This is acontinuing process and has been going onin order to make additions, deletions, andrefinement of methodology. Such pharma-copoeias are yet to gain recognition bydrug regulatory authorities in somecountries.

Manufacture

Globally, the pharmaceutical industry hasgrown enormously. In Asia, excludingJapan, China and India have registered aphenomenal growth in the pharmaceuticalsector, producing both formulations andbulk drugs. However, in all these efforts,the share of medicinal plants is rather low.

According to Kurup, there are over4500 pharmacies in SEAR producingherbal medicines.1 In India, herbal drugproduction is over Rs. 7000 millionannually. While the large majority oftraditional practitioners all over the Regioncontinue to prepare their own recipes foruse in their practice, several public sector

and private manufacturing units have comeup in India, China, Indonesia and Nepalto produce herbal drugs in large quantitiesfor sale in the country and for export.

Modern pharmaceutical technologyhas been used to prepare herbal dosageforms such as tablets, pills, sachets andmixtures. Partial or total automation hasbeen employed. In China, Korea andThailand, governments have establishedherbal gardens and the plants areharvested in appropriate seasons. Theseare then processed according to thedirections provided by the ancient texts but,wherever possible, the process is automatedusing mixers, granulators, fluid bed dryers,tableting machines, coating pans,automatic bottling, labelling and strippackaging, etc.

Several pharmaceutical manufacturershave introduced in their manufacturingactivities Good Manufacturing Practices(GMP) as recommended by WHO,wherever possible.

Quality Control is usually done bysubjecting the raw materials as well asfinished products to i) Physical tests suchas colour, taste and disintegration rate, ifwarranted, and ii) Chemical tests: tests foralkaloids, or glycosides, etc., includingchromatographic tests.

All this needs substantial developmentalresources which are usually provided by themodern pharmaceutical industry.

EpilogueResearch is the hallmark of progress andrationality. Herbal medicines have beenused for centuries and are still patronizedby large sections of the people, particularlyin the rural areas in developing countries.These remedies have to be evaluated fortheir efficacy and safety so that their usebecomes more rational and they can thenbe adopted in modern therapeutics


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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 Asparagusracemosus (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 saponin isolated fromAsparagus racemosus (wild) (Shatawari) on uterine muscle. Ind. J.Pharmacol. 1969;31: 175.

5. Attiso M.A. Phytopharmacology and phytotherapy. Robert Bannerman (Ed.) et al. WHOpublication. Geneva. 1983; 194.

6. World Health Organization. Quality control methods for plant material. WHOpublication. Geneva. 1998.

7. Fransworth Norman R. The Napralert database as an information source for applicationto traditional medicine. In: Traditional medicine and health coverage. Robert HBannerman (Ed.) et al. WHO publications. 1983; 184.

8. Lele R.D. New interface between Ayurveda and modern medicine. The Indian Journalof 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 andnatural products. 2000; 32: 581.

11. Ghosh D. Thejomoorthy P. and Veluchamy. Anti-inflammtaory and analgesic activity ofoleonolic 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. Indiandrugs. 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 onthe central nervous system. J.Ethnopharmacol. 1984A; 11: 331.

16. Bagi M.K., Kalyani G.A., Denmo T.J., Kumar K.A. A preliminary pharmacologicalscreening of abutilon medicine, analgesic activity. Indian Drugs. 1984; 22: 69.

globally. Some higher plants which are ofmedicinal interest should be carefullyinvestigated in all aspects57,58 because theyoffer great possibility for achieving abreakthrough in respect of several diseasesfor which there is no satisfactory therapyin modern medicine. Countries shouldtherefore provide both financial as well as

technical human resources. Technologymissions and policy commitment at thehighest political level, and internationalcollaboration at national and regionallevels, would serve to speed up researchand development in the field of herbaldrugs.


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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 ofTylophora 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 Chakraborty E.H. Effect of bitter gourd, Momordica charantia seeds andglybenclamide 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 ResearchInstitute, 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 diureticactivity. J.Ethnopharmacol. 1981; 3: 15.

24. Patnaik G.K. and Dhawan B.N. Evaluation of spasmolytic activity of clausmarin. Anovel 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., Acharya S.B., Pathak N.K.R. and Biswas M. Preliminarypharmacological 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 studieson 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 mentoflavonefrom 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 onavoidance 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 mentalretention capacity in rats. Ind.J.Pharmacol. 1985; 17(Sappl.): 1.

31. Srivastava A.K., Srivastava R. and Dixit V. Pharmacological studies on fruits of Meliaazadirach. 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 theirbioactivity, 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 leafand chlorophyllin following dietary supplementation to mice. Environ, Mol. Mutagen.1996; 28: 121.

37. Ghafoorunnisa, Reddy V., Sesikaran B. Palmolein & groundnut oil have comparableeffects 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,South India. 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 aftercurry leaf (Murraya koenigii) and mustard (Brassica juncea) feeding in rats. IndianJ.Med.Research. 1995; 102:84.

42. Sharathchandra J.N., Patel K., Srinivasan K. Digestive enzymes of rat pancreas andsmall 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 grandisLinn, 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 7,4diomethyl ether, a flavone from Andrographis paniculata on experimentally inducedulcers. Indian. Pharm. Sc. 1981; 43: 159.

45. Rege N., Dahanukar S. and Karandikar S.M. Hepatoprotective effects of Tinosporacordifolia 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 andformulations as Hepato-biliary drugs: an overview. J.Clinical Pharmacol. Ther. 1996;7: 11.

48. Saraswathi D.S., Suja R. Gurumurthy P., Shymala Devi C.S. Effects of liv.100. againstantitubercular 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 plantorigin: 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 ofHibiscus rosa-sinensis. Planta Medica. 1982; 44: 171.

52. Chakraborty A., Chowdhary B.K. and Bhattacharya P. Clausenol and clausenine thecarbon alkaloids form Clausena anisata. Phytochemistry. 1995; 40: 295.

53. Agnihotri S. and Vaidya A.D. A novel approach to study antibacterial properties ofvolatile 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 Antibiotic Bulletin. 1996; 38: 53.

55. Jairam S. and Thygarajan S.P. Inhibition of HbsAg secretion from Alexander cell line byPhyllanthus 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.

Current status –Country situation

Traditional medicine in the WHOSouth-East Asia Region

Dr. Kin Shein

Traditional medicine in BangladeshDr. Md. Aftabuddin Khan &Dr. S.K. Chowdhury

Traditional medicine system inBhutan

Drungtsho Dr. Pema Dorji

Koryo medicine of KoreaDr. Choe Thae Sop

Indian system of medicine andhomoeopathy

Mr. L.V. Prasad

Native traditional medicine inIndonesia

Dr. Ketut Ritiasa &Dr. Niniek Sudiani

Dhivehibeys in MaldivesDr. Abdulla Waheed

Indigenous medicine in MyanmarDr. U. Kyaw Myint Tun

Traditional medicine in NepalDr. Rishi Ram Koirala

Indigenous system of medicine inSri Lanka

Dr. Lal Rupasinghe

Thai traditional medicine as aholistic medicine

Dr. Pennapa Subcharoen


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Traditional medicine in the WHO South-East Asia Region

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traditional medicine (TM) is an importantpart of health care. In countries of theSouth-East Asia Region, althoughmodern medicines are now increasinglyavailable throughout different levels ofhealth care, TM has maintained itspopularity since it has been used forgenerations in the past. In recent years,many developed countries have alsobegun to take interest in herbal medicine,acupuncture and alternative systems ofmedicine. Consequently, there isincreasing trade among countries inmedicinal plants and, to a certain extent,traditional remedies as well. It is thereforebecoming important that the safety,efficacy and proper use of TM are takenup as among the important areas fordevelopment or strengthening in thecountries of the Region.

All Member Countries of the South-East Asia Region (SEAR) have beendeveloping and strengthening their TMprogrammes. Many countries are in theprocess of introducing TM and traditionalmedical practitioners (TMP) in primary

Traditional medicine inthe WHO South-EastAsia Region

health care (PHC). However, the potentialof services that can be provided by theTMP is far from being fully utilized. TMand TMP have significant potential forcontributing to the national health servicesand for the attainment of the goal ofHealth for All.

Traditional systems of medicinein South-East Asia RegionCountries of SEAR have a rich heritage ofvarious systems of traditional medicine.Bangladesh, India, Nepal and Sri Lankahave people practising Ayurveda, Unaniand /or Siddha Medicine(s). TM known asJamu has flourished in Indonesia. Thetraditional medicine of DPR Korea is Koryomedicine while the TM of Maldives is calledDhjivehi Beys. Bhutan, Myanmar and Thaitraditional medicines are practised in therespective countries. Thus, systems oftraditional medicine in various countries ofthe Region have a significant role to playin the provision of health care as they arebeing used by those living in the cities aswell as by the majority of the populationwho live in the rural areas. Apart from thesesystems, homoeopathy, nature cure andyoga are also practised in a number ofcountries of the Region.

Kin Shein

IGeneral introduction

n many countries of the world andespecially in the developing countries,


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WHO has been assisting the MemberCountries in the following areas: Nationalprogramme development in the variousaspects of TM; traditional health systemsand operational research; standardization,quality control and proper utilization oftraditional and herbal medicines; training

of human resources and exchange ofinformation.

The development of various systems oftraditional medicine in countries of theSouth-East Asia Region are described bythe national authorities in the ensuingchapters.

Koryo medicine in Korea

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heritage, has contributed to the healthpromotion of the people and treatment ofdiseases for thousands of years.

Existing historical works record that inthe 5–7th century BC famous Koreandoctors were sent for treating the elite onthe invitation of the neighbouring kings.Korean acupuncture specialists crossedover to Japan and taught acupunctureskills and trained expatriate trainees in ourcountry. This makes it clear that in thosedays our Koryo Medicine was of a very highquality.

Theories of Koryo Medicine weresystematized through clinical practices andexperiences and, whether big or small, wereintegrated and published by contemporarymedical scientists. These have been preser-ved and handed down from generation togeneration and are even now consideredas valuable references in the field of KoryoMedicine.

For example, “Uibangryuchui’’ (MedicalEncyclopaedia), a world-famous workpublished in 1443, is an unparalleledmasterpiece and consisted of 366 volumes.A prominent Japanese medical historian,Mikisake, highly praised Uibangryuchui asthe foremost world medical encyclopaedia

Koryo medicine of Korea

not found anywhere else.Although various kinds of theories and

therapies of Koryo Medicine such as drugprescription, acupuncture and moxibustionhave many advantages, (some legendaryand non-scientific) scientifically plannedclinical trials have been carried out tovalidate the claim of Koryo medicine. Koryomedicine products can be combined withallopathic medicine treatment.

DPRK has a well-knit Koryo medicalservice system. In the Ministry of PublicHealth, Koryo Medicine Guiding Sectiongives guidance on traditional medicalservices. At the Central level there is aGeneral Hospital of Koryo Medicine; all ofthe 12 provinces have Koryo medicinehospitals, and each city and county hospitalhas a Koryo treatment department.

All the Koryo Medicine institutions inDPRK are State-owned.

Basic research is also being carried outon Koryo medicine – these includeidentification of the components of herbalmedicine, pharmacology of herbs, theprinciples of meridian practices andacupuncture, and clinical trials with herbaldrugs – in combination as well as singly.

The following table gives an idea of theextent of services under Koryo medicine inthe country.

Choe Thae Sop

K oryo Medicine, the nation’s tradi-tional medicine and precious medical


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Traditional medicine system in Bhutan

279

it came into existence in the country duringthe 16th century. During the reign ofShabdrung Ngawang Namgyel and firstHereditary Monarch, there were somephysicians who served as personalphysicians and some were privatepractitioners. Among the physicians, somehad been trained in Tibet and the restobtained knowledge from their forefathers.

Until 1966, this system was notregularized and there existed only privatepractitioners, but since 1967 it has beenregularized and recognized by theGovernment of Bhutan and is consideredas one of the important national healthsystems under the Health Division. This wasdone in order to preserve our own traditionas well as to give the general public a choicebetween the two systems.

Training

As mentioned above, till 1970 there wasno regular training for Dungtsho(traditional doctor). A training foundationstarted in 1971 and in 1978 it wasinstitutionalized and a training curriculum(five years) was developed. Since then

Traditional medicinesystem in Bhutan

regular training is being given. After thecompletion of the five-year course, in linewith the national health policy, the studentsare given practical training in modernmedicine (allopathic system) for threemonths, and thereafter undergo a furtherthree-month attachment course with seniortraditional physicians at the Institute ofTraditional Medicine Services.

Medicine

Seventy per cent of the raw materials areobtained within Bhutan and these arefurther categorized as follows

Snogo-smen - High-altitudemedicinal plants;Throg-smen - Low-altitude medicinalplants;Sa-smen/Do-smen - Mineral origin;Sog-smen - Animal origin;Tsha-chu - Hot spring;Sman-chu - Stone-heated bath withherbal medicated water.In the preparation of Bhutanese

traditional medicine no chemicals are usedor mixed; the method is purely natural.

In the past, all the medicines wereprepared manually; small-scale mecha-nized production started only in 1982 with

Pema Dorji

The traditional system of medicine inBhutan is known as gSo-ba-rig-pa and


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assistance from the World HealthOrganization. Now all the products areproduced mechanically but strictly inaccordance with GMP (Good Manufa-cturing Practices) regulations, emphasizingquality control. Our products areformulated in different dosage forms like

Ril-bu - Pills;Gor-lab - Tablets;Byugs-smen - Medicated

ointments;Tung-smen - Syrup;Shub-lden - Capsule.

Hospital

Until 1979, it was functioning as adispensary and became a hospital only inthat year after shifting fromDechenchholing to Kawang Jangsa. It isour plan to establish indigenous units inall 20 districts, and we have now alreadyestablished 15 units in 15 districts aroundthe country, attached with modern districthospitals. The target is to cover all the 20districts with indigenous units by the year2002.

The objective of attaching indigenousunits with the modern hospitals is mainlyto give a choice to the patients and tocross-check as to which system is moreeffective for what kind of diseases.

Diagnosis

One of the important aspects of treatmentis correct diagnosis. This is done in thefollowing ways:

Pulse reading;Urine analysis;Eye and tongue examination;Discussion with the patients, mainly ontheir medical history.

In children, in whom it is difficult to findthe radial pulse, diagnosis is made bylooking at the blood vessels of the ear lobes.

Treatment

Besides treatment with medicine, patientsare also treated with surgical procedures,which are never as invasive as modernsurgery practice. These include:

gSer- - Acupressure withkhab golden needle;Me-rtsa - Moxibustion by herbal

compound;Me-burn - Cupping;Tshug - Cauterization, which

consists of eight types;Dugs - Applying heat and

cold to parts of thebody without burningor cauterizing; itconsists of twomethods:

Grang- - similardugs to cold spongingTsha-dugs - applying warm

poultices;Byugs-pa - Medicated oil

massages;Lum - Vapour treatment

consists of twomethods;

Chu-lum - herbal bathRlang-lum- steam bath;

A nationwide survey is being made toidentify the medicinal plants available aswell as the hot and cold springs which areused for treatment.

The quality control laboratory is beingstrengthened for the standardization ofmedicinal plants.

Traditional medicine in Bangladesh

275

health care since olden times. Because oftheir potentialities and close associationwith the culture and tradition of the people,traditional systems of medicine haveassumed a unique position in the healthcare of the people living in even theremotest areas of the country. There areseveral types of traditional medicalpractitioners in the country and theirspectrum ranges from Unani and Ayurvedicpractitioners qualified institutionally orthrough some years of apprenticeship, topersons who are born into a family oftraditional healers and learn traditionalmedicine from the family.

Present Status: Status ofUtilization – by Category

In spite of the development of an extensivenetwork of a modern health care deliverysystem all over the country, traditionalsystems still play a significant role indelivering health care at the communitylevel. A recent study conducted in the rural

Traditional medicinein Bangladesh

areas of the country on the use oftraditional medicine revealed that amongthe sick family members, one monthpreceding the day of interview, 37.6 percent had been treated by villagepractitioners. Allopathic (MBBS) doctors,hakims, kabiraj, health assistants (HA) andhomoeopathic practitioners providedtreatment to 16.7 per cent, 16.2 per cent,9.5 per cent, 8.6 per cent and 6.8 per centof cases, respectively. The study also revealsthat, of 57 deaths, initial treatment wasprovided by MBBS doctors in 29.8 per centcases, homoeopathic in 5.3 per centcases, Unani 1.7 per cent cases, Ayurvedic17.5 per cent cases, and villagepractitioners in 28.1 per cent of the casesbefore death. A significant proportion ofthe community members (39 per cent) haveknowledge about medicinal plants and 13per cent of cases with simple ailment weretreated by them with herbs. It was alsofound that community members usevarious metals, salts, minerals and animalproducts for self-treatment. This findingreveals the level of confidence of the villagecommunity in traditional medicine in thecountry.

Md. Aftabuddin KhanS.K. Chowdhury

TIntroduction

raditional medicines have existed inBangladesh as an important basis of


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Government Policy onTraditional Medicine and itsDevelopment

The Unani and Ayurvedic systems havebeen recognized by the Government sinceBritish rule and, after the liberation ofBangladesh, the Government intensified itsefforts for their continuous developmentand to raise the quality of services.Professional bodies of Unani, Ayurvedicand Homoeopathic medicines have beenincluded in the planning process of nationalservices. A few of the steps taken aredescribed below:

Administrative set-up for NationalProgramming – The post of Director,Homoeopathy and TraditionalMedicines has been created under theDirector- General of Health Services toassist him to deal with all mattersrelating to traditional medicine to plan,implement, monitor and controlprogrammes in traditional medicine.The Director is assisted by a DeputyDirector, an Assistant Director andnecessary supporting staff at centrallevel;Educational facilities and Training ofTraditional Practitioners – There areseveral educational institutes ofTraditional Medicine offering diplomacourses of four years’ durationestablished in different areas. FiveAyurvedic and 10 Unani Institutes arerecognized by the Bangladesh Boardof Unani and Ayurvedic system ofMedicine. These institutes receivefinancial and technical support fromthe Board;Establishment of Unani and AyurvedicDegree College – The Governmentestablished a Unani and AyurvedicDegree College at Mirpur in 1989.

This college offers two degrees in therelevant areas – Bachelor of Unanimedicine and Surgery and Bachelor ofAyurvedic medicine and Surgery;Status of trained manpower (Diplomaand Graduate practitioners of Unaniand Ayurvedic Medicine) – At presentthere are more than 1000 registereddiploma practitioners of Unani andAyurvedic Medicine. Nearly 150 Unaniand Ayurvedic physicians havegraduated till end of July 2000. Inaddition, more than 3000 Hakims andKabiraj have attended certificatecourses organized by the Board.

Case Management Facilitieswith Traditional Medicine –Public and Private Sector

There is only one 100-bed hospital (50 forUnani and 50 for Ayurvedic Systems)working as a teaching hospital for theGovernment Unani and Ayurvedic DegreeCollege. The hospital can accommodatea maximum of 50 male and 50 femalepatients. It also provides outdoor medicalservices.

The Government diploma institutionand some of the non-governmentaldiploma institutions also provide outdoormedical services in Unani and AyurvedicMedicine.

Currently, 30 Unani and Ayurvedicmedical graduates are posted at 30Government district hospitals. Thesephysicians are providing outdoor servicesat these hospitals.

Most of the practitioners having adiploma are practising all over the countryboth in the urban and rural areas. A largenumber of them are also working incommercial organizations and productionunits.

Traditional medicine in Bangladesh

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Legislation and Regulation

Control of practices of Unani andAyurvedic Practitioners – Since thebeginning, the Government ofBangladesh has been keen to develop,promote, protect and control thepractice of Unani and AyurvedicMedicine. The Homoeopathic,Ayurvedic and Unani Practitioners Actof 1965 was revised in 1983 and twoActs were enacted in 1983 – theHomoeopathic Practitioners Act andthe Unani and Ayurvedic PractitionersAct. The Unani and Ayurvedic Boardwas formed under these Acts. TheBoard is responsible for the implemen-tation of Government objectives for thedevelopment, promotion and prote-ction of traditional medicine besidessupporting research in this field;Unani and Ayurvedic Drug and Acts –The Unani and Ayurvedic drug industryhad been outside the purview of theDrugs Act of 1940. On 12 June1982, the Government of Bangladeshpromulgated the “Drugs (control)Ordinance, 1982” to control themanufacture, import, distribution andsale of drugs. Section 3(d) of theordinance reads: “Drug” shall have thesame meaning as in the Act and shallalso include any substance exclusivelyused or prepared for use in accor-dance with the Ayurvedic, Unani andHomoeopathic or Biochemist systemsof medicine;National Formularies for Unani andAyurvedic Medicines – The BangladeshUnani and Ayurvedic Board, under theauthority vested in it by the BangladeshUnani and Ayurvedic Ordinance (Act.)83, has compiled two formularies, viz.,National Formulary for Unani Medicineand National Formulary for Ayurvedic

Medicines. These two medical systemshave formularies for commercialproduction. Approximately 50 per centof these formulae are manufactured inthe traditional medicine factories. Thesetraditional preparations are controlledby the Drug Administration Directorate.Registered practitioners can, by virtueof their registration, manufacture on asmall-scale the medicines they need fortheir own patients.

Medicinal Plants

Medicinal plants are the major ingredientsof Unani and Ayurvedic medicines. Thegeographical location, climate andtopographic conditions of Bangladeshhelps the growth of most of these plantslocally in different areas of the country.However, due to continuous massivedeforestation, destruction of homesteadtrees/plantations, frequent naturaldisasters, commercial mono-cultureplantations, etc., the availability of most ofthese precious medicinal plants will bereduced, and these plants may even be indanger of extinction. If such a trendcontinues, these plants will scarcely beavailable locally to meet the needs of themanufacturing plants in the near future.

In Bangladesh there are approximately5000 plants, of which 1500 to 2000plants are covered through differentethnobotanical and ethnomedicinalsurveys. Conservatively, a minimum of1000 plants have medicinal value.

Integration into the NationalHealth Care System

The Government of Bangladesh hascreated facilities to provide alternativemedical care in the existing Governmenthospitals at the district level along with


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modern medicine, facilitating integration oftraditional medicine in the national healthdelivery system. The operational activitieshave been processed under the closesupervision of the district health authoritiesfor quality and effective output.

Research and Studies

It has been observed that considerableresearch has been carried out inBangladesh during the last few decades.

The Bangladesh Institute of Researchand Rehabilitation in Diabetes, Endocri-nological and Metabolic Disorders(BIRDEM) is carrying out research on anti-diabetes plants. The International Centrefor Diarrhoeal Diseases Research,Bangladesh (ICDDR,B) is carrying outresearch on anti-dysenteric medicinalplants. In the Department of Pharmacy ofJahangirnagar University in-depth work isunderway on different aspects of thepharmacology of Ayurvedic medicines.

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heritage, has contributed to the healthpromotion of the people and treatment ofdiseases for thousands of years.

Existing historical works record that inthe 5–7th century BC famous Koreandoctors were sent for treating the elite onthe invitation of the neighbouring kings.Korean acupuncture specialists crossedover to Japan and taught acupunctureskills and trained expatriate trainees in ourcountry. This makes it clear that in thosedays our Koryo Medicine was of a very highquality.

Theories of Koryo Medicine weresystematized through clinical practices andexperiences and, whether big or small, wereintegrated and published by contemporarymedical scientists. These have been preser-ved and handed down from generation togeneration and are even now consideredas valuable references in the field of KoryoMedicine.

For example, “Uibangryuchui’’ (MedicalEncyclopaedia), a world-famous workpublished in 1443, is an unparalleledmasterpiece and consisted of 366 volumes.A prominent Japanese medical historian,Mikisake, highly praised Uibangryuchui asthe foremost world medical encyclopaedia

Koryo medicine of Korea

not found anywhere else.Although various kinds of theories and

therapies of Koryo Medicine such as drugprescription, acupuncture and moxibustionhave many advantages, (some legendaryand non-scientific) scientifically plannedclinical trials have been carried out tovalidate the claim of Koryo medicine. Koryomedicine products can be combined withallopathic medicine treatment.

DPRK has a well-knit Koryo medicalservice system. In the Ministry of PublicHealth, Koryo Medicine Guiding Sectiongives guidance on traditional medicalservices. At the Central level there is aGeneral Hospital of Koryo Medicine; all ofthe 12 provinces have Koryo medicinehospitals, and each city and county hospitalhas a Koryo treatment department.

All the Koryo Medicine institutions inDPRK are State-owned.

Basic research is also being carried outon Koryo medicine – these includeidentification of the components of herbalmedicine, pharmacology of herbs, theprinciples of meridian practices andacupuncture, and clinical trials with herbaldrugs – in combination as well as singly.

The following table gives an idea of theextent of services under Koryo medicine inthe country.

Choe Thae Sop

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Indian system of medicine and homoeopathy

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of these systems date back to 5000 yearsBC. These systems have taken care of thehealth needs of the people and havesurvived due to their strengths, efficacy oftreatment and drugs. India has the uniquedistinction of having six recognized systemsof medicine under Indian Systems ofMedicine and Homoeopathy (ISM&H). TheIndian systems are Ayurveda, Siddha,Unani, Yoga & Naturopathy. Within theambit, however, of Indian Systems ofMedicine and Homoeopathy is covered theHomoeopathy system, though it originatedin Germany and came to India in the early18th century. This system has gotcompletely assimilated, accepted andenriched like any other Indian system ofmedicine.

The Ayurveda system of medicine isof great antiquity and dates back to about5000 BC Ayurveda is a branch of AtharvaVeda, which is the repository of and treatiseon the knowledge and wisdom of greatsages and seers, acquired, tried and handeddown to succeeding generations. Ayurvedais not only a system of medicine, but alsorepresents a way of healthy living. It isholistic in approach and enshrines the

Indian system of medicineand homoeopathy

complete philosophy of health. It is well-documented. The most exhaustive classicon medicine is Charaka Samhita; SushrutaSamhita is an exhaustive treatise on surgicalprinciples and procedures. Ksyapa Samhitaexclusively deals with matters of maternityand child health. The four key concepts ofAyurveda which guide the preventive,promotive and curative aspects of thepractice of Ayurveda are : PanchMahabhutas, Tridoshas, Sapta Dhatus andThree Malas. Though it is ancient in origin,the system is modern in approach.Undergraduate education in Ayurveda hasa course curriculum and training schedulefor five-and-a-half years, including clinicalexposure. It has eight distinct branches ofteaching disciplines corresponding tomodern systems. Postgraduate courses areof three years’ duration. The training inAyurvedic medicines and surgery isregulated by a statutory body, namely, theCentral Council of Indian Medicine(CCIM). The registration of physicians,practice and ethics are governed by theregulations made by the Council. The drugsare manufactured according to formularies;pharmacopoeial standards have been laiddown. Drug manufacture is licensed andregulated under the Drugs & Cosmetics Act,

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1940. It uses materials of plant origin formost of its products, which are natural, safe,cost-effective and efficacious. Therapeuticsunder the Ayurveda system includeShamana Therapy, Shodhana Therapy,Satyavajaya Therapy, Panchakarmatreatment and Rasayana Therapy. Its widenetwork of physicians and infrastructure ofmedical institutions, hospitals, dispensariesand manufacturing units make Ayurveda themost widespread Indian system providinghealth care to the people of India. Some 196undergraduate and 49 postgraduatecolleges are imparting education, and3,66,812 registered practitioners areengaged in health care. About 8400pharmacies are manufacturing drugs, bothclassical and proprietary. Intramural andextramural research and clinical trials,separately and in collaboration with moderninstitutions with proper protocols adoptingscientific parameters, are being conductedextensively to enrich and develop this system.

The Siddha System of medicine isalso one of the oldest systems beingpractised in India for centuries. Theprinciples and doctrines of the Siddhasystem, fundamental and applied, aresimilar to Ayurveda. It is also holistic inapproach. This system emphasizes thatmedical treatment should be oriented notmerely to disease but should also take intoaccount the patient, his environment, sex,age, habits, mental frame, habitat, diet andphysical condition. The human body is aconglomeration of three humours, sevenbasic tissues and waste products of thebody. Their equilibrium is good health, andany disturbance or imbalance leads todisease or sickness. In the Siddha system,the drug preparation is largely based onplants, but minerals and metals are alsoused for drug preparation. The educationalpattern, regulation of education, regis-tration of practitioners, practice and ethics

are governed by the regulations framed bythe Statutory Council. Drug standar-dization, official formularies, licensing andmanufacture of drugs are governed by theDrugs and Cosmetics Act, 1940. Thereare dispensaries, hospitals, pharmaciesand research units under the Siddhasystem. Two undergraduate colleges andone postgraduate college are impartingeducation in the Siddha system.

The Unani System of medicineoriginated in Greece and came to Indiathrough the Arabs. It flourished in thecountry for centuries under the patronageof successive rulers. Today, it is one of therecognized systems of medicine. Thissystem is also holistic in approach andbases its philosophy on the humoral theory.The human body is made up of sevencomponents, such as the Elements,Temperament, Human organs, Spirits,Faculties and Functions. Unani is popularwith the masses and is extremely efficaciousin certain chronic indications. Under-graduate and postgraduate education,registration of physicians, practice andethics are regulated by the same Councilas for Ayurveda and Siddha. Most of theUnani classical texts are in Arabic, Persianand Urdu, but are being translated intoEnglish. The diagnosis takes into conside-ration the temperament, structure, strengthof facilities, the type of factors operatingon the patient from outside, etc. Unanitreatment uses regimental therapy, diettherapy, pharmaco therapy and surgery.In this system, although the generalpreference is for single drugs, compoundformulations are also used in the treatmentof various complex and chronic diseases.The drug licensing, manufacture andquality of products are regulated under theDrugs and Cosmetics Act, 1940. There arepractitioners, hospitals, dispensaries andpharmacies under the Unani system, in

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addition to 40 undergraduate and threepostgraduate teaching institutions. A totalof 40,478 practitioners of Unani areregistered with the Council and 549manufacturing units are engaged in drugmanufacture. Official formularies forUnani drug manufacture have beenpublished and pharmacopoeial standardshave been laid down. Extensive andintensive extramural and intramuralresearch, clinical trials, etc., havedeveloped and enriched this system.

Homoeopathy originated in Germanyand came to India in the early 18th century.It has been practised in India for about twocenturies and has become a popularsystem of medicine. This system is basedon four demonstrable principles: the lawof similars, the law of direction of cure, thelaw of single remedy and the law ofminimum dose. Disequilibrium in thefunctioning of the organs of the bodyimplies sickness. Cure of disease involvesrestoring the equilibrium. Symptoms aretreated as a reaction of the defencemechanism of the body. Treatment throughdrugs is given to further strengthen thedefence mechanism and help it inovercoming the disease. In diagnosis, everycase is treated on a uniquely individualbasis and patients with the same diseasemay be prescribed different medicines. Thephysician has to consider every individual’smental, emotional and physical pathologyin order to understand the peculiar waysin which the patient’s defence mechanismis reacting. Thus, a very comprehensiveand unique individualizing process isinvolved in making a proper diagnosis. Theeducational curricula for U.G. and P.G.courses, registration of practitioners,practice and ethics and related matters aregoverned by the Central Council ofHomoeopathy, a statutory council. Itfollows the same pattern of U.G. and P.G.

education. It has a wide network ofeducational institutions imparting U.G. andP.G. education. Registered physicians,dispensaries and hospitals are providinghealth care. About 1,89,000 practitionersare registered with the Council. It has 149undergraduate and 15 postgraduatecolleges. Homoeopathy’s popularity isgreatly enhanced by its cost-effectivenessand the absence of adverse effects if thedrugs are administered in prescribeddoses. It has evolved pharmacopoeialstandards, of which several volumes havebeen published. Drugs standardization andthe quality of drugs manufactured bypharmacies are regulated by the Drugs &Cosmetics Act, 1940.

Yoga and Naturopathy are basicallydrugless therapies. The concept andpractice of yoga originated in India severalthousand years ago. It is one of the sixsystems of Vedic philosophy. It is alsoholistic and seeks complete harmonyamong the body, mind and the thinkingprocess. Yoga has been found useful in theprevention of diseases, mitigation and cureof diseases and promotion of health. Yogaadvocates an eight-fold path known as“Ashtanga Yoga” for the all-arounddevelopment of the human personality.These are: Yama, Niyama, Asana,Pranayama, Pratyahara, Dharma,Dhyana, and Samadhi. These componentsadvocate restraint, observance of austerity,

Homoeopathy’s popularity isgreatly enhanced by its cost-effectiveness and the absenceof adverse effects if the drugs

are administered inprescribed doses.


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physical postures, breathing exercises,restraining the sense organs, contem-plation, meditation and Samadhi.Researches are fortifying and validating thepreventive, promotive and curative aspectsof Yoga.

Naturopathy is a recognized system ofmedicine. Its philosophy is fully based onthe holistic approach. Naturopathy believesthat health is the normal and harmoniousvibration of the elements and forcescomprising the human entity and disease isabnormal or non-harmonious vibration ofthe elements and forces. The primary causeof disease is violation of the laws of nature.It advocates a natural way of living, and thetreatment covers regulation of eating,drinking, breathing, etc., elementaryremedies, biochemical remedies,mechanical remedies and mental remedies.Naturopathy advocates diet therapy,hydrotherapy, mud therapy, fasting therapy,massage therapy, etc. Naturopathytreatment has no side or after-effects. Theseare simple, scientific, easy, cost-effectivemethods and can be practised by everyone.

There are five degree collegesconducting bachelor courses in Naturo-pathy and Yogic practices of five-and-a-halfyears’ duration. These are affiliated tovarious universities. A large number ofinstitutions are conducting diploma andcertificate courses. There are a number ofgood Yoga and Naturopathy treatmentcentres. There is the National Institute ofNaturopathy, Pune, and the Morarji DesaiNational Institute of Yoga, New Delhi, underthe Central Government, as well as aresearch council, namely, the CentralCouncil for Research in Yoga andNaturopathy, New Delhi.

All drug-based systems under ISM&H,namely, Ayurveda, Siddha, Unani andHomoeopathy, largely use medicinal plantsas raw materials for the preparation ofdrugs. To develop the medicinal plantsector, this department has set up aMedicinal Plants Board to coordinate allefforts to conserve, cultivate, process andmarket raw materials with a view to makingavailable standard products relevant toeach medical system.

Dhivehibeys in Maldives

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medicine that Maldivians have beenpractising since time immemorial.

Though the origin of dhivehibeys is lostin the dark recesses of history, there areindications that a well-developed medicinalsystem existed in the country throughoutthe 800-year known history. Indeed, thiswould have been a survival necessity in anisolated archipelago nation.

The original dhivehibeys depended onlocally available ingredients, mostly freshherbs. Often the practitioners used whatthey called ‘fassangu’, a term that referredto the five main parts of a plant. Thingschanged when communication with theoutside world improved, bringing in freshideas and new ingredients. The fresh ideasmostly came from Unani textbooks inArabic and Urdu. The new ingredientscame from Ceylon and India in the formof dry herbs and compounds.

Today dhivehibeys reveals strongUnani influences. Thus, the systemattributes many diseases to changes inbody constitution and associates them withelements such as air, heat (correspondingto fire in Unani) and water that aresupposed to flow in the body. Many of the

Dhivehibeys in Maldives

therapies and ingredients are also basedon the Unani system. Thus, cupping,cauterization and massage find a place inthe local system. Despite these similaritiesmost scholars agree that dhivehibeys isdistinct from Unani medicine.

The old masters of dhivehibeys wereexperts at feeling the radial pulse andmaking observations. They, however, lackeda sound basis for analysing them further toidentify the underlying conditions. Likemany other alternative systems ofmedicine, dhivehibeys had only a vagueunderstanding of diseases and theirclassification. Therefore, the diagnoses itmade were also vague, often equatingsymptoms with disease. When dealing withexternal injuries this may not have been amajor a drawback, but with internaldiseases it definitely would have. Interestingly,ruggalubeys, the branch of dhivehibeysdealing with bone injury, continued to bepopular long after other branches declined.

The modern period of dhivehibeys maybe said to have begun with Dhon Beyya ofAddu Atoll. He wrote a treatise ondhivehibeys, which he passed on throughhis illustrious pupil, Hussein Salahuddeento Addu Hussein Manikfan. Manikfan, whowent on to become a leprosy expert, was

Abdullah Waheed

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the founder of a family of practitioners, whostill continue to be active.

During the first half of the 20th century,dhivehibeys flourished and producedmany notable practitioners such asIbrahim Faamuladheyri Kilegefaanu,Naifaru Dhonkaleyfaanu, Ahmed Kaamiland Badeegey Mohammed Didi. They wereinstrumental in popularizing new conceptslearnt from Unani medicine throughout thecountry and ushering in what can bedescribed as the golden era ofdhivehibeys. The era ended when modernmedicine came during the ’50s andgradually weaned patients away from thetraditional system.

Along with the decline in dhivehibeys,its practitioners also largely disappeared,since not many new entrants came forwardto replace the aging masters. Heera YousufFulhu was perhaps the last survivor fromthe golden era.

Tragically, many aging practitionersdied without having an opportunity to passon their knowledge to the next generation.Centuries of accumulated knowledge intheir collective memory was thus irrevo-cably lost. A monograph on individualingredients and a few handwritten manu-scripts are the only records that survive.

Despite the absence of written textsand the lack of a formal system for sharinginformation, existing sources of knowledgeagree remarkably on the general principlesof dhivehibeys. However, when it comesto details, different schools of thoughtrepresented by traditional families havedisagreements. For example, for treatingbone injuries all schools agree on theingredients of the dressing. But fortempering it the Gaddaduge schoolbelieves in applying strong heat, whereassome others believe in applying onlymoderate heat with sunlight.

At various times many distinct branchesof dhivehibeys flourished to cater to thevarying needs of the society. In earlier timesa priority need was the treatment of battlewounds resulting from recurrent skirmisheswith the ubiquitous pirates. Historicalanecdotes indicate that the branch ofdhivehibeys called kandifaarubeys (literally,treatment of sword wounds) was highlydeveloped in those days. Another branchof dhivehibeys was lolubeys, or thetreatment of eye diseases. Ruggalubeysspecialized in treating bone disorders. Therewere also practitioners who specialized incircumcision.

Dhivehibeys was never far fromspiritual healing or fanditha as the nativescalled it. Some of the most successfulpractitioners were those who could get theright mix of the two. One of the last expo-nents of this technique was IhavandhooHajee, who successfully combined hispotions with charms and prayers.

With the advent of effective Westernalternatives some branches such askandifaarubeys and lolubeys have virtuallydisappeared. But some others continue tobe popular. A large part of the populationstill depend on ruggalubeys to heal theirfractures and the overwhelming majority goto dhivehibeys practitioners for circumcision.

In recent years the Government hastaken several steps to develop dhivehibeys.This includes the appointment of a high-level committee and a chair fordhivehibeys at the Faculty of HealthSciences of the Maldives College of HigherEducation. The committee has recognizedthat improving access to herbs is the keyto preserving dhivehibeys. Otherwise,more and more patients are going to findit not only easier but also cheaper to buyan aspirin at the neighbourhood store thanto go searching all over the island forimpossible ingredients.

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been influenced by Buddhist philosophy.Prior to the Second World War, certaincommittees recommended that this systembe recognized by the Government, but noaction resulted. Four years after Myanmarattained its independence in 1948, theMyanmar Indigenous Medical Committeewas formed. It drafted the IndigenousMyanmar Medical Practitioners Board Act,which was promulgated in 1953, withamendments in 1955, 1962, and 1987.It established an Indigenous MyanmarMedical Practitioners Board, whosefunctions are to advise the Government on,inter alia, the revival and development ofIndigenous Myanmar Medicine, relatedresearch and the promotion of publichealth; Section 11 specifies as a particularfunction of the Board “suppression ofcharlatans or quacks who are earning theirliving by means of indigenous Myanmarmedicine”. The Board is also empowered(subject to the prior sanction of the Head ofState) to prescribe the subjects forexamination in indigenous MyanmarMedicine, to register practitioners, or toremove their names from the register if a

Indigenous medicine inMyanmar

defect in character or infamous conduct isestablished. Section 24 of the Act prescribesthat, subject to the provisions of section 23of the Myanmar Medical Act, in order tosign a medical certificate required by the lawto be signed by a medical practitioner, anindigenous medical practitioner must beregistered. Similarly, unless he or she hasobtained the prior sanction of the Head ofState, an indigenous medical practitionerwho is not registered may not hold certainspecified appointments in publicly supportedhospitals and other health facilities.

Section 7 of the Indigenous MyanmarMedical Practitioners Board Rules, 1955,provides for the registration of suchpractitioners in six classes. The system ofclassification is essentially based on thedivision of Myanmar medicine into fourbranches (Desana, Ayurveda, astrology,and Vizzadara). In section 9 of the Rules,details are given of the knowledge requiredfor registration in the particular classes.Provision is also made, in section 10, forauthors of works on indigenous medicineto be registered in one of three classes; itis indicated in this section that monks maynot be registered as medical practitioners.

Under Section 12 of the Rules, theBoard is to seek ways and means of

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consolidating into a single system the fourbranches of medicine currently practised;the Board is likewise to undertake studiesand research and advise the competentauthorities on standardizing the methodsof treatment provided in dispensariesoperated by the Government.

The Indigenous Burmese MedicalPractitioners Board Amendment Act of 1962introduced new sections 22-A and 28-Aempowering the Chairman of theRevolutionary Council of Burma to, (i) Cancelthe registration of indigenous medicalpractitioners, (ii) Prescribe qualifications forregistration, and (iii) Terminate the servicesof any or all of the members of the Boardand appoint new members in their place.Under these powers, a new Board wasappointed to initiate the re-registration ofpractitioners. The Department of IndigenousMedicine was established on the 3rd ofAugust 1989.

Education and trainingAn educational institution known as theInstitute of Indigenous Medicine wasestablished by the Ministry of Health in 1976,offering a three-year training programme.

OrganizationThe second-grade department was formedin mid-1989 by upgrading the branch ofindigenous medicine under the Departmentof Health. The staff strength at that timewas about 700. In late 1997, the Depart-ment was again upgraded into a first-gradeone, expanding the manpower up to 1796consisting of four main divisions, viz.,administration, medical care, research anddevelopment, and herbal garden and drugproduction.

Law and RegulationTo keep abreast with the changingcircumstances, the Department reviewed

the aforementioned Act and has updatedand revised it as the Traditional MedicalCouncil Law, which was enacted on 14January, 2000, by the Government. Atpresent there are over 8000 traditionalmedicine practitioners registered under thesaid law.

In 1996, the Government promu-lgated the Traditional Medicine Law in orderto control the production and sales oftraditional medicine drugs systematically.This was followed by a series of notifica-tions concerning registration and licensing,labelling and advertising.

Education and Training inTraditional MedicineThere is one Institute conferring diplomain Traditional Medicine, situated inMandalay, the second capital of Myanmar.This institute was opened in 1976 and isattached to the 50-bed teaching hospitalwith the aim of eradicating bogus medicalpractitioners by producing full-fledgedpractitioners, to update traditionalmedicine to modern standards, to carry outresearch work in traditional medicine, toproduce skilled researchers, and to givecitizens effective treatment by traditionalmedicine.

It is a three-year diploma course,followed by a one-year internship. Till the1997–98 academic year, the number ofstudents awarded diploma totalled 890.The yearly intake of candidates is 100 atpresent. The Institute has its ownmedicinal plant garden for teachingdemonstrations. The Department is nowplanning to upgrade the Institute tobecome a degree-conferring one in thenear future.

In addition, the Institute also conductsa one-year course for outside TraditionalMedicine Practitioners who have nocertificates or licences to treat patients.

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Those who are successful in the course willhave the licence to practise as TraditionalMedicine practitioners.

Medical Care ServiceThere are two 50-bed traditional medicinehospitals, one each in Yangon andMandalay, and three 16-bed hospitals inother parts of the country.

For rural and township communities,the Department has established 194township traditional medicine depart-ments attached with their own outpatientclinics. If necessary, the patients arereferred to both Western medical hospitalsand the nearest traditional medicinehospitals.

Since 1999 was designated by WHOas the International Year for Older People,primary health care and medical servicesby traditional means serve the elderlypopulation more by paying greaterattention to the diseases prevalent amongelderly people such as metabolic diseases,e.g., diabetes.

Registration and Legislationof Traditional MedicineDrugsAccording to the Traditional Medicine Law,all the traditional medicine drugs producedin the country have to be registered andthe manufacturer must have a licence toproduce them. This has been done since1996 after the promulgation of this law.There are altogether 3962 registered itemsof drugs and 632 manufacturers havealready got the licences for production.Good Manufacturing Practices areconsidered before giving the licence. Inaddition, the Department is also involvedin the control of advertisements of thesecommodities.

Cultivation of medicinal herbsand maintenance of herbalgardensWith the main aim of producing enoughraw materials for the Department-owneddrug manufacturing factories, theDepartment has been establishing onegarden after another for the cultivation ofmedicinal herbs. Thus, there are nowaltogether nine gardens with a total areaof over 120 acres. Since herbal gardeningis still in its infancy, only 20 per cent of thearea has been utilized at the moment. Theyare situated in different parts of the countrywith different weather and soil conditions,so that different kinds of species can becultivated, depending on their climate andthe nature of the soil.

Traditional medicinemanufacturing factoriesThe traditional drugs used in townshiptraditional medicine clinics and hospitalsare provided by two traditional medicinemanufacturing factories situated one eachin Upper and Lower Myanmar. The yearlyproduction of each factory is 10,000 kgsand the drugs are produced according tothe national formulary. In addition, thesefactories also manufacture 12 kinds of drugsin tablet form for commercial purposes.

Research and DevelopmentThe main tasks in this sector are to carryout basic analysis for traditional drugs forregistration purposes and standardizationof commonly used medicinal plants andquality control analysis for Department-owned drug production factories.

Promotion of the systematic utilizationof TM among the people is done bydisseminating information through themass media and by conserving old palm-leaf manuscripts regarding TM which aretranslated into Burmese for publication.

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Ayurveda and other traditional medicalpractices. Ayurveda is a cultural andscientific heritage of this country. Nepalhas been free from major foreign invasionsin its history and has unique socio-culturaland traditional practices. Both culturallyand traditionally, the country has been abridge between India, Tibet and China.Since pre-historical times, there have beenmany ethnic groups in Nepal possessingunique cultural and healing practices.These unbroken traditions of healingpractices play a big role in Nepal’s healthcare systems.

Traditional Medical Systemsin Nepal

The traditional medical systems in Nepalare as follows:

AyurvedaThis is the oldest authentically recorded life-science in existence today. This is a part ofthe National Health System and has aGovernment-run network throughout thecountry.

Traditional medicinein Nepal

Institutions and Networks ofAyurveda in Nepal

The main Governmental organizations forAyurveda are as follows.

Department of AyurvedaThis is the highest institution under theMinistry of Health for Ayurveda in thecountry. The Department is responsible forAyurveda Health Policy, implementation,planning, monitoring and provision ofservices throughout the country. Thisdepartment was established in 1981 andconsists of the following network:

Ayurvedic HospitalsThere are two Ayurvedic hospitals: a 100-bed hospital located in Kathmandu and a15-bed hospital in Dang district in theMiddle-west region.

District Ayurveda Health CentresThere are 50 district Ayurvedic healthcentres, one in each district, and it isproposed to open five every year till alldistricts (75) are covered. These institutionsare based on the New Ayurveda HealthPolicy.

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Zonal Ayurveda DispensariesThere are 14 zonal Ayurvedic dispensariesin each zone. It is planned to merge thesedispensaries into the district AyurvedaHealth Centres.

Peripheral AyurvedicDispensariesThere are 211 Ayurvedic dispensariesspread over different parts of the country.These are the only units in the health sectorthat utilize the local resources of medicinalherbs abundantly available in the country.

Rural Ayurvedic PharmaciesThere are three rural Ayurvedicpharmacies, and an additional pharmacyis planned to be established this year. Thesepharmacies are managed by and locatedwithin zonal and district Ayurvedicdispensaries.

Singha Durbar VaidhyakhanaVikasa Samiti (SDVKVS)The SDVKVS was established during theMalla dynasty (355 years ago). This is theonly Governmental unit manufacturingAyurvedic medicines in Nepal. Since1994, SDVKVS is being run by aDevelopment Board under the Ministry ofHealth.

Ayurveda Training and AcademicInstitutionsThe following are the academic andtraining institutions in the country:

Ayurveda CampusThis is the only campus that trains Ayurvedagraduates (BAMS, a 5½-year course) in thecountry. It is a constituent campus of theInstitute of Medicine, which is one of thetechnical institutes of Tribhuvan University.Nearly a decade ago, this campus wasconducting pre-university training courses

(Ayurveda Auxiliary Course – 15 months– and Ayurveda Certificate-level course –36 months).

Mahendra Sanskrit University-Affiliated InstitutionsOf recent origin are private Ayurvedainstitutions, affiliated to Mahendra SanskritUniversity, that provide Ayurveda certificate-level training courses (30 months).

Council of Technical Educationand Vocational Training (CTEVT)This council has given affiliation to theprivate sector providing 15 months’training to Ayurveda auxiliary workers forthe past four years.

Council of Ayurvedic MedicineThis council has recently been formed bythe Ministry of Health. This is a regulatoryand legislative body for Ayurvedic courses,manpower, institutions, practitioners andtraditional healers in Nepal. Ayurvedicgraduates are registered with this council.Similarly, certificate-level trainees (30months), other trainees (15 months) andtraditional healers are also enrolled in thiscouncil, which is also responsible fordeveloping a data bank of traditionalhealers, practitioners and their recipes.

Quality Control of GMP ofAyurvedic ProductsUp to now GMP of Ayurvedic products hasto be based on Ayurvedic principles. InNepal, there is no proper unit for qualityassessment for Ayurvedic or traditionalherbal products.

Traditional Herbal/SpiritualTherapiesA large number of the population is stilldependent on these practitioners. Basically,they follow some ethno-traditional, tantrik,

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spiritual and Ayurvedic knowledge. Theestimated number of these practitioners inNepal is 400,000. Though they are notincluded in the official system of healthcare, they are wellknown by differentnames in different communities.

HomoeopathyThis system has recently been recognizedas a national health system and a homoeo-pathy hospital is run by the Government.The Unani system of medicine is alsoincorporated in this hospital.

NaturopathyThis is not an official system of medicine,but it has been well-practised by thecommunity. Training in naturopathy isprovided by the private sector. There areprivate hospitals, training centres, clinicsand dispensaries in the country.

AmchiAmchi is a Tibetan medicine or healingpractice existing in the upper-Himalayanregions. Though this is not an official systemof medicine, there are two types ofpractitioners in this field. Some of them areinstitutionally trained and others follow thetradition.

Main Constraints

Qualified, competent and trainedmanpower is a primary prerequisite for anyinstitutional development. Ayurveda andother traditional systems are facing a severecrisis of manpower development, mobi-lization and leadership. There is no propertraining programme for traditional healers.Academic and other institutions are beingrun with poor budgetary support, planning,infrastructure and leadership.

Indigenous system of medicine in Sri Lanka

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of medicine, which has been practised bythe people since time immemorial. TheAyurvedic system of medicine from NorthIndia, the Siddha system of medicine fromSouth India and the Unani system ofmedicine of the Arabs enriched withcontributions from the traditional systemof medicine called Desheeya Chikithsa ispopularly known as the “Indigenous systemof Medicine in Sri Lanka”.

The Government of Sri Lanka recog-nized this system as an alternative system ofhealth care by establishing a Departmentof Ayurveda under the Ministry of Healthand Indigenous Medicine. Presently theMinistry of Indigenous Medicine and theDepartment of Ayurveda are responsible forthe development of the Indigenous System,including training, registration, research,hospital care and production of Ayurvedicdrugs.

A well-amalgamated health careoperating system, made up of the endemictraditional system and the Ayurvedicsystem, is in operation to suit therequirements of the people of this land.

In 1929, two training institutes forproducing doctors in the Ayurvedic system

Indigenous system ofmedicine in Sri Lanka

of medicine were institutionalized. Thesyllabi and subject matter of both consistedof Ayurveda and Traditional Medicine.Thus, at present the country has two setsof Ayurvedic physicians, one set trained bytheir ancestral teachers, physicians, andthe other institutionally trained cadres, bothcommanding the respect and venerationof the public. Although the modes ofpractice followed by these two groups arevery similar with respect to the systems andprinciples, there exists considerabledifference as to the actual medicationsused. Institutionally trained practitionersuse more of Indian-based medicaments,whereas traditional physicians use more oftraditional therapies taught and trained topractise by their ancestral teachers.

They evolved the following highlydeveloped divisions of traditional medicineand these services are still available to thepeople.

Fractures and dislocations;Snake-bite poisoning andhydrophobia;Eye diseases, sinusitis;Neurological diseases;Mental diseases;Diarrhoeal diseases;Kamala (Hepatitis).

Lal Rupasinghe

Sri Lanka is a country of rich heritage,one of which is its indigenous system


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This country enjoys the services of15,000 traditional and Ayurvedicpractitioners, 70 per cent being traditionalphysicians, trained by their gurus and whohad acquired knowledge through years ofexperience as well. The remaining 30 percent are institutionally trained, obtaining aDiploma or Degree after undergoing a six-year curriculum course, as a part of whichthey are taught the basics and essentialsof traditional medicine on the above-mentioned specialities. In addition to theabove-mentioned course, a three-yeardiploma course is available in the countryto train, as physicians, youngstersdescended from families whose forefatherswere traditional physicians.

The traditional and Ayurvedic systemof medicine by Government Policy isrecognized as a component of the nationalhealth service. Indigenous medicalpractitioners who fan out throughout thecountry, especially to the remote rural areaswhere the Western medical and health caredelivery system does not reach, offerinvaluable service to the people. Recent

surveys conducted revealed that well over45 per cent of the entire population seeksAyurvedic and traditional medicalassistance in spite of the mere 1.4 per centof the entire health budget it is receivingannually.

The Department of Ayurveda managesan intricately woven network of health caredelivery outlets throughout the country. Thedetails are as follows:

Sri Lanka is the only country where thetraditional medical fraternity together withthe Ayurvedic component enjoys the statusof a cabinet portfolio in the whole of theSouth-East Asia Region.

Table Ayurved delivery outletsTeaching Hospitals 2Central Dispensaries 122Provisional Hospitals 46Local Dispensaries 231Research Institute 1National Institute ofTraditional Medicine(Teaching and Training only) 1Herbal Gardens 5

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for thousands of years, is part of the culturalheritage and wisdom of the country. Ourancestors had accumulated preciousexperience of holistic health in the fightagainst disease. The different elements ofThai traditional medicine have been derivedfrom wisdom handed down from gene-ration to generation, from observations, oldmanuscripts and instructions provided atinstitutes of Thai traditional medicine. Thaitraditional medicine is closely linked toBuddhism. Diagnosis in Thai traditionalmedicine does not only concentrate ondiagnosis of disease but goes into thedifferent theories and hypotheses ofdisease.

Thai traditional medicine believes thatthe following six causes are the main sourceof disease:

Variation in the elements;Seasonal variation;Age variation;Place variation;Time variation;Behavioural variation.

Thai traditional medicineas a holistic medicine

Variation in the elements

The body consists of four body elementsor Dhatus. It is believed that imbalance anddisharmony between the four bodyelements cause disease. The four bodyelements are:

The earth body element, which refersto any entity that is non-liquid, tangibleand visible;The water body element, which meansthe fluid composition of the humanbody, e.g., blood, tears, nasal mucoussecretion and urine;The wind body element, whichcirculates throughout the body;The fire body element, which burnsthe food which is consumed andtransforms it into body waste material.

Human disease can be traced back toirregularity and abnormality in these fourbody elements.

Seasonal variationThe different seasons could causeimbalance of the four body elements. Inthe rainy season, for example, the wind

Pennapa Subcharoen

Thai traditional medicine, which haslooked after the health of the people


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body element could be responsible for afever. Humans should adjust themselves tothe diseases which occur in the differentseasons. These are given below:

Summer - Diseases of fireelement;

Rainy season - Diseases of windelement;

Winter - Diseases of waterelement.

Age variationAge can be related to the propensity of aparticular disease to occur in a particularperson. Different age-groups are corre-lated with the diseases of a particularelement. This relationship is shown below:

Primary age (0–16 years)Water element diseases;Middle age (17–32 years)Fire element diseases;Old age (over 32 years)Wind element diseases.

Place variationThe environment has a relationship with theoccurrence of a particular disease. Illnesscan be caused by a different geographicallocation, extremes of temperature or anew water supply. It is suggested that suchan influence could be mediated throughthe immune system. Information as regardsthe birthplace of the patient or the actualplace of residence may give the physicianclues as regards the diseases which arelikely to afflict the patient. The correlationbetween geography and diseases is givenbelow:

High mountains are associated withdiseases of the fire element;Rain, water and mud are associatedwith diseases of the wind element;Rainwater, soil and groundwater arerelated to diseases of the waterelement;

Salt water, mud and the beach arerelated to diseases of the earth element.

Time variationThe time of the day or night has aninfluence on the different body elements orDhatus. These are described below:

06.00–10.00 a.m. and18.00–22.00 p.m.Nasal secretion problems orindigestion;10.00 a.m.–14.00 p.m. and22.00 p.m.–02.00 a.m.Fever caused by the fire element,stomach ache or hunger pains;14.00 p.m.–18.00 p.m. and02.00 a.m.–06.00 a.m.The wind element causes giddiness,feeling of being worn out, exhaustionand fainting in the afternoon.

Behavioural variationCertain behavioural patterns are asso-ciated with disease. Some of these are:

Having too much or too little food andeating spoilt food; imbalance inactivities such as standing, sitting,walking or lying down;Exposure to hot or cold weather;Going without food, water and sleep;Delayed defecation or urination;Overwork;Excessive sorrow;Excessive anger.

Diagnosis

A correct diagnosis is extremely importantas a wrong diagnosis would lead toinappropriate treatment, which could befatal. The method of arriving at the correctdiagnosis in Thai traditional medicineconsists of two factors – history-taking andphysical examination.


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History-takingAttention is paid to the birth date of thepatient because it shows the essentialelements or Dhatu of the patient. Thehistory would also indicate illnesses whichoccurred during childhood, seasonalillnesses, lifestyle and behaviour whichcould have related to the illness.

Physical examinationThe physical examination consists ofconfirming the characteristics of theessential elements, palpation of the wristpulse, checking the body temperature,checking the disordered organ, exami-nation of the blood, using meditation forchecking the cause of illness and checkingthe astrological configuration.

Curative methodsThai traditional medicine is holisticmedicine and takes into considerationseveral factors which could be associatedwith the illness. Some of these are givenbelow:

Factors created by nature, such as thebasic elements of the human body, theseason and the need for taking herbalfood and medicine and alteringbehaviour;Behavioural factors have to be takeninto account. The need for exercise andphysical stretching (Ruesee dat Tone)have to be kept in mind. Thai traditionalmassage and meditation, which is aprinciple of the Dharma treatment,need to be kept in mind. The treatmentcould be:

Physical treatment such as exerciseand body exercises, including bodytwisting;Moral treatment such as medi-tation and merit making;Treatment which consists of

altering lifestyle so that the fourelements and the external environ-ment are in balance.

Use of herbal food or medicine foradjusting the elements of the body toachieve balance. This consists of usingherbal food for adjusting the Dhatu,using herbal food according to theseason and administering such foodfor adjusting the Dhatu according tothe taste of the herbal medicine. Thesetastes are cool taste (to adjust the fireelement), hot food (to adjust the windelement), delicate taste (to adjust thewater element) and nine other tastesto adjust the body elements such asastringent, sweet, intoxicating, bitter,creamy, aromatic and sour, spicy andsalty;The herbal food should be adminis-tered according to the body elementor Dhatu. Examples are given below:

Body element of earthThese persons should have food withastringent, sweet, creamy and salty flavourssuch as raw guava, mangostein, pumpkin,rambutan, taro, bean, milk and molasses.

Body element of waterThese persons should eat food with sourand bitter flavours such as lemon, orange,pineapple, tomato, cavilla fruit, magosaand kiffer lime.

Body element of windThese persons should eat spicy food suchas ginger, galingale, lemongrass, pepper,sweet basil and holy basil.

Body element of fireThese persons should eat food with bitteror tasteless flavours such as morning glory,watermelon, cassia, ivy gonro and tigerherbal.


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Healing is carried out by using a single-herb preparation or a mixed medicinalplants prescription. Mixed herb prepara-tions are used for chronic diseases.

Advantages andcharacteristics of holisticmedicine

Holistic medicine places emphasis onlifestyle, health promotion and diseaseprevention;Holistic medicine creates a warm andempathic relationship between thepractitioner and the patient. Propermental health of the patient is essentialfor treatment;Treatment by holistic medicine laysemphasis on the patients’ Dhatu orElement;Holistic medicine can cure chronicdiseases which are induced by stress.

Traditional Thai massage

Thai traditional massage is based on theindigenous wisdom which the Thai peoplehave adopted from their ancestorscenturies ago. Massaging is a way oftreating sickness; it starts by relievingtiredness or pain by the patient pressingon the pain himself. When he cannotmassage himself he should ask somebodyto massage him. This pattern has deve-loped from massage by the family tomassage at the village-level and later onto massage on a commercial scale.

Two patterns of Thai Traditional Massage:Unofficial Thai Massage (FolkMassage);Royal Thai Massage.

Unofficial Thai massageThis massage is given by persons to eachother in a family or in the village. This typeof massage is carried out not only by handbut also by standing on the patient, pushing,pulling and kneeling him by using also theelbow, knee, forehand and edge of the foot.This type of massage relieves tiredness andpain and also develops warm and goodrelationship among the family members.

Royal Thai massageThis massage is given to the King and theRoyal family. In this type of polite massage,only the hand is used. The person carryingout the massage does not come close tothe member of the Royal family, does notbreathe into the person undergoing themassage and does not turn up his face, asit is disrespectful.

The characteristics of the Royal Thaimassage and folk massage are givenbelow:

Royal Thai massageGive a massage in a polite manner bywalking on knees towards the patientand by not breathing directly on him;Start massage from the back of thefeet;Give the massage only by using thehands, thumbs and fingers. The armsshould be straight;Give the massage to the patient whenhe is sitting, lying on the back, lying ina side position but not when he is lyingon his stomach;The person doing the massage doesnot bend part of the body of the patientbeing massaged with force by using hisknees or elbows;The massage has an effect on theorgans and tissues by enhancing the


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circulating system and the nervoussystem. The person who carries out themassage should, therefore, have aknowledge of anatomy and shouldpossess the skill of massaging theblood vessels and nerves.

Folk massageStart the massage from the feet;Give the massage to the patient whilehe is sitting, lying on the back, lying ina side position but not when he lies onthe stomach;Bend the joints and parts of the bodywith force using the knees and elbows;The massage has an effect on theorgans and tissues.

Thai traditional massage is a valuableaspect of Thai traditional medicine; it isable to relieve disease and assuage pain.The massage has a beneficial effect on the

body systems necessary for maintaininggood health. For example, it strengthensthe circulatory system, removes wastes, actsas a diuretic, relaxes the nervous systemand relieves pain. Some of the types of painfor which it is effective are headache,displaced shoulder joint, neck pain,sprained ankle, backache and kneecappain. It is effective also in diseases of theelderly such as paralysis, limpness,flatulence, constipation and reduced sexualefficiency.

The benefits of Thai massage and thesafety while carrying it out depend on theexpertise of the Thai practitioner. He shouldknow the body and the condition of healthof the patient. He should know the principleof massage and know what not to do andhe should know how much weight heshould apply to make it suitable for thepatients.

List of contributors

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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 Systemsof 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 GynaecologicalEndocrinology, Department of Obstetrics and Gynaecology, GenevaUniversity Hospital, Geneva, Switzerland.

8. Dungtsho Pema Dorji, Director, Institute of Traditional MedicineServices, Bhutan.

9. Dr. B. B. Gaitonde, Former Director, Haffkine Institute, Bombay,Banda Sindhudurg, India.

10. Dr. Lestari Handayani, Health Services Research and DevelopmentCentre, 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 ScienceAcademy, 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 ofMedicine & Homoeopathy, Ministry of Health & Family Welfare,New Delhi, India.

20. Dr. Ketut Ritiasa, Director of Traditional Medicine and CosmeticsControl, Ministry of Health, Jakarta, Indonesia.

21. Dr. (Mrs.) M. Roy Chaudhury, Former Toxicologist, National Instituteof Immunology, New Delhi, India.

22. Professor Ranjit Roy Chaudhury, Emeritus Scientist, National Instituteof Immunology, New Delhi, India.

23. Dr. Lal Rupasinghe, Commissioner of Ayurveda, Department ofAyurveda, 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, WHOCollaborating Centre for Research and Standardization in TraditionalMedicine, Pyongyang, DPR Korea.

27. Dr. Pennapa Subcharoen, Director, National Institute of ThaiTraditional Medicine, Department of Medical Services, Ministry ofPublic Health, Nonthaburi, Thailand.

28. Dr. Niniek Sudiani, Head, Sub-Directorate of Traditional MedicineRegistration, Ministry of Health, Jakarta, Indonesia.

29. Dr. Haryadi Suparto, Health Services Research and DevelopmentCentre, National Institute of Health Research and Development,Ministry of Health, Surabaya, Indonesia.


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30. Dr. Agus Suprapto, Health Services Research and DevelopmentCentre, National Institute of Health Research and Development,Ministry of Health, Surabaya, Indonesia.

31. Dr. U. Kyaw Myint Tun, Director-General, Department of TraditionalMedicine, 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 IntegratedChinese & 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), WorldHealth Organization, Geneva, Switzerland.

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