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Traditional Medicine in ASIA PDF
Traditional Medicine in ASIA PDF
in Asia
Edited by
ii
Contents
Preface
All countries in the South-East Asia Region of the World Health Organization (WHO)
have a heritage of traditional systems of medicine. There are large numbers of
traditional medicine practitioners who provide help and service to the ill and the
needy. Some of these practitioners are qualified doctors who have taken a five-year
course in the system of medicine they practise; there are others who have learnt
their system of medicine and the use of the different plants from their forbears,
while there are still others who offer their services after working with practitioners
and learning from them.
It is important that this unique knowledge, often found in ancient texts, be utilized
by countries to the maximum extent possible without endangering the environment
and destroying the very plants which are the source of the medicine. Unfortunately,
this too is happening. There are many ways in which the practitioners of these
systems and the products and plants they use could be more effectively utilized for
the benefit of the countries and their people. Greater use could be made of these
medicinal plants at the primary health care level so that all persons could have recourse
to herbal medicine–particularly those living in areas without any allopathic health
care coverage. Further research directed at a few of the chronic diseases against
which more drugs are needed, such as diabetes, bronchial asthma and arthritis,
could lead to the discovery of new drugs for these conditions. Regulated and selective
export of some of these medicinal plants being eagerly sought after in other parts of
the world could considerably enhance the foreign exchange earnings of countries
with this biodiversity. Careful planning is needed so that such a programme could be
launched without detriment to the environment and without reducing the availability
of the medicinal plants in the countries. The very large numbers of trained and
semi-trained practitioners of the traditional systems of medicine could become more
involved in the national health care systems of the countries. Such involvement can
come about only as a result of some regulation of the systems being followed, the
products used for health care and the practitioners of such systems.
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Contents
Contents
SYSTEMS
Ayurveda 3
Dr. P.N.V. Kurup
Unani medicine 31
Hakim Syed Khaleefathullah
Chinese Acupuncture-Moxibustion 75
Prof. Deng Liangyue
Fundamentals of Yoga 93
Swami Niranjanananda Saraswati
and Dr. Rishi Vivekananda Saraswati
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Traditional Medicine in Asia
POLICY ISSUES
Harmonization of traditional and modern medicine 115
Prof. Zhu-fan Xie
TECHNICAL ISSUES
Legislation and regulation of traditional systems of medicine– 195
systems, practitioners and herbal products
Dr. D.C. Jayasuriya
Dr. Shanti Jayasuriya
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Contents
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Systems
Ayurveda
Dr. P.N.V. Kurup
An overview of traditional Chinese medicine
Dr. Hongguang Dong
Dr. Xiaorui Zhang
Unani medicine
Hakim Syed Khaleefathullah
Traditional system of medicine in Indonesia
Dr. Lestari Handayani
Dr. Haryadi Suparto
Dr. Agus Suprapto
Koryo system of medicine in DPR Korea
Dr. Choe Thae Sop
Chinese Acupuncture-Moxibustion
Prof. Deng Liangyue
Fundamentals of Yoga
Swami Niranjanananda Saraswati
and Dr. Rishi Vivekananda Saraswati
Traditional Medicine in Asia
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Ayurveda
Ayurveda
P.N.V. Kurup
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Traditional Medicine in Asia
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Ayurveda
Tridosha – Vata, Pitta and Kapha – are rise of body temperature, burning
the psychobiological dimensions or sensation, indigestion, etc.; ii) Ranjaka Pitta,
biological rhythms regulating the entire which has a role in blood formation with
functioning of the human body. These the pathological manifestation of anaemia;
doshas are formed by the Panchama- iii) Sadhaka Pitta, which is responsible for
habhutas. Vata is formed by the combi- intelligence and memory with pathological
nation of Akash+Vayu and has the manifestation for lack of concentration,
properties of cold, light, coarse and dry, loss of intelligence, loss of sleep, etc.; iv)
Pitta by Teja having hot and liquid and Alochaka Pitta, which is responsible for
Kapha by Jala+Prithvi with cold, heavy, vision with pathological manifestations
solid, smooth and moist properties. Vata, pertaining to eye and vision; and v)
Pitta and Kapha are of five types having Bhrajaka Pitta, which regulates body
physiological functions and pathological complexion, body heat regulation, etc., with
manifestations.7 pathological manifestations like vitiligo,
The five types of Vata include, i) Prana discolouration and skin diseases.
Vayu, which strengthens the vital capacity, The five types of Kapha include,
improves the intellectual power, respiration, i) Avalambaka Kapha, which is responsible
deglutition, and the activities of the sense for the lubrication of joints, pericardium
organs, etc., with pathological with pathological manifestations like
manifestations like hiccough, flatulence, stiffness of the joints and chest pain; ii)
breathing troubles, etc.; ii) Udana Vayu, Kledaka Kapha, which disintegrates food,
which regulates strength, encouragement, maintains the fluid, lubrication, etc., with
colour, knowledge, intelligence, memory, pathological manifestations like indigestion
etc., with pathological manifestations of the and mucoid stool; iii) Bodhaka Kapha,
eye, ear, nose and throat; iii) Samana Vayu, which is responsible for feeling the taste of
which improves digestion and metabolism, various substances with pathological
transformation of nutrients, circulation of manifestations like dryness of mouth and
lymph and expulsion of urine, stool, etc., palate and loss of sensation of different
with pathological manifestations like tastes; iv) Tarpaka Kapha, which provides
anorexia, diarrhoea and abdominal nutrition to the sense organs with
tumour; iv) Vyana Vayu, which regulates pathological manifestations like loss of the
blood circulation, sweating, contraction, activities of the sense organs; and
taste, ejaculation of sperm, development v) Shlesaka Kapha, which lubricates all
of all the tissues, etc., with pathological body joints with pathological manifes-
manifestations like fever and convulsion; tations of the bony joints.
and v) Apana Vayu, which regulates The body and the mind are the two
expulsion of urine, stool, sperm, complementary constituents of a living
menstruation, etc., with pathological being, its dynamic normalcy being
manifestations of urinary and the uterine responsible for health and its imbalance
tract and ano-rectal diseases. for disease.
The five types of Pitta include, i)
Pachaka Pitta, which regulates digestion The mind exhibits three properties:
of food, stimulates the digestive enzymes z Sattva (intelligence), which is signified
and separates the waste products with by goodness, virtue, excellence,
pathological manifestations of anorexia, wisdom and good sense;
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Ayurveda
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Traditional Medicine in Asia
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Ayurveda
Pizhichil
In this therapeutic measure, warm
medicated oil is poured all over the body,
followed by massage, in seven positions
in a systematic manner for the treatment of
diseases of the nervous system like paralysis,
sciatica, osteoarthritis, musculo-skeletal,
neuro-muscular and degenerative diseases.
Pizhichil is very useful as a health restora- Shirobasti treatment in Ayurveda
tive measure for elderly persons when it is
regularly used once a year or so. This
treatment cleanses the minute channels in are prepared from plants like Arka and
the body of morbid substances. Snuhi by using their milk or herbal alkaline
material and tying it at the site. The
Shirobasti 22 advantage of this therapy is that the
This is an oil treatment applied to the head patients may remain mobile during the
in which a leather belt is tied to the clean- treatment. It can also be carried out on
shaven scalp. The junction of the scalp patients for whom modern surgery is
and leather belt is sealed with paste contra-indicated.
prepared from wheat flour or black gram.
Medicated oil is then poured into it and Role of Ayurveda in Primary
kept for the stipulated time. This is Health Care
recommended for headaches, myopial
conditions, insomnia, psychiatric illnesses, Ayurveda has laid due emphasis on the
epilepsy, hair fall, etc. It improves the preventive and promotive aspects of
functioning of the sensory systems and health, in which dietetics and way of life,
removes exhaustion. according to Prakriti (psychosomatic
constitution), play an important role. The
Shirodhara 23 balance of Vata, Pitta and Kapha leads to
This therapeutic measure is carried out by a healthy state and disturbance in this
pouring oil or medicated liquids on the equilibrium leads to diseases. If one
forehead for treating headaches, vertigo, follows the daily routine and seasonal
insomnia, anxiety, etc. It is also useful in routines as prescribed under personal
many psychosomatic disorders and hygiene and socio-behavioural conduct,
hypertension. then health can be preserved and diseases
prevented by developing the capacity to
Ksharasutra 24 adapt to the cosmic changes which have
This Alkaline Thread Therapy is a an impact on the human biological
popular herbal treatment for ano-rectal system. The violation of these principles
diseases like fistula-in-Ano and disturbs the equilibrium of doshas
haemorrhoids (piles) under the speciality increasing susceptibility to diseases.
of Shalyatantra. The medicated threads
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Ayurveda
growth of the baby. The nutritional Tinospora cordifolia, etc., are good
deficiency may cause anaemia, malnu- immunity-promoting drugs which can play
trition and other vitamin deficiencies which an important role in primary health care
can be corrected by available food articles from the preventive, promotive and curative
in the rural areas such as carrot, cabbage, points of view.
milk, leafy vegetables and pulses. With Extensive research has shown that
regard to family planning, drugs like some of the medicinal plants exert specific
Hibiscus rosa-sinensis and Piper longum action on various vital organs. They not only
Linn have shown promising results after promote the normal functioning of the
scientific investi-gations. Withania organ but also take care of the disease-
somnifera, Asparagus racemosus, condition as well.
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Ayurveda
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Ayurveda
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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.
16
An overview of traditional Chinese medicine
An overview of traditional
Chinese medicine
Hongguang Dong
Xiaorui Zhang
Fundamentals of TCM
According to some estimates, a large
number of people in many developing As an important part of the Chinese
countries rely heavily on traditional culture, TCM has evolved into a unique and
practices to meet their primary health care complete medical system during the long
needs. 1 In China, although Western history of China. The Huang Di Nei Jing
medicine is available, the majority of the (The Yellow Emperor’s Classic of Medicine
population still rely on zhongyi (Chinese or Canon of Medicine) was the first
medicine or traditional Chinese medicine, monumental classic which systematically
or TCM) to solve their health problems. documented the etiology, physiology,
Western medicine and Chinese medicine diagnosis, treatment and prevention of
are practised side by side at every level of disease. This work was probably compiled
the national health care system.2 over several centuries by various authors
With a history of over 2000 years, the and consists of two parts: Su Wen (Plain
TCM practice offers natural, safe and Questions) and Ling Shu (Miraculous Pivot,
effective therapies and cures for many also known as Canon of Acupuncture). It
diseases with much less side- effects. TCM takes the form of a dialogue between the
takes a unique theoretical and practical legendary Yellow Emperor and his minister,
approach to health. In treatment, it Qi Bo, on the topic of medicine. Its
includes the use of various intervention appearance between 300 BC and 100 BC
modalities, such as Chinese medication, marked the establishment of TCM.4 One
acupuncture and moxibustion, Tuina striking difference between TCM and
(massotherapy), dietary, and Qigong.2, 3 Western medicine is in the way in which
These modalities may be used separately the human body is observed, and hence
or in combination to effect a treatment. the difference in the concept of health.
TCM differs in fundamental ways from Chinese medicine holds a holistic view
Western medicine. This paper is thus of the human body. It stresses the overall,
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An overview of traditional Chinese medicine
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Traditional Medicine in Asia
Medical Problems” in chapter 77: “If Liver corresponding external manifestations. For
is diseased, it can invade the Spleen, the this reason, TCM* does not emphasize the
Spleen must therefore be tonified before it anatomy of the human body. Although TCM
is affected” uses similar names for organs as those used
To guide the therapeutic method: The in Western medicine, and many of these
“Classic on Medical Problems” in chapter organs perform similar functions as
698 presents a classic interpretation: “If recognized in Western medicine, they in fact
deficiency is found in the son organ, one do not reflect completely the same concepts.
would tonify the mother organ; if excess is For example, in Chinese medicine, each
found in the mother organ, one would visceral organ is a comprehensive system
sedate the son organ”. and performs a set of physiological functions
which often cover an area related to but
The human body much larger than those in its anatomical
In Chinese medicine, much stress is laid on sense.
the observation of the outward physiological The visceral organs are divided into
and pathological manifes-tations of the three categories according to their
human body. It is believed that all internal morphological features and physiological
organs and their activities will have their functions.
* Some terms in TCM are the same as those in Western medicine, but they may mean quite different things. In order
to avoid confusing them with the notions of Western medicine, these terms are italicised to remind readers. Some
terms applied directly from TCM are also italicised to remind readers.
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An overview of traditional Chinese medicine
The five zang organs: these are body is formed; when qi dissipates, the
substantial in morphology, and function to body “dies”.11 Qi has variously been
store the “essence of life”. They include “liver, translated as “energy”, “vital energy”, or
heart, spleen, lung, kidney”. “life force”; however, it is almost impossible
The six fu organs: these are hollow in to capture the exact concept fully in one
morphology, and their function is to English word or phrase; therefore we have
transport and transform foodstuff. They decided to use its original Chinese word:
consist of the “small intestine, large Qi.
intestine, gall bladder, stomach, bladder The sources of qi can be divided into
and sanjiao (triple energizer: a collective the inborn and the acquired. The inborn qi
term for the three portions of the body is the innate vital essence stored in the
cavity)” “kidney” which was inherited from the
“Extraordinary organs”: these are parents at the moment of conception, and
hollow in morphology, and their function augmented postnatally which is a
is to store the “essence of life”. They are combination of the essence absorbed by
the “brain, marrow, bone, vessels, gall the “spleen” from food and fresh air which
bladder and uterus”. is inhaled by the “lung”. The two sources
Each of the zang organs is linked to a of qi are gathered in the chest and form
fu organ. The function of one organ in TCM zhengqi (genuine qi), which circulates
may include the functional activities of through the body’s organs and tissues.
several anatomically defined organs in Since qi is invisible, it can only be perceived
Western medicine. For example, the through its actions. For instance, the
“kidney” in Chinese medicine is not just the deficiency of the “kidney qi” means the
organ that excretes urine; it stores the deficiency of energy required for the
“essence of life”, controls reproduction, functioning of the “kidney” (namely, the
growth and development and is closely hypofunction of the “kidney”). Generally
related to the “brain, marrow and bones”. speaking, qi has five functions: it i) Serves
Thus, in TCM the concept of “kidney” as the energy source of body activities, ii)
includes most of the functions of the urinary Warms and nourishes the body,
system, some functions of the endocrine iii) Defends the body surface against
system, and something similar to those of invasion by any pathogenic factor, iv)Is the
the pituitary-adenocortical-gonadal axis.10 vehicle of transportation inside the body,
and v) Maintains the normal positions of
Material basis of the vital body organs.12, 13 Blood: The concept of
activities of the human body blood in TCM is not the same as it is in
Qi: The major premise of TCM is that all Western medicine. In TCM, the blood is a
living things, including human beings, have vital nutrient substance in the body. It is
a life force within them. This essential vital formed from the combination of essence
biological energy, which is invisible, is of food, which is derived via digestion and
known in Chinese philosophy as qi absorption by the spleen and the stomach,
(pronounced: chee; often also written as and fluids containing nutrients. The kidney
‘chi’). Qi circulates regularly along the also contributes to the formation of blood
meridians in the body. Disruption in this as it is the kidney-stored essence that
flow is believed to be responsible for produces bone marrow. After being
diseases. When qi gathers, the physical formed, blood circulates in the vessels
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An overview of traditional Chinese medicine
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An overview of traditional Chinese medicine
and interior, cold and heat, deficiency and Chinese materia medica developed
excessiveness. Differentiation of patholo- continuously by the addition of new herbs,
gical conditions in accordance with the together with a re-evaluation and addition
eight principal syndromes is the foundation of new uses for existing herbs. Among
for all the other methods of syndrome these, two pieces of work need to be noted:
differentiation. It signifies the location and Xin Xiu Ben Cao (Newly Revised Materia
nature of disease, the confrontation Medica, 659 AD) was considered to be the
between the pathogenic factor and body first official pharmacopoeia in China,
resistance, as well as establishes the compiled and issued by the Government.
principle of treatment. Ben Cao Gang Mu (Compendium of
Differentiation syndromes according to Materia Medica, 1596) is considered as a
the pathological changes of zang fu organs world-renowned classic, written by Li Shi-
are based on the symptoms and signs zhen (1518–1593 AD).
obtained by four diagnostic methods when The concept of Chinese medicine
qi and the blood of the internal organs are differs from that of the synthesized drugs
out of balance. This method of syndrome in the ways their properties are determined.
differentiation is applied to identify the Chinese medicines are determined mainly
particular disharmony of a specific internal by the outcomes of their clinically observed
organ. interaction within the human body.
The terminology used in describing the
Intervention in TCM pharmacology of Chinese medicine
includes: property; taste or flavour; action
Chinese medication of ascending, descending, floating and
Chinese medication is the primary sinking; attributive of meridians, and toxicity.
component of TCM and is used commonly Properties or four properties of herbs:
in China. Chinese medication involves the Based on their therapeutic effects, there are
use of herbal medicine, animal parts and four ways of describing property: cold, hot,
minerals. The term “herb” used in Chinese warm, cool. For example, herbs effective
medicine often goes beyond the traditional for the treatment of heat syndromes are
concept of “plant”, since the 6000– 8000 endowed with cold or cool properties,
substances used include, in addition to while those effective for cold syndromes are
numerous plants, substance from animals herbs with warm or hot properties.
and minerals. Taste: Sour, bitter, sweet, pungent, and
According to Chinese history, Chinese salty taste of herbs. They are the expression
medicine arose from mythical medicine to of the feature of the herb’s actions; thus
become a system of herbal medicine. Shen the taste does not necessarily mean the real
Nong Ben Cao Jing (Divine Husbandman‘s taste of the herb.
Classic of Materia Medica; or Shen Nong‘s Action of ascending, descending,
Herbal) is the first work (25–220 AD) floating and sinking: Direction of a herb’s
which prescribed the therapeutic effect of action. The ascending and floating herbs
herbs and other materials. It contains 365 have an upward and outward effect, while
entries. These are botanical (252 entries), descending and sinking herbs have a
zoological (67 entries), and mineral (46 downward and inward effect. The action
entries) substances. Beginning with Shen of a herb can be changed by processing
Nong Ben Cao Jing, the literature of or by combined use with other herbs.
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An overview of traditional Chinese medicine
(mugwort), a kind of herb in Chinese called translated as pressing and dragging, and
Ai (moxa). Generally speaking, moxibustion Na as grasping. It belongs to external
is applied in cold syndrome, deficient therapy and has evolved over thousands
conditions and chronic diseases. of years. As a component of TCM inter-
Moxibustion may be used in combination vention, tuina is based on a solid theoretical
with acupuncture or separately to effect a background, and includes basic theories,
treatment. diagnostic methods and syndrome
differentiation of TCM, particularly the
Qigong theory of meridians. In addition, tuina is
The term qigong is composed of two also involved in a series of different kinds
Chinese characters, qi and gong, where of specific manipulation techniques.
qi can be translated roughly into English Tuina has its own specific benefits and
as “vital energy”, and gong as “method” advantages in a wide range of applications.
or “performance”. Qigong is a system of Tuina is used in both prevention and
exercise performed by taking a proper treatment of diseases. It may be used in
posture, adjusting breathing and the treatment of internal and external
concentrating the mind and uniting vital conditions, traumatic injury, and muscu-
essence and energy and mentality as a loskeletal, gynaecological, obstetric and
whole for physical training, health paediatric diseases.
preservation, prevention and treatment of Stringent and comprehensive practi-
diseases.14 Since qi plays an important role tioner training is important. When
in the vital processes of the human body, it performing tuina, the physician must first
is natural that regulation of the flow of qi concentrate his mind, regulate his
can be used as a method to preserve health breathing, and actuate the qi and power
and prevent diseases. Qigong is different of his entire body towards his hands, elbow
from physical exercises. The latter is aimed or other part of body with the requirement
at building up health or at restoring the of treatment, then apply manipulation on
body’s physical functioning by enhancing certain points or areas of the patient’s body
strength, whereas the former is focused on to stimulate the flow of qi and blood in
the mobilization of functional potentialities order to normalize the function of zang fu
through regulating the mind and and balance yin and yang.
breathing. In other words, physical exercise
is purely somatic, whereas qigong therapy Proper use of TCM
is generally psychosomatic. Another
difference between physical exercise and In TCM, the conception of the organism
qigong is that physical exercise expands as a whole and diagnosis and treatment
energy by tensing up the muscle and based on overall analysis of symptoms and
accelerating the heart beat and signs are two key elements. Diagnosis,
respiration, while qigong works to relax, prevention and treatment of illness in TCM
calm and regulate breathing so as to rely on a holistic approach towards the sick
accumulate vital energy in the body. individual, and disturbances are treated at
the physical, emotional, mental, spiritual
Tuina and environmental levels simultaneously.
The term Tuina is composed of two Chinese Safety issues are of paramount
characters, Tui and Na. Tui can be concern. Since Chinese medicine is
27
Traditional Medicine in Asia
“natural” and has stood the test of history, minimal in the hands of a well-trained
it is often automatically perceived as being practitioner.16 Reports show that one of
harmless. It is true that Chinese medi- the more common problems of
cations in general are less toxic and safer acupuncture is forgotten needles.17 Life-
as compared to synthetic drugs or other threatening adverse reactions are possible
forms of therapy, but they are by no means with acupuncture treatment; 18, 19, 20
free from adverse effects. however, these are usually caused by
The question of the toxic potentials of practitioners who have not received any or
herbs has long been recognized in Chinese adequate training. Qualification in medical
pharmacopoeia, and relevant theories practice is important. There should be no
have been developed to avoid harmful uses exception in the case of Chinese medicine.
or combinations of potentially toxic herbs,
such as the theories of “Eighteen Prospects for TCM
Incompatibilities”, “Nineteen Antagonism”
and “Contraindication during pregnancy”, TCM is, by definition, traditional, but this
“Pao Zhi” (herbal process). These theories in no way prevents it from evolving. Great
continue to guide the Chinese pharma- progress has been made since the past
copoeia to this day. decade in efforts to understand the
Quality assurance procedures must be mechanisms of TCM, especially the
strictly enforced in order to standardize physiological effects of acupuncture. In the
herbal medicine. Chemical tests and assay meantime, efforts to combine TCM with
procedures must be used to supplement biomedicine in China have also accumu-
the traditional standards of the Chinese lated a great amount of experience and
pharmacopoeia. data. More concerted efforts are needed
Concerns have also been expressed relating to theoretical studies which may
regarding the safety of acupuncture. The elucidate the fundamentals of TCM through
risks associated with acupuncture have acquired knowledge in Western medicine.
been shown to be very small compared to Another challenge lies in how to clinically
orthodox interventions.15 In November combine TCM and Western medicine more
1997, an Acupuncture Consensus effectively which may eventually contribute
Statement made by the National Institute to the organic integration of these two
of Health in the United States mentioned: schools of medicine.
“One of the advantages of acupuncture is One frequent criticism regarding
that the incidence of adverse effects is researches in TCM is the quality of such
substantially lower than that of many drugs research. Improving the methodology
or other accepted procedures for the same and devising an approach for the specific
conditions.16” In general, side- effects from use of researches on TCM may be a
acupuncture procedure itself have been worthwhile task.
28
An overview of traditional Chinese medicine
References
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systems. BMJ 1997;315:115–17.
3. Diehl D.L. Acupuncture for gastrointestinal and hepatobiliary disorders. J.Altern.
Complement Med. 1999;5:27–45.
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Suwen with Commentary. 1995. Boston Massachusetts, Shambhala.
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16. 1995; Beijing. China, New World Press.
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Advanced TCM Series 101. 1997; Beijing. China, Science Press.
8. Qin Y.R. Classic on Medical Problems. 1978; Beijing. China, People’s Health
Publication House.
9. Williams T. The idea behind Chinese medicine In: The Complete Illustrated Guide to
Chinese Medicine. 31–34. 1996. Great Britain, Element Books.
10. World Health Organization. Standard acupuncture nomenclature (second edition).
1993; World Health Organization.
11. Yuan R., Lin Y. Traditional Chinese medicine: an approach to scientific proof and
clinical validation. Pharmacol.Ther. 2000;86:191–98.
12. NG LKY, Liao S.J. Acupuncture: Ancient Chinese and Modern Western. A Comparative
Inquiry. J Altern. Complement Med. 1997;11–23.
13. Morey S.S. NIH issues consensus statement on acupuncture. Am.Fam.Physician.
1998;57:2545–46.
14. Xie Z.F. Qigong and Health Preservation In: Classified Dictionary of Traditional Chinese
Medicine. 533–555. 1994. Beijing. China. New World Press. Beijing 100037.
China.
15. MacPherson H. Fatal and adverse events from acupuncture: allegation, evidence, and
the implications [see comments]. J Altern. Complement Med.1999;5:47–56.
16. Moyad M.A., Hathaway S., Ni H.S. Traditional Chinese medicine, acupuncture, and
other alternative medicines for prostate cancer: an introduction and the need for more
research. Semin.Urol.Oncol. 1999;17:103–10.
17. Yamashita H., Tsukayama H., Tanno Y., Nishijo K. Adverse events in acupuncture and
moxibustion treatment: a six-year survey at a national 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 systematic
review [see comments]. Pain. 1997;71:123–26.
19. Norheim A.J., Fonnebo V. Adverse effects of acupuncture [letter] [see comments].
Lancet. 1995;345:1576.
20. Yamashita H., Tsukayama H., Tanno Y., Nishijo K. Adverse events related to acupuncture
[letter]. JAMA 1998;280:1563–64.
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Unani medicine
Syed Khaleefathullah
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or drive for organs and functions; and contaminated with these foul earthly
finally vital force – the metabolic energy for bodies, no infection can occur. The Spanish
the organization and differentiation of life. Arab physician, Ibn-E-Khatima knew that
These are hypotheses imported from the man is surrounded by minute bodies,
physics and biology of Avicenna’s time and which enter the human body and produce
thus deserve not ridicule but serious disease. Dr Grunner, the translator of Al-
consideration as helpful generalizations. Qanon of Avicenna, remarks in his preface
Avicenna’s mode of presentation gives that the above two views considered
the impression of concepts being true for together give us glimpses of modern germ
all times. It is this impression which led his therapy.
successors to regard the pursuit of other Unani Tibb was introduced in India by
medical literature as superfluous and thus Arab and Persian settlers. The Unani
acted as a deterrent to progress for several physicians paid special attention to the
centuries. It was, however, not the fault of medicinal herbs found in India and wrote
Avicenna that he presented it as such to books on the therapeutic qualities of these
general practitioners and there is no herbs.
reason for us to avoid the dispassionate India has produced eminent Unani
examination of Al-Qanon for useful ideas. physicians. A few among them are Hakim
The most frequently quoted surgeon Ajmal Khan and Hakim Abdul Hameed in
during the middle ages was Abul Qasim northern India, and Hakim Zahoorul Huq,
Al-Zahrawi. His book, Al-Tasrif, was used Hakim Mohammed Muqeem, Shifa Ul
as a textbook until the beginning of the 17th Mulk and Hakim Syed Maqdoom Ashraf
century. Hippocrates systemized the tibb in southern India.
and gave it the status of ‘’Science’’. Galen
established its foundation on which the General Principles
Arab physicians constructed an imposing
edifice. Concepts
The greatest name in botany is Ibn-Al- Unani Tibb is based on the humoral theory.
Baytar (1248 AD). His book, Al-Jami-Li This theory supposes the presence of four
Mufaradat Al-Adviya Wa Al-Aghziyah, humours in the body – blood, phlegm,
contains all Greek and Arabic literature on yellow bile and black bile. The temperament
botany and Materia Medica. of a person is accordingly expressed by the
The Unani physicians were also words sanguine, phlegmatic, choloric and
advanced in midwifery and performed the melancholic, according to the prepon-
operation of “Cranio Clasty” for the derance in him/her, respectively, of the
delivery of the dead foetus. Zahrawi’s book, above humours. The humours are assigned
Al-Tasreef, is full of such examples. He was temperaments. Blood is hot and moist,
the first to describe the Walcher’s position phlegm is cold and moist, yellow bile is hot
in obstetrics. and dry, and black bile is cold and dry.
The modern “Germ Therapy” is in fact Drugs are also assigned tempera-ments.
a reflection of the views of the Unani Every person is supposed to have a unique
physicians who realized the connection humoral constitution, which represents his
between foul bodies and putrefaction. In healthy state. Any change in this brings
this connection, Avicenna has discussed in about a change in the state of health. A
detail that unless a bodily secretion is power of self-preservation or adjustment,
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when perceptions are not from outside but z Health – The bodily functions are
are inferences drawn from external carried on normally;
impressions and recognition. This consists z Disease – The opposite of health, in
of five powers: (i) Composite senses: Its which one or more functions or forms
function is to collect in one place all the of the organs are at fault;
external recognitions, (ii) Imagination: It z Neither health nor disease – There is
retains all material collected by composite neither complete health nor disease. As
senses, (iii) Conception: It co-relates all the in the case of old people or those who
external recognitions and draws are convalescing.
conclusions from them, (iv) Memory: It
retains conclusion, and (v) Modifying Disease can be classified into two types:
faculty: This power is possessed only by (1) Simple disease that completes its course
human beings which gives us the capacity without complications. It involves simple
to explain one thing in different ways and organs, compound organs, or both
which interprets all internal and external and is differentiated as,
recognitions. (a) Diseases of temperament: These
Motive power is of two types, (i) Power affect only simple organs. When
that is the cause of motions, and (ii) Power compound organs are involved it is
that causes motions. through the affection of their
(c) Vital power: Power that maintains life composing simple organs. Diseases
and enables all the organs to accept of temperament are thus always
the effect of psychic power. The seat of referred to as affecting simple organs
this power is (i) Heart – the centre of and not compound organs;
vital life, (ii) Brain – the centre of (b) Diseases of structure: These
sensation and movement, and involve compound organs which
(iii) Liver – the centre of nutrition. are composed of simple organs
and are in reality the instruments
Functions of body functions;
This includes the movement and functions (c) Diseases of continuity and
of the various organs of the body. Every dislocations: These affect both
organ has a primary innate faculty (force simple as well as compound
or drive) for nutrition by which it absorbs, organs. In the latter case, loss of
retains, assimilates and integrates the food continuity involves compound
material into tissues and excretes the organs directly and independently,
wastes. Some organs are also capable of and not through the involvement
influencing the activity of other organs while of simple organs which compose
certain other organs have no such faculty. them. Dislocation is a loss of
It is on account of such differences that continuity in a joint but without
the various organs of the body are damage to any of its individual
described as (i) receptors as well as components.
effectors, (ii) receptors, (iii) effectors, and (2) Complex disease does not mean the
(iv) neither receptors nor effectors. simultaneous occurrence of several
States of the body: According to Unani diseases in one person, but the presence
Tibb the states of the body are grouped of a number of abnormal conditions in
under three heads. They are, the form of a single disease.
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medium; the broad, narrow and medium pulse in this respect is the pulse of average
and the high, low and medium. A pulse fullness between the two extremes.
which is large in length, breath and height
is called a pulse of large volume and the Temperature
one which is small in these dimensions is The pulse may be hot, cold or moderate in
called the pulse of small volume. The temperature.
average pulse between these two is known
as the pulse of medium volume. Similarly, Rate (Frequency)
a pulse which is large in breadth and height The pulse is rapid when the period between
is known as a bounding pulse and that the two beats is less than the normal. It is
which is small in this respect is called a thin slow when this period is long. A medium
pulse. A pulse which is average between pulse in this respect is of the average rate
these two extremes is a medium pulse. between the two extremes.
Strength Constancy
The pulse as felt by the fingers may be A pulse may remain constant or vary in
strong, feeble or medium. A strong pulse respect of the features mentioned above.
is the one which during expansion strikes The variation may extend over several beats
forcibly against the physician’s palpating or involve a single beat, or part of a beat,
fingers. A feeble pulse is the opposite of a e.g., the pulse may be rapid in one beat
strong pulse and a medium pulse in this because of increased (metabolic)
respect is midway between the two. requirement of the body and weak in
another beat due to reduced vitality. The
Speed (Velocity) five features of the pulse, which vary in a
The velocity of pulse-beats may be quick, beat, are, size – as large or small; strength
sluggish or medium in speed. A quick pulse – as strong or weak; velocity – as quick or
is one in which the duration of individual sluggish; frequency – as rapid or slow, and
beats is shorter. A sluggish pulse is the consistency – as hard or soft. The pulse
opposite of a quick pulse and a medium may thus be constant or varied. A constant
pulse, in this regard, is of the average speed pulse remains absolutely unaltered, i.e., it
between the quick and the sluggish pulse. is smooth and even in respect of all the
above-mentioned features. If the pulse
Consistency (Elasticity) remains constant in any of the five features,
The vessel wall may be soft, hard or it is known as being constant in that
medium. A soft pulse is one which is easily particular feature, i.e., constant in strength
compressed (with the fingers) while a hard or rate. Similarly, a pulse which is variable
pulse is the opposite of a soft pulse. A may vary in only one or two features of the
medium pulse in this respect is the average pulse.
between the two.
Regularity
Fullness (Volume) An irregular pulse may be regularly
The pulse may be full, empty or medium. A irregular or irregularly irregular. A regular
full pulse is one which feels as if the artery is irregularity is the one which is repeated in
full of blood. An empty pulse feels the a systematic manner. The irregularity is
opposite of the full pulse and a medium simple when it pertains to a single feature
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of the pulse. It is complex when more than concomitants of a healthy life, and (ii)
one feature is involved, e.g., the pulse Subsidiary, which are not so necessary.
shows two different types of irregularities
but each one is so repeated that both Effects on the pulse of factors inimical to
irregularities form a single cycle of a regular the body are:
complex irregularity. An irregularly irregular z Temperament: The effects of various
pulse is the converse of the above. abnormal temperaments have already
been described.
Rhythm z Compression of the vessel: This
The rhythm of the pulse is the time relation changes the form of the pulse by
between the two periods of movement and suppressing the strength and thus
the two periods of rest. When these making it inconstant. When the
relations are not perceived, the rhythm is pressure is overwhelming the pulse
taken to be the relation between the period becomes irregular and arrhythmic.
of rise and the period of rest in two The compression may or may not be
consecutive pulse beats. In short, the from an inflammatory mass.
period of movement should be compared z Strength: Dispersal of strength makes
with the period of rest. The pulse may thus the pulse weak, as in severe pain, and
be eurhythmic or dysrhythmic. psychological factors also cause severe
dispersal.
Dysrhythmic pulse is of three varieties:
z Pararhythmic, in which the rhythm of Urine
a child’s pulse is like that of the pulse
of a young man; The following conditions have to be
z Hetrorhythmic, in which the rhythm of observed so that the information derived
a child’s pulse corresponds to that of out of it is reliable. The specimen should
an old man’s pulse; be of overnight urine. Urine should be
z Etrhythmic, in which the rhythm is so collected in a clear and colourless bottle in
utterly abnormal that it does not the morning on empty stomach and not
correspond to the rhythm of any age. retained for too long after collection.
Marked deviations of rhythm indicate The individual should not have used
gross derangement in the body. diuretics or any sustenances which colour
the urine. Undue mental and physical
The factors which govern the pulse are of exertions should be avoided as these too
two types: colour the urine, e.g., fasting, lack of sleep,
z Intrinsic factors: These are of a fatigue, hunger and outbursts of anger
general type and are fundamentally make the urine red or yellow. Coitus gives
responsible for the formation of pulse a marked oily appearance to the urine.
and are thus known as the consti- Vomiting, diarrhoea and polyuria also
tutional factors; change its colour and density. In infants
z Extrinsic factors: Although these are and children, urine does not give any
not directly concerned with the reliable indication because milk feeding
formation of the pulse, they do produce hides the proper colour and consistency
changes in it and are thus, (i) Absolute of urine. Also, their phlegmatic nature
as those which are necessary tends to hold back the pigments and
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excretes them in a smaller quantity. Since indicates jaundice, (ii) Quality – bubbles
children are relatively weaker and more being large, coarse, fine or small. Coarse
delicate and sleep longer than adults, their foam indicates that the eliminated matter
urinary findings are apt to be misleading. is viscid, (iii) Quantity – excess of foam
It is only when the examination is points to excess of reeh, (iv) Persistence of
carried out with due observance of the froth shows that the eliminated matter is
above-mentioned rules that it provides viscid. Increased viscosity of urine is a bad
helpful indications. Let it be known that sign in kidney disease since it shows
urine gives direct information only about abnormal phlegm or sauda is present in
the functional condition of the liver, urinary the system, or this organ has become
organs and the vascular system, and it is unduly cold in temperament.
through these findings that the functional
state of other organs is also learnt. Urine Odour
examination is a particularly reliable test Urine of sick persons never has the same
of the functional efficiency of the liver, odour as that of healthy persons. If the urine
especially of its convex part. is odourless, it points to either a cold
The points to be noted about urine are temperament or excessive immaturity of
colour, density, turbidity or transparency, humours.
sediment, quantity, odour and froth.
Colour: The various shades of colour Quantity
observed by the unaided eye, i.e., white, Scanty urine means impairment of vitality.
black and the intermediate shade. If urine is scanty in spite of taking adequate
Density: The thickness and thinness of fluids it is likely to be due to excessive
urine. Density is different from the turbidity perspiration or diarrhoea. The passage of
and transparency of urine. Thick urine may a large quantity of urine is a sign of early
be clear like the white of an egg, fish glue recovery, especially if the urine is pale and
or olive oil. Sometimes it is thin and yet looks is being passed freely.
like turbid water. Urine becomes turbid from
the suspension of dark-coloured particles. Mature urine (normal for health)
Transparency: This is the opposite of Mature urine is of moderate density and
turbidity. Turbidity differs from sediment. In pale yellow in colour. If there is sediment, it
turbidity the particles are intimately mixed is of laudable type as described above,
with urine while the sediment is quite namely, white, smooth, light and moderate
distinct and separate from the liquid part smell, i.e., free from malodour but not
of urine. Colour is the result of dissolved totally without smell.
particles while turbidity is due to suspended
particles. Urine at different age periods
Sediment: Refers to the deposit and During infancy urine tends to be white
also to the suspension of material denser because of milk feeding and moisture in
than usual, i.e., it refers to the deposited the temperament. In childhood urine is
as well as the suspended matter. thick, viscid and inclined to be excessively
Froth: This is due to the admixture of frothy. At maturity it is yellowish and of
reeh in the liquid urine during micturition. moderate density. In middle age it is pale
The points to be noted about froth are and watery but may, at times, become thick
(i) Colour – dark or orange-coloured froth from the elimination of waste matter. In old
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age urine is pale, watery and of low density. or irritating humour expelled by the liver
If it becomes dense it points to stone into the neighbouring organs being hurried
formation. out with the stools.
Stools Colour
Stools are normally of faint yellow colour.
Quantity When they are a darker shade of yellow then
This is judged by taking into consideration there is excess of bile. Stools which are pale
the amount of food consumed. Large stools indicate defective digestion and lack of
indicate abundance of humours while scanty maturation. White stools denote obstruction
stools their deficiency. Stools are retained in the bile duct and jaundice. If stools contain
through obstruction in the caccum, colon offensive white pus, it is likely to be from
or small intestine as a prelude to colic. rupture of an abscess. Stools resembling pus
Sometimes the stools may be scanty due to are often passed by healthy persons of
weakness of the expulsive faculty. sedentary habits and those who have given
up exercise. These stools are not bad as they
Consistency indicate purification and elimination of the
Liquid stools point to indigestion or body rendered sluggish from lack of
obstruction. Weakness and obstruction of exercise, as mentioned in the section on
the messentric vessels produce liquid urine. Deep yellow stools passed at the
stools by interfering with the absorption height of an illness are a sign of good
of fluid into the portal vein. Sometimes maturation. However, these stools may be
catarrh produces liquid stools. Laxatives a warning of the illness having got worse.
also have a similar effect. Viscid stools are Black stools are generally due to excessive
a sign of wasting but the stools then are combustion or maturation. Sometimes the
foul smelling. When stools are not foul black colour is due to the intake of coloured
smelling they indicate excessive quantity substances or wine having helped in
of some abnormal and viscid humour. eliminating sauda. The worst type of black
Sometimes viscid stools result from the stool is the one which has been excessively
presence of some mucilaginous matter in burnt. This type of stool is, however, not only
the food which, because of excessive heat, black but has acidity and putrefaction as
has not been digested properly. Frothy revealed by the appearance of froth on its
stools result from excessive heat or the contact with the ground. Such acidity is bad,
excess of reeh. Stools become dry from whether in stools or vomit. These stools are
exhausting illness or strenuous work also shiny. However, black stools which arise
causing dispersion. Dry stools are also from destruction from moisture and
passed during polyuria and in cases of excessive dispersion instead of ending in
excessive heat in the body. Dry food and death have good prognosis. Green and
constipation also make the stools dry. bluish stools indicate failure of innate heat.
Hard and dry stools with mucus Stools of unusual colours are unhealthy.
indicate delay in the passage of stools or
lack of irritable bile. When there is no Froth
evidence of delay in bowels and no sign of Stools which, instead of being firm and
excessive mucus, the cause is likely to be compact, are puffed up like cow dung are
the presence of some thin purulent material a sign of reeh.
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Unani medicine
Time
The Unani system
If stools are passed on quickly, there is likely
to be some disturbance such as excess of considers that food and
bile or weakness of the retentive faculty. drinks taken as nutrients
When there is a delay in the passage of constitute the building
stools there is either weak digestion, cold material of the body,
temperament of the intestines or excess of
including the humours.
moisture.
Flatus
Stools are passed noisily with the air is polluted, indoors should be preferred.
elimination of wind. The best type of air is that which is pure,
clean, and free of vapours from ponds,
Other means of diagnoses ditches, bamboo fields, water-logged areas
In addition to the above, other conventional and vegetable fields, especially of cabbage
methods of diagnosis such as inspection, and herb-rockets. It should not be polluted
palpation, percussion and auscultation with vapour arising from the dense
have also been used by Unani physicians. overgrowth of trees, such as yew-trees,
Regular case history of the patient is walnuts and figs. It is also essential that
recorded and maintained as is evident from air should be free from pollution with foul
the books of Rhazes and Avicenna. gases. Good air should be open to fresh
breeze and it should come from the plains
Preservation of Health and mountains. It should not be confined
to pits and depressions where it warms up
Definition of health quickly by the rising sun and cools down
Health is a state in which the temperament immediately after sunset. Air which is
and structure of the human body are such surrounded by recently painted or plastered
that all its functions are carried out in a walls is not fresh. Air is not healthy if it
correct and whole manner. produces choking or discomfort.
The Unani Tibb recognizes the influence
of surroundings and ecological conditions Food and Drink
on the state of health. It has laid down six Avicenna was the first to observe that dirt
essentials for the prevention of disease. and polluted water were carriers of disease
These essentials are: and emphasized the need for keeping water
free from all impurities. Food and drink after
Air being taken by mouth affect the body by
Avicenna, the famous Unani physician, their (i) Quality, (ii) Elementary constitution,
says that the change of environment relieves and (iii) Essence. The Unani system
the patient of many diseases. He has also considers that food and drinks taken as
emphasized the need for open, airy houses nutrients constitute the building material of
with proper ventilation, playgrounds and the body, including the humours.
gardens. Air is deemed fresh when it is Therefore, the selection of foods for general
free from pollution with smoke and vapour. nutrition and in correcting imbalances
It should be free and open and not forms the core of the Unani system of
enclosed by walls or under cover. If outside healing.
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(h) Cauterization: By this, the pathogenic and quantity of food. Many books are
matters which are attached to some available on this subject in Unani Tibb.
structures are removed or resolved. It
is applied (i) To prevent the spread of Pharmacotherapy
destructive lesions, (ii) To strengthen Natural drugs like plants, minerals and of
organs which have become cold in animal origin are widely used when
temperament, (iii) To remove putre- compared to synthetic ones used in modern
factive matters which are firmly pharmacy.
adherent to the tissues, and (iv) to arrest (a) State of drugs: Drugs having states
haemorrhage. opposite to those present in the disease
(i) Purgatives: Purgatives and laxatives are used.
are widely used by Unani physicians. (b) Drugs Temperament: It is supposed that
This method has a resolving, anti- drugs have their own tempera-ment
spasmodic and detoxicating effect. due to their special constituents. Some
(j) Vomiting: Emetics are used in certain drugs are composed of ingre-dients
cases for relief. having the opposite qualities, one
(k) Exercise: Physical exercise has great quality acting in a way contrary to the
importance in the treatment of certain other, and these qualities are
diseases as well as in the maintenance accommodated in two different parts
of the healthy condition of an of the drugs. Ingredients possessing
individual. Unani physicians have laid special actions are called active
down rules regarding hard, moderate principles of the drugs. This theory of
and light exercises and have also temperaments of the drugs is based on
indicated the timings and conditions for analogy and careful experiments.
various physical exercises. (c) Potency of drugs: Drugs are graded
(l) Leeching: This is a unique method. into four degrees according to their
Application of leeches is better than potency.
cupping in drawing the blood from (d) Mode of Action: The mechanism or
deeper tissues. Certain conditions have mode of action of a drug can be
been laid down for applying this explained only partially. Unani
method. Leeches should be collected, physicians have tried to explain this as
preferably a day earlier. They should be follows:
held upside down to empty the z The direct action of a drug is the
stomach and sponged clean of the result of its physical or acquired
dirty viscid slime. Leeches with large characters;
heads and black, grey or green colour z Drugs mainly act by heat,
should be avoided. The application of coldness, moisture or dryness;
leeches is most useful in the treatment z Some of the drugs have peculiar
of skin diseases such as favus, characteristics, which influence the
ringworm, freckles and mole. body when these drugs are
administered.
Dietotherapy (e) Division of drugs according to quality:
Unani medicine lays great stress on treating z First group – This group contains
certain ailments by the administration of drugs with a hot temperament such
specific diets or by regulating the quality as heat-producing drugs.
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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.
46
Traditional system of medicine in Indonesia
Traditional system of
medicine in Indonesia
Lestari Handayani, Haryadi Suparto
and Agus Suprapto
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Traditional system of medicine in Indonesia
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Traditional Medicine in Asia
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Traditional system of medicine in Indonesia
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52
Traditional system of medicine in Indonesia
a living by selling jamu gendong. Surti, who tasted. The processed jamu is poured into
is 40 years old, lives in a 3 m x 4 m rented several clean bottles. She uses the same
room. She shares the room with her process to make other kinds of jamu. To
husband, who works as a dawete seller, a make jamu pahitan,g in particular, the jamu
15-year-old daughter, and another materials are boiled in a special container
daughter who is married with a three-year- but no sugar is added. In about an hour,
old child. The small room has a single bed, eight kinds of jamu have been processed
a simple wardrobe, a wooden rack and stored in 22 bottles.
attached to the wall, a basket containing At around 6:00 a.m., Surti starts selling
bottles, and a number of pockets and her jamu, covering her daily route on her
plastic bags hanging on nails. In the corner bicycle. She places 14 bottles on a wooden
is a small wooden table which is heaped rack at the rear of her bicycle, and another
with various things, including a small radio. eight bottles in the bamboo basket, to be
The room, which has a small fan, is small sold by her daughter. Her daughter,
and rather dark even in the daytime, as it wearing a kabaya,h walks in another
is lit only by a 25-watt bulb. A bicycle with direction, carrying the basket on her back.
a wooden frame to carry bottles poised on It seems that Surti already has certain
its back is also in the room. customers. Riding slowly into a lower socio-
The entire family wakes up with economic dwelling complex, which she
Shubuhf at about 4:30 a.m., after which visits routinely, she rings the bells as a
they begin working. Surti immediately starts signal to her customers. A few mothers and
preparing her cooking utensils, stove and young household attendants come out to
pan to boil water. Next, she adds a quantity buy jamu. When she is sure that there are
of red sugar and some white sugar to the no more buyers, she proceeds to a complex
water. She then lays a mat on one side of where a group of men are busy with
the room, where she prepares a number construction work. A number of workers
of plastic jars, a funnel, liquid filter, dipper come forward to buy jamu and she greets
and steel mortar with its pestle. them with a pleasant smile. The workers
She takes jamu materials out of plastic relish the jamu. By 10:00 a.m., most of
bags and jars, and places them on the floor. her bottles have been sold and she goes
After the water has boiled, she prepares home. Her daughter is already there,
certain materials for the jamu to be having sold all her jamu bottles as well.
compounded. Sitting on a wooden Every day, Surti manages to sell 14
barstool, she processes jamu with great bottles of various kinds of jamus. Jamu
skill. She adds jamu materials (there can kudu laos is believed to be good for
be three to five kinds of materials), and then hypertension and for improving blood
pounds them into a fine mixture. Next, she circulation; Jamu pahitan relieves the
takes plastic jars and fills them with the itching caused by allergies, parasitic
sugar liquid and the pounded jamu infections and diabetes mellitus; Jamu
mixture. The liquid is then stirred and cabe puyang is good for muscle stiffness
e Dawet is a kind of drink made of syrup containing small portions of boiled rice.
f Shubuh is a Muslim morning prayer
g Pahitan is a very bitter jamu.
h Kabaya is a special traditional Javanese dress.
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Traditional system of medicine in Indonesia
machine. Some producers cannot even industrial jamu is varied, depending on the
compound jamu, so they purchase the producer’s capacity to promote his
compound powder, divide it into several products. Some big industries have even
small packets and sell them. Often, they opened special outlets in supermarkets and
also use kitchen utensils to process jamu.5 luxury malls, which cater to the middle- and
Home industries produce jamu forms higher-income groups. But, as most jamu
that can be readily served. The producers consumers belong to the lower economic
compound jamu materials and then grind stratum, promoting techniques which are
them to a fine powder. This is packed in friendly for lay people would be more
plastic or paper packets and then re- popular. The same applies to the marketing
packed in bigger paper packets that are system. Most industrial jamu sellers have
labelled. Some are packaged very well, limited capital and vend their products in
while others are simply packed. An small kiosks. Such businesses are beginning
advanced method of jamu processing to thrive in dwelling complexes and
comprises the production of pills, either markets. The jamu is sold at an affordable
dried or moistened with honey. Some price and the products are sometimes
producers pack jamu powder in capsules varied. The most popular variation is
for consumers who do not like the taste of dissolved jamu mixed with egg yolk and
jamu. Though very rare, some produce honey. Then there are the peripatetic jamu
jamu in the form of tablets. Pills, capsules sellers like Surti, who visit residential
and tablets are packed in labelled plastic complexes on carriages or bicycles,
pots. Besides producing jamu to be taken complete with musical instruments. Their
orally, producers also manufacture jamu products are suited to the consumer’s
for external use like boboki (lubricants), needs, and have different brand names.
pilisj and parem.k These three are sold in Jamu sellers serve the drink sinom, after
the form of big pills or powders, which can the customer has had the jamu to
be easily mixed with water. Godoganl , overcome its bitter taste. A simple way of
which is compound jamu in the form of consuming jamu is by buying it at a kiosk,
raw material, has to be boiled for extracting and then having it there. Jamu gendong
its essence and is then taken orally. sellers also provide industrial jamu to
Compound jamu godogan is packed in complement their product.
labelled or unlabelled transparent plastic
bags. 5 Jamu provided by herbalists
The market for industrial jamu is very Herbalists include those who use local herbs
large, as the culture of consuming jamu is grown in various areas of Indonesia, and
already institutionalized in most of the those who use materials from outside the
country. These days, industrial jamu seems country. The latter are mostly from China,
to be more popular than traditionally made Saudi Arabia or Pakistan. They use
jamu since it is more convenient to materials from their own countries, though
consume and store. The market for some also add local materials.
55
Traditional Medicine in Asia
Javanese herbalists stroking her hair, the jamu seller asks her a
The Javanese community can easily buy few questions regarding her complaints,
jamu from one of many traditional markets which the girl answers shyly. After skilfully
almost anywhere on the island. The getting her answers, the herbalist takes a
provinces of Yogyakarta and Central Java, pinch of jamu powder from the wooden
which are well-known cultural centres, have boxes and jars. After completing the
many traditional markets where jamu compound jamu, the herbalist hands it to
peddlers sell the jamu racikan (blended the mother with some instructions on how
jamu) made by them in accordance with to administer it. The mother pays her some
the consumer’s needs. Basically, there are money.
two types of Javanese herbalists: (i) Those Soon after, a young woman comes to
who compound, prepare and sell fresh the kiosk. The two hug each other, and have
jamu materials, and (ii) Those who a long, friendly chat occasionally
compound and sell dried jamu materials. punctuated with laughter. They seem to be
As the community has long been aware of aunt and niece. The niece also sells jamu
these herbalists’ skills in compounding (jamu gendong) in other cities. She wants
jamu, it uses their blended jamu for specific a stock of materials, including jamu
illnesses. Yogyakarta’s case will provide an pahitan, for the next three months. She
insight into their roles. notes these down on a piece of paper, and
arranges to collect them the following day.
Case 3 Not far from this kiosk, in a corner of
A 60-year-old mother runs a small kiosk at the traditional market, many mothers in
the roadside in front of Yogyakarta’s market. typical Javanese attire guard their
Usually she sits calmly on a dilapidated merchandise, some of which is lying in
wooden chair and sometimes she stands in tampahsm and some in bamboo baskets.
her kiosk talking to prospective customers They sell fresh jamu materials and their
in her warm and friendly voice. Various dried staple stock comprises various leaves,
herbs lie in small containers inside radishes, varieties of lemon, something
partitioned wooden boxes in the kiosk. The wrapped in banana leaves, and various
materials include temulawak, mesoyi rhizomes. Some of the sellers are busy
(Crytocarya massoy Kosterm), kayu legi serving their customers. A middle-aged
(Glycyrrhiza glabra), adas (Foeniculum woman asks one of them for jamu for the
vulgare) seeds, turmeric and temu ireng. postnatal care of her daughter. The jamu
Some are stored in neatly arranged jars of seller asks when the delivery took place,
various sizes on a rack attached to the wall. quickly fills a small plastic bag with certain
On the floor may be seen several brown leaves, rhizomes and radishes. She also
paper bags containing stocks of jamu picks up some lime and three lemons. She
materials. A woman accompanied by her then explains how to clean and boil these
15-year-old daughter comes along and a materials, and tells her that their concentrate
friendly conversation ensues. The woman should be given orally for postnatal care.
wants to buy jamu to treat her daughter for She advises the woman not to throw away
dysmenorrhoea (severe pain during the residues as they can be percolated again
menstruation). Holding the girl’s hand and the following day. Lime and nipis lemon are
56
Traditional system of medicine in Indonesia
used as bobak perut n for postnatal care. For this, the patient has to lie down on a
After the bobok has been applied, the bed in a manner that facilitates the process
abdomen should be twisted with a of puncturing the abdomen, back, legs
bengkung.o The mother pays and leaves. and hands.
Shortly afterwards, a young mother in For the sale of compound jamu, a sin
modern dress comes to buy jamu for body she charges a fee based on the price of
odour. The jamu seller takes out beluntas the ingredients. This charge is higher than
leaves, turmeric, tamarind leaves and some that of other traditional healers, as some
red sugar and asks the lady to boil these at materials are imported from China.
home. Many other buyers who purchase
jamu materials without asking for Jamu based on Raw Material
compounding can also be seen. Indonesia is a tropical country with forests
containing thousands of small and large
Chinese herbalist (sin she) plants, and several species of animals. The
A sin she is a Chinese herbalist skilled in country’s natural resources, as well as its
compounding jamu, as well as performing cultural and ethnic variety, have had an
acupuncture and acupressure. Usually he influence on the way traditional medicines
compounds his jamu on his own, or asks are prepared. Plants (herbal medicine),
the patient to make the jamu according to animals and minerals are all used in the
his recipes. A sin she does not always preparation of traditional medicines.
provide the jamu himself; instead, he often
jots down some in Chinese on a piece of Jamu from plants (herbal medicine)
paper, like a medical prescription. The Nearly all kinds of jamu produced by big
customer has to buy the material from a jamu industries, small-scale home
Chinese drug store. The following is a industries and herbalists are made from
detailed account of how a sin she practises. medicinal plants (herbs). There are about
A sin she’s practice is relatively more 940 plant species that have therapeutic
formal. His name and hours are written on effects, but the jamu industry uses only
a board outside his clinic. Sin she‘s practise about 200 species. In general, the plant
mostly in big cities. The room in which a species used as jamu in different parts of
sin she practises is like a physician’s clinic, Indonesia are the same. However, some
complete with a waiting room and an areas have their own specifications in this
examination room. An attendant admits regard, e.g., kayu pasak bumi (earth
patients and is in charge of the adminis- wooden pike) is used only in Kalimantan.
trative procedures. Examination is The jamu made by both industries and
conducted according to traditional herbalists usually utilizes a number of plant
Chinese medicine methods, i.e., by species; rarely is just a single plant used.
anamnesis (asking about the patient’s The number of plant species used for a
complaints and symptoms), and checking particular kind of jamu usually ranges from
the pulse at both wrists while continuing 5–10. Certain jamus contain 30–40
with the anamnesis. Many patients are species. Home-made jamu contains just
treated with acupuncture or acupressure. two to three plant species.3, 4, 6
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Traditional Medicine in Asia
58
Traditional system of medicine in Indonesia
i.e., soil that is water-blended, then dried education, most are in elementary school
and cut into slices, as it contains iron. Lime or junior high school, and some have
is used as bobok, i.e., to lubricate and received no formal education at all.
warm the abdomen of postnatal women.6 According to traditional perspectives,
diseases may be categorized as rational
Other Traditional Practices and irrational. The former are believed to
People opt for traditional healing be caused by the disturbance of
techniques for a variety of reasons. The homeostasis, such as an imbalance in
major reasons are that they are accessible nutrition. Irrational diseases are said to be
and acceptable in social, cultural and caused by mystics. Supernatural/magic
economic terms. The other benefits are that healers, who believe in the existence of such
traditional healers make home visits, ailments, often cure the latter, as well as
without charging any fixed fee. Another certain strange problems, such as the
reason is the inadequacy of modern removal of nails, stones, iron and other
medicine in treating certain cases, such as objects embedded in the abdomen.
cancers at an advanced stage, or irrational Traditional healers usually do not have
ailments like santet or tenung.p The a special room in which to examine their
community learns of the existence of patients. In fact, they do not have a name
traditional healers by word of mouth, board, fixed hours or fees. Most of them
though these days magazines and practise on a part-time basis, though some
newspapers also carry advertisements and who are well-known do work full-time as
information on the subject. traditional healers. The latter have many
Traditional practitioners in Indonesia patients, which can be seen from the long
have acquired their knowledge and skills queues of patients awaiting consultation.
not through formal education, but from Some have in-patient facilities to
their parents. Some learn while assisting complement outpatient services. A
established practitioners, some of whom traditional healer often combines a number
teach their skills to just one or two trusted of traditional techniques, like massage and
persons. A few healers claim to be graced jamu, magic treatment and jamu, and so
by wangsit,q which comes to them either on.
through dreams or after performing The following section focuses on
“special deeds”, such as fasting, abiding traditional healing practices that are
by certain taboos, or living in seclusion. commonly used by the community, such
Many traditional healing skills, as traditional methods of bone healing,
however, are mass taught through an attending to deliveries, kerikan and
informal process. These include circumcision.
acupressure, urut massage,r acupuncture
and the skill of compounding jamu either Traditional Bone Setting
for males or females. The age of the pupils Almost all ethnic groups in Indonesia have
ranges from 20 to over 60 years. While traditional bonesetters (TBSs), who thrive
some have acquired higher levels of both in urban and rural areas. These
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Traditional Medicine in Asia
healers honour certain ethnic concepts in betadine, rivanol, alcohol, sterile gauze and
their practice. In Java, the TBS is commonly cotton. Patients with open fractures are
referred to as sangkal putung. These referred to the local health care centre.
healers can help cure any kind of complaint Some healers even have informal
related to bone fracture (e.g., complete, partnerships with nurses practising in the
incomplete or multiple fracture), joint local institution.
dislocation, as well as muscle sprains. The The pattern of treatment used by
reason why people choose TBSs is because different healers is similar. The difference
they are easily accessible, both in terms of lies only in the way they express their
expense and distance, as well as to avoid supernatural or magical powers, e.g., in
invasive surgical procedures.10 the kind of jimat (charm), special oil or
Of the traditional bone-setting special water used. The processes of
techniques, some are purely traditional treatment and diagnosis are simultaneous.
while others attempt to incorporate certain For example, by uttering special prayers
modern techniques.3, 10, 11 The procedure (mantra), the healer diagnoses as well as
is as follows. A specific mantras is chanted fixes the fractured bone. Joint dislocation
to a patient or he is given a drink which is is managed by pressing, pulling and
treated by chanting mantras. Some healers massaging the affected area. The manner
use charms, like a stone or a keris.t The of handling the problem depends on
patient is asked to drink water into which individual cases.
the charm has been dipped. It is believed To heal a fracture, the areas around
that through the medium of drinking water, the site of fracture are first massaged in
the prayer or charm would help relieve the order to relax the muscles. The bone is then
ailment. A TBS does not ask many repositioned and aligned correctly. This is
questions. By simply observing the fracture followed by continuously massaging the
and touching it physically, he identifies the area with a special oil. During the process
exact problem. Many healers say that their of treatment, the patient is asked to move
feelings guide them in determining the the injured part, which is then pressed
specific problem and the method of again. The materials used to secure the
handling it.11 This faculty of feeling is said area are hardboard paper, the stem of
to be acquired through special deeds. banana leaves, bamboo or wood, though
To convince the patient and her/his modern TBSs use elastic bandages.
family about his diagnosis, the healer often Whatever the material used, the dressing
employs a symbol. For instance, to is opened every three to four days to assess
demonstrate whether or not the bone is the alignment. The patient then receives
fractured, the healer feels a banana and if another massage. In-patients are given a
the flesh is found to be broken, it means daily massage.11
that the bone is fractured.11 Some, however, The effectiveness of the traditional
utilize modern techniques such as X-rays. healing process is judged more by the
Some healers, especially those living in extent to which it meets the expectations
cities, treat a fracture with modern of the patient and his/her family.
techniques, medicines and materials, like Psychological support is also considered
60
Traditional system of medicine in Indonesia
important. A patient is considered to have tools, like bamboo knives (welat) to cut the
recovered if he is able to move the injured umbilical cord. Crushed pepper leaves or
part or walk, even if movement is painful kunyit together with salt is applied to the
or unsteady. However, some healers define pole of the umbilicus.13 Some of the more
recovery as the ability to perform in a daring TBAs go a step further to facilitate
normal way. The extent of recovery may be problematic deliveries. For instance, they
assessed by asking the patient to lift may push the abdomen downward in
weights; if no pain is experienced, it signifies difficult cases, or grope inside the uterus
recovery. to disentangle the placenta. TBAs perform
special ceremonies or chant prayers
Traditional Birth Attendants (mantra) during the process of delivery.
Many deliveries in Indonesia are still TBAs make daily visits to the mother’s
assisted by traditional birth attendants house to take care of her and the baby, for
(TBAs), who may be either trained or 35–40 days after delivery. They bathe the
untrained. TBAs practise under the baby, massage both the baby and the
supervision of health centre personnel, mother, and also help prepare for birth
namely midwives. A programme to staff ceremonies. The placenta is bathed and
villages all over the country with midwives several uborampeu are made to it. It is then
was launched with the aim of providing buried in front of the house, and the spot
mothers access to professional help for is lit by a lamp at night. A ceremony is
deliveries.12 TBAs are expected to assist performed when the dried up umbilicus is
these midwives. Though the Government severed from the baby’s stomach. Such
is trying to prevent the proliferation of TBAs, ceremonies are performed at every step in
this is not possible as the community still the baby’s growth. Apart from taking care
seems to need them. of the baby and the mother, TBAs also help
Some communities prefer TBAs to in household work, like washing the baby’s
midwives. One reason for this is that the clothes, preparing jamu for the mother, and
TBA is one of the local people, and thus so on.13
understands the local culture and is already
familiar with members of the community. Traditional Circumcision (Khitan)
TBAs not only assist with deliveries, but Since most Indonesians are Muslims,
also render certain other services. For circumcision is obligatory for male children.
example, they take care of women all Traditional circumcision is practised widely
through pregnancy and advise them about in Indonesia, the demand for it arising from
the norms to be followed during this period. the belief that the prayer performed during
TBAs provide jamu as well as massages to the ceremony has a healing power. It is also
relieve fatigue. A special massage is done believed to have certain other advantages,
to fix the foetal presentation, if necessary.(13) e.g., the child is said to experience less pain
As deliveries are natural events, the and fear, and the healing process is faster.
techniques used by most TBAs are similar. The skill of performing traditional
They simply wait through the process of circumcision is learnt from parents or
delivery, until the baby is born naturally. family members who know how to do it. To
Some untrained TBAs still use traditional be a khitan practitioner, one needs to
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Traditional Medicine in Asia
perform special deeds, in accordance with One ethnic group in East Java, which
certain Muslim norms. These deeds include believes in traditional circumcision, has a
fasting for 40 days, and going without a different custom. The khitan practitioner
meal for 24 hours on the last day. The is asked to cut off a small part of the
person can only drink water at the time of prepuce before the doctor or the nurse is
Maghrib.v For a traditional circumcision, asked to complete the procedure. This is
either the practitioner goes to his patient’s perhaps explained by the belief that it is
house, or the patient comes to him. only a khitan practitioner who can
The techniques used for khitan do not perform the prayers properly, so he should
vary much—basically, the practitioner cuts initiate the process.
the prepuce of the penis. In the purely
traditional technique, the prepuce is held The Practice of Kerikan
in place by a clamp of wood, bamboo or The practice of kerikan is well-entrenched
tusk, and then cut with a sharp knife. No in Indonesian society, especially among the
local anaesthetic or medicine is used. The people of Java. The word kerikan, which
patient is merely given water before the has its roots in the Javanese language,
procedure. However, nowadays most means to peel off or remove a surface layer
practitioners use modern medicines and that is unwanted. Thus, kerikan is a healing
tools, like scissors and modern knives. technique which consists of scraping the
Antiseptics like rivanol, betadine and affected area of the body. It could be the
alcohol, and materials like cotton and chest, back, abdomen, neck, arms or legs.
gauze are used. A few practitioners Usually, coins and spoon-holders are used
prescribe antibiotics to prevent infection for scraping, complemented by the use of
and analgesics to relieve pain. The herbs like onions and kajuputi oil.14 Kerikan
following is an account of a traditional is commonly used as a first-aid method
circumcision: during illnesses. Generally, it is quite
The boy who is to go through khitan is effective in providing relief from the
given a new sarong, white shirt and cap symptoms of non-infectious diseases.
by his parents. After the son is ready and Traditionally, it is believed to be very effective
all the preparations have been made, the for masuk angin.w Kerikan may be used
practitioner begins the process. After to treat almost all people, from a one-year-
chanting a special prayer, he clamps the old child to an elderly person. Kerikan can
prepuce of the penis and cuts it quickly with cure children of abdominal distension,
a sharp knife. The wound is dressed with cough and laboured breathing, nausea
gauze. The boy then wears the sarong, shirt and vomiting, diarrhoea, and fever. Adults
and cap. To prevent the wound from use kerikan to obtain relief from toothache,
touching the sarong, a supporting wooden intercostal ache, chest pain, backache,
frame is used, in the ventral surface of the acute oedema, insomnia, fatigue,
lower abdomen. Purely traditional headache, fever and other complaints.
practitioners used only prayers or mantras A family member of the patient
for pain relief and recovery. performs the procedure. The scraping is
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Traditional system of medicine in Indonesia
done over the affected part of the body. some areas, like Lombok, Madura and East
Frequent and continuous scraping makes Java. The tools used are varied and include
the skin turn a specific colour and produces a buffalo/bull horn, coconut shell and
erythematous stripes. It is believed that the rubber kop.
degree of redness reflects the severity of To begin with, the inside of a coconut
the illness. The redder the skin, the more shell or a buffalo horn is heated, for
severe the ailment. Inexplicably, the patient example, by a candle. The concave surface
feels more comfortable. During the process of the shell is then applied to the skin of
of kerikan, the patient does uwat.x This the affected area. Due to the negative
movement would stretch the muscles, pressure, the shell sucks in the skin. The
which in turn would improve blood shell is removed once the negative pressure
circulation and help the body reach ceases. The process results in a circular
homeostasis. All these are ways of effecting erythematous protuberance. A more
a recovery.14 modern technique consists of using a kind
The patient could undergo kerikan in of pump that can suck in the skin without
a sitting or supine position. To enhance the the use of heat.
effect of the procedure, a number of oils
like coconut or kajuputi oil, or analgesic The Practice of Traditional
balm are commonly used. Kerikan should Massage
be done as follows. The coin should be used Massage therapy is practised everywhere in
with a strong but smooth pressure. On an urban and rural areas. The therapist could
average, one stripe of kerikan is produced be a male or a female, usually above the
after 20–30 strokes of scraping. A good age of 40 years. Massages can be of two
tool for scraping is one that is blunt but is types, urut massage and reflexive massage.
able to produce deep pressure, so that it A masseuse learns the skill either from other
can reach the deeper muscles. Kerikan masseuses, by attending a course, through
should be done thoroughly and trial and error, or from books.
sequentially in a proper order, over the skin Urut massage is beneficial for fatigue,
surface. The sequential procedure is known myalgia, cough and muscle stiffness.14 The
as tapis. The direction of scraping should whole body is massaged, with the focus
follow the bundle of the muscle, called turut on the affected areas. Women and children
(meaning to follow) so that the target points are given massages by females and men
can be located. Warm oil is commonly used by males. Urut massage includes the
after kerikan. massage given by TBAs to postnatal
women and babies. Fussy babies are
The Practice of KOP frequently taken to TBAs for this purpose,4
The method of kop is similar to kerikan, as it is believed that fever and fussing are
but the tools used are different. In kop, the caused by muscular problems. A mother
skin of the affected part of the body is can ask the TBA for walik dadah.y
sucked upwards to produce an erythe- Reflexive massage focuses on
matous effect. This method is employed in particular points in the palm of the hand
x Uwat means writhing, which occurs because of pain, ticklishness or the sensation of heat.
y Walik dadah is a massage to change the position of the uterus into one of retroflexion with the aim of
preventing pregnancy.
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Traditional Medicine in Asia
and the sole of the foot. This type of A person who wants traditional timung
massage, believed to have originated in care is first undressed and seated on a
Egypt and China, is very popular in chair, covered with mats made of pandan
Indonesia. The technique used is similar to leaves. Under the chair is a pan on a lighted
that of acupuncture. While some reflexive stove. The pan contains several herbs and
masseuses use their hands to give the boiling water. The steam, which contains
massage, others use a special tool, like a the essence of the herbs, warms the body.
wooden or a metal stick. The steaming process lasts for about half
Reflexive massages can be given to an hour. The technique is often combined
people of all age groups. A person can with massage.
learn the methods on his own, then attempt
to try them out and practise them. Therapy of Gurah
Malfunctioning organs can be identified by Gurah is a therapeutic technique that uses
examining certain points in the palm or special extracts of herbs to clear the nasal
sole, the assumption being that specific cavity and pharynx of mucus. It is claimed
points are associated with different body that gurah benefits asthma, rhinitis,
parts, like the intestines, spleen, pancreas, common cold, haemoptysis and pertussis.15
heart, and so on. It is believed that reflexive The technique is believed to have originated
massage can help treat all diseases, from pesantren.z Its original aim was to
including infectious diseases, because it improve the quality of the voice of those who
improves the immunity status of the patient. read out the Koran. However, these days
According to the doctors who practise people of all kinds use the technique in many
reflexive massage, this kind of massage areas of Java. According to a gurah
enhances general fitness, relieves practitioner in Central Java, anybody can
depression and is of benefit in other learn the technique.
emotional ailments.3, 4 The gurah method is very simple. The
healer instils a special liquid into the
The Practice of Timung patient’s nostrils. The liquid is prepared by
The technique of timung used for therapy the healer and contains certain herbs, of
or body care, employs steam enriched which the common ones are Srigunggu
with various herbs. Traditional timung, (Clerodendron javanicum) or Awar-awar
which originated in Kalimantan, focuses (Ficus septica) leaves and turmeric. Honey
especially on body care, including skin is also used. The extracts of the herbs are
care and preparing the bride for marriage. diluted to a weak concentration. The
Timung can be practised for the same patient lies supine with the neck bent
purposes by family members at home. The backwards. The liquid is then instilled into
herbs required are available in the market. the nostrils for about three to five minutes
Many fitness centres in the cities offer through a funnel made of banana leaves.
timung. It is claimed that besides The composition of ingredients is adjusted
improving fitness, the technique also according to the patient’s condition. The
relieves a number of ailments, like process heats up the nasal cavity and the
common cold, rheumatic complaints, mucus flows out automatically. When the
fatigue, and so on. mucus is being discharged, the patient has
z Pesantren is a place where people learn how to read the Koran, the Muslim holy book.
64
Traditional system of medicine in Indonesia
to either sit up or lie on his stomach. He of magic. Many magic healers have opined
remains in that position until the mucus that certain diseases are caused by
stops dripping. This therapy is often something that is rationally unacceptable.
combined with jamu remedies, and An ailment can result from the curse of a
sometimes with massage.15 rival who has hired a black magic
practitioner (dukun santet) to harm the
Therapy based on a Religious subject. It is quite common for magic
Approach healers to remove strange objects like nails,
As a majority of Indonesians are Muslims, stone and iron which may be embedded
therapy based on the religion of Islam is in the patient’s abdomen or some other
fairly common. This approach is commonly part of the body.
mistaken to be similar to a supernatural A magic healer sometimes uses certain
one, as the methods are similar. In the tools as a source of magic power. A number
religious approach, based on Islamic of charms are believed to possess magic
teachings, the healer advises patients to power that can help in the process of
perform special prayers or deeds. healing. These include the eye of finger
The clients need not fulfil any special rings, a special bark called pring temu rose
prerequisites to avail themselves of such (meetingros of bamboo), keris, a piece of
therapy. The prayer and ibadah (deeds to cloth with Arabic letters printed on it, and
come closer to God) vary depending on soil wrapped in white cloth. Only magic
individual needs, particularly the kind of healers possess such articles, though some
ailment. Commonly, the patient is asked give the patient a portion of it to guard him.
to drink water that has been sanctified by
the chanting of special prayers. Some Therapy for removal of tumours
healers write Arabic letters on a plate, then Cancer is one of the most dreaded
fill it with water and ask the patient to drink diseases. People seek cures from magic/
it. Other healers give the patient a piece of supernatural healers because treatment
paper or cloth with Arabic letters printed involves invasive procedures and they are
on it, which the patient must keep in a suspicious of modern medicine or find
certain part of his/her house to guard the modern treatment unaffordable. The
family. following techniques are used by healers
A religious healer is usually the leader to remove tumours.
(chief person) of pesantren, or men who
are learned in Muslim teachings (Kyai). Case 4
Usually, he requires no training to give A traditional practitioner called “Gus” (the
therapy and his capacity to heal is seen as nickname for a son of Kyai, or a man whom
God’s blessing. Such healers often help people respect) is believed to heal patients
people deal with family issues arising from with his supernatural powers. Not only can
health problems. In fact, some pesantren he remove tumours, he can also cure many
help drug abusers and treat psychological diseases, like paralysis and psychosis. In
ailments. fact, he even helps in solving problems that
are not related to health. His technique for
Supernatural or Magic Therapy removing tumours is totally different from
As mentioned earlier, irrational diseases those used in modern medicine. Gus first
are believed to be caused by some source uses a knife to cut open the tumour but,
65
Traditional Medicine in Asia
later, he uses only his fingernails. The traditional healer in Tuban, East Java,
excised tumour is handed over to the claims to have the ability to displace the
patient. The wound is dressed with gauze tumour into a goat. Either the patient or a
or cotton. No antiseptic is used. member of his family visits the healer and
Gus does not charge a fee, but patients tells him about the problem. After
may contribute voluntarily, for which the understanding the disease, the healer asks
healer provides a box. He has many pupils the family to buy a goat and bring it to him.
who learn the Koran from him and, at He performs certain ceremonies and utters
certain times, they chant prayers together a mantra, after which the goat is
(isthighosah). However, Gus does not slaughtered. The goat’s organs are
impart his therapeutic technique to his checked to ascertain whether the patient’s
pupils, though they help him in curing his disease has been transferred to the goat.
patients. For example, in a case of hepatoma, the
Another kind of supernatural healer is liver of the slaughtered goat would show
one who is able to remove tumours without signs of hepatoma, such as a lump or a
touching the patient. After registration, the change in colour. The diseased portion of
patient writes out his/her complaints on a the organ should be thrown away, while
piece of paper, which is handed over to the the healthy portion may be cooked and
healer. The healer sends the paper back to eaten. If the cancer is in too advanced a
the patient after writing (in Javanese) about stage, the healer usually admits his inability
the disease, the procedure to be followed to cure it.
and the fee. If a patient agrees to these
recommendations, he lies down in a supine Therapy of susuk
position while the healer goes up to the Susuk is one or many small rod/s,
second floor of his house. The healer later commonly made of copper or gold, though
comes down and gives the patient a brief some healers use diamond. The susuk is
glimpse of a lump of bloody flesh, said to implanted in a certain part of the body to
be the removed tumour. If the patient keep it healthy. Before a susuk is implanted,
desires, he can ask a doctor for an the patient is advised to fast for two nights
ultrasonographic (USG) examination. and days. But some traditional implanters
Besides removing tumours, the healer feel that they themselves can take over this
prescribes jamu remedies or recipes which deed. Some others do not lay down any
are available in drug stores. conditions. If the person implanting the
Women healers in the rural areas of East susuk is not an expert, or if certain
Java use a different technique. They remove prerequisites are not fulfilled, the procedure
the tumour by sucking the area with the is believed to have unexpected
mouth. If the tumour has been successfully consequences, such as death. Some believe
removed, the healer brings out some bloody that the untoward consequences can be
flesh (supposed to be the removed tumour) prevented by rubbing kelor (Cucumis
from her mouth. Such healers also provide sativus) leaves on the body of the user.
complementary jamu remedies. It is said that the skill of implanting
Another technique consists of susuk is acquired by performing certain
displacing the tumour from the patient’s deeds, like performing ngebleng.z z The
body into another creature (animal). A kind of susuk to be implanted depends on
zz In Ngebleng fasting, a person must go without food or drink, for a number of days.
66
Traditional system of medicine in Indonesia
the client’s demand. The fee varies, from the stomach. The nails would be
depending on the kind of metal used. The expelled from the body automatically by
more expensive the metal/material, the vomiting.
more potent the effect of the procedure. In Indonesia, there are many groups of
The technique of implantation seems inner power practitioners, such as the Satria
fairly easy. The implanter inserts the susuk Nusantara group. In fact, some have
into a specific part of the body after wiping branches overseas. The major focus of the
the skin and then rubbing it with pepper members of these groups is on maintaining
leaves. The susuk may become less potent and improving their health; only a few utilize
or lose its potency altogether if the client their expertise to treat patients. The
breaks certain taboos. The presence of the respiratory exercises can also produce
susuk in the body can be ascertained by supernatural powers, which lighten the body
an X-ray. and make one capable of accomplishing
various feats. For example, an expert
Therapy using inner power becomes so light that four persons can lift
Therapy with inner power is a technique him if he stands on a newspaper. One can
which utilizes energy emitted by the human even see or read with his eyes closed.
body. Such energy is acquired by regulating
respiration or doing respiratory exercises. Conclusion
With regular exercise and by abiding by a
number of basic principles, one can These traditional practices of medicine are
accumulate inner power and use it to treat just a few of the many currently in use in
others. Inner power is said to heal several Indonesia. Several methods or techniques,
diseases like diabetes, hypertension and with their variations, have not been
cancer. It is also used for non-therapeutic discussed in this paper. These traditional
purposes, like protecting the body from real practices stand testimony to Indonesia’s
or magic assault.(16) rich cultural heritage.
This type of therapy can be of the active The safety and efficacy of the techniques
or passive kind. In active healing, the healer used in the traditional system of medicine
uses his own inner power to treat patients, are questionable. Most of the traditional
while in passive healing the patient obtains practices have not yet been studied
inner power from the healer. A healer treats systematically by modern science. However,
a patient without touching him. The energy it is beyond doubt that they serve a large
emitted from the healer’s hands enters the portion of the Indonesian population. Any
area to be treated. An expert healer is said effort to do away with such practices would
to be capable of curing patients who are be unsuccessful, as these forms of health
far away, with or without a medium. The services have their own markets. The
medium could be a photograph, or any Indonesian Government’s effort to promote
possession of the patient. For example, a and develop traditional medicine into a safe
healer in Indonesia can cure a patient in and effective option is a good policy, which
the US. The technique is also used for could contribute towards achieving greater
curing magic ailments, like removing nails equity in health services.
67
Traditional Medicine in Asia
References
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 and
Development 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 and
Development, 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 I
and II. Jakarta: Ministry of Health. 1989.
13. Handayani L. et al. Leading to comprehensive delivery services. Yogyakarta: Gajahmada
University. Report series 70. 1997.
14. Krido Wiyoto S.S.K. Traditional medicine practices using massage, kerikan/kerokan
and 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.
68
Koryo system of medicine in DPR Korea
Koryo system of
medicine in DPR Korea
Choe Thae Sop
69
Traditional Medicine in Asia
70
Koryo system of medicine in DPR Korea
71
Traditional Medicine in Asia
72
Koryo system of medicine in DPR Korea
Almost all KM hospitals are equipped with z To decisively enhance the quality of
clinical laboratories and various diagnostic health care in the country by combining
equipment, enabling KM doctors to use Koryo and modern medicine;
modern methods of diagnosis.1 z To scientifically explain the real nature
of the meridians and the therapeutic
Collaboration between Koryo mechanism of acupuncture;
and modern medicine in z To study the components and
research activities pharmacological action of various
Persons in charge of research projects for medicinal plants;
the modernization and rationalization of z To use medicinal plants with knowledge
KM are obliged to first study the KM of their components and their influence
classics on the subject of research. In on the internal organs;
summing up the project, the researcher first z To use the best possible methods of
gives an overview of the description in the treatment.
classic, and then states the findings of his
research. The State has allocated sufficient funds
Such research activities are undertaken for the translation of all ancient medical
to either scientifically prove or invalidate the classics, including three well-known
descriptions in the classics. The lectures classics which were published in modern
delivered by Professor Ranjit Roy Korean from the seventh to the nineteenth
Chaudhury on the clinico-pharmaco- centuries. Today, the translated versions are
logical methodologies during his visit to used extensively as reference books in
DPR Korea still serve as a programmatic educational, research and medical
guide for our research activities.1 activities.
In order to discover the best possible
National policy for development methods of treatment, the State actively
of Koryo medicine encourages health workers to gather
The aims of the national policy are: information on folk cures popular among
z To preserve, utilize and develop the the country’s inhabitants, and to carry out
national medical heritage – a major research activities to scientifically establish
objective to which the State attaches the efficacy of selected cures.1,4
great importance;
z To actively encourage medical workers Clinical and basic studies for the
to use KM, a target facilitated by the development of drugs
fact that the country has no regulation Studies for the development of drugs are
that can obstruct its development; carried out mainly by the GHKM, the
z To do away with the unscientific and Korean Academy of Medical Science,
superstitious elements contained in the Institute of Materia Medica and the
national medical heritage, and pharmacological sections of medical
assimilate and utilize only the superior universities.
ones in public health services; The funds required for these research
z To diagnose diseases through modern projects are provided for in the State
methods, considering that the budget.
conventional method of merely feeling A project is proposed at the Science
the pulse lacks a scientific basis; Council of the institution concerned,
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Traditional Medicine in Asia
endorsed by MOPH, and then carried out. Newly developed drugs replace
In the GHKM alone, 30– 40 projects are existing drugs with similar or inferior
implemented each year. A clinical study is action. The latter are then weeded out,
conducted under approved conditions, and their production and utilization is
with a placebo group to adjudge the discontinued.1,4
relative efficacy of the drugs to be
developed by clinico-pharmacological Utility of Koryo Medicine
observation.
For basic studies, the GHKM puts in As a national medical heritage, KM enjoys
considerable effort to identify the State protection and its utilization is actively
components and the pharmacological encouraged.(3,4) In no other country is the
action of medicinal plants. Studies to clarify State developing KM with such a high
the therapeutic mechanism of acupuncture degree of commitment, nor is any other
and the real nature of the meridians are country providing all its inhabitants high-
also being carried out. quality KM health care, free of charge.
The results of the study are reviewed In spite of the fact that KM is being
by the Science Council of the institution promoted, it is not well-known all over the
concerned. world.
In the case of a drug, the approval of In Juche 78 (1989), WHO nominated
the MOPH has to be obtained so that it the GHKM as its collaborating centre for
can be used as a standardized formulation. traditional medicine. Since then, it has
Newly developed drugs which have been annually been publishing technical
standardized are manufactured in the information in English and has distributed
pharmaceutical factories of hospitals as it widely to many countries. Especially in
per the requirement of the hospital. If a recent years, the uniqueness of KM in DPR
drug shows really marked benefits, it is Korea has become known in many
included in the State production plan, and countries through these publication
is manufactured in the central and local activities, with the financial support of
pharmaceutical factories in large WHO, SEARO.
quantities.
References
1. Choe Thae Sop (1999). Development history of traditional medicine in DPRK, Korea
Today, 7:35–36, Juche 88 (1999).
2. Ro Jung Rye, Hyangyakjipsongbang, an ancient classic (85 Vols).
3. Choe Thae Sop (1995). Primary health care and herbal self-medication, Technical
Information, WHO C.C. for TM, 7:5–11.
4. Choe Chang Sik (1995). Traditional medicine in DPRK, Technical Information, WHO
C.C. for TM, 7:1–5.
5. Ho Jun (1610). Tonguibogam (25 Vols).
6. Ro Jung Rye, Yu Hyo Tong et al. (1445). Ulbanryuchwi (365 Vols).
74
Chinese acupuncture–moxibustion
Chinese acupuncture-
moxibustion
Deng Liangyue
T he science of acupuncture–moxibustion
is an important component of traditional
Chinese medicine (TCM). It is the study of
ncture analgesia has revealed some sectors
of the functional mechanism of acupu-
ncture. These achievements have been
the meridians and collaterals, acupoints, internationally recognized in academic
acupuncture techniques, and the laws of circles, and China thereby enjoys a pre-
prevention and treatment of diseases by eminent position in this field. In the 1950s,
acupuncture–moxibustion. Thousands of scientific research on acupuncture–
years ago, ancient Chinese medicine used moxibustion concentrated on publishing
bian stone (needle stone) as an instrument and popularizing the basic knowledge of
for the treatment of diseases, and then this science and generally summarizing the
discovered the points and invented special clinical practice of acupuncture–
acupuncture instruments. Gradually, the moxibustion. In the 1960s, clinical
“theory of meridians and collaterals”, a research on acupuncture–moxibustion and
system of treatment rich both in practice and acupuncture anaesthesia was carried out.
in theory, was founded, and has been In the 1970s, numerous organized studies
applied worldwide. For thousands of years, were undertaken on the clinical
acupuncture–moxibustion has contributed applications and principles of acupuncture
immensely to the growth and health of the anaesthesia and on the mechanism of
Chinese population. Today, even with the acupuncture analgesia. In the 1980s,
rapid development of medical science, it is research on the clinical applications and
regarded as an important part of the principles of acupuncture–moxibustion
Chinese cultural heritage. and acupuncture anaesthesia as well as
Since the foundation of new China, the research on meridians and collaterals, was
science of acupuncture–moxibustion has brought together in an organized and
developed rapidly due to the attention and planned manner. In November 1987, the
support provided by the Government. World Foundation of Acupuncture–
Numerous studies have been carried out, Moxibustion Societies (WFAS) was
particularly in the functional mechanism of established in China, with its head office
acupuncture–moxibustion, which has in Beijing. Professor Hu Ximin of China was
given it a leading role in modernizing TCM. elected president of the First Conference
Research on the mechanism of acupu- of WFAS. In the 1990s, the science of
75
Traditional Medicine in Asia
76
Chinese acupuncture–moxibustion
therapy on nausea, vomiting, various painful medicines, and is used during operations
diseases (including postoperative pain, while the patient remains conscious.
dysmenorrhoea, tennis elbow, and myositis Acupuncture anaesthesia resulted from the
fibrosa, etc.), or pain induced by combination of modern anaesthesiology,
chemotherapy or operation. Other areas surgery and the neurosciences. Acupun-
where acupuncture could be used were cture analgesia in China has a history of
discussed. These included the after-effects more than 2000 years. It was introduced
of stopping of smoking, management of as early as the Yellow Emperor’s Internal
drug dependence, osteoarthritis, sequelae Classics. Acupuncture anaesthesia started
of wind stroke, and headache and asthma, in the late 1950s. On 30 August, 1958,
and it was agreed that acupuncture therapy with the cooperation of the Departments
in these cases was appropriate. A statement of Otorhinolaryngology and Acupuncture,
was made after the meeting about the the First Shanghai Municipal People’s
efficacy of acupuncture which further Hospital replaced allopathic anaesthesia by
influenced the worldwide application of acupuncture analgesia, and successfully
acupuncture–moxibustion. performed a tonsillectomy. A new chapter
was thus started in the history of
Meridian diagnosis acupuncture. During the past 40 years,
Research on the pathological reaction of practitioners of acupuncture anaesthesia
meridian points, for example, parae- have, on the one hand, been conducting
sthesiae, tissue abnormality, change in the demonstration operations with acupun-
volume of electric conduction and change cture anaesthesia, evaluating the treatment
in thermal sensitivity, has boosted the effects and documenting experiences while,
application of the diagnosis of differen- on the other hand, there have been efforts
tiation according to the tenderness of to solve the problems of “incomplete
meridians and points. Many scholars have analgesia and insufficient relaxation of the
tried to diagnose meridians and collaterals abdominal muscles”. The “theory of
with the aid of devices developed by the acupuncture–medicine composite anaes-
modern technologies of physiology, thesia” was launched in the 1980s, under
biochemistry, acoustics, optics, electricity, which the anaesthetic effect is achieved by
thermal, magnetics and computers. These acupuncture along with a small dose of
instruments not only increase the accuracy medicine which not only preserves the
of diagnosis, but also have a good advantages of the operations by
therapeutic effect. acupuncture anaesthesia, but also
increases the effect of analgesia.
Acupuncture anaesthesia Nowadays, some medical organizations in
Acupuncture anaesthesia is a new method China and abroad are continuing further
of administering anaesthesia that is based research on the method of acupuncture–
on clinical acupuncture analgesia. This is medicine composite anaesthesia for those
used in the treatment of complications special situations where medical anaes-
following surgical operation. It has been thesia is unsuitable.2,3
developed according to the theory of Up till the late 1970s, more than 200
meridians and the principle of acupuncture acupuncture anaesthesia operations had
functions. It functions mainly by needling been carried out. Acupuncture anaes-
the points along with supplementation by thesia is now applicable for more than a
77
Traditional Medicine in Asia
78
Chinese acupuncture–moxibustion
79
Traditional Medicine in Asia
80
Chinese acupuncture–moxibustion
81
Traditional Medicine in Asia
scholars have observed that varying of some active substances in the body,
stimulation and parameters produces changes the number of receptors and
different clinical therapeutic effects. their reactions, alters the cell
Han Jisheng observed that when membrane and the blood–cerebral
electric stimulation is applied in barrier permeability, and influences the
acupuncture treatment twice weekly, enzyme-inducing activity of the drug.
the therapeutic effect may gradually Therefore, on the one hand,
accumulate. Using relatively weak endogenous drug-like substances in
stimulation (2 mA is better than 1 mA) the body are activated to perform a
and a relatively longer duration therapeutic effect while, on the other
between two treatments (treatment hand, the therapeutic effect of the
applied once weekly) may achieve exogenous drug is enhanced.
better relief for chronic pain. Thirty (4) Development and application of the
cases of cerebral haemorrhage treated apparatus of acupuncture and
by acupuncture with CT scan moxibustion, development in the areas
guidance denote that the acupuncture of optics, electrothermal, magnetic and
technique for promoting brain computer technologies has led to the
functions and resuscitation obviously development of a variety of acupunc-
accelerates the absorption of cerebral ture and moxibustion apparatus. These
bleeding. In the application of have been designed and manufactured
suppurative moxibustion for asthma, in keeping with optimal stimulating
the relationship between the season parameters according to the findings
and the pain present or absent during of acupuncture pain suppression
the treatment has been analysed. research. The electro-acupoint
(3) The clinical combination of stimulator, electrothermal needle
acupuncture and moxibustion with instrument, laser needle apparatus,
medicaments to raise the therapeutic low-frequency electric therapeutic
effect has been common practice and apparatus, electrothermal moxibus-
diseases are managed using this tioner, permanent magnetic needle,
combination in various clinical etc., are examples of such apparatus
departments. The medicaments and have been frequently used in
applied are in the form of oral acupuncture clinics and for
administration, acupoint injection, experimental research. Sterilized
muscular injection, venous injection disposable needles and needles with
and subcutaneous absorption. applicators (tubes) are examples of the
Medicaments may enhance the modernization of acupuncture
therapeutic effect of acupuncture,18 equipment. With regard to moxibu-
depending on the type and dosage of stion, the moxibustioner and non-
the drug used. The therapeutic effect smoke moxa stick promote the deve-
produced by the combination of lopment of moxibustion. Application of
acupuncture and medicaments is not these new technologies and new
merely the addition of the original effect approaches enables traditional
of the two, but is more than that. A Chinese acupuncture and moxibustion
probable mechanism is that: practices based on experience, to be
acupuncture, by inducing the release developed in modern scientific ways.
82
Chinese acupuncture–moxibustion
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84
Chinese acupuncture–moxibustion
85
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86
Chinese acupuncture–moxibustion
87
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88
Chinese acupuncture–moxibustion
89
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References
1. Wang Xuetai. The present situation and the future development of acupuncture and
moxibustion. Collection of Academic Articles for the 10th Anniversary of the Founding of
the World Federation and Acupuncture Societies. 1997.
2. Zhang Ren. The history of the development of acupuncture anaesthesia in China (1st
edition). Shanghai Science and Technology Literature Publishing House. March 1989.
3. Qian Xinzhong (chief editor). Acupuncture anaesthesia in China, Vol. 1 (1st edition). Shanxi
Science and Education Publishing House. December 1987.
4. Liu Xinlian, 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.
90
Chinese acupuncture–moxibustion
5. Sun Guixia, Chen Jingtao, Chuan Jianjun. Clinical observation on 141 cases of bronchial
asthma treated with acupuncture and moxibustion. Journal of Acupuncture and Moxibustion
Clinic. 1994. 10(2):13–15.
6. Yang Shufang. 224 cases of hemoptysis of TB treated by atropine and acupuncture at
Yintang. Integration of Traditional Chinese Medicine and western medicine on Practical
Clinical First Aid. 1995. 2(2):67.
7. Zhou Jiren, Fang Depei, You Haiqing. Impact of acupuncture on the left cardiac function and
humoral endocrine of ectatic myocardosis patients with heart failure. Shanghai Acupuncture
and Moxibustion Journal. 1992. 11(3):3–4.
8. Lu Hongxia, Zhang Zhenhui, Zhang Yunxiu. Observation of the therapeutic effect of the
treatment for 200 cases of hemiplegia of wind stroke by acupuncture combined with immune
functional regulation instrument. Chinese Acupuncture. 1996. 16(3):27–28.
9. Sun Jiqing, Wang Shaokai, Chen Jinglan. Observation on the therapeutic effect of 37 cases
of acute myocardial infarction treated with integration of Traditional Chinese Medicine and
western medicine. Journal of Chinese Medicine and Pharmacology. 1992. 1:34–36.
10. Cai Ligao. Observation on the short-term therapeutic effect of acupuncture treatment for
37 cases of chronic primary thrombocytopenic purpura. Acupuncture Research. 1988.
13(3):255–259.
11. Ouyang Qun, Jiang Yi, Ma Defeng. Impact of salt-insulted indirect moxibustion at Shenque
(CV8) on the immune function of the organism–animal experiment and clinical evidence.
New Chinese Medicine. 1992. 24(2):30–32.
12. Zhang Yongchen, Jia Hongling, Liu Yutan. Situation of the acupuncture treatment in the last 14
years for urinary stone. Chinese Acupuncture and Moxibustion. 1994. 14(5):273–276.
13. China Acupuncture and Moxibustion Society. Acupuncture and moxibustion in the new
century. Chinese Science and Technology Publishing House. 1998:826.
14. Chen Daoqing, Wang Bingkun, Zhou Liya. Treatment of 102 cases of facial nerve inflammation
by combination of acupuncture and herbal therapy. Chinese Folk Therapies. 1996. 3:23.
15. Qian Zhiyun. Some experience on the acupuncture treatment for drug addiction. Chinese
Acupuncture and Moxibustion. 1997. 17(12):735–736.
16. Zhou Janwei. Progress of the research on prevention and treatment of AIDS by acupuncture
and moxibustion both in China and the World. Chinese Acupuncture and Moxibustion.
1996. 16(9):54–56.
17. Bao Fei. Application of acupuncture and moxibustion to the treatment of malignant tumor.
News Report of Medical Research. 1997. 26(3):36–38.
18. Xu Shaofen, Cao Xiaoding, Xu Zhenbang. Research on the enhancement of pain suppression
effect of acupuncture by medicaments. Acupuncture Research. 1991. 61(3–4):240–242.
19. Tang Jingshi, et al. Research on the pain suppression of the afferent nerve by acupuncture.
Acupuncture Research. 1989. 59(1–2):135.
20. Zhu Bing. Scientific foundation of Acupuncture and Moxibustion. Qingdao Publishing
House. 1998:87–109.
91
Fundamentals of Yoga
Fundamentals of Yoga
Niranjanananda Saraswati
Rishi Vivekananda Saraswati
93
Traditional Medicine in Asia
ground, and the path of wisdom came to with in anatomy, physiology and physical
the fore. This was the age of the medicine.
Upanishads. Pranamaya Kosha – The energy body
(prana). Western science largely ignores
Upanishadic Age this, yet it represents an area for real
The greatest thinkers and sages are from improvement in therapy. The wise people
that time. The culture was well-structured conceived that all creation is suffused with
and secure. It was an agrarian economy, pranic energy and called it mahaprana.
stable and fertile, giving opportunity for The localized collection, associated with the
leisure and for delving into the depths of body, is the pranamaya kosha.
human consciousness. Manomaya kosha – This consists of the
mind and the functions of rationality,
People went through the four recognized interaction, expression of emotion, belief,
stages of life: the conscious, subconscious and uncon-
z Brahmacharya: The students, who scious mind. This is the part dealt with in
learnt the spiritual teachings, and the psychology and psychiatry.
ways of controlling the mind, as well Vigyanamaya kosha – This is the
as the vocational education to prepare dimension of our psychic abilities, wisdom
them for their work to support their and understanding, which are higher than
family in the next stage. the manomaya qualities.
z Grihastha: The householder stage, Anandamaya kosha – This is the
when they married, had children and sheath of bliss, when the ego is merged
fulfilled their social responsibilities. with super-consciousness.
z Vanaprastha: After fulfilling the This concept was fully incorporated
householder responsibilities, they were into yoga and is the foundation of its great
able to go into the solitude of the forest benefit as it attends to the whole person.
for contemplation and meditation, Thus, yoga is ultimately a spiritual journey,
which led to the next stage. but can easily be a science of health and
z Sannyasa: Renunciation, and concen- therapy, and can be used when things go
tration on spiritual realization. wrong in any or all five dimensions of the
person.
The results of the contemplation of the The Mandukya Upanishad indicates
wise people came out in more than 10,000 the process to alter the states of
Upanishads. Over time these have been consciousness. These are the wakeful state
whittled down to approximately 108, of (jagriti), where consciousness operates
which 10 are considered major Upani- through the senses, the dream state
shads. Two of these are especially important (swapna), where the senses are withdrawn
for yoga: and we experience the subconscious
The Taittiriya Upanishad classifies the mind, and deep sleep (nidra), where
entire human entity into five dimensions of awareness of the individual self is lost.
existence, the koshas (sheaths) which inter- Above these is the state of turiya, which is
penetrate each other, each being more transcendental consciousness that can
subtle than the last: observe all three lower states. The first
Annamaya kosha – Matter, the three have certainly been recognized by
physical body. This is the part of us dealt Western psychology, though only in the
94
Fundamentals of Yoga
last century, but turiya is not acknow- yoga. When people discuss the subject of
ledged at all. health, they usually categorize their work
in terms of the different forms of illness. In
Puranic Age our opinion, this is not dealing with
After the Upanishadic Age came the ‘health’, it is dealing with sickness and
Puranic Age. This period was the time of abnormality. The subject of ‘health’ surely
the writing of the two great epics, the deals with ways in which we can stay
Ramayana and the Mahabharata. The healthy in all dimensions of our being, and
Ramayana describes the life of Sri Ram and yoga is pre-eminent in this area. It cares
his wife Sita. It includes the Yoga Vashistha, for our physical well-being, general vitality,
which is in the form of instructions given to mental balance and tranquillity, emotional
Ram about life, wisdom and knowledge by balance and direction, our higher mental,
his Guru, Vashistha. psychic and intuitive abilities, and the
The Mahabharata, another epic, awareness of our spiritual reality. Yoga is
contains the Bhagavad Gita, which is a a holistic and extensive system of attaining
dialogue between a spiritual master, and maintaining health in its widest sense.
Krishna, and his disciple, Arjuna. Krishna As well as the many useful practices
clearly explains, among many other yoga teaches, the lifestyle improvements
principles, the synthesis of action and that it recommends help us to live in a much
meditation in life, a branch of yoga known more harmonious and useful way and
as Karma Yoga with which we will deal later. improve the quality of our relationships with
Raja Yoga is best illustrated by the Yoga other people. It has been said that the best
Sutras of the great Sage Patanjali. It is a way to have good friends is to be a good
psychological approach to human friend. The person who absorbs the
development, a science of mind control teachings of yoga certainly becomes a
centring on meditation. This is also called good friend, because of their better
Ashtanga Yoga, the yoga of eight limbs, personal discipline and more considerate
and we will deal with it in detail later. attitude to other people and their needs.
Hatha Yoga is described in In this way our life becomes less stressful
Swatmarama’s Hatha Yoga Pradipika and and this flows on to better health all round.
the Gheranda Samhita by Sage Gherand. Yoga philosophy teaches us to
These texts contain a set of purification understand the real meaning of our lives.
techniques known as the shatkarmas, In this age, in so many communities people
which work on the vitality aspect, balancing have lost the sense of meaning in their lives.
the energy with the mental force. These This is leading to a serious vacuum in their
are important in yoga therapy and indeed self-esteem, their attitudes to their fellow
in the prevention of illness, and will be dealt human beings and their world in general.
with at length later. A ‘meaningless’ life is perceived as one that
is worthless, and so suicide, murder, cruelty
The Main Yogas and their and war atrocities are rife at this time.
Contribution to Health The practices of yoga bestow many
benefits. From the health point of view,
We have defined yoga as a system of prevention of physical, mental and
lifestyle, philosophy and practices. In this emotional illness is most important.
section we will deal with different types of However, yoga can be used as a therapy
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also, and there is a large body of research tell us that in order to achieve balance we
which has demonstrated the effectiveness need to first purify the gross body. For this
of the many yoga practices in curing or purpose, hatha yoga recommends the
relieving illness. We will consider some of following cleansing techniques, known as
these in this article. shatkarmas (please note that all practices
in this paper are mentioned only for
The forms of yoga we will discuss are: description and not for instruction. They
z Hatha Yoga – The yoga of purification; should only be learnt under the guidance
z Raja Yoga – The yoga of the mind, of of a qualified yoga instructor).
introspection;
z Karma Yoga – The yoga of action with Shatkarmas
meditative awareness; (1) Neti – The practice has been simplified
z Jnana Yoga – The yoga of knowledge by Swami Satyananda Saraswati, and
and wisdom; the technique can be found, with all
z Mantra Yoga – Ehich deals with the the other practices in this section, in
vibratory aspects of our nature. his book Asana, Pranayama, Mudra,
Bandha.(1) Neti aims to clean out the
Hatha Yoga nostrils and paranasal sinuses of the
Originally, Hatha Yoga was designed to head, of stale and purulent mucous,
balance the mental and vital functions of and to balance the flows of the breath
the person, prior to meditation, in order to by decongesting the mucous
attain higher states of consciousness. membranes of the nose. It is usually
For thousands of years, the yogis have practised by pouring warm salt water
said that vital energy – prana – pervades through the individual nostrils, but if
the whole universe, both manifest and un- the nasal passages are very much
manifest, whether animate or not. Modern blocked, it can be done with a catheter.
physicists now agree with this, and they call Neti is effective for treating chronic
it ‘background energy’. They tell us that it sinusitis and asthma.
also forms the substrate of matter. They (2) Dhauti – The word means ‘cleansing’
say that matter is just organized energy, – there are six forms of dhauti:
and can be converted back to it, albeit with z Danda dhauti – Cleaning teeth,
the release of vast amounts of energy – ears and tongue;
the atom bomb is an example. z Vatasara dhauti – Swallowing air
When energy or prana is un-manifest, and burping it up again, which is
it is known as mahaprana; when it is in said to ventilate the inside of the
human existence, it is divided into chitta stomach, cleaning it with air;
shakti and prana shakti, the mental and z Vaman dhauti – (same as kunjal
the vital forces. Hatha Yoga aims at kriya) – Quickly swallowing four
creating a balance between mind and glasses of warm salty water and
energy. The different amounts of air vomiting it back. Good for acidity
flowing through the nostrils correspond to and clearing the lungs, it can be
these forces and should alternate for fixed used to treat asthma. If used early
periods of time during the day. If they are in an asthma attack it can actually
not balanced, neither are we. The Hatha stop the attack. It dilates the
Yoga Pradipika and the Gheranda Samhita bronchial tubes and causes the
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Fundamentals of Yoga
secretion of thin mucous, which (3) Basti – Yogic enema, cleans out the
cleans out the respiratory tract. It lower intestine. It is not needed if one
probably does this by either is doing shankhaprakshalana.
stimulating the sympathetic (4) Nauli – Advanced practice that needs
nervous system or retarding the excellent control of abdominal
action of the parasympathetic muscles.
nervous system; (5) Kapalbhati – (transl. ‘frontal lobes’ +
z Varisara dhauti – Also called ‘to shine’). In this practice, there is
shankhaprakshalana, this forced exhalation and passive
technique cleans out the whole inhalation. It is said to stimulate the
intestinal tract. The practitioner frontal lobes of the brain, and so clear
quickly swallows two glasses of the mind of disturbance, and allow it
warm salty water, then does a to become one pointed and
series of five postures (asanas), concentrated. It also increases the
which open the valves of the vitality.
stomach and intestines, eight times (6) Tratak – Visual concentration on one
each. This technique of swallowing point, develops mental concentration,
the water and practising the asanas mind control, clarity and calmness. It
is repeated until clear fluid comes stimulates melatonin hormone
out of the bowels. It is excellent secretion.
for constipation, but it also forms Done in this sequence, the shatkarmas
the mainstay of the yoga treatment are designed to clean and purify the gross
for diabetes. There is a shortened body (neti, dhauti and basti), then
version, laghoo shankhapraksha- stimulate the pranic energy (nauli), then
lana, in which only three rounds stop mental dissipation (kapalbhati), and
are done. People with high blood then concentrate the mind (tratak). After
pressure, hernia, peptic ulcer or this preparation, the practices of
cardiac illness should not do it, but meditation can progress smoothly.
it is generally quite safe and easy; Nowadays, it is usual to include in
z Vastra dhauti – Swallowing a long hatha yoga, the group of techniques called
piece of cloth, and gently pulling it asanas, pranayamas, mudras and
back up. This is also good for bandhas.
asthma, and probably works the
same way as vaman dhauti. It Asanas
sounds difficult, and may be so for Asanas are the postures usually associated
some people at first, but most with the name ‘yoga’. They vary in
people can generally master it; complexity from simple stretching practices
z Vahnisara dhauti is also called to difficult advanced postures. It should
agnisar kriya; the muscles of the be noted, however, that even the simplest
front of the abdomen are rapidly asanas can have a profoundly beneficial
contracted and relaxed, with the effect.
breath held out. It strengthens and Asanas affect all dimensions of the
massages abdominal muscles and person, especially the body-mind
organs, and stimulates the connection. Swami Satyananda states in
digestive fire. Asana, Pranayama, Mudra, Bandha.1
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stimulates the pelvic nerves and tones the z A person who has mastered yoga can
urinary and genital systems. As a result, it teach the practices to other people
raises low libido and helps erectile when the need arises. In some cases
dysfunction in men, and vaginal dryness it can be used as a form of yogic first
in women. It relieves the symptoms of aid. Many a time a yoga teacher has
depression and can also immediately taught vaman dhauti to a person in
neutralize other emotions. For example, if the early stages of an asthma attack
a person wants to control crying, laughing, and stopped it.
or even coughing, applying moola bandha
will stop it. Raja Yoga
The practices of hatha yoga combined
with the techniques of meditation form the Until we can calm the disturbances of the
foundation of Yoga Therapy. The blockages mind, we will always have problems with
– mental, emotional, physical, psychic and our mental and emotional states, difficulties
spiritual – that stop us from realizing our in our behaviour and relationships, and be
fullest potential, are the same ones that unable to attain our true potential. Raja
cause most illnesses. The yoga practices yoga, the yoga of meditation, shows us
were developed for spiritual evolution, but how to calm the mind and realize who we
they can be just as easily applied to relieving really are.
illness. There are a number of advantages The principles of raja yoga are set out
of yoga used in this way: in the Yoga Sutras written by Sage Patanjali
z After we have learnt the practices, they about 2,500 years ago. As it is laid out in
are free of charge. So if we benefit from eight consecutive steps, it is also known as
them, we do not have to continue ashtanga Yoga (eight-fold path), which has
paying for medicines. This can be sequential steps through:
reflected at a national level where vast (1) Yamas
amounts of money, which would have (2) Niyamas
been spent on pharmaceutical drugs, (3) Asanas
can be saved by governments. (4) Pranayamas
z The practitioner gains mastery over (5) Pratyahara
whole areas of his/her life, becomes (6) Dharana
independent of outside sources of (7) Dhyana
treatment, and is able to apply the (8) Samadhi.
practices at any time they are needed.
For instance, a person with asthma who The yamas and niyamas are recom-
masters vaman dhauti has a means to mended moral codes, which the
stop an early attack any time. The practitioner is to integrate into life more and
person with anxiety that leads to panic more as time goes on:
attacks, can settle the anxiety with many
practices such as bhramari pranayama, Yamas
ujjayi pranayama, and yoga nidra and The purpose of the yamas is to harmonize
avoid the panic. Then by a virtuous the external environment and our
circle effect, because they know they responses to it:
have the practices, their anxiety about Ahimsa – Feeling of non-violence
the possibility of panic also reduces. towards all things, from thoughts, words
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and deeds. As one develops ahimsa, one Ishwara pranidhana – Belief in higher
detects one’s violence to be more and more reality.
subtle, but also that there is less violence Why moral codes in a work on
around one. meditation? Paramahamsa Satyananda
Satya – Truthfulness – this also involves says in Four Chapters on Freedom.(2)
our thoughts, words and deeds. We must “The yamas are designed to harmonise
be truthful at all these levels, sincere and one’s social interactions, and the niyamas
true to ourselves as well. But truth should are intended to harmonise one’s inner
not be used to intentionally hurt another. feelings. All the rules, yamas and niyamas,
Asteya – Honesty – This means not are designed to reduce friction between
stealing other peoples’ possessions, but it one’s outer actions and inner attitudes.
also means internal honesty, simplicity and There is a two-way relationship: the mind
sincerity. stimulates external actions and external
Aparigraha – Non-possessiveness – actions stimulate the mind. If the external
This is really the result of developing actions are not harmonious, then the mind
detachment. We care for our possessions will be disturbed. Conversely, a disturbed
or the people in our lives, but we are not mind will tend to produce disharmonious
addicted to them. acts.”
Brahmacharya – Being established in He goes on to state: “The rules are not
the higher reality (nature of Brahman). easy to apply, but even limited application
Often equated with celibacy, but that is just will lead to greater peace of mind. Perfect
a small part; in that state, carnality has no application can only arise with self-
place. realisation”, but we can continue to improve
as our life goes on.
Niyamas
Special codes of self-restraint aimed at Asanas
internal discipline: These are the yoga postures. The Yoga
Saucha – Cleanliness of the body, Sutras define asana as “that posture which
external and internal, neatness and order is still and comfortable”; this refers to
in our environment, and purification of the meditative postures.
mind. The hatha yoga shatkarmas are Swami Niranjanananda in Yoga
designed to help with this. Darshan3 says the human body is capable
Santosha – Contentment, being of five movements and the yoga postures
satisfied with what we have. This develops (dealt with in the hatha yoga section)
as we do; our demands become fewer, our reproduce these:
life becomes simpler and so we are more z Natural, like walking (stretching
contented. postures such as pawanmuktasana);
Tapas – Austerity – As we live simply z Dynamic, like running (dynamic
we become better able to cope with postures such as salute to the sun);
hardships. z Adaptable, like comfort in the folded
Swadhyaya – Self-study – Analysis and positions (e.g., forward and backward
knowledge of our own personality, becoming bends);
aware of our strengths, weaknesses, z Balance, like standing still (balancing
ambitions and needs. asanas);
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we need for the job comes our way, and attitudes such as efficiency, renunciation,
everyone we need to help us comes along equanimity, egolessness and duty in one
at exactly the right time. It all happens so action is difficult. The thrust of karma yoga
regularly that we realize these could not is to have these concepts combined in one
possibly be coincidences. Then a higher thought, one action, in one moment. Once
realization starts to dawn within us. When these different ideas are combined, then
we are non-attached, it is possible to we can proudly say we are practising
exhaust our karmas, which is another aim karma yoga.”
of karma yoga. However, until then we can do the best
Conversion of negative into positive – we can to have that attitude. In the
Some people habitually see the positive side workplace, at home with the family, when
of a thing (optimists), others the negative we are with other people, and indeed even
side (pessimists). Karma yoga is a process when we are alone, relating to ourselves,
of converting our negative attitudes into we can remember to apply the above
positive ones. principles. Then over time, it will become
Duty or dharma – In Yoga Darshan by second nature in all our actions, bringing
Swami Niranjanananda Saraswati,3 this a peace of mind that most people never
point and karma yoga in general is attain. Karma yoga clears the mind of
described thus: phobias, insecurities and complexes, and
“The last attribute of karma Yoga is makes it steadier for further practices and
consideration of every action as a duty. Do for life. The ultimate state is total serenity
your duty, because action is superior to in the midst of intense action.
inaction. Action when performed with the
idea of duty produces a very deep Jnana Yoga
experience of bhakti (devotion), surrender,
belief, trust and faith in a higher nature, a Literally jnana means ‘wisdom’ or
higher reality guiding us. This duty is to be ‘knowledge’. So jnana yoga means the
understood in relation to one’s individual yoga of real knowledge. This knowledge
dharma, social dharma, global dharma is not intellectual, acquired from books and
and universal dharma. different sources of communication. It is
“When one develops the awareness of an advanced yogic sadhana (spiritual
dharma, as an inherent commitment of practice), a process of self-inquiry with a
duty or obligation to other beings, then one concentrated mind. Jnana yoga is linked
develops a giving or helping nature. Many with the Vedanta of Indian philosophy,
times people talk about, and believe in which is a path of inquiry into Brahman,
giving, a helping hand to others. Our the Absolute.
actions, which outwardly may seem like In order to understand the Brahman
helping, do not necessarily convey the same or the Absolute, the process of jnana yoga
feeling to others. Often, even the desire to begins with self-analysis. The form of self-
help others carries with it some kind of analysis is not high, abstract or abstruse;
ulterior motive, whether for gain or profit. it is very definite. In fact, the practices of
We should not be restricted to the idea of pratyahara and dharana may be classified
some kind of personal gain. as part of jnana yoga also, because
“Initially the practice of karma yoga is through these practices we analyse
difficult, because to combine so many ourselves. What is happening at the level
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Fundamentals of Yoga
need. These needs include pursuit of does not confuse it with the permanence
knowledge in a field of specialization that of the ultimate.
results in realizations of one’s unique Vairagya means ‘detachment’; it is
potential. Although few people reach this freedom from raga (attraction) and
level, everyone has a self-actualizing need. dwesha (repulsion), it is dispassion and
In order to become self-actualized, the non-attachment to the fruits and benefits
persons must be well-adjusted and self- of one’s activities.
fulfilled. Maslow has given 15 characteri- Both viveka and vairagya continue to
stics of a self-actualized individual which grow and manifest in different behaviour
include efficient perceptions of reality, and modes of adjustment, and with
acceptance of self and others, spontaneity, expanding areas of consciousness through
simplicity, task-oriented attitude, self- jnana yoga sadhana. Jnana yoga is a
discipline and self-reliance, sense of higher order sadhana and not meant for
appreciation, mystic experiences, every one. It has to be combined with other
compassion and sympathy for humanity, practices of yoga as per the tendencies and
creativeness, harmony with culture, need nature of the practitioner. Some who are
for privacy and a life of detachment. Taken dynamically inclined can practise jnana
together, these characteristics seem to refer yoga if they combine it with karma yoga.
to the spiritual awakenings and are very People whose emotions are charged can
similar to a self-realized yogi as described practice jnana yoga by combining it with
in jnana yoga. bhakti yoga (the path of devotion,
The different sequential needs as expression of the heart, of emotions).
propounded by Maslow refer to the three Those who have potential psychic abilities
interactive aspects of evolution of the human can practise jnana yoga combined with raja
personality as conceived in yogic literature. yoga. Only those with indomitable will can
They are from body awareness (annamaya practise jnana yoga by itself. So jnana yoga
kosha) to spiritual enlightenment and is generally considered a supplement to
experience of inner bliss (anandamaya meditation, dhyana. In dhyana there is
kosha) through the psychological total identification and merger of the mind,
awakening (manomaya kosha). and in jnana there is full experiential
We find that Maslow’s need structure knowledge of that merger. So jnana and
highly resembles the yogic theory of self- dhyana combined give the experience of
realization. However, yogic literature is very samadhi.
rich in terms of techniques or practices,
called sadhana, to achieve the highest level Mantra Yoga
of self.
Jnana yoga practices develop two The word mantra is generally translated as
distinctive qualities in the practitioner. They ‘sound vibration’, but the literal translation
are viveka and vairagya. is ‘the force which liberates the mind from
Viveka is the power of discrimination bondage’. However, mantras have effects
between the real and the unreal, the eternal in all aspects of the person, not just the
and the decaying. Viveka provides mind. The mantras used in yoga are
understanding and knowledge of reality formed from combinations of the sounds
and illusion. The person with viveka of the 50 Sanskrit alphabet characters,
perceives the world as a changing play and which correspond to different energy
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centres in the psychic body. Mantras which one’s own yoga instructor who is
are composed of those sounds create experienced in the science of mantra.
vibrations in specific areas of the psychic
body. Their vibrations have effects on our Some research data on Yoga
physical bodies and our mental functioning.
Physical effects – Since the mantras, As we have seen, yoga covers a broad
when sounded audibly, vibrate the range of techniques applicable to all
appropriate parts of the physical body, any aspects of life. This needs to be taken into
problems in those parts that respond to account when examining yoga research,
vibration, improve when the appropriate since there are many articles that discuss
mantras are repeated. For instance, the relaxation, hypometabolism, etc., which
last letter of the often-used mantra, OM, are directly or indirectly related to yoga,
produces a humming sound, which vibrates although this relationship may not be
the head area. It is an excellent practice explicitly stated.
for relieving tension, headache and chronic
sinusitis. Similarly, other mantras especially Yoga and Cardiovascular Disease
vibrate the chest area, and are good for Considerable research data have been
relieving tension there. In this way, if one collected on yoga’s capacity to influence
knows the area of action of mantras, one the cardiovascular system and improve
can virtually prescribe an appropriate function. Research has focused on
mantra for that area. hypertension and coronary artery disease
Mental effects – If mantra is the force in particular. Yoga is seen to be a good
that liberates the mind from bondage, what alternative to exercise, because of its
is this bondage? It has two aspects, additional relaxation effect, and the fact
impurities (mala) and oscillation (vikshepa). that it can be finely adjusted to the physical
The impurities are the sum total of all the needs of the individual person.
negative impressions deep in the mind. They The research on hypertension is now
are the result of past problems in all areas conclusive as a result of more than 30 years
of our mental being, and relate to such areas of data.4,5,6,7 In 1969, Datey successfully
of our life as love, joy, security, power and treated 53 per cent of 47 patients suffering
self-esteem. Mantras activate these parts from hypertension using the meditation
of our mental apparatus and allow technique of shavasana. There have been
memories to surface where they can be dealt several studies, which have compared
with and eliminated. The other aspect of various meditative practices and their
the mind, vikshepa, is the oscillation and effects on blood pressure. Bagga and
distraction of the mind; the internal Gandhi compared shavasana with
monologue goes on all day, the desires, the Transcendental Meditation© and found that
fears, the plans, the disappointments, the both techniques lowered heart rate and
mind is never at peace. By repeating the blood pressure, and increased skin
mantras with one-pointed awareness, the resistance; however, a mantra-based
oscillations can be quietened and the mind meditation practice was relatively more
becomes tranquil and peaceful. significant.8
Psychic effects – Mantras can also be There have been a number of studies
used to awaken our psychic potentials, but on the heart itself and it has been shown
this subject is better left to be imparted by that yoga improves cardiovascular
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Fundamentals of Yoga
efficiency.9,10 Carson, et al., investigated (10 per cent fat in the diet, whole foods
the effect of a relaxation technique on vegetarian diet, aerobic exercise, smoking
coronary risk factors and found that cessation, and group psychosocial
relaxation had a significantly beneficial support).15 Ornish showed that a group
effect on plasma lipids, weight, blood who maintained lifestyle changes for one
pressure and blood glucose.10 Carson year had a 4.5 per cent relative
found that the use of a relaxation technique improvement in the decrease of their
might be considered beneficial in reducing baseline stenosis, and 7.9 per cent after
the risk factors. five years. These figures may seem small,
Tulpule used yoga in the treatment of but they translate into a significant
myocardial infarction.11 He found that improvement in the person’s functioning.
simple yoga postures and pranayama L.Bernardi, et al., have shown that after
(sukhasana, shavasana, bhujangasana, one month of training in yoga pranayama,
matsyasana, etc.) were beneficial, when patients with chronic heart failure had a
taught to 102 male patients with significant improvement in oxygen
myocardial infarction who practised for one saturation and exercise perfor-mance.16 In
year. The results indicated that yoga is easy chronic heart failure, impaired pulmonary
to learn; it needs no medical supervision, function can itself contribute to oxygen de-
and it can be practised at home as part of saturation and reduced physical activity.
a rehabilitation programme. Yoga Bernardi found that by slowing the
significantly reduced long-term mortality in breathing rate to 3–6 breaths per minute
the yoga group compared to controls and using the ‘complete yogic breath’ the
had a high rate of rehabilitation. Only three patients were able to reduce ventilation by
out of the 102 subjects practising yoga died 40 per cent, but increase oxygen
during one year, while 13 of the 103 saturation, with a substantial improvement
controls died. Significantly, no patient in in ventilation to perfusion ratio. The
the yoga group developed any evidence of method by which this is thought to work is
cardiac decompensation or dysrhythmia that deeper and slower breathing makes
during the one year while doing the yoga more efficient use of the diaphragm with
practice. no increase in respiratory workload.
Generally speaking, yoga is taught in Apart from its capacity to improve
conjunction with other techniques in order physiology, yoga can be seen as an ideal
to produce a synergistic effect. There have form of exercise for heart disease and blood
been several studies showing that multi- pressure when it is practised with a relaxed
factorial approaches have many benefits mind, and appropriate to the situation of
and that one approach alone may not give the individual patient. All patients need to
as good a result.12,13,14 engage in exercise programmes to
Jurek, et al., showed that the addition rehabilitate their hearts and blood pressure.
of a behavioural intervention (biofeedback- However, exercise programmes are
assisted relaxation) produced a decrease recommended for a select group of
in blood pressure beyond that associated patients, and there are definite contrain-
with the diuretic alone.12 Ornish has dications to exercise testing in-patients.
produced reversal in coronary artery This may be due to the fact that many
occlusion using a combination of yoga people strain, because they have a fixed
meditation and intensive lifestyle changes idea of how aerobic exercise should be.
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Tulpule, for example, said that yoga is, rate, blood pressure and skin resistance.
“completely free of complications, whereas They showed that there is a strong link
at every centre exercise has produced either between breath and autonomic control.
death, arrhythmia, severe angina or Pratap, et al., showed that there is no
precipitated myocardial infarction”.11,17 major change in blood gases after
pranayama in normal subjects.26 However,
Fitness L. Bernardi, et al., in 1998 showed that after
Gharote, Ganguly, Bhole and Karambekar one month of training in yoga pranayama
have shown that yoga increases fitness and there was a significant improvement in
vital capacity. This is an essential part of oxygen saturation and exercise perfor-
rehabilitation.18,19,20 mance in patients with chronic heart failure.
Prakasamma and A. Bhaduri also showed
Asana that patients with pleural effusion, who
K. N. Udupa and R. H. Singh from Benares practised prana-yama, demonstrated a
Hindu University have done much research quicker re-expansion of the lungs in most
on the effect of yoga asana on of the measures of lung function.27
stress.21,22,23 Udupa has studied bioche-
mical parameters such as catecholamines, Chronic Illness in General
cholinesterase, mono-amine oxidase, Goyeche has reviewed research high-
diamine oxidase, plasma cortisol, serum lighting the ability of yoga to be of great
PBI, serum proteins, and blood sugar. He use in chronic illness as a method of
measured students practising yoga versus rehabilitation.28 He cites studies on the use
normal exercise and found that yoga of yoga and meditation in cancer,
induces more vital effects than exercise, headache, migraine, asthma, emphysema,
which works mainly on muscle. Different sinusitis, ulcers, diabetes, gastro-intestinal
types of yogic practices produce different disorders, spondylosis, arthritis, and mental
effects. disorders, including anxiety and
Gopal, et al., studied the effects of depersonalization.
asana and pranayama on pulse rate, Herbert Benson and Goodale have
blood pressure and respiratory functions.6 shown that meditation and the relaxation
He showed that yoga practitioners when response is an effective treatment for
compared with controls had greater vital physical and emotional pre-menstrual
capacity and tidal volume, and a relaxed symptoms and is most effective in women
respiratory rate. Also, diastolic blood with severe symptoms.29
pressure was less in the yoga group Uma, et al., showed that yoga
indicating decreased sympathetic tone. demonstrated a highly significant improve-
M. S. Garfinkel, et al., showed that ment in IQ and social adaptation para-
asanas improve grip strength and pain meters in a yogic group as compared to
reduction in patients with carpal tunnel controls.30
syndrome.24
Preventive and Promotive
Pranayama Measures
Morse, et al., studied the effect of yoga Dr W. Selvamurthy reported the findings of
and breath on the autonomic nervous a study conducted by the Defence Institute
system.25 Such were measured for heart of Physiological and Allied Sciences of
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Fundamentals of Yoga
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Munger. Bihar. India. 1989.
3. Niranjanananda Saraswati Swami. Yoga Darshan. Sri Panchdashnam Paramahamsa
Alakh Bara. Deoghar. Bihar. India. 1993.
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12. Jurek H.E., et al. Interaction of biofeedback-assisted relaxation and diuretic in treatment
of essential hypertension. Biofeedback and diuretic treatment of essential hypertension.
1992; 17 (2): 125.
13. Ornish D.M., et al. Effects of a vegetarian diet and selected Yoga techniques in the
treatment of coronary heart disease (abstract). Clinical Research.1979; 27: 720A.
14. Ornish D.M., et al. Can lifestyle changes reverse coronary atherosclerosis? The
Lifestyle Heart Trial. Lancet. 1990; 336: 129.
15. Ornish D., et al. Intensive lifestyle changes for reversal of coronary artery disease.
JAMA. 1998; 280: 23.
16. Bernardi L., et al. Effect of breathing rate on oxygen saturation and exercise performance
in chronic heart failure. Lancet. 1998; 351: 1308.
17. Haskell W.L. Cardiovascular complications during exercise training of cardiac patients.
Circulation. 1975; 57: 920.
18. Gharote M.L. Physical fitness in relation to the practice of selected yogic exercises.
Yoga Mimamsa. 14 April 1976; DVIII
19. Bhole M. Effect of Yoga practices on vital capacity. Indian J. of Chest Disease. Jan–
April 1970; XII (1 and 2).
20. Ganguly S. and Gharote M. Cardiovascular efficiency before and after Yoga training.
Yoga Mimamsa. 1974; 17: 89.
21. Udupa K.N., et al. Studies on physiological, endocrine and metabolic response to the
practice of Yoga in young normal volunteers. J. Research Indian J. Medicine. 1971; 6:
345.
22. Udupa K.N., et al. Certain studies on psychological and biochemical response of
hatha Yoga in young normal volunteers. Indian J. Med Res. 1977; 61: 237.
23. Udupa K.N. and Singh R.H. Scientific Basis of Yoga. JAMA. 1972; 220: 1365.
24. Garfinkel, et al. Yoga-based intervention for carpal tunnel syndrome. JAMA 1998;
280:18.
25. Morse D.R., et al. A physiological evaluation of the Yoga concept of respiratory
control of the autonomic nervous system activity. Int. J. Psychosomatics, 1984; 31
(1): 3.
26. Pratap V., et al. Arterial blood gases in pranayama practice. Perceptual and Motor
Skills. 1978; 46: 171.
27. Prakasamma M. and Bhaduri M. A study of Yoga as a nursing intervention in the care
of 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 mentally
retarded children: a one-year controlled study. J. Mental Deficiency Res: 1989; 33:
415.
31. Selvamurthy W. Yoga in the Army, Yoga. May 1998; Issue 3. (Journal published by
Sivananda Math, Munger, India).
32. Singh V.A. and Madhu. A study of the effect of yogic practices on certain psychological
parameters. Indian J. Clinical Psychology. 1987; 14: 80.
33. Barnes and Nagarkar S. Yoga education and scholastic achievement. Indian J. Clinical
Psychology. 1989; 16: 96.
34. Sridevi K., Sitamma M. and Rao K.P.V. Perceptual organization and Yoga training. J.
Indian Psychology.1995; 13: 21.
35. Bhushan L.I. Yogic lifestyle and psychological wellbeing. Yoga. May 1998; Issue 3.
(Journal published by Sivananda Math, Munger, India).
112
Policy issues
Harmonization of traditional and modern
medicine
Prof. Zhu-fan Xie
Role of traditional systems of medicine in
national health care systems
Mrs. Shailaja Chandra
A framework for cost-benefit analysis of
traditional medicine and conventional
medicine
Dr. G. Bodeker
Development of training programmes for
traditional medicine
Dr. Palitha Abeykoon
Dr. O. Akerele
Traditional Medicine in Asia
114
Harmonization of traditional and modern medicine
Harmonization of
traditional and modern
medicine
Zhu-fan Xie
Common features of
T he age-old wisdom of the people of
every country has been crystallized into
different systems of traditional medicine,
traditional medicine systems
Basic theories of various
each nation having its own system/s. Some
traditional systems
of these traditional systems are well-
established, supported by theories and rich There are similarities in the basic theories
experience and recorded in writing, such of various systems of traditional medicine.
as the Indian system of Ayurveda, the Ayurveda considers human beings in their
Muslim system of Unani, traditional totality, in their subtle relationship with the
Chinese medicine, ancient Greek medicine universe, and postulates the theory that a
and the systems that evolved from it, and human being is a microcosm of the
the humoral theory and therapy of Latin universe. Therefore, there is a close
America. But traditional medicine in some relationship between the two. Ayurveda
other parts of the world has merely been believes that the human body and all matter
practised and handed down verbally from in the universe are made up of the five great
generation to generation, without any elements: earth, water, fire, air and ether.
written record. Whether sophisticated or All the physiological processes in the
not, the systems of traditional medicine human body and the pathogenesis of
served as the only means of health care various diseases can be explained by the
for ages, till modern biomedicine came into three doshas: motion (vata), energy (pitta)
being. and inertia (kapha).(1) In ancient Greece,
In contrast to modern biomedicine, the authors of the Hippocratic Corpus all
which was founded on the basis of presumed that bodily processes, health and
modern natural sciences, most traditional disease could be explained in the same way
systems of medicine originated in and as other natural phenomena. According
developed according to the principles of to the Hippocratic humoral system, all
ancient schools of philosophy. A things are composed of the four elements
description of their characteristic features – fire, air, earth and water – and are formed
follows. by the union of matter, as well as the four
qualities of hot, cold, dry and moist. The
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Traditional Medicine in Asia
elements in the human body are Yin and yang refer to the two fundamental
represented by yellow bile (fire), black bile principles, ever opposing and comple-
(earth) and phlegm (water), while air is menting each other. Their ceaseless motion
directly supplied by respiration.2 The Unani gives rise to all changes in the world,
system postulates the presence in the including in the spheres of physiology,
human body of four humours; blood, pathology, diagnosis and treatment. The
phlegm, yellow bile and black bile. Arkan doctrine of the five elements further explains
(elements) forms the universe as well as the the inter-relationship of yin and yang.
human body. 3 Traditional Chinese Therefore, the different systems of
medicine regards qi as the basic traditional medicine are based on a
constituent element of the universe. Qi common dialectic way of thinking, and
produces everything, including human various parts or constituents of the body
beings. Together with the five elements, are viewed as an organic whole, with an
wood, fire, earth, metal and water, with their emphasis on a balanced relationship
characteristic properties and inter- between them.
relationships, qi explains the composition
and phenomena of the universe, as well Correlation between the mind
as the physiological and pathological and body
processes of human beings. It is thus clear Ayurveda considers the body, mind and
that the various systems of traditional soul as complementary to each other. All
medicine view the human body and the imbalance and disease in the body begin
universe as an integral whole. with an imbalance or stress in the
awareness, or consciousness, of the
Basic concepts of health and individual. Therefore, mental techniques
disease such as meditation are considered
In Ayurveda, the body remains healthy so essential to the promotion of healing and
long as a balance is maintained between prevention.4 According to Hippocrates, the
the three invisible forces of vata, pitta and mind and body profoundly affect each
kapha, and disease results when they go other, and cannot be considered as
out of balance. 1 In ancient Greece, independent entities. Health consists of a
Hippocrates believed that good health healthy mind in a healthy body, and it is
resulted from an equilibrium between the always necessary to consider the “whole”
four humours in the body, as well as from person while treating a patient. The basic
harmony between the body and the philosophy of Unani medicine is that the
environment. He regarded illness as some body, composed of matter and spirit,
form of imbalance.2 In the Unani system, should be taken as a whole because
disease is regarded as an expression of an harmonious life is possible only when there
imbalance of the humours or a is a proper balance between the physical
disturbance in their harmony.3 According and spiritual functions.3 In traditional
to traditional Chinese medicine, good Chinese medicine, mental activities and
health results from the maintenance of a emotions are taken as functions of the
normal dynamic balance between yin and corresponding visceral organs: spirit is
yang within the human body, and between attributed to the heart, while excessive joy
the human being and circumstances. A injures the heart; soul is attributed to the
yin–yang imbalance gives rise to disease. liver, while anger injures the liver, and so
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Harmonization of traditional and modern medicine
on. Thus, mind and body, emotions and The achievements of the natural
viscera, are parts of an integral whole. sciences and the reductionistic
No matter how diversified the various approaches, and the use of analytical
systems of traditional medicine in the methodologies, brought about a medical
spheres of diagnosis, treatment and revolution in the West – medieval medicine
management of diseases and patients, they was transformed into scientific biomedicine.
have a common viewpoint which may be The revolution started with anatomy, which
summed up by the term holistic medical explored the precise structure of the human
model or holism. body. The microscope not only became an
essential aid for anatomists, but also
Basic concepts of modern furthered pathological study from the
biomedicine organic and histological levels to the
cellular level. Progress in the physical
In the Middle Ages in the West, the sciences inspired experimental investi-
domination of religion and feudalistic gations in physiology. Breakthroughs in
monarchy greatly hampered the develop- chemistry, such as the study of energy
ment of the natural sciences, and conversion in the human body, also held
obstructed the progress of medicine. Thus, great promise for medicine. In the latter
medieval medicine was shrouded in the half of the 19th century, the “bacterio-
mists of theology. logical revolution” clarified the true
Modern western medicine was first pathogens of many communicable
established in the 18th century, during the diseases. Along with the advance of
“enlightenment” in Europe. The new natural anatomy, physiology, pathology and
sciences created by Galileo, Descartes, bacteriology, clinical medicine also
Newton, Boyle and others no longer progressed, particularly in respect of
conceived of the world in terms of qualities diagnostics and surgical operations. A new
and elements, but as consisting of particles system of medicine – modern biomedicine
of measurable sizes, shapes and motion. – was thus formed and developed in the
Descartes saw the body as he saw the world, West. This system is different from the
in mechanical terms. This new and influential traditional systems, not only in terms of
philosophy was one that reduced biological concrete knowledge and practice, but also
processes to mechanical events.5 with respect to the underlying philosophical
Closely related to mechanism is views.
reductionism, which explains the properties
of the whole entirely by the properties of Conflicts between traditional
the parts that compose it. In medicine, medicine and modern
reductionism offers explanations in terms biomedicine
of physical, chemical and mechanical
principles. The biomedicine which thus Owing to the fact that traditional medicine
evolved “considers biological entities more and modern medicine evolved on the basis
or less as equal to the sum of their of different philosophical assumptions and
anatomical parts and endeavours to with different methodological approaches,
elucidate molecular, physiological and conflicts are bound to arise when the two
pathological mechanisms believed to form systems are used simultaneously in the
the basis of biological processes”.6 same country or area. Different countries
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Traditional Medicine in Asia
have found different ways of solving this and acquaintances had experienced by
problem, but since the People’s Republic using traditional methods of treatment.
of China seems to be one of the countries Second, traditional remedies were simple,
that has harmonized well the functioning convenient and affordable, and had fewer
of the two systems of medicine, the side-effects. Modern biomedicine, on the
developments which took place in China other hand, often necessitated surgical
are described as an example. procedures, which could cause pain and
Modern biomedicine was introduced result in complications. Third, the unique
in China in the late 19th and early 20th philosophy underlying traditional medicine
centuries. At this juncture, China felt the was well-received by the common people,
urgent need to firmly establish and assert and had no satisfactory parallel in modern
its national identity, and to gain biomedicine. Traditional medicine had a
competence in various spheres. In addition unique theoretical system which was well-
to the need for new political and received by the common people and could
technological initiatives, the issue of health not be replaced by modern biomedicine.
and medicine also came to the forefront. Some of the traditional medical expressions
Particularly after the Revolution of 1911, and terminologies had already been
many intellectuals who were frustrated by absorbed into the language of the common
China’s failure to forge ahead began to people. Last but not the least, medical
re-evaluate the country’s traditional culture professionals well-trained in modern
in the light of what they perceived to be the Western biomedicine were to be found only
key to the success of the West – modern in some big cities. With the ban on
science. A Descartian faith in the potential traditional medicine, the vast majority of
of science to solve mankind’s problems led the Chinese population had no access to
them to embrace Western biomedicine. At health care of any kind. This scenario gave
the same time, they denounced traditional rise to a bitter conflict between the
practices as defunct remnants of the old traditional practitioner and the modern
order. These, they felt, were impeding doctor, as well as between the common
China’s modernization. They blasted people and the Government.
traditional physicians for being ignorant It was only after the founding of the
and irrational, and condemned their system People’s Republic of China in 1949 that
of medicine as an amalgam of supersti- attempts began to be made to revive
tions incompatible with scientific progress.7 traditional Chinese medicine, and to
In 1929, the Central Government passed harmonize it with modern medicine.
a Bill “to ban traditional medicine in order
to clear the way for developing medical Policies to harmonize
work”. traditional and modern
However, in spite of the persecution it medicine
suffered, traditional Chinese medicine has
never been eliminated, nor replaced by To begin with, the Chinese Government
modern biomedicine. First, most Chinese formulated official policies to protect and
people continued to believe in traditional develop traditional medicine. In 1950, it
medicine, not so much because of their stipulated “uniting the traditional Chinese
cultural background, but more because of and modern western medical profe-
the benefits that they, their family members ssionals” as one of the guiding principles
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Harmonization of traditional and modern medicine
of health work. A major reason for this was brilliant theorists would emerge through the
that traditional medicine had been of great integration of both systems. In 1978, Deng
benefit to the Chinese population, Xiaoping requested governments at all levels
especially the common people, who loved to “provide good and favourable
and endorsed the system. Also, according conditions for the development and
to the statistics of 1949, the total improvement of Chinese medicine”. The
population of mainland China was 5.4 present leader, Jiang Zemin, has empha-
hundred million, while the number of sized that practitioners of traditional and
doctors formally trained in modern Western medicine should strive for greater
Western medicine was only 38,875, i.e., unity still, and learn from and complement
the ratio between these doctors and the each other so as to promote integration of
population was approximately 1:14,000.8 the two systems.9
The situation in rural areas was much The Government has adopted a series
worse, with most of the trained modern of measures for the implementation of its
doctors concentrated in the big cities. Of policies. These include the establishment
all the practitioners of either system, the of administrative bodies at the central and
majority (about 80 per cent) were trained local levels for the execution of policy,
in traditional medicine. exploitation of human resources,
The Constitution promulgated in 1982 development of related academic organi-
and the present Constitution declared that zations and publications, gathering and
the State should “develop both modern summarizing of the knowledge of
medicine and traditional medicine”. Thus, experienced traditional medical doctors,
the Chinese Government has clearly put and setting up of institutions for clinical
both systems of medicine at par, and practice, education and research (both for
“realizing modernization and globalization traditional and integrated medicine). One
of traditional Chinese medicine” is seen as of the most powerful organizations for the
a task of primary importance. The implementation of these policies is the
Constitution advocates that “traditional relatively independent State Administration
Chinese medicine and Western medicine of Traditional Chinese Medicine, which
should unite and learn from each other, provides protection to traditional
mutually complement each other and medicine.10
improve together, in order to promote the
integration of traditional Chinese and Incorporation of traditional
western medicine”.9 medicine in modern hospitals
Besides the official policies, the remarks
made by the leaders of China have had a The first step adopted by the Government
great impact on the development of in the 1950s for the purpose of “uniting
traditional medicine and its harmonization the traditional Chinese and modern
with modern medicine. In 1958, Mao Western medical professionals” was the
Zedong declared that “traditional Chinese incorporation of traditional medical doctors
medicine is a great treasure-house, and into the staff of hospitals of modern
efforts should be made to explore and raise medicine, as well as the establishment of
it to a higher level”. He called upon hospitals of traditional Chinese medicine
Western-trained doctors to learn traditional (TCM). Doctors in ancient China used to
Chinese medicine and hoped that some see outpatients only in clinics or in the
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Traditional Medicine in Asia
patients’ homes. There were no institutions even though several hospitals devoted
for in-patients. Hospitals began to be set exclusively to TCM have been set up.
up in the early 20th century, once modern
Western medicine was imported into Establishment of TCM
China, but working in these hospitals was hospitals
the privilege of Western-trained medical
professionals. By 1950, the word Advantages aside, the inclusion of
“hospital” had been defined in China as practitioners of traditional medicine in
an institution providing modern Western hospitals had certain limitations. These
medical and surgical treatment, and doctors were always in a minority, and the
nursing care. To remedy this situation, TCM patients referred to them were often those
departments were established in most whom modern methods of treatment had
hospitals. This made matters easier for failed to help. Thus, their role became
patients referred to traditional medicine largely limited to such cases and they were
practitioners. In some hospitals or not in the mainstream of hospital services.
specialized departments, TCM doctors In order to allow them greater initiative,
were appointed directly as staff members and also to provide training bases for
in the departments of Western medicine, students of traditional medicine, TCM
thus creating improved opportunities for hospitals were established. The number of
the exchange of ideas and cooperation TCM hospitals and beds has been growing
between doctors of both systems. rapidly (Table 1). In 1997, there were
This step seemed to facilitate 10,789 general hospitals of Western
collaboration between doctors of the two medicine with 1,485,625 beds, and 2424
systems. Practitioners of modern medicine TCM hospitals with 223,696 beds. The
became particularly interested in traditional ratios between the number of the two types
methods of treatment when the latter of hospitals and the number of beds
succeeded where modern methods had allotted to each were roughly 1:4.5 and
failed. On the other hand, the TCM doctors 1:6.5, respectively.11 (It should be noted
also required a modicum of knowledge of that at present, general hospitals of
Western medicine, in order to function Western medicine in China are simply
effectively in a set-up run on modern lines. called general hospitals because none of
Many hospitals of Western medicine still them is exclusively devoted to Western
have a department of traditional medicine, medicine.)
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Harmonization of traditional and modern medicine
The difference between the two types Moreover, in most cases the methods of
of hospitals lies chiefly in the methods of treatment were highly individualized and
treatment. Generally speaking, TCM varied from person to person. Therefore,
hospitals are equipped with facilities for it is difficult to convince modern-trained
modern laboratory diagnosis and medical doctors to believe in the
emergency treatment. Therefore, the staff effectiveness of traditional medicines. After
of these hospitals also includes a few the inclusion of traditional medical
professionals trained in modern Western practitioners in hospitals of modern
medicine. Some Western-trained doctors medicine and the establishment of TCM
prefer to shift to TCM hospitals. hospitals, it became possible to carry out
The establishment of TCM hospitals comparative clinical trials. At first, the
has played an important role in the diseases studied were those that were
harmonization of traditional and modern difficult to cure with modern Western
medicine. The earlier conflict between the medicine, such as chronic nephritis,
two systems had found expression not only chronic hepatitis and chronic gastritis.
in the contempt in which the practitioners Traditional treatment for these diseases
of modern medicine held the “unscientific” often achieved better results than
practices of traditional medicine, but also contemporary Western treatment. The
in the traditional medical practitioners’ most convincing evidence came from an
exaggeration of the helplessness of epidemic of encephalitis B which broke out
modern Western medicine in the treatment in the early 1950s in northern China. In
of chronic diseases. While the TCM doctors those days, modern medicine could do
were not as virulent as their rivals, they, too, little to help encephalitis patients, and
needed to compromise. In TCM hospitals, could barely provide even symptomatic
modern Western medical professionals relief from the high fever. Traditional
proved the value of their work either by treatment, however, cured a large number
carrying out laboratory tests for diagnosis of serious patients and reduced the fatality
or by the emergency treatment of a chronic considerably. In the mid-1950s,
case. Harmonization between the two traditional treatment of haemorrhoids
medical systems is possible only if they made a strong impression on modern-
begin to respect each other. trained surgeons. Traditional necrotizing
therapy for haemorrhoids and ligation
Confirmation of the efficacy therapy for anal fistulae succeeded in
of traditional medicine curing more than 90 per cent of patients.
Moreover, recovery was quicker and
Traditional Chinese medicine has a there was less suffering than with modern
brilliant history, but whether it is still of surgery. The treatments were well-
practical value depends upon its received by the patients. By the end of
advantages over modern biomedicine, the 1950s, the analgesic effect of
particularly as far as its efficacy is acupuncture was acknowledged by all
concerned. Traditional literature contains and acupuncture analgesia was
numerous case reports of successful successfully used for tooth extraction and
treatment of various diseases, but the tonsillectomy. In the 1960s, modern
diseases were not diagnosed, observed or medical circles came to acknowledge the
recorded in a modern, scientific way. benefits of herbal treatment for diphtheria
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Traditional Medicine in Asia
122
Harmonization of traditional and modern medicine
After the early 20th century, once the Establishment of colleges and
rule of the feudal dynasties came to an end, universities of traditional
this education system stopped operating. medicine
This had little impact on the health services After the founding of new China in 1949,
available to the common people, as most in order to implement the new policy of
of the practitioners they consulted were developing traditional medicine, it was
trained in the master–apprentice style, or urgently felt that the educational system for
had learnt from their family members or TCM should be promoted to a higher level.
elders. The latter type of practitioner was In 1956, four TCM colleges were esta-
held in high esteem by the people. There blished in Beijing, Shanghai, Guangzhou
were other practitioners who studied and Chendu, four big cities situated in the
medicine on their own. These included northern, southern, eastern and western
literati who had failed the imperial regions of China. Since then, a regular
examination for officialdom, or shifted their higher educational system has been
interest from the management of state developed for the training of traditional
affairs to the management of diseases. The medical personnel. The single-minded
large volume of medical literature was of devotion of the Government resulted in the
great use to those who wanted to teach rapid expansion of the number of TCM
themselves. According to the catalogue colleges, which increased from five in 1957
compiled jointly by the China Academy of to 30 in 1995. The number of students
Traditional Chinese Medicine and the enrolled increased from 1021 in 1957 to
Peking National Library, the number of 39,786 in 1995 (Table 2). Furthermore,
medical works collected before 1959 was since the late 1990s, some TCM colleges
7661.14 Most of them were written in the have been promoted to university level. The
classical literary style, which ordinary duration of training has been extended to
people could not follow easily, but the seven years for the specialty of general
literati could. Since the Chinese literati were medicine, and five years each for
Confucian scholars, those who practised acupuncture and traditional health
medicine were also called Confucian protection and rehabilitation. It should be
physicians. noted that China’s traditional medicine is
In the 19th century, modern Western not limited to the traditional medicine of
medicine was introduced into China, the Han nationality; it also includes the
posing a serious challenge to TCM, traditional systems of medicine of minority
including the TCM educational systems. nationalities, such as Tibetan medicine.
Private medical schools of TCM, run by Among the traditional medical colleges,
famous physicians, began to appear by the one is a college of minority medicine.
end of the 19th century. The schools of Parallel to the growth of colleges and
Western medicine – initially the missionary universities, secondary schools of TCM were
medical schools, and later public and also established, and there has been a
private medical schools – soon surpassed steady increase both in the number of
the TCM schools, both in number and in schools and of students enrolled. Other
scale. In the late 1940s, TCM schools were than the regular schools, correspondence
on the verge of extinction. schools have also been started for
paramedical professionals to give them the
opportunity of receiving practical training.
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Traditional Medicine in Asia
* The number of TCM students enrolled includes those enrolled in TCM colleges and universities, and those enrolled
in a TCM department or specialty in Western medical colleges and universities.
124
Harmonization of traditional and modern medicine
been revised five times since then. The last with the legal status of traditional medical
(sixth) edition, which consisted of 32 practice and the licensing system for
textbooks for various specialties of traditional medical professionals. In China,
traditional medicine (general medicine, traditional medical practice is officially
herbology, pharmaceutics, acupuncture recognized as being equivalent to modern
and moxibustion, and orthopaedics and Western medicine. Since in traditional
traumatology), was completed in 1994– practice the diagnosis is often made in a
1995. Besides the 32 TCM textbooks, the different way from that in modern Western
standard textbooks for TCM colleges medicine, a national standard entitled
include another six textbooks on modern “Classification and Coding of Diseases and
Western medicine, one each for anatomy, Syndromes in TCM”, as well as criteria for
physiology, pathology, biochemistry, the diagnosis and efficacy evaluation were
fundamentals of diagnosis, and internal promulgated in the 1990s. This has further
medicine. These courses are offered not only strengthened the legal basis of traditional
to train the TCM graduates for their future medical practice.
practice, but also to facilitate the exchange In order to guarantee the competence
of ideas between them and medical of traditional medical professionals, a
professionals trained in modern Western licensing and accreditation system similar
medicine, thus facilitating the harmonization to the one that applies to Western medical
of the two systems of medicine. professionals has been adopted. The
A large number of traditional medical system of promotion for medical profe-
practitioners have now been trained. ssionals of both schools is the same. There
According to official statistics, the number are four ranks of medical doctors: resident,
of qualified medical doctors in mainland physician/surgeon-in-charge, vice-chief
China in 1998 was 2,724,670, 9.38 per physician/surgeon and chief physician/
cent (255,641) of whom were traditional surgeon. The salary of each rank is the
medical doctors and 0.41 per cent same in the case of both schools. Other
(11,077) integrated medical doctors. The remuneration paid according to the quality
number of practitioners with secondary and quantity of medical practice may vary
medical education was 1,235,212, of from individual to individual, but these
whom 5.67 per cent (70,085) were differences have nothing to do with the
traditional practitioners. 15 Thus, an particular system of medicine being
appropriate and adequate number of practised. A hard-working, experienced
traditional medical professionals have been physician of traditional medicine is usually
trained to meet the people’s health care paid just as much, if not more, than his
needs. Western medicine counterpart.
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Traditional Medicine in Asia
issues. These are the modernization of have not only contributed to the progress
traditional medicine, and the integration of in many areas of medicine, but have also
traditional and modern medicine. There is been playing a particularly important role
a large overlap between the two, but they in encouraging cooperation and harmoni-
are different theoretically. Modernization of zation between practitioners of the two
traditional medicine refers to the appli- systems. Broadly speaking, their achieve-
cation of modern scientific theories, ments have been in the following areas.
knowledge and methodologies in the study
of TCM, as well as the adoption of modern Proposal of modern scientific
science and technology to develop TCM. In explanation for traditional
this way, it would not only contain distinctive medical theories
Chinese features, but also be relevant in It is mainly the unique theories underlying
modern scientific terms. Integration of TCM that make it so difficult to understand.
Chinese and Western medicine involves Some of these are actually ancient Chinese
discovering the common points between philosophical ideas, which, though rather
the theories of the two systems, a process quaint, are not disconsonant with modern
of mutual learning so that each can benefit perspectives. Some other theories, however,
the other, and combining the best elements such as the concept of visceral organs, are
of the two systems so as to establish a new misleading. While the anatomical
system of medicine. description and names of these organs
Both for modernization of traditional correspond to those in modern Western
medicine and integration of the two medicine, the physiological and patho-
systems, it is essential for traditional medical physiological expositions on them are so
practitioners to learn modern medicine, different from modern concepts that they
and for Western-trained doctors to learn cast doubts on the correctness of TCM.
traditional medicine. Measures to facilitate Extensive studies carried out by the
both were taken in the 1950s, but it was “integrated” doctors have revealed that
the latter that seemed to work more each visceral organ in TCM is actually
efficiently. While summarizing this viewed as a comprehensive functional
experience, the former Chairman of the system rather than an individual internal
Chinese Government, Mao Zedong, organ. Also, greater emphasis is laid on
lauded the efforts in this direction and the inter-relationships among the functional
called on more Western-trained doctors to systems than on the consideration of
devote themselves to the integration of the individual organs. For example, the word
two systems. Since then, many types of kidney in TCM signifies far more than an
courses have been started to help Western- organ of the urinary system; besides urine
trained doctors learn traditional medicine. secretion, the kidneys are believed to be in
Moreover, research institutes for integrating charge of the endocrine function
the two systems, as well as integrated (particularly the function of the hypotha-
hospitals and clinics, have been set up for lamic–pituitary–adrenocortical,
Western-trained doctors who wish to carry hypothalamic–pituitary–gonad and
out research and practices in integrated hypothalamic–pituitary–thyroid axes),
medicine on completing the courses. At myeloid haemopoiesis, bone metabolism,
present, there are about 12,000 high- and a few brain activities. That is why
ranking “integrated” medical doctors. They kidney tonics are considered to be effective
126
Harmonization of traditional and modern medicine
in the treatment of many disorders besides the treatment of various painful conditions,
renal diseases, such as in aplastic anaemia, as long as it does not interfere with the
osteoporosis, the menopausal syndrome, treatment of the primary lesions.
anovulatory menstrual disorders, sexual Modern Western medicine still finds it
disturbances and certain geriatric diseases. difficult to treat viral diseases, and interferon
Why these seemingly unrelated is of limited clinical use in China due to its
functional activities are lumped together in high cost and side-effects. However,
one group is difficult to explain in terms of controlled clinical studies have shown
modern physiology and pathology. many medicinal herbs and herbal formulae
However, research using sophisticated to be effective in the treatment of viral
techniques and knowledge of molecular diseases such as influenza, viral hepatitis,
biology and genetics has found a rational viral myocarditis and epidemic haemo-
basis for these traditional Chinese rrhagic fever. Some herbal ingredients used
concepts. Similarities have been found in for treatment have also been demonstrated
the abnormal changes occurring in the to have antiviral effects in laboratory
various diseases clubbed into one category, experiments.
and the changes have been successfully
remedied with the administration of herbal Combined treatment with
formulae according to this theory. superior results
Both modern and traditional medicine have
Discovering advantages of their own strong points. It is but natural to
traditional medicine through speculate that a combination of their strong
comparison with modern points may lead to better results.
Western medicine Comparing the traditional and modern
While modern Western medicine has made treatment of bone fracture, Chinese
rapid strides, particularly in the 20th orthopaedic surgeons found that while the
century, TCM evolved many centuries ago. use of modern technology and methodo-
Whether the latter still has advantages over logy had many advantages, traditional
modern Western medicine is a question that treatment, too, had its own advantages: it
is widely debated. It is the doctors proficient often achieved more rapid union. Further
in both traditional and modern medicine studies revealed that the traditional
who are best qualified to answer this. approach advised only relative fixation, with
Comparative clinical and experimental appropriate compression and stress on the
studies have revealed the advantages of site of fracture, following manipulative
traditional treatment in many diseases or reduction and timely functional exercise.
conditions. In many instances, traditional They, therefore, designed a new method
treatment is more effective and has fewer of treatment based on the principle of
side-effects. It is also more affordable than combining mobilization with immobili-
modern Western treatment. Acupuncture zation, instead of extensive immobilization
analgesia is a good example. The analgesic and complete rest. This method has resulted
effect of acupuncture is comparable with in a marked reduction in the period for
that of morphine or meperidine and, at the clinical union and has minimized the
same time, the process has minimal side- complications of fracture treatment.
effects and no addiction-inducing The treatment of cancer poses a major
properties. It is hence recommended for problem to modern medicine and the
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Traditional Medicine in Asia
128
Harmonization of traditional and modern medicine
toxic shock in severe infections, and Chinese Medicine and Pharmacy, and the
resuscitation of patients in coma. Chinese Association of the Integration of
(4) Development of new preparations of Traditional and Western Medicine, were set
traditional drugs to make their up in the late 1970s and early 1980s. The
administration more convenient, former sponsors the Journal of Traditional
acceptable and efficient, for example, Chinese Medicine, and the latter the
the manufacture of some herbal Chinese Journal of Modern Developments
formulae in the form of aerosols and in Traditional Medicine (later renamed
injections. Chinese Journal of Integrated Traditional
(5) Creating a database from the and Western Medicine). Both journals are
experience of experts in traditional published in Chinese as well as English.
diagnosis and treatment of certain Besides these two leading journals, there
diseases, for example, pattern are dozens of other journals in the fields of
identification and herbal medication in traditional as well as integrated medicine.
patients with viral hepatitis. The work of researchers in these
research institutions is no longer confined
Development of research to determining the efficacy of traditional
Traditional medicine, an age-old heritage medicine. They also study the following
culled from years of experience, is bound to aspects: (i) The elucidation of the basic
contain some valuable elements but theories of traditional medicine, such as the
inevitably it also contains some aspects theory of yin–yang and qi, the unique
which are no longer useful. It is therefore doctrine regarding the physiology and
necessary to carry out scientific research in pathophysiology of the internal organs
order to separate the grain from the chaff, (called “visceral manifestations” in TCM),
and to develop and improve the useful and the theory of the meridian system,
elements. (ii) the rationale behind the differentiation
In the late 1950s, the Chinese of disease patterns and the identification
Government began establishing research of syndromes, which are based on a
institutes with a view to facilitating the unique, holistic approach, and (iii) the
exploration of the real value of traditional mechanisms of traditional therapies, and
medicine and developing it further. Over pharmaco-logical studies of individual
the years, there has been an increase not medicinal herbs and compound formulae.
only in the number of personnel trained in In brief, the research addresses not only
traditional medicine, but also in that of the issue of whether traditional treatment
research institutions (Table 1). In the works but also of how and why it works.
1950s, most of the results regarding the Since the late 1970s such research has
efficacy of traditional medicine were progressed through the collaboration of
obtained from hospitals, both of Western traditional, Western and “integrated”
medicine (with the cooperation of traditional doctors, who may be working in hospitals,
medical doctors) and TCM. Later, however, medical colleges, universities or research
research began to be conducted mainly at institutions of either traditional or modern
research institutions. Moreover, to facilitate medicine. 16 The following examples
the exchange of information among illustrate this.
researchers, two national organizations, A concept unique to traditional
the China Association of Traditional medicine is that of “blood stasis”. This not
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130
Harmonization of traditional and modern medicine
and rhizome of Salvia miltiorrhiza) for oral able to answer the basic question as to why
or sublingual administration to relieve these pain-killing substances are produced
angina pectoris. These can be easily used in the body.
by Western-trained medical professionals, Acupuncture is effective in the
and have become a part of the routine treatment of a number of disorders other
treatment prescribed by them. As for the than pain, particularly functional disorders
traditional practitioners, they were marked either by hyperfunction or
unfamiliar with most of the diseases listed hypofunction. For example, it helps in
above, at least in terms of the Western views lowering the blood pressure in hypertension
on the pathogenesis and diagnostic and elevates it in hypotension. It is useful
criteria. Research has inspired them to keep in relieving retention and helps in
abreast of the relevant information incontinence of urine. Acupuncture is also
uncovered by modern Western medicine. beneficial for patients with muscle spasm
It is difficult to classify the intravenous and nerve paralysis. Clinical observations
drip of ligustrazine for ischaemic cerebro- and experimental studies have revealed the
vascular disease and the sublingual regulatory mechanism of acupuncture
administration of compound danshen pills treatment. In fact, its analgesic effect can
for angina pectoris as either traditional be attributed to its regulatory mechanism.
Chinese therapies or modern Western Yet another category of disease that can
therapies. However, doctors of both be treated by acupuncture is infections.
systems are now using these as routine Although acupuncture is seldom used for
treatment. They are often called “integrated this purpose now, the results it can achieve
therapies” since they have originated from are of great academic significance. Clinical
traditional medicine and been modified by and experimental studies have confirmed
the modern approach. the therapeutic effect of acupuncture in the
The successful application of treatment of bacillary dysentery and
acupuncture for anaesthetic purposes in malaria. Controlled clinical trials have
surgery shook not only China but the entire repeatedly shown that the effect of
world. Needless to say, it aroused the keen acupuncture in bacillary dysentery is
interest of researchers everywhere. comparable to that of furazolidine, and that
Research was carried out on two main the mechanism involved is the enhance-
aspects: (i) The clinical aspect, including ment of the patients’ immune function.
evaluation of the efficacy of the technique, Another example is the research on
its improvement, and determination of the “tonification”. One of the characteristic
indications, and (ii) The laboratory aspect, features of traditional diagnosis is to
including the mechanisms by which determine the confrontation between the
acupuncture provides relief from pain. The antipathogenic capability of the human
latter stimulated the study of pain and pain- body and pathogenic factors. The former
relief, particularly among the modern includes all kinds of functional activities and
medical community of China, as well as in the substances required for fighting these
some other countries. These studies pathogenic factors, as well as for
resulted in the discovery of endorphins and maintaining good health. Whenever the
related substances, the release of which antipathogenic capability is insufficient to
during the process of acupuncture relieves overcome the pathogenic factor, illness
pain. However, the studies have not been ensues. Therefore, all illnesses can be
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Traditional Medicine in Asia
classified into two main categories: Tonification, on the other hand, attempts
(i) Those caused by lowered antipathogenic to stimulate the patient’s own capability.
capability, called “deficiency” conditions, Even when used to replenish the required
and (ii) Those caused by excessive substances, in most cases the aim of the
pathogenic factors, called “excess” treatment is to stimulate the body to produce
conditions. The former are treated by the these substances instead of directly
principle of “tonification”, i.e., the adminis- substituting them. Ginseng, the most
tration of various tonics to strengthen the famous traditional tonic, is a good example.
vital functions and/or replenish the It increases the anti-stress function, but
required substances. contains no corticosteroid; by stimulating
The purpose of treatment in traditional the hypothalamic–pituitary–adrenocortical
and modern medicine is often the same, axis, it induces the body to synthesize and
but the approach is different. According release corticosteroid. Also, though it
to the approach of modern Western contains no estrogen or testosterone, by
medicine, deficiency is made up mostly by stimulating the hypothalamic–pituitary–
supplying the substance concerned, i.e., gonadotrophic axis, it acts like a sex
replacement therapy. For example, thyroxin hormone in both males and females. It
is administered for hypothyroidism, enhances thyroid function, but contains no
adrenocorticosteroid for adrenocortical thyroxin. It promotes the release of insulin,
deficiency, and gamma-globulins or but does not cause hypoglycaemia; on the
specific antibodies for immunodeficiencies. contrary, it can be used for treating
Indeed, replacement therapy is often of hypoglycaemia induced by insulin. Thus, the
vital importance, such as for patients who advantages of traditional tonification are
need blood transfusion for massive loss of that it seldom causes side-effects, and there
blood. Its promptness in correcting the is usually no “withdrawal syndrome” when
deficiency is incomparable. the treatment is discontinued. The major
Replacement therapy, however, also disadvantage is that its therapeutic effect is
has its disadvantages, especially if used usually not as prompt as that of modern
over a long period. These include the need replacement therapy. Also, it is of limited
to carefully determine the dosage and benefit once the related tissue has been
frequently adjust it. Overdosage causes totally destroyed.
severe side-effects or complications, while Both acupuncture and tonification
underdosage does not relieve the therapy are guided by the principle of
symptoms. Another important disadvan- stimulating the body’s natural healing
tage is that of drug dependence in chronic power or functional potentiality. On the
cases. Replacement therapy cannot other hand, modern biomedicine has made
stimulate the recovery of the diseased rapid progress on the basis of the
tissues or organs; on the contrary, it may replacement principle of treatment. Organ
cause atrophy of the tissues or further transplantation, too, is based on the
reduction of function due to disuse. That is principle of replacement, and has been
why, for example, sudden discontinuation invaluable to many patients, with plenty of
of prednisone therapy may cause an promise for the future. There is great scope
adrenal crisis, and a rapid and over- for traditional medicine, with its rich
whelming intensification of chronic adrenal experience in the mobilization and
insufficiency. utilization of the body’s potentialities, and
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Harmonization of traditional and modern medicine
References
1. Svoboda R.E. (1993) Ayurveda : Life, Health and Longevity. Penguin Books.
2. Conrad L.I., Neve M. Nutton V., Porter R., Wear A. (1995). The Western Medical
Tradition: 800 BC to AD 1800. Cambridge University Press.
3. Said H.M. (1983). The Unani system of health and medicare. In: Traditional Medicine
and Health Care Coverage. World Health Organization, Geneva, Ed: Robert H.
Bannerman, John Burton and Ch’en Wen Chieh. pp 61–67.
4. Alternative Medicine: Expanding Medical Horizons (1992). A Report to the National
Institute of Health on Alternative Medical Systems and Practices in the United States,
prepared under the auspices of the Workshop on Alternative Medicine. Chantilly. VA,
p. 79.
5. Farquhar J (1994). Knowing Practice: The Clinical Encounter of Chinese Medicine.
Westview Press. Boulder/San Francisco/Oxford.
6. Eskinaze D.P. (1998). Factors that shape alternative medicine. Journal of the American
Medical Association. 1998, 280: 1621–1623.
7. Yip Ka-che (1995). Health and National Reconstruction in Nationalist China.
Association for Asian Studies Inc. p. 27.
8. Huang Yongchang (1994). National Conditions of Health in China (in Chinese).
Shanghai Medical University Press; pp 151–154.
9. Zhu Qingsheng (2000). Adhering to stress on both Chinese and Western medicine
and promoting their integration, strive for the construction of Chinese socialistic
health services (in Chinese) Zhongguo Zhongxiyi Jiehe Zazhi (Chinese Journal of
Integrated Traditional and Western medicine). 2000; 6(2): 82–87.
133
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10. Zhu Qingsheng. Strive for the Adaptation of Traditional Medicine to the Demands of
Health-Care. Chinese Journal of Integrated Traditional and Western Medicine. 6(2):
82–87.
11. Zhang Wenkang (Editor-in-Chief) Zhongguo Weisheng Nianjian (Year Book of Health
of the People’s Republic of China) People’s Health Publishing House. 1999. p. 392
and 428.
12. Huang Shuze and Lin Shixiao. Dangdai Zhongguo de Weisheng Shiye (Health Services
in Contemporary China) Vol. II. China Social Science Press. 1986, pp. 68–92. (in
Chinese).
13. Zhen Zhiya and Fu Weikang, Zhongguo Yixueshi (Chinese Medical History. People’s
Health Publishing House. 1991. p. 201–210 (in Chinese).
14. Ma Jixing (1990). Lore of Traditional Chinese Medical Literature (in Chinese). Shanghai
Press Science and Technology. p.16.
15. Zhang Wenkang (Editor-in-chief). Zhongguo Zhongyiyao Nianjian (Year Book of
Traditional Chinese Medicine of the People’s Republic of China). China Traditional
Medicine Press. 1999. p. 492. (in Chinese).
16. Chen Ke-ji. Forty years of integrated medicine in China. Chinese Journal of Integrated
Traditional and Western Medicine. 1997, 3(3): 162–166.
17. Deng Pingxiu. Zhongyi Xiandaihua he Zhongxiyi Jiehe Yanjiu Fangfa (Research
Methodology on Modernization of Traditional Chinese Medicine and Integration of
Chinese and Western Medicine). A chapter of the book Yixue Bianzhengfa (Medical
Dialectics) edited by Peng Ruicong. People’s Health Publishing House. 1992; pp.
152–160. (in Chinese).
134
Role of traditional systems of medicine in national health care systems
Role of traditional
systems of medicine in
national health care
systems
Shailaja Chandra
135
Traditional Medicine in Asia
not contain synthetic ingredients, are being In terms of priorities, the epidemio-
freely manufactured and exported. Many of logical situation compels governments to
the remedies have their roots in the use of confront basic public health problems,
plants for their medicinal value. With the leaving little time, space or funds for
growth of consumer demand on the one including traditional medicine approaches
hand and the current socio-political which are necessarily individualistic, slow
ideologies on the other, governments have and difficult to monitor and evaluate. On
been trying to grapple with the task of yet another plane lies the clinical approach,
approaching the traditional medicine extended through allopathic dispensaries
practitioners and products in a way that can and hospitals designed to treat individual
be simple and meaningful enough to make and specialized problems with modern
a significant improvement to people’s daily diagnostics and drugs.
lives while ensuring safety. In this pursuit, With such a wide difference in concepts
the government has naturally to confer and approaches, is it at all possible to bring
legitimacy only on such systems, practices, about any kind of integration which would
therapies and drugs which have been be of significant benefit to the people? Are
investigated and found to be efficacious and comparisons between the loss of
where a process of standardization can be productivity on the one hand (which
assured. This exercise, however, calls for the invariably calls for strong medication) and
integration of several facets which go into the elimination of side-effects on the other
the making and practice of traditional (albeit with gentler but slower traditional
medicine, which requires an understanding drugs) at all possible? Can one weigh the
of the sector, its strengths and weaknesses short-term benefits of getting back to work
and what will work. over the long-term benefits of avoiding
Traditional medicine in every country dependence on strong drugs and
wherever it has a strong base, has emerged resistance patterns? Is there at all a case
out of an individual physician’s approach for identifying which part of the traditional
to the problems of an individual patient systems can be integrated into a health
spreading to the family, and later the system? Where does traditional medicine
community. Rooted in traditional medicine fall between the public health approach on
is the belief that every person belongs to a the one hand and the specialist-driven
broad stereotype and problems can be hospital-based approach on the other?
treated by understanding the individual’s Where will the inclusion of traditional
personal traits and specific factors which medicine work to the greatest advantage,
have brought about disequilibrium. and can there be a policy on its integration
Whereas Western allopathic medicine has into the health system?
a reductionistic approach and looks upon These are some of the issues which
the removal of the symptoms of disease as policy-makers administering the health
the main objective, Traditional Medicine sector have to grapple with, and at the
does not see only a single remedy or a back of every decision-making process lies
single approach as being suitable for all the question of whether the alternative
people. Symptoms are seen only as an offered by traditional medicine will lead to
indication of a deeper malaise which is not a significant improvement over the current
necessarily considered to be caused by situation, sufficient to call for a change of
physiological factors alone. policy. Would governments like to introduce
136
Role of traditional systems of medicine in national health care systems
137
Traditional Medicine in Asia
138
Role of traditional systems of medicine in national health care systems
In India, the Department of Indian matically lead to their use. The calibre of
Systems of Medicine and Homoeopathy of the practitioner and his skills decide whether
the Ministry of Health has published Home patients place reliance on the system. In
Remedies for Ayurvedic2 and Unani3 India, there is a vast infrastructure
medicines and circulated them for use by comprising more than 2854 traditional
community leaders, extension workers, medicine hospitals with 49,353 beds,
nurse midwives and school teachers at the 400,000 institutionally trained practi-
village level. tioners of Ayurveda, Unani, Siddha and
Homoeopathy, more than 387 colleges of
The Use of Traditional Drugs where indigenous medicine, and more than
Therapeutic Claims are made 22,000 dispensaries mostly situated in the
For the wider sale of processed drugs where rural areas of the country.4 The practi-
therapeutic claims are made, licensing is tioners have attended a five-and-a-half-
a prerequisite. Legislation to enforce year degree course after completing the
licensing and registration is available in final year of school. They have been
countries like India, Indonesia and Sri registered by a statutorily elected
Lanka assisted by pharmacopoeias and professional Council called the Central
texts which are recognized under the drugs Council of Indian Medicine. People come
enforcement legislation of the country. India of their own volition to access traditional
and Indonesia have also introduced care, particularly for certain chronic
Good Manufacturing Practices (GMP) for ailments. In some states of India like
traditional drugs which cover the Maharashtra and Tamil Nadu, the
requirements relating to the qualification traditional medicine practitioner is very
of employees, the responsibility of the much a part of the primary health care
quality control managers, essential system and provides diagnosis and
requirement of space, equipment, treatment in the same health facility along
documentation of processing and with allopaths. In times of national disasters
packaging methods and need for self- like cyclones, floods and earthquakes,
regulation, coupled with enforcement by under Government orders traditional
the licencing authorities. India, China, medicine practitioners provide their own
Bhutan, Indonesia and Thailand have emergency medical relief, more specifically
national drug lists for use in primary health to prevent diarrhoea, dysentery and skin
care and in hospitals. These examples can ailments and to help people overcome
be emulated with advantage as such lists shock and disorientation. They have been
bring about confidence in the user and the used extensively during outbreaks of
utilization patterns can be studied for Japanese encephalitis where homoeopathy
modifications in stocking policy. was found to have particular efficacy.
When the practitioner is part of the
Use of Traditional Medicine in health system, his registration after
More Complicated illnesses completion of a recognized educational
In the case of complicated illnesses, simply course is absolutely necessary. The public
stating that these drugs are recognized by have a right to receive standardized
the Government and that they can be safely treatment and drugs and to hold practi-
used for self-care and primary health care tioners responsible for the medication they
for all kinds of diseases will not auto- administer.
139
Traditional Medicine in Asia
Ayurveda Homoeopathy
140
Role of traditional systems of medicine in national health care systems
141
Traditional Medicine in Asia
importance as they all have an impact on Biotechnology, Science & Technology and
quality. For traditional medicine to get a Commerce have come together to evolve
foothold on a sustained basis, the quality a coordinated approach to the develop-
of the medicine has to be assured. There is ment of the medicinal plant sector. A
a world of difference between the efficacy Medicinal Plant Board has been establi-
of a medicine made from plants cultivated shed to coordinate all the activities under
and harvested using good agricultural the Department of Indian Systems of
practices and that derived from plants Medicine and Homoeopathy which also
uprooted from the wild.25 has the responsibility to lay down standards
In most countries, even in those where for traditional medicine drugs. Despite this
the use of traditional medicine is strong, policy-level support, the role of traditional
the cultivation of medicinal plants is at medicine in the health system will be
present limited to a few items, most natural decided by only one factor, i.e., the curing
products being collected by villagers and and health-giving ability of the practitioners
tribal people from wastelands and forests. and the remedies on a sustained basis.
For want of training, they may destroy the
whole plant instead of collecting just the Standardization, a Pre-requisite
part to be used. Re-plantation and for Quality Control of Traditional
propagation is left to nature. Collection not Medicine Drugs
done during the proper season often Standardization of plant-based drugs is
detracts from the efficacy of the end extremely difficult because presently very few
product. The networking of collection is quality control tests are available in most
under the control of traders and the countries using traditional medicine. In their
material collected is sold in the nearby absence, there are no methods to evaluate
township from where it reaches regional the contents and the quantities as claimed
centres for domestic use or export. Enligh- on the label. Quality control is required at
tened industries do, however, cultivate three stages, namely, when the raw material
plants so as to be assured of standard is used, for confirming the process
quality and the presence of active undergone by the drug during manufacture,
ingredients. They have invested in recruiting and at the finishing stage. The shelf-life or
botanists and standardization experts in date of expiry needs to be indicated and the
order to access quality raw material. Some possibility of mixing modern drugs has to
of these industries have their own R&D be strictly eliminated and strong deterrents
facilities where documentation is imposed to discourage such practices.
maintained and quality assured through Measures to test the absence of pesticide
finger printing, HPLC and TLC tests. residues, heavy metals and aflatoxin have
However, small manufacturing industries to be taken through proper regulation and
rely on market sources which have many testing.26, 27 At least a few important markers
attendant problems which affect quality. have to be identified through TLC (finger
In India, at the federal level the printing) and the process of making random
Departments in charge of traditional checks has to be institutionalized and
medicine (Indian Systems of Medicine and penalties imposed if non-permissible
Homoeopathy under the Ministry of Health substances are found or the medicine does
and Family Welfare), the Department of not conform to safety standards. For patent
Environment and Forests, Agriculture, proprietary drugs, manufacturers must be
142
Role of traditional systems of medicine in national health care systems
asked to provide the recipes. Consumers authorized to conduct quality control tests
must be kept informed about how they can and issue certification is also contemplated.
access quality products and where tests can Traditional medicine can play a role in
be undertaken if doubts about quality are the health system of a country if the system
experienced. and its medicaments have been prepared
In India, pharmacopoeial standards in a manner that inspires confidence in the
for 158 drugs are available and 634 quality and the Government supports the
formulations have been published in the use of such systems with the needed
Ayurvedic Formulary of India. Likewise, controls.36,37 Without this input, traditional
for Unani medicine pharmacopoeial medicine can grow only in a haphazard
standards are available for 45 drugs and way and public confidence may get eroded
a Unani Formulary for 603 formulations over time. Issues of quality have to be
is available. In respect of Homoeopathy, confronted squarely and national and
pharmacopoeial standards are available provincial governments have to be made
for 916 drugs.28-35 aware of what is acceptable across the
In Ayurvedic and Unani formulations, world. Only then will traditional medicine
sometimes a single medication has over 50 be able to achieve its due position in the
ingredients and certainly even the simplest health system.
medicines have 6–10 ingredients involving
the use of different parts of several plants. Issues of Integration
Standardization is not a simple task and it
has to be undertaken and institutionalized Indian Government’s Policy on
if the traditional medicine sector is to Traditional Medicine
secure a niche for itself in the health system. The Central Council for Health and Family
Scientists have given numerous Welfare, set up under Article 226 of the
suggestions about the standardization and Constitution of India, is the highest policy-
quality control of herbal drugs. In India, making body which lays down policy for
the problems have been addressed all sectors covered under the health
through a variety of measures, some of portfolio. It meets once a year and consists
which have already been implemented and of the federal health ministers, state health
some are still in the process of being ministers, eminent health experts, NGOs
introduced. In order to give an impetus to with an interest in health, and officials of
Quality Control and Standardization, the the central and state governments.
Department of Indian Systems of Medicine The Council in its last meeting held in
and Homoeopathy has initiated schemes 1999, inter alia, recommended that at
to help strengthen the State Pharmacies
and State Drug Testing Laboratories to
become models for the proper formulation Traditional medicine can play
of quality medicine for use in the public a role in the health system
sector and Government-run hospitals and of a country if the system
dispensaries. Side by side, recognition of and its medicaments have
private laboratories which possess the been prepared in a manner
equipment and the scientific and technical
manpower as stipulated, and act as that inspires confidence
Government-approved laboratories in the quality.
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Traditional Medicine in Asia
least one physician from the Indian Systems The Government of India has set up a
of Medicine and Homoeopathy (ISM&H) Population Commission to address the
should be available in every primary health whole issue of population stabilization. The
centre in every state and that vacancies Commission has further set up a High
caused by non-availability of allopathic Powered Advisory Group on Mainstrea-
personnel should be filled by ISM&H ming of Indian Systems of Medicine and
physicians. The Council also resolved that Homoeopathy (ISM&H) into the health
specialist treatment centres for ISM&H system. The terms of reference seek to:
should be introduced in rural hospitals and z Review the status of Reproductive and
a wing should be created in the existing Child Health (RCH) services extended
state and district-level Government by ISM&H practitioners, their infrastru-
hospitals so that the benefits of these cture and personnel;
systems are made available to the general z Identify areas where ISM&H practi-
public, according to their choice. It has tioners can be used more effectively by
also been resolved that expenses on upgrading their knowledge and skills;
treatment received in traditional medicine z Select effective ISM&H practices which
hospitals should be recognized for can augment the existing RCH approach;
reimbursement as is already permitted in z Specify significant legislative, admini-
the case of Central Government strative and schematic changes which
employees. All these measures have been need to be introduced to achieve the
recommended to all state governments and objective of utilizing ISM&H and their
the action taken thereon is regularly practitioners to the best advantage.
monitored at the central level. This is the first time that a separate
high-powered group has been set up for
Mainstreaming Indian Systems of using the strategies of ISM in population
Medicine and Homoeopathy for stabilization, a major area of focus for the
Population Stabilization Indian Government.
The Government of India has adopted a
‘National Population Policy 2000’ and, for Integration of Traditional
the first time, a Chapter has been Medicine into the Reproductive
introduced on mainstreaming the Indian and Child Health Programme
Systems of Medicine and Homoeopathy For the first time, drugs of the Ayurvedic
(ISM&H). The Policy seeks to use the and Unani systems have been incorpo-
institutionally qualified practitioners of rated into the kits of nurses and midwives
ISM&H (who have completed a five-and- in the sub-centres of seven states and four
a-half-year degree) and utilize their services cities, to be extended to the whole country
to fill the gaps in manpower at appropriate later. The same drugs are also to be made
levels in the health infrastructure. The Policy available in the kits of female extension
also seeks to increase utilization of ISM workers in over 5,00,000 centres
institutions, dispensaries and hospitals for providing supplementary nutrition to
health and population-related progra- pregnant and lactating women and
mmes. What is particularly noteworthy is children below six years. The traditional
that the Policy advocates the use of tried drugs have been selected to take care of
and tested ISM medicines at the village and common problems and are being centrally
household level. procured and tested before being added
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Role of traditional systems of medicine in national health care systems
to the kits. This will further help the health developed a vaginal contraceptive
systems to take care of a large number of (spermicidal agent) from Neem Oil
women and children as a first line of care (Azadirachta indica) in the form of pessary,
through traditional medicine. which has been approved for clinical trials.
Meanwhile, but again for the first time, This product of DIPAS has overcome the
the Ayurvedic concepts of the Healthy inconveniences of using the oil as such,
Mother and Child are to be studied through being done by the CCRAS.
an operational research project under the The work on Pipplyadi Yoga, a herbal
joint aegis of the Indian Council of Medical contraceptive, is already undergoing
Research and the Central Council for clinical trials in five allopathic centres with
Research in Ayurveda and Siddha (CCRAS). allopathic clinical investigators. Both these
Five states and 10 blocks have been initiatives will be a boon to rural women if
identified for this study. The areas cover the highly effective cheap contraceptives are
overall approach to reproductive and child developed.
health, including menstruation, antenatal These examples show how the benefits
care, preparation for delivery, vomiting in of Indian medicine are being brought into
pregnancy, loss of appetite, constipation, the mainstream of health care where they
gaseous distention, acidity and diarrhoea, are poised to play an increasingly important
treatment of oedema, loss of sleep, piles and role.
anaemia, delivery and its management,
contraception and the management of the Does Traditional Medicine Have
newborn. In regard to neonatal and child a Role in an Allopathic Set-up?
health, the areas include care of the Different countries have made different
newborn, precautions during the first week kinds of efforts to assimilate traditional
after birth, supplementary food for the medicine into the normal health system.
infant, general growth and development of This has met with varying degrees of
the child, management of diarrhoea, success. Some examples of how India has
constipation in children and eradication of given a role to traditional medicine in the
worm infestation. The entire approach is health sector are described below.
traditional and the applications are simple In a 900-bed general allopathic
enough to be administered by Ayurvedic hospital in New Delhi (the R.M.L. Hospital),
practitioners, nurse midwives, traditional services for Homoeopathy and Unani
birth attendants or even at the household treatment are available under the same roof.
level. This again is the first time that a joint In another 1500-bed allopathic hospital
operational research study combining (Safdarjung Hospital), Ayurvedic and
research talent from allopathy and Homoeopathic treatment is available.
traditional medicine will be undertaken to Medicines are either given by the practi-
determine the benefits of the Ayurvedic tioners or through the Central Government
approach in this area. The objective is to Health Scheme (CGHS) to government
identify areas of greater relevance and employees.
significance, which could be introduced in The attendance pattern in the traditional
the Reproductive and Child Health medicine clinics was analysed over a six-
Programme. month period. The main findings were that
The Defence Institute of Physiology and in Ayurveda, among the chronic diseases,
Allied Sciences (DIPAS) has successfully arthritis (sandhi vata) accounted for 10.8
145
Traditional Medicine in Asia
146
Role of traditional systems of medicine in national health care systems
The Unani system appears to attract postgraduate level for teaching and
the largest number of people for research and this approach is continuing
rheumatoid arthritis (waja-ul-mafasil) and even today. The M.D. Ayurveda
vitiligo among chronic diseases, common Programme of the Faculty of Ayurveda is
cold (nazla-wa-zukam) and dyspepsia (su- also open to MBBS graduates. For such
e-hazm) (Table 3). candidates, the first-year M.D. Course is
a special preparatory course and there is
Institute of Medical Sciences, a separate examination for the two
Banaras Hindu University, streams. But the Final M.D. Ayurveda
Varanasi – An example of examination and teaching is common for
integration both the streams. They undergo the same
Banaras Hindu University (BHU) is training in the 2nd and 3rd year, clear the
probably the first institution which same examination and get the same
conceived the idea of integrating the degree.
ancient and modern systems of medicine The University has also passed an
both at the level of education and Ordinance through which a candidate
professional practice, 73 years ago, when holding an M.D. degree in Ayurveda may
the first ever integrated Ayurvedic College be registered for a Ph.D. degree in the
was established. Subsequently, this model respective speciality of modern medicine
became controversial and was opposed and vice versa.
by the mainstream of Ayurvedic
organizations, and the Ayurvedic College Medical Research in BHU
of BHU was closed in 1960 but an The M.D. Ayurveda and Ph.D. Ayurveda
integrated education was started at the scholars adopt modern parameters of
147
Traditional Medicine in Asia
study but they also adopt parallel Ayurvedic prescription of a practitioner) at other
parameters such as determination of places. Whether traditional medicine can
Prakriti, Ayurvedic Diagnosis, Status of Agni at all be used effectively both in the public
and Ama. In all cases the main guide for health area and in clinical practice as an
the thesis-level research is a teacher from adjunct or an adjuvant has no uniform
the Faculty of Ayurveda but there are one answer. At the same time, there are a large
or two co-guides from modern medicine number of approaches which may be used
or the basic medical sciences. to advantage with a little effort, but that
There are no formal rules or policy requires a policy backup and regulatory
formed for this collaboration. The pattern systems to make such strategies work.
has evolved spontaneously and mutually Since it is difficult to generalize, a few
over the years. examples are given about how the public
can be benefited.
Cross-referrals in BHU
The treatment and patient care in BHU Manual Therapy like Yoga
Hospital too is on an integrated pattern. Yoga is known to be effective in the
The main morbidity areas in which the management of various disorders and
patients are referred for Ayurvedic indexed research papers have shown
treatment at BHU involve: improvement in cases of anxiety neurosis,
Fistula in ano, chronic rheumatic depression, arthritis, bronchial asthma,
diseases, residual psychosis and anxiety constipation, hypertension, respiratory
disorders, chronic colitis and IBS, diseases diseases, back pain, insomnia and postural
of the liver and jaundice, degenerative defects. The most important way that Yoga
brain disease and neuropathy and can contribute in improving the state of
terminally sick patients of all kinds declared well-being of a large number of individuals
incurable and/or financially unable to is if governments were to introduce the
afford modern treatment. Most cases are practice of yogic asanas in schools and
referred to the Department of Kayachikitsa also if classes were to be held for the benefit
or Internal Medicine. of the general public. In New Delhi, such
classes are run in the mornings and
Practical areas where evenings at a Central Institute for Yoga
Traditional Medicine can be (MDNIY), separately for men and women
used effectively in the Health and these can be accessed free of cost.
System The general public can participate at will.
During summer, when schools are closed,
Traditional medicine falls into several the institute establishes 101 camps in
different segments, from the highly different residential localities of Delhi for the
researched and documented to that which benefit of residents by paying for the
has been practised through oral tradition, services of a Yoga teacher after prior
from manual therapy and manipulation to screening for their capability, commu-
faith healing. There are also important nication skills and knowledge of yogic
systems like Homoeopathy which are postures. The yogic asanas with meditation
routinely accessed over the counter in some have helped countless people to maintain
countries but restrictions continue on the physical and mental equilibrium.
use of the medicine (except on the The Defence Institute of Physiology
148
Role of traditional systems of medicine in national health care systems
and Allied Sciences (DIPAS) has done licensed and sold with proper labelling and
extensive work on looking at the effect of product information. In some countries like
Yoga on soldiers working in extreme the United Kingdom, allopathic practi-
climatic conditions as well as the effect of tioners undergo a one-year course in
vegeta-rianism, yoga and meditation on Homoeopathy and can practise the system.
persons having over 50 per cent blockage In India, students have to enrol after the
of at least one artery with the results being school level and undergo a five-and-a-half-
followed up after six months. Cardiologists year degree course to be allowed to
from top allopathic institutions tested the practise. Homoeopathy is particularly
results through angiography and the remarkable in being able to treat routine
outcome has shown extremely promising problems, skin and other allergies, gastric
results. In this way, patients have been problems and children’s ailments. It is
enabled to overcome apparently possible to list at least 40 simple remedies
intractable problems through simple and which could be sold through chemists over
cheap strategies within their control and the counter without prescription, in 5 ml.
devoid of side-effects. vials, so that there is no misuse. These 40
Several specialized institutions in the medicines are intended for common
allopathic sector as well as those commi- ailments to relieve symptoms to aid early
tted exclusively to Yoga are conducting restoration of normalcy. It is necessary to
extensive research on the tremendous improve access to these simple medicines
healing properties of Yoga and its strengths. and to sensitize people, who should be
This is one of the cheapest ways of involving encouraged to use such remedies. Several
the community in health promotion and in simple booklets are available which
making it a community effort. The health describe the condition as well as the mode
system only needs to screen the Yoga of administration of the drugs and the
teacher, extend occasional supervision and dosage. Since Homoeopathy is a gentle
to see that nominal payments are made and effective medicinal science, its use
for the classes. The community can be left should be integrated into the health system
to decide the teacher’s acceptability. In more effectively.
order to make this a part of the health
system, it is necessary to involve the local Traditional Therapies which can
Government machinery in the rural and be integrated to advantage
urban areas, community leaders, schools Research studies have also shown the
teachers and doctors in-charge of PHCs. beneficial effects of Ksharasootra and
Through this approach, a number of Panchakarma, two Ayurvedic therapies.
problems can be taken care of without Ksharasootra comprises the use of
medication. Ayurvedic medicated thread in the
management of fistula-in-ano, and
Homoeopathy multicentric trials have been conducted at
Homoeopathy is recognized as a system the collaborating centres of the Indian
of medicine in many countries and a large Council of Medical Research on 265
number of drugs are available over the patients where the approach was
counter in the United States, as well as in compared with conventional surgery. The
several European and other countries. It is finding showed that the long-term outcome
extremely important that the drugs are of Ksharasootra is better than surgery,
149
Traditional Medicine in Asia
although the initial healing time is longer. cular and certain orthopaedic disorders.
It is an effective, ambulatory and safe Ksharasootra has provided an alter-
alternative treatment for patients with native for those patients who either do not
fistula-in-ano, the main advantage being want surgery or who have encountered
that general anaesthesia is avoided and the recurrence of the problem after conven-
chance of recurrence of the problem is nil. tional surgery. In fact, it has been seen at
Another highly acclaimed procedure in the KEM Hospital, a large allopathic
Ayurveda refers to Panchakarma, which hospital in Mumbai, that cases of fistula-
constitutes a part of the therapeutic in-ano undertaking surgery have declined
approach in the treatment of diseases as considerably ever since Kshar-Sutra has
well as for the prevention and promotion been offered as an alternative. The cost of
of health care. Panchakarma therapy these measures is nominal given the
comprises five purificatory and therapeutic outstanding relief they have given patients.
procedures consisting of oilation and There are applications similar to
fomentation of the body followed by Panchakarma available throughout the
medicated emesis, purgation, medicated traditional system of medicine in most
enemata, nasal insufflation and blood countries of South-East Asia which would
letting. Five modified procedures of oilation be worth incorporating in general hospital
and fomentation of the body have come wards and other in-patient facilities.
to be known as Keraliya Panchakarma.
These include Sirodhara (dribbling of oil on Folk Medicine and Tribal
forehead), Sarvangaseka (dribbling of oil Remedies
on the whole body while massage is done) Every country has its own list of traditional
Pinda sweda (fomentation with hot remedies and countries need to document
medicated balls of cooked rice, etc.). these after observing local people and their
Annalepa (besmearing of cooked and practices. This is important because this
medicated rice on the whole body) and information is often the foundation of larger
Sirolepa (application of thick medicated discoveries and inventions, and since this
paste on the crown of the head). These are information is passed down by word of
followed by specific dietary measures each mouth, it is likely to be lost forever. It is
time. Panchakarma has been used in important to engage botanists, foresters
treating many critical diseases like diabetes, and NGOs working in this area to prepare
cardio-vascular diseases, hypertension, lists of such tribal, folk and village remedies.
arthritis, rheumatoid arthritis, osteoporosis, In India, the Central Council for
and degenerative disorders. Research in Ayurveda and Siddha
Both these procedures have been (CCRAS),38 and the Central Council for
advocated by the Department of Indian Research in Unani Medicine (CCRUM)
Systems of Medicine and Homoeopathy for have observed and documented over
being extended to allopathic hospitals 10,000 such remedies, although not all
where large numbers of patients of them can be used and not all the plants
congregate. Panchakarma has been found are readily available. Yet, these remedies
to give significant relief well beyond what represent the knowledge of the people and
drugs and physiotherapy can achieve, the intellectual property of the country.
particularly for symptoms and ailments Unless these are documented, it will be
caused by neurological and neuromus- difficult to give benefit to the country and
150
Role of traditional systems of medicine in national health care systems
the community. Health departments must Government with a Secretary, who reports
appoint the right blend of survey staff to to the Union Ministers for Health. Public
document this knowledge, which will health is a State subject under the Indian
otherwise disappear forever along with the Constitution and 18 state governments in
disappearance of forests, tribal commu- the country have set up Directorates of
nities and village doctors. Having Indian Systems of Medicine & Homoeo-
documented it, the next step is to identify pathy. Some states have independent
areas of current importance where the ministers in-charge of the non-allopathic
remedy appears to offer a net advantage recognized systems. India has the following
over available medicaments and to conduct capacity in the traditional medicine sector
observational or animal studies (in the case (Table 4).
of unknown plants) to test their efficacy.
151
Traditional Medicine in Asia
152
Role of traditional systems of medicine in national health care systems
and skills acquisition if they are to treat available. The list comprises some 315
patients at a level beyond that of home medicines falling under 19 categories of
remedies for common ailments. diseases and problem areas. It has been
Traditional medicine practitioners who calculated that health departments would
have undergone a degree course are fully need to set aside about $950 per facility
qualified to perform tasks like supervision per year if classical (generic) medicines are
of TB drug intake, dispensation of malaria used for an OPD clinic visited by 50
drugs and screening of STI and RTI cases. patients a day. Such lists are available in
They can facilitate referrals, undertake other countries too. Several of them are
counselling and advocacy for the manufactured in Government-owned
prevention of HIV/AIDS and help identify pharmacies or are purchased from
cases of cataract blindness. Since most manufacturers.
health system managers are doctors from There are over 9000 licensed
the public health stream, they do not readily pharmacies manufacturing a vast array of
accept this paradigm, which is why drugs catering to a wide range of human
governments need to declare and as well as veterinary problems. Their
implement a policy on the utilization of preparations conform to original classical
these practitioners. The challenge is to texts or with some deviations, which put
encourage traditional practitioners to them in the category of patent proprietary
primarily use their own systems and to build medicines. These medicines are available
awareness among the public that relying with allopathic chemists who stock Indian
on traditional remedies for common medicines or with special grocers. The
problems could be safer in the long run. public in India are well-acquainted with
The practitioners can nevertheless be these remedies, which are aggressively
assigned specific duties after being advertised and marketed throughout the
screened for their knowledge and skills, and country.
trained in fulfilling public health responsi- Ayurvedic medicines generally
bilities besides practising their own systems. comprise several items.31–34 These include:
In order to see that this does not lead to z Arka – Arkas are liquid preparations
such practitioners practising allopathic obtained by condensation of vapours
medicine, governments need to specify by the process of distillation.
what can be done by such practitioners and z Pak – Avaleha – Avaleha or Leha is a
should supervise and monitor their work. semi-solid preparation of drugs,
prepared with the addition of sugar or
Issues of access to Traditional candy and boiled with the prescribed
Medicine drug juice or decoction, useful for
For any traditional medical system to work chronic ailments. These preparations
successfully, medicines of standard quality are usually tonics.
must be available at reasonable prices. In z Chyawanprash – is an example of
India, the problem has been addressed by Avaleha and is useful as a health tonic
specifying an Essential Drug List to be used in any season. It is especially indicated
at the dispensary and hospital levels for the for chronic respiratory problems and
kind of ailments for which people generally general debility. Apart from being
seek the services of traditional medicine particularly useful in warding off
practitioners and where drugs are easily chronic coughs and respiratory
153
Traditional Medicine in Asia
154
Role of traditional systems of medicine in national health care systems
conscience require one to do. Debates a responsibility to ensure not only the
about investment in tertiary health versus efficacy of the medicine but, more
primary health, health insurance versus important, its safety. This can only be done
voluntary safety nets for the poor, public by making available quality medicine and
health versus preventive care, standard registering the practitioners who can be
setting versus voluntary accreditation and held accountable. The experience of India
self-regulation, and over-diagnostics versus clearly shows that it is possible to have
the family physician approach, abound in traditional systems which can be used
every country. Through all this runs an strongly and effectively to reinforce the
important thread which essentially health system. However, what is essential
determines whether health systems is strong policy support to give the system
really work, and that refers to the public national stature, resources to conduct
demand, consumer satisfaction and cost- evidence-based research and to include
effectiveness. practical strategies for different traditional
Consumer demand for improved medical practices to provide an alternative
health outcomes, more choices, less side- or to complement the work of the normal
effects, less resistance patterns, less intake health system.
of chemicals and synthetic drugs, greater In this paper, an effort has been made
reliance on natural and environmentally to place a few examples of what is possible,
friendly products, all have pointed to the what can still be done and what is already
burgeoning interest in natural plant-based being done before a public that wants to
products and a desire to go back to nature understand how it can be done and where
and investigate and re-package old it would be most relevant. Not all prescri-
strategies, prescriptions and antidotes to ptions given in this paper can be applied
meet the emerging problems of today. universally or emulated entirely. They
Traditional medicine has much to offer and require investment in time and resources
the sheer volume of empirical knowledge to understand where traditional medicine
and the areas of application are so can contribute most meaningfully, resulting
voluminous that it would be difficult to ever in better health outcome. But, most
conclude which system, which drug and important of all, they require an open mind
which application is superior to another. to the development of health systems which
Traditional systems which are highly rise above the ordinary, an end to the hubris
documented and which are backed by that surrounds traditional medicine today
statute and by regulatory and enforcement and the strength to determine what can
mechanisms, are bound to be taken more be offered to a hungry and curious public
seriously than those which depend only on with a sense of legitimacy that the situation
the faith of the consumer or the confidence demands. Now is the time to make better
generated by word of mouth, howsoever use of the traditional system to augment
convincing it may be. Since the medication access to health care, based on empirical
of an individual can lead to all kinds of evidence, public demand and cost-
effects years from now, governments have effectiveness studies.
155
Traditional Medicine in Asia
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A framework for cost-benefit analysis of traditional medicine and conventional medicine
159
Traditional Medicine in Asia
At present, the public in both developing can be as readily applied to the utilization
and industrialized societies appear to be of traditional and complementary health
using conventional medicine as well as TRM services as to mainstream medical services.
or CM in an integrated way, wherever this The starting point for the choice of
is possible.4,5 The question of cost savings methodology is the research question being
presumes a different question: that of posed. This may be positioned from the
substitution. In other words, while the public public sector perspective: namely,
is combining health services in a pluralistic determining those health care interventions
manner, integrating conventional and CM/ that maximize health gains in a society and
TRM into their overall care programme, the to determine allocative efficiency, viz., the
choice that is posed within an economic basis for deciding how best to choose on
framework is: ‘Can traditional therapies allocating resources to one form of
substitute for conventional treatments?’ If treatment over another. Other research
not, the combination of traditional and questions may reflect the perspective of an
modern medicine can be seen, from an insurer, where the issues are different.
economic perspective, as simply adding to
the cost of care. Cost descriptions
Underlying the dichotomy between the This would entail collecting and collating all
tendency of consumers to combine health costs involved in providing a particular
care approaches from conventional and traditional health care service. This
TRM, and the practice of medical insurers approach provides baseline data for further
and health care providers to seek the single studies, but does permit other providers to
least expensive care option, rests the deeper know what the costs of a particular
policy issue of whose perspective and treatment programme may be. This type of
priorities should determine the nature of research does not provide data on
care that is offered – the consumer, the therapeutic outcomes.
purchaser, or society in general. In applying
or interpreting economic analyses of Cost-comparison research
traditional health care services, it is first This entails a comparison of the costs of
necessary to specify the perspective from two or more treatments which are designed
which the analysis is being conducted. to achieve a common outcome. White and
Thus, issues of economics can be weighed Ernst (2000) have noted that a limitation
against questions of ethics, consumer of this approach is that treatments,
choice, quality of life and the wider societal including drugs, rarely have directly
impact of a particular intervention. With comparable outcomes.3 Thus the cost-
this perspective as our starting point, it will comparison is at risk of being a comparison
be useful to consider the various metho- of the proverbial ‘apples vs. oranges’ type.
dologies used in assessing the economic
merits of health care approaches. Cost-effectiveness analysis
These studies are designed to measure the
Methods of economic analysis costs of producing a change in a particular
health outcome, e.g., life years, blood
A range of methodologies exist for pressure. In their analysis of different
examining the economic issues associated economic methodologies for assessing
with the provision of health care.6 These health care strategies, White and Ernst
160
A framework for cost-benefit analysis of traditional medicine and conventional medicine
point out that this approach overlooks other sort of framework for the analysis of TRM
benefits that a therapy may generate as in light of conventional medical options.
well as such negative effects as unpleasa- The first of these is a powerful social trend,
ntness of the treatment or side-effects. namely, the growing public demand for
TRM and CM worldwide. The second is the
Cost-utility analysis move by governments towards integrating
This is primarily oriented to assessing traditional health services into national
patient satisfaction with a treatment. health care and the need for TRM progra-
Instruments used may be a quality-of-life mmes and departments to justify the value
instrument, such as the WHO Quality of of their sector in both therapeutic and
Life Assessment Scale. While comparing economic terms.
different treatments and their outcomes in In the following sections, we will review
terms of patient satisfaction, this metho- the issues involved in each of these broad
dology does not address the question of forces or emerging societal trends. Then
whether the treatment is worth the financial we will move to a consideration of the cost
outlay on it. issues entailed in traditional health care
services. Finally, there will be a conside-
Cost-benefit analysis ration of the policy implications of these
At the centre of this approach is a trends and the beginnings of a framework
methodology designed to assess patients’ for the economic analysis and comparison
willingness to pay (WTP) for the benefits that of traditional and conventional health care
the treatment provides. This is then services.
compared with the actual cost of the
treatment to determine if it provides value Utilization
for money. A challenge of this approach is
to define outcomes in monetary terms. This The widespread demand for TRM services
challenge has meant that very few sound has been recognized as an enduring
studies have been done to determine the phenomenon and early calls for TRM to
cost-benefit issues associated with be replaced by modern medical services
traditional therapeutic modalities. A further have now given way to recognition that
limitation is that WTP does not necessarily some degree of formalization of these
indicate ability to pay (ATP). health services might offer the public
Households may persist in paying for increased standards of quality and safety.
care, but to mobilize resources they may In both industrialized and developing
sacrifice other basic needs such as food societies, use of CM and TRM is on the
and education, with serious consequences rise.
for the household and individuals within it. In 1993 research at Harvard University
The opportunity costs of payment make the found that 30 per cent of Americans were
payment “unaffordable” because other using some form of CM on a regular basis.
basic needs are sacrificed.7 In 1998, the same research team reported
that this number had increased to 40 per
Backdrop to the Economic cent of the population. 1 Research
Analysis of Traditional Medicine published in The Lancet in 1996 reported
There are at least two major forces at work that 40 per cent of Australians were using
that drive the growing demand for some some form of CM. 2 In April 1999,
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Traditional Medicine in Asia
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A framework for cost-benefit analysis of traditional medicine and conventional medicine
caters for the health needs of 80 per cent to traditional healers in central Sudan
of the African population.9 This figure indicated that children under 10 years did
echoes an earlier estimate of 80 per cent not take part in visits. Most visitors were
made by Koumare (1983).10 between 21 and 40 years (61%) and were
However, some estimates of use are women (62%). They were less educated
strikingly low. Shiferaw (1993), for example, compared to the general population in the
reports on an interview-survey of perceived area. The main reasons given for attending
morbidity in a rural community in South- traditional healers were treatment (60%)
western Ethiopia, where 55.4 per cent of and blessing (26%).13
those reporting illness took no action at all; In Mali, men are more likely to prefer
30.3 per cent applied to health institutions, traditional treatments for malaria than
9.2 per cent reported self-care, and only women, 14 and more boys than girls
5.2 per cent visited a traditional healer.(11) believed in herbal medicine in a survey in
By contrast, research done at Mogopane the Sudan.15 It has been suggested that
Hospital in North-eastern Transvaal, South women are less likely to be treated at
Africa, showed that nine out of 10 patients modern facilities, and are more likely to
who come to the out-patients department resort to traditional medicines.16
first consult traditional healers.12 People with a serious health condition
Clearly, studies of community groups may seek THC before accepting modern
and of hospital populations address the medical services. In Malawi, 37 per cent
needs and choices of different populations of TB patients reported attending a
with different health profiles. In planning traditional healer prior to attending the
services such differences need to be health service. By the time a final diagnosis
accounted for. of TB was made, most patients had visited
Age and gender are factors in the several different care providers: private
utilization of THC services. A study of visitors practitioner (69 visits), village clinic (64)
163
Traditional Medicine in Asia
and traditional healer (40), and 32 patients to attend traditional healers, in Kenya 40
reported taking some form of traditional per cent of sick children were taken to the
remedy at home.17 mganga [traditional healer] and 55 per
Travel time can be a factor in the choice cent to the clinic; 26 per cent of the
of traditional over modern medical services. mothers said that both sources of treat-
Among comments made by traditional ment were consulted.19
midwives in South Africa, in a study by There are usually differences between
Troskie (1997),18 was that “the nearest urban and rural populations in their use of
hospital is 20 kilometres far”. Similar TRM and modern medicine. While 95 per
responses were recorded from clients. In cent of urban women who attended
Kwale district, Kenya, which has one health modern medical clinics in South Africa
service facility for 12,000 people, it has strongly advocated mixing traditional and
been estimated that 24 per cent of the western antenatal care, only 63 per cent
population has a health facility within two of rural clinic attenders found this practice
kilometres distance, 58 per cent within five acceptable. All groups favoured Western
kilometres and 83 per cent within 10 over traditional care in cases of serious
kilometres.(18) By contrast, THC services pregnancy complications.28
are readily available. Every village has a
number of traditional healers and birth Asia
attendants, each with their own
specializations.19 In India, it has been found that the
Similarly, in India, rural women in influence of family structure is significant.
Gujarat were more likely to use services The presence of the mother-in-law is
which were closer to home, other things associated with a greater use of traditional
being equal. The “travel” variable (including healers.20
time and travel costs) is a more important Inadequacies in and scarcity of modern
factor determining the use of modern and medical services can contribute to the use
traditional services among women in the of traditional health services. Less than half
study area than the actual direct costs of (44%) of Chinese immigrants studied in the
the service.20 USA had used Western health services in
In the case of malaria, selection of first- the US within the previous 12 months; 20
line treatment varies from area to area. per cent reported that they had never used
Sometimes, herbal remedies are given at them. Chinese physicians stated that many
home as the first-line treatment,21,22 Chinese patients are not satisfied with
especially in mild cases of malaria.23,24 American doctors because of the inflexibility
Sometimes, herbs are the second line after of appointments, short visit, long waiting,
treatment with chemotherapy has distrust and miscommunication.29
failed.25,26 Munguti (1998) found that in In a study of health service utilization
a rural area of Kenya, seven per cent used in four villages in India, the most common
herbs as the first choice of treatment, 17 complaint by a majority of those surveyed
per cent as the second choice, and 14 per was that “medicines are never available”
cent as the third choice.27 at the primary health centre, followed by
There can be contrasting patterns of discourteous behaviour of the staff and
use across countries and regions. Whereas health personnel, “doctors never
young children in Sudan were found not available”, “doctors demand money for
164
A framework for cost-benefit analysis of traditional medicine and conventional medicine
165
Traditional Medicine in Asia
166
A framework for cost-benefit analysis of traditional medicine and conventional medicine
167
Traditional Medicine in Asia
upper respiratory tract infections were the lines of Western biomedicine and
being prescribed an average of four oriental medicine (OM) is one of the
separate drugs, always a combination of prominent aspects of the health care
Western and Chinese.36 A challenge of service. This was established by law in
integrated health care is the need to 1952.
conduct research to determine which In 1996, there were 9299 licensed
illnesses are best treated through one OM practitioners compared to 59,399
approach rather than the other. The Western practitioners. OM doctors operate
Zheijang study reported that, in practice, in the health care services in the same way
simultaneous use of both types of treatment as other medical care providers, with some
is so commonplace that their individual notable differences. The private sector is
contributions are hard to assess. dominant in OM, with almost all OM
In South Korea, the parallel operation hospitals and primary clinics being privately
of two independent medical systems along owned and operated. The great majority
of OM doctors work in self-employed
private settings at the primary care level.
In 1995, the concentration in urban areas
of OM clinics and hospitals (95.1%) was
higher than that of Western medical clinics
(90.6%) and hospitals (86.4%). Political
conflict between the OM and modern
medical sectors has been high during the
1990s over issues of fees, ability to sell and
prescribe traditional herbal medicines and
licensing of traditional practitioners.
The level of coverage of OM in the
National Medical Insurance is low and, as
noted in the section on Finance, there is
reluctance on the part of most OM practi-
tioners to provide insurance cover for OM.37
A policy guideline on OM was adopted
for the Seventh Project of the 5-year
Economic and Social Development Plan
in Korea (1992–1996). The guideline set a
goal for full integration of Western and
Oriental medicine by the year 2001. A
number of short- to medium-term mea-
sures were recommended to improve the
quality of OM care: promotion of clinical
cooperation, training of OM consultants
and lifting the customary ban on OM
doctors’ employment in the public hospital
sector. An OM care unit was set up for
the first time in the National Medical Center
in 1991.37
168
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169
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170
A framework for cost-benefit analysis of traditional medicine and conventional medicine
171
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outlines activities to be carried out from proposition for a mix of traditional and
2000–2004, and will be reviewed every modern medicine is an agenda of incorpo-
two years. It proposes, among other rating the former into the political-
aspects, the need to develop a compre- economic arena and cultural hegemony of
hensive training in TRM from basic and biomedicine.46 Clearly, if TRM is to be given
secondary to tertiary levels. a formal place in national health care, this
A ‘Ghana Herbal Pharmacopoeia’, process needs to be done not only in close
containing scientific information on 50 consultation with the traditional health
medicinal plants, has been published. A sector, but taking direction from them as
second volume is currently in preparation. to appropriate models of partnership,
Efforts are being made to integrate TRM into formalization and training.
the official public health system and it is One commentator has outlined six
expected that by the year 2004, certified recommendations for effective integration
and efficacious herbal medicines will be that cover many of the major salient issues:
prescribed and dispensed in hospitals and z Promotion of communication and
pharmacies. The Ghanaian Government mutual understanding among different
has set aside the third week of March every medical systems that exist in a society;
year as a Traditional Medicine Week, starting z Evaluation of TRM in its totality;
from the year 2000. z Integration at the theoretical level and
In Nigeria, the National Agency for the practical level;
Food and Drug Administration and Control z Equitable distribution of resources
(NAFDAC) has taken steps to regulate and between traditional and modern
control TRM products with a view to Western medicine;
ensuring their safety, efficacy and quality. z An integrated training and educational
In consultation with traditional healers and programme for both traditional and
researchers, NAFDAC has developed modern Western medicine;
guidelines on regulating herbal medicines. z A national drug policy that includes
Recently, the Government of Nigeria traditional drugs.5
approved a national policy on a Traditional
Medicine Code of Ethics. Draft legislation Recognizing the need for a policy to
has been prepared to establish national reflect public health care demands and
and state Traditional Medicine Boards to patterns of use, the 12th Commonwealth
enhance the regulation of TRM practice Health Ministers’ Meeting in November
and promote cooperation and research in 1998 established a Working Group on
TRM.45 Traditional and Complementary Health
Clearly, planning for the formalization Systems47, 48 (Nelson, 1998; Bodeker,
of traditional health services has many 1999). The Working Group was commi-
dimensions that need to be addressed, ssioned to develop an action plan to
depending on the state of current sectoral promote and integrate traditional systems
development, level of political will, budget of health and CM within national health
resources available, training infrastru- systems, giving consideration to:
cture, the model of formalization suitable z Policy Framework, including:
to and preferred by the country and by the provision of services
traditional health care community. It has conservation of medicinal plants and
been argued that, underlying the general related intellectual property rights;
172
A framework for cost-benefit analysis of traditional medicine and conventional medicine
173
Traditional Medicine in Asia
174
A framework for cost-benefit analysis of traditional medicine and conventional medicine
An older woman I knew in Papua New Guinea did not perform any visible
economic activity, being old and weak. On the surface she consumed rather
than produced resources; thus there was little incentive to spend still more
on maintaining her health.
But what of the value of her knowledge and wisdom in the resolution of family
conflicts?
What of her value in the education of the children through myths, storytelling
and personal history?
What of her knowledge of herbal and household remedies for common
illnesses?
How to assess in monetary terms the fact that she can call upon the support
of other community members in times of hardship, just as she has assisted
them in times past?
These are vital contributions to the continued health of her community, but
we have a long way to go before we can cost them.
Too often the economic spotlight is turned upon the more straightforward
task of assessing the cost of her arthritis or her chronic obstructive lung
disease: inevitably, she shows up as a negative item on the balance sheet.
(Hill, 1997)(55)
175
Traditional Medicine in Asia
for building relevant and viable traditional ward’s profit, under the market model of
health services. In Sri Lanka, Aluwihare health care provision that is in place, is the
(1997) has examined sets of figures on 15–25 per cent mark-up for prescribed
such indicators as infant mortality and medications, so the changed incentive
women in the labour force. His finding is system has become associated with
that national aggregate data do not help increased polypharmacy.59
in the appropriate targeting of resources. Under the market system, many TCM
Rather, the best way would be to target hospitals in China operate at a deficit, as
the parts of the country where the figures better equipped Western hospitals attract
are the least satisfactory, as a dollar there more patients. As TCM is largely an
would have produced a better effect than outpatient, low technology specialty, most
10 dollars in an area which had better of the income of traditional hospitals comes
parameters.58 The use of data that are from the sale of drugs. Even with the 25
disaggregated by place and time is a more per cent mark-up allowed, it is hard to cover
effective way of identifying “weak” points operational costs. While Government
where specific action is needed. This subsidies currently ensure survival, there is
would require that TRM utilization no surplus for improving services and
studies be incorporated into national further market reforms may threaten this
health service research as well as studies subsidy system.36
on the availability, quality and cost of The experience in Taiwan is that
traditional health services on a region-by- insurance coverage for TRM would more
region basis. than double the use of TCM. Whereas
35.4 per cent of Taiwanese reported using
Health insurance for traditional TCM regularly, 86 per cent of the public
medicine would support the coverage of Chinese
As noted in the section on Utilization, health medicine by the new National Health
insurance coverage can lead to a Insurance and 79 per cent would use
substantial increase in the use of TRM Chinese medicine if it does.5
services. In a Korean immigrant population High profitability of TRM can lead to
in Los Angeles, 24 per cent of the its custodians resisting moves to provide
uninsured used traditional healers, insurance coverage for their services and
compared with 59 per cent of persons with products. In Korea, where the profit margin
Medicaid only and 71 per cent of those of herbal medicines is variously estimated
with other types of insurance including to be 100–500 per cent compared to their
Medicare and Medigap coverage. basic cost,37 the population utilize herbal
In China, although traditional health medicines on a large scale.37 The amount
services are covered by health insurance, of reimbursement for herbal medicine
only about 12 per cent of the population under the National Medical Insurance
has comprehensive medical insurance that (NMI) scheme was approximately 50 billion
covers the cost of hospitalization, and the Korean won in 1993. This was estimated
proportion of uninsured people may be as to be only a small portion of total expendi-
high as 50 per cent.59, 49 In hospital ture on herbal medicines.37 The high
settings, insured patients are more likely to returns on herbal medicine boosted the
receive TCM.59 This is due to the fact that socio-economic status of TRM doctors to
one of the primary sources of a hospital the extent that about two-thirds (64%) of
176
A framework for cost-benefit analysis of traditional medicine and conventional medicine
177
Traditional Medicine in Asia
178
A framework for cost-benefit analysis of traditional medicine and conventional medicine
taining old stereotypes of inferior services at the theoretical and practical levels.
and knowledge in TRM. If health insurance Governments and inter-national organi-
coverage is provided for TRM, national zations, such as WHO, should work to
schemes should be weighted in support of ensure that there is equitable distribution
continued access by the poor to TRM. of resources between traditional and
A necessary backdrop to economic modern Western medicine.
analyses is a social analysis which examines An integrated training and educational
the extent to which there is demand for programme is needed for both traditional
traditional health services, who the clients and modern Western medicine. And finally,
are, what the conditions are that they bring there is a need for a national drug policy
for treatment, and how they rate the quality that includes traditional drugs.
of both traditional and conventional health Economic analysis of TRM is necessary.
care services. Political priorities can frame As we have seen, there are five broad
and set the pace of formalization of THC. means of conducting such research: cost
The traditional health sector is, can and descriptions; cost-comparison studies;
should be part of this equation in the cost-effectiveness analysis and cost-utility
interests of ensuring appropriate develop- analysis. The selection of methodology will
ments in policy, regulation, accreditation, depend on who is asking the question –
service development, standards of practice, Government, insurer, consumer advocate,
training and research. etc. A necessary starting point is transpa-
A comprehensive yet flexible infra- rency in stating the priorities lying behind
structure is necessary to address the the research and the research question,
diverse areas within the THC sector. These e.g., cost-savings, quality of life improve-
include: legislation, regulation, financing, ment, etc., in order to enable a balanced
research, product development, education interpretation of the outcomes of the
and training , and sustainable medicinal research.
plant production. Cost-benefit research is needed and,
Priority areas for collaboration include increasingly will be done. While comparing
diseases such as TB, malaria64 and HIV/ outcomes and costs of traditional and
AIDS.(65) Here new sets of economic conventional interventions, care is needed
questions present themselves and these to avoid the charge that is sometimes
must include the ethics of not evaluating made that cheap medicines are being
the medicines that the public uses for home- produced for poor people, with some
treatment of serious diseases. disregard for quality and efficacy.
A mechanism is needed for sharing As this is a nascent field, it would
experience in policy and service benefit from the emergence of a specialized
development both within and between group of researchers who are linked,
countries. Communication and mutual potentially via the internet, to share
understanding should be promoted among experience, models of research and
different medical systems that exist in a findings. Such a group would work to
society. In evaluating TRM, this should be develop priorities in an international
done as a system in preference to selecting research agenda, refine evaluative
single therapeutic modalities to be methodologies and articulate ethical and
evaluated for a specific effect. Integration cultural perspectives to broaden the scope
of health services should be coordinated of economic analyses.
179
Traditional Medicine in Asia
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182
Development of training programmes for traditional medicine
Development of training
programmes for
traditional medicine
Palitha Abeykoon
O. Akerele
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Traditional Medicine in Asia
are left to their own devices which often Some lessons and questions
means recognized traditional health from past experiences
practitioners and/or charlatans. This
situation highlights one facet of the social To place education and training as a sub-
injustices that are being perpetrated, system in the health system in South-East
knowingly or unknowingly, by policy- Asia, it is useful to examine some of the
makers and administrators in most relevant experiences that have been
developing countries. accumulated and which are of direct
Most, if not all, traditional medicine relevance to these countries. A small
practitioners are inadequately trained for number of these experiences have been
the tasks that they perform in their extracted and summarized here as it would
communities. In spite of this, licensed and help in the elaboration of national health
unlicensed practitioners continue to be policy related to traditional medicine.
readily available to the sick in rural and We have useful lessons from a number
peri-urban settings, prescribing ethical and of African countries that have attempted
non-ethical as well as rational or irrational to bring traditional medicine into the
modern medical drugs to those they see in mainstream of the health services, often
their daily practices. In the main, their without much success. For example, one
activities are restricted to curative practices country, at independence, tried to correct
only. the situation inherited by adopting policies
The education and training of and promulgating legislation that were
traditional practitioners becomes a crucial encouraging to traditional practitioners
issue in this context. Of course, it is also a but, at the same time, alienated them from
fact that education and training responses the formal health personnel.2 Conse-
per se will not address, let alone solve, quently, the existing gap between the two
many of the problems and issues related types of practitioners further widened.
to the incorporation of traditional medicine Cooperation and collaboration should
to complement the modern systems of be brought about as a purposeful part of
medicine in our countries. This paper the overall development of the national
outlines some of the contextual issues in health policy and not as a result of
the integration of traditional medicine with injudicious or hasty adoption of policies to
the general health care services, and promote traditional medicine which, in fact,
suggests a rational framework and some have often tended to discredit it. The
practical guidelines for the development of identification and categorization of the
human resources in traditional medicine. various traditional practitioners should be
Therefore, the list of issues and the a national undertaking with the intention
suggestions offered in this paper do not of improving health benefits for the people,
pretend to be exhaustive. However, taken as has been done in China, India, Mexico,
together, they are key questions and issues Sri Lanka and Thailand.
to be answered before designing any A good policy should be the ultimate
meaningful education and training expression of a consensus and, therefore,
programme for traditional medicine, the necessity of involving traditional medical
including defining the role of traditional practitioners at all stages of this process
health practitioners in the district health cannot be overemphasized. Such consul-
system. tation is most easily achieved when there is
184
Development of training programmes for traditional medicine
185
Traditional Medicine in Asia
186
Development of training programmes for traditional medicine
z Educators and trainers acting in z The roles have social and managerial
ignorance of planning and manage- as well as technical aspects that require
ment have abandoned the logic of an interdisciplinary approach to role
purposeful education and the relevance definition and training;
of their programmes to the needs of z The roles of each health worker include
society; establishing and maintaining important
z Health services managers who act relationships with others, and this
independently of plans and education requires consideration of the overall
and training have given away their most function of a team as well as training
important management tools, for teamwork;
including the influencing of the health z The roles involve close interaction with
personnel they want to utilize. communities, which requires not only
an understanding of the nature of that
Defining the characteristics of interaction, but also calls for the
graduates of educational and participation of communities in the
training programmes process of role definition.
It seems obvious that the roles to be fulfilled
by graduates of educational and training Key questions/issues and some
programmes should serve as a basis for answers
determining the content and methods of (1) How can the formal health services
learning, yet this process is seldom given work with traditional practitioners for
careful attention. Most often, the roles are the benefit of the population? Why?
taken for granted, based largely on Because so far, traditional practitioners
outmoded recollections, or on the assum- have been excluded from exercising any
ption that graduates can adapt to the responsibility in most national health
situation in which they find themselves. services.
Furthermore, the training institutions often (2) How can a traditional medicine
do not even consider it necessary to train infrastructure be created? Why?
students for well-defined roles and Because, without a clearly defined
functions. When graduates complain infrastructure, through which tradi-
that their preparation was not adequate, tional health practitioners themselves
the programmes are only occasionally could be heard and which could be a
modified. regulatory body in relation to ethical
To ensure the relevance of health and professional matters, there is likely
manpower preparation, it is necessary that to be chaos.
there is a full understanding of the personal (3) How to sensitize, orient and use health
and professional competencies, including professionals and others so that they
the intellectual and practical skills, values, may support the national traditional
and attitudes required if health workers are medicine programme? Why?
to function effectively in the settings to which Because, if they are brought into a
they are assigned.5 The development of such constructive relationship with the
an understanding involves several problems: programme, they will continue with
z The roles to be filled may not yet exist their biases and hamper Government
but are planned; this is a common efforts to put traditional medicine on a
occurrence in evolving health systems; sound footing.
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Traditional Medicine in Asia
(4) How to review health legislation (6) How to develop a national drug policy
concerning traditional medicine? that includes traditional medicine?
Why? Why?
Because, most of the present legislation Because, importing drugs is always very
in this field is outdated or irrelevant and costly and consumes scarce foreign
needs to be revised to conform with the currency. Developing traditional
new policies adopted. In any case, a remedies of proven efficacy and quality
reasonable and enforceable legislation will not only promote self-reliance but
would greatly enhance the implemen- will also encourage research workers
tation of traditional medicine activities. to investigate other traditional
(5) How to define the role of bilateral and remedies more carefully.
multilateral assistance? why? (7) How to formulate up-to-date research
Because, any external support should and development policies in traditional
be consistent with Government policies medicine? Why?
and priorities; otherwise, it may lead Because, at present research policies
to unnecessary and wasteful invest- in most countries do not reflect the role
ment in esoteric projects which have of traditional medicine in health
no direct relevance to the people’s services. New research and develop-
health needs. ment policies could greatly assist
188
Development of training programmes for traditional medicine
institutions in addressing the critical (e) In parallel with the work outlined
problems now being faced. above, it will be necessary to undertake
(8) How to finance traditional medicine a survey of the national situation in
activities? Why? respect of the practitioners, the
Because, the introduction of traditional population’s preferences and needs,
medicine activities will require adequate resources, special problems, etc., upon
budgetary appropriations. A sound which a sound national health plan
programme and budget that maximizes reflecting the role of traditional
the effective use of all available resources medicine may be formulated. Practi-
needs to be evolved. tioners of traditional medicine should
(a) There is no single or simple approach be engaged in these activities and the
to the problem of how to involve results should be made widely known
traditional practitioners in national to the general public as well as to the
health systems, especially at the health professions.
primary health care level. Dedicated (f) The institution of practical, low-cost
and sincere action on the part of all traditional medicine activities need not
concerned will be required to foster a await the results of these surveys. One
collective effort to generate and of the first activities should be the
implement policies best suited to any generation of a public debate that
given country. should include special educational
(b) The first step could be the establishment efforts for the public (press, TV and
of a National Council for Traditional radio), distribution of information on
Medicine, that could be charged with traditional medicine, and short courses
responsibility for preparing a national for traditional practitioners and
strategy of laying down a broad plan conventional health personnel, as an
of action to be followed by the initial step, to secure their involvement.
Government. The Council should be
multidisciplinary and multisectoral in There are three basic changes and
nature, with appropriate represen- reorientations that are needed in the
tation of the different types of traditional education and training programmes in
practitioners involved. traditional medicine. Firstly, more attention
(c) Major policy issues need to be must be paid to problem-solving skills as
identified quickly, priorities determined the current curricula are overburdened with
and mechanisms established to propose the pursuit of knowledge and information,
the various options and courses of much of it is irrelevant to the priority tasks
action open to the Government, with needed to meet the health problems of
ad hoc groups being formed to tackle communities. The curricula also need to
specific issues. be more problem-oriented and community-
(d) Adequate finance should be assured oriented, if not community-based. In
under the Government’s regular addition, appropriate teaching and
budget for the support and promotion learning strategies need to be developed
of traditional medicine activities. for traditional medicine practitioners to
External finance should be considered work in teams.
as only supplementary to the Secondly, the education and training
Government’s main effort. programmes in traditional medicine need
189
Traditional Medicine in Asia
190
Development of training programmes for traditional medicine
should be sequential and progressive, and among them in this subject. It would be
specific learning objectives should be easier when, and if, the two systems are
derived from the competencies required for available to the community in some
more effective and efficient performance.6 integrated or coordinated manner so that
Here, there are greater opportunities than the practitioners communicate regularly
with basic-level programmes to pursue with each other.
multi-professional or team-and-problem-
oriented approaches to education. Conclusion
Since the purpose of continuing
education is enhanced job performance in Many years have passed since the World
the health services, it must be associated Health Assembly first urged interested
with other factors that contribute to high governments to give adequate importance
levels of staff morale and productivity. to the utilization of their traditional systems
Continuing education is, therefore, not only of medicine with appropriate regulations
a part of the training component of human as suited to their national health system
resource development, but of human (Resolution WHA30.49). So far no clear
resources management as well. In China picture as to how this was to be imple-
these aspects are reasonably well- mented in many countries has evolved and
articulated in the continuing education of many public health administrators look on
traditional medicine practitioners. It traditional medicine with continued
requires cooperation between the trainers cynicism. Without a proper understanding
and the health service managers. at Government level of the issues involved
and the creation of an informed body of
Orientation of medical students opinion on the subject among the health
and practitioners in traditional profession and the public, there will be no
medicine significant move to utilize traditional
In order to foster and generate an medicine in national health systems.
atmosphere of cooperation between the One tends to speak as if the traditional
practitioners of modern and traditional forms of medicine and their practitioners
medicine, one requirement would be to are each homogeneous entities. It is,
orientate the students and practitioners of however, important to distinguish between
Western medicine in traditional medicine. the “formalized” traditional systems of
This should therefore be taken up as a medicine, such as Ayurveda, Unani, and
parallel activity. In India, for example, it is Chinese traditional medicine and the
now compulsory for medical students to practice of those practitioners who are
have a certain number of hours of recognized by their communities as being
instruction dedicated to traditional competent to provide health care. These
medicine. This is a good start and, later, it practitioners serve a long apprenticeship
may be possible to incorporate some and their knowledge is handed down from
assessments also into this. It would be generation to generation, mainly by word
desirable to similarly orientate the of mouth.
practitioners of Western medicine in There are also various types of healers
traditional medicine, but this would be a whose practices are based on spiritual or
much more difficult exercise as there would moral convictions and others more difficult
be few available ways of generating interest to define but who, nevertheless, are
191
Traditional Medicine in Asia
References
1. Primary Health Care. Report of the International Conference on Primary Health Care.
Alma-Ata USSR. 6–12 September 1978. Geneva. World Health Organization. 1978
(“Health for All” Series, No. 1).
2. Stephan, J. “Legal Aspects: patterns of legislation concerning traditional medicine.”
In: Bannerman, R. H. et al. ed. Traditional medicine and health care coverage: a
reader for health administrators and practitioners. Geneva. World Health Organization.
1985.
3. Akerele, O. “Towards the utilization of traditional Medicine in National Health Services”
In: American Journal of Chinese Medicine. Vol. XIV. Nos.1–2. 2–10.
4. Report of the Regional Consultation on Development of Traditional Medicine in
South-East Asia region. World Health Organization. New Delhi. 14–17 September,
1999. Regional Office for South-East Asia. 1999.
5. Health Manpower Requirements for the Achievement of Health for All by the Year
2000, through Primary Health Care. Technical Report Series 717. Geneva. World
Health Organization. 1985.
6. Guilbert, J.J. Educational Handbook for Health Personnel. World Health Organization.
Geneva. 1981.
192
Technical issues
Legislation and regulation of traditional
systems of medicine - systems, practitioners
and herbal products
Dr. D.C. Jayasuriya
Dr. Shanti Jayasuriya
Standardization, pre-clinical toxicology
and clinical evaluation of medicinal plants,
including ethical considerations
Prof. Ranjit Roy Chaudhury
Dr. Mandakini Roy Chaudhury
Protection of traditional systems of
medicine, patenting and promotion of
medicinal plants
Prof. Carlos M. Correa
Research, drug development and
manufacture of herbal drugs
Dr. B.B. Gaitonde
Traditional Medicine in Asia
194
Legislation and regulation of traditional systems of medicine – systems, practitioners and herbal products
Legislation and
regulation of traditional
systems of medicine –
systems, practitioners
and herbal products
D. C. Jayasuriya
Shanti Jayasuriya
a Law No. 23/94/ADP of 19 May 1994 promulgating the Public Health Code (IDHL, 1995, 46 (4), 452).
195
Traditional Medicine in Asia
196
Legislation and regulation of traditional systems of medicine – systems, practitioners and herbal products
197
Traditional Medicine in Asia
198
Legislation and regulation of traditional systems of medicine – systems, practitioners and herbal products
e WFPMM, Self medication: progress built on tradition (Swiss Pharma 11a/91), pp. 54–91; Drug Information Journal,
Vol. 27, 1993, pp. 145-168; and Chaudhury, R.R. Herbal medicine for human health, New Delhi, WHO, 1992
199
Traditional Medicine in Asia
200
Legislation and regulation of traditional systems of medicine – systems, practitioners and herbal products
reportedf the presence of several scheduled The dispensing and sale of medicinal
poisons and controlled substances, products and medicinal plants are
including betamethasone, dexamethasone, governed not only by the laws dealing
chlorpheniramine, mefanamic acid, specifically with drug regulation but also
phenylbutazone, and dexachlorphe- by those dealing with the health-related
niramine, in both domestically produced professions. Statutory provisions relating to
and imported herbal medicinal products. medicinal plants, where they exist, are
This resulted in the confiscation of stocks based on a range of different approaches
and the banning of these products from and modalities. In France, for instance,
domestic markets. certain essential oils derived from plants
may be sold or supplied to the public only
Approaches to the export of by pharmacists. In the Republic of Korea,
medicinal plants herbal practitioners – a category of health
A few countries require all exports to be professionals who need to pass an
regulated. In Spain, for instance, the export examination to be granted this status –
of medicinal plants is subject to the may sell herbs by preparing them in
issuance of a certificate of guarantee by accordance with the specifications in
the competent pharmaceutical inspectorate. oriental medical books or prescriptions of
Other countries which cultivate oriental medical doctors.
medicinal plants have sought to promote In the United Kingdom, herbal
exports by specifying the competent remedies are sold on a retail basis by
regulatory authority in the legal text. In Mali, shopkeepers (e.g., ‘health foods’ shops,
for instance, one of the statutory responsi- supermarkets, grocers); herbalists (i.e.,
bilities of the Office of Pharmacy is to persons who make and sell herbal
promote the export of products of its own remedies to persons who consult them);
research and manufacture, particularly and pharmacists. In Bulgaria, only persons
drugs based on medicinal plants. Similarly, in possession of medical qualifications may
the National Pharmaceutical Office of receive authorization by the Ministry of
Benin is required to promote the export of Health to prescribe medicinal plants. In
medicinal products. Brazil, medicinal plants may be dispensed
In some countries, however, specific only within pharmacies and herbalists’
restrictions are applied to the export of shops. Lesotho has a system – admini-
protected plants. In Mali, prior authori- stered by the Universal Medicinemen and
zation of the Director-General is required Herbalists Council – of licensing medicine-
for any activity involving the collection of men and herbalists. In Morocco, there is a
medicinal plants for export. In 1976, a statutory prohibition on the simultaneous
WHO expert group on traditional practice of the profession of physician,
medicines 9 called upon countries to dental surgeon and midwife, on the one
regulate the export of medicinal plants for hand, and that of a herbalist, on the other,
commercial purposes – a call that remained even if the latter is otherwise qualified to
largely unnoticed until the elaboration of practise any of the other professions. Those
the United Nations Convention on licensed as a herbalist may sell any
Biological Diversity. medicinal plant and parts of any such
f Annon. Contaminated herbal medicines in Malaysia. SCRIP, No. 1892, 28 January 1994, p. 19.
201
Traditional Medicine in Asia
plant, with the exception of those plants of Tanzania, the Institute of Medical
included in the list of poisonous substances, Research and Medicinal Plants of
and no herbalist may store or sell any other Cameroon, and the National Institute for
pharmaceutical preparation or speciality. Research on the Traditional Pharmaco-
poeia and Traditional Medicine of Mali have
Labelling, Advertising and a statutory responsibility to undertake
Promotion research relating to medicinal plants.
Few regulatory texts have specific provisions
concerning the labelling, advertising and Conclusions
promotion of medicinal plants. Those that Despite increasing pressures for the
do address these issues tend to extend to introduction of controls, relatively few
herbal medicines the general provisions countries have enacted specific legislative
applied to other medicinal products. A few measures to control either the use of
countries do have discrete and specific medicinal plants or of herbal preparations
provisions derived from them in respect of which there
Norway requires herbs and blended is only limited data concerning their quality,
herbs available over-the-counter (OTC) to safety and efficacy. Legislative texts of those
carry the following warnings countries that have developed systems for
“The medicinal effect of this the scientific and technical assessment of
preparation has not been assessed by the the quality, safety and efficacy of medicinal
public authorities responsible for the plants, as well as guidelines formulated
control of medicaments”. under the aegis of the World Health
Brazil requires the botanical classi- Organization, define the criteria for
fication of the medicinal plant to appear assessment and the procedures to be
on labels and wrappers. No proprietary followed in undertaking such assessments.
name is required in China either for As the assessment of medicinal plants
medicinal plants or for decoctions cannot be guided by systematic or long
prepared in accordance with Chinese experience, it is important that drug
traditional medicine. Indonesia requires regulatory authorities wishing to regulate
that traditional drugs intended for clinical medicinal plants as well as assess them
trials must be labelled with the words make the maximum use of the accumulated
“intended for Clinical Trials; Not for Sale”. wisdom of those authorities with more
Gambia prohibits all advertising of experience in this relatively unchartered
products derived from plants cultivated in territory. The new United Nations Convention
the country and used as traditional on Biological Diversity offers a stimulus to
medicines, unless specific approval has countries that wish to review the control of
been obtained from the Medicines Board. medicinal plants within a framework that
maintains a balance between reasonable
Research and Institutional exploitation and conservation.
Mechanisms
Several African countries provide for further Traditional Medical
research on medicinal plants. The National Practitioners
Pharmaceutical Bureau of Burundi, the
Central Laboratory at Mototo in Guinea, Traditional medical practitioners exist in
the National Institute for Medical Research almost every society; not all prefer to be
202
Legislation and regulation of traditional systems of medicine – systems, practitioners and herbal products
called as “traditional medical practitioners” part that they can play in the system of
because with the advent of the Western comprehensive health care (health
system of medicine, Western medical promotion, prevention of disease and
practitioners have come to enjoy an almost disability, diagnosis and early treatment
monopolistic position, with the attendant of disease and rehabilitation.”g
status, privileges and concessions. In some
countries, by law there are restrictions in A definition of a traditional health
the use of the term “medical practitioner” practitioner is found in the Public Health
or “doctor’, thus placing traditional Code of Guinea of 1997:h “A traditional
medical practitioners at a disadvantage. It health practitioner is a person recognized
has never been easy to establish the precise by the community in which he lives as
role and status of traditional medical competent to carry out diagnoses with
practitioners. Community acceptability, local sociocultural foundations and
political patronage and perception as a contribute to the health and physical,
source of last resort when practitioners of mental, social, and spiritual well-being of
other systems have failed to provide relief the members of the locality concerned.” In
are some of the factors that come into play addition to this definition, there are separate
in determining the recognition to be definitions of traditional therapists;
accorded to them. Attempts have been traditional midwives; herbalists; and,
made by some countries to initiate a medico-druggists. These are reproduced
process of dialogue and consultation with below:
a view to arriving at some compromise.
Mauritania, for instance, established a Traditional A person recognized by his
working group on medicine and the therapist locality as being competent to
pharmacopoeia: carry out diagnoses and
“to determine the situation of dispense health care based on
traditional medicine and the traditional the concepts of disease and
pharmacopoeia in Mauritania and, in disability that prevail in that
particular: locality;
z to examine the most appropriate and Traditional A person recognized as
realistic ways and means of establi- midwife competent to provide health
shing an honest dialogue between the care to women and newborns
official health services and traditional before, during and after
practitioners in the spirit of the delivery, on the basis of the
objectives of health for all by the year concepts prevailing in the
2000 through primary health care; locality concerned;
z to propose the most appropriate Herbalist A person who has a know-
mechanisms for identifying traditional ledge of the customs and sells
medical practitioners who are medicinal plants;
amenable to such a dialogue in order Medico- A person who has a know-
to determine and acknowledge the druggist ledge of the customs and sells
g Decision No. 1831 of 9 December 1981 establishing a working group on medicine and the pharmacopoeia (IDHL,
1983, 34 (1), 122).
h Law No. L/97/021/AN of 19 June 1997 (IDHL, 1999, 59 (2), 162).
203
Traditional Medicine in Asia
204
Legislation and regulation of traditional systems of medicine – systems, practitioners and herbal products
205
Traditional Medicine in Asia
206
Legislation and regulation of traditional systems of medicine – systems, practitioners and herbal products
207
Traditional Medicine in Asia
References
1. Wolffers I. Traditional practitioners and western pharmaceuticals in Sri Lanka. The
Context of Medicines in Developing Countries. Amsterdam. Klluwer Academic
Publishing. 1988: 47–56.
2. Nakajima H. Our earth and our health. Natural resources and human health-plants of
medicinal and nutritional value. Amsterdam. Elsevier. 1992: 1.
3. Akerele O. Nature’s medicinal bounty: don’t throw it away. World Health Forum.
1993; 390.
4. Reid W.V., et al. A new lease on life. Biodiversity prospecting: using genetic Resources
for sustainable development. Washington D.C. World Resource Institute. 1993: 7.
5. Kobe Conference. Plants of medicinal and nutritional value. Natural resources and
human health. Amsterdam. Elsevier. 1992: xi.
6. De Klemm C. Medicinal plants and the law. Conservation of medicinal plants.
Cambridge. Cambridge University Press. 1991: 265.
7. WHO. Guiding principles for small national drug regulatory authorities. In: WHO
Expert Committee on Essential Drugs: Fifth report. WHO Technical Report Series.
Geneva. World Health Organization. 1992; 825: Annexure.
8. Jayasuriya D.C. The regulation of pharmaceuticals in developing countries: legal
issues and approaches. Geneva. World Health Organization. 1985.
9. WHO. African traditional medicine. Brazzaville. WHO. 1976; (TRS No. 1):20.
10. Stepan J. Legal aspects. Traditional Medicine and Health Care Coverage. Geneva.
WHO. 1983: 290–313.
208
Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations
Standardization,
preclinical toxicology and
clinical evaluation of
medicinal plants, including
ethical considerations
Ranjit Roy Chaudhury
Mandakini Roy Chaudhury
209
Traditional Medicine in Asia
been clearly brought out by Handa in his can be seen in many countries of South-
contribution to the Regional Consultation East Asia.
on Development of Traditional Medicine in The need for standardization has long
South-East Asia Region held in New Delhi been recognized. The World Health
from 14–17 September, 1999.2 Bottle- Organization organized an Inter-Regional
necks in the standardization of herbal drugs Meeting on Standardization and Use of
include dependence on wild sources for the Medicinal Plants at Tianjin in China in
plants leading to variation in quality, November 1980.3 Participants clearly
adulteration and substitution of the active pointed out the problems relating to
plant material by inactive, cheaper varieties standardization of herbal medicines and
of non-medicinal plants, and in many cases the tremendous need for immediate work
incorrect identification of the plant itself. in this field. A second conference, also
This is because the same plant may have organized by the Western Pacific Regional
different local names at different locations Office of the World Health Organization
while sometimes different plants have the at Tokyo in 1986, identified three areas of
same local name. A good example of the priority research.4 Research on standardi-
latter is that the plant which is commonly zation was one of these areas. Standardi-
known as Punarnava, a quality-of-life zation, it was stressed, means standardi-
enhancer, is collected under the botanical zation of the raw material, standardization
name of Boerhaavia diffusa and also of the method of production and quality
collected under the name Trianthema control of the final product. The Regional
portulacastrum (Vishakarpara). This would Consultation at New Delhi held in 1999[2]
certainly lead to problems in standardizing again highlighted the need for standardi-
Boerhaavia diffusa if some Trianthema zation but added some new features to this
portulacastrum is also contained in the issue.
sample. Parikh2 in his presentation at the New
The loss in medicinal plants due to Delhi meeting organized by the World
ecological degradation has led to a Health Organization made a strong plea
shortage of the actual plants and for cultivation of medicinal plants rather
substitution by other non-medicinal plants. than collection from the wild. Standardi-
One example is the preparation of a herbal zation of herbal preparations from plants
drug from the bark of the plant Caesalpinia which are cultivated would be easier for
sappan (Patranga). When this bark is the following reasons. The availability of the
collected, the bark from other plants such plant material would be assured and the
as Pterocarpus marsupium (Vijayasara), supplies could be controlled. The quality
Gluta travancorica and Toona ciliata of such plants would be reliable, identi-
(Nandivriksha) or Cedrela toona are fication totally accurate and adulteration
substituted for Caesalpinia sappan. Other would not be an issue. Further, in this
examples which have been found in India system the environment would be main-
relate to the substitution of the bark of tained. Other possible advantages would
Saraca indica (Ashok) by the bark of be the possibility, in these controlled
Trema orientalis (Jivanti) and substitution conditions, of carrying out agronomic
of the plant Holarrhena antidysenterica manipulation and genetic improvement.
(Kutaja) by the plant Wrightia tinctoria (Asita A reference was also made by Parikh2
kutaja). Similar instances of adulteration to the global market for medicinal plant
210
Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations
products which had been estimated to be WHO Geneva, which followed the 1992
of the order of five trillion dollars in 2050. document “Quality control methods for
Only those countries which invest imme- medicinal plant material”. Investigators
diately and well in setting up standardi- interested in details of the methodology
zation of herbal products could hope to proposed for use are requested to study
exploit this worldwide growth in the need the publication brought out in 1998.
for herbal products. Countries will, in the Another positive development has been
years to come, not allow products which the publication of Herbal Pharmacopoeas
are not standardized to be sold. which have laid down the standards for the
Another major constraint in setting up different procedures. WHO has recently
standardization procedures is the non- brought out its first Pharmacopoea
availability of standards against which containing standards for plants. Other
products could be assessed by chemical pharmacopoeas available include the
or bioassay methodology. British Herbal Pharmacopoea (1990),
Advances have been made in the last Japanese Standards for Herbal Medicines
10 years in the standardization of herbal (1993), Ayurveda Formulary and
products. It is expected today that the Standards for Ayurvedic Formulations
following macroscopic, microscopic, (1978), the Central Council for Research
physicochemical and biological tests in Indian Medicine “Pharmacopeal
should have been carried out before any Standard for Ayurvedic Formulations
plant material is released for use. (1987), the Ayurvedic Pharmacopoea of
z Macroscopic examination; India (1989), the Unani Pharmacopoea
z Microscopic examination; (2000), National Formulary of Unani
e.g. Anatomical structure Medicine – Part I (1984) and Part II (2000),
Detailed study of fragments; the Pharmacopoea of the People’s Republic
z Physiochemical testing of China and the Indian Herbal Pharma-
e.g.Boiling point; copoea (1998), volumes one and two.
Freezing point; In spite of these advances, standardi-
Absorption coefficient; zation of herbal preparations needs to be
Loss on drying; given a big boost by governments in the
Ash value; Region if the tremendous potential of
Refractory index; ancient heritage and biodiversity is to be
Optical ratio; used for the people of the countries for
Water/alcohol soluble solid; delivering improved health care. Herbal
Spectroscopic analysis; medicines would be much more widely used
Thin-layer chromatography – R.F. nationally and internationally, would be
value; much more accepted and would tremen-
Gas liquid chromatography. dously enhance health care if improved
z Biological testing where appropriate standardization provides credibility to the
e.g. Digitalis bioassay. quality of the medicines used. Unfortu-
nately, there are very few centres for
A big step forward towards improved standardization of herbal products in the
standardization of plant medicines was the Region, too few qualified and trained
publication in 1998 of the “Quality control experts in this area of expertise, and a lack
methods for medicinal plant material”5 by of sustained funding for standardization
211
Traditional Medicine in Asia
212
Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations
213
Traditional Medicine in Asia
documentation of such an effect, then the no rigid framework, as has been prepared
preparation can be used clinically. Lack of for synthetic drugs, will ever be possible.
documentation of a side-effect or a harmful So much depends on the way the extract
effect does not always mean that there is or plant is administered, the duration of
no such effect. It may not have been use, the dose and so many other factors
observed or, even if observed, it may not that the framework established by the
have been documented. In fact, the WHO Chandigarh group in 1980 and broadly
publication13 on “General Guidelines for accepted by the Indian Council of Medical
methodologies on research and evaluation Research and the World Health Organi-
of traditional medicine” makes this point zation can remain only a framework. The
when it states clearly “Absence of reported actual requirements may have to be slightly
or documented side-effect is not an absolute altered from plant to plant. The actual tests
assurance of safety of herbal medicine. to be carried out in the Chandigarh model
However, a full range of toxicology tests may and the duration have been described in
not be necessary. Tests which examine Tables 1 and 2. The tests recommended
effects that are difficult or even impossible by WHO are given in Table 3. This has
to detect clinically should be encouraged. been given in detail in the 1996
Suggested tests include immunotoxicity, document of the Western Pacific Region
genotoxicity, carcinogenicity and repro- of WHO.11 Another point which needs to
ductive toxicity”. This latest WHO Guideline be made is that evaluation of literature
(2000)[13] does not take a step backward does not mean only anecdotal information
but takes a broader perspective on the need that a plant has been used for centuries
for toxicological evaluation of herbal without inducing any side-effect. This sort
remedies. It still reiterates that: “Only when of information has very limited value.
there is no documentation of long historical However, if some clinical studies have been
use of a herbal medicine or when doubts carried out then the value of absence of
exist about its safety, should additional side-effects is enhanced. These clinical
toxicity studies be performed”. There studies should, however, be looked at
appears to be some anomaly between the carefully especially with regard to the study
two quotations from the same document design, the number of patients, the specific
but then this field is full of anomalies. It is diagnosis, the dose used, the duration of
noteworthy that due to a resurgence of administration of the herbal medicine, and
interest in traditional medicines much the criteria used for assessing the
thinking is going on and will continue to go treatment.
on in this area of herbal medicine preclinical Researchers, public health adminis-
toxicology. The need for WHO to assist trators and drug regulatory agencies are
countries in regulating the use of traditional interested in developing guidelines for
medicines regarding their safety and efficacy toxicological assessment of herbal
was one of the specific recommendations remedies which would, on the one hand,
made by the Ministers of Health of the WHO ensure that patients are not subjected to
South-East Asia Region at their meeting held the toxicity of the remedies and, on the
in New Delhi in September 1998.12 other, not hamper the development and
What comes out very clearly is that use of these medicines. The modified
there has to be flexibility in the toxicological Chandigarh model14 being used in several
requirements for herbal medicines and that countries could be a starting point. This
214
Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations
215
Traditional Medicine in Asia
consists of the usual acute toxicity studies requirements for specific plants depending
complemented by six-week subacute on their earlier use, experimental results
toxicology studies with three doses in two and the manner in which it is sought to be
phylogenetically different species like the rat used.
and the rabbit species and a control series.
The following observations are made daily: Clinical Evaluation
weight, food intake, water intake and
general behaviour. The following tests for Clinical trials in the past have been carried
looking at haematological, hepatic and out largely by clinicians and clinical
renal effects specially need to be carried pharmacologists with experience in clinical
out before and at the end of six weeks trial methodology of synthetic drugs but no
before sacrificing the animal. background of herbal or traditional systems
An autopsy has to be carried out on of medicine, or by traditional medicine
every animal at the end of the study and on practitioners and experts who have very
any animal which died during the course of little idea about the conduct of clinical trials
the study. Histopathological studies need to according to modern concepts of clinical
be carried out on every organ at the autopsy pharmacology.
both for control and herbal remedy-treated The results of such trials are therefore
animals on the high dose. If the animals on not acceptable to the larger scientific
the high dose show histopathological community and the practitioners of the
changes then the same histopathology modern system of medicine, allopathy, who
should be carried out on animals need clear-cut evidence of efficacy and lack
administered the intermediate dose. of side-effects of herbal remedies in well-
Other tests could be added on if conducted clinical trials before they would
thought necessary. These are tests for consider use of such medicines.
immunotoxicity, carcinogenicity, genoto- An important challenge for clinical
xicity and reproductive toxicity. Teratology researchers in the 21st century is to
studies should also be carried out, as has conduct clinical evaluation of traditional
recently been completed15 for a combi- medicines within the specific framework of
nation of Embelia ribes (Vidanga), Piper rigorous clinical pharmacological principles
longum and borax which is now being without ignoring or trampling on the
evaluated in Phase II clinical trials as a concepts and practices of traditional
contraceptive. Such an effort was described systems of medicine (Chaudhury, 1992).14
in ancient textbooks of Ayurveda 2500 Fortunately, more and more multidisci-
year ago. plinary centres are being developed with
Earlier studies have also shown that this objective in mind. It is also salutary that
this model is effective in detecting toxicity. specialists and practitioners of the Chinese
Semecarpus anacardium (Bhallatak) was Traditional System of Medicine in China and
going to be clinically evaluated as a specialists in Ayurvedic and Unani
contraceptive but the six-week toxicity study medicines in India have no objection to the
demonstrated an effect on the white blood use of modern concepts of the metho-
count which was not acceptable.16 The dology of clinical trials in evaluating the
plant was therefore not investigated further. efficacy and side-effects of herbal
It is hoped that this review would help preparations used in these traditional
investigators to fashion the toxicology systems (Chaudhury, 2001).[17] Conside-
216
Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations
rable effort has been made in the past two However, the preparation needs to be made
decades to develop a herbal contraceptive and administered in exactly the same way
keeping in perspective the concepts of as has been described in those books. A
Ayurveda and the traditional systems of synthetic or traditional medicine cleared for
medicine.18 Again, the Indian Council of use for a certain disease condition needs
Medical Research has taken the plant fresh approval if it is to be used for a different
Pterocarpus marsupium from its use in condition or if it is to be administered by a
folklore and Ayurvedic medicine to Phase different route, or if it has excipients not
III clinical evaluation for the treatment of stated in the ancient books referred to earlier.
diabetes mellitus using well-accepted A product or a new combination of herbal
clinical pharmacological principles.19 It is medicines will be treated as a new drug and
now being handed over to industry for will have to be approved for clinical
pharmaceutical development and evaluation.
marketing. In addition to approval of the national
The basic principles in the clinical drug regulatory agency, an investigator has
evaluation of herbal remedies are, of to obtain the clearance of the Institutional
course, the same irrespective of whether a Ethical Committee and, if necessary,
synthetic compound or a herbal prepa- clearance of the National Ethical
ration is being evaluated. However, there Committee or the Ethical Committee of the
are also very important differences which agency supporting the clinical evaluation.
need to be kept in mind. In the next few Thus, when Vicoa indica was clinically
pages these basic concepts will be evaluated as a herbal contraceptive based
delineated. The differences inherent in on observations made by public health
clinical evaluation will then be described personnel on its use in a tribal community,
with examples from the Indian programme, ethical approval was obtained from three
which has taken note of these differences agencies – the local Institutional Ethical
and modified the clinical trial methodology Committee at the Postgraduate Institute of
accordingly. Finally, the grey areas still Medical Education and Research,
awaiting clarification and elucidation will Chandigarh, where the trial was
be discussed. conducted, the Ethical Committee of the
Before any drug is administered to a Indian Council of Medical Research, New
human subject or a patient for purposes of Delhi, and the Ethical Committee of the
clinical evaluation, the approval of the Population Foundation of India, which
national drug regulatory authority has to be supported the clinical trial. (Chaudhury,
obtained. While this is mandatory and 1983).20 This is not the place to describe
essential for all synthetic drugs, the national the composition and functioning of
Government may, in some circumstances, Institutional Ethical Committees or the
allow traditional medicines to be evaluated different nuances of obtaining informal
without formal or informal approval of the consent of each person who enters the
regulatory authority. This has to be clearly trial, although a little more will be
spelt out. In India, for example, the Office mentioned about informed consent when
of the Drugs Controller General allows, discussing some ethical aspects of clinical
without further need of approval, plant evaluation of herbal products.
preparations described for their therapeutic Once informed consent is obtained,
effect in 27 ancient books and treatises. then clinical evaluation could begin. The
217
Traditional Medicine in Asia
chief investigator is solely responsible for The studies are usually limited to 3–4
the trial and can stop the trial any time he/ centres. The studies should be carried in a
she feels that it is not in the interest of the randomized double-blind manner unless
patients to further carry on the trial. This this is not possible. However, a well-
could be due to serious adverse effects planned and well- conducted single-blind
being observed or could even be because study in certain circumstances, particularly
results at some other centre published with herbal medicines, could also yield
recently had clearly shown the benefits of unequivocal and scientifically valid
a particular treatment. In such circums- conclusions.
tances, it may be difficult to continue a trial
which would provide perhaps the same Phase III
result two years later. The reader is referred The purpose of these trials is to obtain
to the Ethical Guidelines for Biomedical adequate data about the efficacy and safety
Research on Human Subjects published by of drugs in a larger number of patients of
the Indian Council of Medical Research in both sexes in multiple centres, usually in
2000. 21 comparison with a standard drug and/or
Clinical evaluation of any synthetic or a placebo if a standard drug does not exist
plant product is carried out in five phases. for the disease under study.
Phase I Phase IV
The objective of Phase I of a clinical trial is After approval of the drug for marketing,
to determine the safety of the maximum usually given after assessment of the results
tolerated dose of the herbal product in of Phase III trials, the Phase IV studies or
healthy adults of both sexes. At least two post-marketing surveillance is undertaken
subjects should be administered each dose to obtain additional information about the
to establish the safe dose range, pharma- drug’s risks, benefits and optimal use. A
codynamic effects, and adverse reactions, rare side-effect or a side-effect not recorded
if any, with their intensity and nature. An in strictly controlled trials could be
investigator trained in clinical pharma- discovered in Phase IV studies.
cology should carry out these studies and
clinical emergency help and resuscitation Phase V
facilities must be available at the centre These are studies in which the drug is used
where the Phase I trials are being carried as it would be used in the community. The
out. Such a Phase I study has recently been strict monitoring of Phase II and Phase III
carried out with a herbal preparation being clinical trials and the follow-up inherent with
evaluated for its contraceptive effect post-marketing surveillance would both be
(Chaudhury, 2000).18 absent in these Phase V clinical trials. The
efficacy and side-effects of the drugs would
Phase II be seen in field conditions.
These are controlled studies conducted in
a limited number of patients of both sexes Multicentric trials
to determine therapeutic effects, effective Reference has been made earlier to
dose range and further evaluation of safety. multicentred studies. It is important to carry
Normally, 20–25 patients should be out such studies and yet it is not easy to
studied for assessment of each dosage. organize, coordinate and conduct these
218
Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations
219
Traditional Medicine in Asia
with extracts of these plants was found as ment of research hypotheses, testing those
effective as surgery in anal fistula in an hypotheses in daily clinical practice and
open, randomized, multicentred trial.22 referring clinical techniques”. To be
However, it is a challenge for the clinical meaningful, single-case designs should
pharmacologist to plan, as far as possible, have a common protocol which could be
double- blind randomized multicentred the basis of collaborative research between
clinical trials even with traditional practitioners.
medicines. The double-blind flexible dose,
randomized, multicentred trial of Observational Studies
Vijayasara, Pterocarpus marsupium, in Another approach which could be used is
diabetes mellitus was one such study.19 to carry out Observational Studies. The
Another ongoing study is a double- traditional medicine practitioner continues
blind, randomized, multicentred trial of his treatment without modifying it in any
Pipallyadi Vati as a herbal contraceptive.18 way and the clinical investigator observes
whether clinical improvement takes place.
Use of a placebo The data are recorded by the traditional
The use of a placebo is decreasing in medicine practitioner and separately by the
comparative clinical trials because in most investigator carrying out these studies.
clinical conditions there already exists a More studies of this type should be carried
treatment. The new drug should therefore out. It could provide a valuable model for
be compared against that existing drug. It studying both the efficacy and the safety
would be unethical to give a placebo, i.e., of herbal medicines. Such a study is in fact
a similar looking, smelling tablet containing being coordinated by the first author in
no medication to one group of patients for Mumbai where the allopathic doctors at
a disease when a known remedy exists. A a well-known allopathic hospital are
placebo still has a role in conditions where working together with traditional medicine
no cure exists. In such conditions an open practitioners in a leading Ayurvedic hospital.
trial with objective laboratory and clinical The protocols are prepared jointly but
measurements to record the effects of a patients are being treated at an Ayurvedic
new drug as compared to a placebo may hospital. The Ayurvedic physi-cians give the
also be justified. treatment for bronchial asthma and arthritis
according to an agreed protocol. The
Single-Case Studies results of the treatment are assessed
In addition to open, single-blind and separately by the physicians of the modern
double-blind clinical trials, it is also possible system of medicine and by the Ayurvedic
to obtain information from single-case physicians. These are then compared as
studies for the evaluation of the efficacy of regards the effectiveness of the treatment
a herbal medicine. This has been parti- and the side-effects seen.
cularly pointed out in the WHO Document
“General guidelines for methodologies on Indian Council of Medical
research and evaluation of traditional Research Network
medicine”, which was discussed at a WHO In the past 12 years, the Indian Council of
meeting in Hong Kong in 2000.13 The Medical Research (ICMR) has set up a
report states “Such studies, i.e., single-case unique network throughout the country for
studies, are appropriate for the develop- carrying out controlled clinical trials of
220
Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations
221
Traditional Medicine in Asia
222
Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations
Mumbai study, perhaps for the first time in Chinese Traditional Medicine, Ayurveda or
modern clinical trial methodology, stratified the Unani System of Medicine are to be
the subjects of asthma according to carried out at an allopathic hospital by
whether gastrointestinal symptoms are a practitioner of the allopathic system of
associated with the asthma and Ayurvedic medicine, then it is incumbent on him to
drugs administered accordingly. In any have as a coinvestigator a physician from
clinical trial of asthma, all patients would the traditional system in which that remedy
have been included and then divided into is used. This principle would also hold good
groups. The result of such a trial would not if an Ayurvedic physician wants to evaluate
be accepted by the pratitioners of an allopathic drug. An allopathic physician
traditional medicine. would have to be taken on as a
Another important feature of medicinal coinvestigator.
plants is that many of them induce an When a folklore medicine is ready for
immunostimulant effect without exerting commercialization after it has been found
any specific therapeutic effect. In ordinary effective, then, as stated in the Indian
clinical trials this is difficult to measure. Council of Medical Research Ethical
However, it would be well worth measuring Guidelines, the legitimate rights/share of
when clinical trials of herbal remedies are the tribe or community from whom the
planned. In addition to studying the knowledge was gathered, should be taken
efficacy of the plant and the side-effects care of appropriately while applying for the
induced by it, the amount of Satisfaction Intellectual Property Rights and Patents for
felt by the patient and the Quality-of-Life the product.
Parameters could also be studied. This is The preclinical toxicological require-
particularly important when a herbal ments before clinical trials have already
remedy is being assessed alongside a been considered from a regulatory and
synthetic compound. legal point of view. Ethically it may not be
necessary to carry out such studies if much
Ethical Considerations is known about the plant from ancient
literature and if the plant is already in use
Several of the ethical considerations which provided it is to be evaluated in the same
need to be kept in mind when planning and form. When an extract of a plant or a
conducting clinical evaluation of traditional compound from a plant is to be clinically
medicines have already been discussed. evaluated for a new therapeutic effect, it
These are aspects of clinical trials such as should be treated as a new entity and the
the need for clearance from the Institute full range of acute, subacute and chronic
Ethical Committee and Informed Consent. toxicity data will have to be generated as
The responsibilities of the Chief Investigator required by the national drug regulatory
apply equally to clinical evaluation of authority.
synthetic drugs or herbal medicines. Is it ethical to add on a traditional
There are, however, some special medicine to the standard allopathic
features when traditional medicines are treatment to assess whether the dose of
being evaluated. These will be discussed the allopathic drug could be reduced or
below. whether the side-effects induced by the
When clinical trials of herbal drugs used allopathic drug brought down? Normally
in traditional systems of medicine such as it would not be justified to combine
223
Traditional Medicine in Asia
References
1. Proceedings of Third International Congress of Asian Medicine. Mumbai. 1990.
2. Report of a Regional Consultation on development of Traditional Medicine in South-
East Asia Region. WHO-SEARO. New Delhi. 1999.
3. Report of an Inter-Regional meeting on Standardization and Use of Medicinal Plants.
WHO. WPRO. Manila. 1980.
4. Report of a consultation on medicinal plants. WHO. WPRO. Manila. 1986.
5. Quality control methods for medicinal plant material. WHO. Geneva. 1998.
6. Chaudhury, R.R. (1980), Controversies in clinical evaluation of antifertility plants.
Clinical Pharmacology and Therapeutics. 474. P. Turner, (Ed.) Macmillan. New York.
7. Gallelos, A.J. (1983). The Zoapatle 1 – A traditional remedy from Mexico emerges to
modern times. Contraception. 27, 211.
8. Report of a WHO Consultation on Traditional Medicine and AIDS : Clinical Evaluation
of Traditional Medicine and Natural Products. WHO. Geneva. 1990.
9. WHO Guidelines for Assessment of Herbal Medicines. WHO. Geneva. 1991.
10. Research Guidelines for evaluating the safety and efficacy of herbal medicines. WHO.
WPRO. Manila. 1993.
11. WHO Technical Report Series No. 863 on “Guidelines for assessment of herbal
medicine”. WHO. 1996.
224
Standardization, preclinical toxicology and clinical evaluation of medicinal plants, including ethical considerations
12. Report of Sixteenth Meeting of Ministers of Health. WHO South-East Asia Region.
New Delhi. WHO. 1998.
13. General Guidelines for methodologies on research and evaluation of traditional
medicine. WHO. Geneva. 2000.
14. Chaudhury, R.R. Herbal medicine for human health. WHO-SEARO. New Delhi. 1992.
15. Roy Chaudhury, M., Chandrasekharan and Mishra, S. (2001). Embryotoxicity and
teratogenecity studies of an Ayurvedic Contraceptive. Pippalyadi Vati. J.
Ethnopharmacology. 74, 189.
16. Vaishnav, R., Sankaranarayanan, A., Chaudhury, R.R., Mathur, V.S., and Chakravarti,
R.N. (1983). Toxicity studies on proprietary preparation of Semecarpus anacardium.
Indian Journal of Medical Research. 77, 902.
17. Chaudhury, R.R. (2001). Commentary: Challenges in using traditional systems of
medicine. Brit.Med. J. 322, 164.
18. Chaudhury, R.R. (2000). Proceedings of Symposium on Current Status of Fertility
Regulation. C.M. Gupta and Chaudhury S.R. (Ed.) Central Drug Research Institute.
Lucknow. 11–21.
19. Chaudhury, R.R. (2001). Antidiabetic effect of Vijayasar – Pterocarpus marsupium.
Pharmacology and Therapeutics in the New Millennium. S.K. Gupta (Ed.) Narosa.
New Delhi. 355–356.
20. Chaudhury, R.R. (1983). Plant contraceptives: translating folklore into scientific
application. 5: 58. Advances in Maternal and Child Health. Jelliffe, D.B. and Jelliffe,
E.F.P. (Ed.) Oxford University Press. Oxford.
21. Ethical Guidelines for Biomedical Research on human subjects. Indian Council of
Medical Research. New Delhi. 2000.
22. Shukla N.K. et al. Multicentric randomized controlled clinical trial of Ksharasootra
(Ayurvedic medicated thread) in the management of fistula-in-ano. Indian Journal of
Medical Research (B) 94. June 1991. 177–185.
23. Indian Council of Medical Research. Annual Report. New Delhi. 1994.
24. Verma, V. Ayurveda – a way of life. Samuel Weiser Inc. New York . 1995.
25. Majumdar, A. Bioregulating Principles: Tridoska in Ayurveda – The Ancient Indian
Science of Healing. Wheeler Publishing House. New Delhi. 1998.
225
Protection of traditional systems of medicine, patenting and promotion of medicinal plants
Protection of traditional
systems of medicine,
patenting and promotion
of medicinal plants
Carlos M. Correa
i For instance, the per capita consumption of TM products is, in Malaysia, more than double that of modern
pharmaceuticals. TM is even significant in more advanced developing countries such as South Korea, where the
per capita consumption of TM products is about 36% more than that of modern drugs (1, p. iii).
ii The TRIPS Agreement has imposed the obligation to recognize product patents for pharmaceuticals.
iii See, e.g., 2, p. 1.
iv In particular, trade secrets protection, which relates to undisclosed information of a commercial and technical
nature, may apply to different components of TM .
227
Traditional Medicine in Asia
v See 5.
vi It has been estimated that around 7500 plant species are utilized in indigenous medicine, many of which (such
as indigo) have multiple uses. see, e.g., 6, p. 170.
228
Protection of traditional systems of medicine, patenting and promotion of medicinal plants
b) Methods of diagnosis and treatment, level. These are passed through oral
including physical, mental and spiritual tradition and may be called, “people’s
therapies, which are influenced by the health culture”, home remedies or folk
culture and beliefs dominant in a remedies. They have a vital place in primary
particular community.vii The traditional health care in developing countries.1
therapies may encompass the use of
certain biological materials, including Individual/collective possession
dosage and forms of administration TM may be possessed by individuals
thereof, and rituals applied by healers (“individual knowledge”).viii In some cases,
as part of their traditional healing for instance, healers use rituals as part of
methods. their traditional healing methods, which
often allow them to monopolize their
Codification knowledge, despite disclosure of the
The codification of TM varies significantly. phytochemical products or techniques
A distinction can be made, particularly in used.8
Asia, between the codified systems of In other cases, knowledge is in the
‘traditional medicine’ and the non-codified possession of some but not all members
medicinal knowledge, which includes of a group (“distributed knowledge”). There
“folk”, “tribal” or “indigenous” medicine. is, hence, asymmetric information between
Thus, in India, the system of medicine groups but not within a given group of
consists of two major tendencies: the folk persons, even though the latter may not
and the codified traditions. Folk traditions be aware that others share the same
are handed down orally from generation knowledge.11
to generation. The codified tradition Finally, a certain kind of knowledge may
consists of medical knowledge with be available to all the members of a group
sophisticated theoretical foundations (“common knowledge”), such as in cases
expressed in thousands of manuscripts of knowledge on herbal-home remedies
covering all branches of medicine. which is held by millions of women and
Examples are Ayurveda, Siddha, Unani and elders.ix
the Tibetan tradition.7
The Ayurvedic system of medicine, in Commercial value
particular, is codified in the 54 authoritative TM may encompass commercial value when
books of this system. In contrast, the “folk” its application, and notably the delivery of TM
medicine is based on traditional beliefs, products, can be made trough commercial
norms and practices based on centuries- channels. While some TM can be used and
old experiences of trials and errors, understood outside its local/traditional/
successes and failures at the household communal context, this is not always the
vii Physical methods of treatment involve muscle manipulation and massage. Mental methods of treatment involve
self-discipline in the form, for instance, of a strict diet. Spiritual methods of treatment involve prayers and use of
holy water (9, p. 167).
viii Reviews of anthropological literature reveal that concepts close or equivalent to individual forms of IPRs are quite
common in indigenous and traditional proprietary systems (see, e.g., 10, p. 69).
ix For an alternative classification of modalities of knowledge possession based on the concept of “negative” and
“positive” community, see 15, p. 185).
229
Traditional Medicine in Asia
230
Protection of traditional systems of medicine, patenting and promotion of medicinal plants
has otherwise been made available to the TM knowledge has been previously used,
public, for instance, through public use, in even for long periods. One example would
any country before the date of filing of a be the case of a traditional knowledge used
patent. in a small community, when the information
“Prior art” generally includes any has not been diffused beyond the
publication of the invention prior to the date community’s members. There are also cases
of the patent application. This concept may in which the traditional healers have kept
be defined so as to also include precedents confidentialxi certain aspects of their
that have not been divulged before that treatment and associated medicines, a
date, but which demonstrate that a third practice that may be more frequent than
party had previously reached the same often believed.
invention. This approach has been followed An important issue is whether the
in some US decisions, based on Corona identification of the chemical srtucture of
Cord Tire Co. vs. Dovan Chem. Corp. (US an active substance which is responsible
Supreme Court, 1928), where a prior for the therapeutic effect of a known
invention of another party, not publicly product, may lead to the granting of a
known, was deemed as destructive of patent or whether it should be deemed that
novelty for a second invention. Likewise, no novelty exists. In the case Merrill Dow
novelty may be destroyed in certain cases Pharmaceuticals v. Norton & Co. (1996)
by the information contained in previous the court held that it was not necessary for
patent applications.x 14 an active substance to be identifiable or
The novelty requirement will generally reproducible for it to have been made
impede the patentability of TM knowledge available to the public.xii
that has been openly used for many years, The novelty requirement may not be an
and, in some cases, published in different obstacle to obtaining patents on TM in
forms. This is likely to apply to a large part countries where a relative novelty standard
of TM. is applied. In the United States, for instance,
In order to destroy novelty, however, the according to article 102 of the Patent Law,
prior use must generally be such that access
to the information would have allowed a A person shall be entitled to a patent unless:
third party to execute the invention, without (a) the invention was known or used by
significant further research. There may be others in this country, or patented or
situations in which novelty may not have described in a printed publication in
been lost despite the fact that the relevant this or a foreign country, before the
x In Europe, however, the information contained in a prior, non-published, patent application is not considered for
the purposes of considering the existence of “inventive step”.
xi In the Mobil case, for instance, the Enlarged Board of Appeal of the European Patent Office decided that the word
“available” carries with it the idea that, for lack of novelty to be found, all the technical features of the claimed
invention in combination must have been communicated to the public, or laid open for inspection. Under the
European Patent Convention, a hidden or secret use, because it has not been made available to the public, is not
a ground for objection to validity of a European patent (Mobil/Friction-Reducing Additive (1990) O.J. E.P.O. 93;
(1991)(see 9, p. 166).
xii Lord Hoffmann exemplified this situation with the case of Amazonian Indians, who believed that the effect of the
cinchona bark on malaria was due to “the spirit of the bark”. The Indians, however, should be said to have known
about quinine even though they did not know its chemical structure (9, p. 166).
231
Traditional Medicine in Asia
xiii The PTO’s decision came in response to a request for reexamination of the patent by the Coordinating Body for the
Indigenous Organizations of the Amazon Basin (COICA), the Coalition for Amazonian Peoples and Their
Environment, and lawyers at the Center for International Environmental Law (CIEL).
232
Protection of traditional systems of medicine, patenting and promotion of medicinal plants
xiv For example, less than 50 per cent of the examinations conducted by said Office refer to relevant background
bibliography; the examination is by and large limited to analysing previous patents. See, 21.
xv The extent of patentability of biological materials in the USA has not been addressed yet, however, by the Supreme
Court.
233
Traditional Medicine in Asia
xvi “Biological material which is isolated from its natural environment or processed by means of a technical process
may be the subject of an invention even if it already occurred in nature” (article 3.2).
xvii See, e.g., 23, p. 213.
xviii See, the proposal for review of article 27.3. (b) of the TRIPS Agreement submitted by Kenya on behalf of the African
234
Protection of traditional systems of medicine, patenting and promotion of medicinal plants
isolate the compounds that explain the cases where a composition is a simple
therapeutic effects of certain traditional mixture of diverse components and where
medicines. In addition, traditional healers there is some chemical reaction between
and communities generally lack the skills them.23
and resources necessary to follow the Many examples of patents granted on
complex procedures of patents systems combinations of plants for therapeutic
and, in particular, to face the costs of regis- purposes can be mentioned, for instance,
tration both locally and abroad.xix EP 0519777 relating to formulations
It should also be noted that since the made out of a variety of fresh plants; and
granting of patents is dependent on each WO 93/11780 on a skin therapeutic
national law, the non-patentability in one mixture containing cold-processed Aloe
country does not mean that “pieces” of TM vera extract (with yellow sap and aloin
could not be patented in another country. removed).
If protection were obtained without the
authorization of the healers/communities Production and extraction
that developed or possessed them, it would processes
be possible to request the nullification of Many TM products are obtained through
the patent in the foreign country.xx fractionation, purification or concentration.
The processes for obtaining such products,
Extracts and formulations if novel and non-obvious, may also be
While, as mentioned, the patentability of patented.
natural products may be limited by patent There are numerous examples of
rules, it is possible to obtain protection (if patents relating to extraction and other
the patentability requirements are met) for processes for the preparation of medicines
extracts or formulations of natural based on natural products, such as ES
products. 475.812 on a process for the extraction
Examples of patents of this type of organic compounds with therapeutic
include US 4178372 on hypoallergenic activity from plants; ES 2010127 for the
stabilized Aloe vera gel: US 4725438 on preparation of a medicine for skin
an Aloe vera ointment; US 4696819 on reparation; EP 0530833 on a process to
anorexic material extracted from coca prepare hard gelatine capsules containing
leaves; and EP 0513671 on “Commipho- Chinese herbal extracts; ES 8801986 for
ra mukul” extracts. preparation of a jus or gel of aloe; ES
393347 on a process for the extraction of
Combinations an active ingredient from anacardium
Patents may be obtained, if the patentability occidentale; and US 4956429 on a
requirements are met, for combinations method of making a coca leaf flavour
and preparations. This is normally the case extract.
with modern pharmaceuticals, both in
xix The costs for the international protection of an invention are somewhere in the range of $ 40,000–$ 50,000,
including registration and maintenance fees.(25)
xx Examples were the actions initiated by the Government of India in relation to a patent on turmeric granted in the
United States, and the already referred action against the ayahusaca patent. In both cases, the USPTO finally
revoked the patents.
235
Traditional Medicine in Asia
xxi A bill enacted in 1996 (amending US patent law, 35 USC 287.c) determined, however, that the use of patented
surgical procedures cannot be subjected to infringement suits. See, e.g., 23, p. 220.
xxii Thus, in Europe, first medical indications have been dealt with as a product claim, whereas the second medical
indication (that is, when a new use is discovered for a product that already had pharmaceutical use) as a process
claim.
xxiii See, e.g., 23, p. 208.
xxiv See, e.g., 26, p. 120.
236
Protection of traditional systems of medicine, patenting and promotion of medicinal plants
a known product patentable as such under general principles of patent law. Unless in connection with the new
purpose the product is forced to be present in an amended new form.
237
Traditional Medicine in Asia
238
Protection of traditional systems of medicine, patenting and promotion of medicinal plants
face. Due to the principle of territoriality, prevent grant of such patents and
protection at home would not prevent the biopiracy”.12
misappropriation of the protected know- Among the projects initiated in India
ledge in other countries or that such know- to impede the consideration of such
ledge would continue to be considered as knowledge as “new” and, therefore, paten-
belonging to the public domain. table in some jurisdictions, “Gene
Developing countries (notably Latin Campaign” has undertaken work on
American and Caribbean) have also documentation of biodiversity and
actively promoted the increased involve- knowledge relating thereto aimed at three
ment of the World Intellectual Property tribal populations: the Munnars in South
Organization (WIPO) in the discussion Bihar (in the Chotanagpur region); the Bhils
and development of a “sui generis” regime of Madhya Pradesh, and the Tharus of the
for traditional knowledge.xxxv Terai region. Medicinal plants and
knowledge related thereto was sought to
Curbing “biopiracy” be documented with the help of educated
Despite the general agreement in the tribal youth. Elders in the village, medical
developing world about the importance of practitioners and traditional healers were
obtaining a recognition for traditional consulted in the collection and under-
knowledge, the main concern of some standing of the information.12
countries has been to avoid the “biopiracy” The documentation of traditional
of traditional knowledge and to ensure knowledge, in the Indian Government’s
benefit sharing (as provided for under views, permits not only the prevention of
articles 15 and 16 of the CBD), rather than “biopiracy”; it may also provide a basis for
the establishment of a system of positive the sharing of benefits arising out of the
appropriation. Thus, the Government of use of such knowledge, though documen-
India has stated that tation per se will not facilitate benefit
“In the recent past, there have been sharing with the holders of such
several cases of biopiracy of traditional knowledge.12
knowledge (TK) from India. For preventing In addition, Section 36 (iv) of the Indian
such instances in the future there is a need Biodiversity Bill provides for the protection
for developing digital databases of prior of knowledge of local people relating to
art related to herbs already in the public biodiversity through measures such as
domain. Following patents on brinjal, etc., registration of such knowledge, and
in India, an exercise has been initiated to development of a sui generis system. For
prepare easily navigable computerized ensuring equitable sharing of benefits arising
database of documented TK relating to from the use of biological resources and
use of medicinal and other plants (which associated knowledge, Sections 19 and 21
is already under public domain) known as stipulate prior approval of the National
TK Digital Library (TKDL). Such digital Biodiversity Authority (NBA) before their
databases would enable Patent Offices all access. While granting approval, NBA will
over the world to search and examine any impose terms and conditions, which secure
prevalent use/prior art, and thereby equitable sharing of benefits. Section 6
xxxv A proposal for the establishment of a Committee to deal with these issues was submitted to the WIPO Governing
Bodies in September 2000.
239
Traditional Medicine in Asia
provides that anybody seeking any kind of to TM treatments that the exercise of such
IPR on a research based upon biological rights would entail.
resource or knowledge obtained from India While an option to deal with TM is to
needs to obtain prior approval of the NBA, work within the sphere of IPRs,
which will impose benefit-sharing conditions. governments should aim to promote the
Section 18 (iv) stipulates that one of the use of TM for preventive and curative health
functions of NBA is to take measures to care rather than to protect it under rights
oppose the grant of IPRs in any country that may restrict its diffusion. An example
outside India on any biological resource is provided by Act No. 8423 (1997) of the
obtained from India or knowledge Philippines, which aims “to accelerate the
associated with such biological resource. development of traditional and alternative
In the Patent (Second Amendment) Bill health care” by improving the manu-
1999, the grounds for rejection of the facture, quality control and marketing of
patent application, as well as revocation traditional health care materials
of the patent, include non-disclosure or (Section 3.d).
wrongful disclosure of the source of origin This promotional approach may be
of biological resource. It has also been combined with a misappropriation regime
made incumbent upon patent applications aimed at avoiding the monopolization of
to disclose the source of origin of the TM and related biological materials. Such
biological material used in the invention in a regime – just as in the case of trade
their patent applications. secrets – would not be based on the
The Andean Group Decision 391 has granting of exclusive rights (i.e, on a ius
already established that any IPR or other prohibendi) but only on the right to prevent
claims to resources shall not be considered or require a compensation for the use of
valid, if they were obtained or used in traditional knowledge when it has been
violation of the terms of a permit for access acquired, for instance, in a manner contrary
to biological resources residing in any of to legitimate rules and practices on
such countries, as regulated under that access.13
Decision. The promotion of TM requires much
more than defining the appropriate
Improving access to TM framework for IPRs protection. Attention
A possible negative impact on the access should be paid to research and develop-
to health care of the strengthening of IPRs ment (R&D) and to the condition for the
in developing countries has been stressed use of such knowledge.
in recent analyses, including some studies Developing countries only account for
by the World Health Organization.(31) The a minor part (around 4 per cent) of world
recognition or establishment of new types R&D,32 and a significant part of the scarce
of IPRs on TM may reduce, rather than resources devoted thereto are applied to
enhance, access to medicines and health issues that have been defined by and are
treatment, particularly by the poor. In of primary interest to developed
dealing with TM, developing countries countries.33 Though the technical capacity
should, therefore, very carefully balance the to undertake clinical trials in order to
expected benefits from a possible IPRs-like establish the safety and efficacy of TM
protection of TM, with the costs that are products exists in many developing
likely to arise from the limitations on access countries, this is a costly endeavour for
240
Protection of traditional systems of medicine, patenting and promotion of medicinal plants
the use of TM, Shaman Pharmaceuticals, abandoned its multimillion-dollar effort to bring new drugs from the
rainforest.
xxxix WHO has developed Guidelines for this purpose (see 34).
241
Traditional Medicine in Asia
country of origin. Patent owners enjoy, in the norm to cover other products (‘yacun’
effect, the right to prevent any commercia- and ‘para-para’).
lization, including imports, of a patented
product.xl Conclusions
A similar problem may be faced if the
plant varieties used to produce a TM TM plays an important role in the health
product were protected under breeders’ care systems of developing countries. The
rights in the country of import. Breeders’ diffusion of TM products is also significant
rights are a type of intellectual property in developed countries. The commercial
rights that are exercised in respect of value of TM has raised divergent views on
propagating materials of plant varieties. the need and scope for protection of TM
The UPOV (Union for the Protection of Plant under IPRs. Some governments, scholars
Varieties) Convention provides an inter- and NGOs have voiced the need to protect
national framework for the protection of TM under existing or new forms of IPRs
such varieties. The TRIPS Agreement has protection, as a means to recognize and
obliged all WTO Member Countries to compensate the creators and possessors
provide a patent or an effective “sui of such knowledge. Others object to that
generis” protection (or a combination of possibility for ethical, economic or other
both). reasons. However, there is, in general,
If breeders’ rights were obtained by agreement on condemning “biopiracy”,
unauthorized parties on plants used for TM, that is, the unauthorized appropriation
the countries of origin thereof would also under Western IPRs systems of traditional
find a serious barrier, since breeders’ right- knowledge and biological materials.
holders enjoy a similar set of exclusive rights The concept of TM embraces different
with regard to imported products. categories of knowledge that may be
Finally, it should be borne in mind that subject to various types of IPRs, if the
many medicinal plants face extinction or conditions for protection are met. Several
severe genetic loss. Overexploitation of components of TM, including products and
such plants in order to satisfy export processes and, in some countries, uses and
demands can aggravate these risks. methods of treatment, can be covered by
Hence, governments should control trade patent rights. In fact, a large number of
in medicinal plants in the framework of patents have been granted in relation to
broader policies for the conservation and natural products, combinations, extracts
sustainable use of such plants. Peru, for and preparations thereof, as well as
instance, passed a law in July 1999 which processes of production. The application
bans the non value-added export of some of patents to TM, however, faces important
botanical species with known healing obstacles, in particular due to the novelty
properties, which had become the target requirement and to the costs and
of massive extraction by foreign labora- complexity of procedures before patent
tories. The law covers the two best-known offices.
medicinal plants in Peru’s indigenous While designing national policies on
pharmacopoeia: ‘cat’s claw’ and ‘maca’; TM, a careful assessment of the possible
and legislators are considering expanding objectives and implications of IPRs
242
Protection of traditional systems of medicine, patenting and promotion of medicinal plants
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 of
ethnobiological knowledge: reconciling industry and indigenous interests”. Intellectual
Property Journal. No.12.
4. Medeiros Costa Neto, Eraldo. (1999). “Traditional use and sale of animals as
medicines in Feira de Santana City, Bahia, Brazil”. Indigenous Knowledge and
Development Monitor. Vol.7. Issue 2.
5. Zhang, Xiaorui. (1998). “Significance of Traditional Medicine in Human Health Care”.
Paper presented at WIPO Asian Regional Seminar on Intellectual Property Issues in
the Field of Traditional Medicine. New Delhi. India. October 7–9.
6. Shankar, Darshan. (1996). “Tribal and rural farmer-conservers”. In: Agrobiodiversity
and Farmers’ Rights. Swaminathan Research Foundation. No.14. Chennai.
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7. Shankar, Darshan; Hafeel, Abdul and Suma, T. (1999). “Cultural Richness of Green
Pharmacy”. Compas Newsletter. No. 2.
8. Bhatti, Shakeel. (2000). “Intellectual property rights and traditional medicines”. Prepared
for WHO-ASEAN Meeting on the TRIPS Agreement and its Impact on Drug Supply.
Jakarta.
9. Koon, Ong Chui. (1999). “Intellectual property protection of traditional medicine
and treatments in Malaysia”. Blakeney, Michael (Ed.). Perspectives on Intellectual
Property. Intellectual property aspects of 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”. in
Brush, Stephen (Ed.). Genes in the field. On-farm conservation of crop diversity.
IPGRI/IDRC/Lewis Publishers (p. 242).
14. Merges, Robert P. (1992). Patent law and policy. Cases and materials. Contemporary
Legal Educational Series. Boston.
15. Drahos, Peter. (1997). “Indigenous knowledge and the duties of intellectual property
owners”. Intellectual Property Journal. No.11.
16. Correa, Carlos. (1999). Access to plant genetic resources and intellectual property
rights. Background Study Paper No. 8. FAO. Rome.
17. The Croucible Group. (2000). Seeding Solutions. Vol. 1. IDRC-IPGRI. Rome.
18. Mooney, Pat. (1998). “The parts of life. Agricultural biodiversity, indigenous knowledge
and the role of the third system”. Development Dialogue. Special Issue. Uppsala
(pp 152-154).
19. Wegner, Harold. (1994). Patent law in biotechnology, chemicals & pharmaceuticals.
Stockton. Chippenham (p. 224).
20. Barton, John. (2000). “Reforming the patent system”. SCIENCE. Vol. 287. 17 March.
21. Aharonian, Greg. (2000). “Patent examination system is intellectually corrupt”. Patnews.
1 May.
22. Bent, S., Schwab, R., Conlin, D., and Jeffrey, D. (1991). Intellectual property rights in
biotechnology worldwide. Stockton Press. New York.
23. Grubb, Philip. (1999). Patents for chemicals, pharmaceuticals and biotechnology.
Fundamentals of global law, practice and strategy. Clarendon Press. Oxford.
24. Thurston, J. and Burnett, Hall. (1988). “Genentech Inc. vs. The Wellcome Foundation
Ltd. How important is the decision for the biotechnology industry”. European Intellectual
Property Review. No. 2.
25. Hofinger, S. (1996). “Determinants of an Active Patent Policy – An Empirical Study”.
European Patent Convention. No. 3.
26. Hansen, Bernd and Hirsch, Fritjoff. (1997). Protecting inventions in chemistry.
Commentary on chemical case law under the European Patent Convention and the
German Patent Law. WILEY-VCH. Weinheim.
27. Stieger, Werner. (1982). “Article 54 (5) of the Munich Patent Convention: An Exception
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28. Blakeney, Michael. (2000). “Protection for indigenous or traditional works (e.g.
folklore): Has the Time Come?”. Fordham University School of Law. International
Property Law & Policy. Annual Conference. April.
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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 for
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Traditional 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).
245
Research, drug development and manufacture of herbal drugs
Research, drug
development and
manufacture of herbal
drugs
B. B. Gaitonde
247
Traditional Medicine in Asia
leaves, flowers, fruits, seeds and roots. organ leads to disease. Acupuncture is said
There are also elaborate descriptions of the to stimulate Yin or Yang and restore the
methodology for the preparation of normal flow of Qi.
medicines (dosage forms) and methods of Numerous herbs or medicaments
detoxification of mineral products. made from animal parts are thought to
Most fascinating are the descriptions help in restoring the balance of Yin and
of the pathogenesis of diseases based on Yang when disturbance manifests as
the concept of Tridosha: Vata, Pitta, Kapha. disease. It describes measures to remain
It is postulated that the human body is healthy and prevent or treat disease.
composed of five elements (Panchmaha- Traditional Chinese medicine has produced
bhutas) and is in perfect health when the over 10,000 medical books, and described
“Three Doshas” are in a state of equili- over 5000 herbal drugs. Most countries
brium. Disease produces imbalance of in the Western Pacific Region have been
Doshas and, depending upon the nature influenced by traditional Chinese medicine.
and extent of imbalance, an appropriate These medicines are complex mixtures
management strategy is employed to bring of plants, animal parts or products,
back the body to its original equilibrium.(1) minerals and metals. However, plants and
Ayurveda describes very methodically plant products form the dominant part of
the pharmacology of “Drugs and Diet”, the materia medica of traditional medicine
both being accorded equal importance in practised in different parts of the world and
the management of a patient. Charaka’s in particular in Asia, especially China,
classification of plants was based on their India, Korea, Philippines, Indonesia and
therapeutic uses and properties. Each Tibet. In India, for example, the Charaka
medicine and also dietetic article have in Samhita (treatise), dating back to 900 BC,
them what Ayurveda describes as Rasa lists 341 plants and plant products for
(taste) Vipaka (alteration or metabolism in medicinal use. Susruta, who practised
the body), Virya (potency) and Prabhava surgery about 600 BC, described 395
(specific action/potential which is beyond medicinal plants. Vagbhatta practised
the rasadi attributes of the drug). Thus, in Ayurveda in Sindh (now in Pakistan) around
Ayurveda drugs are prescribed to treat an the 7th century AD and wrote an unrivalled
individual and not just his disease, depen- treatise on the principles and practices of
ding upon the predominant property of the medicines called Ashtangahridaya which
medicament and the Prakriti (Vata, Pitta or provides systematic descriptions of
Kapha) of the patient. medicinal plants and mixtures of plant
In the Chinese system of traditional products, minerals or metals. Bhava-
medicine, the human body is considered prakash, written by Bhavamishra in about
as a single entity. Normal body functions 1550 AD, describes 470 medicinal plants.
are a result of the harmonious, balanced It is thus evident that traditional medicines
behaviour of elemental forces called Yin- offer a wide range of herbal medicines,
yang and Wuxing. Other concepts are often classified therapeutically.
Zang fu (internal organs) and Jing luo
(channels and collaterals), and Qi, a vital Research Policy
force circulating in the body. Continuous
circulation of Qi is believed to promote Most countries in the South-East Asia
health, while interruption of Qi in any Region (SEAR) have a political commitment
248
Research, drug development and manufacture of herbal drugs
249
Traditional Medicine in Asia
250
Research, drug development and manufacture of herbal drugs
251
Traditional Medicine in Asia
memory and intellectual performance, has seeds, or roots, etc.). It would also be
an elaborate method of preparation of the necessary to study the method of prepa-
oil from the plant. ration of dosage forms used in traditional
Another problem encountered in practices, treatment formulae, dose and
research on herbal medicine relates to mode of administration to patients.
seasonal variations in the activities of In this connection, a rational model
plants. It has been reported that some developed in China is the use of retros-
plants, when collected only in a particular pective data on plants or animals to
season, show activity. Samples collected in analyse the rationale of their use in Chinese
other seasons are devoid of active medicine. Thus, 248 plants and animal
principles and therefore biological activity. drugs used in over 700 polypharmacy
prescriptions were studied for their
Ethno-Pharmacognostic rationale, if any, based on the published
Research reports of their pharmacological actions,
complete with any available folklore claims.
Although there are elaborate descriptions If there was any correlation between
of medicinal plants using various reported pharmacological effects with use
synonyms, in the ancient treatises there are in Chinese medicine, it was presumed that
hardly any botanical descriptions as in there is a rational basis for its use.
modern pharmacognosy. The usual Another important consideration given
practice in ancient times seemed to be for by the Chinese is what is described as
a practising physician to collect plants from “Conversant evolution”. If a particular
his surroundings and prepare the drugs traditional medicine is used for the same
himself for use in his practice. It is not purpose by peoples widely separated by
unusual to find that a herbal medicine used geographical distances or belonging to
in different parts of a country for a different religious, ethnic or cultural
particular ailment contains plants widely backgrounds, a strong possibility of its
varying in botanical characterizations. For being “really effective” was accepted and
example, it has been reported that samples further research was undertaken.
of Shankha Pushpi (Convolvulus Ethno-botanical studies involve
pluricalis), used by traditional practitioners macroscopic and microscopic descrip-
in different parts of India, contain widely tions, preparation of plant specimens for
varying plant species. It is therefore a herbarium and also a preliminary
necessary to study the ethno-practices in chemical analysis to identify chemicals such
different parts of SEAR countries, collect as alkaloids, glycoside, terpenes, sesqui-
samples of medicinal plants, and subject terpenes, etc.
them to pharmacognostic studies
employing modern methodology. In such Napralert Database
a study it would be important to collect
information not only on the plant itself but A computerized database on the chemistry
on the time of collection, cultivation, and pharmacology of natural products is
harvesting, the mode of preservation, now available at the University of Illinois,
conditions in which it is used (fresh or USA. This department is now headed by
dried), parts of the plant in use (whole plant, Dr Fong. The database covers over 4595
leaves, stems, bark, flowers, shoots, fruits, genera of plants, animals and micro-
252
Research, drug development and manufacture of herbal drugs
organisms. It provides useful information From the early days, when pharmaco-
on plants used in traditional medicines and dynamic studies were done to determine
can be used for literature search before the effects of drugs on systems and tissues,
planning an elaborate research i.e., on circulatory or nervous systems, etc.,
programme.8 the scientists working in this field are now
It is possible to obtain from the involved in identifying the molecular basis
database names of plants of a specific of drug action, interactions with receptors
country or area: plants with pharmaco- (both extra and intracellular) effects on
logical data on specific activity, i.e., transmission mechanisms or interaction
hypoglycaemic, antitumour, antifertility, etc. with cytokines. With the cloning of
receptors through recombinant DNA
Agrobotanical Research technology, research methodology has
been further refined.2
Such research is necessary for the Classical pharmacological studies on
identification and evaluation of the natural experimental animals, using crude or
distribution of the plant species. Research refined plant extracts, have yielded some
on conditions of soil, weather, or type of fruitful data. On a global basis, about 130
manure used for cultivation of the plant drugs, all single entities extracted from
and the effect on seasonal variations in the higher plants or modified chemicals, are
growth and properties of the plant would currently used in modern medicine.2
also form a part of such agrobotanical However, such a classical “phyto
studies. Such studies are important for pharmacological” approach has not been
undertaking the cultivation of medicinal cost-effective. In fact, out of 200 new
plants and making herb gardens. chemical entities (NCE) introduced in
medicinal chemistry globally, only about 2
Pharmacological Studies per cent were based on higher plants.(2)
The National Cancer Institute (USA),
Modern pharmacology has made remar- beginning in 1959, screened over the next
kable progress in the last four decades. 25 years, 180,000 plant extracts covering
253
Traditional Medicine in Asia
3500 plant genera but this tremendous 1997)2 gives examples of some important
effort did not yield a single marketable remedies which are the result of such
drug.2 This has weaned major pharma- investigative approach.
ceutical companies away from plant From the Table, it is evident that
research and instead made them go in for traditional medicines offer investigative
synthetic drugs. In synthetic drug research, leads to undertake further studies to assess
once any innovative breakthrough and establish their therapeutic utility in a
occurred, several “me-too” drugs flood the number of clinical conditions, especially
market. Several examples can be given those diseases in which modern medicine
about the success of this approach, such offers very limited therapy. In Ayurveda, for
as NSAID, ACE, inhibitor, B-lactamase example, there is a group of drugs called
inhibitors, quinolones and B-blockers. This “Rasayana” or life promoters or rejuve-
has no doubt proved cost-effective. nators, which can be investigated in terms
In spite of what has been said above, it of modern physiological parlance, as anti-
must be emphasized that the ethnothe- inflammatory, antioxidants, immunomo-
rapeutic use of traditional medicines dulators, antiaging, etc.8
provides clues for searching for plant drugs,
identifying their active principles, Specific Screening Models
synthesizing their analogues, and leading
to their introduction in modern therapeutics. Experimental pharmacology offers several
The following Table (adapted from Sukh Deo, screening models to screen crude or semi-
254
Research, drug development and manufacture of herbal drugs
purified herbal drugs for therapeutic from Cyperus rotundus possesses anti-
activities based on traditional usage.9,10 inflammatory activity comparable to
Some of the models used in the screening hydrocortisone.12 Tinospora cordifolia was
programme are discussed. reported by Pendse, et al (1981), as
The criteria for selection of plants possessing anti-inflammatory activity
mentioned under each of the activities can against both acute and chronic inflamma-
be summarized as follows: tion comparable to non-steroidal anti-
z Plants are in use by traditional practiti- inflammatory agents.13
oners in a particular clinical condition; Potassium embelete, a quinone obtai-
z Preliminary pharmacological studies ned from Embelia ribes, was reported by
have yielded promising leads; Atal, et al (1984), as a potent, centrally
z Plants are mentioned in the ancient acting analgesic. It was reported to possess
texts as useful in certain diseases, a highly therapeutic index and lack absti-
particularly those for which there are nence syndrome.14 Similarly, Solanum
no effective or safe drugs in modern melangena was reported by Vohra, et al
medicine, e.g., diabetes, arthritis; (1984 a), as possessing non-narcotic
z Ancient texts providing leads for analgesic activity.15 Petroleum ether extract
selection of plants for screening for of Abutilon indicum was shown to possess
such conditions as cancer, stress, analgesic activity against acetic acid-
rejuvenation. induced writhing in mice and has a good
margin of safety.16
Anti-inflammatory, Analgesic- Antiallergic Activity
Antipyretic Activities
Several plants are used in traditional
Several herbal remedies have been medicines for treating allergic conditions
screened for anti-inflammatory, analgesic such as bronchial asthma, urticaria,
and antipyretic activities using appropriate eczema and allergic rhinitis. These are
screening models. A simple and commonly usually screened in animal models on the
used method to study anti-inflammatory basis of their antihistaminic or antiserotonin
activities, though not ideal, is carageenin- activities in isolated tissue systems such as
induced oedema of rat paws. Analgesic isolated intestine and isolated lung
activities have been studied in animal perfusion. Other models used are passive
models to assess pain relief in acid-induced cutaneous anaphylaxix in rats (PCA),
writhing in mice or by tail clip method in histamine contents, or release by antigens.
rats. Antipyretic activity has been studied
in animals with induced fever. Plants showing some antiallergic activities
Several plants have shown anti- are:
inflammatory activities in a number of z Piper longum;
screening models and would need further z Tylophora indica.
studies. Thus, Randia dumetorum contains
orionic acid 3 B-glucoside, which was Dry fruits of Piper longum reduced PCA
reported by Ghosh, et al (1983), as in rats and also prevented histamine-
possessing anti-inflammatory activities in induced bronchospasm in guineapigs.17
the exudative and proliferative phases of Similarly, Tylophora indica alkaloids were
inflammation in rats.11 B-sitosterol isolated found to posses activity comparable with
255
Traditional Medicine in Asia
disodium cromoglycate.18 Because of their primed with saline and measuring urine
extensive use in Ayurvedic preparations and output in a fixed time period. A dose
supportive experimental evidence, both the response study is planned, and the effect
plants would need further evaluation. on sodium or potassium excretion can also
be assessed.
Hypoglycaemic Activity
Diabetes mellitus has been described in Plants showing diuretic activity are:
ancient texts on traditional medicine both z Milingtonia hortensis;
in China and India. In Ayurveda, Charaka z Toddalia asiatica;
has given an elaborate description of the z Cucumis trigonus.
disease and has prescribed the dietetic
regime and drug treatment. Millingtonia hortensis showed a
Following are some of the herbal significant natruratic effect without
remedies screened for diabetes. The most affecting potassium excretion to any great
often used screening model is alloxan- extent.21 Toddalia asiatica was reported to
induced hyperglycaemia in rats and contain coumarins which possess diuretic
rabbits. Some plants screened for the activity though less potent than hydrochlo-
hypoglycaemic activity are: rothiazide.22 Similarly, Cucumis trigonus
z Acacia catechu; was also reported to possess some degree
z Gymnema sylvestre; of diuretic activity.23
z Momordica charantia;
z Leucaena leucocephala; Spasmolytic Activity
z Hamiltonia suaveolans; These drugs are used to relieve spasm of
z Pterecarpus marsupium. smooth muscles as in bronchial asthma,
renal colic or colicky pain in abdomen.
Gymnema sylvestre is used in Several test systems have been used to
combination for the control of diabetes and assess the spasmolytic activity of the plant
was reported to regulate blood sugar in extracts. Commonly used ones are
experimental animals by affecting insulin- isolated guineapig ileum, spasm induced
dependent enzymes.19 Momordica chara- by acetyl chloline or histamine and
ntia contains a polypeptide posse-ssing tracheo-bronchial tree of guineapigs.
hypoglycaemic activity(20) and the plant was Since histamine has been implicated in
shown to be effective in both juvenile and bronchial asthma, its release or that of
maturity onset diabetes, probably due to other cytokines, induced by histamine
increased insulin release from pancreas. releasers or stabilization of mast cell
Diabetes is a complex metabolic granules, has been studied to assess the
disorder which, according to the traditional effects of plant extracts on various local
medicine concept, needs management of hormones.
diet, physical activity, emotional problems
and appropriate drug combinations. Some of the plants screened for
spasmolytic activity are:
Diuretics z Clausena pentaphyla;
Drugs of this class are used in several clinical z Corydalis meifolia;
conditions, such as dropsy, hypertension z Symplocos spicata;
and acute left ventricular failure. Diuretic z Corchorus tridens;
activity has often been studied in rats z Selaginella rupestris.
256
Research, drug development and manufacture of herbal drugs
257
Traditional Medicine in Asia
258
Research, drug development and manufacture of herbal drugs
ushna (hot) or sita (cold) and the patients, commonly used include hepatic damage
depending on their Prakriti, are advised to induced by carbon tetrachloride in rats,
take or avoid one or the other. Sarkar, et al both as acute and chronic hepatic injury.
(1996), have reported on the clastogenic Alcohol, isoniazide, pyrazinamide or
and non-clastogenic effects of Indian paracetamol-induced hepatic injury in rats
spinach.36 Momordica charantia,36 edible has also been used to produce hepatic
oils,37,38 Curcuma longa,39 Fenugreek,40,41 injury. However, there is no animal model
and Mentha spicata.42 to simulate chronic progressive hepatitis or
cirrhosis.
Anti-peptic Ulcer Activity
Acid peptic disease is treated with remedies The following are commonly used herbal
which restore equilibrium of humors in the medicines as hepatoprotectives:
body. There is, therefore, no appropriate z Tinospora cordifolia;
test model to assess the activity of herbal z Acacia catechu;
medicines in this disease complex. z Piper longum;
However, commonly used models to test z Phyllanthus niruri;
antipeptic ulcer activity are experimentally z Eclipta alba;
produced ulcers in rats by pyloric ligation, z Picrorhiza kurroa.
or immobilization, and prednisolone or
histamine-induced ulcers in guineapigs. Rege, et al (1984b), have reported that
Herbal drugs proposed for this condition chronic liver damage was prevented by
are: Tinospora cordifolia.45 Similarly, Acacia
z Tectona grandis; catechu prevented chronic damage of liver
z Andrographis paniculata. but not the acute variety. Piper longum is a
drug most commonly advocated in Ayurveda
Ethanol extract of the bark of Tectona for the treatment of liver disorders. However,
grandis was studied by Pandey, et al (1982), in studies by Rege, et al (1984c), it only
and showed anti-ulcer activity in rats and seems to restrict fibrosis.45 Picrorhiza kurroa
guineapigs.43 Vishwanathan, et al (1981), and Eclipta alba have been extensively
reported a similar activity of a flavone investigated for hepatoprotective activities
isolated from Andrographis paniculata.44 (Pilankar, Ph.D thesis submitted to Mumbai
Several such plants used in combination by University).46 These drugs form important
traditional practitioners in gastric disorders ingredients of Ayurvedic preparations such
should provide leads from animal experi- as Liv 52 or Liv 100 marketed in India for
mental studies for clinical evaluation. liver disorders. Vaidya, et al (1996), have
reviewed experimental and clinical research
Hepatoprotective relating to the hepatoprotective effects of
Modern medicine does not offer any Ayurvedic formulations.47 Saraswathi, et al
specific hepatoprotective drugs. Viral (1998), have reported on the hepato-
hepatitis or liver cirrhosis is treated sympto- protective activities of Liv 52 and Liv 100,
matically and by diet rather than drugs. which are mixtures of herbal drugs
Traditional medicine, in particular extensively used in liver disorders such as
Ayurveda, offers several medicinal plants progressive hepatitis, and cirrhosis.48 It was
with possible hepatoprotective activity. shown that hepatic enzyme activity was
Experimental test models which are protected by these preparations.
259
Traditional Medicine in Asia
260
Research, drug development and manufacture of herbal drugs
261
Traditional Medicine in Asia
purified components can, after elution, be compounds satisfy the appropriate stereo-
tested for biological activity in an appro- structure. Computer modelling has already
priate test system. Thus, by such highly yielded a number of compounds of herbal
sophisticated methodology it is possible to origin with therapeutic possibilities.
proceed from “plant to drug”.2
Drugs derived from plants as pure Molecular Approach to Drug
chemicals have been in therapeutic use for Development
almost a century. Some of the plant consti-
tuents have yielded novel chemical entities, In recent years there have been tremen-
leading to their synthesis and the prepa- dous advances in understanding how drug
ration of their analogues or derivatives. molecules modify cell functions. After Paul
Some examples of such drugs derived from Ehrlich postulated that drug molecules
plants are given in the following Table. interact with specific areas on cell mem-
brane or inside the cell called “receptors”,
Table 3. Drugs derived from plants such receptors have now been identified
Source Plant Active Constituent and their stereo-chemistry studied. With
Digitals lauata Digoxin advances in genetic engineering the
Ephedra vulgaris Ephedrine receptors have even been cloned. It is now
Rauvolfia serpentina Reserpine
possible to study drug receptor interactions
and their kinetics and therefore it is possible
Cinchona bark Quinine
to evaluate the therapeutic potential of
Artemesia annua Artemisinin
several naturally occurring phytochemicals
Commiphora mukul Guggulusterones
derived from higher plants.
Asparagus racemosus Shatavarin
While most investigators in this area of
Picrorhiza kurroa Picroside drug development would prefer to work on
Adhatoda zeylanica Vasicine synthetic drugs, the potentials of herbal
Atropa belladona Atropine medicines offering interesting chemical
Papaver somniferum Morphine entities are enormous. This type of develop-
ment can only be undertaken by the
pharmaceutical industry. Considering that
Plant Culture their annual turnover exceeds US$ 200
This is a recent addition to bio-technology billion globally and the R&D inputs of some
in plant research. In vitro plant cultures dominant pharmaceutical companies is in
under varying experimental conditions result the vicinity of 10–15 per cent of their
in bioproducts with novel chemical turnover, it is possible for such frontline
structures and biological activities. industrial houses to invest in R&D on the
basis of leads provided by materia medica
Structure-based Designs and practices of traditional medicine.
262
Research, drug development and manufacture of herbal drugs
herbal drugs are complex combinations uniform and high quality raw materials
and are often prepared by a variety of which are fundamental for quality assu-
methods described in the ancient texts. rance, the trend is towards domestication
Very often these methods are not well- of plants (herbal gardens), genetic impro-
standardized and therefore the end- vement or use of plant-culture techniques.
product may not yield consistent results.
The tests on the final product or dosage Safety of Herbal Medicines
forms are not often available in the old
treatises. It is therefore essential to under- Any medicinal preparation, whatever its
take extensive research and development origin, has to be safe for human or animal
for quality control and standardization. use. Since traditional medicines, parti-
Herbal preparations contain active cularly of herbal origin, have been in use
ingredients of plant parts or materials in a over several centuries, these are presumed
crude or processed form. India, China, to be free from toxic effects. These presum-
Thailand and Indonesia have prepared ptions do not seem to be valid in all cases
pharmacopoeias of herbal medicines considering that medicinal plants contain
which describe the botanical characteristics highly toxic chemicals such as glycosides,
or pharmacognosy of individual plant alkaloids, or saponins and cytotoxic agents.
materials, their chemical characterizations, There is a likelihood that herbal medicines
including the spectrum of active ingre- in general have overall less toxicity than
dients, both quantitative and qualitative, synthetic compounds. Furthermore, the
methods of preparation, and some tests traditional methods of preparation of
on the final product. However, much more dosage forms and combinations of several
research is needed in this field, particularly plants are supposed to reduce or eliminate
for developing methods for quality control toxicity and make the final product safe for
to be used by the authorities for regulatory therapeutic use.
control and for their harmonization and Elaborate toxicity studies prescribed by
improvement by different countries in the regulatory authorities for “New Drugs” are
South-East Asia Region. not required for those herbal medicines
The combination of scientific studies which are either described in ancient
and traditional knowledge should be the treatises or are in use as folklore for several
hallmark of such research. Scientific centuries. However, most regulatory
methods presently used include studies on authorities would require some toxicity data
botanical characteristics and chemical in two or more species of animals before
studies using instrumentation analysis such allowing such drugs to be adopted in
as neutron activation techniques. Since this national pharmacopoeia or in therapeutic
type of research would require adequate practice.
resources, both human and financial, it can Once the active principles from a
best be undertaken either by commercial herbal drug are isolated in chemically pure
companies or through international form and their analogues are prepared,
collaboration. such “New Drugs” would require elaborate
Variations of plant material harvested toxicity studies.
from different geographical areas in There are a few reports on adverse
different seasons pose a serious problem reactions to herbal medicines. Very often
in standardization. In order to obtain there is a lack of proper observation in
263
Traditional Medicine in Asia
264
Research, drug development and manufacture of herbal drugs
need for elaborate preclinical studies. The Plants considered medicinal and
modern-medicine clinician should work available locally in abundance will fall into
with a traditional practitioner for evaluating two groups: i) Those described in either
the clinical efficacy of the drug therapy, traditional or modern literature, either singly
using dosage forms used by the traditional or in combination, and ii) Those which are
practitioners. This is important because “folklore”. In the case of the first group,
there are examples where dosage forms based on the literature survey, a protocol is
of herbal drugs prepared by modern prepared for clinical evaluation taking into
pharmaceutical methods may not yield the consideration all the available information
expected results. such as agro-botanical and ethno-pharma-
Having established efficacy and cognostic data, phytochemical data,
“Clinical Safety”, the next step would be to pharmacodynamic studies and acute and
evaluate dosage forms and the appropriate subacute toxicity data.
dose of the medicine, with the objective of In the case of “folklore” medicines,
adopting these in modern pharmaco- careful observations and study of “folklore
poeias. At that stage, drug regulatory practices”, the traditional method of
authorities should be consulted to find out preparation and rituals accompanying the
if it is possible to lay down standard quality administration of the medicine are prere-
control methods and establish large-scale quisites for planning clinical evaluation. At
production facilities. this stage, the objective is simply to assess
265
Traditional Medicine in Asia
the efficacy of the herbal medicine. Having inflammation and degeneration. Phyllan-
validated the claim, it would be necessary thus niruri, or Picrorhiza kurroa are
to plan an elaborate research programme examples of herbal medicines investigated
in order to adopt the drug in modern for their effectiveness in liver disorders
clinical practice. based on Ayurvedic concepts, and this has
Research and development of herbal led to the isolation of a novel chemical
drugs for specific chronic diseases should structure. Asparagus racemosus is
follow more or less the same approaches described as galactogogue and used in
as in the case of “folklore” medicines. In lactating mothers. Its investigation has
this type of research, a careful study of resulted in the isolation of Shatavarin, a
traditional literature, the concepts of health chemical with a novel structure. As
and diseases, descriptions of the pathoge- mentioned earlier, Artemesin and Arete-
nesis of the specific condition, and the mesinine isolated from Artemisia annua in
mechanisms of drug action as described China has proved a very valuable drug in
in ancient treatises, are all important and the treatment of falciparum malaria. This
necessary before embarking on such type is based on the use of the plant in fevers
of research. mentioned in ancient Chinese medicines.
It is also necessary to try to correlate
modern concepts of the pathogenesis of Pharmaceutical Technology
disease with the traditional concept. For
example, the Rasayana drugs mentioned Herbal medicines, used by traditional
in Ayurveda as health promoters can be practitioners, are administered to patients
conceived to act as “antioxidants” or in several dosage forms. These are
immunomodulators, and Celastrus prepared according to methods prescribed
paniculatus (jyotishmati) described in in ancient traditional treatises. For
Ayurveda as a promoter of memory could example, Ayurvedic classics mention
act through receptor activation or regene- elaborate pharmaceutical methods for the
ration. Sushruta has described treatment preparation of a medicament. Usually the
of obesity and lipid disorders (medoroga) dosage forms prepared according to
with the use of a gum resin from Ayurvedic texts are distillates (Arka)
Commiphora mukul called “Guggulu” in fermented products (Asavas and Aristas),
Sanskrit. Sushruta gives an elaborate Linctuses, (Avaleha), powders (Churna),
description of the etiology and pathoge- incinerated material (Bhasma), pills or
nesis of the disease, which has a conside- tablets (Vati/gutika), and decoction
rable resemblance to the modern concepts (kwatha).
of atherosclerosis. Dr C. Dwaraknath, the As mentioned earlier, it is important
then advisor to the Government of India that traditional pharmaceutical technology
on traditional medicines (1969), proposed is investigated thoroughly before changing
a collaborative study on this plant for its over to modern technology. It is possible
use in atherosclerosis or hyperlipidaemia. that the therapeutic properties of the
This study has led to the isolation, dosage forms are preserved only when
identification, and characterization of a these are prepared according to traditional
new structural type, Guggulusterone. A pharmaceutical methods, and this aspect
similar approach has been adopted for therefore needs investigation.
herbal drugs in the treatment of liver
266
Research, drug development and manufacture of herbal drugs
267
Traditional Medicine in Asia
globally. Some higher plants which are of technical human resources. Technology
medicinal interest should be carefully missions and policy commitment at the
investigated in all aspects57,58 because they highest political level, and international
offer great possibility for achieving a collaboration at national and regional
breakthrough in respect of several diseases levels, would serve to speed up research
for which there is no satisfactory therapy and development in the field of herbal
in modern medicine. Countries should drugs.
therefore provide both financial as well as
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270
Current status –
Country situation
Traditional medicine in the WHO
South-East Asia Region
Dr. Kin Shein
Traditional medicine in Bangladesh
Dr. Md. Aftabuddin Khan &
Dr. S.K. Chowdhury
Traditional medicine system in
Bhutan
Drungtsho Dr. Pema Dorji
Koryo medicine of Korea
Dr. Choe Thae Sop
Indian system of medicine and
homoeopathy
Mr. L.V. Prasad
Native traditional medicine in
Indonesia
Dr. Ketut Ritiasa &
Dr. Niniek Sudiani
Dhivehibeys in Maldives
Dr. Abdulla Waheed
Indigenous medicine in Myanmar
Dr. U. Kyaw Myint Tun
Traditional medicine in Nepal
Dr. Rishi Ram Koirala
Indigenous system of medicine in
Sri Lanka
Dr. Lal Rupasinghe
Thai traditional medicine as a
holistic medicine
Dr. Pennapa Subcharoen
Traditional Medicine in Asia
272
Traditional medicine in the WHO South-East Asia Region
Traditional medicine in
the WHO South-East
Asia Region
Kin Shein
273
Traditional Medicine in Asia
WHO has been assisting the Member of human resources and exchange of
Countries in the following areas: National information.
programme development in the various The development of various systems of
aspects of TM; traditional health systems traditional medicine in countries of the
and operational research; standardization, South-East Asia Region are described by
quality control and proper utilization of the national authorities in the ensuing
traditional and herbal medicines; training chapters.
274
Koryo medicine in Korea
281
Traditional Medicine in Asia
282
Traditional medicine system in Bhutan
Traditional medicine
system in Bhutan
Pema Dorji
279
Traditional Medicine in Asia
280
Traditional medicine in Bangladesh
Traditional medicine
in Bangladesh
Md. Aftabuddin Khan
S.K. Chowdhury
275
Traditional Medicine in Asia
276
Traditional medicine in Bangladesh
277
Traditional Medicine in Asia
278
Koryo medicine in Korea
281
Traditional Medicine in Asia
282
Indian system of medicine and homoeopathy
283
Traditional Medicine in Asia
1940. It uses materials of plant origin for are governed by the regulations framed by
most of its products, which are natural, safe, the Statutory Council. Drug standar-
cost-effective and efficacious. Therapeutics dization, official formularies, licensing and
under the Ayurveda system include manufacture of drugs are governed by the
Shamana Therapy, Shodhana Therapy, Drugs and Cosmetics Act, 1940. There
Satyavajaya Therapy, Panchakarma are dispensaries, hospitals, pharmacies
treatment and Rasayana Therapy. Its wide and research units under the Siddha
network of physicians and infrastructure of system. Two undergraduate colleges and
medical institutions, hospitals, dispensaries one postgraduate college are imparting
and manufacturing units make Ayurveda the education in the Siddha system.
most widespread Indian system providing The Unani System of medicine
health care to the people of India. Some 196 originated in Greece and came to India
undergraduate and 49 postgraduate through the Arabs. It flourished in the
colleges are imparting education, and country for centuries under the patronage
3,66,812 registered practitioners are of successive rulers. Today, it is one of the
engaged in health care. About 8400 recognized systems of medicine. This
pharmacies are manufacturing drugs, both system is also holistic in approach and
classical and proprietary. Intramural and bases its philosophy on the humoral theory.
extramural research and clinical trials, The human body is made up of seven
separately and in collaboration with modern components, such as the Elements,
institutions with proper protocols adopting Temperament, Human organs, Spirits,
scientific parameters, are being conducted Faculties and Functions. Unani is popular
extensively to enrich and develop this system. with the masses and is extremely efficacious
The Siddha System of medicine is in certain chronic indications. Under-
also one of the oldest systems being graduate and postgraduate education,
practised in India for centuries. The registration of physicians, practice and
principles and doctrines of the Siddha ethics are regulated by the same Council
system, fundamental and applied, are as for Ayurveda and Siddha. Most of the
similar to Ayurveda. It is also holistic in Unani classical texts are in Arabic, Persian
approach. This system emphasizes that and Urdu, but are being translated into
medical treatment should be oriented not English. The diagnosis takes into conside-
merely to disease but should also take into ration the temperament, structure, strength
account the patient, his environment, sex, of facilities, the type of factors operating
age, habits, mental frame, habitat, diet and on the patient from outside, etc. Unani
physical condition. The human body is a treatment uses regimental therapy, diet
conglomeration of three humours, seven therapy, pharmaco therapy and surgery.
basic tissues and waste products of the In this system, although the general
body. Their equilibrium is good health, and preference is for single drugs, compound
any disturbance or imbalance leads to formulations are also used in the treatment
disease or sickness. In the Siddha system, of various complex and chronic diseases.
the drug preparation is largely based on The drug licensing, manufacture and
plants, but minerals and metals are also quality of products are regulated under the
used for drug preparation. The educational Drugs and Cosmetics Act, 1940. There are
pattern, regulation of education, regis- practitioners, hospitals, dispensaries and
tration of practitioners, practice and ethics pharmacies under the Unani system, in
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Indian system of medicine and homoeopathy
285
Traditional Medicine in Asia
286
Dhivehibeys in Maldives
Dhivehibeys in Maldives
Abdullah Waheed
289
Traditional Medicine in Asia
the founder of a family of practitioners, who At various times many distinct branches
still continue to be active. of dhivehibeys flourished to cater to the
During the first half of the 20th century, varying needs of the society. In earlier times
dhivehibeys flourished and produced a priority need was the treatment of battle
many notable practitioners such as wounds resulting from recurrent skirmishes
Ibrahim Faamuladheyri Kilegefaanu, with the ubiquitous pirates. Historical
Naifaru Dhonkaleyfaanu, Ahmed Kaamil anecdotes indicate that the branch of
and Badeegey Mohammed Didi. They were dhivehibeys called kandifaarubeys (literally,
instrumental in popularizing new concepts treatment of sword wounds) was highly
learnt from Unani medicine throughout the developed in those days. Another branch
country and ushering in what can be of dhivehibeys was lolubeys, or the
described as the golden era of treatment of eye diseases. Ruggalubeys
dhivehibeys. The era ended when modern specialized in treating bone disorders. There
medicine came during the ’50s and were also practitioners who specialized in
gradually weaned patients away from the circumcision.
traditional system. Dhivehibeys was never far from
Along with the decline in dhivehibeys, spiritual healing or fanditha as the natives
its practitioners also largely disappeared, called it. Some of the most successful
since not many new entrants came forward practitioners were those who could get the
to replace the aging masters. Heera Yousuf right mix of the two. One of the last expo-
Fulhu was perhaps the last survivor from nents of this technique was Ihavandhoo
the golden era. Hajee, who successfully combined his
Tragically, many aging practitioners potions with charms and prayers.
died without having an opportunity to pass With the advent of effective Western
on their knowledge to the next generation. alternatives some branches such as
Centuries of accumulated knowledge in kandifaarubeys and lolubeys have virtually
their collective memory was thus irrevo- disappeared. But some others continue to
cably lost. A monograph on individual be popular. A large part of the population
ingredients and a few handwritten manu- still depend on ruggalubeys to heal their
scripts are the only records that survive. fractures and the overwhelming majority go
Despite the absence of written texts to dhivehibeys practitioners for circumcision.
and the lack of a formal system for sharing In recent years the Government has
information, existing sources of knowledge taken several steps to develop dhivehibeys.
agree remarkably on the general principles This includes the appointment of a high-
of dhivehibeys. However, when it comes level committee and a chair for
to details, different schools of thought dhivehibeys at the Faculty of Health
represented by traditional families have Sciences of the Maldives College of Higher
disagreements. For example, for treating Education. The committee has recognized
bone injuries all schools agree on the that improving access to herbs is the key
ingredients of the dressing. But for to preserving dhivehibeys. Otherwise,
tempering it the Gaddaduge school more and more patients are going to find
believes in applying strong heat, whereas it not only easier but also cheaper to buy
some others believe in applying only an aspirin at the neighbourhood store than
moderate heat with sunlight. to go searching all over the island for
impossible ingredients.
290
Indigenous medicine in Myanmar
Indigenous medicine in
Myanmar
U Kyaw Myint Tun
291
Traditional Medicine in Asia
consolidating into a single system the four the aforementioned Act and has updated
branches of medicine currently practised; and revised it as the Traditional Medical
the Board is likewise to undertake studies Council Law, which was enacted on 14
and research and advise the competent January, 2000, by the Government. At
authorities on standardizing the methods present there are over 8000 traditional
of treatment provided in dispensaries medicine practitioners registered under the
operated by the Government. said law.
The Indigenous Burmese Medical In 1996, the Government promu-
Practitioners Board Amendment Act of 1962 lgated the Traditional Medicine Law in order
introduced new sections 22-A and 28-A to control the production and sales of
empowering the Chairman of the traditional medicine drugs systematically.
Revolutionary Council of Burma to, (i) Cancel This was followed by a series of notifica-
the registration of indigenous medical tions concerning registration and licensing,
practitioners, (ii) Prescribe qualifications for labelling and advertising.
registration, and (iii) Terminate the services
of any or all of the members of the Board Education and Training in
and appoint new members in their place. Traditional Medicine
Under these powers, a new Board was There is one Institute conferring diploma
appointed to initiate the re-registration of in Traditional Medicine, situated in
practitioners. The Department of Indigenous Mandalay, the second capital of Myanmar.
Medicine was established on the 3rd of This institute was opened in 1976 and is
August 1989. attached to the 50-bed teaching hospital
with the aim of eradicating bogus medical
Education and training practitioners by producing full-fledged
An educational institution known as the practitioners, to update traditional
Institute of Indigenous Medicine was medicine to modern standards, to carry out
established by the Ministry of Health in 1976, research work in traditional medicine, to
offering a three-year training programme. produce skilled researchers, and to give
citizens effective treatment by traditional
Organization medicine.
The second-grade department was formed It is a three-year diploma course,
in mid-1989 by upgrading the branch of followed by a one-year internship. Till the
indigenous medicine under the Department 1997–98 academic year, the number of
of Health. The staff strength at that time students awarded diploma totalled 890.
was about 700. In late 1997, the Depart- The yearly intake of candidates is 100 at
ment was again upgraded into a first-grade present. The Institute has its own
one, expanding the manpower up to 1796 medicinal plant garden for teaching
consisting of four main divisions, viz., demonstrations. The Department is now
administration, medical care, research and planning to upgrade the Institute to
development, and herbal garden and drug become a degree-conferring one in the
production. near future.
In addition, the Institute also conducts
Law and Regulation a one-year course for outside Traditional
To keep abreast with the changing Medicine Practitioners who have no
circumstances, the Department reviewed certificates or licences to treat patients.
292
Indigenous medicine in Myanmar
Those who are successful in the course will Cultivation of medicinal herbs
have the licence to practise as Traditional and maintenance of herbal
Medicine practitioners. gardens
With the main aim of producing enough
Medical Care Service raw materials for the Department-owned
There are two 50-bed traditional medicine drug manufacturing factories, the
hospitals, one each in Yangon and Department has been establishing one
Mandalay, and three 16-bed hospitals in garden after another for the cultivation of
other parts of the country. medicinal herbs. Thus, there are now
For rural and township communities, altogether nine gardens with a total area
the Department has established 194 of over 120 acres. Since herbal gardening
township traditional medicine depart- is still in its infancy, only 20 per cent of the
ments attached with their own outpatient area has been utilized at the moment. They
clinics. If necessary, the patients are are situated in different parts of the country
referred to both Western medical hospitals with different weather and soil conditions,
and the nearest traditional medicine so that different kinds of species can be
hospitals. cultivated, depending on their climate and
Since 1999 was designated by WHO the nature of the soil.
as the International Year for Older People,
primary health care and medical services Traditional medicine
by traditional means serve the elderly manufacturing factories
population more by paying greater The traditional drugs used in township
attention to the diseases prevalent among traditional medicine clinics and hospitals
elderly people such as metabolic diseases, are provided by two traditional medicine
e.g., diabetes. manufacturing factories situated one each
in Upper and Lower Myanmar. The yearly
Registration and Legislation production of each factory is 10,000 kgs
of Traditional Medicine and the drugs are produced according to
Drugs the national formulary. In addition, these
According to the Traditional Medicine Law, factories also manufacture 12 kinds of drugs
all the traditional medicine drugs produced in tablet form for commercial purposes.
in the country have to be registered and
the manufacturer must have a licence to Research and Development
produce them. This has been done since The main tasks in this sector are to carry
1996 after the promulgation of this law. out basic analysis for traditional drugs for
There are altogether 3962 registered items registration purposes and standardization
of drugs and 632 manufacturers have of commonly used medicinal plants and
already got the licences for production. quality control analysis for Department-
Good Manufacturing Practices are owned drug production factories.
considered before giving the licence. In Promotion of the systematic utilization
addition, the Department is also involved of TM among the people is done by
in the control of advertisements of these disseminating information through the
commodities. mass media and by conserving old palm-
leaf manuscripts regarding TM which are
translated into Burmese for publication.
293
Traditional medicine in Nepal
Traditional medicine
in Nepal
Rishi Ram Koirala
295
Traditional Medicine in Asia
296
Traditional medicine in Nepal
297
Indigenous system of medicine in Sri Lanka
Indigenous system of
medicine in Sri Lanka
Lal Rupasinghe
299
Traditional Medicine in Asia
This country enjoys the services of surveys conducted revealed that well over
15,000 traditional and Ayurvedic 45 per cent of the entire population seeks
practitioners, 70 per cent being traditional Ayurvedic and traditional medical
physicians, trained by their gurus and who assistance in spite of the mere 1.4 per cent
had acquired knowledge through years of of the entire health budget it is receiving
experience as well. The remaining 30 per annually.
cent are institutionally trained, obtaining a The Department of Ayurveda manages
Diploma or Degree after undergoing a six- an intricately woven network of health care
year curriculum course, as a part of which delivery outlets throughout the country. The
they are taught the basics and essentials details are as follows:
of traditional medicine on the above-
mentioned specialities. In addition to the Table Ayurved delivery outlets
above-mentioned course, a three-year z Teaching Hospitals 2
diploma course is available in the country z Central Dispensaries 122
to train, as physicians, youngsters z Provisional Hospitals 46
descended from families whose forefathers z Local Dispensaries 231
z Research Institute 1
were traditional physicians. z National Institute of
The traditional and Ayurvedic system Traditional Medicine
of medicine by Government Policy is (Teaching and Training only) 1
recognized as a component of the national z Herbal Gardens 5
health service. Indigenous medical
practitioners who fan out throughout the Sri Lanka is the only country where the
country, especially to the remote rural areas traditional medical fraternity together with
where the Western medical and health care the Ayurvedic component enjoys the status
delivery system does not reach, offer of a cabinet portfolio in the whole of the
invaluable service to the people. Recent South-East Asia Region.
300
Thai traditional medicine as a holistic medicine
301
Traditional Medicine in Asia
body element could be responsible for a z Salt water, mud and the beach are
fever. Humans should adjust themselves to related to diseases of the earth element.
the diseases which occur in the different
seasons. These are given below: Time variation
z Summer - Diseases of fire The time of the day or night has an
element; influence on the different body elements or
z Rainy season - Diseases of wind Dhatus. These are described below:
element; z 06.00–10.00 a.m. and
z Winter - Diseases of water z 18.00–22.00 p.m.
element. Nasal secretion problems or
indigestion;
Age variation z 10.00 a.m.–14.00 p.m. and
Age can be related to the propensity of a z 22.00 p.m.–02.00 a.m.
particular disease to occur in a particular Fever caused by the fire element,
person. Different age-groups are corre- stomach ache or hunger pains;
lated with the diseases of a particular z 14.00 p.m.–18.00 p.m. and
element. This relationship is shown below: z 02.00 a.m.–06.00 a.m.
z Primary age (0–16 years) The wind element causes giddiness,
Water element diseases; feeling of being worn out, exhaustion
z Middle age (17–32 years) and fainting in the afternoon.
Fire element diseases;
z Old age (over 32 years) Behavioural variation
Wind element diseases. Certain behavioural patterns are asso-
ciated with disease. Some of these are:
Place variation z Having too much or too little food and
The environment has a relationship with the eating spoilt food; imbalance in
occurrence of a particular disease. Illness activities such as standing, sitting,
can be caused by a different geographical walking or lying down;
location, extremes of temperature or a z Exposure to hot or cold weather;
new water supply. It is suggested that such z Going without food, water and sleep;
an influence could be mediated through z Delayed defecation or urination;
the immune system. Information as regards z Overwork;
the birthplace of the patient or the actual z Excessive sorrow;
place of residence may give the physician z Excessive anger.
clues as regards the diseases which are
likely to afflict the patient. The correlation Diagnosis
between geography and diseases is given
below: A correct diagnosis is extremely important
z High mountains are associated with as a wrong diagnosis would lead to
diseases of the fire element; inappropriate treatment, which could be
z Rain, water and mud are associated fatal. The method of arriving at the correct
with diseases of the wind element; diagnosis in Thai traditional medicine
z Rainwater, soil and groundwater are consists of two factors – history-taking and
related to diseases of the water physical examination.
element;
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Thai traditional medicine as a holistic medicine
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304
Thai traditional medicine as a holistic medicine
circulating system and the nervous body systems necessary for maintaining
system. The person who carries out the good health. For example, it strengthens
massage should, therefore, have a the circulatory system, removes wastes, acts
knowledge of anatomy and should as a diuretic, relaxes the nervous system
possess the skill of massaging the and relieves pain. Some of the types of pain
blood vessels and nerves. for which it is effective are headache,
displaced shoulder joint, neck pain,
Folk massage sprained ankle, backache and kneecap
z Start the massage from the feet; pain. It is effective also in diseases of the
z Give the massage to the patient while elderly such as paralysis, limpness,
he is sitting, lying on the back, lying in flatulence, constipation and reduced sexual
a side position but not when he lies on efficiency.
the stomach; The benefits of Thai massage and the
z Bend the joints and parts of the body safety while carrying it out depend on the
with force using the knees and elbows; expertise of the Thai practitioner. He should
z The massage has an effect on the know the body and the condition of health
organs and tissues. of the patient. He should know the principle
of massage and know what not to do and
Thai traditional massage is a valuable he should know how much weight he
aspect of Thai traditional medicine; it is should apply to make it suitable for the
able to relieve disease and assuage pain. patients.
The massage has a beneficial effect on the
305
List of contributors
List of contributors
1. Dr. Palitha Abeykoon, Former Director, Health Technology &
Pharmaceuticals, WHO-SEARO, New Delhi, India.
2. Dr. O. Akerele, former Advisor, Traditional Medicine, WHO HQs.,
Geneva, Switzerland.
3. Dr. Gerard Bodeker, Chair, Global Initiative For Traditional Systems
(GIFTS) of Health, Green College, University of Oxford, Oxford,
U.K.
4. Mrs. Shailaja Chandra, Secretary, Department of Indian Systems
of Medicine & Homoeopathy, Ministry of Health & Family Welfare,
New Delhi, India.
5. Mr. S.K. Chowdhury, Associate Professor, Department of Pharmacy,
Jahangirnagar University, Bangladesh.
6. Professor Carlos M. Correa, Director, Master Program on Science
& Technology Policy and Management, University of Buenos Aires,
Buenos Aires, Argentina.
7. Dr. Hongguang Dong, Clinic of Infertility and Gynaecological
Endocrinology, Department of Obstetrics and Gynaecology, Geneva
University Hospital, Geneva, Switzerland.
8. Dungtsho Pema Dorji, Director, Institute of Traditional Medicine
Services, Bhutan.
9. Dr. B. B. Gaitonde, Former Director, Haffkine Institute, Bombay,
Banda Sindhudurg, India.
10. Dr. Lestari Handayani, Health Services Research and Development
Centre, National Institute of Health Research and Development,
Ministry of Health, Surabaya, Indonesia.
11. Dr. D.C. Jayasuriya, Attorney-at-Law, DCJAY Law Associates,
Nawala, Sri Lanka.
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List of contributors
309