TRADIONAL MEDICINE DEVELOPMENT:COMING TOGETHER IN THE NEW SOUTH AFRICA

• TRADIONAL MEDICINE DEVELOPMENT:COMING TOGETHER IN THE NEW SOUTH AFRICA
  
  1.Anne Hutchings, 2.Indres Moodley and 3.Dumisane Nzima
  1. Department of Botany, University of Zululand
  2. Department of Pharmacy, University of the Witwatersrand
  3. Department of Psychology, University of Zululand
  
  Abstract
  
  Lack of enabling legislation has inhibited development of the rich botanical and cultural resources of South Africa, concerning traditional medicine and control of plant exploitation. With the advent of a democratic government and calls for an improved health care system, better utilization of these resources is urgently needed. Past problems of communication between various research institutes, traditional and allopathic medicine, and traditional healing organizations can be overcome by the combined efforts of academics, health care professionals and traditional healers.
  
  This paper outlines some recent developments in building bridges between the different partners involved. One important development has been the formation of a national association of researchers and practitioners involved in indigenous plant use. Arising out of this association is a collaborative research programme between the universities of the Witwatersrand, Zululand and Durban-Westville. The programme involves the biological screening of extracts from selected indigenous plants. Many of which are used traditionally. Information on indicated therapeutic and toxic properties of the plants will be communicated to healers. Contracts to ensure confidentiality and equitable profit sharing on developed products between researchers and healers in the partnership will be drawn up.
  
  Other initiatives include collaboration between the University of Zululand, the Awnings' National Association and a local hospital involving recognition measures for healers, the role of healers in primary and mental health care, and the setting up of a traditional healing centre and community healing gardens. A short video filmed from various meetings called by the Awnings' National Association will be shown. Practitioners discuss ethics and a training session in plant usage is depicted.
  
  INTRODUCTION
  
  The need for some form of coming together, of crossing cultural barriers and of sharing resources for the purpose of the social enrichment of the new South Africa is one which has been felt and expressed by many of its people. This is particularly evident in the fields of healing and research. Ethnopharmacology, a term new to many South Africans, is one area where exciting collaborative ventures are beginning to take place.
  The lack of legislation on bioprospecting and control of the use of our rich but threatened botanical resources is an important issue that impinges on our subject. A recent report states:
  
  At present the export and use of South Africa's biological diversity is virtually uncontrolled. Commercial exploitation of the county's genetic resources takes place in a policy vacuum.(Laird and Wynberg, 1996, p7)
  
  The question urgently needs resolutions but will be only briefly touched upon in this paper as we wish to focus more on the coming together of traditional and allopathic healing and also on the collaborative research on plants that could enable us try to resolve some of the huge health problems facing the country. Some major past restrictions and their effects on the relationship between the two systems are outlined, together with recent indications of change on an official level. A more detailed account of what is currently happening on local levels in which the authors have been involved is presented. It should be pointed, however, that there have been various meetings, workshops and publications since the early seventies, hotly debating the issue of collaboration.
  
  SOME SIGNIFICANT EVENTS AFFECTING THE RECOGNITION OF TRADITIONAL HEALERS
  
  1974 - Clause 36 of the Medical, Dental and Supplementary Health Services Professions Act, No.56.
  
  The above clause states that it is an offence for any registered practitioner to practice in collaboration with a non-registered person to perform acts pertaining to the medical or dental professions.
  
  The passing of this act had the effect of illegitimising the profession, causing practitioners to become secretive about their activities. Sinister impressions of the profession brought about by an earlier Suppression of the Witchcraft Act have been reinforced by stories in the popular press of sensational claims or muthi murders, and by common usage of the term witchdoctor, sometimes even by those in favour of some form of collaboration. Traditional practitioners were not seen as members of a profession that had a recognizable code of ethics or one that could become a valuable resource to the health care system. Although a few papers in professional medical journals advocated further investigation for positive purposes, correspondence on the issues tended generally to lay emphasis on perceived harmful effects, no indication that traditional healing became less used, the often quoted figure of 80% of patients choosing this system still seems widely accepted.
  
  In the late 1980s the government of the day made some approaches to traditional organizations for discussions on possible recognition(pers comm. Mr S.J. Mhlongo). This matter remained largely unresolved, partly due to fragmentation and disunity among the various groups of healers.
  
  Numerous tradition-healing organizations are now found in all provinces of South Africa - Laird and Wynberg (1996) estimate that between 200 and 300 organizations exist. Some of these appear to function as no more than certificate issuing schemes for the purpose of moneymaking for the issuers.
  
  Change in a provincial legislature
  
  In 1989 the KwaZulu legislature officially changed their laws to the extent that so-called Black Medicine men, herbalists and midwives were allowed to practice their professions, subject to certain provisions. A register was drawn up with the help of members of the oldest organization in Zululand, the Awnings National Association (INA). Membership was to be renewed every year, but qualification procedures were not made clear.
  
  Changes of attitude since April 1994
  
  Following the first election of a democratic government in April 1994, the first ever presentation on the registration and control of traditional medicines in South Africa was made to the Medicines Control Council by a Traditional Doctor on the 22nd of July.
  
  This was made by Tr. Dr Solomon Mahlaba on behalf of a working group that had met after a decision taken by the Medicine Control Council that such a working party should meet. It was proposed that a traditional medicines committee should be formed to guide all aspects of the registration and control of traditional medicines. The committee would also be required to liaise with other bodies such as the pharmaceutical committee, the adverse drug reactions monitoring unit of the council, traditional healers associations in South Africa and elsewhere in Africa, the World Health Organization, medical aid societies, the pharmaceutical industry and academic units in South Africa.
  
  The Minister of Health requested that the matter be addressed at a provincial level.
  
  Soon after this, discussion on ideas for traditional medicine policy for South Africa was held at the annual congress of the South African Pharmacology Society held in Cape Town in September, 1994. It was decided that WHO guidelines should be followed and also that traditional medicines should be categorized in a similar method to that used in the TRAMIL project undertaken in the Caribbean Islands. TRAMIL'S three categories are TOX (toxic), INV (experimental data inadequate to support the claimed uses) and REC (experimental data supports the uses of plants) (Farnsworth, 1993). The need for constant consultations with traditional practitioners was stressed but few healers were in fact present at this meeting.
  
  Various forums and meetings were held at universities and other research institutions. Although the South African Indigenous Plant Use Forum produced a network directory in 1995, published by the Foundation for Research and Development (FRD), and also a series of indigenous plant use news letters between 1992 and 1996, there is not at present much apparent active networking on a national level. The problem of lack of unity between various groups of healers still besets many attempted discussions on registration.
  
  In 1995 a draft of the proposed KwaZulu-Natal Health Act indicated that recognition of traditional healers was to be further investigated (pers comm. Dr N Mtalane). The public was given an opportunity to make submissions and, in a radio phone-in programme, the need for legal control of traditional practices was expressed. Department officials and the parliamentary Committee of Health expressed the view that a governing council should be formed to control practice and to formalize working relations within the total health structure.
  
  In June 1997 public hearings were held in all provinces and also on a national level to investigate more fully the feasibility of recognizing traditional healers.
  
  The following questions were presented for those wishing to make submissions in KwaZulu Natal:
  
  1.How can traditional healers organize themselves into one Provincial structure?
  2.How will they administer/control their practice?
  3.How will they get trained and acquire certificates?
  4.Unfit for work certificates - can they issue these and can they safeguard against abuse?
  5.Medical Aid and Health Insurance - can they be allowed access to that funding?
  6.What is the impact of traditional medicine on nature conservation?
  
  Outcomes of these deliberations have not yet been published. A presentation made at one of these hearings by a small group of members of the Awnings National Association (INA) and two researchers of the University of Zululand at a local hospital will be discussed later in this paper.
  
  ETHNOPHARMACOLOGY AND ITS RELATIONSHIP TO NATURAL PRODUCT RESEARCH IN SOUTH AFRICA
  
  Ethnopharmacology is a multidisciplinary study concerned with the scientific investigation of indigenous drugs which links bioscientific research with traditional empirical knowledge (Etkin, 1993). The core disciplines involved are anthropology, botany, chemistry and pharmacology. Its purposes are twofold and seek both to establish new leads to drug development, and to promote the use of safe, affordable and efficacious ethnomedical preparations. Although the Journal of Ethnopharmacology has been in publication for some years, the European Society of Enthnopharmacology was founded in March 1990, when the first European Symposium on Ethnopharmacology was held at the International Congress Centre in Metz, France.
  
  This event was attended by more than 250 participants from about 20 countries representing national associations having a common interest in the study of traditional pharmacopoeias and representing more than 1500 specialists, including medical doctors, pharmacists, botanists, historians of medicine and pharmacy, and anthropologists (Fleurentin et al, 1990).
  
  The major goal of the Society was to promote cooperation within Europe in the field of Ethnopharmacology by:
  
  (a)facilitating the exchange of information
  (b)promoting the harmonization of research activities - European specialists
  (c)organizing or participating in the organization of international scientific meetings
  (d)promoting cooperation with developing countries
  (Fleurentin, 1990, p13).
  
  No society of Ethnopharmacology has yet been formed in South Africa, but the above objectives are obviously appropriate to related research and development in the country. An interim steering committee for Indigenous Plants Use (IPU) was set up in 1991 with the help of the FRD. Several meetings on scientific collaboration took place at various universities but perhaps one of the most significant of these, because of its combination of researchers and traditional practitioners, was a workshop held at the University of the Witwatersrand in October 1995. The focus of the workshop was the protection of intellectual property rights resulting from discovery of medicinal or other properties from naturally occurring products. Discussion centered here on the need for:
  
  1.Policy formulation on intellectual property rights of traditional healers and researchers.
  2.Control of bioprospecting
  3.Equitable distributions of profit for marketable materials
  4.The need to form an association of researchers and other interested individuals.
  
  Items 1, 2 and 3, relating to policy, were discussed by Sarah Laird and Rachel Wynberg at the IPU in Stellenbosch in 1996, who interviewed a number of the scientists present, as well as other individuals and organizations. A report has since been published (Laird and Wynberg, 1996) but the issues are not yet fully resolved and only one traditional healer is listed among the organizations and individuals with whom discussions were held.
  
  Item 4 has been followed up and three meetings to discuss this matter have been held at the National Botanical Institute (NBI) Herbarium in Durban. Participants at these meetings included representatives from nine universities, two technicians, two healers' organizations and the National Botanical Institute. The collaboration of botanists, chemists pharmacologists, traditional healers and medical practitioners is needed for such projects.
  
  A formal constitution of the association has been drawn up and postal ballot for executive members is currently being held. A Confidentiality Agreement has also been drafted.
  
  Aims of Association:
  
  1.To promote the study and research of South African Indigenous Biological Resources (terrestrial and marine), based on the principle that the benefits of such activity must be retained for the benefits of South African traditional users, researchers and society.
  
  2.To promote collaboration with researchers in other countries for research of South African Indigenous Biological Resources (terrestrial and marine) based on the principle that the benefits of such activity must include the interests of South African traditional users, researchers and society.
  3.To organize meetings, to lobby authorities and to undertake other activities to the furtherance of the above.
  
  Membership
  
  Membership is open to any one with the above interests.
  Current members come from the following institutions:
  The National Botanical Institute, The National Awnings Association, vista University, The University of Cape Town, The University of Durban-Westville, the University of Pretoria, the University of Venda, the University of the Western Cape and the University of Zululand and from the following disciplines:
  
  Anthropology, Biochemistry, Botany, Chemistry, Microbiology, Pharmacology, Psychology, Taxonomy and traditional and Allopathic Medicine.
  
  At present South Africa does not appear to have an organized infrastructure to undertake systematic screening of plant extracts. With the utilization of existing facilities and expertise, it should be possible to establish a central screening laboratory and to harness the available pharmacological and biochemical techniques to form a national screening service.
  
  INDICATIONS OF ACTIVITY IN SOUTH AFRICAN MEDICINAL PLANTS
  
  A search of the Noristan Database indicated that out of a total of 350 plants selected for screening, 31% showed marker activity, 48% were moderately effective and 21% were considered inactive.
  
  INDICATIONS OF THERAPEUTIC POTENTIALS FROM TRADITIONAL ZULU LEADS
  
  General
  
  Research undertaken at the University of Zululand over the last nine years, culminated in the publication of an inventory of Zulu medicinal plants last year (Hutchings et al, 1996). Although the majority of the 1032 plant species included have not been fully investigated, data included on chemical constituents and biological properties of these and related species indicates possible scientific support for many of the plants used.
  
  Potential analgesic activity
  
  A recent study on the screening of extracts from 39 plants traditionally used in Zulu medicine for headaches or anti inflammatory disease showed that 66% had high prostaglandin synthesis inhibitory activity (Jager et al., 1996).
  
  Potential anti-malarial activity
  
  Four plants tested for antimalarial indications against rosette forming organism have all been found positive (Rohitalall, et al., 1997).
  
  Potential tuberculosis activity
  
  Some of our own screening tests have shown that 12 of 16 plants used for respiratory ailments have shown some activity against Mycobacterium smegmatis while 10 also showed activity against M. tuberculosis.
  
  Potential therapeutic treatment in psychological disturbance
  
  The UZ Psychology Department has investigated relationships in diagnosis and treatment methods of psychological disturbance among patients. These are often part of a culture bound syndrome and the department has published a number of papers since 1977. One of these showed a significant agreement in the diagnosis and treatment by traditional and clinical practitioners working on the same group of psychiatric patients (Edwards, 1986). A corresponding patient perception of helpfulness was shown.
  
  SOME PRODUCTIVE/POTENTIALLY USEFUL PLANTS FROM SOUTH AFRICA
  
  Some plants that have been used in patented pharmaceutical products, or are likely to prove therapeutically useful if further developed are shown in Table 1 below.
  
  TABLE 1:
  
  SOME PRODUCTIVE/POTENTIALLY USEFUL PLANTS FROM SOUTH AFRICA
  
  
  
  Plant Therapeutic Indication Reference
  
  
  
  Aloe aboresens wound healing, anti- Kameyama & Shinso and other Aloe spp cancer 1979
  
  Helichysum aureo- Herpes zoster, anti- Pers.comm.
  
  nitens and other bacterial Dr. M. Jacobs
  
  spp.
  
  Hypoxis colchii- immunostimulant, anti- Drewes and
  
  folia and other cancer, prostrate gland Lienberg 1983;
  
  spp. hypertrophy Albrecht et al., 1995
  
  Warburgia anti-ulcer, anti-fungal Taniguchi & Kubo,
  
  salutaris molluscicidal 1993; Pers comm.
  
  S E Drewes
  
  
  
  Xysmalobium anti-spasmodic, anti- S Schmitz et al., 1992
  
  undulatum diarrhea +Invasive alien
  
  Chromalaena wound healing, burn Thang et al., 1996
  
  odorata healing
  
  
  
  Although all the patented products from indigenous plants indicated in Table 1 were developed from South African plants, often with the involvement of South African scientists, none of them have been available in south Africa. Xysmalobium undulatum has been cultivated in Germany for eighty years and the various drugs derived from the root, including Uzara and Dymensural, used for dysentery and after birth cramps, have been available in Germany for a long time. Harazol, a preparation for the treatment of prostrate gland hypertropy from Hypoxis colchiifolia has also been available in Germany for about twenty years. Wound healing patented products from Aloe arboresescens are available in Japan, where they have been derived from plants cultivated in that country. Chromalaena odorata, the only alien cited in the table, is locally known as the Triffid weed and has contributed to the decline in the number of available medicinal plants because of its invasive properties. Knowledge of how to prepare the apparently very effective cream for wound healing developed in Asia would be a useful addition to local healers' armoury.
  
  SOME RECENTLY INITIATED COLLABORATIVE RESEARCH PROGRAMMES
  
  Screening of potentially useful plants:
  
  Arising out of the discussions being held to establish an association, a collaborative research programme has been initiated between various departments at the Universities of Durban-Westville, Natal, the Witwatersrand and Zululand.
  
  Current and proposed fields of research include malaria, tuberculosis, Human Immuno Defiency virus, schistosomiasis vector control and cancer. Selected plants have already been harvested and screening procedures initiated.
  
  The following protocol is to be adopted: Selected Medicinal Plants
  
  Extraction, Crude extracts,Bioassay,Active Extract, Fractionation,Bioassay, Pure Active,Sructure Determination
  Novelty Determination,Development Candidate
  
  Traditional healers involved will have information on observed activity and developments communicated at appropriate stages of the research and will share in any benefits accruing from their participation.
  
  Conservation:
  A medicinal plant garden is already established at the University of Zululand and the development of a further area as an ethnobotanical reserve on the campus has been initiated. These would be further stocked with suitable material to serve both the needs of local healers and researchers. A collaborative project with the National Botanical Institute has investigated the characteristics of plants cultivated by traditional healers in three rural and two township gardens in KZN. These research findings have been applied to the development of medicinal plant displays at the eight NBI gardens, where practical cultivation courses are to be held for traditional healers, gatherers, market vendors, entrepreneurs and local community groups.
  
  Recognition and involvement of traditional healers in Primary Health Care
  
  Researchers at the University of Zululand and the Inyanga's National Association (INA) have recently undertaken the following steps in an effort towards achieving unity and possible recognition for traditional healers:
  
  Primary Health Care workshops
  
  A pilot workshop on gastro-intestinal complaints was held for a small group of healers at the University of Zululand in November 1996. Since then discussions have been held with the local state hospital, members of the INA and local tribal authorities. It is hoped to hold these on a monthly basis and a set of videos on AIDS, Gastro-Intestinal Parasites, Gastro-enteritis, nutrition and TB have been obtained. The workshops will be planned according to community needs expressed by the healers and communities participating in the project.
  
  Training and qualifying procedures
  
  The INA have inaugurated a programme whereby meetings are held in various areas of KZN to explain the need for healers to have membership of a professional and recognized body. We have attended three such meetings and videotaped one of these, as well as a training session held for healers at a school and two examinations, conducted by the INA, one at a tribal court and at the UZ campus. We have also made a submission to a recent public hearing, summarized below;
  
  POINTS INCLUDED IN RECOMMENDATIONS MADE BY UNIZUL/INA GROUP
  
  1.The process of organizing existing healers associations under one provincial structure has been initiated through the setting up of an interim steering committee. Each of the associations involved in KwaZulu-Natal should be represented on this committee and should adhere to the guidelines established by the committee concerning ethical matters and safety precautions.
  
  2.An executive committee with the power to suspend members for unethical practices should be in place. Meetings are currently being held in various areas of KwaZulu Natal to define ethics and explain these to members joining the association. All associations recognized by the Provincial structure should adopt such practices.
  
  3.Communication channels should be established between traditional Healers and Hospitals and mechanisms set up so that any harmful practices observed by either hospital or healers with respect to traditional medicine be communicated to all concerned.
  
  4.No certificates be recognized where qualifying procedures have not been documented and accepted by an established examining committee. Although many healers' organizations presently register members on receipt of fees, the implementation of training sessions and qualifying practical examinations whereby members have to be able to recognize traditionally used plants, to explain their usage and properties and to answer questions on appropriate treatment of ailments has been initiated by the INA.
  
  5.We recommend that training in Primary Health Care and problems of conditions not previously treated traditionally, including AIDS and hypertension, be undertaken through local hospitals and other organizations through workshops where this is available. Such collaboration should be documented and results communicated through the steering committee. A pilot project is being initiated between us and the Superintended and other members of Ngwelezane Hospital.
  
  6.Lists of Traditional Healers should be compiled by local committees of accepted healing associations, in association with hospitals and clinics willing to collaborate where this is established. These lists should be submitted to the Provincial structure and should be made available to employers willing to accept them, as some firms in the Richard's Bay area have indicated they are prepared to do. Legislature should be considered at a later stage.
  7.Issues of Medical Aid membership should be allowed following discussions and careful investigation of procedures and protection against abuse.
  8.All efforts to involve traditional healers in the growing of plants, the establishment of healing gardens and farming projects, and collaboration with the Parks Boards should be encouraged. Investigations into improved cultivation and harvesting procedures should be undertaken by researchers and communicated to traditional Healers.
  
  9.Discussions should take place as soon as possible with the Department of Health so that traditional Healers can be utilized, particularly in the fields of Tuberculosis management, AIDS counseling and caring, and mental health care, where existing systems within the state are already overburdened. Proposals for collaborative work should be made and implemented as soon as possible.
  
  CONCLUSIONS
  
  The open approach adopted by the traditional healers collaborating in this study, their careful insistence on the involvement of local authorities and communities and willing collaboration with the University of Zululand and local hospital represents a real break-through from the past. Built up lack of trust does not disappear overnight, but the development of projects such as those outlined could enrich health services in South Africa.
  
  Collaborative ethnopharmacological projects could also be of benefit to South African health by providing leads for the development of new drugs. Perhaps more importantly in the immediate future, validation studies could lead to the enhancement of treatment for some of the severe health problems by the addition of locally available resources.
  
  The formation of the proposed association to protect the intellectual property rights of traditional healers and researchers and to promote control of bioprospecting is necessary in order to conserve biological resources for the benefit of the people of South Africa.
  
  Acknowledgements
  
  
  
  Financial help in meeting travelling costs for AH and IM is gratefully acknowledged from the Universities of the Witwatersrand and Zululand and, for AH, the Anglo-American and De Beers Chairman's Fund.
  
  
  
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