Quote of the month: “The main challenge remains the uncompleted effort to properly define what traditional medicine is, where it starts and stops, codifying the huge armamentorium of herbs / medicines, and how it relates to newer terminology like 'alternative medicine', 'complementary medicine', 'herbal medicine / herbalists', 'Native doctor', etc, etc.” Joseph Ana, HIFA Member, Nigeria
WHO defines Universal Health Coverage as follows: “all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services”. During January, HIFA members considered a recent study, focusing on traditional medicine (TM) in Cambodia, where it is a popular source of treatment. The authors note that TM is becoming increasingly commercialised and unaffordable to many poor people. They suggest that TM 'needs to be included in a national conversation about achieving Universal Health Coverage'. This prompted a global conversation on HIFA. Should TM be included in national plans for Universal Health Coverage, and if so, how?
As Joseph Ana explains in our Quote of the Month, there is an even more fundamental question: what is TM? In Nigeria, Joseph’s home country, TM is also popular and is used by the majority of the population. The national government has long been supportive of traditional medicine providers (TMPs), a relationship which began on an informal basis in the nineteenth century, and eventually received formal recognition in 1966. In the 1970s and 1980s, conferences, training programmes, accreditation and regulatory frameworks all helped drive national expansion of traditional medicine, boosting TMP numbers and gaining widespread acceptance for TM amongst the Nigerian population. Yet the Nigerian government has yet to achieve the successful integration of TM within its healthcare system, largely because a standard definition of TM does not yet exist. Quoting a senior Nigerian ‘orthodox’ doctor, Joseph Ana summed up the impasse as follows: “you cannot compare omalanke [a hand-pushed cart] to space shuttle just because both are forms of transportation”.
Despite this, many Nigeria-based TMPs continue to seek professional endorsement, motivated by the promise of enhanced professional credibility and a higher income. They are, however, somewhat reticent when asked about their methods and treatments. “While I was Director General of Nigerian Institute of Medical Research ”, Innocent Achanya Otobo Ujah told the HIFA forum, “I was inundated with the desire of Traditional Medicine Practitioners to collaborate with the Institute, but once discussions commenced, it was difficult to know what they really were up to.” Recently, some TMPs have re-opened discussions with the NIMR, and Innocent is hopeful that this will result in a clearer picture of TM in practice.
In the meantime, research continues to emerge, highlighting major concerns, not only about the efficacy and safety of TM, but also its potential to cause serious harm or death, whether directly or indirectly.
“The current investment going into research and development of herbal products is unprecedented. It is very sad to note that in a country like Nigeria where over 80% of her population relies on herbs for daily health needs, only few of such herbs have been validated using research”. This was how HIFA Member Augustine Onyeaghala portrayed the disturbing dichotomy of traditional medicine in Nigeria for HIFA members, citing a recent study conducted in Ibadan, which evaluated ten herbal products, randomly purchased from mobile vendors, shops and distribution outlets. Only 20% of these products had full registration with the National Agency for Food and Drug Administration and Control (NAFDAC), whereas 80% had attained only “listed status”. Closer examination of the actual products, however, revealed more serious concerns: 80% of the research sample provided neither disclaimers nor directions for use, and the same proportion made “various treatment claims”.
Elsewhere on the HIFA forum, however, research into the impact of snakebite and determinants of fatal outcomes in Nepal found that 'initial consultation with a traditional healer' is one of the factors associated with an increased risk of death from snakebite. Yet Nepal’s current response to snakebite remains unchanged from 13 years ago when HIFA Coordinator Neil Pakenham-Walsh was visiting a hospital in southern India: “On enquiring about the dead body of a boy in the morgue of a large public hospital, I was told this was a typical case: bitten by snake, taken to traditional healer, symptoms became progressively worse, died on way to hospital”.
The experience of Nepal further reinforces why achieving the HIFA vision is vital. Simple, life-saving interventions are already available locally in Nepal – the research emphasises the importance of ensuring rapid access to them - but reliance upon incorrect information continues to result in preventable deaths.
So what is the role of TM in UHC? It can be argued that UHC is defined on the basis of effective services and therefore any intervention (whether TM or allopathic) needs to demonstrate its effectiveness if it is to be considered for inclusion. What is without doubt is the need for TMPs to recognise and refer urgently all life-threatening cases to the formal health system. The debate continues...
With thanks to this month’s contributing HIFA members: Joseph Ana (Nigeria), Lead Consultant and Trainer at the Africa Centre for Clinical Governance Research and Patient Safety in Calabar, Nigeria. Innocent Achanya Otobo Ujah (Nigeria), Professor and Director General at the Nigerian Institute of Medical Research (NIMR). Augustine Onyeaghala (Nigeria) is a Biomedical Scientist, Clinical Research Scientist, Quality Assurance Professional and Author. His areas of specialization are Herbal Medicine, drug development, clinical and translational research.
Metrics: In January 2018 we exchanged 197 messages from 95 contributors in 39 countries (Afghanistan, Australia, Bangladesh, Belgium, Botswana, Burkina Faso, Cameroon, Canada, Czech Republic, Germany, Ghana, Honduras, India, Iran, Ireland, Italy, Japan, Jordan, Kenya, Lebanon, Liberia, Lesotho, Malawi, Nepal, Netherlands, Nigeria, Norway, Pakistan, Peru, Rwanda, South Africa, Sri Lanka, Switzerland, Tanzania, Uganda, UK, USA, Zambia, Zimbabwe). Our top contributors were Joseph Ana (Nigeria) and Najeeb Al-Shorbaji (Jordan). Thank you all for sharing your views and your experience.
Photo credit: © 2012 Arturo Sanabria, Courtesy of Photoshare