[back]

ANNEX l

PROBLEMS WITH DEVELOPING WORLD MEDICALIZATION
AND THE TRADITIONAL MEDICINE ALTERNATIVE

The medicalization of large parts of the Third World . . . has occurred in the context of the destruction of whole systems of traditional philosophies in the name of science and health. Present patterns of dependence are a product of this . . . evolution. The addictive nature of the new pill culture may as one of its unwanted consequences have played a role in creating and sustaining poverty in the Third World. The price of foreign products is often out of proportion to the purchasing power of the poor, who thus may squander a large part of their income in the pursuit of what may be illusory hopes of benefit.. . . Pharmaceuticals are an inappropriate solution to many major health problems and . . . their consumption often does not meet the health needs of people.

Goran Sterky, Dag Hammarskjold Foundation, Uppsala, Sweden.

The Disturbing Dilemma of Developing World Medicalization
India--An Alarming Case In Point
A Compelling Voice of Protest
The Traditional Medicine Alternative
Critical Conclusions and Directions
References

THE DISTURBING DILEMMA OF DEVELOPING WORLD MEDICALIZATION

Some leading international health officials, such as Robert Bannerman of the World Health Organization, have legitimately raised the concern that "orthodox" and "conventional" health care services--as devised for and administered to Developing World populations--remain culturally alienating and "economically unobtainable." He also maintains that, whether in the Developed or Developing Worlds, the disparity between the actual benefits and the high costs of Western medicine continues to be an issue of major socioeconomic and political concern. As part of this picture, it is noted that in the Developing World, roughly one third of all health care costs are devoted to "the drug bill alone," with relatively poor countries importing such drugs against payments in scarce hard currency.1

Charles Medawar, Director of a London-based research unit, Social Audit Ltd., has conducted extensive international research on the issue of medicalization practices in the Developing World. He has documented the following disturbing conclusions in an article on the need for the strengthening of international regulation in pharmaceutical practice:2

Medawar also provides evidence which suggests that the World Health Organization's (WH0) intimate cooperation and "contractual relations with many pharmaceutical companies," inter alia, cripples its capacity to effectively represent and support the most fundamental health needs of the Developing World through developing a system of care in which the most prevalent and serious health needs are met. Multisectoral measures which are safe, effective, simple, and uncostly hold the answer to attaining sustainable and long term health improvement. Indeed, without due leadership in this direction he contends that "Health for All by the year 2000 must appear a sham."

Even where the WHO has been able to advocate a more rational public sector approach to medical practice in the Developing World, as in its 1981 Action Program on Essential Drugs and Vaccines, the fact remains that in most Developing World countries there is readily available in the private sector from 10 to 20 times as many pharmaceutical products as the 250 which are recommended in the Organization's Action Program.

According to Sterky ". . . in some Third World countries, up to 75 percent of the drugs moving in the market may be outside the control of health ministries." This active trade in up to 4,000 drug products is largely monopolized by powerful transnational corporations. In fact, it is estimated that 90 percent of the world's production of commercially marketed pharmaceuticals originates in the industrialized countries, with this percentage growing.3


INDIA--AN ALARMING CASE IN POINT

Trisha Greenhalgh's seminal survey of 2,400 individual patients under treatment in the public and private medical sectors of India is illustrative of conditions which are becoming increasingly prevalent throughout much of the Developing World.4 It will thus be reported on in some detail.

Her research confirmed that drugs which have a high incidence of side effects or a "significant risk of fatal idiosyncrasy" are being sold over the counter and prescribed by doctors for trivial complaints. Chloramphenicol, barbiturates, anabolic steroids and high dosage oestrogen preparations "are used freely, often from bizarre indications and in unsuitable dose regimens."

She refers to one national study which estimates that India is experiencing between five to ten thousand deaths annually, from chloramphenicol-induced aplastic anaemia alone. High dose estrogen-progesterone (EP) although containing warnings of teratogenicity (potential to cause birth defects) remain the cheapest and most widely employed pregnancy test in the country.

Furthermore, medical drugs which have been banned in Western countries due to their dangers are actively prescribed, dispensed and marketed. A few cases include: phenylbutazone, which has been associated with more deaths in Britain than any other drug; and clioquinol which is officially accepted as a "safe drug," in apparent ignorance of the major scandal in which literally tens of thousands of people were left crippled from the drug, with its manufacturer, Ciba Geigy conceding full blame.

Greenhalgh further reports that the pharmaceutical industry argues that "these drugs have not been shown to be hazardous to the Asian population," and that it awaits the results of post-marketing surveillance before withdrawing them. In her words "this is less a cry for objectivity, than a justification for exploiting the sorry state of medical audit." Indeed, case records are rarely kept by doctors engaged in private practice, and polypharmacy remains rife, so most adverse drug reactions remain inevitably undetected. Even if they were detected, there exists no system for the reporting of suspected reactions, and there is no official procedure or mechanism for alerting doctors of suspected adverse reactions in new drugs.

This situation is further compounded by the fact that to all appearances with the exception of teaching hospitals, postgraduate education in clinical pharmacology remains the "unchallenged province of representatives from the pharmaceutical industry."

Simple solutions appear to be ignored. For example, 30 percent of all child deaths in the nation are due to diarrhoea, yet in over 90 percent of such cases oral rehydration is ignored by practicing medical doctors. In the population, millions are known to have a Vitamin A deficiency, with as many as 30 thousand children being blinded each year. This occurs despite the fact that "a fresh mango provides many weeks supply of Vitamin A for a child and costs much less than a bottle of vitamin syrup."

To conclude this summary of Greenhalgh's findings, I would share her following observation.

. . . one cannot ignore the long term effects [and the ethical implications] of encouraging a poorly educated population to develop blind faith in the infallibility of modern medicine, and the magical properties ofprescribed pills . . . . people who are too poor to buy rice are being led to believe that they need a cough mixture for every cough, an antibiotic for every sore throat, and a tranquiliser to solve the problems of everyday life.


A COMPELLING VOICE OF PROTEST

Mira Shiva, Coordinator of the Voluntary Health Association of India, drawing upon her practical experience as a medical doctor in her home country, protests that low cost, self reliant, and indigenous "health care alternatives" have been unduly marginalized with the rapid growth of the medical-industrial complex. Indeed, while clinics and drug dispensing units,, nursing homes, drug marketing outlets, and diagnostic labs have literally mushroomed throughout the nation, at rapidly escalating costs, there has been "no significant and substantial change in the health status of the people."

She further contends that:

Simple health care solutions, for example changes in diet, simple massages, home remedies and herbal medicines, which are as relevant today as in the past . . . have been gradually excluded from the health care scene, because of an assumed superiority of modern drugs for all kinds of health problems. This assumed "scientificity" has not been demonstrated by comparing the existing and new pharmaceuticals with alternative therapies in terms of efficacy, side effects, drug interaction, costs, acceptability, and availability.

Shiva also puts forward the view that the worldwide indigenous traditions encompassed a superior holistic concept of health and disease, in which the use of medicines served to complement and not displace more fundamental and broadly based nutritional and environmental provisions. She concludes by stating that:

. . . the concept of the universalization of the pharmaceutical medical solution . . . irrespective of the nutritional and health status of patients [and or recipients] in deprived areas, is irrational. . . . It also indicates an unhealthy First World bias on the part of drug exporters, transferors of technology and propounders of myths.5

THE TRADITIONAL MEDICINE ALTERNATIVE

The human experimentation with and exploration of plant medicines has evolved over the millennia to what is a current usage of some 20,000 plant species, which remarkably--according to scientists Phillipson and Anderson, of the School of Pharmacy on London--"form the major sources of medicine for the population of the majority of the World.6

Nonetheless--as the preceding sections portray--initially in the First World and now universally, there has been an aggressively pursued and increasingly actualized goal to displace this traditional knowledge and practice system, with commercially marketed Western pharmaceuticals. Commercially subsidized and influenced university-based medical curricula have fimctioned to shift the focus and faith of medical practitioners--and in turn those they practice upon--from plant medicines, towards what is considered a modernized pharmacopoeia. This public faith receives continual reinforcement through the medium of public media advertising. (It should be noted that approximately 75% of modem commercial pharmaceuticals are strictly synthetic chemical substances,7 that without exception, bear toxic and thus harmful side effects.)

It is widely acknowledged that synthetic agents can be far more easily patented and thus profited from. This, inter alia, has led Pharmacological researchers such as de Smet (Royal Dutch Association for the Advancement of Pharmacy, the Hague, Netherlands) and Rivier, (Institute of Legal Medicine--The University of Lausanne, Switzerland) to suggest that the predominant view that traditional plant medicines are of marginal value "could well be an economic verdict, rather than a well balanced scientific judgment." They go on to "deplore the commonly held belief that the study of traditional agents is nothing but an evaluation of outdated exotic, which cannot be relevant for Western Medicine.8 Their view is backed by Labadie, who has conducted extensive research on traditional plant medicine at the State University of Utrecht in the Netherlands. He confirms that although it "in general represents a still poorly explored field of research," there is nonetheless a compelling basis for recognizing "the international relevancy of research and development in the field of traditional drugs. . . .9

This relevancy that Labadie speaks of, has in part arisen from the growing recognition of the practical limitations, high costs, and iatrogenic features incidental to allopathic (conventional) medicine, with such awareness being the most prevalent in the First World, where it has been the most widely practiced. Consequently, there has arisen in very recent decades--from the lay to professional levels--a significant counter-movement towards according "natural," (variously termed e.g., nature based, lifestyle, and holistic) approaches to health care more prominent recognition and employment.

An important part of this increasingly worldwide trend has been the prominent re-emergence of an integrated science termed ethno-pharrnacology. Although it central focus is on traditional pharmacognosy (medicines derived from natural sources), it is necessarily interdisciplinary in scope encompassing the functional co-relationship and integration of scientific data in the areas of cultural anthropology, archaeology, linguistics, history, botany, toxicology, botany, chemical physics, and biochemistry. Furthermore, it entails both the preventive and therapeutic dimensions of medicine.10

University of Messina pharmaco-biologist Anna de Pasquale in conducting a detailed historical review of plant derived medicine, which she has coined "The Oldest Modern Science," came to the conclusion that

The re-examination of nature in the search for new therapeutic means has obtained remarkable results. The study of ancient official drugs, which had fallen into disuse . . . has brought about a re-discovery of therapeutic means used for millennia . . . . [ethnopharmacology], this millenarian precursor of medical sciences, is still alive and vital and it has its own place in the future of man. It possesses all the premises to enable it to give a substantial contribution to a more efficacious and rational research of medicaments. . . .11 (Eugene Linden's September 23, 1991 article in Time "Lost Tribes Lost Knowledge," cites M. Balick's (Director of the New York Institute of Economic Botany) observation that only 1,100 of the earth's 265,000 species of plants have been thoroughly studied by Western scientists, but as many as 40,000 may have medicinal or undiscovered nutritional value for humans. He concludes with the recommendation that traditional "healers . . . can help scientists greatly focus their search for plants with useful properties.")

Anne Mcllory's article "Medical secrets of the forest" in the February 18, 1991 issue of The Toronto Star speaks of the renewed interest of a limited number of Western scientists in the "enormous" potential of traditional plant medicines. Such interest has of course taken on much greater urgency as the forests, and the elders who've retained this knowledge appear to face impending extinction. One noteworthy example where this renewed interest has richly paid off is found in the rosy periwinkle, which now ftimishes an extract providing Western medicine with an 80 percent recovery level for the once fatal condition of childhood leukaemia.

In going back to the 1978 Alma Ata Conference on Primary Health Care, we find pragmatic approval given--at a political level--to the recommendation that essential drugs and biologicals be locally produced and distributed "at the lowest feasible cost." In concert with this recommendation, the Conference recognized the need to curb the growing over-dependency on medical drugs. It was further affirmed that "proved traditional remedies be incorporated in primary health care, including the establishment of effective "supply systems."12 In the Words of Medawar," The importance of local medical need is recognized in the AlmaAta recommendation on drugs, partly in the provisions on local manufacture and use of indigenous remedies."13

From within the WHO, Bannerman has since gone on to play a vital role in encouraging a renewed reliance upon "well known and tested herbal medicines in primary health care." He refers to a growing interest on the part of Developing World governmental and research institutions in Africa, Asia, and Latin America with respect to the possibilities of further developing and re-utilizing their own medicinal plant resources. He forcibly argues that:

. . . medicinal plants are generally locally available and relatively cheap, and there is every virtue in exploiting such local and traditional remedies when they have been tested and proven to be non-toxic, safe, inexpensive and culturally acceptable to the community. . . . There are many records of traditional therapies employing herbal medicines that are said to be effective against common ailments and usually without any side-effects. . . The cultivation of medicinal plants and herbs can also be linked with the production of vegetables and fruit with high nutritive value that should be of particular benefit to mothers and children.

(While conducting an evaluation mission in Northeast Thailand, the writer, in the company of UNICEF Officer Dr. Supote Prasertsri, visited the Reanunakorn District Health Centre to examine its experimental traditional plant medicine program. Program Director Pradit Tongyus--who also directs the Centre's health, mental health, nutrition and sanitation services--explained why he was inspired to establish the program. His own son developed a serious urinary infection which failed to respond to regular antibiotic treatments throughout 10 days of hospitalization. Upon turning to a known local plant medicine, virtually all symptoms of infection subsided within a 10 hour period. He went on to describe various local plant medicines which had proven to be non-toxic and highly efficacious in the remediation of a wide range of conditions such as: burns; herpes simplex; snake and scorpion bites, kidney stones, ulcers, and high blood pressure. Indeed, such reputable attestations exist worldwide, and only await honest inquiry and further clinical testing.)

As well, Bannerman recommends that community health workers be afforded with a working knowledge of the therapeutic value of local medicinal plants, including their identification, cultivation, collection, preparation, and therapeutic application. He maintains that provisions for such training and practice represent a fundamental strategy to the strengthening local and community self-reliance in health care.14

One of the key arguments of those who would oppose this is view, is that before such medicines can be employed there must be extensive and detailed testing of each specific plant medicine, extraction and refinement of the active ingredients, followed by official recognition and approval. However, there are some basic reasons why this conventional drug development methodology is not only impracticable, but as well unnecessary.

A significant number of plant medicines have been used successfully for centuries, and in some cases millennia. Where there has been a long and established history of efficacy, no apparent adverse side effects, and social acceptance, the only common sense response is to fully permit and encourage continued usage. Researchers such as de Smet and Rivier forcefully maintain that the endorsement of and reliance upon traditional plant medicines in the Developing World, cannot and should not be made conditional upon the full assemblage and weighing of "chemical, pharmacological, clinical and toxicological evidence," as such requirements "would be untenable in the developing countries . . . where Western alternatives for traditional therapies may be unavailable, unpayable or socially unacceptable."

Consequently, the most practical course recommended--as a means of attaining more "immediate health care improvement"--is to conduct simple assays on a series of traditional plant medicines, rather than undertake costly and detailed chemical, clinical and toxicological studies of each and every particular medicine.15 As an added and important point, internationally such "simple assays"--as well as some very sophisticated pharmacological and clinical studies--already exist on a number of traditional plant medicines, with the former primarily found in the bio-etbnographic, and the latter in the bio-science literature.


CRITICAL CONCLUSIONS AND DIRECTIONS

As a fitting synthesis of the issues and concerns as raised in this paper, we can turn to the outstanding work of the Dag Hammarskjold Foundation in Uppsala, Sweden. The Foundation convened a landmark international seminar in 1985 on the issue of attaining Another Development in Pharmaceuticals. The following salient observations are derived from the "Summary Conclusions" of the Foundation's report on the seminar, which had both public and private sector representation from Europe, Africa, Asia, and Australia.

  1. The pharmaceutical industry has evolved and been sustained, in part, by encouraging the vision of human health problems as being solvable only by technological means. A contrived international "pill-popping culture" may be in the short-term economic interests of the industry, however it effectually undermines the vital long term interest of attaining "indigenous," and "self-reliant" health development.
  2. There has been too great a tendency to dismiss traditional medicine as unscientific and superstitious, while accepting unquestioningly all that is new. This is true despite the fact that traditional forms of medicine at times "yield better results" than those which can be obtained by the use of "modem pharmaceuticals."
  3. Perhaps more important than the actual nature of traditional remedies, was the holistic perception of the nature of illness and the healing process. This view often led to the use of therapies which enhanced the healing process through treating the whole being, rather than the specialized "targeting" of specific symptoms.
  4. Medical policies and practices must be "ecologically sound," viz. avoiding the "unnecessary pollution of patients bodies with toxic chemicals." The pharmaceuticals market should be replaced by programs and therapies for better health. The crisis will be solved only by a fundamental change both in the training of health workers, and in the thinking of a community which has "been seduced into believing that every ill can be solved by a little pill."
  5. Both the mystique of professional monopolies of expertise and transnational corporation monopolies of technology, which in concert deny development to the South, "must be shattered." Medicine should be "endogenous," that is primarily derived from the cultural, human and material resources available to each society.16

It is the view of the writer, that to ignore these conclusions and oppose these recommendations will be but to help insure the continuation of oppression, poverty, and disease throughout the Developing World. Furthermore, it will serve to deny both the developed and developing nations with the enormous opportunity of properly assessing and accessing a vastly untapped reservoir of vital experiential knowledge, insights, and plant medicines which may tragically perish with the older generation of increasingly marginalized and threatened indigenous "nature based" societies.

 

REFERENCES

1 Bannerman, R., "The Role of Traditional Medicine in Primary Health Care," in Traditional Medicine and Health Care Coverage--A reader for health administrators and practitioners, 1983, edited by Bannerman, R., Burton, J., and Wen-Chieh C., The World Health Organization, Geneva, Switzerland, p. 319

2 Medawar, C., "International Regulation of the Supply and Use ofP harmaceuticals," in Development Dialogue, Vol. 25, 1985, The Dag Hammarskjold Foundation, Uppsala, Sweden, p. 16-34

3 Sterky, Goran, "Another Development in Pharmaceuticals: An Introduction," in Development Dialogue, Vol. 2, 1985, The Dag Hanunarskjold Foundation, Uppsala, Sweden, pp. 5 and 6

4 Greenhalgh, T., "Drug Prescription and Self-Medication In India: An Exploratory Survey," in Social Science and Medicine, Vol. 25, No. 3, 1987, Pergamon Journals Ltd., Great Britain, pp. 307-316

5 Shiva, M., "Towards a Healthy Use of Pharmaceuticals--An Indian Perspective," in Development Dialogue, Vol. 25, 1985, The Dag Hammarskjold Foundation, Uppsala, Sweden, pp. 69-72

6 Phillipson, J. David, and Anderson, L., "Etlmopharinocology and Western Medicine," in Journal of harmocolo Vol. 25, 1989, Elsevier Scientific Publishers Ireland Ltd., pp. 61 and 65

7 lbid, p. 71

8 de Smet, P., and Rivier, L., "A General Outlook on Ethnopharmocology," in Journal of Ethnopharmocology, Vol. 25, 1989, Elsevier Scientific Publishers Ireland Ltd., pp. 130 and 131

9 Labadic, R., "Problems and Possibilities in the Use of Traditional Drugs," plenary lecture presented at the Second International Congress on Traditional Asian Medicine, September, 1984, Surabay, Indonesia

10 de Smet, P., and Rivier, L., "A General Outlook on Ethnopharacology," p. 127, and see, de Pasquale, A. "Pharmacognosy: The Oldest Modern Science," in Journal of Ethnopharmacology, Vol. 11, 1984, Elsevier Scientific Publishers Ireland Ltd., p. 13

11 de Pasquale, "Pharmacognosy," pp. 13 and 16

12 Primary Health Care, Report of the International Conference on Primary Health Care Jointly Organized by the WHO and UNICEF, at Alma-Ata, USSR, September 6-12, 1978, published by the WHO, Geneva, Switzerland, 1978

13 Medawar, "International Regulation of Pharmaceuticals," p. 19

14 Bannerman, "The Role of Traditional Medicine," p. 326

15 de Smet, P., and Rivier, L., "A General Outlook on Ethnopharmacology." pp. 135 and 136

16 Dag Hanimarskkiold Seminar on Another Development in Pharmaceuticals, June 3-6, 1985, "Summary Conclusions," in Develoment Dialogue, Vol. 2, 1985, The Dage Hanunarskjold Foundation, Uppsala, Sweden, pp. 130-143

See also: