Bringing Medicine to the Masses of Africa (when they are swimming in it?)

In many parts of the developed world, the practice of medicine by relying on such tools as herbs, meditation, trance, acupuncture, ionised water etc. is tolerated under the rubric of “complementary medicine”.

In the United Kingdom, for instance, many public hospitals, such as the famed St. Mary’s in London’s Paddington, even have dedicated complimentary medicine wings, even though there is never any confusion about orthodox, “science-based”, medicine being the reigning sovereign [1].

The joke is that we prefer to think in similar terms in Africa too.

It would have been funny were it not for the fact that in Africa more than 75% of the population are estimated to rely, at least partly, on traditional medicine for their primary and secondary healthcare needs [2].

Yet, the observers, commentators and so-called policy experts holding sway over the continent’s health sector continue to pretend as if we can afford to treat traditional medicine as the poor cousin of the mainstream medical system.

Take Ghana’s “Standard Treatment Guidelines” and “Essential Medicines List” documents for example. The former is the summary of recommendations made by the Ministry of Health for the benefit of physicians managing the most common ailments afflicting Ghanaians. I spent a significant amount of time this week leafing through the 20 or so chapters of this bulky tome and found it very interesting reading. [3]

The latter document is produced by the same policy specialists in the Ministry of Health. It lists some 150+ medicines by their generic names and commends them to physicians for prescription in response to the conditions constituting the bulk of Ghana’s disease burden. The National Health Insurance Scheme is required to subsidise these recommended medicinal items in order to enhance access by ordinary people. [4]

As you might have guessed already, the documents have scant regard for herbal medicine.

I was extremely intrigued by the section in the Standard Treatment Guidelines (STG) dedicated to haemorrhoids (the common “piles”), a once rare ailment that now regularly torments many in West Africa as a consequence of the increasing popularity of low-fiber, refined carb-heavy, diets.

The medicaments prescribed in the STG in connection with the clinical management of piles had such names as: “gentamicin”, “metronidazole”, “diazepam”, “senna”, and “liquid paraffin”. There is no award for noticing the total absence of herbal medicines on this list. If you lived in Accra, or indeed any of the relatively better-endowed, cities of West Africa, your first instinct would be to burst into laughter.

So few of the general population avail themselves to the antibiotic and analgesic-centric treatment regimes suggested by the STG for piles that for the typical observer of the terrain the guidelines might as well not exist. The typical self-respecting Ghanaian city dweller opts for any one of the myriads of herbal concoctions and will stub their nose at any surgery-prescribing physician ambling about professing to be managing their piles! I will leave what pertains in the rural areas to your imagination, dear reader.

So on what basis are herbal medicines, produced locally here for centuries, and an inherent part of the productive heritage of our indigenous industrial systems, excluded by stroke of national policy?

Before I create the conditions for the mass lynching of government policy experts in Accra or elsewhere in the region, I should hasten to add that the designers of the STG couldn’t have added herbal medicines to the list even if they had wanted to.

To rationalise both the use of medicines and spending from the national kitty arising from government’s subsidisation of their use, the Essential Medicine List and the STG both employ the generic names of medicines rather than their brand names [5].

You may recall my mentioning “metronidazole” in an earlier discussion. You may have rolled your eyes a little bit and continued reading without the least hint of recognition. Same would probably not have been the case had I mentioned “flagyl”. You would most likely have recognised this as a well-known antibiotic, and connected the dots immediately. If you are the kind of person who dabbles in these things, you probably would have tied “flagyl” to “Sanofi-Aventis” and wryly wondered whether this wasn’t a veiled advertisement for the giant French pharmaceutical company.

Exactly. The policy in many African nowadays is to deemphasise brands and wherever possible to promote generics in order to rationalise costs and improve access (see an interesting take on the matter from Australia).

For herbal medicines to attain the status of admission into national treatment regimes will require an unprecedented effort at standardisation (see a common view from India).

Ghana, for instance, has developed a basic herbal “pharmacopoeia” [6], which is in essence an inventory of plants and their well-tested medicinal properties. Such efforts would need to be intensified. Because until there is a clear record of carefully and systematically collated body of evidence tying some properly defined plant compound to medicinal outcomes, the integration of herbal medicines into the orthodox healthcare system would not be possible.

The problem is that tying these systematically defined plant compounds to medicinal outcomes require subjecting them to a testing regime, which at some point should involve human subject testing [7]. In most parts of Africa, the practice has been for the orthodox pharmaceutical regulators to demand results showing that plant compounds do not exhibit “acute toxicity” (very crudely put: whether one would not be poisoned within 48 hours of taking such medicine). Once they have satisfied themselves that this sub-minimal requirement has been met, they register these medicines for public consumption.

Orthodox medical practitioners would, of course, not be so magnanimous. They also want the “chronic toxicity” data, that is to say: the long-term effects of such medicines on organs like the liver and kidney, before considering even the sub-minimal criteria met. This however is the realm of late phase clinical trials. [8]

The herbalists and plant medicine entrepreneurs can, to be blunt, scarcely afford such indulgences. The local laboratories usually lack the means to provide the service to enough of the 100,000 or so practitioners anyway. In Ghana, for instance, the only laboratory believed to be genuinely close to this competence is the Noguchi Memorial, which is based in Accra and by some accounts beyond the reach (both financially and geographically) of most plant medicine entrepreneurs.

The interesting thing is that local entrepreneurs who decide to produce the less angst-ridden orthodox pharmaceuticals usually come up against similar challenges at a somewhat higher level. According to an official of the Ghana Food & Drugs Board (the equivalent of the MRHA in the UK and FDA in the USA), the reason why no Ghanaian pharmaceutical manufacturer has so far been pre-qualified by the WHO to be able to supply pharmaceutical products to such major global procurers as the Global Fund is primarily because the West African nation of 23.5 million lacks “bioequivalence centers”. Very crudely, what this means is that when a Ghanaian company produces commercial samples of a duly standardised molecule with established medicinal properties, the facilities rarely exist for said manufacturer to demonstrate that her products are indeed “equivalent” to the established formulation with regard to the expected curative properties (see how the Ethiopians are wrestling with this).

The good news is that various Ghanaian laboratories are improving their capacity to measure chronic toxicity at a level correspondent to advanced animal testing. That should satisfy the regulators. But it would not necessarily satisfy all the doctors. The more orthodox ones might insist that the registered plant medicines also demonstrate “efficacy” and be produced under “quality” conditions. The battery of tests required to establish these principles cannot be properly performed in non-certified labs, and there are concerns whether the regulators themselves are sufficiently equipped to handle these matters [9].

Back to square one then, it would seem.

My good friend Dr. Kofi Busia [10] of the West African Health Organisation has no time for these longwinded, self-serving, distractions. He has studied these matters extensively, and is completely convinced that it is a lack of creative policymaking that is standing in the way of integrating herbal medicine into the mainstream health system.

Throughout my discussion, I have given so much weight to the concern of orthodox doctors that one could have been misled into believing that there is no such thing as herbal medicine practitioners. Oh but they exist. If only we could focus on properly certifying and titling them.

There are already degree programs in herbal medicine in some of Ghana’s top universities. As far as the graduates of these programs are concerned, there is little cause for alarm. The Traditional Medicine Practice Council, which has been around for over a decade in Ghana, can do all the licensing required.

The issue is that the vast majority of herbal medicine practitioners did not graduate from formal programs of study in this field. Many people still acquire their competences in herbal medicine through informal apprenticeships. How may such be accommodated?

It is especially at this juncture that Dr. Busia likes to stress creative policymaking. If as a policymaker you were minded to admit ethnographic evidence, a ton could be provided in support of a particular herbal remedy that has been in use for centuries within a community that has spent significant amounts of time to evaluate the long-term effects and curative potential of said remedy. There are many who would argue that such evidence is superior to that obtained from 3 or 5 years of lab-mimicking clinical testing.

Dr. Busia can surprise you for days on end with his knowledge of the colourful array of cures sourced from the world of plants. [11]

At any rate, as my friend at the Food & Drugs Board is wont to say: people are using these medicines in large quantities every day. You better acknowledge that fact and find ways to adapt to it or you can wait till the mountains melt into the valleys waiting for it to adapt to you [12].

Notes:

[1] See a comparative account of different traditional medicine regimes around the world:
http://apps.who.int/medicinedocs/en/d/Jh2943e/7.21.html

[2] The WHO is careful to clarify that the oft-quoted “80%” figure may prevail in some countries but not in all. My sources in the plant medicine community are however adamant that most surveys consistently come up with more than three-fourths being reliant on herbal medicines. I note from a paper that I reference below, however, that one such survey turned up 51% for maternal mothers in a West African community.
http://www.who.int/mediacentre/factsheets/fs134/en/

[3] The latest edition of these documents can soon be accessed online here:
http://ghndp.org/index.php?option=com_content&task=view&id=47&Itemid=1
The more observant readers will note that it took more than 6 years for Ghana to update the previous one.

[4]  You may read more about the interplay of insurance systems and access to essential medicines here:
www.popcouncil.org/pdfs/GEMI_FinalReport_Winter2010.pdf
The focus is on Ghana, but as in many healthcare issues in Africa, you will soon find that issues tend to cut across geographical boundaries.

[5] A good overview of the subject can be accessed here:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2486664/

[6] Please see:
http://openlibrary.org/books/OL1197131M/Ghana_herbal_pharmacopoeia.

[7] Efforts are rife to better understand the dynamics of clinical testing in the African terrain.
http://www.edctp.org/Current-Call.410+M5e12c078de5.0.html
www.who.int/entity/ictrp/network/pactr2/en/index.html
 
[8] A useful technical brief re pre-clinical acute toxicity studies:
www.crcnetbase.com/doi/pdf/10.1201/EBK1420045604-c4

[9] The WHO is trying to spearhead the drafting of “current Good Manufacturing Practices” (cGMP) frameworks for developing countries. See:
apps.who.int/medicinedocs/en/m/abstract/Js14215e/

[10] See this seminal piece: http://findarticles.com/p/articles/mi_m0FDN/is_2_10/ai_n14731873/?tag=co...

[11] Check out this database for an interesting collection: http://www.metafro.be/prelude. Last accessed on 15 October 2010.

[12] You have probably noticed that I very quickly deplaned to “herbal medicine” even though I began my submissions with the all-encompassing term, “traditional medicine”. This was entirely deliberate. The piece of Ghanaian legislation that deals with traditional medicine begins the definition with these surreal words: “the beliefs and ideas...”. Any attempt to deal with the horrors of trying to systematise traditional medicine would have led to a treatise several pages long and many times more incoherent. Especially also, when there is a dry hint that perhaps systematisation and standardisation aren’t always the gems of wisdom they are usually held up to be.

[i] See a comparative account of different traditional medicine regimes around the world:
http://apps.who.int/medicinedocs/en/d/Jh2943e/7.21.html

[ii] The WHO is careful to clarify that the oft-quoted “80%” figure may prevail in some countries but not in all. My sources in the plant medicine community are however adamant that most surveys consistently come up with more than three-fourths being reliant on herbal medicines. I note from a paper that I reference below, however, that one such survey turned up 51% for maternal mothers in a West African community.
http://www.who.int/mediacentre/factsheets/fs134/en/

[iii] The latest edition of these documents can soon be accessed online here:
http://ghndp.org/index.php?option=com_content&task=view&id=47&Itemid=1
The more observant readers will note that it took more than 6 years for Ghana to update the previous one.

[iv]  You may read more about the interplay of insurance systems and access to essential medicines here:
www.popcouncil.org/pdfs/GEMI_FinalReport_Winter2010.pdf
The focus is on Ghana, but as in many healthcare issues in Africa, you will soon find that issues tend to cut across geographical boundaries.

[v] A good overview of the subject can be accessed here:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2486664/

[vi] Please see:
http://openlibrary.org/books/OL1197131M/Ghana_herbal_pharmacopoeia.

[vii] Efforts are rife to better understand the dynamics of clinical testing in the African terrain.
http://www.edctp.org/Current-Call.410+M5e12c078de5.0.html
www.who.int/entity/ictrp/network/pactr2/en/index.html

[viii] A useful technical brief re pre-clinical acute toxicity studies:
www.crcnetbase.com/doi/pdf/10.1201/EBK1420045604-c4

[ix] The WHO is trying to spearhead the drafting of “current Good Manufacturing Practices” (cGMP) frameworks for developing countries. See:
apps.who.int/medicinedocs/en/m/abstract/Js14215e/

[x] See this seminal piece: http://findarticles.com/p/articles/mi_m0FDN/is_2_10/ai_n14731873/?tag=co...

[xi] Check out this database for an interesting collection: http://www.metafro.be/prelude. Last accessed on 15 October 2010.

[xii] You have probably noticed that I very quickly deplaned to “herbal medicine” even though I began my submissions with the all-encompassing term, “traditional medicine”. This was entirely deliberate. The piece of Ghanaian legislation that deals with traditional medicine begins the definition with these surreal words: “the beliefs and ideas...”. Any attempt to deal with the horrors of trying to systematise traditional medicine would have led to a treatise several pages long and many times more incoherent. Especially also, when there is a dry hint that perhaps systematisation and standardisation aren’t always the gems of wisdom they are usually held up to be.

This article was originally published on October 19, 2010
Related TopicsHealth & Fitness, Health education

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