Prof David Katerere, Tshwane University of Technology Research Chair in Pharmaceutical & Biotech Advancement in Africa (PBA2)
Traditional medicine is defined by the World Health Organisation (WHO) as healthcare which is embedded in traditions and people’s heritage. It ranges from the use of herbal medicine all the way to traditional bone setting which is quite common in some countries like Nigeria. It includes techniques such as meditation, so-called mindfulness, acupuncture as well as aromatherapy. It has a long history of use among many different ethnic groups and has proven its utility. How it works and why it works cannot always be explained by modern science.
Every tradition in the world, whether it’s European (Nordic, Gaelic, Germanic, etc), Chinese, African, Japanese or Amazonian has a place for traditional medicine in one form or another. Thus, traditional medicine is widely used around the world. This may be due to lack of access to modern medical facilities, cost of care (for instance the cost of pharmaceutical medicine) and the fact that conventional medicine cannot cure the majority of diseases, and there are beliefs around the cultural and spiritual causes of illness which only the traditional medical approach is seen to treat.
The WHO recently held the first traditional medicine summit. One of the main drivers behind this initiative was the recognition by the WHO of the role that traditional medicine and traditional approaches played during COVID-19 in many developing countries. For instance, people used herbs such as Artemisia afra and Lippia javanica for immune support and soap plants such as aloe became important for hand sanitising.
The summit is an important milestone which should give impetus to mainstreaming and integrating traditional medicine into conventional healthcare systems. To do this, in addition to policy changes, there is the need for continued research and development in the sector. Traditional medicine must not be viewed as static but it must evolve as traditions evolve and new knowledge is generated. For instance, the standardisation of dosing is important and can be accomplished by presenting herbal medicines in pharmaceutical dosage forms such as capsules, teabags and tablets.. Research now needs to build more evidence around the effectiveness of these interventions, and how traditional medicine practitioners can be mobilised to become part of the healthcare system. Practice research may focus on integration healers as community health care workers, or into mother and child health programmes as traditional birth attendants or offer mental health or psychotherapy services in the community.
Recognition in South Africa
In South Africa, there is a clear regulatory distinction between complementary and traditional medicine. The latter is recognised as being indigenous to the cultural groups of South Africa while the former is defined as medicine from any allied health discipline which is not indigenous to South Africa. By law it is that which is practised by healthcare professionals who are registered with the Allied Health Professions Council of South Africa (AHPCSA). These disciplines include Traditional Chinese Medicine, Western Herbal, Homoeopathy, and Aromatherapy.
African Traditional Medicines (ATM) is currently excluded from regulation by the South African Health Products Regulatory Authority (SAHPRA). This is because it is generally not formulated into pharmaceutical dosage form and sold in formal retail outlets, though there are exceptions. The fact that it is not regulated is actually positive as regulations can easily hamper the development of a nascent sector. There is a view among some traditional health practitioners that regulation will lead to legitimacy and acceptance. This is an incorrect view. ATMs are emerging from a history of suppression under colonial and apartheid authorities. It is a wonder that they survived such sustained attacks, including from religious influences and so-called modernisation/westernisation. So, while ATM may not carry legitimacy from the healthcare system and formalised structures, it continues to be respected and utilised by many (black) people in the country. And therein lies its legitimacy.
While regulating the product (through SAHPRA) might have negative consequences, the regulation of the actual practitioners is important in order to protect consumers. There is much being done in that sense; the Traditional Medical Practitioners’ Act of 2007 established the Traditional Health Practitioners’ Council, though it seems to be still an interim council to this day. Nevertheless, the National Department of Health has a directorate for the sector which is progressive.
So, from a practice perspective, there is recognition. However, what needs to happen is that these practitioners need to have standardised training and then be registered as with the other healthcare professionals. To do this, there is a need for a framework of minimum professional and ethical standards pertaining to the healers and the products, and how the product is handled. This needs to be done to weed the charlatans from legitimate healers. There are success stories in other African countries such as Mali.
Investing in clinical testing of ATMs
In terms of regulating the products/medicines, it is important that these have some level of regulation especially when they make specific medical claims or where the ingredients may include endangered species. One of the big barriers is that clinical testing is usually not possible because of the costs involved.
There are various universities and government agencies working on various research projects in the traditional medicine sector. At Tshwane University of Technology we are engaged in several projects initiated by the South African Medical Research Council, Technology Innovation Agency and AU-NEPAD. We only work on projects which have funds and thus are unable to entertain walk-in requests since these studies can be costly.
One project funded by the South African Medical Research Council and Technology Innovation Agency is trying to validate the claims around a product by a traditional healer that his product (Moliherb and a control called Iminohoney) can be used to manage HIV. It’s a very complex study with potential ethical issues which we will have to work around when we start the clinical testing phase. For now, we are doing pharmaceutical development (to standardise the dosing) and testing to check on safety of the product. These studies take long, and we have to get the buy-in of SAHPRA (which we are working on). The healer also understands that this will not happen overnight and that the results might not be what he hoped for. We must be objective and accept if the product does not work.
We also have worked on a nutrition drink, Niselo, which is now on the market. It is a fermented sorghum-based drink, essentially a traditional food drink. Sorghum is a good source of protein, energy and vitamins (something that is recognised traditionally) and using probiotics (which in traditional settings is generated by fermentation) helps to improve digestibility. This product is now commercially available as a functional food for use in convalescence, gut health and weight management.
The traditional nutraceutical products are always interesting and under-researched. We have started a study on growing and testing indigenous African mushrooms. They have both nutritional and medical applications.
Lastly, we have a project on cannabis. Tshwane University of Technology in collaboration with the Council for Scientific and Industrial Research has set up a Cannabis Research Hub which works on extraction technologies and formulation of cannabis oils and by-products. Our particular interest is to develop affordable safe medicines for critical areas such as cancer pain management and women’s health from cannabis varieties indigenous to the region.
The AU-NEPAD project, which is called Project Bijimi, is aimed at strengthening the community health care sector. An important intervention would be looking at how traditional healers can be trained and integrated into the formal health care system as first aid responders managing health emergencies in the community, supporting patients with chronic conditions and offering services to pregnant mothers.
We owe it to ourselves to invest in the traditional medicine sector because, not only can it create jobs in communities, but it can also enhance healthcare. Traditional healers are well respected in their communities and can therefore be conduits for combating social ills (e.g. drug abuse, GBV), and also managing diseases (e.g. HIV testing and referral, identifying chronic diseases).
For me as a scientist, the investment ought to be in research and development to validate the use of the medicines and also to discover new drug leads. We should be supporting integrative medicine where traditional healers and medical doctors or healthcare practitioners work together and understand different healing modalities.
Medicine regulatory authorities such as SAHPRA need to support these efforts by enabling such research and also training their personnel in understanding the research. When I meet colleagues from Germany, I am amazed at how their regulator allows clinical testing and enables development of products from their traditional medicine sector – there is something African regulators can learn from them. – Health-e News