COMPLEMENTARY ALTERNATIVE MEDICINES for PHC 400L 2.docx

**COMPLEMENTARY ALTERNATIVE MEDICINES** The term complementary medicine or alternative medicines are used inter-changeably with traditional medicine in some countries. They refer to a broad set of health care practices that are not part of the country's officially recognized mode of treatment and a...

**COMPLEMENTARY ALTERNATIVE MEDICINES** The term complementary medicine or alternative medicines are used inter-changeably with traditional medicine in some countries. They refer to a broad set of health care practices that are not part of the country's officially recognized mode of treatment and are not integrated into the dominant health care system. Individuals that require health care are faced with the choices of the type of "professional" to patronize whether orthodox or alternative practitioners which include all forms of traditional medicines. The large proportion of individuals in all countries including the highly industrialized nations, do patronize alternative medicine practitioners. In African Nations, including Nigeria, more than 80% - 90% do use traditional medicines for one reason or another. **Traditional Medicine** This can be described as the total combination of knowledge and practices, whether explicable or not, used in diagnosing, preventing, or eliminating a physical, mental, or social disease and which may rely exclusively on past experience and observation handed down from generation to generation, verbally or writing. This definition can be further extended for African by including a phrase such as "while bearing in mind the original concept of nature which include the material world, the sociological environment whether living or dead and the metaphysical forces of the universe". Traditional medicine is widespread throughout the world. As a result of the worldwide diversity in cultures, various countries have altered this original definition to suit their particular mode of treatment. In other to accommodate all, WHO defines Traditional medicine "As a sum total of the knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness". **Incantation** Incantations are a form of play on words (similes) written or delivered orally in poetic form apparently to conjure up forces (efficacies in a medicine). Medicinal incantations are in some ways like praise songs addressed to human beings or gods; their purpose is to awaken the powers of the ingredients hidden in the medicine. Incantations are used in traditional medicine in various ways: 1. There are situations in which only an incantation is required to give the effect desired. An example is when a witness is to be prevented from giving evidence or to speak the truth in a court. An incantation recited by appropriate person within or outside of the court room at the appropriate time can cause the witness to lose his memory or falter, so that his evidence becomes unreliable. In some communities, it is also be used to remove some snake venom or treat headache. 2. There are instances in which both incantations and herbal recipes are required. Example to the local treatment of bullet wounds or local extraction of bullet pellets from the body. Also is treatment of snake bites in some communities. 3. There are instances that no incantations are required. Examples include the use of *Azadirachta* *indica* to treat malaria; use of *Ocimum gratissimum* to treat diarrhea and dysentery. **Herbalist** This refers to a traditional healer that specializes in the use of herb to treat various ailments. He is expected to be highly knowledgeable in the identification, collection, preparation, efficacy, toxicity and dosage of herbal medicines. He uses plant parts, sometimes animal parts and inorganic residues and insects. His preparations could be: i. Powder for oral administration with pap or drink ii. Powder rubbed into cuts made with razor or sharp knife on any part of the body iii. Preparations boiled or soaked in water or local gin. iv. Preparation pounded with native soap and used for bathing. v. Pastes or ointments in palm kernel oil or shear butter. vi. Soup which is consumed by the patient **Medicinal Plant** A medicinal plant is any plant which, in one or more of its organs, contains substances that can be used for therapeutic purposes or which are precursors for the synthesis of useful drugs. A definition of medicinal plants should include the following: a. Plants or plant parts used medicinally in galenical preparations (e.g. decoctions, infusions, etc) e.g. Cascara bark, *Azadirachta indica*. b. Plants used for extraction of pure substances either for direct medicinal use or for the hemi-synthesis of medicinal compounds (e.g. hemi-synthesis of sex hormones from diosgenin obtained from *Dioscorea* species). c. Food, spice, and perfumery plants used medicinally e.g. ginger. d. Microscopic plants, e.g. fungi, actnomycetes, used for isolation of drugs, especially antibiotics. Examples are ergot (*Claviceps purpurea* growing on rye) or *Streptomyces griseus;* e. Fibre plants, e.g. cotton, flax, jute, used for the preparation of surgical dressings. **Definition of Herbal Medicine** By strict definition, an herb is a plant whose stem is soft, non-woody and dies down to the root after flowering. From medical point of view, the term 'herb' is often applied more generally to any plant part or whole plant, all of which can be used to flavor food, supplement nutrient or treat medical illnesses. Herbal medicines can therefore be defined as any recipe or drug material prepared from plants either in whole or part with or without animal parts in some cases. WHO defines herbal medicine as "Finished labeled medicinal products that contain as active ingredients aerial or underground part of plants, or other plant material or combinations thereof, whether in the crude state or as plant preparations". The plant material includes ground, juices, fatty oils, essential oils and any other substance of this nature. WHO states that medicines containing plant material with chemically defined active substances, including chemically defined isolated constituents are not considered to be herbal medicines. Exceptionally, in some countries herbal medicine may contain by tradition, naturally organic or inorganic active ingredients which are not of plant origin. Herbal medicines as defined by WHO, can be classified into three categories: 1. Phytomedicines or phytopharmaceuticals sold as over the counter (OTC) products in modern dosage forms such as tablets, capsules and liquids for oral use. 2. Dietary supplements containing herbal products, also called nutraceuticals available in modern dosage forms. These two types of herbal medicines are used by consumers in developed countries and those in urban areas of developing countries. These herbal medicines are gradually occupying increasing shelf space in modern Pharmacies. 3. Herbal medicines consisting of either crude, semi-processed or processed medicinal plants. Thes have a vital place in primary health care in developing countries like Nigeria. **Advantages of Herbal Medicine (Practice)** 1. Herbal Medicine is cheaper than orthodox medicine or modern medicine. The higher cost of the later is due to modern health technology involved, higher cost of basic commodities as well as the wages of the personnel involved; and the cost of advertising the products. 2. The practitioners are more accessible to most of the population. In developing countries between 60% - 65% of the population rely on herbal medicines. This is due to shortage of hospitals and health centres, as well as of the medical and paramedical staff needed to man modern health care delivery systems. 3. Herbal medicine or TM enjoys a wider acceptability among the people of developing countries than does modern medicine. This is because it blends readily into the socio cultural life of the people in whose culture it is deeply rooted. The acceptance could also be due to economic reasons and others seek medical help because of the belief that certain types of disease (like psychological or mental cases) only respond to traditional cures. 4. Herbal medicine is a potential source of new drugs (e.g. Artemisinin from *Artemssia annua*), source of cheap starting products for the synthesis of known drugs (Diosgenin from *Discorea* species), or a cheap source of known drugs (such as reserpine from *Rauwolfia* species). 5. It has been claimed that there is a greater likelihood of material products being accepted by the body than synthesis substances. Also, the concentration of active principle in the plant is usually small and it is further diluted when a decoction is prepared. Such aqueous decoction is believed to have a greater bioavailability to the body than some synthesis formulations. 6. As some herbal multi component preparations are claimed to have effects on several ailments, some patients find them more convenient for consumption than several different tablets or mixtures in addition to an injection. 7. The practitioners are very accessible with no formal protocol before consultation such processes like registration, undergoing a test, seeing a nurse etc. are absent. **Disadvantages** 1. Lack of scientific proof of efficacy. Most of the claimed uses of some herbs are not subjected to any scientific proof or investigation. 2. Imprecise diagnosis -- As most of the practitioners lack knowledge of pathology of certain diseases, there is high tendency that they make wrong diagnosis. A diagnosis of stomach trouble could mean indigestion, an ulcer or cancer of the stomach. As a result of improper diagnosis, symptoms are usually treated rather than the disease a situation that can sometimes lead to further complications. 3. Lack of precise dosage -- This is not true nowadays as many herbalists do specify dosage, even using such terms as teaspoonful etc. and varying the dose with the age of the patient. 4. Unhygienic method of preparation -- Both the herbalists clinic and mode of preparing medicines are often very unhygienic when compared to modern medical practice. This can be rectified turn regular training programmes. 5. Occultic practices and witchcraft -- Not all herbal preparations involve the use of sacrifices to improve or effect their efficacy. Some are done deliberately to let the recipe look important to the consumer. However, the occult practices and witchcraft make researches into the traditional uses of such herbs difficult. **TRADITIONAL MODE OF PSYCHIATRIC MANAGEMENT** Psychiatric disease is a kind of ailment that affects the mental perception, alertness, and formation of an individual. Such individuals lose mental coordination, the ability to perceive, conceive, receive and respond to issues affecting him/her or others around him in a normal way. As a result of such ailments, the individual may become restless, violent, withdrawn or imbecilic in nature. **Causes of mental disorders** In the mythology of some societies, the mania and hysteria and other odd behaviours expressed by the patient are interpreted as manifestations of supernatural beings within the person. Among the Yorubas, the native doctors share the opinion that small pox is one of the most frequent causes of mental illness. The Igbos also believed that "Agwu ishi" symbolizes justice (immoral rectitude) and uses "ofo and oga" as weapons. Unlike her counterpart the "Amadioha" the god thunder which kills by thunder and lightning when offended, "Agwu-ishi" does not kill instantly, rather her punishment is mental illness. Others among the Yorubas are of the believe mental illness is caused by the work of enemies, "afowofa" (mental illness brought down upon oneself) e.g. (i) Cannabis abuse, (ii) abuse of alcohol, other intoxicants and drugs (iii) bringing down supernatural forces upon oneself. They also believe in: - **Hereditary factor.** From either parent at the time of conception; in the blood - "Ode ori" -- a less severe mental disorder as a cause of psychotic symptoms, - Through the breast milk of psychotic mother - Meeting evil spirits - Head injury - Contagion -- from saliva or body secretions - Epilepsy - Emotional problems - Witches - Breaking of taboos by a pregnant women results in affected offspring. - Severe fever etc. In the orthodox medicines, mental disorders are caused by physical factors which involve observable physical influences or changes and psychological or emotional influences. The important factors usually involve - Hereditary (or genetic) factors - Physical illnesses -- these may directly affect the functioning of the brain e.g. head injury, infections, stroke, epilepsy, endocrine disorders. - Abnormalities of neurotransmitters in the brain - Degenerative disease, particularly in the elderly. - Adverse experiences, which may operate in childhood as well as in adulthood. Additional factors especially stressful experiences may precipitate active symptoms of the illness in the predisposed individual. For instance, it may be precipitated by the stress of childbirth, or stress of financial difficulties. There are also cases where the causation is difficult to ascertain. For such cases, doctors use the umbrella term "idiopathic" meaning the cause is still to be ascertained. **Diagnosis of mental disorders** Treatment of any ailment is preceded by proper diagnosis of the problem by competent and appropriate health professionals. The diagnosis serves as the basis for treatment, referral and subsequent discharge. Clinical diagnosis of mentally sick patients is based on their perceived interpretation of issues, feelings and behaviour haphazardly as registered in their tortured consciousness. Though it is a function of how the patient is perceived, it is also a consequence of the perceiver, the physician or healer. In the Western mode of psychiatry, diagnosis depends on history taking. Some psychiatrists do not make a diagnosis on the very first interview in cases where the patient has to be admitted to the ward for observation. Because the mentally ill is usually not critical of his situation and unable to give any formal information about himself, information about the patient is usually offered by the relatives. He may be aware that he has only a slight discomfort or may insist that there is nothing wrong with him and wonder why he has been brought to the hospital. Therefore, in orthodox practice, diagnosis of mental ailment is a joint effort of the psychiatric team, patients and relatives. Diagnosis, may involve the observation on the certain symptoms like depression and other mood disorders e.g. distractibility; indiscretion (excessive involvement in pleasurable activities), grandiosity; flight of ideas; activity increase; sleep deficit (decreased need for sleep); talkativeness (pressured speech); rage; abandonment terror; suicidal behaviour. In traditional ethnopsychiatry, diagnosis is achieved through the process of divination -- using "Ifa" oracle and mainly through intuitive perception of the healer based on the observable behaviour of the patient which may include the mood disorders mentioned above. The patient may not utter a word but only presents himself or is presented by his kins while the healer is supposed to know all the troubles with the patient. Among the Igbos, "Ara" is the major diagnostic category while among the Yorubas "*were*" is the major diagnostic category, others include "*were alaso*" etc. **Classification** In orthodox practice, the 10^th^ Edition of the International classification of diseases classifies mental disorders in to 10 major groups each of which contains a number of individual conditions. The ICD 10 also provides the criteria on the basis of which each disorder may be diagnosed. Some of them include: 1. F00 -- F09: Organic including symptomatic mental disorders. 2. F10 -- 19: Mental and behaviour disorders due to psychoactive substance use. 3. F20 -- 29: Schizophrenia, schizotypal and delusional disorders. 4. F30 -- 39: Mood (affective) disorders. 5. F40 -- 48: Neurotic, stress-related and somatoform disorders 6. F60 -- 69: Disorders of adult personality and behaviour 7. F70 -- 79: Mental retardation (Learning ability) 8. F90 -- 98: Behavioural and emotional disorders with onset usually occurring in childhood and adolescence. In traditional medicine, classificatory systems differ from culture to culture. In most systems, the classifications take cognizance of causation as well as the clinical presentations of the individual conditions. The causation or etiological classification may be important at times because it largely influences the treatment to be employed. Apart from aetiological classification, common mental disorders recognized by Yoruba traditional healers as observed in clinical presentation include: 1. Were gidi -- (true madness) considered in orthordox medicine as psychotic disorders. 2. Were alaso -- associated with good dress (mania) 3. Were sigidi gbari -- madness of statue-like rigidity (catatonic state) 4. Dindinrin -- mental retardation withdrawn, suspicions state. 5. Danidani -- regressed psychotic state (residual schizophrenia) 6. Abisinwin (post-partum psychosis) 7. Were agba (psychosis of old age) 8. Ipa were (psychosis associated with epilepsy) 9. Inarun (weakness, somatic complaints, tearfulness) -- depressive illness or somatization disorder, anxiety states. **Treatment** Just like any other ailing individual the mentally ill deserves to be treated. Treatment in orthodox practice can be categorized into physical and psychological. The physical treatments act through direct alternations in brain function e.g. drugs used in treating schizophrenia block the actions of the neurotransmitter dopamine in specific parts of the brain. The psychological treatments produce behavioural change and symptoms relief through manipulation of experiences, which in turn affects the functioning of the brain. In the simplest form of psychotherapy, the individual is assisted to explore his problems and is assisted to take the rigid steps to resolve them. Example of such psychotherapy treatment includes counseling, supportive psychotherapy behaviour therapy, cognitive behaviour therapy, etc. In traditional medicines, the psychiatric healing homes are like the Western locked-up psychiatric ward in setting but apparently differ in practice. The patients may be brought by relatives in shackles when they are violent. Some may be stripped, shaved and given tranquilizer or beaten to tranquility and put to sleep. Crude drugs used in ethno psychiatry include *Rauwolfia vomitoria* (roots), *Voacanga* species, *Securidaca longipendiculata, Tabernamontana* species (Apocynaceae), *Parguetina nigrescens* (Periplocaceae), *Jatropha* species (Euphorbiaceae), *Kalanchoe crenata* (Crassulaceae), *Allium escalonicum* (Alliaceae)*, Aframomum melegueta, Xylopia aetinopica (*Annonaceae), *Musa sapientum* (Musaceae). These medicinal plants are prepared in form of decoctions, concoctions, infusions as appropriate for ingestion. Some medicines also applied as snuffs, incense, burnt medicines or as form of soup. Other methods employed include incantations, sacrifice, putting of medicines under the patients pillow, impression of "Ifa" marks in medicines before application, ritual bathing, ritual shaving. Some are made to confess their evil deeds while some treatment may involve initiation into cults like Agwu, Ekpo and Jegede masquerade to ensure successful treatment. The purpose of initiation into the cults is different and depends on the culture of the area, the purpose of such cults. In ethno psychiatry, the community has roles of play in ensuring treatment for the mentally ill who is deemed as capable of causing havoc to himself or members of the community. In the African setting, the community is reviewed as having superiority over individuals and as such enforces the elders in the family of the patient to carry out whatever is required to ensure proper treatment of the patient. The community also ensures that the issue to stigmatization is down played in other to fully integrate the patient into the society. **THE GLOBAL PATTERN OF INTEGRATION OF TRADITIONAL AND ALTERNATIVE SYSTEMS OF MEDICINE WITH ORTHODOX MEDICINE.** 1. The exclusive (monopolistic) system or rejection system. In this system only the practice of modern scientist medicine by professionals and auxiliaries is recognized as lawful with the exclusion of and sanctions against all other forms of healing. This system was attempted by the colonial rule with the introductive of orthodox system which was ignored by most people patronizing the traditional leaders. The systems was tried in Kenya but failed as observed in other parts of the world. 2. The tolerant system: Here, only the practice of modern medicine is recognized officially although only to the extent that practitioners of various forms of traditional medicine are tolerated by law. This form of relationship does not create enough room for development of traditional medicine. The ideals and benefits cannot be adequately harnessed within the system because of limited or restricted interactions. 3. The Inclusive System: This gives room for the recognition of traditional medicinal practice as a special part of the healthcare structure. The inclusive system allows enough interaction between traditional leaders and orthodox practitioners to foster cooperation, collaboration and development in the two systems. In the system, the services of orthodox medical personnel can be sought to assist the training and development programmes in the traditional system. Through this, orthodox medicine will have better opportunity to increase or improve the modern medicinal formulations derivable from herbs and traditional medicines. From traditional medicinal herbs, new orthodox medicines can be developed. Modern doctors who wish to study traditional medicine will also be more opportune and confident to do so. The benefit of meaningful collaboration and integration to the general populace is improved health care. Nigeria is at this stage. 4. The integrated system: In this system, there is official promotion of the integration of both orthodox and tradition medicines within a single recognized service. Integrated training of health practitioners is the official policy of the government. This kind of system is practiced in China, Nepal and South Korea. To ensure a proper integration of both orthodox and traditional medicines i. There should be legal official recognition of traditional medicine by the government ii. There should be legal and official reorganization of traditional leaders iii. Standardization and classification of the various levels of competence of traditional leaders iv. There should be quantitative and formal training and retraining of traditional leaders. v. Standardization of traditional medicine practical vi. Acceptable packaging and dispensing traditional medicines, vii. Devotion of adequate funds towards the development of tradition medicine viii. Regular organization of symposia, workshops and conferences to ensure interaction between the practitioners of the orthodox and traditional medicines.