E-DRUG: Bringing Medicine to the Masses of Africa
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[this comment on the treatment of haemorrhoids in the new Ghana STG
document and the lack of herbal treatments is probably worth reading.
The original piece and all references can be found at
http://tech.ashoka.org/node/4538 Sorry, long article. WB]
Bringing Medicine to the Masses of Africa (when they are swimming in
it?)
Submitted by Bright Simons on October 19, 2010 - 10:49am
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[i].
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[ii].
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.
[iii]
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.[iv]
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[v].
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"[vi],
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[vii]. 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.[viii]
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[ix].
Back to square one then, it would seem.
My good friend Dr. Kofi Busia[x] 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.[xi]
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[xii].
[References and original layout available at
http://tech.ashoka.org/node/4538 WB]