Chapter I,ii,iii-sept 9 (badette)

CHAPTER I

INTRODUCTION Modern medicine, with its arsenal of manufactured drugs and advanced technological devices, presents a big disparity from the folk traditional healing with the use of medicinal plants through comparison of their practices and principles. Suffused in the concept of modernity is the idea of efficiency in treatment, reproducibility of medications and predictability of results; as such, modern practitioners have criticized traditional medicine as inferior.

However, high cost

of modern medicine, especially those manufactured abroad, and their unavailability in remote areas led to the continued dependence of rural folks on medicinal plants as their primary therapeutic means and has resulted in the need to re-evaluate the potential of these medicinal plants as an alternative treatment resource. The Philippines is endowed with rich and varied flora, which are known to have medicinal properties since ancient times. The native folk herbalist or “albularyo” of olden times were skilled in the use of local plants to cure varied illnesses. They utilized the different parts of the plant to form decoctions and concoctions and passed this knowledge on folk medicine from one generation to another. To date, folk herbalists and their use of medicinal plants are still widely practiced in rural areas of the country. In a survey conducted by UPLB in 766 barangays or villages in 12 regions of the country, 1687 plants were found being used folk herbalists; of such, 120 medicinal plants have been scientifically validated for safety and efficacy and 10 are being endorsed by the DOH as effective therapeutic alternatives to pharmaceutical preparations, the “Sampung Halamang Gamot”. But it is highly possible that there are more plant species that can be classified medicinal given the Philippines' rich and diverse flora. The engenderment of discipline of ethnopharmacology arises from such thought, and the need for the development of such field. Ethnopharmacology is the interdisciplinary scientific exploration correlating ethnic groups, their health and how it relates to their physical habits and methodology in creating and using medicines. Despite the need; however, there is yet to be a systematic research strategy towards the identification, characterization and evaluation of such medicinal plants and steps towards

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resolving this is still primitive. As an initial step; therefore, there is a need to develop a database on medicinal plant utilization and documentation.

SIGNIFICANCE OF THE STUDY Despite advancements in technologies and coming of the modern era, poverty is still one of the most debilitating problems among third world countries. A lot of people still do not have access to basic necessities, such as food, shelter and education; and in such state of economic deprivation, it has been difficult for the low income group to prioritize one of the necessities in life, health care. This compelled the Department of Health of the Philippines to reappraise traditional medicinal therapy, and endorse the use of the ten herbal medicines clinically proven to have therapeutic value in the relief and treatment of various aliments in place of expensive pharmaceutical preparations, known as the “Sampung Halamang Gamot program.” Moreover, medicinal plants address not only the need for access to medicine as a component of health services but also to the need for increased income for farmers and as a significant contribution to the national economy. Such advantageous effects, however, are a long way from reality. Currently, the distribution and diversity of medicinal plants is not well documented that productive research and development in the field cannot be instigated. Therefore, the results of this research is vital for the current characterization and evaluation of our biodiversity, as well as for the future researches that will need the database collected as baseline prevalence for their study on local medicinal plants. The results can also be used by DOH to identify and gauge the health practices of Pulilan, Bulacan. And lastly, documentation of the collection of local medicinal plants is the first step in information exchange that is important in the conservation and usage of such flora. The nature of the topic is also important, because shedding light on herbal medicinal therapy will increase awareness and attention on the medicinal plants; ultimately leading to a more reliable information on the traditional use of medicinal plants, more focused and cheaper product based drug discovery, and serve as a bridge between traditional and modern medicine. Lastly, this research will give the group an opportunity to perform a community-based qualitative and quantitative study. It will provide knowledge, experience and know-how to explore the field of ethnopharmacology in the Philippines.

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GENERAL OBJECTIVE: To document the different medicinal plants prescribed by folk herbalist and its relationships to the Sampung Halamang Gamot endorsed by the Department of Health.

SPECIFIC OBJECTIVES 1. To determine the most common medicinal plants being prescribed for common disease indications. 2. To determine the parts, formulations and prepartions of medicinal plants being prescribed for common disease inidcations. 3. To identify the plants used by folk herbalists for common disease indications. 4. To determine which medicinal plants being used by the folk herbalists belong to the “Sampung Halamang Gamot.” 5. To determine the conformity of the folk herbalist for the use of the “Sampung Halamang Gamot” to its endorsed indications.

SCOPES AND LIMITATIONS

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DEFINITION OF TERMS Medicinal Plants-

natural herbs from plants for the treatment or prevention of diseases,

disorders and the promotion of good health. These plants can be finished, labeled, medicinal products that contain as active ingredient/s aerial or underground part/s of plant or other materials or combination thereof, whether in the crude state or as plant preparations. Plant material includes juices, gums, fatty oils, essential oils, and other substances of this nature. Medicines containing plant material(s) combined with chemically defined active substances, including chemically defined, isolated constituents of plants, are not considered to be herbal medicines. A list of medicinal plants for common disease indications will be made based on the interview. Data will be gathered with the use of Section B of the data collection tool. Folk Herbalist -

person especially in rural areas who used medicinal plants and other

alternative materials and procedures to heal. They are general practitioners and dispensers of primary health care. As with the other healers, there is usually a history of a healer in the familyline and their healing considered a "calling," a power or ability bestowed by a supernatural being, often, attributed to the Holy Spirit. Often lacking in formal education, his skills are based on and honed from hand-me-down practices and lore, with a long period of understudy or apprenticeship with a local healer. This study will refer to a folk herbalist as any kind of alternative medical practitioner referred by health care worker who is a resident of Puilan ,Bulacan and knowledgeable about medicinal plants and prescribes and/or makes use of plants or plant parts in his treatment regimen. They will be regarded as respondents in the course of the study. The term is translated as 'albularyo' in Filipino. Sampung Halamang Gamot (SHG)- The ten medicinal plants endorsed by the Department of Health through its "Traditional Health Program". All ten (10) herbs have been thoroughly tested and have been clinically proven to have medicinal value in the relief and treatment of various aliments. It includes the following plants: Akapulko (Cassia alata) Ampalaya (Momordica charantia) Bawang (Allium sativum) Bayabas (Psidium guajava) Lagundi (Vitex negundo) Niyog-niyogan (Quisqualis indica L) 4

Sambong (Blumea balsamifera L.) Tsaang Gubat or Wild Tea (Ehretia microphylla Lam.) Pansit-pansitan Ulasimang Bato (Peperomia pellucida) Yerba Buena (Mentha spicata)

COMMON DISEASE INDICATIONS -refers to the all the indications which the SHG is endorsed for, this includes the following: fever, cough, bronchitis, ringworm, diabetes, gout, kidney stone, diarrhea, sore throat, diuretic, irregular menstruation, toothache, abdominal pain, arthritis, skin disease, wounds and burns.

CHAPTER II 5

REVIEW OF RELATED LITERATURE Traditional medicine provides essential healthcare to the people and long before modern medicines were introduced, herbal medicines has been widely used in the Philippines. Today, the use of traditional medicine has expanded and gained tremendously with wide global acceptance and popularity. Considering the expensive western medical treatment, which most Filipinos could not afford, the practice of traditional medicine achieved great importance. The traditional healers were the one who tested the curative effects of the herbal medicines on their patient with try-and-error basis. This knowledge and skill has been handed from several generations. The folklore herbalists received in return the moral support and the psychological comfort from their patients. In the olden days, they are of high social status and well respected. The availability of the modern drug is starting to increase at much cheaper prices, thus, the popularity of herbal medicines has begun to decline but mostly in urban areas. Despite of the campaigns to make available medical services in rural areas, the services are still far from adequate today. The people who belong to the economically challenge class who live far from the district towns and are in need of health care the most are still unable to come to the hospitals. These people who are the majority of the population of the Philippines divert their healthcare needs to the folklore herbalists and be medicated with herbal plants. In 1992, the Department of Health (DOH), through former Health Secretary and former Senator Juan M. Flavier, first came out with the Traditional Medicine Program by virtue of Administrative Order No. 12. This special program was tasked to promote and advocate traditional medicine nationwide. In order to institutionalize the program, the drafting of a traditional medicine law started in 1994. Then in 1997, President Fidel V. Ramos, appreciate the importance of traditional medicine in the country.1

PHILIPPINE INSTITUTE OF TRADITONAL AND ALTERNATIVE HEALTH CARE 1

Philippine Institute of Traditional and Alternative Healthcare. [www2.doh.gov.ph/pitahc/] Accessed last 30 July 2007

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The timely approval of Republic Act 8423 (R.A. 8423) otherwise known as the Traditional and Alternative Medicine Act (TAMA) of 1997 gave rise to the creation of the Philippine Institute of Traditional and Alternative Health Care (PITAHC), a government owned and controlled corporation (GOCC) attached to the DOH to answer the present needs of the people on health care through the provision and delivery of traditional and alternative health care (TAHC) products, services and technologies that have been proven safe, effective and affordable.2 PITAHC has the vision of “Traditional and alternative health care in the hands of the people”. According to Republic Act 8423 Traditional and Alternative Medicine Act of 1997, alternative healthcare is the sum of total knowledge, skills, and practices on health care, other than those embodied in biomedicine, used in the prevention, diagnosis and elimination of physical or mental disorder. On the other hand, traditional medicine is the sum of total knowledge, skills and practices on health care, not necessarily explicable in the context of modern, scientific philosophical framework but recognized by the people to help maintain and improve their health towards the wholeness of their being, the community and society, and their interrelations based on culture, history, heritage and consciousness. The world health organization states that traditional medicine is based on indigenous theories, beliefs and experiences that are handed down form generation to generation.3 A better understanding of PITAHC could be obtained from reading the following objectives: •

To encourage scientific research on and develop traditional and alternative health care systems that have direct impact on public health care;

•

To promote and advocate the use of traditional, alternative, preventive and curative health care modalities that have been proven safe, effective, cost-effective and consistent with government standards on medical practice;

•

To develop and coordinate skills training courses for various forms of traditional and alternative health care modalities;

•

To formulate standards, guidelines and codes of ethical practice appropriate for the practice of traditional and alternative health care as well as in the manufacture, quality control and marketing of different traditional and alternative health care materials,

2

Philippine Institute of Traditional and Alternative Healthcare. [www2.doh.gov.ph/pitahc/] Accessed last 30 July 2007 3 http://herbal-medicine.philsite.net/doh_herbs.html

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natural and organic products, for approval and adoption by the appropriate government agencies; •

To formulate policies for the protection of indigenous and natural health resources and technology from unwarranted exploitation, for approval and adoption by the appropriate government agencies;

•

To formulate policies to strengthen the role of traditional and alternative health care delivery system; and

•

To promote traditional and alternative health care in international and national conventions, seminars and meetings in coordination with the Department of Tourism, Duty Free Philippines, Incorporated, Philippine Convention and Visitors Corporation and other tourism-related agencies as well as non-government and local government units. 4 According to the Department of Health, the health sector in the Philippines falls short in

meeting several problems due to several reasons [1] inappropriate health delivery system such as, poor hospital facilities, fragmented primary health system, ineffective delivery mechanism for public health program, and misdistribution of health human resources, [2] inadequate health regulatory mechanisms such as gaps in regulatory mandates, lengthy and laborious regulatory systems and processes and inadequate human resources and facilities resulting in poor quality of health care, high cost of privately provided health services and high cost of drugs, [3] poor health care financing such as inadequate funding, inefficient sourcing, and ineffective allocation. To be able to transform the health system into that would ensure the delivery of cost effective services, universal access to essential services and adequate and efficient financing, major reforms must be undertaken. Pursuing the needed improvement, the entire health sector sets a mission of “to ensure accessibility and quality of health care to improve the quality of life of all Filipinos, especially the poor.” The DOH as the lead agency on health sets the vision for the nation’s health, “Health for All Filipinos.”5

4

Ibid.

5

Complementary and Alternative Medicine: A prescription for Medical Tourism. [pmtcongress.rxpinoy.com/downloads/Galindez-Prescription-CAM.pdf ] Accessed Last 30 July 2007

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SAMPUNG HALAMANG GAMOT In accordance to the mission of the DOH, the department endorsed a “Traditional Health Program” in which ten (10) herbs have been thoroughly tested and have been clinically proven to have medicinal values. The following is the list of the top ten medicinal plants in the Philippines. 1. Akapulko (Cassia alata) - also known as "bayabas-bayabasan" and "ringworm bush" in English, this herbal medicine is used to treat ringworms and skin fungal infections. 2. Ampalaya (Momordica charantia) - known as "bitter gourd" or "bitter melon" in English, it most known as a treatment of diabetes (diabetes mellitus), for the non-insulin dependent patients. 3. Bawang (Allium sativum) - popularly known as "garlic", it mainly reduces cholesterol in the blood and hence, helps control blood pressure. 4. Bayabas (Psidium guajava) - "guava" in English. It is primarily used as an antiseptic, to disinfect wounds. Also, it can be used as a mouth wash to treat tooth decay and gum infection. 5. Lagundi (Vitex negundo) - known in English as the "5-leaved chaste tree". It's main use is for the relief of coughs and asthma. 6. Niyog-niyogan (Quisqualis indica L.) - is a vine known as "Chinese honey suckle". It is effective in the elimination of intestinal worms, particularly the Ascaris and Trichina. Only the dried matured seeds are medicinal -crack and ingest the dried seeds two hours after eating (5 to 7 seeds for children & 8 to 10 seeds for adults). If one dose does not eliminate the worms, wait a week before repeating the dose. 7. Sambong (Blumea balsamifera)- English name: Blumea camphora. A diuretic that helps in the excretion of urinary stones. It can also be used to treat edema. 8. Tsaang Gubat (Ehretia microphylla Lam.) - Prepared like tea, this herbal medicine is effective in treating intestinal motility and also used as a mouth wash since the leaves of this shrub has high fluoride content. 9. Ulasimang Bato (Peperomia pellucida) - also known as "pansit-pansitan" it is effective in fighting arthritis and gout. The leaves can be eaten fresh (about a cupful) as salad or like tea. For the decoction, boil a cup of clean chopped leaves in 2 cups of water. Boil for 15 to 20 minutes. Strain, let cool and drink a cup after meals (3 times day).

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10. Yerba Buena (Clinopodium douglasii) - commonly known as Peppermint, this vine is used as an analgesic to relive body aches and pain. It can be taken internally as a decoction or externally by pounding the leaves and applied directly on the afflicted area.6 Some of the ten herbal medicines in the Philippines that were approved by the DOH were already sold to the market as tablet forms.

One is Lagundi, which is a therapy for

bronchospasm in bronchial asthma, chronic bronchitis and other bronchopulmonary disorders. Another is sambong, which can be used to treat kidney stones, urinary tract pain and burn sensations, it also increases urinary output in certain conditions characterized by edema or fluid retention. Tsaang Gubat can be used to provide relief for abdominal colic. These herbal plants were already included in the PNDF Vol.1, 5th Edition, 2000.7

ETHNOPHARMACOLOGY Ethnopharmacology is the scientific study that correlates ethnic groups, their health practices, and how it relates to their physical habits and methodology in creating and using medicines. It incorporates the social science of ethnology and the medical science of pharmacology. It is related to botany in that many pharmaceuticals are delivered through plants.8 Combining the approaches of medical anthropology, phytotherapy, and pharmaceutical science, this discipline explores medicinal plants in indigenous cultures, which includes the bioactive compounds, and the sustainable development and production of nature-derived therapeutics.9 Hence, ethnopharmacology studies the pharmacological aspects of a culture's medical treatment as well as its social appeal. This includes taste, symbology, and religious context. Through this, a culture's exposure to pharmacological substances can be determined.10 It is also often associated with ethnopharmacy, but while the aim of ethnopharmacology is the bio-evaluation of the effectiveness of traditional medicines, the former deals instead with much broader trans-disciplinary aspects related to the study of the perception, usage, and 6

Department of Health Republic of the Philippines. [http://www.doh.gov.ph/taxonomy/term/403] Accessed Last 30 July 2007. 7 Department of Health Republic of the Philippines. [http://www.doh.gov.ph/taxonomy/term/403] Accessed Last 30 July 2007 8 (1996) "Ethnopharmacology: The Conjunction of Medical Ethnography and the Biology of Therapeutic Action", Medical Anthropology: Contemporary Theory and Method. Praeger Publishers, 132-133, 151. 9 http://www.ethnopharmacology.org/ 10 http://medicinus.info/research/areas/ethnopharmacology/

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management of pharmaceuticals but not necessarily traditional medicines within a given human society. When investigating a natural product used by a certain culture as a medicine, it is important that the methods of collection, extraction, preparation are the same or similar to those used by the ethnic group, as it is these processes which have allowed safe usage of the substance and give it its safety record.11 In recent years the preservation of local knowledge, the promotion of indigenous medical systems in primary health care, and the conservation of biodiversity have become even more of a concern to all scientists working at the interface of social and natural sciences but especially to ethnopharmacologists. They are particularly concerned with local people’s rights to further use and develop their autochthonous resources. Accordingly, today’s ethnopharmacological research embraces the multidisciplinary effort in the: • Documentation of indigenous medical knowledge • Scientific study of indigenous medicines in order to contribute in the long-run to improved health care in the regions of study • Search for pharmacologically unique principles from existing indigenous remedies. Consequently ethnopharmacology will

contribute

to

the development

of

new

pharmaceutical products for the markets. Also, truly anthropologically-oriented research on medicinal plants requires not only a detailed understanding of these medicines, but also the scientific support to autochthonous developments in order to make better use of these products. The knowledge that some herbs and plants possess medicinal compounds has been applied since time immemorial. Ethnopharmacology investigations classically involved traditional healers, botanist, anthropologist, chemist and pharmacologists (Raza).12 The practice of which was passed on from one generation to the next. It was the early people who understood that therapeutic plants have the capacity to be very effective, yet with no or minimal toxicity. Historical data shows that discovery of several important drugs of herbal origin owe to 11

Heinrich, Michael. UUBook Review Editor, JEP

12

Raza M. A role for physicians in ethnopharmacology and drug discovery (2006 April 6). [http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16459039&ordina lpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum] Accessed last 30 July 2007.

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the medical knowledge and clinical expertise of physicians (Raza).13 The transformation of digitalis from a folk medicine, foxglove, to a modern drug, digoxin, illustrates principles of modern pharmacology that have helped make drugs safer and more effective (Goldman P.). 14 Indeed today many pharmacological classes of drugs include a natural product prototype. Aspirin, atropine, ephedrine, digoxin, morphine, quinine, reserpine and tubocurarine are a few examples of drugs, which were originally discovered through the study of traditional cures and folk knowledge of indigenous people. Although the therapeutic and medicinal properties of such resources have been apparent, it has only been recently that focus on ethnopharmacology became a concern. 15 In terms of research, the first formal study was published in 1979 as the pioneer article in the Journal of Ethnopharmacology.16 Consequently, this has prompted the opening of a new area for research. An advocacy runs, to allow the local people in further using and developing the autochthonous resources that are abundant. Also, research in this field has permitted the following: a) documentation of indigenous medical knowledge; b) health care improvement through the scientific study of indigenous medicines; and c) the search for pharmacologically unique principles from existing indigenous remedies.17 According to Raza, rising cost of modern drug development is attributed to the lack of classical ethnopharmacological approach. Physicians can play multiple roles in the ethnopharmacological studies to facilitate drug discovery as well as to rescue authentic traditional knowledge of use of medicinal plants. These include: (1) Ethnopharmacological field work which involves interviewing healers, interpreting traditional terminologies into their modern counterparts, examining patients consuming herbal remedies and identifying the disease for which an herbal remedy is used. (2) Interpretation of signs and symptoms mentioned in ancient texts and suggesting proper use of old traditional remedies in the light of modern medicine. (3) Clinical studies on herbs and their interaction with modern medicines. (4) Advising 13

Raza M. A role for physicians in ethnopharmacology and drug discovery (2006 April 6). [http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16459039&ordina lpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum] Accessed last 30 July 2007. 14 Goldman P. Herbal Medicine Today and the Roots of Modern Pharmacology [www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15216922&dopt=Abstract] Accessed Last 30 July 2007. 15 International Society for Ethnopharmacology. 2007. Journal of Ethnopharmacology. [http://www.ethnopharmacology.org/] Accessed last 30 July 2007. Ibid. 16 International Society for Ethnopharmacology. 2007. Journal of Ethnopharmacology. [http://www.ethnopharmacology.org/] Accessed last 30 July 2007. 17 Ibid.

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pharmacologists to carryout laboratory studies on herbs observed during field studies. (5) Work in collaboration with local healers to strengthen traditional system of medicine in a community. 18 Physician's involvement in ethnopharmacological studies will lead to more reliable information on traditional use of medicinal plants both from field and ancient texts, more focused and cheaper natural product based drug discovery, as well as bridge that gap between traditional and modern medicine (Raza).19 In the study of Aburjai et al, in which collection of information from local population concerning the use regional medicinal plants; identify the most important species used; determine the relative importance of the species surveyed and calculate the informant consensus factor (ICF) in relation to medicinal plant use. Data collection relied predominantly on qualitative tools to record the interviewee's personal information and topics related to the medicinal use of specific plants. In the rural people of India, traditional herbal medicine is predominantly practiced, especially remote areas such as the Uttara Kannada District in Western Ghats of Karnataka.20 Local traditional healers play an important role in the management of health problems of the native population due to socio-economical and geographical factors. In the present study, 92 traditional medicine practitioners/healers from various regions of Uttara Kannada district were interviewed to collect information on the use of herbal treatments. Information was also collected on the method of preparation, dose and duration along with the botanical names, family and local names of the medicinal plants. The plants were then collected and identified (Hegde et al).21 An ethnobotanical and medical study was carried out in the Navarre Pyrenees, an area known both for its high biological diversity and its cultural significance. As well as the compilation of an ethnopharmacological catalogue, a quantitative 18

Raza M. A role for physicians in ethnopharmacology and drug discovery (2006 April 6). [http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16459039&ordina lpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum] Accessed last 30 July 2007. 19 Raza M. A role for physicians in ethnopharmacology and drug discovery (2006 April 6). [http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16459039&ordina lpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum] Accessed last 30 July 2007. 20 Aburjai T. et al. Ethnopharmacological Survey of medicinal herbs in Jordan , the Aljoun Heights Region. [http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=15216922&dopt=AbstractPlus] Accessed Last 30 July 2007. 21 Hedge HV et al. Herbal care for reproductive health: ethno medicobotany from Uttara Kannada district in Karnataka, India. [http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=15216922&dopt=Abstract Plus] Accessed Last 30 July 2007.

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ethnobotanical comparison has been carried out in relation to the outcomes from other studies about the Pyrenees. Information was collected using semi-structured ethnobotanical interviews and the data was analyzed using quantitave indexes: Ethnobotonicity Index, Shannon-Wiener's Diversity, Equitability and The Informant Consensus Factor. The official review has been performed using the official monographs published by the WHO, ESCOP and the E Commission of the German Department of Health (Akerreta et al). 22 Since the Journal of Ethnopharmacolgy was published numerous studies in the Journal dealing with medicinal and other useful plants as well as their bioactive compounds have used a multitude of concepts and methodologies. In many cases these were interdisciplinary or multidisciplinary studies combining such diverse fields as anthropology, pharmacology, pharma-cognosy, pharmaceutical biology, natural product chemistry, toxicology, clinical research, plant physiology and others (Soejarto, D.D., 2001, Journal of Ethnopharmacology 74). September of 2000, the board of the Journal of Ethnopharmacology took the initiative and proposed a revised statement to the editors and the publisher. With the new statement by boards of the Journal of Ethnopharmacology drawing the attention to the importance of nature-derived products (plant extracts and pure compounds) in the healthcare of the original keepers of such ethnopharmacological knowledge. This needs to be a primary goal of truly interdisciplinary ethnopharmacological research.23 Ethnopharmacology will also contribute to the development of new pharmaceutical products for the markets. Also, truly anthropologically-oriented research on medicinal plants requires not only a detailed understanding of these medicines, but also the scientific support to autochthonous developments in order to make better use of these products. 24 The Journal of Ethnopharmacology is dedicated to the exchange of information and understandings about people’s use of plants, fungi, animals, microorganisms and minerals and their biological and pharmacological effects based on the principles established through international conventions. Early people confronted with illness and disease, discovered a wealth of useful therapeutic agents in the plant and animal kingdoms. The empirical knowledge of these medicinal substances and their toxic potential was passed on by oral tradition and sometimes recorded in herbals and other texts on materia medica. Many valuable drugs of today (e.g., atropine, ephedrine, tubocurarine, digoxin, reserpine) came into use through the 22

Akerreta S. et al. First comprehensive contribution to medical ethnobotany of of Western Pyrenees. [http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=15216922&dopt=AbstractPlus] Accessed Last 30 July 2007. 23 International Society for Ethnopharmacology. 2007. Journal of Ethnopharmacology. [http://www.ethnopharmacology.org/] Accessed last 30 July 2007. 24 International Society for Ethnopharmacology. 2007. Journal of Ethnopharmacology. [http://www.ethnopharmacology.org/] Accessed last 30 July 2007.

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study of indigenous remedies. Chemists continue to use plant-derived drugs (e.g., morphine, taxol, physostigmine, quinidine, emetine) as prototypes in their attempts to develop more effective and less toxic medicinals.25 The use of plants, plant extracts or plant-derived pure chemicals to treat disease is a therapeutic modality, which has stood the test of time. There is a revival of interest in herbal products (botanicals) at a global level and the conventional medicine is now beginning to accept the use of botanicals once they are scientifically validated (Gilani et al).26 Some examples of ethnomedicine are gaining the popularity among the modern physicians due to the high cost involved in the development of patentable chemical drugs (Gilana et al).27

Ethnopharmacological Studies

OTHER RELEVANT INFORMATION International organizations and policy-makers consider the presence of primary health care, including Western primary health-care services (PHCs) to be the solution to health problems in remote and impoverished areas. Health-care institutions in developing countries consist of governmental health services, nongovernmental organizations (NGOs), traditional healers, and private practice. In such areas, not only does Western health care coexist with traditional medicine (TM) which includes both self-care with medicinal plants and consultation with specialized traditional healers, but conflicts with such health practice in those areas. the residents of local communities are having difficulty integrating Western medicine as part of improving their health due to reasons such as the cost of consultation, high travel distance, perception of illness by patients as non-serious, and impersonal treatment of patients by the medical staff. Moreover, some local health beliefs serve as obstacles to the use of pharmaceuticals. For example, the Vietnamese believe that antibiotics should be minimally used for those with a “hot” body (i.e. suffers from fever) because these medications are also considered “hot,” therefore, producing no cooling effect on the body. In other areas of the world, such as the women in periurban Brazil, preferred medicinal plants over pharmaceuticals because of the low cost and that medicinal plants do not produce the side effects of 25

International Society for Ethnopharmacology. 2007. Journal of Ethnopharmacology. [http://www.ethnopharmacology.org/] Accessed last 30 July 2007. 26 Gilani AH et al. Trends in Ethnopharmacology. [http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=15216922&dopt=AbstractPlus] Accessed Last July 30 2007 27 http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=15216922&dopt=AbstractPlus

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pharmaceuticals. Hence, in local communities the use of medicinal plants as primary healthcare is more culturally acceptable than Western medicine. It was presumed that the earliest form of herbal medicine was marshmallow root, a common grass said to be chewed by our closest evolutionary cousins, chimpanzees and bonobos, to relieve an upset stomach. Likewise, hyacinth (a diuretic) causes the tissues to expel excess water, is rich in tannins and alkaloids, and has a bitter, or pungent taste. As tribal human societies grew, a small body of knowledge grew regarding which plants were beneficial for a certain ailment, until the role of a tribal herb lore specialist became known. As human societies shifted to an agronomical view of the world, the cultivation of plants for medicine provided an important role; eventually, herbal lore and herbal remedies became codified, first with the Egyptians, then with the Greeks in the Western tradition, and the knowledge base was slowly accumulated upon by the Romans. It's from the Greeks in particular that the foundation of modern medicine – of not just prescribing a treatment, but recording what the treatment was, and what its impact was, got started. In India, the herbalist tradition was Ayurvedic, focusing on the use of metals, herbs and parts of animals generally considered inedible, prepared in solution. These herbs and other compounds are used in varying proportions to remedy specific ills, and may be applied internally as pills or infusions, topically as ointments, inhaled as smoke, or pressed to the body as powders. In the Americas, without a written tradition to work from, most herbalism is carried by oral traditions from various tribes; this has proven invaluable when looking for herbal remedies in the rain forests and Andean uplands. Much of the American herbal tradition is tied to shamanism and spiritualism. In China, herbalism and herbal remedies were used as an adjunct to acupuncture, and the medical morphology in use is of balancing qui or chi, the life force energies, which have yin and yang elements; in Chinese herbalism, the aim is to bring the systems of the body, treating it as an electrical system, back into balance, which is a tactic commonly expressed in modern, or syncretic herbalism.28 28

http://www.herbalremediesinfo.com/history-of-herbal-medicine.html, Copyright 2007 Marc Neveux Herbal Remedies Info

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The Department of Health has been promoting products of medicinal plants as alternative medicines. According to the DOH secretary, their low costs and effectiveness will be an advantage for the health needs of many Filipino families as they have been a subject of extensive research by Filipino scientists. The Department of Science and Technology announced that 102 plants have been “scientifically validated for safety and efficacy.” Ten of these plants are under different stages of development, and that studies have been completed on sambong, lagundi, and akapulko. DOST said that from sambong and lagundi alone, a local marker of herbal drugs is earning millions of pesos. However, recent reviews of the scientific literature on herbal medicinal products warned that medicinal plants are not free of risk. One such review was conducted by scientists from the Department of Complementary Medicine, Universities of Exeter and Plymouth, United Kingdom. Their study, published in the journal Pharmacoepidemiology and Drug Safety in 2004, focused on the toxicity, interactions, and quality of herbal products. Toxicity data indicate that some herbal drugs "have the potential to cause

serious

adverse

events

and

fatalities."

They

"affect

pharmacokinetic

and

pharmacodynamic factors and thus cause herb-drug interactions." Contamination, adulteration, or substitution of botanical material has repeatedly put patients in danger, and that most often implicated are herbal drugs from Asia.29 Although it is widely perceived that "natural" products are safe, the evidence suggests that its use is not without risk. Of 90 patients with rheumatoid arthritis, 82% had tried more than one form of alternative medicine or therapy, including dietary modification, and 31% of these patients had experienced at least one adverse effect. Of 1701 consecutive patients admitted to the Prince of Wales Hospital, Hong Kong, three (0.2%) had had adverse effects attributed to traditional Chinese medicines and 75 (4.4%) to "Western" medications. A review of 5563 enquiries received by the National Poisons Unit, London, showed that 77.7% involved vitamin preparations and 19.3%, herbal extracts, royal jelly, hormonal products and other natural products. Exposure was linked to adverse effects in 49 (0.9%) of these cases. Adverse effects of herbal medications may be intrinsic or extrinsic. The patient's age, genetic constitution, nutritional state, concomitant diseases and concurrent medication may affect the risk and severity of adverse events, as can consumption of large amounts or a wide variety of herbal preparations, or long-term use.

29

Flor Lacanilao, PhD, Research on medicinal plants, http://www.bahaykuboresearch.net/index.php?module=article&view=47

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Intrinsic effects are those of the herb itself and are characterised, as for pharmaceuticals, as type A (predictable, dose-dependent) and type B (unpredictable, idiosyncratic) reactions. Yohimbine, an alkaloid found in Pausinystalia yohimbe bark that has

2

-adrenoceptor antagonist activity, is taken for male impotence, and can cause hypertension and anxiety in a predictable, dose-related manner (type A reaction); it has also been associated with the serious idiosyncratic reactions of bronchospasm and increased mucus production when taken in normal doses by a patient with severe allergic dermatitis (type B). Type A reactions with herbal preparations also include effects with deliberate overdose or accidental poisoning and interactions with pharmaceuticals. Extrinsic

effects

refer

to

problems

related

to

commercial

manufacture

or

extemporaneous compounding. Potential failures to adhere to a code of Good Manufacturing Practice, while not specific to herbal medicine, can occur, particularly in developing countries where such a code is not in place. This makes it more difficult for medical practitioners and other health professionals to assess the adverse effects of herbal preparations compared with pharmaceuticals. Misidentification: It is essential that plants are referred to by their binomial Latin names for genus and species; misidentification can occur when other names are used. For example, the scientific name of the Chinese herb that is variously transliterated as "dong quai", "dong guai", "danggui" and "tang kuei" is Angelica polymorpha (formerly sinensis). The common English name "angelica" and the latinised name "Radix Angelica" could refer either to this species, which is used in Australia, or to the European species Angelica archangelica, depending on the country of origin. Misidentification can result in erroneous associations being made, with potential clinical implications. Plant material can be misidentified at the time of the manufacturer's bulk purchase or when wild plants are picked. Lack of standardization: The therapeutic/toxic components of plants vary depending on the part of the plant used, stage of ripeness, geographic area where the plant is grown, and storage conditions. Therefore, batch-to-batch reproducibility of plant material should be assessed in the production of marketed products, but, in practice, product variation in herbal medicines can be significant. The content of ginsenoside, the glycosylated steroid to which most of the biological activity of ginseng (Panax ginseng) has been ascribed, was examined in 50 commercial brands

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of ginseng sold in 11 countries. In 44 of these products, the concentration of ginsenoside ranged from 1.9% to 9% w/w; six products contained no ginsenoside, and one of these six contained large amounts of ephedrine (for which a Swedish athlete was accused of doping). Contamination: During growth and storage, crude plant material can become contaminated by pesticide residues, microorganisms, aflatoxins, radioactive substances and heavy metals; lead, cadmium, mercury, arsenic and thallium have been reported as contaminants of some overseas herbal preparations. In a case series of five patients in the United Kingdom with lead poisoning from Asian traditional remedies, the preparations implicated contained 6%-60% w/w lead by weight. The Australian Code of Good Manufacturing Practice specifies detection of microorganisms and leaves estimation of other contaminants (not specified in internationally recognised pharmacopoeial standards) to the discretion of manufacturers. Substitution: A report of nine cases of rapidly progressive interstitial nephritis in young women taking a Belgian slimming treatment led to the discovery that Aristolochia fangchi, containing the nephrotoxic component aristolochic acid, had been introduced in place of Stephania tetrandra. Eighty cases have now been identified and more than half of these patients developed terminal renal failure. Adulteration: The intentional use of pharmaceutical adulterants has been reported. Cases of acute interstitial nephritis, reversible renal failure, loss of blood pressure control and peptic ulceration have been reported with a product called "Tung Shueh" pills, taken for arthritic complaints. The product contained mefenamic acid and diazepam, neither of which was included on the label. Adulterants can also be added by unethical herbalists compounding preparations for individual patients. In a recent Victorian court case, a Chinese herbalist was prosecuted for adding a steroid cream to a herbal preparation, which produced severe facial erythema in a patient. Incorrect preparation/dosage: The processing of crude plant material carried out by a manufacturer, CAM practitioner or the patient is a major determinant of the pharmacological activity of the finished product. A Western Australian patient had a heart attack when he failed to follow a herbalist's instructions to boil aconite (a restricted plant in Australia) in three pints of water for one hour and take the decanted liquid; the patient increased the dose and shortened the boiling time. Boiling changes the alkaloid composition, rapidly reducing the plant's toxicity, and can substantially reduce microorganism contamination.

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Another point to consider is that the activity of crude plant material may differ from that of the purified constituents, as some constituents may modify the toxicity of others. Inappropriate labelling/advertising: In early 1996, a direct-mailing campaign to individuals who had purchased exercise bicycles included information on seaweed (Fucus vesiculosus) patches for weight loss. Seaweed, or kelp, contains iodine, and it was claimed that the patches would reverse hypothyroidism by releasing iodine into the body, speeding up the body's metabolism, resulting in weight loss. This claim was unproven. Hyperthyroidism has been reported in people who take kelp products orally, and if iodine were to be absorbed transdermally it could lead to hyperthyroidism in susceptible individuals. The TGA became aware of the product promptly and secured promise that no further supplies would be imported, but keeping abreast of potentially unsafe products is a mammoth task. 30

CHAPTER III

METHODOLOGY 30

Anna K Drew and Stephen P Myers, Safety issues in herbal medicine: implications for the health professions, The Medical Journal of Australia, http://www.mja.com.au/public/issues/may19/drew/drew.html, 1997

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This is a cross sectional study that documents the different plants prescribed by Folk Herbalists in Pulilan, Bulcan and its relationships to ten medicinal plants endorsed by the Department of Health. The information in this research will be gathered through personal interviews of the traditional medical practitioners, particularly folk herbalists, in Pulilan, Bulacan. Prior to the interview, a standard questionnaire [see Appendix B] will be formulated by the researchers regarding the beliefs and practices of these folk herbalists. Comparison between the data collected and the 10 Medicinal Plants endorsed by the DOH will be done. This would validate that the medicinal plants utilized by the folk herbalists correspond to the approved indication.

Description of the Respondents The folk herbalists residing in Pulilan, Bulacan will be the respondents for this study for they are the ones most knowledgeable of medicinal plants. They are members of the society who prescribe these plants for certain indications. They are the ones who can provide most reliable data which this study would need.

Description of the Study Area Pulilan is a small town in Bulacan composed of nineteen (19) barangays. Although considered as industrially-competitive, Pulilan has no public hospital of its own. People tend to consult the nearest medical clinic, private tertiary hospital or popular folk herbalists. Many Pulilenios believe on the cost effectiveness of herbal medicine because of its availability and efficiency for their ailments. The rich soil in Bulacan contributed not only to the livelihood of the community but also to the growth of certain plants that can be useful in the relief of their undesirable condition. The use of herbal medicine was strengthened by the recommendations of some relatives and most importantly, by some folk herbalists. Some seek folk herbalists due to financial factors and the unavailability of a public hospital that would respond to their need for health assistance. Barangay Health Center are available however, they have very limited supply of drugs and worse, the less fortunate people

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could not afford even the half-priced generic drugs available in the Botika ng Barangay resulting to poor compliance. These people would depend on the folk herbalists who give health service in kind. Pulilan, Bulacan is forty-seven(47) kilometers away from Manila and will take only a 30 to 45 minute-drive which makes it very accessible for the group to perform the study. Also, the proximity and the small land area of Pulilan allow the researchers to abide by the scope and time frame of the study through easy monitoring and follow-up. Moreover, the participation of reliable health workers and officials in the community and the nearby place to stay during the course of the study will assure the safety and security of the group. Demographic Data Pulilan is one of the 24 towns of Bulacan province, located in about its center—from north to South—with an area of about 3,000 hectares. It is bounded on the North by Apalit in Pampanga; on the East by Baliuag; on the South by Plaridel; and on the West by Calumpit. The Angat River cutting its way through the Eastern edge of Baliuag, and the Southern fringes of Pulilan down to the tributary of Manila Bay Southwest of Calumpit, serves as the boundary with Plaridel.

Its

feature

is

flat

and

the

soil

is

suited

to

farming.

The first time Pulilan was settled was unknown but if existing records of the towns of Calumpit and Baliuag, between which the town lies, be made a basis, it could be deduced that in the early part of the 17th century it could have had a sprinkling of settlers. (Calumpit was declared s town in 1575, and Baliuag recently celebrated her 300th anniversary). It is presumed that the settlers spread themselves in far-apart groups along the riverbanks for two reasons: first, water facility secondly, the profound attraction of water to them. The word "Tagalog" in a contraction of "taga-ilog" a name ascribed to this ethnic group of Malays who had the reputation for cleanliness through their profuse use of water. (Bulacan.com.ph)

DATA COLLECTION Data will be gathered by administering a face to face interview guided by a structured interview schedule. All interviews will be recorded using an audio recording device. This is to facilitate follow-up in case on the spot transcriptions become inappropriate.

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It is important to note that there is no official listing of folk herbalists in the municipality of Pulilan, Bulacan. With this, in order to identify and locate the respondents, referrals will be the main means.

Referrals and Endorsements The Health Center is the establishment that provides healthcare to residents, it is composed of doctors, dentists, nurses, midwives, medical technologists, laboratory aides and barangay health workers. Barangay health worker (BHW) refers to a person who has undergone training programs under any accredited government and non-government organization and who voluntarily renders primarily health care services in the community after having been accredited to function as such by the local health board in accordance with the guidelines promulgated by the Department of Health (DOH). They are the ones responsible for monitoring the health situation at the level of barangay. This makes BHWs, barangay health officials and municipal health officials to be most knowledgeable of available alternative healthcare within a barangay and municipality. And so, their referrals and endorsements they will be the main tool to identify the folk herbalist in the community. In order to validate these referrals and endorsements the triangulation method will be imposed.

Triangulation Triangulation will be used as a cross-checking tool to assess the credibility of the respondents. Three criteria will be used to comply with the requirements of triangulation: i.

Endorsement from the Barangay Health Care Office; A referral of the traditional medical practitioners, particularly the folk

herbalists, was obtained from the Barangay Health Care Office. The researchers will be guided by the Health Care Officer (HCO) and a number of BHWs to verify that the people to be interviewed are authentic traditional medical practitioners. Aside from verbal endorsement, the HCO and BHWs will also be asked to quantitatively grade the recommended folk herbalist using a rubric sheet [see Appendix B], which will be facilitated by the researchers.

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ii.

Confirmation by the folk herbalists that they practice the use of medicinal plants; The use of a rubric sheet will also allow the folk herbalists to self-assess.

This will be done in the same manner as to how the HCO and BHWs will accomplish the rubric sheet. iii.

An interview will be conducted by the researchers. The group of researchers will be divided into 5 subgroups. Each subgroup will

be assigned to interview two to three (2-3) folk herbalist. Using a standard questionnaire, the folk herbalists will be asked regarding the different medicinal plants used in their practice. This would include the following: a) indications, b) part of the plant used, c) preparation and d) route of administration. A separate rubric sheet will be answered by the researchers, the grade of which will be based from the consistency of the folk herbalist’s answers. The score of each folk herbalist will be equal to the average of the three corresponding rubric sheets; that from the HCO, the folk herbalist and the researcher. A score of < 75 would indicate unreliability, whereas a score of > 75 indicates reliability and gives credibility to the folk herbalist. DATA COLLECTION TOOL The group developed a standardized interview schedule with Filipino translations. This is to facilitate the interview to be done among folk herbalists. Its format and structure was patterned from a questionnaire from an ethnomedicinal research by Dr. Vendivil. The questions were edited according to the level of understanding of the target population and according to the particular information needed for the study. Generally, the tool is composed of four parts namely namely letter of consent, part A, part B and part C. The letter of consent is geared towards informing the respondent of the interview that will be done. With this, the respondent will be asked to sign a consent form stating that he/she is voluntarily cooperating. Part A includes respondent information, interview information, referral details and preliminary questions to filter the eligibility of the respondent. The respondent information includes details such as age, sex, address, occupation, contact number. These details will be used merely as reference in case follow-up will be made. In data analysis, respondents will be regarded as respondent numbers not by their names, in order to facilitate confidentiality. Part B involves a table comprising of cells for the following information:

24

Plant, part used, preparation, dosage, source and notes. This part will be arranged according to indication. Part C is basically the same as part , but this will be specific for the Sampung Halamang Gamot endorsed by the DOH. Validation and approval of the tool will be sought from certified statisticians. Also the interview schedule will be pre-tested among 3 folk herbalists in manila. This is to foresee probable difficulties which may be encountered during actual data collection. The tool will be adjusted accordingly to the foreseen difficulties from the pre-test and recommendations from authorities. Appropriate orientation, training and familiarization will be done among all data collectors. This is to standardize the approach in an interview and thus minimize bias.

PLANT IDENTIFICATION After administering an interview, plant samples of all the mentioned specimen will be collected. Proper protocol for plant handling and collection will be implemented. Also to facilitate identification and documentation, digital photographs will be used as tool as well.

DATA ANALYSIS The information on the plants and their uses will be utilized to establish pharmacological knowledge in Pulila, Bulacan. Quantitative analysis of the data collected will be used to obtain the following: most cited plants species, plants to which most uses were attributed, different uses, parts of plants used, method of preparation, details of administration and dosage. The indications for the use of the plants will be categorized into 10-20 groups based on the data that will be collected. From this, the Informant Consensus Factor (ICF) will be calculated for each cateorgy of ailments. This will be used to identify agreements of the informants on the reported cures for the groups ailments31,32,3,4. The formula for ICF is as follows: 31

Teklehaymanot, T. & Giday, M. Ethnobotanical study of medicinal plants used by people in Zegie Peninsula, Northwestern Ethiopia. Journal of Ethnobiology and Ethnomedicine 2007,3:12. 32 Akerreta, S., Cavero, R.Y., Calvo, M.I.. First comprehensive contribution to medical ethnobotany of Western Pyrenees. Journal of Ethnobiology and Ethnomedicine 2007,3:26.

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ICF = (nur – nt) / (nur – 1) where nur = number of use citations in each category nt = number of species used The fidelity level (FL) will also be determined as a tool for quantitative analysis. It is the percentage of informants claiming the use of a certain plant for the same major purpose 1. The formula for FL is as follows: FL(%) = (Np / N) x 100 where Np = number of informants that claim a use of a plant species to treat a particular disease N = number of informants that use the plants as a medicine to treat any given disease In addition, a qualitative comparison will be done to determine the differences or similarities in the indication of plants being used by folk herbalists with those included in the “10 Halamang Gamot” endorsed by the Department of Health.

3

Gazzaneo, L.R.S., de Lucena, R.F.P., De Albuquerque, U.P. Knowledge and use of medicinal plants by local specialists in a region of Atlantic Forest in the state of Pernambuco (Northeastern Brazil.) Journal of Ethnobiology and Ethnomedicine 200,1:9. 4 Kisangau, D.P. Lyaruu, H.V.M. Hosea, K.M., Joseph, C.C. Use of traditional medicines in the management of HIV/AIDS opportunistic infections in Tanzania: a case in the Bukoba rural district. Journal of Ethnobiology and Ethnomedicine 2007,3:29.

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