Biodiversity Traditional Knowledge and Community Health - Final

UNU-IAS Policy Report
Biodiversity, Traditional
Knowledge and Community Health:
Strengthening Linkages
Health is not a commodity that is given. It must be generated from within. Health action
should not be imposed from the outside, foreign to the people; it must be a response of the
communities to problems they perceive, supported by an adequate infrastructure. This is
the essence of the fltering inwards process of primary health care.
Dr. Halfdan Mahler, Former Director General of WHO
United National University
Institute of Advanced Studies
6F, International Organizations Center
Pacifco-Yokohama, 1-1-1 Minato Mirai
Nishi-ku, Yokohama 220-8520, Japan
Tel +81 45 221 2300
Fax +81 45 221 2302
Email unuias@ias.unu.edu
URL http://www.ias.unu.edu
printed on Forest Stewardship Council
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Policy Report
Unnikrishnan P.M. and M.S. Suneetha
Collaborators
United Nations Environment Programme (UNEP), Nairobi
Foundation for Revitalisation of Local Health Traditions (FRLHT), Bangalore
ETC-COMPAS, Leusden
United Nations Development Programme-Equator Initiative, New York
Copyright United Nations University and United Nations Environment Programme, 2012
The views expressed in this publication are those of the authors and do not necessarily reflect the views of
the United Nations University or the Institute of Advanced Studies, United Nations Environment Programme,
Foundation for Revitalisation of Local Health Traditions, ETC-COMPAS or the United Nations Development
Programmes Equator Initiative.
United Nations University Institute of Advanced Studies
Pacifico-Yokohama 1-1-1 Minato Mirai
Nishi-ku, Yokohama, 220-8502 Japan
Tel: +81-45-221-2300 Fax: +81-45-221-2302
Email: unuias@ias.unu.edu
URL http://www.ias.unu.edu/
ISBN 978-92-808-4531-0 (pb)
ISBN 978-92-808-4528-0 (eb)
UNU-IAS/2012/No.5
Cover Photo Credit: Shutterstock/Subbotina Anna, Spices and antique Mortar with pestle
Design and Layout: Xpress Print Pte Ltd
Printed by Xpress Print Pte Ltd in Singapore
Printed on Forest Stewardship Council (FSC) certied paper using soy-based ink
Contents
5
Message from the Director .............................................................................................. 6
Acknowledgements ......................................................................................................... 8
Executive Summary .......................................................................................................... 9
List of Abbreviations ...................................................................................................... 10
Box Items ....................................................................................................................... 12
Introduction ................................................................................................................... 13
Biodiversity, Ecosystem and Health.............................................................................. 13
Traditional Knowledge in Health ................................................................................. 14
Health Sector Challenges ............................................................................................ 15
Section I The Policy Context .......................................................................................... 17
Health-Related Development Goals ............................................................................ 21
Millennium Development Goals .................................................................................. 21
Section II A Community Health Approach Synergizing Bio-Resources and
Traditional Knowledge ................................................................................... 24
1. Biological Resources ............................................................................................... 26
2. Knowledge Resources............................................................................................. 34
3. Human Resources ................................................................................................... 39
4. Community Health and Nutrition ........................................................................... 43
5. Equity and Livelihoods ............................................................................................ 50
6. Interculturality, Integration and Institutionalization ................................................. 52
7. Education ............................................................................................................... 56
8. Protection and Right-Based Approaches for Community Knowledge ...................... 58
9. Socio-Cultural Landscapes ...................................................................................... 61
10. Partnerships and Networking ................................................................................ 62
Section III Conclusions .................................................................................................. 65
International Policy Contexts ...................................................................................... 68
Integrated Rapid Assessment Protocols ....................................................................... 68
Potential Strategies ..................................................................................................... 70
Appendix Collaborators .............................................................................................. 73
References ..................................................................................................................... 76
Contents
Message from the Director
6
Two decades have passed since nations of the world assembled in Rio de Janeiro
and agreed to adopt a sustainable development (SD) agenda, promising to chart a
development path that is equitable, environmentally just and economically rewarding.
We now stand at a crossroads looking for the right path towards the world we want.
The prognosis is not encouraging. According to many studies conducted by research
or policy bodies, we seem to have made some progress, but still fall far short of what is
required to sustain current levels of well-being. Negative environmental trends continue
to be exacerbated by human interventionsprimarily led by a model of unsustainable
and conspicuous consumption
The unsustainable conversion of natural capital for supporting this emerging consumer
culture while ignoring the ecological consequences to economies and other aspects of
well-being has become quite entrenched. The extraordinary emphasis on developing
produced capital appears to have overwhelmed all other aspects of natural capital
required for our well-being.
On the positive side, there is expanding awareness and a growing acknowledgement
of this gap in our planning and implementation processes. Increasing resolve to align
production activities with environmental and equity considerations, and efforts aimed
at reforming global institutional structures to create more synergies and effective
implementation of relevant policies are welcome signs of change. Indeed, the eleventh
meeting of the Conference of the Parties to the Convention on Biological Diversity
(CBD-COP11) is seen as an opportunity to streamline various decisions and focus on
implementing them to achieve the different objectives of the Convention, and more
broadly, that are relevant to global goals.
Research and capacity building activities at the United Nations University Institute of
Advanced Studies (UNU-IAS) have examined various aspects related to the rubric of
governance challenges in achieving SDfrom a focus on broad-based development
and well-being at the community level, equity issues related to urbanization and its
implications for environmental resources, to innovations that could aid in achieving
global goals for policy-making for SD. This report analyses the need and potential of
strengthening traditional understanding and practices related to health at the community
levelan area that has not been sufficiently addressed in planning processes. Unlike
mainstream health interventions, this involves a comprehensive assessment of various
contributing factors to health, including biological resources, knowledge and human
resources, socio-cultural resources and related policy processes.
Our broader research indicates that despite the exalted nature of global goals, they
become relevant only when defined and shaped into pragmatic objectives and actions.
This would require cooperative action by all stakeholder groups, implying that future
policy processes need to ensure their relevance at various levels to guarantee successful
implementation. This is no easy task, but by no means an impossible one. Current
accepted standards of practice and business norms must be re-oriented to include a more
consultative policy setting with all major actor representatives. It would require designing
regulations that acknowledge the need for balance among all forms of capital, and
incentives that provide equitable access to resources and services.
7
There are a number of expectations from the outcomes of CBD-COP11, particularly on
how the decisions will be transformed into action and results. UNU-IAS stands ready to
work with its existing and future collaborators to transform our aspirations into reality as
we move forward in translating the sustainability agenda into action.
Govindan Parayil,
Director, UNU-IAS and Vice-Rector, UNU
October 2012
Acknowledgements
8
Acknowledgements
The authors would like to gratefully acknowledge the following people for their valuable
comments, suggestions and support at various stages during the preparation of the
report: Balakrishna Pisupati, G. Hariramamurthi, Padma Venkat, Darshan Shankar, Wim
Hiemstra, Volker Mauerhofer, Sam Johnston, Govindan Parayil, Kathryn Campbell,
Anastasiya Timoshyna, Eileen de Ravin, Makiko Arima and Chiharu Takei. Contributions
from different organizations towards the case studies is gratefully acknowledged.
Executive Summary
9
Healthy ecosystems and biodiversity are sources of various services that nurture life and
enhance human well-being. While the relevance of biodiversity to mainstream health
is clear, as seen in commercial use of biological resources by pharmaceuticals, their
relevance to the health care of people in insufficiently connected and economically
disadvantaged regions of the world can be considered to be much more profound. These
regions are rich in resources (such as medicinal or nutritional and related knowledge), but
they lack in sufficient public health care infrastructure and personnel.
Use of biological resources for health care has been developed in different cultures in
different ecosystems based on available resources and the perceptual and intellectual
acuity of people living therein. Commonly referred to as traditional medicine, it is
practiced both non-formally as local healing traditions by traditional healers/shamans,
and formally through recognized medical systems distinct from their western counterpart.
Despite the differences among these diverse traditional systems, it can be pointed out
that they share a common philosophy to health and healing, defined by their focus on
non-material or non-physical dimensions, and a comprehensive approach to health
that integrates physical, mental, social and ecological factors of well-being. Health in
this approach largely pertains to not just physical healing, but it also involves a mosaic
of practices and resources that relate to mind-body-nature balance, nutrition, lifestyle
practices and livelihoods.
Given the recent attention on universal and improved health care access for all, there
is a renewed interest to strengthen the potential of traditional medicine and health
practitioners to fulfill this role. As the medical armamentarium primarily consists of
biological resources, it is important to also ensure their sustainable use. There are
several initiatives at the macro and local levels that exemplify good practice in achieving
both sustainable use of natural resources for traditional medical purposes, as well as
accessibility for marginal and local communities. However, such good practices are still
restricted to pockets of project activity, and it is time that their relevance in global health
and related policies receives deserved recognition. While replication of similar models
may not be feasible across various socio-cultural contexts, their principles can easily be
modified to suit local realities. The successes bring to the forefront, the areas that need
attention.
Ensuring sustained availability of biological resources and sufficient access to good quality
health care for all members of society is a clear and necessary objective. Sustainability
and equity are closely connected, especially in rural communities of developing countries,
as health care is primarily delivered by native healers or community health workers or
householders using biological resources. Given the low reach of modern doctors and
health care facilities, and the knowledge and experience possessed by knowledgeable
local actors, it becomes imperative to involve the latter more actively in health care
delivery systems. Further, protecting such knowledge from erosion and misappropriation
also needs to be addressed urgently.
There is much that is being attempted successfully on the ground, which indicates that
the above goals are achievable. However, these experiences need to be consolidated and
strengthened further for political feasibility, visibility and momentum.
Executive Summary
List of Abbreviations
10
APCTT Asia Pacific Centre for Transfer of Technology
APTMNET Asia-Pacific Traditional Medicine and Herbal Technology Network
ART Antiretroviral Therapy
ASHA Accredited Social Health Activists
AYUSH Ayurveda, Yoga, Unani, Siddha, Homeopathy
BAU Business as Usual
BD Biological Diversity
BfN German Federal Agency for Nature Conservation
BGCI Botanic Gardens Conservation International
BMZ German Federal Ministry for Economic Cooperation and Development
BPHW Back Pack Health Workers
CAF Chao Phraya Abhaibhubejhr Hospital Foundation
CAM Complementary and Alternative Medicine
CAMP Conservation Assessment and Management Plan
CAPTURED Capacity and Theory Building for Universities and Research Centres in
Endogenous Development
CBD Convention on Biological Diversity
CBO Community-Based Organization
CBSG Conservation Breeding Specialist Group
CIDA Canadian International Development Agency
CITES Convention on International Trade in Endangered Species of Wild Fauna and Flora
CKR Community Knowledge Register
COHAB Co-operation on Health and Biodiversity
COP Conference of the Parties
CSIR Council for Scientific and Industrial Research
CTCT Community to Community Training
DALHT Documentation and Assessment of Local Health Traditions
DANIDA Danish International Development Agency
ECCAP Ethics and Climate Change in Asia and the Pacific
FAO Food and Agriculture Organization
FF Ford Foundation
FRLHT Foundation for Revitalisation of Local Health Traditions
GEF Global Environment Facility
GIFTS Global Initiative for Traditional Systems of Health
GIZ Gesellschaft fr Internationale Zusammenarbeit
GMCL Gram Mooligai Company Limited
GSPC Global Strategy for Plant Conservation
ICH Intangible Cultural Heritage
ICIMOD International Centre for Integrated Mountain Development
ICSU The International Council for Science
IDRC International Development Research Centre
IFAD International Fund for Agricultural Development
IISC-MAP International Standard for Sustainable Wild Collection of Medicinal and
Aromatic Plants
IISD International Institute for Sustainable Development
ILO International Labour Organization
IMO Institute for Marketecology
11
IPC International Patent Classification
ITPGR International Treaty on Plant Genetic Resources for Food and Agriculture
IUCN International Union for Conservation of Nature
JICA Japan International Cooperation Agency
JOICFP Japanese Organization for International Cooperation in Family Planning
LHT Local Health Traditions
MA Millennium Ecosystem Assessment
MDG Millennium Development Goals
MPCA Medicinal Plant Conservation Area
MPCP Medicinal Plant Conservation Park
MPSG Medicinal Plant Specialist Group
MSSM Mount Sinai School of Medicine
NGO Non-Governmental Organization
NRHM National Rural Health Mission
NSSO National Sample Survey Organisation (now National Sample Survey Office)
NTFP Non-Timber Forest Produce
OHCHR Office of the High Commissioner for Human Rights
OTC Over-the-Counter (Drugs)
PHC Primary Health Care/Primary Health Centre
PLWHA People Living with HIV and AIDS
PRA Participatory Rural Appraisal
RITAM Research Initiative on Traditional Antimalarial Methods
SDC Swiss Agency for Development Cooperation
SEARO South-East Asia Regional Office
SHG Self Help Groups
SIPPO Swiss Import Promotion Programme
SSC Species Survival Commission
THP Traditional Health Practitioner
TK Traditional Knowledge
TKDL Traditional Knowledge Digital Library
TKRC Traditional Knowledge Resource Classification
TRM Traditional Medicine
UNCCD United Nations Convention to Combat Desertification
UNCTAD United Nations Conference on Trade and Development
UNDP United Nations Development Programme
UNEP United Nations Environment Programme
UNESCAP United Nations Economic and Social Commission for Asia and the Pacific
UNESCO United Nations Educational, Scientific and Cultural Organization
UNFPII United Nations Permanent Forum on Indigenous Issues
UNHCHR United Nations High Commissioner for Human Rights
UNIDO United Nations Industrial Development Organization
UNSCN United Nations Standing Committee on Nutrition
WHO World Health Organization
WIPO World Intellectual Property Organization
WSSD World Summit on Sustainable Development
WWF World Wildlife Fund (now World Wide Fund for Nature)
Box Items
12
Box Items
1. Medicinal Plant Conservation Areas and Parks (MPCAs, MPCPs), India
2. Conservation Assessment and Management Plan (CAMP), IUCN
3. Medicinal Plant Conservation and Community Health, Lao PDR
4. Sustainable Harvest, Community to Community Training, India
5. Documentation and Participatory Rapid Assessment of Local Health Traditions
(DALHT), India
6. TRAMIL Model, Caribbean Islands
7. Participatory, Observatory Clinical Studies, Switzerland, Mali and Mauritania
8. MPCN Healers Model, India
9. Training of Traditional Health Practitioners, Uganda
10. Reviving Poison Healing, Friends of Lanka, Sri Lanka
11. Reproductive Health and Traditional Birth Practitioners, India
12. Research Initiative on Traditional Antimalarial Methods (RITAM), United Kingdom
13. Haichi System A Community Health Programme, Japan
14. Home Herbal Gardens, India
15. Food and Health, Okinawa, Japan
16. Back Pack Health Workers Training for Refugee Health, Thailand and Myanmar
17. Iron Deficiency Anaemia, India
18. Medicated Water A Preventive Strategy for Waterborne Diseases, Kerala, India
19. People Living with HIV/AIDS (PLWHA), South Africa and Uganda
20. Community Enterprise Village Herbs (Gram Mooligai Company), India
21. Community Enterprise Ampika, United Kingdom and Peru
22. Community Enterprise Jambi Kiwa, Ecuador
23. Community Enterprise ICIMOD, Nepal, Bhutan and Bangladesh
24. Intercultural Hospital, Chile
25. Mainstreaming Traditional Medicine into Official Primary Health Care, India
26. Chao Phraya Abhaibhubejhr Hospital Foundation (CAF), Thailand
27. Capacity and Theory Building for Universities and Research Centres on Endogenous
Development (CAPTURED), Ghana, Bolivia and India
28. Traditional Knowledge Digital Library (TKDL), India
29. Community Registers and Protocols
30. Oxlajuj Ajpop, Guatemala
Introduction
13
Introduction
Even a narrowly focused emphasis on the utility of biological resources and ecosystems
to human beings illustrates the multiple benefits we derive from them related to our
well-beingfrom basic needs such as food, medicine, shelter and fibre to cultural and
aesthetic values through sacred sites and ecological landscapes (Millennium Ecosystem
Assessment, 2005). Their contribution to meet our health care needs continues to be
singularly significant both in terms of modern pharmaceuticals (Chivian and Bernstein,
2008; Newman and Cragg, 2007) and in terms of use in traditional medicine (WHO,
2005). This is in addition to the fact that healthy ecosystems foster healthy populations
due to better sanitation, availability of health and nutritional resources, and presence
of natural agents for prevention or management of diseases. For all the complexities
in organisms and factors that cause illness, nature also has a rich repertoire of defense
mechanisms that need to be discovered through systematic inquiry.
Traditionally, biological resources have been used extensively for health care and healing
practices. Ethnobiographical accounts narrate their widespread and informed use among
various populations and cultures. Knowledge related to their use is specific, and usually
depends on a complex understanding of the resource base, the human body, nature
naturehuman interactions and cultural mores within an inherent epistemological
and ontological premise. The foundations or principles of such knowledge are usually
passed over generations and broadly defined within the common refrain of traditional
knowledge related to health.
In local communities, health practitioners trained in traditional and non-formal systems of
medicine play a crucial role linking knowledge on characterization of biological resources
and health-related knowledge to provide affordable health care in their contexts. Further
up, there are several formally recognized practitioners of traditional medical systems,
also known as Complementary and Alternative Medicine (CAM) practitioners, formally
trained in different systems of medicine such as Ayurveda, Traditional Chinese Medicine,
Kampo, Siddha, Tibetan, Unani and so on. Such systems have been institutionalized and
integrated into health systems in respective regions or countries, and the production
systems of medicinal products are becoming increasingly standardized. It is estimated that
the worldwide annual market value of herbal medicine is around USD 60 billion (Tilburt
and Kaptchuk, 2008), with industrial estimates that the value would rise to USD 90
billion by 2015 (Global Industry Analysts, 2012), riding on a wave of increased demand
fuelled by factors such as cost efficacy and higher perceptions of safety. In countries like
India a large percentage of medicinal plants are collected from the wild leading to an
increasing pressure on natural resources on account of the growing demand of natural
products (FRLHT, 1999; 2009).
Biodiversity, Ecosystem and Health
Decision X/20 of the tenth meeting of the Conference of the Parties to the Convention
on Biological Diversity (COP CBD) affirms the need to identify and strengthen priorities
on biodiversity and health between relevant institutions such as the World Health
Organization (WHO), the CBD, other international organizations and pertinent national
Introduction
14
agencies dealing respectively with public health and environmental resources.
1
This stems
from the logic that ecosystems and biological resources play a central role in ensuring
the health and well-being of humans. The roles extend not just to the health of human
populations but to the health of other life forms on which we depend. While we will
not dwell on the interconnectedness of various life forms here, the pertinent point is
that ecosystems and biological resources provide us with essential materials for medicine,
nutrition, and aesthetic and spiritual satisfaction. Apart from the natural resources, bio
geocultural diversity has fostered the creation of vast knowledge systems especially
highly developed in relation to health.
Traditional Knowledge in Health
Traditional medical knowledge spans various dimensions relating to medicines, food
and nutrition, rituals, daily routines and customs. Traditional knowledge on health can
range from home level understanding of nutrition, management of simple ailments
and reproductive health practices to treatment of serious chronic illnesses or addressing
public health requirements. Interlinkages to geography, community, worldviews,
biodiversity and ecosystems make traditional health practices diverse and unique. Thus,
while it might be entirely plausible that communities in similar ecosystems with similar
geographical characteristics use similar medicines, there are bound to be differences in
the process of preparation and delivery of the medicine and socio-cultural connotations
to the understanding and management of a disease. An illustrative example is the use of
different species of the Aristolochia plant across diverse communities around the world,
for treating poisonous bites, its usage embedded in a shared myth (Payyappallimana,
2009). It is important to note that such knowledge is not restricted to any particular
period in time, and constantly undergoes revaluation in the local contexts. Local
pharmacopoeia have also been developed over a long period of humanbiodiversity
interactions and are unique in terms of compatibility to local contexts, easy accessibility
of resources and hence, cost efficacy.
Although there may be variations in the modes of knowledge production and diffusion
among communities prescribing to different worldviews, there are numerous parallels
in their value systems (Suneetha, 2008). A philosophical underpinning across such wide
knowledge systems is their shared worldview of an inherent relationship and sharing
of key elements between the macro and microcosmsthe outside world and a living
being. These systems are also defined by their focus on non-material or non-physical
dimensions, and a comprehensive approach to health, keeping in mind physical,
mental, social, emotional, spiritual and ecological factors of well-being. The presence
of the knowledge in popular and public domain facilitates informed self-help and
preventative health practices, and provides a social character and spiritual dimension and
comprehensive concepts of health and illness than exists in Western medicine (Van der
Geest et al., 1997).
Parallel to these are the allopathic or modern medicine practitioners who rely
predominantly on medicines developed by pharmaceutical companies, who in turn still
primarily look to natural products, and in several instances to traditional use of natural
1
Convention on Biological Diversity (CBD), 2010. Decision X/20 Cooperation with other conventions and
international organizations and initiatives. [online] Montreal: CBD. Available at: <http://www.cbd.int/
decision/cop/?id=12286> [Accessed 20 July 2011].
Introduction
15
products, for drug development. Examples would include some of the major common
drugs directly derived from or modeled after natural compounds such as aspirin, quinine,
taxol, digitalis, artemisinin, vincristine, vinblastine, etc. (Herndon and Butler, 2010). As the
famous study by Farnsworth et al. (1985) highlighted, 74 per cent of the 119 compounds
derived from higher plants used in biomedicine around the world have the same or
related use as in folk knowledge. Thus, the links with biological resources, related
traditional knowledge and ecosystems at every level and system of health care delivery
are tenacious.
Health Sector Challenges
The global health sector increasingly faces a complex dilemma of enormous advances
in welfare in parts of the globe, and high scarcity of resources in other regions. As
the World Health Organization reminds us, one-third of the global population in least
economically developed and transition economies still do not have access to essential
modern health care (Bodeker et al., 2005). While there has been some increase in
funding through private channels, inadequate financing by governments continues to
be a limiting factor to access material and human resources for health care services.
Heavy burden of communicable diseases (such as HIV, malaria, tuberculosis, pneumonia,
diarrheal diseases), coupled with chronic diseases (such as diabetes, ischemic heart
diseases), persistently affect lives in these regions. Indomitable challenges such as
high maternal and child mortality and emerging and re-emerging diseases (infectious,
chronic, and lifestyle-related), are typical constraints to welfare brought on by factors
that are social (rapid demographic changes and urbanization), institutional (increasing
privatization and health costs,
2
vertical and centralized programmes without adequate
attention to the local context, under-utilization of public health care, migration of
medical professionals), and biophysical in nature (environmental changes and related
epidemics) (Nambiar et al., 2007). Conversely, developed countries face health challenges
from changing demographic patterns, like ageing population, increase in chronic and
lifestyle-related diseases, low fertility, increasing fiscal burden on account of welfare
programmes, high-technology-dependent diagnosis and care, and escalating health care
costs.
The high-technology-based, urban-centred, curative medicine has penetrated across
nations as the universal model of health care (Magnussen et al., 2004). In such a system
health planners are confounded with multiple challenges of integrating preventive
and promotive health with curative medicine. Due to these complex and continuing
challenges, principles of universal access based on contextual needs with stress on
preventive and promotive health, through participatory, self-reliant intersectoral
collaboration in health planning have become an unrealized ideal. This again highlights
the need to refocus on self-reliant models of health care delivery.
It has become quite clichd to say that biodiversity rich regions in the south suffer
the most from inequities in availability, accessibility and affordability of health care
(Millennium Ecosystem Assessment, 2005c). With growing alienation of communities
from the natural environment (Roe, 2010) due to various factors, a concomitant erosion
of cultural systems including health practices and resource base occurs resulting in a
2
For example, in countries like India, expenditure for health among rural families is one of the major
causes leading to poverty (see Reddy et al., 2011).
Introduction
16
situation where even while relevant knowledge exists, its practice is poor. Such erosion
of practices is further accentuated by an education system that fails to recognize the
relevance of these practices or inherent methods, thereby distancing younger generations
from exploring such areas (Battiste, 2010). This implies that it is often not for the lack of
efficacy that traditional knowledge (TK) is discarded but due to lack of adequate socio-
political support. There is clearly a strategic social importance of such ethno-medical
traditions as the most low cost, accessible and safe health option for ensuring health
security to millions of rural households. These TK-based traditions are critical to support
in the light of the failure of mainstream medicine to deliver primary health care. Similarly,
the role of traditional health practitioners in the community health context is understood
as filling a lacuna in modern health care access. It has to be recognized that in most
societies they do play a critical complementary role in parallel to the professionalized
health system, an aspect which needs to be better appreciated. This calls for a multi-
pronged approach where various resources need to converge, including those related
to local health traditions. Experiences of the last two decades show that there is high
relevance in aligning biodiversity conservation goals with a community health approach
(Miththapala, 2006).
Currently, traditional knowledge based health practices are promoted either by the
state, which predominantly focuses on health care delivery; by civil society organizations,
whose focus primarily relates to conservation and health; or the private sector through
production and marketing of medicines, supplements and health care services. Concerted
policy attention on various nodes that provide health resources, various practices
and governance measures remains insufficient. While there are several reports that
independently highlight issues relating to biological resource use or traditional medicine
(as for instance, WHO and IUCN reports); studies that comprehensively address concerns
related to conservation, sustainable use and equity related to biological resources;
together with issues related to equitable access to effective health care and nutrition,
and human and bio-cultural resources required thereof to achieve development goals
at the local level of governance are few (Roe, 2010). Most studies focus on biodiversity
resources and health linkages in the context of modern pharmaceuticals with only a few
from a community health perspective. This report seeks to summarize and highlight the
depth of health and biodiversity linkages in a community context of planning towards
various development objectives.
The report is organized as follows: Section 1 elaborates the policy context of community
health, environment and development. In Section 2, challenges related to biological
resource use, traditional knowledge and local level health delivery systems are
highlighted, along with case studies on how these issues may be addressed effectively.
Section 3 concludes with some suggested action plans and policy directions that will help
synergize efforts to achieve related policy goals.
Section I The Policy Context
17
In the broadest sense, the utilities we derive from biological resources include among
others food, shelter, fuel, health, livelihoods, and cultural and aesthetic satisfaction. These
aspects of well-being, in fact, are subsumed in the broader definition of health which is
a state of complete physical, mental and social well-being and not merely the absence
of disease or infirmity.
3
In most traditional health cultures, health equates physical, mental, social, spiritual
and ecological balance. According to the traditional Ayurveda system of medicine, the
being is a miniature representation of the universe; and, equilibrium in humannature
relationship is critical for health and well-being (Sushruta Samhita).
4
Health is considered
as an interactive outcome of personal attributes, habitual experiences and interaction
with the environment, whereas well-being can relate to multiple factors such as material
comfort, health, freedom of choice and action, social support systems and security
(Payyappallimana, 2010).
The relationship of health with regard to development is well articulated by the WHO,
which states as follows:
Health is both a resource for, as well as an outcome of, sustainable development.
The goals of sustainable development cannot be achieved when there is a high
prevalence of debilitating illness and poverty, and the health of a population
cannot be maintained without a responsive health system and a healthy
environment. Environmental degradation, mismanagement of natural resources,
and unhealthy consumption patterns and lifestyles impact health. Ill-health, in
turn, hampers poverty alleviation and economic development.
5
Ensuring access to good quality health carewhether physical or economical has been
a major challenge to planners and policymakers. This has been the case since the 1970s,
when the Alma Ata declaration (1978) mandated Health for All by the year 2000
and further called for an integration of traditional health practitioners and traditional
medical knowledge in public health policies to the more recent Millennium Development
Goals (MDGs) (2000), where three of the eight goals pertain to health. A quick transect
through the different policies relevant to traditional knowledge, biodiversity and health
gives us clues to the wide range of sectoral interests.
The rights of indigenous peoples to their customary practices were first recognized by the
International Labour Organization (ILO) Convention in 1957. With the Earth Summit and
the adoption of the Convention on Biological Diversity at Rio de Janeiro in 1992, political
recognition of the relevance of traditional knowledge and practices came about. Principle
22 of the Rio Declaration on Environment and Development calls for a recognition of
and a respect for the knowledge and practices of local and indigenous communities in
environmental management towards achievement of sustainable development. Agenda
3
Preamble to the Constitution of the World Health Organization as adopted by the International Health
Conference, New York, 19 June to 22 July 1946.
4
Sushruta Samhita, 1975. Delhi: Motilal Banaras Dass Publishers, 62.
5
WHO, undated. World Summit on Sustainable Development. [online] Available at <www.who.int/wssd/
en/> [Accessed 24 September 2012].
18
21 further specifies a need for appropriate integration of traditional knowledge and
experience in national health systems, and to conduct research in traditional knowledge
related to preventive and curative health practices (Chapter 6 of Social & Economic
Dimensions Protecting & Promoting Human Health).
6
More recently, this was affirmed
by international conventions, declarations and positions (see Table 1 for a list of pertinent
policy instruments).
Table 1: Multilateral Instruments of Relevance to Traditional Knowledge
Policy Position
Indigenous People and Human Rights, Self-Determination
1 Indigenous and Tribal Peoples
Convention (ILO) 1957
States that due account shall be taken of the cultural and
religious values and of the forms of social control existing among
indigenous populations.
2 The International Covenant on
Economic, Social and Cultural
Rights (OHCHR) 1966
Protects rights of individuals and peoples to self-determination
and means of subsistence.
3 Indigenous and Tribal Peoples
Convention (ILO) revised in
1989
Calls for rights of indigenous peoples to be actively involved in
decisions related to their development and their right to continue
with their ways of life and choose their priorities.
4 UN Declaration on Rights of
Indigenous Peoples (UNPFII)
2006
Declares right to self-determination, and to determine access to
their cultures, resources and knowledge.
Biodiversity, Traditional Knowledge and Communities
5 Conventi on on Bi ol ogi cal
Diversity (CBD) 1992
Calls for the need to respect, preserve and maintain traditional
cultures and encourage customary use of biological resources in
line with principles of sustainable use and conservation; need to
ensure equitable sharing of benefits among TK holders; and the
need to obtain prior informed consent of providing parties to
access biological resources and related knowledge on mutually
agreed terms between the parties.
COP10/Decision 20 affirms the need to identify and strengthen
priorities on biodiversity and health between relevant institutions
and national agencies dealing respectively with public health and
environmental resources.
Sets forth the Aichi Biodiversity targets related to the Strategic
Plan of the Convention on Biological Diversity 20112020 (Target
14 specifically mentions health and biodiversity linkages; several
other targets relate to allied fields for good health including
ecosystem resilience, genetic diversity, etc.).
Includes community protocols as part of international regime on
access and benefit-sharing (ABS) especially relating to community
rights to resources, knowledge and practices.
6 UN Convention to Combat
Desertification (UNCCD) 1994
Encourages the use and protection of TK related to ecological
developmentsubject to their respective national legislation
and/or policies, exchange information on local and traditional
knowledge, ensuring adequate protection for it and providing
appropriate return from the benefits derived from it, on an
equitable basis and on mutually agreed terms, to the local
populations concerned.
6
United Nations, 1993. Agenda 21: Earth Summit The United Nations Programme of Action from Rio.
New York: United Nations publications.
19
Policy Position
7 International Treaty on Plant
Genetic Resources (ITPGR), FAO
2001
Affirms farmers rights and TK which allows for benefit-sharing
and participatory decision making on use of plant genetic
resources.
Traditional Knowledge and Development
8 United Nations Educational,
Sci ent i f i c and Cul t ur al
Organization - International
Council for Science (UNESCO-
ICSU) Declaration on Science
and the use of Traditional
Knowledge 2002
Calls for co-existence of knowledge systems and suitable
integration for contemporary needs.
9 World Summit on Sustainable
Development (WSSD) 2002
Plan of Implementation: Calls for sensitive framing of policy
actions incorporating traditional knowledge in various sectors,
and accounting for poverty, health and environment linkages. In
the specific context of Health and Sustainable Development, the
Plan seeks to Promote the preservation, development and use
of effective traditional medicine knowledge and practices, where
appropriate, in combination with modern medicine, recognizing
indigenous and local communities as custodians of traditional
knowledge and practices, while promoting effective protection
of traditional knowledge, as appropriate, consistent with
international law (53(h) of Plan of Implementation of the WSSD).
Health
10 World Health Organization
(WHO) Traditional Medicine
Strategy 1978, 1995, 2002,
20022005, 2008
Calls for integration of traditional medicine in health systems,
national regulation focused on quality, safety, efficacy, access and
rational use.
11 Food and Agr i cul t ur e
Organization / WHO (FAO/
WHO) Food-Based Dietary
Guidelines
FAO/WHO Food-Based Dietary Guidelines (FBDG) provide
a framework following a preventive lifestyle approach calls
for culturally sensitive action taking into consideration the
traditional food practices, customs, cooking practices etc., and
with awareness of the needs of the target groups within these
populations.
12 Uni ted Nati ons Standi ng
Commi ttee on Nutri ti on
(UNSCN)
States the role of traditional knowledge related to food in
maintaining nutrition and health.
Protection of Traditional Knowledge, Cultural Resources
13 World Intellectual Property
Organization (WIPO)
Provides sui generis models for protection of traditional cultural
expressions, traditional knowledge and folklore.
14 UNESCO Convention for the
Safeguarding of Intangible
Cultural Heritage (ICH) 2003
Protects oral expressions, performing arts, social practices and
rituals, knowledge and practices concerning nature and universe
and traditional craftsmanship.
15 UNESCO Conventi on on
Protection and Promotion
of the Diversity of Cultural
Expressions 2005
Reaffirms the importance of the link between culture and
development.
Ecosystems and Well-being
16 Off i ce of t he Hi gher
Commission for Human Rights
(UNHCHR) 2000
Affirms right to highest attainable standard of health States
have obligation to refrain from prohibiting or impeding
traditional preventive care, healing practices and medicines.
17 United Nations Environment
Programme - International
I nsti tute for Sustai nabl e
Development (UNEP-IISD) 2004
Identified ability to use traditional medicine as one of 10 resources
of well-being.
20
Hence, over time, two areas where the contemporary relevance of traditional knowledge
has been fairly well-acknowledged include the management of the environment and
natural resources, and the delivery of health care.
Firstly, research related to governance and management of the environment has been
conducted across research institutes, academia and international agencies resulting in a
large body of evidence on traditional wisdom in this and related spheres of activity (see
for instance Farnsworth et al., 1985; Miththapala, 2006; Bodeker, 2007; 2008; Berkes,
2008; Belair et al., 2010).
Secondly, over the past three decades, the WHO has produced several policy documents
on development and promotion of traditional medicine (TRM) relating to regulation;
guidelines on quality, efficacy, safety, rational use; research and clinical trial guidelines;
good manufacturing practices; training of traditional health practitioners; conservation
of natural resources, sustainable use; good agricultural practices; intellectual property
protection; specific role in HIV/AIDS; standardization and classification of concepts and
terminologies; consumer awareness and other areas.
Various WHO regional offices have developed specific guidelines based on regional priorities
and needs. For example, the first atlas of TRM outlining the status of these policies in various
member states was published by WHO Kobe Centre in 2005. The WHO has 19 collaborating
centres on traditional medicine for furthering development of the sector.
Increasingly, the vital role of traditional medicine and conservation of related resources
and ecosystems in achieving better human health and well-being needs is being
articulated in institutional reports and activities guiding policy setting. Article 34 of the
United Nations Committee on Economic, Social and Cultural Rights resolution of 2000,
which dwells on the right to the highest attainable standard of health, urges states []
to refrain from prohibiting or impeding traditional preventive care, healing practices and
medicines. A conceptual framework on poverty and well-being, defined in a United
Nations Environment Programme (UNEP) and International Institute for Sustainable
Development (IISD) report, considers the ability to use traditional medicine and continue
using natural elements found in ecosystems for traditional cultural and spiritual practices
as two of the ten resources of well-being (UNEP and IISD, 2004).
The Convention on International Trade in Endangered Species of Flora and Fauna
(CITES) has promoted sustainable use of natural resources by monitoring trade of
endangered species of flora and fauna. The Food and Agriculture Organization of the
United Nations (FAO) has developed many policy resources on non-timber forest produce
including medicinal plants. The UN Conference on Trade and Development (UNCTAD)
promotes protection of traditional knowledge and trade and development opportunities
using medicinal resources through initiatives such as the Biotrade. The UN Industrial
Development Organization (UNIDO) has been recommending support for industrial use
of medicinal plants, improved technologies for standardization, and building capacities of
member countries. The UN Economic and Social Commission for Asia Pacific (UNESCAP)
has created a web-based hub for buyers and sellers of herbal technology through its
Asia Pacific Center for Technology Transfer (APCTT). The World Intellectual Property
Organization (WIPO) has supported initiatives for IPR protection of traditional medical
knowledge. Other international organizations such as The Commonwealth Secretariat,
21
European Union, World Bank and World Trade Organization also have programmes on
specific aspects in traditional medicine. Similarly, non-governmental bodies such as the
Ford Foundation, World Wide Fund for Nature (WWF), IUCN, TRAFFIC and several others
have been assisting initiatives related to TRM (WHO, 2002).
Health-Related Development Goals
Despite the multiplicity of policies, goals and targets with regard to health, environment
and development, we are still far from achieving their objectives, chiefly because health
development focuses more on biomedicine than on broader determinants and inter-sectoral
linkages to health. The mainstream system therefore, inadequately recognizes pluralistic
approaches. However, with diversity of choice becoming more important, and with academics
and the public increasingly concurring that any single system of knowledge cannot solve
the mounting problems of humanity (Rai et al., 2010), broad goals and indicators for
development are often criticized for their universal approach. Assessing the failures of
Alma Ata proposal for health for all, researchers opine that marginalization by member
states, unprecedented health issues like HIV/AIDS and shifting of health priorities towards
the Millennium Development Goals (MDGs) are key reasons for the lack of attention to
primary health care (Anonymous, 2008). In the following section we look at the potential of
integrating traditional knowledge related to health within the light of MDG goals.
Millennium Development Goals
Three of the MDGs focus on health and others have indirect links.
7
Despite the challenges
in achieving the goals (United Nations, 2011), it is noteworthy that in the last few years, all
policies related to development, environment or health have striven to demonstrate their
alignment in achieving the MDGs. The MDGs do give more weight to achieving health
objectives, as they relate closely to various development-related parameters. The MDG
indicators, while representing a least common denominator to achieve broader targets
and goals, stop short of capturing wider impacts and synergies that may be capitalized to
achieve the targets. For instance, by overlooking the role of the informal sectors in any of
the indicators, the goals draw a blind over much of the horizontal planning processes that
occur in the delivery of various services to well-being, including health (Anonymous, 2010).
Thus, while the indicator on managing HIV/AIDS captures access to antiretrovirals, they do
not integrate it with the means to enhance immunity through food, nutrition, or measures
to address social stigma. Whereas they may be considered relevant to some other goals,
attempts to draw linked solutions are not visible. Reorienting the indicators to capture
such complexities might enable a better implementation process. Researchers concur that
a primary health care (PHC) approach and the goal of universal health access are essential
to achieve MDGs and this should be through appropriate, acceptable and affordable
health care (Walley et al., 2008). In line with the key tenets of a primary health care (PHC)
approach, this also calls for promoting community and individual self-reliance through a
participatory approach and making appropriate use of local resources.
In the table below, we highlight the specific goals and targets that pertain to health
related MDGs with remarks on their relevance to community-based approaches using
traditional medicine and biological resources to achieve health security and development
7
Reduce child mortality by two-thirds by 2015 (Goal 4); reduce maternal mortality by 75 per cent (Goal 5)
and tackle HIV/AIDS, malaria and tuberculosis (Goal 6).
22
aims. Here, we outline potential areas of engagement of traditional medicine or
community resource governance mechanisms with relevant targets of each of the goals,
and relate the same to the Aichi targets of the Convention on Biological Diversity (CBD).
Though preliminary, we believe that such areas of engagement based on sustainable use
of natural resources, improving health, nutrition and livelihoods will have a positive effect
on the welfare of local communities. In the next section, we further elaborate on the
specific components of linkages using case studies of community-based good practices
from various regions.
89
Table 2: MDGs and Aichi Targets Linkages and Potential Areas of Engagement
with Traditional Medicine, Nutrition and Governance
Goal Relevant Targets Potential Areas of
Engagement
Aichi Targets of the CBD and
Community Health
8
Goal 1:
Eradicate
poverty and
hunger
Target 1.C
(Reduce hunger)
Improving access to nutrition
through promotion of
traditional foods and products,
creating awareness and use of
seasonal foods, preservation
and processing methods
Preservation of diversity of
knowledge and conservation
of resources that could lead
to development of traditional
food based dietary guidelines
Promotion of knowledge,
resources and activities
relevant to adaptation and
enhanced resilience to
environmental changes
T1, 2, 4, 13, 18,19 (Awareness
of values of biodiversity, poverty
reduction strategies, sustainable
production and consumption,
genetic diversity, local traditional
knowledge, increase knowledge,
S&T)
T4, 6, 7, 8, 13,18 (Sustainable
production and consumption,
sustainable harvesting, sustainable
management, pollution reduction,
genetic diversity, local traditional
knowledge)
T1, 7, 8, 9, 10, 12, 13, 15,
18, 19 (Awareness of values
of biodiversity, sustainable
management, reduce pollution,
invasive alien species, vulnerable
ecosystems, prevention of
extinctions, genetic diversity,
ecosystem resilience, local
traditional knowledge, increase
knowledge, S&T)
Goal 4: Reduce
child mortality
Target 4.A
(Reduce under-five
mortality rate)
Promotion of antenatal, post
natal and maternal care related
cultural practices of positive
value
Capacity building for better
birth-related practices
9
T1, 14, 18, 19 (Awareness of
values of biodiversity, ecosystem
services, local traditional
knowledge, increase knowledge,
S&T)
8
Aichi biodiversity targets of the Convention on Biological Diversity: T1 (awareness of values of
biodiversity), T2 (poverty reduction strategies), T3 (reduction of negative subsidies), T4 (sustainable
production and consumption), T5 (reduction in habitat loss), T6 (sustainable harvesting), T7 (sustainable
management), T8 (reduction in pollution), T9 (invasive alien species), T10 (vulnerable ecosystems), T11
(protected areas), T12 (prevention of extinctions), T13 (genetic diversity), T14 (ecosystem services), T15
(ecosystem resilience), T16 (Nagoya Protocol), T17 (Adoption and implementation of NBSAPs), T18 (local/
traditional knowledge), T19 (increase knowledge, S&T), T20 (increase financial resources). For more
information, please see https://www.cbd.int/sp/targets/ .
9
Studies indicate that around 60 per cent of deliveries are carried out solely by traditional birth attendants
in the developing world (Kruske and Barclay, 2004).
23
Goal Relevant Targets Potential Areas of
Engagement
Aichi Targets of the CBD and
Community Health
Goal 5: Improve
maternal health
Target 5.A
(Reduce maternal
mortality ratio)
Target 5.B
(Universal access
to reproductive
health)
Assessment of local knowledge
related to contraception,
maternal health care and
improvement of reproductive
health practices and promotion
of positive practices
Improvement of professional
skills of traditional birth
attendants
Integration of trained and
skilled professionals in
traditional medicine for
obstetric care for antenatal
care coverage
T12, 14, 18, 19 (Prevention in
extinctions, ecosystem services,
local traditional knowledge,
increase knowledge, S&T)
Goal 6: Combat
HIV/AIDS,
malaria and
other diseases
Target 6.A (Halt
and reverse the
spread of HIV/AIDS)
Target 6.B
(Universal access
to treatment for
HIV/AIDS)
Target 6.C
(Halt and begin
to reverse the
incidence of
malaria and other
major diseases by
2015)
Examination and promotion
of the role of traditional
knowledge and practices in
malaria prophylaxis
Exploration of traditional
medicine-based drug
development
Integration of traditional
health professionals in HIV care
Exploration of development
of traditional medicine-based
comprehensive programmes
on other infectious diseases
T5, 7, 8, 13, 14, 15, 18, 19,
20 (Reduction in habitat loss,
sustainable management,
pollution reduction, genetic
diversity, ecosystem services,
knowledge, S&T, increase in
financial resources)
Goal 7: Ensure
environmental
sustainability
Target 7.A
(Reduce
biodiversity loss,
achieving by
2010 a significant
reduction in the
rate of loss)
Target 7.C
(Reduce
proportion of
people without
sustainable access
to safe drinking
water and basic
sanitation)
Encouragement of community
level good practices
on sustainable use and
management of medicinal,
nutritional and cultural
resources
Identification and
strengthening of traditional
knowledge-based practices for
safe drinking water
T3, 4, 5, 6, 7, 8, 9, 14, 15, 18, 19
(Reduction in negative subsidies,
sustainable production and
consumption, reduction in habitat
loss, sustainable harvesting,
sustainable management,
pollution reduction, invasive
alien species, ecosystem services,
knowledge, S&T)
Goal 8: Develop
a global
partnership for
development
Target 8.A
(Develop trading
and financial
system)
Target 8.E
(Enhance co
operation for
access to essential
drugs)
Improvement in access to
safe and effective traditional
medicines
Encouragement of fair and
equitable standards for
commercial presence in global
markets
T19, 20 (Increase knowledge, S&T,
increase in financial resources)
Section II A Community Health Approach Synergizing Bio-Resources and Traditional Knowledge
24
Section II A Community Health Approach Synergizing Bio-
Resources and Traditional Knowledge
Implementation of policies for public health in a bio-culturally diverse context confronts
various challenges, ranging from physical resource availability to peculiarities of socio-
political and cultural contexts. This therefore calls for diversified approaches in their
formulation that are sensitive to local priorities and contexts. In the case of health,
studies have shown that a pluralistic approach of intervention integrating traditional
resources and medical knowledge enables better health outcomes (Dummer and Cook,
2008).
There are several non-government organizations and other self-regulated associations
advocating community-based health and conservation strategies integrating traditional
medical resources. Their experience demonstrates a clear need for a comprehensive
assessment of local needs, available resources (knowledge, natural, socio-cultural,
economic and human) and contexts, including community worldviews, reasoning
methods, values and norms. However, such an approach has hardly been integrated
into the national health plans or institutionalized as a development practice. This section
focuses on the various elements that need to be promoted to contribute effectively
to this approach, using case studies of good practices from various regions. These
assessments do not represent a homogenous methodology. It is hoped that inferences
from the case studies will enable a better understanding of context-specific development
plans. The case studies are organized under categories such as biological resources,
knowledge resources, human resources, community health, equity and livelihoods,
education, institutionalization, integration with health programmes, protection of
knowledge, socio-cultural landscapes, and partnership and networking.
25
Palmyra Manuscript
(Photos: FRLHT)
A traditional medicine box
A traditional health practitioner in Chile
26
1. Biological Resources
It has been well-documented that we use highly diverse biological resources for health
and nutritional purposes across and within countries and ecosystems. Estimates suggest
that globally between 50,000 and 70,000 species of medicinal plants are used in
traditional and modern medicinal systems (Schippmann et al., 2006), of which about
3,000 are traded internationally (Lange and Schippmann, 1997). There is also high
use of fauna and their products in traditional medicine, assessments on whose use are
sparse. Due to over harvesting and habitat loss, approximately 15,000 species (or 21 per
cent), of the global medicinal plant species are endangered (Schippmann et al., 2006).
However, there is still no systematic country-wide comprehensive documentation of such
information. The advantages of actively promoting the use of such resources relate to
their affordability, accessibility and cultural acceptability. Factors such as indiscriminate
use of the resources, and changes to habitats due to natural factors or destructive
practices can endanger them and their ecosystems, thereby affecting such local initiatives.
Resources are also being increasingly sourced for modern medicinal products as well as
health supplements. A large percentage of medicinal plants are collected either from
forests or buffer areas. It is estimated that the wild collection ranges from 80 per cent
in countries like China where there is higher focus on cultivation, to near total wild
collection in countries like South Africa where 99 per cent of the 500 traded plants are
sourced from the wild (Hamilton, 2004).
Medicinal plant conservation received policy attention following the Chiang Mai
conference in 1988 with the slogan Saving Plants Saving Lives, which asserted a
primary health care approach in tandem with conservation and sustainable development
goals. This also brought to the forefront the role of international organizations in
supporting national level conservation programmes for medicinal plants. Subsequently, in
1993 the WHO along with the International Union for Conservation of Nature (IUCN) and
World Wide Fund for Nature (WWF) published guidelines for conservation of medicinal
plants which was later revised in 2003 (WHO, 1993; 2003), following a consultative
process with more civil society groups and the private sector.
10
Various threat categories
for medicinal plants, viz. extinct, endangered, vulnerable, rare, indeterminate, and
insufficiently-known, have been developed. This has been further complemented by the
WHO guidelines on good agricultural and collection practices to ensure quality, safety of
medicinal products and ecologically-sound agricultural practices. However, attention to
resources such as fauna or minerals and metals has been fragmented. In the last three
decades, several international organizations and programmes such as UNDP, Global
Environment Facility (GEF), IUCN, Botanic Gardens Conservation International (BGCI),
WWF, TRAFFIC, FAO, UNCTAD, UNIDO, UNESCO, Danish International Development
Agency (DANIDA), and Gesellschaft fr Internationale Zusammenarbeit (GIZ), among
others, have been involved in various aspects of conservation of medicinal plants, and
other non-plant resources. Despite such support, there is relatively little political focus
and efforts for up scaling of project-based conservation strategies, especially those that
are community strategies. However, as several countries are in the process of recognizing
customary or traditional resource rights of communities and fostering the evolution of
10
The WHO/IUCN/WWF/TRAFFIC Guidelines on Conservation of Medicinal Plants are in the process
of being finalized following a multistakeholder process. It will provide the baseline for medicinal
plants conservation and sustainable use for governments and private sector. See press-release:
http://www.traffic.org/home/2011/10/19/conservation-of-medicinal-plants-top-of-who-agenda.html.
27
community commons over lands and resources (Corrigan and Granziera, 2010; Rights
and Resources Initiative, 2012), developing such strategies will be crucial. This then calls
for a national or sub-national identification of key traditional medicine-linked biological
resources, inventorying them, assessing their conservation and use status, examining
their trade, and designing a management plan at appropriate levels of administration.
Studying socio-cultural aspects viz., local knowledge and customary practices related
to conservation and their integration are also vital. The management plans could
include in situ and ex situ conservation projects, with further linkages to livelihood
security or enterprise activities. Such assessments and management programmes need
be participatory in nature in order to ensure effective implementation and compliance
involving a number of experts such as conservationists, ecologists, health professionals,
taxonomists, pharmacologists, breeders, horticulturists, resource economists, sociologists,
traders, industries, traditional health practitioners and relevant members of local
communities.
Box 1 Medicinal Plant Conservation Areas and Parks (MPCAs,
MPCPs), India
There is a growing consumption of natural resources by the natural product industry. For
instance, consider the case of India. Studies suggest that 960 medicinal plant species are
the source of 1,289 botanical raw drugs that are traded in Indian markets and are used
by around 9,000 herbal industries in the country. Of this, 81 per cent (780) of species in
active trade are entirely or largely sourced from the wild (Ved and Goraya, 2008). The
alarming point is that of the wild collection more than 70 per cent is collected through
destructive practices as stem, wood, bark, roots or even a whole plant is used (FRLHT,
1999; 2009). In addition to this, the demand for plant resources for modern industries
including pharmaceuticals, botanics and cosmetics is also on the rise (Laird and Wynberg,
2008). This rise in demand, along with various other factors such as loss of forests,
encroachment and conversion, destructive practices such as grazing and overharvesting
have led to the destruction of genetic diversity and habitats of several valuable natural
resources. It is estimated that in India, around 300 plants and a few faunal species are
in various threat categories. Cultivation of such resources is not yet a viable economic
option due to preference for wild sourcing given lower costs, in addition to a general lack
of information on agro-techniques (Hamilton, 2004).
The Foundation for Revitalisation of Local Health Traditions (FRLHT) in India initiated
an integrated approach of in situ and ex situ conservation programmes for medicinal
plants. The establishment of Medicinal Plant Conservation Areas (MPCAs) in India was
a response to conserve medicinal plants in their natural habitats and preserve their
gene pool, with the support of state forest departments. MPCAs extend over different
bio-geographic zones with various inherent types of habitats and micro-climates.
They are established in cooperation with the State Forest Departments. It is a national
effort, exclusively to study the medicinal plants in the natural habitats and to develop
strategies for management of rare, endangered and vulnerable species. Between 1993
and 2012, 112 MPCAs were established across 13 Indian states in a unique model of
public private partnership. FRLHT, in collaboration with the Ministry of Environment
and Forests (Government of India) and through support of DANIDA, UNDP and GEF,
has been spearheading this programme. Such areas provide a good locale for studies
on threat assessment, population studies, mapping and community participation. This
28
has been an impactful programme and the Planning Commission of India recommended
the establishment of 200 MPCAs across the country (10
th
Five Year Plan, 2002).
11
There
is a recent move also to recognize these locations as biodiversity heritage sites. The
initiative has highlighted importance of publicprivate partnership as well as joint forest
management among various stakeholders including policymakers.
A related initiative is the establishment of Medicinal Plant Conservation Parks (MPCPs)a
community-based ex situ conservation initiative aimed at sustainable use of medicinal
plant resources and preserving knowledge associated with their use. Coordinated by
FRLHT along with other NGOs and community-based organizations, a chain of MPCPs
has been set up in various parts of India.
12
Such parks play a key role as community
conservation education centres. Within a geographical region, communities have been
mobilized to create ethno-medicinal forests, resource centre housing herbaria, crude
drug collections, local pharmacopoeia database based on community knowledge,
community and home herbal gardens, seed banks, outreach nurseries for promotion
of cultivation and sustainable wild collection of medicinal plants, trade and enterprise
development that aid in income generation. The initiatives affirmed the role of cultivation
as a complementary approach to conservation. The initiative provided two key lessons:
(1) conservation of live habitats and an ecosystem-based field conservation approach
with due consideration of local biological and cultural diversity have specific advantages
compared to conservation through seed banks or databases, and (2) conservation
strategies have to be balanced with local development priorities.
Box 2 Conservation Assessment and Management Plan (CAMP), IUCN
Given that financial resources, human resources and efforts available for conservation
of medicinal resources are limited, prioritization and assessment of the threat status of
medicinal plants to streamline conservation action is much needed. To accomplish the
prioritization of species within reasonable time and cost, the Conservation Breeding
Specialist Group (CBSG) of the Species Survival Commission of the IUCN has developed
a rapid assessment methodology called the Conservation Assessment and Management
Plan (CAMP).
13
The objective of a CAMP programme is to provide strategic guidance for
application of intensive management and information collection techniques to threatened
plants. They also provide a comprehensive means of testing the applicability of the IUCN
criteria to threatened taxa. This approach has been in use since 1993 after its first field
test in the island of St. Helena, in the Pacific, followed by several workshops in India.
A CAMP workshop is targeted as a decision-making tool locally and is an intense,
participatory process among various stakeholders such as field botanists, foresters,
ecologists, taxonomists, wildlife managers, scientists and user groups such as industries
and community members. Detailed information about each taxon under review including
data on the status of populations and habitats, their distribution and environmental
stochasticity in the wild are considered and recommendations for intensive conservation
action are discussed. The process utilizes information compiled by experts on the taxa
from published and unpublished sources. This results in recommendations on known
11
See http://planningcommission.nic.in/plans/planrel/fiveyr/10th/volume2/10th_vol2.pdf.
12
See http://mpcpdb.frlht.org.
13
See http://www.bgci.org/worldwide/article/0049/.
29
threats, management actions in the wild and captivity and further research priorities at
global, national or subnational levels. For example, during the first workshop held in
Bangalore on medicinal plant species of south India in 1995, with FRLHT, 36 medicinal
plants were assessed and assigned threat status as per IUCN red list categories. This
was followed by a series of workshops that has resulted in the development of a list of
medicinal plants across various states in India with their threat status ranging from lower
risk to critically endangered. The programme has also designed appropriate management
plans for various states and bio-geographic regions.
Box 3 Medicinal Plant Conservation and Community Health, Lao PDR
Responding to local concerns related to unsustainable resource use and needs for socio-
economic empowerment, international organizations and donors have been supporting
local activities related to conservation, sustainable use of resources and economic
development. The following example from Lao Peoples Democratic Republic (Lao PDR) is
a case in point.
The Cham people in Ninh Thuan province of Lao PDR have a long established medical
tradition, influenced by eastern Indian and Chinese systems. It was estimated that a
significant percentage of the population, especially from the villages of An Nhon and
Phuoc Nhon in Xuan Hai Commune, produce traditional medicines as a livelihood option.
Around 300 species from 97 plant families were identified as plants used for medicine
preparation. Apart from being used for domestic purposes, these plants are also sold in
dried form to neighbouring countries. Given the destructive harvesting practice, coupled
with increasing demand for the herbs, non-efficient production processes leading to high
wastage, and the naturally dry weather conditions in the region, the population of most
plants started dwindling to alarming levels.
A project was drawn up to demonstrate a sustainable model of conservation of medicinal
plants that links to the traditional knowledge of the Cham people in the region to sustain
medicine production as a livelihood activity. This activity was supported financially by the
United Nations Development Programmes (UNDP) Small Grants Programme (SGP). The
major activities included strengthening the knowledge and capacity of the Cham people
on conservation strategies for medicinal plants (including conservation gardens or home
herbal gardens as appropriate); developing traditional medicine production providing
self regulations for use of medicines and for health services, in general; improving
the commercial viability of medicines by developing brands for producing villages and
exploring interlinked livelihood options through formation of craft villages.
By design, the project seeks to develop holistic solutions to its health, livelihood and
conservation concerns. Given the scalability of the project, it could be appropriately
replicated in other similar community contexts.
14
14
See http://sgp.undp.org/web/projects/14434/conservation_and_development_of_medicinal_plants_of_
cham_community_in_ninh_thuan_province.
30
Box 4 Sustainable Harvest, Community to Community Training, India
The FairWild Standard provides a set of best practice guidelines for the sustainable use
and trade of wild harvested medicinal plants.
15
The FairWild Standard assesses the harvest
and trade of wild plants against various ecological, social and economic requirements.
Use of the FairWild Standard helps support efforts to ensure that plants are managed,
harvested and traded in a way that maintains populations in the wild and benefits rural
producers. The FairWild Standard was developed following the merger of two initiatives:
International Standard for Sustainable Wild Collection of Medicinal and Aromatic Plants
(ISSC-MAP) developed by IUCN Medicinal Plants Specialist Group, WWF Germany,
TRAFFIC, and the German Federal Agency for Nature Conservation (BfN); and the original
FairWild Standard developed by Swiss Import Promotion Programme (SIPPO), Forum
Essenzia e.V. and Institute for Marketecology (IMO).
Following its development, FairWild Standard (then ISSC-MAP) was piloted in a number
of locations around the world to test its applicability for ensuring sustainable wild
harvesting under the project Saving Plants that Save Lives and Livelihoods, supported
by the German Federal Ministry for Economic Cooperation and Development (BMZ). In
India, the pilot projects were implemented by FRLHT and TRAFFIC India.
FRLHT has been a key partner in the operationalization of this initiative since its
inception. A pilot study was conducted in Agumbe village of Karnataka, India. Through
a participatory planning approach involving various stakeholders such as scientists and
community members, a task team was set up for mapping resources and evolving a
sustainable harvesting strategy. As part of the methodology following a documentation
of medicinal plant-related knowledge and NTFP collection practices, resource assessments
were conducted for selected species. Training was provided for mapping and assessing
different harvest methods. It was found that a well-organized stakeholder group can
plan and implement an effective participatory resource management strategy. Apart
from standardizing and field testing the methodology, training modules for wider user
groups have been developed. This will be a useful strategy for biodiversity or joint
forest management committees through a community to community training (CTCT)
programme.
The FairWild Standard was also implemented in other countries of Asia, South America,
and Europe (see report Wild for a Cure).
16
In addition to being used by communities for
the management of medicinal plant resources, the FairWild Standard principles can be
used by industry, to support the development and/or strengthening of national resource
management policies and regulations. It is also recognized as the best practice to inform
CITES non-detriment findings (NDF), and as a practical tool for implementing and
reporting against sustainable use objective of the Global Strategy for Plant Conservation
(GSPC), as well as the CBDs Aichi targets 4 and 6.
15
See http://www. fairwild.org.
16
See http://www.traffic.org/home/2010/9/15/sustainable-wild-plant-harvesting-proves-a-global-success.html.
31
Endangered species
of medicinal plants
(Photos: FRLHT)
32
Focus Areas
1. Assessment of use, trade and threat status of medicinal plants and other natural
resources at national and sub-national levels and development of suitable
management plans integrating the social, economic and ecological dimensions
2. Build on and strengthen community-based participatory models of conservation
action (in situ and ex situ) and sustainable use within biodiversity planning
strategies and integrate them with health care and livelihood programmes
3. Regulate collection, encourage sustainable harvest practices and cultivation by
communities (including marginalized farmers) to reduce stress on wild populations
of medicinal resources
4. Capacity building of resource managers and other relevant stakeholders in
conservation-related processes
5. Regional and international networking and up scaling existing good practices in
the area of conservation and sustainable utilization of medicinal resources
6. Strengthen the engagement of the private sector and communities reliant on
harvesting of medicinal plants, towards development of sustainable use strategies
and their implementation
33
Medicinal plants used for primary health care in India (Photos: FRLHT)
34
2. Knowledge Resources
To reiterate a statement made earlier, some peculiar features of traditional knowledge
are its diversity and its dynamic nature which evolves in response to new stimuli.
Across sectors, it can be seen that some of the knowledge are codified, some are even
institutionalized. For instance, countries like India and China have strong codified forms
of traditional medical knowledge systems spanning over three to four millennia in the
form of Ayurveda, siddha and unani medical systems in South Asia; traditional Chinese
medicine (TCM), acupuncture, and kampo in East Asia. These systems are based on their
own unique worldviews and conceptual as well as theoretical frameworks, and have
distinctive understanding of physiology, pathogenesis, pharmacology and pharmaceuticals
discrete from that of biomedicine. Whereas in most countries, traditional knowledge
is largely in oral formeither in public or private domains. By extension, the level of
expertise, unlike modern science, is heterogenous and internal validation methods differ
substantially despite an underlying philosophical principle of the interconnectedness of
social and natural worlds. These range from highly developed ways of perception and
understanding, classification systems (ethno-taxonomies) to metaphysical percepts.
Conventional approaches of natural product chemistry-driven health care solutions
are time-consuming and resource-intensive. While affirming their need to develop
new health care solutions, they do not apply easily to community health contexts that
require simpler and rapid assessments. Traditional approaches have been tested over
time empirically albeit without adequate documentation. A major challenge thus is to
document such experiences and thereby foster a participatory learning process to
identify the strengths and gaps and to build on and supplement current practices in
a culturally sensitive way. Consequently, a validation exercise of traditional knowledge
within a community health programme will have to account for its relevance to the local
needs through an inclusive, reflexive approach while reviewing them in the light of peer
reviewed research materials. This involves identification of knowledge and practices, their
current status, the designing of an appropriate methodology for their assessment, and
development of a management plan for promotion of good practices.
One of the main objectives of the exercise would be to build a communitys confidence
in its knowledge and practices while promoting them as active social traditions and
protecting them from misappropriation. Various social science tools such as community
mapping or focus group discussions can be applied sensitively to capture the complexity
of such knowledge systems.
Box 5 Documentation and Participatory Rapid Assessment of Local
Health Traditions (DALHT), India
Documentation and participatory rapid assessment of local health traditions (DALHT) is
one of the methods used today by several community-based organizations in India, for
assessing and promoting best practices of communities and healers. This is also used
as a mechanism to protect the intellectual property rights of community knowledge.
Apart from assessing the efficacy of practices, it also helps to differentiate and identify
sound practices. This takes into consideration the worldviews/epistemologies of folk
practitioners and carriers of household knowledge.
35
DALHT was first designed as a participatory rapid assessment programme by FRLHT, India
in order to find the best health practices in selected communities of southern India. This
involves a community-based assessment in which local traditional health practitioners,
allopathy and Ayurvedic physicians, botanists and field workers play key roles in arriving
at a consensus about a prioritized local practice for a community health programme.
The basic principle of this assessment is a consensus of opinion among different
medical systems about the management of a health condition. Through such a process
best practices within the community are identified and promoted, incomplete practices
are supplemented with knowledge from other sources, and distorted practices are
discarded. It was found that nearly 70 per cent of the practices had supportive evidence
from Ayurveda and modern pharmacology on their prescribed uses. A related finding
was that around 55 per cent of the positively assessed plants can be easily grown in
home gardens or are locally available (Santhanakrishnan et al., 2008). Based on the local
pharmacopoeia, simple users manuals are prepared in vernacular with details relating to
their use for their wide promotion within the community through training programmes.
The method has the following steps:
36
Figure 1: Documentation and Participatory Rapid Assessment of Local Health
Traditions
Steps
Training by FRLHT to
NGO/CBO, key
stakeholders on
different steps of
DALHT
Documentation by CBO
of repeatedly used
remedies from local
knowledge holders
Data on health practices
for selected health
conditions
Prioritization of health
conditions through PRA
Prioritized list of health
conditions
Documentation through
literature referencing on
symptoms and remedies
for specic conditions
from codied systems as
well as from modern
research studies
Substantiating
references for the
practices from codied
as well as research
literature
Participatory Rapid
Assessment of health
practices by communities,
local healers, codied
system physicians as well
as modern medical
practitioners to identify
effective remedies
Remedies that are:
1.Positive promote
2. Distorted discard
3. Incomplete add info
4. Still not understood
study further
Field trials,
clinical
research,
publication
Training
programmes
to
households
Product
development
through local
enterprises
Establish
community
and home
gardens
Outputs
Source: FRLHT, 1999.
37
Box 6 TRAMIL Model, Caribbean Islands
Traditional Medicine for the Islands (TRAMIL) is an applied ethno-pharmacological
research programme in the Caribbean targeted at rationalizing health practices based
on the use of medicinal plants. It assesses the current use of medicinal plants in different
countries of the Caribbean. For this, a proportionate (to population) survey of sample
households in a community on health conditions and types of intervention (from
traditional healers, medical doctors or home remedies) is conducted.
The survey follows a sequential order and statistical approach and captures details related
to major health conditions and medicinal plant resources used with descriptions and
locations. Interviews are generally not conducted by a trained medical doctor as they
tend to analyse responses and hence influence them. A herbarium of plants used for
therapy is made if the plants cannot be easily located or sourced. The process allows a
prioritization of five to ten health conditions for the study area and helps in designing
appropriate intervention strategies based on local priorities and relevance.
This has been applied since 1984 in several countries such as Antigua and Barbuda,
Barbados, Belize, Colombia, Costa Rica, Cuba, Dominica, the Dominican Republic,
Grenada, Guatemala, Haiti, Honduras, Jamaica, Nicaragua, Panama, San Andrs, Saint
Lucia, Saint Vincent and the Grenadines, Venezuela; the French overseas regions of
Guadeloupe and Martinique; the Commonwealth Puerto Rico; and the Mexican state of
Quintana Roo.
Box 7 Participatory, Observatory Clinical Studies, Switzerland, Mali
and Mauritania
Traditional medicine has been increasingly pressured to undergo clinical studies for
assessment of safety and efficacy. While traditional use was considered sufficient in many
countries this is changing rapidly in the context of the growing standing of evidence-
based medicine. Some WHO regions (like the South-East Asian Regional Office [SEARO])
hold the position that if the usage of a traditional medical practice is within a local
community with experience in using the remedy, it need not undergo any toxicity or
efficacy studies unless it is marketed outside the community. Many researchers contend
that randomized controlled trials should use more locally relevant assessment methods
which are less technical in design, less time-consuming and more cost-effective.
Antenna Technologies, a Swiss NGO working in Mali, Mauritania and Switzerland has
developed a low cost clinical study methodology for traditional medicines through
promoting better dialogue between scientists and traditional health practitioners. These
clinical study approaches conducted by Antenna, especially in key public health areas
like malaria, include methods such as retrospective treatmentoutcome population
surveys, prognosisoutcome method (traditional healers treatments are monitored by
modern physicians), and dose escalating prospective study (detecting dose response in
humans) method. Such methods are cost effective and may be closer to the practical
context (Graz et al., 2007).
17
The gap in these semi-formal systems is a lack of capacity
of stakeholders who conduct the studies in sharing their experiences related to the
designing and implementing these studies with the scientific and policy-making
17
See http://www.antenna.ch/en/.
38
communities in an acceptable form. Addressing this would enable knowledge sharing
with other communities and adoption of similar efforts elsewhere, influence national and
international policy making and enthuse rigorous research involving relevant research
institutes and scientists.
Focus Areas
1. Formulate interdisciplinary ethno-medical studies based on community needs
2. Development of local pharmacopoeia through documentation and participatory
assessment of community knowledge, and thereby generate primary evidence
through a social process
3. Capacity building of concerned in design, implementation and communication of
experiences in a standard format
39
3. Human Resources
Traditional medical knowledge holders or traditional health practitioners (THPs) are
highly dispersed ranging from highly institutionalized practitioners (complementary
and alternative medicine practitioners) to those who practice occasionally or on a
part-time basis in households, who take care of health needs within their families
or neighbourhoods. Easy access, cost efficacy, cultural familiarity and better cultural
cognition by healers, flexible fee payment systems (outcome payment) and efficacy are
characteristic reasons why patients choose such therapies (Diallo et al., 2006).
18
It is
estimated that about 60 to 70 per cent of child deliveries are carried out by untrained
birth attendants (Bodeker, 2010; Kruske and Barclay, 2004). In India, 36.6 per cent of
child deliveries are managed by traditional birth attendants compared to 35.2 per cent
managed by doctors (Sadgopal, 2009). Doctor to population and healer to population
ratios in many countries vary considerably. For instance, Uganda, Tanzania and Zambia
have a healer to population ratio ranging from 1:200 to 1:400 while the ratio of
allopathic practitioners to population is 1:20,000 (WHO, 2002); and India has a healer to
population ratio of 1:1,500. (Abraham, 2005).
According to the 2008 World Health Report, the transition from community-based
traditional care providers to professional care has been faster than imagined. However
projections on professionalization of birthing care suggest that by 2015, in sub-Saharan
Africa, only 40 per cent of child deliveries will be through professional care whereas in
South and South-East Asia it will be 60 per cent. This shows the continued presence
of THPs and the need for their better integration. It needs to be reiterated that lack of
access to professional care alone is not the reason for supporting traditional practitioners,
but efficacy and cost play central roles in their presence, hence the complementary role
that they play in health system should be recognized.
THPs specialize over a wide range of health conditions including general practice,
traditional orthopedics, birth attending, poison healing, spiritual therapies, mental health,
traditional ophthalmology; and pediatric, skin, gastrointestinal, respiratory and veterinary
care. Such practitioners continue to be driven by social legitimacy rather than by formal
legal recognition. Hence, although the knowledge is utilized actively, such practitioners
fall outside the frame of reference of any planning process. They have an unrecognized
public health care role as caregivers, health educators, family counselors or community
therapists, in addition to functioning as priests, ritual specialists, diviners, teachers and
community leaders.
Generally, THPs are selectively utilized to suit broader health interventions, while
neglecting the local needs and holistic dimensions of their knowledge. For instance,
in many countries traditional healers are trained to impart centrally designed health
messages among communities on issues such as HIV/AIDS or tuberculosis while their
own practices that make them relevant in their contexts are often sidelined (Payyappalli,
2010). Concerns relating to inadequate recognition of traditional health practices and
practitioners, securing rights to resources, traditional lands and ownership of knowledge
and benefits from use of resources and knowledge; concerns over sustenance of
practices and lack of successors; incompatibility with mainstream knowledge systems and
18
Studies have shown that continued adherence to local TRM providers and practices is not only due to
lack of access to modern health care, but also due to positive outcomes perceptions (Diallo et al., 2006).
40
learning processes; and enabling peaceful existence and preservation of diversity affect
meaningful integration of such healing systems within mainstream health care delivery
systems (ibid.). Often criticized for lack of quality and safety regulations and assessments
as defined by modern parameters, traditional health practices end up being perceived as
loosely defined, with interesting information but lacking scientific rigour and credentials.
Given the width of the prevalent practices, it is urgent that appropriate and sensitive
methods of peer-appraisal, regulation and accreditation of THPs are evolved.
The challenge is to identify such actors and their expertise, integrate them into a
professional and peer review process, improve their knowledge through relevant capacity
building programmes and assure intergenerational transfer of such knowledge. Several
civil society initiatives are focusing on building networks of healers within and between
territorial boundaries. Three successful models are highlighted below. Though they are
successful, it is important that these programmes be linked with the local administrative
structures to be effective and accountable.
Box 8 MPCN Healers Model, India
Since 1993, FRLHT has been promoting local healer activities in various states of India.
Through the Medicinal Plant Conservation Network (MPCN), promoted by NGOs working
with different rural communities, traditional healers associations have been formed at
state, district, taluka and block levels (different levels of administration) which conduct
regular meetings and exchanges among healers. Self-regulatory guidelines on operation
of each association have been evolved through a participatory process based on the
contextual peculiarities of each state. Healers associations along with local level NGOs
and government forest departments have been actively engaged in supporting medicinal
plant conservation programmes in various states and have established several herbal
gardens. Similar initiatives have also been promoted by other NGO networks across India.
These networks have also developed appraisal systems of healers capacities and training
programmes in selected areas for practitioners such as bonesetters and traditional birth
attendants. Action research interventions in key health areas such as malaria, anaemia,
and chikungunya, among others, have also been initiated by these networks, in addition
to the organization of several medical camps, and district and state level conventions of
healers associations aimed to foster increased networking among the members.
To encourage and promote healing traditions, FRLHT has been conferring the
Paramparika Vaidya Rathna (Traditional Healer Expert) Award to the folk healers in
recognition of their services rendered to rural communities in their region since 1995.
The network (MPCN) has arranged several healer exchange visits within the country and
among other South Asian, and African and Asian countries. In 2009, an international
healers exchange programme involving 161 healers from 18 African, Asian and Latin
American countries was organized in Bangalore which resulted in setting up a National
Task Force to draw guidelines for official and legal recognition of traditional health
practices and healers by the Department of AYUSH, Government of India.
41
Box 9 Training of Traditional Health Practitioners, Uganda
Promotion of Traditional Medicines (PROMETRA) is an international NGO working to
alleviate poor health conditions and services utilizing traditional medicine since 1971.
19

PROMETRA-Uganda, a national chapter of PROMETRA, engages with healers in activities
related to capacity building. A unique initiative includes training programmes designed
for healers and youth from communities on the use of traditional medicinal resources and
practices. These are conducted under the banner of Bujia Forest Schools.
Capacity building of healers is provided in terms of exposure to potential value addition
and income generation activities, culturally sensitive disease prevention and management
of environmental conservation. In addition, PROMETRA facilitates networking of healers
from different parts of Uganda.
Apart from healers networking and capacity building activities, PROMETRA also works
to integrate traditional medicine in national health systems in order to improve free
choice of medicine for citizens, protect biodiversity and participatory forest management,
promote research on medicinal plants, protect traditional knowledge and reinforce
institutional capacities of civil society actors for a healthy environment and sustainable
development.
Box 10 Reviving Poison Healing, Friends of Lanka, Sri Lanka
Poisonous bites are a leading cause of morbidity and mortality in rural areas of
developing countries. Whereas traditional health practitioners had contributed a great
deal in the management of such conditions, such healers are moving away from the
practice today, resulting in loss of knowledge. Friends of Lanka, an NGO in Sri Lanka
has promoted documentation of practices, research and networking of such healers.
Around 75 healers (men and women) have been identified from a population of 8,000,
treating various conditions such as snake-bites, insect bites and certain food or natural
poisons. This indicates a high healer to population ratio. An association of the healers
was formed. Treatment methods are documented and shared, including mantras (chants)
and live demonstrations. Rare medicines are prepared in monthly group activities so that
costs can be reduced. The association has also initiated assessment of natural resource
availability and methods for conservation and sustainable use through home and
community gardens.
The National Department of Indigenous Medicine has a procedure for traditional health
practitioners to register, which is considered difficult as it entails having to go through
a formal interview and other procedures. Some of the healers have already formally
registered through such a process but most prefer to gain social recognition through
good service. They have also initiated networking with other local and regional healer
associations. Though the association intends to do research, it has not been able to develop
a cordial relationship with the universities in the region. However, they have initiated a
joint research on social services through snake-bite healers with Peradeniya University.
An encouraging sign is that, on the whole, there is a positive attitude in the government
medical department for promotion of such practices (Attanayake et al., 2006).
19
See www.prometra.org.
42
Box 11 Reproductive Health and Traditional Birth Practitioners, India
Traditionally, women have played a central role in keeping the traditional practices of
community health alive. This is due to the fact that around 70 per cent of the health
problems are taken care of at the household level, as a first response.
20
The inherent
linkage between health and nutritional knowledge is mostly transferred through women
in traditional communities. Women provide maternal and child health services in most
societies. Studies point out that 60 to 70 per cent of the child births around the globe
are carried out by traditional birth attendants (Bodeker, 2010; Kruske and Barclay, 2004),
which is a woman-dominated occupation. This does not relate to delivery alone but also
to ante and post-natal care. This points to the need to ensure intergenerational transfer
of such knowledge and at the same time to bring in such practitioners more actively
towards providing community health.
The Centre for Health Education, Training and Nutrition Awareness (CHETNA) is a
non-governmental organization based in Gujarat, India, which has been working with
traditional birth attendants in the state. The Dai Sanghathan (Association of midwives)
launched 2,005 organized traditional birth attendants from 15 districts. Founded
by seven dais (midwives) and seven NGOs, it is currently coordinated by CHETNA and
works to improve maternal and new born health. This provides a platform for dais to
communicate their collective voices, carry out capacity development and better integrate
itself into the public health system through state as well as national level advocacy.
Over the years the membership has increased to 7,264 dais from 24 organizations of
15 districts. Apart from organizing state and national level conventions for creating
awareness and for advocacy, the association has also made self-regulatory standards and
accreditation by giving identity cards and developing a capacity enhancement curriculum.
Another major activity has been arranging learning visits for dais to nearby states.
Focus Areas
1. Plan integration of traditional health practitioners and other knowledgeable
community members and their good practices in health programmes based on
contextual needs
2. Create legal recognition and regulations for such practitioners and improve
support as per the local needs
3. Promote self-regulatory associations in line with national regulations for health
practitioners and accreditation systems
4. Devise strategies for their amicable relationship with biomedical professionals and
referral systems
5. Improve access to resources and devise mechanisms to assure intellectual property
rights of undocumented knowledge
7. Formulate educational strategies for continued intergenerational transfer of such
relevant knowledge as active social traditions
8. Promote regional and international exchange of learning among traditional health
practitioners
20
Kleinman, A., 2002. The global transformation of health care : cultural and ethical challenges to
medicine. [online] Bethesda, MD: National Institute of Health. Available at: <http://videocast.nih.gov/
Summary.asp?File=10463> [Accessed on 31 August 2012].
43
4. Community Health and Nutrition
An area requiring more attention in the health, biodiversity and traditional knowledge
intersect is the integration of traditional medical knowledge in public health systems. This
area has received insufficient policy focus, despite its significant role in the development
of preventive and curative drugs used in public health care. A chief concern regarding
such integration relates to safety and efficacy of such practices and most research focuses
on clinical and experimental medicine or regulatory challenges while ignoring the public
health potentials (Bodeker and Kronenberg, 2002). Furthermore, the production and use
of such knowledge and resources do not align well with centralized, vertical planning
and implementation processes due to variances of scales, availability of resources, and
technological asymmetries. This highlights the need to have locale-specific, horizontal
integration processes in place. Experience suggests that traditional medicine can play
a central role in the case of significant areas of public health concerns such as HIV,
malaria, parasitic infestations, and nutritional disorders (Bodeker, 2007), indicating that
appropriate research and capacity building networks need to be built to ensure two way
communication between the different medical systems.
Box 12 Research Initiative on Traditional Antimalarial Methods
(RITAM), United Kingdom
Tackling malaria, one of the most deadly infectious diseases, has been flummoxed by
increasing resistance to modern antimalarial drugs. This has resulted from an over-
emphasis on single drug therapies. Besides, poor people often cannot afford modern
drugs, or lack access to them due to an inadequate medical infrastructure. In this
context, the relevance of including traditional medicine in the repertoire of choices
available for prevention and cure of malaria is being explored. One such initiative is the
Research Initiative on Traditional Antimalarial Methods (RITAM), a group of international
researchers established in 2001, and working on traditional antimalarials with more than
200 members from over 30 countries. A systematic literature review by RITAM indicates
that numerous plant species are used to treat malaria or fever. In India, FRLHT has been
assessing the effectiveness of antimalarial remedies from folk health traditions. Before
assessing traditional medicine for malaria prevention through a community-based
approach, several preparatory steps are undertaken. Some of them include the following
steps:
literature survey on plant drugs used for malaria management,
documentation of traditional antimalarial remedies and dietary rules suggested by
folk healers for malaria prevention,
compilation of pharmacological references for toxicology and efficacy of these
practices from Ayurvedic and modern medical literature.
Malaria prophylaxis is one of the activities taken up by FRLHT in India. Communities in
selected endemic areas follow a regimen of malaria prevention (mainly consisting of an
herbal decoction) during the monsoon season for a selected period. Safety of the practice
is assured and the remedy is prepared fresh on specific days at a community centre.
Using a cohort study approach, a group that does not follow this regimen is compared
44
with those that do. The documentation done in several regions has shown positive
results in malaria prevention, indicated by statistically significant positive outcomes.
While promoting such region-specific remedies, detailed pharmacological studies are also
conducted for understanding the mechanism of their action. The study also adheres to
all necessary ethical requirements. Free prior informed consent is obtained from both the
community members who share the knowledge and who follow the regimen.
Implementing traditional medical knowledge through community-based participatory
approaches is feasible and urgently needed in order to find solutions to the continuing
high incidence of malaria in regions where it is endemic (Unnikrishnan and Prakash,
2007). Similar studies on various aspects of malaria have been carried out by RITAM
partners in various countries.
Box 13 Haichi System A Community Health Programme, Japan
Haichi (also known as okigusuri) is a traditional medical public health care model based
on the concept of self-help medication that originated in Toyama, Japan during the
seventeenth century. This was an efficient household care system where herbal medicine
distributors travelled across Japan for distributing essential medicines to every household
(JOICFP, 1980).
This has its base in a legend of the Edo period. In 1690, in the Edo castle, acute
stomach ache of a feudal lord from Fukushima prefecture (in northern Honshu) was
quickly relieved after taking a medicine from a lord of Toyama, Masatoshi Maeda. At the
request of many lords, a medicine distribution system for special kampo medicines from
Toyama was started. Today, though other prefectures also have such a system, it is mostly
dominated by Toyama pharmaceutical industries.
Toyama is the third largest prefecture in terms of pharmaceutical production in Japan
after Saitama and Shizuoka, valued at JPY 517 million for the year 2008 with 89
companies working in this sector.
21
Of this, 28 (31.5 per cent) companies specialize in
the haichi medicines. Thus, Toyama boasts 52.3 per cent of the total household medicine
distributing system. The medicine distribution system is based on a senyo kori (first use
and pay later) principle. The distributor goes to each household at fixed periods of a
year and hands over the medicine box. During subsequent visits the distributor collects
the charge for the medicines used. In the past, the visits of medicine distributors
synchronized with rice harvest seasons. Today, the box contains 10 to 20 kinds of
essential drugs in 3 categories of over-the-counter (OTC) drugs which are internal,
external remedies and plasters, among others. All such medicines are regulated for
household use by the Ministry of Health, Labour and Welfare and thus cannot contain
medicine usually prescribed by a doctor. While the medicines are being distributed, they
are classified according to efficacy and risk. The contra-indications or special precautions
are explained to the households. The client information is well-documented in kakebacho
(registers), or in a database through a handy electronic device today. Distributors are
trained regularly (generally for two weeks) on key health messages and usage of the
medicine box. It is noteworthy that the system has contributed to the health of the
21
Presentation by the Pharmaceutical Policy Division, Health and Welfare Department of Toyama Prefectural
Government of Japan, Haichi Medicine Sales System in Toyama, at the Nippon Foundation Meeting in
Toyama, Forum of Traditional Medicine in ASEAN, 5 June 2010.
45
people since the Edo period. The business area covers all parts of the country extending
from the northernmost prefecture of Hokkaido to the Kyushu region in the south (JOICFP,
1980). Though it historically started as a kampo medicine programme, it continues even
today with modern pharmaceuticals also being part of the medicine box.
This approach has now been promoted in some of the East Asian countries.
Vansemberuu, an NGO from Mongolia has been implementing Promotion of Traditional
Medicine Project in Mongolia since 2004, designed and funded by The Nippon
Foundation. A Family Medical Kit, designed based on traditional Mongolian medicine
is distributed along the lines of the Japanese model. The project is especially focused
on providing primary health care services for rural citizens of Mongolia. The project was
introduced at the international conference of the World Health Organization in 2007
as a successful model of including traditional medicines in primary health care services.
The governments of Thailand and Myanmar have also taken up similar projects in their
countries.
Box 14 Home Herbal Gardens, India
In many developing societies, health costs predispose rural indebtedness (Van Damme
et al., 2003). A self-reliant approach to managing simple, common health conditions
can reduce the health expenditure for poor rural households. Home herbal gardens, as
conceived by FRLHT, are a collection of 15 to 20 prioritized medicinal and nutritional
plants and have become a good model for a self-reliant community health programme.
Apart from being a conservation milieu for medicinal plants it also addresses nutritional
challenges. In most rural communities, knowledgeable women take care of certain
primary health needs of the family members and the gardens become a handy resource
for them. Some women, by taking the role of suppliers of seedlings for the programme
also earn supplementary incomes.
For over 15 years, FRLHTs programme on home herbal gardens has been helping to
reduce poverty and reviving local knowledge of medicinal plants and traditional health
practices. Today 200,000 home gardens across 10 states in India are used to meet the
primary health care needs of some of the poorest households, while reducing their health
expenditure. A majority of participants are now contributing fully to meet the costs of
raising their medicinal plants. Studies conducted show that there is substantial health
cost saving on account of usage of home remedies (Hariramamurthi et al., 2006).
Box 15 Food and Health, Okinawa, Japan
Rapid lifestyle changes and an ageing population have resulted in increase in non-
communicable chronic diseases; continuing poverty and inequity and environmental
degradation have contributed to continuing malnutrition and infectious diseases, among
others. Under nutrition, especially protein energy malnutrition, deficiencies of vitamin A,
iodine and iron continue to be major issues in most developing countries. Conversely, in
transition economies, increasing unhealthy diet patternshigh saturated fat and high salt
intake, high calorie and low fibre dietslead to a different set of health issues. Access to
sufficiently nutritious food is a fundamental factor in good health.
46
There is increasing attention towards the issue of diet simplification and its impact on
nutrient deficiencies, excess energy consumption and non-communicable diseases.
Todoriki et al. (2004) point out how life expectancy decreased among the Okinawan
population especially among men in the recent period due to a substantial change in
food habits of the population from the pre-war (18791945) to post-war (1945
1972) period. The study argues that there was a change in the staple diet from sweet
potato to rice; shift from low calorie to high calorie diet; increased intake of fat as well
as imported, processed food due to the influences of American occupation as well as
mainland Japan. Their intake of seaweed also decreased considerably in the post-war
period. The study highlights how social, political, economic and cultural factors influence
nutritional preferences and overall health and well-being.
Countries usually include public food intervention programmes in child nutrition schemes.
There is also increased attention on locally available foods which are considered vital
in food system transition (Johns and Eyzaguirre, 2006). Today there is high erosion of
traditional knowledge and practices related to food production and a rapid reduction of
food source diversity. It might be possible to reverse this trend through documentation,
identification and research and training on relevant aspects of food and nutrition. An
approach that integrates socio-economic as well as cultural and local epistemological
frameworks enhances understanding of the various inter-related issues. This could lead
to nutritional guidelines based on local knowledge and practices and further strengthen
local production and consumption systems. The WHO suggested switching from
nutrition-based dietary guidelines to food-based dietary guidelines (WHO Western Pacific
Region, 1999). Such an approach is necessary to understand and integrate traditional
food practices. Health food traditions relate to various dimensions from agricultural
practices, food processing and cooking methods to consumption practices.
Box 16 Back Pack Health Workers Training for Refugee Health,
Thailand and Myanmar
Health care access for populations in special conditions, such as refugees, is a subject
of keen interest to policymakers. While a basic human right, health care access to such
populations is often stymied by political compulsions. Lack of qualified personnel in
modern medicine and infrastructure in the areas of concentration is a primary reason
for inadequate access: Myanmar refugees based in the ThailandMyanmar border faced
such a situation. Endogenous efforts to establish a clinic (Mae Sot Project), under the
strong leadership of a doctor who was one of the refugees (Cynthia Maung), that offers
both in-patient and out-patient care, were challenged by insufficiencies in personnel and
medical resources. The Clinic worked with the Global Initiative for Traditional Systems of
Health (GIFTS of Health) in designing a programme of intervention including traditional
healers, who were among the refugees and were also connected to each other through
an informal network. It was found that the refugees preferred to consult with traditional
healers for primary health care needs, while preferring western medicine for acute
conditions. It was also observed that cooperation between western clinical services and
traditional health practitioners was closely linked to their well-being which includes
cultural continuity and refugee identity. Clinical paramedical staff from among the
refugees and outreach health workers, known as Back Pack Health Workers (BPHWs),
47
who carry medical supplies in backpacks to remote villages and refugee communities and
modern medical staff at the Mae Tao Clinic constitute a health workers group. Two main
outcomes came out of this process:
1. A community-based programme to establish services of traditional healers in the
villages, supported by their networks of herbalists to exchange knowledge and
provide mutual support in activities such as training in traditional medicine for
BPHWs,
2. A research programme to investigate traditional health care approaches as used by
refugees to inform refugee agencies.
Training programmes are conducted focusing on food poisoning and vomiting,
diarrhoea and dysentery, HIV/AIDS, tuberculosis, malaria, wounds and skin diseases,
and incorporating modern medical perspectives and possible traditional medicine
interventions, especially where western medical services are not available. Topics related
to diagnosis, differentiation between plants, safety of herbal drugs, ethics including
intellectual property rights pertaining to traditional medical knowledge, plant rarity and
conservation, and the theoretical framework of Burmese traditional medicine are also
discussed. The programme was funded by a combination of grants from local NGOs and
from patient contributions (Bodeker, 2004).
Box 17 Iron Deficiency Anaemia, India
Iron deficiency anaemia (IDA) is a major nutritional problem in India and many other
developing countries. The WHO estimates that over 30 per cent of the worlds population
suffer from anaemia. The uniqueness of IDA is that it is the only nutritional disorder
that is also widespread in the developed countries. Conditions such as malaria, HIV/
AIDS, hookworm infestation, schistosomiasis and tuberculosis are important predisposing
factors for anaemia.
22
In India the incidence of anaemia is highest among women and
young children varying between 60 and 70 per cent (Park, 1997). The groups with the
highest prevalence are pregnant women (50 per cent), infants and children of one to
two years (48 per cent) and adolescents (30 to 55 per cent). It is estimated that about
20 per cent of women in the productive age group are iron deficient when compared to
men, which is about 2 per cent (Mohan, 1998). Present evidence suggests that a high
prevalence of folate deficiency anaemia in pregnancy is also a universal phenomenon
(Park, 1997).
Poor bio-availability of iron, hookworm infestation, malaria, frequent and short interval
pregnancies and related blood loss are some of the specific factors cited in India leading
to anaemia. A community-based, participatory approach to tackle the problem of
anaemia is important. Studies suggest that coordinated social action through introduction
of locally available green leafy vegetables, nutritional and medicinal plants through home
gardens, demonstration of iron rich cooking and creating nutritional awareness can have
a positive impact on reducing anaemia. An All India Coordinated Research Project on
Iron Deficiency Anaemia supported by the Department of Science and Technology and
implemented by the Agarkar Research Institute shows positive outcomes of such social
22
See http://www.who.int/nutrition/topics/ida/en/index.html.
48
action through community participatory programmes (Rao et al., 2011). Large scale
projects like the Home Herbal Garden (HHG) programmes implemented by FRLHT also
highlight the importance of cost effective, community-based solutions for tackling the
issue especially in rural communities (Hariramamurthi et al., 2006).
Box 18 Medicated Water A Preventive Strategy for Waterborne
Diseases, Kerala, India
Kerala, a southern Indian state with a population of 31.8 million, is at par with the
developed countries in all its health indices. In the international health care development
context, Kerala forms a unique health care model of high health status at low per
capita expenditure. Kerala has been the focus of several studies on health system
developmentin particular, it was one of the candidates of the Good Health at Low
Cost studies conducted by the Rockefeller Foundation around 25 years ago. Studies on
improved health of the state suggest a strong relation between health status and cultural
knowledge traditions, and are illustrative of how traditional knowledge can interact with
modernity in a complex way. The system has promoted positive attitudes to health care,
diet, personal hygiene, and sanitation that have been conducive to the acceptance of
more modern approaches.
One of the unique practices is related to hygienic handling of water using traditional
knowledge. In India, water-related diseases constitute around 80 per cent of health
problems. Despite its progress in general development indicators, Kerala ranks low in
access to potable water. Various reasons such as open wells on which a large percentage
of households depend as source of water, their contamination through pit toilets and
septic tanks (which are most common) affect the quality of drinking water. However the
state has controlled waterborne diseases substantially through consumption of water
boiled with local herbs across urban and rural households. While assuring microbial-free
water, it also provides health co-benefits through the medicinal properties of the herbs.
The practice has been well-integrated into the society and several medicinal products are
available in the market. Though this case requires more extensive studies on the precise
nature of the benefits, it demonstrates how local resource/knowledge-based adaptations
can have positive impact on public health and well-being (Payyappallimana and Koike,
2010). There are several other traditional practices across India such as storing water in
copper vessels that have been proven to be both effective and time cost-effective for
assuring microbial-free water.
Box 19 People Living with HIV/AIDS (PLWHA), South Africa and
Uganda
South Africa has a high number of HIV/AIDS-affected people. Inadequacy of the public
health system to respond to the high cost of antiretrovirals and the continuing social
stigma make many patients seek health through traditional health practitioners (THPs).
THPs also provide psychological and spiritual support to the affected. In South Africa,
there has been increasing policy attention for national regulation, registration and
training of THPs, for care as well as for improving referral systems. The Traditional Health
Practitioners Act of 2007 regulates efficacy, safety and quality of their services. Self-
regulating healer associations federated at provincial level have also been working for
49
improving services. This has proved important especially in the context of high utilization
of THPs by HIV/AIDS patients. THPs are expected to play a key role as a gatekeeper in
training and supporting family members as well as in promoting home gardens for health
and nutrition. PLWHA, using traditional medicine, have reported that they use traditional
therapies for relief of pain, fever, skin rash, cough, diarrhoea, herpes zoster, herpes
simplex and tuberculosis (COMPAS, 2011).
THETA is an NGO based in Uganda working on bettering health care in disadvantaged
communities since 1995. A key focus of THETA is improving capacities of institutions
and health workers in the area of HIV/AIDS prevention and care through integration of
traditional medicine and other alternative management approaches. With this objective,
this NGO has been working with various health care institutions in several districts in
Uganda. They work with community leaders, traditional health practitioners, and
community-based organizations for better health planning at the local level. They have
trained a number of traditional health practitioners in prevention and care of HIV through
integration of their traditional knowledge.
23
Focus Areas
1. Identification of specific areas where traditional medicine can contribute to public
health, their systematic validation and promotion
2. Integration of traditional medical approaches to public health in relevant
educational systems
23
For details see http://thetaug.org.
50
5. Equity and Livelihoods
There is a major increase in the international trade of medicinal plants which is expected
to be over USD 800 million per year. Around 400,000 tonnes of medicinal plants is
exported from Africa and Asia yearly (Leaman and Mulliken, 2006). A major portion
of this is sourced from unorganized sectors that directly support rural livelihoods in a
considerable way and assume importance.
Development is conventionally defined in terms of economic growth, and usually does
not account for informal sectors such as traditional health delivery systems. The
asset specificity provided by the resourceknowledge links can be utilized to achieve
development objectives in local communities. Traditional knowledge and resources
from an ecosystem are parts of supply chains of products (e.g., medicinal products,
raw materials) and services (e.g., health care, nutrition). Income that is generated
and distributed equitably from such activities provides an incentive to conserve such
knowledge and resources, while also resulting in better health and nutrition outcomes
(Suneetha and Pisupati, 2009). Possible enterprises include collection and sale of non-
timber forest produce, cultivation of medicinal/nutritional resources, semi-processing,
small scale production of medicines and related health products, and capacity building at
various levels. Linking such enterprises to market-based instruments such as certification
schemes, and supply contracts (to the extent that it is supportive of sustainable resource
use), among others further enables retention of better incomes and benefits at the
producers level.
Box 20 Community Enterprise Village Herbs (Gram Mooligai
Company), India
A community-owned enterprise by womens self-help groups (SHGs) in Tamilnadu state
of India, called Gram Mooligai Company Limited (GMCL), promoted by FRLHT, supplies
medicinal raw materials through collection and cultivation. The womens groups are
shareholders in the company. GMCL has developed ecosystem-based herbal products that
were derived from the DALHT exercise (mentioned earlier). While initially the products
developed were over-the-counter (OTC) medicines and for common conditions such as
fever, cough and wounds, the product range now includes products for diabetes that are
on prescription. The SHG shareholders directly benefit through buy-back arrangement of
the herbs, employment for distribution of products through the Sangha (group) network
as well as through profit sharing.
Box 21 Community Enterprise Ampika, United Kingdom and Peru
Ampika Ltd. is a Company that specializes in developing nutraceuticals and functional
foods, and in bio-discovery of natural products for prescription use, utilizing plant
resources from the Peruvian Amazon based on the knowledge of traditional healers
from the region. The company was established by Francoise Barbara Freedman, a social
anthropologist from the University of Cambridge based on her long interactions with
indigenous people in the Peruvian Amazon. Ampika was developed from funds provided
through the Cambridge Enterprise Seed Funds, a unique initiative to support commercial
ventures of research faculty and to bridge social responsibility with economic interests.
51
Recently, Ampika was involved in fostering the development of a dental numbing gel to
relieve pain, based on the knowledge of the use of the plant Acmella oleracea, from the
healers of the Keshwa Lamas tribe with whom Freedman works in Peru. The gel is now in
advanced stages of clinical trials, and could possibly be approved around 2015. A portion
of the profits would be ploughed back into the community for their various health and
well-being needs.
24
Box 22 Community Enterprise Jambi Kiwa, Ecuador
In this case, developmental aspirations of indigenous women, with a good knowledge
of use of medicinal plants in Ecuador, were steered to a happy conclusion through the
involvement of various partner organizations in supportive roles. Initially started by a
group of women in the late 1990s to capitalize on market demand for medicinal herbs,
and at the same time revitalize local traditions of herb use for medicine and cosmetics,
the enterprise soon grew to cater to the demand of local industries including the herbal
tea sector. From being suppliers of raw herbs, the womens group quickly became
legally registered involving more staff from the community who were engaged in the
development of value added products. This was facilitated by sourcing funds from
networks including UNDP and civil society, especially those based in Canada. Currently,
the women claim benefits from improved health awareness and delivery, better diffusion
of economic risks and higher recognition of gender equity (Cunningham, undated).
Box 23 Community Enterprise ICIMOD, Nepal, Bhutan and Bangladesh
Aiming to link conservation with development objectives, the International Centre for
Integrated Mountain Development (ICIMOD) developed a programme on enhancing
local livelihoods by encouraging communities from the highlands of countries such as
Nepal, Bhutan and Bangladesh to undertake cultivation, value addition and marketing
of specific medicinal plants of high value found in each country. ICIMOD offers technical
services with respect to improved production practices, processing and value addition and
improved market intelligence dissemination services.
25
Focus Areas
1. Promote community-based enterprises through traditional medicinal resources and
products
2. Streamline policies related to access to resources and equitable sharing of benefits
(ABS) to also include value addition activities at the local level
24
For more information, see http://www.ampika.co.uk.
25
See http://www.icimod.org/?q=392.
52
6. Interculturality, Integration and Institutionalization
Traditional knowledge is often not recognized by mainstream society as scientific
on account of its varying methods, resulting from diverse worldviews and ways of
understanding (Haverkort and Reijntjes, 2010). TK has been characterized as non-
dualistic, dynamic, informal, secret and sacred, spiritual, time-related and non-linear
in nature. Methods are also intuitive and meditative, with an emphasis on reciprocity
(ibid.). For the same reasons, it is not an easy task to validate such knowledge using the
theoretical standards and measures used to assess modern scientific methods. However,
it is a fact that these sciences exist in parallel to dominant systems and are pursued by
different populations, implying a greater need for respectful co-existence between them,
and to foster appropriate integration between the sciences and methods (ICSU, 2002).
The following table provides a quick comparison between different approaches to health
between modern and traditional systems of medicine.
Table 3: An Epistemological Comparison of Traditional and Modern Approaches
to Health
Aspects Modern Biomedicine Traditional Medicine
1 Approach & disease
classification system
Structural Functional
2 Location Largely organ-specific or
localized*
Systemic
3 Causality Single causality Multiple causality
4 Reasoning method Linear Non-linear and circular reasoning
5 Causative reason Organism-centred Immunity-centred
6 Nature of knowledge Objectivity-centred Subjectivity-centred
7 Nature of assessment Quantitative Qualitative
8 Health/disease assessment Technology-centred, outside
the context
Subjective, in the context
9 Diagnostic approach Universalization Individualization
10 Domains Physical (often mental),
disease-centred
Physical, mental and spiritual, illness-
centred
11 Treatment focus Curative focus, importance
given to drugs, surgery
Prevention focus, importance given to
drugs, food, lifestyle
12 Treatment strategy Targeted medicine Formulation concept
13 Line of treatment Treating a specific
manifestation at a given time
Stage-wise management
14 Outcome Effect is important Effect should not lead to after effect
15 Knowledge/practice focus Method/institution-centred Physician-centred
* Recently, approaches such as system biology have become more acceptable in biomedicine.
Lack of appropriate methodologies is a key challenge in integrating the two different
knowledge systems. At the same time there are no significant academic efforts to
develop appropriate intercultural methodologies at a theoretical level.
53
Gains from integration of different systems are more visible and perhaps efficient
when steeped in community-led processes, where such combinations occur in practice.
However, experience also suggests that such integration processes can have certain
challenges (Shankar and Unnikrishnan, 2004). For instance, it becomes difficult to
capture traditional wisdom outside a traditional pedagogy, making it difficult to
capture nuances in a particular knowledge system. Furthermore, the explicit economic
opportunity costs for such processes are high, as the incomes that can be derived from
alternative activities are higher. While recognizing that some kind of institutionalization is
inevitable, it appears that cooperative enterprise models function more effectively.
Box 24 Intercultural Hospital, Chile
The Mapuche comprise the largest indigenous group of Chile, with around 700,000
people, constituting 4 per cent of the total population. The Mapuche consider health to
be related to a harmonious relationship with the environment and give much importance
to the role of rituals and homeland to healing. This entrenched worldview is at variance
with the mainstream health care approach, and a biomedical doctorMapuche patient
interaction is often constrained. Patients seek out both Mapuche and modern medicine,
and through the establishment of intercultural hospitals and clinics, intervention of choice
has been addressed since 2006. This also additionally addresses the language barrier
problem, as many Mapuche do not speak the dominant Spanish language. In addition,
it fosters an acknowledgement of and understanding for other health care systems and
possible integrative approaches.
In the Mapuche worldview, a number of diseases are caused by spiritual, social and
mental imbalance which can be managed only by a trained healer. Western medicine-
trained doctors along with Mapuche healers and spiritual leaders attend to the patients
jointly at the Nueva Imperial Hospital near Temuco, one of three such hospitals in Chile.
This creates a platform for dialogue among various practitioners while cross-referencing
and complementing each other. What is also significant is that this is covered by the
National Health Insurance Scheme, Fonasa. Traditional health practitioners serving at
the facilities express their happiness that even in a modern environment of a hospital,
they have freedom to relate with the forces of nature and carry out their rituals or offer
prayers.
There is a long way to go before such a model becomes part of the public health service,
though Mapuche has been strongly advocating the need for more such facilities. Due
to dwindling of medicinal plant resources in the country, Mapuche practice is becoming
difficult. A support group has been set up for sustainable collection of medicinal plants.
This network is currently working on a legislative proposal to gain recognition of the
Mapuche system of health by the National Congress and the Chilean Ministry of Health
(Moloney, 2010).
54
Box 25 Mainstreaming Traditional Medicine into Official Primary
Health Care, India
For a large percentage of people in India, the government Primary Health Centres (PHC)
are their sole resort for health care. However, in a highly populated country like India
there is a huge challenge to provide quality modern health care for the underprivileged.
26

Improving quality of services and enhancing human resources have been recommended
by the National Planning Commission for addressing the critical challenges of health
care. Community participation, a core principle of primary health care needs to
be strengthened (Lawn et al., 2008). As part of the National Rural Health Mission,
accredited social health activists (ASHA) have been playing a pivotal role in educating the
communities and delivering primary health care. At the same time, traditional medical
knowledge and practitioners are not integrated well.
27
At a national level, the government launched the National Rural Health Mission (NRHM)
in 2005. The NRHM is mandated to strengthen the public system of health services
with architectural correction so as to ensure equal access to quality health care
especially to the marginalized populations. NRHM adopted Mainstreaming of AYUSH
and Revitalisation of Local health traditions as one of its strategies to strengthen public
services.
A unique model is in trial to integrate traditional knowledge and practitioners into
the primary health care system in 24 PHCs which includes 20 allopathy centres and
4 Ayurveda dispensaries. This is being done through the Karuna Trust, a voluntary
organization based in Karnataka state of India, and has played a central role in health
system development in the state through an equitable and integrated model of health
care, education and livelihoods. The programme is implemented through 25 arogyamitras
(volunteers called friends of health) from selected primary health centres. Priority
health problems, health practices and local medicinal plants for these conditions are
identified and their safety and efficacy are assessed through a participatory approach. It
undertakes a comprehensive programme including traditional medicine manufacturing
unit, and the establishment of home and community herbal gardens. Over 250 traditional
healers and knowledgeable women from communities were identified. Detailed
community biodiversity and health knowledge registers were prepared and published.
The programme has been successful in increasing confidence among community
members in their practice and at the same time integrating them into conventionary
primary health care.
26
This has led to a doctor to patient ratio of about one is to ten thousand. Such low ratios also do not
make medical care affordable. The shortage is more pronounced in our rural communities as the majority
of the doctors live and practice in cities. There must be deliberation on why this is happening and what
could be the solutions. From the Speech of Her Excellency Smt. Pratibha Devisingh Patel, President of
India, at the concluding function of the Platinum Jubilee Celebration of the Medical Council of India, 1
March 2009. See http://presidentofindia.nic.in/sp010309.html.
27
Such a possibility was first acknowledged in the Alma Ata Declaration on the occasion of the first
International Conference on Primary Health Care, 1978: (VII.7) Primary Healthcarerelies, at local and
referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community
workers as applicable, as well as traditional practitioners as needed, suitably trained socially and
technically to work as a health team and to respond to the expressed health needs of the community.
55
Box 26 Chao Phraya Abhaibhubejhr Hospital Foundation (CAF),
Thailand
Chao Phraya Abhaibhubejhr Hospital Foundation (CAF) in Prachin Buri, Bangkok
started in 1983 as a unique model of institutionalization of traditional knowledge. The
foundation focused on conservation of traditional knowledge, resources, revitalizing of
traditional local practices of food, healthy lifestyles, and cultural traditions apart from
clinical care. A self-reliant community health care model has been established through
these approaches. Documentation of traditional knowledge and creation of a database;
networking of health practitioners and community knowledge holders in the north
(border between Thailand and Myanmar), northeastern and southern Thailand and
their exchange programmes; supporting basic needs of such practitioners; community-
based assessment and cross-checking with scientific data and research; promoting
conservation as well as organic cultivation and semi-processing of medicinal plants;
community capacity development; product development (such as herbal medicines, food
supplements and cosmetic products) based on local knowledge through strict quality
control as per good manufacturing practices and their ethical commerce are some of the
major activities. The local cultivation promoted through a buy-back arrangement with
the foundation has been instrumental in supporting additional income for community
members. The products developed have been popular. For example, Thao Wan Prieng,
a capsule used for reducing muscle pain and stiffness is widely used by the communities.
To foster awareness among the younger generations, the foundation organizes youth
camps in forests on local health traditions and biodiversity. Some of the major challenges
in their work are erosion of traditional knowledge due to an ageing practitioner
population, inadequate market linkages for medicinal plants and products, and
inadequate implementation of traditional knowledge and biodiversity-related regulations.
Source: Interview with Supaporn Pitiporn, Chao Phraya Abhaibhubejhr Hospital
Foundation, Bangkok, 26 November 2011.
Focus Areas
1. Promote academic work for better methodologies for research and integration of
traditional knowledge systems
2. Create awareness among health professionals on the relevance of integration
3. Up scale good practices of integration through relevant policy measures
56
7. Education
The dominant education and research systems tend to enhance knowledge and
technologies with universal standards, rather than supporting the needs of specific
regions or populations (Haverkort et al., 2003). A dearth of comprehensive theoretical
approaches to assess the role, economic potential and policy implications of traditional
knowledge is a key reason for disregarding traditional cultures (Jenkins, 2000). Since
most of the traditional environmental and medical knowledge among communities
is oral in nature, revival of the social processes of their generation, preservation and
transfer within the communities needs to be studied well. Culturally and locally
relevant educational practices need to be enabled and processes such as social learning
should be promoted, as management of bio-cultural resources to achieve health and
development cannot be approached uni-dimensionally. Designing and implementing
culturally appropriate pedagogies and their integration into formal and informal
learning processes are therefore part of this process. As a large part of traditional
medical knowledge is experience-based and orally transmitted, such knowledge is better
transmitted in contexts that do not necessitate classroom-based learning. This then calls
for a transformative or reflexive learning process and the development of transdisciplinary
methodologies to studying nuances of TK, in addition to developing human
understanding through the generation of evidence, development of skill assessment
methods and mechanisms for collaboration and peer review. This is well-echoed in the
principles of the United Nations Decade on Education for Sustainable Development
(DESD) which aims, among other objectives, to foster and mainstream intercultural
approaches within a social learning process through multi-sectoral, collaborative and
interdisciplinary methods.
Box 27 Capacity and Theory Building for Universities and Research
Centres on Endogenous Development (CAPTURED), Ghana, Bolivia
and India
CAPTURED is the accumulation of a number of experiences and initiatives that aim at
revitalization of endogenous knowledge systems in a context of ongoing decolonization
and development of culturally appropriatesystems of higher learning and research. It was
developed as a response to a situation where education systems in Africa, Asia and Latin
America were primarily modeled on a western worldview, while indigenous worldviews
struggled to articulate their relevance to the societies to which they belong. Partners
of the CAPTURED programme contribute to the building of capacities of academic and
development workers to enhance endogenous development. This is development based
mainly, though not exclusively, on the locally available resources, local knowledge, culture
and leadership. Endogenous development is open to integrating traditional as well as
outside knowledges and practices.
CAPTURED is a collaborative programme of the University for Development Studies,
Ghana; Universidad Mayor de San Simon, Bolivia; Foundation for Revitalisation of Local
Health Traditions, India; and ETC/COMPAS, the Netherlands. CAPTUREDs main goals are
to develop innovative forms of higher education that contribute to revitalize indigenous
ways of knowing based on a dialogue between academic and endogenous scientific
communities, and to jointly build theories on endogenous development and strengthen
57
the institutional capacities of the related universities in endogenous research and
training. CAPTURED brings together 16 universities from 4 continents to cooperate and
share experiences in enhancing research, capacity building and field work in support of
endogenous development.
Despite the intuitive appeal of the concepts, challenges in operationalizing integration
of knowledge streams include knowing what is endogenous and defining
transdisciplinary approaches, and more specifically the availability of academic capacity
to orient such research.
Focus Areas
1. Promote education models that integrate experience-based subjective knowledge
2. Foster receptivity of traditional healers and their knowledge systems into
mainstream education systems
3. Reinforce intergenerational transfer of knowledge and skills in communities
through appropriate pedagogical systems, sensitive to traditional approaches
4. Reorient research and educational methods to include transdisciplinary perspectives
58
8. Protection and Right-Based Approaches for Community Knowledge
Traditional knowledge, as mentioned earlier, exists in diverse categories. Much of the
oral knowledge is held by individuals or closed groups within communities or even
shared parallelly by communities in similar ecological systems, with varying customary
norms for sharing. In countries such as China and the Indian subcontinent, substantial
knowledge exists in codified forms in classical medical texts spanning over 3,000 years.
Additionally, ethno-botanical studies have also documented health traditions in various
communities across the world over the last three centuries. In the context of multilateral
policies related to knowledge access, such knowledge is subject to national sovereignty
(as in the Convention on Biological Diversity) and market exclusivity (Agreement on Trade
Related Intellectual Property Rights). Evidently, access to traditional knowledge cannot
be easily ascertained as delineations between prior art and innovation become blurred.
Consequently, conflicts on ownership and exclusive use have defined much of the period
of natural product exploration.
Policy planners and various stakeholders have been striving to find amicable mechanisms
to protect and promote the rights of holders and innovators of traditional knowledge.
As it is important to ensure easy and free access to knowledge, it is equally important to
ensure social equity. While attempts at inventorying knowledge have received increasing
attention over the last decade, several of the experiential elements related to TK cannot
be captured in such documentation or protected, unless they are promoted as active
social traditions (Shankar and Unnikrishnan, 2004).
Box 28 Traditional Knowledge Digital Library (TKDL), India
With concerns regarding attribution and ownership of knowledge still high, measures
and tools that enable protection of traditional knowledge are being explored. The
collective and oral nature of TK challenges existing paradigms of protection. Despite
their decentralized nature, protection of these knowledge systems needs to be under
the purview of national systems, but at the same time the knowledge systems should
facilitate local innovations. One such effort involves documentation and inventorying of
such knowledge, especially in digital databases. As health-related knowledge has been
more commonly accessed for developing new medicines and continues to be profiled as
the primary sector where misappropriation of knowledge, practices and resources occur,
searchable databases pertinent to health-related TK that ensure the protection of related
resources and knowledge are being developed.
A unique database project called Traditional Knowledge Digital Library (TKDL) was
developed through a collaboration between the Council for Scientific and Industrial
Research (CSIR), the Indian Ministry of Science and Technology, and the Ministry
of Health and Family Welfare (Department of AYUSH). An interdisciplinary team of
Ayurveda, Unani, Siddha and Yoga experts, IT experts, scientists, and legal experts
manages the digital library. It involves documentation of the traditional knowledge
available in the public domain in the form of existing literature related to Ayurveda,
Unani, Siddha and Yoga, in digitized format in five international languages: English,
German, French, Japanese and Spanish. Traditional Knowledge Resource Classification
(TKRC), an innovative structured classification system for the purpose of systematic
arrangement, dissemination and retrieval has been developed for about 25,000
59
subgroups against a few subgroups that were available in earlier versions of the
International Patent Classification (IPC) related to medicinal plants, minerals, animal
resources, effects and diseases, methods of preparations, mode of administration, etc. By
providing information on traditional knowledge existing in the country, in languages and
formats comprehensible to patent examiners at International Patent Offices (IPOs), the
database contributes immensely to prevention of the grant of wrong patents.
In parallel, various organizations through Community Knowledge Registers (CKRs) are
undertaking a similar exercise to document oral knowledge or knowledge in the informal
domains. Chiefly led by non-governmental organizations, these registers attempt
to rally community members to discuss and document their knowledge and practices
in different categories of resource use or practices based on two premises: (1) that by
documentation, they establish prior art over the knowledge and resource use, and (2) it
promotes greater use and practice of the knowledge within the community, eventually
reinforcing such use as strong social traditions.
Box 29 Community Registers and Protocols
Generation of Community Biodiversity Registers is promoted as a sui generis
documentation system to protect biodiversity-related traditional knowledge (Gadgil et
al., 2000), and has been incorporated in the national laws of countries (such as India)
and executed through biodiversity management committees (the lowest governance unit
level) that are engaged in systematic documentation of local resources and knowledge.
More recently, communities have been articulating their rights over their knowledge
and resources by developing their own bio-cultural community protocols (Bavikatte et
al., 2010). Defined by communities, these highlight the legal rights that are vested to
communities by virtue of international and national laws and provide a self description
of the community profile, their resources, rights and responsibilities. They also provide an
indication on the terms of engagement with external agents. These documents therefore
can be viewed as legal tools that foster protection of rights of communities within their
contexts.
Focus Areas
1. Encourage development of community knowledge registers and bio-cultural
protocols and link them with national databases for protection
2. Build on and upscale good practices of ethical and equitable agreements with
international collections and industries related to use of traditional knowledge and
natural resources for research or commercial purposes
60
Medicinal plant nursery
Medicinal plant conservation programme - Various forest types, India
Documentation of medicinal plants
Herbaria collections
Village enterprises based on medicinal plants, India
(Photos: FRLHT)
61
9. Socio-Cultural Landscapes
Survival and vitality of knowledge and resources depend on the socio-cultural contexts
in which they are embedded. Typically, such knowledge and resources are found to be
most vibrant among communities close to culturally important landscapes. These could
relate to socio-ecological production landscapes (e.g., satoyama in Japan) or conservation
systems (e.g., sacred groves, ceremonial sites) or health domains (e.g., sacred healing
sites). Such landscapes contribute immensely to health and well-being, therefore
necessitating a close inquiry into the functional interlinkages within such systems, and
maintenance of their dynamism.
Spiritual and sacred sites within landscapes/ecosystems are common and defining
features of communities living in close proximity to nature. These sites, due to their
cultural significance, are usually robustly governed by customary norms and are also sites
of refuge for biological resources. They are linked to health and healing processes and
are especially relevant in healing related to mental health. Mostly these are historically
community-protected areas often specific to ethnic communities and religions. Such
locations have strong linkages to psychosomatic healing with both biophysical (natural)
as well as socio-cultural factors playing a vital role. These sites offer a new field for
interdisciplinary research due to their unique role in conservation. Protection of such
landscapes requires the collaboration of various stakeholders such as indigenous
communities, faith groups and government agencies (Sponsel, 2008).
28
Box 30 Oxlajuj Ajpop, Guatemala
Oxlajuj Ajpop is an NGO that works with indigenous Mayan populations in Guatemala
following the signing of a peace treaty after the war in Guatemala in 1996. Several
indigenous families had been deeply affected spiritually during the war, unable to
provide traditional burial rites to the dead. Offering legal support and counseling to
the families, Oxlajuj Ajpop aimed to assist in rebuilding the social fabric of the people
through a focus on principal values of Mayan culture, authority and spirituality. The
organization comprises seven Ajqijabs (Mayan priests) organizations, from various
linguistic areas of the country, and involves about 1,100 Mayan elders. Much attention is
given to the revitalization of sacred Mayan sites to promote the conservation of natural
resources and the knowledge related to natural medicines, in addition to fostering the
Mayan cosmovision of harmony between humanity, divinity, nature and the cosmos.
They also are sites that facilitate inter-cultural learning, linking education on sustainable
development to traditional Mayan knowledge related to various fields including Mayan
astronomy, astrology, spirituality, mathematics, natural medicine, literature and epigraphs.
This also aims to make traditional knowledge more relevant to the welfare of the
communities.
Focus Areas
1. Encourage further interdisciplinary research studies examining the relationship
between socio-cultural landscapes and health and well-being
2. Identify key areas for protection and promotion of bio-cultural sites like sacred
groves and therapeutic landscapes, including areas like heritage education
28
See http://www.eoearth.org/article/Sacred_places_and_biodiversity_conservation.
62
10. Partnerships and Networking
Based on the relationship between the sets of stakeholders, partnerships in this sector
can be categorized as being donor partnerships and knowledge and implementation
partnerships. Strong networks are built between local civil society organizations,
communities in an ecosystem, educational institutions and other relevant stakeholders
including local scientific establishments utilizing ecosystems and resources. Supporting
such linkages is vital to sustain any initiative on the ground. These also help to assure
basic safety and quality standards of products and services.
In terms of donor partnerships, several intergovernmental, international and national
organizations are engaged in providing resources supporting conservation and
development, specifically related to health care. UN agencies such as the United Nations
Development Programme (UNDP), Global Environment Fund (GEF), UNCTADs Biotrade
Initiative, and international donor organizations such as International Development
Research Centre (IDRC), International Fund for Agriculture Development (IFAD), Ford
Foundation (FF), Nippon Foundation, Christenson Fund, and government agencies
such as DANIDA, Canadian International Development Agency (CIDA), Swiss Agency
for Development Cooperation (SDC), SwedBio, and Japan International Cooperation
Agency (JICA) have continued to support various projects related to conservation of
medicinal resources and livelihood activities based on traditional knowledge and skills
with broader development and equity goals. Agencies such as UNEP, UNESCO, UNEPs
World Conservation Monitoring Centre (UNEP-WCMC) and the Equator Initiative, foster
studies with implications for implementation of biodiversity and health action plans.
Other groups, such as IUCN, WWF, TRAFFIC and BGCI, foster conservation, sustainable
use, and regulation of trade of wild and natural resources. Emphasis is placed on
capacity development of communities, institutions and governance structures. NGOs, of
national and international dominion, and community-based organizations (CBOs) are also
involved in national or local scale project activities, especially those related to mobilizing
community health action, healer networks and networks of conservation sites.
Knowledge and implementation partnerships typically involve a research organization or
network of researchers working towards raising scientific evidence and awareness about
the benefits of biodiversity in health and nutrition. Some prominent examples include the
Harvard Project on biodiversity and health,
29
the WHO-led MA report on ecosystems and
human well-being,
30
the research and implementation partnership on biodiversity, health
and well-being between UNESCO - Scientific Committee on Problems of the Environment
(UNESCO-SCOPE) and UNEP,
31
Biodiversity Indicators Partnership between UNEP-WCMC,
WHO and SwedBio,
32
network of WHO collaborating centres on traditional medicine,
33

UNU-IASFRLHTCOMPASEquator Initiative collaborative programmes on research and
capacity building,
34
the TRAMIL network in the Caribbean, research networks promoted
by GIFTS of Health pioneering policy advocacy by the Co-operation on Health and
Biodiversity (COHAB), Ecohealth, technology sharing network facilitated by the Asia-
Pacific Traditional Medicine and Herbal Technology Network (APTMNET-UNESCAP),
29
See http://chge.med.harvard.edu/resource/howourhealthdependsbiodiversity.
30
See http://www.maweb.org/documents/document.357.aspx.pdf.
31
See http://unesdoc.unesco.org/images/0018/001897/189744e.pdf.
32
See http://www.bipindicators.net/LinkClick.aspx?fileticket=NF5vC6bqyWg%3D&tabid=92&mid=857.
33
See http://who.int/medicines/areas/traditional/collabcentres/en/.
34
See http://www.ias.unu.edu/sub_page.aspx?catID=9&ddlID=2026.
63
Training programmes for healers, Uganda
Training programmes for healers, Uganda
Learning Exchange between healers, India
Training programmes for traditional healers,
Uganda
(Photo: FRLHT)
64
Medicinal Plant Specialist Group of the Species Survival Commission of IUCN, Local and
Indigenous Knowledge Systems (LINKS) project of UNESCO, work on health and nutrition
by Bioversity International, and McGill University, and the medicinal plant conservation
and traditional medicine revitalization programme supported by FRLHT in India.
National or international recognition spurs scaling up processes of community activities.
In addition to this, it focuses policy attention on such local activities that contribute to
broad-based development, apart from reinforcing confidence within the community,
contributing to better review mechanisms and standards, and fostering intercultural/
intercommunity exchanges. While progress is evident in terms of cooperation by
multilateral agencies, national support, especially in the biodiversity and the health
sector, still needs to catch up. Further, given the insufficient progress made in enhancing
community health in remote locations, it is imperative that innovative ways of financing
be designed to address this issue.
Focus Areas
1. Devise innovative national, international funding mechanisms for up scaling
existing good practices, cross-cutting domains related to health, biodiversity and
traditional knowledge
2. Develop an institutional framework for linking various local, regional and global
initiatives in the sector
Section III Conclusions
65
Healthy ecosystems and biodiversity are sources of various services that nurture life
and enhance human well-being. Of the several services, a cross-cutting one is the
contribution that biodiversity makes to secure health of people and life forms in all its
manifestationsphysical, mental and spiritual.
The linkages between traditional medicine and biodiversity get strengthened through
three processes, interlinked at various degrees. First, a primarily medical approach that
includes efforts at integration of traditional medicine in health care delivery largely
supported by the WHO or other international efforts. Emerging challenges in this process
relate to safety, quality, efficacy, access, rational use and regulation through national
policies on traditional medicine.
However, the process is confined to specific unmet health needs with less attention
on overall development of traditional medicine. The second process involves a market-
oriented approach focusing on drug development or tourism promotionwhere the
focus is on health products and services as marketable commodities. Generally, the
attention is on bio-medical products given the emphasis of regulations on standardization
and other universal principles. However, traditional health practices are marketed
increasingly through health spas, personalized medicine and related approaches.
The last process is one that is related to a community-based approach driven largely by
civil society organizations with a conservation focus, including resource management,
livelihoods and health programmes. This is implemented mostly through a grassroots
mobilization process of health practitioners, botanists, conservationists as well as
community institutions. Such an approach shows an allegiance to the Alma Ata primary
health care model, and includes models such as the barefoot doctors strategy in China
or the more recently accredited social health activist programme in India with a focus
on improving health access instead of an institutionally delivered health care model.
Given the centrality of biodiversity in human lives, there still exists a need to explore
sustainable strategies for maintenance of health using these resources and linking with
local knowledge and practices in developing countries. This is relevant even in developed
countries with increasing attention and demand for alternative and complementary
approaches to health and well-being.
It is quite evident from the experiences highlighted in the case studies above, such as
the large scale medicinal plant conservation programmes with a public health dimension
(e.g., home herbal gardens), that these projects have had a significant impact in
generating awareness among different stakeholders regarding the role of traditional
medical knowledge in community health care as well as the need for conservation
of biological resources. Further, one can also discern that several programmes and
arguments related to conservation and promotion of traditional health cultures were
initiated during the 1990s. However, sufficient progress has not been built upon the
momentum generated by these programmes. Several community-based projects were
driven and steered by civil society organizations, although supported by publicprivate
partnerships or donor funds. Despite the success of these projects in demonstrating
workable solutions to meet conservation and primary health care needs, their scale of
operation has not been enhanced. Several factors could be attributed for this:
66
There is a clear need for including broader health determinants while setting goals
related to health and development. This should include ecological and socio-
cultural factors that contribute to good health.
Integrating conservation priorities in health system planning needs more attention,
with sufficient research on evidence of safety, efficacy and quality standards.
Further, there has been inadequate reflection on how community health
approaches can be integrated into institutional delivery mechanisms, more
specifically within the contexts of local pharmacopeia and the mainstream
requirement for standardized products.
An emphasis on capturing market values from high-end medical products has
resulted in sidelining issues related to promotion of self-reliant health care
systems. The inclination towards high external resource dependency especially
in pharmaceuticals and medical technologies disincentivizes local innovations in
traditional medicine and health care.
A critical issue is that through a top-down health care approach, the societies have
organized themselves to be more disease-centric (with supporting institutions,
research, industry, government departments, strategies and programmes) than
wellness-centric. A paradigm shift in the mind set as well as in systems and
structures to wellness (prevention/promotion) is a challenge, yet essential. For this
shift to occur, internalization (not mere awareness) and practice implementation
are essential. To make good health practice, habit is crucial, to which research
and science and technology can add value. Effective communication and training,
however, are necessary, especially on simple day-to-day practices, which we
tend to take for granted. It should be noted that western biomedicine turned
the corner around a century back, with a massive mind set shift with respect to
public health interventions. They did this by just implementing good strategies
for sanitation, hygiene and clean drinking water. This took care of the majority
of health problems. A similar concerted movement is required for a wellness
paradigm shift.
At the community level, erosions in family fabric and support system, and
alienation of primary health care from households into the premises of
government-delivered health systems are big contributors to the decline of health
care. Self-reliance holds the key and it is necessary to focus on instilling confidence
and capacity among households to handle diet, nutrition, lifestyles, conduct and
primary health care.
At the national and sub-national levels, challenges have arisen with regard to
the governance of health systems and coordination of implementation structures
to meet goals related to health and conservation. This is primarily due to the
overlap between the line departments in implementation. Whereas parts of the
programme relate to the Ministry of Health, other aspects relate to the Ministry
of Environment as well as the Ministry of Education. An added layer is the non-
synchronicity in implementation of regulations across a supply chain of biological
67
resources from the forests through collectors to traders and industrial bodies. It is
important to strengthen these linkages and build convergence for a coordinated
action for community health programmes.
There are challenges in sustaining the support of financial resources, which is
still heavily dependent on donor funds. Traditional health promotion and related
conservation schemes, focused chiefly on medicinal plants, were seen more
as avenues for economic development and hence expected to become self-
supporting over time. To realize self-sufficiency, costs of delivery of various related
services from resource collection to distribution and infrastructure to identify and
support healers need to be thought out more comprehensively. There is a critical
need for innovative approaches for funding mechanisms in the area.
At the policy level, there appears to be a tendency towards non-realistic target
setting. Implementation mechanisms for such targets still rely primarily on formal,
mainstream processes such as modern infrastructure and trained doctors, while
including and appropriately training specialists outside the modern realm of
training especially as the community health workers level might have hastened the
processes to achieve various goals. A reflexive learning approach to development
is especially important in this context where no single knowledge system has
sufficient conceptual, theoretical or practical authority in addressing health
challenges.
While attempts to document and protect traditional medical knowledge in
searchable and other inventories are important in terms of defensively protecting
such knowledge from misappropriation, efforts to use such knowledge to
augment community health are still insufficient. Attempts to open such inventories
for research purposes (as seen in the TKDL) still play into mainstream drug
development processes than local health care delivery. This stymies efforts to use
and expand such initiatives to provide better community and public health care.
High erosion of traditional knowledge and lack of perceived support for traditional
health practitioners have evidently led to a decrease in the receptivity and transfer
of all aspects of such knowledge between generations. It has been observed that
in cases where the knowledge system is perceived to bring in recognition and
supplemental income, younger generations are more keen to learn, develop and
sustain them.
We often see that the dominant education and research systems tend to enhance
knowledge and technologies using universal standards, without much attention
to the capacities and needs of specific regions or populations (Haverkort et al.,
2003). A dearth of comprehensive theoretical approaches to assessing the role,
economic potential and policy implications of traditional knowledge is believed to
be key to the disregard of traditional cultures (Jenkins, 2000). This then calls for
the design and implementation of culturally appropriate pedagogical methods with
an intercultural inclination and transdisciplinary approach, and their integration
into formal and informal learning processes. Examples such as the DALHT illustrate
68
that it is possible to develop workable methodologies of this nature. This would
further require an enhancement of capacities of facilitating agencies such as NGOs
and public sector organizations.
There appears to be a clear need for designing a radical and innovative approach
to integrate traditional medicine into mainstream health systems. This would
require full institutional backing from various related governmental and non-
governmental agencies that link supply chains of medicinal resources with health
practitioners and consumers with the highest standards of quality, safety and
efficacy determined by an interdisciplinary panel of experts.
A central argument we put forth for traditional medicine to be contemporarily
relevant is the necessity to have a full understanding of the contextual dynamics and
expertise underlying it, and further translate this understanding to practical community
programmes. This would involve fostering a cross-learning between different knowledge
systems, and trans-learning between different disciplines such as conservation, health
and development. The learning experience should also be accessible to mainstream
health professionals. Obviously, the scope of such an approach extends beyond health
and environment to include broader concepts of well-being and ecological integrity and
resilience of the constituent parts.
International Policy Contexts
The two international instruments that have a direct influence on the development of
the linkages between health and biological resources are the WHO and the CBD. Their
goals intersect in areas related to ensuring availability of medicinal resources, and the
role of traditional medical practitioners/communities in using these resources to provide
health care. While the CBD recognizes the rights of communities over their knowledge
and practices, the WHOs focus has been on ensuring safe and effective health care
to populations, especially to those whose first point of contact for health delivery is a
traditional healer. However, official documents of the WHO focus on setting standards for
national health systems, with limited guidelines for community level health practices. It is
important and quite urgent that the organization provides such advice. The decision X/20
of the Conference of the Parties to the Convention on Biological Diversity (CBD COP),
which calls for cooperative action between relevant organizations to promote health
and biodiversity goals is a step in the right direction. The increasing cooperative activities
initiated between the CBD and the WHO are a welcome development (CBD, 2012).
Integrated Rapid Assessment Protocols
From the foregoing, it is clear that there is a need to bring together the expertise
gained in assessment and development of biodiversity and in community health. Several
international and national agencies have designed rapid assessment protocols to enable
management of resources or development needs as the case may be. The examples of
IUCNs CAMP methodology, FRLHTs DALHT methodology or Antennas Rapid Clinical
Trial Approach are cases in point. Despite their merits, the complementarity between
such sectoral approaches has been under-explored. Having a comprehensive assessment
protocol that will give due consideration to the different constituencies and stakeholders
will enable better coordinated planning. Below is a conceptual schema (Figure 2).
69
Figure 2: An Integrated Assessment Framework for Biodiversity, Traditional
Knowledge and Community Health
Intervention Areas Assessment
Biological resources
(threat, harvest, use,
trade, cultivation)
Knowledge/practices
relating to health and
nutrition (local
priorities, sound
practices, innovations,
evidence)
Human resources
(capacity needs,
networking,
accreditation)
Socio-cultural
resources (cultural
landscapes,
governance structures,
practices, local needs,
priorities and
capacities, livelihoods)
Community health
interventions
Conservation ( in
situ/ex situ) &
sustainable use
Protection of
knowledge
(documentation/
community protocols,
databases)
Livelihoods
Access to good
health and well-
being
Conservation
and sustainable
use of biological
resources
Research
Monitoring &
action
programmes
Training/
education
Policy
engagement
Governance
mechanisms,
regional and
international
networking
Strategies & Mechanisms Outcomes
Such assessment strategies should integrate different social levels such as communities,
civil society groups, non-governmental organizations, formal and informal education
institutions, local administrative structures, and national, international and multilateral
policy forums. It is also important to appraise local governance systems to include such
programmes in community development planning. Role of civil society organizations
is critical and a good mechanism needs to be evolved for publicprivate partnership. It
also requires a multidisciplinary team with public health specialists (epidemiologists,
statisticians), health practitioners, biologists, specialists from the forestry sector, IT
specialists, socio-economists, legal experts, policy experts, nutritionists and social workers,
among others.
The different good practices highlighted through the case studies, and many others are
still restricted to pockets of project activity, and it is time that their relevance in global
health and related policies be better highlighted, and understood. While replication of
similar models may not be feasible across various socio-cultural contexts, their principles
can easily be modified to suit local realities. The successes bring to the forefront, the
areas that need attention.
Clearly the focus needs to be on ensuring sustained availability of biological resources
and sufficient access to good quality health care for all members of society. In rural
communities, especially in developing countries, both objectives tend to go together
given that to a considerable extent, health care is delivered by the native healers or
70
community health workers within the communitiesusing various biological resources,
in addition to other interventions for the purpose. Given the low reach of modern
doctors and health care facilities and the knowledge and experience possessed by the
local healers, it becomes imperative to involve the latter more actively in health care
delivery systems. This assumes significance in the light of the recent revisit of primary
health care by the WHO. There is also increasing interest among urban populations
seeking alternative health care, and hence, there is relevance in providing a diversity
of choices. However, how such involvement can be accomplished in consonance with
ensuring sustainable use of biological medicinal resources along with good quality and
safe health care services and products has to be appropriately defined. Further, protecting
such knowledge from erosion and misappropriation also needs to be addressed urgently.
Potential Strategies
The above concerns may be addressed through certain focused strategies outlined below:
Assessment methods to inventorize resources and knowledge used in health care
Conduct integrated assessments of biological resources and traditional health
practices in an ecological and community context. This would enable prioritizing
conservation and development strategies and could capture details that may not
figure into mainstream assessments. The inventorizing process would also entail
identification, documentation, participatory and interdisciplinary assessment and
promotion of relevant practices for rural community health and well-being, and
strengthen conservation and sustainable harvest approaches.
Knowledge validation, generation and use Develop and promote appropriate
integrative methodologies for assuring quality, safety and efficacy of traditional
medical practices based on standards within and across medical systems.
Capacity building for different stakeholders Better recognize and integrate
traditional healers through an appropriate and culturally sensitive accreditation
process, coupled with efforts at revitalizing household health and food traditions.
Capacity building is also required in management, collaboration, techniques/
skills for awareness building, research, marketing, etc., among communities,
governments, traditional health practitioners as well as scientists.
Cross-learning between different knowledge systems Enhance traditional medical
education and studies related to biological resources and management through
formal, informal and non-formal learning processes. In addition to this, there is
a need to strengthen policy-relevant research examining various intricacies in the
resourcetraditional knowledgehealthdevelopment domain.
Development of mechanisms for protection of traditional resources and knowledge
Strengthen and promote existing tools, viz., databases and registers that
are sensitive to community values, and at the same time allow innovation and
promote good practices as active social traditions.
71
Linking with economic development objectives It is no surprise that the various
dimensions associated with community health relate to multiple sectors. Promoting
enterprise development based on medicinal and nutritional resources and services,
and development of new, appropriate and feasible technologies that could
enhance productivity, would further complement conservation measures.
Expansion of partnerships with different stakeholders Increase partnerships
at local, national, regional and global levels by supporting/facilitating enhanced
networking among various stakeholders, such as in value chain partnerships, peer
group/learning partnerships among and between peer groups.
Effective communication strategies There is a need for effective communication
strategies to raise awareness of different stakeholders such as governments,
research, industry, consumers and the public.
At the country level, some degree of a comprehensive approach is claimed by civil society
organizations. Although their attempts are dispersed and hardly represent a concerted
nation-wide effort, ways to synergize community initiatives with policy processes, and
identify critical areas of engagement are required.
There is much that is being attempted successfully on the groundindicating that the
various health and biodiversity related goals are achievable. However, these experiences
need to be consolidated and strengthened further for political feasibility, visibility and
momentum. Although not easy, it certainly is a task that is bound to deliver better health
and well-being!
72
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Appendix Collaborators
73
The United Nations University Institute of Advanced Studies (UNU-IAS) is one of
the research and training institutes and programmes of the UN University system. UNU-
IAS conducts research, postgraduate education and capacity development, both in-house
and in cooperation with an interactive network of academic institutions and international
organizations. The institutes research combines the social sciences with some of the
physical and life sciences and is aimed at the development of informed policy-making to
address global concerns.
www.ias.unu.edu
United Nations Environment Programme (UNEP) acts as the voice of the
environment within the United Nations system. It provides leadership and encourages
partnership for the wise use and sustainable development of the global environment.
Among its many activities, UNEP assesses environmental conditions, develops
environmental instruments, strengthens institutions and facilitates the transfer
of knowledge for sustainable development through partnerships with other UN
organizations, governmental and non-governmental organizations, and the private and
civil sectors.
www.unep.org
74
Foundation for Revitalisation of Local Health Traditions (FRLHT) has a vision
of enhancing the quality of medical relief and healthcare in rural and urban India
and globally by creative application of rich medical practices, action oriented research,
education, training and community services based on Indias Traditional Health Sciences
and thus revitalize Indian medical heritage. FRLHT has identified three thrust areas to
fulfill this vision. They are the following:
Demonstrating contemporary relevance of theory and practice of Indian Systems of
Medicine
Conserving natural resources used by Indian Systems of Medicine
Revitalisation of social processes (institutional, oral and commercial) for
transmission of traditional knowledge of health care for its wider use and
application
www.iaim.edu.in
ETC-COMPAS (COMPAring and Supporting endogenous development) is an
international network implementing field programmes to develop, test and improve
Endogenous Development (ED) methodologies. Endogenous development is based
on local peoples own criteria of development, and takes into account the material,
social and spiritual well-being of people. The COMPAS programme is coordinated by
the ETC Foundation in the Netherlands. The network has several CBONGOUniversity
partnerships that focus on the link between revitalizing local health traditions and
sustaining the natural resource base.
www.compasnet.org
75
The Equator Initiative is a partnership that brings together the United Nations,
governments, civil society, businesses, and grassroots organizations to build the capacity
and raise the profile of local efforts to reduce poverty through the conservation and
sustainable use of biodiversity. Started in 2002, the Equator Initiative evolved in response
to: the fact that the worlds greatest concentrations of biodiversity are found in countries
also beset by the worlds most acute poverty; and the evolving trend of local leadership
in advancing innovative projects in biodiversity conservation and poverty reduction. As
sustainable community initiatives take root throughout the tropics, they are laying the
foundation for a global movement of local successes that are collectively making a
significant contribution to achieving the Millennium Development Goals (MDGs), as well
as adapting to and mitigating the effects of climate change. The Equator Initiative is
dedicated to:
Celebrating successful local initiatives.
Creating opportunities for sharing community experiences and good practices.
Informing policy and fostering an enabling environment for local action.
Building the capacity of grassroots organizations to deliver results and scaleup
impact.

www.equatorinitiative.org
References
76
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Health is not a commodity that is given. It must be generated from within. Health action
should not be imposed from the outside, foreign to the people; it must be a response of the
communities to problems they perceive, supported by an adequate infrastructure. This is
the essence of the fltering inwards process of primary health care.
Dr. Halfdan Mahler, Former Director General of WHO
United Nations University
Institute of Advanced Studies
Pacifco-Yokohama, 1-1-1 Minato Mirai
Tel +81 45 221 2300
Fax +81 45 221 2302
Email unuias@ias.unu.edu
URL http://www.ias.unu.edu
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