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Health Challenges Of 21st Century

 

By Koirala, Dr Rishi Ram M.D. (Ayu)
Consultant Ayurveda Physician
Registrar, Council of Ayurvedic Medicine-Nepal
Email:
ayurveda@wlink.com.np

Abstract
Nobody deny that poverty, malnutrition, hunger, poor quality of water and sanitation, injuries and violence, tobacco, indoor pollution, alcohol, unsafe sex etc are major risk factors for burden of diseases in SAARC countries. Lower respiratory, prenatal condition, diarrhea-diseases, TB, asthma, malaria and other infectious diseases are high in these, especially in rural area. Dyeing for any person at any age, especially infants and under five children is still unacceptably high. Life expectancy at birth is very low, especially for female.

 

More than 60% of the population of the world has been using their traditional medicine as a primary form of treatment, however the potential of indigenous treatment methods to improve public health is currently undervalued, which has negative consequences for the quality and equity of global health. If traditional medicine is not adequately integrated into policy frameworks for health care in developing countries, the irreplaceable social capital accumulated over generations will be squandered.

To capture, protect, and commercial exploit the natural resources, medicinal plants, Traditional Medicine and their related intellectual property rights for the overall sustainable growth and development of the member-countries.

Preamble
Health is recognized as a fundamental component of well being. The state of the public health in the world has recorded tremendous progress. In spite of this improvement, the world is suffering today from increasing health gap like the economic gap so glaring between the developed and developing countries. People in the poor countries are suffering from preventable common diseases whereas the people in the developed world are facing the problem of chronic maladies. Like the wide gulf in health services between the rich and poor countries there are noticeable differences between the rich and poor people in all the countries irrespective of their economic status regarding access to health facilities.

Trying to address health issue only from the medical point of view is not only enough but also may be counter productive. Health is a multi-dimensional issue involving social, cultural, economical and political aspects. Moreover each society especially with ancient conventions has their own traditions of health and disease and obviously they have survived for millenniums. Therefore, it is important to give high priority of these values while formulating policies and activities, rather imposing globalization on these societies across the board.

The whole population of South Asia has got a strong tradition of Ayurveda, which has elaborate traditions of how to conduct oneself during the day and different seasons. The population at large still follows a great deal of that tradition. It is evident from the survey I had conducted in 1996 in six mountainous village development areas of Nepal in which not a single qualified medical practitioner was there. The health of the people was fully taken care of by about 300 traditional practitioners who used 150 local plants described in Ayurveda. It shows that the local population has got still a strong dependence on this traditional medicine.

We cannot imagine a situation especially in the developing countries without the use of the traditional medicine and complementary alternatives medicine. It is a must. It is a positive development that the traditional medicine is fast invading the developed society, which is evident from its growing popularity in the countries like US and some European countries.

Health challenges in Nepalese context
Poverty, malnutrition, hunger, poor quality of water and sanitation, injuries and violence, tobacco, indoor pollution, alcohol, unsafe sex etc are major risk factors for burden of diseases in Nepal like in other least developed countries. As result, lower respiratory, prenatal condition, diarrhea-diseases, TB, asthma, malaria and other infectious diseases are high in Nepal, especially in rural area. Reproductive health is still major reason for death of women and children. Dyeing for any person at any age, especially infants and under five children is still unacceptably high. Life expectancy at birth is very low, especially for female.

The geographical and economic realities in Nepal exclude dramatic changes in the existing scenario, and it is inconceivable that the country will be able to expand and afford the health care system as envisaged. Essential drug supply is an important component of basic health care, and currently is insufficient even for the existing health post for more than a few months. Furthermore, it is not likely that the situation will improve in view of the economic indicators of the nation. The irony of the situation is this that the increasing provision of health care facilities simultaneously increases the dependency on the import of drugs.

The numbers of hospitals, nursing homes, health services and medical colleges in private sectors has been increasing year by year and there contribution is remarkable in health sector. The sector has to some extent forced the public sector to remain competitive. The good thing is that the competitive and board-based services are available in qualitative and quantitative terms.

Despite very poor economic condition and difficult geographical structure, the nation has provided primary health care centers for every village development committee. Nepal has getting tremendous success in several programs in health sector especially in immunization, vaccination, family planning, eradication and others. However, overall health status of the nation is still unsatisfactory and extreme lack of essential infrastructure.

Traditional Medicine in 21st Century
Over two decades ago, the WHO made the Alma Ata declaration that there should be an international effort to achieve a level of health for all people that will permit them to lead a socially and economically productive life, by the year 2000. It is now disturbingly clear that this goal has no been reached, and that health discrepancies have been widened in that time.

A potential reason for the failure to achieve “health for all” could be the lack of acknowledgement of traditional medicinal, and the subsequent neglect of a valuable aspect of health care delivery. The incorporation of traditional doctors and medicinal plants into a primary health care is not only cost effective, but utilizes available resources in a socially and culturally sensitive manner.

More than 60% of the population of the world has been using their traditional medicine as a primary form of treatment, however the potential of indigenous treatment methods to improve public health is currently undervalued, which has negative consequences for the quality and equity of global health. If traditional medicine is not adequately integrated into policy frameworks for health care in developing countries, the irreplaceable social capital accumulated over generations will be squandered.

Western science has become more interested in traditional and indigenous knowledge and practices, realizing that they may hold the key to finding useful solutions to current problems, often in combination with modern scientific and technological knowledge. Despite the growing recognition of traditional and indigenous knowledge as a valuable, it has generally been regarded under western intellectual property laws as information in the “public domain”, freely available for use by anybody. Moreover, in some cases, diverse forms of traditional and indigenous knowledge have been appropriated under intellectual property rights by researchers and commercial enterprises, without any compensation to the knowledge's creators or possessors.

The WHO Traditional Medicine Strategy paper 2002-2005 explains that traditional, complementary and alternative medicine attracts the full spectrum of reactions, ranging from uncritical enthusiasm to uninformed skepticism. Yet the use of traditional medicine remains widespread in developing countries. In many parts of the world, policy-makers, health professionals and the public are wrestling with the question about the safety, effectiveness, quality, availability, preservation and further development of this type of health care. Meanwhile, in many developed countries, complementary and traditional medicine is becoming more and more popular. The percentage of the population, which has used complementary and traditional medicine at least once, is 48% in Australia, 50% in Canada, 42% in USA, 38% in Belgium and 75% in France. The multinational companies are far ahead in this field to grab the opportunity.


Traditional Medicine and Nepal
This country is one of the richest in culture, tradition, and knowledge of Ayurveda and traditional health practices. In fact, Ayurveda has a strong cultural and scientific heritage in this country. Nepal eluded foreign invasions in its history and has unique socio-cultural and traditional practices. These practices still exist today, in various different ways such as: ethnic or tribal groups, social, familial, generation to generation, ritual, or ceremonial practices, daily routines or spiritual practices, diets or self-healing practices, traditional healers, yogis, monks, lamas etc among the institutional trained practitioners.

The majority of people in Nepal continue to rely on this system of health care. Ayurveda and the traditional medical wisdom and practices are prevalent in the community and are totally dependent on locally available medicinal herbs, knowledge, technology and their application. The country has contributed many valuable medicinal and aromatic plants, locally termed as jadibuti, and the indigenous people have been using them in traditional ways for their health and economy since time immemorial. This system contributes a major role in the health care system.

Resources of Traditional Medicinal in Nepal
A. Classical manuscripts
:
Ayurveda is a system of health which is based on its basic principles, the consciousness, proto-elemental, time, space, and its evolving theories concepts. It has deep history in taxonomical, pharmacokinetic, pharmacological, and clinical studies of drugs and the findings are used for the detail study of individual constitution, pathological states, disease conditions, drugs, formulations, forms, and dosages. Therefore, these manuscripts are not merely documents of individual records, but they provide widespread theoretical foundation and explanation. There are nearly 4000 copies of hand written manuscripts that exist. These manuscripts are written on leaf, bark and hand made papers. The languages are Sanskrit, Pali, Newari, Nepali and other local languages, and are also recorded in Tibetan language. The contents of these manuscripts are concerned with plants, flowers, food, animals, cosmetics, minerals, tantric, basic principles, life conducts, diseases, yoga, rituals, environment, astrology, crystals, Ayurveda philosophy and more. These authentic manuscripts are the real wealth of this country.

B. Traditional Practitioners/Healers their knowledge, practices, concepts, innovations, technology, and recipes:
These groups of traditional practitioners are deeply rooted in the culture of Ayurveda. They have aspired to reach the cultural values, norms, and respect of the people. They are readily available and work as a member of close relatives or family members. They are capable of managing a diversity of health problems with locally available resources. They are the repository of this culture and science, and are the wealth of the nation. A large number of the population still depends upon these practitioners. Traditional and indigenous knowledge has been used for centuries by indigenous and local communities under local laws, customs and traditions. Fundamentally, they follow Ayurvedic, ethno-botanical, ethno-traditional, tantrik, spiritual and Amchi knowledge. This knowledge has been transmitted and evolved from generation to generation. The estimated number of these practitioners in Nepal is 400,000. Although they are not included in the official system of health care as a health practitioner, their role is highly important. Some of them who are currently practicing are the 23rd generation of practitioners in their family. This generation to generation practice is handed down through the family and also through master-disciple tradition. In a survey done by consultants, it was found that there were four hundred fifty five traditional practitioners identified and interviewed. They were from 142 villages of six Village Development Councils of the Gorkha district. Most of the practitioners were familial with the knowledge passed down through generations

C. Herbal resources
Herbal resources are other forms of Ayurvedic wealth. The geographical structure and advanced bio-diversity has made it possible for the Himalayan country to lodge numbers of valuable medicinal plants. The medicinal and Aromatic database of Nepal covers 1624 species of plants found in wild state or cultivated or naturalized or imported belonging to 938 genera and 218 families. These are known to be used as medicine in Nepal.

As described in Ayurveda, the Himalayan Jadibuti are used for healthy body and happy mind. These are used in different means such as toiletries and cosmetics; incense and aromas; health promoting agents, supplements and medicines; natural manures, pesticides; environmental cleaning and protection; food, food additives and drinks etc

Some realities:

• Herbal resources are one of the major sources of income for those people living in the rural areas of Nepal. People are dependent on it for immediate economic benefit.
• Collection of medicinal herbs, their utilization in local area, raw herb trade in national and international levels, herbal production, extraction and all other herb-base activities are fully dependent on the wild cultivation, except for a few examples.
• No scientific technology and equipment is used for collection by local people and they are not aware of knowledge of harvesting. As a result, unnecessary parts of plants or sometimes whole plants have been collected instead of the required part. For example, if only the roots are needed, they pick up the whole plant; or if only the leaves are required, a whole branch is cut down. It is another reason why the herbs are in danger of extinction.
• Smuggling of valuable and rare species, trading without official registration and recording to save taxes, collection in unfavorable seasons, are also recognized as big problems for herbal resources.
• Production units for the production of various products including Ayurvedic drugs should be actively promoted by establishing manufacturing units in different local areas focusing on availability of herbs. Instead of producing ourselves, we are selling raw materials at a cheap price and purchasing final products made from our own herbs at a substantially higher cost.
• The local plant collectors, even local traders, are not aware of the final destination of their herbs and the actual value. They determine the price of herbs by evaluating the economic situation, not by the medical and other values of the herbs. That is why, instead of a justifiable sharing of benefit, all benefits have been flowing into other’s pockets. This is an evil fate of the poor and innocent Nepalese.
• Careful commercial cultivation of medicinal and aromatic plants as a natural resource needs to occur in order to meet national as well as international demands, and to preserve the natural balance.
• People of Nepalese family have been using indigenous herbs in their kitchens, whether as spices or medicines. The history of microscopic and laboratory research is very recent compared with our ancient manuscripts and practices. If research serves only modern science (as seeing most research is funded by I/NGOs), it will never see the real potential of medical use of our herbs.
• Some of the rare and endangered species of plants are now seriously under threat since they are being patented by developed and powerful countries. This is a result of our individual, institutional and organizational weakness and negligence. We have nationally published important authentic texts on our herbs, but have failed to bring justice to the terminologies, technology and uses of plants related from Ayurveda and traditional knowledge, of which we are practicing in our daily life.
• We do not have the set-up or structure for full pipeline quality control of plants and products, starting from identification, cultivation, harvesting, drying, transporting, and semi-processing, along with related pathological microorganisms, pesticides, chemical fertilizer, heavy metal tests and certification. Even though we possess these capacities, they are not of international standard and no awareness or recognition is given to the producers and collectors. Therefore, we are failing to realize and not utilize the full of value of plants.
• An inconsistent and inappropriate revenue system, which has caused difficulties in the private and general public.


Institution/organization of Ayurveda in Nepal
The institution of Ayurveda is the first health service provider as well as academic health technician-producing institute, whose inception was before the arrival of modern medicine. However, the century old heritage is running at tortoise pace due to extreme lack of responsible and accountable organizations/institutions for preservation, promotion, and development of this sector. They are unable to capitalize on this resource, even in the least amount.

Ministry of Health
In the Ministry of Health, the HMG/N has already set up a focal unit – Ayurveda & Alternative medicine Branch which is responsible to develop necessary planning, policies, rules and regulations regarding all kinds of traditional medicine existing in country and play vital role in corporation, coordination and direction other organization related to TM under the ministry. The following organizations/ institutions are working currently under the ministry.

• Department of Ayurveda: This Department is under the Ministry of Health who looks after government networks of Ayurveda and policy and planning. The constraints of manpower, visionary leadership, budgetary allocation, prioritization of activities, and lack of activity monitoring matrixes has severely damaged the development of this sector. There are 285 services units in the districts and periphery.
• Ayurveda Hospitals: Two Ayurveda hospitals are running in Kathmandu and Dang with all sorts of resource constraints.
• District Ayurveda Health Centers: 55 DAHC throughout the country
• Zonal Ayurveda Dispensaries: 14 ZAD throughout the country
• Local Ayurveda Dispensaries: 216 LAD throughout the country

• Council of Ayurvedic Medicine: Recently this council began its activities for national registration and regulation of Ayurveda professional and traditional healers and academic institutions. Following three categories of professional has been registered.

1. Ayurveda Physicians: Graduates are registered as a full fledged member of the council.
2. Ayurveda Para medicals are registered under a sub-committee of the council.
3. Traditional Ayurveda practitioners are enrolled and licensed for their practice. For this that is having three generations of practicing of Ayurveda and at least minimum of 50 years age groups (deadline is for one year) are eligible for enrolling. Due to this limitation of council, many other traditional healers are not able to get enrollment for licensing practice. The discussion is going on to amend this clause and incorporate training component to upgrade their knowledge and bring them into the main stream.
• Academic Institutions: Ayurveda Institutes: The first formal technical education started in the country was in Ayurveda. In 1928 AD Nepal Rajakiya Ayurveda Vidyalaya was started in Naradevi for the production of Ayurveda manpower i.e. Vaidyas of all levels up to Acharya, equivalent to a Bachelor of the present day standards in contrast to the technical education in the modern system. In spite of the fact that Ayurveda is traditional and that formal education began much earlier than arrival of the modern medical system, since the advent of “democracy” in 1950, the emphasis and all out efforts has been on the modernization and expansion of modern health services. Ayurveda Campus TU is the continuing institute of Ayurveda Vidhyalaya, which is operating under severe constraints of budget and planning. Other training Institutes under MU and CTEVT in the periphery are running only with vested business motives.
• Ayurveda Pharmaceutical Sector: There is one government owned producing unit, Singha Durbar Baidhyakhana Vikas Samiti (started from Malla dynasty 357 years ago with a high reputation in its history) running below capacity and constraints of quality measures. There are 32 other private Ayurveda pharmaceutical companies, with limited capacity and some of them are not functioning all of the time. All these production units are having problems with quality (in all level), and sustainable supply of raw materials. They are lacking in quality production protocols, manpower, and technical assuring measures.
• Other Public, Development Partners’, I/NGO and Private Organizations and Institutions involved in Medicinal plants including NTFP: There is a significant number of institutions involved in this sector. There is minimal coordination within the Ayurvedic sector, which is very important and vital for the overall development of the country and Intellectual property rights issues.

Constraint in TM in country context
Traditional medicine in Nepal is still in shadow due to lack of priority and overall policy, and planning. Policies are formulated without enough exercise and discussion, lack of far-sight-ness, and far behind international standards and trends. Budget allocation makes it impossible to run activities on a long-term basis. Similarly, there is extreme lack of sound interrelationship amongst public, development partners, I/NGOs and private organizations and institutions to develop policies, planning, and research work and services activities. Outcomes of research work- it is difficult to assess the outcomes of all involved institutions/organizations for their contributory role in the over-all development of the country and Intellectual Property rights.

As result, huge amount of national budget has been flowing out for import of chemical as well as Ayurvedic drugs where raw material is being export in cheap cost. Production, manufacturing and marketing organization of Ayurvedic drugs are in huge loss due malfunctioning. Natural resources like medicinal plants, traditional healers, practitioners, manuscripts are in threat of piracy and intellectual property right by powerful countries. Health care services are being dependent to donor countries and commercialized due to random acceptance of globalization.

It has to be appreciated that the country has getting success in certain health programs like family planning, immunization and eradication of several diseases. But, overall status of the country has remain stagnant and there is no real improvement as the government claims.

Strategy for 21st Century in country context

Ayurveda, unfortunately it has never received priority in the nation’s five-year planning and budget allocation for every year, only a repetition of the assurance that “ Ayurveda and Traditional Medical practices and production units will be given priority and developed” as monolog. This sector has been running without sufficient skillful manpower and strong leadership since long time. As a result, the Ayurveda professionals, traditional healers, practitioners, traders, manufactures, are highly frustrated and dissatisfied. The country is loosing its real wealth, many of these resources are in position of extinction, and Ayurveda is unable to capitalize for the sake of overall development.

Focusing on the panic situation, recently in Nepal, an authentic and powerful apex body under the ministry of health has been proposed to be established which is responsible for identification, utilization, protection and development of natural as well as cultural wealth.

Establishment of National Natural Resources, Medicinal Plants and Ayurveda Authority
Objective:
To capture, protect, and commercial exploit the natural resources, medicinal plants, Traditional Medicine and their related intellectual property rights for the overall sustainable growth and development of the member-countries.

To meet the above objective following activities are designed:

A) Establish Documentation, Information Dissemination and Training centers

Documentation:
- Traditional healers, their recipes, and technology.
- Medicinal and Aromatic plants (MAPs) and flora.
- Classical manuscripts (Old and handwritten).
- Recent development and research.
- Properties right activities.

Information Dissemination:
- Therapeutic and other values of medicinal and aromatic plants.
- Research developments, primary health care, diets, practices, environments etc.
- Market its demand and potential.

Training:
- Primary health workers, health professionals, traditional healers, school teachers, students, volunteers and general public, birth attendants, social workers, and women volunteers.
- Other related field professionals and scholars.
- Resource identification, data collection, and protection.
- Quality and sustainable farming, cultivation, growing, harvesting, drying, semi-processing, value adding, storing, transportation, production and trading,
- Inventory of local technology, improving and developing the appropriate technology and skills, and transferring these skills to the local community,
- Preservation of species, and sustainable use of nature, maintaining the environment, and bio-diversity.

B) Research and Development Center
- Operational Research; Traditional knowledge, innovate research, family traditional research, community based research, institutional and industrial research.
- Institutional collaboration, cooperation, goal identification and plan formation.
- Identification of the importance of Nepal’s physiographic position and phytogeographic zones.
- Explanation of the history of plant exploration and recent development in plant science within Nepal.
- Study of the status and value of plant diversity, the protected area system. and occurrence of endemic and threatened plant species.
- Resource conservation for medicinal and aromatic plants.

. C) Intellectual Property Right Research and Development Center
• Identifying and clustering inventions that have distinct possibilities of being commercially worked
• Building and strengthening the core technical and scientific competencies of its various research groups
• Exploiting external and internal technology relationships by creating linkages between participation in national and international research, and development programs to benefit innovation system
• Identifying and documenting traditional knowledge for external protection, or scrutinizing filing of non-original inventions
Capturing the knowledge
• IP declaration form
• The lab note book


Protecting the knowledge
• Decisions regarding patenting
• Keeping IP as a trade secret.
• Drafting the patent application.
• Filing aboard.
• Monitoring the patent application.

Exploiting the knowledge base
• Licensing of IP
• Publicity
• Collaboration with the industries
• Creation of Digital Library
• Research base interventions
• Transliteration

D. Strengthening of the existing Institutions / organization:

• Role identification, and monitoring
• Infrastructure, human resource management, financial and other resources mobilization.

Recommendation:

Integration of Traditional Medicine into the national health care services is a must for the developing countries. Traditional Medicines are more cost effective and reliable and also encourage reducing dependency for donation for health from rich countries. SAARC nations are rich in their traditional medicine and natural resources. The member countries have good future.

It is not impossible to capture Western and American markets if they join hands for collective efforts. Health status of these nations is poor since they are unable to afford the modern medicine. There is no the other alternative except integration of traditional medicine with nation health policy for improvement of health status.

Focusing on this situation, the following activities are recommended for promotion of traditional medicine in SAARC countries.

1. Development of SAARC Herbal Gardens: For the preservation, conservation, development and protection of these natural resources, herbal garden in different altitude of different zone of all countries should be developed so that rare and endanger species could be preserved. Not only for the researchers, scientists, academics and students, would these be wonderful places to visit for herb traders, manufactures and others.

2. Production and trade of Ayurvedic drugs:

3. Exchange programs for students and professionals:

4. Exchange of science and technology:

5. Intellectual Property Right: For the protection of medicinally and commercially valuable plant species, traditional knowledge, technology and product, SAARC countries has to develop a strong policy that can

6. SAARC-Ayurveda Council:


Conclusion

SAARC-Ayurveda Council is an urgent need


REFERENCES:

1. WHO Policy Perspective on Medicines, no 2 May 2002, World Health Organization, Geneva
2. Report of Regional Consultative Meeting, 14-17 Sept 1999, WHO (Regional Office for South-East Asia), New Delhi
3. The Use of TM in Health Care System, 17th Meeting of Ministers of Health of Countries of SEAR, Yangon, Myanmar, 12-14 Sept 1999, South-East Asia region, WHO
4. Health in Nepal-Realities and Challenges, Resource Center for Primary Health Care, December 1997
5. Working Group workshop, 7th May 2002, Towards a Health Sector Strategy, organized by Ministry of Health, Kathmandu
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