Role of Traditional Medicine in Primary Health Care

According to World Health Organization (2002: 7), “Traditional medicine refers to health practices, approaches,knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being.”Further the term ʻcomplementaryʼ and ʻalternativeʼ medicine (and sometimes also non-conventional or parallel) are used to refer to a broad set of healthcare practices that are not part of countryʼs own tradition, or not integrated into the dominant healthcare system. Based on this broad definition it may be hard to find a region without some form of TCAM practice. As per the context in which it is practiced or the form of knowledge, often it is called in various ways such as traditional medicine, alternative medicine, complementary medicine, natural medicine, herbal medicine, phyto-medicine, non-conventional medicine, indigenous medicine, folk medicine, ethno medicine etc. Chinese medicine, Ayurveda, Herbal medicine, Siddha, Unani, Kampo, Jamu, Thai, Homeopathy, Acupuncture, Chiropractic, Osteopathy, bone-setting, spiritual therapies, are some of the popular, established systems.Several classifications have been attempted for defining and classifying traditional medicine. It is pointed that there is no homogenous body of medical thought and practice which can be put under one name (Van der geest 1997,Patwardhan 2005) WHO strategy (2002: 8) also makes a similar remark that the term ʻalternativeʼ refer to large heterogeneous categories defined by what they are not than what they are.Whereas there is wide diversity at a practical level, a basic philosophical underpinning of all such knowledge systems is their acceptance of a shared worldview which is an inherent relationship and sharing of key elements between the macro and microcosm─ the outside universe and a living being. Few other common dimensions are ecological centeredness, focus on ʻnon-materialʼ or ʻnon-physicalʼ dimensions, and a comprehensive approach to health, keeping in mind physical, mental, social, emotional, spiritual, ecological factors in wellbeing. Citing the African traditional medicine situation, Van der Geest et al. (1997) points out some of the key unifying features of any traditional medical knowledge as, popular and public domain knowledge relating to self help; a social character; religious dimension; orientation to prevention; and comprehensive concepts of health and illness than in the Western tradition. Further, one can see broad similarities at the theoretical level of traditional medicines such as their focus on functional aspects of health and diseases; systemic understanding of health and disease; multi causality approach; a circular method of cause effect reasoning; subjective, qualitative, individualized and personalized management; preventive focus; attribution of importance to physicianʼs wisdom; etc. Knowledge generation is mostly through subtle observations and experiences within the context i.e. an individual or the nature (Unnikrishnan 2009). Some of these defining features have key policy implications today.

1.1 Forms of Traditional Medical Knowledge

In countries such as India, China and many other parts of Asia one can observe traditional medical knowledge in various forms such as codified medical systems, folk systems, allied disciplines and new systems of knowledge.

1.1.1 Codified Medical Systems

These are also known as great traditions. Ayurveda, Siddha and Unani medical systems in Indian subcontinent or Traditional Chinese medicine and Acupuncture in China, have evolved in a historical period spanning over 3─4 millennia with their own unique worldviews, conceptual, theoretical frameworks and elaborate codified literature. For example the oldest medical text of Ayurveda, Charaka samhita is estimated to be written and redacted through various versions from 1,500 BC─200 AD. Such codified medical traditions have unique understanding of physiology, pathogenesis, pharmacology and pharmaceuticals, which is different from Western biomedicine. These medical systems have been professionalized since last millennia and have been integrated into the national health programs. For instance in India, there is a Central Council for Indian Medicine and there are national institutes for each of the six systems of medicine. The education system is well developed with over 300 university level programs across the country. According to Patwardhan (2005), “historically, terms alternative, complementary or traditional medicine all referred to a genre of health care practices or services that got bound together as a class through the logic of reductio-ad-absurdum, defined by a criteria of ʻabsence from the mainframe of ʼ what has come to be known as modern medicine.” In Ayurveda there are different specialty areas such as kaya cikitsa (general medicine), bala cikitsa (paediatrics), graham cikitsa (psychiatry), urdhvanga cikitsa (ENT and eye), salya cikitsa (surgery), damstra cikitsa (toxicology), jara cikitsa (rejuvenation) and vajikarana cikitsa (sexual and reproductive health) each with unique taxonomy of health and disease. Licensed practitioners are registered under the Indian Medicine Practitioners Act and there are over 9,000 licensed TCAM industries in the country. There is a central research authority with research and development programs on several aspects and the education and practice are regulated under the Indian Medicine Central Council Act 1970.

1.1.2 Folk Medicine

The folk knowledge traditions which are mostly orally transmitted are more diverse, ecosystem and ethnic community specific with household level health practices (home remedies for primary health care, food recipes, rituals, customs), specialized healing traditions like bone setting, poison healers, birth attendants, veterinary healers, general healers etc. These are generated over centuries by communities and use components of ecosystems (plants, animal and mineral/metal derivatives) that are primarily locally available, easily accessible and often cost effective. It varies hugely owing to social, ecological and historical circumstances. Hence, countries with similar ecosystems are often found to nurture similar health practices indicating the strong linkages between environment and health. These are also known as indigenous medicine, ethno medicine, bush medicine, little traditions etc. In most countries where traditional medicine is not formalized, it largely remains in the non-codified folk knowledge form. Diversity, collective ownership guided by customary laws, adaptability to changing contexts and oral transmission are some of the prominent characteristics of this knowledge. Unlike common understanding, it is highly dynamic thus contemporary and not pertaining to a period in time. While knowledge generation and transmission might vary with cultures, there are several similarities in the value systems and modes of transmission of knowledge among communities. Often it is not recognized as ʻvalid knowledgeʼ by scientists as it is combined with beliefs and values.

1.1.3 Allied Forms of Health Knowledge

There are allied forms of health knowledge such as yoga, tai-chi, qigong, kalari, and judo-seifuku, various forms of meditations, breathing techniques, and massage techniques, among many others which are related to wellbeing. Though these are not purely medical systems they have been adapted as health applications and contribute to health sector immensely.

4.Role of Traditional Medicine in Public Health

4.1 Inadequacies in Health System

According to the World Health Organization, one third of the global population has no regular access to essential modern medicines, and in parts of Africa, Asia and Latin America, about half of the population faces shortage of minimum healthcare. Studies on public health in the developing world repeatedly point to inadequacies in health care financing by the states which has led to a situation of highly limited material and human resources for healthcare services. Patwardhan (2005) cites the density of physicians of modern medicine per 100,000 persons in various countries as on year 2004 as: Rwanda 1.9, Ethiopia 2.9, Uganda 4.7, Benin 5.8, India 51.3 and China 164.2. This is in contrast to countries such as Australia and the USA where the figures are 249.1 and 548.9 respectively. This reveals the glaring inequities in health care delivery in developing countries. External resource oriented, foreign technology based and vertically designed healthcare programs have been a major stumbling block for not achieving desired health outcomes in many developing countries. WHO identifies that the main constraints are low literacy and income levels, socio-cultural beliefs and practices, and suboptimal utilization of health facilities. Heavy burden of communicable diseases such as HIV, malaria and other parasitic diseases, pneumonia, diarrhea, tuberculosis, coupled with chronic diseases such as diabetes, ischemic heart diseases etc., (a situation often referred as double burden), persistently torment lives in these countries. High maternal and child mortality, rapid demographic changes and urbanization, under utilization of public healthcare, ineffective health support systems for poor population, increasing privatization of health facilities, migration of medical professionals, environmental changes and related epidemics are some other major public health concerns in such economies. High out of pocket spending on health in countries like India, which is around 78%, and lack of appropriate health insurance or social security are other concerns. Added to this, in the wake of globalization and WTO regime, there is a perceived challenge of increased inaccessibility and unavailability of healthcare to the economically disadvantaged people of such societies (Nambiar et al. 2007). To quote Nambiar et al. further, “a major challenge for health care planners is integrating health promotion and disease

4.2 Relevance of TCAM

In many regions of the world where modern healthcare is not readily available or affordable, public continue to rely on traditional medicines which are based on locally available natural resources and cultural knowledge. In a public health context, availability, accessibility, affordability, utility, quality, efficiency and equity have relevance in respective order in promotion of traditional medicine17). While much of the attention in TCAM sector has been given to address clinical, regulatory and supply oriented issues, there is a general neglect of wider public health dimensions (Bodeker and Kronenberg, 2002). Quantitative research to ascertain levels of existing access (both financial and geographic) and qualitative research to clarify constraints to extending such access are important (WHO 2002). The focus should be for those diseases which represent greatest burden for poor populations. According to Kleinman (2002) health seeking arenas can be classified into three: home level, informal and professional sector. Of this, home level covers 75% and in every 1,000 illness episodes 750 never get outside of family sector and are managed through household means. Rest 25% is divided among professional sector such as hospital, clinics of biomedicine or western medicine, Chinese medicine, Ayurvedic medicine etc., and the non-professionalized, folk sector such as local healers, lay therapists with no institutional support18). Such a classification brings about a picture of the potential interventions of TCAM.

4.3 Health in Own Hands─Importance of Self Help and Home Level Care

Large scale community interventions like home herbal gardens in India have demonstrated that many simple primary health care problems like fever, upper respiratory tract infections, gastro-intestinal problems such diarrhea, dysentery, worm infestations, hepatitis, anaemia, arthritic conditions, and certain gynecological conditions can be managed at household level through simple herbal home remedies and early identification and interventions. Reproductive health and nutrition forms two important aspects of household care. Considerable health cost saving has been found through this program apart from health and nutrition benefits (Hariramamurthi et al. 2007). A similar approach of an efficient household care is the Toyama herbal medicine distributors who traveled across Japan for distributing essential medicines which remains an exemplary model of public health system in rural areas (JOICFP 1983). These and several such models attest to the potential of community interventions through TCAM for simple ailments.

4.4 Role of TCAM in Communicable Diseases

In communicable diseases such as malaria, HIV, traditional medicine has proved its significance. Global incidence of malaria is around 300 million per year leading to mortality as high as 1.124 million and around 40% affected population have no access to effective modern drugs (Wilcox and Bodeker 2007). Two of the major drugs used in malaria management such as quinine and artemisinin are derived from traditional medical knowledge in Peru and China respectively. Traditional medicine is an important source for several such potential drugs for contemporary applications in various infectious diseases. A recent survey showed that 78% of patients living with HIV/AIDS in the USA use CAM medicines (WHO 2002: 14) and similar patterns have been reported in many other developed and developing countries. A number of systematic studies on efficacy are slowly emerging suggesting antiretroviral, immunomodulatory and opportunistic infection reducing effects of traditional management methods

4.5 Role in Chronic Diseases

Longer life expectancy in developed countries as well as newly emerging economies have brought increased risks of chronic, debilitating diseases such as cardiovascular diseases, musculo-skeletal disorders, cancer, diabetes and mental disorders. It is an accepted fact that TCAM is playing an important role in care of such chronic diseases. Systematic studies and wide dissemination of potentials of traditional medicine are required for further popularization of such methods.

4.6 Relevance of Local Healers as Health Care Providers

Folk healers continue to play a key public health role contributing to availability of human resources in countries where the population to physician ratio is high (see Figure 2). Apart from general healers, traditional orthopaedic practitioners, birth attendants, poison healers, spiritual therapists, mental health providers, healers specialized in eye, pediatric conditions, skin diseases etc., are some of the specialty areas. Estimations suggest that around 60% of child deliveries in the world are managed by traditional birth attendants. Though many official policies do not recognize them, more countries are realizing the community health education role that healers can perform.

5.History and Current Status of Health Sector Integration

Various perspectives exist regarding integration of traditional medicine with conventional health sector. From a utilitarian point of view it is thought that knowledge of TCAM can be validated and absorbed for enhancing contemporary medical knowledge. There are several examples of drugs like Artemisia for malaria, salicylic acid for fever and so on of such integration. A syncretic perspective believes in merging together aspects of both systems to form a new system. Complementarity, a popular approach today, is a situation where TCAM plays a supportive role in the health system as it happens to be in many developed countries. A co-evolution perspective thinks that different forms of knowledge evolve simultaneously, in the first place on the basis of their own dynamics and partly as a response to their interaction/dialogue with other forms of knowing. A trans-cultural and transdisciplinary synergy approach advocates that sciences acknowledge that they represent one type of knowledge among others and that knowledge is always culturally embedded and forming part of historic development. Both can benefit from comprehensive interaction. There is also a romantic view wherein TCAM is considered basically ʻgoodʼ and should have the right to remain as it is. There is another view that TCAM is marginalized by conventional medicine in a hierarchical health system. Yet another paternalistic view is that TCAM has to be continuously updated by scientific studies (Haverkort 2006). Among these the utilitarian view remains dominant and many drugs have been developed and integrated based on traditional medical knowledge. In an ʻintegrated systemʼ, TCAM is officially recognized and incorporated into all areas of health care provision which means that it is included in countryʼs national drug policy; providers and products are registered and regulated; therapies are available at hospitals and clinics (both private and public); treatment with TCAM is reimbursed under health insurance; relevant research is undertaken; and education in TCAM is available. Countries like China, Republic of Korea and Vietnam can be considered as having such an integrated system. In an ʻinclusive systemʼ, TCAM is not fully integrated into all aspects as in countries such as Equatorial Guinea, Nigeria, Mali, Canada and India. In a ʻtolerant systemʼ, the national health care is based entirely on allopathy, but some TCAM practices are allowed under law (WHO 2002: 8). The Alma Ata declaration in 1978 at the WHO international conference on primary health care was a milestone policy perspective in integrating TCAM practices which recommended inclusion of proven remedies into national drug policies and regulatory measures. It also ascertained that health is the state of complete physical, mental and social well being and not merely the absence of disease or infirmity, signaling a synergy with TCAM philosophy. Prior to this itself, Asia has seen much progress in incorporating TCAM into national policy which can be models for developed countries (Bodeker 2001: 164). Countries like China from 1950s had incorporated traditional medicine through the famed barefoot doctors program. Critics argue that this has ended in ʻbiomedicalisationʼ and resulted in a diluted form of traditional Chinese medicine. It is also argued that currently health system has transformed into a hierarchical system of pluralism as conventional medicine achieved both structural superiority and functional strength (Lee 1998). In Japan too from the Edo period a well established public health system with traditional medicine integration existed through the Toyama medicine distributors (JOICFP 1983: 2), however this had to give way to allopathic medicine during Meiji restoration era and later traditional medicine was revived in the 1970s owing to high consumer demand. However traditional culture especially related to food and health is well integrated into modern technological development in Japan which is stated as a reason for high life expectancy in the country. In South Asia too traditional medicine development started in early decades of 20th century. India took a pluralistic approach and parallel model where Ayurveda was promoted independently during the post independent period. Though it benefitted traditional medical systems in their self reliant development, they have not been integrated fully into the public health system due to enduring opposition from conventional medicine. While there are WHO policy directives for integration of TCAM at international level, national governments have been slow to respond. At the same time public find appropriate ways to integrate various systems as per need. Researchers have argued that while international bodies and national governments may be enthusiastic about certain ways of integration, communities who are the beneficiaries may be less enthusiastic and maintain differing views about it for a variety of reasons (Vander Geest 1990: 1032). Thus the contradiction between public choices and national policies is evident although a slow change is seen since the last decade as evidenced in the increase in number of countries developing national policies. TCAM which was backed through a consumer or community supported movement in the past, is slowly obtaining state patronage through such proactive national policies.

6.Key Challenges

In the recent decades though there have been certain international and national policies for preserving and promoting traditional medicine, the progress of their implementation has been rather slow. Additionally these policies fall short of adequately addressing a number of concerns related to TCAM such as safety, efficacy, quality, rational use, availability, preservation and development of such health care, sustainable use of natural resources and assuring equity in transactions at various levels and so on (WHO 2002, Bodeker et al. 2007). Lack of sound scientific evidence relating to safety and efficacy, problems in ensuring quality and rational use, inadequate understanding of socio-cultural context of their practice and usage, protection of intellectual property rights of knowledge holders, assuring sustainable natural resource use, regulation and capacity building of non-formal practitioners, developing appropriate methodologies for evaluation, resolving conflicts with mainstream medicine are some of the key challenges in the sector.

6.1 Safety, Efficacy, Quality

Towards the end of 19th century traditional medicine production shifted from a home level production to cottage industry and subsequently to large industrial mass production. For instance, today in India there are over 9,000 registered pharmaceutical industries of various Indian systems of medicine. Though the percentage of large industries is less, quality control is a major challenge. According to WHO, the quantity and quality of safety and efficacy data available on TCAM are far from sufficient to meet the criteria needed to support its use worldwide. This is due to variety of reasons such as lack of proper documentation, appropriate policies and even a suitable research methodology. It is argued that while modern medicine emphasizes on a scientific approach, and content that is value-free and unmarked by cultural aspects, TCAM have developed rather differently with much influence by the culture and historical context in which they first evolved. Their epistemic framework, principles, concepts and practice are quite different from those of Western biomedicine (Shankar et al. 2006). They generally tend to focus on a holistic approach to life, equilibrium between mind and body and the environment and adopt a preventive approach (WHO 2002) thus making it difficult to develop appropriate methodologies without harming these unique features. Moreover issues such as chemical complexity of multiple plant based formulations are also challenges for developing a suitable methodology for research. In popular parlance there is a general understanding that herbal medicines are safe. However reports of toxicity in traditional medicines have been a matter of concern currently. A recent study reported heavy metal content in Ayurvedic herbal preparations sold in the American market and have recommended mandatory toxic heavy metal testing for all herbal products. Researchers argue that such studies are important and needed, however are more related to the quality control failures of the mass manufacturing activities. Often these reports are wrongly interpreted and have a negative implication on the use. Effective quality control and regulation are certainly needed without limiting public access to these preparations or resorting to restrictive trade practice, at the same time ensuring public interest (Patwardhan 2005). There has been no development of alternate standards and methods at any national or international level. Thus there are also differing risk assessments in different regions for TCAM. Like in other products, varying regulations in different countries often create double standards for export and domestic consumption of herbal products especially in developing countries. In many countries usage in tradition is considered a reason for exemption from strict safety regulations for TCAM, which may not be valid in all instances. According to Shia et al. (2007), when traditional medicine is practiced outside its original context and practiced as complementary or alternative medicine, there is a need for increased vigilance due to differing population characteristics, modification of formulations and methods of the transported knowledge. According to WHO, as a general rule evaluation of TCAM should take care of its medical, historical and ethnological background of herbal products and traditional experience of its use. European Union is adopting a ʻtraditional use registrationʼ procedure for herbal medicines. Similarly many other countries are introducing such systems. Safety monitoring for herbal medicines is also increasing. Adverse experiences from plants such as Aristolochia, drug interactions of St. Johnʼs wort and toxicity of Kava-kava have increased awareness among public and scientific community. Under reporting and poor quality of data provided by users are major challenges for regulators (Barnes 2007). Countries with their own traditional medical systems are more likely to measure risks against benefits. Also in countries where TCAM is recently becoming popular, safety is often considered prime compared to efficacy like in the USA (Shia et al. 2005). and lack of awareness about consequences of drug interactions. This fact points to a need to strengthen physician-patient relationship and building awareness about the potentials and likely problems of such therapies both among patients and conventional medical practitioners.

6.2 Rational Use

Information, education and communication are three major pillars of rational use. Qualification and licensing of providers, proper use of products of assured quality, good communication between TCAM providers, allopathic practitioners as well as patients and provision of scientific information and guidance for public (WHO 2002) are some of the key challenges in assuring rational use. Proper consumer information is most important in facilitating appropriate usage of TCAM. WHO has its mission in essential drugs and medicines policy to help save lives and improve health by articulating policy and advocacy positions, working in partnership, producing guidelines and practical tools, developing norms and standards, stimulating strategic operational research, developing human resources and managing information (WHO 2002: 5). A country specific essential drug list for TCAM would facilitate sustainable and prioritized production and consumption of TCAM medicines.

6.3 Education

Two dimensions have been identified as important in education. The first one is to ensure that the knowledge, qualifications and training of TCAM practitioners are adequate. Secondly, there is a good understanding between TCAM practitioners and that of conventional medicine and there is complementarity in the practice. There are various models with respect to education. In some countries TCAM courses are integrated into allopathic medical education. Elsewhere TCAM courses are taught in the same duration and manner in which allopathic courses are designed. In some regions TCAM is taught through short term courses. In many developing countries informal, experiential learning by apprenticing with physicians continues to be the major trend. All of them have their own attendant issues. While little attention may be paid by allopathic students when it is integrated into their curriculum, a university level formal education for TCAM makes it difficult to transfer many of the experience based aspects of tradition in an institutional milieu. For example pulse diagnosis or the understanding of vital points or certain non physical methods of treatments are seldom taught in Indian Ayurvedic universities today. Similarly short term courses also fall short of giving sufficient learning for students about certain experiential elements. While experiential learning through apprenticing with a healer used to be the method traditionally, today it does not find its place in an overwhelmingly formalizing system and due to lack of recognition for those trained in family traditions.

6.4 Accessibility and Cost Effectiveness

Over 50% of deaths in developing countries are due to five infectious diseases. Common communicable diseases are widely prevalent in areas where access to modern drugs is limited (WHO 2002: 24). In the developing countries TCAM continues to be comparatively inexpensive though it is feared that a technology intensive production process would make TCAM unaffordable. For the health sector to improve, measures such as improving physical and economic access, preventive strategies, wellness management, promotion of best and essential practices in both communicable and chronic diseases, increased cooperation between various medical systems, sustainable natural resource use, protection of intellectual property rights, and equitable transactions are vital.

6.5 ”Bio-medicalisation” of TCAM

Formalization of TCAM is resulting in increasing “biomedicalisation” of TCAM practices as they are being integrated into the formal health systems. Fears about safety and efficacy, hierarchical relationship of medical systems, economical and political factors including global dominance of the west, unfamiliarity with TCAM approaches among policy makers, are all playing a negative role in this phenomenon (Bodeker et al. 2007: 76). This contributes to erosion of local knowledge especially relating to non-material or metaphysical aspects, continued marginalization of practitioners, increasing absorption of best drugs and practices into allopathic knowledge and so on. Conflict with formal systems in many countries even those with strong history of TCAM, is a major issue as allopathic professionals in most regions have strong reservations and sometimes total disbelief about the benefits of TCAM (WHO 2002).

6.6 Research

A large number of present modern drugs are from traditional medical knowledge. Experience of drugs like Artemisia, St. Johnʼs wort has boosted confidence among pharmaceuticals to establish the efficacy of other extensively used TCAM therapies (Patwardhan 2005). However recent reviews have shown that clinical trials in TCAM have been scanty and inadequately designed.19) The low level of research has slowed development of national standards and integration efforts. There is an increase in research on TCAM in Japan and China while in other countries research programs have been bare minimum. TCAM therapies and drugs can often be equated with modern surgical procedures without any rigorous clinical trials and are based on individual case reports of patient series. It is said that before randomized clinical trials are taken up, ethnographic, epidemiological, observational, survey and cohort methodologies are important for developing comprehensive research designs. Care should be exercised to be sensitive to the theoretical, clinical and cultural assumptions of the modality or system being evaluation in order to ensure that such research designs adequately measure what one thinks is being studied (Bodeker and Kronenberg 2002: 1589). It is a welcome situation that in some countries, exemption is given to medicines with history of use to pass to the phase three clinical trials with preliminary toxicity studies. Epidemiological and public health mapping exercises are neglected aspects in the TCAM field. They are important to study population based effects of TCAM use as well as creating data on the presence and quality of service by TCAM providers, especially in areas where there is limited access to conventional health care (Bodeker and Burford 2007: 434). There are also insufficient contributions from social sciences to TCAM and most studies consider cultural knowledge as a stumbling block for health sector development. The Chochrane of TCAM found that article indexed as alternative medicine formed only 0.4% of the total number of Medline listed articles for the period of 1966─1996. However this is steadily improving showing a positive trend (WHO 2002: 22).

6.7 Evidence Based Medicine (EBM)

EBM has emerged as an important dimension in modern medical care. The modernist attitude towards traditional knowledge has been as ʻeither modernize or disappearʼ. In a context where the mightiest comes to be identified with the best reason (Couze and Featherstone 2006: 459)20), traditional medicine is in a challenging process of proving itself through a completely different epistemology. However public preferences are moving in a direction where science is not the starting point for health decision making (Terasawa 2004, Janska 2005). It is feared that imposition of EBM, research on selected aspects of TCAM through randomized controlled studies, and the absorption of successful practices as evidence based ʻmodernʼ medicine would result in medical absorption and finally resulting in an erosion of ʻalternateʼ approaches to health.

6.8 Intellectual Property Rights and Equitable Benefit Sharing

Discussions on ownership issues of TCAM have been centered on two major multilateral bodies. The Convention on Biological Diversity and the World Trade Organizationʼs (WTO) agreement on Trade Related Intellectual Property Rights (TRIPS) which advocates exclusive rights on any invention under patents, geographical indications, trade secrets and trademarks and makes no distinction for traditional knowledge. TRIPS take the position that ownership is fully based on registration of innovations. While there are discussions ongoing on how to synergize and find a balance between these two conventions, the topic assumes high importance as researchers and pharmaceutical industries are increasingly looking for better products and commercial applications.

6.9 Natural Resources and Their Sustainable Use

TCAM is highly dependent on biodiversity and there is increasing demand for plants, animal and mineral resources. This has led to a situation of endangering many important medicinal plants. There is still no country wise estimation of medicinal plant diversity, data on cultivated and wild sources and trade data in terms of domestic and export demand. There is also insufficient data on agro-technology of medicinal plants. Variation in active ingredients in plants collected from different agro-climatic locations is also a major problem. Though many countries have initiated efforts of both insitu and ex-situ conservation of medicinal flora and fauna, efforts in this area remain abysmally low and confounded by non-transparency. It is estimated that in countries like India 95 % of medicinal resources are harvested from the wild through unsustainable collection methods. Around 300 medicinal plants in the country have been categorized under different levels of threat status (FRLHT 2002)21). WHO has prepared guidelines on good agricultural practices but the implementation of this has also been low.

6.10 Local Healers

From the local healers point of view lack of successors, erosion of knowledge, conflicts with mainstream knowledge, lack of recognition, restrictive regulations for collection of medicinal materials, lack of adequate intellectual property protection, incompatibility of local ownership values with contemporary laws are some of the key concerns.

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