Globalisation of medicine: African medicine

I remember asking a history teacher at school why we studied history and I asked a similar question of myself as I researched this article… ‘Why examine the history of African medicine?’…

I am by no means a medical historian, but took on the challenge to compose an FPM article for Black History Month. In my research for the article, I came across the following quote, which I can’t attribute to a particular author…’We study history so that we can know the past, engage in the present and impact the future’. I thought this very apt, for surely this is what we aim to do as FPM physicians?

This article will touch on…

Medical practice development
Historical and present day global and African examples of medical products, instruments and techniques
Medical professional migration
Healthcare research representation for ethnic minorities
Healthcare and medical organisations

Globalisation of medicine

In the present day our practice is influenced by sharing of knowledge, skills and innovation from across the world and has been commonplace for millennia. The need to combat SARS-CoV-2 has bought the need for this cross-fertilisation of ideas to occur at an accelerated rate into sharp focus. Medical curricular are peppered with Greek and Latin terminology, academic institutions, professional organisations and museums across the world display examples of instruments and other items which illustrate how patients have been managed in different cultures and geographies. The UK NHS is one of the world’s largest employers and was set up after WW2; from the outset staff were brought in from across the commonwealth to meet the ambitions of the British Government and demands from UK population, and this practice of now global healthcare professional recruitment has continued to the present day.¹

Framing medical practice

When people move for whatever reason from their country and culture of origin, they take their cultures and ethnic identities with them to the host culture and country. This includes healthcare practices and expectations which may impact not only the individual but family, friends and the wider community. Greater comfort with home or traditional remedies and suspicions about certain Western practices are not unexpected. We must understand why and when this is likely to occur and mitigate against it to ensure we have equity in medicines understanding and usage across diverse, multi-ethnic populations.

I highly recommend visiting the Science museum in London, which now houses the largest medical exhibition in the world². Along with many other institutions this museum is re-examining the way it has developed its collections, in light of increasing awareness of ethnic, racial, gender and other forms of bias, to learn from the past and improve how the museum engages in the future.³

It’s clear that in most of the Western world we have a medical approach which is built on a historic model of European superiority however it is increasingly the case that patients of all ethnicities are seeking out alternative approaches. A prime example is TCM – Traditional Chinese Medicine. Although acupuncture was originally a feature of traditional Chinese medicine, the WHO reports it is now used worldwide; according to reports supplied by 129 countries, 80% of them now recognize the use of acupuncture.^4,5,6 Other practices such as Ayurveda are also increasingly sought out and popular.

Western medicine has been at times dismissive, framed practices in a disparaging manner or conveniently forgotten the contributions from African medical practice.^7,8 The ancient Egyptians practiced medicine with highly professional methods. They had advanced knowledge of anatomy and surgery and treated a range of diseases including dental, gynecological, gastrointestinal, and urinary disorders and could diagnose diabetes and cancer. They used therapeutics extended from different plants to include several animal products and minerals. Some of these plants are still used in the present day. Fortunately, they documented their life details by carving on stone, clay, or papyri. Although a lot of these records have been lost or destroyed, the surviving documents represent a huge source of knowledge in different scientific aspects including medicine.⁹

Traditional medicine (TM) is the sum total of knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures that are used to maintain health, as well as to prevent, diagnose, improve, or treat physical and mental illnesses.

TM that has been adopted by other populations (outside its indigenous culture) is often termed complementary or alternative medicine. Traditional medicine is an important and often underestimated part of health services and has a long history of use in health maintenance and in disease prevention and treatment, particularly for chronic disease. The World Health Organization (WHO) reported that 80% of the emerging world’s population relies on traditional medicine for therapy and over recent decades, the developed world has also witnessed an ascending trend in the utilisation of complementary or alternative medicine, particularly herbal remedies. The WHO traditional medicine strategy 2014–2023 aims to support Member States in developing proactive policies and implementing action plans that will strengthen the role traditional medicine plays in keeping populations healthy.¹⁰

T&CM practices vary widely from country to country with certain practices regarded differently depending on the culture, understanding and accessibility of conventional medicine. In the African Region, TM knowledge and practices have been passed on orally among traditional health practitioners for many generations. In recent years, some countries have strengthened training programmes to develop the knowledge of traditional health practitioners and in some countries TM is included in university curricula for health profession students including various universities in the Economic Community of West African States, Democratic Republic of Congo, South Africa and Tanzania.

Herbal medicines include herbs, herbal materials, herbal preparations, and finished herbal products that contain parts of plants or other plant materials as active ingredients. While 90% of the population in Ethiopia use herbal remedies for their primary healthcare, surveys carried out in developed countries like Germany and Canada tend to show that at least 70% of their population have tried CAM at least once.¹¹

It is likely that the profound knowledge of herbal remedies in traditional cultures, developed through trial and error over many centuries, along with the most important cures, was carefully passed on verbally from one generation to another and modern allopathic medicine has its roots in this ancient medicine. It is likely that many important new remedies will be developed and commercialised in the future from the African biodiversity by following the leads provided by traditional knowledge and experiences.

The extensive use of traditional medicine in Africa, composed mainly of medicinal plants, has been argued to be linked to cultural and economic reasons and the WHO encourages African member states to promote and integrate traditional medical practices in their health system.

Looking ahead… Africa has huge unmet healthcare needs for longstanding complex reasons and we rightly applaud recent long awaited advances such as the malaria vaccine which has taken more than three decades to develop^12,13 – much more investment and innovation is required to bring address the adverse healthcare outcomes that are so commonplace across multiple disease areas. Initiatives by governments, NGOs, industry, regulatory bodies and other parties will be critical to address ever-changing healthcare needs in Africa and other regions with emerging economies. It is clear that a mix of healthcare approaches are required.^14,15

Research and development has a disproportionately low number of black and minority ethnic participants in the US – which is also the case in other countries with diverse populations reflecting both voluntary and forced migration and very few African research centres participate in clinical trials resulting in little data being accrued which reflects these populations across multiple diseases ranging from cancer to COVID-19 and cardiovascular disease. Reasons for this are multiple and often complex including access to healthcare facilities and historical clinical trial wrong-doing amongst others.¹⁶ These populations and their regulatory bodies are increasingly asking for proof of relevance of these medicines to their populations – evidence is often lacking specifically in African people from clinical trials programmes or real-world data collection.^17,18,19,20

Initiatives by governments, NGOs, industry, regulatory bodies and other parties will be critical to address ever-changing and vast unmet healthcare needs in Africa and other regions with emerging economies. Making Medicines in Africa: The Political Economy of Industrialising for Local Health²¹ is a collective endeavour seeking to find ways to link technological development, investment and industrial growth in pharmaceuticals to improve access to essential good quality medicines, as part of moving towards universal access to competent health care in Africa to address the vast unmet health needs of the sub-continent. The authors aim to shift the emphasis in international debate and initiatives towards sustained Africa-based and African-led initiatives to tackle this huge challenge. Without the technological, industrial, intellectual, organisational and research-related capabilities associated with competent pharmaceutical production, and without policies that pull the industrial sectors towards serving local health needs, the African sub-continent cannot generate the resources to tackle its populations’ needs and demands. Research for this book has been selected as one of the 20 best examples of the impact of UK research on development. See https://www.ukcdr.org.uk/what-we-do/impact-success-stories-global-impact-of-uk-research/ for further details.

Policy makers are making some progress… Addis Ababa, 2019: The African Union Heads of State and Government adopted the treaty for the establishment of the African Medicine Agency (AMA) which once ratified by member states will serve as the continental regulatory body that will provide regulatory leadership, to ensure that there are harmonized and strengthened regulatory systems, which govern the regulation of medicines and medical products on the African continent. The Agency will regulate the access to safe, effective, good quality and affordable essential medicines and health technologies. AMA will do this through coordination of on-going regulatory systems, strengthening and harmonizing efforts of the AUC, RECs, Regional Health Organizations (RHOs) and member states, providing regulatory guidance.²²

What can we do as FPM physicians to address these global health challenges?

As pharmaceutical physicians we are often small cogs in a huge machine and it’s easy to see how we could be tempted to continue with a ‘this is too big for me to fix approach’ when the issues of how to ensure the voice of the patient is heard. All patients, wherever they may be and wherever they are from, must be heard and their needs addressed in an equitable manner. Reflecting on some of the huge global events of the last 18 months in particular (the impact of the pandemic, movements for rights of ethnic and racial minorities and climate change) demonstrates how inter-connected and inter-dependent we all are.

It may be that you already have a day job in global health, or with a product that is specifically in global development or marketed for populations that may often be under-represented (including the global South). If you are not in this group is it possible to do more to include increase inclusion and the voice of those who are not often heard, or to broaden the engagement of your colleagues to improve the decision-making? These actins could progress equality, diversity and inclusion in all aspects of our profession, both locally and globally.

Later in the year I shall reflect in an FPM ‘fireside chat’ on whether we can do more as a community of physicians to improve equality, diversity and inclusivity in our day to day practice both locally and globally. Details of this event will be announced soon. Please join me, and contribute to this discussion.²³