Ethical considerations in African traditional medicine: a response to Nyika

Like other so-called 'parallel' practices in medicine, traditional medicine (TM) does not avoid criticism or even rejection. Nyika's article 'Ethical and Regulatory Issues Surrounding African Traditional Medicine in the Context of HIV/AIDS' looks at some of the issues from a traditional Western ethical perspective and suggests that it should be rejected. I respond to this article agreeing with Nyika's three major criticisms: lack of informed consent, confidentiality and paternalism. However, as traditional healers are consulted by over 70% of South Africans before any other type of healthcare professional, a blanket negation of TM is not possible, nor is it politically feasible. A pragmatic approach would be to work within the current structures for positive change. I point out that, as all cultural practices do, TM will change over time. Yet, until some regulations and change occur, the problem of harm to patients remains a major concern.     

Ethical and regulatory issues surrounding African traditional medicine in the context of HIV/AIDS

It has been estimated that more than 80% of people in Africa use traditional medicine (TM). With the HIV/AIDS epidemic claiming many lives in Africa, the majority of people affected rely on TM mainly because it is relatively affordable and available to the poor populations who cannot afford orthodox medicine. Whereas orthodox medicine is practiced under stringent regulations and ethical guidelines emanating from The Nuremburg Code, African TM seems to be exempt from such scrutiny. Although recently there have been calls for TM to be incorporated into the health care system, less emphasis has been placed on ethical and regulatory issues. In this paper, an overview of the use of African TM in general, and for HIV/AIDS in particular, is given, followed by a look at: (i) the relative laxity in the application of ethical standards and regulatory requirements with regards to TM; (ii) the importance of research on TM in order to improve and demystify its therapeutic qualities; (iii) the need to tailor-make intellectual property laws to protect traditional knowledge and biodiversity. A framework of partnerships involving traditional healers' associations, scientists, policy makers, patients, community leaders, members of the communities, and funding organizations is suggested as a possible method to tackle these issues. It is hoped that this paper will stimulate objective and constructive debate that could enhance the protection of patients' welfare.     

Perceptions and uses of Chinese medicine among the chinese in Hong Kong

The present paper was based on both qualitative observations and quantitative survey data. Major findings are as follows: (1) The sacred or magical-religious tradition of Chinese medicine is accepted by a relatively small portion (roughly one-fifth) of the ordinary Chinese people in urban Hong Kong, and is relatively more popular among women or less educated people. (2) Both the classical-professional and the local-empirical traditions of secular medicine are resorted to by many Chinese people (over one half) either for treating diseases or for strengthening their constitution. The acceptance of secular Chinese medicine does not vary significantly among different sex, age, education, or income groups. It should be noted that secular Chinese medicine is often used in addition to or in combination with modern Western medicine. (3) It appears that most people are more confident in the Chinese medical tradition than in Chinese-style practitioners in Hong Kong, and that people's confidence in secular Chinese medicine has been increasing in recent years. (4) There are reasons for the confidence in secular Chinese medicine. Chinese medicine is generally perceived to be better than or as good as Western, scientific medicine in some ways, such as for tonic care, for fewer side effects, for curing the cause (not symptoms) of diseases, and for treating certain diseases. Therefore, to ordinary Chinese people, Chinese and Western medicine may perform either equivalent or complementary functions. (5) As regards the process of seeking medical care, most people seem to follow the pattern of moving from self-medication, using Chinese and/or Western home remedies, to Western-style doctors, to Chinese-style practitioners, and finally to a Western medical hospital. Policy and theoretical implications of these findings are discussed.     

Herbal medicine use in the districts of Nakapiripirit, Pallisa, Kanungu, and Mukono in Uganda

ABSTRACT: BACKGROUND: Traditional medicine (TM) occupies a special place in the management of diseases in Uganda. Not with standing the many people relying on TM, indigenous knowledge (IK) related to TM is getting steadily eroded. To slow down this loss it is necessary to document and conserve as much of the knowledge as possible. This study was conducted to document the IK relevant to traditional medicine in the districts of Mukono, Nakapiripirit, Kanungu and Pallisa, in Uganda. METHODS: An ethnobotanical survey was conducted between October 2008 and February 2009 using techniques of key informant interviews and household interviews. RESULTS: The common diseases and conditions in the four districts include malaria, cough, headache, diarrhea, abdominal pain, flu, backache and eye diseases. Respondents stated that when they fall sick they self medicate using plant medicines or consult western-trained medicine practitioners. Self medication using herbal medicines was reported mostly by respondents of Nakapiripirit and Mukono. Respondents have knowledge to treat 78 ailments using herbal medicines. 44 species, mentioned by three or more respondents have been prioritized. The most frequently used part in herbal medicines is the leaf, followed by the stem and root. People sometime use animal parts, soil, salt and water from a grass roof, in traditional medicines. Herbal medicines are stored for short periods of time in bottles. The knowledge to treat ailments is acquired from parents and grandparents. Respondents' age and tribe appears to have a significant influence on knowledge of herbal medicine, while gender does not. CONCLUSION: This survey has indicated that IK associated with TM stills exists and that TM is still important in Uganda because many people use it as a first line of health care when they fall sick. Age and tribe influence the level of IK associated with herbal medicine, but gender does not.     

A critique of race-based and genomic medicine

Now that a composite human genome has been sequenced (HGP), research has accelerated to discover precise genetic bases of several chronic health issues, particularly in the realms of cancer and cardiovascular disease. It is anticipated that in the future it will be possible and cost effective to regularly sequence individual genomes, and thereby produce a DNA profile that potentially can be used to assess the health risks for each person with respect to certain genetically predisposed conditions. Coupled with that enormous diagnostic power, it will then depend upon equally rapid research efforts to develop personalized courses of treatment, including that of pharmaceutical therapy. Initial treatment attempts have been made to match drug efficacy and safety to individuals of assigned or self-identified groups according to their genetic ancestry or presumed race. A prime example is that of BiDil, which was the first drug approved by the US FDA for the explicit treatment of heart patients of African American ancestry. This race-based approach to medicine has been met with justifiable criticism, notably on ethical grounds that have long plagued historical applications and misuses of human race classification, and also on questionable science. This paper will assess race-based medical research and practice in light of a more thorough understanding of human genetic variability. Additional concerns will be expressed with regard to the rapidly developing area of pharmacogenomics, promoted to be the future of personalized medicine. Genomic epidemiology will be discussed with several examples of on-going research that hopefully will provide a solid scientific grounding for personalized medicine to build upon.     

Towards the scientific validation of traditional medicinal plants

A large proportion of the population of developing countries usestraditional medicine alone, or in combination with Western drugs to treat awide variety of ailments. There has seldom been effective collaborationbetween the traditional and Western medical practitioners, largely due tothe perception that the use of traditional and herbal medicines has noscientific basis. With the renewed interest from Western countries in herbalremedies, and the increasingly urgent need to develop new effective drugs,traditionally used medicinal plants have recently received the attention ofthe pharmaceutical and scientific communities. This involves the isolationand identification of the secondary metabolites produced by the plants andused as the active principles in medical preparations. Research into thescientific validation of southern African medicinal plants used in thetreatment of pain and inflammation, hypertension and parasitic diseasesincluding those with anthelmintic, anti-amoebic, anti-bacterial and anti-bilharzia activity, is the current focus of studies conducted at the ResearchCentre for Plant Growth and Development.     

Sex and gender in medicine

Gender specific medicine is a part of gender-research, which has been insufficiently considered up to the present in medicine, sanitation and politics. Part of the scientific medicine simply ignores the knowledge that men and women are different in feeling, thinking and social acting without any question. Doctors often incline to treat all their patients as if there was just one gender: i.e. the male one. It is without dispute that men and women vastly suffer from the same diseases, but they often go through them quite differently. The female body seems to work differently from the male one in nearly all respects--starting with the brain, going on with the heart, cardiovascular, lungs, stomach and intestines and ending up with the skin and immune order. Identical cases of illnesses bring about different symptoms on both sides. Therapeutics therefore have to be appropriate for the specific gender. This however demands complete thinking in preventive measures, therapy, development of one's education and research. Exactly for this reason the new "gender-model" is absolutely important and necessary in medicine as a new pattern of thinking. Only in this way one can realize a comprehensive revaluation of health and disease of both sexes. Pre-eminently one has to convince people that the embedding of "gender" both in medicine and the surrounding area is much more useful than costly from the scientific, political and individual point oft view.     

Quantifying the Trade in Cycads (<Emphasis Type="Italic">Encephalartos</Emphasis> Species) in the Traditional Medicine Markets of Johannesburg and Durban,South Africa<Superscript>1</Superscript>

Quantifying the Trade in Cycads ( Encephalartos Species) in the Traditional Medicine Markets of Johannesburg and Durban, South Africa. Cycads have been used for traditional purposes for centuries, mainly as a source of starch during droughts and famines. In South Africa, Encephalartos species are traded for traditional medicine (TM) in local TM markets. The 2009 IUCN Red Data assessment for South African flora lists 78% of the 37 indigenous Encephalartos species as “Threatened”, with three species already “Extinct in the Wild” (EW). South African cycads face an extinction crisis, primarily due to collecting for the horticultural trade. The trade in Encephalartos for TM also has a significant impact on several species, and is largely understudied. In this paper, the trade in Encephalartos for TM was quantified in South Africa’s two largest TM markets, Faraday in Johannesburg and Warwick in Durban. Harvesting of South African Encephalartos for TM involves the removal of bark strips and/or whole stem sections. Encephalartos species were sold at 26% and 13% of the stalls at Faraday and Warwick, respectively, with an estimated 9.0 metric tons traded at Warwick in 2009. Stem samples purchased in the markets were assigned to stem diameter size classes using a size class chart, and regression analysis was used to validate the allocations. Most harvesting was from sub-adult and adult cycads, and it appears that bark strips are removed from large arborescent plants, whereas smaller individuals and subterranean-stemmed species are harvested by removing the entire plant. There is generally a positive relationship between stem diameter and leaf base length as well as stem diameter and pith radius. The former can be used as a predictor of stem diameter size class for market samples that prove difficult to assign to diameter classes using the chart. Overall, this is the first study to quantify the trade in Encephalartos for TM in South Africa with reference to the size classes of the plants traded.     

转化医学研究中生命伦理学辩护的现况分析与前瞻思考

转化医学作为一门新兴学科,运用多学科交叉策略来推动医学发展,从临床实践中发现问题,将其凝练成科学问题进行基础医学研究,再将研究成果应用到疾病诊断、治疗和预防过程中,使其真正发挥作用,是一个从基础医学到临床应用的双向进程。转化医学已逐步融入各个学科,并在干细胞研究、生物标志物、细胞信号转导、药物及器具研发及个体化医学等各个领域发挥重要作用。随着转化医学研究深入,一些临床试验势必对人体存在一定伤害和潜在危险,存在各种伦理问题。虽说科学研究与伦理道德是一对相互冲击的矛盾,但两者在总体上又是一致的,共同决定着社会前进步伐。科研的重大进步必然会对伦理道德提出更高要求,而伦理道德的高标准又规范、引导、促进科学研究朝着正确方向迈进,两者相辅相成。鉴于伦理辩护对于转化医学研究强有力的支撑,建议在转化医学研究中能进一步完善伦理监管体系,发挥机构伦理委员会的功效,持续加大伦理培训的力度,强化研究人员的伦理道德修养,从而为转化医学的发展夯实人文基础。     

Evidence-based medicine,opinion-based medicine,and real-world medicine

The freedom of a doctor to treat an individual patient in the way he believes best has been markedly limited by the concept of evidence-based medicine. Clearly all would wish to practice according to the best available evidence, but it has become accepted that "evidence-based" means that which is derived from randomized, and preferably double-blind, clinical trials. The history of clinical trial development, which can be traced to the use of oranges and lemons for the treatment of scurvy in 1747, has reflected a progressive need to establish whether smaller and smaller effects of treatment are real. It has led to difficult concepts such as "equivalence" and aberrations such as "meta-analysis." An examination of evidence-based practice shows that it has usually been filtered through the opinions of experts and journal editors, and "opinion-based medicine" would be a more appropriate term. In the real world of individual patients with multiple diseases who are receiving a number of different drugs, the practice of evidence-based (or even opinion-based) medicine is extremely difficult. For each patient a judgment has to be made by the clinician of the likely balance of risks and benefits of any therapy. Good practice still requires clinical freedom for doctors.     

Behavioral convergence and institutional separation: An analysis of plural medicine in Sri Lanka

In Sri Lanka, as in India, two formally structured systems of medical service exist side-by-side. While Western-style biomedicine is believed to be useful, Ayurvedic medicine is also well established and commonly used. Underlying one explanation for the existence of plural medical systems is the idea that traditional and Western systems of medicine provide unique treatments for distinct problems, and patients having certain characteristics select them accordingly. A brief review of several studies in Sri Lanka suggests, however, that Western and Ayurvedic physicians practice medicine in similar ways, are selected for treatment of very similar symptoms, and from the patient's point of view are aften indistinguishable from each other. A second structural explanation rests on the fact that, as institutions, Western and Ayurvedic medicine have effectively divided up territory and jobs to the satisfaction of each; this division allows for upward mobility, through medicine, for young people from different segments of society. Thus these medical systems persist, not because each provides something unique for patients, but because they provide access to status and power for the physicians themselves.     

From traditional Chinese medicine to rational cancer therapy

Many natural products and derivatives thereof belong to the standard repertoire of cancer chemotherapy. Examples are Vinca alkaloids, taxanes and camptothecins. In recent years, the potential of natural products from plants, notably from medicinal plants used in traditional Chinese medicine (TCM), has been recognized by the scientific community in the Western world. To provide an example of the most recent developments in this field, we have selected several compounds, namely artesunate, homoharringtonine, arsenic trioxide and cantharidin, that are found in natural TCM products and that have the potential for use in cancer therapy. Controlled clinical studies have shown that homoharringtonine and arsenic trioxide can exert profound activity against leukaemia. Increased knowledge of the molecular mechanisms of TCM-derived drugs and recent developments in their applications demonstrate that the combination of TCM with modern cutting-edge technologies provides an attractive strategy for the development of novel and improved cancer therapeutics.     

Metabolomics study of diabetic retinopathy using gas chromatography-mass spectrometry: a comparison of stages and subtypes diagnosed by Western and Chinese medicine

Diabetic retinopathy (DR) is a serious microvascular syndrome of diabetes, and is one of the most frequent causes of blindness in the world. It has three progressive stages with complex metabolic deregulations in the holistic system of Western medicine. Chinese medicine classifies DR into two different syndrome types; integrating Western and Chinese medicine to treat DR is a validated therapeutic approach in China. In this research, the systemic metabolite change of DR was investigated from the viewpoint of both Western and Chinese medicine, using metabolomics based on gas chromatography-mass spectrometry. The data revealed both perspectives can reflect the metabolic patterns, development and differentiation of DR, and the data also had good correlation and complementarity in characterizing the process of DR. Potential biomarkers of DR based on the two perspectives indicated the alterative modes of metabolites and metabolic pathways in the disease, e.g. the disturbance in fatty acids, amino acids and glucose, etc. The results showed the usefulness and validity of combining both Western and Chinese medicine to study the subtypes of DR and the mechanisms involved.     

Health in China. Traditional Chinese medicine: one country,two systems.

China is the only country in the world where Western medicine and traditional medicine are practised alongside each other at every level of the healthcare system. Traditional Chinese medicine has a unique theoretical and practical approach to the treatment of disease, which has developed over thousands of years. Traditional treatments include herbal remedies, acupuncture, acupressure and massage, and moxibustion. They account for around 40% of all health care delivered in China. The current government policy of expansion of traditional facilities and manpower is being questioned because many hospitals using traditional Chinese medicine are already underutilized and depend on government subsidies for survival. Research priorities include randomised controlled trials of common treatments and analysis of the active agents in herbal remedies. As more studies show the clinical effectiveness of traditional Chinese medicine, an integrated approach to disease using a combination of Western medicine and traditional approaches becomes a possibility for the future.     

转化医学：现代医学发展的动力

Translational medicine is a class of medicalresearch that proposes a two-way interaction betweenlaboratory and clinical research[1].Elias A.Zerhouni,the director of the National Institutes of Health(NIH),     

Transfusion medicine in the era of proteomics

Blood components (BCs) are highly complex mixtures of plasma proteins and cells. At present, BC and blood derivatives (BDs) quality control is mainly focused on standardized quantitative assessment, providing relatively limited information about products. Unfortunately, during the production, inactivation, and storage processes there is the risk of changes in their integrity, especially at the protein level, which could cause negative effects on transfusion. It is therefore a major challenge to identify significant alterations of these products, and, in this context, proteomics can play a potentially relevant role in transfusion medicine (TM) to assess the protein composition of blood-derived therapeutics, particularly for identifying modified proteins. It can provide comprehensive information about changes occurring during processing and storage of BCs and BDs and can be applied to assess or improve them, therefore potentially enabling a global assessment of processing, inactivation and storage methods, as well as of possible contaminants and neoantigens that may influence the immunogenic capacity of blood-derived therapeutics. Thus, proteomics could become a relevant part of quality-control process to verify the identity, purity, safety, and potency of various blood therapeutics. A more detailed understanding of the proteins found in blood and blood products, and the identification of their interactions, may also yield important information for the design of new small molecule therapeutics and also for future improvements in TM.

Proteomics, together with genomics in the near future, will presumably have an impact on disease diagnosis and prognosis as well as on further advances in the production, pathogen inactivation and storage processes of blood-based therapeutics.     

Conscientious objection in healthcare: How much discretionary space best supports good medicine?

Daniel Sulmasy has recently argued that good medicine depends on physicians having a wide discretionary space in which they can act on their consciences. The only constraints Sulmasy believes we should place on physicians’ discretionary space are those defined by a form of tolerance he derives from Locke, whereby people can publicly act in accordance with their personal religious and moral beliefs as long as their actions are not destructive to society. Sulmasy also claims that those who would reject physicians’ right to conscientious objection eliminate discretionary space, thus undermining good medicine and unnecessarily limiting religious freedom. I argue that, although Sulmasy is correct that some discretionary space is necessary for good medicine, he is wrong in thinking that proscribing conscientious objection entails eliminating discretionary space. I illustrate this using Julian Savulescu and Udo Schuklenk’s system for restricting conscientious objections as a counter‐example. I then argue that a narrow discretionary space constrained by professional ideals will promote good medicine better than Sulmasy’s wider discretionary space constrained by his conception of tolerance. Sulmasy’s version of discretionary space would have us tolerate actions that are at odds with aspects of good medicine, including aspects that Sulmasy himself explicitly values, such as fiduciary duty. Therefore, if we want the degree of religious freedom in the public sphere that Sulmasy favours then we must decide whether it is worth the cost to the healthcare system.     

Programme for specialization in family medicine

A programme for specialized training in family medicine at Tel Aviv University Medical School provides four years of postgraduate study, two of which are in recognized hospital departments and two in clinics recognized for training in family medicine. At the end of this four-year period the graduate must submit a thesis of original work or an approved research project on an aspect of family medicine. Continuing contact of the trainee with both the family medicine clinic and the hospital departments is maintained throughout the period. While in hospital the trainee spends half a day a week in the family clinic with his personal tutor, and when in the clinic he spends half a day a week in the hospital.This programme has been provisionally accepted as meeting the formal requirements of the Israel Medical Association for specialization in family medicine, and the first physician has started training.