Where Covid-19 treatments have divided the world and brought opprobrium to Donald Trump, a controversial African medicine has helped forge some common purpose, writes Fatima Khan
Has the WHO kissed and made up with traditional medicine men and women? Or has it merely realised tough love and tersely worded statements are no way to win hearts and minds?
Witness the subtle change in tone in two statements issued by the World Health Organisation on herbal medicine and Covid-19 in the past few months.
In May the UN-mandated body issued a carefully worded communique, insisting the same rigor in testing and approvals required of conventional medicine be applied to traditional cures. Africans deserved the same high standards as those enjoyed in the rest of the world, it said in what may have been a play for the moral high ground.
This was around the time the Madagascar Cure, an artemisia-based formulation, was getting a lot of attention, including ringing endorsements by the heads of states of Tanzania, Madagascar, Guinea-Bissau, Equatorial Guinea and Gambia. Artemisia annua is a medicinal plant used in the treatment of malaria among other things, but research into its efficacy with Covid-19 is still at an early stage.
Now, some four months later, the WHO has issued a more placatory statement, proclaiming that an expert panel that it helped form had endorsed a protocol for Covid-19 herbal medicine clinical trials.
And there are expectations it will speed the development process.
Professor Motlalepula Gilbert Matsabisa, who chairs the expert committee, said he hopes the generic clinical trial protocol would be immediately used by scientists in Africa.
Matsabisa, who is also the Director of Pharmacology at the University of the Free State, said this would ensure people can benefit from the potential of traditional medicine in dealing with the pandemic.
Dr Ossy Kasilo, of the WHO Africa Essential Medicines staff and regional adviser for traditional medicine, confirmed its Regional Expert Advisory Committee on Traditional Medicine for Covid-19 resolved to endorse the protocols for Covid-19 clinical trials on African traditional herbal medicines at a virtual meeting.
The committee includes representatives of the WHO, the African Union and its agency the Africa Centres for Disease Control, according to a 19 September statement. It follows the launch of the committee in July 2020.
At the time of the May statement, much of the world was in the grip of the pandemic, the search for a cure or treatment had become polarizing. But now, as we appear to be settling into a more pragmatic phase in our Covid-19 journey, in Africa at least, efforts are being made to forge some kind of unity of purpose, to bring the different camps a little closer together.
Heat and light
With a little less heat and a little more light in the debate, some of the issues surrounding the Madagascar Cure, or Covid Organics as it’s also known, have crystallised. These include the traditional medicine versus conventional medicine debate, the way in which traditional healers are viewed, the pros and cons of Artemisia annua and Artemisia afra, and the length of time it can take to do good research.
Nceba Gqaleni, of the Africa Health Research Institute, and an Adjunct Professor at the Durban University of Technology, who is part of a team researching Covid Organics and other African traditional remedies, welcomed the September endorsement, which extends the WHO’s Solidarity protocol to traditional medicines.
The protocol is for therapeutics against Covid-19, established in January 2020. Its overall goal is a large international study designed to generate robust data to “rapidly demonstrate which treatments are the most effective”.
Gqaleni said until now there had been no clinical trial protocol to support multi-country clinical evaluation of traditional medicine for Covid-19, except for the Solidarity protocol for repurposed drugs.
“The September 2020 resolution makes for ease of approval of clinical trials by regulatory authorities in each country where a clinical trial will take place through sharing such expertise of designing a standard protocol. Of course each medicine will have its nuances that need to be addressed,” says Gqaleni.
It’s not like the latest resolution marks a change of heart for the WHO, though. It has long sought to work with traditional medicine, but on terms. Its General Guidelines for Methodologies on Research and Evaluation of Traditional Medicine protocol has been in place since the 1990s. It seek to harness traditional treatments, while stressing the need for quality, safety and efficacy.
The resolution is also part of efforts to manage an old conflict between advocates of conventional and traditional medicines. Although in a way this is a false dichotomy: it needn’t be either or, say many academics.
And the WHO’s May warnings against products “that have not been robustly investigated” and were “distracting” from prevention measures although addressed to an African audience find a familiar echo in the rebuke it issued to proponents of other unproven conventional medicine therapies, like hydroxychloroquine, the Donald Trump favourite.
Amid all this, sometimes overlooked is the extent to which many of the medicines we use today have ancient histories.
The willow tree’s medicinal use, for example, was first documented in the Ebers papyrus, circa 1500 BC.
Salicin, which originated from the willow, provided the inspiration and basis for the purely synthetic drug we call aspirin today.
Then again, it’s not solely about whether a folk medicine works or not, but the proper manner in which it should be used. This is a concern for both the conventional and traditional camps.
When reports surfaced in July this year of people abusing Artemisia afra, the Traditional Healers Association warned against its misuse “without the instructions of indigenous knowledge holders”.
Artemisia afra, also known as African wormwood, lengana, wilde als and umhlonyane, is found widely in South Africa. It is among the country’s most popular medicinal plants and used by people of many cultures.
Which takes us back to the Madagascar Cure.
“For reasons of trade secrets or protection of intellectual property, Madagascar has not disclosed all the contents of their formulation except for one ingredient that has been in the public domain,” Gqaleni said.
That ingredient is the Artemisia annua plant, also known as sweet wormwood.
Surprisingly, Roving Reporters found that among the healers we canvassed, there was debate about whether Artemisia annua or Artemisia afra was the plant du jour.
The same debate was taking place among scientists who use plants as the starting point for developing treatments.
There appears to be at minimum two routes which scientists could employ if they were using traditional medicine as a starting point towards potential Covid-19 treatments. The routes would involve either pure compounds or plant extracts containing a mixture of compounds.
Among researchers in the drug discovery and pharmacology fields, there is a strong respect for the traditional healing approach, but with caveats.
Professor Kelly Chibale, the Department of Science and Innovation South Africa Research Chair in drug discovery, says traditional medicine has an important role to play, but more rigour was required.
“We must respect traditional healers, and not dismiss them,” says Chibale, who is based at the University of Cape Town, adding, “We must take traditional medicine as a serious starting point for further scientific investigation. We should gather data that will prove or disprove any claims made regarding traditional medicine.”
Large-scale human clinical trials were needed to establish efficacy and safety, including optimising the correct dosage and dosage intervals, duration of treatment and long-term safety, he said.
Abroad, researchers from the Max Planck Institute of Colloids and Interfaces, in Potsdam, Germany, were collaborating with ArtemiLife, a US based company.
Along with medical researchers in Denmark and Germany, they were testing pure artemisinin and extracts from Artemisia annua for activity against Sars-CoV-2.
The national director of the Indigenous Knowledge-Based Technology Innovation Unit of the South African Department of Science and Technology, Dr Aunkh Chabalala, confirmed research is being done on Artemisia afra and Covid-19. The research is multi-faceted and encompasses soil and agronomical sciences, phytochemistry, pharmacology, in-vitro studies, pre-clinical and clinical studies.
Gqaleni and Chabalala use the approach of reverse pharmacology.
Chabalala, who is also an applied epidemiologist, said, “The main objective of ‘reverse pharmacology’ is to scientifically develop safe, efficacious and high quality natural medicines while appreciating prior and documented indigenous knowledge used for known diseases.”
While developing natural medicines in a systematic manner reverse pharmacology also shortens the route from research to market or commercialisation. This includes the clinical application of the natural products.
Chabalala emphasised that most African medicines are multi-herb formulations rather than made with a single herb.
“It’s a rare and unique opportunity I have to use science to unearth the gems in our traditional medicines and indigenous knowledge,” Gqaleni said.
But how long would we have to wait for the results of the research?
Chabalala says it is difficult to say when the results of their research will be available, but he was optimistic preliminary data should be available by the end of the year.
With the generic clinical trial protocol for herbal medicines, endorsed by the WHO, hopefully, we’ll get results sooner. – Roving Reporters
- Fatima Khan is an associate editor of Roving Reporters. She has a background in laboratory research and education.