History

	Research in traditional medicine has been encouraged and sponsored by the government since the beginning of this century, with varying emphases and degrees of enthusiasm in different periods. In general, attitudes of researchers and research institutions towards traditional medicine and its practitioners have become more sympathetic, and, understandably, more rational.
	In the Sudan, modern medicine, though no more than 80 years old, has made major changes in everyday life. Up-to-date, however, facilities are unevenly distributed, and, even when they are available, are either difficult to reach, or not the first choice of the ill or their attendant relatives. Even now, between 75% and 85% of the entire population of Africa rely almost entirely on traditional medicine. In fact, recent alarming figures in some countries show that as little as only 5% of the entire population care to avail themselves of Western medicine in the hospitals and clinics in African cities.[1] Similarly, over eighty percent of deliveries all over the world are said to take place outside medical establishments. Authentic figures for the Sudan are not available. Nonetheless, traditional medicine and its practitioners have generally been kept away from the main stream of modern biomedicine.
	In the first years of the British reconquest of the Sudan in 1899, the colonial power recognized the importance of research that will help in understanding the country and its people better.[2] A lot of ethnographical and anthropological work was conducted among the various ethnic groups of the country by government expatriate staff, many occupied unique posts and established, over time, intimate relations with the Sudanese. During their stay, either of personal initiative or following directives of the Government, observed, recorded and reported various customs including medical practices and beliefs. Also as early as 1903, the Wellcome Research Laboratories in Gordon Memorial College, Khartoum, directed attention to the need to facilitate the investigation of poisoning cases by the experimental determination of toxic agents, particularly the obscure potent substances employed by the local people. Consequently, several pioneering reports on native medical practices in different parts of the Sudan were published. Other studies covered subjects such as the fauna and flora of the country, food, water, hygiene, sanitation, customs and habits affecting health.[3] In addition, the Wellcome Laboratories contained a museum that collected various artifacts: surgical instruments, splints, amulets, and other local articles relevant to health and disease.
	Sanderson reviewed the material that was published in the Sudan Notes and Records since its inception in 1918 until 1964. He noted that the articles that were related to medicine were published before 1948, and that they were mainly on traditional medical lore.[4] However, even these were too few to mention: Ahmad Abd Al-Halim’s article on local medicine in the northern Sudan,[5] and Hussey’s description of a faki’s clinic in Muslim Sudan.[6] Other traditional medical data is included in the anthropological and ethnographic accounts of the different tribes of the Sudan. The Sudan Medical Journal, the sole organ of the medical profession, testifies to the lack of interest of Sudanese scholars in traditional medicinal lore. Apart from three articles by Ahmad Abu Al-Futuh Shandal,[7] Munir Beiram,[8] and M. A. Haseeb nothing else of note appeared in this journal.
	A number of expatriate staff developed interest in Sudanese customs while conducting their official duties, and contributed substantially to our understanding of certain customs and practices. Notable of these are Ina M. Beasley,[9] Miss Elaine Hills-Young,[10] and Miss Mabel Wolff. All of whom contributed actively in the campaign for the eradication of female circumcision and other harmful female practices.

Recent activity

	In the seventies, more organized laboratory research started. Its main objectives were to validate claims of efficacy that healers attributed to their medicinal recipes, and to analyze medico-legal samples that had been collected in cases of injury or death, which were suspected to be due to poisoning. Other studies dealt with theories and concepts of traditional medicine, its clientele, the healers’ roles, and the national materia medica.
	In 1977 the WHO eastern Mediterranean Advisory Committee on Biomedical Research reported that traditional medicine was one of the resources of the region that had received scant attention. It consequently recommended the exploration of means of incorporating traditional healers within the health service. Also several WHO resolutions were passed in 1978 at the 31st World Health Assembly (WHA) regarding the promotion of traditional medicine.[11] These resolutions initiated a general programme to promote and support the use, development and adaptation of diagnostic, therapeutic and rehabilitative technologies, and the proper use of medicinal drugs, appropriate for specific national systems and institutions.[12]
	The programmes of the Organization of African Unity (OAU) on traditional medicine, also regarded the matter as one of high priority.[13] The Scientific, Technical and Research Commission (STRC) of the OAU held a conference on African medicinal plants and Pharmacopoeia in Dakar (Senegal) in 1968. The conference resolved that efforts should be directed by African scientists towards finding scientific evidence for the efficacy or otherwise of traditional medicines. For its part, STRC assists in research in that field, organizes conferences and publishes a specialized journal called Journal of African Medicinal Plants and a newsletter.
	The Association of Medical Schools in Africa (AMSA) in 1979 deliberated exhaustively on traditional medicine, and, after passing a number of resolutions, recommended that the medical schools: teachers and learners including medical and paramedical students should recognize the role of traditional medicine in their environment, participate in research in this field with a view to identifying the positive and negative aspects of traditional medicine, and ensure that students are exposed to the practices of traditional medicine.[14]

EMRO

	In 1978, a WHO working group developed a questionnaire to collect base-line information on the state of traditional medicine in the countries of the eastern Mediterranean Region (EMRO).[15] On reviewing the questionnaire, EMRO noted that, though varying degrees of interest in the field of traditional medicine were shown in all countries of the region, many problems still beset the integration of traditional medicine with the existing health delivery system. Some underlying issues were:
	how can the available manpower resources of traditional healers be effectively utilized?
	what can be done to improve the knowledge, skills, attitudes and competence of traditional healers?
	to whom are traditional healers to be responsible and accountable?
	how should their credibility and acceptability be assessed in the community?
	to what extent does the community mobilize and support the integration of the two systems?
	which priorities in health care should be set for traditional healers and what would be the economic implications of this?
	The questionnaire, however, helped in several other ways. The range of traditional medical practices and the variety of backgrounds of beliefs, patterns of health care, and the degree of utilization of the different forms were outlined in each country of the Region. It was officially expressed in this questionnaire that in the Sudan a wide array of practices fall under the heading of traditional medicine—varied surgical, orthopaedic and midwifery practices, a wealth of medicinal recipes based on distinctive socio-cultural and magico-religious backgrounds, and rich and varied ethno-psychiatric techniques and institutions. In addition, the Islamic influences that characterise Sudanese culture have added important religious and spiritual dimensions to lay-health care delivery.

Government initiatives

	As far as research and planning policies are concerned, the story is different. The Sudan, at the highest political level, is committed to the primary health care (PHC) approach for achieving Health for All by the Year 2000. The PHC approach has been adopted because it offers the most viable strategy for attaining this collective goal, not only for its economic appeal but also because it offers the most appropriate solution to the pattern of morbidity and mortality. The approach calls for the utilization of appropriate local resources, including traditional medicine; the aim is to bring together modern scientific medicine and tried and tested traditional practices, and to offer both within the framework of the local health system. This will entail supporting the formulation of relevant national policies and the development of practical organizational and coordination mechanisms between the health institutions, related social sectors and community agencies.
	Indeed, the Sudan’s commitment to PHC preceded the Alma Ata Conference, putting the Sudan in the forefront of international sponsoring of primary health care. The National Health Programme of 1975[16] included a comprehensive PHC Programme,[17],[18] that was launched in 1977. Sadly, both programme documents failed to recognise the role traditional medicine can play in national health development. Though community participation in promoting health is the mainstay of PHC, healers were, surprisingly, not regarded as potential participants and contributors. Even at an educational level, traditional medicine was ignored in the PHC community health workers’ manual designed in 1977.[19] Later revisions have not repaired this omission.
	Subsequent review and evaluation missions of the National Health Programme have equally failed to identify this deficiency. One mission reviewed the PHC Action Plan. It confirmed that the services had been designed to be comprehensive, to focus on community needs through the provision of preventive and curative activities, and to satisfy the needs of under-served communities. The Review Report reiterated the basics of PHC as applied to the Sudanese plan, saying:
	“Promotive services consist of participation, stimulation and involvement by the Community Health Worker (CHW) in community development activities at village level. This is to be done in collaboration with existing social and political organizations in the village …. And that the Plan has introduced a new cadre of CHW selected by their communities …. And that PHC design relies to a large extent on community contributions for facility construction …. And that it provides for standard lists of drugs, supplies and equipment for the related levels of health care delivery system …. [It also noted, in an approving tone] that to a large extent community participation is synonymous with community donation of money for social services …. For PHC, communities provide assistance in facility construction, maintenance, upgrading and even by paying a nominal fee for services to help running costs.”[20]
	The Mission failed to see the role traditional medical practitioners can play as community health workers already chosen and trusted by their communities; neither did it acknowledge the role these selfsame healers can play as the leaders of their communities which they often are. It also neglected to mention any part traditional medicines might play in supplementing the essential drug list. It was clear that the system of traditional medicine was not addressed at all, let alone conceived of as a source of help.
	A joint WHO/UNICEF/MOH/US AID evaluation of the implementation of PHC in four selected provinces in the Sudan was carried out during the period March 20th to April 10th, 1982.[21] The evaluation mission reported on dayat al-habl (habl midwives) and village midwives in four provinces: Kassala, North Kordofan, Upper Nile and Bahr Al-Ghazal. No other traditional healers or practices were mentioned. The evaluation team reporting on northern Kordofan described habl midwives in the region saying:
	“TBAs [traditional birth attendants] are fairly prevalent in North Kordofan, particularly among the nomadic community. They are involved mainly in conducting and managing the deliveries. Though the TBAs indicated no mortality or morbidity during their years of practice, tutors at the village midwives’ school reported incidence of tetanus, bleeding and both stillbirths and maternal mortality. TBAs were well recognized in the communities and receive reimbursement for their services in cash or in kind. They do not have any direct contact with the PHCU and hence they are not supervised by any health personnel. In one instance a TBA did refer a bleeding woman to CHWS. TBAs do appreciate the services rendered by the CHW and utilize it as needed. Younger TBAs expressed a need for ‘receiving training and appropriated tools’ for improving the service they render. It is important to note that the TBAs interviewed do not perform female circumcision in the community.”[22]
	In spite of this awareness that habl midwives are providing essential services, no further mention of their role is made in the report. Also, several projects executed in the Sudan have not evaluated rationally the useful role of traditional midwives. One example is the Rural Health Support Project (RHSP) that covered wide regions of the country. This is a USAID project authorized with life-of-project funding of $ 18 million in 1980 to strengthen the capability of the Government to provide primary health care and MCH/FP services in the project area. A mid-term evaluation was carried out in February 1985. The evaluation team failed again to see any role traditional healers can play in rural health development. It had this to say about community-based participation and community development:
	“Although stressed in the project design, the RHSP has done little if anything to facilitate community-based participation, nor has it encouraged community development in the North. Nonetheless, there are several examples of existing community concern and involvement in health care. Communities have contributed to Village Health Committees and Patient Friendship Committees, as well as to Area, Rural and Village Councils. The RHSP should build on and integrate their activities with existing community groups.
	The evaluation team recommends the promotion of community participation and bottom-up planning. The project should focus efforts at the Village Council level, providing incentives and logistics for health workers to work together to plan community participation activities. We suggest an increased pivotal role for the Health Visitors and Community Health Workers.[23]
	The team was even skeptical about the help village chiefs were giving to the PHC Programme:
	“In some cases the village Chief has provided substantially for the construction of the PHC Unit, but there is a real danger here that, even with the best of motives, this undermines the feeling of community ownership of the unit (especially since the Chiefs play a leading role in the selection of the persons to be trained as CHW’S, although we have no evidence that they are overly assertive).”[24]

The Medicinal and Aromatic Herbs Research Unit

	The plant kingdom in all countries has lent itself to the trials and errors of man, and offered an unfailing treasury of medicinal ingredients. Several countries have given due attention to this field, and some have developed elaborate pharmaceutical industries. In the Sudan, the Medicinal and Aromatic Herbs Research Unit (MAHRU) was established in 1970, affiliated to the Medical Research Council of the National Council for Research, to carry out research in medicinal plants with the main emphasis on herbal taxonomic, pharmacognostic, chemical, galenical, toxicological, and pharmacological experimental research. It was also stipulated that the Unit should take care of research in aromatic plants and their industrial and commercial uses. In twenty years of activity, wide areas of the country were surveyed for herbal specimens, inventories made, and a herbarium maintained for the various specimens. Taxonomic, phyto-chemical and pharmacological screening was performed on the collected samples.[25]
	One researcher in the Unit has lately made efforts to publish part of the amassed data. Gamal Al-Ghazali has produced a small booklet entitled Medicinal Plants of the Sudan.[26]The booklet covers twenty medicinal plants popular in Erkowit. The author has described and illustrated the plants with line drawings. Each plant entry includes the vernacular and taxonomic names, habitat, distribution, chemical constituents and a brief mention of uses. The booklet has the relevant references. Apart from this modest contribution, the Unit boasts of no achievements at all.
	Khartoum Trading and Projects, a private company in Khartoum, has published an earlier booklet[27] describing 41 plants with profiles reminiscent of those described in MAHRU. Each entry in this booklet includes the vernacular and the taxonomic names, habitat, distribution in the Sudan, chemical constituents, and uses. It is neither illustrated nor referenced, and bears no hint about its authors or sources.

Traditional Medicine Research Institute

	Up to 1979, institutional research in traditional medicine was confined, understandably, to the field of medicinal plants. In the Sudan, however, it has been noted, and for several reasons, that though some attention was given to medicinal plants, the rest of the field of traditional medicine has been almost totally ignored. Efforts have thus been directed to make this omission good, and the idea of founding TMRI emerged.
	In 1979, a memorandum entitled Organization of Research in Traditional Medicine in the Sudan was presented to the Medical Research Council for appraisal. The memo highlighted the recent official resurgence of interest in research in traditional medicine throughout the world, and the reasons behind this movement. It also outlined the field of traditional medicine, and its tremendous potential benefits for the country. The memorandum stressed the often-quoted justifications: that in traditional medicine many domains are touched on other than medicine proper, and that because of this multi-disciplinary nature a national body is needed to draw up a unified policy for research. This body should also coordinate activities and foster cooperation between researchers so that duplication of effort is avoided, and manpower and money are used efficiently and effectively. It should have a policy that safeguards against the scientific isolation of workers involved in traditional medicine inside and outside the country, and against the harmful dissipation of data and material. It should also facilitate the storage, retrieval, dissemination, and exchange of knowledge. Moreover, and more importantly, it should ‘generalize the matter’, make research activities in traditional medicine operational, more realistic and more official.
	To realize these goals, the memo suggested the establishment of what it then called the Institute for Research in Traditional Medicine, and suggested also that it should be affiliated to the Medical Research Council. The proposed Institute was envisaged as functioning provisionally through three prototype units covering definitive fields of traditional medicine, namely: phytotherapy, physical therapy, and psychotherapy (including parapsychology). The fact that phytotherapy research had already been taken care of was also noted. The memo also proposed that the existing institutions in the field should work with objectives revised if necessary to ensure effective and complete coverage. The need for in-depth studies of traditional theories and concepts of health and disease, was duly stressed. Provisional responsibilities and objectives of the envisaged institute were suggested.[28]
	The memo was not taken seriously by the Medical Research Council, and certainly not by the ad hoc committee set up to look into it. The latter did not even convene to discuss the matter, and the Council did not pursue it any further. Other avenues were sought to achieve the objectives set in the memo. This time the Ministry of Health was approached, and though the main function of the Ministry is health care delivery rather than pure research, yet the Minister of Health at the time, Mr. Khalid Hassan Abbas, responded immediately and issued two directives to form the necessary committees to look into ways of organizing the efforts necessary to make the best use of traditional medicine.[29] The second directive, in particular, was made in response to a programme in the Sudan Broadcasting Service given by the author of this book highlighting the importance of traditional medicine, and need for official recognition and support.[30]
	Following the second directive, a multi-disciplinary committee was appointed by the Minister of Health, and a working paper was prepared for its perusal.[31] The committee unanimously endorsed the memo, and agreed on the proposals offered, namely establishing what was later called the Traditional Medicine Research Institute. The Committee’s unanimous agreement later received the joint endorsement and support of the Ministry of Health and the National Council for Research. As suggested in the memo, both bodies agreed that the proposed institute should be affiliated to the Medical Research Council.
	The Traditional Medicine Research Institute (TMRI) was founded in 1981, in the belief that traditional medicine is an integral part of a rich and varied indigenous culture, and that in it, many domains and disciplines other than medicine are touched on. Later, TMRI took several initiatives. For the first time in the Sudan, it brought together in one institution many scholars from human and behavioural sciences with as many others from the health sciences. Both were represented in its policy-making Board of Directors.
	TMRI has been envisaged as a national action-oriented research institute with the following objectives:[32]
	1.        To draw up a national policy to stimulate, organize and direct multi-disciplinary research in traditional medicine in the Sudan.
	2.        To evaluate traditional medicine in the light of modern science, in order to maximize useful and effective practices and discourage harmful ones.
	3.        To promote the integration of valuable knowledge, attitudes, and skills in traditional medicine including appropriate foreign technologies (e.g., acupuncture) into the existing health delivery system.
	4.        To relate programmes of research to the country’s general policies and its socio-cultural needs.
	WHO, both at its Headquarters and Regional office in Alexandria,[33] recognised at once the ability and readiness of TMRI to contribute to its global programme of traditional medicine, and it was designated a WHO Collaborating Centre for Traditional Medicine in 1984, (see page 372)

TMRI Approaches

	It has been mentioned repeatedly that a large proportion of the population depended either totally or partially on traditional healing methods. It may be the only kind of health care available, but often people feel more comfortable with these methods than with Western types which give different explanations for an illness, and use a different approach in treatment from that which they are accustomed to. TMRI has always stressed the role traditional medicine can play in primary health care. Because of the intrinsic qualities believed to be inherent in traditional medicine, and the general neglect or ignorance of policy-makers of the capabilities of traditional health management, a traditional primary health care model (TPHCM) is proposed as a strategy for research and planning. TPHCM identifies the areas in which traditional medicine can contribute to primary health care programmes. These are essentially the following:
	1.        using the resources of traditional healers.
	2.        supporting the essential drug list.
	3.        identifying appropriate health protective, and promotive practices for incorporation in general health schemes.
	The model views healing at primary level as person-to-person care where the healer is identified by name. His interaction with members of his community is based on mutual understanding of the worth of each member of the group. There, everyone, including the healer, is doing his or her best, and quality control is achieved by role fulfillment, satisfaction of community members and communal peer pressure.
	The model makes use of the already well-established traditional medical units to link with those of the primary care network. A major priority, hence, in this policy draft is to support the maseeds and the therapeutic villages as comprehensive social institutions. Since the arrival of Islam in the Sudan, these villages, some of which are 300 years old, have been comprehensive social institutions. It is therefore of paramount importance to identify these villages and make use of their capabilities by grafting psychiatric and other components of modern health care onto them. Also, the model sees traditional healers as potential recruits reinforcing primary health care manpower. As early as 1948 Tigani Al-Mahi clearly coined the concept of the therapeutic village that was tested later in practice and has proved its worth in treating the mentally ill elsewhere in Africa.[34] He befriended his contemporary traditional healers and established bilateral referral systems with many of them. This arrangement helped many patients who would otherwise have been considered incurable. The model also recognizes religious healers as men of great power and authority in the Sudan; so much so, that they should be involved in the planning, implementation, and evaluation of health programmes in their respective communities if those programmes are to succeed. A basic approach adopted by TMRI is, then, to enhance working relations with the religious healers, and to implement appropriate reorientation and training programmes suggested to involve them as community health workers in nomad and rural communities.
	The model aims to fulfil the principle of community participation in its entirety, and in reality, not rhetoric. Training analogous to that given to midwives is advocated for the different categories of healers. The training programmes do not aim at incorporating them into the government service, nor do they suggest a system of remuneration or supplementary income to keep them in practice. They advocate instead an approach that would enhance their competence and ensure safety in practice. Whenever efforts are made to identify trainers, devise courses, or prepare manuals for training traditional medical personnel, due attention is paid to the social status and authority of healers in general. Their autonomy, individuality, social status, and prestige are not disturbed in any way. Competitiveness between healers and other community workers is actively avoided, while co-operation and mutual support is fostered.
	Women in several regions of the country have many roles within the family unit and community. They are involved in food procurement, processing, preserving, menu choice, water collection and purification, washing and cleaning. They are the informal traditional PHC practitioners in every home, looking after the young, aged and handicapped. They have sole charge of childcare and the upbringing of infants. Nonetheless, they are frequently under privileged, deprived and suppressed, are often of a lower educational standard than men, and when they are employed they are concentrated in low-paying jobs. Emphasis is, thus, given to the role women can play as community health workers on an equal footing with men in their capacity as mothers, housekeepers, sanitary overseers, and in their exclusive role as midwives.

Research activities

	To realize its goal, TMRI has endeavoured to draw attention to the field of traditional medicine through various activities. It was envisaged that the major part of TMRI programme could be executed through local collaborating centres alluded to in page 374. TMRI, however, developed several major research programmes that, besides fulfilling their objectives, would also help in stimulating interest in traditional medicine, and open channels to make use of the resources of all levels of research. The projects are intended to provide the necessary information to discover why a community uses traditional medicine and recipes, and why certain customs are practised despite being painful, and sometimes detrimental to health. Examples of these projects include:
	Female Circumcision in the Sudan: Establishment of an information and resource center. The overall objective of this project is to collect, collate and store the Sudanese literature on the subject in the form of citations, and texts, keeping a mailing list of scholars and activists concerned, whether individuals, groups or institutions, wherever they may be. Data is made available to researchers in a computer data base and in individual monographs.
	Traditional practices affecting the health of women, newborns, and children. The immediate objective of this project is to survey, document and study the traditional practices associated with women and children during pregnancy and childbirth. The results will, one hopes, be useful in designing appropriate educational programmes and child care messages to help mothers, midwives, health visitors and community health workers. The results should also help in suggesting appropriate strategies for health education and in correcting misconceptions and ignorance concerning food values, and the body’s requirements in the different stages of life.
	Traditional management of gastrointestinal disturbances and diseases in early childhood. The objectives of this project are to provide physicians, attending community health workers and helpers, midwives, nurses and, indeed, the mother, with simple, easy-to-prepare traditional recipes for gastrointestinal disturbances, all of which have been verified as effective, safe, simple, available and affordable. It also aims at stimulating the pharmaceutical industry by providing material for pilot studies. Several plants alleged to be effective in gastrointestinal disturbances were identified, phyto-chemically screened, and pharmacologically tested. The most useful items were chosen and appropriate recommendations on how to make them as widely available are given.
	Health care in Gezira: pattern and determinants. The overall aim of this study is to provide information on appropriate planning and implementation of primary health care in rural areas. The study will collect and analyze data on the availability and utilization of both the professional (mainly Government) and the traditional medical sectors. Information on health coverage and the factors identified as influencing patterns of utilization, which to some extent reflect peoples’ attitudes to sickness and health, will provide suggestions on how the two sectors could be used for provision of a better health care service. The goal is to achieve a wide range of coverage and reasonable access for the entire population. Of special concern, is a more culturally-appropriate and affordable means of primary care for the mentally-ill. Suggestions will also include recommendations for using more appropriate resources whenever and wherever possible.

Management and resources

	Research in traditional medicine is multi-disciplinary, involving the input of many sciences and arts. It benefits greatly from the methodologies of the behavioural sciences such as sociology, anthropology, history, folklore, economics and politics. Equally, it benefits from those of the natural sciences: medicine, pharmacology and botany, in addition to veterinary science and agriculture. The programme, thus, stresses the need for multi-disciplinary approaches, links, coordination, and team work with all concerned parties. The funding obtained from regular national budgets, or self-help, may not be enough to cover the activities of the ambitious programmes. This is especially so when satisfying basic human needs becomes a pressing priority stretching the country’s tight resources. Appeals for extra-budgetary support from the national and international donor communities should be planned to strengthen the national resources. Continuous consultation and coordination with EMRO/WHO, WHO/TRM, Geneva, continues, and the resources of other UN agencies, particularly UNIDO, UNICEF, UNESCC), and UNDP, etc. should be requested if necessary.
	The traditional medicine programme is oriented towards the concept of PHC, self-help, self-reliance and the development of community resources. Locally, the programme aims at greater collaboration with all programmes that have a particular interest in traditional medicine. Also, for effective coordination of research activities undertaken by the national institutions and research centres, links with EMRO/WHO and WHO/TRM, Geneva are essential. Through these links, the national institutions are brought into contact with international and local funding agencies, and the exchange of technical expertise is facilitated.
	The targets and approaches of TMRI programme have been elaborated in great detail, and have been designed to be followed up with stringent evaluation criteria at institutional and national levels.