ARTÍCULO ORIGINAL

Cuban collaboration with the Program for Applied Research and Diffusion of Medicinal Plants in the Caribbean (TRAMIL)

Colaboración cubana con el Programa para la Investigación Aplicada y la Difusión de Plantas Medicinales en el Caribe (TRAMIL)

  ]]>  

Francisco Morón Rodríguez;^I Lionel Robineau-Germosén^II

^I MD. PhD. Professor in Pharmacology. Medical Sciences University of Havana. Central Pharmacological Research Unit. Havana City, Cuba.
^II MD. MSc. University of Antigua & Guyana, Guadalupe, France.

RESUMEN

Palabras clave: plantas medicinales, investigación, colaboración regional, Cuba, Caribe.

ABSTRACT

INTRODUCTION: people use widely medicinal plants to solve primary health problems in Caribbean countries. Our research unit has kept a close collaboration with TRAMIL (Program for Applied Research and Diffusion of Medicinal Plants in the Caribbean) since the III TRAMIL Scientific Workshop was held in Havana in 1988. We also have coordinated the Medicinal Plant Cuban Research Program (1988-2004) to incorporate medicinal plants in our National Health System. Pharmacological and toxicological applied research to validate traditional medicinal uses has some characteristics and challenges.
OBJECTIVE: The aim of this lecture is to expose our experience during 20 years. ]]> METHODS: it was reviewed the main impacts as well as our published results and those included in TRAMIL´s Caribbean Herbal Pharmacopoeia during 1988-2008.
RESULTS: it is shown the Program and our collaboration, the scientific-validated medicinal plant uses which has been incorporated to Cuban National Health System and our results in pharmacological and toxicological studies in 30 different species. Most of toxicological experiments indicated that traditional uses were safe and a high number of them were validated in preclinical experimental models.
CONCLUSIONS: our data indicate that TRAMIL is a well established regional scientific network which may be useful for health systems and medical universities and there are a high percentage of traditional medicinal plant uses which may be supported with preclinical evaluation.

Key words: medicinal plants, research, regional collaboration, Cuba, Caribbean.

INTRODUCTION ]]>

The main form of traditional medicine in Cuba involves the popular use of plants as a means to resolve health problems. The roots of these practices are found in the historical and social development that resulted in the rise of the Cuban nation. The first reference to our medicinal plants occurred within ten days after the Spaniards arrival on the north coast of Holguín Province, in Cuba's eastern region. Under the date of November 5, 1492, Christopher Columbus' diary notes: "It is remarked that an Indian said, by sign, that almáciga is good for problems of the stomach".¹

This entry leads one to believe that the same plant currently known as almácigo (Bursera simaruba (L.) Sarg.), a native species found mainly in coastal and wooded zones was used by the Cuban aboriginal population to treat stomachaches and diarrhea. These same uses continue today, through decoction of the plant's leaves, bark, roots or resin. However, the recent arrivals erred in naming the species showed to them by the aboriginals after a medicinal plant found in Spain: almáciga or almácigo (Pistacia lentiscus L.), which has certain similarities but is a different tree. Erroneous common names were often given to our species by the Spaniards, Africans and Chinese as part of the process of trans-cultural assimilation.

Our traditional medicine is a result of the integration of aboriginal cultures with the Spanish, African, Chinese and Yucatecan cultures that came successively to the Island after its discovery on October 27, 1942. At that time, the indigenous population totaled approximately 100,000, having established themselves some four millennia before the Spaniards' arrival. Cuban aborigines arrived by means of different migratory patterns. It seems that the first arrived via the Strait of Florida and the last descendents of the Arawak Indians, called "Taínos" by the Spaniards arrived via the archipelago of the Antilles.

The latter immigrants left an imprint that would shape Cuban medical historiography. Aboriginal medicine in Cuba survived its own people as a legacy for the colonizers up to the eighteenth century. One historical event involved the concession by the Santiago de Cuba Town Council, in 1609, of a license to practice medicine to the indigenous healer Mariana Nava, the first women to exercise this profession in such a legal manner.²

The development of traditional Cuban herbal medicine shares more similarities than differences with the experiences of other countries in the Caribbean basin. From colonial times to the present, many investigators have dedicated efforts to the study of Cuban medicinal plants. One of the most renowned, eminent Cuban botanist Juan Tomás Roig Mesa (1877-1971), wrote the following in the prologue to his book Plantas medicinales, aromáticas o venenosas de Cuba [Medicinal, Aromatic or Poisonous Plants of Cuba] in 1945:

We have sought to encourage our men of science to study these plants, verifying whether the virtues attributed to them are certain, so that they may then be used scientifically, thus removing the trade of these drugs from the amateurs'hands ¾if not charlatans¾ whose recommendations have more than once produced fatal results.³

]]> Roig's idea of promoting the systematic study of our medicinal plants by Cuban scientists was followed only by some individuals and exceptional institutions. Increasing scientific activity in this field did not begin until the 1980s, motivated to a great degree by the World Health Organization's recommendation that member countries promote the use of traditional medicinal resources in their health systems. In 1984 and 1985, a national ethnomedical survey was carried out in order to identify plants, plant parts, their uses and how they are applied by the population. The study was designed and executed mainly by young university professors and students, advised by more experienced researchers. This national collective named itself the Juan Tomás Roig Group, in honor of the late botanist.⁴

Two years previously, the TRAMIL Program (Applied Research and Education Program of Traditional Medicinal Plants in the Caribbean) had begun and was implementing surveys according to a new methodology on the neighboring island of La Española [Hispaniola], shared by Haiti and the Dominican Republic.

The implementation of ethnomedical surveys according to different methodologies does not allow for the extrapolation of results. However, both investigations enabled Cubans involved in this field to verify the coincidence between species or plant parts and uses found to be significant by TRAMIL and those identified in the Cuban survey and other studies carried out in Cuba during the 1980s.

TRAMIL Program

It was born out of a common effort from the Caribbean Regional Office of the International Organization for the Environment and Development in the Third World (enda-caribe), the Laboratory of the Natural Substances of the University of Medicine and Pharmacy, Port-au-Prince, the Federation of Rural Associations of Zambrana-Chacuey, Dominican Republic, and the Clinic SOE of Thomonde, in the Central plain of Haiti in 1982. It aim was to improve and rationalize the popular medical practices based on the use of medicinal plants.

In the Central America and Caribbean regions, it has been shown that medical herbs are not only part of cultural heritage but also that their use represents an important tool and support in primary health cares when scientifically validated. Ministries of Health and Universities of the region have shown their interest to carry out joint efforts in order to obtain regional agreements, to obtain benefits from scientifically validated medical herbs and to promote health care policies able to integrate this resource.

During 27 years, TRAMIL has been combining efforts of researchers and institutions working in the field of Central America and Caribbean medical herbs, in a multidisciplinary way. Ethnobotany studies, identification of species, chemical, pharmacological and toxicological studies of medical herbs used and broadcasting of information to communities are all part of this effort (table 1). This program integrates collaborators and specialists from different fields and they come from: Antigua, Belize, Bolivia, Brazil, Costa Rica, Colombia, Cuba, Dominica, France, Grenada, Guadeloupe, Guatemala, French Guyana, Haiti, Honduras, Martinique, Mexico, Nicaragua, Panama, Puerto Rico, Dominican Republic, Saint Lucia, Trinidad and Tobago and Venezuela. (http://www.funredes.org/endacaribe/Repertorio/english/carte.html )

Since 1982, TRAMIL and its collaborators have been working in a common objective: medical herb use under scientific criteria of security and efficacy (table 1). ]]>

Beginning of Collaboration with TRAMIL

Cuba's process of integration into and collaboration with the TRAMIL Program began gradually. The first participant from the Vice Ministry of Science and Technology, under the Ministry of Public Health of Cuba (MINSAP) attended the Second Scientific Workshop held in Santo Domingo, Dominican Republic, in November, 1986.

In 1987, the Cuban Minister of Health started to organize its first medicinal plant research program. It was organized a national program of pharmacological and toxicological validation, with the medicinal plants most commonly used by the Cuban population according to data provided by the Juan Tomás Roig Group survey.

In December 1987, at the Medical Sciences University of Santiago de Cuba, it was held a national meeting with professors and investigators from the main groups that were studying medicinal plants in medical universities (including one from each faculty of medical sciences in each province) and in research centers. It was formed a Cuban Medicinal Plant Research Network, composed of 30 groups.⁵

Between November 27 and December 3, 1988, we held the Third TRAMIL Scientific Workshop in the city of Havana, organized jointly by enda-caribe and the Ministry of Public Health of Cuba (MINSAP). Twenty-three delegates from Germany (former FRG), Brazil, Colombia, Chile, Dominica, the Dominican Republic, France, Guadalupe, Guatemala, Honduras, Martinique, Peru and Sweden, together with 16 Cuban researchers⁶ spent long, intense days analyzing targeted species. We established the first validation commitments (scientific research to validate TRAMIL´s significant plant part/preparation/use or TRIGs), and participants shared all of their results with the group, thus complementing the scientific information available on the discussed plants. ]]> This event helped us to learn more about TRAMIL and its methodology, to promote scientific exchange, and to consolidate our collaboration.

TRAMIL and Cuban medicinal plant networks were interested in studying a lot of same species, so the need for collaboration between both programs became marked soon.

Results and Impacts

One of the first results was the implementation of a survey using the TRAMIL methodology in Casilda, a village in the province of Sancti Spiritus on the southern coast of Cuba's central region, in 1990. It was the only investigation of this type to have been completed in the country. Some of the species (parts/uses) that were found to be significant were then validated within the context of program cooperation and are now in the Caribbean Plant Pharmacopoeia.

That year, it became evident that a profound economic crisis would soon affect Cuba, resulting from the abrupt loss of economic and commercial relations with the former socialist countries of Eastern Europe. This problem was aggravated by the intensification of the United States' economic, financial and commercial blockade. One of the activities that would suffer severe resource limitations was public health and the provision of medicines to the Cuban population. For this reason, we hurriedly began to search for information and to analyze which phytotherapeutic resources could alleviate the medicine shortage that would soon occur. The three main sources of information were: published or unpublished results of national investigations, pharmacopoeias, and the drafts of plant monographs from the Fourth TRAMIL Seminar held in Tela, Honduras, in November 1989 and which later would become the book Hacia una Farmacopea Caribeña [Toward a Caribbean Pharmacopoeia],⁷ which we had received as program collaborators.

The group of multidisciplinary Cuban specialists from different sectors proposed 51 plants, their parts, preparation and uses, with sufficient validation of their safety and effects, and with the understanding that their availability in the country would enable their use within the national health system. This recommendation became the Ministry of Public Health Directive for the Legalization of Medicinal Plant Use in the National Health System, signed on May 5, 1990.^8,9

Of the 51 species approved by the Ministerial Directive, 33 (64.5%) were from TRAMIL. Nine more were subsequently incorporated into the National Traditional and Natural Medicine Program (table 2), and 41 of these species were listed in the first edition of the Caribbean Herbal Pharmacopoeia.¹⁰ ]]> In addition, a group of experts was formed and would become MINSAP's National Commission on Medicinal Plants in 1992, under the Vice Ministry of Science and Technology. The group began to prepare an informative publication on medicinal plants entitled FITOMED, first covering the species from the above-mentioned Ministerial Directive but later preparing monographs of more than 150 plants.^11-14

We also prepared a publication on plants that are potentially toxic or that have reported adverse effects, entitled FITOTOX.¹⁵ These materials were oriented mainly toward health professionals, but they were also an essential reference of the Cuban press and other media for dissemination to the population. In all of these dissemination efforts, TRAMIL monographs on different species were a vital source because of the quality of information they contained.

The diffusion of medicinal plants including those of TRAMIL has been carried out permanently in higher medical education centers. The main national actions have included:

— Incorporation into the study programs of courses in the fields of Medicine, Stomatology, and Nursing since 1993.
— Incorporation into medical residency programs and, in particular, that of Integral General Medicine.
— Graduate courses.
— Master's degree program in Traditional and Natural Medicine.¹⁶

Other local actions have included the following: ]]>

— Dissemination material on TRAMIL species common to Haiti and Cuba for the first group of collaborating physicians (Nov. 2000).
— University extension efforts such as the grandparents' circle (La Lisa, Havana) developed by the Central Laboratory of Pharmacology (LCF) of the Medical University of Havana.

The Central Laboratory of Pharmacology (LCF) is an entity focusing on scientific and technological development. Since its founding in 1988, its mission has been to coordinate research and teaching about medicinal plants in MINSAP. It has maintained close collaboration with TRAMIL since its inception, signing an official collaboration agreement in 2000. Cooperation has been mutually advantageous, and both parties are willing to maintain and increase their collaboration to the fullest possible extent.

We plan to continue validation studies of common species, to strengthen dissemination efforts, to prepare teaching materials, and to update plants and their uses in the national health system based on the second edition of the Caribbean Herbal Pharmacopoeia.

All of this has contributed to the fact that physicians and stomatologists, as professionals who make prescriptions within the health system, use traditional and natural medicine (including medicinal plants) for therapeutic purposes and in their clinical instructions. In 2005, for example, out of a total of 39,206,257 medical instructions or orders from external consultations, 28 % were treatments with different procedures that have been incorporated into healthcare, such as medicinal plants, acupuncture, homeopathy and others.¹⁷

We believe that, in order for health professionals to use medicines rationally ¾ including medicinal plants, they must receive appropriate knowledge and skills as part of their educational curriculum, during residency as specialists, and in graduate studies (master's and other degrees and courses.)

The Medical Sciences University of Havana, the largest in Cuba, is responsible for preparing and perfecting the courses of study of the five programs (medicine, stomatology, nursery, health technology and psychology) and of the 60 medical and stomatological residencies. These are national-level courses applied in all higher centers of medical education.

Within all of the programs, the pharmacology class covers contents (uses, parts, preparation, dosage, adverse effects and warnings) and skills (selecting the most appropriate medicine for each patient) with respect to scientifically validated medicinal plants. Most of this involves the uses of scientifically validated plant parts that appear in the Caribbean Plant Pharmacopoeia, towards which we have collaborated actively, especially since 1999. ]]> We are making efforts to perfect the medical studies program. Monographs on plants in the Caribbean Plant Pharmacopoeia (TRAMIL) and approved for use by MINSAP have been incorporated in the complementary bibliography for students.

Similarly, the graduate level of studies includes:

a) The study of medicinal plants in medical residency programs, especially important in the residency for General Integral Medicine since these will be the specialists who provide primary healthcare services.
b) A master's degree in Traditional and Natural Medicine, which may be taken by all health professionals in Cuba or those working as collaborators in 74 other countries.¹⁸

In both graduate programs, the supporting bibliographies on medicinal plants include monographs from the above-mentioned pharmacopoeia. In addition, we are working on one publication for students and health professionals and another for the general population, covering the uses of plant parts validated by TRAMIL.

Collaboration with TRAMIL ¾ as well as the support of projects such as TRAMIL-CA (Phase III) with the International Development Research Center (IDRC) of Canada from 1999 to 2002; enda-europe / Ministry of Foreign Affairs of France (MAE) / TRAMIL (involving the European office of the NGO Environment and Development in the Third World, the Ministry of Foreign Affairs of France, and TRAMIL), an effort that initiated in 2003 and will conclude this year; and with the Association for the Research and Valorization of Natural Resources of Martinique (ARVARNAM)¾ has been mutually beneficial and has contributed notably to the progress of our efforts in research, teaching and dissemination among the population (table 3).

]]> Now, we can ask ourselves: is it necessary ethopharmacological research to validate traditional plant uses?

Yes, because:

— 80 % of health problems are treated in Primary Medical Care.
— Most of people use, at least, few traditional plant remedies as first treatment.
— People use medicinal plants according to culture and it does not depend on official health care accessibility and quality.

We must not conclude without a brief comment about the sustainability of our work. We believe that our efforts will continue. Research, validation and the dissemination of medicinal plants with scientifically-validated uses, both among students and professionals and among the population, are health needs that have been fully identified by MINSAP and by our university.

]]> REFERENCES

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  ]]>

Recibido: 3 de noviembre de 2009.
Aprobado: 2 de diciembre de 2009.

Prof. Francisco Morón Rodríguez. Central Pharmacological Research Unit. Faculty of Medical Sciences "Dr. Salvador Allende". Carvajal s/n entre Agua Dulce y A, Cerro, Havana City 12000, Cuba. E-mail: moron@infomed.sld.cu ]]> 1 1988 2 2004 3 1988 2da ed 1125 4 1989 5 2 2 249-53 5 1995 9 1-2 1-2 24-49 6 1989 1988 La HabanaSanto Domingo 318 7 1991 474 8 1991 7 3 3 276-84 9 MINSAP 1990 10 1998 363 11 MINSAP 1991 130 12 MINSAP 1993 117 13 MINSAP 1994 69 14 MINSAP 1995 60 15 MINSAP 1995 75 16 1997 1 1 1 35-9 17 MINSAP 2005 18 MINSAP 2008 19 2005 2da ed 486 20 2005 2me ed 21 2007 2nd ed 22 2007 117 23 2008 117 24 2008 117 25 2006 26 2006 27 2005