Perspectives in Health Magazine
The Magazine of the Pan American Health Organization
Volume 7, Number 3, 2002
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Perspectives in Health Magazine |
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In Venezuela’s Amazon, Western and traditional medical practitioners are learning to work together to meet the health needs of indigenous communities.
 An indigenous Venezuelan woman harvests a native Amazonian plant used by traditional healers to treat menstrual cramps. |
Isla Ratón will be home for the next 10 months to Jenny García, a newly qualified Venezuelan doctor who came to the island to fulfill a rural service obligation required of all Venezuelan physicians. García runs the local medical post and is responsible for visiting the dozens of outlying communities in the Autana region. Although she’s been here only a couple of months, she seems right at home, despite the stifling northern Amazonian climate. More important, she has already come to terms with what might be called the local medical competition: the native shamans who have practiced traditional healing on the island in virtually the same manner for centuries.
"We have to respect the popularity of traditional medicine," García explains to a visitor, betraying not a hint of resignation. "The shaman is a very important figure here; we can’t compete with him. What we do instead is alternate traditional medicine with Western medicine. We share information with, and ask for assistance from, traditional medical practitioners.”
García’s attitude reflects a new collaborative approach to traditional medicine that is being promoted by public health advocates, not only in Venezuela, but internationally as well. It parallels a growing interest among people in developed countries in traditional medical practices— from acupuncture to herbal remedies—as "alternative medicine," as well as growing commercial interest in modern pharmacological applications of traditional medicinal plants.
More important, the new approach recognizes that traditional healing practices, based on local cultures and resources and developed over centuries, can be effective and in any case remain the most readily accessible form of health care for millions of people in developing countries.
"Traditional medicine, including collective knowledge about cures, self-care strategies and other traditional practices, is a fundamental part of community resources," says Rocio Rojas, an expert on indigenous health at the Pan American Health Organization (PAHO). "Gaining better knowledge of these practices is essential for developing strategies that will improve access to and quality of health care for indigenous populations."
The Amazon rainforest occupies the heart of South America and is a treasure house of both ethnic and biological diversity. For Venezuela and other governments in the region, providing health care and other basic services to indigenous Amazonian communities is a major challenge that has put relations between Western and traditional medicine on the national political agenda.
In recent years, Venezuelan authorities have drawn up legislation formalizing that relationship in the national health system. Article 122 of the new constitution (which took effect in 2000) recognizes indigenous patients’ right to culturally appropriate treatment and establishes doctors’ duty to take local beliefs and cultural norms into account. A proposed national health law, currently before the National Assembly, expressly states that "indigenous people have the right to use traditional systems of health care and traditional medicine … but this right does not in any way prejudice their right to access state health care systems."
Jorge Luis Prosperi, PAHO adviser on health systems and services in Caracas, believes this new legal framework is one of the most advanced in the Americas. He considers it a "necessary first step toward delivering appropriate services."
The next, and more complicated, step is for Venezuela’s Ministry of Health to understand fully the needs and culture of the indigenous communities it has the responsibility to reach. In some parts of the Amazon, including Isla Ratón, health workers have been working with specific communities for many years and have built up an understanding of the local language, culture and health needs. This has helped them build cordial, cooperative relations with shamans and other local traditional practitioners.
A collaborative approach
Jenny García, in Isla Ratón, credits her predecessors of the past five or six years with establishing friendly relations with the island’s traditional Piaroa and Guajibo practitioners. She speaks enthusiastically about the mutual respect that has developed between the Western medical staff and local shamans.
Patients seek out both kinds of medical care, García explains, and both doctors and shamans respect the others’ abilities. "The shamans also come to us," she says. "Their style of medicine is consultative rather than selfish. If they see a serious case, they will always send the patient to a doctor as well."
Autana’s mayor, Bernabe Arana, himself a Piaroa, says he and other islanders make health choices according to the type of medicine they feel is more appropriate to their individual case or symptoms. "If I have diarrhea, then of course I wouldn’t go to the shaman; I’d go straight to the medical post," Arana explains matter-offactly. "But if it’s an illness that has lasted for three weeks or a month I’d go to a shaman."
García notes that the shamans she knows tend to specialize in ailments caused by the "evil eye," such as psychological problems and headaches or chronic fatigue. Such illnesses are seen as the result of curses, broken taboos or divine displeasure and are treated with prayers, healing spells and purification rituals. But traditional practitioners also employ more practical methods, for example, using medicinal plants and plant infusions to treat conditions ranging from menstrual cramps to skin infections and common wounds. García believes that more serious cases almost always make their way to the medical post with its Western-style care.
Isla Ratón’s residents may be more open to government health workers and Western medicine at least in part because their island, by Amazonian standards, is less remote and has been relatively well served by its contact with outsiders. The island has electricity, and a pump brings fresh water up from underground reserves. There are schools run by the Catholic Salesian Order, and, in addition to García’s small health post, there is a basic medical laboratory. Communications remain difficult, however; radio is the only way to contact the outside world, and motorized canoes are the only transport available.
Two months into her stay here, García is generally positive about the infrastructure and systems in place. "We try to visit an isolated community every week or two," she says. "We carry out check-ups and immunize people, but it’s clearly very limited what we can do in that time. Luckily, the local nurses I’ve seen are excellent."
Indeed, the area’s nurses are a prime example of the cooperative give-and-take approach. They are all members of indigenous communities who have attended courses in "simplified medicine" provided by Venezuela’s Ministry of Health with technical assistance from PAHO. In this way, according to PAHO adviser Prosperi, they learn the basics of Western medicine but also retain their traditional knowledge of indigenous medical techniques.
Graduates of the courses live with their communities in the most remote parts of Autana but are in constant radio contact with the medical post on Isla Ratón. They can ask for advice from or refer patients to García, who in turn can transfer the sickest to a hospital on the mainland. The system generally works well, although the distances involved mean that sick patients sometimes face days of canoe travel to reach the medical post or the mainland hospital if air transport is not available.
Electronic health map
 Jenny García, a newly qualified Venezuelan doctor, with her medical post’s nurse. García sees local shamans as allies in providing health care to the remote indigenous communities she serves. |
The process is still in its infancy, but Rivero hopes eventually to produce a file on each of Venezuela’s 32 indigenous communities, 19 of which are located in the Amazon. Each file would include disease and mortality statistics, relevant cultural and linguistic information, population estimates and details about community representatives and traditional medical practitioners. These fact-packs would then be provided to health workers posted to indigenous communities, including those in the rural doctors program.
The improved information also would allow the ministry to allocate health resources better, a key concern in the Amazon, where transporting medicines to outlying health posts can be extremely difficult and costly. For example, Amazonian indigenous groups who migrate during the year are affected more by certain illnesses at certain times. Medical staff working with those groups need to know, for example, that they will need more antimalaria treatments when these groups settle in an endemic malaria area, but more supplies of diarrhea treatments when they locate near a polluted river.
Upstream from Isla Ratón on the banks of the Orinoco River is Puerto Ayacucho, capital of the Venezuelan Amazon. The small city is home to the region’s only hospital and is the supply base and administrative center for the health authorities responsible for serving the scattered communities of the Amazon.
Puerto Ayacucho is also home to the powerful Regional Organization of Amazonian Indigenous Peoples, or ORPIA. The group’s headquarters was originally built as a small tourist resort before being taken over by the organization in the early 1990s. "We liberated it," ORPIA’s president, José Gregorio Diaz Miraval, says with a smile.
After years of struggle, during which the ORPIA offices were the target of arson attacks and thefts, the organization has won its battle for legal recognition of indigenous rights and has now set as a top priority the struggle for better health care.
Pedro Jaro, ORPIA’s health coordinator, says he is pleased with the Ministry of Health’s new emphasis on responding to communities’ specific needs, noting that ORPIA has been urging health authorities for some time to tailor programs to individual communities rather than try to implement a "one-size-fits-all" policy.
 A Piaroa mother and her child in the entrance to their tatched hut home on Venezuela's Cataniapo River. The country's new constitution mandates respect for indigenous beliefs and cultural norms in the provision of health care services. |
ORPIA is also concerned that despite the new constitutional and legal protection for indigenous medicine, much traditional knowledge is still at risk, particularly as communities begin to adopt Western habits and gradually abandon aspects of traditional culture. The organization sponsors an exchange program that brings shamans together to discuss their work and pool their knowledge. Rivero sees such programs as crucial to the survival of the body of indigenous knowledge and believes the ministry would likely provide financial support for the scheme.
Indeed, the ministry already sponsors a similar pilot project among the Wayuu of western Venezuela. Wayuu communities have created "intercultural homes" (casas interculturales) where mothers can leave their children in the care of community elders, who pass on their culture to the younger generation. The homes also provide meals, and shamans treat patients there and talk to the children. The project has proved a resounding success, and Rivero believes the scheme would work with other communities if it were adapted to their specific cultural needs.
As for Western-style health workers, Rivero says the efforts now under way to help them understand indigenous culture are critical and should significantly enhance their effectiveness in Amazonian communities. "Among the Yanomami it is taboo to name the dead, for example," she says. "And if we are going to talk about HIV/AIDS we need to know how each culture addresses sex. We have to be sensitive to what they want. It’s no longer a case of turning up with vaccines and telling everyone to form a line with their sleeves rolled up."
Sharing the Amazon's secrets
The Amazon is believed to hold from a third to half of the earth’s biological diversity, and the region’s indigenous medical practitioners are the keepers of centuries of accumulated knowledge about natural medicinal resources. Scientists believe they may hold the key to the discovery of important new drugs that could benefit millions of people around the world.
The current debate in Venezuela centers on how best to exploit this traditional knowledge for the benefit of the communities that supply it. PAHO adviser Jorge Luis Prosperi agrees that indigenous groups must receive benefits from their knowledge, but he insists that this knowledge should be shared with legitimate researchers.
"I don’t doubt that scientists could visit the Amazon to extract the active properties of some plants to make millions out of patented medicines," he says. "But it is correct and fair that legitimate research takes place. Just as I believe indigenous groups have a right to access the breakthroughs and knowledge of the modern world, I believe that Western society has a right to learn about these medicinal plants. They can’t be solely the property of the indigenous community or the shaman."
Venezuela’s national science foundation, FUDECI, recently launched a major project to collect data about medicinal plants from Amazonian indigenous groups. The information is gathered by field researchers and stored in a searchable database known as BioZulua, administered from Caracas by FUDECI.
The contents of the database remain the intellectual property of the individual indigenous communities, and the Venezuelan government and FUDECI hope to raise money for the groups by charging international pharmaceutical companies for access to their knowledge.
FUDECI’s director general, Ramiro Royero, says the project has already produced some extremely interesting prospects and is generating considerable international interest. "No pharmaceutical company has seen this material yet, but when two or three different groups from different areas are using the same plants to treat the same ailments, then it’s obvious there’s something in the plant that would be worth investigating," he says.
Users of the BioZulua database can search by species, geographic location, ethnic group or even by ailment. For example, companies interested in developing new herbal headache remedies could look at all the plants used for this purpose by indigenous groups throughout the Venezuelan Amazon. The database also includes video footage of shamans collecting and preparing medicinal plants, as well as images of how patients respond to treatment. It provides genetic profiles of every plant entry and the global positioning system coordinates of where exactly it grows. "We have tried to be as comprehensive as possible. We even include a photo of the first person to tell us about the plant," Royero says.
 Ramiro Royero, director general of FUDECI, hopes to raise funds for indigenous health care by charging international pharmaceutical companies for access to information in the BioZulua database. |
FUDECI hopes the BioZulua database will encourage interested pharmaceutical companies to contact the project’s administrators rather than approaching indigenous groups directly. "Our database provides added value and it will be much cheaper for companies to buy information from us than to send teams of researchers undercover into the Amazon," Royero says.
The BioZulua project could well serve as a model for similar schemes around the world. Several other countries in Latin America and Africa have expressed an interest in the project’s methodology, and the governing committee of the World Intellectual Property Organization recently invited Royero to deliver a paper on BioZulua at its Geneva headquarters.
Its supporters say BioZulua eventually could generate several millions of dollars that could be used to meet the heavy financial costs of providing improved health and other services for indigenous Amazonian communities.
Out of the Amazon
The Amerindians of the Amazon Basin have for centuries been reaping medicinal benefits from the region’s rainforests. "The natives were the first to carry out clinical testing, to experiment with new plants, to combine natural substances; they have always been alchemists," says Gordon Cragg, an expert in indigenous medicine at the U.S. National Cancer Institute.
The Amazon has contributed dozens of substances to Western medicine. Among the best known are curare, an essential component of modern anesthetics, and quinine, used to treat one of the world’s most important diseases, malaria.
Quinine is extracted from the bark of the cinchona tree and was used for centuries by native Amazonians to reduce fever. In 1820 two French pharmacists isolated it chemically, and in 1944 it was reproduced in the laboratory. "Traditional medicine was the inspiration and the foundation of drugs against [malaria]," says Cragg. "Although today you find case resistance to quinine-based medicines in many places, for a long time it was essential."
A Washingtonian, Richard Gill, discovered the properties of curare and was a pioneer in bridging Amazonian and Western medicine. After graduating from college, he traveled in 1929 to Ecuador, where he struck up a friendship with the natives and began to unravel the "pharmacopoeia" of the jungle. When in 1934 he was diagnosed with multiple sclerosis, he thought that the powerful poison used by the natives on the tips of their arrows might be an alternative therapy. Curare acts by blocking certain chemical receptors so nerve impulses cannot reach the muscles. Thus, Gill reasoned, a medication based on curare might be useful in treating MS or Parkinson’s disease.
He organized an expedition with more than 100 members that penetrated deep into the forest and succeeded in extracting the secret of producing curare. He also discovered 75 other botanical species potentially useful for medical treatments. He recalled his experiences in an expedition film and book titled White Water and Black Magic. Although curare did not prove useful in treating MS, its relaxant qualities were useful in the development of anesthetics. Since Gill’s findings, neuromuscular blocking has been an essential part of anesthesia.
More recent examples of Amazonian medicinal contributions include chanca piedra ("shatterstone"), use by native peoples to cleanse the internal organs and treat kidney stones; manaca, an anti-inflammatory used to treat endocrine system problems; and iporuru, the plant base for a number of remedies for muscular and joint pain.
"Potentially, there are many medications that could be extracted from tropical plants, and the strange thing is that different species often produce the same substance," says Cragg. He adds that many rainforest substances stimulate the immune system, which makes them a useful complementary therapy to other treatments.
Besides the Amazon, other regions in the Americas have made important contributions to modern medicine. An Aztec medicine extracted from the ñame (a type of yam) is now used as a steroid hormone in birth control. The main ingredient in Taxol, used in the treatment of breast cancer, is extracted from the Pacific yew tree, which grows in the western U.S. states of Oregon and Washington.
"What is fundamental is to provide the appropriate formula and to know the correct dose for each intervention. Nature is wise, and the indigenous inhabitants knew just what to take and in what quantity. Westerners should learn from them," says Cragg.
—Paula Andaló
