Concluding Thoughts

A re-cap of issues raised in 1 through 3.

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Substantial transformations in HM presentation in urban Ghana have occurred in the last decade leading, significantly, to: precipitous erosion of traditional animistic beliefs, adoption of marketplace concepts, value-addition to crude extracts in the form of packaged product prepared with semi-industrial/commercial scale manufacturing processes under hygienically sound conditions, vigorous expansion of available recipes and aggressive promotion of formulated products through marketing campaigns that relies on the use of unorthodox strategies to stimulate purchasing decisions.  Urban communities are advantageous for HM user features characterization because the sampled populations tend to be relatively socio-economically and educationally heterogeneous and thus tend to generate a broad range of user features that are beneficial for the provision of comprehensive understanding of contemporary use culture. Survey interviews from a nationally representative urban population in Ghana will indicate that HM use is driven by the desire to improve health; the convenience and the relative low cost of self-diagnosis and self-medication; the assumption of natural products' safety; and the dissatisfaction, attributable to limited efficacy and undesirable side effects, with physician-prescribed allopathic medical drugs.

Despite the diverse socioeconomic backgrounds and different educational levels of this urban community, prevalence estimates will surprisingly be high and will be comparable to levels within rural populations. High prevalence of urban community HM use will be coincident with rise in urban-level awareness of the prophylactic and therapeutic effects of HM; persistent easy access to wide varieties of formulation types in ready-to-use forms; declining users perception of its inefficacy and growing user perception of its safety. Most users will undoubtedly be young (18-45 years), single males with educational levels up to Senior High School. Users will posit that they rely on HM therapies for the management of a wide range of symptoms and for the improvement in short-term and long-term health outcomes.  HM is mostly administered orally, either acutely or chronically, as the sole prophylactic or therapeutic agent or as a complement to prescription medication. Widely known raw herbal plants with excellent historical proven efficacy and safety perceptions are also available for ‘in-house recipes’ linked with home-made remedies. Unreported adverse side effects and low shelf-life of ready–to-use formulations limit the long-term use of some HM formulations as prophylactic agents.

HM use in Ghana has dramatically outpaced its underlying efficacy and safety scientific evidence base. Lack of efficacy assessment through clinical trials and safety assessment through toxicological and pharmacological studies has inexorably narrowed its scientific evidence base. Lack of isolation of pure bioactive compound(s) have also hampered prospective scientific studies that have translational implications including the identification and the structural characterization of key bioactive species, the biochemical mechanism underlying its therapeutic action as well as the delineation of the bioactive compound’s absorption, distribution, metabolism and excretion profiles. But HM requires comparable level of scientific scrutiny as AM if it is to provide broad policy initiatives to guide its complementary integration into AM care facilities in Ghana. Stronger FDB institutional oversight on good manufacturing practices that can assure reproducible bioactivity and eliminate fake and adulterated formulations can focus on the authentication of herbal plants by genetic origin and on the standardization, using chromatographic fingerprints, of HM products by active ingredients.

Users often combine more than one HM formulation(s) or take HM and AM drugs simultaneously. In combination, the activity of bioactive constituents may be altered synergistically to improve treatment outcome or antagonistically to produce adverse health effects. An alert system that prompts stakeholders of reported adverse HM-HM interaction and harmful HM-AM drugs interactions will improve safety through the elimination of antagonistic interactants. Safety concerns should additionally be enlarged to cover the broad spectrum of reckless use behavior and should emphasize the stringent adherence to dose levels with its implied appropriate use frequency and the avoidance of use of multiple HM formulations simultaneously and the use of HM in combination with adverse substances including alcohol and AM drug interactants. High use of alcohol-based bitters by the increasingly younger demographic groups is yet to be recognized as a public health problem. A better understanding of the socio-medical context in which HM bitters use occur, can assist in the design of effective and possibly culturally-tailored solutions to problematic drinking that has been inevitably associated with alcohol-infused bitters use.

HM care centers provide easily accessible hospice-based HM care for the acutely ill and for patients with intractable diseases for which AM treatment have produced less than satisfactory treatment outcome. But clinically relevant, evidence-based, policy decisions on herbal medicinal care centers in Ghana are needed to streamline operation and to provide oversight over providers with no formal training in medicine.

A unified model that will be informed by survey responses will indicate that contemporary Ghanaian HM presentation is driven by unmet medical needs, effected with a wide assortment of formulations that are mostly orally administered with less than stringent dose and shaped by excellent safety and efficacy perceptions that are often tenuous and have no scientific evidence base. The contemporary use culture can also be inferred from additional diverse perspectives that include changes in historical usage of herbal plants, changes in the demography of users and changes in the health beliefs of urban populations. The constellation of these perspectives leads to an awareness of the increasing complexity of factors that control contemporary HM use culture in Ghana. 

Future detailed survey and scientific studies along this direction of research will fill significant vacuums of information on this understudied but highly pertinent issue and the findings will have broader significance with respect to evolving trends of HM use in Ghana. HM still plays critical roles in health care in Ghana as demonstrated by the high urban prevalence estimates. And the impact of HM on Ghana’s socio-cultural and medical landscape is deep and certainly long-lasting. But HM remains an area of widely used clinical care in Ghana that still requires further scientific research to define risks and to enumerate benefits. Researchers can use this evolving picture to improve contemporary understanding of HM use among urban Ghanaians. A recommendation on increasing studies into HM is vital as several new avenues on contemporary HM use culture are open for investigations that could have important clinical, epidemiological, and translational implications for disease management. A multidisciplinary study on HM emphasizing conceptual and methodological challenges as well as highlighting regulatory issues can also inform policy development. Scientific studies using molecular biological tools under the scientific regulatory umbrella of the FDB may generate biochemical mechanistic insights on herbal formulations that can complement existing research much of which relies on survey data and on anecdotes. Factual scientific context within which contemporary HM is embedded needs to evolve to buttress its evolving increasing signs of change.