"The medicine from behind": The frequent use of enemas in western African traditional medicine.

ETHNOPHARMACOLOGICAL RELEVANCE: Purgative enemas form an integral part of African traditional medicine. Besides possible benefits, serious health risks of rectal herbal therapy have been described in literature. To design appropriate health education programs, it is essential to understand traditional herbal practices and local perceptions of health and illness. Little is known about the herbal ingredients of enemas in Sub-Saharan Africa and consumers' personal reasons to use them. AIM OF THE STUDY: To analyze the importance of enema use with regard to plant species used and illnesses treated in West and Central Africa, to understand the local health beliefs that underlie frequent enema use and to evaluate which recipes and practices could be beneficial or harmful. MATERIALS AND METHODS: We extracted data from 266 ethnobotanical questionnaires on medicinal (in particular women's health and childcare) and ritual plant use in Ghana, Benin and Gabon. Plants mentioned during interviews were vouchered and identified in herbaria. Health issues treated by means of enemas were ranked according to the number of plant species used for a specific illness. We compared our results with findings of medical research on benefits and risks of enema use in Sub-Saharan Africa. RESULTS: We recorded ca. 213 different plant species used in hundreds of recipes for rectal insertions, mostly in Ghana and Gabon. Stomachache, abdominal pain, female infertility and birth facilitation were treated with the highest number of plants species. Cleansing the intestines of young children to promote their health by getting rid of 'dirt', instead of treating constipation, was an important cultural practice that required the rectal application of herbal medicine, as well as other cultural bound health issues like stimulating children to walk at an early age. Tradition, the bitter taste of herbal medicine and the rapid effect of enemas were frequently mentioned reasons for enema use. DISCUSSION AND CONCLUSIONS: Literature indicates that although enemas can help to improve the hygienic conditions of a household with young infants, frequent enema use can pose serious risks like direct toxicity caused by harmful ingredients, mechanical injury and infections. In Africa, enemas containing herbal medicine are common methods of administering herbal medicine for a variety of diseases, rather than just medicinal treatments for constipation as previously thought. Health professionals should be aware of the extent of, and motivation behind enema use to develop culturally appropriate education programs, especially targeted at vulnerable groups such as elderly people, parents of young infants and pregnant women.

Ghana's herbal market.

ETHNOPHARMACOLOGICAL RELEVANCE: Medicinal plant markets not only provide a snapshot of a country's medicinal flora, they also reflect local health concerns and the importance of traditional medicine among its inhabitants. This study aimed to describe and quantify the Ghanaian market in herbal medicine, and the diversity of the species traded, in order to evaluate their economic value. MATERIALS AND METHODS: Initial visual surveys on the markets were followed by a detailed quantitative survey of 27 stalls in August 2010. Market samples were processed into herbarium vouchers and when possible matched with fertile vouchers from the field. RESULTS: We encountered 244 medicinal plant products, representing 186-209 species. Fourteen species were sold at more than 25% of the market stalls. Seeds and fruits that doubled as spice and medicine (Xylopia aethiopica, Monodora myristica, Aframomum melegueta) were in highest demand, followed by the medicinal barks of Khaya senegalensis and Pteleopsis suberosa. Plants sold at the market were mostly used for women's health, in rituals, as aphrodisiacs and against sexually transmitted diseases. An estimated 951tons of crude herbal medicine were sold at Ghana's herbal markets in 2010, with a total value of around US$ 7.8 million. Between 20 and 30% of the Ghanaian medicinal flora was encountered during this survey. Roots were less dominant at the market than in dryer parts of Africa. Tons of Griffonia simplicifolia and Voacanga africana seeds and Fadogia agrestis bark are exported annually, but data on revenues are scanty. None of these species were sold on the domestic market. CONCLUSION: Our quantitative market survey reveals that the trade in Ghanaian herbal medicine is of considerable economic importance. Regarding the specific demand, it seems that medicinal plants are used to complement or substitute Western medicine. Further research is needed on the ecological impact of medicinal plant extraction.