TRAMIL ethnomedicinal survey in Jamaica.

Journal of Ethnopharmacology ∎ (∎∎∎∎) ∎∎∎–∎∎∎

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TRAMIL ethnomedicinal survey in Jamaica D. Picking a, R. Delgoda a, N. Younger b, L. Germosén-Robineau c, I. Boulogne c, S. Mitchell d,n a

Natural Products Institute, University of the West Indies, Mona, Kingston 7, Jamaica Tropical Metabolic Research Institute, University of the West Indies, Mona, Kingston 7, Jamaica TRAMIL (Program of Applied Research for Traditional Popular Medicine in the Caribbean), Laboratoire de Biologie et de Physiologie Végétales, Campus de Fouillole, Université des Antilles et de la Guyane, 97157 Pointe-à-Pitre Cedex (Guadeloupe), France d Medicinal Plant Research Group, The Biotechnology Centre, University of the West Indies, Mona, Kingston 7, Jamaica b c

art ic l e i nf o

a b s t r a c t

Article history: Received 10 December 2014 Received in revised form 17 April 2015 Accepted 18 April 2015

Ethnopharmacological relevance: A survey was undertaken in Jamaica to document medicinal plants frequently used in the treatment or prophylaxis of illness and trends in their use, following the methodology established by the TRAMIL network. TRAMIL, a Caribbean-wide applied research programme, scientifically evaluates and documents the efficacy and safety of medicinal plant remedies used for primary health care. Initial results from this survey, on an aspect of safety, focusing on the concomitant use and prevalence of medicinal plant use in combination with pharmaceutical drugs in Jamaica, were published in an earlier paper in 2011. This paper now reports survey results on the ethnobotanical use of medicinal plants by Jamaicans. Materials and methods: A survey using a structured and modified TRAMIL questionnaire was administered to 407 adults selected randomly from systematically selected households within randomly selected clusters. The clusters were selected from each of the three areas that were purposefully selected. Key findings: Respondents identified their use of 107 botanically identified medicinal plants distributed in 51 plant families to treat illnesses or maintain health in the previous twelve months. Fourteen plants, with significant use equal to or greater than 20% for a specified health issue were shortlisted, representing Jamaica's first submission to the TRAMIL database. Andrographis paniculata (Burm. f.) Nees (Rice Bitters) was reported as a plant remedy with significant use for the first time in a TRAMIL survey. Informant consensus factor (ICF) values were high for a number of health issues such as mental health (nerves, insomnia, etc.), respiratory system (cold/flu/cough etc.) and for health maintenance with tonics (washout and blood cleanse), indicating strong cultural coherence in medicinal plant selection for these categories. Forty two per cent (113/270) of medicinal plant users utilised mixtures, combining more than one plant. Leaf material was the most commonly used plant part (69%), with fresh material (98%) most commonly prepared as a tea for internal use by decoction (87%). The majority of medicinal plant respondents sourced plants from their backyards (75%) and cited grandmothers (33%) and mothers (32%) as their main sources of information. Jamaicans reported limited use of complementary and alternative medicine (CAM), supporting the assertion that a significant number of citizens in developing countries continue to rely on the use of medicinal plants for primary healthcare. Conclusions: Medicinal plant use continues to play an important role in primary healthcare in Jamaica. Fourteen plant remedies with significant use are reported, five previously reported elsewhere and recommended (REC) for the same health condition. Eight plant remedies, including one Jamaican endemic, are reported for different health issues for the first time to TRAMIL and will be investigated (INV) for the new health conditions, together with one plant remedy reported for the first time. This latest survey will be followed by literature reviews, appropriate laboratory screens (TRIG) and community outreach activities (TRADIF) in Jamaica. & 2015 Elsevier Ireland Ltd. All rights reserved.

Jel classification: Ethnomedicinal field studies Quality traditional medicines Keywords: Biodiversity hotspot Ethnomedicine Informant consensus factor Jamaica TRAMIL Traditional knowledge

n

Corresponding author. Tel.: þ 1 876 977 1828; fax: þ1 876 977 3331. E-mail addresses: [email protected] (D. Picking), [email protected] (R. Delgoda), [email protected] (N. Younger), [email protected] (L. Germosén-Robineau), [email protected] (I. Boulogne), [email protected] (S. Mitchell).

1. Introduction The World Health Organisation (WHO) defines Traditional Medicine (TM) as “the sum total of the knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, used in the

http://dx.doi.org/10.1016/j.jep.2015.04.027 0378-8741/& 2015 Elsevier Ireland Ltd. All rights reserved.

Please cite this article as: Picking, D., et al., TRAMIL ethnomedicinal survey in Jamaica. Journal of Ethnopharmacology (2015), http://dx. doi.org/10.1016/j.jep.2015.04.027i

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D. Picking et al. / Journal of Ethnopharmacology ∎ (∎∎∎∎) ∎∎∎–∎∎∎

maintenance of health, as well as in the prevention, diagnosis, improvement or treatment of physical and mental illnesses” (World Health Organisation (WHO), 2002, 2013). The practices of TM continue to be widely used internationally with those demonstrating safety, efficacy and quality playing a significant role in achieving equitable access to healthcare (WHO, 2002, 2013; Cordell, 2011; Cordell and Colvard, 2012). In many countries TM is the main, or in some cases the only, source of healthcare. However, its use is not restricted solely to those countries with limited conventional healthcare provision but continues to be used in countries where conventional medicine is predominant in the national healthcare system (Cordell, 2011). Equitable healthcare access is being negatively affected by a narrowing of pharmaceutical drug development programmes, with a contemporary focus on antivirals, central nervous system ailments, inflammatory diseases, metabolism and oncology, whilst the health requirements of over one billion people include the need for treatments for ascariasis, Chagas' disease, dengue fever, diarrheal diseases, hepatitis C, leishmaniasis, leprosy, lymphatic filariasis, malaria, necatoriasis, onchocerciasis, rabies, schistosomiasis, trypanosomiasis, tuberculosis and yaws (Jarvis, 2010; Cordell et al., 2012). At a time when a number of countries continue to face severe austerity, TM is accessible, affordable and trusted by a large number of people. TM, enhanced by evidence-based research, also offers longer term opportunities to help address the increase in non-communicable diseases that now affect most developing and middle income countries, and to help address the significant mismatch between global health requirements and contemporary drug development programmes (WHO, 2002, 2013; Jarvis, 2010; Cordell, 2011; Mitchell, 2011a; Cordell et al., 2012; Newman and Cragg, 2012; Luciano-Montalvo et al., 2013). Addressing issues of safety, efficacy and quality are key aspects of the WHO strategy to establish a strong evidence base for TM, a fundamental precursor to its development as a reliable source of primary health care, and subsequent integration into national healthcare systems. Additionally, sustainable use and cultivation of medicinal plants is a critical aspect of ensuring equitable access to healthcare (WHO, 2002, 2013; Cordell, 2011). In some regions the growing market for medicinal plants poses a significant threat to biodiversity, with excessive wildcrafting rather than cultivation, increasing the extinction of endangered species, together with destruction of natural habitats and resources (Cordell, 2011, 2012). In the Caribbean region, the Traditional Medicines in the Islands network (TRAMIL) has undertaken approximately 50 TRAMIL surveys to date, in countries including: Antigua, Belize, Barbados, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Granada, Guadeloupe, Guatemala, Haiti, Honduras, Martinique, Mexico, Nicaragua, Panama, Puerto Rico, Saint Lucia, Saint Martin, Saint Vincent, Tobago and Venezuela (Weniger et al., 1986; Giron et al., 1991; Robineau, 1991; Germosén-Robineau and Soejarto, 1996; Longuefosse and Nossin, 1996; Germosén-Robineau et al., 2005; Alvarado-Guzman et al., 2009; Volpato et al., 2009; Boulogne et al., 2011; GomezEstrada et al., 2011; TRAMIL, 2014). A key aspect of the TRAMIL program is the documentation and conservation of traditional knowledge and biodiversity, using ethnomedicinal surveys. TM in the Caribbean follows an oral rather than a written tradition, a practice that is coming under increasing pressure with the widely reported loss of biodiversity-based traditional knowledge (Ramirez, 2007; Alvarado-Guzman et al., 2009; Boulogne et al., 2011; Vandebroek and Balick, 2012). In addition, the Caribbean region is one of 25 global biodiversity hotspots characterized by very high concentrations of endemic species which are experiencing exceptional habitat losses (Myers et al., 2000). Following a TRAMIL survey, plant remedies are shortlisted that are shown to have significant levels of use (SIG). Investigations (TRIGS – TRAMIL investigations) are ordered to validate each popular use, testing for toxicity and efficacy of the specific plant

67 extracts corresponding to the documented traditional use, and the 68 remedies are said to be under investigation (INV). With this info69 rmation, TRAMIL collaborators promote the use of specific plant 70 remedies, which have been deemed effective for specific conditions 71 which can be treated at home (REC) and discourage the use of others 72 which are shown to be toxic (TOX). Recommended (REC) recipes are 73 placed in the Caribbean pharmacopeia, through which TRAMIL com74 municates ethnopharmacological information on medicinal plants 75 to local doctors, pharmacists and other health care professionals. 76 TRAMIL also organizes community outreach programs, TRAMIL diff77 usion (TRADIF), aimed at communicating the results of the surveys, 78 and subsequent investigations, to the communities that participated. 79 To date, over 90 medicinal plant remedies, evaluated by TRAMIL, 80 have been recognized as safe and effective treatments and incorpo81 rated into primary healthcare programs in Cuba, Dominican Republic, Honduras, Nicaragua and Panama (Farnsworth et al., 1985; Robineau, Q3 82 83 1991; Germosén-Robineau and Soejarto, 1996; Hoareau and DaSilva, 84 1999; Martin, 2004; Alvarado-Guzman et al., 2009; Boulogne et al., 85 2011; TRAMIL, 2014). 86 The Jamaican TRAMIL survey was undertaken between 2008 87 and 2009 with the aim of identifying the significant traditional 88 uses of plant species and to learn more about TM use in commu89 nities of three areas in Jamaica, representative, respectively, of 90 urban and rural dwellers on the island, according to the TRAMIL 91 methodology. We hypothesized that TM use continues to be highly 92 prevalent in primary healthcare in Jamaica. Whilst undertaking the Jamaican TRAMIL survey, additional infor93 mation was gathered on the concomitant use of pharmaceutical drugs 94 with medicinal plants, a key aspect of medicinal plant safety. The 95 results and analysis of such concomitant use was published, together 96 with details of the socioeconomic and demographic profiles of med97 icinal plant and medicinal plant concomitant drug users in 2011 98 (Picking et al., 2011). Following detailed analysis, this paper now 99 reports for the first time, the ethnomedicinal plants shortlisted for 100 inclusion in the TRAMIL database (TRAMIL, 2014), use of medicinal 101 plant mixtures, preparation methods, sources of plant material, 102 reasons for use, sources of information, contraindications, side effe103 cts, use of other forms of complementary and alternative medicine 104 (CAM), and a list of all botanically identified medicinal plants used by 105 Jamaicans sampled in the survey. 106 107 108 109 2. Material and methods 110 111 2.1. TRAMIL methodology 112 113 TRAMIL has a distinct and unique methodology comprising sur114 veys, bibliographic researches and experimental laboratory studies, 115 following both a quantitative and qualitative approach to the popular 116 uses of medicinal plants. The methodology begins with an ethno117 pharmacological participative survey where questions are asked first 118 about how the health condition was treated and not the plants used 119 (Martin, 2004; Boulogne et al., 2011; TRAMIL, 2014). 120 The frequency of plant remedy use mentioned by respondents, 121 for a given health condition, is then calculated using the following 122 formula: 123 Freq: ¼ N i =N p 100 124 125 where Freq. is the frequency (%), Ni is the number of respondents 126 that used that plant remedy to treat a particular health condition 127 or to maintain health, Np is the overall number of respondents 128 who used plant remedies to treat that particular health condition 129 or approach to maintaining health (Martin, 2004; Boulogne et al., 130 2011; TRAMIL, 2014). 131 Medicinal plant remedies, identified in a survey, are shortlisted 132 for inclusion in the TRAMIL database, when the calculated frequency



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(Freq.) is 20% or higher. In addition, a minimum value of five was set for the Ni and Np values, in consultation with TRAMIL. The TRAMIL group chose this minimum frequency to exclude anecdotal use (Martin, 2004; Boulogne et al., 2011; TRAMIL, 2014). The shortlisted plants are then documented by their scientific name, family and local name. Frequency, health issue, voucher number, plant part used, preparation mode and means of administration, are included. The shortlisted plant remedies are classified as significant use plant remedies (SIG) (TRAMIL, 2014). 2.2. Jamaica TRAMIL survey The survey was conducted in Jamaica, between 2008 and 2009, through collaboration between the Natural Products Institute and the Biotechnology Centre, both at the University of the West Indies, Mona Campus, Kingston. Following the TRAMIL methodology (TRAMIL, 2014) a list of the health conditions most impacting the Jamaican population, using data from the Ministry of Health (MOH, 2005), were incorporated within the questionnaire. After obtaining prior informed consent, survey respondents were asked to identify conditions treated in the previous twelve month period, to minimize recall bias. In addition, respondent's details were collected in such a way as to guarantee anonymity, following the guidelines set forth by the University of the West Indies. For each health condition identified, respondents were then asked about their use of medicinal plants. Full details of the questionnaire are detailed in the previous paper, reporting the concomitant use of medicinal plants with pharmaceutical drugs (Picking et al., 2011). Based upon previous surveys conducted by the Natural Products Institute in 2004 (Delgoda et al., 2004) and 2006 (Delgoda et al., 2010) a minimum sample size of 256 participants was established. A sample size of at least 256 participants adequately estimates 80% prevalence of medicinal plant use with a margin of error of 5% based upon a 95% confidence interval (CI). This figure was then inflated by 40%, to approximately 360, to accommodate for the effect of cluster sampling on the variation of parameter (prevalence) estimates. The survey team set out to conduct 400 interviews. In previous TRAMIL surveys the person interviewed has been the mother, who is traditionally seen as the gatekeeper of family health (Longuefosse and Nossin, 1996; Boulogne et al., 2011; TRAMIL, 2014). However, for the Jamaican survey, the decision was made to randomise the choice of adult respondent in each household based upon the experience of previous Jamaican surveys (Mitchell, 2011b) in which men were also found to be active participants in medicinal plant use. 2.3. Survey area Jamaica, at 11,000 sq km (4411 sq mi), is the third largest by area and the largest English speaking island in the Caribbean Sea, located at latitude of 181150 N and longitude 771300 W, 145 km (90 miles) south of Cuba (Watts, 1987; Lee, 2006; UWI, 2012). The island measures 230 km from east to west and varies in width between 35 and 82 km (Evelyn and Camirand, 2003). A mountain range runs through the interior from east to west, with the highest point reaching 2256 m (7402 ft) at Blue Mountain Peak (Watts, 1987; Lee, 2006). Over half the country is above 305 m (1000 ft) (Asprey and Thornton, 1953; GofJ, 2003) with narrow coastal plains surrounding the mountain range comprising 20% of the land area (Lee, 2006). Jamaica experiences a maritime tropical climate with a hurricane season from June through November and two rainy seasons in May and October/November. Average temperatures are 28 1C (82.4 1F) at sea level and 15 1C (59 1F) at 2000 m (Lee, 2006).

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Jamaica's varied topography, geology and hydrology supports a 67 diverse range of ecosystems (Tole, 2001; Dougal et al., 2006). Jamaica 68 has a wealth of flora and fauna with a high proportion of endemic 69 species of flora, ranking it fifth among the world's islands (Killmer et 70 al., 2006; Lee, 2006). Such a high level of endemism represents an 71 important gene pool, with significant potential medicinal, horticul72 tural and genetic value, much of which has yet to be explored (GofJ, 73 1989; UNFAO, 1989; Mitchell and Ahmad, 2006; Mitchell, 2011a). 74 Indigenous plants include guava (Psidium guajava L.), papaya (Carica Q5 75 76 papaya L.), pimento (Pimenta dioica (L.) Merr.) and pineapple (Ananas 77 comosus (L.) Merr.) (Lee, 2006; McGlashan et al., 2008). Many plants 78 have been introduced following colonization in the sixteenth century 79 with plants from countries including Africa, China, India and the 80 United Kingdom. Introduced plants include ackee (Blighia sapida K.D. 81 Koenig), breadfruit (Artocarpus altilis (Parkinson) Fosberg), coconut 82 (Cocos nucifera L.), mango (Mangifera indica L.), banana and plantain 83 (Musa spp.) and marijuana (Cannabis sativa L.) (Lee, 2006; McGlashan 84 et al., 2008). 85 A Government of Jamaica report in 2004 estimated that the 86 island had 30% forest coverage (GofJ, 2004). A significant propor87 tion of the island's tropical limestone forests are to be found along 88 the Cockpit Country, a range of karst terrain (egg-box shaped hills 89 and valleys with many caves, formed as limestone was dissolved 90 by acidic rain and ground water), on the western part of the island, 91 while, located in the north, secondary forest cover the Dry 92 Harbour Mountains (Tole, 2001). The Cockpit Country is particu93 larly noted for its high level of endemism with over one hundred 94 species of endemic plants identified to date (Lee, 2006). 95 Jamaica is made up of 14 parishes: Clarendon, Hanover, Kingston, 96 Manchester, Portland, Saint Andrew, Saint Ann, Saint Catherine, Saint 97 Elizabeth, Saint James, Saint Mary, Saint Thomas, Trelawny and 98 Westmoreland (Fig. 1) (PIOJ, 2005; STATIN, 2010). 99 The current population is 2,889,187 (2012 estimate) (STATIN, 100 2010; UWI, 2012), with approximately 54% living in urban areas 101 (Killmer et al., 2006; UN, 2007), with half of these urban dwellers 102 concentrated in the capital, Kingston. The Kingston Metropolitan 103 Area overlaps three parishes (Kingston, Saint Andrew and Saint 104 Catherine), with a population of 700,000 and a population density 105 of approximately 1528 persons per sq km (JRC, 2004). Overcrowd106 ing characterizes the composition of Jamaica's urban centres, with 107 urban slums comprising approximately 36% percentof all urban 108 centres on the island (UN, 2007). 109 English is the official language spoken and written in Jamaica. 110 However Jamaica has its own unique language, known locally as pat111 ois, spoken widely throughout the island and internationally across 112 the Jamaican diaspora. Some linguists refer to patois as Jamaican 113 creole, which is defined as an English creole language with a mix of 114 Central and West African tribal languages that adopted some of the 115 English vernacular of the 17th and 18th century during the period of 116 slavery between 1655 and 1838 (Devonish and Harry, 2004; Harry, 117 2006; UWI, 2012). 118 The Jamaican population is made up of a number of different 119 ethnic groups, 92% black, 6.06% mixed, 0.75% East Indian, 0.19% 120 Chinese, 0.16% white, 0.07% other, 0.65% not reported (STATIN, 2012). 121 As previously reported (Picking et al., 2011), this cross-sectional 122 study was undertaken across three locations, one urban, Kingston, 123 the capital city of Jamaica and two rural, Dallas in St. Andrew and 124 Flagstaff in St. James (Cockpit Country) (Fig. 1). Communities in 125 urban areas were selected to provide a broad demographic profile 126 from wealthier ‘uptown’ to less wealthy and poor ‘garrison’ and 127 ‘downtown’ communities. Those in the rural areas were selected 128 to provide demographic profiles of two rural communities, one 129 relatively close to an urban area and non-maroon, the second, 130 deeply rural, located within the Cockpit Country, a documented 131 biodiversity hotspot (Lee, 2006) and home to a Maroon commu132 nity (Campbell, 1988).



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Fig. 1. Map of Jamaican parishes indicating the study areas (PIOJ, 2005): insert A, Flagstaff, Cockpit Country; insert B, Dallas; insert C, Inner city community, Kingston.

The 14 parishes in Jamaica are sub-divided into enumeration districts (EDs). Five ED's (clusters) were chosen within each location. The number of interviews to be conducted in each location, the sampling fraction, was established in proportion to the population size of that location. This was achieved by dividing the required number of interviews (400) by the total number of households in the sample frame (2576) and multiplying this number by the number of households at each location: Kingston (907), Dallas (1037) and Flagstaff (632). For each location, the sampling fraction was then divided by the number of ED's to give the required number of interviews per ED. In each ED, households were selected systematically by dividing the number of households in that ED by the number of interviews required, providing a skip pattern. One adult per household was selected randomly and interviewed. All maps and population statistics were provided by the Statistical Institute of Jamaica (STATIN) (STATIN, 2010; Picking et al., 2011). Further details of the survey are given in our earlier publication (Picking et al., 2011) 2.4. Ethnobotanical data collection All plant material, gathered during the survey, was submitted to the Herbarium at the University of the West Indies, Mona, Jamaica, for identification by Mr. Patrick Lewis, Botanist and Herbarium Curator. 2.5. Data analysis Survey data was documented utilizing Epidata version 3.1. Categorical data analysis was performed with the statistical package STATA version 10 (StataCorp, 2010) to provide association between variables and measures of frequency (using chi-squared test and Fisher's exact test as appropriate), which, together with the TRAMIL methodology,

was used to identify the significant traditional uses of plant species, and to learn more about the traditional medicine of the country.

2.6. Informant consensus factor (ICF) The informant consensus factor (ICF), is a widely used method for analysing quantitative data in ethnomedicinal field studies based on the works of Trotter and Logan (1986). The ICF gives information about the consensus or consistency of the informants for the treatment of specific illness categories (Heinrich et al., 2009). The ICF indicates if the surveys' information is homogenous. ICF values close to zero indicate that plants are chosen randomly or that there is significant disagreement between respondents on the choice of plants used for the treatmentof particular health conditions, body systems or maintenance of health. Values close to one indicate that plants are collectively used by a significant proportion of respondents. This factor provides an indication of the cultural coherence of a community in selecting a set of medicinal plant remedies used in the treatmentof a certain illness category but no indication about the importance of individual plant remedies used (Trotter and Logan, 1986; Heinrich et al., 2009; Boulogne et al., 2011). The ICF is calculated using the following formula: ICF ¼ N ur –Nt =Nur 1 where Nur is the number of citations of use in each category and Nt, the number of species used (Trotter and Logan, 1986; Heinrich et al., 2009; Boulogne et al., 2011). The two methods of analysis, frequency of citation (TRAMIL) and ICF, together provide a critical and quantitative understanding of local plant use (Heinrich et al., 2009).


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3. Results 3.1. Socioeconomic and demographic profiles of medicinal plant users Details of the socioeconomic and demographic profiles of medicinal plant users are reported in our earlier paper, together with an analysis of the use of medicinal plants in combination with pharmaceutical drugs. In this earlier paper, we identified that 72.6% (270/372) of respondents used medicinal plants to treat illness and/orto maintain health in the previous twelve months (Picking et al., 2011).

3.2. Plant families In our previous paper we reported that survey respondents identified their use of 116 medicinal plants in the previous twelve months (Picking et al., 2011). We now report the botanical identification of 107 (92%) of these 116 medicinal plants (Appendix A, Table A7). These plants are distributed in fifty one plant families with the more frequent plant families, in order, being, Fabaceae, Lamiaceae, Asteraceae, Malvaceae and Piperaceae. Fig. 2 identifies the top 25 of the 51 plant families identified. The species of Fabaceae most frequently cited was Gliricidia sepium Kunth (Maranga), a widespread and fast growing shade tree (Adams, 1972). The most frequently cited species of Lamiaceae was Clerodendrum thomsoniae Balf. (Rice and Peas), a climbing shrub native of West Africa (Adams, 1972). The species of Asteraceae most frequently cited was Eupatorium odoratum L. (Jack-inthe-Bush), a common glabrate shrub (Adams, 1972). The Malvaceae most cited was Cola acuminata (P. Beauv.) Schott and Endl. (Bissy), a native tree of tropical West Africa (Adams, 1972) and the most cited Piperaceae was Piper amalagoL. (Jointer), a glabrous shrub or tree (Adams, 1972). Araceae

1

Anarcardiaceae

1

Zingiberaceae

2

Vitaceae

2

Solanaceae

2

Smilacaceae

2

Phytolaccaceae

2

Myrtaceae

2

Moraceae

2

Apocynaceae

2

Amaryllidaceae

2

Amarantaceae

2

Acanthaceae

2

3.3. TRAMIL results Table 1 identifies those ethnomedicinal plant species of 20% or higher that were shortlisted and submitted to the TRAMIL database for further evaluation. A total of 14 plants are included in the shortlist, which details the specific health issue treated, together with plant parts used and methods of preparation and administration. The aerial and whole plant of Andrographis paniculata, prepared as a decoction and used as a blood cleanser in Jamaica, is identified as a significant use for the first time by a TRAMIL survey. Specimens, for each of the TRAMIL shortlisted plants,were collected and submitted to the Herbarium (Fig. 3). Photos for each plant were taken and submitted to TRAMIL and botanical nomenclature checked in Tropicos, an international botanical database maintained by the Missouri Botanical Garden (Tropicos, 2012). 3.4. Informants consensus factor (ICF) ICF values varied between 0.0 and 0.88. The highest ICF was recorded for mental health issues(nerves, insomnia, depression), indicating the highest level of cultural coherence for the selection of medicinal plant remediesused to treatthis illness category, whilst the lowest ICF values were reported for the cardiovascular system, eyes, prostate problems and teeth (Table 2). 3.5. Use of medicinal plant mixtures

3.6. Medicinal plant parts used

3

Urticaceae

3

Poaceae

3

Euphorbiaceae

3

Boraginaceae

3

Apiaceae

3

Annonaceae

3

Leaves were the most commonly used part in preparing medicinal plant remedies, used by 69% of respondents. Other plant parts most frequently used were aerial, 50%, branch, 41%and whole plant, 26% (Fig. 5). 3.7. Preparation methods Respondents used a number of methods to prepare medicinal plant material for both internal and external use. The most common method of preparing medicinal plant remedies was from fresh plant material (Fig. 6) decocted and taken as a tea for internal use (Fig. 7) and rubbing for external use (Fig. 8).

4

Malvaceae

5

Asteraceae

5

Lamiaceae

Eight of the 107 plants botanically identified are endemic or occur as endemic varieties, Boehmeria jamaicensis Urb. (Doctor Johnson), Bidens reptans (L.) G. Don (var. tomentosa O.E. Schulz) (McKatty Weed), Oryctanthus occidentalis(L.) Eichler (Godbush), Peperomia amplexicaulis (Sw.) A. Dietr. (Jackie's Saddle), Pilea microphylla (L.) Liebm. (var. microphylla) (Baby Puzzle), Piper amalagoL. (var. nigrinodum) (Black Jointer), Rhytidophyllum tomentosum (L.)Mart.(Search-mi-Heart) and Smilax balbisiana Kunth (Chainy Root) (Appendix A).

In this study, 42% (113/270) of medicinal plant users, used at least one combination of plants, or mixtures, to treat specific health conditions or maintain health, compared to 58% (157/270) who used only an individual plant in their medicinal recipe. Medicinal plant users (270) identified a total of 350 recipes using single plants or two or more plants in combination: 186 recipes comprised of single plants (53.2%), 145 comprised two to three plants (41.4%), 18 recipes comprised of four to five plants (5.1%) and one comprised of six or more plants (0.3%) (Fig. 4).

Verbenaceae

Piperaceae

5

9

Fabaceae

11

3.8. Medicinal plant sources

Number of medicinal plant species (n)

Fig. 2. Distribution of botanically identified medicinal plant species (n¼ 107) by plant family showing the top 25 of 51 families identified.

Three quarters of medicinal plant users sourced plants from their own yards (Fig. 9).


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Table 1 TRAMIL Shortlist: medicinal plant use where the level of use (Freq.) is equal to or greater 20% for a specific health issue (plants listed alphabetically). Local name

Voucher Health issue Part useda (F or D)b Preparation

Scientific name

Family

Allium sativum L. Aloe vera (L.) Burm. f.

Amaryllidaceae Garlic Xanthorrhoeaceae Sinkle Bible

n/v 35468

Andrographis paniculata (Burm. f.) Nees Annona muricata L. Bryophyllum pinnatum (Lam.) Oken Chenopodium ambrosioides L.

Acanthaceae Annonaceae Crassulaceae Amaranthaceae

Rice Bitters Soursop Leaf of Life Semicontract

35372 35467 35466 35476

Cymbopogon citratus (DC.) Stapf Eupatorium odoratum L. Momordica charantia L.

Poaceae Asteraceae Cucurbitaceae

Fever Grass Jack-in-the-bush Cerasee

35474 35475 35477

Opuntia cochenillifera (L.) Mill. Piper amalago L. Petiveria alliacea L.

Cactaceae Piperaceae Phytolaccaceae

Tuna 35479 Jointer 35464 Guinea Hen Weed 35469

Blood-cleanse Blood cleanse Nerves Cold Intestinal worms Fever Cold Blood-cleanse Bellyache/gas Tonic Washout Backache Bellyache/gas Headache

Rivina humilis L. Zingiber officinale Roscoe

Phytolaccaceae Zingiberaceae

Dogblood Ginger

Painful periods Wh (F) Bellyache/gas Rhiz (F)

35470 n/v

Hypertension Washout

c

Clove (F) Lf/gel (F)

Decoct/natural Blend/decoct/ infuse Lf/gel (F) Blend/decoct Aer/Wh (F,D) Decoct Lf (F,D) Decoct/infuse Lf (F) Decoct/juice Wh/Lf&St/Lf (F,D) Decoct/infuse/juice Lf (F,D) Lf/Lf&ST (F,D) Aer (F,D) Aer (F,D) Aer (F,D) Aer (F,D Lf (F) Lf&St/Wh/Rt (F,D) Rt/Lf&St (F)

Infuse/decoct Decoct Decoct Decoct Decoct Decoct Macerate Decoct Crush/compress Decoct Decoct

Admind

Freqe %

Oral Oral

28 54

Oral Oral Oral Oral Oral

33 21 83 51 73

Oral Oral Oral Oral Oral Oral Oral Oral Inhale/ ext Oral Oral

70 33 67 44 40 22 50 21 23 67 25

a

Aer: aerial; Gel: jelly like substance; Lf: leaf; Rhiz: rhizome; Rt: root; St: stem; Wh: whole. F: fresh and D: dried. Decoct: actively boil plant material for several minutes; natural: no preparation; infuse: pour boiling water onto plant material and steep; macerate: soften by soaking in a liquid. d Ext: external use n/v: not vouchered (commonly sourced from supermarkets, markets and health stores). e Freq.¼Ni/Np 100, where Ni is the number of respondents that used that specific plant remedy to treat a particular health condition or to maintain health; Np is the overall number of respondents who used plant remedies to treat that particular health condition or approach to maintaining health. For example: Bryophyllum pinnatum Ni ¼ 82, Np ¼ 160, therefore Freq.¼82/160 100¼ 51.3%. b c

Fig. 3. Voucher samples submitted to the University of the West Indies Herbarium for four of the TRAMIL shortlisted plants: (A) Annona muricata (Soursop) (35467); (B) Chenopodium ambrosioides (Semicontract) (35476); (C) Cymbopogon citratus (Fever Grass) (35474); (D) Momordica charantia (Cerasee) (35477).

3.9. Reasons cited for self-medicating with medicinal plants

3.11. Contraindications and reported side-effects

The most frequently cited reason for using a medicinal plant to treat an illness or maintain health was simply that the remedy worked (Fig. 10).

Where respondents indicated their use of medicinal plants, they were asked if there were times when it would not be appropriate or safe to use the remedy. Only two percent of medicinal plant users identified possible contraindications with two percent stating that a particular medicinal plant should be avoided during pregnancy (Table 3) with Rivina humilis L. (Dogblood), Momordica charantia L. (Cerasee), Aloe vera (L.) Burm.f. (Sinkle Bible) and Boehmeria jamaicensis Urb. (Doctor Johnson) being the plants cited by respondents. In addition, one respondent stated that Momordica charantia L. (Cerasee) was contraindicated in diabetics prior to blood tests to avoid interfering with, or ‘masking’ test results.

3.10. Sources of information and knowledge Information on the use of medicinal plants was predominantly sourced from grandmothers (33%) and mothers (32%). Interestingly fathers (10%) and grandfathers (6%) were also a prominent source of information. Doctors (0.7%) and radio/TV (0.7%) were the least cited sources of information (Fig. 11).


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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66

Table 2 Informants consensus factor (ICF) of the plants used in the treatment of specific health issues by medicinal plant respondents. Health condition

ICF value

Nerves/insomnia/depression Cold/cough/flu Blood cleanse Constipation Bellyache/gas Fever Washout Worms Skin problems Backache Diarrhoea Headache/migraine Painful periods Hypertension Tonic Vomiting/food poisoning Arthritis Diabetes Sinusitis Asthma Cut/wound Prostate problems

0.88 0.87 0.84 0.80 0.77 0.73 0.71 0.70 0.59 0.58 0.55 0.50 0.50 0.44 0.40 0.38 0.36 0.33 0.27 0.26 0.22 0.00

2

Tincture Ferment

6

Blend

7 12

Maceration

15

Infusion

18

Natural

21

Juice

87

Decoction %

Fig. 7. Preparation methods employed by medicinal plant users (n ¼270) ranked by prevalence for internal use.

Powder

53.2

%

1

Bath

3

Poultice

3

Compress

4

41.4

7

Rub

5.1

1 plant

2-3 plants

7

0.3

4-5 plants

%

6+ plants

Fig. 4. Prevalence (%) of medicinal plant recipes - composed of one plant, two or three plants, four or five plants, or more than six plants (n ¼350).

Fig. 8. Preparation methods employed by medicinal plant users (n ¼270) ranked by prevalence for external use. 75

69 50 41 %

34

%

26

27

14

14

9

8

5

3

1 1

Yard Fig. 5. Plant partsused by medicinal plant users (n¼270).

Quail Dry

Countryside

Market

Shop

Fig. 9. Source of plants used by medicinal plant users (n¼270), ranked by prevalence.

12 38 98

Fresh

Of those respondents who did experience some type of side effect, bellyache/gas and vomiting were the most reported. The medicinal plants associated with the reported side effects are listed in Table 5.

%

Fig. 6. Dry, fresh or quailed (partially dried) use of plant material by medicinal plant users (n¼ 270) ranked by prevalence.

Only four percent of respondents reported experiencing any side effect when taking medicinal plants in the previous twelve months (Table 4).

3.12. Complementary and alternative medicine (CAM) use Respondents were asked if, in addition to using medicinal plants as home remedies, they had used any other forms of complementary and alternative medicine (CAM) in the last twelve months. Massage and reflexology were the only two CAM modalities identified by a small number of respondents (Table 6).


67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132


8

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66

Not stated/other reasons 11%

Table 5 Reported side effects by medicinal plant users (n ¼270), ranked by prevalence.

Tradition 1% Readily available 1%

It works 87%

Reported side effects

n

%

Bellyache/gas Vomiting Diarrhea Hypotension (BP too low)

3 3 2 2

1.1 1.1 0.7 0.7

N.B. Medicinal plants linked to reported side effects. Bellyache/gas: Aloe vera (L.) Burm. f. (Sinkle Bible) (2); Bryophyllum pinnatum (Lam.) Oken (Leaf of Life) (1). Vomiting: Picramnia antidesma Sw. (Majoe Bitter) (2); Helicteres jamaicensis Jacq. (Corkscrew) (1). Diarrhea: Aloe vera (L.) Burm. f. (Sinkle Bible) (2). Hypotension: Ocimum micranthum Willd. (Barsley) (1); Artocarpus altilis (Parkinson) Fosberg (Breadfruit) (1).

Fig. 10. Reasons for using herbal medicine (n¼ 270), ranked by prevalence.

Doctor

1

Radio/TV

1

Table 6 Reported use of other Complementary and Alternative Medicine (CAM) modalities by medicinal plant users (n¼ 270), ranked by prevalence. 2

Elders Books

3

Community

3 5

Other Relative

6

Grandfather

10

Father

13

Friend

32

Mother

33

Grandmother %

Fig. 11. Information source for medicinal plant users (n ¼270), ranked by prevalence.

Table 3 Stated contraindications for the medicinal plants used by respondents in decreasing order of frequency (n¼ 270), ranked by prevalence. Contraindications

n

%

Pregnancya Prior to blood sugar testb

5 1

1.9 0.4

a Medicinal plants identified were: Aloe vera (L.) Burm. f. (Sinkle Bible); Momordica charantia L. (Cerasee); Rivina humilis L. (Dogblood); Boehmeria jamaicensis Urb. (Doctor Johnson). b Medicinal plant identified to avoid before taking a blood sugar test: Momordica charantia L. (Cerasee).

Table 4 Reported incidence of side effects by medicinal plant users (n¼ 270), ranked by prevalence. Side effects

n

%

No Yes

260 10

96.3 4.1

4. Discussion This survey represents the first Jamaican study to statistically follow the TRAMIL methodology (TRAMIL, 2014) and to contribute to the Caribbean wide TRAMILdatabase. Results from this survey build on knowledge from previously published studies, on the use of medicinal plants by Jamaicans (Asprey and Thornton, 1953, 1954, 1955a, 1955b; Landman and Hall, 1983; Michie, 1992; Sobo, 1996; Gardner et al., 2000; Delgoda et al., 2004, 2010; Mitchell and

CAM modality

n

%

Massage Reflexology Aromatherapy Acupuncture Ayurvedic medicine Chinese medicinal plants Diet/nutritional therapy Homeopathy Naturopathy Osteopathy/chiropractic Shiatsu Spa/hydrotherapy

2 1 0 0 0 0 0 0 0 0 0 0

0.7 0.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Ahmad, 2006; Mitchell, 2011b), and sets out to contribute information not previously documented. Following a similar approach to that taken in a previous survey by Gardner et al., (2000), areas were purposefully selected with similar demographic characteristics to urban and rural Jamaica in consultation with STATIN (STATIN, 2010). It is therefore likely that these findings are representative of the use of medicinal plants by all Jamaicans. The distribution of plant families by medicinal plant users is similar to the most recent TRAMIL survey in Guadeloupe (Boulogne et al., 2011) in which the five most frequent plant families cited were Fabaceae, Lamiaceae, Euphorbiaceae, Malvaceae and Asteraceae compared to Fabaceae, Lamiaceae, Asteraceae, Malvaceae and Piperaceae in the Jamaican survey (Fig. 3). It is interesting to note that only two of the top five plant families are represented in the TRAMIL shortlist (Table 1), Asteraceae (Eupatorium odoratum L.) and Piperaceae (Piper amalago L.) and that the top five families do not include the top three plants most cited by respondents, Momordica charantia L. (Cucurbitaceae), Bryophyllum pinnatum(Lam.) Oken(Crassulaceae) and Aloe vera(L.) Burm.f.(Xanthorrhoeaceae) (Appendix A) (Picking et al., 2011). Of the 107 botanically identified medicinal plants (Appendix A), eight are endemic (7.5%) and one of these, Piper amalagoL.(var. nigrinodum), is shortlisted for its notable medicinal use, according to the TRAMIL methodology (Martin, 2004; TRAMIL, 2014). Piper amalago L. var.nigrinodum) and a second of the endemics, Rhytidophyllum tomentosum (L.) Mart., have undergone some form of screening at the University of the West Indies (UWI) Mona campus in Jamaica and found to exhibit significant medicinal or agricultural bioactivity (Durand et al., 1962; Williams and Mansingh, 1993; Mansingh and Williams, 1998; Seeram, 1998; Facey et al., 1999; Jacobs et al., 1999; Mitchell and Ahmad, 2006). In a review of


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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66

medicinal plant research undertaken at UWI, Mona between 1948 and 2001, nine percent of the plants screened were identified as endemic. Whilst the proportion of endemics was relatively low, those endemics screened demonstrated a significant level of bioactivity, 23% for endemics compared to 11% for non-endemics (Mitchell and Ahmad, 2006). Following the TRAMIL methodology (Martin, 2004; TRAMIL, 2014) respondents identified fourteen plants distributed in thirteen plant families as medicinal plants with significant uses and these fourteen plants have been shortlisted and included in the Caribbean-wide TRAMIL database (Table 1). Comparing the Jamaican shortlist with several other TRAMIL surveys, respondents in Martinique identified 94 plants with significant uses (Longuefosse and Nossin, 1996), Puerto Ricans identified six (Alvarado-Guzman et al., 2009), Guatemalans 12 (Giron et al., 1991), and residents of two islands in Guadeloupe identified 22 and 18 plants respectively (Boulogne et al., 2011). The shortlisted TRAMIL plants represent culturally significant species which are likely to be more effective, used for a more common disease or prophylactically, easily available or have special cultural significance (Heinrich et al., 2009). Plant species that did not make the TRAMIL shortlist are more likely to be ineffective for the condition(s) reported, be used for less prevalent diseases, have become less popular due to cultural change, to have been incorrectly identified during interview, have become rare species and difficult to source or belong to cultural fringe knowledge (Heinrich et al., 2009). Six of the 14 shortlisted TRAMIL plants are cited for their use in predominantly self-limiting conditions of the respiratory system and gastrointestinal tract and three plants for their use as tonics to maintain health (Table 1). In the first report from this survey (Picking et al., 2011), the popular use ‘tonics’ grouped plants, said to act as blood cleansers, plants used as laxatives for ‘washout’, and plants said to have aphrodisiac properties. In Jamaica, these tonics, made from local plants (Mitchell, 2011b), are traditionally taken on a regular basis to maintain health and strengthen the body and have been well documented elsewhere (Asprey and Thornton, 1953, 1954, 1955a, 1955b; Robertson, 1982, 1990; Lowe et al., 2001; Austin and Thomas, 2003; Payne-Jackson and Alleyne, 2004; Warner, 2007; Austin and Thomas, 2010; Mitchell, 2011a; van Andel et al., 2012). It is interesting to note that Momordica charantia L., is included on the TRAMIL shortlist as both a tonic and a treatment for GI tract problems. Andrographis paniculata (Burm. f.) Nees (Rice Bitters) is reported as a plant remedy with significant use for the first time in a TRAMIL survey (TRAMIL, 2014). This seems surprising, given its long history of traditional use in a number of countries and broad range of bioactivities, identified through extensive published research, including: anti-tumor; anti-angiogenic; antidiabetic; antiinflammatory; anti-HIV; anti-hepatitis; antitussive; anti-venom; cerebroprotective; hypoglycemic; anti-ulcer; hypolipidemic; immunostimulant; inhibiting the progression of diabetic nephropathy; nootropic; NF-κB inhibitor (Kuhn and Winston, 2001; Sheeja et al., 2007; Pekthong, 2008; Pekthong et al., 2008; Shi et al., 2008; Saranya et al., 2011; Kumar et al., 2012; Lu et al., 2012; Nugroho et al., 2012; Radhika et al., 2012; Uttekar et al., 2012; Xu et al., 2012; Yang et al., 2012; Kale et al., 2013; Nugroho et al., 2013; Chen et al., 2014; Kou et al., 2014; Lee et al., 2014; Lin et al., 2014; Nosalova et al., 2014; Nugroho et al., 2014; Suriyo et al., 2014). Five of the medicinal plant remedies listed (Table 1) are recommended by TRAMIL (REC) for the same health issue and using the same plant part and preparation method, based upon previous surveys, literature reviews and laboratory screens. These are Bryophyllum pinnatum(Lam.) Oken (Leaf of Life) for cold, Chenopodium ambrosioides L. (Semicontract) for intestinal parasites, Cymbopogon citratus (DC.) Stapf (Fever Grass) for fever, Petiveria alliacea L. (Guinea Hen Weed) for headache, and Zingiber officinale Roscoe (Ginger) for

9

flatulence and stomach pain (TRAMIL, 2014). With the exception of Andrographis paniculata (Burm. f.) Nees (Rice Bitters), the remaining eight plant remedies have previously been reported as plants with significant uses, but not for the same health condition, or using the same plant part or preparation method, and are therefore classified as under investigation (INV), until literature reviews and appropriate laboratory screens have been completed. The informants consensus factor (ICF) values reported were relatively high for a number of health issues, body systems and for health maintenance (Table 2) (mental health with 0.88, respiratory system with 0.86, tonic with 0.82, GI tract 0.79). These figures indicate strong cultural coherence in the selection of medicinal plants used in the treatment of these health conditions and body systems, and in the case of tonics, in the maintenance of health (Heinrich et al., 2009; Boulogne et al., 2011). Medicinal plant safety, through the identification of potentially toxic plant remedies, is a key aspect of the TRAMIL methodology (TRAMIL, 2014). Gardner et al. (2000) previously noted the absence of two plants, Crotalaria fulva Roxb. (Consumption Weed) and the endemic Senecio discolor Desf. (Whiteback), previously associated with reported cases of veno-occlusive disease (VOD) in the Jamaican population (Bras et al., 1954, 1961; McLean et al., 1964; Nelson et al., 2007; Paul and Seaforth, 2011). Reassuringly neither plant is reported in this latest survey, and neither plant appears to have been reported across the Caribbean region in other TRAMIL surveys (TRAMIL, 2014). The use of medicinal plant mixtures (combining more than one plant) is an area that is poorly reported in ethnobotanical studies, and the botanical and phytochemical aspects of these complex combinations has received limited attention in the Caribbean region (Cano and Volpato, 2004). However, some studies have taken place, for example in Cuba (Cano and Volpato, 2004; Volpato et al., 2009), the Dominican Republic (Vandebroek et al., 2010), Martinique (Longuefosse and Nossin, 1996) and Trinidad (Clement et al., 2005) and in a parallel study of bitter tonic use in West Africa and the Caribbean (van Andel et al., 2012). In Jamaica, reference to the use of medicinal plant mixtures, predominantly by traditional healers, has been documented by several authors (Robertson, 1982, 1990; Zampieron and Kahmhi, 1999; Lowe et al., 2001; Austin and Thomas, 2003, 2010; Payne-Jackson and Alleyne, 2004; Warner, 2007; Harris, 2011; Mitchell, 2011b). The use of root tonics is an important aspect of Jamaica's ethnomedical heritage, with utilisation of these medicinal plant mixtures by community members and commercial entities (Warner, 2007; McGlashan et al., 2008; Mitchell et al., 2008; Mitchell, 2011b). Vandebroek et al., (2010) note that root tonics have a history of use by specialists, such as traditional healers, in the treatment of more serious health conditions and as such, tend to fall outside the use of medicinal plants by self-medicating households. In this latest survey, we identify that 42% of medicinal plant users utilise medicinal plant mixtures made up of two or more plants compared to 58% who only reported using single plant recipes. A little over 50% of recipes comprised single plants (Fig. 4), with very few respondents using more than six plants, compared to an average of 13 plants used in root tonics (Mitchell, 2011b). The use of medicinal plant mixtures is an important and understudied aspect of traditional medicine use which justifies further research (Vandebroek et al., 2010). Decoction was by far the most cited preparation method for internal use (Fig. 7) and it is interesting to note that the plant material most used was leaves (Fig. 5). In many traditional medical systems, decocting or boiling is reserved for hard and woody plant material, whilst infusion is used for softer material, and in particular material with known volatile content (Mills and Bone, 2000; Hoffman, 2003). It should be noted that the majority of respondents identified their use of decoction in which the plant material is boiled for not more than ten minutes. This is in contrast


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10

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66


to the practice of deep decoction utilised in the preparation of root tonics in which root, bark and leaf material is actively boiled for one to two hours or until the water level is reduced to half (Mitchell, 2011b). The standard TRAMIL methodology (TRAMIL, 2014) recommends the interviewing of women and preferably the mother of the household. However, it was decided for this survey to randomise the choice of respondent in each household. We report that the primary source of information was grandmothers and mothers, 65%, with a secondary choice being grandfathers and fathers, 16%, thus justifying their inclusion in this study, and making it clear that knowledge continues, predominantly, to be passed down from generation to generation through an oral tradition. A key goal of TRAMIL is to ensure that such traditional knowledge is recorded and safeguarded for future generations (TRAMIL, 2014). Very few respondents identified contraindications for the medicinal plants used (Table 3). A review of the literature indicates that several of the medicinal plants cited have known contraindications. For example, the most popular medicinal plant, Momordica charantia L. (Cerasee), has traditionally been used as an abortifacient (Sobo, 1996) and various parts of the plant have weak uterine stimulant activity, and its use in pregnancy is therefore not recommended. Its active constituents can be transferred through breast milk, and it is therefore not recommended for use in breast feeding mothers. All parts of cerasee are proven to lower blood sugar levels and it is therefore not recommended in persons with hypoglycemia (Kuhn and Winston, 2001; Taylor, 2005; Alternative-Medicine-Review, 2007). The reported level of side effects was low (Tables 4 and 5),and though not quantified, there was a general perception amongst respondents, that as natural products, medicinal plants are generally considered to be safe. As far as the authors are aware, this represents the first time an attempt has been made to quantify the use of CAM modalities across a representative sample of the Jamaican population. As can be seen from the results (Table 6), levels of CAM use, other than medicinal plant use,are very low, with most respondents having little knowledge or access to other CAM practices. Internationally, CAM use is increasingly popular, with reports of use as high as 80% in rural Japan (one year prevalence) (Shumer et al., 2014). In a systematic review of UK CAM surveys, carried out between 2000 and 2011, an average 41% of respondents reported their use of CAM in the previous year (Posadzki et al., 2013). A systematic review of German surveys, undertaken since 1993, reported CAM levels of between 40% and 62% (one year prevalence) (Linde et al., 2014). The types of CAM practices most commonly reported include herbal medicine, homeopathy, acupuncture, dietary supplements and manual therapies (van Andel et al., 2013). Previous reviews have indicated that, for many industrialized countries, 50% of the population regularly choose a broad range of CAM treatments, whilst citizens in developing countries have fewer options to choose from, other than the use of medicinal plants (Bodeker, Kronenberg, 2002; van Andel et al., 2013).

Andrographis paniculata (Burm. f.) Nees (Rice Bitters) is reported as a plant remedy with significant use (SIG) for the first time in a TRAMIL survey. Five of the plant remedies have previously been recommended by TRAMIL (REC) for the same health issue, using the same plant part and preparation method. Eight of the plant remedies, including one Jamaican endemic, are classified as under investigation (INV), requiring literature reviews and appropriate laboratory screens. Informant consensus factor (ICF) values were high for a number of body systems, health issues and for health maintenance, e.g. mental health (insomnia/nerves/depression) and tonics, indicating strong cultural coherence in medicinal plant selection for these categories. The majority of respondents stated that they used medicinal plants because they work, cited their mothers and grandmothers as their main source of knowledge, prepared fresh leaf material by decoction for internal use, from plant material sourced from their own backyards. A significant percentage of respondents identified their use of medicinal plant mixtures, an aspect of traditional medicine poorly reported in the literature, warranting further research. Jamaicans reported limited use of CAM, which, together with the previously reported us of medicinal plants by 72.6% of Jamaicans, reported in Picking et al., (2011), lends further support to the assertion that a significant number citizens in developing countries continue to rely on the use of medicinal plants for their primary healthcare. The results of the survey are being followed by ongoing scientific validation and toxicity studies, and plans for outreach activities (TRADIF) in Jamaica. In addition, the results of the survey, together with the results focusing on the concomitant use of medicinal plants with pharmaceutical drugs (Picking et al., 2011), are being communicated to local doctors, pharmacists and other health care professionals.

Acknowledgements We thank the Commonwealth Scholarship Commission, the University of the West Indies Postgraduate Research Fund, the Environmental Foundation of Jamaica, the Forest Conservation Fund and the International Foundation for Science (Sweden) for funding support. The authors express their gratitude to respondents who so graciously gave their time and generously shared their traditional knowledge during the survey. We thank and acknowledge the hard work and dedication of Devon Lindsay who helped coordinate and manage the survey across the three areas. Thanks also to community leaders and others for facilitating the surveys, guidance in their areas and botanical collection: Kelvin Clarke, Mike Grizzle the late Mr. Black, Melinda Brown, Dolphy Powell, Mr. Dallas and Garfield McNaughton, Shanti. We also thank Mr. Patrick Lewis, Botanist and Herbarium Curator at the University of the West Indies for his advice and identification of all botanical samples.

5. Conclusion Fourteen medicinal plants met the criteria set by TRAMIL for inclusion in the TRAMIL database and represent the first submission by Jamaica.

Appendix A See Table A7.


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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66

11

Table A7 The 107 botanically identified medicinal plants identified by medicinal plant users (n¼ 270), ranked by prevalencea. Scientific name

Family

Local name(s)

Voucher

n

% (n/270)

Momordica charantia L. Bryophyllum pinnatum (Lam.) Oken Aloe vera (L.) Burm. f. Eupatorium odoratum L. Annona muricata L. Zingiber officinale Roscoe Solanum torvum Sw. Allium sativum L. Gliricidia sepium Kunth Piper amalago L. (var. nigrinodum) 1 Stachytarpheta jamaicensis (L.) Vahl Andrographis paniculata (Burm. f.) Nees Clerodendrum thomsoniae Balf. Rivina humilis L. Morinda citrifolia L. Opuntia cochenillifera (L.) Mill. Polyscias guilfoylei (W. Bull) L.H. Bailey Cymbopogon citratus (DC.) Stapf Chenopodium ambrosioides L. Rhytidophyllum tomentosum (L.) Mart.b Bidens reptans (L.) G. Don (var. tomentosa O.E. Schulz)b Petiveria alliacea L. Desmodium canum Schinz & Thell. Priva lappulacea (L.) Pers. Hyptis verticillata Jacq. Picramnia antidesma Sw. Citrus aurantiifolia (Christm.) Swingle Cassia alata L. Artocarpus altilis (Parkinson) Fosberg Pothomorphe umbellata (L.) Miq. Bambusa vulgaris Schrad. ex J.C. Wendl. Picrasma excelsa (Sw.) Planch. Lippia alba N.E. Br. ex Britton & P. Wilson Bidens pilosa L. Pseudelephantopus spicatus (Juss. ex Aubl.) C.F. Baker Cassia occidentalis L. Mentha piperita L. Pimenta spp. Lindl. Smilax regelii Killip & C.V. Morton Mikania micrantha Kunth Terminalia catappa L. Psidium guajava L. Argemone mexicana L. Justicia pectoralis Jacq. Achyranthes indica (L.) Mill. Cordia globosa (Jacq.) Kunth Tournefortia hirsutissima L. Cannabis sativa L. Zebrina pendula Schnizl. Alysicarpus vaginalis (L.) DC. Rosmarinus officinalis L. Salvia serotina L. Cola acuminata (P. Beauv.) Schott & Endl. Cecropia peltata L. Annona reticulata L. Eryngium foetidum L. Symphytum officinale L. Hippobroma longiflora (L.) G. Don Tamarindus indica L. Thymus vulgaris L. Peperomia amplexicaulis (Sw.) A. Dietr.b Prunus L. spp. Foeniculum vulgare Mill. Syngonium auritum (L.) Schott Cocos nucifera L. Tillandsia recurvata (L.) L. Erythrina corallodendron L. Ocimum micranthum Willd. Acalypha wilkesiana Müll.Arg. Oryctanthus occidentalis (L.) Eichlerb Hibiscus sabdariffa L. Hibiscus rosa-sinensis L. Trophis racemosa (L.) Urb. Musa spp. Peperomia pellucida (L.) Kunth

Cucurbitaceae Crassulaceae Xanthorrhoeaceae Asteraceae Annonaceae Zingiberaceae Solanaceae Amaryllidaceae Fabaceae Piperaceae Verbenaceae Acanthaceae Lamiaceae Phytolaccaceae Rubiaceae Cactaceae Araliaceae Poaceae Amaranthaceae Gesneriaceae Asteraceae Phytolaccaceae Fabiaceae Verbenaceae Lamiaceae Picramniaceae Rutaceae Fabaceae Moraceae Piperaceae Poaceae Simaroubaceae Verbenaceae Asteraceae Asteraceae Fabaceae Lamiaceae Myrtaceae Smilacaceae Asteraceae Combretaceae Myrtaceae Papaveraceae Acanthaceae Amaranthaceae Boraginaceae Boraginaceae Cannabaceae Commelinaceae Fabiaceae Lamiaceae Lamiaceae Malvaceae Urticaceae Annonaceae Apiaceae Boraginaceae Campanulaceae Fabaceae Lamiaceae Piperaceae Rosaceae Apiaceae Araceae Arecaceae Bromeliaceae Fabaceae Lamiaceae Euphorbiaceae Loranthaceae Malvaceae Malvaceae Moraceae Musaceae Piperaceae

Wild Cerasee, Cerasee Leaf of Life Sinkle Bible Jack-in-the-Bush, Christmas Bush, Jackney Soursop Ginger Susumber Garlic Maranga, Quick Stick, Never Die Jointer, Black Jointer, Black Betty Vervine, Porter Weed Rice Bitters Rice and Peas Dogblood Noni, Hog Apple Tuna Aralia Fever Grass Semi Contract Search-mi-Heart McKatty Weed, Marigold Guinea Hen Weed, Gulley Root, Duppy Weed Strong Back, Sweetheart Fasten-pon-coat, Clammy Bur, John Charles Majoe Bitter, Macary Bitter Lime King of the Forest, Candlestick, Ringworm Shrub Breadfruit Cowfoot Bamboo Bitter Wood, Jamaican Quassia Colic Mint, Cullen Mint, Spanish Needle Dog's Tongue, Packy Weed Dandelion, Piss-a-bed, Wild Coffee, Stinking Weed Peppermint Pimento Jamaican Sarsaparilla Guaco Bush, Quaco Bush, Kwaku Bush Almond Guava Thistle, Mexican Poppy, Yellow Thistle Fresh Cut Devil's Horse-Whip Black Sage Chigga Nut, Cold With, Horse bark Cannabis, Ganja, Marijuana, Weed Red Water Grass, Wandering Jew Medina Rosemary (fine) Chicken Weed, Little Woman Bissy Trumpet Tree Custard Apple Spirit Weed, Fit Weed, Culantro Comfrey Madam Faith Tamarind Thyme Jackie's Saddle Plum Fennel Five Finger Coconut Old Man Beard Fence Stake, Cutlass Bush, Duppy Machete Barsely Joseph Coat Godbush, Mistletoe, Scorn-the Earth Sorrell Shoeblack, Hibiscus Ramoon Banana Pepper Elder

35477 35466 35468 35475 35467 n/v 35964 n/v 35962 35464 35963 35372 23207 35470 35295 35479 35961 35474 35479 35969 35970 35469 35963 35971 35473 35972 35266 35973 35974 35968 35975 35252 35976 35366 35977 34205 n/v 35234 35978 35979 35980 35981 6979 35982 35380 21803 35983 30649 35984 35897 31188 35966 35965 35985 27545 35986 35331 35987 35792 n/v 35988 35989 35990 26514 n/v 35374 35991 35992 35993 35994 27804 35995 32712 n/v 35360

114 93 68 61 41 37 35 34 27 26 26 24 24 22 21 20 19 16 15 15 13 13 11 11 9 9 9 8 8 7 7 7 7 6 6 6 6 6 6 5 5 5 5 4 4 4 4 4 4 4 4 4 4 4 3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2

42.3 34.4 25.2 22.6 15.2 13.7 13 12.6 10 9.6 9.6 8.9 8.9 8.1 7.8 7.4 7 5.9 5.6 5.6 4.8 4.8 4.1 4.1 3.3 3.3 3.3 3 3 2.6 2.6 2.6 2.6 2.2 2.2 2.2 2.2 2.2 2.2 1.9 1.9 1.9 1.9 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7


67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132


12

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66

Table A7 (continued ) Scientific name

Family

Local name(s)

Voucher

Polypodium phyllitidis L. Pilea microphylla (L.) Liebm. (var. microphylla)b Allium cepa L. Anacardium occidentale L. Annona squamosa L. Daucus carota L. Catharanthus roseus (L.) G. Don Mandevilla torosa (Jacq.) Woodson Bursera simaruba (L.) Sarg. Croton linearis Jacq. Ricinus communis L. Abrus precatorius L. Arachis hypogaea L. Entada gigas (L.) Fawc. & Rendle Moghania strobilifera (L.) J. St.-Hil. ex Kuntze Stylosanthes hamata (L.) Taub. Ocimum basilicum L. Plectranthus amboinicus (Lour.) Spreng. Satureja brownei (Sw.) Briq. Persea americana Mill. Ceiba pentandra (L.) Gaertn. Helicteres jamaicensis Jacq. Turnera ulmifolia L. Plantago major L. Zea mays L. Hydrastis canadensis L. Smilax balbisiana Kunthb Capsicum frutescens L. Boehmeria jamaicensis Urb.b Cissus sicyoides L. Vitis tiliifolia Humb. & Bonpl. ex Schult. Curcuma longa L.

Polypodiaceae Urticaceae Amaryllidaceae Anarcardiaceae Annonaceae Apiaceae Apocynaceae Apocynaceae Burseraceae Euphorbiaceae Euphorbiaceae Fabaceae Fabaceae Fabaceae Fabaceae Fabaceae Lamiaceae Lamiaceae Lamiaceae Lauraceae Malvaceae Malvaceae Passifloraceae Plantaginaceae Poaceae Ranunculaceae Smilacaceae Solanaceae Urticaceae Vitaceae Vitaceae Zingiberaceae

Cow's Tongue Baby Puzzle, Lace Plant Onion Cashew Sweetsop Carrot Periwinckle, Ram Goat Rose incorrectly ID'd as Milkweed Red Birch Rock Rosemary Castor Oil John Crow Bead, Carb's Eyes, Red Bead Vine Peanut Trash Cacoon Wild Hops Donkeyweed, Cheesy Toes Basil French Thyme Penny Royal Pear (Avocado) Cotton Tree Screw Trea, Corkscrew Ramgoat Dashalong English Plantain Cornsilk Goldenseal Chany Root Bird Pepper Doctor Johnson Snake Withe, Pudding Withe Wild Grape Turmeric

7700 35996 n/v 33735 33732 n/v 35757 35997 35363 35365 35998 35999 n/v 24212 36006 36000 30705 35382 36001 23760 27450 36002 23337 29094 n/v n/v 36003 30857 36004 21368 36005 n/v

a b

n

% (n/270) 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

0.7 0.7 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4 0.4

The top 50 medicinal plants in this table are reported in Picking et al. (2011, Table 5), and the full list is provided here for completeness. Endemics n/v: not vouchered (commonly sourced from supermarkets, markets and health stores).

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Ethnomedicinal survey of various communities residing in Garo Hills of Durgapur, Bangladesh.

Ethnomedicinal survey of plants used in the treatment of malaria in Southern Nigeria.

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Leprosy in Jamaica.

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Rheumatic disease in Jamaica.

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Inflammatory bowel disease in Jamaica.

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Aging trends: Jamaica.

Healthy Eating in Jamaica: The Cost Factor.

Transformations in maternity services in Jamaica.

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Tumours of the testis in Jamaica.

Sexuality among fathers of newborns in Jamaica.

The use of herbal remedies in Jamaica.

Educational Health Disparities in Cardiovascular Disease Risk Factors: Findings from Jamaica Health and Lifestyle Survey 2007-2008.

Are famine food plants also ethnomedicinal plants? An ethnomedicinal appraisal of famine food plants of two districts of bangladesh.

Associations between neighborhood effects and physical activity, obesity, and diabetes: The Jamaica Health and Lifestyle Survey 2008.

Ethnomedicinal plants used for snakebite in India: a brief overview.

Gastroenteritis in London and Jamaica: a clinical and bacteriological study.