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Access • Data measuring access levels and affordability • Official recognition of the role of traditional medical practice providers 96 | Traditional medicine • Cooperation between traditional medical practice providers and allopathic practitioners • Attention to the unsustainable use of medicinal plant resources generic stromectol 3mg otc. National policy and regulation Regulatory/legal mechanisms During the colonial period order stromectol 3mg on-line, traditional medical practice was discouraged or prohibited in most African countries discount stromectol 3mg with amex. A legal framework for the practice of traditional medicine is in place in 53% of states and management bodies for the coor- dination of matters pertaining to traditional practice in 57%. In 2006, South Africa established a Directorate of Traditional Medicine within the Health Ministry and in 2007 enacted the Traditional Practitioners Act (No. In 2008 a Draft National Policy on African Traditional Medicine (Government Gazette No. As pointed out by Twumasi and Warren,34 local associations of traditional healers have always existed in Africa, formed along ethnic/linguistic (Figure 5. Amalgamation of these local associations into a single national umbrella body, speaking with one voice and with a uniform code of practice and criteria for registration/ accreditation, has proved difficult in many African states. It must be remembered that African traditional health systems have cultural and spiritual as well as physical components. A cautionary note in this regard has been sounded by MacCormack:35 Traditional medical practice in Africa | 99 Figure 5. Their office in that group and the entire corporate group’s role in the local society, must be allowed for in health planning which seeks to achieve health for all through community participation. Plucking the practitioners, or the chemicals from their herbal reme- dies, out of the context of healing and transferring them to the university, is a gesture of goodwill but it is not truly a collaborative association of plural medical systems. Iwu23 noted that ‘the African medical system does 100 | Traditional medicine not fall into the sphere of what is known as “alternative medicine”, but is rather a complementary but different medical system that uses medicine in a more or less conventional manner for the treatment of diseases. It employs, in a fundamental sense, the same basic methods as Western medi- cine, with additional contributions from the spiritual dimension, which gives the healing depth and meaning within the African cosmology and experience. The South African Draft National Policy (2008) on African Traditional Medicine explicitly states that, while aiming at the institutionalisation of traditional medical practice, it does not envisage integration of traditional medical practice within the allopathic system; the intention is that the two systems will function side by side under the state healthcare umbrella. Equitable distribution of benefits with respect to indigenous knowledge systems While it is widely acknowledged that indigenous knowledge merits protec- tion and that the holders of such knowledge are entitled to benefits derived from its use, there is no consensus at present as to how this is best achieved. The required legis- lation was enacted in South Africa in 2004 (South African Environmental Management: Biodiversity Act No. The regulations implementing those terms that relate to bioprospecting, access and benefit sharing (section 97(1): d–h) state that permits will be required for all bioprospecting activi- ties (which include those based on traditional knowledge). Benefit-sharing agreements will have to be drawn up between all would-be bioprospectors and stakeholders, according to a specified template. Regulation 10(3) lays down principles for identifying stakeholders, including communities or parts of communities. An interesting test case in this regard is that of the San peoples in southern Africa, whose claim to intellectual property rights in the use of Hoodia (Figure 5. In most African states, no public financing Traditional medical practice in Africa | 103 mechanisms or private insurance programmes exist for traditional healthcare services, the costs of which are paid out of pocket by the patient. Efficacy/safety/quality Efficacy – an adequate evidence base for traditional medical practice therapies and products Considerable research effort on the part of the multinational pharmaceutical industry was devoted during the period 1985–2000 to bioprospecting, guided by ethnobotanical ‘leads’. The purpose was new drug discovery for the treat- ment of essentially first-world health problems, e. The generally adopted approach was that of bioassay-guided fractionation in order to isolate one or more ‘actives’ that might lend themselves to laboratory synthesis and/or subsequent structural modification. An example is the isolation of the alkaloid galanthamine from Balkan Galanthus (snowdrop) spp. Since the year 2000, the main thrust of ethnomedical screening of African plants appears to have shifted from the domain of the multinational pharmaceutical industry47 to that of public research institutions or private enterprises within individual African states. The focus of this research has also shifted, with less emphasis on first-world diseases and more on the major causes of mortality/morbidity in Africa, e. An example of a national initiative is the current South African research and development programme for novel drug development from indigenous medicinal plants (see www. Initially destined to run over 3 years (2004–6), the programme is on-going and has published some of its preliminary findings. When we came to the Coperbergh in October, it was being gathered from the surrounding hills by everybody (to serve as a supply for the whole year).

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It is effective by virtue of its α-agonist activity which reverses vascular dilatation and oedema buy generic stromectol 3mg on line, and its Mechanism of action β2-agonist activity which produces cardiac stimulation and Antihistamines are competitive antagonists of histamine at bronchodilatation buy stromectol 3mg without a prescription. Stop any drug or blood/blood product that is being irizine and loratadine have half-lives that permit once or administered intravenously discount stromectol 3mg overnight delivery. If infection is the cause, the presence of a foreign body should be excluded and appropriate antibacterial therapy pre- Key points scribed. If the symptoms are due to allergy, the first step in ther- Antihistamines and therapy of allergic disorders apy is allergen avoidance and minimization of exposure (e. However, complete avoidance is difficult • Antagonists at H1-receptors; widely available agents, often without prescription (e. For patients with mild intermittent symptoms, • Used to treat hay fever and urticaria, and also used as either intranasal antihistamine (e. In children, topical cromoglicate ancilliary properties, and are longer acting (e. The British National Formulary summar- izes the recommended schedule of vaccinations. Ensure that the patient is not sensitive to antibiotics used in when mixed with antigen or injected into the same site. Live vaccines should not be given to pregnant prolonged; women, nor should they be given to patients who are immuno- • various immune cells are attracted to the site of injection suppressed. Live vaccines should be postponed until at least and the interaction between such cells is important in three months after stopping glucocorticosteroids and six months antibody formation. There are a number of such substances, usually given as mixtures and often containing lipids, extracts of inactivated tubercle bacilli and various mineral salts. Interleukin-2 is effective treatment for metastatic melanoma • Live vaccines produce protracted immunity and some and renal cell carcinoma (Chapter 48). Currently, there are two types of immunoglob- Live vaccine immunization is generally achieved with a sin- ulin, namely normal and specific. It contains antibodies to required (and are not in a combined preparation) they may be measles, mumps, varicella, hepatitis A and other viruses. Inactivated vaccines usually require sequential Uses doses of vaccine to produce an adequate antibody response. The duration of with hepatitis A and measles and, to a lesser extent, to protect immunity acquired with the use of inactivated vaccines ranges the fetus against rubella in pregnancy when termination is not from months to years. Bruton’s agammaglobulinaemia, Wiskott–Aldrich syn- tremor which she said she had noted for the last 48 hours. The most common adverse effects occur during the first infu- How can you explain the markedly elevated trough sion and are dependent on the antigenic load (dose) given. They include the following: Answer • fever, chills and rarely anaphylaxis – most commonly seen In this patient, the development of an acute epileptic seizure in the context of a very high ciclosporin trough concentration with the first dose, and reduced by slow administration indicates ciclosporin toxicity; epilepsy is a well-recognized and premedication with antihistamines and toxic effect of high ciclosporin concentrations. The difficult glucocorticosteroids; issue in the case is why she developed high ciclosporin blood • increased plasma viscosity – caution is needed in patients concentrations (in the face of normal renal and hepatic func- with ischaemic heart disease; tion) when she was adamant that there had been no alter- ation in the daily dose of ciclosporin she was taking, nor had • aseptic meningitis (high dose). Further questioning defined that she was drinking Contraindications about 1L/day of grapefruit juice – a taste she had acquired Normal immunoglobulin is contraindicated in patients with while on holiday in California. The patient had her ciclosporin dosing stopped until the concentration was 300μg/L. This immunoglobulin is used to prevent a rhesus-negative mother from forming antibodies to fetal rhesus-positive cells that enter the maternal circulation during childbirth or abortion. This prevents a subse- quent child from developing haemolytic disease of the newborn. Second-generation antihistamines: actions and efficacy in the management of allergic disorders. Circulation A 35-year-old woman had a cadaveric renal transplant for 2004; 110: 3858–65.

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Respect carries with it tion buy cheap stromectol 3mg, and scholarship require creative integration an openness to learn and grow trusted stromectol 3mg. Values and beliefs of of multiple ways of knowing and understanding various cultures are reflected in expressions of re- through knowledge synthesis within a context of spect and caring purchase 3 mg stromectol with mastercard. Nursing knowledge is em- nected with others, not the disease or problem, is bedded in the nursing situation, the lived experi- the focus of nursing. The nurse is authentically present choices, how to choose, and how to live daily with for the other, to hear calls for caring and to create choices made. The school-based to well-being and what priorities exist in daily life community wellness centers and satellite sites in of the family. Nursing and social work practice the community become places for persons and based on practical, sound, culturally acceptable, families to access nursing and social services where and cost-effective methods are necessary for well- they are: in homes, work camps, schools, or under being and wholeness of persons, families, and com- trees in a community gathering spot. Thinking about children and families “at Transitional care is that in which clients and fami- promise” instead of “at risk” inspires an approach lies are provided essential health care while being to knowing the other as whole and filled with enrolled in a local insurance plan that will partially potential. Over several weeks, clients are as- sisted to enroll in long-term forms of health-care Respect and caring in nursing require full insurance and related benefits and are referred to a participation of persons, families, and more permanent source of health care in the com- communities in assessment, design, and munity. Respect and caring in nursing require full par- ticipation of persons, families, and communities in Enhancing care describes nursing and social assessment, design, and evaluation of services. This method that provided by a local health-care is defined as a “route of knowing” and “a route to provider. The environment, one of and families can be known, and care designed, the oldest concepts in nursing described by offered, and evaluated (Barry, 1998; Parker, Barry, Nightingale (1859/1992), is not only immediate & King, 2000). Another nursing visionary, Lillian Wald, Community, as understood within the model, was witnessed the hardships of poverty and disenfran- formed from the classical definition offered by chisement on the residents of the lower Manhattan Smith and Maurer (1995) and from the Peck’s exis- immigrant communities; she developed the Henry tential, relational view (1987). According to Smith Street Settlement House to provide a broad range and Maurer, a community is defined by its mem- of care that included direct physical care up to and bers and is characterized by shared values. This ex- including finding jobs, housing, and influencing panded notion of community moves away from a the creation of child labor laws (Barry, 2003). Acknowledging ing: colleagues within the practice and discipline, the interrelatedness of all living things energizes other health-care colleagues from varied disci- caring from this broader perspective into a wider plines, grant funders, and other collaborators. Kleffel (1996) described this as “an ecocentric notion of a transdisciplinary care is an exemplar of approach grounded in the cosmos. Another defining ronment, including inanimate elements such as characteristic of community, according to Peck, is rocks and minerals, along with animate animals and willingness to risk and to tolerate a certain lack plants, is assigned an intrinsic value” (p. The practice guided by the model re- rects thinking about the interconnectedness of all flects this in fostering a creative approach to pro- elements, both animate and inanimate. Teaching, gram development, implementation, evaluation, practice, and scholarship require a caring context and research. The intention to know others as experts in their self-care while listening to their hopes and dreams for well-being creates a com- Structure of Services munion between the client and provider that and Activities guides the development of a nurturing relation- ship. Knowing the other in relationship to their The model is envisioned as three concentric circles communities, such as family, school, work, wor- around a core. Envisioning the model as a water ship, or play, honors the complexity of the context color representation, one can appreciate the vi- of persons’ lives and offers the opportunity to brancy of practice within the model, the amor- understand and participate with them. This includes participants in inquiry are focused on (a) consultation and collaboration: groups, parents/guardians, school faculty, and non- building relationships and community with mem- instructional staff, after-school groups, parent/ bers and collaborating about scholarship, policy, teacher organizations, and school advisory coun- outcomes, practice, research, educational needs of cils. The services provided within this circle might school nurses and advanced practice nurses, and include: (a) consultation and collaboration: building sustainability through ongoing and additional relationships and community, answering inquiries funding; (b) appraisal and evaluation: school nurs- on matters of health and well-being, providing in- ing and advanced practice faculty organizations service and health education, serving on school offer a milieu for discussion and appraisal of the committees, reviewing policies and procedures; (b) services provided at the centers. Organizations in appraisal and evaluation: conducting community this circle include Florida Department of Health: assessments, appraising care provided, evaluating Office of School Health, Florida Association of outcomes, and promoting programs that enhance School Nurses, Florida Association of School well-being for individuals and communities. Health, National Association of School Nurses, Na- tional Assembly of School-Based Health Centers, and the National Nursing Centers Consortium. The core service of consul- advising groups include the school district and tation and collaboration is a primary focus of prac- county public health department, the county tice, beginning with nursing and social work health-care district, Children’s Service Council, colleagues and extending to participating clients, American Lung Association, and the American Red families, policy makers, funders, and legislators.

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Another modern way of delivering herbs is through granulated herbs buy cheap stromectol 3mg on-line, which are highly concentrated powdered extracts purchase 3mg stromectol with amex. These powders are made by first preparing the herbs as a traditional decoction order 3 mg stromectol amex, after which the decoction is dehydrated to leave a powder residue. Practitioners can mix these powders together for each patient into a custom formula. The powder is then placed in hot water to recreate the decoction, which eliminates the need to prepare the herbs at home, but still retains much of the original decoction’s potency. Example of a prescription An example of the ingredients for a dried herb prescription is shown in Figure 6. Chinese patent medicines Pre-made formulae are available as pills, tablets, capsules, powders, alcohol extracts, water extracts, etc. Most of these formulae are very convenient because they do not necessitate patient preparation and are easy to take. These products are usually not as potent as the traditional extemporaneous Traditional Chinese medicine | 157 preparation of decoction described above. They are not ‘patented’ in the western sense of the word because there are no exclusive rights to the formula. All Chinese patent medicines of the same name have the same proportions of ingredients. A medicine known as ‘four gentleman decoction’ (si jun zi tang) is an example of such a product. The formula comprises: • Main herb: Radix panax ginseng (ren shen), to enhance spleen qi • Associate: Rhizoma atractylodis macrocephalae (bai zhu), to strengthen the spleen and dry off the ‘dampness’ • Adjuvant: Sclerotium poriae cocos (fu ling), to assist the main and associate herbs • Guide: Radix glycyrrhizae uralensis (zhi gan cao), to harmonise the other three herbs and regulate spleen qi. Under the Drug Administration Act 2001 post-marketing surveillance of adverse drug reactions is mandatory in China. Whenever an adverse reaction event occurs, the manufacturer, the medical institutions and the seller are obliged to report it. The main legislation requires that medicines placed on the market must have a licence, which requires meeting standards of safety, quality and efficacy. These licensing conditions pose inappropriate demands on most herbal medicines, because plants are chemically complex and variable, active constituents are not always known and the huge costs cannot be recouped through patenting. Under the 1968 Act, herbal remedies are exempt from the licensing requirement if either the herbal remedy is made up on the premises from which it is supplied, after a one-to-one consultation (Section 6. These exemptions only apply to plant remedies, so medicines containing non-plant ingredients require a medicine licence. In recent years these provisions, which provide no specific regulation for herbal medicines, have been considered inadequate to ensure their safety and quality. There are a number of reasons including: adverse effects from some herbal ingredients (natural does not mean safe); misidentification of some Figure 6. Traditional Chinese medicine | 159 herbs and occasional substitution of toxic for safe species; illegal inclusion of prescription-only drugs or heavy metals in some ‘herbal’ medicines; microbial contamination; and discovery of problematic herb–drug interactions. This establishes a registration scheme for industrially produced over-the-counter herbal medicines, under which manufacturers have to demonstrate safety and quality, but not efficacy. Quality is guided by European good manufacturing practice, and safety is protected by requiring evidence of at least 30 years of safe use, of which at least 15 years must be within the European Community. There is a lead-in time to allow manufacturers and suppliers to make the necessary adjustments, but after 2011 any over-the-counter herbal product that is not registered under this scheme will be illegal. This lead time is, however, only for products that were on the market before April 2004. Such medicines will not have to be licensed and, because they are not industrially produced, will not have to be registered under the European Directive. There are, however, concerns about the quality and safety of herbal medicines supplied by this route. The issue is how to strengthen the public’s protection while preserving their access to herbal medicines. First, members of the statutory register can be tied, through a codes of practice, to suppliers that have been audited and demonstrated satisfactory standards of quality assurance. The Register of Chinese Herbal 160 | Traditional medicine Medicine has provided a good model for such an arrangement through its Approved Suppliers scheme. As it will be illegal to practise under the title of herbalist or Chinese medicine practitioner without membership of the register, the public will have stronger assurance about the quality of Section 6.

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