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Health topics /
Traditional, complementary and integrative medicine

Traditional, Complementary and Integrative Medicine

Traditional medicine Traditional medicine has a long history. It is the sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness. Complementary medicine The terms “complementary medicine” or “alternative medicine” refer to a broad set of health care practices that are not part of that country’s own tradition or conventional medicine and are not fully integrated into the dominant health-care system. They are used interchangeably with traditional medicine in some countries. Herbal medicines Herbal medicines include herbs, herbal materials, herbal preparations and finished herbal products, that contain as active ingredients parts of plants, or other plant materials, or combinations.

The WHO Traditional Medicine Strategy 2014–2023 was developed and launched in response to the World Health Assembly resolution on traditional medicine (WHA62.13). The strategy aims to support Member States in developing proactive policies and implementing action plans that will strengthen the role traditional medicine plays in keeping populations healthy. Addressing the challenges, responding to the needs identified by Member States and building on the work done under the WHO traditional medicine strategy: 2002–2005, the updated strategy for the period 2014–2023 devotes more attention than its predecessor to prioritizing health services and systems, including traditional and complementary medicine products, practices and practitioners. The strategic objectives are:

To build the knowledge base for active management of T&CM through appropriate national policies;
To strengthen the quality assurance, safety, proper use and effectiveness of T&CM by regulating products, practices and practitioners;
To promote universal health coverage by integrating T&CM services into health care service delivery and self-health care.
Traditional medicine
International Regulatory Cooperation for Herbal Medicines (IRCH)
Global Centre for Traditional Medicine
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India commits US$ 85 million to WHO Global Traditional Medicine Centre

15th annual meeting of the WHO International Regulatory Cooperation for Herbal Medicines (WHO-IRCH) network

Charting an evidence-based roadmap for WHO Global Traditional Medicine Centre collaborations

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Article contents

Traditional medicine and indigenous health in indigenous hands.

Gerard Bodeker Gerard Bodeker University of Oxford, Green Templeton College and Columbia University, Department of Epidemiology
, and Kishan Kariippanon Kishan Kariippanon University of Wollongong, School of Health and Society
https://doi.org/10.1093/acrefore/9780190632366.013.155
Published online: 28 February 2020

An estimated 370 million Indigenous people reside in 90 countries and make up 5% of the global population. Three hundred million Indigenous people live in extremely disadvantaged rural locations. Indigenous people have suffered from historic injustices due to colonization and the dispossession of their lands, territories, and resources, thus preventing them from exercising their right to development according to their own needs and interests. Across the board, Indigenous people have poorer health outcomes when compared to their non-Indigenous fellow citizens.

Cancer, respiratory disease, endocrine, nutritional, and metabolic disorders, primarily diabetes, affect Indigenous people disproportionately. Newborns of Indigenous women are more than twice as likely to be of low birth weight as those born to non-Indigenous women. Indigenous rates of suicide are the highest in the world.

For public health to be effective, a social determinants approach, along with health interventions, is insufficient to create lasting health impact. Partnerships with Indigenous organizations, Indigenous researchers, and the professionalization of health workers is essential. Integration of traditional medicine and traditional health practitioners can enable the Western biomedical model to work in partnership with Indigenous knowledge systems and become more locally relevant and accountable.

The Indigenous health workforce is increasingly using evidence-based, innovative approaches to address the shortage of health professionals as they move toward universal health coverage. Internet, mobile, and communication technologies are enhancing the mobilization of Indigenous health efforts and the support for health workers in rural locations. Presented are country examples of integrated medicine and Indigenous partnerships that effectively implement health interventions.

community health worker
traditional medicine
social determinants of health
social media and indigenous health

Introduction

An estimated 370 million Indigenous people reside in 90 countries, approximately 5% of the global population. Approximately 300 million Indigenous people live in extremely disadvantaged rural locations, constituting 15% of the global poor (United Nations, 2013 , 2017 ). Indigenous people have suffered from historic injustices due to colonization and the dispossession of their lands, territories, and resources, preventing them from exercising their right to self-determination and self-management. Under international law, Indigenous people also have exclusive rights to their traditional medicines to maintain their health practices, including the conservation of vital medicinal plants, animals, and minerals. As individuals, Indigenous people have the right to social and health services without discrimination.

In the African continent, there are an estimated 14.2 million Indigenous people who live in remote and inaccessible areas with poor infrastructure and harsh terrain. African states such as Kenya, Rwanda, Burundi, and the Democratic Republic of Congo are yet to acknowledge and recognize their Indigenous citizens who, as a result, are not represented in the database of international agencies or most national censuses (African Commission on Human and Peoples’ Rights, 2005 ; United Nations, 2017 ).

China has the world’s largest concentration of 105 million Indigenous people. The South Asian region has an Indigenous population of 95 million, where India alone has 84.3 million. There are an estimated 30 million Indigenous people in South East Asia, and 15 million in Western Asia (United Nations, 2017 ).

The Indigenous people who represent approximately 1.7% of the total population in the United States are known as American Indians, Alaska Native, and Native Hawaiians (United States Census Bureau, 2010 ).

In Canada, the collective term for Indigenous people is First Nations. The First Nation consists of distinct nations such as Metis and Inuit. The total number of Canadians who identify as Indigenous is 1.4 million and make up 4.3% of Canada’s total population of 30 million (United Nations, 2017 ).

The Indigenous people of the South American continent are subdivided into the Central, South American, and the Caribbean region, with a population of 45–50 million people. They make up almost 600 Indigenous groups who mostly reside in rural locations (United Nations, 2013 , 2017 )

In the Pacific region, the Australian Indigenous population in 2011 made up 669,900 of the total 24.6 million population (Australian Bureau of Statistics, 2014 ). In Aotearoa (New Zealand), there are 682,724 Maori or Pacific Islanders of the total 4.84 million population (Stats New Zealand, 2013 ). There are 8 million Indigenous people in Papua New Guinea, 850,000 Indigenous Melanesian Fijians, and 260,166 Indigenous Melanesians in New Caledonia (United Nations, 2013 ).

The Arctic region consists of the Inuit of Greenland and the Sami of the Sapmi traditional lands and the northern borders of the Russian Federation. Although statistical data are not conclusive, 20,000 Sami live in Sweden, 50,000–65,000 in Norway, 8,000 in Finland, and 2,000 in Russia (United Nations, 2013 , 2017 ). The Inuit make up 56,000 of the 58,000 residents in Greenland.

In the following sections of this article, the public health status and the social determinants that affect Indigenous people are discussed, as well as how the Indigenous health workforce increasingly uses evidence-based, innovative approaches to address the shortage in health professionals as they move toward universal health coverage. The article also includes a section on the integration of Indigenous knowledge and traditional medicine (TRM) with the Western biomedical model for tackling health challenges at a local level.

Public Health Status of Indigenous People

A landmark study identified the variation of health status in the Indigenous population, describing the health and social status of Indigenous and tribal people relative to benchmark populations. Research from 28 communities across 23 countries showed poorer outcomes for Indigenous nations across the board (Anderson et al., 2016 ).

Indigenous infant mortality rates varied by state and ranged from a third higher to more than double the rate for non-Indigenous infants. Newborns of Indigenous women were more than twice as likely to be of low birth weight as those born to non-Indigenous women. The most moderate average birth weights for infants were those whose mothers used marijuana with tobacco or tobacco and alcohol. Overall, life expectancy was lower by 17 years for Indigenous women and men.

The leading cause of death among males and females in most nation-states was cardiovascular disease (CVD), with rates of up to 30% higher than the non-Indigenous population. The next leading cause of death for Indigenous males was injuries. These included automobile accidents, intentional self-harm, and assault (3.0 times that of the total male population). Cancer (1.3), respiratory disease (3.9), and endocrine, nutritional, and metabolic disorders, primarily diabetes (7.3), affect Indigenous people disproportionately. The most frequent causes of death for Indigenous women, after CVD, were cancer (1.6 times the total female population), endocrine, nutritional, and metabolic disorders (11.7), injuries (2.9), and respiratory diseases (3.6). Lung cancer is among the leading forms of cancer for Indigenous males and females, and cervical cancer is a significant cause of death for Indigenous women.

Leading infectious diseases among Indigenous people are tuberculosis, hepatitis A, B, and C, sexually transmitted infections, HIV–AIDS, Haemophilus influenza type b, pneumococcal disease, and meningococcal disease. Poverty, overcrowding, malnutrition, smoking, alcohol, and drug abuse are key risk factors for this constellation of communicable diseases.

Diarrheal disease and eye, ear, and skin infections are also significantly higher among Indigenous people, especially among young children. Levels of disability are estimated to be at least double that of the general population (Bodeker et al., 2018 ).

Despite uncertainty over definitions of mental health and mental illness and inadequate data on mental health problems, Indigenous people have high levels of mental health challenges and stress. A prominent manifestation of this is the rate of suicide. Based on sex-specific rates for the Australian population, suicide rates are more than 2.8 times for Indigenous males and 1.9 times more than expected for Indigenous females compared to the non-Indigenous people. MacRae et al. ( 2012 ) noted that these rates mask high youth suicide rates, where Indigenous to non-Indigenous ratios are 3.4 for males and 6.1 for females in the 15–24 age groups.

Health and environmental risk factors include tobacco, alcohol, and other drug use, poor nutrition, low income, limited education, high unemployment, high levels of stress, social marginalization, poor working conditions and housing, and gender-related challenges. These in turn interact with cultural and traditional factors to influence behavior, health status, and health outcomes.

Global Incidence of Indigenous Suicide Rates

A global estimate of 800,000 suicide deaths was recorded in 2016 (WHO, 2016 ) and is in the top three causes of death among males and females aged 15–44 years old, with an annual global age-standardized rate of suicide at 10.7 per 100,000 population. Studies from industrialized economies such as the United States (Herne, Bartholomew, & Weahkee, 2014 ), Canada (Macaulay et al., 2012 ), Australia (Pridmore & Fujiyama, 2009 ), Aotearoa New Zealand (Beautrais & Fergusson, 2006 ), and Norway (Silviken, 2012 ) have shown a consistent increase in suicide rates among Indigenous populations and a substantial proportion of disparities in comparison to non-Indigenous people. Colonial history, structural violence, and the forced removal of children to “weaken family ties and cultural linkages and indoctrinate children into a new culture—the culture of the legally dominant Euro-Christian Canadian society” (Truth and Reconciliation Commission of Canada, 2015 , p. v) have given birth to a modern, socially engineered phenomenon. As a result, intergenerational trauma is a contributing factor to social and mental health problems.

A global and systematic investigation of suicide in Indigenous nations has revealed several pertinent issues (Pollock et al., 2018 ). Rates in high-income countries were highest among rural and sparsely populated Indigenous communities. The Palawan in the Philippines has the highest crude suicide rate (134 per 100,000) while Indigenous populations in Malaysia and Fiji are under seven per 100,000 population. The disparities between populations are more extensive in the measure of relative effect. In 102 Indigenous populations and 69 studies, Pollock et al. ( 2018 ) found rate ratios between China and Brazil or Canada to differ from 0.04 to more than 20. However, one study reported a suicide rate of zero for an urban Brazilian population compared to the general population rate of 4.8 per 100,000 in the same city (de Souza & Orellana, 2013 ).

Suicide rates have accelerated among the Inuit of Greenland (from 2.4 per 100,000 to 110.4 per 100,000) since the early part of the 20th century . An increase in suicides in the Aboriginal and Torres Strait Islander population in the Northern Territory, Australia (6.1 per 100,000 to 50.4 per 100,000) was noted between 1981 and 2002 , and in the Micronesian islands (from 4.3 to 25.8 per 100,000) within a relatively short period of time between the 1960s and the late 1980s (Pollock et al., 2018 ).

There are many challenges for Indigenous people to access mental health care that is relevant and culturally appropriate, and is more often compounded by generalizable interventions from a “best practice” paradigm. Little importance is given to producing local Indigenous-led mental health programs that incorporate Indigenous knowledge, medicine, and culture. Despite clinical trials such as gatekeeper training (Sareen et al., 2013 ), hospital-based intervention programs (Hatcher et al., 2011 ), and mHealth applications (Tighe et al., 2017 ), “adverse and limited effects on suicide-related outcomes for Indigenous people” were reported (Pollock et al., 2018 , p. 12).

Interventions designed with Indigenous knowledge systems specifically to address suicide that is integrated with evidence-based public health and clinical interventions were reported in countries such as Canada and in the Arctic region (Goebert et al., 2018 ; Rasmus et al., 2019 ). Pertinent outcomes of Indigenous-led interventions include the creation of supportive communities and resilient families who instilled a sense of pride in Indigenous identity and enhanced connections to people and place while inspiring hope. These results argue for a key theme in communities where self-management, self-policing, and culturally based solutions offer the most viable means of tackling socially based health problems. An example from Micronesia is a culturally based intervention which supports traditional practices that provide a pathway for the individual as well as the community. Social structures that influence individual outcomes in Micronesia include adhering to cultural protocols, respect for leaders, and sharing of resources at a communal level to help provide a pathway for an individual’s life. This does not mean that individual opinions are not welcomed but rather that they are considered in light of the standpoint of their traditional leaders and interpersonal sensitivities (i.e., gender, sexuality, and confidentiality) (Hezel & Francis, 2013 ).

The Social Determinants of Indigenous Health

The current public health status and health outcomes of Indigenous nations are intrinsically linked to the social determinants of health. Social determinants are related to how economic, social, and political policies are implemented to alleviate the burden of morbidity and mortality (Preda & Voigt, 2015 ). As a result of their poor social and economic status, the lack of culturally appropriate education, employment, and housing, as well as physical and environmental conditions widen the gap in health outcomes between Indigenous and non-Indigenous populations (De Andrade et al., 2015 ).

The Cuban Dengue Prevention Program and Eradication of Aedes aegypti is an example of a social determinants approach to tackling public health challenges underpinned by legislation. The program is an intersectoral collaboration and a community-based participatory model supported by public health policy collaboration between local government, community organizations, the Ministry of Public Health, medical doctors and health professionals, as well as water resources management and some civil society organizations. Outcomes from these efforts shed light on the lack of government organizations involved in multisectoral action and community partnerships. Partnerships that enhance local needs assessments are essential for an intersectoral move toward universal health coverage and sustainable development (De Andrade et al., 2015 ).

The impact of colonization and policies such as the Aboriginal Protection Act of 1869 in Australia were dimensions of a comprehensive scheme to control the lives of Aboriginal people. The continuing effect of such historical policies, the lack of reparation, and the lack of recognition of colonial impact continue to hurt programs designed to reduce health inequalities (Griffiths et al., 2016 ). Colonial methods of deconstructing cultures, systems, and structures have enabled an unequal distribution of power between Indigenous and non-Indigenous people. Therefore the devaluation of Indigenous ways of knowing and their traditional medicine persists in present-day society ( 2020 ). Griffiths et al. ( 2016 ) provide an example by drawing on the low uptake of Indigenous definitions of health in the administration of health systems designed specifically for Indigenous populations.

The global public health status of Indigenous people needs to be considered in the context of the environment, where an individual is born, grows, learns, plays, and works. An understanding of the lived experience of Indigenous people is a prerequisite for designing effective public health interventions. Collaborative approaches, the professionalization of the Indigenous workforce, and taking into account Indigenous knowledge systems may hold the key to improved health and well-being outcomes.

Indigenous Health Workforce Professionalization

The United Nations Declaration on the Rights of Indigenous Peoples ( 2007 ) emphasizes their right to education and health, including access to traditional medicine (TRM) and the utilization of traditional knowledge in promoting and maintaining their health and well-being. Indigenous communities have taken control of their health and have developed innovative public health programs. In this regard, many have included the custodianship of their traditional lands as a foundational step toward reconciliation. Increasingly, Indigenous young people are trained as community health workers, nurses, and doctors while maintaining their connection with traditional health practitioners. These integrated services are reporting positive outcomes.

There are six areas for development that participants in an Australian study described as challenges for public health to tackle in an Indigenous context (Kendall & Barnett, 2015 ), as follows:

An overall aversion to Western medical systems and colonial history;

Health care professionals insufficiently trained in cultural sensitivity or cultural competence may alienate Indigenous people from health services;

A prevalent “colonial” or top-down communication style may impede building trust and rapport in the community;

A dissonance between the collective nature of health and well-being from an Indigenous standpoint and the individualistic processes of the Western biomedical model may add to the problem; and

The challenge for public health practitioners to understand that the holistic Indigenous approach to health is more than a medical or somatic condition.

Personal information from physicians in the Pacific who are active in primary health care indicates that they may face professional liabilities in not prescribing pharmaceuticals that are known to address health problems and in trying to address them with lesser-tested or regulated traditional remedies.

Some evidence of efficacy, known safety, cultural acceptance, lower cost, and widespread availability of traditional remedies are factors that have led to standardized traditional medicines taking a place alongside mainstream medicine when safety and efficacy are known (see Willcox et al., 2015 ).

A key theme in communities is that self-management, self-policing, and culturally based solutions offer the most viable means of tackling socially based health problems. Since WHO’s Alma Ata Declaration of Primary Health Care (WHO, 1978 ), traditional health systems have been a formal focus of policy development at both the international and the national level. The Alma Ata Declaration (WHO, 1978 ), adopted by WHO and UNICEF, stated that primary health care (PHC) is an essential element of health care based on practical, scientifically sound, and socially acceptable methods, supported by technology made universally accessible to individuals and families in the community through their full participation and at an affordable cost. PHC engages with the population of interest through community health workers (CHW), as well as through physicians, nurses, midwives, and traditional medicine practitioners who are socially and technically trained to work as a team and to respond to the expressed health needs of the community.

Who are these CHWs and what are their characteristics? CHWs live locally, typically have completed their secondary education, and are trusted members of the community. They often debut as volunteers before gaining employment. The professionalization of CHWs only began in the early 2000s, and since 2005 , a key development hs been the ubiquity of mobile phone coverage into remote, rural, low-income localities (Huang et al., 2018 ). Mobile technology has enabled supportive supervision, real-time data monitoring, and expert system guidance. More online tools from 2010 coincided with the emergence of smartphones that enabled new public health applications such as Dimagi’s CommCare (Mishra et al., 2018 ).

The effectiveness of CHWs has been increased through rapid diagnostic technology. For example, in malaria testing and treatment, the efficacy of the Millennium Villages Project relied heavily on the new roles of CHWs in 10 sub-Saharan African countries. CHWs are remunerated, trained, supervised, and provided with mobile technology, information systems, and backpacks with medical kits. The Ebola epidemic that severely impacted countries such as Sierra Leone, Guinea, and Liberia in 2014 was found to be due to a lack of CHWs as well as a lack of trained professionals with local contextual knowledge and skills to act in the early phases of the disease. In the context of Indigenous communities, traditional health practitioners (THPs) constitute an on-the-ground resource for CHWs capable of mobilizing around public health issues and participating in integrated health service development despite the lack of systematic and continuing professional development from government programs (Huang et al., 2018 ).

Incorporating Traditional Medicine in Indigenous Health Interventions

Most traditional medicine (TRM) systems have a theoretical basis, a materia medica , a range of therapeutic modalities, an empirical approach to treatment, and a tradition of training. Extensive scientific research has been conducted and published on TRM. Some TRM has been proven to be safe and effective through controlled clinical trials. Some TRM practices are dangerous (e.g., hepatotoxicity or herb–drug interactions) or ineffective.

A key point is that in both rural and urban areas, there is a demand for TRM and patients seek guidance in selecting from traditional and modern healthcare options. Given the trust of local communities in TRM and its practitioners, partnerships with THPs is warranted and is based on mutually respectful exchange. Increasingly, in line with WHO’s policies, partnerships have been developed between modern and THPs.

The World Health Organization’s Global Atlas on Traditional, Complementary and Alternative Medicine (Bodeker & Ong, 2005 ) provided the first global overview of utilization and policy development in the TRM sector. Half of the world’s population uses these approaches regularly and pay out of pocket to do so. By this standard, there is nothing “alternative” about these approaches to healthcare. Instead, they constitute a collective majority body of health practices.

In Africa, regular use of TRM is assessed at around 80% of the population. In Asia, more than half of the population uses it, with variations across urban and rural areas (i.e., higher use in rural areas) and across educational levels (i.e., a bimodal curve exists, with high use at low educational and income levels and at the highest educational and income levels).

The World Health Organization produced a strategy on Traditional and Complementary Medicine (T&CM), which looks ahead to the year 2023 (WHO, 2014 ). WHO’s Traditional Medicine Strategy 2014–2023 has two key goals:

To support member states in harnessing the potential contribution of T&CM to health, wellness, and people-centered health care; and

To promote the safe and effective use of T&CM through the regulation of products, practices, and practitioners.

WHO has outlined three strategic objectives for meeting these goals:

Building the knowledge base and formulating national policies;

Strengthening safety, quality, and effectiveness through regulations and support testing; and

Promotion of universal health coverage through the integration of T&CM services and self-health care into national health systems.

According to WHO, TRM not only maintains its function in primary health care in developing countries (70–80% of the population in India and Ethiopia still depend on TRM and practitioners for primary health care), but its use has expanded widely in many developed countries, and is referred to as Complementary or Alternative Medicine (CAM). For instance, 70% of the population in Canada and 80% of people in Germany have used TRM as CAM treatment.

Much of the use of TRM by those with higher levels of income and education is for health promotion and disease prevention, widely referred to as wellness.

The editorial in the September 2018 edition of Bulletin of the World Health Organization , titled “Healthy living, well-being and the sustainable development goals,” and coauthored by Amina Mohammed, Deputy Secretary-General of the United Nations, and WHO’s Director General, Tedros Adhanom Ghebreyesus, identified three strategic priorities:

universal health coverage;

health security; and

improved health and well-being.

While these priorities are laudable, there is a growing concern about the viability of some of these sustainable development goals, particularly universal health coverage. WHO’s Assistant Director-General for Special Initiatives, Ranieri Guerra, wrote in August 2018 that:

There is general agreement that the over-optimistic assumptions of the SDGs are now passing through a reality check that indicates where we need to re-prioritise and move resources accordingly. According to progress reports so far, it is insufficient to meet the goals and targets set for 2030 . (Guerra in Bodeker et al., 2018 , p. 5)

Integrating Indigenous Knowledge With Modern Healthcare Practices: Country Studies

The arctic region: norway and fennoscandia.

Sami people of the Arctic region still have a long and continuous relationship with traditional healers, even after the first district medical doctor scheme had been established there in 1836 . With a distance of at least 125 miles from local communities, the high cost of traveling made modern health care inaccessible. Traditional healers, however, were local, free, and culturally sensitive (Langås-Larsen et al., 2018 ). The study by Langas-Larsen and colleagues ( 2018 ) found that family networks (family, kin, friends, and neighbors) held an important role in patient management and especially in the maintenance of health and well-being. This network has been responsible for offering help with practical tasks and with supporting close kin. In some cases, they may be asked to contact traditional healers for providing their services in the hospital.

The Sami residing in Fennoscandia use a cultural form of singing called “yoik.” Singing in general has been found not only to be a form of self-expression but a tool that enables self-regulation with music therapy, promising therapeutic potential in neurological and psychological disorders (Hämäläinen et al., 2018 ). Yoik therefore can be a means for emotion regulation and stress relief for individuals. As a cultural artifact, such cultural practice has promoted sociocultural resilience and reinforced Indigenous identity.

The prevention and control of the HIV epidemic in Myanmar requires regular engagement at a local level, particularly with men who have sex with men (MSM) and transgender women (TW). This public health challenge affects some Indigenous and diverse gender and sexual identities among same-sex attracted men. Despite the known risk to the MSM and TW community, less than half reported in 2016 receiving an HIV test in the prior 12 months (as reported by the National AIDS Program, 2016 ). Nondisclosure of MSM to family and friends is a strategy to avoid stigma and discrimination. Adding to the latter is the criminalization of homosexual acts through anti-homosexual legislation, resulting in a reduced level of access to health services among MSM and TW (Arreola et al., 2015 ; Veronese et al., 2019 ). However, according to Veronese et al. ( 2019 ), the National AIDS Program is addressing the structural and social stigma of this community through a call for their engagement through a discreet use of peer-based outreach and digital health promotion.

Grameenphone (GP) has introduced a mobile phone-based health service delivery model that builds on the capabilities framework pioneered by Amartya Sen (Meier & Stiglitz, 2002 ). The service has over 74 million subscribers and has increased access to services for Indigenous people who could not afford to consult a registered doctor face to face. The social impact of the GP project has been further illustrated by the experience of an Indigenous secondary school girl who called the Healthline service (the service has been rebranded to “Tonic”) and developed a better understanding of her body (Palas et al., 2017 ).

The following is a short account of the teenager’s experience, using a pseudonym:

Radhika declined her grandmother’s offer of a traditional method of protection for her menstrual cycle. Traditional methods often utilize old cloths, cotton, or tissue. These items are repeatedly used without cleaning, drying, or laundering, and 90% of the time they are stored in an unhygienic, hidden place (Mondal et al., 2017 ). From Radhika’s reading of her home economics textbook, she learnt that the traditional method was a health hazard and a risk factor for urinary tract cancer. Her body was going through changes, which caused much physical pain and discomfort during her periods. It took her several months to muster the courage to speak of this with a female teacher. Radhika said, “the first experience of my period was very challenging and I was too shy and confused as to what to do.” The teacher provided Radhika with the number of Healthline. Radhika called and described her concerns to a doctor who not only suggested to use sanitary napkins but also prescribed some medicine. Radika recalled her kind female doctor in her own words and said that as a result, “I did not hesitate to discuss my problem with her which I could not discuss with anyone else before.” (Palas et al., 2017 , pp. 73–74)

The story of Radhika offers a cameo of a teenage girl overcoming cultural and societal barriers to improve her well-being through the use of an online service, namely Healthline. Even though she was interviewed by a male, according to Palas et al. ( 2017 ), her ability to speak without fear or shame was due to her behavior change outcomes as a result of being supported by women in talking about her issues openly through her interaction with Healthline.

North America

A high turnover of health professionals is one of the challenges of health care provision in regions with vast distances between remote localities and urban centers. The Nunavik in the region of Northern Quebec have looked at the use of social media as a means to promote health information and to address the need for community engagement in remote locations. Although young people are the primary users of social media, a wide variety of age groups utilize Facebook, including unilingual Inuktitut speaking elders. The Inuit elders have integrated Facebook and traditional methods of communication into their routines to ensure that the younger generation may benefit from traditional knowledge and culture.

Despite the prohibition by the Quebec health system on the use of Facebook, community social and health workers who work directly under the Nunavik health system, found a way to work around this rule and engage with the Indigenous community outside of their regular working hours. The “Feeding My Family” Facebook page is an example of integrating technology and health promotion into the discourse of health in the community. The members of this page, numbering more than 20,000 as of 2019 , first began to show concern over the effects of high food prices on family health. These online posts of photos and comments slowly evolved into a community action rally or protest in several localities. The use of Facebook to generate full community participation grew into a robust regional effort to transform the Western biomedical model and health services as well as to advocate for an integrated model prioritizing Inuit values and knowledge (Diamond & Starks, 2018 ).

The Yukon, a region of Canada’s northwest, has a population of 38,455 and is home to 14 First Nations communities (Yukon Bureau of Statistics, 2017 ). The Council of Yukon Indians inspired the diversifying of professional health training by stating “the whole Yukon is our school. In the past, we learned from our surroundings” (Council for Yukon Indians, 1973 , p. 21, in Diamond & Starks, 2018 ). By decolonizing, indigenizing, and making reconciliation efforts, Yukon College is striving to put health professional training into Indigenous hands.

Nation Initiative staff also deliver a short workshop on competencies related to understanding First Nations heritage, culture, governance, and contemporary challenges through their worldview. Students have an opportunity to learn collaboratively about traditional foods, Indigenous epistemology, and the importance of ceremony related to end of life. As a result, students can provide more meaningful interactions with their future clients and respect traditional knowledge and Indigenous perspectives on health and well-being (Diamond & Starks, 2018 ).

Researchers Airhihenbuwa and colleagues argue that “to change negative health behaviors, one must first identify and promote positive health behaviors within the cultural logic of its context” (Airhihenbuwa, Ford, & Iwelunmor, 2013 , p. 78). The Center for Alaska Native Health Research designed an intervention program based on Indigenous knowledge called the Qungasvik (ph. Kung-as-vik/Toolbox) Training and Teachings manual . This training package is delivered by Native Alaskans who are leading the development and evaluation of strengths-based and protective factors to reduce the risk for Alaska Native suicide and alcohol abuse. The men’s communal house, or “qasgiq,” which in one of its possible meanings is “to encircle,” is a living space used for an extended kinship structure among men during the winter months. The qasgiq process, led by elders, is based on community action and promotes equality in the community. The intervention includes planning, reflection, and a series of activities during a 3-year time frame, targeting young people and their development and the need to be exposed to Native values, knowledge, and practice, as well as to live the customary yuuyaraq, or “way of life” (Ra s mus et al., 2019 ).

What is prominent about this intervention is the use of Alaska Native knowledge on space, symbols, and metaphors, where the qasgiq is a place to learn essential survival skills in a postcolonial world. Healing is embedded in the qasgiq, through re-establishing “collectivity, interdependence, equanimity, and encircling.” The program aims to enable youth to gain positive wellness outcomes (Rasmus et al., 2019 , p. 49).

The focus on culture was historically reduced in importance during the intervention design phase. But increasingly, Indigenous frameworks and paradigms are translated into interventions that complement and strengthen Western ideas of public health. In turn, the growth of the Qungasvik and the success of the qasgiq model will influence self-determination in health services and public health research among Alaska Natives (Rasmus et al., 2019 ).

United States

A randomized controlled intervention was implemented as part of the Tribal Health and Resilience in Vulnerable Environments study. The researchers partnered with tribally owned and operated supermarkets in the Chickasaw Nation and Choctaw Nation of Oklahoma. The goal was to increase the purchase of healthy foods, fresh vegetables and fruits, as well as to reduce food insecurity in the community (Blue Bird Jernigan, D’Amico, & Keawe’aimoku Kaholokula, 2018 ). The collaborative relations with tribal commerce leaders involved co-developing all aspects of the study that included designing a specific store assessment tool, testing the right food for taste and acceptability, and designing the marketing and signage. As a result, the tribal commerce leaders greatly enhanced the external validity of the evidence-based healthy retail strategies and augmented self-reported survey data with objective store-level measures, including food costs and sales (Blue Bird Jernigan et al., 2018 ).

Studies that focus on internal validity, such as randomized control trials, lack the translation and dissemination of learning to real-world settings with high variabilities, such as in Indigenous contexts, where culture, Indigenous medicine, knowledge, and acceptability are complex issues. The National Institutes of Health has brought critical attention to the importance of translational research and has identified external validity as key to the problem of utilization of evidence- based practice . Efficacy trials must include greater diversity in participants, especially Indigenous participants, and hand back intervention design and implementation in collaborative practice to balance the internal and external validity issues in interventional studies (Blue Bird Jernigan et al., 2018 ).

South America

Community mental health: projeto quatro varas.

An influential and innovative community mental health model in Fortaleza-Ceara, northeast of Brazil, called Projeto Quatro Varas , was co-founded by Adalberto Barreto, a psychiatrist and mental health researcher, and his brother, Airton Barreto, a lawyer. Adalberto Barreto generated the community therapy (CT) methodology to provide community care grounded in both societal and academic understanding. He developed the CT program initially in the favela of Fortaleza after carrying out research showing that local curanderos , who use herbs and other traditional cultural remedies, have a positive impact on community health (Neville, 2008 ).

The CT program consisted of a range of components, including collective therapy circles, “living pharmacies” (i.e., herbal medicines), and curing houses with complimentary treatments. He studied the importance of parteiras (traditional female obstetricians), the value of razeiros and rezadeiras , and the cultural treatment of death, marital conflicts, and neighborhood disputes.

The CT approach has now become widely diffused throughout Brazil and is used among many different groups and populations, mainly through formal partnerships established between the Universidade Federal do Ceara and various levels of federal, state, and municipal health services. In research conducted in 10,000 community therapy circles and 100,000 consultations, 88% of attendees had experienced improvement through community therapy and its support system. Based on these research findings and the success of more than 600,000 therapeutic sessions, Barreto managed to get CT approved as national public health policy and trained 1,100 government public health and social assistance employees (Barreto & Grandesso, 2010 ).

Other countries in the region as well as countries in Africa and cities in France have built relationships with the CT movement and Barreto, establishing community mental health programs based on the principles of a local therapist, traditional knowledge, self-help, mutual support, and program evaluation (Ashoka Foundation, 2018 ).

The Matses Traditional Medicine Encyclopedia

A tribe called the Matses in the Amazon (Brazil and Peru) are trying to protect their language, knowledge, stories, and culture from extinction through the production of a comprehensive 500-page encyclopedia. The encyclopedia, a combined effort and a first of its kind by shamans of an Amazonian tribe, is written in their language to protect their medicinal knowledge from appropriation by researchers and corporations. The encyclopedia, written from the perspective of the Matses shamans, incorporates flora and fauna into the nature of diseases of their people. Although this is a historical and pertinent production, the long-term benefits of such an effort must be supported by long-term apprenticeships and experience, which pose a challenge in the recruitment of participants.

The encyclopedia is a resource to train new shamans and mentor them in their youth with the knowledge of experienced shamans before they pass on, as well as to preserve their way of life and the medicinal plant knowledge of their people. The encyclopedia, which took 2 years to compile, includes an entry on Matses master healers. Each entry is sorted by disease name, an explanation on how to identify its symptoms, its etiology, and the preparation processes and plant sources to be used to address the illness. It also includes alternative therapeutic options. The Matses also use photos to accompany each entry in the encyclopedia . Preservation of traditional healthcare practices, however, requires a specific plan, and maintenance of traditional methods with the help of mentors, as suggested here, is essential for the continuity of a culture and of Indigenous knowledge.

Makere University and PROMETRA Uganda: Partnership for the Scientific Investigation of Important Traditional Medicines

Uganda has a long history of research in TRM. As far back as the 1960s, a government team began documenting the traditional medicinal knowledge of many of Uganda’s 111 districts. A monumental task, this national ethnomedical survey continued for almost 30 years and resulted in a comprehensive written record of the national TRM heritage. The document is stored as a set of typed volumes at both Makere University and at the National Chemotherapeutics Research Institute, both of which are in the capital, Kampala.

In a collaboration as part of the European Union-funded Multi-University Initiative on Traditional Healthcare (MUTHI), Uganda’s Makerere University in Kampala, Mbarara University in Southwest Uganda, and PROMETRA Uganda created a legal framework to partner in investigating essential traditional medicines for scientific evaluation (Bodeker, Weisbord, et al., 2018 ).

Several people involved in herbal medicine as well as groups of traditional healers were invited to a meeting at Makerere University. Most THPs were ready to work with the Makarere team. However, they did harbor fears that the researchers could steal their medicinal formulae and profit from them, as is an often realistic concern of traditional knowledge holders in general.

The Makerere team expressed interest in the partnership and assured the THPs that the main objective of the project was to contribute to improving TRM, mainly herbal medicine, and to place safe and standardized herbal medications, registered with the National Drug Authority, on the open market.

The Department of Traditional Medicine

Mali benefits from an unusually high level of government support for research and development of TRM. The Department for Traditional Medicine (DMT) within the National Institute for Research on Public Health (part of the Ministry of Health), was founded in 1968 . Since 1979 , one of its aims has been the development of standardized “medicaments traditional ameliorés,” or improved traditional herbal medicines (Willcox et al., 2012 ; Willcox et al., 2015 ).

In Mali, the objective to develop phytomedicine for home-based management of malaria (HMM), with the aim of symptomatic improvement and prevention of severe malaria, was seen as an effective and innovative public health policy. If the preventive population-based treatment were found to be effective, the plant would be cultivated and prepared locally as a first-line treatment for presumed malaria.

The primary outcome measure in this research program was “clinical recovery” on Day 28, without the need for second-line treatment. An important secondary outcome measure was the incidence of severe malaria, which is a crucial outcome in public health terms. Large numbers of patients were needed to demonstrate non-inferiority because severe malaria is a relatively rare event. Another approach is to see whether the incidence of severe malaria is kept below a pre-specified level in both groups. A previous study in a similar context showed that age-specific incidence (age <5 years) of severe malaria in untreated patients with presumed malaria was about 11%, and in patients treated at home with chloroquine (the standard treatment at that time) was about 5% per month (Sirima et al., 2003 ). The aim was therefore to keep the age-specific incidence of severe malaria (in patients aged <5 years) below 10%, and ideally, at ≤5% in both groups.

Over 28 days, second-line treatment was not required for 89% (95% CI 84.1–93.2) of patients treated with the locally used herbal antimalarial Argemone mexicana versus 95% (95% CI 88.8–98.3) treated with artesunate-amodiaquine (ACT). The observed age-specific incidence of severe malaria (in children aged 0–5 years) was 1.9% in both groups ( A. mexicana and ACT) over the first 28 days of follow-up. The follow-up was extended to 3 months and, over this time, the age-specific incidence of severe malaria was 2% per month in the herbal group and 1% per month in the ACT group. With 95% confidence, the age-specific incidence of severe malaria in both groups was <6% per month (Willcox et al., 2011 ).

The research team has documented a 3.5-fold increase in the use of A. mexicana for the treatment of uncomplicated malaria and an 8-fold decrease in the consultation of traditional healers for severe malaria (Graz et al., 2010 ). The research team is working to scale this program up, leading potentially to substantial reductions in mortality from malaria and delays in the appearance of resistance to conventional drugs such as artemisinin combination therapies.

As a challenge to public health, malaria was overcome with sustainable efforts, especially in the area of indigenous malaria. Sustained surveillance and expedited responses for each malaria foci achieved such results, particularly in achieving zero reported cases of indigenous malaria in 2017 (Feng et al., 2018 ).

A robust policy and a centralized approach for malaria control and elimination was guided by three strategic guidelines, seven national criteria, and five technical plans. This multipronged approach mobilized social resources (Feng et al., 2018 ) and the achievement is partly owned by the malaria training programs held from the provincial to the village level. Health workers from higher up in the health system were more interested in the technical aspects of malaria prevention, while township and village health workers trained in fieldwork coordination and targeted public health interventions better suited for the context in regard to case detection and investigation (Lu et al., 2018 ). China has demonstrated that the incorporation of health workers at all levels of government, especially those on the ground in rural and remote villages, was crucial to prompt prevention, detection, and treatment of cases.

The Institute of Applied Dermatology, Kerala

In the traditional medicine sector, skin and wound treatments were estimated to account for approximately one third of all traditional medicines (Balick & Cox, 1996 ). This figure may not include the natural products regularly applied to healthy skin in many parts of the world to promote hygiene, such as “soap plants” and emollients.

Community dermatology is a concept that extends the focus of care delivery from the individual patient who comes to see the doctor about a skin problem to a proactive intervention to improve the care of skin and treat diseases that present with skin signs in the broader communities in which people live (Ryan, 2015 ). Programs that use local health care workers, those that use traditional practices, and those that involve other groups such as burn care experts are all manifestations of the same basic principle for achieving the best results; teams are usually multidisciplinary and sensitive to local practices and needs.

The Institute of Applied Dermatology (IAD) was founded in 1999 by dermatologist S.R. Narahari along with nine other interdisciplinary senior medical professionals. In 2014 , the Government of Kerala established its Center for Integrated Medicine and Public Health in the IAD under public–private partnership for furthering activities of research, development, and operations related to community dermatology. The IAD is collaborating with seven institutions and universities to enhance the evidence, application, and impact of integrated medicine in dermatology.

The IAD, a not for profit organization in Kasaragod, Kerala, devised a suitable program that employs locally available supervisors and user-friendly technology at low cost. In 2004 , the IAD launched an integrated treatment protocol to reduce lymphatic filariasis morbidity by combining Ayurveda, yoga, and compression therapy supplemented, when necessary, with modern dermatology drugs to treat bacterial entry points.

Narahari et al. ( 2013 ) designed a treatment that included skin wash, phanta soaking (an Ayurvedic infusion made of Rubia cordifolia in hot water), yoga and breathing exercises before and after Indian manual lymph drainage (limb massage against the direction of hair growth using an oil specially prepared for lymph drainage), compression therapy, and bacterial entry points using pharmaceutical medicines. A total of 730 patients completed the 3.5-month follow-up. Inflammatory episodes decreased from 37.5% to 28.3% in one district and from 37.6% to 10.2% in the second district. A lymphatic filariasis-specific quality of life questionnaire revealed an overall improvement in all domains.

The authors note that this cost-effective integrative treatment protocol has adapted all the principles of primary healthcare, namely community participation, intersectoral coordination, user-friendly technology, and equitable distribution, which may be adapted globally.

Pacific Region

In the 11th annual Closing the Gap report on the health of Aboriginal Australians, little progress was shown and only two of the seven targets were met to reduce inequalities for Aboriginal and Torres Strait Islander peoples’ social determinants ( The Lancet , 2019 ). The report’s editorial called for a complete overhaul of the national strategy and focus on equitable expenditure, with a particular emphasis on putting Aboriginal health in Aboriginal hands. From social marketing to clinical practice, Indigenous knowledge systems and collaborative research methods need to be front and center of the Closing the Gap strategy.

Indigenous health workers from Aboriginal and Torres Strait Islander nations in Australia are actively engaged in oral health interventions across the lifespan in their localities. Training programs have varied from a three-module program delivered in a classroom with a 60-hour on-the-job training component to a 1- or 2-day workshop on oral health education and hygiene, and training with an early childhood oral health screening tool (Villarosa et al., 2018 ).

The Kaholo Project incorporated a traditional Hawaiian dance in hula to prevent cardiovascular disease in Native Hawaiians with hypertension. While historically the traditional hula dance was prohibited by Christian missionaries and later by legislation, the hula remains a popular and acceptable dance among Native Hawaiians and is woven into the context of community life, where behavior change is possible and more efficacious. Kahalokula et al. ( 2017 ) found the dance as a form of physical activity effective in reducing systolic blood pressure and in improving social functioning.

Palau, Micronesia

Palau is an archipelago of over 500 islands, part of the Micronesia region in the western Pacific Ocean. Around 70% of deaths in the Pacific are due to non-communicable diseases (NCDs) such as cancer, diabetes, and cardiovascular and respiratory ailments, according to the Pacific Islands’ Non-Communicable Disease Roadmap ( 2014 ).

Medicinal plants are widely used in the Pacific, and Palau specifically, for the management of common ailment and NCDs. The Palau Primary Health Care Manual is a compilation of traditional ethnomedical information about plants, presented by the authors within the context of Western medicine. The Manual offers data on the traditional use, pharmacology, and toxicology of a wide range of plants in treating common ailments and injuries and for women’s and men’s health, as well as for managing NCDs (Dahmer et al., 2018 ).

In subsequent research, a “reverse pharmacology” study published in the Journal of Ethnopharmacology found that seven out of ten people in Palau self-prepared a medical concoction using Morinda citrifolia L. for diabetes and Phaleria nishidae for obesity. These are the two most frequently used medicinal plants in the archipelago. Researchers reported that for excess weight, M. citrifolia L. was associated with better outcomes than P. nishidae Kaneh. ( p = .05). In the case of diabetes, when comparing P. nishidae and Morinda citrifolia , the former was statistically more often associated with a reported outcome of “lower blood sugar” ( p = .01). The researchers noted that while statistical association of some 30 plants and their reported outcomes were not proof of effectiveness or safety, this approach can help local researchers identify further studies of plants or methods that can bring the most benefit to the population (Graz, Kitalong, & Yano, 2015 ; Kitalong et al., 2017 ).

Papua New Guinea

Family planning studies in Papua New Guinea (PNG) have often overlooked the importance of Indigenous knowledge and cultural systems, especially the views of Indigenous women (Hinton & Earnest, 2011 ). However, since the 1970s, village birth attendants (VBA) and village child health workers (VCHW) have been able to bridge this gap as part of a complex socioeconomic policy process. This resulted in the reduction of PNG’s maternal mortality, with “an estimated 250 deaths per 100,000 live births (down from 733 per 100,000), and reported infant mortality of 48 deaths per 1,000 live births (a reduction from 65 deaths per 1,000 live births) between 2009 and 2012” (Kampblijambi et al., 2018 , p. 18).

In comparing the shift in community knowledge and the impact on living standards, the VBAs and VCHWs, both female and male, observed that there had been many positive outcomes. One of the changes in the community as a result of the education and training of VBAs and VCHWs was the reduction of blame for deaths to witchcraft and sorcery and an increase in awareness of the real causes of deaths in the community (Kampblijambi et al., 2018 ).

Another example of the impact on training local health workers was that mothers saw the importance of reducing the size of their family. While women often turn to traditional medicine for contraception, there has been an increase in acceptance of vasectomy in Goroka, in the highlands of PNG. However, these great efforts on the part of volunteer health workers could be threatened by a lack of financial incentives and support from organizations and the government due to its “voluntary” aspect (Kampblijambi et al., 2018 ).

Aotearoa New Zealand

In Aotearoa, the use of funding contracts as an incentive is to clarify roles and create transparency in the process of aligning goals between government agencies (as funders) and health care providers. These funding contracts bring with them unique challenges to Maori health providers.

The He Pinkinga Waiora (Enhancing Well-being) Implementation Framework is a planning tool used for funders and policymakers to collaborate with Maori health organizations in assessing the effectiveness of services and innovative interventions. As Maori health organizations are better equipped to implement services that target long-term conditions such as diabetes, a consistent method is applied to implement systems-thinking interventions with intersectoral integration of health and social services. This systems-thinking approach is aligned with Maori knowledge systems in health care delivery mentioned elsewhere as whanau- and client-centered care (Oetzel et al., 2017 ).

The Impact of Traditional Medicine in Addressing the Social Determinants of Indigenous Health

The approach of health interventions that tackle the social determinants of Aboriginal and Torres Strait Islander health, such as education, poverty, and housing, has received criticism for its top-down policy approach (Senior & Chenhall, 2013 ). There is little room for discussion on the way individuals and indigenous communities engage with health determinants at the micro level to create change from their standpoint. In a study of Aboriginal health beliefs in a remote community in the Northern Territory of Australia (Senior & Chenhall, 2013 ), researchers understood from their participants that the first course of action was to seek out bush medicines (traditional medicine) when ill. It is common to find some Aboriginal people underutilizing health services despite the provision of education or the implementation of health promotion campaigns. This interrelationship between some Aboriginal people and health service providers is a freedom that some must exercise as a pathway to self-determination, just as it is recognized and accepted in non-Indigenous or Anglo-European societies that resist coercion to be healthy.

In Canada, the First Nations have for thousands of years extensively utilized plant resources in traditional midwifery practice. Traditional midwifery proliferation into the greater community of North America has brought with it dignity and much-needed respect for traditional methods of birthing. The traditional knowledge of the First Nations is incorporated into modern midwifery through collaborative efforts under a framework that states the following:

. . . respect for, and use of, Indigenous knowledge and practices in the development and implementation of public health programs can only hope to succeed if the holders of that knowledge are allowed to define (the parameters) of its utilisation . . . (NAHO, 2008 , p. 17, in Cole, 2017 )

The re-establishment of Indigenous midwifery in North America, including the licensing of modern midwives and the construction of traditional Aboriginal birthing centers, was an achievement born from grass-roots efforts of the First Nations communities.

The Internet, Social Media, and Mobile Phones in Indigenous Health

The exponential growth of social media sites such as Facebook, Twitter, Instagram, YouTube, and the relatively newer Snapchat and WhatsApp has had a significant impact on the way people communicate and consume media, making it a ubiquitous source of information and a platform for knowledge exchange (Anderson & Perrin, 2017 ). Social media creates enormous potential for health organizations to engage, connect, and communicate with their target audiences. The often hard-to-reach population of Aboriginal and Torres Strait Islanders are among the most common adopters of social media (60% of Indigenous population used Facebook compared to 42% of non-Indigenous Australians) (Hefler et al., 2018 ).

The online content analyzed by Hefler et al. ( 2018 ) ranged from common health-related topics such as mental health, nutrition, exercise, and tobacco cessation and are generally visually prominent online and offline as a result of health promotion and social marketing activities. In addition, a broad discussion of the social determinants of health includes the importance of maintaining Aboriginal culture and language, connection to land and bush tucker, and the reinforcement of Aboriginal identity (Hefler et al., 2018 ).

The use of technology or media to create, share, and comment on stories and metaphors on health-related topics enables Indigenous epistemology and knowledge construction. According to Torres Strait Islander scholar Martin Nakata, knowledge construction is embedded in a variety of ways such as “storytelling, memory making, narrative art and performance; in cultural and social practices, of relating to kin, of socializing children in ways of thinking [and] transmitting knowledge” (Kariippanon & Senior, 2018 , p. 34).

Research conducted on the role of the internet and communication technology in raising a new consciousness among Indigenous people in Bangladesh, referencing Amartya Sen’s five freedoms (political freedom, economic freedom, social freedom, transparency guarantees, and protective security), found compelling positive results (Ashraf, Grunfeld, & Quazi, 2015 ). The Grameenphone Community Information Center’s (GPCIC) programs, for example, created new opportunities in “income generating activities, education, health, improved transparency and disaster warnings” (Ashraf et al., 2015 , p. 12). A young man from the GPCIC program shared his view of how the program benefitted his single mother:

My mother runs the family since my father passed away many years ago. She is the only earning source of our family who makes and sells handicraft goods. Since she is getting older, I thought to help her by any means. One of my friends from GPCIC told me that an Internet website could be an alternative way to sell handicraft goods. I joined GPCIC, learned website designing, and used this skill in selling the products. This helped me boost sales and thereby enabled me to better help the family. (Ashraf et al., 2015 , p. 9)

In Australia, through a culturally sensitive and appropriate process of engagement and sampling of study participants in a remote locality in the Northern Territory, insights into the interaction between technology and Indigenous people can reveal how digital public health interventions are perceived (Kariippanon & Senior, 2017 ). The potential of digital public health interventions is often limited by a lack of dialogue between health services and target audiences. Health service providers discreetly fear online discussions, as they may provide an uncensored platform for critique, which may hurt the reputation of the health service provider (Kariippanon & Senior, 2018 ). When public health content is designed to factor in a conversational process by using new methods, such as ethnographic filmmaking which captures interactions, discourse, performance, narratives, body language, culture, law, and ceremony, the messages are found to be better suited to Indigenous populations in a culturally relevant manner.

Ethics of Conducting Research With Indigenous People

The history of research with Indigenous people was historically a tool and strategy for colonization (Tuhiwai-Smith, 1999 ). Unsustainable developments have historically plagued Indigenous people, and Grenier ( 1998 ) suggests that this is due to a lack of Western researchers consulting with stakeholders and incorporating Indigenous knowledge.

The use of community-based participatory research (CBPR) and tribal-driven participatory research (TDPR) methods in the Indigenous context has become a highly sought after method that acknowledges the different ways of being and knowing while being flexible in its approach to the evaluation of interventions (Richmond, Peterson, & Betts, 2008 ; Wilson, 2008 ; Thomas, Donovan, & Sigo, 2010 ).

The Australian Institute of Aboriginal and Torres Strait Islander Studies’ guidelines for ethical research urge researches to consider nine main categories when designing research initiatives in partnership with Indigenous people or Indigenous organizations. Researchers must provide clear explanations in their research protocol on how these requirements are met. The categories are as follows: consultation, negotiation, mutual understanding, respect, recognition, involvement, benefits, outcomes, and agreement (AIATSIS, 2018 ). The Canadian approach is similar to the Australian process in that a comprehensive ethical framework for research is provided. The need for community-informed consent, research agreements, and protection of communities’ cultural and sacred knowledge are front and center of the framework. Ethical guidelines also include stem cell research and best practices for research involving children and adolescents (Government of Canada, 2019 ).

Research partnerships with Indigenous communities can be complex and require transparent, long-term relationships where trust-building and rapport are established before any research is conducted. The intricacies of building trust with the Native American communities in Montana, for example, involves sharing power while embracing a mix of stakeholders such as tribal members, health care professionals, and Native and non-Native researchers (Christopher et al., 2011 ). Tribal governments are now in a viable position to conduct and manage their research agenda to achieve their goals. Their efforts are consistent with the core principles of TDPR, which must involve a full partnership between researchers and the community of interest through the life of the project,, from planning through implementation and evaluation (Mariella et al., 2009 ).

In distinguishing generic research from TDPR, or CBPR, a typical research program involves the approach of “experts” who come into a community to gather information and leave (helicopter research) or where outside researchers visit a community, gather limited information, and leave with their data as “trophies” (safari research) (Mariella et al., 2009 ).

The International Society of Ethnobiology (ISE), cited by Willcox et al. ( 2015 ), provides a set of questions for researchers to reflect upon at each stage of the research process. According to Willcox et al. ( 2015 , p. 285), respecting “intellectual property rights is possible even in a context where the knowledge is not owned by a clearly identified person or group of people, and when plants are not being developed for commercial purposes.” Mutual trust is essential between researchers and the communities through the use of agreements on benefit sharing. A brief overview of the ISE Code of Ethics is provided here. Further details can be found in Bodeker, van ‘t Klooster, and Weisbord, ( 2014 , pp. 817–818):

Prior rights and responsibilities;

Self-determination;

Inalienability;

Traditional guardianship;

Active participation;

Full disclosure;

Educated prior informed consent;

Confidentiality;

Active protection;

Precaution;

Reciprocity, mutual benefit, and equitable sharing;

Supporting Indigenous research;

The dynamic interactive cycle;

Remedial action;

Acknowledgment and due credit; and

Recognition of community values and goals, particularly regarding collective harm, and the development of full partnerships between institutions and communities is essential to keeping with the core principles of CBPR and TBPR. Along with these, encouraging community participation in all aspects of the research through skills transfer and building research capacity would ensure that research and its findings are sustainable, beneficial to the community, and conducted respectfully (Mariella et al., 2009 ).

A common pattern is observed when studying the variety of country cases that have implemented an integrated approach to healthcare provision vis-à-vis the inclusion of Indigenous voices and knowledge of traditional and complementary medicine. The integration of traditional and complementary medicine ranges from organizational or high-level policy implementation to community-led grass-roots efforts, with assistance from a range of diverse professionals, both Indigenous and non-Indigenous. A research gap that may potentially be of importance is in regard to the development of small- to medium-scale business models that can be sustainable and generate income for Indigenous communities globally as well as enhance their contribution to the local economy. The impact of social entrepreneurship on health outcomes manifests itself through capacity building and strengthening local agents of social change to act where governments and not-for-profits have not been successful. The small- to medium-scale business models utilize an interdisciplinary framework to solve complex health and socioeconomic problems. Some entrepreneurs still rely partly on philanthropic funding but the aim is to become self-sustaining and to create employment while raising social and human capital in resource-poor settings (Hsiao, Lee, & Chen, 2016 ; Lim & Chia, 2016 )

The advancement of the global public health status of Indigenous people lies in the self-management of Indigenous health services. It includes the employment and training of a skilled local health workforce. Indigenous people have a right to incorporate and determine what are culturally appropriate and sensitive public health interventions as well as health services that are relevant to their local context. Professionalization of the Indigenous health workforce and a more nuanced local approach to public health interventions have resulted in raising a positive community identity of self-determined Indigenous nations. A flow-on effect of self-management has resulted in many Indigenous-led designs of interventions, health education resources, online communications, and the use of the internet and mobile technology to engage with hard-to-reach populations.

A call for Western biomedical frameworks to seek out and enable partnerships with Indigenous knowledge systems, as well as integration of traditional medicine as part of these partnerships’ core business is becoming a common phenomenon in many Indigenous contexts. The employment of youth as peer outreach and health workers, equipped with smartphones and in-depth knowledge of the culture, tradition, and language of their people, as well as possessing evidence-based medical skills, is becoming an increasingly common practice in many countries.

The Indigenization of the concept of well-being has implications for future research. In the future, it will be important that Indigenous-led research investigates local meanings of well-being in order to create more complex public health planning that incorporate Indigenous knowledge systems and cultural aspirations. Such research is respectful and beneficial to Indigenous people only when done in partnership and involving multiple stakeholders, particularly Indigenous researchers and their governing organizations.

Demystifying traditional herbal medicine with modern approach

Fu-Shuang Li 1 &
Jing-Ke Weng ORCID: orcid.org/0000-0003-3059-0075 1 , 2

Nature Plants volume 3 , Article number: 17109 ( 2017 ) Cite this article

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Plants have long been recognized for their therapeutic properties. For centuries, indigenous cultures around the world have used traditional herbal medicine to treat a myriad of maladies. By contrast, the rise of the modern pharmaceutical industry in the past century has been based on exploiting individual active compounds with precise modes of action. This surge has yielded highly effective drugs that are widely used in the clinic, including many plant natural products and analogues derived from these products, but has fallen short of delivering effective cures for complex human diseases with complicated causes, such as cancer, diabetes, autoimmune disorders and degenerative diseases. While the plant kingdom continues to serve as an important source for chemical entities supporting drug discovery, the rich traditions of herbal medicine developed by trial and error on human subjects over thousands of years contain invaluable biomedical information just waiting to be uncovered using modern scientific approaches. Here we provide an evolutionary and historical perspective on why plants are of particular significance as medicines for humans. We highlight several plant natural products that are either in the clinic or currently under active research and clinical development, with particular emphasis on their mechanisms of action. Recent efforts in developing modern multi-herb prescriptions through rigorous molecular-level investigations and standardized clinical trials are also discussed. Emerging technologies, such as genomics and synthetic biology, are enabling new ways for discovering and utilizing the medicinal properties of plants. We are entering an exciting era where the ancient wisdom distilled into the world's traditional herbal medicines can be reinterpreted and exploited through the lens of modern science.

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Li, FS., Weng, JK. Demystifying traditional herbal medicine with modern approach. Nature Plants 3 , 17109 (2017). https://doi.org/10.1038/nplants.2017.109

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DOI : https://doi.org/10.1038/nplants.2017.109

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Traditional Medicine vs. Modern Medicine

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In the modern society, traditional medicine is considered the most appropriate way to treat sick people. In other words, modern medicine should incorporate technology-based medicine and traditional practices. This would let the doctors to dispense medicine in the best possible way to satisfy each cultural group. Modern doctors and physicians tend to neglect traditional practices in favor of modern technologies.

This creates a conflict between traditional medicine and modern medicine. In this regard, effective healing is affected because patients are reluctant to disclose information to doctors that do not consider culture when asking questions. As Anne Fediman observes, the misunderstanding between patients and doctors affects service delivery in a number of ways. This clearly shows that culture plays a significant role in enhancing the healing process. It makes sense to argue that little medicine and little need facilitate healing.

In her book, Fadiman (1998) notes that Lia could have lost her life due to cultural differences between her parents and doctors. Doctors interpreted Lia’s condition differently, because they believed that she suffered from ordinary epilepsy. On the other hand, Lia’s parents believed that their daughter suffered from a traditional disease.

They based their interpretation on the Hmong culture, which was considered powerful in the community. Doctors could not embrace the ideology of the Hmong community because they believed the culture was inferior to science. On their part, Lia’s parents questioned the methodology employed by doctors when diagnosing diseases.

This misunderstanding could have been resolved in case doctors understood the cultural values of Lia’s parents. For instance, doctors could have used records from Lia’s parents to identify the medical problem. The author shows that culture helps understand the way of living of a particular community. Doctors can come up with the best ways of delivering their services if they understand cultural practices. In the modern society, western medicine is believed to be accurate, yet it is full of mistakes.

Religiously, colonialism shaped the religious practices of Americans because people were forced to abandon traditional religious beliefs in favor of modern forms of religion. For instance, people were forced to adopt Christianity and drop traditional religions. In fact, religion was used to pacify the population.

Even in the modern society, religion is still used to pacify the population. Ethnically, colonialism generated ethnocentrism whereby people would identify themselves with certain ethnic groups. This led to discrimination because groups would judge others using their cultural standards.

Fadiman, A. (1998). The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures . New York: Noonday Press.

Gurung, R. (2010). Health psychology: A cultural approach . Belmont, CA: Wadsworth Cengage Learning.

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Traditional Indigenous medicine in North America: A scoping review

Nicole redvers.

1 Department of Family & Community Medicine, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, North Dakota, United States of America

2 Arctic Indigenous Wellness Foundation, Yellowknife, Northwest Territories, Canada

Be’sha Blondin

Associated data.

All relevant data are within the manuscript and its Supporting Information files.

Despite the documented continued use of traditional healing methods, modalities and its associated practitioners by Indigenous groups across North America, it is presumed that widespread knowledge is elusive amongst most Western trained health professionals and systems. This despite that the approximately 7.5 million Indigenous peoples who currently reside in Canada and the United States (US) are most often served by Western systems of medicine. A state of the literature is currently needed in this area to provide an accessible resource tool for medical practitioners, scholars, and communities to better understand Indigenous traditional medicine in the context of current clinical care delivery and future policy making.

A systematic search of multiple databases was performed utilizing an established scoping review framework. A consequent title and abstract review of articles published on traditional Indigenous medicine in the North American context was completed.

Of the 4,277 published studies identified, 249 met the inclusion criteria divided into the following five categorical themes: General traditional medicine, integration of traditional and Western medicine systems, ceremonial practice for healing, usage of traditional medicine, and traditional healer perspectives.

Conclusions

This scoping review was an attempt to catalogue the wide array of published research in the peer-reviewed and online grey literature on traditional Indigenous medicine in North America in order to provide an accessible database for medical practitioners, scholars, and communities to better inform practice, policymaking, and research in Indigenous communities.

Introduction

The United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) was a pivotal document for the world’s Indigenous Peoples [ 1 ]. In addition to being quoted in numerous policy, research, and community initiatives since it was adopted, the declaration is now being used to evaluate the adequacy of national laws; for interpreting state obligations at the global level; and by some corporations, lending agencies, and investors in regards to resource and development opposition on Indigenous lands [ 2 ]. Article 24 of the declaration states that “Indigenous peoples have the right to their traditional medicines and to maintain their health practices, including the conservation of their vital medicinal plants, animals, and minerals” (UN document A/RES/61/295). The World Trade Organization has stated that “traditional medicine contributes significantly to the health status of many communities and is increasingly used within certain communities in developed countries. Appropriate recognition of traditional medicine is an important element of national health policy” [ 3 ].

The United Nation’s Economic and Social Council President in 2009, Sylvie Lucas, stated that “[t]he potential of traditional medicine should be fostered. … ‘We cannot ignore the potential of traditional medicine’ in the race to achieve the Millennium Development Goals and renew primary health care for those who lacked access to it … traditional medicine [is] a field in which the knowledge and know-how of developing countries was ‘enormous’—and that was a source of hope for improving the world’s health-care situation” [ 4 ].

In November 2008, member states of the World Health Organization (WHO) adopted the Beijing Declaration [ 5 ], where they recognized the role of traditional medicine in the improvement of public health and supported its integration into national health systems where appropriate [ 6 ]. The declaration also promotes improved education, research, and clinical inquiry into traditional medicine, as well as improved communication among health-care providers [ 6 ].

Research into some types of complementary and alternative medicine (CAM) practices has received large amounts of funding. For example, the US National Institute of Health has a division called the National Center for Complementary and Alternative Medicine (NCCAM), which in 2010 had a budget of US$128.8 million dollars [ 7 ]. Before the Beijing Declaration, sixty-two countries had national institutes for traditional medicine as of 2007, up from twelve in 1970 [ 4 ]. Despite this, there has been a complete lack of acknowledgement of the Indigenous traditional knowledge (TK) currently being used in many CAM professions. In some cases, there has been direct cultural appropriation of traditional medicine and practices by CAM or other biomedical groups in North America [ 8 ]. Although outdated, given the lack of scholarship in this area, a 1993 estimate put the total world sales of products derived from traditional medicines as high as US$43 billion [ 9 ]; however, only a tiny fraction of the profits were and are being returned to the Indigenous peoples and local communities from where these medicines were derived. In the early 1990s, it was estimated that “less than 0.001 per cent of profits from drugs developed from natural products and traditional knowledge accrue to the traditional people who provided technical leads for research” [ 10 ].

So, despite some progress on a global level in CAM research and practice, many Indigenous medicine systems around the world are still often given the back seat when it comes to both acknowledgement and practice within the conventional medical-care setting. The terms and attributes used for traditional medicine, such as ‘alternative’, translates into an epistemological discomfort regarding the identity of these medicines [ 11 ] that automatically sets a power differential from conventional care. In 2007, The Lancet published an article in which the authors stated, “[w]e now call on all health professionals to act in accordance with this important UN declaration of [I]ndigenous rights—in the ways in which we work as scientists with [I]ndigenous communities; in the ways in which we support [I]ndigenous peoples to protect and develop their traditional medicines and health practices; in our support and development of [I]ndigenous peoples’ rights to appropriate health services; and most importantly in listening, and in supporting [I]ndigenous peoples’ self-determination over their health, wellbeing, and development” [ 12 ].

In his 2008 dissertation, (Gus) Louis Paul Hill noted that there is a paucity of literature on Indigenous approaches to healing within Canada specifically, and little documentation and discussion of Indigenous healing methods in general [ 13 ]. With this, there is currently no formal Canadian (or US based) Indigenous health policy framework or national adopted policy on Indigenous traditional medicine [ 14 , 15 ], and no broad application and endorsement of Indigenous ways of achieving wellness markers that are self-determined in an already marginalized community (demonstrated by a lack of funding and accessibility to these services generally).

Despite this being an emerging scholarship area, with a clear lack of reflected national health policy, there is increasing evidence on the use of traditional Indigenous medicine in certain areas of need such as in substance abuse and addictions treatment [ 16 – 21 ]. When Canadian Indigenous communities were asked about the challenges currently facing their communities, 82.6% stated that the most common issue was alcohol and drug abuse [ 22 ] and that traditional medicine itself is a critically important part of Indigenous health [ 23 ], including in the support of addictions. Due to the often upstream, structural, and socio-political [ 24 ] factors driving substance abuse in addition to other health ailments in Indigenous communities, advancing co-production of treatment options such as utilizing traditional medicine that already fits into an Indigenous paradigm may ensure four key steps to wellness occur: decolonization, mobilization, transformation, and healing [ 25 ].

The present study

Despite the documented continued use of traditional healing methods, modalities, and their associated practitioners by Indigenous groups across North America, widespread knowledge of this domain is presumed elusive among most Western-trained health professionals and systems. This despite the fact that the approximately 7.5 million Indigenous peoples who currently reside in Canada and the United States (US) are most often served by Western systems of medicine. There is current exploration in the literature on how cultural competency and safety impacts health disparities across diverse populations; however, there is little attention to how traditional Indigenous medicine systems fit into this practice area. Therefore, an account of the state of the literature is currently needed in this area of traditional Indigenous medicine to provide an accessible resource tool for medical practitioners, scholars, and communities in the North American context to better understand Indigenous traditional medicine in the context of current clinical care delivery and future policy making. In addition, having baseline literature on this topic area available for use in cultural safety training, and diversity and inclusion training on or off reservations, is warranted and in need.

Considering the paucity of accessible information on traditional Indigenous medicine, in addition to the lack of cohesive understanding on what traditional healing is within the Western context, the purpose of this present study is–

to catalogue the current state of the peer-reviewed and online grey literature on traditional medicine in the North American context by identifying the types and sources of evidence available, and
to provide an evidence-informed resource guide for medical practitioners, scholars, and communities to better inform “practice, policymaking, and research [ 26 ]” in Indigenous communities.

The methodology for this scoping review was a mixed-methods approach (Western-Indigenous). The first four steps of the scoping review were conducted within a Western methodological approach as outlined by Pham et al. [ 27 ] and based on the framework outlined by Arksey and O’Malley [ 28 ] with subsequent recommendations made by Levac et al. [ 29 ] (i.e., (1) combining a broad research question with a clearly articulated scope of inquiry, (2) identifying relevant studies, (3) study selection, and (4) charting the data). For the fifth step, as outlined by Arksey and O’Malley [ 28 ], (i.e., (5) collating, summarizing, and reporting the results), we utilized a dominant Indigenous methodology that places a focus on personal research preparations with purpose, self-location, decolonization and the lens of benefiting the community [ 30 – 32 ]. Although this research process did include the Western conceptions of collating, summarizing, and reporting the results as per outlined and described by Arksey and O’Malley [ 28 ], there was a very clear intent of identifying ourselves, the authors, as being rooted within Indigenous communities, and within an Indigenous worldview. This meant that we were not able to critique or provide commentary to contradictory evidence found in the scoping review process, as it is not culturally appropriate to provide this type of analysis within the topic area of traditional medicine through an Indigenous worldview. As Saini points out, utilizing self-determined Indigenous methodologies is “critical to ensure Aboriginal research designs are not marginalized due to perceptions that they are somehow less valid or sophisticated than their counterparts” [ 33 ] at the community or systems level.

The sixth methodologic step in our scoping review, as advanced by Levac et al. [ 29 ], incorporates a consultation exercise involving key stakeholders to inform and validate study findings [ 26 ] and was done in parallel to all steps of the work. This was another mixed-method bridging step, where one Indigenous Elder who is considered a content expert in their respective community was utilized to ensure placement of the research in the Indigenous context despite the use of Western metrics for the data-collection portion of the work (as opposed to an academic or other institutional stakeholder). It must be noted that Indigenous Elders’ engagement with research is often solely for the purpose of benefiting their community [ 30 – 32 ]. This therefore creates a unique stakeholder engagement process that roots the research not to a specific Western-defined method or process but to a set of traditional Indigenous protocols (unwritten community directives defined through an Indigenous worldview) that must be followed to ensure uptake and acceptance of the work by Indigenous communities themselves. In essence, the ‘validation of study findings’ (as outlined by Levac et al. in their sixth methodologic step [ 29 ]) is not culturally malleable and needed to be changed to a process of reviewing the rules and parameters (i.e., traditional protocols) around how traditional medicine should be talked about in the context of research. The authors are both immersed in work with Indigenous communities and peoples and understands the importance of Indigenous research processes to move away from the conformity of Western notions of the scientific deductive process of new knowledge development, and instead to work towards providing space for the translational voices within Indigenous communities and peoples [ 34 ]. The review methodology was defined a priori.

Eligibility criteria, procedures, and search terms

Only articles published in peer-reviewed academic journals or easily accessible online reputable organizational documents and dissertation works that were formally published (i.e., online grey literature) were included. No limits were put on the type of research conducted, whether qualitative, quantitative, commentary, or otherwise given the specific nature of the topic and the assumed limited studies available for review. Studies were included if they made reference to traditional medicine, or if they noted specific traditional medicine interventions or practitioners (i.e., sweat lodge, traditional healers, etc.). Ethnobotanical, plant physiology, and reviews of specific Indigenous plants were excluded from this scoping review as they were most often not based on the context of traditional medicine but the function and action of the plant itself. All studies up until June 29, 2020 were included in the review.

The authors did not specify a definition for ‘traditional medicine’ before selecting studies for this review, which was purposeful. There is currently a vast array of traditional medicine modalities, practices, and people across North America who may have varying definitions or interpretations of the terms and practice. This therefore required a broad inductive and immersive approach to allow the community of researchers in this area to provide their own definitions regionally, which therefore made an impact on the breadth of articles found. All the variants of the words for traditional medicine that were used to include articles were based on existing knowledge, a pre-screen of the available literature, and consultation with an Elder (see S1 Table and ‘title and abstract relevance screening’ section).

No restrictions were put on language for the initial search; however, only English language articles were considered for inclusion. This was also due to a complete lack of peer-reviewed articles written in an Indigenous language being noted in prior work, in addition to the prospective difficulties and budget needed to attain translation support. With a multitude of Indigenous languages in North America, there is an unfortunate lack of access to translators for projects such as these. Articles that were outside of the continental US and Canada were also excluded (i.e., Pacific Islanders, etc.), in addition to those from Mexico despite the proximity of traditional lands within and to the US. This was due to differences in traditional medicine practice and agents in those areas. Books and book reviews were not included due to the difficulty in verifying their content. North American Indigenous was defined to be First Nations, Inuit, Métis, American Indian, Alaskan Native or the respective Bands and Tribes within the region. As demographic terminology changes depending on the region of the continent, it was important to ensure complete capture of the eligible literature by utilizing both Canadian and US Indigenous terminologies. A two-stage screening process was used to assess the relevance of studies identified in the search as further outlined below.

The scoping review process and search terms were developed with the aid of a medical librarian (D.O) in discussion with the lead author (N.R.). The search was created in PubMed using a combination of key terms and index headings related to North American Indigenous peoples and traditional medicine (see S1 Table ). The search was completed between December 27, 2018 and June 29, 2020 by searching the following databases with no limits on the start date, language, subject, or type: PubMed, EMBASE, PsycInfo, Elsevier’s Scopus, PROSPERO, and Dartmouth College’s Biomedical Library database due to the breadth of databases available in this library. In addition, manual searches of the following websites were completed: Indigenous Studies Portal, University of Saskatchewan [ 35 ]; National Collaborating Centre for Aboriginal Health [ 36 ]; the Aboriginal Healing Foundation’s archived website documents [ 37 ]; and the International Journal of Indigenous Health, which includes archives from the Journal of Aboriginal Health . Google Scholar was searched by inspecting the first two pages of results and then subsequently screening the next two pages if results were identified until no more relevant results had been found. The reference lists of randomly selected articles were manually searched with a “snowball” technique utilized to identify any further literature that may have been missed in the first search round until saturation of the search had been reached.

Title and abstract relevance screening

A title and abstract relevance form was developed by the author (N.R) in a session during the Elder consultation (B.B), mainly by the a priori identification of the search terms used and as listed in the S1 Table . As the goal was to capture as much available literature on the subject as possible, the title and abstract review were non-restrictive other than the stated eligibility criteria and search terms noted above. The reviewer was not masked to the article authors or journal names as this was not a results-based review. Some article titles did not have an abstract available for review and were therefore included in the subsequent full review to better characterize the content relevance to the topic area. If there was a question on the relevance of an article for inclusion, the Elder was brought into the discussion (B.B) as the final authority for the decision on whether to proceed with inclusion.

Data characterization, summary, and synthesis

After title and abstract screening, all the citations that were deemed relevant to the topic were kept in the scoping review database ( S2 Table ). All full text articles were obtained once identified as eligible; however, as the intent was not to provide critical review of the articles, they were not catalogued based on the completion of a full text article review. Instead, all articles were kept in the database from the title and abstract screening alone for the categorization process, ensuring that no judgement was placed on traditional medicine topics in keeping with an Indigenous methodological paradigm. Therefore a quality assessment procedure was not performed on the articles included in this scoping review as noted (e.g., Critical appraisal of qualitative research [ 38 ]) for a few reasons:

The purpose of this review was to map the existing state of the literature on this topic and not to analyze the results of the included articles, and
The vast array of formats and methodologies used in the Indigenous traditional medicine literature make the dominant Western metrics of validity simply not applicable to the current research purpose.

All citations found were compiled in a single Microsoft Excel 365 ProPlus spreadsheet. Coding of articles was done based on title and abstract review alone, with an Elder advisor to aid identification of categorical themes. Themes were based and developed by way of traditional knowledge (TK); however, it was noted in the synthesis process that there was often substantial overlap between themes. In these cases, a priority category was given for the ease of database creation which means that the categorical themes cannot be looked at as being black and white. Traditional Indigenous medicine is often very complex in its practice; however, an attempt was done to ease classification by assessing for the most discussed or most focused research topic(s) in each article.

Due to the substantial overlap of search terms used for traditional medicine in other disciplines (i.e., traditional medicine can be the term used from the Indigenous perspective or from the Western perspective), the initial search yielded thousands of articles.

Based on a review of the title and abstracts, 249 articles met the criteria for inclusion (see S2 Table for the full database of articles included). A full article review was conducted when the initial screen left questions about the relevance of the research for inclusion. Broad inclusion was purposeful, as by ensuring a wide capture of the literature was categorized, future research and program needs have a more complete database to pull information from. Articles ranged in date from the earliest year of publication, being in 1888, to the most recent publication, being in 2020 ( Fig 1 ). Sixty two percent of the articles were published prior to 2009 (n = 154) with the average year of publication being 2001.

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There were five overlapping categorical themes that emerged in the review including: General traditional medicine, integration of traditional and Western medicine systems, ceremonial practice for healing, usage of traditional medicine, and traditional healer perspectives. Fig 2 summarizes the selection process and findings.

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General traditional medicine

There were 126 articles identified for this category with the majority of the publications being from 2009 and earlier (75%, n = 95). Thirty-three of the articles were based in Canada, one was based in both Canada and the US, and the remaining ninety-two were based in the US alone. The publication dates for articles spanned a wide time period between 1888 and 2020 (average year of publication was 1997), with the majority being commentary or qualitative in nature.

In the review of this category, it became clearly evident that the terms or conceptualizations applied to traditional medicine or its variants (i.e., traditional healing, Native American healing, etc.) were very generalized. Specifically, the general research topics ranged from trying to answer the question of what is traditional medicine [ 13 , 39 – 41 ], to asking questions on the efficacy and acceptance of traditional medicine [ 42 – 44 ], to the applicability of traditional medicine with specific disease states [ 45 – 47 ], in addition to stories of healing by recipients of traditional medicine practice or approaches [ 48 , 49 ].

According to Alvord and Van Pelt, traditional medicine is described in the Navajo culture as a medicine that is performed by a hataalii , which is someone who sees a person not simply as a body, but as a whole being with body, mind, and spirit seen to be connected to other people, to families, to communities, and even to the planet and universe [ 50 ]. In helping to clarify the intent and purpose for utilizing a traditional Indigenous medicine approach, Hill describes it as “the journey toward self-awareness, self-knowledge, spiritual attunement and oneness with Creation” and “the lifelong process of understanding one’s gifts from the Creator and the embodiment of life’s teaching that [an] individual has received” [ 13 ]. The traditional medicine practitioner’s role in the healing process has been described as their being an instrument, a helper, the worker, the preparer, the doer in the healing process with the work using the “medicines” being slow, careful, respectful, and embodying a sense of humility [ 51 ].

Also of note in this section of articles, was the subtle distinction between the terms ‘traditional healing’ compared to the actual using of ‘traditional medicines’. The core of ‘traditional healing’ was said to be or attaining spiritual ‘connectedness’, in which there were many stated ways for developing this in order to have a strong physical body and mind [ 52 ]. In essence, this ‘connectedness’ could be with or without the actual use of what we would call a ‘medicine’ in Western terms achieved instead through being in harmony with the natural environment, through fasting, prayer, or meditation, or through the use of actual ‘traditional medicines’ that could include plant- and herb-based medicines [ 52 ].

Quantitative data analysis within the general traditional medicine category of articles was rarely performed. When quantitative analysis was performed, it was usually done in a mixed method format that utilized survey tools alongside qualitative approaches (e.g., interviews, focus groups) [ 53 – 55 ]. For example, a mixed methods study by Mainguy et al., found that the level of spiritual transformation achieved through interaction with traditional healers was associated with a subsequent improvement in medical illness in 134 of 155 people ( P < .0001), and that this association exhibited a dose-response relationship [ 55 ]. In another mixed-methods study by Marsh et al., a 13-week intervention with “Indigenous Healing and Seeking Safety” in 17 participants demonstrated improvement in trauma symptoms, as measured by the TSC-40, with a mean decrease of 23.9 (SD = 6.4, p = 0.001) points, representing a 55% improvement from baseline [ 53 ]. Furthermore, in this study all six TSC-40 subscales demonstrated a significant decrease (i.e., anxiety, depression, sexual abuse trauma index, sleep disturbance, dissociation, and sexual problems) [ 53 ].

It was clear from the review of articles in this category that a large number of the articles were written from an observational or commentary perspective by non-Indigenous scholars (e.g., anthropologic perspectives) [ 42 , 56 ]. Those written more than twenty years ago often had titles or content that would not be considered culturally appropriate in today’s scholarly work. For example, an article by Walter Vanast from 1992 was titled, “‘Ignorant of any Rational Method’: European Assessments of Indigenous Healing Practices in the North American Arctic” [ 57 ]. Considerations for the issue of quality and accuracy in this body of literature will be addressed in the discussion section of this paper.

Integration of traditional and Western medicine systems

A total of 61 articles in this category were reviewed, with publication dates ranging from the year 1974 to the year 2019 (average year of publication was 2006). Sixteen percent (n = 10) of these articles were from nursing journals, and 39% (n = 24) were articles from mental health and/or substance abuse journals. Of the total number of articles in this section, 61% (n = 37) were based in the US, with the remaining being from Canada (n = 24).

Articles in this category fell into overlapping subsets within the overarching theme of the integration of traditional Indigenous medicine systems with Western medicine systems. There were articles specifically calling for physicians and other healthcare providers to better collaborate with traditional healers [ 58 , 59 ], and also calls for health “systems” to better coordinate and work with Indigenous medicine systems and associated practitioners [ 60 – 62 ]. Some of the articles focused on cultural accommodations, and awareness and attitudes in medical settings towards traditional medicine and healers [ 63 – 65 ]. Lastly, a number of articles reviewed existing medical environments, practitioners, and facilities that had either piloted or fully integrated traditional and Western medical care under the same roof or practice [ 24 , 66 – 69 ].

The integration of traditional medicine into existing medical education environments was showcased through a residency training program as described by Kessler et al. [ 70 ]. In 2011, the University of New Mexico Public Health department and their General Preventive Medicine Residency Program in the United States started to integrate traditional healing into the resident training curriculum with full implementation completed by 2015. An innovative approach was used in the teaching delivery by utilizing a compendium of training methods, which included learning directly from traditional healers and direct participation in healing practices by residents [ 70 ]. The “incorporation of this residency curriculum resulted in a means to produce physicians well trained in approaching patient care and population health with knowledge of culturally based health practices in order to facilitate healthy patients and communities” [ 70 ].

Other articles in this section described the role of nurses in advocating for Indigenous healing programs and treatment. In research by Hunter et al., healing holistically can be said to match the time-honored values seen in the nursing profession: caring, sharing, and empowering clients [ 71 ]. Participant observations demonstrated that health centers could support progression along a cultural path by providing traditional healing with transcultural nurses acting as lobbyists for culturally sensitive health programs directed by Indigenous peoples [ 71 ]. This need for advocacy and awareness building on traditional ways of healing were emphasized throughout this category of articles.

According to Joseph Gone, “Lakota doctoring [traditional healing] remains highly relevant for wellness interventions and healthcare services even though it is not amenable in principle to scientific evaluation” [ 72 ]. In reference to Indigenous healing practices in general, Gone states that in Indigenous settings “we already know what works in our communities” and this claim seems “to reflect the vaunted authority of personal experience within Indigenous knowledge systems [ 72 ].

Some scholars noted the potential harms of not moving towards a respectful dialogue between the two systems of medicine (i.e., Western and Indigenous). A noted article by David Baines, an Indigenous physician from the Tlingit/Tsimshian tribe in Southeast Alaska, describes one of his patients who had metastatic lung cancer [ 73 ]. The patient had an oncologist but also went to a traditional healer to help deal with the pain she was having [ 73 ]. When the patient told the oncologist she was seeing a traditional healer, the oncologist got angry and wanted to know why she wanted to see a “witch doctor” [ 73 ]. The patient was offended and angry and refused to go back to the oncologist. She ended up dying a very painful death. Dr. Baines noted that it is important to remember we have the same goal—a healthy patient [ 73 ].

Ceremonial practice for healing

Thirty articles were identified for this category. Important sub-categories became apparent in the review, including sweat lodge ceremonies (n = 15), traditional tobacco ceremonies and use (n = 6), birth and birthplace as a ceremony (n = 2), puberty ceremonies (n = 4), and using ceremony as a model for healing from a relative’s death or from trauma (n = 3). There were only eight Canadian studies published in this category, with the majority being based in the US (n = 22).

Sweat lodge ceremonies (SLC) have been practiced by many Indigenous nations since ancient times. SLCs are used as a process of honoring transformation and healing that is central to many Indigenous traditionalisms [ 74 ]. Gossage et al. examined the role of SLCs in the treatment for alcohol use disorder in incarcerated people [ 75 ]. The Dine Center for Substance Abuse Treatment staff utilized SLCs as a specific modality for jail-based treatment and analyzed its effect on a number of parameters. Experiential data was collected from 123 inmates after SLCs with several cultural variables showing improvement [ 75 ]. Gossage et al. also reported results from a similar prior study that analysed data for 100 inmates who participated in SLCs [ 75 ]. The research found that incarceration recidivism rates for those SLC participants was only 7% compared with an estimated 30–40% for other inmates who did not participate in such ceremonies [ 75 ]. Another study by Marsh et al., gathered qualitative evidence about the impact of the SLC on participants in a trauma and substance-abuse program and reported an increase in spiritual and emotional well-being that participants said was directly attributable to the ceremony [ 76 ].

Much of the existing literature on ceremonial tobacco focuses on either the perception of usage or the usage in general by Indigenous peoples in the region examined. In research done by Struthers and Hodge, six Ojibwe traditional healers and spiritual leaders described the sacred use of tobacco [ 77 ]. Interviews with these traditional healers confirmed that “sacred tobacco continues to play a paramount role in the community and provides a foundation for the American Indian Anishinabe or Ojibwe culture. They reiterated that using tobacco in the sacred way is vital for the Anishinabe culture [as] tobacco holds everything together and completes the circle. If tobacco is not used in a sacred manner, the circle is broken and a disconnect occurs in relation to the culture” [ 77 ].

The exploration of ceremonies surrounding birth and the relationship that is created through birth practices were outlined in a few studies reviewed for this category [ 78 , 79 ]. Ceremony was referred to in this context as the practice of what can be considered “rituals of healing”, noting that pregnancy itself “is carrying sacred water” [ 78 ]. As Rachel Olson points out, “[b]ringing people “back” to practicing ceremonial ways is seen as a healing process from the trauma encountered by First Nations peoples in Canada, as well as a way to both maintain our connection to the land and water, and to keep that same land and water safe for future generations. The implication in this is that by restoring our connection to the land through ceremony, other structural issues will again come into balance” [ 78 ].

Usage of traditional medicine

Data collection was completed in reservation and urban Indigenous communities to determine the usage rates of traditional medicine by Indigenous peoples. There was a total of 14 articles published on this topic, which included over 650 participants combined who completed surveys or interviews. Five studies were completed in Canada, and the remaining were completed in the United States (n = 9). Seventy-nine percent of the studies were published prior to 2009 (n = 11). The average year of publication was 2002 with publication dates ranging from 1988 to 2017. Rates of usage of both traditional medicines and traditional healers varied per region. Relevant findings are summarized in Table 1 .

Author	Year	Location	N	Key Findings
Garro [ ]	1988	Ojibwe community, Manitoba	35	Four informants stated they did not use traditional medicine while the majority reported successful treatments with most reporting at least three episodes of traditional medicine treatment.
Waldram [ ]	1990	Saskatoon, Saskatchewan	226	19% had a past consultation with a traditional healer. 27% had used herbal medicines or sweetgrass with the majority being within the last three months. 100% of those that had a past consultation with a traditional healer had an Indigenous language as their first language.
Garro [ ]	1991	Anishinaabe reserve community, Manitoba	468	17% of cases involved visits to medicine men to request a diagnosis. Visits to an Anishinaabe healer occurred in 21% of the cases. 7% of visits to medicine men took place without consulting physicians, either prior to or after the visit to the medicine man. Of the 61 households visited, 62% reported visits to medicine men during the case collection period. In all but a few cases, treatment by medicine men was viewed positively by the reporting households for the specific illness condition in question.
Marbella et al. [ ]	1998	Urban Indian Health Service clinic in Milwaukee, Wisc.	150	38% of the patients see a healer, and of those who do not, 86% would consider seeing one in the future. Sweat lodge ceremonies, spiritual healing, and herbal remedies were the most common treatments. More than a third of the patients seeing healers received different advice from their physicians and healers. The patients rate their healer’s advice higher than their physician’s advice 61.4% of the time. Only 14.8% of the patients seeing healers tell their physician about their use.
Kim et al. [ ]	1998	Navajo Reservation-Indian Health Service Hospital	300	62% of Navajo patients had used Native healers and 39% used Native healers on a regular basis.
Wyrostok et al. [ ]	2000	Canadian First Nation Students	99	Over 80% of respondents affirmed there interest in learning more about Native healing. Participants strongly supported traditional healing practices as something that should not be forgotten. 80.8% of participants reported at least some previous experiences with specific traditional healing practices.
Buchwald et al. [ ]	2000	Urban primary care program, The Seattle Indian Health Board	869	70% of urban American Indian/Alaskan Native patients in primary care often used traditional health practices and use was strongly associated with cultural affiliation.
Gurley et al. [ ]	2001	Vietnam veterans in the reservation communities of the Southwest and Northern Plains	621	17.1% of the Southwest reservation respondents and 4.7% of the Northern Plains reservation respondents saw a traditional healer for a physical health problem. 18.5% of the Southwest reservation respondents and 5.0% of the Northern Plains reservation respondents saw a traditional healer for a mental health problem.
Van Sickle et al. [ ]	2003	Navajo families with asthmatic members	35	46% of families had previously used traditional healing; however, only 29% sought traditional healing for asthma.
Novins et al. [ ]	2004	Enrolled members of a Northern Plains or a Southwest tribe	2595	Traditional healing provided a greater proportion of care for psychiatric (63.8% in the Southwest, 36.1% in the Northern Plains) than for physical health problems (44.6% and 13.9%). Compared with their counterparts in the Northern Plains, service users from the Southwest were more likely to use traditional healing only (22.0% vs. 3.5%) for physical health problems.
Cook [ ]	2005	Mi'kmaq First Nation community health clinic	100	66% of respondents had used Mi’kmaq medicine, and 92.4% of these respondents had not discussed this with their physician. Of those who had used Mi’kmaq medicine, 24.3% use it as first-line treatment when they are ill, and 31.8% believe that Mi’kmaq medicine is better overall than Western. Even among patients who have not used Mi’kmaq medicine, 5.9% believe that it is more effective than Western medicine in treating illness.
Moghaddam et al. [ ]	2013	Urban Indian health and community center (AIHFS), Detroit	389	Analyses indicated that experiences of discrimination in healthcare settings were significantly associated with participation in traditional healing. Nearly half of the Detroit sample (48%, n = 185) had used traditional services.
Greensky et al. [ ]	2014	Fond du Lac Band Reservation	21	66% of participants described using traditional practices for healing and pain relief; 90% of individuals interviewed endorsed inclusion of traditional health practices into their medical care.
George et al. [ ]	2017	Two First Nations communities in Ontario	613	About 15% of participants used both traditional medicines and healers, 15% used traditional medicines only, 3% used a traditional healer only, and 63% did not use either. Of those who did not use traditional healing practices, 51% reported that they would like to use them. Common reasons for not using traditional practices were not knowing enough about them, and not knowing how to access or where to access them.

Overall, the perception of traditional medicine amongst Indigenous people were positive. Several studies noted that access was an issue for many respondents who had the stated desire to use traditional medicine or see a traditional healer but did not know where to go for this support or treatment.

Traditional healer perspectives

The viewpoints of traditional healers themselves are an important contribution to this research topic. There were 18 studies that elicited the perspectives from Elders and traditional healers ranging in dates of publication between 1993 and 2019 (average year of publication was 2011). Twelve studies were either fully or partially based in the US, with nine articles published in either nursing or mental health related journals.

Moorehead et al. describe discussions held with a group of traditional healers on the possibilities and challenges of collaboration between Indigenous and conventional biomedical therapeutic approaches [ 93 ]. The participants recommended the implementation of cultural programming, the observance of mutuality and respect, the importance of clear and honest communication, and the need for awareness of cultural differences as a unique challenge that must be collaboratively overcome for collaboration [ 93 ].

It is not culturally acceptable to alter the words or provide an interpretation of the words of traditional healers. The following are some notable excerpts from traditional healer interviews that occurred in the literature reviewed:

The doctors and nurses at a local hospital asked me to speak to them on natural medicines . So I did . You could tell the doctors have a hard time trying to understand traditional healing and the use of plants to heal…it is hard for them to understand . Some of them got up and left when I started to talk about how you have to develop a relationship with the plant world…They sometimes have a hard time if things are not done their way…I respect the medicine , I just wish Western medical persons would understand [ 94 ] … When we gather medicine…the plant has a spirit in it…and…the spirit of those plants stays in the medicine…Every individual is different…every remedy is different…because specific things work for specific people…We’re made up of four parts…physical , mental , emotional , and spiritual . Sometimes sickness can be caused by imbalance within a person . When we do Indian healing…it goes to the source of the problem…not to the symptoms [ 94 ]. It’s a very powerful gift that we’ve been given…I am not a healer…I am only an instrument in that whole process . I am the helper and the worker , the preparer , and the doer . The healing ultimately comes from the Creator…With the lighting of that smudge , holding that eagle feather while we pray…these sacred medicines , these sacred pipes , and everything that we carry in our bundles . That’s where the strength comes from…from those medicines , from Mother Earth , and from the Creator … You are a part of creation , you’re a part of everything…there is this interrelatedness of all things , of all creation , and everything has life…we’re a whole family . And we’re related to all living things and all beings and all people [ 95 ]. I’ve been saying it for years . We need more medicine people . We need more Native healers…male and female [ 96 ].

It was apparent throughout the articles reviewed for this category that many traditional healers were not opposed to Western medicine; however, many had voiced concerns that Western medicine seemed to not respect them (i.e., didn’t respect their way of thinking or disregarded their knowledge base). Overall, a deep understanding and appreciation for the long-standing colonial injury felt in many Indigenous communities demonstrated through the cumulative effects of trauma ‘snowballing’ across generations [ 94 ] has become a platform for much of the traditional healers’ work in their home communities. To work with these present and historical harms, there was a clear advocacy among many of the traditional healers interviewed for ensuring the availability of therapeutic talk within cultural settings in addition to ceremonial participation to help facilitate healing and the revival of traditional spiritual beliefs [ 97 ].

This scoping review identified 249 articles that were predominately qualitative in nature, pertaining to traditional Indigenous medicine in the North American context. Although there was broad coverage of the topic area, it became apparent that many of the published articles were written from an ‘outsider’ perspective (i.e., observational research by scholars outside of the Indigenous communities themselves). With this, there was a slight shift noted in the type of research that was completed on traditional medicine around the 2000s. Prior to this date, it became apparent by the writing style used by many authors (i.e., they, them, etc.) that the articles were very much written “about” Indigenous people and their traditional medicine practice(s). Although post-2000 there was still quite a large volume of articles written by non-Indigenous scholars, there was an increasing presence of articles authored or co-authored by Indigenous people themselves [ 13 , 60 , 68 , 72 , 76 ]. The significance in this regard is notable as the presentation of Indigenous medicine by outside researchers often misses key cultural nuances, sometimes uses inappropriate or even insulting terminology, has a tendency to make assumptions that are not always correct (implicit bias), and presents an application or integrationist perspective that comes from what is often perceived to be a dominant Western knowledge system. As this type of ‘outsider’ scholarship serves as the foundational academic and clinical knowledge base for many of the current assumptions around traditional medicine, it was important to catalogue where some of the noted bias comes from.

Although it can be culturally inappropriate to assume there are pan-Indigenous ways of looking at traditional medicine and its practice (due to often stark differences in the practice of traditional medicine regionally), similar sentiments were expressed throughout many of the published articles. One was the assumed dominance of conventional medicine over traditional medicine practice, presented sometimes unconsciously through Western providers’ or researchers’ accounts of the subject and the language used. One possible consideration in this respect is that Indigenous-based interventions were often defined by a Western methodological approach and governance structure, which could be said to constrain and change the descriptions or programs themselves into something they were not actually meant to be. One solution to this issue would be to utilize an Indigenous methodological approach, governance structure, and reporting approach for these interventions, and then adapt the Western system to this approach and structure instead [ 58 ]. This would better ensure the centering of an Indigenous worldview and knowledge system through a truly self-determined Indigenous model with a potentially higher degree of success.

There is often a misperception that Indigenous peoples are in need of Westernized science in order to ‘legitimize’ our knowledge and healing systems [ 98 ]. It was clear from the literature reviewed on traditional healer perspectives that there was great opportunity for Western medicine and providers to learn about other ways of looking at health and disease in a form of respectful cooperation with Elders and Indigenous communities. This is consistent with the work of Berbman in 1973 who tells a story about a psychiatrist who brought some Navajo medicine men into his practice to demonstrate some of the things that he does in his practice [ 99 ] (i.e., the psychiatrist’s intent was to teach the medicine men). The psychiatrist demonstrated putting a Navajo woman under hypnosis for the medicine men.

One of the medicine men stated, “I’m not surprised to see something like this happen because we do things like this, but I am surprised that a white man should know anything so worthwhile… they [then] asked that my subject … diagnose something [while under hypnosis]. I objected, saying that neither she nor I knew how to do this and that it was too serious a matter to play with. They insisted that we try, however, and finally we decided that a weather prediction was not too dangerous to attempt. …When my subject was in a deep trance, I instructed her to visualize the weather for the next six months. She predicted light rain within the week, followed by a dry spell of several months and finally by a good rainy season in late summer. I make no claim other than the truthful reporting of facts: She was precisely correct” [ 99 ].

It was also evident through the articles reviewed that many Indigenous peoples using traditional medicine do not disclose this use to their Western healthcare providers. This reflects on the importance of developing culturally safe health systems and healthcare providers with strong communication skills for diverse patient settings. The story told by David Baines about the oncologist calling the patient’s traditional healer a “witch doctor” was a clear example of a lack of respect for utilizing a shared decision-making methodology for best outcomes in a clinical setting [ 73 ]. Implicit as well as overt bias against medical pluralism in diverse settings needs to be acknowledged and addressed in often authoritarian institutional settings [ 100 , 101 ] for best patient outcomes.

Overall, there has been a recent push with somewhat more acceptance in certain conventional medical settings towards supporting traditional Indigenous medicine interventions as demonstrated in some of the literature in this scoping review; however, the question remains whether or not “these efforts tend to represent political achievements more so than bona fide epistemological reconciliation” [ 72 ]. With continuing and significant health disparities existing in Indigenous populations in North America [ 102 ], a broader concerted effort needs to be mobilized and operationalized to ensure that Indigenous self-determined ways of knowing in relation to health and delivery of care is prioritized. Initial outcomes are promising in regard to traditional medicine’s benefit for Indigenous peoples in self-determined healthcare environments and settings. This has been clearly demonstrated by some of the literature reviewed here, yet, without more formalized support from all levels of the healthcare system, it will be difficult to expand these benefits and health outcomes to all Indigenous peoples who desire this type of care. This review and database ( S2 Table ) will hopefully serve as a repository for a portion of the academic literature contributing to practice, policy making, and research on this topic. This effort is aligned with Article 24 of the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP):

Indigenous peoples have the right to their traditional medicines and to maintain their health practices, including the conservation of their vital medicinal plants, animals, and minerals [ 1 ].

Limitations

This scoping review was an attempt to catalogue the literature in the area of traditional Indigenous medicine in the North American context. The use of defined categories may give the impression of distinct traditional medicine themes unrelated to each other; however, due to the wholistic nature of traditional medicine, there will always be substantial overlap between concepts given the interconnected nature of all aspects of Indigenous healing practices. Categorical themes were used to help create some organization of the large body of literature aiding with delineating future research needs as well as for the ease of pulling for programmatic and policy needs.

It is possible, due to the substantial overlapping terminology with other fields, that some articles may have been missed in the search strategy. With this, an effective search strategy in this field would require the searcher to be familiar with how Indigenous medicine terminology is commonly used and applied in academia to be able to correctly select and screen articles from a very large databases of mixed disciplines. Traditional medicine terminology can be complex and can be referenced using other languages or simply geographic location. Due to this, any published articles that used unique ways of referencing traditional medicine or were described using an Indigenous language term could have caused additional articles to be missed; however, due to saturation being reached in the methods review, we feel the literature was well represented in our database. Regardless, this comprehensive database ( S2 Table ) of the available literature should not be considered exhaustive of all available material on this topic.

From an Indigenous worldview, culture and cultural practices can be looked at and examined as being a form of medicine. Even traditional language can be considered a form of cultural medicine [ 103 ]. This review excluded studies to this effect due to the variation in interpretations that are possible in this area; however, this exclusion was not intended to degrade or minimize the importance of culture as a healing strategy in any way. Due to the need to capture one defined area of this topic on traditional medicine and healing as a first step, further research can now build upon this work by evolving the scholarship area to be inclusive of all facets of Indigenous healing.

Traditionally within Indigenous communities, knowledge on traditional healing or the medicines themselves was and is passed down through a strong oral tradition that often involves deep ceremonial practice. As knowledge transmission in the North American context most often does not include a written record, historical and present-day information on community practice in this area is rightfully held within Indigenous communities themselves. This form of knowledge needs to be recognized, honored, and respected in the context of the traditional protocols that the respective community follows under the guidance of their Elders. This knowledge is the true knowledge that is most often not reflected in written academic scholarship. Some Indigenous communities have become more engaged with research as you will have seen throughout this review; however, some choose not to engage in this form of knowledge transmission for a variety of important reasons. This review, although detailed, is therefore only a small snapshot of the vast knowledge that exists within Indigenous communities in North America.

A critical review of the retained full text articles was not completed as the intent was to provide a representative and complete database on this topic. In addition, the vast array of formats and methodologies used in the Indigenous traditional medicine literature make the dominant Western metrics of validity simply not applicable to the current research purpose. Because it is not culturally acceptable to critique traditional Indigenous medicine, an Indigenous methodology was honored. Using an inclusive framework for this topic, several articles that were not written by Indigenous peoples or communities were included, which in some cases portrayed gross stereotypes from ‘outside’ observations of traditional medicine practice(s). The reader is therefore advised to exercise caution when utilizing information from ‘outside’ observational and older studies that may not be reflective of actual and current Indigenous community perspectives on the topic discussed. To this end, we highly recommend prioritizing the respectful engagement of Indigenous scholars and/or their scholarship, community members, and local knowledge holders to better ensure the concepts and resources presented here will be grounded and relevant within any local or cultural context.

This scoping review identified 249 articles pertaining to traditional Indigenous medicine in the North American context with the following categorical themes being identified: General Traditional Medicine, Integration of Traditional and Western Medicine Systems, Ceremonial Practice for Healing, Usage of Traditional Medicine, and Traditional Healer Perspectives.

Although effort has been made to better accommodate Indigenous ways of knowing and healing into healthcare settings and delivery models, self-determined options for traditional Indigenous healing are still lacking in Western institutions. This scoping review underscores the crucial need to further examine the dynamics of healthcare relations in a post-colonial context, with more open spaces for dialogue surrounding the use of Indigenous traditional healing often desired in racially diverse medical settings. The prerequisite to move closer to transformative practice in this area involves prioritizing further research and communication on this topic with a focus on applied self-determined interventions and programming.

Supporting information

S1 checklist, acknowledgments.

A very heartfelt thank you to all of the Indigenous Elders and communities who have shared their stories and perspectives throughout this body of literature. Special thanks to Margo Greenwood, PhD, at the National Collaborating Center for Indigenous Health (NCCIH) for her helpful guidance on this project in addition to Daisy Goodman, CNM, DNP, MPH, for her ongoing support and helpful recommendations with the writing process. Thank you also to Devon Olson of Library Sciences at the University of North Dakota for aid in the search term development process.

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The author(s) received no specific funding for this work.

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Traditional Medicine

To the Editor:

“ How to Talk to Your Child’s Doctor About Alternative Medicine ” (Here to Help, March 7) raises important issues but does so in a culturally insensitive manner that undermines the legitimacy of traditional medicine in modern life.

The writers, all doctors, encourage caution in the use of pseudoscientific treatments, and in doing so, don’t acknowledge the role of traditional healers in the cultural life of many Americans.

Traditional healing practices, like Ayurveda, Chinese medicine and Native American medicine, have existed for millenniums and provide health benefits. By suggesting caution in the case of “alternative” treatments used largely by affluent white Americans, and ignoring traditional healing, the article underscores a larger issue in Western medicine: doctors’ lack of cultural competence concerning indigenous and minority populations.

If Western medicine refuses to acknowledge the legitimacy of indigenous knowledge, then how can these populations learn to trust their health professionals?

GREG BLOCKI, BROOKLINE, MASS.

The writer is a doctoral student in occupational therapy at Boston University.

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Biobots arise from the cells of dead organisms − pushing the boundaries of life, death and medicine

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Life and death are traditionally viewed as opposites. But the emergence of new multicellular life-forms from the cells of a dead organism introduces a “ third state ” that lies beyond the traditional boundaries of life and death.

Usually, scientists consider death to be the irreversible halt of functioning of an organism as a whole. However, practices such as organ donation highlight how organs, tissues and cells can continue to function even after an organism’s demise. This resilience raises the question: What mechanisms allow certain cells to keep working after an organism has died?

We are researchers who investigate what happens within organisms after they die . In our recently published review , we describe how certain cells – when provided with nutrients, oxygen, bioelectricity or biochemical cues – have the capacity to transform into multicellular organisms with new functions after death.

Life, death and emergence of something new

The third state challenges how scientists typically understand cell behavior. While caterpillars metamorphosing into butterflies, or tadpoles evolving into frogs, may be familiar developmental transformations, there are few instances where organisms change in ways that are not predetermined. Tumors, organoids and cell lines that can indefinitely divide in a petri dish, like HeLa cells , are not considered part of the third state because they do not develop new functions.

However, researchers found that skin cells extracted from deceased frog embryos were able to adapt to the new conditions of a petri dish in a lab, spontaneously reorganizing into multicellular organisms called xenobots . These organisms exhibited behaviors that extend far beyond their original biological roles. Specifically, these xenobots use their cilia – small, hair-like structures – to navigate and move through their surroundings, whereas in a living frog embryo, cilia are typically used to move mucus.

Xenobots are also able to perform kinematic self-replication , meaning they can physically replicate their structure and function without growing. This differs from more common replication processes that involve growth within or on the organism’s body.

Researchers have also found that solitary human lung cells can self-assemble into miniature multicellular organisms that can move around. These anthrobots behave and are structured in new ways. They are not only able to navigate their surroundings but also repair both themselves and injured neuron cells placed nearby.

Taken together, these findings demonstrate the inherent plasticity of cellular systems and challenge the idea that cells and organisms can evolve only in predetermined ways. The third state suggests that organismal death may play a significant role in how life transforms over time.

Microscopy images of a black blob fusing together two groundglass walls in three panels, and a green web plugging a gap in a web of pink

Postmortem conditions

Several factors influence whether certain cells and tissues can survive and function after an organism dies. These include environmental conditions, metabolic activity and preservation techniques.

Different cell types have varying survival times. For example, in humans, white blood cells die between 60 and 86 hours after organismal death. In mice, skeletal muscle cells can be regrown after 14 days postmortem, while fibroblast cells from sheep and goats can be cultured up to a month or so postmortem.

Metabolic activity plays an important role in whether cells can continue to survive and function. Active cells that require a continuous and substantial supply of energy to maintain their function are more difficult to culture than cells with lower energy requirements. Preservation techniques such as cryopreservation can allow tissue samples such as bone marrow to function similarly to that of living donor sources.

Inherent survival mechanisms also play a key role in whether cells and tissues live on. For example, researchers have observed a significant increase in the activity of stress-related genes and immune-related genes after organismal death, likely to compensate for the loss of homeostasis . Moreover, factors such as trauma , infection and the time elapsed since death significantly affect tissue and cell viability.

Microscopy image of developing white and red blood cells

Factors such as age, health, sex and type of species further shape the postmortem landscape. This is seen in the challenge of culturing and transplanting metabolically active islet cells , which produce insulin in the pancreas, from donors to recipients. Researchers believe that autoimmune processes, high energy costs and the degradation of protective mechanisms could be the reason behind many islet transplant failures.

How the interplay of these variables allows certain cells to continue functioning after an organism dies remains unclear. One hypothesis is that specialized channels and pumps embedded in the outer membranes of cells serve as intricate electrical circuits . These channels and pumps generate electrical signals that allow cells to communicate with each other and execute specific functions such as growth and movement, shaping the structure of the organism they form.

The extent to which different types of cells can undergo transformation after death is also uncertain. Previous research has found that specific genes involved in stress, immunity and epigenetic regulation are activated after death in mice, zebrafish and people , suggesting widespread potential for transformation among diverse cell types.

Implications for biology and medicine

The third state not only offers new insights into the adaptability of cells. It also offers prospects for new treatments.

For example, anthrobots could be sourced from an individual’s living tissue to deliver drugs without triggering an unwanted immune response. Engineered anthrobots injected into the body could potentially dissolve arterial plaque in atherosclerosis patients and remove excess mucus in cystic fibrosis patients.

Importantly, these multicellular organisms have a finite life span, naturally degrading after four to six weeks . This “kill switch” prevents the growth of potentially invasive cells.

A better understanding of how some cells continue to function and metamorphose into multicellular entities some time after an organism’s demise holds promise for advancing personalized and preventive medicine.

Bioengineering
Synthetic biology
Regeneration
Cell biology
Self-assembly

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Analytical Methods

A synchronous-fluorescence analysis method combing with simple one-step extraction for determination of leonurine in traditional chinese medicine †.

* Corresponding authors

a College of Chemistry and Chemical Engineering, Shanghai University of Engineering Science, Shanghai, 201620, China E-mail: [email protected] , [email protected]

b Shanghai Key Laboratory of Plant Functional Genomics and Resources, Shanghai Chenshan Botanical Garden, Shanghai 201602, China E-mail: [email protected] , [email protected]

Synchronous fluorescence spectroscopy (SFS) technology exhibits significant advantages in identifying target fluorescence signals within complex mixtures of multiple fluorescent compounds, owing to their closely overlapping spectra. In this study, a SFS method is reported for the first time for the direct analysis of leonurine in drugs containing concurrent natural products. By setting the wavelength interval (Δ λ ) to 30 nm, the characteristic emission peak of leonurine is observed at 307 nm, which increases proportionally with the concentration of leonurine without spectral overlap from other fluorescent species. The limit of detection (LOD) is estimated to be about 0.22 μM, and a low linear range of 0 to 20 μM is obtained. The common cations, anions and concomitant compounds display no interference with the SFS signal of leonurine, supporting the practical application of this method. Thus, we successfully applied this SFS method to detect leonurine in several real samples (leonurus granules, capsules, ointment and pills), in which the good relative standard deviation (RSD) values (0.04–4.24%) and recoveries (95.63–113%) were obtained. As a result, this work provides an efficient and convenient method to identify the target active compound from natural products without complex pre-treatment to diminish the fluorescent chaos that might be serving a potential role in the study of traditional Chinese medicine.

Graphical abstract: A synchronous-fluorescence analysis method combing with simple one-step extraction for determination of leonurine in traditional Chinese medicine

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A synchronous-fluorescence analysis method combing with simple one-step extraction for determination of leonurine in traditional Chinese medicine

W. Sun, L. Wang, X. Zhang, M. Liu, P. Liu, P. Xu and Y. Qu, Anal. Methods , 2024, Advance Article , DOI: 10.1039/D4AY01233J

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Article contents

Introduction

Public Health Status of Indigenous People

Global Incidence of Indigenous Suicide Rates

The Social Determinants of Indigenous Health

Indigenous Health Workforce Professionalization

Incorporating Traditional Medicine in Indigenous Health Interventions

Integrating Indigenous Knowledge With Modern Healthcare Practices: Country Studies

North America

United States

South America

The Matses Traditional Medicine Encyclopedia

Makere University and PROMETRA Uganda: Partnership for the Scientific Investigation of Important Traditional Medicines

The Department of Traditional Medicine

The Institute of Applied Dermatology, Kerala

Pacific Region

Palau, Micronesia

Papua New Guinea

Aotearoa New Zealand

The Impact of Traditional Medicine in Addressing the Social Determinants of Indigenous Health

The Internet, Social Media, and Mobile Phones in Indigenous Health

Ethics of Conducting Research With Indigenous People

Further Reading

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Traditional Medicine vs. Modern Medicine

Traditional Indigenous medicine in North America: A scoping review

Be’sha Blondin

Conclusions

Introduction

The present study

Eligibility criteria, procedures, and search terms

Title and abstract relevance screening

Data characterization, summary, and synthesis

General traditional medicine

Integration of traditional and Western medicine systems

Ceremonial practice for healing

Usage of traditional medicine

Traditional healer perspectives

Limitations

Supporting information

Funding Statement

Data Availability

Traditional Medicine

Biobots arise from the cells of dead organisms − pushing the boundaries of life, death and medicine

Disclosure statement

Life, death and emergence of something new

Postmortem conditions

Implications for biology and medicine

University Relations Manager

2024 Vice-Chancellor's Research Fellowships

Head of Research Computing & Data Solutions

Community member RANZCO Education Committee (Volunteer)

Director of STEM

Analytical Methods

Supplementary files

Article information

A synchronous-fluorescence analysis method combing with simple one-step extraction for determination of leonurine in traditional Chinese medicine

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