Promoting Herbal Medicine in Uganda

Traditional health practitioners and government working together

The status of traditional medicine in Uganda

More than 60% of Uganda’s population depends on traditional medicine because it is accessible, affordable and culturally familiar. With an estimated traditional health practitioner for every 200-400 Ugandans (compared to 1 western- trained doctor per 20,000), herbal medicine has long been used to manage a range of common conditions, including malaria, digestive and respiratory problems, toothaches, skin diseases, and childbirth complications. This document examines the relationship between Uganda’s Ministry of Health and a traditional herbalist, its strengths, challenges and its implications for future policy. The Cross-Cultural Foundation of Uganda worked with the Natural Chemotherapeutics Research Laboratory (NRCL) and a herbalist, Hajji Zakariya Nyanzi, to prepare these pages.

NCRL identified Hajji Nyanzi, a farmer and traditional health practitioner in Mubende district, as exemplary because of his experience, willingness to share information and long standing collaboration with NCRL, the AIDS Support Organisation (TASO) and THETA, the Traditional and Modern Health Practitioners Together against AIDS and other diseases.

The emerging policy framework

Until recently, there has been only limited recognition of the contribution made by Uganda’s traditional health practitioners to primary health care. This is in part because of the colonial legacy, during which culture was branded as negative and primitive (The 1957 Witchcraft Act outlawed traditional medicine and is still on the statute books), and in part because of an education system that rarely values local knowledge. Efforts are however now being made to promote traditional medicine. The NCRL Director, Dr Grace Nambatya, notes that Government’s current interest can be traced back to a 1987 Health Sector review, which revealed Uganda’s limping health care system. In spite of this, an invisible hand seemed to be at play, as the health status of Ugandans was not as disastrous as expected: traditional healers were then identified as a key contributor to primary health care. It was therefore recommended that they be brought into the mainstream health sector.

The Ministry of Health in time opted for a public-private partnership in which traditional health practitioners would be recognised as private partners. More recently, a new policy on Traditional and Complementary Medicine has been drafted to regulate the practice of traditional medicine, to focus on research and development and to encompass protection, cultivation, propagation and sustainability of traditional medicinal plants.
The Ministry has also submitted a Bill for the establishment of a semi-autonomous body, the National Council of Indigenous and Complementary Medicine Practitioners, to support collaboration between the “modern” health sector and traditional practitioners and to regulate the latter, while protecting their intellectual property rights.

Working with the Natural Chemo- therapeutics Research Laboratory

The Ministry of Health started to promote research and conservation of medicinal plants with the establishment of the NCRL in 1963. At the time, however, efforts to verify and authenticate traditional medicinal products were in part constrained by the absence of well-established associations of traditional medicine practitioners.
Today, traditional healers have formed associations to represent their collective interests. NCRL provides financial and technical support to practitioners to identify medicinal plants, and to assess the efficacy and toxicity of their herbal medicines, following established standards. Once validated as safe for human consumption, a healer’s product is recorded as such, and the healer is encouraged to have his product notified by the National Drug Authority (NDA).

After notification, herbalists are required to track and to submit further information on the safety and effectiveness of their products, before registration with the NDA. NCRL gives them advice on these procedures and on expanding the production of medicinal products, where appropriate.

It may itself process and package selected medicines as prototype samples. NCRL also offers training to practitioners through their Associations in herbal garden management and conservation, processing and packaging (including labelling with expiry dates), hygiene and protection against HIV/AIDS. Traditional healers, on their part, provide information on herbal medicine and practices, and share detailed information on the medicines that have proven effective. This contribution is acknowledged on the labels of herbal medicines samples packaged by NCRL.

NCRL has undertaken considerable research to transform raw herbal products into validated, registered, well-packaged and labelled medicines: by the end of 2007, 80 products had been notified as safe and effective for public consumption. With positive findings on the effectiveness of traditional herbal medicine on malaria and HIV opportunistic diseases, the World Health Organisation is currently funding further research in this area through NCRL. With training, the quality and presentation of herbal medicine has also improved, thus providing healers with better income. Dr Nambatya also points out that NCRL has come to appreciate the healers’ approach to health care: not only do they apply remedies, they also diagnose holistically, referring to the patient’s psychology and social, natural and cultural environments.

Hajji Zakariya Nyanzi

A herbalist of many years’ experience, Hajji Nyanzi has consolidated his knowledge and practice by joining various groups promoting traditional medicine: first a local association, the Kitalegelwa Group of traditional healers, then THETA, where his medicine for malaria was assessed, processed and packaged for distribution to the public. He also joined Uganda N’eddagala Lyalyo, a national association of traditional healers, where he learnt about other opportunities to improve his herbal medicine, and was advised to take his products to the NCRL for assessment.

Hajji Nyanzi currently supplies herbal medicine to patients within and beyond his community, as well as to NCRL and THETA. Hajji Nyanzi produces herbal medication in powder and liquid form for malaria, fibroids, and some HIV/ AIDS-related conditions (commonly locally referred to as ‘kadomola’ [jerry can]), among others. These have been used by his patients for some years, according to him, to good effect. NCRL and THETA have singled out his remedy for malaria as most effective. NCRL has trained Hajji Nyanzi in processing and packaging herbal products, in protection against HIV infection, and in managing herbal gardens. The Laboratory has sent some of his products for notification, including for malaria and fibroids, and Hajji Nyanzi is in the process of registering some of these with the NDA.

He welcomes the tests carried out by NCRL and feels these add value and market appeal to his products. The Laboratory packages and sells some of these products, and monitors patients taking his medicine. It also links Hajji Nyanzi to these patients so that they discuss progress or any challenges faced. NCRL pays him for medicines supplied at an agreed price: Ushs 30,000 per 750 grams of his herbal medicine for malaria, for instance. Although not formally contracted by NCRL, the Laboratory recognises his contribution by providing him with some funds to manage his medicinal establishment and to train other healers. In addition, NCRL staff visit him, make reference to his work and refer national and international visitors to him for learning and exchanges.

A challenging relationship

While the linkage between Hajji Nyanzi and NCRL has presented opportunities and benefits for the parties involved, it has also highlighted challenges. First, production costs are high, including the local authority’s licence to harvest medicinal material from the forest. This involves a long search for plants, carried out on foot or using a bicycle when ferrying bulky items. Hajji Nyanzi uses simple equipment to process his medicine, mostly wooden mortars and pestles.

After processing, his products are stored in plastic containers and used bottles, for sale. He has opened several retail outlets in the region, but all closed down because of mismanagement, weak supervision and dishonest shop attendants. Applying the skills acquired from NCRL for drying and packaging herbal medicine is costly, he says – at least Ushs 2 million to buy the necessary equipment – a sum beyond his means.

Despite NCRL’s inability to do so, Hajji Nyanzi expects to be generously financed, as he suspects that the Laboratory is generating much income from his intellectual property. This would include support to purchase the equipment he needs, justified by his long- standing relationship with the institution and the successful validation of his medicine. Hajji’s also regrets that his link with NCRL is not formalised by a letter, memorandum of understanding, or identity card. This, he feels, is necessary for his credibility, beyond his name on package labels, and to distinguish him from practitioners who are not linked to the Laboratory and whose products have not been validated.

Learning beyond the individual relationship

This individual case underlines three observations of broader relevance: A policy vacuum – The current legislation to promote and protect traditional medicine is outdated. The process of policy development has been slow, owing to low prioritisation of traditional medicine in the health sector, limited finances, and insufficient advocacy to make traditional medicine, its benefits and opportunities visible.

Such a vacuum results in several constraints: first, negative perceptions of the value and quality of herbal medicine are perpetuated in the absence of effective quality control and regulation of traditional practitioners’ practice, especially since abuses, including human sacrifices, are known to exist. A second constraint concerns the protection of intellectual property rights. Partly because they have been disregarded – even repressed – during the colonial and post-colonial periods, traditional healers are suspicious of the motive of those who have now rather suddenly developed an interest in their knowledge. A limited understanding of patenting and intellectual property rights also intensifies a reluctance to disclose knowledge, for fear of exploitation and that this may be ‘stolen’. Thus, according to Hajji Nyanzi, a number of traditional practitioners are still secretive about the contents of their medicine, resulting in indigenous medicinal knowledge remaining concealed, and some effective medicines not being validated or produced on a large scale.

NCRL staff also report that a healer may grow suspicious half-way through a validation process and then withhold some information or withdraw entirely. Similarly, although the NDA is charged with the responsibility of registering products, a fear persists among healers that neither this process nor liberal trade policies provide any assurance that their knowledge will be safeguarded or that they will benefit, should this be utilised by an investor. Registration is also a lengthy, centralised process that requires follow-up in Kampala. This can be costly for traditional practitioners who often live far away and cannot afford to travel to the city regularly.

Patenting is then perceived as suitable for commercial traders in or near the city centre. A third constraint concerns environmental protection. Herbal gardens can provide easy access to medicinal plants, can help to preserve rare and commonly used species and to conserve the environment, in addition to creating employment for traditional healers and small farmers. Herbal gardens and cultivation of rare medicinal plants are therefore essential if benefits are to be sustained. Policies to promote and protect medicinal plants, such as through controlling the felling of trees with medicinal value for construction or charcoal, are currently inadequate. Other policies, such as on agricultural zoning, farmer cooperatives and commercial farming, could also be adjusted to ensure the sustainability of medicinal plants.

Income generation, quality and public-private investment – Traditional herbal medicine is used by a large percentage of our population and provides a potential source of household income. It is therefore in the interests of traditional healers, development workers, health workers and the private sector to promote the production of quality herbal medicine. Once medicine has been validated or registered, and demand for it has increased, traditional healers are however challenged because they seldom have the capacity to produce in bulk, while maintaining quality. Large scale commercial production of validated herbal medicine requires professional management and presentation skills, which individual practitioners currently lack, although they may have access to sufficient supplies to meet the demand. In some cases, deteriorating quality has been noted, pointing to the need to establish linkages with local industries to invest in large- scale, consistent quality production. Lack of entrepreneurship skills, including in marketing, packaging and record keeping, also results in limited economic benefit for the traditional healers and may lead to a reluctance to share information with whoever can commercialise their products. In addition, potential investors stay away from commercial traditional medicine production and distribution, because of the absence of the necessary policy framework, leaving traditional healers with limited avenues to access funds. An appropriate policy environment would help in attracting investors interested in joint ventures, with better prospects for profitability for all concerned.

Accessible research, resources and documentation –

 Research funding is limited in Uganda, and this poses particular challenges in the field of traditional medicine, given the high costs involved (up to U.shs. 40 million per specimen). Validation requires time, specialised and costly testing equipment, with spares that cannot be obtained locally. Sending samples for testing to other countries is also expensive. Neither is NCRL in a position to provide substantial financial support to healers because of its own financial constraints. Having formal relationships is also held back by NCRL’s current legal status, although this is likely to change in the near future, when it will be allowed to enter into formal partnerships with associations of traditional healers. Further, the sample analysis work carried out at NCRL can only guide other agencies, such as the National Bureau of Standards and the Export Promotion Board to give additional assistance to healers. Limited resources slow down validation, to the disappointment of some healers. Patrick Ogwang, NCRL pharmacist and researcher, therefore observes that, while much useful knowledge exists among healers, the demand for validation far exceeds the capacity of the Laboratory and there are many pending applications. After testing, reports also need to be simplified so that healers can fully understand the results in terms of toxicity, safe dosage, appropriate administration and storage.

With limited research, analysis and documentation, negative attitudes towards embracing traditional herbal medicine as a resource are not dispelled. The benefits of establishing and maintaining linkages between traditional medicine practitioners and modern medical institutions are then difficult to promote. Where advances have been made with this type of collaboration, the benefits and challenges of mainstreaming into modern medical practice also need to be analysed and documented, so that development actors identify areas for intervention and how traditional knowledge may complement their initiatives.

Conclusions and recommendations

With many of us returning to nature for health and nutritional remedies, a linkage between traditional healers and NCRL presents opportunities from which we all stand to benefit. These benefits could be diverse: the traditional practitioner can gain from sales and his clients from his contribution to primary health care. The Ministry of Health can benefit from savings on imported medicines, and from improved access and quality of herbal medicine for all. The economy can benefit from exports of Ugandan herbal medicine and from gainful employment for smallholder farmers cultivating medicinal plants on a commercial basis. This would help both public and private sectors to see traditional medicine and practice as a resource that can be harnessed, professionalized and turned into commercial gain. Further, collective efforts to promote traditional medicine will not only generate economic and health benefits, but also restore a sense of pride in an important part of our cultural heritage.

Recommendations

Legal framework. The establishment of the National Council of Indigenous and Complementary Medicine Practitioners or its equivalent must now be expedited so that a policy framework facilitates collaboration, funding, validation and the development of traditional medicine. Aspects that deal with intellectual property rights and patenting need enforcing and traditional practitioners informed about its provisions and implications, to help them feel freer to share their knowledge.

Policy implementation. With a wealth of biodiversity and indigenous knowledge, Uganda has the potential to develop traditional medicine into a valuable resource. The traditional healers’ contribution to health care in particular needs to be recognised by providing funds, facilitating fora where they can discuss their concerns, and referring the public and other stakeholders to them. This includes using the Traditional Medicine Day to promote herbal products and their use in the prevention and management of disease. Adequate resources must be allocated and linkages created to facilitate the implementation of plans to improve the quality, volume and sustainability of herbal medicinal production and use.

Nationwide comparative research, documentation and cost benefit analyses of using traditional medicine are needed to improve their usage. This requires expanded facilities at NCRL and the creation of regional research and testing laboratories, as well as simplified and decentralised validation and registration processes to encourage traditional practitioners to register their products. The promotion of herbal medicine could be included in the terms of reference of Community Development and District Health officers to facilitate their identification, the verification of their effectiveness and to establish the potential for commercial production. This would also help to institutionalise district-level health partnerships: a Private-Public partnership health desk in every district could host centralised and district information on health resources, including indigenous knowledge. Research findings on the value of traditional medicine could be disseminated via the popular mass media, including radio stations and video halls.

Enhancing economic value. The commercialization of herbal medicine should be promoted, and its economic benefits to individual herbalists and the general public highlighted as a means to poverty reduction at household and national levels. Clear memoranda of understanding need to be developed to put the traditional healers’ expectations into perspective and allow them to negotiate from the onset the benefit they expect from partnership with other parties, including Government. They also need to be equipped with skills to manage the commercial production and sale of validated medicine, or to link them with public and private organizations that can enhance their services and products for commercial use.

Environment conservation. Aspects of environmental sustainability need to be incorporated in commercial herbal medicine promotion and the establishment of herbal gardens encouraged, especially for rare medicinal plant species. Availing land for research and for private sector commercial production would contribute to environmental conservation, in addition to health benefits.

Education and knowledge. Uganda needs to invest in curriculum development, training and capacity building to sustain existing knowledge and to promote new knowledge through formal and informal education at various levels – community sensitisation, as well as primary, secondary, and tertiary education. NCRL needs to respond to the call from the National Curriculum Development Centre to help incorporate traditional healers’ knowledge into the relevant educational curricula.

Traditional herbal remedies used in the management of sexual impotence and erectile dysfunction in western Uganda

About 70 – 80% of the Ugandan population still rely on traditional healers for day-to-day health care. In some rural areas the percentage is around ninety compared to 80% reported world-wide WHO had earlier estimates that the usage of traditional medicine in developing countries is 80 %. This is an indication that herbal medicine is important in primary health care provision in Uganda. There are several reproductive ailments that local communities have been handling and treating for ages such as sexual impotence and erectile dysfunction (ED). The concept of reproductive health care has been focusing mainly on women disregarding men and yet men are part.

Erectile dysfunction, sometimes, which also may imply to refer to “impotence,” is the repeated inability to get or keep an erection firm enough for sexual intercourse. The word “impotence” may also be used to describe other problems that interfere with sexual intercourse and reproduction, such as lack of sexual desire and problems with ejaculation or orgasm. Roper defines erectile dysfunction as the total inability to achieve erection, an inconsistent ability to do so, or a tendency to sustain only brief erections (premature ejaculation). Pamplona-Roger defines impotence as the inability to finish sexual intercourse due to lack of penile erection. These variations make defining ED and estimating its incidence difficult. For purposes of this publication, since ethnobotanical indigenous knowledge (IK) cannot clearly distinguish between these two terms, then erectile dysfunction and sexual impotence are both used. The local people who are providers of this information are not in position to classify these two conditions.

The estimated range of men worldwide suffering from ED is from 15 million to 30 million. According to the National Ambulatory Medical Care Survey (NAMCS), for every 1,000 men in the United States, 7.7 physician office visits were made for ED in 1985. By 1999, that rate had nearly tripled to 22.3. This is in USA, where statistics are clearly compiled, the level of awareness and education is high as compared to sub Saharan countries like Uganda. This is a clear indication that there are many silent men, particularly couples affected by ED.

Reproductive Health care is the second most prevalent health care problem on African continent. Reproductive health care did not appear on the health agenda until recent after the Cairo conference on population and the Peking conference on women that it indeed became a live issue. In some instances RH certainly includes the RH needs of the youth or adolescents.

According to Uganda’s health policy priorities, men’s reproductive health is not given any mention. The national health policy focuses on services like family planning, diseases control like STI/HIV/AIDS, malaria, perinatal and maternal conditions, tuberculosis, diarrhoeal diseases and acute lower respiratory tract infections that are given priority. The sexual and reproductive health rights in Uganda focus on maternal and child mortality, family planning and the like exclusive of men’s sexual needs and rights.

The causes of ED are varies from one individual to another. For whatever cause, since an erection requires a precise sequence of events, ED can occur when any of the events is disrupted. This sequence includes nerve impulses in the brain, spinal column, and area around the penis, and response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa. Thus, ED causes reported include, damage to nerves, arteries, smooth muscles, and fibrous tissues. These are often as a result of diseases, such as diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, vascular disease, and neurologic diseases that account for about 70 percent of ED cases. NIH reported that between 35 and 50 percent of men with diabetes experience ED. NIH further reported that the usage of many common medicines such as blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine (an ulcer drug) can produce ED as a side effect. Nevertheless, psychological factors such as stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure cause 10 to 20 percent of ED cases. In addition, men with a physical cause for ED frequently experience the same sort of psychological reactions (stress, anxiety, guilt, depression). Other possible causes are smoking, which affects blood flow in veins and arteries, and hormonal abnormalities, such as not enough testosterone.

In modern medication of erectile dysfunction, the oral prescription medication of popular Viagra (Sildenafil) is effective, but in some men it is not compatible and Sildenafil works in less than 70% of men with various etiologies and has certain side effects. The availability of Viagra has brought millions of couples to ED treatment. Oral testosterone can reduce ED in some men with low levels of natural testosterone, but it is often ineffective and may cause liver damage. Other drugs such as Yohimbine, papaverine hydrochloride [used under careful medical supervision], phentolamine, and alprostadil (marketed as Caverject) widen blood vessels. However, this available modern medication for the ED in men is very expensive for most of the rural people in Ugandan and other developing countries. Yet, in traditional medicine, there are several medicinal plants that have been relied on for use in the treatment of ED. This ethnobotanical indigenous knowledge has not been earlier documented and scientifically validated for efficacy and safety, future drug discovery and development.

Therefore, this particular study was carried out purposely to document medicinal plants used by traditional medical practitioners to treat ED and sexual impotence and other male erectile related conditions in western Uganda. This manuscript only covers the ethnobotanical documentation of medicinal plants used in the management of erectile dysfunction excluding the socio-cultural aspects. The socio-cultural aspects in details will be presented in the next manuscript covering the broad range of reproductive health ailments management using the indigenous knowledge in western Uganda.

Cultivated Medicinal Plants used in treatment of Sexual Impotence and Erectile Dysfunction in Western Uganda

Family	Scientific Name	Local Name	Habit	Parts Used	Preparation	Administration
Alliaceae	Allium cepa L.	Katunguru (NY, KI, RU) Onion (Engl.)	H	ST-BU, L, RT	chewing, cooking	oral in water and in food
Alliaceae	Allium sativum L.	Tungurusumu (KO) Garlic (ENG)	H	ST-BU, L, RT	chewing, cooking	oral in water and in food
Cannabaceae	Cannabis sativa L.	Njayi (GA) Njaga (NY) Marijuana (ENG) Mbangi (SW)	S	L	chewing, smoking	oral, inhaling fumes
Capparaceae	Cleome gynandra L.	Esobyo/Amarera (KO) Eshogi (NY)	H	L, R, FL	chewing, cooking	oral or as food
Malvaceae	Sida tenuicarpa Vollesen	Keyeyo (RU)	H	L	pounding, boiling	oral
Papilionaceae	Arachis hypogaea L.	Binyebwa (NY, RU) Ground nuts (ENG)	H	SE	roasting	oral as food
Rubiaceae	Coffea arabica L.	Mwani (NY) Arabica Coffee (ENG)	S	SE	roasting, chewing	oral as a beverage
Solanaceae	Capsicum frutescens L.	Kamurari (GA) Eshenda (NY) Red pepper (ENG)	H	FR	pounding, boiling, chewing	oral in food
Zingiberaceae	Zingiber officinale Roscoe	Ntangahuzi (NY), Ntangawizi (SW), Ginger (ENG)	H	RH	pounding, boiling	oral in tea, porridge, milk as a beverage

Wild-harvested Medicinal Plants used in treatment of Sexual Impotence and Erectile Dysfunction in Western Uganda

Family	Scientific Name	Local Name	Habit	Parts Used	Preparation	Administration
Anacardiaceae	Rhus vulgaris Meikle	Mukanja (NY) Mukanza (RU)	S	B, R, L	chewing, boiling	oral and eaten as raw fruits
Asclepiadiaceae	Mondia whiteii Skeels	Mulondo (GA)	H-CL	R	chewing, boiling, pounding	oral in water, in tea and in food
Asteraceae	Vernonia cinerea (L.) Less.	Kayayana (GA)	S	L, R	chewing, boiling	oral
Balsaminaceae	Impetiens sp.	Entungwabaishaija (NY)	H	WP	chewing, boiling	oral
Caesalpinaceae	Cassia didymobotrya Fresen.	Mugabagaba (NY) Mukyora (RU) Mucora (KO)	S	L, R	chewing, boiling	oral
Caesalpinaceae	Cassia occidentalis L.	Mwitanzoka (NY, KO)	H	L, R	chewing, boiling	oral
Canellaceae	Warburgia ugandensis Sprague	Mwiha (RU)	T	B, L, R	pounding, boiling	oral in tea or porridge
Celastraceae	Catha edulis	Mairungi (NY, RU), Miira (SW)	S	L, ST	chewing	oral by chewing fresh leaves and young stem.
Euphorbiaceae	Flueggea virosa (Willd.) Voigt	Omukarara (RU) Omukalali (KO)	S	L, R	pounding, boiling	oral
Euphorbiaceae	Tragia brevipes Pax.	Engyenyi (NY)	H-CL	L	pounding, boiling	oral
Mimosaceae	Acacia sieberiana Scheele	Munyinya (NY, RU)	T	B	pounding, boiling	oral
Mimosaceae	Dichrostachys cinerea (L.) Wight & Arn.	Muremanjojo (RU)	T	B	pounding, boiling	oral
Myricaceae	Macrotyloma axillare (E.Mey.) Verdc.	Akaihabukuru / Kihabukuru (RU)	H-CL	L, RT	pounding, boiling	oral
Myricaceae	Myrica salicifolia Hochst. ex A.Rich.	Mujeje (NY)	S	R, B	pounding, boiling	oral
Palmae	Phoenix reclinata Jacq.	Akakindo (NY), Mukindo (NY)	S	L, R	pounding, boiling	oral
Phytolaccaceae	Phytolacca dodecandra L’Herit	Muhoko (NY) Ruhuko (KO)	S	L, R	pounding, smearing	smear on ripe banana and roast
Polygonaceae	Coffea spp.	Mwani (NY) Wild Coffee (ENG)	S	SE	roasting, chewing	oral as a beverage
Polygonaceae	Hallea rubrostipulata (K.Schum.) J.F. Leroy	Muziiko (NY)	T	B, R	pounding, boiling	oral
Polygonaceae	Rumex abyssinicus Jacq.	Mufumbagyesi (NY) Mufumbijesha (RU) Kasekekambaju (GA, KO)	S	L, ST	chewing	oral
Polygonaceae (S.Moore) Bremek.	Tarenna graveolens Munywamaizi (NY)	Munyamazi (KO, RU)	S	B, L, R	pounding,	oral boiling
Rutaceae	Citropsis articulata Swingle & Kellerman	Muboro (NY, RU) Katimboro (KO, TO)	T	B,R	pounding, boiling, chewing	oral as beverage in tea
Sterculiaceae	Cola acuminata Schott & Endl.	Ngongolia (SW), Engongoli (KO, RU) Cola nut (ENG)	T	FR	Roasting, pounding, chewing	oral in tea, porridge, milk as a beverage
Tiliaceae	Grewia similis K. Schum.	Mukarara (RU)	S	L, B	pounding, boiling	oral
Urticaceae	Urtica massaica Mildbr.	Engyenyi (NY)	H-CL	WP	pounding, boiling	oral

The medicinal plants used such as Citropsis articulata, Cannabis sativa, Cleome gynandra and Cola acuminata are frequently utilized. Some of these plants (Citropsis articulata, Cola acuminate) are already under sale for treating these conditions. Their propagation is on-going in western Uganda in places like Rukararwe Partnership Workshop for Rural Development Centre in Bushenyi District and researchers personal experience at Rukararwe. Rukararwe is a non-governmental organisation that is processing herbs, running a famous herbal clinic and with a medicinal plants arboretum and medicinal plants agro-forestry.

A plant like Cleome gynandra is a popular vegetable used all over Uganda and is on sale in most markets. Other medicinal plants that are food stuff include Allium cepa (onions), Allium sativum (garlic), Rhus vulgaris, Capsicum frutescens(red pepper) and Zingiber officinale (Ginger) are also on sale in most markets of Uganda and internationally. In addition, the roots of Mondia whiteii are used as an aphrodisiac for males and for improving female sexuality (women’s Viagra) in most areas of Uganda particularly in urban centres and the Kampala City. To date, Mondia whiteii has been an old traded medicinal plant in most in Kampala. Recently the patented ‘Mulondo Wine’ a drink flavoured by the roots of Mondia whiteii has hit the national and international markets. The Mulondo Wine is also believed to be an aphrodisiac for both men and women.

The herbal medicines used in the management of sexual impotence and erectile dysfunction are mainly prepared by pounding, chewing and boiling and are mainly orally administered. The traditional healers treat sexual impotence and ED by prescribing some of these herbs in tea or using local beers, fermented milk and porridge. Some herbs are herbs are roasted or smoked such as coffee before administration. The dispensing of herbal medicines used in sexual impotence and ED using local beers, fermented milk and porridge possibly the alcoholic content improves on the kind of active chemicals extracted than water alone.

Some studies carried in and outside Uganda show that some of these plants listed in the management of sexual impotence and ED may be potent. Some of these medicinal plants are regarded as traditionally aphrodisiacs, implying that they have ability to increase sexual desires. For instance, Cola acuminata fruits are widely used herbal remedies in ED and are harvested from the forests of Democratic Republic of Congo. The Cola acuminata fruits contain about 2% catechine-coffeine (Colanine). The roasted seeds in Europe are used as strong stimulant, in addition to the treatment of migraine, neuralgia, diarrhoea and stimulant or cardiotonic, loss of appetite, antidepressant and melancholy (severe form of depression). Coffee is drunk for certain migraine, nausea, resuscitation and diuretic. Coffee is a famous stimulant used world over as a beverage. However, the wild coffee species are more popular in treating ED and are believed to contain more alkaloids (caffeine). Coffee is further reported to be a nervous system stimulant (Pampalona-Roger, 2000). Cannabis sativa (Marijuana) is smoked by mentally sick and impoverished men⁷. C. sativa is like morphine, it is an opioid analgesics. Allium sativum (garlic) is used in treatment of diabetes, high blood pressure, prevention of arteriosclerosis (hardening of the arteries and is one of the causes of ED). Garlic reduces blood sugar levels and blood cholesterol levels which are the direct causes of ED if not checked.

The Zingiber officinalis (ginger) volatile oils from the rhizome are used for stimulating the nerves and making then sensitive. Capsicum frutescens in many African cultures is a known powerful stimulant and carminative. Capsicum frutescens (chilli) contains enzyme capsaicine that helps in blood clotting (fibrinolytic) and people who consume C. frutescens seldom suffer from heart attack. In addition, the pharmacological tests showed that the capsaicin chemical compound from Capsicum frutescens acted like powerful stimulant of the receptors participating in circulatory and respiratory reflexes.

Phytolacca dodecandra leaves and roots are pounded and smeared on ripe banana and then the ripe banana roasted before being eaten for treating erectile dysfunction. However, care has to be taken Phytolacca dodecandra is poisonous. Cola acuminata fruits are mixed with other plants in Benin to treat primary and secondary sterility. Cola acuminata is also said to be diuretic and laxative when administered orally. Some Acacia species are regarded as aphrodisiacs in Niger. Cassia species have high repute as drugs and poisons. For instance, Cassia sieberiana is used urinary problems, impotence and kidney diseases in Mali. In Burkina Faso, Cassia occidentalis is used as a stimulant. Flueggea virosa is famous medicine in African cultures. Flueggea virosa used in sterility, aphrodisiacs, stimulant, rheumatism, arthritis, spermatorrhoea, kidney and liver problems among many other diseases treated.

In Uganda gender specific malfunctions or complications or diseases and conditions in reproductive health care are not given the due regard and the suffering persons tend to shy away. Sexual impotence and ED in men is considered a secret affair and the suffering persons keep quite or seek medical help in privacy. The psychologically affected men will try other women to test the viability of their manhood. The same is true, women with spouses with such erectile problems may be tempted to go outside their marriage vows to satisfy their sexual needs. This can also lead to HIV/AIDS exposure and result in broken homes and marriages. The consequential outcomes of promiscuity, low self-esteem, polygamy, sexually transmitted diseases including HIV/AIDS are more detrimental to the individuals and society.

Only the few elite (educated) and with money seek modern medical care privately and secretly. The description of impotent men in western Uganda among the Banyankore ethnic grouping is literally translated as the persons having no legs (Kifabigyere, Runyankore Dialect) to imply that the penis is dead (cannot bear children). There are other various terms used to describe such men with sexual impotence and ED like the one trampled by a goat, [Akaribatwa embuzi (empene), Kinyankore dialect]. In other places they called, such men who were unable reproduce as “Ekifera in Kinyankore meaning worthless). The men who were unable to have children were not supposed to be given the positions of responsibility or leadership because they were regarded as abnormal. Socially these men were excluded from society, even on drinking joints for the local brew or beer, they are not expected to talk and if they talked, they are hushed. Even women and children always taunted the suffering individuals. Socio-economically, sexual impotence and ED is demeaning and tortures the sufferers by reducing their self-esteem and worthiness in the society. Culturally, in olden days, the impotent men married wives and entrust their wives to very close friends and or relatives to bear them children. In central Uganda, the men with erectile problems are equalled to car engines that cannot start on their own [non-starters] or cars whose batteries have no or low charge (‘Takuba self’, Luganda dialect).

Although there are few men who are born absolutely impotent, the number of men with erectile problems are many especially those tending to 50 years and above. Pfizer reported that about 40% of men above years, 50% of men above 50 years, 60% of men above 60 years and in any population are affected by ED. ED has profound effect on psychological well being, it can be devastating, it can lead to low self-esteem, depression, negative effect on relationships and reduced life satisfaction. Among several other causes, aging is one of the factors leading to ED. There are some other social causes of ED such as high unemployment rates, and diseases like diabetes, hypertension, HIV/AIDS, high cholesterol levels, stress, smoking and obesity. ED is slowly creating adverse problems in homes in Uganda and particularly, among the mid-aged and old men. The men with sexual impotence and erectile dysfunction deserve proper diagnosis of the conditions and treatment. Thus, the plant remedies described may be healthy if administered

Erectile dysfunction is a common problem in men of all ages than publicly perceived. Since, I started the research in reproductive health care; the commonest question asked by men is related with medicinal plants that empower male sexuality. So far, several males have been consulting on the treatment of ED using herbal remedies, either by themselves or through friends.

The proved herbal remedies with therapeutic values such as Prunus africana used in the treatment of hypertrophy in male genitalia is indicative that some herbals may be potent though not yet studied comprehensively. However, most of the herbal remedies used in male ailments are not well documented and researched. The dangers of loosing valuable indigenous knowledge (IK) on sexual impotence and ED are likely to occur because westernization in the present generation. This indigenous knowledge in medicine ought to be documented for future use and sustainable utilisation. According to the convention on biological diversity (CBD), specific reference is made to the need to protect the world’s indigenous cultures and traditions (Art. 8 of CBD). This article points out that national legislation need to respect, preserve and maintain knowledge, innovations and practices of indigenous and local communities encompassing traditional life styles relevant for the conservation and sustainable use of biodiversity. UNEP argues nations to have an urgent action to safeguard indigenous cultures and their knowledge.

From the conservation point of view, medicinal plants usage will continue to grow in popularity as people seek ways to support health naturally and gently. So far, over 72% of these medicinal plants used in ED conditions were harvested from the wild. Yet, there is increasing trend in usage of traditional medicine in developed countries. The dramatic increase in herbal remedies usage will continue to rise since WHO has taken on monitoring of all unconventional medicine according to the traditional medicine strategic plan of 2002 to 2005. Most medicinal plants have proved successful sources or have acted as leads of effective ingredients that today’s drug companies often look first to traditional places such as the rain forests, forest animals and traditional healers for clues to guide their drug development efforts. Furthermore, the harvesting of medicinal plants from the wild places such as the forest reserves, national parks in QEBR is a point of concern whereby no viable mechanisms have been put in place to propagate them. The plant parts harvested especially those of wild medicines such as roots and stem, pose threat to the future survival of natural reservoirs if domestication strategies are not adopted in the near future.

This calls for serious conservation strategies of plant targets in drug development borrowing from the indigenous knowledge of the local people. For instance, medicinal plants documented in this study like Warburgia ugandensis and Cirtopsis articulata used in erectile dysfunction and sexual impotence and ED need to be conserved based on their demand and medicinal value to the people. In the event of increased biotechnology and the use of modified living organisms in agriculture, health and environment, most people will go for natural products. Furthermore, research in natural products is on the increase in both developed and developing nations to show that there is renewed interest in medicines of natural origin.

The medicinal plants used in male-related conditions will be very significant in the present and future generations. From the researchers point of view, the usage of herbal remedies in managing sexual impotence and erectile dysfunction is useful because of long history of utilisation of some herbs that are perceived as effective. Thus, the establishment of rapport between modern health workers through collaborative ventures with traditional healers, relevant NGOs like Rukararwe in Bushenyi by having close supervision and monitoring of herbal treatments in such conditions is noble. Ministry of Health through its research wing in traditional medicine the Natural Chemotherapeutics Research Laboratory in Wandegeya has role to play in advocacy of traditional medicine. In addition, Public-Private Partnership in Health Care Delivery Desk Office in Ministry of Health and distinguished researchers in herbal medicine need to network, collaborate and have policy in place for herbal medicine as an alternative form of health care in Uganda. The traditional herbal medicines, relevant to the needs of ailing Ugandans can be tried out after being licensed by the National Drug Authority. In our view, sexual impotence and erectile dysfunction are real silent conditions affecting Ugandan men. Additionally, further investigations into the safety and efficacy of these traditional herbal remedies used in the treatment of erectile dysfunction and other male-related conditions are recommended in Uganda.

Conclusion

Long before the advent of Western medicine, Africans had their own way of dealing with diseases and it worked for them. African traditional healers or diviners were intelligent enough to prescribe traditional solutions to diseases whether it had spiritual or physical causes with little or no side effect. When it is psychological, the person is sometimes counselled and is given the necessary attention. In the light of this,

African traditional healing is intertwined with cultural and religious beliefs, and is holistic in nature. It does not focus only on the physical condition, but also on the psychological, spiritual and social aspects of individuals, families and communities. (Truter 2007:57)

Moreover, the reason why African traditional medicine is popular in Africa is because they are both available and cheap. Having said this, I wish to end with the statement: ‘Don’t be quick to judge, be ready to learn new things and make the right choices as it pleases your faith and conscience’.