Herbal medicine is big business

Traditional remedies are loved by the people, championed by traders, and make millions for the government. But they can also kill. Here’s everything you need to know about Ghana’s herbal medicine industry.

There are 600 herbal medicines registered for sale in Ghana, but regulators believe there are many more available.

“I have four leading brands, but the one that moves like water is Venecare.” Theodore Tetteh is founder of the Tinatett Herbal company. “Anything that has got to do with sexually transmitted disease – but not HIV – it takes care of it, just like that.” It also takes care of the pain men sometimes feel when they urinate, he says, sounding increasingly evangelical. And another reason people like it so much are that, according to Tetteh, it improves their sex lives.

“It’s the fastest-moving product in the country, and it works like magic.” Tetteh is sitting in one of his 15 herbal medicine shops, in the Spintex Road industrial area of Accra, Ghana’s capital city. The shelves are a riot of brightly coloured boxes and bottles, most of them filled with remedies manufactured in a small factory a short drive away. Tinatett was one of the first companies to mass-produce herbal drugs in Ghana. Now it is one of the leading manufacturers, with around 32 products, including malaria drugs, aphrodisiacs and slimming pills. Tetteh will not reveal his sales, but says they are in the millions of Ghanaian cedi (£1 is about 5 cedi, $1 is about 4 cedi).

Over at the shop’s counter, a customer is shaking a bottle of Tinatett’s typhoid remedy and asking the shop assistant if he can open it. The last time he bought this stuff it stank like a gutter, he says. He went back to the store he got it from, where they apologised – they said it was a factory error – and gave him a replacement. The bad batch has not soured him on the remedy, he says: he knows it works, he has been using it for years.

Around 70 per cent of people in Ghana depend on herbal medicines for almost all their healthcare. For many of them, there is no question about whether herbal medicines work: they just do, and they have for centuries.

Bodies as diverse as the World Health Organization (WHO) and the Ghana Federation of Traditional Medicine Practitioners’ Associations have concluded that if the majority of people have been using herbal medicines for generations to no obvious ill effect, they are probably safe. Actively stopping people from using traditional remedies, especially when there are few affordable, accessible alternatives, could do more harm than good.

So until recently, the job of regulators has been to weed out dangerous concoctions and the most outrageous claims. But over the past ten years, herbal medicine has become big business. The practice has gone from the preserve of highly trained healers in far-flung villages to the most nakedly commercial part of the country’s healthcare industry.

There are plantations and factories pumping out remedies for everything from mild exhaustion to full-blown diabetes. Herbal clinics – some of them government-backed – are popping up all over the country, and there are dozens of herbal drug stores in every major city.

Despite this, nobody – not the manufacturers, not the WHO, not the Ghana Federation, not Ghana’s Ministry of Health – knows how much this industry is actually worth. What they do know is that more and more people are using herbal medicines, and these remedies are finding their way across borders, to other countries in West Africa and to consumers in Europe and the US. This growing popularity has finally forced regulators to take a closer look at the industry, setting up a long-delayed confrontation between tradition, commercialism and science.

Drug Lane

The heart of Ghana’s herbal boom is Drug Lane, an aptly named tangle of licensed chemical sellers, herbal drug shops and pharmacies in Accra’s teeming market district. One of the dozens of tightly packed stores is Peptee Enterprises. There’s a glass counter full of expensive aphrodisiacs about a foot from the entrance, clearly signalling the priorities of Ghanaian consumers. The shelves behind are crammed with hundreds of commercially produced herbal remedies.

There are bottles of Adom Koo Mixture, extra strong, for piles and waist pain, which cost 4 cedi, and blue boxes of Medi-Moses Prostacure tea, a “natural food supplement to improve urine flow” in older men, yours for a hefty 50 cedis. There is also the highly popular Rooter Mixture, for malaria, typhoid and jaundice, which costs 6 cedi. In comparison, the WHO-recommended treatments for malaria will set you back between 12 and 30 cedis, which is a massive difference in a country where the poorest residents live on around 5 cedi a day.

On a hectic afternoon in March 2016, the queue in front of the counter spills out into the lane. Market women in aprons pop in from their stalls outside. Men in crisp, white shirts come from across town. One customer spends 100 cedis on a prescription from the herbal medicine clinic at Police Hospital; the next guy spends just 1 cedi. A fashionably dressed young woman asks quietly for Tinatett Venecare (8 cedi). A large man conducting an obviously fake phone call asks: “My friend wants to know: which aphrodisiac works quickest?”

Manager Ebenezer Tomoah, or one of the three other people behind the counter, plucks the bottles and boxes off the shelves. One patron leans over the counter and whispers something to Tomoah, who disappears into an upstairs stockroom. He comes back down discreetly clutching a handful of glass vials containing an amber liquid, which he deposits in the man’s hands.

One woman comes in to hand Tomoah a photocopy of a letter from the Ghanaian Food and Drugs Authority (FDA) announcing the registration of “Pranko Herbal Mixture”. Tomoah says manufacturers do this all the time.

Two different regulators – the FDA and the Pharmacy Council – inspect the stores on Drug Lane, he says, but the inspectors do not always know which herbal medicines are licensed for sale and which have been smuggled over the border or illegally imported from China, so Tomoah says he keeps the letters on file as proof. (The Pharmacy Council, which regulates chemists and drug stores, says it only inspects herbal medicine shops when there have been reports that they are illegally selling orthodox drugs.)

Tomoah writes the sales down in a dog-eared ledger; he is too lazy to set up a computer, he says. The store had originally started out selling toiletries in 2008, but business was slow. The owners wanted to turn it into a pharmacy, but the licence cost too much. So in 2014, they switched to the product line that’s taken over Drug Lane: herbal medicines. Business picked up quickly.

In 2015, there were almost 600 herbal medicines registered for sale in Ghana, but regulators believe there are many more available: “The system is not fool proof, it’s not like orthodox medicine where we have almost absolute control,” says Yaw Kwarteng, head of the Department for Herbal Medicine at the FDA. Still, they’re making progress, he says. “Twelve years ago there was no regulation at all.”

The FDA took over regulation of food, cosmetics, chemicals, medical devices and medicines in 1997. But this was years after the first entrepreneurs started producing herbal drugs in industrial quantities. It took the best part of a decade to convince those manufacturers that they needed regulation and safety measures such as instructions and dosage cups. It was particularly difficult to convince them that they should not be dispensing by the gallon.

Regulation has not slowed the industry down. “We see outrageous combinations,” says Kwarteng. “If there’s money to be made, they’ll make all sorts of claims.” The registration process for herbal medicines is designed to weed out those claims. It was influenced by places with thriving traditional medicine industries such as India and china.

In Ghana, the first hurdle for manufacturers is proving their concoction will not kill people. The medicines go to an FDA-approved lab where they are tested for stability, toxicity and contamination. Most fail that last test, Kwarteng says. The FDA visits factories to point out where the contamination is happening, which is often everywhere: these are usually pretty basic production lines with people doing everything by hand.

Then the FDA does another set of tests, to catch out manufacturers who submit fake samples or switch ingredients. “A product came for re- registration, and the initial registration went well, it was purely herb,” Kwarteng says. “Subsequent [samples] we got were laced with a Viagra-type chemical.” Some cases are even more dangerous. One product, said to boost patients’ immunity, was actually just used motor oil.

But do manufacturers have to prove that these medicines work? Until 2011, as long as the concoction showed signs of working in a lab, a manufacturer could claim that it treated pretty much anything, within reason. If it was meant to treat malaria, all it had to do was successfully kill malaria parasites  in a test-tube.

Patients were using herbal medicines to treat diabetes, cancer and even HIV. Their conditions were getting worse. There were reports of kidney and liver failure. So, in 2012, the government put new, more stringent regulations in place. It would only register remedies for what were described as common ailments: upset stomachs, headaches, haemorrhoids and, curiously, malaria.

That year, the number of approved herbal remedies fell from 520 to just 158.“ [Manufacturers] are not able to easily register products for, say, typhoid, gonorrhoea, hypertension, diabetes,” says Kwarteng. Now, to register remedies for chronic diseases or any other conditions considered serious by the Ministry of Health, you need to perform clinical trials. There hasn’t been a single one yet.