Health traditions of Sikkim Himalaya

Ancient medical systems are still prevalent in Sikkim, popularly nurtured by Buddhist groups using the traditional Tibetan pharmacopoeia overlapping with Ayurvedic medicine. Traditional medical practices and their associated cultural values are based round Sikkim’s three major communities, Lepcha, Bhutia and Nepalis. In this study, a semi-structured questionnaire was prepared for folk healers covering age and sex, educational qualification, source of knowledge, types of practices, experience and generation of practice, and transformation of knowledge. These were administered to forty-eight folk healers identified in different parts of Sikkim. 490 medicinal plants find their habitats in Sikkim because of its large variations in altitude and climate. For 31 commonly used by these folk healers, we present botanical name, family, local name, distribution, and parts used, together with their therapeutic uses, mostly Rheumatoid arthritis, Gout, Gonorrhea, Fever, Viral flu, asthma, Cough and Cold, indigestion, Jaundice etc. A case treated by a folk healer is also recounted. This study indicates that, in the studied area, Sikkim’s health traditions and folk practices are declining due to shifts in socio-economic patterns, and unwillingness of the younger generation to adopt folk healing as a profession.


INTRODUCTION
The three ethnic groups of Sikkim, the Lepcha, Bhutia, and Nepalis, have long practiced their traditional systems of medicine and have a strong belief in herbs. 490 medicinal plants find their habitat in Sikkim due to its large variations in altitude and climate. [1] Ancient medical systems abound in Sikkim, and are still popular, nurtured by Buddhist groups for their traditional Tibetan Pharmacopoeia. [2] The tribals of Sikkim have immense faith in herbal medicine based on trial and error experience gained continuously from generation to generation. The various traditional healers across the globe have diverse beliefs and practices, but the common aim of all is to cure ailments and maintain human health. Any medical system operates in society according to the prevailing environment of the region and cultural manifestations operating within it. [3] In Sikkim Himalaya, geographical factors have not only contributed to this, but also prevented close contact with other developed indigenous systems of medicine. Human societies living in high-altitude areas remain isolated due to poor accessibility and harsh climate. Their geographical conditions stimulate them to develop a unique health culture. In Sikkim, this is a mixture of Lepcha, Bhutia, and Nepali practices for the prevention of disease, promotion of health, and treatment of disease. These unique practices are undocumented and passed on from one generation to next by word of mouth. [4] Studies are available concerning demographic and practice patterns of folk medicine in other developing counties. Such kinds of serious work are rarely available in India, although we have a strong knowledge base, strong belief, and acceptance. [5] So the present study aimed to document the various plants used by Sikkim's folk healers, practice patterns, demographics, and their socioeconomic condition with the future prospects of their tradition.

Study area
The present study is mainly focused on health tradition, various plants used by the folk healers, and their socioeconomic status present in three ethnic groups (Lepha, Bhutia, and Nepali communities). The study area encompassed four of Sikkim's districts.

Study methods
Different trips were arranged to different places in Sikkim to identify folk healers. The study was conducted in collaboration with the State Medicinal Plant Board to identify the Folk healers. The healers were identified or selected as per their reputation as narrated by local people. We conducted one training workshop to educate the healers about their strengths and weaknesses, and to give fundamentals on vital sign. We interacted with the healers and collected personal data together with information about their feelings. Raw materials used for curing different ailments, and folk healers' beliefs concerning them were collected and complied during field surveys and workshops over the period January 2007 to December 2008. A semistructured questionnaire was prepared for folk healers in whch age and sex, educational qualification, source of knowledge, types of practices, experience and generation of practice, and transformation of knowledge were studied in 48 identified folk healers in different areas of Sikkim.

Brief history of health culture in Sikkim
Sikkim is known to the Lepchas as "Nye-mael-liang" meaning paradise. It is also called "Ren-Jong" meaning the land of ancestors. The present name Sikkim is of Nepali origin and derived from Sukhim meaning new house or new place. Another derivation from the Sanskrit word Sikhim suggests the meaning mountain country. Lepchas are an indigenous tribe not only in Sikkim but also in north Bengal. Besides them, the Bhutia (from Tibet) and Nepalis (from Nepal) are also inhabitants of Sikkim.
Historically, Sikkim did not have any strong centralized political power before the 17 th century. It is also accepted that the Lepchas were the autochthonous people of the state who had long before migrated there from South East Asia. The contact between Lepchas and Bhutias is believed to have begun around 1275 AD. After the coronation of the first Chogyal (king) in 1642, a treaty was signed between them. [6] Culture is the foundation of civilization, and a social strength, which is enriched by the transforming power of knowledge and experience. The health culture of Sikkim is a composite heritage of practices of medicine in different rituals and other measures of prevention and cure. [7] These three major Sikkim communities practice their systems of traditional medicine based on their cultural values as follows:

Lepcha medical practices
Lepchas constitute about 13% of the total population of the state they inhabit in the Dzongue reserve of North Sikkim district. The concept of health and illness among the Lepchas is entirely guided by belief in the supernatural. The Lepchas mainly follow the Mahayana sect of Buddhism. They have their own script, and distinct costume, language, and culture. Uses of medicinal plants are described in the Lepcha epics called Namthar, Tengyur, and Domang. They acknowledge certain semidivine beings or guardian spirits known as "Lungzee," who are not gods but worthy of respect like a huge tree, a cluster of trees, grass, a tarn, a cave or a special hillock, and other natural objects. If they are ignored or any disrespect is shown to them by defiling or polluting, by answering nature's call etc., it may invite suffering to the village or the particular individual; they may suffer from serious sickness or even die.
According to the Lepchas, the world is governed by good spirits -and evil spirits (Mung). All natural calamities such as bad harvests, draught, hailstorm, and other misfortunes are believed to be the actions of evil spirits, i.e., Mung. On the other hand, good health and vitality, good harvest, and prosperity are attributed to actions of good spirits. [8] Since the Lepchas are basically animist, traditionally only the Bongthings (male Lepcha priests) and Muns (the female Lepcha priestess) are called during sickness and for cultural and funeral ceremonies. Such is the influence of the mun/ bong things, that even after the introduction of Buddhism, the lamas performed their pujas in close association with them. The Mun, however, perform rituals connected with supernatural forces in which the lamas have no role.
Pougorip/Totola (Oroxylum indicum) [9] is a medicinal plant used in Ayurveda as an ingredient in Dashamula. It also plays an important role in the Lepcha culture. The Lepchas believe that it is not even touched by the bees, signifying the purity and chastity of a virgin girl, and it is used as liver tonic and antidiabetic medicine. The fruit of the plant is shaped like a huge sword. The seeds from inside the fruit are flagellated like paper silk, and are used in any auspicious ceremony similarly to the use of haldi/turmeric in Hindu culture. Chi (millet beer) plays a very important role in Lepcha culture and used to drink to good health. [10] Bhutia medicinal practices The Bhutias place great emphasis on coercive rites of to exorcise and destroy demons. Like the Lepchas, the execution of religion is in the hands of trained specialists called pau, neyjum, and lamas, paus being male and neyjums female. During the process of curing, a pau enters a trance state, to communicate with the spirits and discover why they have afflicted the patient with illness. Another approach to diagnosis is by divination with the help of a plate full of rice. The pau shakes the plate until the symbol of the evil spirit appears in the rice. The pau performs Phuphi by offering money, eggs, and clothes which have been circulated thrice over the patient's head to the malignant spirit. [11] These things are thrown out and only the clothes are brought back. It is believed that patients will be cured within three days of the ritual.
All Sikkim people's settlements are adorned with prayer flags, or Dacho, which are said to carry good fortune to the individual in every direction. These flags are of four types -the Lung-ta which is square in form, and contains a horse with mystic figure at the center. It is hung on the ridges of the house and in the vicinity of settlements; the chonpen, long, narrow and rectangular in shape, is tied to twigs of trees or to bridges or to bamboo flag posts; the Gyal-tsen dse-mo, which is like lung-ta, but contains a larger holy text; and the great luck charm, which is pasted on the walls of the house or folded up and worn around the neck as a charm for good fortune. Luck flags are flown only after performing certain specific lamaic worship. Waddell states that most of the lamaic worship is derived from demonolatry, "A few of the most intelligent Lamas become Tsi-pa lamas who are astrologers. As in the rest of South Asia,all the laity understand that astrological choice of time is absolutely essential for each of the three great epochs of life, viz., birth, marriage and death; and also at the beginning of each year to have a forecast of the year's ill-fortune, such as health problems, and to have appropriate remedies drawn up."

Nepali medical practices
Nepalis believe that supernatural forces are involved in the creation of illness. Dami and Jhakries are performed during the puja for physical and mental diseases and Phedangba in particular for the Limboo community. Folk uses of herbs such as Oroxylum indicum (hypertension), Fraxiknus floribunda (gout), Panax pseudoginseng for longevity, Ephedra gerardiana for asthma, Elshcolzia blanda and Mahonia nepalensis [12] in eye-trouble and eczema, and of Urtica parviflora (young inflorescence) as a clearing and invigorating agent after child-birth by local women folk, are of great value. Rhizome of Budo-Vokati (Stible rivlaris) is considered to be good for lumbago. [13] It is crushed and taken as decoction after boiling in water or chewed like betel nut for relief of body ache. Flowers of Pandanus nepalensis, said to be aphrodisiac and induce sleep, are found in Sikkim up to 1752 m altitude and worn by girls in their hair to win their lovers. The plant's roots taken with milk are said to prevent abortion; the flowers are said to remove headache and weakness, and their seeds to cure broken hearts. [14] The healing practices of these three ethnic groups are a mixture of personalistic and naturalistic theories of illness. According to personalistic theories, illness may be linked to transgressions of a moral or spiritual nature. They may involve inappropriate behavior, violation of social norm, or breaches of religious taboos on the part the patient. Naturalistic theories view illness as a disharmony between the person and the environment. Perception of illness is highly culture related. [15]

Uses of medicinal plants in Sikkim
Medicinal plants used by the different folk healers are presented in alphabetic manner with Latin name, distribution, parts used, and the specific disease for which it was used [          The socioeconomic standards of Sikkim folk healers were also studied. It was found that most folk healers (48%) have a monthly income in the range Rs.1000-3000, while only 8% folk healers are earn over Rs. 9000 per month[ Table 9]. Most importantly, 80% of the folk healers were ready to find alternative means of earning and wanted to leave their tradition. Also they are not happy with their profession. An attempt was made to know the ways of transformation of existing knowledge in the studied population. It was found that 28(58.33%) folk healers had not transferred their knowledge to anybody, even after the age of 50, 15(31.25%) folk healers had transferred their knowledge to their sons and daughters. [Graph-2] The health traditions of Sikkim are linked with the ancient philosophical systems that make connections between the cosmic and terrestrial, between the outer and inner environment, and between the external and internal body. The people of Sikkim access folk medicine easily from the surroundings for little or no cost, and it is considered effective as well as acceptable as a method of treatment. It would be difficult to change the faith of elderly people in Sikkim in traditional medicine even if allopathic drugs were available. They are scared to use modern medicine as allopathic medicines are strong and chemical-based, need doctor's prescription, and are not free of side effects.
Health professionals need to understand that what patients believe about their illness and which methods of cure they consider effective and acceptable are as culture related as their perception of illness.

Case study of folk healing practice
Mr Chintamoni Dabani [ Figure 1] of Chengay Lakha, East Sikkim, is a traditional folk healer aged about 60 years; he has been successfully practicing herbal medicine for 40 years having acquired his knowledge from his father. He treats ailments such as fever, jaundice, gastritis, wounds, burn, female disorders, and infertility.
An example of his method of treating fever is as follows: a patient came to his house having been suffering from fever with headache for 2 days. He checked the patient's pulse and advised him to take decoction of Swertia chirayata stem and leaves 3-4 times daily for 3 days. The patient returned to normal after 3 days without allopathic medicine. In Figure 2, another folk healer is seen displaying his medicine in a market.

CONCLUSION
Of Sikkim's rich plant biodiversity, the 31 medicinal plants in the table 1 are the most used in traditional healing practices. Scientific validation, reverse pharmacological and observational studies are required for them, and for the various belief-based treatments of the three Sikkim communities. Then, this traditional knowledge could be utilized for primary health care, and to generate employment. Sikkim's folk traditions are gradually declining in this Trans Himalayan region, as few in the new generation are coming forward to adopt folk healing practice as a profession. There is a significant shift in the socioeconomic pattern of so the folk healers of Sikkim, the department of AYUSH is actively trying to revitalize Sikkim's local health traditions and folk healing practices by conducting training workshops and seminars. The challenges are to educate folk healers about their weaknesses and strengths, to attract young stars to adopt this profession by means of monetary benefits, and to preserve the knowledge and in the face of modernization. The greatest challenge in this new millennium is to integrate the traditional knowledge with modern medicine, identify molecules for use in modern medicine, to decelerate the pace of environmental degradation, and to make the region's economic development eco-friendly.