Traditional medicinal plants used to treat cancer, tumors and inflammatory ailments in Harari Region, Eastern Ethiopia

Traditional medicinal plants used to treat cancer, tumors and inflammatory ailments in Harari Region, Eastern Ethiopia

South African Journal of Botany 122 (2019) 360–368 Contents lists available at ScienceDirect South African Journal of Botany journal homepage: www.e...

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South African Journal of Botany 122 (2019) 360–368

Contents lists available at ScienceDirect

South African Journal of Botany journal homepage: www.elsevier.com/locate/sajb

Traditional medicinal plants used to treat cancer, tumors and inflammatory ailments in Harari Region, Eastern Ethiopia N.F. Bussa a, A. Belayneh b,⁎ a b

Haramaya Institute of Technology, Department of Food Science and Post-harvest Technology, Haramaya University, P.O. Box 138, Dire Dawa, Ethiopia School of Biological Sciences and Biotechnology, College of Natural and Computational Sciences, Haramaya University, P.O. Box 282, Dire Dawa, Ethiopia

a r t i c l e

i n f o

Article history: Received 13 April 2018 Received in revised form 5 June 2018 Accepted 21 March 2019 Available online 5 April 2019 Edited by B. Van Wyk Keywords: Cyphostemma adenocaule Ethnomedicine Gofla Hydnora abyssinica Keledo

a b s t r a c t Global health reports indicated that cancer and inflammatory ailments are increasing and the highest cause of mortality. These health problems are alarmingly increasing and becoming the national health concern of Ethiopia. It is well recognized that the use of medicinal plants in the treatments of diseases, including cancer and inflammation, are common in traditional medicine. Therefore, this study explored age-old traditional practices of using medicinal plants used to treat cancer locally called gofla, tumor local called keledo, and inflammatory ailments by Harari and Oromo communities. Semi-structured interviews, discussions and guided field walks constituted the data collection methods from 72 (52 male and 20 female) systematically selected informants including 12 traditional herbalists (key informants). Informant Consensus Factor (ICF), Relative Frequency of Citation (RFC), Fidelity Level (FL), Relative Importance Index (RI), Cultural Importance Index (CII), and binomial test were employed in data analysis. Thirty-nine traditional medicinal plant species in 38 genera and 29 families were used for cancer, tumor, and body inflammations treatments. Remedial preparations added to 50 formulations for the treatment of 17 different ailments listed under the three major categories. Preparation of paste from fresh parts accounts for 20% followed by concoctions of respective parts for internal application (18%) and crushed fresh parts for topical application (16%). There was no significant difference in ICF values of the three categories (p N .05), i.e. tumor (0.91), inflammations (0.89), and cancer (0.88). RFC values ranged from 0.79 to 0.06 and FL from 46.67 to 66.67%. The highest RFC was recorded for Cyphostemma adenocaule (0.79), followed by Hydnora abyssinica (0.75), Zanthoxylum usambarense (0.73), and Plumbago zeylanica (0.68). The study area harbored valuable traditional medicinal plant species used for the treatment of cancers, tumors, and inflammations and reputable indigenous knowledge, which attracted the phytochemical and pharmacological analyses as well as the conservation of species and associated ethnomedicinal knowledge. © 2019 SAAB. Published by Elsevier B.V. All rights reserved.

1. Introduction Cancer and inflammatory problems are among the most prominent human diseases, which have stimulated scientific and commercial interest in the discovery of newer anticancer, anti-tumor, and antiinflammatory agents from natural sources (Mbaveng et al., 2017). Approximately 60% of drugs used for cancer treatment have been isolated from natural products (Reddy et al., 2003; Gordaliza, 2007) including chemotherapeutic drugs from plant products such as vinblastin, vincristine, terpenoids, phenolics, Taxus diterpenes, and Podophyllum lignans (Cragg and Newman, 2005; Tan et al., 2006; Kaur et al., 2011). More than 3000 plant species worldwide have been reported to exert cytotoxicity (Graham et al., 2000; Stankovic et al., 2011; Solowey et al., 2014), although this is thought to be a conservative estimate of less than 10% of the estimated number of plant species on Earth. ⁎ Corresponding author. E-mail address: [email protected] (A. Belayneh).

https://doi.org/10.1016/j.sajb.2019.03.025 0254-6299/© 2019 SAAB. Published by Elsevier B.V. All rights reserved.

The main strategies used for the selection of plant species in cancer/ tumor/inflammatory drug discovery include random screening, chemotaxonomic information, and ethnomedical knowledge (Alonso-Castro et al., 2011; Solowey et al., 2014). For example, the cytotoxic effect exerted by crude methanolic extract of Vernonia glaberrima leaves and its phytoconstituents against taste cell lines has verified the ethnomedicinal use of the plant against skin cancer (Alhassan et al., 2018). In addition, the preparation procedures indicated in traditional systems can also suggest the best extraction method for bioactive constituents (Alonso-Castro et al., 2011). Therefore, documenting and safeguarding traditional medicinal plants and their associated indigenous knowledge have become central issues in natural resource management. In Ethiopia, sacred forests associated with church sights have assumed great biocultural importance in the conservation of biodiversity in the highly fragmented natural vegetation of the country. The ancient city of Harar, which is more than 1000 years old (UNESCO, 2006), is the capital of the Harari Region. In this ancient and historic

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place, a peculiar mountain, locally known as “Garaa Hakim” (Oromo language) or “Aw Hakim” (Harari language) is the major source of traditional medicinal plants. Though there are additional connotations among the Harari community, the term “Garaa Hakim” or “Aw-Hakim” literally refers to the physicians' mountain. The mountain is still serving the local communities and traditional healers to collect traditional medicinal plants. Due to the diversity of plant species on that mountain, diverse nature habitats of the study area, and ancient history and civilization of the local communities, we hypothesized that the medicinal plant diversity and the value of associated indigenous knowledge would be particularly high. Our ethnobotanical investigation focused on the traditional medicinal plants used by the Harari and Oromo people which have been applied to treat human ailments such as severe wounds, tropical ulcers, cancer (symptomatology locally called gofla) and tumors, swellings on a part of the body (keledo). In addition, dermatological conditions such as hard swellings, abscesses (a swollen area within body tissue, containing an accumulation of pus), calluses (thickening or hard-thickened area on skin), itch, skin ulcers, bruises, and warts locally called kintarot were considered. We explored whether the long history of the traditional practices are related to medicinal plant diversity, cultural importance, and informant consensus in the study area, and a decline in indigenous knowledge with respect to the identity and use of traditional medicinal plants in the study area could be detected.

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2. Materials and methods 2.1. Study area The study area, included the historic city of Harar and surrounding areas, located in eastern Ethiopia 515 km from Addis Ababa, the capital city of the country. The elevation ranges from 1300 (Erer Valley) to 2200 (Aw-Hakim Mountain) meters above sea level (m.a.s.l.). The general topography of Harar and the surrounding areas is dominated by mountainous and surging landforms, including rugged terrain, steeply sloping hills, and valley bottoms (HPRS PEDB, 2015). The Hakim Mountain is located at the southern margin of Harar and it forms the highest peak (2200 m.a.s.l.) of elevation, having a north to south orientation (Fig. 1). The mean annual daily temperature is 19.2 °C, while the annual mean minimum and mean maximum daily temperatures are 13.0 and 25.2 °C, respectively. The warmest months are February to May while the coldest months are November, December, and January. The length of growing period ranges from 94 to 135 days, which has recorded fluctuations of 5–10 days in 10 years (HPNRS-PEDB, 2015). The annual rainfall is highly variable ranging between 275 and 1000 mm and the mean annual rainfall is 669 mm. The rainfall in the region has a weak bi-modal pattern, occurring from February to April (short rainy season) and June to August (long rainy season). The total population of the region is 231,173 (male 116,580 and female 114,592) with annual population growth rate of 2.6% (HPNRS-PEDB, 2015).

Fig. 1. Study area map with sampled KEBELES (the smallest administrative unit in Ethiopia).

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2.2. Ethnobotanical data collection Participatory Rural Appraisal (PRA) techniques were employed to collect data, as recommended by Martin (1995) and Cunningham (2001). Ethnobotanical data were collected in two different rounds, from April to May 2016 and August to September 2017. The data were collected from six randomly sampled Kebeles the smallest administrative units in Ethiopia, two urban and four rural Kebeles, Gelmeshira and Harar Ketema from urban locations, and Sofi, Awu-Umer, Erer Hawaye, and Hasengedo from rural Kebeles (Fig. 1). Ethnobotanical information on medicinal plants, particularly those used for treating cancer, tumors, and inflammation treatments, were collected from 72 informants (52 men and 20 women) who belonged to Harari and Oromo communities. Among these, 12 key informants (traditional healers) were selected with the assistance of community leaders, elderly people, and members of local community. Purposive sampling techniques were used for selecting key informants (2 women and 10 men), while stratified random sampling was used to select informants (40 men and 20 women). Households at the selected study sites were registered and stratified into three age groups, youths (25–35, n = 30), adults (35–60, n = 22), and elders (above 60, n = 8) to find out how the knowledge varies with age. Before carrying out the interviews and group discussions, traditional ceremonies and blessings of the Harari and Oromo cultures were conducted and oral Prior Informed Consents (PIC) obtained from every respondent. Semi-structured interviews with the 72 informants and group discussions (six groups were formed with average members of five per group) were administered in the local languages, Harari and Afan Oromo. Basic information was collected regarding the local name (s) and traditional descriptions of the medicinal plant species used for cancer, tumors, and inflammations, specific types of ailments treated or controlled in these categories, plant parts used, conditions and methods of preparations, routes of remedial administration, and any major drawbacks or side effects of using the plants for medicine. Practical observation sessions were conducted while the traditional healers were preparing remedies and treating the patients. In addition, guided field walks with key informants were employed to collect voucher specimens of each medicinal plant species, with notes and photographic documentation. Additional interviews with key informants were carried out in the field to ensure that evidence was gathered for the plant species identified in habitat by the key informants. These activities were conducted twice with each informant to confirm the validity and reliability of the species identification and recorded information. Specimens were collected and numbered, and later identified using taxonomic keys in the relevant volumes of the Flora of Ethiopia and Eritrea (Hedberg and Edwards, 1989; Edwards et al., 1995, 1997, 2000; Hedberg et al., 2006a) and through visual comparisons with authenticated plant specimens kept at the Herbarium of Haramaya University (HHU). Two voucher specimens per species were deposited in HHU.

2.3. Data analysis The ethnobotanical uses were analyzed following Martin (1995) and Cotton (1996). Total number of plant species; growth forms (trees, shrubs, climbers, herbs) in percentage; parts used; number of remedies prepared; number of ailments treated in the three disease categories; formulation types, and route of administration were all assessed. The quantitative analysis was focused on the degree of agreement among the different informants concerning the use of plant species, the benefits, and importance to treat cancer, tumors, and inflammatory ailments. Quantitative indices including Informant Consensus Factor (ICF), Relative Frequency of Citation (RFC), Fidelity Level (FL), Cultural Importance Index (CII), Diversity of Uses (DU), and Relative Importance Index (RI) were calculated.

2.3.1. The informant consensus factor (ICF) The ICF of each medicinal species, describing the proportion of informants who independently reported its use against a disease category, was calculated using the formula Trotter and Logan (1986): ICF ¼ ðnur–ntÞ=ðnur–1Þ where, nur is the “number of use-reports in each disease category” and nt refers to “the total number of species used for that disease category”. 2.3.2. Relative frequency of citation (RFC) The RFC index of each medicinal plant species documented in this study was calculated based on the Frequency of Citation (FC) values as follows (Tardío and Pardo-De-Santayana, 2008): RFC = FC/N, where N is the total number of informants. FC was calculated as FC = (Number of times a particular species was mentioned)/(total number of informants) × 100. Then the RFC index was calculated by dividing the FC value of each species by the total number of informants participating in the survey (N). 2.3.3. Fidelity level (FL) The fidelity level (FL), the percentage of informants claiming the use of a certain plant for the same major purpose, was calculated according to the following formula (Alexiades and Sheldon, 1996): FLð%Þ ¼ Np=Nt100 where “Np” is the number of informants who independently suggested the use of a plant species for a particular use (single use mention); ‘Nt’ is the total number of informants who mentioned the same plant for any other uses (total use mention). 2.3.4. Relative importance index (RI) According to Tardío and Pardo-De-Santayana (2008), this index was calculated with the following equation: RIs ¼ fRFCsð maxÞ þ RNUs ð maxÞg=2 where, RFCs (max) is the relative frequency of citation over the maximum, which is obtained by dividing FCs by the maximum value in all species of the survey {RFCs (max) = FCs/max(FC)}. RNUs (max) is the relative number of use-categories over the maximum, obtained dividing the number of uses of the species by the maximum value in all species of the survey {RNUs (max) = NUs/max (NU)}. 2.3.5. Cultural importance (CI) and use diversity (UD) The cultural importance index (CI) is the sum within species across all plant-uses of the number of informants reporting a plant-use over the number of informants reporting the plant (Tardío and Pardo-DeSantayana, 2008); diversity of uses (DU) is the Shannon Index of uses (Begossi, 1996). A binomial test was run using the R package OneTwoSamples (Zhang, 2013) to evaluate the depth of knowledge with age categories in which pair wise age category test was considered. Two-sample t-test (Zhang, 2013) was also run to evaluate the depth of knowledge between traditional healers and randomly selected informants. P-value of less than 0.05 was taken as indicative of a statistically significant difference. 3. Results and discussion 3.1. Diversity of medicinal plants and their uses A total of 39 plant species belonging to 38 genera and 29 families, which are used to treat cancer, tumors, and inflammatory ailments were identified and documented among the traditional healers (key

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Table 1 List of traditional medicinal plants used for cancer, tumor, and inflammation treatments with their Relative Importance Index (RI) values. Family

Scientific name/voucher No.

Vernacular name

Habit PU

Disease treated

MP and PA

RI index

Acanthaceae

Boke (O)

H

Root

Internal cancer

Kontomme(O)

H

Leaf

Anacardiaceae

Ozoroa insignis Del./AHU49

T

Root

Crushed and bandage

0.29

Apiaceae

Heteromorpha arborescens (Spreng.) Cham. & Schltdl./AHU80 Pimpinella ahmarensis Abebe*/AHU74 Caralluma speciosa (N.E. Br.) N.E. Br./AHU11 Caralluma speciosa N.E. Br. Caralluma speciosa N.E. Br.

Rukeylu, Garri (O) Ali-hanqaa(O)

Cancer/inflammation/ gofla Tropical ulcer

Crushed, boiled with coffee husk locally called HASHARA and used like tea Boil leaf paste with edible oil and drink

0.28

Amaranthaceae

Blepharis maderaspatensis (L.) B. Heyne ex Roth/AHU70 Pupalia lappacea (L.) Juss./AHU172

Sh

Leaf

Powder put on wound

0.31

Harmel(O)

H

Root

Tropical ulcer/severe wound External body swelling

Concoction taken oral

0.37

Ya'ii Bera (O)

H

Stem

Gangrene

0.55

H H

Stem Stem

External body swelling Under skin cyst

0.56 0.56

Harmel hari (O)

Sh

Leaf

gofla on head

Powdered with stem of Gloriosa superba and bandage Crushed and bandage Ground with Gloriosa superba stem and bandage Paste mixed with butter and bandage

Saritii, hiddii saree (O) Kerebicho(H,O)

CSh

Root

Breast tumor

Concoction taken oral

0.31

Sh

Kleinia pendula (Forssk.) DC./AHU205 Senecio lyratus Forssk./AHU84

Afrasha(O)

PH

Tuberous root Stem

Internal cancer (soft tissue sarcoma) External body swelling

Ground with Hydnora johannis tuber and put 0.4 in the daily food as well as drink a solution Warm decoction bandage on swollen part 0.24

Bal-kutal(H)

PH

Campanulaceae

Canarina abyssinica Engl./AHU71

Harmel (O)

CH

Capparis sepiaria L./AHU25

Riga gange (O)

Sh

Boiled with tea or coffee husk/HASHARA or coffee leaf/KUTI and drink Concoction rub on swollen part and drink filtrate Crushed and bandage

Colchicaceae

Gloriosa superba L./AHU110

Harmel Kubra (O)

CH

Leaf

Internal cancer (soft tissue sarcoma) Leg swelling (leg hematoma) Swollen part & suppurated Under skin cyst

0.38

Capparidaceae

Leaf and root Tuberous root Leaf

Paste tied on tumor

0.44

CH

Leaf

Gangrene

0.45

Internal cancer

Crushed with succulent Caralluma speciosa and dressing Concoction taken oral and fresh tuber eaten Warmth and tie on it

0.28

Paste tie on head

0.26 0.65

Asclepiadaceae

Asparagaceae

Gomphocarpus fruticosus (L.) Ait.f subsp. flavidus (N.E. Br.) Goyder/AHU79 Asparagus africanus Lam./AHU153

Asteraceae

Echinops kebericho Mesfin*/AHU78

Gloriosa superba L. Convolvulaceae

0.21

0.27

0.41

0.28

Gumna-kul(O, H) Hidi (O)

Sh

Cucurbitaceae

Ipomoea marmorata Britt. & Rendle/AHU98 Cucumis prophetarum L./AHU217

CH

Tuberous root Fruit

Fabaceae

Acacia brevispica Harms/AHU122

Hameyssaa (O)

Sh

Leaf

Hydnoraceae

Hydnora abyssinica A.Br./AHU28

Shifa'a weyn (H), Tuqa (O)

HPH

Bark and root

HPH PH

Root Root

External body swelling External body swelling

Ground with Echinops kebericho tuber and put in the daily food as well as drink a solution Decoction taken oral Paste tie on swollen part

Digelo Serkema (O) Roman (H) Bal-toke (O)

E

Breast swelling

Concoction taken oral

0.27

External body swelling External body swelling

Decoction and drink hot infusion Crushed and bandage

0.28 0.45

Hidda hantuutaa (O) Bal-toke (O)

CH

Stem and leaf Fruit Tuberous root Root

External tumor/ keledo

Paste and bandage

0.26

H

Cancer-external sever swelling External body swelling

Crushed and inserted through small opening 0.27

Shunkurta Gara (O)/Yari-muz (H) Merxas(O)

Tuberous root Bulb and leaf

External body swelling Internal cancer

Concoction filtrate taken oral Decoction and drink hot infusion

0.95 0.73

H

Root Root and leaf Root

Paste and bandage

0.78

Maymaqoo(O) Maymaqoo(O) Saqamonya

PH PH H

Rhizome Rhizome Root

Bone cancer (osteonecrosis) Internal cancer Breast cancer Internal cancer

Decocted hot infusion taken oral Concoction taken oral Concoction taken oral

0.26 0.26 0.23

Kurkura (O)

T

Leaf

External body swelling

Concoction used as herbal bath

0.21

Laleeysaa(O)

PH

Root

External body swelling

0.27

Geda(O)

Sh

Leaf

External body swelling

Decoction used oral as hot infusion and for soft massage on swollen part Decoction and spoonful filtrate in a cup of tea taken oral

Hydnora abyssinica A.Br. Ocimum cufodontii (Lanza) A.J. Paton/AHU81 Loranthaceae Erianthemum aethiopicum Wiens & Polhill/AHU88 Lythraceae Punica granatum L./AHU208 Menispermaceae Cissampelos mucronata A. Rich./AHU94 Stephania abyssinica (Dillon & A. Rich.) Walp./AHU91 Moraceae Dorstenia barnimiana Schweinf./AHU97 Eulophia petersii Rchb.f/AHU163 Orchidaceae Lamiaceae

Plumbaginaceae

Plumbago zeylanica L./AHU147 Plumbago zeylanica L.

Unknown

Plumbago zeylanica L. Polygonaceae

Rubiaceae

Rumex abyssinicus Jacq./AHU90 Rumex abyssinicus Jacq. Delphinium dasycaulon Fresen./AHU96 Ziziphus spinachristi (L.) Desf./AHU82 Rubia cordifolia L./AHU83

Rutaceae

Toddalia asiatica (L.) Lam./AHU86

Ranunculaceae Rhaminaceae

T CH

PH

H H

Wound and Swollen body part Cancer related fever (Hyperpyrexia) Internal cancer

0.31

0.83 0.23

Cooked bulb eaten and smoke bath, dressing 0.5 with leaf paste

0.28

(continued on next page)

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Table 1 (continued) Family

Scientific name/voucher No.

Vernacular name

Habit PU

Disease treated

MP and PA

RI index

Geda(O)

Sh/T

Bark

0.37

Geda(O)

Sh/T

Bark

Paste and bandage

0.65

Qamaxari (O)

H

Leaf

Paste tie on swollen part

0.21

Solanum nigrum L./AHU85

Hidi (O)

H

Leaf and fruit

Paste and bandage

0.36

Sh PH

Root Stem and leaf Tuberous root Tuberous root Root

Mild under skin swelling Swelling of joints (arthritis) Mild under skin swelling Painful and expanding swelling on finger (algia) Under skin tumor Internal cancer

Concocted and filtrate taken oral

Solanaceae

Zanthoxylum chalybeum Engl. Var chalybeum/AHU89 Zanthoxylum usambarense (Engl.) Kokwaro/AHU87 Datura stramonium L./AHU95

Crushed and tied on tumor Concoction filtrate taken oral

0.23 0.32

External body swelling

Crushed and bandage

0.86

Suppurating wounds

Powdered and bandage

0.63

Internal cancer

Concoction taken oral

0.28

Verbenaceae Vitaceae

Witenia sominifera (L.) Dunal/AHU50 Hide-budei (H) Chascanum gillettii Bal-kutal (H) Moldenke/AHU93 Cyphostemma adenocaule (Steud. ex Harmal adi (O) A. Rich.) Desc./AHU76 Cyphostemma adenocaule (Steud. ex A. Rich.) Desc. Rhoicissus tridentata (L. f) Wild & Drummond/AHU92

Buri guraa sedi (O)

CH CH CSh

⁎endemic species, Sh-shrub, T-tree, ST-Shrub/tree, CH-climbing herb, CSh-Climbing shrub, PH-Perennial herb, H-herb; HPH-Holo-parasitic herb; E- Epiphyte, Part Used (PU), Method of Preparation (MP); Part Administered (PA), O-Oromo language, H-Harari language.

informants) and randomly selected informants of Harari and Oromo communities. Seventeen of these medicinal plant species (43.5%) belonged to 7 families and the remainder (56.5%) were distributed to 22 families, with just 1 species per family. The three families, Asteraceae, Rutaceae, and Solanaceae were represented by three species each followed by Apiaceae, Asclepiadaceae, Menispermaceae, and Vitaceae had two species each. The documented traditional medicinal plants showed diversity at the species, genus and family levels (Table 1). All 38 plant species were collected as wild in the natural vegetations, whereas one species (Punica granatum L.) was found in cultivation as a fruit tree. The mount Hakim-Gara/Aw-Hakim study area harbors high levels of botanical diversity and is a well-known site for collection of traditional medicinal plant species. Twenty-nine of these medicinal plant species (74.4%) were collected from this mountainous landscape. As stated by 78% of the respondents, the name “Hakim-Gara” could also refer to the healing mountain since “Hakim” refers to physician and “Gara” refers to mountain. Most of the plant species reported in this study were also reported by different authors as used for the same health problems (Akah and Nwafor, 1999; Bosch, 2004; Matu, 2011; Anteneh et al., 2012; Chinsamy et al., 2014; Ochwang'i et al., 2014; Tuasha et al., 2018; Worku, 2016); examples include Cissampelos mucronata A. Rich., Cyphostemma adenocaule (Steud. ex A. Rich.) Desc., Echinops kebericho Mesfin, Eulophia petersii Rchb.f, Gloriosa superba L., Hydnora abyssinica A. Br., Plumbago zeylanica L., and Zanthoxylum usambarense (Engl.) Kokwaro. As the heritage site, beyond traditional medicinal plants used to treat cancer, tumor, and inflammatory ailments, the study area could harbor diverse ethnospecies used for various disease categories. A comprehensive ethnomedicinal study conducted in the other heritage site, Dire Sheikh Hussein, in the southeast of Ethiopia, indicated that the heritage site harbors various medicinal plants including those medicinal plants that have been widely used long time ago (Demie et al., 2018). Disease concepts for cancer, tumors and inflammation are described broadly by the well-known generic local names called “gofla” and “keledo” used among the traditional healers and communities. Gofla is the generic name understood generally as benign and malignant cancers among the Oromo and Harari communities. Goflas are internal and external types of tumors from an emic perspective and, in most cases, the internal gofla were known to be cancer. Local communities and traditional healers recognized external swollen body parts as external gofla, referring to external inflammations. Similarly, the generic local term keledo is used for tumors of different types including subcutaneous cysts and swellings. This could be considered as culture-bound and local

classifications, which have to be understood from an emic perspective. During fieldwork, ethnopharmacologists and medical anthropologists aim to understand the classification of diseases and illnesses from within the culture (Peter et al., 2015; Demie et al., 2018). Analysis of the growth habits of the plant species showed that annual herbs constitute the highest number of species (nine species) and epiphyte (Erianthemum aethiopicum Wiens & Polhill) and Holoparasitic herb (Hydnora abyssinica) were the least number of species, each represented by one species. Most of the documented species were annual herbs (23.1%), followed by shrubs (20.5%), and perennial herbs (17.9%). These three growth forms constituted 61.5% of the traditional medicinal plants used to treat cancer, tumor, and inflammatory ailments (Fig. 2). Similar results were reported with corresponding studies conducted elsewhere (Ghorbani et al., 2011; Anteneh and Negussie, 2014; Malla et al., 2015; Faruque et al., 2018). This can be related to the floristic composition of the study area, which is dominated by bush and scrubland vegetation types with diverse herbaceous understory and climbing plants on the mount Hakim-Gara/Aw-Hakim, valleys, gorges, and rocky mountains. The use of herbaceous plant species for traditional medicinal purpose are more preferred than woody plants due to comparative ease of collection, simplistic remedial preparation, and could have little impact on the conservation of source natural vegetation (Giday et al., 2007; Ermias et al., 2013; Malla et al., 2015). Among the reported medicinal plant species, 8 different plant parts were used for 50 remedial preparations (Fig. 3). The roots were the most utilized plant parts (30.3%) followed by leaves (28.4%), and tuberous root (13.2%) in the formulations. The collection of root parts for

Holoparasitic herb

Percentage

Epiphyte

Number of species

Shrub/tree Climbing shrub Tree Climbing herb Perrenial herb Shrub Annual herb 0

5

10

15

20

25

Fig. 2. The distribution of traditional medicinal plant species in growth form/habit.

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18 16 14 12 10 8 6 4 2 0

35 30 25 20 15 10 5 0

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medicine. There are a number of reports in the literature regarding the lack of precision for oral doses as a major drawback on the application of traditional medicinal plants (Giday et al., 2007; Birhan et al., 2011; Ermias et al., 2013). This could have serious health repercussions in comparison to the ailments, which are treated by the traditional medicine. For example, a study suggested that the powder preparation as well as ethanolic extract of Hydnora abyssinica roots induced toxic effects on Wistar rats. Although the observed toxic effect might be due to the dosage and/or frequency of administration, it should be noted the necessity of standardization of the drugs in traditional medicine (Yagi et al., 2011). 3.3. Frequency of citation (FC) and fidelity level (FL)

Fig. 3. The use of different plant parts in remedial preparation, number, and percentage of preparations per plant part.

medicinal purpose could have an effect on the survival of the plant (Cunningham, 2001; Anteneh et al., 2012). The most frequently used plant parts are roots and tubers (43.4%). Harvesting medicinal plants is therefore destructive to the natural vegetation of the study area but likely to be sustainable, since 82% of the remedies prepared from roots and tubers were from herbaceous annuals, and their harvesting could have little impact on the floral diversity of the study area. 3.2. Methods of preparation and routes of administration The informants reported 50 different remedial preparations, categorized into 11 types, from the 39 medicinal plant species used to treat cancer, tumors, and inflammatory ailments. In the traditional system, 17 different human ailments in three major categories of cancer, tumor, and inflammations were recognized. Out of the total formulations, 20% were prepared in the form of paste from fresh parts, of which 18% were used for internal application and crushed fresh parts constituted 16% for external application (Table 2). The majority of remedies (89%) were prepared from a single species. Exceptions included the stems of Caralluma speciosa N.E. Br. and Gloriosa superba pulverized together and bandaged for gangrene, as well as the root of Echinops kebericho and bark of Hydnora abyssinica minced and taken orally with daily meal for internal gofla. A number of sources (Giday et al., 2007; Anteneh et al., 2012; Malla et al., 2015; Demie et al., 2018) have also reported that a single medicinal plant species was used more frequently for remedial preparations. Oral route of administration (internal usage) and topical (dermal) applications (external usage) were equally represented as modes of administration. A lack of uniformity was frequently observed among informants regarding the doses recommended for oral remedies during prescription and treatment, especially in relation to the route of administration, where oral application accounted for 50% and lack of precise dose could be a major problem for the efficacy and side effects of the Table 2 Methods of remedial formulations of the traditional medicinal plants by the users and traditional healers and number of their preparations. Methods of remedial formulation types

Number of preparations

Percentage

Paste from fresh parts Concoctions Crushed Hot infusion Powdered Concoctions and filtrate Decoctions Dried for smoke bath Cooked parts eaten Fresh parts eaten raw Warmth

10 9 8 7 6 4 2 1 1 1 1

20 18 16 14 12 8 4 2 2 2 2

The 10 top plant species with the highest frequency of citation based on overall effectiveness to treat cancer, tumors, and inflammations were analyzed separately for the two groups of informants, traditional healers (n = 12) and randomly selected informants (n = 60). Among the 10 top plant species, Cyphostemma adenocaule has the highest FC value i.e., traditional healers (71.3%) and randomly selected informants (41.1%), used to treat external body swelling (edema). Whereas, Canarina abyssinica Engl. has the least FC value for both informant groups, traditional healers (36.4%) and randomly selected informants (18.8%), which has been used to treat leg swelling or leg hematoma (Table 3). The higher frequency of citation showed the importance of the species for the local communities and attracted more attention for their conservation and scientific evaluation in the study areas (Martin, 1995; Cunningham, 2001). Though the species types and diseases treated correspond between the two informant groups traditional healers (TH) and randomly selected informants (RI), the two-sample t-test result indicated that there was significant difference (p N .05) of FC values between TH and RI (t = 6.0705, df = 21.1, p = 2.05e-06). The depth of knowledge of medicinal plant species for informants within the age category ranged 25–35 (youth) was found to be relatively low (p = .007) whereas for informants within the age category above 60 (elderly) was rich (p = .002). The depth of knowledge of informants within the age category ranged 36–60 (adult) was (p = .004). The binomial test (b = 3.09, SD = 64.2, p = 1.08e-03) on the depth of ethnomedicinal knowledge between young, adult, and elderly informants showed significant differences (p N .05) with a higher value of standard deviation (SD), which could be attributed to the difference in number of sample size. The age group above 60 were represented by least number (n = 8) compared to young (n = 30) and adult (n = 22) age groups. This was due to the demographic characteristic of the population where elderly people accounted for only 3.3% of the total population. Therefore, an elderly Table 3 Plant species with the highest frequency of citation based on overall effectiveness to treat the corresponding human ailments. No.

Plant species

Disease(s) treated

FC(%) of TH

FC(%) of RI

1

Cyphostemma adenocaule

2 3

Zanthoxylum usambarense Plumbago zeylanica

4

Hydnora abyssinica

5 6 7 8 9 10

Cissampelos mucronata Senecio lyratus Echinops kebericho Zanthoxylum chalybeum Pimpinella ahmarensis Canarina abyssinica

External body swelling Suppurating wounds Swelling of joints External body swelling Bone cancer/osteonecrosis Internal cancer External body swelling Internal cancer External body swelling Internal cancer Internal cancer Mild under skin swelling External body swelling Leg swelling

71.3 52.4 64.6 64.2 54.0 38.6 62.2 54.5 51.6 48.0 46.4 42.4 42.0 36.4

41.1 34.2 40.0 38.4 32.0 22.4 38.0 32.6 30.4 35.0 28.6 22.0 22.6 18.8

FC = frequency of citation, RI = randomly selected informants, TH = traditional healers (key informants).

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Table 4 The fidelity level (FL) of top five species, which have been resulted above 50% FC. No.

Plant species

Disease(s) treated

Np

Nt

FL(%)

1 2

Zanthoxylum usambarense Hydnora johannis Cissampelos mucronata Cyphostemma adenocaule

5

Plumbago zeylanica

38 40 23 22 41 23 35 22 18

57 63

3 4

Swelling of joints External body swelling Internal cancer External body swelling External body swelling Suppurating wounds External body swelling Bone cancer Internal cancer

66.67 63.49 36.51 62.86 54.67 30.67 46.67 29.33 24.00

35 75 75

FC = Frequency of Citation; Np = the number of informants who independently suggested the use of a plant species for a particular use (single use mentioned); Nt = the total number of informants who mentioned the same plant for any other uses (total use mentioned).

person would have the least probability to be captured in the random sampling method. There is a significant difference between TH and RI in depth of knowledge about the traditional medicinal plants used for the treatment of cancer, tumors, and inflammations. In addition, the elderly people in the age category above 60 had a profound knowledge of the type and usage of medicinal plants than the young (Hedberg and Edwards, 1989; Hedberg et al., 2006a; Hedberg et al., 2006b; HPNRS, Planning and Economic Development Bureau (PEDB), 2015; Kaur et al., 2011; Malla et al., 2015; Martin, 1995; Matu, 2011; Mbaveng et al., 2017; Muzila, 2006; Muzila, 2008) and adult (36–60) age categories. Our findings attest to alarming deterioration of indigenous knowledge of medicinal plants in this culturally important world heritage site. The difference in depth of knowledge and the decline of indigenous knowledge of traditional medicinal plants and their usage between generations is cause for concern (Ermias et al., 2013; Anteneh and Negussie, 2014; Demie et al., 2018). Wide scale ethnobotanical study is needed to urgently document indigenous knowledge. The Relative Frequency of Citation (RFC) values for species identified in this study ranged from 0.79 to 0.06. The highest RFC above 0.50 was recorded for Cyphostemma adenocaule (0.79), followed by Hydnora abyssinica (0.75), Zanthoxylum usambarense (0.73), and Plumbago zeylanica (0.68). The fidelity level (FL) quantifies the importance of a species for a given purpose. In this respect, the top five plant species, with above 50% FC (Table 3), were further analyzed for FL in percentage. Then four plant species showed FL above 50% for at least one specific disease treated by these plant species (Table 4). The change in their rank could be attributed to the effect of total use mentioned, which had an impact on the value of FL of a particular traditional medicinal plant for a particular disease type. Plumbago zeylanica showed less than 50% FL in all disease categories mentioned. This could be due to a relatively high number of use-reports, which might have reduced the FL value. The RFC values showed a substantial level of agreement on the therapeutic value of the traditional medicinal plant species in the study area. The ethnomedicinal plants species having high RFC values indicated abundant application and widespread knowledge of them among the local communities (Faruque et al., 2018) and further afield. For example,

leaves of Cyphostemma adenocaule heated over a fire are applied, as a compress, to reduce swellings in east African countries (Bosch, 2004). A paste made from roots was applied topically to draw abscesses and reduce swellings in northern Ghana, and the root has been investigated for the presence of compounds with anti-inflammatory, antimicrobial and antitumor activities in South Africa (Bosch, 2004). Phytochemical studies revealed the presence of alkaloids and glycosides which are reported for the first time being characteristic of the root of Hydnora abyssinica while tannins, phenols, steroids, flavonoids, terpenoids, and fatty acids confirms reports of other similar studies on the Sudanese Hydnora abyssinica (Yagi et al., 2012; Onyancha et al., 2015). The phenolic compounds in this case flavonoids and tannins, possess biological properties such as anti-carcinogen, anti-inflammation, antiarteriosclerosis, cardiovascular protection, and improvement of endothelial function as well as inhibition of angiogenesis and cell proliferation activities (Yadav and Agarwala, 2011). A stem bark and root bark decoction of Zanthoxylum usambarense is commonly taken by the Maasai people for the treatment of malaria, backache, painful joints and rheumatism and also as an emetic and purgative (Matu, 2011). Wide variety of alkaloids has been isolated from the stem bark and root bark of Zanthoxylum usambarense (Matu, 2011). The root paste Plumbago zeylanica contains plumbagin, which can be applied for the treatment of muscular pain, rheumatic diseases, sore and generalized swelling in India (Sharma and Kaushik, 2014). Cissampelos mucronata (FL = 62.86%) has a potential medicinal value as an anti-ulcer agent and is mainly traded in local markets in Africa (Akah and Nwafor, 1999; Muzila, 2006; Muzila, 2008). In, general ethnomedicinal systems and studies laid the foundation for such in-depth studies and validated the claimed traditional values among the diverse cultural communities.

3.4. Informant consensus factor (ICF) A total of 17 different ailments were reported and categorized under the broad definitions of cancer, tumor, and inflammation. The ICF values of these three broad categories ranged from 0.88 to 0.91. The ICF analysis showed relatively high values indicating the higher consensus in the treatment of these health problems in the study area. The highest ICF value 0.91 was for tumors (nine species used) followed by 0.89 for inflammations (17 species used), and relatively small ICF value was 0.88 for internal cancer (23 species used) locally have generic name of gofla (Table 5). Though there was a slight difference in ICF values, warranting pharmacological investigation, it was in line with previous studies (Giday et al., 2007; Ermias et al., 2013; Anteneh and Negussie, 2014; Faruque et al., 2018) where the ICF value were greater than 0.5 clusters. The cultural importance (CI) and use diversity (UD) indexes placed Cyphostemma adenocaule, Hydnora johannis, Cissampelos mucronata, Zanthoxylum usambarense, and Senecio lyratus ethnospecies in the top rank (Table 6). In all parameters of importance matrix similar set of traditional medicinal plant species were top ranked except some disorder in their rank between measurable indices. When the ethnospecies have high importance values in all indices, it could elucidate the importance

Table 5 Informant Consensus Factor (ICF) by category of ailment. S. no.

Category of ailment

No. of UR

No. of species

ICF value

1 2 3

Mild to severe Tumor: Under skin cyst, mild tissue inflammation, under skin tumor, breast tumor Inflammations: Breast swelling, leg swelling, painful and expanding swelling on finger, swelling of joints, external body swelling Cancer: Breast cancer, gangrene, bone cancer, cancer on head, severe fever related to cancer, tropical ulcer, internal cancer, sever swollen body part with wound, suppurating wounds

86 149 178

9 17 23

0.91 0.89 0.88

UR = Use report; ICF = Informant Consensus Factor.

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References

Table 6 Cultural importance and use diversity matrix of top 10 ranked TMP. TMP species

CI

UD(H′)

Cyphostemma adenocaule Hydnora johannis Cissampelos mucronata Zanthoxylum usambarense Echinops kebericho Senecio lyratus Plumbago zeylanica Pimpinella ahmarensis Zanthoxylum chalybeum Rumex abyssinicus

1.46 1.34 1.12 0.84 0.64 0.62 0.42 0.34 0.22 0.22

0.68 0.56 0.51 0.43 0.48 0.64 0.44 0.22 0.28 0.38

TMP - Traditional medicinal plants; CI - Cultural importance index; UD - Use diversity.

of those species for the respective applications by the local communities (Paniagua Zambrana et al., 2017). 4. Conclusions This ethnomedicinal study showed that the Harari and Oromo communities in the study area rely on traditional medicinal plant species for the treatment of cancer, tumors, and inflammatory ailments. They are also knowledgeable about the identities and applications of these medicinal plants. Frequency of citation, fidelity level, cultural importance, and informant consensus factor showed that notably Cyphostemma adenocaule, Hydnora abyssinica, Zanthoxylum usambarense, and Cissampelos mucronata are most valued for the treatment of cancer, tumors, and inflammatory ailments by the traditional healers and local communities. The mechanisms of action of these species and their active compounds with anticancer, antitumor, and antiinflammatory effects, need to be studied. It has been stated that about 50% of the preparations were taken internally without paying adequate attention to the precise dosage. Therefore, considering the serious health effect of the prescribed amount, optimal doses for plant extracts in the traditional remedial preparation should be considered seriously. In addition, the result showed the unfortunate decline in ethnomedicinal knowledge in this age-old and prehistoric study area. The deterioration of indigenous knowledge of medicinal plant use between generations could stimulate an urgent ethnobotanical study for in-depth investigation of indigenous knowledge before it is lost. Authors' contributions Both authors NB and AB, designed the study, collected and analyzed the data, and wrote the manuscript. AB identified the medicinal plant species. Both of authors read the final manuscript and agreed on its submission. Competing interests We declare that we do not have competing interests. Funding This work was supported by Haramaya University [grant code: HURG 2015/06/01]. Acknowledgements We would like to acknowledge Haramaya University for financial support and the local communities in general and informants in particular of the study area for their various supports and valuable information in this study. Thanks to the Harari Region culture and tourism office for facilitation of activities during the field work.

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