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Apitherapy in Community-based health care in Nepal
Naomi M. Saville
Paper for the Hive Products Session of the 7th IBRA Conference on Tropical bees: management and diversity
& 5th Asian Apicultural Association Conference, 19-25 March 2000, Chang Mai, Thailand

1 Introduction
'Apitherapy' may be defined as the therapeutic use of bee products including bee venom / bee stings, honey, pollen, beeswax, royal jelly and propolis. The practice of apitherapy has been common in many parts of the world for centuries and recently has received increasing attention from bee scientists (Mizrahi and Lensky 1997) and alternative health practitioners (Rose 1994, Croft 1987, Rowell and MacFarlane, Walji 1996). With knowledge of the potential benefits of apitherapy to the poorest of the poor, a test of apitherapy in village-based health care was made in the district of Jumla, West Nepal.

1.1 Advantages of apitherapy in areas where health services are extremely restricted
Cheap or Free

Safe

Nutritious

Effective

1.2 Jumla district and problems with health services there
Jumla district lies in the least developed Karnali Zone of Nepal, ranking 7th from worst out of 75 districts in terms of a composite index of development (Banskota et al 1997). One doctor is posted in the district hospital to serve the entire population of Jumla (>75,000 people). Despite government provision of health post buildings at strategic points throughout Jumla, staffing by well-trained health workers is insufficient to meet requirements. Often health posts are not staffed or have no or severely restricted medicines. Most health workers lack the necessary diagnostic skills to treat anything except the most common and easily diagnosed diseases. Drugs are inappropriately prescribed and their uses are not well explained to illiterate village people. Even in the treatment of bacterial diarrhoea, amoebic dysentery, giardia and worms (very common intestinal parasites) inappropriate drugs are often prescribed in high dosages, even for young babies. 

Creation of resistance in micro-organisms by not completing the course of drugs is not even well understood by villagers or health workers. Villagers tend only to take drugs prescribed to them until symptoms are relieved. Then, they put them aside to treat another family member when they fall sick, saving trouble and expense. This inappropriate use of anti-microbial medicines has frightening long-term implications throughout the developing world. Overuse coupled with under-dosages is bound to lead to resistance in pathogens eventually. In addition to the inadequacy of government health services in Jumla, attitudes of villagers make it difficult for allopathic treatment to be effective. Many people reach the hospital and die soon afterwards, because treatment started too late. This then reinforces village the concept that the hospital is a place to be avoided whenever possible. Prior to visiting the hospital, villagers use local shamans or faith healers, and / or locally available (ayurvedic) herbs. Such treatments could be improved by the judicious application of bee products. Cold mountain climatic conditions, carrying of extremely heavy loads with poor footwear, insufficient clothes, and malnutrition cause high incidence of arthritis, back pain, infertility and other problems. Heavy work (such as dealing with axes, sickles, firewood and timber, manual weeding and digging, washing pots and clothes with ashes and use of ice cold water) leads to damage to the hands and feet in the form of cuts, grazes and chapping. Cold mountain winds cause chapped faces and hands. Inhalation of soot from Pinus wallichiana fires causes chronic chest infections, and susceptibility to TB and pneumonia. Malnutrition and its associated health problems are also common.

1.3 Assessment of the risk of anaphyllactic shock
Allergy to bee sting in rare and severe cases can cause anaphyllactic shock, a massive immune response that results in loss of blood volume and subsequent failure of the heart and lungs. Anaphyllactic shock is the most significant factor limiting use of bee sting therapy, but for the poorest of the poor the risk may be smaller relative to those they face daily. Many Jumla people are obliged to carry loads greater than 50 Kg along narrow slippery mountain paths often with no or poor quality footwear. They must climb trees to obtain firewood or cut grass from slippery cliff edges. Each year people die in the process of carrying out such work and many infants die before 5 years. TB, Pneumonia, influenza and gut infections kill hundreds of people in the district each year. Seen from the perspective of this very high risk environment, the risk of an allergic response to a bee sting becomes slightly less significant than it might be for people living in more developed areas. Bees are kept in every village and many people have already had the experience of being stung by bees and often know whether they react adversely or not. Apis cerana bees are not aggressive and their stings are slightly less painful than that of the larger Apis mellifera. Hence, Jumla people are less afraid of being stung than people in more developed areas.

It was in this context that Apitherapy was tested as an alternative or supplement to the existing indigenous and governmental health services existing in Jumla district.

2. Methods
Application of apitherapy was tested as part of an integrated programme of participatory action research into beekeeping development in Jumla district, between July 1995 and October 1999. Apitherapy practice was integrated into general beekeeping and extension activities (Saville 1999, 2000), providing farmers with information as follows:

Since the project trained local 'farmer-trainers' from the Himalayan Beekeepers Association Jumla (HIBA) to conduct beekeeping training and extension activities (Saville 2000), the main proponents of apitherapy were local beekeepers. During training in beekeeping or hive making or during extension follow-up visits to beekeepers' communities, the HIBA 'farmer-trainers' practised bee sting therapy on anybody eager to try the treatment. Similarly, the author and local counterparts working with her the Karnali Technical School / ICIMOD trial and demonstration apiary provided bee sting treatment to any visitors who suffered with arthritis or similar chronic pain in the joints.

3. Results
3.1. General uptake of 'apitherapy'
During the course of the 4.5 year programme of action research in Jumla district, many people increased their awareness of the value of honey, beeswax, pollen and bee stings. This was assessed in Participatory Monitoring and Evaluation exercises with all 71 groups that received training. In most cases, farmers claimed that they had at least partly understood the value of apitherapy and many people, including many women, claimed to have tried bee sting therapy upon themselves or friends with positive results. Analysis of 25 of the 71 PM&E exercises conducted showed the pooled opinions from 14 men's groups and 11 women's groups. They considered themselves to have understood bee sting therapy to 60%, making of beeswax creams to 87%, uses of honey as a medicine to 88% and nutritional usage of pollen to 40% of full understanding.

3.2. Documentation of results of bee sting therapy
A questionnaire survey with recipients of bee sting therapy showed that in 31 cases of (mainly) arthritic pain in joints, bee sting therapy reduced pain and immobility and in many cases removed it altogether. 22 were cured; 4 showed improvement; 2 failed to be cured; 1 developed an allergic response; and 2 results were unknown.

Anecdotal records totalled more than 70 cases of successful treatment. Several cases of immediate relief of chronic pain upon receiving just one sting were observed. A man who had been unable to move, and was needing to be carried to the hospital one day's walk away, was cured and able to get up again after a course of 15 stings over 2 days. Only two cases of allergic reaction to bee sting were found.

3.3. Acceptance of bee sting therapy
It was found that Jumla people easily accepted the practice of bee sting therapy and were generally not surprised by its effectiveness. This may be connected with the traditional use of nettle (Urtica dioica) stings for treatment of swelling and pain in joints and the use of hornet (Vespa sp.) stings therapeutically in some cases. Indigenous knowledge upon the value of bee stings was not common, but in one community a beekeeper had realised that bee stings reduced the pain of his chronic arthritis. He volunteered to harvest honey for all his community members so that he could get plenty of stings!

3.4 Potential application of local herbs in beeswax ointments
Local oils of Prinsepia utilis (local name 'Dhatelo') and Prunus communis (local name 'Galne aru') were found to be highly effective in skin preparations for chapped skin, especially lips, hands and feet. Oil from the seed of Cannabis sativa traditionally used as an analgesic massage oil for pain and fevers, was mixed with beeswax to make a massage ointment that was highly effective for the treatment of chronic pain (arthritis).

Local herbs identified as potentially useful to combine in beeswax healing creams included:

3.5Indigenous knowledge on use of honey medicinally
The importance of unheated honey as a medicine is well known to Jumla people. Traditionally raw unheated honey combined with Picrorhiza scrophulariaefolia (locally known as 'katuko' or 'kutki') cured coughs. It is well known as a treatment for heartburn, gastric disorders, stomach ulcers, chapped skin, spots and boils, burns, effects of altitude (when combined with buckwheat flour), snake bites, poisoning, and for many other problems. Many believe that for colds and fevers no sweet substances should be consumed, including honey. Honey is considered to encourage pus production, for example application of honey to a boil should make it swell and burst.

All beekeeping families keep sealed combs of 'raw' honey at home for medicinal and spiritual purposes. Indeed the traditional value of this 'raw' honey is so great that the belief arose that to sell raw honey would anger local deities. Unfortunately this belief, together with unhygienic harvesting methods, including cutting of brood combs and unsealed honey, also led to the practice of heating honey directly in a pan on the fire. This severely reduces the medicinal value. The training and extension project implemented attempted to halt this practice by raising awareness of the benefits of raw honey.

Discussion and conclusion
For people of remote areas without sufficient health services, keeping a bee colony in the house wall or on the compound is equivalent to installing a self-restocking medicine cabinet! All bee products have medicinal applications, which can be exploited more thoroughly through apitherapy than in indigenous healing practice. Training schemes for practitioners in apitherapy should include a thorough grounding in the symptoms and treatment of anaphyllaxis and other less serious allergic responses. In the case of bee sting therapy in Nepal, there is scope for the integration of traditional skills of using acupressure points. Traditional healers in the Lama communities of Tibetan origin use acupressure / acupuncture related practices. Thus, if Buddhist people will agree to practice a therapy that involves worker bees dying after they have stung, there is scope for introducing bee sting therapy with them.

Apitherapy was found to have enormous application in very remote Himalayan situations where health services are severely limited. Similar tests of apitherapy in other areas of the world are called for and wider application of apitherapy in beekeeping development programmes is suggested.

References

Acknowledgements
The author would like to thank: Hari Hansraj for introducing the practice of bee sting therapy to her in Trinidad and Tobago in 1994; Satananda Upadhaya, Narayan Prasad Acharya for assistance with data collection; Karna Bir Sunar and all the farmer trainers and farmer members of the Himalayan Beekeepers Association Jumla and Surya Social Service Society (4S) Jumla for willingly accepting apitherapy practice and teaching it to others; ICIMOD for project management; Austroprojekt and the Government of Austria for funding the project and for employing the author from October 1996 to October 1999; DFID for employing the author from April 1995 to October 1996.

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