Traditional medicine among people of Pakistani descent in the capital region of Copenhagen

Author’s Accepted Manuscript Traditional medicine among people of Pakistani descent in the capital region of Copenhagen Sara Ramzan, Jens Soelberg, Anna K Jäger, Lourdes Cantarero-Arévalo www.elsevier.com/locate/jep

PII: DOI: Reference:

S0378-8741(16)32160-2 http://dx.doi.org/10.1016/j.jep.2016.11.048 JEP10592

To appear in: Journal of Ethnopharmacology Received date: 31 May 2016 Revised date: 21 November 2016 Accepted date: 29 November 2016 Cite this article as: Sara Ramzan, Jens Soelberg, Anna K Jäger and Lourdes Cantarero-Arévalo, Traditional medicine among people of Pakistani descent in the capital region of Copenhagen, Journal of Ethnopharmacology, http://dx.doi.org/10.1016/j.jep.2016.11.048 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Traditional medicine among people of Pakistani descent in the capital region of Copenhagen Sara Ramzan1,*, Jens Soelberg2, Anna K Jäger3, Lourdes Cantarero-Arévalo1 1

Section for Social and Clinical Pharmacy, Department of Pharmacy, Faculty of Health and Medical

Sciences, University of Copenhagen, Universitetsparken 2, 2100 Copenhagen, Denmark 2

Museum of Natural Medicine, University of Copenhagen, Universitetsparken 2, 2100 Copenhagen,

Denmark 3

Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University

of Copenhagen, Universitetsparken 2, 2100 Copenhagen,Denmark *Corresponding Author ([email protected])

Graphical Abstract

Abstract: Ethnopharmacological relevance Studies show that ethnic minorities continue to use their cultural traditional medicines also after migration to the West. Research in this field is necessary, given that little is known about traditional medicines’ impact on health-related problems. This study sheds light on the issue through a qualitative study among ethnic Pakistanis residing in Denmark. Aim of the study The study addresses perception, knowledge and attitudes regarding the use of medicinal plants among Pakistanis living in Copenhagen. We furthermore document and identify the medicinal plants used in households. Materials and methods Data were collected through in-depth, semi-structured interviews with sixteen ethnic Pakistanis aged 30 to 80 years. Interviews were transcribed verbatim and analysed through Emerson’s two-phased analysis method. Medicinal plant products in the interviewees’ households were collected, photographed, identified and deposited at Museum of Natural Medicine at University of Copenhagen. Results A total number of 121 Pakistani traditional medicines were identified, and found to represent both medicinal plants and foods. The average number of quoted Pakistani Traditional Medicines was 18 (N=16). Interviewees independently reported the same traditions for preparation and consumption of Pakistani traditional medicines. Factors that play a role in choosing to use Pakistani traditional medicines are frequent visits to Pakistan, belief in the healing power of totkas (homemade medicinal preparation), religious knowledge and the occurrence of recent illness within the family. Further, the upkeep of traditional use depends on the availability of Pakistani traditional medicines. Conclusion

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The study enhanced understanding of ethnic Pakistanis’ perception and continued use of traditional medicines within the household after migration to the West. In the context of Western biomedicine, little is known of the potential toxicity and side-effects of many of the Pakistani traditional medicines found to be used in households in Copenhagen.

Keywords Traditional medicine, Pakistan, herbalism, Pakistani migrants, health beliefs, health practices 1.0 Introduction Complementary and alternative systems of medicines including traditional medicines (TM) have been practiced for centuries. They are available all over the world regardless of the availability of western biomedical healthcare. In non-Western countries the use of complementary or alternative medicine (CAM) is encountered to be up to 80 %, while around half of the Western world’s population is estimated to depend on CAM (Bodeker and Kronenberg, 2002; Shaikh, 2005; Shaikh et al., 2009). The reasons for the use of CAM are considered to be dissatisfaction with Western biomedicine, concerns regarding side-effects of drugs and also personal belief favouring holistic orientation of health (WHO, 2001a; Shaikh et al., 2009). Over the last few decades the interest for CAM has been increasing, particularly in herbal medicines. The use of TM and CAM varies between countries. According to the World Health Organization (WHO) CAMs are used in the prevention, diagnosis and treatment of various ailments. This especially applies in the poorest parts of Asia and Africa where the access to essential drugs is limited. WHO encourage member states to support TMs and formulation of policies with appropriate regulations to promote safe and effective use (WHO, 2001a; WHO, 2001b). “Traditional medicine refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being” (WHO, 2003). WHO exemplify their definition of traditional medicine systems with traditional Chinese medicine, Ayurveda and shamanistic traditions. Moreover, they define complementary and alternative treatment as: “a broad set of health care practices that are not part of that country's own tradition and are not integrated into the dominant health care system”(WHO,2016; SRAB,2016). When using the word traditional in this paper it is meant as health traditions, which the participant perceives to originate from Pakistan.

Migration gives cause for several challenges in the health-care, partially in regard to health and illness situations, but also in the meeting with the health-care system. The reliance on traditional medicines is rarely studied in Denmark, and thus there is very little knowledge on the determinants for traditional medicine use. The high number of use of traditional medicine among immigrants in other western countries (Sandhu and Heinrich, 2005; Pieroni et al., 2005; Pieroni and Torry, 2007b; Pieroni et al., 2008a; Pieroni and Gray, 2008b; Ceuterick et al., 2008; van Andel and Westers, 2010; Kujawska et

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al., 2011; Jennings et al., 2015; Xavier and Molina, 2015) indicates the importance of conducting a similar study in Denmark. This study will seek to identify the frequency of traditional medicines used among Pakistani descents on household level.

Self-treatment with traditional medicines is a strong part of the Pakistani cultural heritage and plays a crucial role for the majority of the population. However, other reasons for consulting CAM healers are affordable fees, availability of the provider, family pressure and opinion of the community (Shaikh, 2005; Bazmi et al., 2003). Studies suggest a tendency of medicinal pluralism among ethnic Pakistanis in Denmark. They seek healing from various sources all with different disease explanatory models. They spontaneously use a combination of disease explanatory models and health-care sectors (Mygind, 2006; Rashid, 2006). A Danish register-based study among ethnic minorities showed that the use of medicines for chronical diseases such as cardiovascular diseases, diabetes, schizophrenia and depression was lower than expected. The study suggests this to be due to compliance problems (Søndergård et al., 2009). Another study showed that 65% of ethnic minorities above 50 years did not take their medications as prescribed by their doctor. In the same study it was reported by one third of the interviewees that they take medication which is not prescribed for them, and 50 % were reported to be taking medicine which they had brought back from their home countries (Vinther-Jensen and Primdahl, 2010). However, use of traditional medicines is not included in these studies and thus research on attitudes to traditional medicines and compliance behaviour is lacking in the literature. In this study Kleinman’s concept of explanatory model of illness (Kleinmann, 1980) was used as theoretical inspiration to develop the interview guide. Interviews were conducted to obtain knowledge on the following research questions and their supplementary questions: 

Which medicinal plants do the users know about?



What influences their perceptions about medicinal plants?



How many of the mentioned traditional medicines did they have in their homes?

The aim of the interviews was to get an understanding of recent use and knowledge of Pakistani Traditional Medicines (PTMs), health beliefs and sources of knowledge among Pakistanis living in Copenhagen. It was also within the scope to collect samples of traditional medicines from the informant’s homes.

2.0 Materials and methods The fieldwork for this study was conducted by first author over a four month period (June 2015September 2015) in the Capital Region of Copenhagen, Denmark. The methodological approach has been two-fold: i) qualitative research ii) collection of plant medicines.

2.1 Qualitative research

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Qualitative research was selected because it generates in-depth understanding of participants’ experience, knowledge, feelings, attitudes and motivation (Martin, 2007; Kaae and Traulsen, 2015). This approach was taken to get insight into which values Pakistanis give traditional medicine after migrating to Denmark. All the interviews except two were conducted in the informant’s homes.

2.1.1 Recruitment of informants Participants were recruited from the Capital Region of Copenhagen. This region was chosen as 16.0 % of the population is ethnic minorities or descendants (Danmarks statistik, 2012). The Capital region is per 2016 defined as København, Frederiksberg, Dragør, Tårnby, Albertslund, Ballerup, Brøndby, Gentofte, Gladsaxe, Glostrup, Herlev, Hvidovre, Høje-Taastrup, Ishøj, Lyngby-Taarbæk, Rødovre, Vallensbæk (Danmarks statistik, 2007).

Based on the research questions the objective of this study primarily targeted first generation migrants and descendent with interest in traditional medicines. Later the target group was modified to only include individuals who were born in Pakistan. It was within the aim of the project that the informants had first-hand experience with the practises of traditional medicines back home and a desire to share their knowledge.

2.1.2 Sampling Invitation letters were written in Danish, Urdu and English. Several approaches were taken to recruit informants for the study. Firstly, informants were recruited through GP practices, these were contacted through email and phone, and those practice who were willing to hand out invitations received invitation letter in all three languages by post. Secondly, the invitation letters were sent out to researcher’s personal network through Facebook and email. The invitation was also reposted on friends walls and shared in relevant Facebook groups. Announcements were made in the Pakistani community radio channel Radio Humwatan as well as at the Friday prayer at Muslim cultural institute. Medical practices spread across the Capital region of Copenhagen was also contacted and provided with invitations letters in all three languages.

As the initial recruitment process was challenged with lack of interest from PTM users it was decided to snowball within social networks. Individuals who were perceived to have high knowledge about PTMs by their socials network were contacted. Purposive sampling is considered to be an effective mean to recruit informants with high levels of knowledge (Rashid, 2006; Jennings et al., 2015).

2.1.3 Data collection Sixteen semi-structured interviews were conducted and the duration of the interviews varied from twenty minutes to an hour. First author conducted the interviews in Danish, Urdu which is the national language in Pakistan and the dialects Punjabi or Pothwari. English was also used to a lesser extend during these interviews. The interviews were conducted in the informants’ homes.

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A semi-structured interview guide was prepared with inspiration from Kleinman’s concept of explanatory model of illness (Kleinman, 1978). The first three interviews were pilot interviews. Here the interview guide was tested in Urdu and Punjabi. The interview guide was initially formulated in English and translated to Urdu. In those interviews where interviews were conducted in dialects the Urdu interview guide was used. It had beforehand been considered how questions could be worded in dialect. It was considered to translate the interview guide into Danish but the English version was satisfying for the interviews and was used as a guideline during Danish interviews. The English interview guide is available as supplementary material, Appendix A. The interviews were transcribed verbatim into English. The transcriptions were replayed, -read and corrected twice. Additionally all the transcriptions except the Danish interviews were replayed, -read and corrected by a native Pakistani. The interview transcriptions was analysed by Emerson’s two phased analysis method (Emerson 1995, 166). The analysis was started by open coding of the transcript material and commenting with short memos. This allowed analytical themes and ideas to form until new ideas stopped occurring. In the second phase incidents and statements were compared across the transcript.

2.2 Medicinal plant collection 2.2.1 Samples During the interviews informants were asked if it would be convenient to see their pantries after the interview. For some informants this was a chance to recall more PTMs, use and knowledge while others gave samples without further explanation. Some food-medicines were not collected but seen or reported mentioned as something they usually have at home.

2.2.1 Identification of Pakistani traditional medicines Botanical nomenclatures follow the rules of Medicinal Plant Name Services (MPNS, 2015) portal. Folk name, English name or trade names were searched in the portal in order to get a reliable scientific nomenclature for the plants. The folk name and scientific nomenclature was searched together in Google and verified by articles, when available, published in PubMed. A third verification was done visually by comparing the collected plants with images found in relevant articles or websites.

2.3 Data analysis 2.3.1 Knowledge evaluation To present the knowledge about medicinal plants obtained from jotted notes, field notes and transcripts more clearly alternative knowledge condensation has been used. Thus, all meaningful statements on knowledge about PTMs have been rewritten to shorter and concise statements where the informant’s phrases are used.

All personal identifiers have been removed from the results so the person cannot be identified through details of their stories.

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2.3.2 Identification of medicinal plants Each of the available PTMs were collected, photographed (Supplementary materials, appendix B), identified and deposited at Museum of Natural Medicine at University of Copenhagen.

3.0 Results and discussion 3.1 Sociodemographic profiles of the informants

Table 1: Schematic presentation of sociodemographic profiles.

IP#

Origin in Pakistan

Interview language

Gender

Age

Years since migration

IP1

Kharian

Urdu

Male

61-70

41-50

IP2

Lahore

Punjabi

Female

51-60

31-40

IP3

Kohat

Urdu

Female

31-40

1-10

IP4

Gujar Khan

Pothwari

Female

61-70

21-30

IP5

Jhelum

Urdu

Male

61-70

41-45

IP6

Sialkot

Urdu

Female

51-60

41-50

IP7

Gujrat

Urdu

Female

70

21-30

IP8

Lahore

Urdu

Female

31-40

0-10

IP9

Gujrat

Urdu

Female

41-50

21-30

IP10

Kunjah

Punjabi

Female

70

30-40

IP11

Sialkot

Danish

Female

41-50

41-50

IP12

Dina

Punjabi/Pothwari

Female

71-80

41-50

IP13

Dina

Punjabi/Pothwari

Female

31-40

11-20

IP14

Kharian

Urdu

Female

41-50

21-30

IP15

Sialkot

Urdu

Female

41-50

10-20

IP16

Kharian

Danish

Female

21-30

21-30

+

+

The 16 informants (14 females, 2 males) ranged from age 30 to 80 years with a median age of 54 years. All informants were born in Pakistan and spoke different dialects according to the region of origin. The majority of the interviews were conducted in Urdu. All the participants (16) are now living

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widespread all over the 29 municipalities of the Capital Region of Denmark. The participants originate from six cities located in different provinces of Pakistan.

According to Kvale (1994) a good way to determine the number of informants is when you start recording the same information over and over again, in other words, when saturation has been reached (Kvale, 1994; Christensen, 2007:68-69). Following these guidelines a fixed number of informants were not defined, but rather an estimate of at least 10 and maximum 25.

The informants reported that it was mainly women who did the cooking and thus also the main caregivers in the household. This is similar to findings by Pieroni et al. (2008a) where males were reported as ‘observers’ and ‘maybe users’. This tendency can be suggested to be due to cultural and traditional norms in the gender roles between ethnic minorities (Rashid, 2006).

3.1.1 Recruitment Sampling through network is an effective method as Ethnic Pakistanis are a part of a collective culture which means that information that comes from family and community is more trusted (Rashid, 2006). The cons of using the network could be that the sample is on more specific network groups and thus not necessary representative. On the other hand, the purpose is to collect as much traditional knowledge as possible, and the exchange of knowledge is stronger in the social network.

3.1.2 Interviews Qualitative method was suitable for this study as it allowed researcher to see the plants the informants had in their homes and also get a one to one relationship with the informants. Individual interviews were more favourable than focus groups as it was desired to collect oral traditions. Thus, it was a wise decision to choose this method as it allowed comparing knowledge and use between individuals.

Some of the informants found it hard to free-list traditional medicines and then elaborate on their use. To help the informants they were allowed to free-list illnesses and accordingly mention which medicinal plants they used and how. In very few cases researcher motivated the informants by naming illnesses and the informants elaborated on the PTMs they knew about.

3.2 Knowledge about Pakistani traditional medicines Table 2 is a schematic presentation of all recorded PTM listed by their Urdu folk names, their botanical names, family name, English name, reported use and number of quotation of the species. The most important Urdu terms used by informants can be found in supplementary materials as Supplementary materials, appendix C.

Six of the mentioned PTMs have not been identified. Most of the recorded PTMs are consumed raw, taken with water or prepared as a kehwa (traditional green tea) in the presence of a variety of different

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spices. All the informants were able to mention examples of recent use of PTM either for themselves or by someone within the household. The Danish speaking informants mainly mentioned the vernacular names of the PTM suggesting that their traditional knowledge is inherited from their family, mainly mothers. The collected samples are considered to be the most commonly used plants. Some food-medicines were not collected, but seen or reported mentioned as something they usually have at home, while other PTMS were rarer and therefore imported after visiting Pakistan or sent to their home address in Denmark by family members.

Table 2 Knowledge about Pakistani traditional medicines reported by users by their Urdu Folk name, 1

scientific name, family and their use .

#V N

Traditional name

Scientific name

Family name

English name

Purpose

Other information

#R

Medicinal plants and foods N/A

SR014

Adrak

Ajwain Po: jamaan

Zingiber officinale Roscoe

Trachyspermum ammi

Zingiberaceae

Apiaceae

Ginger

Bishop's Weed/ carum seeds

All purpose, sore throat, mucus, nazla zukaam, relaxation

Stomach upset, diarrhoea, constipation, diabetes, promote weight loss, cough, colic

Sore throat, mucus; 1) Mixture of equal quantities of honey, vinegar, lemon juice and ginger. Taken spoon wise 2-3 times a day. Adults needs more than children. You can also add lemon. 2) Chew a little piece in your mouth 3) Drink as a juice. Man-o-salwa, meaning food of heaven. Stomach ache; 1) used alone or with Bishop's seeds 2) Sprinkle with salt.

16

11

Generally stomach health; Take one spoon on empty stomach or add to boiling water and drink. Cough, sore throat; chew it. Colic; Make boiled sugar water and also add some ajwain. Digestion; helps digest food Can be used preventive for cold. Commonly called phakki.

N/A

Akhroot

Juglans regia L.

Juglandaceae

Walnut

Diabetes

1 Diabetes; 1) available as powder mixed with neem and karela. 2) Soak overnight and make salaan

SR036 / SR037

Amla

Phyllanthus emblica L

Phyllanthaceae

Indian gooseberry

Diabetes, shiny hair

3

N/A

Anar

Punica granatum L.

Lythraceae

Pomegranate

Pure heart

Pure heart; whoever eats three per year will keep his heart pure and the devil won’t be able to take over his heart.

1

SR016

Anardana

Punica granatum L.

Lythraceae

Pomegranate seeds

Anaemia

Often used in chutney and savoury.

2

Shiny hair; wash hair in water

1

Where scientific name is not given the PTM has not been identified. Where purpose or other information is not given the informant has not given or known the exact use of the PTM. #VN is the voucher number ad #R is the number of informants reporting the PTM.

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N/A

Angoor ka juice

Vitis vinifera L.

SR035

Anjeer

Ficus carica L.

Vitaceae

Moraceae

Grape juice

Figs

Constipation

Constipation; infants can be given a few tablespoon a couple of times a day Diabetes; Grapes are not recommended for those with diabetes. They should consume more vegetables instead.

1

Cough, diabetes, blood pressure, obesity, constipation

Cough; 1) In two cups of water add 3 figs and tablespoon nigella seeds. When the water has boiled down to one cup filter. Add honey for sweetness. Recommendation from Tib-e-nabwi. 2) Soak overnight. Eat the figs and drink the water. Should help over 2-3 days.

5

Diabetes, blood pressure, obesity; Should be taken on empty stomach N/A

Atah

Triticum aestivum L.

Poaceae

Flour

N/A

Badaam

Prunus armeniaca L.

Rosaceae

Almond

Face mask

Grind almonds and mix with foamed milk and apply on skin.

1

N/A

Badaam ka tail

Prunus armeniaca L.

Rosaceae

Almond oil

Dandruff

Used in a mixture with sarson ka tail and Vaseline

1

SR013

Badian

Pimpinella anisum L.

Apiaceae

Anise

Kashmiri chai.

1

N/A

Ber

Ziziphus mauritiana Lam.

Rhamnaceae

Indian jujube

Hair loss

Boil in water and wash hair to increase shine and strength.

1

N/A

Beri ke patte

Ziziphus mauritiana Lam.

Rhamnaceae

Indian jujube leaves

Skincare, hair care

Use the leaves to wash your hair.

1

N/A

Bhang/ bhasan

Cannabis sativa L.

Cannabaceae

Hemp

Teeth ache

Sedative effect. Bitter taste.

1

SR028

Banafshah

Viola odorata L.

Violaceae

sweet violet

Cold

Bought from Pakistan. Taken as a chai/kehwa. Use instructions from package.

1

N/A

Baingan

Solanum melongena L.

Solanaceae

Eggplant

Metabolism, pain relieve

N/A

Besan

Cicer arietinum L.

Gram flour

Facewash

Whisk yoghurt into a cream, mix with besan and apply on skin. Adding haldi to the mixture is beneficial.

2

SR042

Chai Po: Chaa

Camellia sinensis L.

Theaceae

Tea

Stomach health, relaxation

Constipation; make chai. Add lemon, peppermint, green cardamom Relaxation. Make a chai. Also add a piece of ginger

3

SR029

Chamomile

Matricaria chamomilla L.

Asteraceae

Chamomile tea

Cold, fever, clear eyes

Also called gul-e-babuna in urdu.

8

N/A

Chaawal

Oryza sativa L.

Poaceae

Rice

Diarrhea

Don’t use spices. Take yoghurt.

SR025

Chili powder

Capsicum annuum L.

Solanaceae

Crushed red pepper

SR019

Dalchini

Cinnamomum verum

Lauraceae

Cinnamon

SR006

Dimbar

X

X

X

1

SR034

Dukh Malanga

Salvia hispanica L.

Lamiaceae

Chia seeds

1

Fabaceae

3

3

Reduces fever, relaxing effect. Clear eyes; runny and irritated eyes can be cleared by making a tea and applying on and around eyes. Use cotton. Can be taken preventive. 2 1

Cholesterol, heart patients, diabetes

Diabetes; throw a stick into boiling water and drink throughout the day. Often used for kehwa. Flavour. It is a garam masala and shouldn't be used in too big quantities.

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6

N/A

Gajar

Daucus carota L.

Apiaceae

Carrot

Eye sight

Eaten peeled or as juice.

2

N/A

Gandum Pu: Kanaak

Triticum aestivum L.

Poaceae

Common wheat

N/A

Guggul

Commiphora wightii

Burseraceae

Indian bdellium-tree

Depression

Soak it at night time and drink in the morning. Add sugar if necessary. Bitter. Recommendation from Tib-enabwi. Rarely used PTM.

1

N/A

Gul basi

Mirabilis jalapa L.

Mirabilis jalapa L.

Four o’clock plant

Injury, joint pain

Rarely used PTM.

1

N/A

Gwar patta

Aloe vera L.

Xanthorrhoeace ae

Aloe vera

Pimples

Use the milk from the plant to reduce pimples. Rarely used PTM.

1

SR024

Haldi

Curcuma longa L.

Zingiberaceae

Turmeric

Cancer, stomach illnesses, inflammation, injury, beauty, sore throat, nazla, zukaam, fed after childbirth

Stomach ache, sore throat; Mix with milk and drink. Cancer; commonly used preventive by Indian's. Injury; 1) Heat up olive oil mixed with haldi. When the oil is medium hot apply on the injured place with cotton. Bandage it including the cotton. 2) Make a paste of water and haldi and apply on the outside of injured place. After childbirth; beneficial to take haldi in hot milk in order to heal the inside of the body Also mentioned as being used instead of painkillers. Taseer garam. Cold; take steam of haldi. Best at bedtime. Do not eat or drink anything after taking steam.

9

N/A

Hara dhania

Coriandrum sativum L

Apiaceae

Corriander leaves

N/A

Hari mirch

Capsicum frutescens L.

Solanaceae

Green chili

N/A

Imli

Tamarindus indica L.

Fabaceae

Tamarind

N/A

Ispaghol

Plantago ovata

Plantaginaceae

Psyllium seeds

Constipation, loose stool

Constipation; mix two tablespoons into water. Loose stool; Eat two tablespoons of the seeds and drink water on top of it. Diarrhea; Make a pudding of psyllium seeds and yoghurt.

1

SR032

Jaifal

Myristica fragrans Houtt

Myristicaceae

Nutmeg

Pain

Grind, heat in oil and massage. Taseer garam.

1

SR010

Jalwatri

Myristica fragrans Houtt

Myristicaceae

Mace flower

SR041

Jamun

Syzygium cumini L.

Myrtaceae

Black plum

N/A

Jamaa

Eruca vesicaria L.

Brassicaceae

Rocket

SR033

Jau

Hordeum vulgare L.

Poaceae

Barley

General illness

Used in talbina mentioned in Hadith.

2

N/A

Kachur

Curcuma zedoaria

Zingiberaceae

White Turmeric

Acne, skin problems, tooth cavities

Mostly used for children and adults. Mostly used in Gujar Khan area. Bitter.

1

N/A

Kadoo

Cucurbita maxima

Duchesne Cucurbitaceae

Squash

Blood pressure, constipation

Mash or grind the squash. Fry slightly in a little oil and season with salt and pepper. Store for 2-3 days in fridge.

5

SR015

Kadi patta

Murraya koenigii L.

Rutaceae

Curry leaf

1 Metabolism, pain relieve

Be aware if you have stomach ulcers or haemorrhoids. Strong spice.

3

1

2 Diabetes, acne

Diabetes; 1) Eaten raw. 2) Dried fruit can be grinded and taken to reduce blood sugar. Take with cinnamon and honey Acne; grate jamun and apply on face to cleanse skin

3

2

2

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SR011 / SR030

Kali mirch

Piper nigrum L.

Piperaceae

Black pepper (whole and powder

Sore throat

Sprinkle on shahad in case of mucus, cough or sore throat. Black pepper can be substituted with adrak ka juice. Garam masala.

9

N/A

Kala amlok

Diospyros lotus L.

Ebenaceae

Date plum

Digestion

Eaten raw. Rarely used PTM.

1

N/A

Kala zeera /shahi zeera

Carum carvi L.

Apiaceae

Black cumin seed

Sore throat, mucus

1

SR004

Kalonji Pu: Kalwanji

Nigella sativa L.

Ranunculaceae

Nigella seed

General health, stomach ache, constipation, heart health, sore throat, tooth cavities, diabetes, general pain

Take with shahad to get relief within a couple of hours. Rare and expensive. Cure for everything but dead Stomach gas; Mix with salt and take with a glass of water. Constipation; Mix the oil from plant with milk and drink Sore throat; 1) Make a kehwa of the seeds and add shahad. 2) Lubricate the throat with the oil 3) Chew the seeds along with a drop of lemon to helps starting problems of the throat. Tooth cavities; Keep a few seeds between your teeth and suck on them throughout the day to avoid tooth cavities. Diabetes; The absorbed ‘water’ after chewing the seeds twill reduce sugar levels. Pain; use the oil to massage both internally and externally. Heart patients are recommended to take this. Taseer garam.

N/A

Karachal herb

X

X

X

X

Mainly used by hakeems. Rarely used PTM.

1

N/A

Karela

Momordica charantia L.

Cucurbitaceae

Bitter gourd

Diabetes

1) Eaten as handi 2) Boil and drink the water at morning and night 3) Take raw as a juice 4) Also found in mixes with neem and amla.

3

SR009

Kash-kash

Papaver somniferum L.

Papaveraceae

Poppy seeds

Insomnia

Take one teaspoon in milk for insomnia. Used in sweet dishes in winter time. Taseer garam. Used to heat the body in cold areas.

1

N/A

Kasni

Cichorium intybus L.

Asteraceae

Chicory

Multiple diseases

Rarely used PTM.

1

N/A

Kasuri methi

Trigonella foenumgraecum L.

Fabaceae

Fenugreek dry leaf

Stomach ache

Gently ground 100 g crystal salt, 100 g black salt and 200 g fenugreek. Take a spoonful when feeling any kind of stomach ache.

2

N/A

Khajoor

Phoenix dactylifera L.

Arecaceae

Date

Energy, constipation

Energy; Take in odd numbers (3, 5, 7) with a glass of warm milk. Recommendation from hadith.

4

N/A

Kharbooza

Cucumis melo L.

Cucurbitaceae

Melon

Stomach health, constipation

Taseer dhandi.

2

N/A

Kheera

Cucumis sativus L.

Cucurbitaceae

Cucumber

Eye mask, dark circles, swollenness

Apply slices of cucumber on the eyes for about 10 minutes.

1

SR026

Khushk dhania

Coriandrum sativum L

Apiaceae

coriander seeds

N/A

Kiwi

Actinidia deliciosa

Actinidiaceae

Kiwi

Blood pressure

Eaten raw.

1

SR039

Kubani ka badaam

Prunus armeniaca L.

Rosaceae

Apricot kernel

Cancer

Cancer; preventive take 3-4 apricot seeds daily

1

N/A

Lahsun Po: thoom

Allium sativum L.

Amaryllidaceae

Garlic

Heart problems, blood circulation, blood pressure, ear ache

Heart health; 1) 1-3 fresh cloves along with a slice of bread. Within 15-20 minutes you will see a reduction of blood pressure. 2) Take it as chutney. Ear ache; Fry garlic in oil so it becomes golden brown. Cool down and apply in ear. Do not use

8

7

3

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the garlic pieces. Not mafak meaning suitable for everyone.

SR022

Lahsun powder

Allium sativum L.

Amaryllidaceae

Garlic powder

2

N/A

Limo Po/pu: nimbu

Citrus × limon L.

Rutaceae

Lemon

Cough, influenza, nails

Cough, influenza; Taken in warm water, chai or kehwa. Nails; Apply on nails for shine Shiny hair; Squeeze a lemon at the size of a lime , dilute it in water and apply after shower.

7

N/A

Long

Syzygium aromaticum L.

Myrtaceae

Clove

Tooth ache

Chew a single clove between teeth for 5-10 minutes to relieve tooth ache.

7

N/A

Liban

Boswellia sacra Flueck.

Burseraceae

Frankincense

Remove superstition, black magic, germs

Mix equal amounts of frankincense, guggle and marmakhi. The mixture is so strong that even a reptile snake will die from it. Rarely used PTM.

1

N/A

Marmakhi

Platycladus orientalis L.

Cupressaceae

Tree of life / biota

See uses for frankincense. Rarely used PTM.

1

N/A

Masoor daal

Lens culinaris Medik.

Fabaceae

Red lentils

N/A

Mehndi

Lawsonia inermis L.

Lythraceae

Henna

Shiny hair

Either mix in water or add an egg.

1

N/A

Miswak

Salvadora persica L.

Salvadoraceae

Tooth brush tree/ mustard tree

Teeth hygiene

Use once a day or when you do wudu [ritual washing].

1

SR005

Methi dana

Trigonella foenumgraecum L.

Fabaceae

Fenugreek seeds

SR012

Moti/kali elaichi

Amomum subulatum Roxb.

Zingiberaceae

Black cardamom

Diabetes

Eat it morning and night to keep the sugar level down. Often used in Kehwa Taseer garam.

5

N/A

Mulethi

Glycyrrhiza glabra L.

Fabaceae

Liquorice

Sore throat

Eat from the wooden stick.

1

SR038

Namoli

X

X

X

X

X

1

N/A

Nariyal

Cocos nucifera L.

Arecaceae

Coconut

Face mask, hair shine

Face mask; apply on face for moisture Hair shine; Apply in hear and wash out.

1

N/A

Nashpati

Pyrus L.

Rosaceae

Pear

Constipation

Eat your pears soft

1

SR038

Neem

Azadirachta indica

Meliaceae

Margosa tree

Diabetes

1) Taken as a juice 2) Also found in mixes with karela and amla 3) crush them and swallow with water

3

N/A

Palak

Spinacia oleracea L.

Amaranthaceae

Spinach

Stomach health, anaemia

Eaten with other greens such as rai and pudina.

1

N/A

Patta ghobi

Brassica oleracea L.

Brassicaceae

Cabbage

N/A

Peela amlok

Diospyros kaki L.

Ebenaceae

Persimmin

Laxative

Eaten raw.

1

N/A

Piyaz

Allium cepa L.

Amaryllidaceae

Onion

Solution for every disease, Vomit

No matter which disease you have it is a must. Vomit; Stick long into a whole onion and put in boiling water. Boil one glass of water into half. Suits both children and adults.

4

1

2

3

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SR003

Pudina

Mentha canadensis L.

Lamiaceae

Peppermint

Stomach ache, vomiting, nausea, constipation

Take a little handful alone or as kehwa. A few drops kehwa every few hours. Can also be used for children by adding a few drops of milk in their feeder. Taseer dhandi

8

SR006

Rai/ sarson

Brassica nigra

Brassicaceae

Black mustard

Diabetes, cholesterol, dandruff

Take a spoonful daily for diabetes and lower cholesterol.

2

SR008

Unknown

X

X

X

Cold, mucus

Used for chiit

SR017

Safaid zeera Po: Jeera

Cuminum cyminum L.

Apiaceae

Cumin

General health

N/A

Sarson ka saag

Brassica nigra

Brassicaceae

Mustard

N/A

Sarson ka tail

Brassica nigra

Brassicaceae

Mustard oil

SR020

Sabaz/ choti elaichi

Elettaria cardamomum L.

Zingiberaceae

Green cardamom

N/A

Santra Malta

Citrus × aurantium L.

Rutaceae

Bitter orange

N/A

Sikandar

X

X

SR036

Sikhakai

Sapindus trifoliatus L.

Sapindaceae

SR040

S1inghara Pu:Singhare

Trapa natans var. bispinosa Roxb.

SR021

Saunf

Foeniculum vulgare Mill.

N/A

Soy

SR002

Dandruff; see sarson ka tail. 1 7 2 Dandruff; Used alone or as a mixture. Ear ache; Heat mustard oil on frying pan and fry cloves. When it has cooled down apply in ear with ear buds. Cloves can be replaced with adrak. Headache; Apply to the roots of the hair.

9

Used in different kehwa for flavour.

6

Strong heart

Eaten raw. Man-o-salwa, meaning food of heaven.

1

X

Cancer

Those who suffer from cancer should eat as much as possible to get cured. Recommendation from Tib-enabwi. Rarely used PTM.

1

South Indian Soapnut/ Three-leaf Soapberry

Shiny hair, lice

Shiny hair; dissolve in water and wash the hair. The hair will stay naturally black for a longer time. Lice; Kills lice. Combined with amla for hair care.

1

Water chestnut

Joint lubricant (knees)

Mix into milk and drink.

1

Apiaceae

Fennel

Breath, eye sight, loose stool, digestion

Eye sight; Soak in water and use as drops for steady eye sight. Breath; use as chewing gum. Loose stool; make kehwa with moti elaichi and pudina. Digestion; slightly brown and sweeten with desired amount desiccated coconut and if available also dhania daal or alternatively sugar. Stomach gas; water and add fennel to it as a homemade alternative to gripe water (infants).

8

Glycine max

Fabacea

Soybean

Sundt

Zingiber officinale Roscoe

Zingiberaceae

Whole dried ginger

N/A

Tamatar

Solanum lycopersicum L.

Solanaceae

Tomato

N/A

Tarbooz

Citrullus lanatus (Thunb.)

Cucurbitaceae

N/A

Tea tree oil

Melaleuca alternifolia

Myrtaceae

Lythraceae

Dandruff, ear ache, headache

1 Dry form of ginger. Taseer becomes even hotter by drying.

1

Acne, skin brightener

Homemade facial mask/bleach of lemon and tomato juice. Blend and apply in routine.

2

Water melon

Stomach health, urination

Eaten raw. Taseer dhandi.

1

Tea tree oil

Warts, acne

Warts; Use continuously 3-4 times a day until it disappears. Same procedure with apple cider. Acne; Dilute oil apply to skin to reduce acne.

2

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SR023

Till

Sesamum indicum L.

Pedaliaceae

Sesame

N/A

Za’atar

Thymus vulgaris L.

Lamiaceae

Thymus

N/A

Torri

Luffa aegyptiaca Mill.

Cucurbitaceae

ridge gourde

Constipation

All kind of vegetables are useful.

1

N/A

Tumba

Citrullus colocynthis L.

Cucurbitaceae

Colocynthi

Diabetes, eyes

Diabetes; absorbed through walking on it with feet. Mentioned in Tib-e-nabwi. Eyes; Used as phakki. Not edible. Bitter

3

N/A

Yasamin oil

Jasminum officinale L.

Oleaceae

Jasmin

Hair shine

SR018

Zafran

Crocus sativus L.

Iridaceae

Saffron

Cold, pneumonia

Cold; Make a kehwa. Pneumonia; Take two of their leaves in water and let the patient have it. Food colouring. Most expensive ingredient among Pakistani spices.

1

N/A

Zaytoon ka tail

Olea europaea L.

Oleaceae

Olive oil

Joint pain, general pain, stomach gas, sore throat in infants, injury, constipation, shiny hair

Joint pain; 1) massage into joints 2) massage the calves and put to sleep (infants) Stomach gas; massage the stomach area and press the legs against the stomach to let the gas out (infants). Constipation and smooth intestines; take two spoonful of oil. Sore throat; massage the tonsils (infants). Injury; heat up olive oil, add salt and let it rise. When the salt is slightly browned turn off the heat. Apply on the injured place when the oil is medium hot and bandage. You can also use haldi. . Shiny hair; Massage scalp and hair. Do not oil for more than two hours it closes the pores. Any kind of ache; Make a tea of 12 g s olive oil and 1 g nigella seeds. Let it boil a single time. Filtrate and store. Can be used for any kind of ache on body for instance ear ache, haemorrhoids and cold. Oil can be substituted with vinegar. Vinegar should not be used in ear and nose.

6

#VN

Name

English name

Mixtures of

Purpose

Hair

Oil is used for hair.

1 1

1

Other information

R. #

Animal products N/A

Ghee

Ghee

Constipatio n

Given to infants.

2

N/A

Milk

Milk Fizzy drink

Stomach gas, dizziness and warmness.

Take fizzy drink in milk. This will also help if feel dizzy or warm.

2

N/A

Milk

Skin

Let milk foam and use the cream to apply on the skin.

1

N/A

Yoghurt

Face scars

Increases glow. Mix ingredients.

1

Face mask

Carrots Yoghurt

Page 14 of 26

N/A

Shahad

Honey

Honey

Sore throat, wounds burns, teething, migraine, damages lungs

N/A

Shahad

Hone Milk Ghee

Honey

Constipatio n

N/A

Shahad

Honey Lemon Glycerin e Rose water

Honey

Skin brightener, hand whitener

N/A

Namak

salt water

Salt

N/A

Namak ka pani

salt water

Salt Water

N/A

Crystal salt

-

-

N/A

Kali nimmak

Black salt

SR-031

Phatkari

Alum

SR-031

Phatkari

N/A

N/A

Sore throat; Take a spoonful Wounds; Apply on the skin to avoid infection. Burns; Might prevent burning marks after small accidents. Teething; Apply on teeth to reduce pain. Migraine; Use ear buds and apply in nose. Damaged lungs; boil water, add a spoonful of honey. Take it in the morning on empty stomach to repair damaged lungs.

16

1

Make a tonic of the mentioned ingredients and apply on face or hands.

1

Put salt directly on the wound to rinse.

1

Sore throat, mucus

Gurgle to relieve sore throat and mucus

3

-

Rarely used PTM.

1

Minerals Wounds

1

Honey Alum

Growing teeth, sore throat

Mix with honey and apply it on the teeth. In case of sore throat lubricate the inside of the throat. Used for infants and small children three times in total.

3

Alum

Clean drinking water

100 gram alum in 10 litre of water. Really effective in clay pot cooler.

1

Kohl/ Hashmi surma

Kohl

Clear eyes, strengthen eye sight

Grind kohl and apply in the eyes with a stick.

1

Multani mitti

Fuller's earth Gram flour

Acne

Mix the ingredient with water and apply on face.

1

Fuller's earth

Commercial products N/A

Vaseline

N/A

Vicks

SR-027

Joshanda

1 Vicks

Mucus

Heat the water, add some Vicks and breath the steam. Best at night time to avoid exposure to cold.

5

Sore throat, cold

Mix with honey. Available in bags or loose.

1

Warts

Use continuously 3-4 times a day until it disappears

1

Refined products N/A

Saib ka sirg

Apple cider

N/A

Saib ka sirg

Apple cider

Apple cider Sugar`

Dandruff, itchy scalp

Mix apple cider vinegar and sugar into a paste. Apply on scalp. Use small amounts as large amounts can give side-effects.

1

N/A

Misri

Rock sugar

Peppermin t

Stomach ache

Few leaves of peppermint in warm water. Add rock sugar to sweeten. Take a few drops.

1

Page 15 of 26

Rock sugar N/A

Sirga

Vinegar

N/A

Yakhni

Chicken soup

N/A

Talbina

N/A

Jalebi

Taseer cold. Germs

1

Food Chicken Ginger Garlic Cumin Salt Pepper

Fever, cold and flu

Make a yakhni from chicken, mutton or lamb meat. Boil the meat including the meat with mentioned spices.

1

Rarely used PTM.

Jalebi

Ongoing cough

Boil jalebi in milk and eat it either with or without milk.

1

Best before bedtime N/A

Khitchri

N/A

Salan

Curry

Loose stool

1

Loose stool

1

Ritual remedies N/A

Kalma

Self protection

Chant Bismillah Ar-Rahman Ar-Raheem to protect yourself. Can be done anywhere and before any act.

1

N/A

Surah rehman

Mentally disturbance

Chanting surah rehman has been proven to help mentally disturbed people. Wird.

1

N/A

4 qul

Black magic

Black magic can be removed by reading 3 qul. According to hadith.

1

N/A

Barish ka pani

Tuberculosi s

Mix in equal amounts and take morning, evening and night . Rarely used PTM.

1

Rain water

Rain water Honey Olive oil

Figure 1 illustrates that 84 % of the recorded PTM represents medicinal plants and foods. Certain foods were consumed in order to obtain precise medicinal actions. Most of PTM are thought to aid nazla zukaam and to be anti-diabetic. A discrete portion of PTMs are considered to be “good for health”, “good for stomach health” or “skin problems”. Others are reported to be “good for heart health” and “good for the blood”.

Page 16 of 26

2%

4% 4%

Medicinal plants

3% 4%

Animal products

3%

Minerals Commercial products Refined Products 80%

Food Ritual remedies'

Figure 1: Classification of the quoted TM’s quoted by Pakistani migrants.

3.3 Use of Pakistani traditional medicines It appears like PTMs are used as a substitute for over-the-counter remedies for acute illness and a supplement to western treatment of chronic diseases. The use includes traditions for use of PTMs in relation to nazla zukaam, high blood pressure, cholesterol, diabetes, pregnancy and birth. Many of the uses are identical to those recorded in Pakistan (Shaikh et al., 2009) and among Pakistani migrants in the UK (Pieroni et al.,2007a; Pieroni et al.,2008a).

Table 2 reports, adrak, ajawain, haldi and kali mirch to be the four most popular PTM (see appendix D for an extended list of most frequently quoted PTMs). These are used for ailments such as nazla zukaam, sore throat, mucus, stomach illnesses, relaxation, inflammation, increase of beauty and quoted by more than 50 % of the participants. When PTMs are used in therapeutic context they may be i) taken alone ii) taken with other spices in mixtures and iii) added to foods. The reported mixtures are made as kehwa, chutney, garam masala or others. PTMs used for nazla zukaa and dandruff are used for both adults and children, mixtures for chutney are used for adults only and garam masala is used for cooking purposes. Kehwas are for instance taken for nazla zukaam, to ease digestion, joint pain and more. There are no specific recipes as informants report to use what is available in the pantry.

Informants reported to be in compliance with their diabetes medication and take PTM alongside to control their diabetes. As presented in table 2, 13 different PTMs are consumed as preventive healthcare for diabetes. Similar patterns have been recorded among Pakistanis in other countries (Bhopal, 1986; Fagerli et al., 2005; Pieroni et al., 2008a). Other studies suggest that poor compliance (Mygind, 2006) is more likely to be related to language difficulties rather than disease explanatory models (Bhopal, 1986). On the other hand it raises the importance of a cultural specific strategy for managing diabetes in everyday life.

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Further the informants reported to use garam masala. This was consumed to aid digestion, for aroma, as well as after consuming baadi foods, meaning foods which are perceived to have a bloating effect e.g. potatoes and rice.

3.4 Motives for Pakistani traditional medicine use in Pakistani descent homes The health practices of informants are pluralistic and vary by a combination of beliefs, perceptions together with familial and social influences. They are influenced by health systems such as biomedicine, Ayurveda and Islamic guidelines.

3.4.1 Health-seeking behaviour The informants trust TMs but they don’t trust traditional healers. Instead they gain knowledge about traditional care from old scripts such as Tib-e-nabwi and Hadith as well as oral traditions. It is clear that their understanding of the relation between body, health, illness and lifestyle differs from how western biomedicine is perceived by the majority understanding in Denmark. To increase the possibility of adaption of health-related behaviour it is important that doctors understand and accept the cultural background and lay knowledge that Pakistanis hold (Rashid, 2006; Mygind, 2006). The informants distinguish between ‘us’ and ‘them’ in their narratives. Informants report that ‘people in the West don’t understand their explanatory model, and thus they do not consult their physician about their use’ of PTMs. Thus, they seek an atmosphere of trust and acceptance so they feel encouraged to share their PTM use with their healthcare professional. Bhopal (1986), reports that a fear of disapproval and a belief that doctors don’t understand Asian medicine is the main reason for lack of communication.

Regarding the health-seeking behaviour 11 out of 16 informants stated that they preferred PTM for minor ailments and only rely on western medicine in case of more serious diseases. One informant (IP11) stated that she never goes to the doctor while another informant (IP16) stated that she in the last few years has changed from using a lot of western medicine to traditional treatments. None of the informants reported to have visited a traditional healer. Their main reasons were that their families back home only went to the doctor or that they don’t trust traditional healers. All the informants also reported that they do not believe in religious healers (back home) such as peer faker. They quoted the use of ritual remedies such as kalma, surah rehman, four qul and Bismillah from the Quran (Table 2).

3.4.1 Family traditions The participants report that they seek help from their home and close circle for minor ailments. Adaption of family traditions is the most frequently mentioned source of knowledge. It is common that traditional knowledge is spread orally through the social network of family and community until it is collected (WIPO). Hansen et al. report (Hansen, 2008) that health behaviour depends on factors such as country of birth, generation and length of stay in the new country. There is not observed any pattern between knowledge and years since migration. The theory of ‘frozen societies’ that suggest

Page 18 of 26

people who migrated earlier have more knowledge (Pieroni, 2008a) is not seen in this study. Further, the informants express that they sense a change of cultural rules as young girls lack interest in using PTMs in the household. This is contrary to a study (Elverdam, 2007) conducted among a group of mothers with Pakistani background. This study found that the women had traditions in connection to pregnancy, delivery, duration of maternity leave, infants and small children.

Informants stated that they still use PTM from Pakistan because they are familiar with the use through their elders and close relations and also because they are perceived to be ‘safe’. Using spices, garam masala, chutney and mixtures within the household thus seemed to be a part of the Pakistani cultural identity. In other studies on pluralistic societies it is found that continuous use of traditional medicine after migration strengthens the ethnic identity (Pieroni et al., 2008a; van Andel et al., 2010). Based on the informants’ narratives of sick family members, it can be suggested that women in their young adulthood are motivated by personal reasons such as living with their parents and after marriage having children and living in joint families.

3.4.2 Islamic guidelines The participants use narrations from sources such as hadith and Tib-e-nabwi. “The medicine teachings from the Prophet (SAW) himself, that is most effective, most authentic and most reliable...” (IP8) and “The Quran [the Islamic sacred book] is a complete book. It has a cure for everything. Spirituality and cure for black magic. Allah [God] has sent a complete guidance through hazoor pak [Prophet Muhammad]. And through this we have cure. And we take benefit from it” (IP9).

Eating well and having a balanced diet is considered important. Informants are motivated by how the Quran recommend them to look after their health: “Shahad[honey] is very commonly used in our houses and what else (pause) usually the herbs mentioned in Quran I try to use them in daily diet” (IP8).

3.5 Hot and cold concepts When informants were asked about totkas, homemade medicinal preparations, they mentioned hot and cold effects of the PTMs. This theme was not covered by the interview guide, but as informants were asked to elaborate on this concept it was discovered that there was a shared explanatory concept among the informants.

The benefits of taking certain spices and vegetables are defined to be according to their garam aur thandi taseer meaning their hot or cold effects on the body. Several informants explain how a cold body state can be treated by consuming warm food. A vegetable or spice is considered to be garam when it makes you warm when you are feeling cold inside. The beliefs about hot and cold effects are prevailed in the Pakistani culture and informants are aware that this is a popular cultural wisdom.

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Concepts of hot and cold effects on the body appeared when the informants were asked about the use of the reported PTMs. Diet is considered to be important for health. This view seems to be unchanged from Pakistan where myth and misconceptions about food are widely spread (Mull,1992; Bazmi et al.,2003). The roots of this theory emerge from the system of Unani medicine. In Pakistan this system is practiced by all sectors of society (Bazmi et al., 2003). Other countries such as China (Koo, 1984) and Mexico (Messer, 1981) have parallel systems of hot and cold concepts. Although the concept of hot and cold is subjective, it is still scientifically relevant to address and identify the patterns of use.

3.6 Side-effects and toxicology The informants do seem to have created their own rules for when medicinal plants are considered to be safe or effective to use. They for instance make use of medicinal plants suggested from Tib-enabwi (As-Suyuti, 2015) and other books, which they respect and trust to suggest effective medicine. Interviewee (IP7) underlines the importance of using sources critically when referring to narrations of the Prophet: “What the prophet [Muhammad] has said, is hundred per cent true but everyone has different level of tolerance… Allah [God] has given all of us intelligence. We should know which kind of area we live in and our own nature”. Nasri and Shirzad (2013), wrote that self-treatment with most medicinal plants is safe. In their study they proposed simple guidelines for the use such as only making use of herbs recommended from respected sources and to make sure only using medicinal plants which are properly researched.

The informants reported to give children smaller doses than adults. The importance of doses for adults varied between the informants. Some mentioned that one should start out with a smaller dose than recommended and build it up while others didn’t mention anything about it. Likewise the duration of treatment before seeking help from outside varied between informants. PTMs with taseer garam were considered to be more powerful and ‘strong’ and consequently not something everyone can tolerate in the same amounts. Only one informant (IP7) directly reported to stop using a medicinal plants due to suspected side-effects: “Kalonji [black seeds] is also used for weight loss. It’s very garam [warm].. I ate that. I don’t know if I lost weight but I felt like I had some problems with PAIS [partial androgen insensitivity syndrome] so I stopped using it”. Another informant (IP1) mentioned that there is risk associated with taking mirch to speed up the digestion, and therefore those with stomach ulcers and haemorrhoids should avoid consuming them. “… For these it is poisonous. Thus, they should stay away from it. And it's also very dangerous for those who suffer from hemorrhoids...”.

The majority of the informants report that they consider PTMs to be safe and effective. This is not different from people from other parts of the world where an increasing number of people report to use medicinal plants because they are considered to be free from side-effects (George, 2011; Nasri and Shirzad, 2013). Some medicinal plants which the informants consider to be safe e.g. gwar pata, Ispaghol, mulethi , bhang are in the literature reported to have potentially toxic effect (George 2011; Pieroni et al., 2008a; Tamilselvam et al., 2014). Further, surma which is considered to clear out the

Page 20 of 26

eye and increase eye sight among Pakistani migrants in Denmark has been found to contain high amounts of lead (Aslam, 1979). As some restricted medicinal plants were found in the homes of participants it has confirmed the suspicion that some of these plants are imported from Asia and Europe (Pieroni et al., 2008a; George, 2011).

On basis of the narratives of the informants it can be suggested that they are more critical towards where they get their knowledge from, rather than where they obtain medicinal plants from. Further, none of informants had reported side-effects to any qualified health practitioner or the Health and medicine authorities. The importance of pharmacologically assessing safety and efficiency of medicinal plants can be raised, given that it was only possible to obtain toxicological literature on a few herbal remedies and the effect of a prolonged use of PTMs is still unknown.

3.7 Medicinal plants collected in Pakistani descent homes The informants were able to name all but one of the samples. PTMs seen during the interviews altogether counts 95 foods and spices (see supplementary materials appendix E for specification on collected and non-collected plants). The PTMs, which were not collected, were mostly fresh vegetables bought locally such as onion, ginger, garlic, thyme etc. It was not important to the informants where they got their PTMs from. The informants reported that the availability of the PTM varies. Spices are available in most stores, but informants prefer to buy them from Pakistani shops. Less common vegetables are found to be available in Pakistani stores. PTMs, which are only available from the hakeem, are either sent to Denmark or brought to Denmark through friends and family, who visited their home country.

Changes in and adaption of medicinal plant use from the new country has been unavoidable after migration. Vegetables and spices are found to be convenient, inexpensive and effective as self-care for common illnesses. Informants reported that some medicinal plants are not available and as a consequence traditional practices cannot be maintained. Informants report various strategies such as; substitution of unavailable medicinal plants, obtaining the original plants through special stores, and social network that links informants with their families in Pakistan. This is consistent with previous findings among Pakistani migrants in the UK and other parts of Europe (Pieroni et al., 2008a; Volpato, 2008).

4.0 Conclusion The informants report to use western biomedicine along with Islamic traditions. Illness and health is explained with the hot and cold concept together with narrations of the Prophet. More than half of the informants reported to use PTMs for minor illnesses and only consult Western biomedicine when they considered their condition to be more serious. Thus, it is obvious that after migration the pluralistic system has been complemented by the Danish health-care system. In this way new ways to perceive disease and treatments are added without letting any of the old ones go.

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This qualitative study resulted in an enhanced understanding of Pakistanis’ use of traditional medicines and thus makes an important contribution to the limited literature on this topic. Through qualitative interviews the knowledge and use of PTMs was examined among 16 ethnic Pakistanis in the Capital Region of Denmark. The age of informants was between 30 and 80. A total number of 121 items were identified , 95 were found to be medicinal plants and food, 26 were found to belong to other categories such as animal origin, minerals, refined products, commercial products and ‘ritual remedies’. The majority of the quoted PTMs are very little known in western herbalism. The use of PTMs depends on the availability. Pakistanis frequently use their social network to obtain otherwise unreachable PTMs.

There is semantic perception of the healing properties of food. This study shows that the informants independently report the same traditions for use of PTMs for minor ailments as substitution for overthe-counter medication and supplementary to western biomedicine. PTMs are taken alone or with other PTMs depending on their use. The preventive consumption was mainly for chronic disease while the treatment was for minor ailments such as nazla zukaam, high blood pressure, diabetes, dry scalp, and there were especially a lot of treatments for toddlers.

Factors that play a role in choosing PTMs are frequent visits to Pakistan, belief in the healing power of totkas, religious knowledge and the occurrence of recent illness within the family. The informants value their knowledge and perception of illness occurring due to imbalances, although they do know that this is not the dominant perception in Denmark.

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