Introduction: Global mental health and traditional medicines
The global mental health (GMH) movement aims to establish a world in which every human
can access mental health services based on two fundamental principles: respect for
human rights and evidence-based treatments. Despite being criticized, especially for
its neocolonial tendency to impose psychiatric systems that defy local epistemologies,
this movement is garnering increasing attention.
The anti-psychiatry movement led to the first mental health reforms based on human
rights, which notably influenced World Health Organization (WHO) policies and the
development of ethnopsychiatry. However, despite the vast anthropological literature
supporting the importance of traditional health systems for the well-being of local
communities, the recognition of traditional medicines and healers is highly marginalized
within the GMH agenda.
For example, WHO’s Mental Health Action Plan 2013–2020 acknowledges the value of traditional
medical systems only subsidiarily, qualifying them as “informal”: “Greater collaboration
with ‘informal’ mental health care providers, including families, as well as religious
leaders, faith healers, traditional healers, school teachers, police officers and
local nongovernmental organizations, is also needed.”
Similarly, the Lancet Commission on Global Mental Health and Sustainable Development’s
report mentions traditional healing systems only when stating that “[g]lobal mental
health practitioners have shown that integrating understanding of local explanatory
models of illness experiences is possible while respecting the complementary role
of Western biomedical and local traditional approaches to treatment.”
Paradoxically, in most parts of the Global South, traditional healers are more numerous
than mental health workers, and they constitute the main health resource that local
populations use and believe in. For example, in Ghana, with a population of 27 million,
there are only 18 psychiatrists, 19 psychologists, 72 community mental health officers,
and 1,068 mental health nurses. In contrast, around 45,000 traditional healers are
reportedly operating in this country.
However, there is a scarcity of institutional documents and international GMH proposals
that consider investing in traditional medical practices and research.
In today’s globalized world, a large diversity of people from a broad range of genetic
and cultural backgrounds coexists and travels throughout various territories and countries.
Traditional healers conduct ceremonies in Western countries, and Westerners travel
into indigenous territories in search of traditional treatments. Thus, different medical
systems, backed by their respective epistemologies, coexist. If traditional practices
and epistemologies are not properly addressed within the GMH movement and WHO’s Mental
Health Action Plans, this may pose a challenge to health-related human rights. Among
these rights, it is worth noting that everyone has the right to enjoy the highest
attainable standard of physical and mental health and the right to enjoy the benefits
of scientific progress and its applications.
In specific cases where psychoactive plants containing internationally scheduled substances
are used for mental health purposes, as is the case with certain South American plants
(containing what Western pharmacology considers hallucinogenic compounds), people
are vulnerable to possible criminal prosecution. In the case of indigenous peoples
for whom those plants are part of their traditional medical systems, the right to
access their traditional medicines and to maintain their health practices may also
Thus, this complex scenario produced by contemporary globalization offers some challenges
to reflect upon.
Traditional healing practices involving psychoactive plants: Human rights challenges
Worldwide interest in ayahuasca and related traditional Amazonian medical systems
is typical of contemporary globalization.
Ayahuasca is a highly widespread tool within traditional Amazonian health systems.
In 1986, pioneering work that brought together all available ethnographic information
on ayahuasca found over 400 bibliographical references, referring to over 70 different
Amazonian ethnic groups in which it was traditionally used and over 40 different vernacular
names given to the decoction.
Today, those figures may represent only a small part of the bigger picture. Ayahuasca
is a decoction containing the leaves of the vine Banisteriopsis caapi, which is rich
in harmaline alkaloids, and of the shrub Psychotria viridis, which contains DMT (N,N-dimethyltriptamine),
which is a Schedule I substance controlled by the 1971 Convention on Psychotropic
Substances. Although ayahuasca itself is not scheduled in the international drug control
treaties, its use is prosecuted in many countries, even in the case of indigenous
peoples who travel outside their original territories. Ayahuasca became so popular
among Westerners as a self-care practice that even psychiatrists and pastoral counselors
have called for their colleagues to be ready to discuss spiritual, healing ayahuasca
experiences with their clients, despite their epistemological divergence from psychiatry
and their ontological divergence from monotheistic religions.
Also, ayahuasca’s adverse effects are frequently reported in the scientific literature.
An initial epistemological challenge becomes evident here. Both scientific and traditional
mental health treatments often involve psychoactive compounds. However, biomedicine
views mental disorders as biochemical imbalances that psychoactive drugs might restore;
meanwhile, Amazonian medicine views spiritual forces as being at work and psychoactive
plants as a means to harmonize the individual with the surrounding spiritual world.
This harmonization tries to achieve an alignment between the individual, the community,
the ecosystem, and even the geographical territory. The case of ayahuasca is also
paradigmatic, as it shares its neurochemical mechanism of action with antidepressants.
Whereas in biomedical systems clinical trials are used to demonstrate the safety and
efficacy of psychoactive drugs, regarding traditional ethnobotanicals, safety and
efficacy are demonstrated by the long history of use. Although Western countries accept
traditional plants as medicines, their safety and efficacy must be proven according
to biomedical criteria. This can get really challenging when applied to non-biomedical
medical systems with conceptions of safety and efficacy that may not be equivalent.
An important consideration arises here: article 15 of the International Covenant on
Economic, Social and Cultural Rights recognizes everyone’s right to enjoy the benefits
of scientific progress and its applications, and the states parties that signed this
covenant agreed to respect the freedom indispensable for scientific research. In practice,
these rights are conceived of and applied in the context of Western epistemologies,
leaving aside traditional approaches to mental health and related research.
These issues are addressed (although not exclusively within the context of mental
health) in the recently adopted General Comment 25 by the United Nations Committee
on Economic, Social and Cultural Rights. The general comment states that “[l]ocal,
traditional and indigenous knowledge, especially regarding nature, species (flora,
fauna, seeds) and their properties, are precious and have an important role to play
in the global scientific dialogue” and that “[i]ndigenous peoples and local communities
all over the globe should participate in a global intercultural dialogue for scientific
progress, as their inputs are precious and science should not be used as an instrument
of cultural imposition.” Nevertheless, traditional treatments should not be the only
option available, and “States parties must guarantee everyone the right to choose
or refuse the treatment they want with the full knowledge of the risks and benefits.”
The right to science is essential in order to adopt a perspective based on human rights
and evidence, since various health-related human rights rely on the right to science,
such as everyone’s right to enjoy the highest attainable standard of physical and
mental health. This is especially relevant, as mentioned above, in the case of indigenous
peoples, and even more so in terms of their use of plants with psychoactive properties
that are under international control. The International Guidelines on Human Rights
and Drug Policy, developed by several United Nations agencies, academics, and civil
society representatives, echo this problematic, specifying that states should “refrain
from depriving indigenous peoples of the right to cultivate and use psychoactive plants
that are essential to the overall health and well-being of their communities.”
Furthermore, General Comment 25 explicitly states that “the prohibition of research
on those substances is in principle a limitation of this right.”
Considering that the general comment defines “science” as encompassing both natural
and social sciences, this makes ethnographical research an option, which could be
more reliable and feasible than biomedicine as a source of evidence for evaluating
traditional medicines involving psychoactive plants.
However, the application of non-biomedical methodologies can be challenging since,
as the same general comment affirms,
knowledge should be considered as science only if it is based on critical inquiry
and is open to falsifiability and testability. Knowledge which is based solely on
tradition, revelation or authority, without the possible contrast with reason and
experience, or which is immune to any falsifiability or intersubjective verification,
cannot be considered science.
The post-colonial and biomedical-oriented aspects of the right to science
Several Western epistemologies—such as psychoanalysis, certain approaches in psychology,
and other social sciences (including certain ethnographies within anthropology)—cannot
always meet these falsifiability and testability criteria. Although those disciplines
and epistemologies are also based on reason, cumulative knowledge, and experience,
their ontological assumptions may not fit within the exigencies of scientific methodologies.
Even research in biological psychiatry might not always meet the criteria of falsifiability
and testability, since it has various flaws. The etiopathogenesis of mental disorders
is completely unknown; there is not a single psychopharmacological treatment that
offers a cure, and, at best, psychiatric drugs serve to treat acute symptoms (such
as panic attacks and psychotic breakdowns) but over the long term can be ineffective
and potentially dangerous. Radical critics of psychiatric drugs consider them to actually
be part of the problem regarding the chronicity of mental illnesses, rather than part
of the solution.
This inefficacy could be partly due to the poor heuristic models of mental illnesses.
In sum, science applied to mental health demands that other disciplines and epistemologies
meet methodological criteria that psychiatry itself does not always fulfill. A broader
framework regarding the assessment of mental health systems should be developed in
which different epistemological approaches, including indigenous ones, are considered.
Global mental health, globalization, and plants containing scheduled compounds
Contemporary globalization involves not only the intentional export of scientific
mental health systems from the Global North to the Global South. Rather, a new and
interesting phenomenon is also occurring whereby traditional medicines are traveling
from the Global South to the Global North. Some traditional medicines involving plants
that contain psychoactive constituents—such as ayahuasca (containing DMT), San Pedro
and peyote (two cacti originally from the Andean region and Mexican deserts, respectively,
that contain mescaline), and iboga (a plant from Equatorial Africa containing ibogaine)—are
gaining increasing popularity all over the world. Among them, ayahuasca is probably
the most popular and widespread.
Ayahuasca has diverse uses among Amazonian cultures, such as in rites of passage from
childhood to adulthood, to strengthen community bonds in interethnic festivals, as
a sacrament (for example, in Brazilian ayahuasca religions), and even as a spiritual
tool to resist neocolonial extractivism.
However, ayahuasca is used in Amazonian cultures mainly as a tool for healing, which
has been widely documented in the ethnographic literature.
Biomedical scientists have also widely studied its neuropharmacology, neuropsychiatric
long-term effects, and therapeutic potentials, finding promising results for mental
health disorders such as major depression, drug dependence, grief, eating disorders,
borderline personality disorders, and post-traumatic stress disorder.
Contrary to what happened with the importation of other psychoactive plants traditionally
used in the Americas, such as coca and tobacco, the globalization of ayahuasca has
seen its incorporation into ritualistic settings where it is used similarly to how
it is used in its original context. These rituals have been conceived of as novel
Meanwhile, thousands of Westerners travel to Amazonian regions each year seeking spiritual
enlightenment and healing from their physical and psychological conditions. Biomedical
researchers are also starting to report the psychological outcomes of traditional
ayahuasca practices among Western participants.
This phenomenon suggests that the GMH paradigm could lead to a turning point where,
contrary to the assumption that the Western mental health model should and will expand,
we are instead witnessing the expansion of traditional forms of healing beyond their
native contexts. This is evident in the case of traditionally and ritually used psychoactive
plants, especially ayahuasca. The manner in which international drug control conventions
have been drafted assumes that traditional cultures will never be capable of expanding
their influence to other territories and societies. This has not been the case. Ways
of healing previously considered outdated and unscientific are being recognized as
highly useful and less costly in terms of adverse effects. Furthermore, Amazonian
health systems, based on a world view that appreciates alignment between the individual,
the community, the ecosystem, and the geographical territory, may serve as a model
for dealing with our mental health crisis that, with the climate emergency and the
COVID-19 pandemic, will dramatically increase. Thus, the GMH agenda should start to
recognize the immense value of traditional medicines based on psychoactive plants,
the ethnographic literature should be used as a legitimate source of evidence regarding
safety and efficacy, and research budgets should be allocated for multidisciplinary
approaches to study non-institutionalized traditional medicines, such as ayahuasca
Furthermore, indigenous epistemologies should be carefully respected because traditional
healers are the true experts on the medical use of these sophisticated technologies,
and appropriate frameworks should be created in which they are considered legitimate
knowledge systems that should be protected not only under the umbrella of cultural
rights and the protection of cultural heritage, but also within the frameworks of
the right to science and the right to health, in compliance with multiple international
treaties and United Nations declarations.
The Western popularization of non-institutionalized, traditional healing systems implies
multiple challenges that deserves in-depth reflection. In fact, this is already happening
in many parts of Amazonia with ayahuasca, in Mexico with peyote, and in Gabon and
Equatorial Guinea with iboga. Biomedical and cultural misappropriation, the over-exploitation
of natural resources for commercial purposes, medicinal plant tourism that threatens
the viability of local community rituals, and disruptions of egalitarian traditional
social systems perverted by economic inequalities are among the challenges faced.
These challenges can be overcome only if they are dealt with from a perspective of
reciprocity that extends beyond the GMH agenda’s narrow recognition of traditional
medical systems involving psychoactive plants. It is therefore necessary to invest
in indigenous epistemological research and practices in order to truly protect indigenous
peoples’ right to science, since this right, beyond its concern with science, involves
much more complex economic and sociopolitical dimensions.