A 2021 survey of herbal health care available throughout Brazil revealed a vibrant diversity of services being offered by the public system. Self-sufficient herbal farming happens in dozens of municipalities, strengthening the bond between communities and local governments. Furthermore, the national policies enacted over the past three decades are deep-rooted in concepts beyond the offer of free remedies for all.

Phytotherapy is thriving in Brazil as part of the largest public health care system in the world. A 2021 study by the Brazilian ObservaPICS (the National Observatory of Knowledge and Traditional, Integrative and Complementary Practices in Health) surveyed health care workers throughout Brazil and found that 555 municipalities have some kind of herb-related practice in place, such as small-scale farming, foraging, processing, clinics, prescription filling, educational activities, or scientific research.1 In those municipalities, at least 326 plant species are being used, from well-known Mediterranean herbs such as sage (Salvia officinalis, Lamiaceae) and thyme (Thymus vulgaris, Lamiaceae) to Brazil’s own guaco (Mikania glomerata, Asteraceae), Brazilian peppertree (Schinus terebinthifolius, Anacardiaceae), carqueja (Baccharis trimera, Asteraceae), barbatimão (Stryphnodendron adstringens, Fabaceae), and sucupira-do-cerrado (Pterodon emarginatus, Fabaceae).

Included in the Sistema Único de Saúde (SUS, or the Unified Health System) — the democratic, universal, and free-for-all Brazilian health care system — phytotherapy is safeguarded by important legislation that has been enacted since Brazil’s redemocratization in 1988. The Medicinal Plants and Herbal Remedies National Policy, which the SUS incorporated in 2006, was an important policy milestone because it widened the population’s access to herbal therapy, incorporated local flora and traditional knowledge into the health care system, and emphasized the sustainable use of the country’s rich biodiversity (see Table 1).

The ObservaPICS survey identified various organizational models functioning in all regions. Phytotherapy in the SUS has been a robust practice for decades, predominantly seen in successful cases of organic medicinal herb cultivation. This, in turn, has encouraged the development of local agricultural clusters. Herbal farming occurs in 35% of the 555 municipalities cataloged by the survey and has continued to grow over the past few years. Places where organic farming is practiced also are diversified and can vary from local health care facilities’ own yards in towns to rural areas farther away. Many families, gardeners, volunteers, and community health agents are involved with herbal farming throughout the country.

These practices are a sign of the viability of the Farmácia Viva (“Living Pharmacy”) national decree (portaria in Portuguese), which Brazil’s Ministry of Health enacted in 2010, incorporating the policy into the SUS as well. This decree regulates the herbal remedies available to the population and herb cultivation in primary health care facilities and surrounding areas. Francisco José de Abreu Matos (1924–2008), one of the most prominent names in the history of herbalism in Brazil, originally conceived this model.

Matos, a pharmacist from Ceará State, was looking for an alternative to the undersupply of essential pharmaceutical medications in the 1980s.2 At the same time, he envisioned an authentic health care system that was pertinent to the social reality of the Brazilian Northeast, rather than the mainstream one that was rooted in a techno-scientific Western model. In the 1980s, the average child mortality in Ceará was much higher than in other Brazilian regions. For Matos, community herbal pharmacies could be a solution to the issue, and he believed these needed to be based on local socio-biodiversity. He traveled extensively, exploring and systematizing the caatinga^† flora. His expeditions incentivized many other researchers to dive deeply into herbal lore and laid the basis for future federal policies. He became internationally renowned, and botanists at the Royal Botanic Gardens, Kew, named a variety of garden croton (Croton regelianus var. matosii, Euphorbiaceae) after him as a tribute.³

Around 1,600 miles away from Matos’ birthplace in northeastern Brazil, one of the most successful “living pharmacies” in the country operates year-round. Farmácia da Natureza Terra de Ismael (Nature’s Pharmacy Land of Ismael) has been serving approximately 120 people per month, without charge, in a rural area in Jardinópolis, São Paulo State, in southern Brazil. A team of eight physicians works at its clinics and prescribes herbal remedies, while another group processes the plants that are grown and sustainably harvested on the pharmacy’s land. Quality control is always performed. A botanical garden, patches of native Atlantic rainforest, and a natural spring are part of the property. From the inner bark of pink trumpet trees (Handroanthus impetiginosus, Bignoniaceae) that grow there, tinctures are made to treat many types of skin conditions, as prescribed by a dermatologist. Other physicians from the clinic recommend different formulations of the Handroanthus tincture for various forms of cancer. In addition, the University of São Paulo, the largest public university in Brazil, in association with Terra de Ismael, offers post-graduate programs to train professionals in Western herbal sciences. Four herbal medicines out of the 150 manufactured at Terra de Ismael were included in a list of the SUS’s essential remedies.4

Another relevant initiative is taking place in Maranhão State in northeastern Brazil. This region boasts a huge biodiversity since it comprises the frontier between the Amazon rainforest and the cerrado.** A public policy passed in 2016 aimed at widening the population’s access to herbal therapies has reached 125 municipalities out of a total of 217 in Maranhão. So far, 50 therapeutic gardens have been opened throughout Maranhão. About 600 health care workers are involved with the project.5 The gardens are located in indigenous villages, quilombos,‡ terreiros,*** and on the outskirts of Maranhão’s municipalities with extremely low Human Development Indices (HDIs; a measure of socioeconomic development). At workshops, community members in Maranhão teach health care workers about their own traditional methods of using herbs. Those workers, in turn, share information from the scientific literature about safe and effective uses of herbs. Families’ common mistakes when preparing homemade remedies are often corrected during these mutually enriching meetings. In the labs of these herbal processing facilities, species such as the tropical Java plum (Syzygium cumini, Myrtaceae) and the leaves of Brazilian orchid tree (Bauhinia forficata, Fabaceae) are made into tinctures to treat chronic diseases such diabetes and hypertension, which are both common in Brazil. The SUS ensures that the remedies are provided for free through proper prescriptions. The outcome of this low-cost, high-gain policy has inspired another state, Acre, in western Brazil, to develop a closely related project called “Living Remedy.”6

Partnerships with public universities and publicly funded research centers also foster phytotherapy in Brazil. These institutions have offered scientific support to the SUS since it was consolidated by Brazil’s Federal Constitution in 1988.

Companies in the private sector are prioritizing phytotherapy research as well. Centroflora, for example, a leading producer of standardized plant extracts in Brazil, completed the Centroflora Inova facility in Campinas, São Paulo State, in late 2020. This industrial micro-plant is dedicated to herbal medicine research, development, and innovation, and is open to partnerships in the sector. Approximately 40 qualified professionals are working in its high-tech facilities and are dedicated to innovative projects based on plant compounds that highlight Brazil’s national biodiversity. One of Centroflora Inova’s current research projects is focused on investigating the genetics of passionflower (Passiflora edulis, Passifloraceae), a native plant from the Amazon. Additionally, Centroflora is planning to launch the online platform Inovafito in 2022 to serve as a centralized resource for the industry, universities, scholars, and investors. The Oswaldo Cruz Foundation (Fiocruz), a prominent Brazilian public health research center, is an important partner in the platform. Ongoing research updates from seven public universities also will be featured on the website.

However, challenges still need to be overcome. A vital task is to establish an institutional framework in which traditional communities, families, farmers, community leaders, and ordinary people have a say in decision-making, thus actualizing concrete citizen participation. Also, as it is part of The Medicinal Plants and Herbal Remedies National Policy’s core principles, phytotherapy still needs to reinforce its role as a valuable means of supporting social justice. In this sense, a lot still needs to be done to set a redistributive policy whereby traditional knowledge holders can benefit from the results of the system. Finally, possibly the most challenging job is to develop mechanisms to safeguard traditional knowledge and knowledge holders while guaranteeing conservation of the rapidly vanishing socio-biodiversity.7

Lilian Caramel is an experienced journalist and received her bachelor’s degree in journalism from the University of the State of São Paulo in Brazil in 1998. She lives in São Paulo and covers a range of topics for magazines, websites, and newspapers. For more than six years, she also lived in British Columbia, Canada, where she was certified as a community herbalist by Pacific Rim College.

Pedro Carlessi received his bachelor’s degree in pharmacy from St. Judas Tadeu University in São Paulo in 2011 and his master’s degree from the Federal University of São Paulo in 2016. He is working on his PhD research in collective health at the University of São Paulo and is a visiting researcher in the Anthropology Department of the Institute of Social Sciences at the University of Lisbon in Portugal. His research takes an interdisciplinary approach that combines anthropology and health sciences.

^† Caatinga: The only biome totally located within Brazil’s borders. It is marked by a semi-arid climate, cacti (Cactaceae), and thorny trees. Despite desert-like conditions, it has a huge diversity of plants with medicinal properties.

** Cerrado: A tropical savanna ecoregion that covers about 25% of Brazil’s territory. Its huge biodiversity has been severely threatened by rapidly expanding GMO soy (Glycine max, Fabaceae) and corn (Zea mays, Poaceae) industrial crops.

‡ Quilombos: Remaining communities of Afro-Brazilians who were resistant to colonial domination by the Portuguese. According to official numbers, Brazil has more than 3,000 quilombos that are protected by law.

*** Terreiros: Places of worship and community living for followers of Afro-Brazilian religions (e.g., Terreiro Casa das Minas in São Luís and Terreiro do Egito in Cajueiro, both in Maranhão State). Medicinal plants are grown widely and used by them as medicine and for magical purposes.

References

1. Medicinal Plants and Herbal Remedies in the Sistema Único de Saúde (Unified Health System) Mapping. Brazilian Observatory of Traditional Knowledge and Complementary and Alternative Medicine website. Available at: https://dadosdepesquisa.fiocruz.br/dataset.xhtml?persistentId=doi:10.35078/DSFRUO. Accessed June 7, 2022.
2. Magalhaes K, Guarniz W, Sá K, et al. Medicinal plants of the Caatinga, northeastern Brazil: Ethnopharmacopeia (1980-1990) of the late professor Francisco José de Abreu Matos. Journal of Ethnopharmacology. 2019;237:314-335.
3. Croton regelianus var. matosii Radcl.-Sm. [Euphorbiaceae]. Plants of the World Online. Royal Botanical Gardens, Kew website. Available at: https://powo.science.kew.org/taxon/urn:lsid:ipni.org:names:305756-2#bibliography. Accessed April 18, 2022.
4. Ambulatório Fitoterápico. Casa Espírita Terra de Ismael website. Available at: https://terradeismael.com.br/2021/04/26/ambulatorio-fitoterapico/. Accessed April 15, 2022.
5. Governo Usa Programa Farmácia Viva para Orientar Maranhenses Sobre o Uso de Plantas Medicinais No Pós-COVIDHealthcare Secretary of Maranhão State website. Available at: www.saude.ma.gov.br/destaques/governo-usa-programa-farmacia-viva-para-orientar-maranhenses-sobre-o-uso-de-plantas-medicinais-no-pos-covid/. Accessed April 17, 2022.
6. Projeto Farmácia Viva é apresentado a secretários municipais de saúde. News Agency of Healthcare Secretary of Acre State. September 26, 2019. Available at: https://agencia.ac.gov.br/projeto-farmacia-viva-e-apresentado-em-xapuri/. Accessed April 18, 2022.
7. MapBiomas v6.0. MapBiomas (Brazil) website. Available at: https://mapbiomas.org/en?cama_set_language=en. Accessed April 18, 2022.