6.1 African decolonisation and PHC: the emergence of traditional medicine at WHO

That WHO should ever have become involved in promoting traditional medicine is perhaps surprising. The organisation is and always has been primarily biomedical in composition. The Secretariat and national delegations largely comprise biomedically trained professionals, while the latter represent governments where biomedicine is generally the official, state-endorsed form of healing. WHO's early initiatives focused on promoting ‘the highest attainable standard of health’ through technical solutions and vertical interventions, such as disease eradication, and its language and logics reflected those of biomedicine (Packard, Reference Packard2016).

However, by the 1960s, the political context in which WHO (and the UN more widely) operated also reflected a dramatically changed world as compared to its inception in 1948 (Cueto et al., Reference Cueto, Brown and Fee2019). Independence movements and decolonisation had swept through Asia and were sweeping through much of Africa, resulting in ballooning UN membership. Newly independent states outnumbered former colonial powers and were able to wrest control of the agenda from them. Thus, it was two African delegations – Guinea and Congo (Brazzaville) – that formally pushed the issue when they introduced a 1969 resolution on medicinal plants and pharmaceutical production in developing countries.Footnote ¹ As Tilley highlights, their resolution emerged ‘in the wake of nearly a decade of African states’ concerted and collective activities on this front’ across UN agencies and the Organisation of African Unity (Tilley, Reference Tilley2021, p. 141). This is not to suggest other countries were uninterested in the topic, as Member States from other regions, such as Asia – and in particular China (admitted to the UN in 1972) – also debated the issue at WHA. Rather, it explains why African countries appeared particularly engaged from the end of the 1960s through to the 1980s. The influence of African delegates on this subject was evident even through the working definition of traditional medicine that WHO arrived at during a 1977 meeting (WHO, 1978c). It was explicitly borrowed from an earlier report by the WHO African Regional Office – and encompassed a number of features that went well beyond the biomedical:

By the mid-1970s, traditional medicine had grown an increasingly prominent profile at WHO. This could be seen with its formal inclusion within Director-General Halfdan Mahler's vision of PHC and the creation of a permanent Traditional Medicine Programme at WHO headquarters. The PHC movement, regarded as WHO's most radical moment, sought to fundamentally reorganise health-care delivery, particularly in global southern countries (Cueto, Reference Cueto2004; Packard, Reference Packard2016). This reorganisation included several components. It enmeshed the promotion of health within broader efforts around political, social and economic justice by calling on Member States to address the social determinants of health, including poverty, lack of education and squalor (WHO, 1975a). It promoted stricter international pharmaceutical standards and export certification schemes to end abusive practices, such as drug dumping, in which low-quality or unsafe drugs that would fail regulatory controls in richer countries were exported to poorer countries (WHO, 1975b). It called for the creation of an Essential Drugs list (a set of necessary, inexpensive pharmaceutical substances of proven quality, efficacy and safety) to counter the flooding of global southern drug markets with profitable drugs for trivial conditions, while basic, potentially life-saving medications were absent.

Most importantly for our purpose, it criticised as inadequate the colonial model of official health care that many countries inherited (urban, hospital-based biomedicine led by qualified physicians and nurses) that left significant portions of the population, particularly in rural areas, underserved (Newell and WHO, Reference Newell1975). This was in stark contrast to the relatively high number of healers in the unofficial sphere of traditional medicine, who were often rurally based, and which people continued to frequent either by choice or because biomedicine was inaccessible. Taking inspiration from China's utilisation of so-called ‘barefoot doctors’, WHO called on Member States to enlist traditional healers (including Traditional Birth Attendants, or TBAs) as part of a wider drive of utilising all available resources to meet the PHC needs of the people and to achieve the ambitious goal of Health for All By 2000. Traditional healers were seen by WHO as a valuable source of culturally acceptable ‘health manpower’ that could be added to the ‘base of the health pyramid’ (Pordié, Reference Pordié2010, p. 59). Healers would continue to deliver traditional medicine, but would, in addition, receive basic biomedical training. It was envisioned that this would enable them to perform limited biomedical tasks (such as dispensing anti-malarials or referring complicated cases to clinics or hospitals) and to discourage any ‘harmful’ traditional healing practices (such as not using a sterilised instrument to cut an umbilical cord). Such training did not, however, seek to penetrate and reorganise the practices and knowledge transmission of healers: that which was not actively harmful according to biomedical knowledge was left undisturbed.

One of the striking aspects of the discussion at this stage was that whether focusing on medicinal plants in 1969 or expanding the analytical scope to include traditional healers in the mid-1970s, state-based, legal regulation did not appear as the obvious solution to dealing with any potential messiness surrounding traditional medicine. Legislation was explicitly marginalised following the 1969 resolution in its accompanying 1971 Director-General's report, which contained a short annex on traditional medicine – the first institutional consideration of the subject. Briefly discussing that traditional remedies were, in some Member States, subject to drug control legislation, Marcolino Candau, the then Director-General, observed that the contribution of such measures could not be evaluated, given that so little was known scientifically about traditional remedies (WHO, 1971, p. 7). While it was recognised in the mid- to late 1970s that regulation of healers should be considered, there was no clear, overall positive regulatory vision in which law would play a central role. Indeed, some documents highlighted that law could be an impediment to utilising healers, given that traditional healing was criminalised in many jurisdictions. A 1977 meeting on promoting and developing traditional medicine, for example, observed that law tended to encourage healing monopolies and protected the entrenched medical system – that is, biomedicine (WHO, 1978c, p. 19). Elsewhere, it encouraged healers to form ‘clubs’ or ‘societies’ to improve their practice, although law did not feature as part of the professionalising vision (WHO, 1978c, p. 39).

The most extensive consideration of legislation took place in a 1975 guideline on training and utilising TBAs, although it was ambivalent as to the positive role that law could play (Verderese et al., Reference Verderese and Turnbull1975, pp. 32–33). It asserted that productive legal regulation, such as light-touch registration and some form of periodic supervision by a clinic, could help improve the practice of TBAs. But it was also keenly aware of the potential danger in turning to law, which could disrupt the delicate normative cultural web in which the TBA operated, alienating her from her community. Any state-based legal regulation must be preceded by extensive education and collaboration with the communities and TBAs in question. This caution around the potentially disruptive effects of state law, as we will see in the following sections, would slowly begin to unwind over the coming years.

6.2 Regulating for PHC: standards for plants, law for healers

The 1978 Alma Ata Conference on Primary Health Care was arguably the zenith of the PHC movement. It issued the landmark Alma Ata Declaration (WHO, 1978a), signed by 134 national governments, which called upon its signatories to promote the radical reorganisation of health care along PHC lines, including the utilisation of traditional medicine (Rifkin, Reference Rifkin2018). It appeared to encapsulate the optimism of the era: that Health for All By 2000 was achievable if states were prepared to be bold and to fundamentally change their conceptualisation of health-care delivery. However, 1978 was also the year in which WHO's promotion of state-based regulation of traditional medicine began to take a more definite shape, embedding assumptions that would come to limit the possibility of alterity in healing.

In addition to the Declaration, the Alma Ata Conference issued a number of recommendations around meeting the needs of PHC. They contained a relatively underappreciated aspect: that legislation was a necessary tool to ‘permit communities to plan, manage and control’ PHC and ‘to allow various types of health workers to perform duties hitherto carried out exclusively by health professionals’ (WHO, 1978b, p. 76). That legislation was a central tool for PHC and, by extension, for regulating traditional healers, who were now to engage in basic biomedical tasks, was solidified the following year, when Mahler relaunched WHO's long-standing Health Legislation Programme. Mahler's report on the subject, published in 1979, highlighted that legislation had the potential to facilitate or derail the goal of Health for All By 2000. Importantly, he linked the issue to the legislative legacies of colonialism: many countries had ‘defective or incomplete’ health legislation and some countries retained colonial legislation that was ‘inappropriate to present conditions’ (WHO, 1979b, p. 4). WHO could assist such countries in preparing health legislation in a number of areas, including the regulation of health manpower, given that PHC had brought new categories of workers – such as traditional healers – under the purview of the state. While it gave no concrete suggestions as to which kinds of legal regulatory techniques could be applied and to what end, Mahler's report (which was endorsed by WHA in 1980) was significant. State law was now framed in general terms as a necessary part of the toolkit for the organisation and regulation of traditional healers if the goals of PHC were to be realised by 2000.

At around the same time, the issue of how to optimise the use of medicinal plants was also receiving attention, as the 1978 Health Assembly passed WHA31.33 (Medicinal Plants) that called for a plethora of international and national standards. This included standardised botanical nomenclature; standards for demonstrating the safety and efficacy of medicinal plant products; standards for the identity, purity and strength of such products; and standardised directions for their use. WHO did not, at this stage, call for legal techniques such as registration or systems of pharmacovigilance for manufactured herbal products. Instead, the production of national and international standards of different kinds were seen as a bulwark against any potential dangers in their utilisation. On the one hand, such a move was in keeping with earlier PHC efforts by WHO around pharmaceutical standards, ensuring that poorer countries should not be subject to low-quality or dangerous pharmaceuticals or therapeutic substances. Similarly, many African governments saw plants in highly political terms as a commodity to be exploited in order to achieve post-colonial, pan-African self-reliance (Langwick, Reference Langwick2010). On the other hand, this was in some respects the first depoliticising move in relation to traditional medicine at WHO. The call for standards already began to foreclose the possibilities for medicinal plants by objectifying them, implicitly calling for their divorce and dislocation from their social contexts, and for privileging explicit, scientific knowledge about them, generated through a laboratory, over other kinds of tacit knowledge. Calling for such standards implied a severing of the link between healer and plant, thereby reducing the latter to little more than ‘materialist props’ (Janes, Reference Janes1999, p. 1803). It also represented a clash of normative orders. The moves towards the soft law of international standards required healers’ knowledge to be made explicit, fixed and verified by scientific analysis, which could run counter to their own standards of secrecy and understandings of remedies as custom-made rather than universal. The vision promoted in the resolution was ‘a sanitized form of “natural or herbal medicine” … devoid of any “magical” elements such as spirits, divination or ancestral knowledge’ (Nichols-Belo, Reference Nichols-Belo2018, p. 722).

There were some cautious voices at WHA, who recognised the potential incongruence of scientific standards with traditional medicine and warned that there was a ‘danger if standardisation and scientific criteria were applied traditional systems would be lost’ (WHO, 1979a, p. 83). However, the approach expressed in the resolution was consistent with the approach taken by many national governments in their own contexts. For example, Ghana, one of the co-authors of the resolution, had recently set up the Centre for the Scientific Research into Plant Medicine. Having done so much around standards relating to drug safety and quality in the 1970s, it appeared to some at WHA that the same standards should logically apply to medicinal plants. As one member of the Executive Board expressed in January 1979 in a discussion of standardising and rigorously testing ‘indigenous drugs’: ‘[t]here can be no double standards when health is at stake’ (1979a, pp. 80–81). Although the call for technical standards and state law were part of the high politics of PHC, their effects were perhaps more paradigm-shifting than anticipated. Once the standardising and legislative regulatory logic were introduced, to plants and healers respectively, it became increasingly difficult to imagine other ways of understanding, organising and approaching these facets of traditional medicine.

6.3 The slow demise of PHC and continued calls for standards and law

As the 1970s gave way to the 1980s, the global political economy underwent a drastic transformation. The ‘decolonisation, democratisation and self-reliance’ of the previous decades were, in the 1980s, replaced by the growing pressure of World Bank-driven policies (Medcalf and Nunes, Reference Medcalf and Nunes2018, p. 417). SAPs gutted health-care budgets and infrastructure, particularly in the African Region. The ideology of PHC and its expression in the Alma Ata Declaration came under attack throughout the 1980s. In light of the new neoliberal paradigm, PHC was seen as too costly, unfocused and unsuited to the type of auditing that was newly favoured in global health. Mahler continued to fight for his vision of PHC and achieved some notable successes during this period, particularly around essential drugs and their regulation. From 1980 onwards, WHO convened biennially the International Conference on Drug Regulatory Authorities (ICDRA), open to all Member States, which aimed to discuss regulatory issues around pharmaceuticals and share best practices. The launch of the influential Revised Drug Strategy in 1986 saw Mahler focus on the ‘rational use’ of drugs, through promoting national drug regulations as a means of improving safety, efficacy and quality (t’Hoen, Reference t'Hoen, Krikorian and Kapczynski2010). In 1987, however, amidst continuing attacks on PHC and an increasingly difficult financial environment both within and outside WHO, Mahler chose not to run for re-election as Director-General and his final term ended the following year. His replacement, Hiroshi Nakajima, took over in 1988.

The slow demise of PHC over the decade did not cause a retreat from traditional medicine. On the contrary, the deleterious effects of SAPs on national health-care systems appeared to incite and galvanise governmental interest, with new meanings becoming attached to traditional medicine and its substance and boundaries continuing to be negotiated in the process. One expression of this renewed interest was linked to the growing perception of plants as pharmacological resources. From the mid- to late 1980s, the world was in the midst of a renewed bioprospecting surge, as technological advancements in laboratory testing of plant material permitted screening ‘with a speed and precision never before possible’ (Miller, Reference Miller2015, p. 52). The position of healers was slowly transformed: they were gatekeepers of plant knowledge that was not necessarily seen as valuable in its own right, but could provide a useful stepping stone for researchers seeking to access powerful plant resources. That many global southern countries were potentially sitting on ‘green goldmines’ generated further tensions between governments, communities, healers and scientists – and between global northern and global southern states (Hayden, Reference Hayden2003; Das, Reference Das2020). It also highlighted that plants were a finite resource in need of protection, leading to new international conservation efforts such as 1988's Chiang Mai Declaration on Biodiversity – a collaboration between WHO, the World Wildlife Foundation (WWF) and the International Union for the Conservation of Nature (IUCN).

Against such a backdrop, then, the narrative was shifting at WHO, from the rehabilitation of culture and the high politics of PHC and its reorganisation of health care, to more practical concerns of crumbling health infrastructure, drug and personnel shortages. At the same time, the perceived necessity for national and international standards around medicinal plants and state-based regulation of healers was emphasised.

6.4 The rise of global herbal medicine

The period from 1988 to 1998, under the stewardship of Director-General Nakajima, was tumultuous for WHO (Walt, Reference Walt1993; Godlee, Reference Godlee1994; Smith, Reference Smith1995; Yamey, Reference Yamey2002). It had been the global health leader in the 1970s, but by the 1990s, it was in danger of being eclipsed by other institutions such as the World Bank, which had initiated its own global health programmes. A mixture of donor apathy towards WHO, particularly towards its Director-General, and the toxic effects of neoliberalisation on the national budgets of global southern countries meant that the organisation continued to face a severely constrained financial environment for much of the decade (Chorev, Reference Chorev2013). This had a direct impact on its activities concerning traditional medicine. The Assistant Director-General asserted in 1993 that ‘in view of the low budget WHO should focus on specific priorities’ with traditional medicine, which at present meant ‘establishing guidelines and assessing research work’ (WHO, 1993, p. 109). Much of its technical work across the decade focused on medicinal plants and herbal remedies. This was partly a response to the various calls from the end of the 1970s onwards, but was also consistent with the 1980s ‘green rush’ (Osseo-Asare, Reference Osseo-Asare2014) that continued well into the 1990s. This had led to significant international advocacy around the conservation of biodiversity and a major pushback against biopiracy, or unauthorised access to genetic material. The 1992 UN Convention on Biological Diversity, which established a sovereign right to a state over its natural resources, was significant turning point in this regard. Against such a backdrop, it is perhaps unsurprising that there was such a focus on herbal medicine throughout the decade, given that they appeared to hold increasingly enormous potential value for community health and for the national economy.

Thus, the value of medicinal plants – both financial and health-wise – was stressed in several resolutions passed by WHA during this time, albeit subject to regulatory validation through the scientific laboratory.Footnote ³ In 1991, WHA44.34 (Traditional Medicine and Modern Health Care) urged Member States to foster co-operation between traditional and ‘modern’ health care, particularly ‘the use of scientifically proven, safe and effective traditional remedies to reduce national drug costs’. It also called on the Director-General to provide further technical guidance in this regard and to fully ‘exploit’ the contribution of ‘scientifically proven’ traditional medicine within all WHO programmes ‘where plant-derived and other natural products’ could lead to new therapeutics. The interest in and promotion of medicinal plants at this time were not limited to the outputs of WHA. World Health published papers extolling the financial and medicinal value of plants, noting how industrial firms were turning to rainforests ‘as a source of either potential new drugs or of compounds from which less toxic or more efficacious drugs can be developed’ (Farnsworth, Reference Farnsworth1996, p. 30). Another paper discussed the growing global market for herbal medicines and noted that safety and efficacy data only existed for a small number of plants and that consequently the ‘establishment and use of regulation procedures and quality control have become major concerns in both developing and industrialized countries’ (Zhang, Reference Zhang1996, p. 5).

Consequently, medicinal plants were subject to a dizzying array of international technical standards throughout the decade that further transformed questions of the safety, efficacy and quality of medicinal plants into a set of bureaucratic guidelines to be followed by national regulatory authorities, manufacturers and others (WHO, 1990a; 1991b; 1998a; 1999b; 2007b; WHO et al., 1993). For example, WHO's Good Manufacturing Practices (GMP) guidelines, the long-standing certification scheme covering pharmaceutical products intended to promote quality, were extended to cover herbal remedies. Similarly, guidelines such as 1998's Quality Control Methods for Medicinal Plants provided several hundred pages of guidance on performing laboratory-based analysis of plants. Each of the technical guidelines sought to control various aspects of the life-cycle of a herbal remedy, such as storage, processing and laboratory testing, in increasingly granular detail, such as what size of instruments to use for which test. The promotion of such technical standards continued the trajectory towards a molecularised, laboratory-based approach to medicinal plants – and the marginalisation of all others – initiated at the end of the 1970s. Moreover, the blurring of the line between scientific standards and the state regulation of plants initiated in the 1980s continued during this period. For example, the 1991 guidelines on the assessment of herbal medicine – produced in response to the 1989 ICDRA request for international standards – were to serve as a model for regulators, as they contained ‘basic elements of legislation designed to assist those countries wishing to develop appropriate legislation and registration’ of herbal medicines (WHO, 1991b, p. 1).

Moreover, the technical standards were to be given statutory, regulatory backing, as WHO began promoting national regulations. While not explicitly calling for the harmonisation of regulatory standards surrounding herbal medicines, WHO published a global review of regulations in 1998, intended to facilitate regulatory information exchange and sharing of best practices. Thus, it provided an overview of over fifty countries’ regulatory regimes, noting, for example, the different regulatory standards triggered by the classification of a herbal remedy as a food supplement or a medicine (WHO, 1998b). It was critical of the weak or non-existent regulatory regimes and suggested that there must, at the very least, be some kind of special licencing regime, which would enable the management of risks to safety, including through post-market surveillance (WHO, 1998b, p. 1). This would permit those herbal remedies making therapeutic claims for minor conditions to be subject to some form of control, without imposing the most stringent, pharmaceutical-style regulatory burdens on manufacturers of herbal remedies.

6.5 Global, well-regulated, depoliticised traditional medicine

Beginning with Gro Brundtland's single term as Director-General (1998–2003), WHO's fortunes were revived (Cueto et al., Reference Cueto, Brown and Fee2019). Brundtland oversaw the implementation of wide-ranging reforms that not only re-established WHO as a credible player in global health, but successfully redeployed the logic of neoliberalism to argue for increased spending on health care by donor countries and organisations, as a matter of macroeconomic good sense (Chorev, Reference Chorev2013). This was, however, a highly targeted form of spending, underpinned by the notion of cost-effectiveness. Money was poured into health interventions that could be measured through quantitative data and for which significant statistical improvements across particular metrics could be demonstrated. One casualty of this renewed focus on cost-effectiveness was the TBA programme – one of the primary figureheads of the 1970s PHC movement and its overlap with traditional medicine. In a 2005 WHO World Health Report, dedicated to the topic of maternal health, WHO declared its own TBA programme a failure (WHO, 2005). It highlighted several fundamental issues with the programme, including a failure to understand the ‘immense cultural gap’ between biomedical care and the activities of the TBA (WHO, 2005, p. 70). Focusing on the negligible impact that the TBA programme had had on maternal and infant mortality rates in different contexts, the report concluded that the money ‘would have been better used to train professional midwives’ (WHO, 2005, p. 70).

However, this negative assessment of the TBA programme specifically did not mean that WHO jettisoned its interest in traditional medicine or even in traditional healers. On the contrary, WHO appeared more invested in the promotion of traditional medicine than ever before. The scattered programmes, resolutions, reports and guidelines were drawn together into global strategies from 2000 onwards (WHO, 2000; 2004d; 2009). Traditional medicine formed the subject of the WHO Congress on Traditional Medicine – a major international conference held in 2008 in Beijing. Not only was WHO invested in promoting traditional medicine, but it appeared to understand its heterogeneity, as evinced in its first Traditional Medicine Strategy (2002 to 2005), which provided a definition similar in scope to WHO's working definition in the 1970s: ‘diverse health practices, approaches, knowledge and beliefs incorporating plant, animal and/or mineral based medicines, spiritual therapies, manual techniques and exercises applied singularly or in combination to maintain well-being, as well as to treat, diagnose or prevent illness.’

It observed that traditional medicine may be:

However, WHO's promotion of traditional medicine at this stage was entirely conditional upon its state-based regulation and standardisation, seen as essential to guarantee safety, quality and efficacy. The consequences this might have for accommodating some key characteristics of traditional healing – its spiritual dimensions, secrecy, mysticism and the oral transmission of knowledge – were notably absent from discussions of these new legal expectations. The promotion of traditional medicine by WHO, despite its expansive definition, therefore created an implicit blindness to its own exclusionary effects that would remain in the years to come.

Moreover, the regulatory and standardising drive appeared to reach even greater facets of the practice of traditional medicine by this point. In the realm of medicinal plants, standards begot more standards that extended inwards, examining new molecular issues such as contaminants and residues in herbal medicines (WHO, 2007a), and outwards, through attempts to control the agricultural practices through which plants were produced (WHO, 2004b). Calls were made for the establishment of pharmacovigilance systems to monitor the safety of herbal remedies on the market (WHO, 2004c). Guidelines were produced that targeted the consumer of traditional medicine, seeking to promote safety by ensuring that they were ‘empowered’ to make the ‘right’ choice when utilising traditional medicine (WHO, 2004a). In the realm of healers, state law was called upon to do more than unambiguously recognise their right to practise or provide statutory backing to self-regulation, as in the 1980s. State regulation and standards began to colonise the realm of training, qualification and accreditation of traditional healing, as a means of guaranteeing the safety, efficacy and quality of practitioners and practices. Training had previously been a concern during the era of PHC, but only insofar as healers were to deliver basic biomedical care, which meant inculcating biomedical knowledge and, in the process, eliminating harmful (from a biomedical perspective) traditional practices. Traditional practices as such, and associated knowledge transmission, were largely left undisturbed. The regulatory and standardising drive had grown by the 2000s and now sought to penetrate and ‘tidy up’ the knowledge transmission of traditional practices and the healing practices themselves.

In 2010, WHO published international benchmarks for training in seven different traditional medicine disciplines: traditional Chinese medicine, Ayurveda, Nuad Thai, Tuina, Unani, osteopathy and naturopathy (WHO, 2010e; 2010a; 2010c; 2010g; 2010f; 2010d; 2010b). This was in addition to a single set of guidelines already published on acupuncture in 1999 (WHO, 1999a). The benchmarks were described as comprising what ‘the community of practitioners in each of these disciplines considers to be reasonable practice in training professionals’ and were directed towards ensuring safety, efficacy and quality (WHO, 2010e, p. vii). This was not in service of some kind of self-regulatory professionalisation, however, but was intended to help authorities establish ‘adequate laws, rules, and licensing practices’ (WHO, 2010e, p. vii). It was important, then, that ‘policy-makers’ were ‘able to standardize the training of practitioners’ as a means of ‘protecting both the providers and the consumers’ (WHO, 2010e, p. viii). The training regime envisioned in the benchmarks was highly formalised, with completed secondary education required as a bare minimum. The training requirements varied between disciplines, but generally consisted of roughly 1,000 hours of clinical supervision, in addition to hundreds of hours of study across various modules. These were internal to the discipline, but also included training in subjects such as human anatomy, pharmacology and physiology, to name a few. Moreover, the training regime was intended to be full-time for two to three years – in other words, akin to university degrees.

While this is ostensibly an attempt to enable governments to include safe, efficacious and quality traditional medicine, it entails fundamentally problematic assumptions and generates myriad exclusions. For one thing, such benchmarking appears to legitimise therapies that can be professionalised, taught and organised like biomedicine – and, conversely, marginalises all others, sometimes against the grain of local communities’ own registers of legitimacy. The preface to the benchmarks even observes that WHO chose to focus on therapies for which countries had already ‘established formal education or national requirements for licensure or qualified practice’ in their respective countries of origin; that is, they were already formally institutionalised at the national level in different contexts (WHO, 2010e, p. x). The benchmarks were a kind of scaling-up to the international level in globally popular forms of traditional medicine and a means of assisting national authorities in properly regulating such practices. This may, in principle at least, work for practices that can be (re)organised around a biomedical model of training, accreditation and licensure, but many forms of traditional medicine elide such tidying-up. Similarly, the assumption that practices can be represented by a neat community that would be willing to act as an interlocutor to the state ignores some of the tensions that animate the relationship between healers and state representative in numerous countries. Where state initiatives seek to produce the form of regulation through professionalisation suggested by WHO, those who come forward to represent ‘traditional healing’ may bear little resemblance with those entrusted by local populations or communities (Fassin and Fassin, Reference Fassin and Fassin1988).

As evinced from the 2014 Traditional Medicine Strategy, the regulatory, standardising drive around practitioners and practices had set its sights well beyond the training of the initial seven disciplines it targeted. It calls on Member States to develop a plethora of standards that, as Wahlberg puts it, amounts to making traditional medicine ‘auditable’ (Wahlberg, Reference Wahlberg, Gale and McHale2015). These include developing indicators for monitoring job performance; ‘practice guidelines’ to ensure safety, efficacy and quality; and standards and regulations covering education, training, accreditation and reimbursement for different kinds of traditional medicine. Not only was WHO advocating the organisation of training of certain disciplines into biomedical-style higher education courses, but it was now promoting practice guidelines – a core component of the evidence-based medicine revolution in biomedicine that has been subject to intense criticism (Timmermans and Mauck, Reference Timmermans and Mauck2005). Moreover, regulations themselves are envisioned as amenable to standardisation and benchmarking: the Strategy is effusive in the power of benchmarks in this regard, as they can be used to evaluate the effectiveness of regulatory frameworks through ‘national audits and reviews as well as by developing and sharing appropriate models at the international level’. Unlike in the 1970s and 1980s, when WHO documents demonstrated an awareness of the limits of state law and when delegates openly questioned whether scientific standardisation would, in fact, destroy traditional medicine, state law and standards are in the 2014 Strategy an unqualified good.