Conceptual graph-based knowledge representation for supporting reasoning in African traditional medicine

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Abstract

Although African patients use both conventional or modern and traditional healthcare simultaneously, it has been proven that 80% of people rely on African traditional medicine (ATM). ATM includes medical activities stemming from practices, customs and traditions which were integral to the distinctive African cultures. It is based mainly on the oral transfer of knowledge, with the risk of losing critical knowledge. Moreover, practices differ according to the regions and the availability of medicinal plants. Therefore, it is necessary to compile tacit, disseminated and complex knowledge from various Tradi-Practitioners (TP) in order to determine interesting patterns for treating a given disease. Knowledge engineering methods for traditional medicine are useful to model suitably complex information needs, formalize knowledge of domain experts and highlight the effective practices for their integration to conventional medicine. The work described in this paper presents an approach which addresses two issues. First it aims at proposing a formal representation model of ATM knowledge and practices to facilitate their sharing and reusing. Then, it aims at providing a visual reasoning mechanism for selecting best available procedures and medicinal plants to treat diseases. The approach is based on the use of the Delphi method for capturing knowledge from various experts which necessitate reaching a consensus. Conceptual graph formalism is used to model ATM knowledge with visual reasoning capabilities and processes. The nested conceptual graphs are used to visually express the semantic meaning of Computational Tree Logic (CTL) constructs that are useful for formal specification of temporal properties of ATM domain knowledge. Our approach presents the advantage of mitigating knowledge loss with conceptual development assistance to improve the quality of ATM care (medical diagnosis and therapeutics), but also patient safety (drug monitoring).

Highlights

► African traditional medicine knowledge in conceptual graph//computation tree logic ► Ties between bioinformatics research and ancestral practices for pharmacovigilance. ► Semantic annotation/indexation in order to perform valuable information retrieval. ► Specification patterns for temporal specification of commonly occurring properties. ► Applications of outlined methodology to medicinal plants from Cameroon and Guinea.

Introduction

In many regions in the world (including Africa, Asia and America) traditional medicine is a socio-cultural reality which has provided a scientific contribution to modern medicine. Given the deficiency of medical doctors in developing countries, traditional health practitioners (THPs) contribute tremendously to healthcare coverage. In some cases, traditional medical practitioners use medicinal plants that have not been actively used in modern medicines (Cragg and Newmann, 2005).

Nowadays, there is a renewed interest in the western world for plants used in traditional medicine that is regularly mixed with orthodox medicines in developing countries. Traditional medicine is “the total sum of knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health and in the prevention, diagnosis, improvement or treatment of physical and mental illness.” (WHO, 2004). Traditional medicines (TM) have incorporated a lot of empirical knowledge combining physical, mental, emotional or social well-being and reflecting the cumulative body of local knowledge that is passed onto generations by oral transmission through traditional health practitioners (THPs) and knowledge holders (Sackey and Kasilo, 2010). African traditional medicine (ATM) has a holistic view on healthcare involving extensive use of physiotherapy and herbalism sometimes combined with some aspects of African spirituality (Onwuanibe, 1979). A disease is often seen in African TM as the failure of complex physical, social and spiritual relationships. Therefore, a diagnosis starts with an examination of both human and supernatural interactions. For instance, when the ailment is mystical, ritual diagnosis is a fundamental part of the traditional healing process for re-establishing social and emotional equilibrium (Tella, 1979). Particularly, the philosophical clinical care embedded in African traditions, culture and beliefs have contributed to making TM practices acceptable and hence highly demanded by the population (Mhame et al., 2010), estimated by the WHO about 80% of people. Indeed, compared to modern practitioners, African Traditional Practitioners (ATP) interact very differently with their patients, using a more patient-centered communication style, to reach common ground with sick persons (Labhardt et al., 2010). Considering sociological and economical factors, TM is a vital health-care resource in developing countries and it contributes positively to the primary healthcare delivery of the local populations, as usually TM appears to be more affordable and less expensive than pharmaceutical drugs for the majority of patients living in Africa. Generally, the experiences have been field-tested for centuries and the relationship of the local people with their ecological systems is codified through language and culture (Martha, 1992). According to the holistic perspective of ATM, the external and internal environment of a patient is considered in the understanding, the prevention, and treatment of diseases. Contrary to the principle of conventional medicine, ATM uses commonly natural products of which the advantage over synthetic compounds rests on their intrinsic potential to provide mild healing effects and induce fewer side effects (Lukman et al., 2007). Meanwhile, both in ATM and conventional medicine, the foundation of disease treatment relies on the correspondences between the clinically active compounds and their biological targets at the molecular level.

The various formats of traditional knowledge are mostly tacit and therefore largely shared in unstructured format. Furthermore, with the lack of scientific evidence on the effectiveness of TM, there are some differences between the healing properties firmly rooted in collective imagination and the therapeutic knowledge actually associated to medicinal plants (Kale, 1995). Many plants have been postulated to have similar activities to pharmaceutical drugs. However, they have not been extensively assessed scientifically in terms of their biological activities (WHO, 2002). Many people believe that because medicinal plants are natural, they are safe with dangers (or not likely to damage something) of an unknown pharmacopoeia. However, TM and its practice, can cause adverse reactions and be harmful if the product or treatment is poor, or if applied improperly or in conjunction with other drugs. The factors of adverse events are numerous. They include misidentification, adulteration, wrong labeling, contamination with toxic or hazardous substances, over dosage, misuse of herbal medicines by either healthcare providers or consumers and use of herbal medicines concomitantly with other medicines (Kasilo and Trapsida, 2010). It is important that patients become more aware of these risks and proceed with caution. Moreover, traditional practitioners need better training and active collaboration and communication between them has to be encouraged.

There is also a need to formalize the most commonly used knowledge for TM, in order to enhance and broaden the long historical use of these medicines. Emphasis should be placed on the need for formalization of traditional health knowledge, which can contribute to discovery and development of new traditional and orthodox medicines (Sambo, 2010). Following the example of biomedicine, the knowledge might at least be well documented with grammatical statements, mathematical expressions, and specification and perhaps consolidated with scientific considerations and substantiation. The documentation and verification of this knowledge can be made towards a formal framework for the search of effective herbal medicines and an education scheme will be phased in gradually for the effective contribution of traditional medicines to mainstream healthcare (Puckree et al., 2002). Only a few countries in Africa (e.g. Ghana and Nigeria) have developed national herbal pharmacopoeias to document medicinal plants that have been found to be effective and to further ensure their safety, efficacy and quality. After their publication, these pharmacopoeias have helped substantiate the alternative medical uses of many African medicinal plants; information on well-controlled clinical evaluations is almost unavailable (Kasilo et al., 2010). For instance, some African plants (e.g. Asparagus africanus (Liliaceae), Crinum glaucum (Amaryllidaceae) and Aframomum melegueta (Zingiberaceae)) are reported to be used in the context of age-related cognitive disorders (e.g. Alzheimer's disease, dementia and memory loss (Adams et al., 2007). In this case, inhibition of the enzymes acetylcholinesterase or monoamine oxidase B seems to be the mechanism of action (Stafford et al., 2008).

Establishing traditional medical resources and knowledge related databases would contribute to document prescriptions used in TM to prevent mismanagement (e.g. poor modes of prescription). This is a prerequisite for a development of a formal methodological framework aiming at the support of traditional medical practitioners and patients in selecting and applying the most appropriate herbal medicines with means to detect flaws in the medical practices and to perform corrective actions. Such a framework would promote the acquisition of knowledge and skills by facilitating the exchange of experiences between traditional medicine practitioners (TMPs) or collaboration between Conventional Medicine Practitioners (CHPs) and TMPs in areas such as referral of patients. There is therefore a need to look for methods of formalizing endogenous knowledge in traditional medicine. This may provide baseline knowledge on the African medicinal plants, feasible pharmaceutical uses and threats to sustainable usage (Ndenecho, 2009). The research work reported in this paper falls within this vision. To do so, our proposal is based on the use of conceptual graphs for temporal properties specification of ATM knowledge in which domain-specific units of knowledge are described with a visual modeling approach instead of expressing by logical formulas. Conceptual graphs benefit from a solid logic foundation and their mode of formal reasoning can rely on logical operators or on graph–theoretical operations.

The rest of the paper is structured as follows. Section 2 exposes the state of the art concerning knowledge acquisition and formalization for ATM and conceptual graph formalism. We outline preliminaries and background regarding the way research scientists and medical doctors capture practices of African Traditional Practitioners. In addition, a motivated case study from the West African sub-region (Guinea) is presented in order to give an actual illustration of the reality in ATM. We detail in Section 3 our approach of formal representation of a set of concepts of ATM domain knowledge and their relationships. Section 4 presents the framework used to implement the conceptual graphs for ATM knowledge formalization and in Section 5 our approach is showcased through an illustrative example treating public health issues in Cameroon. We demonstrate that the proposed formalization approach is capable of tracking and evaluating situations with medicinal plants that may affect Cameroonian health. Finally, Section 6 concludes and discusses future challenges.

Section snippets

Background on capturing TMPs knowledge

In order to facilitate the understanding of the approach that we propose in this paper, we outline in this section the process followed for identifying and selecting the interesting plants for treating a given disease and their mechanism of use in a therapeutic prescription (see Fig. 1).

The resources about plants used by the traditional healers comprises botanical identification of the plants (synonyms and vernacular name), the part of the plant used (e.g. roots, leaves, stem and stem bark,

The EphMRA classification

The EphMRA brings together European research-based pharmaceutical companies operating on a global perspective. The main classification developed by the EphMRA is the Anatomical Classification system (AC-system) jointly with the Pharmaceutical Business Intelligence and Research Group (PBIRG). This classification represents a subjective method of grouping certain pharmaceutical products according to their main therapeutic indication and each product is assigned to one category. There are four

Informal definition

A conceptual graph is a graph with two kinds of nodes respectively called concepts and conceptual relations and must meet the following two conditions (Sowa, 1984): (i) each arc must connect a conceptual relation to a concept (it is said that the graph is bipartite); and (ii) a concept that is not connected can form by itself a conceptual graph. Conversely, any relation must be linked to one concept.

A concept consists of a type and a referent: the types are partially ordered, the referents are

Example of effective herbal medicines

In this section, we report on a significant set of effective medicinal plants collected at the Cameroonian Institute for Medical Research and Medicinal Plants Studies (IMPM). The practice of traditional medicine in the urban environment is evolving, influenced by the proximity and availability of health-care centers and pharmacies. For instance, most urban TP use conventional medicine facilities including medical tests for a diagnosis and/or a post-treatment checking (Hillenbrand, 2006). With

Conclusion and future works

In some situations, traditional medical practitioners use plants that can later be adapted to some feasible pharmaceutical uses with the aid of scientific evidence on the effectiveness (e.g. anti-leukaemia drugs extracted from the Madagascan Periwinkle (Catharanthus roseus) or anti-drepanocytosis medicine FACA (a combination of Fagara xanthoxyloides and Calotropis procera from Burkina–Faso, Ouattara et al., 2009). Traditional medicine knowledge management needs to include a minimum requirement

Dr. Bernard Kamsu-Foguem is currently a tenured Associate Professor at the National Engineering School of Tarbes (ENIT) of National Polytechnic Institute of Toulouse (INPT) and leads his research activities in the Production Engineering Laboratory (LGP) of ENIT-INPT, a research entity (EA 1905) of the University of Toulouse. He has a Master's in Operational Research, Combinatorics and Optimisation (2000) from National Polytechnic Institute of Grenoble, and a PhD in Computer Science and

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    Dr. Bernard Kamsu-Foguem is currently a tenured Associate Professor at the National Engineering School of Tarbes (ENIT) of National Polytechnic Institute of Toulouse (INPT) and leads his research activities in the Production Engineering Laboratory (LGP) of ENIT-INPT, a research entity (EA 1905) of the University of Toulouse. He has a Master's in Operational Research, Combinatorics and Optimisation (2000) from National Polytechnic Institute of Grenoble, and a PhD in Computer Science and Automatic (2004) from the University of Montpellier 2. His current interests are in Knowledge Discovery and Data Mining, Knowledge Representation, Formal Visual Reasoning, Ontology-based Semantic Analysis, Knowledge Exploitation for Collaboration, Decision Support Systems and Intelligent Systems. Application domains include Continuous Improvement process, Industrial Maintenance management, Health Information Systems and Alternative Medical Systems. He has authored or co-authored a number of papers in the international scientific journals such as Expert Systems with Applications, Decision Support Systems, Engineering Applications of Artificial Intelligence, Computers in Industry, Advanced Engineering Informatics, Annual Reviews in Control, International Journal of Production Research and Information Systems Frontiers. He is a reviewer for a large number of international scientific journals such as Engineering Applications of Artificial Intelligence, Concurrent Engineering: Research and Applications, Artificial Intelligence Research, Canadian Journal of Administrative Sciences, International Journal of Computer Engineering Research, International Journal of Production Research, Knowledge Management Research & Practice, Journal of Intelligent Manufacturing, Interacting with Computers, Sensors and Knowledge-Based Systems. Dr. B. Kamsu-Foguem was recently awarded two prizes (Best Paper Award in 2009 and 2011 from the SKIMA - IEEE conferences) and one audience distinction (Most Downloaded Engineering Applications of Artificial Intelligence Article from SciVerse ScienceDirect in 2012) for his research topics in continuous improvement, knowledge reasoning and maintenance management. He is interested in the international network and collaboration with other institutions and researchers related to research projects, course development and delivery.

    Dr. Gayo Diallo is an Associate Professor in computer science at Bordeaux Segalen University, France, since 2009 within the Bordeaux School of Public Health, (ISPED) where he is member of the LESIM research group. Prior to taking this position, he was a postdoctoral researcher at the Laboratory of Applied Computer Science, Futuroscope-Poitiers, France, and a Research Assistant at CERC (City eHealth Research Center), City University of London, UK. He received his Ph.D degree from University of Grenoble 1 Joseph Fourier in 2006, a joint MSc degree from University of Geneva, EPFL and University of Grenoble 1 Joseph Fourier in 2001 and an Engineering degree from National Institutes of Computer Science (INI), Algiers, Algeria in 1999. He is actively pursuing his research in the areas of the Semantic Web technologies and Ontologies, Medical Knowledge Representation and Reasoning and DB&IR integration. And his research work is mainly applied to the medical domain.

    Dr. Clovis Foguem is an Internal Medicine and Geriatric Medicine doctor (MD), former Junior Lecturer of physiology and medical pathology at the Medical and Social National Institute [Cotonou, Benin] and former Clinical instructor and Hospital consultant, in Geriatrics at the Faculty of Medicine and at the CHU (Teaching Hospital) of Besancon [France]. He is now Hospital practitioner at Acute Geriatric Unit of Auban-Moét Hospital Center [Epernay, France]. He has a Master in Sciences, technologies, health with purpose research. Mention biology, health, specialty physiology, neurosciences and Behaviour from Franche-Comté's University: Faculty of Sciences [Besancon, France] and undertakes a PhD on: 'Olfaction and Elderly: study of the olfactory (CN I) and trigeminal (CN V) sensitivities interactions in a geriatric population; constants and pathological specificities' at Center for Food and Taste sciences (CSGA) - UMR 6265 CNRS - UMR 1324 INRA - Burgundy's University [France]. For the work above, on olfaction, Dr C. Foguem was laureate of the Health Research Advancement Award of the Corporate foundation 'Groupe Pasteur Mutualité' (a French mutual's group of leading insurance administered by healthcare professionals) in 2011. He is also particularly interested in elderly epilepsy, neurodegenerative diseases (as Parkinson disease or Lewy Body dementia) and whether pathogenic inflammatory or autoimmune responses can contribute to these disorders in the elderly. Moreover he is also interested in medical knowledge representation and medical clinic design guidelines. He has authored or co-authored twenty-five articles in scientific journals and international conferences. He is peer-reviewer of the Medical press journals: Clinical Interventions in Aging; Degenerative Neurological and Neuromuscular Disease; International Medical Case Reports Journal; Neuroscience and Neuroeconomics; Clinical Medicine Insights.

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