Use of Ethnomedicinal Plants by the People Living around Indus River

The objective of present study was to document and preserve ethnomedicinal knowledge use to treat different human ailments by traditional healers of Dera Ismail Khan region, Pakistan. Field work was conducted between February 2012 and January 2013 using semistructured questionnaires. Data was collected from 120 traditional healers through questionnaire survey. Traditional healers in the study area use 70 plant species mostly herbs (57%) for ethnomedicinal and other purposes. The highest FIC values (0.80) were obtained each for gastrointestinal and kidney problems followed by respiratory infections (0.72) and skin infections (0.73). There was a significant correlation (r 2 = 0.950; p < 0.01) between the age and traditional knowledge of respondent. Direct matrix ranking indicated Morus alba and Dalbergia sissoo as highly multipurpose and threatened species in the study area. The results showed high dependency of local inhabitants on medicinal plants in meeting their primary health care needs. Moreover, the traditional knowledge has been restricted to elder people. Protection measures should be taken in order to conserve precious multipurpose species that are facing overexploitation. Medicinal plants treating major ailments in the region may be subjected to phytochemical and pharmacological investigations for the identification of bioactive compounds.


Introduction
Medicinal plants have important contributions in the healthcare system of local communities as the main source of medicine for the majority of the rural population [1]. Out of the total 422,000 flowering plants reported from the world, more than 50,000 are used for medicinal purposes [2]. About 60% of the world population and 80% of the population of developing countries rely on traditional medicine. According to Bhat et al. [3], more than 4.5 billion people in the developing world rely on medicinal plants as components of their healthcare. The highest popularity of medicinal plant in rural areas is due to high cost of allopathic drugs and side effects [4].
In the early 1950s, up to 84% of Pakistani population was dependent on indigenous medicines for traditional health practices [5], but now this is practiced only in the remote rural areas [6]. Due to modernization, people are getting far from this treasure and this knowledge is eroding at a much faster rate [7]. Ethnobotanical studies in various areas of Pakistan have been carried out [8][9][10][11][12]. It is believed that such studies can constitute the starting point for the development of new drugs and useful substances [13].
The present study was aimed at investigating the traditional utilization of plants of Dera Ismail Khan District located in the north-west region of Pakistan. The study area is the part of the country's richest biodiversity centre and a source of ethnobotanical knowledge. Very few ethnobotanical studies have been conducted in this region. The main objectives of the present study were (i) to identify and explore plant species that are used locally for the treatment and prevention of various diseases, (ii) to document traditional recipes from medicinal plants including methods of preparation, dosage, and modes of administration, (iii) to select candidate medicinal plant species of high priority for phytochemical and pharmacological analyses in our subsequent studies, and (iv) to assess the plants conservation issues of the study area.

Study Area.
The present study was carried out in the Dera Ismail Khan often abbreviated to D. I. Khan, which is a city in Khyber Pakhtunkhwa province, Pakistan ( Figure 1). D. I. Khan is with an area 7326 km 2 and is situated between 31 ∘ .15 and 32 ∘ .32 N latitude and between 70 ∘ .11 and 71 ∘ .20 E longitude [14]. Most of the area of the district consists of flat dry alluvial plain, commonly known as Daman, which makes up more than 80 percent of the area where a large number of streams and hill torrents discharge water [15]. D. I. Khan supports xerophytic and aquatic vegetation and their associated species of wild fauna [16]. Dominant plant species are Acacia modesta, Acacia nilotica, Calotropis procera, Morus alba, and Eucalyptus camaldulensis. The maximum and minimum mean temperature recorded during June is from 42 ∘ C to 27 ∘ C, while in winter season the minimum temperature recorded is 20 ∘ C and maximum temperature is 40 ∘ C [17]. Precipitation mainly falls in two distinct periods: in the late winter and early spring from February to April and in the monsoon in June and July. One of the most famous products of this district is the "Village Dhakki date, " which is exported to the Middle East, United States, and Europe. This district also produces wheat, sugar cane, rice, and a famous variety of mangos. Most of the population of the area is rural with low literacy rate and they also lack modern health facilities; hence, they are more dependent upon natural resources especially plants for their healthcare and to compensate their low income as well.

Data Collection.
Field work was carried out between February 2012 and January 2013. A total of eight field visits were made in four different seasons for data collection. Each visit lasted over 20 days in the field. A total of 120 informants were selected on the basis of information provided by the local administrator and elder people of the study region.   In the morning one cup of this water is used on empty stomach or is used thrice a day for a period as needed. The water is strained and is given orally to the children along with sugar for dyspepsia and typhoid.

2-3 times daily.
Evidence-Based Complementary and Alternative Medicine 5   As needed.

Saccharum benghalensis
Retz. KUH-367 Kana Poaceae Herb/nonendemic Wild Leaves Ash of the leaves is mixed with water, and after an hour it will settle down in the bottom. The strained water is given to the animals suffering from "urine retention" disease.
As needed.  Leaves and fruits Eat their fruit which is helpful in treatment of diarrhoea as well as in blood purification.

Salvadora oleoides
Paste of leaves is used for hair growth.
As needed.
level and to prove the reliability of data collected through semistructured interviews [18]. Questionnaires designed to the respondents (traditional healers) about medicinal plants knowledge were mainly focused on local name of a particular medicinal plant, types of disease treated, mode and method of remedy preparation, parts of the plants used, use of fresh or dry plant parts, use of single or mixture of plants for remedy preparation, mode of administration, dose requirement, and usable duration regarding each medicine. Questionnaires also contained questions regarding sociocultural information.

Medicinal Plants Collection and Preservation.
Plant samples were collected from the field and were dried and compressed in newspapers. Newspapers were changed daily until they remained dry after compression. Identification of plants was done by the expert taxonomists Dr. Waheed Murad and Dr. Azizullah of Kohat University of Science and Technology, Kohat, Pakistan. Scientific names, family names, and publication authors were corrected according to the flora of Pakistan and software index kewensis [19]. Pressed plant samples, plant photographs, and descriptions were assigned voucher numbers and deposited at the herbarium at  the Department of Botany, Kohat University of Science and Technology, Kohat, Pakistan.

Data Organization.
Data was organized and analyzed using Microsoft Excel software. The habits of the plants were categorized into three groups, that is, herbs, shrubs, and trees, using available literature [19]. The status of recorded plants was divided into three groups of wild, cultivated, and both wild and cultivated. The parts used by the healers were categorized into 11 groups, that is, fruit, leaves, whole plant, seeds, bark, root, and so forth. Human ailments treated by the traditional healers were divided into 11 categories such as gastrointestinal infection, respiratory infection, and fever. Route of administration of plant remedies was classified into three groups such as oral, dermal, and both oral/dermal and nasal. Questionnaire data was analyzed for basic categorization of the respondents' gender, age groups, literacy ratio, and occupation.

Informant Consensus Factor (F ).
Descriptive statistics were used to examine and summarize the ethnobotanical data. Based on the information obtained from the informants, the ailments reported were grouped into a total of 11 categories. The F IC results could be useful in prioritizing medicinal plants for further scientific validation of plants and plant products [20,21], as pharmacologically effective remedies are expected from plants with higher F IC values [22]. The informant consensus factor (F IC ) was calculated to estimate user variability of medicinal plants [23,24]. F IC values range from 0.00 to 1.00. High F IC values are obtained when only one or a few plant species are reported to be used by a high proportion of informants to treat a particular ailment, whereas low F IC values indicate that informants disagree over which plant to use [23]. High F IC values can thus be used to pinpoint particularly interesting species for the search of bioactive compounds [24]. F IC is calculated using the following formula: where N ur is the number of individual plant use reports for a particular illness category and N t is the total number of species used by all informants for this illness category.

Direct Matrix Ranking (DMR).
Data on use diversity of multipurpose medicinal plants were evaluated by direct matrix ranking (DMR) exercises as described in Cotton [25] that involved fifteen (ten men and five women) key informants. Participants for this exercise were selected based on their long years of experience as traditional herbal practitioners in the study area as described in Yineger et al. [26].

Pearson's Correlation.
This statistical test was applied between the age of the respondents and number of plants known to them. The test was carried out using SPSS [27].

Results
Among the 120 informants, 50 (41.5%) were male and 70 (58.5%) were female. The largest proportion of the respondents was of the elderly, above 40 years old (Table 1). More than half of the respondents were illiterate (52.5%), whilst most of those with an education received merely primary education (25.8%) which reflects the unavailability of educational institution in the area ( Table 1). Majority of females (90%) were housewives while 44% of males were farmers followed by 24% of shopkeepers. These very basic results also reflect the reality that indigenous knowledge is well established but seems to be decreasing in the younger generation. The indigenous knowledge showed a significant negative correlation ( = −0.95, < 0.01) with the age of the respondents (both male and female) (Figure 2). The present study provides information of ethnomedicinal uses of 70 plant species belonging to 39 families and 62 genera ( Table 2). Out of 39 families, the dominant family with highest number of medicinal plants was Solanaceae (5 species) followed by Moraceae, Poaceae (4 species), and 3 species each in Liliaceae and Asteraceae. Moreover, the local healers mostly use herbs (57%) followed by trees (29%) Evidence-Based Complementary and Alternative Medicine 11 ( Table 2). Of the 70 species, 50% were cultivated while (44%) were wild (Table 2).
Different parts of medicinal plants are used as medicine by the traditional healers (Figure 3). Among the different plant parts, the leaves and fruit (31%) are the most frequently used for the treatment of diseases followed by whole plant parts, roots, barks, tubers, seeds, and stems. Ethnomedicines were mostly taken through oral route (70%) followed by dermal/oral (15%) and dermal (11%). Decoction is the most common method used for remedy preparation ( Table 2). The additives like milk, butter, boiled coffee, and food are commonly believed to serve as a vehicle to transport the remedies. The most commonly treated disease (34%) in the study area was gastrointestinal disorders ( Table 3). The healers used usually fresh plant parts for the preparation of ethnomedicines ( Table 2).
There is no standardized measure on the dose for most of the ethnomedicines in the study area. The dose depends on the traditional healer that prepares the herbs for medicinal purpose or it may also depend upon the disease severity. The dosage of certain plants in the region varied according to the type of illness ranging from two spoonfuls (e.g., for treatment of jaundice using syrup prepared from Azadirachta indica) to a cup or glass (e.g., for blood purification and abdominal pain stained water from fruit of Withania coagulans). Most of the ethnomedicines are prepared using single plant in the region while some others are prepared by the mixing parts of more than one plant; for example, fresh leaves of Mentha viridis and Ocimum basilicum and fruit of Foeniculum vulgare are mixed and boiled to make tea used for stomach problems, equal quantities of fruits of Coriandrum sativum and Foeniculum vulgare are mixed and crushed to make powder and used as carminative, and extract of bulb of Allium cepa and Mentha viridis is mixed and used for cholera.
About 11 disease categories were identified from the investigated region. The highest F IC values were gastrointestinal (0.80), respiratory (0.72), skin infections (0.73) and kidney problems (0.80) ( Table 3). The highest plant use citation was for gastrointestinal disorders (122) followed by kidney problems (37) and respiratory infections (23). The output of the DMR exercise on ten multipurpose medicinal plants enabled to identify which of the multipurpose plants is the most to be under pressure in the area and the corresponding factors that threaten the plant. Accordingly, Morus alba and Dalbergia sissoo ranked first (the most threatened); Zizyphus jujuba ranked second; Tamarix aphylla ranked third; Withania coagulans ranked fourth (Table 4). Results also indicated that those multipurpose medicinal plant species are currently exploited more for fodder, fuel, construction, and agricultural tools purposes besides their medicinal role.

Medicinal Plants and Related Knowledge.
The present study provides information on 70 medicinal plants used in the study area by local traditional healers. The study revealed that the people of the region have been using plant resources for their various ailments. The local people know the useful plants and preparation of recipes through personal experience and ancestral prescription and long utility [28].
Dominance of medicinal plant species from families of Solanaceae, Asteraceae, Poaceae, and Moraceae could be attributed to their wider distribution and abundance in the flora area [29,30]. As leaves and fruits of medicinal plant species were reported to be harvested for most remedy preparations, gathering of medicine may have little negative impact on the species. It is well recognized by conservationists that medicinal plants primarily valued for their root parts and those which are intensively harvested for their bark often tend to be the most threatened by overexploitation [31]. Results also showed prominent use of freshly harvested plant parts for traditional remedy preparation used against various ailments. The recurrent use of freshly harvested medicinal plant materials in the area is reported to be related to the notion of attaining high efficacy using active ingredients of fresh plant parts which they thought could be lost on drying. Other ethnomedicinal inventories [26,32] have also indicated wide use of fresh plant materials for remedy preparations due to reportedly better efficacy related factors than use of dried plant materials.

Growth Form and Status of Medicinal Plants.
Present study elucidates that the herbs are the major growth form used in the region for curing human diseases followed by trees. A high usage of herbs in some studies could be an indication of their abundance, easy availability, and centuries-old traditional knowledge of the healers. The trend of using more of herbaceous plants could be advantageous as it is easier to cultivate them when they are short in supply. According to our study, most of the medicinal plants are being cultivated in the region. The high proportion of woody plants in our survey is likely associated with the ability of trees to withstand long dry seasons, thus resulting in their abundance and year-round availability in arid and semiarid areas. Thus the variation in medicinal plants growth form might be associated with different sociocultural beliefs, ecological status, and variation in practices of traditional healers of different regions or countries.

Preparation, Route of Administration, and Dosage of Medicinal Plants.
The healers of the region mostly used ethnomedicines in decoction form. The medicinal plant decoctions for various ailments might be related to their proven effectiveness over many years of trial and indigenous knowledge accumulated on efficacy of such preparations. Additives (milk, butter, boiled coffee, and food) that are commonly believed to serve as a vehicle to transport the remedies are also necessary to minimize the bitterness, vomiting, and diarrhoea and to make the remedy more palatable. The finding is in line with other studies indicating that the oral route is the most preferred mode of administration [33,34]. Preparation of plant medicines from several plant parts is believed to cure diseases more rapidly compared to single plant medicine [35].

Priority Medicinal Plant Species and the Ailments That
They Treat. The highest number of plant species and highest F IC value were reported for gastrointestinal, respiratory, kidney, and skin infections. This may be related to a high prevalence of these ailments. Gastrointestinal disorders and respiratory infections, particularly cholera, diarrhoea, dysentery, cough, asthma, and bronchitis, are a major concern not only in the study area but also in the whole country and result in high mortality rate if not treated promptly [36].
In our study the lowest F IC value below 0.05 was only recorded for wound healing category, which would typically result from plant use to treat rare diseases; however all other diseases have F IC value above 0.05, suggesting that our survey addressed medicinal plant species commonly used to treat common human ailments in the study areas. The high F IC value medicinal plants contain variety of bioactive compounds and many of them have been scientifically proved by various studies. For example the natives of the region are using a large of number of plants like Solanum nigrum, Calotropis procera, Grewia asiatica, Punica granatum, and so forth for the treatment of diarrhoea, dysentery, and other gastrointestinal disorders, while many plants like Eucalyptus camaldulensis, Coriandrum sativum, Datura metel, and so forth are being used for respiratory diseases. The aforementioned plants contain variety of chemical constituents like tannins, saponins, alkaloids, flavonoids, and phenol compounds that are responsible for their therapeutic action against such diseases [37][38][39][40]. The result indicates that these plants are exploited more for their nonmedicinal uses than for reported medicinal values. Overharvesting of multipurpose medicinal plant species for construction, fuel wood, fodder, and agricultural tools was found to be the responsible factors aggravating the depletion of the highly ranked species in the area.

Indigenous Knowledge.
It was observed during research study that the knowledgeable women were more concentrated as compared to the men of this region of Pakistan. Generally, gender-based differences in medicinal plant knowledge can be derived from experience and degree of cultural contact with curative plants [41]. The study indicates that the aged people of the region have traditional knowledge about more numbers of medicinal plants as compared to younger people which might be due to their least interest. Hussain et al. [42] in South Waziristan and Parveen et al. [43] in the Thar Desert of India have also reported that people older than 35 years of age are more knowledgeable than the young ones on medicinal plants and their uses.

Conclusions
In conclusion, D. I. Khan has plenty of medicinal plants and the people of the region are highly dependent on these plants for medicinal and other ethnobotanical purposes. The people of the region have tremendous traditional knowledge regarding the utilization and preparation of various ethnomedicinal remedies. Moreover, they are using some medicinal plants for multipurpose and posing great pressures on certain medicinal plants like Morus alba and Dalbergia sissoo. Hence, natives should be educated regarding the sustainable usage of medicinal plants. The persistence of traditional knowledge is more among old age people; however, as a matter of concern, young people are taking less interest in such knowledge due to multiple reasons. As such, studies on the documentation of ethnomedicines may be extended to other areas for the protection of traditional knowledge. Further phytochemical analysis, pharmaceutical application, and clinical trials are therefore recommended in order to evaluate the authenticity of ethnomedicines to scientific standards.

Questionnaire of Ethnobotanical Data Collection
Informants' Consent for the Participation in the Study.

Data about Medicinal Plant and Its Use.
Number of plants known.
Names of plants (local names).
Plant part used.
Cultivated/wild. Name of disease(s) treated.
Evidence-Based Complementary and Alternative Medicine 13 Name of plants used for specific disease categories.
Method of crude drug preparation.
Use of single or mixture of plants.

Mode of administration.
Dosage.

Informant Consensus Factor.
Name of plants used against disease category 1.
Name of plants used against disease category 2.
Name of plants used against disease category 3.
Name of plants used against disease category 4.
Name of plants used against disease category 5.
Name of plants used against disease category 6.
Name of plants used against disease category 7.
Name of plants used against disease category 8.
Name of plants used against disease category 9.
Name of plants used against disease category 10.
Direct Matrix Ranking.

Number of plants having NTFPs uses.
Name of plants (local names).

Remarks.
Plant identified as--(botanical name and family). Signature of researcher