Traditional medicines and their common uses in central region of Syria: Hama and Homs – an ethnomedicinal survey

Abstract Context Since ancient times, traditional Arabic medicine (TAM) has been used to treat various diseases in Syria. They are cost-effective with fewer side effects and are more suitable for long-term use compared with chemically synthesized medicines. In addition, the scientific importance is manifested, as this survey proceeds, for the purposes of verifying and documenting these traditional medicines and their common uses. Objective We conducted ethnobotanical and ethnomedicine research on plants traditionally used to treat various diseases in central region of Syria. Methods Information was collected from 2019 to 2021 from the cities of Homs and Hama and their villages, which are two governorates located in central Syria, after interviews with traditional practitioners called Attarin, and many other people. Plant specimens were collected according to different references concerning medicinal plants of Syria, to document the traditional uses of plants at least two of the traditional healers and three other people were asked. Results In this survey, we listed 76 medicinal plants belonging to 39 families in alphabetical order with the parts used and the method of preparation according to their therapeutic use, which are used to treat 106 ailments. Conclusions Many of the uses of medicinal plants mentioned in this survey are still under study. There is no doubt that this study will provide new data that could contribute to further pharmacological discoveries by identifying the active ingredients and their mechanism of effect by doing additional pharmacological work to confirm the alleged biological activities of these plants.


Introduction
Traditional medicine (TM), as defined by the World Health Organization (WHO), is the sum total of the 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 as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness (WHO 2002a(WHO , 2002b. Some TM systems are supported by huge volumes of literature and records of the theoretical concepts and practical skills; others pass down from generation to generation through verbal teaching. To date, in some parts of the world, the majority of the population continue to rely on their own TM to meet their primary health care needs. When adopted outside of its traditional culture, TM is often referred as complementary and alternative medicine (CAM) (Che et al. 2017).
Although modern medicine is currently available in many developing countries, large proportions of the population in these countries still rely to a large extent on traditional practitioners and medicinal plants for therapeutic purposes. TM is often the first choice for providing primary health care in developing countries, and the WHO estimates that more than 80% of healthcare needs in these countries are met by traditional health care practices, being the cheapest and most accessible (WHO 2002a(WHO , 2002b(WHO , 2004(WHO , 2005. The WHO pays special attention to TM and CAM. Resolution (no. WHA13-6) issued by the World Health Assembly (WHA) in 2009 emphasized the need to update the global TM strategy (WHO 2009), so the WHO issued its strategy for traditional (folk medicine) 2014-2023 (WHO 2013).
The United Nations Educational Scientific and Cultural Organization (UNESCO) works to document the medical heritage of peoples within its documentation of the living intangible cultural heritage of peoples and civilizations, through the documentation of TM practices that were included in the UNESCO convention (2003), the convention on biological diversity (1992) and the UNESCO universal declaration on cultural diversity (2001) and the United Nations declaration on the rights of indigenous peoples (2007), and according to the meeting of the UNESCO International Bioethics Committee (IBC) working group on TM and its ethical effects in Paris (2010), it stressed the need to conduct studies that illustrate the use of TM in various regions around the world, and its evaluation in clinical practice and in research and policy (IBC 2013).
In 2017, the International Center for Information and Networks for Intangible Cultural Heritage in the Asia-Pacific region (ICHCAP) under the auspices of UNESCO, issued a book entitled Traditional Medicine in which the Syria Trust for Development in Section VII included TM in Syria (Falk 2017).
Ethno-botany is the scientific study of the relationships between people and plants. It was first coined in 1896 by the US botanist John Harshberger; however, the history of ethnobotany began long before that (Campbell et al. 2002;Amjad et al. 2015). It plays an important role in understanding the dynamic relationships between biological diversity and social and cultural systems (Husain et al. 2008;Amjad et al. 2013Amjad et al. , 2015. Plants are essential for human beings as they provide food, and medicines (Alam et al. 2011;Ahmad et al. 2012).
Traditional Arabic medicine (TAM) is one of the famous traditional medical systems, which is occasionally called Unani medicine, Graeco-Arabic medicine, humoral medicine or Islamic medicine. The subject of TM in Syria has received little attention in the literature, and very little is known about the traditional medicinal substances used nowadays by the Syrian population to treat the most common diseases. Throughout ancient times in Syria, as part of the Levantine Nations (Bilad al-Sham), and other lands in the region, humans used various natural materials as sources of medicines (Jaddouh 2004). In the western countryside of Hama, there is a natural reserve for medicinal plants, which is called the Abu Qubais Protected area in Al-Ghab region (which protect the biodiversity rights of indigenous people and affiliated to the general commission for Al-Ghab administration and development), 509 plant species belonging to 72 families have been recorded (Al-Mahmoud and Al-Shater 2010).
For these reasons, the present investigation gathered the uses of medicinal plants in the centre region of Syria (Homs and Hama), as a supplement for a national survey, and documents the information concerning the uses of medicinal plants, which may serve as the basis of knowledge for a more intensive scientific research.

Study area
Syria is a country located on the east coast of the Mediterranean Sea in southwestern Asia. Syria is bounded by Turkey to the north, Iraq to the east and southeast, Jordan to the south and Lebanon to the southwest. The study area is the middle region of Syria including Homs Governorate and Hama Governorate.
This area has a Mediterranean climate with a long dry season from May to October. In the extreme northwest, there is some light summer rain. On the western region, summers are hot, with mean daily maximum temperatures ranging from low to mid 80 F, while the mild winters have daily mean minimum reaching temperatures low level of 50 F. Only above about 1500 m are the summers relatively cool. In inland the climate becomes arid, with colder winters and hotter summers. In the desert, at Tadmur maximum temperatures in the summer, temperature reaches averages in the ranges of upper 90s to low 100 F, with extremes in the 110 F. In rural areas, work takes place according to the seasonal rhythm of agriculture. Women generally share in much of the agricultural labour. Agriculture constitutes an important source of income, and fruits and vegetables including onions, olives and grapes. Commercially important forest plants include: pistachio, which is important for its oilrich fruit, and plants such as olive trees, grapevines, apricot trees and cumin (Hamid e et al. 2021).
Historically, the ancient Palmyra, also called Tadmur, is an ancient city in south-central Syria (Homs Governorate). An oasis in the Syrian desert, Palmyra contains the monumental ruins of a great city that was one of the most important cultural centres of the ancient world, from the first to the second century according to World Heritage List (UNESCO 2021).

Field work and data collection
Field surveys were conducted between December 2019 and January 2021, to document ethnobotanical information through oral interviews and designed semi-structured questionnaire. Thirty-five villages and 59 districts were visited for field research; 235 people were contacted and 151 of those with ethno-botanical experience agreed to become our informants, including 35 local herbalists (Tabib Arabi) and 10 physicians (who hold a general medicine specialty). The queries were repeatedly made to increase the reliability of the data; interviews with the men were usually carried out in the 'Mukhtar' house where they come together, and with women in their homes, bazaars and gardens. The Syria Trust for Development (which is a national development organization, and has a program called 'Mashrouie' that runs innovative microcredit programs that encourage economic growth in disadvantaged areas) helped us in data collecting. The information gathered during the present study included sociodemographic characteristics of the interviewed informants (age, gender) and ethnopharmacological information, including the local and scientific name of the species, local names, plant parts used, modes of use, conservation method, administration mode and toxicity, all documented data were then translated into English and Latin. Information that had been carried to the region from the outside and that was not used or confirmed was not included and recorded (Weckerle et al. 2018 Only the medication of single herbs was included, while mixtures and multiple recipes were disregarded. The answers that were given with doubt to the questions above were not recorded, and we adopted the information that gave 40% frequency in the collected data, and the data that gave less than that were neglected. Information about diseases diagnosed specifically by physicians and traditional healers was approved, while self-treating diseases were referred to as auxiliary in treatment, nutritional uses were clearly indicated, and some plants were used to prevent disease and improve public health. The information about diseases was divided into three groups when analysing the data (group A: acute diseases, group B: chronic diseases, group C: simple symptoms and signs), and the focus was only on groups B and C.

Taxonomic identification of the species
Medicinal plants being mentioned by the Informants were recorded with local names and photographed. Each reported medicinal plant species was gathered, compressed, dehydrated, mounted on herbarium sheets, and identified; the taxonomic identity of the plants was confirmed by Prof. Abdel Aleem Bello (PhD/Botanical Taxonomy) and Dr. Bayan Tiba (PhD/Botanical Taxonomy) Aleppo University. As far as possible, the name of the plants was updated by consulting the latest literature; generic and species names followed the plant list (http://www.theplantlist.org). All voucher specimens have been preserved during documentation and deposited in the Damascus University, Faculty of Pharmacy, Pharmacognosy Labs Herbarium for future reference, serial numbers were taken from (1 ch to 76 ch ) according to its alphabetical order.

Ethics approval and consent to participate
The study was approved by the Ethics Committee of the University of Damascus. Before beginning data collection, we obtained verbal informed permission in each case site-wide and then individually before each interview. We also informed informants that it was an academic project and that the investigation was for research purposes only, and not for any financial or other benefits. Informants provided verbal informed consent to participate in this study; they were free to withdraw their information at any time. These informants freely accepted the interview. All steps of research are consistent with Ethnobiology Code of Ethics (ISE 2006).

Data analysis
The data collected through interviews of the informants were classified and examined with the statistical program IBM V R SPSS V R Statistics 26 (IBM, Armonk, NY), to determine the proportions of different variables such as ethnopharmacological data. Quantitative value indices were analysed using different statistical quantitative tools, i.e., the use reports (UR) of a species, and use value (UV) (Chaachouaya et al. 2021).

Use value and use reports
The UR of a species or its importance in the culture of a community is denoted by its mentioning rate or its mention frequency by informants. The UR of the species of plants being utilized was evaluated using the formula (Tent e et al 2012): where Ni is the number of times a particular species was mentioned; n is the total number of times that all species were mentioned.
The UV of recorded medicinal plants was determined by applying the following formula (Tabuti et al. 2003): URi is the total number of UR per plants; N is the total of interviewees questioned for given medicinal species.
The UV rate will be more important if there are several useful records for a species, implying that the plant is significant, whereas they will be near 0 if there are few reports compared to its use (Yaseen 2015;Chaachouaya et al. 2021).

Demographic data of informants
In total, 151 local inhabitants of 35 villages and 59 districts were selected based on their experience in traditional uses of plants. Table 1 shows the age and gender wise distribution. All of them were interrogated using semi-structured questionnaires. Generally in Syria, both genders were interested in herbal medicines.

Ethnobotanical and ethnomedicinal uses of plant species
The study area is considered one of the Syrian areas rich in medicinal plants. In the east of it there is a desert (badia), which is dominated by desert and thorny plants, and in the west of it, aromatic plants are spread in the mountains near the eastern coast of the Mediterranean Sea. It is a fact that people in some of these rural areas suffer from poverty, so they depend a lot on folk remedies, and folk healers in these areas provide their expertise at small costs, because the medicinal herbs are cheaper than chemical medicines, and most of the medicinal recipes are available around. However, a large portion of the uses of medicinal plants mentioned in the research are still under study.
A total of 76 medicinal plant species (57.9% are wild and 42.1% are cultivated plants) belonging to 39 families are recorded in the present study; they are being used for a variety of purposes by native people. The detailed inventory is provided in Table 2, which includes botanical names, followed by local name, family and ethnobotanical uses.

Use value of the plants
Medicinal use plants (UV) are utilized to find the most frequently used plant species in the study area. Its value ranged from 0.066 to 0.92 (Table 2). The calculated results of UV showed that Cichorium intybus L., Eucalyptus globulus Labill. was ranked first (UV ¼ 0.92) followed by Fraxinus syriaca Boiss.

Medicinal parts of the plant used
The analysis of the ethnobotanical data showed that central region was best suited to the medicinal plant and rangeland. Ethnobotanical use categories showed that leaves were commonly used parts for making indigenous recipes (28.08%), followed by fruits (19.76%) and seeds (15.6%) then roots (10.4%), flowers (9.36%) and aerial parts (4.16%). Then, the others parts of plant are rarely used (Figure 2).

Modes and conditions of medicine preparation
The analysis of the ethnobotanical data showed that the recipes in the most cases were obtained from single herb, but some of recipes were prepared together, and there is a famous local mixture called Damask tisane (zhourate Shamieh). A mode of TM preparation reported was a decoction (30%), followed by infusion (23%), and then by other method such as fresh herbs, juice, cooked, powder, vinegar and oils (47%) (Figure 3). Considering according to results, most of the plant preparations are used orally (Table 2).

Ethnomedicinal information about treatment the different diseases
The results of questionnaires showed that 20% of the informants were diagnosed with their diseases by a doctor, and 45% were diagnosed with a conventional therapist, and 35% self-diagnosed their diseases, while the results of the questionnaires showed that the evaluation of the treatment by informants as following (58% relied on the disappearance of symptoms, and 24% through the results of laboratory analysis, 18% adopted other methods such as chest radiography, adopting the attending physician's opinion and clinical observation of the improvement of skin diseases, and some of them depended on psychological comfort during treatment as evidence of improvement).
Among these studied plants, 62 are used to treat digestive disorders, 41 for respiratory diseases, including asthma, bronchitis and coughs, 40 for skin diseases, 16 for diabetes, 36 for kidney and urinary tract disorders, 22 for nervous system disorders, six for enhance the body's immunity, two for haemorrhoids, five for fever, eight for heart disorders, five for infertility and impotence, six for treating several types of cancer, two for increasing breast milk production, five for losing weight, four for lowering cholesterol, and two for increasing weight, and six for anaemia, 15 for blood disorder, two anti-toxicant, 19 for arthritis and pain, one for typhoid disorder, eight for infections, six for gynaecological diseases, one for eye inflammation, two anti-toxicant and four for mouth sores. Many of them are still used today, especially those plants recommended for internal uses such as traditional medicinal teas, which mainly consist of remedies for obesity, weight loss, colds, colds, digestive disorders, abdominal pain, constipation and some skin diseases (Figure 4).

Discussion
The use of TAM has spread to treat various diseases in Syria since ancient times. They are cost-effective with fewer side effects and are more suitable for long-term use compared with chemically synthesized medicines.
The ethnobotanical categories indicated that there is large use of medicinal herbs in the area of study, most of them are wild. There is an increased exploitation of medicinal plants by the local population, collectors and dealers of herbal medicines, in line with the demand from the pharmaceutical industry. This caused a sharp decrease in the occurrence and products of medicinal plants. Grazing, deforestation by cutting down trees for heating, and fires were mainly responsible for the reduction of medicinal plants. That is why the government is working on developing strategies to conserve wild plant diversity. Some people collect the medicinal plants for an income. They uproot and collect each part of the medicinal plants in non-scientific way. Thus, to date, a few articles devoted to TM of Syria, such as a study of folk medicine in Aleppo Governorate (Alachkar et al. 2011), and a study about the use of 'Zahraa' (Syrian traditional tisane) (Carmona et al. 2005), and a third one on the medicinal plants in Golan (Said et al. 2002), which is an occupied Syrian territory.
This research aspires to genuinely contribute in providing useful information on the conserving and sustaining the natural resources in the area.
The perspectives in the questionnaire were compared with other ethnomedicine studies in the countries surrounding Syria such as Lebanon (Taha et al. 2013), Jordan (Lev and Amar 2002; Al-Qura'n 2009), Palestine (Friedman et al. 1986;Kaileh et al. 2007), Iraq (Al-Douri 2000) and Turkey (Yeşilada et al. 1995;Sezik et al. 2001). Similarities in various traditional uses in Syria, Lebanon, Palestine and Jordan were observed. This is mainly due to the mutual history of these areas that were previously called Levantine Nations (Bilad al-Sham) (Lev 2002), and there is some similarity with a smaller number of folk uses both in Syria and Iraq, but there is a difference in the folk uses described between Syria and Turkey (Korkmaz et al. 2016;Yerebasan et al. 2020). We compared the folk uses of plants mentioned in related articles on ethnomedicine in these regions with the plants studied in our research to find out the extent of congruence or difference the uses of similar plants.
We did not record significant differences in phytomedicines consumption customs between interviewees of different religions. In general, phytomedicines consumption was often explained and justified by interviewees as family tradition. We did not detect any gender-related differences in phytomedicines consumption. There were no gender differences concerning the common traditional use of medicinal plants. The ethno-medicine data presented herein imply that medicinal plants are important as food and particularly as medicine (traditional healing) for various local people. While chemical medicinal treatments are becoming commonplace, traditional medications are still of huge importance in many rural, poor and remote places.
This study will undoubtedly provide new data that could contribute to further pharmacological discoveries by identifying the active ingredients and their mechanism of effect by doing a lot of pharmacological work to confirm the alleged biological activities of these plants, and the possibility of developing new pharmaceutical formulas cannot be excluded depending on Syrian medicinal plants and their folk uses; as the discovery of artemisinin from Artemisia annua, based on ethnobotanical information (Acton and Klayman 1985), serves as evidence that it is possible to find new and effective medicines using data from TM.     Grapes fruits are popularly used internally as an optimal food to revitalize the body, especially the brain, and it is a good food for the heart, and is considered one of the most important sources of energy for muscles, besides the fruits are used for constipation and gout, the seeds are used as antihypertensives and reduce blood sugar, The seeds are used for menstrual cramps and period regulation, dried fruits called (Zabeb) are used to strengthen the body's immunity, and as general tonic, the seed oil is used (continued)

Limitations
There is insufficient information about the pharmacokinetic efficacy of the medicinal plant species in this study. These herbs have reportedly and traditionally been used as adjuvant to relieve and treat some diseases.

Conclusions
Many of the uses of medicinal plants mentioned in Syria are still under study. This study has been conducted with the aim to generate new concepts that could supplement pharmacological work with potentially further pharmacological discoveries; that is, by   identifying the active ingredients and their mechanism of effect to confirm the alleged biological activities of these plants.

Author contributions
C.H.: Data collection, methodology, investigation, compiled the literature sources, data analysis, evaluation, and interpretation, realisation manuscript, helped in data, and made a substantial contribution to data analysis. A.N.: Evaluation the clinical data, performed data analysis and drafted the manuscript. M.I.H.A.: Review & editing, designed the research and identification of plant species. All contributors understand and accepted the final document. Consent for publication: The study has a consent for publication by the Faculty of Pharmacy -University of Damascus on 10/1/2021.

Disclosure statement
We declare that there is no conflict of interest with any business organization concerning the study.

Data availability statement
Supplementary materials related to this article may be obtained from the authors upon request.