Investigation of China’s Yunnan pharmaceutical industry derived from two ethnomedicines, Yi medicine and Dai medicine

Background: Yunnan Province is a multi-ethnic area located in the southwest of China, and she also is rich in Chinese matiera medica resources, known as the ‘kingdom of plants’. There is abundant of ethnomedicine resources in Yunnan province and many ethnic minorities inherit and retain numerous knowledge of traditional medicine. The biomedicine and big health industry have been the pillar industry of Yunnan since 2016, which is the important pharmaceutical industrial base for Dai Medicine and Yi Medicine in China, for example Yunnan Baiyao with “amazing ecacy” and originating from a Yi medical formula. Yi medicine and Dai medicine of Yunnan Province were investigated in this work focusing on the basic information of Dai patent medicine (DPM) and Yi patent medicine (YPM), including the clinical indications, herbal resources and their sources of traditional knowledge. Methods: The data and information were collected from the published literatures and some public service websites, and the data base of DPM and YPM was established including the information about manufacturer, approval number, clinical indication, prescription composition, dosage form of drug, etc. We investigated the references and literatures including the publicly available pharmaceutical instructions ensuring the authenticity and reliability of the investigation. Results: The results showed that there were 28 varieties of DPMs and 73 varieties of YPMs approved to use in clinical according to the drug regulatory laws of China. In the DPMs and YPMs, about 109 and 197 herbal medicines are recorded in China Pharmacopoeia, 18 and 52 herbs are recorded in Standards for Chinese medicinal materials in Yunnan Province respectively. Nearly 20 herbs have not any quality standard. Among these herbal medicines, there are 10 herbs considered as Dai Medicine and 30 herbs as Yi Medicine. In order to produce these DPMs and YPMs, about 16 animal medicines and 17 rare and endangered medicinal materials would be collected and used. Conclusions: The investigation would provide a more detailed report on Yunnan ethnic medicine industry, and it should be believed reasonably that the ethnomedicine of Yunnan Province will give more choices for human health through scientic experiments and dealing with the sustainable utilization of medicine resources. and enterprise standards play the role in quality standards of ethnic medicines. In this study, it found that in the total 28 DPMs, quality standards of 109 herbal medicines come from Chinese pharmacopoeia; quality standards of 27 herbal are collected in Standards for Chinese medicinal of Province or other provincial herbal quality There 5 Mahan (cid:0)(cid:0)(cid:0) (cid:0), Xiaobaibu leaf &stem of Vitex trifoliaL (cid:0), quality standards have be In the total YPMs, herbal medicines have been collected in Chinese pharmacopoeia and 73 herbal medicines are used with SYNP or other provincial herbal quality standard. 16 herbal medicines no quality standard, Note: than 2 table, (Science SGZP: for Chinese medicinal materials Guizhou Surveys and Statistics on the toxic herbal medicines in DPMs and YPMs in Yunnan Province In traditional medicine of ethnic minorities, herbs with pharmacological activity are likely to be clinically useful, but may also be toxic, especially if used incorrectly or do not master the correct use method. Different from modern drugs, ecacy and toxicity assessments of herbal medicines are based on traditional knowledge and clinical experience rather than evaluation in a laboratory [21] . The causes of toxic medicine usage in Chinese ethnomedicine are related with living environments, religious belief and medical practices concerned with poisons. In China, 83 herbal medicines are ocially recorded and dened as toxic according to the Chinese Pharmacopoeia and the certain number of toxic herbs is also recorded in provincial standards for herbal medicine. categories: toxicity, toxicity, and toxicity . According to the there are 10 toxic used in 11 DPMs, and 6 toxic herbs recorded in Pharmacopoeia and 4 toxic herbs recorded in SYNP. called herbs medicine. YPMs,

materials used in DPM and YPM; (5) the utilization of toxic herbal medicine and the rare and endangered herbal medicine in Yunnan ethnic pharmaceutical industry. In order to achieve these objectives, these methods were accepted and used as follows: (1)

Surveys and Statistics on the varieties and clinical indications of DPM and YPM in Yunnan Province
The CPMs were surveyed and counted, on the basis of ethnic medicine formula preparation of China or the pharmaceutical instructions in which their properties of ethnic medicine were claimed. The results showed that there were 28 varieties of DPMs (Table 3)and 73 varieties of YPMs Table 4  improve the life quality of stroke patients with cerebral infarction [9] . And DDTN could prevent cerebral injury of MCAO rats via decreasing the intracellular Ca 2+ concentration, and inhibiting the release of excitatory amino acids [10] .  In this review, we also counted and analyzed the information of pharmaceutical enterprises which have the right to produce these EPMs legally in China.
According to our statistics, these EPMs are procduced by 39 enterprises, including 2 corporations outside Yunnan province. Some of these companies have to be mentioned. Yunnan Baiyao Group Co.LTD, which is famous for producing Yunnan Baiyao Region, the NeiMonggol Autonomous Region, the Guangxi Zhuang Autonomous Region, Qinghai, Sichuan, Yunnan, and Guizhou Provinces [11] . Besides, the academy group standards and enterprise standards also play the role in quality standards of ethnic medicines. In this study, it was found that in the total 28 DPMs, quality standards of 109 herbal medicines come from Chinese pharmacopoeia; quality standards of 27 herbal medicines are collected in Standards for In the frequency statistics of herbal medicines used in these prescriptions, the total frequency and frequency in DPMs and YPMs were calculated out (Fig. 4).
Chen, Sanqi), ANGELICAE SINENSIS RADIX, Angelica sinensis Oliv. Diels, Danggui and ASTRAGALI RADIX(Astragalus membranaceus Fisch. Bge. Var. mongholicus Bge. Hsiao, Huangqi , which ranked ahead in this statistics, are considered as genuine medicinal materials of Yunnan province. Otherwise, these herbs used in DPMs and YPMs, which are collected and considered as Dai medicine or Yi medicine in SYNP, their information are listed in Table 5.   (Fig. 5). It is an interesting discovery that the number of animal medicines in YPMs is more than that in DPMs. The Yi Nationality as excellent hunters with a long history, were adept in using animal medicines, which is proved with many ancient documents. In Yi Nationality Offering Medicine Scriptures (Yi Zu Xian Yao Jing), written in the early Qing Dynasty of China, the ratio of animal medicines was up to 92.8%. And the animal medicines were divided into 12 types including the insects, meats, bones gallbladders, fats, bloods, sh gall bladders, and hairs etc. In another medical work named Book of Good medicines for treating diseases (Yi Bing Hao Yao Shu, AD.1737), the number of animal medicines reached 152, it accounted for 35.68% of the total number of Yi medicines [12] .
Indeed, animals are therapeutic arsenals that have been playing signi cant roles in the healing processes, which are also known as zootherapy. Animal medicines have been elaborated from parts of the animal bodies, from products of their metabolism (corporal secretions and excrements), or from non-animal materials (nests or cocoons) [13] .Since the pertinence of traditional medicine based on animals cannot be denied, animal medicines used in CPM should be strengthened modern scienti c research. The animal medicines in DPMs and YPMs were set out in Table 6.  (2012),* means the herb has more than 2 origins, and only 1origin is showed in the table.

Medicinal parts of botanical medicines used in DPMs and YPMs
The plant parts used in herbal therapy include seeds, berries, roots, leaves, fruits, barks, owers, or even the whole plants. From ancient times to the present, people have been mainly dependent on crude botanical material for medical needs to retain vitality and cure diseases [14] . In this work, we have analyzed amount of medicinal parts of botanical medicines in DPMs and YPMs (Fig. 6). Statistically, the distribution rules of medicinal parts of botanical medicines in DPMs and YPMs showed similarity, and in the usage frequency of plant parts, Top 3 are Root and Rhizome, Fruit and seed and Whole plant respectively. The different medicinal parts are related to the traditional e cacy of herbal medicines, and on the other hand, the shapes of medicinal parts also are concerned with the nomenclature of some herbs. For example,Huangqin(SCUTELLARIAE RADIX Scutellaria baicalensis Georgi)is called as Rijishi in Yi language in this name, Ri means it is a herbaceous plant, and Ji means root, the medicinal parts of Scutellaria baicalensis Georgi, Shi means the color of yellow [15] .

Surveys and Statistics on the rare and endangered medicinal materials in DPMs and YPMs in Yunnan Province
The rapidly increasing demand for Chinese patent drugs is likely to challenge herbal resources in China. Consequently 80% of the most usually used species cannot meet medical demand [16] . Data analysis showed that 1,800-2,100 medicinal species were facing the challenge of extinction in China [17] .In the China Plant Red Data Book published in 1992, 388 species of plants are listed as threatened, which include 121 as endangered(i.e., rst grade national protection), 110 as rare (second grade national protection), and 157 as vulnerable (third grade national protection). Among these plant species, 77 are typical herbal medicines that account for 19.86% of the total threatened species [18] .Besides, 257 kinds of animal medicines appear in the national key protection name list of wild animals. Although the shortage of medicinal materials is alleviated to some extent since more than 200 kinds of herbs could be arti cially planted, for pharmaceutical enterprises of ethnic medicine, some special herbs are from continuous wild collection without scienti c plans. The rare medicinal materials used in DPMs and YPMs were listed in Table 7, which are protected legally by Chinese government and some international non-government organizations such as International Union for Conservation of Nature. This is the truth that CISTANCHES HERBA (Cistanche deserticola Y.C.Ma, Rouchongrong), GINSENG RADIX ET RHIZOMA(Panax ginseng C. A. Mey, Renshen), GLYCYRRHIZAE RADIX ET RHIZOMA Glycyrrhiza aponic Bat ,Gancao or other rare medicinal materials listed in the catalogues are protected and utilized sustainably in China. But in fact, the number of ethnic speci c herbal medicines in danger is far bigger than that recorded in the catalogues. As a example with RHIZOMA RODGERSIAE Rodgersia sambucifolia Hemsl.or Rodgersia pinnata Franch.,Yantuo ,which is the raw material for YPM depending on mining wild resources, the quantity of excavation exceeds 3000 tons per year, and the wild resources of Rodgersia plants are reduced sharply and resources are damaged severely in Luquan, Yongsheng, Yulong, Heqing and Ninglang of Yunnan province [19] .In light of this, 30 herbal medicines were listed to protect in the Rare Traditional Chinese Herbs of Yunnan Province in Urgent Needs (RTCHYN) [20] . These herbs used in DPMs and YPMs were summarized in Table 8.

Surveys and Statistics on the toxic herbal medicines in DPMs and YPMs in Yunnan Province
In traditional medicine of ethnic minorities, herbs with pharmacological activity are likely to be clinically useful, but may also be toxic, especially if used incorrectly or do not master the correct use method. Different from modern drugs, e cacy and toxicity assessments of herbal medicines are based on traditional knowledge and clinical experience rather than evaluation in a laboratory [21] . The causes of toxic medicine usage in Chinese ethnomedicine are related with living environments, religious belief and medical practices concerned with poisons. In China, 83 herbal medicines are o cially recorded and de ned as toxic according to the Chinese Pharmacopoeia and the certain number of toxic herbs is also recorded in provincial standards for herbal medicine.
Toxic herbal medicines are classi ed into three categories: high toxicity, medium toxicity, and low toxicity [22] . According to the statistics, there are 10 toxic herbs used in 11 DPMs, and 6 toxic herbs recorded in Chinese Pharmacopoeia and 4 toxic herbs recorded in SYNP. Among them, 1 herb is called Dai medicine and 2 herbs belong to Yi medicine. In the 40 YPMs, the toxic herbs are counted to 24, and the number of 12 toxic herbs is collected in Chinese Pharmacopoeia,  Although some toxic herbs used in DPMs and YPMs, these proprietary medicines are considered safe and applied in clinical legally in China because of the unique set of pharmaceutical theories that include particular methods for processing, combining and decocting,which contribute to reducing toxicity as well as enhancing e cacy.For example, in traditional Dai medicine(TDM), the herbs used to reduce poison of toxic herbs are called "YaGei", and "YaGei" theory (YGT or Detoxi cation theory) is considered as aunique supplementary theory of TDM [23] . The Dai herbal medicines named "YaGei" as antidotes could relieve all kinds of adverse reactions caused by food poisoning, drug poisoning and other substances [24] .Besides, in order to keep healthy, Dai people also take antidotes regularly to eliminate the micro toxins in the body, and thus reduce the chance of illness and prolong life.
Due to the lack of more pharmaceutical information disclosed, as well as the lack of basic research, the safety information of these DPMs and YPMs including toxic herbal medinces is insu cient. The modern toxicological evidences of these toxic herbal medicines were collected and also showed in Table 9 and Table 10. Our focus is on these toxic herbal medicines which are known as Dai medicines or Yi medicines. Root of Tripterygium hypoglaucum (LevL.)Hutch (Huobahuagen, ) soaked in wine as oral medicine was recorded in AilaoMateria Medica( ), a book translated and published according to ancient Yi medicine classics,and could be used to treat the arthritis, joint swelling and pain, bruise and sprain [25] . Boenning hauseniases silicarpa Levl.
(Shijiaocao, ) was collected in Materia medica in South Yunnan(Dian Nan Ben Cao, AD.1396-1476) written by Lan Mao, its medicine property characteristics is bitter, pungent and warm, and it could treat chest pain or heartache stomachache and abdominal distension. According to AilaoMateria Medica, Shijiaocao was used to deal with sore throat gastric pain dysentery it also could cure acute gastroenteritis in combination with the parasite of Zanthoxylum bungeanum in Wa Die Yi Medical book , a book proved to be written in the end of Qing dynasty in China [26] . In fact, more evidence in ancient documents would be researched deeply to record the application of these toxic herbs in the medical practice of Yi, Dai or other ethnic minorities in Yunnan. While modern toxicology experiments have provided more toxicity information of these toxic herbs, which are bene t to use them safely and cautiously. Of course, more scienti c research are necessary to identify how these toxic herbs reduce the toxicity and remain effective in the prescriptions. thousands of years of ethnic amalgamation, traditional medicine of different nationalities has appeared a phenomenon of "diversity, integration and difference". According to statistics, about 8000 medicinal species are used in 40 ethnomedicines, which account for over 70% of total traditional Chinese medicine resources in China. Data from National Medical Products Administration of China shows that there are more than 600 kinds of EPMs [ 11 ].EPMs including DMP were collected from 1977 edition of Chinese Pharmacopoeia, some Miao patent medicines and YMPs were collected in Chinese Pharmacopoeia (2015 Edition), and the total number of EPMs reached 39. 26 prescription drugs and 13 OTC drugs are involved [7] . Furthermore, varieties of non-governmental prescriptions that cannot be counted are still use in clinical in the regions inhabited by ethnic groups of China.
This article focuses on traditional Dai medicine and traditional Yi medicine in Yunnan province because their long histories and ancient medical literature. The earliest ancient book of Yi Medicine that can be veri ed is Yuanyang Yi Medicine book, which was found in Yuanyang County of Yunnan Province in 1985 and written in 957 A.D [ 12 ]. The earliest ancient book of Dai Medicine that can be veri ed is Ge Ya San Ha Ya, which was considered to write in 964 − 884 B.C, and another work named Dang Ha Ya Long written in 1323 A.D [53] . According to statistic, there are 1666 Dai medicine (Dai Medicine Records of China, People's Medical Publishing House,2018) and nearly 1400 Yi Medicine [12] , Baiyao mentioned before, series of ethno medicines in Yunnan are successfully industrialized and modernized to promote the modern vitality of ancient ethno medicines and thus serve a wide population range. Tong Shu Capsule, an YPM produced by Yunnan Baiyao Group Co., Ltd., has been approved recently to conduct phase II clinical research in the United States. According to the plan of Yunnan Province, the total output value of pharmaceutical industry will reach 140 billion RMB, with an average annual growth of more than 15% and traditional Chinese medicine including ethnic medicine and natural products account for 75% until 2020 [54] . The conclusions could be obtained from this investigation on Dai medicine and Yi medicine, and we summarized them into 5 aspects.
(1) Except Yunnan Baiyao Group Co., Ltd. and Dihon Pharmaceutical Co. Ltd, most of pharmaceutical enterprises of Yunnan Province for EPMs are small in the production scale, which lead to the limit on abilities of research and development on EPMs. We searched the number of publications of DPMs in CNKI (www.cnki.net), and until now the total number of 163 articles about these 28 DPMs has been published, while the number of documents about Yunnan Baiyao Aerosol has reached 59. It should be known that Yunnan Baiyao Aerosol is only one of CPMs produced by Yunnan Baiyao Group Co., Ltd., and just in 2015, 100 million bottles of Yunnan Baiyao Aerosol were produced, its output value exceeded 1.5 billion RMB. In the same year, the overall sales revenue of Yunnan Baiyao Group Co., Ltd. already achieved 20.74 billion RMB [5] .
(2) Although it could not be acquired about the sales volume of YPMs and DPMs, and whether the herbal sources used in YPMs and DPMs are from wild collection, from the usage frequency in YPMs and DPMs, Ganca, Sanqi and Dengzhanxixin have a high proportion in YPMs and DPMs. The challenges of these herbal resources for sustainable utilization have been discussed before.
(3) The use of toxic herbal medicine is always affecting people's worries about the safety of TCM. Aristolochic acid nephropathy in Belgium and the adverse events of Xiao Chaihu Tang in Japan are the warning of the safety of CPM. More scienti c evidence is needed to prove the rationality and necessity of using toxic herbs in EPMs.
(4) In the medical practice and the process of identifying and using herbal medicine, every ethnic minority mastered and formed their own experiences of using herbs. In this study, the characteristics of using animal medicines by Yi people were found out through the surveys and statistics on the herbal resources in DPMs and YPMs. And it also is certi cated by the ancient medical literature of Yi minority.
(5) The usage methods of Dai and Yi medical prescriptions were recorded with Dai and Yi language historically; the clinical indications DPMs and YPMs are described with Chinese language. It is di cult to master more accurate usage information of DPMs and YPMs because of translation and it will be the next important work.

Conclusions
In the investigation, we can't get the selling information of these DPMs and YPMs because it's a trade secret for the enterprise, which affect our access to collect more information about DPMs and YPMs. On the other hand, it is a hard work to translate ancient Yi and Dai languages to Chinese; we cannot review