The Ayahuasca ritual: Peruvian national cultural heritage and its possible integration into the primary health system. El ritual de la Ayahuasca: patrimonio cultural nacional de Perú

On June 24, 2008, the Peruvian Government declared the “knowledge and traditional uses of Ayahuasca practiced by native Amazonian communities” as National Cultural Heritage. The inspiration that led to this important achievement was to protect the ritual use of the Ayahuasca brew as traditionally practiced for centuries by Amazonian indigenous communities, including its intangible ritual component, the knowledge of the healers and the healers themselves, while also favoring the protection of the environment and the sustainability of the plant resources involved. In the last couple of decades, the mechanisms of action of Ayahuasca and its therapeutic potential in several fields have been investigated in depth. Nevertheless, thirteen years after the enactment of this declaration, regulations that can offer a concrete protection are still pending, while we observe increasing commercial pressure and risks associated with the irresponsible use of Ayahuasca and other psychoactive plants in the context of shamanic tourism.


Introduction
Peru is source of extreme biodiversity. The country is amongst the seven with the richest biodiversity on Earth and possesses myriad ecosystems, genetic resources, and indigenous cultures with outstanding knowledge especially in the fields of food and ancient/traditional medicine that has thrived in Peru for thousands of years (Perú, 2010).
Traditional medical structure in each region of Peru is mostly built around some "plants of power" or psychedelic plants used for medicinal and spiritual purposes (Bussmann and Sharon, 2006;Beyer, 2009). On the north coast, we find the Wachuma cactus also known as San Pedro (Trichocereus pachanoii), Coca (Erythroxylon coca) and Willca (Anadanthera colubrina or Piptadenia macrocarpa) are the central axis of traditional medicine in the High Andean region, while in the Amazon region we find Tobacco (Nicotiana rustica) and the Ayahuasca brew (a combination of Banisteriopsis caapi and Psychotria viridis). These traditional medicinal practices remain today, and with great force no less. The aforementioned plants are used legally in the country, both in their original contexts and in urban areas where they arrived accompanying the migration of citizens and culture.
The Peruvian government has taken on the task of recognizing as cultural heritage the resources and emblematic traditional knowledge of each region of the country, due to an interest in recovery, recognition and preservation of the different traditions and cultural customs found across its territory. As a result, the National Institute of Culture-INC (Perú, 2008) requested the regional government of San Martin, one of the regions of Peru located in the Amazonian basin, to examine its cultural heritage, among which we find the Ayahuasca ceremony. This is how I came to be commissioned by the regional government of San Martin to elaborate on my studies with the purpose of declaring the Ayahuasca ritual a part of San Martin's cultural heritage, a task that I undertook with enthusiasm. This task did not seem difficult because of the abundant information at my disposal due to many years of research and first-hand clinical experience with local patients as well at Takiwasi, an NGO founded in 1992 precisely with the mission of studying and preserving local medical knowledge. This life event culminated on June 24 of 2008, when National Resolution Nº836/INC declared the "Knowledge and traditional uses of Ayahuasca practiced by native Amazonian communities" as Peruvian cultural heritage (Perú, 2008;Giove, 2016). We, the citizens of San Martin, have daily contact with the richness of our own culture, our mythical world, and its enormous potential, which is expressed especially within the system of traditional medicine. Nevertheless, in order to achieve cultural heritage status, it was necessary to consider a precise formula defined by standard guidelines that seemed inadequate when applied to the context of traditional medicine. The latter must be considered as an always open, dynamic and unfinished concept (Mabit and González, 2013), constantly changing as international flows of products and people interweave with local practices.
Cultura y Droga, 27, (33), enero-junio 2022, 17-41 As a large part of ancestral knowledge, traditional Amazonian medicine is passed down orally. The resources, methods, and activities may vary according to the personality, intuition, and knowledge of each curandero 1 . Even the preparation of the Ayahuasca brew, the ritual performed, and its potential benefits differ between curanderos. This simple fact makes it difficult to follow a systematically standardized set of criteria when analyzing this topic. Therefore, we broadened our searches, finding certain common features and including fundamental coincidences or similarities.

Materials and Methods
The present study was done as an in-depth review around four fundamental axes required by the INC, the description of which represented the objective of the research: I. The origin and ancient uses of the Ayahuasca ritual, including historical and anthropological backgrounds, and a description of the ritual and its effects. II. The situational analysis and inclusion within the cultural identity of the San Martin region, demonstrating how the Ayahuasca ritual is a key element of ancestral medicine and Amazonian identity, while registering its features in the western and modern cultural context including how it falls within certain legal frameworks. III. A prospective analysis of the global panorama, including risks and threats to the Ayahuasca ritual. IV. An analysis of the regional and national context as well as how we look forward to appreciating and protecting this cultural heritage in the future.
For the purpose of the present article we focus on the description of the first three axes, which are considered more relevant to an international audience. The data presented are the result, on the one hand, of more than 30 years of research and first-hand experience on the use of ayahuasca for therapeutic purposes, with evidence of its properties provided by clinical practice (Giove, 2002); this includes direct contact and exchange of knowledge with dozens of ayahuasqueros 2 from 1 For the purpose of the present article the words curandero and healer will be used interchangeably to denote somebody who heals with plants, although in the context of shamanic tourism in Peru, the word shaman is also used by locals and foreigners alike as a synonym of healer. This word has been widely discussed and contested as inappropriate for denoting a wide spectrum of traditional healing practitioners (Fotiou, 2020). 2 An Ayahuasquero/a is a healer expert in the use of Ayahuasca. different Amazonian regions. On the other hand, an in-depth review of the literature on the subject has been performed: standard scientific databases including Pubmed, ScienceDirect and Google Scholar were used to access peer-reviewed publications with the aim to acquire up-to-date information.

I. Origin and Ancient Uses of the Ayahuasca Ritual
The historical and anthropological backgrounds of the Ayahuasca ritual have been the subject of many studies and in Peru the brew is still regularly consumed by indigenous and mestizo groups of the western slope of the Amazon basin (Luna, 1984;Andritzky, 1988;Callaway et al., 1994;Desmarchelier et al., 1996).
Although it is not possible to precisely date when this practice started, some archaeological evidence shows that Amazonian tribes used it around 4,000 years ago (Naranjo, 1986). Despite geographical distance and linguistic/cultural differences in the Western Amazon, an estimated 72 indigenous peoples recognize the Ayahuasca vine as sacred and possess detailed knowledge of its use. Within these 72 indigenous peoples, the plant is referred to by 42 different names (Luna, 1984). The name most commonly used in Peru is Ayahuasca: aya means spirits, souls, or dead, while huasca or waska means vine. It can thus be translated into "the vine of the dead" or "vine of the spirits".
Upon studying the yage (Colombian name for Ayahuasca) complex in the Colombian Southwest, Langdon (1979) determined the region to be dynamic and interconnected, with interethnic links made by the common use of certain words. Chaumeil (1991) outlines the concept of shamanic networks based on a review of scripts from the 16 th century, reconstructing the complex relations of the Amazon and the Andes, from the Ucayali basin in Peru to the Guyanas. These relations were based on the exchange of products such as curare, tobacco, coca, yage, and other entheogenic plants.
They were also based on determined hierarchies of power among the healers, with very well defined ethnic/cultural borders.
Within the tribal context, Amazonian healing was fundamentally practiced by men who assumed the role of protecting their ethnic groups through a power demonstrated mostly through the management of energies (Regan, 1983). War against other tribes and among curanderos was common. According to Regan, although it was not forbidden for women to use Ayahuasca for healing, the difficulties put in place by menstruation cycles to lead the ceremonies and the difficulty in learning the craft, among other aspects such as long periods of isolation, made it easier for males to thrive in the field. After menopause, older women could develop a more active and independent role as healers. This is consistent with the statement of a local midwife who told me that a woman can become a healer when she becomes a man, that is to say when she no longer menstruates. This case gives women a certain advantage because tradition states that plants prefer feminine energy.
According to our research, males see the sensibility that women have with medicinal plants as a risk. A female healer can learn more quickly and she can surpass her male counterpart's sensibility to the plants with less effort. Women, however, are considered to be more emotionally fragile, and more susceptible to traps set by sorcerers. It is also said that Ayahuasca's energy is feminine and it is better for this energy to be balanced by a male officiant during a ceremony. Gender relation studies, male/female requirements, masculine/feminine corporeality and complementarity such as the blood as transformative energy while highlighting the importance of women when it comes to healing have been taken into account by Luisa Elvira Belaunde (2005) when drafting the concept of a shamanic reproductive complex. In terms of family health, women have a leading role. Usually it is a woman that detects malaise and manages first aid at home. The seemingly subordinate role of women to their parents or husbands shadows the fact that women constitute much of the memory of ancient knowledge. They act as depositaries of medicinal recipes, traditions, rites, and ikaros (sacred healing songs used in Ayahuasca ceremonies).
The Ayahuasca vine is considered female and even referred to as mother in some ethnic groups, whereas in other groups, the vine is considered male due to its power.
Ayahuasqueros are referred to as masters, those who teach others. By looking at the work of the indigenous people, we can observe that mestizos have learned to use this beverage in an ethno-medical context while respecting the original shamanic traditions. Their practices have incorporated various belief systems that have arrived in the region due to colonization. Scripts by early Spanish colonists (mainly Jesuit priests) about indigenous cultures in the Americas describe the use of ritual healing techniques which involved modified states of consciousness. According to traditions that date back to the Incan period, there have existed powerful healers and sorcerers that lived in tropical forests and in forest highlands. They were considered as mediums between the Upperworld and the Underworld (Randall, 1982).
Guamán Poma de Ayala (1987) refers of how Amazonian healers were regularly transported to Cuzco to heal the Inca.
Bishop Martínez de Compañon included in his Trujillo Codex of Peru (written 1735-1797, edited 1978-1991) around 1,380 watercolors and descriptions about the ethnographic and linguistic customs, personalities, and nature observed during his journey throughout his diocese in Peru that stretched over a wide territory including the coast, the mountains, and the jungle. One of the most outstanding watercolors is that of the Ayahuasca vine that he refers to as "Devil Huasca" along with a description of its effects: When they take it they lose consciousness, because the potion is very strong. They use the potion to communicate with the Demon because they live without judgment. They speak of various hallucinations attributed to a God they say lives inside these plants. Regan (1983) mentions written testimonies of other Jesuit priests who wrote about the Ayahuasca ritual such as José Chantre y Herrera in 1770 and José Pablo Maroni in 1738. They attributed powers of divination to the plant and considered Ayahuasca to be "a hellish potion of singular efficacy deprived of sense". Others such as Ines Muñoz and Martin de Alcántara (Francisco Pizarro's brother) appreciated Ayahuasca's therapeutic potential. On her diary from 1553, Muñoz stated: "It is a vine that the natives call the rope of the dead. It has an extraordinary calming hallucinatory effect. Sorcerers use it for their religious and magical rituals. I believe it will be appreciated by physicians" (Ariansen, 1990).
When the conquerors were faced with this healing method, so foreign to them, they had no choice but to look at it from the perspective of their belief system. The fear, negative connotation, and prejudice they attributed to Ayahuasca are therefore unsurprising. They labeled the medicine as a "diabolic potion" through which they believed the natives made diabolic pacts with the Devil. This could be the reason why the Quechua term "supay", which means "genius/spirit/mother" when referring to a plant, has been commonly mistranslated as "demon".
These ritual practices were prohibited during the Inquisition and they continued underground. The distance between tribal populations favored the persistence of the ritual and migration even promoted its expansion to other ethnic groups.
This all occurred thanks to a previously standing shamanic trade network built up on resistance and cultural protection to further defend their ethnic identity (Chaumeil, 1991;Eliade, 1964Eliade, , 1967. Along with the preservation of the ritual, the natives were able to sustain symbolic regression and return to the primitive memories and feelings linked to foundational myths, broadening of consciousness in adults, and when practiced in collective rites, the ceremonies allowed further social cohesion and group-oriented identity. Thus, the Ayahuasca ritual survived the attacks of colonialism that considered it witchcraft and heresy. The ritual transcended the tribal space, spreading in the Amazon, and ending up in urban areas. Ayahuasca was uncovered to the western world at the end of the 19 th century when the British researcher Richard Spruce took part in a Caapi ceremony with the indigenous Tukano in Brazil. He referred to the Caapi as "an intoxicating beverage" (Spruce, 1873). He then collected the first recorded samples of the Ayahuasca vine, then known as Banisteria caapi. Some years after his journey, he found the same vine among the Guahibo of Colombia and Venezuela (1873), as well as the Zaparo and Quechua-Lamistas in Peru (1908). In 1905, Rafael Zerda Bayon named the harmala alkaloids "Telepathine" due to their premonitory effects. Later, Conrad Vernon Morton named the harmala alkaloids "Yageine" or "Banisterine". Morton also reclassified Caapi/Ayahuasca/Yage under the name of Banisteriopsis caapi.
In the 1930's, researchers launched an investigation to evaluate its potential beneficial effects on pathologies such as Parkinson's disease (Sánchez-Ramos, 1991), Chagas/Trypanosomiasis/African Sleeping Sickness (Hopp et al., 1976), parasitosis (Rodríguez et al., 1982), and cancer (Topping, 1998). Szara (1957) experimented with the effects of intramuscularly administered dimethyltryptamine (DMT), the psychoactive compound contained in the Ayahuasca brew, and compared the effects to be similar to mescaline and LSD due to the resulting euphoria, rapidly moving visuals, closed-eye/open-eye visuals, and hallucinations containing bright mystical colorations.
Research in ethno-medicine and modified states of consciousness in the second half of the 20 th century yielded the first knowledge about the neurotransmitters involved in these experiences. Scientists identified Ayahuasca's alkaloids and their pharmacological and neurophysiological activity in 1972 (Rivier and Lindgren, 1972). The effect of Ayahuasca on mental health disorders was later studied (Frecska, et al., 2016;Hamill et al., 2019). A decrease in depression is observed in subjects who ingest Ayahuasca (Palhano-Fontes et al., 2019), and the Takiwasi Center was founded in 1992 to treat drug addiction with Ayahuasca and traditional Amazonian medicine showing promising efficacy (Giove, 2002;Berlowitz et al., 2019). In the early 90's a group of U.S. researchers created the Hoasca Project in Brazil to focus on the long-term effects of regular Ayahuasca consumption among the members of the Santo Daime church (Metzner, 2006). These researchers played a crucial role in setting a solid scientific base for the positive effects of Ayahuasca.

The Ayahuasca ritual
When faced with the task of elaborating on the technical specifications to prepare the Ayahuasca brew it has been challenging to follow the standard protocol proposed for the registration of a national cultural heritage, since no standardized preparation of Ayahuasca exists. Ayahuasca preparation vary according to each ethnic group and among them. The ingredients depend on the healer's knowledge of which plants can complement what are considered the two basic elements: the vine Ayahuasca and the leaves of the bush Chacruna (Psychotria viridis) (Luna, 2011). The concentration of psychoactive alkaloids may depend upon the terrain the plants are collected from and the thickness of the Ayahuasca vine. The preparation and the way the ritual is performed also vary depending on the desired effect (Chaumeil, 1991;Chiappe, 1976). Therefore, we can describe the common aspects while also noting the differences.
Healers mention that the Ayahuasca vine is the primary plant and that is why the medicine is given the same name: according to them it is the vine that cleans, teaches, and gives content and sense to the visions produced, while the Chacruna gives light and contains the alkaloids required for visions to occur (Luna, 1984;Mabit, Campos and Arce, 1992). Each preparation stage should be ritualized, from the careful and respectful gathering of the plants to the brewing of the potion and the ritual or ceremony when the medicine is ingested. The healer must prepare himself for each phase by following multiple restrictions. He must abide by dietary, sexual, and energetic restrictions because Ayahuasca is a powerful medicine, effective on the physical, emotional, and spiritual levels (Chiappe, 1976). Although some cultural groups drink the crude and watery extract of the plants mixed together, is it more common to boil chunks of the Ayahuasca vine mixed with Chacruna leaves. During this ritual preparation of the medicine, the healer constantly takes care of it, adding more leaves and singing to the brew multiple times over the course of the day (Tresca et al., 2020;. Ayahuasca rituals take place in groups, at night, and are guided by an experienced ayahuasquero. The ayahuasquero's goal is to respectfully open a door towards the invisible or spiritual realm so that he can search for visions or answers to improve the physical, psychological, or spiritual health of his patients who may or may not also be drinking the medicine. At the beginning of the ceremony, the officiant will protect the ritual space, calling for the spirits of the plants and benevolent spiritual beings to accompany the session using the ikaros. He will also use various techniques such as spraying camphor essence, perfumes, and puffing tobacco smoke to modulate the effects of the plant and achieve the goal of healing. Purging and catharsis are also important effects that are sought after (Fotiou and Gearin, 2019).

Effects of Ayahuasca
Serotonergic activity causing stimulation of the limbic system due to orally administered DMT lasts from 4 to 6 hours. The onset of the effects is usually marked by unpleasant physical sensations such as nausea, hypotension, shivers, and fibrillation (small muscle spasms). Around 30 minutes after onset, variable luminous and colored visions begin to appear in the visual field. The person under the effect may see geometric shapes, feel dizzy, and/or hear buzzing or vibrations. Other effects may include, but are not limited to: changes in perceived temperature, altered motor function, yawning, increase in blood pressure, tachycardia, dry mouth, and weakness. Perceptual changes and sensory exacerbation can span over all of the internal and external senses (proprioception). There may also be a crossover between senses such as being able to hear visions, and see sounds (synesthesia). At the peak of these effects, agitation, anxiety, fear, unpleasant and/or terrifying visions, and feelings of imminent death may culminate with cathartic expulsion through vomiting or diarrhea.
The experience also yields the sensation of a spiritual journey. The persons who drink Ayahuasca may visualize themselves in a symbolic universe or in alternate dimensions. Their sense of time and perception of their body will be altered, they may experience hyperesthesia or anesthesia, wellbeing, disproportion to the world, fullness, synchronicity, and they may be able to relive past memories. Vision over themselves, others, and spiritual beings may be broadened as well. They will often experience the necessity to reconcile, to forgive, and to be grateful. In some cases, this reconnection with the transcendental has been described as a sort of cosmic communion (Desmarchelier et al., 1996). This experience can liberate the soul and make the participants feel as if they are free of their physical body.
Eventually, the effects diminish in intensity and they are replaced by lassitude, wellbeing, and inner peace while conserving the memory of what just happened, which later allows the participant to comprehend and integrate the contents of their experience. Integration depends on the participants' world view. They might connect the images they have seen with archaic structures of some sort of collective tribal psyche. The experience of the existence of a superior and transcendent reality that structures ordinary live and gives it meaning will be set into place.
The Ayahuasca ritual is a rite of passage for adolescents in certain Amazonian cultures . It is a medium through which the young man can retake the founding myths, a regression to the source of life. Deshayes (2003) points out that for the Cashinahua people the nishi pae or Ayahuasca implicates confronting one's deepest fears in the context of a spiritual battle. For the Shuar, this experience is a connection with real life, putting day-to-day life in the category of illusion (Harner, 1962).
An important point that we had been trying to make by seeking cultural heritage status for the Ayahuasca ritual is that the medicine does not cause toxicity or dependence when used in its traditional context. We base our knowledge on the empirical experience of healers that use this ritual (Giove, 2002). Literature further demonstrates the absence of toxic reactions (Callaway et al., 1996).

II. Ayahuasca ritual as part of the Amazonian Identity
Currently, the fundamental purpose of the Ayahuasca ritual in San Martin is healing. Along with Tobacco and Toe (Brugmansia sauveolens), Ayahuasca is considered to be the most important plant medicine used in this region of the Peruvian Amazon. A feature of traditional Amazonian medicine is the fact that it is widely based on the management of modified states of consciousness induced by psychoactive substances. The intake of these psychoactive plants is accompanied by sacred rituals, which consecrate its use and demonstrate respect to the plant's spirit.
Through the visions that Ayahuasca produces, indigenous people are able to make contact with an invisible realm where they can prevent spiritual aggressions, shamanic attacks sent by rival tribes or sorcerers, organize day-to-day activities for better survival, and work on personal and communal future while taking hold of ancestral mythology and history (Dobkin de Rios, 1972;Kensinger, 1973).
According to the Amazonian world view, illness is the external manifestation of something that is affecting the physical, psychological or spiritual body. It is a break in the chain of harmony, the chaos before a new state of order. Healing implies the restoration of order which is to be found in the previous or better state. Eliminating the symptoms or signs of illness is not usually enough to reestablish a healthy bond with the spiritual world. With the Ayahuasca ritual, however, healers receive information from the spiritual world and in this way they are capable of detecting the personal structure that the afflicted person must organize in order to regain health. The possible return of harmony into life as a result of the intake of this medicine is one of the reasons why Amazonian inhabitants consider the Ayahuasca ritual as one of their primary sociocultural elements.

Some legal considerations about Ayahuasca consumption
The customary use of the Ayahuasca rituals in several Amazonian cultures has led to its legality in certain areas as a cultural right for many social groups: the ritual is widely accepted for being the central element of spiritual and physical healing.
Although there is proof of the therapeutic potential of entheogenic plants such as Ayahuasca (Frecska, et al., 2016), its prohibition in many countries has resulted in the use of legal loopholes, categorizing the ritual as a religious right in places like Brazil and the United States (Labate and Cavnar, 2018 Care, 1978), Peruvian law recognizes its citizens' right to use alternative healing systems based on their culture of origin. World governments and the World Health Organization (WHO) believe that it is important to study and integrate traditional medicine into primary health systems. The legal framework built up around these topics depends on the corresponding country's government, although psychoactive plants are not a priority and are shadowed by healthcare promotion, childbirth, and efforts for conservation. As for Peru, lack of resources and coverage in the official health system, difficulties for the population in mobilizing to adequate healthcare centers, and economic hardships have caused vulnerable populations to be excluded from an officially established health system that is based on western medicine and fails to integrate traditional knowledge. For 50% of Peruvian households, traditional medicine is the first and sometimes the only treatment option available (Perú, 2018), yet people who practice shamanism in certain regions do so at the risk of imprisonment due to an inadequate legal framework.
Other issues include defense of territory and resources, commercialization of private knowledge and biopiracy. It was necessary for the Coordinator of Indigenous Organizations of the Amazon River Basin (COICA) to act in order to revoke the patent on the Ayahuasca vine registered by Loren Miller of International Plant Medicine Corporation in 1986 (Knight, 1998). A pending patent request on a "synthetic ayahuasca" filed by a German citizen 4 is another source of concern. Within the national process of recovery and protection of traditional knowledge, the Peruvian authorities recognized and regulated the native people's intellectual property rights in the framework of the Nagoya Protocol on access and benefitsharing (Friso et al., 2020). They are offering collective economic compensation and systems of fair trade by means of the registration of certain patents in the name of these communities. Nevertheless, the example of "synthetic ayahuasca" shows how traditional medicines can be easily replicated with semi-synthetic analogues, thus bypassing actions to share benefits. International norms, or even a Declaration of National Cultural Heritage, as in the case of Ayahuasca in Peru, seems not enough to protect plant medicine and traditional knowledge from the claws of capitalism.
On an international level, imprisonment is also a common problem for healers or users of Ayahuasca. The charges put in place is some countries are usually related to "drug trafficking" when in reality people are trying to transport Ayahuasca to a final destination. This frequently experienced problem led to the formation of certain legal defense platforms like the International Center for Ethnobotanical Education, Research and Service (ICEERS). The political and legal debate surrounding Ayahuasca and its use is getting stronger every day.

III. Ayahuasca Within a Globalized and National Landscape: Risks and Expectations
The exponential growth of Ayahuasca's presence in the media began with the first academic articles and blogs written by the likes of well-known poets and authors such as Allen Ginsberg and William Burroughs and has now reached new heights. Currently, an internet search for the word Ayahuasca provides millions results and the contents cover different fields such as legal issues, commercial publicity, spirituality, and information on indigenous cultures. Today, the Ayahuasca ceremony has become an established practice well beyond the Amazon (Labate and Jungaberle, 2011). During its process of globalization and migration from the Amazon to the Western world, Ayahuasca has encountered different legal and cultural responses (Labate and Cavnar, 2018). More recently, Ayahuasca is gaining further attention as a treatment for a wide variety of mental health disorders (dos Santos et al., 2018;Jiménez-Garrido et al., 2020) with a continuous increase of scientific publications in recent years. This trend drives the shift from a local consumption limited to the Amazon basin to a global phenomenon.
The interest generated by Ayahuasca is not simply academic or intercultural, but also leans towards modern society consumerist attitudes that seek to convert spirituality into a commercial commodity at the expense of the rights and beliefs of the indigenous people who originally used this medicine for healing. The search for spirituality in a deritualized world that has lost its link with the sacred is clamorous. Modern society does not designate proper spaces for initiation or contact with the transcendent, therefore, this contact is sought after with the use of different drugs, including Ayahuasca, for recreational purposes. This search has led to an increasing number of psychonauts anxious to collect as many psychedelic experiences as possible. Another result we observe are groups of ayahuasqueros traveling abroad to conduct ceremonies, putting themselves at risk of imprisonment due to prohibition of using psychedelic plants in certain countries.
Substitutes for Ayahuasca are emerging far away from the Amazon. These include Pharmahuasca, a synthetic combination of N,N-DMT and Harmaline, and Anahuasca, an analog of Ayahuasca that produces a similar effect but using different plants such as Syrian Rue (Peganum harmala) acting as monoamine oxidase inhibitor (MAOI) (Samorini, 2019) and Jurema (Mimosa tenuiflora) providing N,N-DMT (Ott, 1996(Ott, , 1999. In the San Martin region of Peru, demand for Ayahuasca experiences encourages legitimate as well as illegitimate healers to further develop the sector of "shamanic tourism" (Fotiou, 2020). Shamanic tourism often makes the participants grow apart from the therapeutic potential and sacred nature of the Ayahuasca ritual. Ceremonies with various entheogenic substances are constantly on offer. These include, but are not limited to: Ayahuasca, Wachuma (Echinopsis pachanoi), Kambo (Phyllomedusa bicolor), Datura (Brugmansia suaveolens), and Cannabis (Cannabis sativa). Sometimes these experiences are offered along with activities such as yoga or tantra, but they do not include parts considered essential in traditional Amazonian medicine such as purges, tobacco smoke puffs, plant/flower baths, a strict diet, and combination with non-psychoactive emetic plants.
In our observation with local healers, purging and fasting are extremely beneficial to accompany the intake of plants: they allow to work on the body and cleanse it before integrating the psychoactive elements of Ayahuasca (Fotiou and Gearin, 2019). The "New Age" current, however, has led consumers to be under the impression that they can become enlightened and connect themselves with the spiritual realm with no effort. In our opinion, this is nothing more than an illusion (Mabit, 2018). This kind of clients tend to attract "healers" with little to no experience who end up taking advantage of these consumers, either sexually or economically (Peluso et al., 2020).
Several researchers including Grob (1999) and Dobkin de Rios (1994) describe this utilization of plant therapy as risky, not because of the cultural implications, but because of its use outside of a therapeutic context without proper knowledge of how to manage psychoactive plants and the experiences that they yield.
On top of that, knowledge of traditional medicine is often lost because it is not transmitted adequately. Healers die and knowledge is lost with them. In some cases, younger generations are simply not interested in learning about traditional medicine due to the long apprenticeship process that becoming a healer implies. To acquire the knowledge, personal sacrifice is required; this type of sacrifice rarely fits in with today's fast-paced lifestyle. In addition to this key difficulty, learning about traditional medicine implies living an alternative lifestyle and sometimes engaging in conflicts or disagreements with other healers or sorcerers, with the general population, and even with the law.
Besides the relationship between master healer and apprentice, there is often tension among healers from different cultural groups stemming from jealousy, power, fear, and antagonism. This prevents healers from unionizing to position themselves before government authorities, making it difficult to establish clear statutes that could further protect traditional knowledge and the resources associated with traditional practices. There are, however, positive examples as well. In Colombia, the Union of Indigenous Yage Doctors of Colombia -UMIYAC, powered by a group of elders, gathered in order to defend the use of yage and created a code of conduct for healers. In the traditional context of Taitas (the name given to elder healers in Colombia), hierarchy is respected and standards are fulfilled. This code ensures proper transmission of ancestral knowledge and recognition of healers (UMIYAC, 1999). On a negative side, we can observe a lot of confusion when it comes to healers within the context of neoshamanism. Some self-proclaimed healers seek to learn on their own, without masters, without limits, without restrictions, and without rigorous work. They seek to follow their "inner master" who in most cases is simply an overinflated ego and not a higher level of consciousness (Mabit, 2018).
Exchange between the modern world and the ancestral world can be mutually enriching but equally dangerous. More and more often, the press reports abuses, complications, and even deaths, attributing these issues to the use of Ayahuasca. It is, however, hard to say whether or not the substance served was in fact Ayahuasca, or whether an additional substance was ingested such as pharmaceuticals or alcohol 5 . Something else that must be considered is the participant's general health as well as the experience of the healer administering Ayahuasca or the ritual performed when serving it. Deaths and violent assaults on healers have been reported by the Peruvian medias as well.
Many years of cultural conflict have led to a sort of prejudice against healers. Those who do not know the profound work of the healer may constantly judge the culture associated with traditional medicine. The healer's mistakes weigh heavily on his reputation, even if these "mistakes" are simply information that emerged during the ceremony and that the participant should further explore. Ayahuasca is not always a pleasant experience and a "bad trip" can be considered a mistake by the Western subject.
In their communities, healers are sometimes accused of malevolent sorcery and are threatened with bodily harm or even death. A jealous healer may also seek to harm a more experienced or successful rival. The Wampis and Awajún people fear the prospect of becoming healers because of the danger of death that exists within their own community due to envy, jealousy, and greed. They fear retaliation, false accusations, and most of all they fear being blamed for any disorder in the community where they live, for which they can be condemned to death. A notable event occurred in 2011 when 20 curanderos were accused of sorcery and spiritually contaminating their community and were murdered. These curanderos belonged to the Shawi indigenous group and the murders were explained as a way of extirpating people who practiced idolatry and were harming the community. The murderers (believed to be part of a religious cult) were neither brought to trial nor imprisoned 6 . In April of 2018, the murder of widely known Shipibo healer Olivia Arevalo at the hands of a Canadian citizen brought to the forefront of Peruvian debate the dysfunctional cultural encounter between those who believe in the use of psychoactive plants as legitimate medicine and those who do not. Olivia Arevalo was an elder healer and leader of the Shipibo-Conibo community settled next to the city of Pucallpa, in Peru. Her murderer was avenged by her own community on the same day. Other recent facts such as the rescue of a young Spanish girl from a religious sect have also put illicit Ayahuasca use into question.

Conclusion
The inspiration at the basis of the Declaration of National Cultural Heritage was to protect the ritual use of the Ayahuasca beverage as practiced by Amazonian communities, including but not limited to the intangible ritual aspect of its use, the knowledge of the healers and the healers themselves, while also favoring the protection of the environment, bio-availability and sustainability of the plant resources.
The Ayahuasca ritual fulfills several functions: in addition to being the basis of traditional Amazonian medicine, it constitutes an important means of cultural reproduction, a source of knowledge, not only in relation to medicinal techniques and resources, but also to the ethical, sociocultural, political and religious domains and consequently to the cultural identity of the Amazonian inhabitants. This is proven by the value it possesses within the various ethnic groups as an instrument of decision-making, initiation to adulthood, connecting with the values of the community, evaluation of common and individual history and even artistic production, as we can observe with the kené, the system of design and cultural expression of the Shipibo-Konibo used especially in fabrics and that is the product of the visions induced by Ayahuasca.
In addition to the ethnobotanical resources that participate in the preparation of the brew, the people who practice this ritual, their knowledge and techniques, deserve recognition and protection. Among the latter, the healing songs, called ikaros, which constitute the intellectual heritage of each healer and the tool to pass on knowledge and healing ability, deserve special mention. The declaration is also related to legal and administrative processes in defense of ethnomedicine, not just in Peru but globally, with emphasis on the rituals associated. The ikaros or besho from the Shipibo Conibo Xetebo people were also declared a cultural heritage of Peru by the Ministry of Culture in 2016 7 . These initiatives are part of a larger cultural movement which attempts to achieve the same status for ancestral practices such as the San Pedro ritual and the use of other sacred plants like Tobacco and Coca.
The concept of territory and the conservation of the environment are also essential elements for the preservation of the Ayahuasca ritual, since practicing it implies a way of life in communion with nature, which provides the appropriate environment and the necessary resources. Faced with commercial and globalizing pressure, it is necessary to protect this practice to avoid its misuse and distortions, such as irresponsible trade, recreational consumption, participation of non-qualified people, charlatanism, the over-exploitation of resources with their subsequent depletion, as well as the expropriation of knowledge and / or the non-recognition of its sacred character for indigenous peoples.
In Peru, there are various organizations successfully investigating and putting into practice the therapeutic and socio-cultural potential of traditional Amazonian medicine. Since 2013, the Takiwasi Center has put in place the Ayahuasca Treatment Outcome Project (ATOP) (Rush et al., 2021) and other local institutions are dedicated to cultural preservation, researching productive aspects of traditional practices and relating them to create inclusive policies focusing on intercultural exchange that may benefit ethnic minorities. Given the ample Peruvian biodiversity, the production of medicinal plants could stimulate economic growth within communities stuck in a cycle of extreme poverty and growing a limited variety of crops. On one side, this would promote the development of local and foreign fair trade of medicine plants; on the other side, this would also require the adjustment of the norms put in place by the pharmaceutical industry concerning the elaboration of products made with traditional medicines.
Nevertheless, thirteen years after the signature and publication of this declaration, regulations that must offer true protection are still pending, while we observe an increasing commercial pressure and risks associated with the irresponsible use of psychoactive plants by amateurs and charlatans. Therefore, it is worth insisting on the recognition and defense of the Ayahuasca ritual and other similar cultural heritages to build bridges and combine efforts to preserve this kind of ancient but still living medicines which feed, adapt and evolve themselves.