recently.

It is time to reintroduce core Tibetan values, and to examine them to see if they
are suited to an active effort to reduce MMR.
Demographers and anthropologists argue that the fertility transition evident worldwide is
now also occurring in Tibet, as women are choosing to have fewer children.[1] Tibetans,
however, are acutely aware of being utterly outnumbered by Han Chinese, and are strongly
pronatalist. China has a policy of allowing two or more children in ethnic minority families.
The strong expectation that Tibetan women should have more than two children is due, in
part, to the ongoing high MMR, and in part to nationalism. However, it is also because,
from a Buddhist viewpoint, to give a sentient being, in the limbo between exiting one life
and entering the next, a chance of human birth, is an act of great compassion. Tibetan
women feel strongly that one of the most deeply compassionate things they can do in life is
to create another precious human rebirth.
This is a reminder of how pervasive Buddhism is in shaping the Tibetan culture, including
the Tibetan sciences of healing. The healing sciences, sowa rigpa in Tibetan, are embedded
in the monastic curriculum of comprehensive training in wisdom and active compassion, in
understanding the nature of reality, and how to liberate others from their sufferings. Sowa
rigpa has medicines specifically for women giving birth, although this is seldom
acknowledged in the MMR literature. Among them is a precious pill, or rilbu in Tibetan,
specifically for postpartum haemorrhage, called zhij 11, which contracts the uterus and
controls bleeding. It has been known and used for centuries, and has long been widely
available throughout rural Tibet as an inexpensive treatment. Zhij 11 can be bought well
in advance, in areas where doctors and clinics are far distant, for a women giving birth to
self-administer.
Zhij 11 is now well-documented, with an English language biography of it as a medicine, a
medical anthropology account of its contemporary use, and a clinical investigation of its
efficacy.[2] Its ingredients are well-known, and their action well-documented. The most
recent review article concludes that: Our analysis supports ZB11s [zhij 11] safety and
effectiveness as a uterotonic with the potential to decrease the risk of PPH, particularly in
low-resource settings, where current allopathic uterotonics face significant barriers to
use. ZB11 has several qualities that make it an attractive uterotonic for prevention and/or
treatment of PPH at the home or community level in Tibet. With over 700 years of history,
it is widely culturally accepted by birthing women, Tibetan healers, and family members
in Tibet. At the same time, it is highly affordable (USD 0.04 per dose) widely available,
does not require electricity or technology for effective storage, and requires minimal
training for administration. Its safety profile is similar to misoprostol, the current
standard of care. In places where access to a steady supply of Western medication may
be limited, this offers an important, less costly alternative. [3]
Although many English language sources state that there is no Tibetan tradition of skilled
birth attendants, and that giving birth is considered polluting, classic sowa
rigpainstructional paintings do show women giving birth attended by several helpers.[4]
In Tibetan Buddhism, at an early stage of the path, the practitioner learns what constitutes
active compassion, on three levels. The first but least effective kindness to pacify the

suffering of others is to offer them material assistance that alleviates the situation
temporarily. This is to be done without thought of reward. The second kind of generosity is
to offer refuge, or shelter, to those in danger to their lives; again to be done without
expectation of reciprocity. The third, and most effective way of cultivating and enacting
generosity is to enable others to access the nature of mind, which is the only lasting and
reliable source of alleviating suffering.
Medicines to alleviate postpartum haemorrhage are part of this holistic approach, in which
temporary interventions are needed, but in the longer term, what is most beneficial is to
understand the cause of suffering and the path that ends suffering, through awakening to
the nature of mind. Zhij connotes pacification of suffering, a term used both for specific
medicines, and for one of the many Buddhist lineages. Sowa rigpa has a comprehensive
discourse of the entire cycle of birth, ageing and death,[5] with a detailed embryology, as
seen from the perspective of the foetus.[6] Rather than atomistically isolating childbirth as
the basis of a stand-alone mode of medical intervention, sowa rigpa understands birth as
part of a cycle that repeats over generations. This healing system is usually termed (outside
of Tibet) Traditional Tibetan Medicine (TTM), as if its herb and mineral pills are its sole
mode of treatment.
However, sowa rigpas strength is in its diagnostics, which frequently detect incipient
problems well ahead of the appearance of overt symptoms detectable instrumentally.
Diagnosis is usually followed by behavioural advice, and suggestions about adopting a
constructive mental attitude, as one might expect of an integrated mind-body therapeutic
grounded in Buddhism. Only after proposing dietary, behavioural and mental changes does
the amchi prescribe medicines. Early diagnosis of pregnancy complications is the key to
MMR reduction, and early diagnosis of somatic imbalances are the great strength of the
skilled amchi.
Whence this strength? The authors of a recent anthropological book call it a science of
healing, a phrase chosen not only as a meaningful translation, but because sowa rigpa is
epistemologically subtle, crossing as it does the boundary between science and creative
practice, between knowledge and experience. A sowa rigpa sensibility is efficacious both in
its coherence and its permeability. [7] This openness to the empirical, coherence and
permeability enable sowa rigpa to be effective, and to adapt to new circumstances, even to
its present constriction under modern state control as a technology stripped of its religious
psychophysiology.
While sowa rigpa has its diagnostic categories, its mapping of the human body/mind and
theories of aetiology and course of diseases, it also counsels a receptive mental quietude in
the physician as an essential preliminary to effective diagnosis. The root text of the whole
sowa rigpa system, in the section on skilful diagnosis, advises: Taking ones time refers to
sitting near the patient for a while, during which time one should carefully listen to each
word of the patient without being distracted by ones own mind and speech.[8]
Developing the capacity to put aside ego and its ideations is a skill specifically taught, as an
aspect of the mind training that is part of learning to be an amchi. Each morning, before

clinical practice begins, it is customary for all clinical staff to jointly recite a text such as
the 21 Praises of Tara, to renew a selfless, altruistic state of mind.
The classic texts on pulse diagnosis methods are highly visual, in a densely packed series of
79 thangka paintings, each of which may contain dozens of instructions, scenarios and
prescriptions. Much of the key thangkas depicting the precise methods of pulse diagnosis
are reproduced in a 50 page section of a recent catalogue (and translation) of sowa
rigpapaintings.[9]
The pulse diagnosis for which sowa rigpa is known is an intersubjective encounter of
doctor and patient in which the doctor has been trained in putting the self aside, an
encounter of equal sentient beings, not a transaction driven by desire to profit from unequal
power.
Diagnosis is best done early in the morning, when the pulse is not perturbed by the days
activities, mental or physical. The Tibetan texts use a rich terminology for the many
different pulses to be identified, starting with the baseline pulse, which itself varies with the
seasons. A normal summer time pulse, for example, should be full and robust, like the call
of the cuckoo. The autumn harvest season pulse is short and rough like a redheaded Tibetan
bird; the winter pulse is retarded, soft and gentle, like the singing of the gull. The spring
pulse should be tense, like the song of the skylark. When it comes to further pulses,
overlaying these baselines, indicative of disease, the Tibetan training manuals use a wide
vocabulary, such as floating, sunken, full, fine, large, small, slippery, puckering, solid, void,
retarded, rapid, mild, tense, weak, rough, hard, soft, flat, slow, intermittent.[10]
The result is that not one but several pulses are detected, leading to a specific diagnosis and
treatment. Amchis are remarkably consistent in their diagnoses, especially of chronic
conditions that enable comparisons across time and between practitioners. They have a
capacity to diagnose signs of imbalance well before overt signals detectable by instruments
are manifest.
As a branch of Buddhist practice, sowa rigpa trains its practitioners to eschew personal
competitive advantage in the healing encounter. This is inbuilt in the mind training slogans
widely memorised in Tibet among lay and monastic Buddhist practitioners: Dont put an
exchange value on things. As one exegete explains: This slogan is about the need for
sincerity and honesty in our spiritual pursuits. We should never use spiritual activities to
further our own dubious and self-centred motivations. We are trying to manipulate a
situation to our own advantage so that we dont have to relinquish our egoistic domain, like
adopting a traders mentality to spirituality.[11] This extends the Marxist argument for a
use economy as preferable to an exchange economy, into the personal sphere, as a standard
for interpersonal behaviour as well as economic behaviour.
The cultural