Social Science & Medicine 48 (1999) 1803±1820

The health transition, global modernity and the crisis of

traditional medicine: the Tibetan case
Craig R. Janes
Department of Anthropology, Program in Health and Behavioral Sciences, Campus Box 103, University of Colorado-Denver, P.O.
Box 173364, Denver, CO 80217-3364, USA

Abstract

The epidemiologic and demographic consequences of the health transition, coupled with worldwide pressures for
health care reform according to neoliberal tenets, will create new opportunities, and well as new problems, for
organized systems of indigenous medicine. Spiraling costs of biomedically-based health care, coupled with an
increasing global burden of chronic, degenerative diseases and mental disorder, will produce signi®cant incentives
for the expansion of indigenous alternatives. Yet this expansion will be accompanied by pressures to rationalize and
modernize health care services according to the structurally dominant scienti®c paradigm. Without concerted e€ort
to maintain native epistemologies, indigenous medical systems face an inevitable slide into narrow herbal traditions
and a loss of those elements of diagnosis and therapy which may be the most valuable and e€ective. Analyzing the
case of Tibetan medicine and other Asian medical systems, I show how this process occurs and how it is resisted. I
conclude by discussing the policy dimensions of this problem. # 1999 Elsevier Science Ltd. All rights reserved.

Keywords: Health transition; Traditional medical systems; Medical pluralism; Tibet

Introduction points to what is now accepted as a basic principle of

Study of the interaction of indigenous and cosmopoli-
tan biomedicine1 in local settings has produced a rich
empirical and theoretical literature. This literature
E-mail address: cjanes@castle.cudenver.edu (C.R. Janes)
medical pluralism: although biomedicine may become
structurally dominant in a particular setting, it does
not displace indigenous, non-biomedical alternatives.
People continue to use the latter, and in economically
developed countries where biomedicine has achieved
enormous structural power and professional sover-
eignty, non-biomedical healing systems continue to

1
There is no satisfactory term to refer to non-Western, indi-
genous medical systems. The most often used term, `tra-
ditional,' invokes an inappropriate sense that such systems are
unchanged and unchanging; neither of which are, of course,
true. The terms `indigenous' or `native' often have ethnic and
political connotations, and suggest that the medical system in
question has been unin¯uenced by non-indigenous elements.
Left without an perfectly acceptable term for general reference
to non-Western-origin medicine, I use the above three terms
interchangeably, believing that despite their semantic inappro-
priateness, they are at least widely understood to refer to
what I intend them to refer to. Likewise, I ®nd it most com-
fortable to refer to Western-origin-medicine that is rooted in
the biological sciences as `biomedicine', despite the fact that
this term invokes a sense of scienti®c `objectivity' which is
inappropriate.

0277-9536/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved.
PII: S 0 2 7 7 - 9 5 3 6 ( 9 9 ) 0 0 0 8 2 - 9
1804 C.R. Janes / Social Science & Medicine 48 (1999) 1803±1820
attract substantial numbers of patients. Why this is the
case is a complex question. Generally speaking,
anthropologists have produced theoretical explanations
which emphasize two factors: ®rst, medical systems
that frame diagnosis and treatment in terms compati-
ble with, or featuring, locally salient belief systems that
hold clear bene®ts for patients attempting to cope with
illness, including but not restricted to simple thera-
peutic ecacy and second, that indigenous medical
resources are perceived to be part of larger, `metamedi-
cal' framework within which ethnicity, nationalism,
rapid social change, and social con¯ict both resonate
with and are expressed through patterns of illness
behavior2.
There is in these two explanations a distinct tension
between the theoretical and the applied. In the 1970s
and 1980s anthropologists observed that indigenous
healers generally recognized valuable resources in com-
peting systems of medicine and were ready and able to
adopt new methods if their social or medical utility
was clear (Landy, 1974; Coreil, 1980). Early, positive
evaluations of the `barefoot doctor' 'program in rural
China, which integrated very basic Chinese and cosmo-
politan medicine in the training of village health
workers, showed to many observers that traditional
medicine could be usefully employed in primary health
care (World Health Organization, 1983, 1986). These
observations, when joined with a scholarly (if not ideo-
logical) appreciation of the important cultural role
occupied by the indigenous healer, led medical anthro-
pologists (among others) in the international health
®eld to advocate initially for greater integration of
indigenous healers in primary health care (e.g. Rubel
and Sargent, 1979; Anyinam, 1987). Although this
argument was supported in practical terms by WHO
policies regarding `traditional medicine' (World Health
Organization, 1978), anthropologists have since dis-
tanced themselves from an integrative approach for
several reasons. Although in the case of traditional
birth midwives or birth attendants there have been
some successes, there have also been signi®cant failures
(Pillsbury, 1982; Bibeau, 1985; Green, 1987; Green,
1988). Most importantly, Lock and others have
2
It would be both impossible and inappropriate here to
provide a complete exegesis of medical pluralism, or to pro-
vide a complete list of references. Throughout this essay I
draw substantially on the work represented by the following:
Crozier (1968), Frankenberg (1980), Kleinman (1980), Leslie
(1980), Lock (1980, 1990), Taussig (1980), Young (1980,
1982), Nichter (1981), Lee (1982), Worsley (1982), Bibeau
(1985), Comaro€ (1985), Singer (1986), Angel and Thoits
(1987), Singer et al. (1988), Lock and Scheper-Hughes (1996),
Rubel and Hass (1996) and the recent edited volumes by
Leslie and Young (1992) and Nichter (1992).
pointed out that the uncritical integration of biomedi-
cine with indigenous medical systems is highly proble-
matic and is impeded by a host of conceptual and
practical barriers (Velimirovic, 1984, 1985; Singer,
1988; Lock, 1990).
In anthropology the retreat from applied approaches
that advocate orchestrated pluralism appears nearly
complete. The applied focus in studies of medical plur-
alism has been replaced with a more self-consciously
theoretical literature. This literature focuses principally
on native epistemologies and the production of knowl-
edge and on the substantial conceptual and practical
gulf that divides biomedicine from indigenous healing
systems (e.g. Lock, 1980; Unschuld, 1992; Farquhar,
1994). A central theoretical problem in this literature is
one of accounting for how ethnomedical systems incor-
porate, subsume or are subsumed by foreign ideas and
the wider structural and symbolic correlates of this
process. As I have argued in the case of Tibetan medi-
cine, there is, generally speaking, a tendency for bio-
medicine, as a signi®cant instrument of modern social
transformation, to assume both structural and cultural
dominance over indigenous medical systems (Janes,
1995). This dominance is one dimension of a larger
process of globalization, and from the perspective of
healing, foreshadows the demise of locally salient and
independent healing resources. In the case of the medi-
cal systems of Asia, there are multiple instances of
well-organized indigenous institutions submitting to
modernization and absorption into a structure of heal-
ing practices that are largely, if not solely, derived
from Western scienti®c epistemology (Lee, 1982).
`Traditional' medicines are transformed from cultu-
rally-speci®c methods for identifying, naming and
treating illness to repositories of herbal concoctions
where assumptions of ecacy rest in scienti®c under-
standing of biochemistry rather than in native epistem-
ologies of the body and its relationship to family,
kinship group, society and cosmos. In extreme cases,
traditional medicine is co-opted by the medical estab-
lishment and distributed without concern for (or
understanding of) possible iatrogenic consequences
(e.g. Lock, 1990).
Outside of a few champions in the halls of inter-
national health agencies, and within these agencies the
debates may be overtly political (Singer, 1988), medical
anthropologists, sociologists and historians of medicine
now seem to view the various calls for legitimizing
and/or integrating indigenous medicines and cosmopo-
litan biomedicine with a fair and understandable
degree of skepticism. However, despite a retreat from
advocacy, the tension between applied and theoretical
approaches remains. Native medical systems are not
likely to disappear and, increasingly, their dicult,
compromised and con¯icted social positions will
demand some formal solution. Indeed, in Taiwan,
 C.R. Janes / Social Science & Medicine 48 (1999) 1803±1820
China and Japan, traditional medicines have been
brought formally into the public medical systems and
are considered legitimate reimbursable services by
insurers. Legitimization has precipitated a number of
signi®cant problems related to professionalization,
licensing standards and iatrogenesis that will require in
the near future, policy solutions (Lock, 1990; Janes,
1995; Chi et al., 1996). Furthermore, health care crises
are looming on the horizon, crises now faced in the
developed countries of North America, Asia, and
Europe, which will likely propel alternatives to biome-
dicine onto the mainstream health policy agenda (e.g.
Chi et al., 1996; Liu, 1998). The health transition,
encompassing growing population, increasing social
inequality, globalization and structural adjustment at
the hands of international ®nancial institutions and a
consequent decline in government investment in health
care services, will likely create a new rationale and a
potentially vast new market, for alternatives to expens-
ive and increasingly inaccessible (and arguably ine€ec-
tive) biomedicine. The need to consider the thorny
issues of ecacy, integration and legitimization will
not disappear, indeed, it will become more pressing.
My purpose in this paper is to reopen the scholarly
discussion of medical pluralism as an applied, health
policy issue. It seems that it is now the time to resolve
the tension between theory and application and ask
how it is possible for indigenous medical systems to
retain their central theoretical and epistemologic el-
ements, and the core elements of diagnostics and
therapy, in what are or are likely to be highly rational-
ized systems of service delivery. Speci®cally, I address
two policy issues. First, it seems clear that the demand
for alternative medicines will draw substantial and
variably motivated government interest over what
should be the future role of indigenous or alternative
(heterodox) medicines in the pluralistic healing systems
of the developing world. As has occurred already in
the United States and in many of the newly industrial-
ized countries of East Asia, governments will be com-
pelled to control and evaluate alternative medicines
(Lee, 1982). What standards should be applied to this
assessment, and how should the state regulate, license
or subsidize non-biomedical services? Secondly, as is
clear from the Asian literature in particular, legitimiza-
tion combined with market competition tends to pro-
duce local variants of indigenous medicines which have
adapted to or in many cases been absorbed into bio-
medicine. If the substantial critique of biomedicine is
valid - that it is often ine€ectual in controlling the suf-
fering, stigmatization, and personal and social crises
produced by many chronic diseases (e.g. Kleinman,
1980, 1986, 1988; Rhodes, 1996) and yet from an epi-
demiological perspective this is precisely the dominant
illness experience produced by the health transition,
then it stands to reason that if indigenous medical sys-
1805
tems are to play an important role, e€orts must be
made to stem their slide into a narrow herbalism or
biomedicine look-a-likes. The anthropological canon
suggests that indigenous medicines o€er not just medi-
cines, which are but materialist props, but alternative
de®nitions of experience that link su€ering to wider
social and cultural phenomena. The principle policy
question here is how to maintain the integrity of a
non-Western system once that system is recognized as
a popular and viable health care option. The crisis of
traditional medicine that I refer to in this paper is not
whether traditional medicines survive, but rather that
these alternative systems may become so much like
biomedicine, so rationalized and `sanitized' of their
alternative epistemological tenets that they may not be
able to meet the human and social needs of the rapidly
approaching health crises produced by structural
adjustment and the epidemiological and demographic
transition.
In this discussion I will use the examples of Tibetan,
and to a lesser extent, Chinese medicines, to show how
global modernity and the health transition compel the
transformation of indigenous medicines so that they
can be scienti®cally justi®ed, while at the same time
these forces are in the process of creating an epidemio-
logical context of chronic, degenerative disease in
which narrow biomedical responses to sickness will be
found insucient. My discussion is divided into four
parts. In the sections entitled ``The health transition''
and ``The case for `traditional' medicine'', I consider
the nature of the health transition and the implication
the health transition has for traditional medicine. In
``Economic globalization and neoliberal health policy'',
I consider the nature of economic globalization and
the impact that this has, and will have, on health pol-
icy in the poorer countries. In ``Tibetan medicine at
the crossroads'', I use the example of Tibetan medi-
cine, a system in the throes of transition, to illustrate
the crisis of traditional medicine. In the Conclusion, I
return to the policy questions posed above.
The health transition
The basic theory of the epidemiologic transition pro-
posed by Omran (1971) suggests a movement in three
stages from an era of `pestilence and famine' through a
transitional stage of receding pandemics, to a ®nal era
of degenerative `man-made' diseases. There is no single
model of the epidemiological transition. The pace of
change varies, as does the pattern of change within a
particular nation or region of the world. In all cases,
the epidemiological transition is closely linked to
demographic and socioeconomic change. It is beyond
the scope of this paper to address the many criticisms
of and additions to Omran's basic model. It is import-
1806 C.R. Janes / Social Science & Medicine 48 (1999) 1803±1820
Table 1
Estimated change in the percent distribution of disability adjusted life years lost, by cause, developing regions of the world, 1990
and 2020. Source: Murray and Lopez (1996)
Cause group
Communicable, maternal, perinatal and nutritional conditions
Noncommunicable diseases
Injuries
ant to acknowledge that patterns of change may vary
enormously depending on local socioeconomic con-
ditions and that an emphasis on non-fatal morbid con-
ditions is likewise an important dimension of
epidemiologic change that, from the perspective of
health services, is important to acknowledge
(Olshansky and Ault, 1986).
The term `health transition' was ®rst suggested by
Caldwell et al. (1990) to encompass the related theories
of the demographic transition and the epidemiological
transition and to extend the theories further to encom-
pass the social and cultural consequences of develop-
ment that drive these shifts in population and
mortality. Most importantly, the idea of the health
transition changes the focus from a concern with vital
statistics to a consideration of the nature of social, cul-
tural and behavioral factors that underlie the transition
and which tend to sustain it in the face of the break-
down of important elements of the health and social
services sectors now being experienced as a conse-
quence of debt crises, political chaos and structural
adjustment (Frenk et al., 1994; Murray and Chen,
1994).
In developing countries the nature of socioeconomic
change and development have generated di€erent var-
iants of the health transition. For example, Frenk et
al. (1989), writing about middle-income developing
countries, have proposed a `protracted polarized'
model of health transition where social inequality, in
many cases increasing and substantial di€erences
between urban and rural sectors leads to a process of
`epidemiological polarization' whereby social and geo-
graphic divisions are re¯ected in epidemiological ex-
perience. Importantly, analyses of mortality declines
show that no single cause of death is related to the
overall pattern of increasing mortality and that chronic
disease mortality generally declines along with other
3
Probably the most important reports were published by
Jamison, Mosley and colleagues, based on research supported
by the World Bank (Mosley et al., 1990; Jamison and Mosley,
1991).
1990 (%) 2020 (%)
41.9 17.6
47.4 68.7
10.7 13.7
causes. While theories of the health transition have not
yet been fully articulated, investigators point to the im-
portance of changing patterns of risks and access to
social and economic resources (Frenk et al., 1994).
The health policy implications of the health tran-
sition have occupied international health agencies and
global development agencies alike. The 1990s saw an
escalation of reports on the policy implications of the
health transition. In these reports the authors argue
convincingly that most developing countries face an
increasing burden of disability from chronic disease,
particularly in the older, more a‚uent and political
powerful segments of the population3. Demands for
care, in the face of continuing commitments to meet
the infectious disease related needs of mothers, chil-
dren and the poor, will place enormous ®nancial press-
ures on governments, many of which are being forced
by international monetary agencies to reduce social
funding and shift health and social services to the pri-
vate sector.
The concern with the health policy consequences of
the health transition provided an important impetus
for reevaluating the methodology of how health stat-
istics are collected and used for international health
policy. The result, the Global Burden of Disease study,
sponsored jointly by WHO and the World Bank, was
designed to estimate the global burden of disease and
disability-adjusted-life-years or `DALYs' (Murray and
Lopez, 1994, 1996). The basic approach of the GBD is
to combine cause-speci®c disability with cause-speci®c
mortality in order to assess the total burden of disease
globally, regionally and within WHO member states.
Findings of the study are remarkable in demonstrating
the increasing importance of chronic disease (see
Tables 1 and 2). For example, the burdens of mental
illness are estimated to account for 11% of the disease
burden worldwide, tobacco will surpass HIV/AIDS as
the number one killer on the planet, and rates of death
and disability from non-communicable diseases are
forecast to increase steadily through the ®rst part of
the next century, while communicable diseases con-
tinue to decline in importance (Murray and Lopez,
 C.R. Janes / Social Science & Medicine 48 (1999) 1803±1820
Table 2
Projected rank order of leading causes of disability adjusted life years lost, 1990 and 2020. Source: Murray and Lopez (1996)
Rank 1990
1 lower respiratory infections
2 diarrheal diseases
3 perinatal conditions
4 unipolar major depression
5 ischaemic heart disease
6 cerebrovascular disease
7 tuberculosis
8 measles
9 trac accidents
10 congenital anomalies
1996). In a compelling summary of the changing pat-
tern of diseases, Frenk et al. (1994), p. 41) suggest that
The epidemiologic transition implies a profound
transformation in the social meaning of disease
becomes a chronic, frequently stigmatizing con-
dition, with increasing psychologic, social and econ-
omic burdens.
It is in the context of this looming social transform-
ation that indigenous medicines may be asked to play
an increasingly important role.
The case for `traditional' medicine
Studies of illness behavior in medical pluralistic con-
texts have shown consistently that non-biomedical
medical systems are used, often in tandem with biome-
dicine, to address complaints that are chronic and are
not easily remediable by available biomedical pharma-
ceuticals (Colson, 1971; Janes, in press). Beyond this
simplistic generalization, local medicines play a com-
plex social and cultural role in providing salient diag-
nostic, `embodied' cultural links to `metamedical'
frameworks of thought (Kleinman, 1980; Worsley,
1982; Lock and Scheper-Hughes, 1996). In this context
they provide a site for the expression of meaningful
idioms of distress and su€ering (e.g. Nichter, 1981;
Janes, 1999). The value of indigenous medicines in fact
probably lies in their ability to produce for lay people
diagnostic discourses that reference centrally important
cultural principles and to follow these with concordant
treatments.
It is beyond the scope of this paper to discuss the
issue of medical ecacy in any detail. Ecacy is a
complex issue that has yet to be satisfactorily
addressed with regard to any medical system
1807
2020
ischaemic heart disease
unipolar major depression
trac accidents
cerebrovascular disease
chronic obstructive pulmonary disease
lower respiratory infections
tuberculosis
war
diarrheal diseases
HIV
(Kleinman, 1980, 1994; Finkler, 1985; Anderson,
1991). Scienti®c biomedicine might de®ne ecacy in
narrow terms re¯ecting objective changes in disease
pathology, however this de®nition is impossibly
narrow and, in many if not most cases, dicult to
assess. Also, beginning with the rhetorical work of
Illich (1976), followed by the empirical work of
McKeown (1976), the value of biomedicine in terms of
population health has been called into question.
Bunker et al. (1994, 1995) have reviewed the evidence
for the relationship of biomedically-based medical care
to mortality, and while they argue that medicine does
have measurable e€ects on life expectancy, the size of
these e€ects are rather small when compared to the
long term increases in life expectancy experienced in
European, North American and currently in middle
income developing countries. Bunker et al., like
McKeown and others, conclude that medicine's pri-
mary impact on health is to improve the `quality of
life'. Accordingly, many of the current standard
measures of treatment ecacy attempt to assess
patients' subjective appraisal of changes to their qual-
ity of life.
Ecacy is thus a complex topic and involves apprai-
sal of a host of factors on multiple levels. If we accept
the fact that a general de®nition of well-being is a sig-
ni®cant aspect of medical ecacy and that a level of
well-being is in part sustainable through medicine's
authority to construct for patients a culturally mean-
ingful clinical reality, then we must also accept that
any medical system which works to provide such an
experience for patients is e€ective (Kleinman, 1980,
1988; Young, 1982) In the case of chronic diseases,
which are by de®nition `incurable', the importance of
resources that sustain or improve individuals' quality
of life cannot be underestimated. The value of tra-
ditional medicine to societies who have experienced, or
1808 C.R. Janes / Social Science & Medicine 48 (1999) 1803±1820
will experience, the health transition would, when
de®ned in such terms, seem apparent.
Unfortunately, the narrowly biological and technical
approach of biomedicine, an approach which domi-
nates the health policy sectors of most countries, often
compels it to demand that traditional medicines adhere
to a rather narrow de®nition of ecacy, a standard
that, in the context of chronic disease treatment, bio-
medicine may not itself be able to meet. Combined
with the dominant view in most nations that Western
science represents the ideal avenue to progress and
general social development, the structural dominance
of biomedicine over alternative systems is assured.
Where indigenous medical systems are well-developed,
as is the case in most Asian countries, this leads to a
situation where biomedicine consigns the practice of
indigenous medicine to a narrow herbalism and, in
some cases, brings some decontextualized elements of
alternative medicine into its own corpus of treatments
(Lee, 1982; Lock, 1990).
Indigenous medical systems are thus, structurally-
speaking, in a paradoxical situation. On the one hand,
the health transition, if the experience of the US and
Europe are repeated, will almost certainly create an
increasing demand for alternatives to expensive, poss-
ibly ine€ective, and often alienating and dehumanizing
biomedicine. On the other hand, government policy,
informed by the general view that Western science and
biomedicine are superior systems and that both rep-
resent the highest levels of social progress, will tend to
limit the practice of traditional medicine to the rather
circumscribed pharmaceutical sector. Of course this
will have negative consequences for the functional
integrity of indigenous systems, particularly their abil-
ity to o€er to patients an alternative clinical reality
which may, in and of itself, be an important dimension
of therapeutic ecacy.
4
This is not to suggest that private, fee-for-service medicine
is somehow a new development. In most of Asia, medicine
was provided on such a basis prior to the involvement of gov-
ernment in health care. What is new, however, are market-
places structured by transnational capital, where indigenous
medical systems compete for clients in an international arena,
sell medicines for global consumption, and are subject to the
powers inherent in a global marketplace.
5
The World Bank de®nes essential public health services as:
childhood immunizations, a school health program, family
planning, health education and nutrition education, tobacco
and alcohol control programs and AIDS prevention pro-
grams. Essential clinical services are de®ned as: short course
chemotherapy for TB, management of the sick child (ORT,
etc.), prenatal and delivery care, family planning, treatment of
STDs and limited care of sickness, including assessment,
advice, alleviation of pain, treatment of infection and minor
trauma.
In Asian countries, indigenous medical systems
appear suspended in a web of countervailing powers
and in¯uences. High rates of utilization and the gen-
eral popularity of traditional medicine demand that it
be given some level of government sanction. Yet the
scienti®c and technological imperative inherent to
Asian modernity compels rationalization of traditional
medicine along biomedical lines. The latter force,
might, all other things being equal, lead to the gradual
absorption of traditional medicine into biomedicine, as
was the case with osteopathy in the US for example
(Baer, 1987; cf, Armstrong, 1987). However, structural
adjustment, economic globalization, and neoliberal
health care reform will provide economic incentives to
sanction traditional medicines and where it is now con-
sidered a legitimate element of government provided
health care, shift it into the private sector4. While this
may provide traditional medical systems some struc-
tural autonomy, these new, predominately market-dri-
ven incentives are no less transformative than
programs of orchestrated integration.
Economic globalization and neoliberal health policy
In 1993 the World Bank issued a major report out-
lining its approach to health development. Titled,
Investing in Health (World Bank, 1993), the report
acknowledged the important role of health in develop-
ment, but pointed out that in low and middle income
countries the health transition will place huge burdens
on public sector health services. The Bank argued that
the rational solution to this impending crisis was to
take a cost-ecacy approach to appraising health ser-
vices, identifying a small package of essential and e€ec-
tive health services worthy of public investment5.
Furthermore, the Bank ignored the social ethics of
health care in favor of an approach that is based on
classic economic theory. Health services were de®ned
as commodities that, with the exception of some
aspects of public health, could be delegated to the mar-
ket sector. Resources de®nable as `public goods', for
example immunization and sewage disposal, were
appropriate targets of public investment, while many
strictly clinical services with limited impact on popu-
lation health, de®ned in narrow epidemiological terms,
were `private goods' best sustained by the private sec-
tor and distributed according to an ethic of market jus-
tice (Beauchamp, 1976).
The World Bank report is based on a reductionist
de®nition of health that emphasizes the central role
of health services: health is de®ned principally as the
absence of disabling disease or death, and only those
interventions that have been shown to have an objec-
tive and cost-e€ective impact on disability and/or pre-
mature death warrant attention by the public sector
 C.R. Janes / Social Science & Medicine 48 (1999) 1803±1820
(Laurell and Arellano, 1996)6. Thus most of the com-
plex ameliorative services for chronic and/or minimally
disabling conditions are considered technically unim-
portant, and to the extent people are willing or motiv-
ated to pay for them, are considered the concern of
the private sector. Governments' role in providing
these services are principally regulatory: acting through
supervision of the marketplace, insurance legislation
and so forth to insure acceptable levels of access,
a€ordability and cost containment.
The World Bank approach to health care is motiv-
ated by the overarching impetus toward more complete
global economic integration, which is dependent on
weakening the role of government in the marketplace,
enhancing global trade, and in the case of developing
countries, creating an infrastructure attractive to
foreign investment. Measures imposed by the World
Bank and the International Monetary Fund (and re-
inforced by the OECD governments in their bilateral
aid programs) to produce such globalization are
together termed ``Structural Adjustment Programs'', or
SAPs7. As Investing in Health makes clear, health
development generally and, as will be seen, the emer-
ging role of traditional medicine, must be understood
in the context of SAPs (Laurell and Arellano, 1996).
Privatizing state enterprises, including health care, is a
key element of structural adjustment; World Bank
health policy is essentially a device to shift the larger
burden of curative services to the private sector, where
it is thereby accessible to foreign investment.
In the context of World Bank-driven (or motivated)
health reform, services such as those provided by tra-
ditional medicine lie clearly in the private sector.
Indeed, traditional medicine may be seen by govern-
ments as an attractive supplement to biomedically-
based health services insofar as traditional medicine is
typically less expensive, often more widely available
6
The World Bank report has been criticized on the basis of
its methodology, inappropriate de®nition of health that does
not include social and economic causes and a lack of atten-
tion to health consequences of poverty (Laurell and Arellano,
1996; Paalman et al., 1998).
7
The conditions attached to structural adjustment loans
include: removing restrictions on foreign investments in indus-
try, banks and other ®nancial services; reorienting the econ-
omy toward export; reducing wages or wage increases to
insure that exported goods are competitive on the global mar-
ket; cutting tari€s, quotas and other restrictions on imports;
devaluing the local currency against `hard' currencies in order
to make exports competitive; privatizing state enterprises and
undertaking a deregulation program to free export-oriented
enterprises from government controls, including those related
to environmental and occupational health. For excellent criti-
cal discussion of globalization, see Bellow and Rosenfeld
(1990) and Mander and Goldsmith (1996).
1809
and typically uses locally available resources.
Furthermore, traditional medicine is potentially
exportable; there is a large and growing market for
Asian medicines in Europe and North America.
However, if under World Bank in¯uence the govern-
ment role in the private health sector is largely con-
®ned to a regulatory presence, related to access and
discouraging practices that in¯ate costs, the level and
degree of control of the practice of traditional medi-
cine by government health bureaucracies may be
reduced. Either way, the new pressures traditional
medicines will face will likely relate to the operation
of the private market and the impact this will have
on quality of services, and access to care, including
medicines.
It is important to note here that the World Bank
health policy position is not simply a prescription for
health policy in developing countries. It is an articula-
tion of the emergent, global view on the role of gov-
ernment more generally and by and large re¯ects the
now dominant political ideology and thus action and
policy, of the OECD countries. The pressure to
reduce public control of health care is thus pervasive
and is part of global conversations about health care
reform. Taiwan, which under enormous public press-
ure, initiated a single-payer insurance system in 1995,
is now moving rapidly to consider various `privatized'
models of insurance, despite the fact that the existing
system has not been given much time to operate and
that there is at present no well-developed health
insurance industry in Taiwan (Liu, 1998). Even
China, despite its strong ideological commitment to
social justice, is now ®rmly embracing neoliberal
strategies to reform its vast public sector, including
forcing health care into the private sector (Yang et
al., 1991; Tang et al., 1994; Hsiao, 1995; Hsiao and
Liu, 1996). Neoliberal approaches to health care ser-
vice distribution and ®nancing now dominate world-
wide, regardless of the development status of the
country under consideration.
Indigenous medical systems are thus subject to three
related and partially countervailing social forces. First,
the health transition has, and will continue to have an
impact on the demand for alternatives to biomedicine.
Lock (1990) has observed, for example, that the rapid
industrialization of Japan has produced numerous
health related problems which in turn favor non-bio-
medical approaches to healing. Furthermore, the ex-
perience of developed countries suggests that
dissatisfaction with biomedicine, dissatisfaction driven
by publicized iatrogenesis, perceptions of ine€ective-
ness, costliness, inappropriate medicalization and so
on, will drive an increased demand for alternatives.
Secondly, increasing demand for alternative medi-
cines will create incentives for some kind of
government intervention in the distribution of
1810 C.R. Janes / Social Science & Medicine 48 (1999) 1803±1820
non-biomedical resources. Providing health care is an
important aspect of the contract between public and
government and there are powerful political incen-
tives for governments to be associated with the pro-
vision of cherished social services (Starr, 1982). The
form that government intervention will take is com-
plex, and will be related to the particular con®gur-
ation of historical, social and cultural forces that
underlie government's general level of involvement in
health care regulation, provision and ®nancing. In
some cases, for example Taiwan, Chinese medicine
has been brought ®rmly into the health system via
the single-payer national health insurance system (e.g.
Chi et al., 1996), which gives the government rather
direct control over speci®c services, medicines and
practices. On the mainland, the central government
has a longstanding interest in traditional medicines
(of several ethnic varieties) and has formally legiti-
mized, and in most cases rationalized, their practice
(Janes, 1995). However, health reform in China has
increasingly pushed most health care into the private
market, where it is subject to local, as well as re-
gional, supply and demand and where it is also sub-
ject to far less public scrutiny than it was during the
Mao era (Janes, in press).
The power of the health care market within a
country, which cannot now be understood as separate
from the global medical marketplace, comprises the
third area of signi®cant in¯uence over systems of indi-
genous medicine. With World Bank policy as the basic
8
The research project upon which this section is based was
carried out over several ®eld periods in the Tibetan
Autonomous Region (TAR) of China in roughly the six years
between October, 1988 and August, 1994. The primary goal
of the research was to conduct ethnographic research on
Tibetan medicine as it was then being practiced in the
Chinese political and economic context. The research was
sponsored by the Tibetan Medical Hospital in Lhasa, which
provided housing and logistic support and, less directly, by
the Tibet Autonomous Region Health Bureau. The research
design included case studies of individuals seeking treatment
at Tibetan medical facilities, interviewing of Tibetan phys-
icians and government (Health Bureau) ocials and obser-
vations of clinical interactions. A random sample of 56
patients strati®ed by age, presenting symptoms and insti-
tutional locus of treatment, were interviewed; these patients
were drawn from an observational exercise in which 718 clini-
cal encounters m Tibetan medical facilities (rural and urban)
were recorded. Forty practitioners of Tibetan medicine pro-
vided their career histories and training experience and 20 key
informants, principally senior ocials in the Health Bureau,
the Tibetan hospital and the Tibetan Medical College pro-
vided information on health policy and the history of Tibetan
medicine more generally.
9
For a more complete discussion of the modern history of
Tibetan medicine, consult Janes (1995).
blueprint, and although government will be motivated
to exercise some measure of regulatory control, indi-
genous medicines in many countries will likely ®nd
themselves transformed in the competitive atmosphere
of the private sector, where they must (and all else
being equal) compete for patient fees, sell medicines
and support clinical facilities. There is contained in
this competitive process a powerful incentive for pro-
fessionalization, i.e. for setting standards (to produce a
standard product), licensing practitioners, controlling
and/or disciplining colleagues and, in short, restricting
competition (Starr, 1982). Furthermore, there is also a
tendency for the organization of a medical system
(regardless of epistemology or structural dominance)
to order itself to the market in such a way as to maxi-
mize use, rather than to maximize service.
Practitioners, clinics and hospitals will be distributed
according to the distribution of economic resources,
rather than according to the distribution of epidemio-
logically de®ned need or demand.
The epidemiological force of the health transition,
the political goals of government and the economic
impetus of the marketplace each have the potential to
have a profound transformative e€ect on indigenous
medical systems. The crisis of traditional medicine lies
in how to navigate these complex and in some cases
countervailing forces without losing the core principles,
values and techniques of the traditional approach and
without submitting completely to the disorienting
attractions of the pro®t-driven health care market-
place. In the following section, I present Asian case
study materials which both illustrate these modern
dilemmas and suggest positive alternatives.
Tibetan medicine at the crossroads8
In the ®ve decades since the Chinese Communist
Party took over control of the government, China has,
through aggressive central planning and an activist,
rural-oriented health policy, made impressive gains in
all the signi®cant indicators of health. An important el-
ement of health care policy in China was the incorpor-
ation of indigenous medicine into primary health care
and e€orts, at times intense, to integrate biomedical
and indigenous Chinese approaches to illness and dis-
ease (see Crozier, 1968).
In minority areas the policy toward non-Han nation-
alities dictated that indigenous customs be respected,
unless those customs were too closely associated with
what were regarded as `feudal superstitions'. Upon
®rst contact with the Chinese, Tibetan medicine, given
its 20th century history as a government-sanctioned, if
not fully sponsored institution, was favorably poised
for ocial recognition by Chinese health authorities9.
Tibetan medicine was early on declared one of the
 C.R. Janes / Social Science & Medicine 48 (1999) 1803±1820
`family of Chinese medicines' and given ocial politi-
cal and economic support similar to that given Chinese
medicine in the Han areas of interior China. Although
the Cultural Revolution was to have a substantial, and
from the perspective of Tibetans, largely negative
impact on Tibetan medicine, as it did on Tibetan so-
ciety and culture as a whole, at no time did Tibetan
medicine lose its state sanction. In the early years of
the Deng Xiao-ping era Tibetan medicine went
through a period of enormous state-sponsored growth,
and was integrated into the structure of primary care
throughout the ethnic Tibetan areas of political China.
Tibetan medicine has to this point weathered reason-
ably well both the internal and external con¯icts of
post-Revolutionary social change.
At present, the authoritative center of state Tibetan
medicine is found in the regional capitol of Lhasa
under the aegis of the regional hospital (the Lhasa
Mentsikhanglo10) of Tibetan Medicine in Lhasa. The
Mentsikhang is now an independent sub-bureau of the
Health Bureau of the Tibet Autonomous Region
(TAR), supervises the training of new doctors and
establishes policy for clinical activities throughout the
region (although its authority over clinics and prac-
titioners outside the major towns and urban centers
have been limited by recent health system reforms).
Tibetan medicine grew very rapidly subsequent to
social and economic reforms instigated in the TAR by
then Premier Hu Yao-bang11. At present the Lhasa
Mentsikhang has a sta€ of 400 physicians and admin-
istrative sta€. Since 1985, 50±60 students per year have
been admitted for training in either the university or
middle school programs, with the majority of these
students now going to work in rural counties of the
TAR and adjacent provinces of China. In 1993 there
were more than 1200 physicians practicing Tibetan
medicine in China.
State reforms of Tibetan medicine a€ected its prac-
tice in two principle ways. The ®rst has been to
emphasize in training a highly materialist discourse on
the body (cf. Kleinman, 1986; Sivin, 1987). An import-
ant consequence of this approach were short-lived
attempts to join Tibetan medicine with biomedicine
10
I will use the transliterated term `Mentsikhang' to refer to
institutions (hospitals, outpatient facilities) dedicated to the
provision of indigenous medicine. The term (Tibetan: sman
rtsis khang ) encompasses both medicine (sman ) and astrology
(rtsis ). See Janes (1995) for a more extensive discussion of
modern Tibetan medicine.
11
It was the death of this liberal reformer that prompted the
tragic Tiananmen demonstrations of 1988.
12
Anecdotal reports by scholars of tobacco use in Asia
suggest that the prevalence rates of smoking among Tibetan
men may be among the highest in the world.
1811
and experimental science. E€orts to integrate Tibetan
and Chinese biomedicine were never as intense as in
Han regions, although since the 1970s the
Mentsikhang has had a research department devoted
to the `modernization of Tibetan medicine' (more on
this below). The second consequence of state legitimi-
zation was to incorporate Tibetan medical training and
practice into the government health bureaucracy. The
deployment of Tibetan medicine as a social bene®t of
Chinese citizenship has changed the social relations of
Tibetan medicine, recasting it as a highly bureaucratic
and internally complex social institution.
The Chinese government under Mao Tse-tung con-
sidered the provision of health care, particularly to
un- and under-served rural populations, to be one of
the ®rst goals of socialist reform (Tang et al., 1994).
Along with public health measures, principally invol-
ving the prevention of infectious disease, the govern-
ment devoted, in the context of its then undeveloped
economy, a tremendous level of human and ®nancial
resources to health. From 1952 to 1990 infant mor-
tality rates plummeted from 250 to 31 deaths per
1000 births and life expectancy increased from 35 to
69 years (Hsiao, 1995, p. 1047). Because it has
achieved these gains at low cost and given that
China's per capita GNP remains low in comparison
to developed countries, the public health and primary
health care system has to a considerable extent
become a model for other developing countries
(Jamison, 1985). Social and economic (®nancing) el-
ements of China's primary health care system were
clear models for the general policies that came out of
the WHO-Alma Alta convention of 1978 (Jamison et
al., 1984; Young, 1989). Of particular note here was
the observation that a key element of China's pri-
mary health care policy was inclusion of traditional
medicine and, at some levels, integration of Chinese
and cosmopolitan biomedicine (World Health
Organization, 1978, 1983, 1986).
Improvements in life expectancy and other health in-
dicators in China are not evenly distributed. The
urban centers speci®cally, and the wealthier and more
developed coastal regions more generally, have experi-
enced the greatest health improvements, while the in-
terior and `frontier' regions of the West and
Southwest, including Tibet, have not fared quite as
well (Ma, 1996). The polarization of the epidemiologic
transition in China will pose a particular challenge to
its health system as it struggles to continue the suc-
cesses it has achieved in reducing childhood mortality
from infectious and parasitic diseases, but faces an
explosive increase of chronic disease. In particular, dis-
ease and disability related to the epidemic of tobacco
use in China, as elsewhere in Asia, will have an enor-
mous impact on the overall burden of disease (Murray
and Lopez, 1996)12.
1812 C.R. Janes / Social Science & Medicine 48 (1999) 1803±1820
Data collected in Tibet between 1988 and 1994 show
that Tibetan medicine has come to play an important
role in the treatment of chronic disease, and in provid-
ing supportive care for those su€ering terminal disease
(Janes, 1995, in press). In a study of health care use
and illness behavior patterns in central Tibet, con-
ducted from 1988 to 1993, we examined use patterns,
illness histories and hierarchies of resort (Janes, 1995,
in press). In a random sample of 56 patients attending
the Tibetan outpatient facility in Lhasa in 1991, strati-
®ed by age and sex, 68% sought care for an illness of
greater than year's duration; of these, 48% reported
symptoms lasting more than two years. Reported hier-
archies of resort were typical of other Asian societies
(see Kleinman, 1980). Acute illnesses, particularly in
children, were usually taken to the local biomedical
hospital. Adults su€ering chronic illnesses, particularly
those which the family identi®ed as distinctly `Tibetan'
problems, for example a disorder of the humor wind,
are taken to Tibetan medical facilities. Many in the lat-
ter category also sought symptom relief from biomedi-
cal practitioners, often noting that `Western' medicines
provided good short term relief, but that Tibetan medi-
cal care was required to `root out' the cause.
In Tibet, as is the case elsewhere along China's eth-
nic frontiers, there are no institution-based facilities for
handling long-term hospitalization needs, or for pro-
viding supportive care to the terminally-ill. Patients
with a terminal diagnosis, or a diagnosis with a poor
prognosis, are sent home to be cared for by family.
Where there is no family, there are special institutions
set aside for housing the ill and elderly. The Lhasa
Mentsikhang has developed a service for all of these
patients, termed, simply, `home bed care'. Younger
Tibetan physicians are assigned to visit home-bound
patients on a weekly basis. During their visits, they
chat politely with family members, ask about pro-
blems, needs and so forth and deliver medicines. In all
of the cases we observed as we followed doctors on
their home-bed rounds, the only supportive health care
being provided was by the Tibetan hospital. As death
rates from cancer, congestive heart failure, stroke and
lung disease increase in Tibet, such supportive care will
become increasingly important, particularly in the con-
text of health care reform.
The political economy of health care in Tibet
The development and organization of health care in
China has roots in the socialist ideology of Mao Tse-
tung. However, despite celebratory discourse in the
West over its achievements, the organization of health
care in China has been subject to serious con¯icts since
the revolution and these con¯icts have greatly acceler-
ated under the modernization programs launched by
Mao's successors (Tang et al., 1994; Hsiao, 1995).
Although medicine in China, in Tibet in particular,
appears rationally organized, this organization belies a
history of con¯ict between urban and rural sectors and
between Western biomedicine and `traditional Chinese
medicines'. Most importantly, health policy has been
constantly reformulated, with each change often
demanding substantial shifts in resources, training pri-
orities and critical political attention (Chen, 1989). As
a consequence, the deployment of primary care in the
Mao era was never completely successful and the inte-
gration of biomedicine and traditional Chinese medi-
cine never fully accomplished (Chen, 1989).
It is perhaps ironic that China's present economic
policy fully embraces the market philosophy of neoli-
beralism. The overall intent of China's economic
reforms is to achieve more rapid economic growth by
suspending centralized government control over the
productive sector in favor of privatization and a re-
liance on market forces, and shifting signi®cant politi-
cal and economic authority to provincial and regional
governments. Social policy has generally followed this
economic policy, resulting in a wholesale state retreat
from the social guarantees that were the hallmarks of
socialist ideology.
Three major changes were implemented in China's
health policy. First, the government reduced the public
funds it had invested in health care, permitting work
units and practitioners to make up the di€erence
through whatever means the newly opened market pro-
vided. The health care system now relies increasingly
on fee-for-service ®nancing mechanisms. Second, the
provincial and regional governments relinquished con-
trol of county health department budgets, and per-
mitted institutions of health care, hospitals and clinics,
to manage their own resources, including the freedom
to make independent capital investments in enterprises
often unrelated to health care. Thirdly, the government
greatly relaxed the rules and regulations that governed
private practice (Hsiao, 1995). The consequences of
this approach are predictable: the greatest degree of
health development, the largest number of practitioners
per person and disproportionately greater resources
are increasingly concentrated where the market works
the best (or provides the most substantial resources),
cities and towns. Under this system, increasing scarcity
and inequity will come to characterize health care in
regions at the margins of China's rapidly growing
economy (Hsiao and Liu, 1996).
Tibet is one of the poorest regions in China.
Economic reforms that swept through the interior of
China with Deng's rise to power came rather late to
Tibet and have been unsuccessful in creating the econ-
omic infrastructure that would sustain opportunities
for Tibetans under current market-oriented policies.
State subsidies originally intended to raise agricultural
and industrial output went primarily to urban-based
 C.R. Janes / Social Science & Medicine 48 (1999) 1803±1820
state enterprises. Because a large number of the
employees of state enterprises are Chinese and Tibet is
considered a hardship post, a massive subsidization in
the form of extra bene®ts and wages is required to
keep Chinese employees in Tibet. Thus much of the
state investment in Tibet has tended to bene®t Han
migrants rather than Tibetans13. Underdevelopment of
the rural sector has in particular undermined the local
economy and has had a serious impact on the majority
of the Tibetan population who live there. As is typical
of market-based reforms, resources have tended to
¯ow to the cities and to the government and business
elite, who are Chinese.
A by-product of reform has thus been the exacer-
bation of ethnic con¯ict, which in turn, fuels resent-
ment of the government and broad-based support for
resistance to Chinese rule. Reforms have not only
13
While the development of rural agricultural and urban
industrial sectors would have provided opportunities for the
Tibetan population, the infusion of subsidies into bureauc-
racy, already Chinese-run enterprises and building programs
tended to favor the Chinese and created the economic con-
ditions for the rapid immigration of thousands of Han into
Tibet between 1985 and the present. In only three months in
1985 alone, more than 60,000 ocial Chinese workers entered
Tibet (Goldstein and Beall, 1991; Sharlho, 1992). With a
growing Chinese population, demand for consumer goods,
Chinese food and services far-outstripped supply, producing a
demand for a wave of volunteer migration to serve immigrant
Han needs (Goldstein and Beall, 1991). This demand, coupled
with reforms to the household registration policy and various
government incentives designed to facilitate migration and
small business development, has brought a huge in¯ux of
entrepreneurs and `penny capitalists' into Tibet from all over
China. Tibetans have not been well positioned to take advan-
tage of these entrepreneurial activities. Because much of the
business is controlled by networks of socially aliated
Chinese, Tibetans, with limited entrepreneurial skills, often
poor command of the Chinese language and subject to conti-
nuing ethnic discrimination by Chinese ocials and employ-
ers, are virtually shut out of the subsidy-stimulated consumer
economy.
14
During the Cultural Revolution Tibetans were subjected
to intense racist discourse. Tibetan culture was attacked fur-
iously by the Red Guard as exemplifying the worst of feudal
barbarism and everything from language to art was
thoroughly denigrated. Conversely, revolutionary Chinese cul-
ture was celebrated as exemplary of what Tibetans should be
striving to become. Although Chinese in the interior of China
also experienced much the same thing, it was not articulated
or perceived as ethnic hatred. The serious and deepening div-
ision between Tibetans and Han can be traced to this period.
Tibetans who lived through this period remember with bitter-
ness these attacks on their language and culture, and these
memories have, in the absence of Chinese e€orts to really
improve the situation, led to a minimizing of social contacts
between Tibetans and Han.
1813
eroded the few social bene®ts Tibetans once realized as
constitutionally-recognized citizens of China, but have
compounded economic inequities with ethnic con¯ict
and perceived racism14. Ethnic con¯ict thus de®nes the
metamedical social and political context within which
Tibetan medicine is both practiced and sought after,
and explains to a substantial degree the particular
social and cultural role that Tibetan medicine now oc-
cupies in the region.
Well o€ the main stage of overt con¯ict and nation-
alist fervor, Tibetan medicine plays two very important
roles for Tibetans. First, in the midst of intense Han
pressures to modernize Tibet and, in the process
expunge elements of what the CCP refers to feudal
superstition and evidence of a history of oppression
and class struggle, Tibetan medicine has largely
escaped concerted state intervention. Unlike religion,
which symbolizes not only the feudal past but is ident-
i®ed with resistance to Chinese sovereignty or `splitt-
ism', Tibetan medicine is ocially safe, non-
threatening and has since the 1980s carefully main-
tained an ethic of service that is entirely compatible
with socialist discourses on social equality. Tibetans
thus have access to an institution which many believe
encompasses genius of Tibetan culture, and, in fact,
represents one of the last public contexts where
Tibetan ideas about the body-mind, social ethics and
the consequences of modernity can be freely and legiti-
mately expressed (see Janes, 1999, in press). Secondly,
given this particular role it is not surprising that
Tibetan medicine o€ers for Tibetans multiple idioms
for expressing the loss of cultural identity, rapid econ-
omic modernization and ethnic/racial discrimination.
It is important to recognize, however, that despite
occupying such a central social and cultural role in
modern Tibetan society, Tibetan medicine as a recog-
nized state institution must also respond to a policy
environment which de®nes the terms that under which
all medical systems in China must function. Of particu-
lar concern here is the extent of market reforms to pri-
mary health care in China and the degree to which
such reforms presently a€ect the practice of Tibetan
medicine.
Health care ®nancing: medicine in the `socialist market
economy'
In Tibet, health care reform occurs in a context of
rural underdevelopment, urban unemployment and
ethnic con¯ict. The consequences have been fourfold:
®rst, state subsidies of medicine at all levels have
declined rapidly, with ®nancing increasingly provided
by individual patients and a small number of enterprise
and labor-based insurance plans. Secondly, the lack of
cash in rural areas has precipitated the decay of the
overall primary health care system. This is particularly
1814 C.R. Janes / Social Science & Medicine 48 (1999) 1803±1820
evident in the area of pharmaceuticals, where supplies
have dwindled rapidly in township and county clinics.
Thirdly, Tibetan medicine has not su€ered as much
from health care reforms as has biomedicine insofar as
ethnic as well as cost issues ensure that it remains the
most accessible resource in rural areas. Fourth, how-
ever, relatively greater urban wealth and demand for
Tibetan medicines in regions external to the TAR will
likely lead to increasing shortages of both experienced
practitioners and a full range of medicines outside
population centers.
In principle, the government (county, prefecture, or
region) owns nearly all health facilities. Since the mid-
1980s, health care reforms have been implemented in
two ways: by sharply reducing the state subsidies pro-
vided for medicines, physician training, and salaries
and by relaxing a variety of policies that favored rural
cooperative-based funding of town and village-based
clinics and health stations (e.g. the `household respon-
sibility system'; Hsiao, 1995). Hospitals and health cen-
ters that once received nearly all of their operating
revenues from central government co€ers, now receive
somewhere between a third and quarter of revenues,
having to make the balance up either directly from
patients and the sale of medicines or by engaging in
other business enterprises, some completely unrelated
to medicine. The collapse of the rural cooperative sys-
tem, which derived funds for health care from the old
commune system's welfare funds, now means that the
majority of rural residents have no health insurance.
The regional Health Bureau has blunted the impact
of these reforms somewhat in Tibet by continuing to
subsidize clinics in the poorest and more remote areas,
and by insuring that the price for medical visits are set
at an a€ordable level. Tibet continues to receive subsi-
dies for social and health services which on a per
capita basis are among the largest in all of China's
provinces and autonomous regions (Jamison et al.,
1984; Sharlho, 1992). Additionally, a small subsidy is
provided for the purchase of medicines from the medi-
cal factories in the prefecture centers, or directly from
the largest medicine factory in Lhasa. The subsidy is
generally insucient, so local clinics attempt to gener-
ate additional funds by selling some portion of their
medicines at a pro®t, particularly the highly desired
`precious pills'. Additionally, supplementary funds are
provided to the regional and prefecture Mentsikhangs
by the Traditional Chinese Medicine department in the
Ministry of Health in Beijing. Income is thus generated
by four sources: continuing health department subsi-
dies; patient fees for services and medicines, grants
from the Oce of Traditional Medicine in Beijing and,
where local conditions permit, from pro®t-making
enterprises.
The main medicine factory in Lhasa, producing the
largest numbers and volume of Tibetan medicines
(over 60,000 kg of 400 di€erent varieties in 1992), has
become an independent ®scal entity, encouraged to
produce for pro®t. It in turn sells drugs at above cost
to Tibetan facilities throughout the region and,
increasingly, internationally. The prefecture medicine
factories, much smaller operations, remained in 1992
part of their respective Mentsikhangs, but were
increasingly de®ned by Mentsikhang administrators as
potentially (and needed) moneymaking enterprises.
Because of high demand for Tibetan medicines
throughout China, Nepal and India and a growing
demand in the West, the incentive to produce for non-
Tibetan markets is now placing enormous pressures on
supplies as well as production standards. Sales of
medicines in 1992 netted approximately 1 million
Yuan (US$200,000) in pro®t to the factory. Rural
counties do not have the resources to compete with
urban and international markets, and rural people can-
not pay urban prices. The consequences are frequent
rural shortages. In order to obtain medicines, a county
clinic must pool its small state subsidy with patient
fees and send a sta€ member, cash in hand, to buy
medicines from one of the medicine factories. Insofar
as the cash is usually insucient to meet rural demand,
rural shortages of medicines are now commonplace.
As the prefecture Mentsikhangs, as well as the
Lhasa Mentsikhang, orient themselves to the market,
there is a concomitant decline in rural services. The
Mentsikhangs invest in local property, build restau-
rants, and, increasingly, are opening private, for pro®t
facilities, sta€ed by the most experienced physicians
and stocked with the best medicines. The Lhasa
Mentsikhang built a private Tibetan clinic in Chengdu
(capital city of Sichuan province) in 1987 and keeps
this clinic sta€ed year round and stocked with a supply
of medicines, especially costly `precious pills'. The
Lhasa Mentsikhang is also considering opening
another clinic in Xian and a second in Chengdu, closer
to the main foreign tourist hotel. In Lhasa the
Mentsikhang opened a large, fancy Tibetan restaurant
and operates several medicine-selling stalls in the city
(it buys medicines from the medicine factory,
repackages these in smaller containers, with mark-up,
and then resells them). The Lhasa Mentsikhang also
operates a clinic for foreign tourists at the Lhasa
Holiday Inn, in 1993 charging approximately US$50
for a consultation (split with the hotel), and an ad-
ditional US$8±10 per week for medicines.
Within the Mentsikhangs, sta€ have been encour-
aged to pool their resources for savings and/or invest-
ment in a variety of potentially pro®t-making
activities. In Tsethang (prefecture capital southeast of
Lhasa) a group of doctors pooled their resources and
built a long line of small shops in front of the
Mentsikhang building. They lease these shops to local,
principally Chinese, business people. The pro®ts on
 C.R. Janes / Social Science & Medicine 48 (1999) 1803±1820
this investment are shared among the physicians them-
selves in order to supplement their salaries. In 1993
doctors in the Lhasa Mentsikhang were contributing
to an investment fund (the purpose of which was
unknown at the time).
With the expectation that the Tibetan hospitals and
clinics generate more of their own revenue, these insti-
tutions are responding by diverting resources away
from rural areas, where medicine is less pro®table, to
the urban areas in Tibet, to the interior of China and
there is even talk of exporting Tibetan medicines more
widely than it is at present. In a 1993 trip to the
United States, the then head of the Lhasa
Mentsikhang inquired widely about the possibilities of
establishing a pro®t-making medicine selling business
(though he was to be discouraged by US Food and
Drug Administration regulations). In the interior of
China Tibetan medicine has become something of a
fad, with increasing demand by Chinese and foreign
tourists alike. Responding to the potential for pro®t
represented by this vast market, the independent
Mentsikhangs are rushing to establish clinics and
export medicines, all at a cost to health care in Tibet.
The better doctors, the more expensive medicines, par-
ticularly the precious pills, are being diverted increas-
ingly to China or to `private' work-unit sponsored
clinics. The medicine factories, responding to increased
demand, are raising prices. This results in local
shortages, both of medicines and skilled, older phys-
icians. In every county and township health facility we
visited, the statement, ``there is not enough money for
medicines'' was a common refrain.
Modernizing Tibetan medicine
Ethnic, economic and political factors may well
guarantee the long-term survival of Tibetan Medicine
on the plateau. Yet the factors identi®ed here cannot,
in and of themselves, prevent Tibetan Medicine from
continuing on the path of rationalization that it started
down many decades ago. Scientism is a powerful force
in modern Chinese and Tibetan societies. Tibetan
medicine, despite its reluctance to embrace alternative
epistemologies, has not been able to fully avoid change
as it has become increasingly subject, via a host of ave-
nues, to cosmopolitan, scienti®c principles.
Biomedicine has in China and, arguably in Tibet,
achieved the cultural authority to de®ne what constitu-
tes disease and alternative systems must grapple with
and at least acknowledge this authority (cf Lee, 1982).
In Tibet this means accepting the legitimacy of mul-
tiple ways of viewing the body and for Tibetan prac-
titioners, reconciling classical epistemology and
nosology with the Chinese variant of biomedicine
(Janes, 1995). Practically speaking, this manner of
reconciliation has two consequences: (1) an increasing
1815
tendency to de®ne the essential theoretical elements of
Tibetan medicine (e.g. the humors) in terms that can
be easily reconciled with modern physiology and (2) a
motivation to do what other alternative medical sys-
tems have done: accept rather than resist Western
scienti®c standards for evaluating treatment ecacy.
This may not necessarily result in a complete accep-
tance of biomedical epistemology; it does however
require that Tibetan medicine accept the cultural auth-
ority of science in its production of a `modern' Tibetan
medicine.
The acceptance of such authority can be seen in a
number of contexts. Perhaps most important for our
purposes here is the self-conscious e€ort on the part of
some of the Mentsikhangs to engage in `research':
work that blends classical study with what are taken to
be the standards of modern science. The Lhasa
Mentsikhang has what it calls a `Research
Department'. The research department was established
in 1973 in order to, in the words of its present director,
``bring scienti®c research methods to Tibetan medi-
cine''. Since this time, work in the research department
has proceeded in two directions: evaluating Tibetan
pharmaceuticals (usually in conjunction with the re-
gional public hospital or the local Army hospital) and
compiling textbooks and monographs on particular el-
ements of Tibetan medicine. The head of the depart-
ment recently ®nished assembling a multiple volume
manuscript that purportedly presents a complete
description and analysis of every known Tibetan medi-
cine. Although this latter activity may be de®ned as
classically `authentic', it should be noted that the
incentives for producing such texts is to provide a
document to serve as a basis for `scienti®c research' on
Tibetan medicine.
It is as yet unclear what impact these research activi-
ties will have on Tibetan medicine. In 1993 the
research department appeared somewhat moribund
and despite lots of talk about building laboratories
and working with biomedical researchers, the level of
ongoing scienti®c activity appeared to be very low. It
is, however, clear that Tibetan medicine must moder-
nize in some fashion in order to remain a viable
resource or at least maintain its ocial standing in the
region. How it modernizes and to what extent and
degree it accepts rather than resists cosmopolitan,
scienti®c domination, will have a signi®cant impact on
the provision of health care services recognizable to a
Tibetan community that is itself changing very rapidly.
The continued development of a viable and distinct
Tibetan tradition will rest in the abilities of
Mentsikhang physicians and scholars to navigate a
complex social and cultural landscape and produce
knowledge that remains rooted in Tibetan cultural
understandings of sickness while at the same time
1816 C.R. Janes / Social Science & Medicine 48 (1999) 1803±1820
acknowledging to some degree the legitimacy of cos-
mopolitan alternatives.
So far it seems that they have been able to do so.
Capitalizing perhaps on the complex ethnic and politi-
cal factors described above, Tibetan medicine has been
able to maintain somewhat more conceptual and epis-
temological autonomy than other Asian medical sys-
tems (e.g. Lee, 1982; Chi et al., 1996). As I have
described elsewhere (Janes, 1995), post 1980 reforms to
social policy in Tibet permitted the Mentsikhangs to
chart independent courses and there has been a strong
sense of revitalization since then. So the e€orts to inte-
grate it with biomedicine have never been particularly
systematic or sustained, and as the low level of serious
activity in the research department shows, tend toward
the more rhetorical and symbolic than the programma-
tic. The discussion of Adams (in press) of how
women's reproductive health care has provided a stra-
tegically important avenue to revitalize Tibetan medi-
cine as being neither traditional or biomedicalized is a
positive example. Whether Tibetan medicine can
become central to a process of cultural revitalization
will rest on the success of these and similar e€orts, par-
ticularly as these e€orts respond to and integrate mod-
ern Tibetan articulations of distress and su€ering.
Conclusions
The modern history of Tibetan Medicine illustrates
well both the looming crises and the important oppor-
tunities that face modern, indigenous medical systems.
The future of Tibetan medicine will be shaped by three
processes: the future direction of `orchestrated plural-
ism' and rationalization that will be shaped by neolib-
eral health care reform policies; a sustained, if not
increasing, demand for service; and the many complex
ethnic and political issues that form the core of the
`Tibet question'. Demand for services and medicines
will continue to drive the growth and development of
the system and will also constitute a powerful incentive
for some level of government intervention, sponsorship
and regulation. However, an otherwise strong tendency
to rationalize the system may be checked by the politi-
cal nature of ethnicity expression in the region and the
central role Tibetan medicine plays in such expression.
Decentralization of state regulation and a decline in
state subsidies may also provide Tibetan medicine with
considerably more autonomy over the practice of
medicine, though government will continue to play a
role in controlling the training and licensure of phys-
icians (training remains government-funded). However
much intellectual and practical independence is
achieved, Tibetan medicine will have to become
increasingly oriented to the private sector and this, as
much as anything, will determine the future accessibil-
ity and integrity of the system.
Once Tibetan medicines becomes fully established as
a desirable commodity, the incentives for multiple
practitioners, of variable skills and backgrounds, to set
up shop as Tibetan healers will be signi®cant. By 1992
we found in our surveys of private practitioners that
many biomedicine-trained physicians were incorporat-
ing Tibetan and Chinese medicines and diagnostic
techniques into their practices. In both urban and
rural areas we documented cases of actively practicing,
self-trained physicians. One NGO, the Swiss Red
Cross, is actively training new Tibetan doctors for pri-
vate practice in rural settings. While all of these recent
developments are in some senses positive with regard
to the availability of Tibetan medicine, there are some
disturbing aspects of these developments which may
bode ill for the future integrity of the system.
Lock (1990) has well-documented the rationalization
of Japanese medicine, and the pro®t driven appropria-
tion of some elements by biomedical practitioners with
poor results. Similarly, Chi et al. (1996) has shown
that there is serious concern with the quality of
Chinese medicine in Taiwan as a consequence of licen-
sure and regulatory policies that tend to restrict the
practice of Chinese medicine to those with little or no
formal training. Until 1998, Chinese physicians with
formal training in Chinese and Western medicine from
China Medical College in Taichung, the only academy
providing formal training in Chinese medicine, were
discouraged from practicing Chinese medicine by laws
which forced them to choose between Western or
Chinese medical practice. Those choosing to practice
Chinese medicine need only pass a state examination
and are not required to have any formal educational
training. Chi et al. (1996) suggests that this system
tends to erode both the quality of Chinese medicine
practice and the faith of the public in Chinese phys-
icians. In the cases of both Japan and Taiwan, the ero-
sion of the traditional scholarly base is a serious threat
to the integrity of the system as a viable resource in
the context of post-health transition epidemiologic pat-
terns. As Lock (1990) has noted, the challenge for all
of these traditions reeling under the in¯uence of the
private market and the meddling of the government, is
to somehow develop a system of standardized practice
that retains the core of the scholarly base. This base
can hardly be maintained without the development of
professional requirements: a standard product requires
standards of training and practice (Starr, 1982). The
Mentsikhang and Medical College in Lhasa remain the
authoritative centers of Tibetan medicine, and the
senior physicians and professors in Lhasa possess sig-
ni®cant cultural authority. The collaboration of the
Mentsikhang with government has managed to main-
tain reasonable professional standards, though the
 C.R. Janes / Social Science & Medicine 48 (1999) 1803±1820
appearance of private practitioners and practitioners
trained outside the formally sanctioned system will
have to be carefully managed. At this point the
Mentsikhang is actively seeking to evaluate the compe-
tence of Tibetan physicians now practicing privately,
particularly in the countryside, although in 1993
Mentsikhang administrators admitted that they had
limited ability to control private practice despite their
e€orts at oversight.
It is naive to expect that indigenous medicines will
be able to avoid some form of integration with biome-
dicine, particularly in countries where it has achieved
ocial legitimacy. Legitimacy and popularity provides
a means for government (as well as insurers and other
commercial interests) to intervene in setting standards
of training and practice. So, while professionalization
of indigenous healers is probably necessary in order to
maintain the integrity of the system, standards of pro-
fessionalization must be protected from such narrow,
competing interests. This will likely be one of the
major challenges faced: how to manage the professio-
nalization of native healers without submitting to stan-
dards dictated by foreign systems. This is an important
policy problem that will need to be informed by criti-
cal discourses on science and broader discussions on
the nature of healing per se that move discussions of
ecacy away from narrowly biological viewpoints.
The market will of course continue to play a domi-
nant role in the transformations of indigenous medi-
cines. Indeed, worldwide health reforms will push most
clinical services out of the public sector. Incentives to
produce native medicines for the mass medical market
have already resulted in the development of large
industries in India and other Asian countries (Nichter,
1996). Multinational pharmaceutical industries have
also become interested in the development of tonics
which are often linked to indigenous herbal medi-
cations and which have the potential of producing
huge pro®ts (Silverman et al., 1987; Silverman and
Lydecker, 1992). In extreme cases, as Lock has
reported for Japan, pharmaceutical companies were
the driving force behind the legitimation of Kanpo
medicine, and are currently its primary purveyors
(Lock, 1990). The commodi®cation of medicines are of
course not only a problem that a‚icts indigenous sys-
tems, but is a major worldwide trend that has had
troubling consequences (Silverman et al., 1987).
Discussion of this problem is well beyond the scope of
this paper. However, the Tibetan data suggests that
the development of professional authority over medical
manufacture and distribution by the institutions of
Tibetan medicine, coupled with government regu-
lations which insure adequate supplies of basic medi-
cations to the countryside, are possible solutions to the
problem.
Finally, and perhaps most fundamentally, a critical
1817
challenge to indigenous medicine is whether native
epistemologies can be promoted while at the same time
foreign elements are productively incorporated. The
problem is principally one of transforming so called
`traditional' medicine, that is, rooted in classical tra-
ditions of sometimes great antiquity, into modern-yet-
native medicine. The analysis by Adams (in press) of a
recently authored Tibetan medical text on women's
health issues has shown that Tibetan physicians are
well aware of the need to resignify Tibetan medicine as
modem. Adams argues that in doing this, physicians
are both modernizing Tibetan medicine and producing
a method for revitalizing Tibetan culture. This tran-
sition from traditional to modern is critical in the case
of Asian ethnomedicines. Up to this point the tran-
sition has been shaped by accession to Western scienti-
®c authority. If ethnomedicines are to be productively
modernized, that is, they are able to incorporate el-
ements of social and cultural modernity, including
science and technology, while at the same time sustain-
ing or reintegrating native epistemological approaches,
they must have the structural autonomy to do so.
The crisis faced by indigenous medicines is that they
will be unable to face the epidemiological consequences
of the health transition. Data from developing and
developed countries show that aging populations, suf-
fering from degenerative and chronic diseases, will turn
increasingly to non-biomedical alternatives for medical
treatment. Yet the very same social and historical pro-
cesses that produce the health transition also entangle
indigenous medicine in social forces that seriously
impede its ability to develop without complete acces-
sion to the authority of Western science. Nations with
viable and well developed indigenous systems face the
prospect of losing the core features of these systems,
and in the process, losing the elements of diagnosis,
treatment and care that have been argued to comprise
the greatest bene®t and which may provide highly
desirable options under the current contexts of neolib-
eral health reform. Protecting indigenous medicine will
require concerted policy e€orts to set professional stan-
dards and provide practitioners, training institutions
and research centers with sucient autonomy to mod-
ernize and revitalize their traditions without losing
core principles. On the side of government, it is par-
ticularly important that the critique of biomedicine be
heard, and heard often, for it is unlikely that indigen-
ous medicines will be granted intellectual autonomy
unless there is a clear understanding of how and why
biomedicine fails and how and why indigenous medi-
cines might be important and useful alternatives. It is
essential that anthropologists and sociologists of health
care participate in these discussions. It is now time for
critical discourse to leave the lecture halls academy
and join the urgent discussions over health reform and
1818 C.R. Janes / Social Science & Medicine 48 (1999) 1803±1820
the health transition in the conference rooms of minis-
tries of health.
Acknowledgements
The research upon which this article is based was
funded in part by a grant from the National Science
Foundation, BNS-9005811 and Faculty Grant and
Fellowship awards from the University of Colorado-
Denver. Writing was supported in part by a Senior
Fulbright Fellowship to lecture in public health at the
National Taiwan University, Taipei.
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