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The Transformations of Tibetan Medicine

Author(s): Craig R. Janes


Source: Medical Anthropology Quarterly, New Series, Vol. 9, No. 1 (Mar., 1995), pp. 6-39
Published by: Blackwell Publishing on behalf of the American Anthropological Association
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ARTICLES

CRAIGR. JANES
Departmentof Anthropology
Universityof Coloradoat Denver

The Transformations of Tibetan Medicine

This article presents a cultural and historical analysis of 20th-century


Tibetanmedicine. In its expansion into the state bureaucracy,Tibetan
medicinehas acceded to institutionalmodernitythroughtransformations
in theory,practice, and methodsfor trainingphysicians.Despite Chinese
rule in Tibet, however, Tibetanmedicine has not yielded completelyto
state interests.Withthe collapsing of the traditionallypluralistic Tibetan
healthsysteminto theprofessionalsector of Tibetanmedicine,contempo-
rary Tibetanmedicinehas become to the laity a font of ethnic revitaliza-
tion and resistance to the modernizationpolicies of the Chinese state.
Theseprocesses are particularlyevident in the elaborationof disorders
of rlung, a class of sicknesses that, collectively, have come to symbolize
the suffering inherent in rapid social, economic, and political change.
[Tibetanmedicine, modernity,ethnomedicine,medicalpluralism,Tibet,
China]

n analyzingmodem Tibetanmedicine, thatis, the medicine thatis now taught


andpracticedin the Tibet AutonomousRegion of China,I proceedalong three
dimensions.First, I discuss the major 20th-centuryevents that have affected
Tibetanmedicinesocially andculturallyin regardto its role in the state,leading to
its presentconceptualand institutionalstatus. Second, I argue that accession to
institutionalmodernity,in terms of both Tibetan medicine's integrationinto the
state health bureaucracyand its conceptualreformulationinto a supralocal,stan-
dardizedsystemof theoryandmethod,has transformedTibetanmedicalknowledge
andhow it is appliedby physiciansin clinical settings.Third,I presentan analysis
of how stateTibetanmedicine,with the demise of nonprofessionalhealing sectors,
has come to representto some Tibetans a forum in which resistance to rapid
modernization,social change, conflict between Han and Tibetans, and political
hegemony can be expressed. I discuss in particulara class of disordersresulting

MedicalAnthropologyQuarterly9(1): 6-39. Copyright? 1995,AmericanAnthropologicalAssociation.

6
TIBETANMEDICINE 7

from an imbalanceof the humorrlung, which to Tibetanpatientsand,increasingly,


to Tibetanphysiciansrepresentsthe sufferingresultingfrom Tibetanconditionsof
rapidsocial, economic, andpoliticalchange.This analysis shows thatthe transfor-
mationsof Tibetanmedicine and Tibetansociety, when consideredtogether,have
contributedto a partialrecastingof explanatorymodels to include the maligning,
corrupting,and disruptingforces of the Chinese state.
In May 1951, the governmentof the then-independentTibetanstateformally
accepted Chinese hegemony, thereby setting in motion the social and economic
transformationof a decentralized,Buddhist,feudal regime into a moder socialist
state. This transformationhas contributedto the region's ever-increasingethnic
conflict between Tibetans and Han Chinese, including sporadic, often violent,
demonstrationsand periodiccrackdownson Tibetanculturalexpression.Tibetan
medicine,alreadyunderpressureto modernizein the early 20th centuryas a result
of the 13th Dalai Lama's efforts to centralizepolitical power and authority,has
become mired in these largerChinese-Tibetanconflicts by virtueof its culturally
significantand religiously salientposition in Tibetansociety.
The intensity of Chinese-Tibetanconflict and government repression of
Tibetancultural expression coincides with the swings in Chinese policy toward
"traditional"culturemore generally and minorityethnic groups ("nationalities")
more specifically. At times Tibetan medicine has been repudiatedin official
revolutionarydiscourse as superstitionemployed by the corruptfeudal elite in its
exploitationof peasantsand nomads. At other times it has been championedas a
valuable resource to the masses, a respected member of the family of "Chinese
medicines."These radicalshiftsin revolutionarydiscoursehave beenaccompanied
by wide swings in the institutionallegitimacy of Tibetanmedicine. Toleratedbut
ignored from 1951 to 1962, Tibetan medicine was officially sanctioned as a
component of the public health system in 1962 and given funds for clinical
operationsand trainingprograms.Four years later, Tibetan medicine was again
delegitimized,and by 1978 it was perchedon the edge of institutionalextinction.
By 1985 Tibetanmedicineemergedagain as a legitimatesectorof the government
health bureaucracyand today plays a significantrole in the provision of primary
healthcarethroughouttheregionwith a substantialoperatingbudgetandover 1,200
practicingphysicians.
Swings in policy, shifts in levels of governmentcontroland scrutiny,and the
forces for modernity that flow from the Chinese state have all contributedto
significanttheoretical,institutional,and clinical transformationsof Tibetanmedi-
cine. This analysis is relatedto an emergingconcernin ethnomedicalresearchthat
health systems, regardlessof origin, be examinedin light of theirhistory,relation-
ship to nationalpolitics, "metamedical"culturalframeworks,and subjugationto
global forces of modernity,includingthose of biomedicine (Crozier 1968; Field
1973, 1976;Frankenberg1980;Janzen1978; Leslie 1980,1992; Leslie andYoung
1992; Lock 1980, 1990; Unschuld 1985, 1992).
This emergingperspectivesuggests thatmodernityhas particularculturaland
socioeconomic consequencesthattogetherreshapeand transformlocal medicines
so that they conform to state political, economic, and cultural authority(Lock
1990). I accept Giddens's (1990) basic sociological formulationof modernityas a
transformationwhereby social institutionsare disembeddedfrom local networks
8 MEDICAL ANTHROPOLOGY QUARTERLY

of social relations.Becoming universal,these institutionsgrow more powerful as


they reflexively come to organize ever greaterareas of the social and cultural
environmentover which they gain increasingknowledge and, thus, power (e.g.,
"bio-power"[Foucault1980a, 1980b]).Medicalsystems, as they modernizein this
fashion,become weddedto thewiderdiscourseson ethnicandpoliticalnationalism,
the politicalrightsof indigenouspeoples, andtherole andauthorityof biomedicine.
Most critically, ethnomedicines,as can be seen in the case of state-legitimized
Asian medicines in particular,may become subjectto the authorityof the modem
bureaucracy."Traditional"authority,buttressedby local networksof social rela-
tions and culturalknowledge, becomes unwieldy in the context of supralocaland
universalizingsystems of knowledge andpractice(Leslie 1980; Leslie and Young
1992). Local manifestationsof modernityconstrainthe social andculturalproduc-
tion of sickness insofar as ethnomedicinebecomes reconciled with the dominant
ideology of the state in question (Lock 1990).
Local communitiesare,however,rarelycompletelysubordinateto those grids
of power in which they find themselves enmeshed.Rather,such communitiesact
as agents in resisting the loss of local control.Studies conductedin Asia over the
past 15 years have shown that despite the social transformationsof Asian medi-
cines, practitionerscontinueto enjoy social and culturallegitimacy at local levels
(however,see Unschuld1992). This legitimacyis reinforcedby the culturalcontent
of the medicine itself; that is, it resonates with "metamedical"frameworksof
thoughtor systems of meaning (Worsley 1982). They serve as a vital and salient
context for the legitimizing of various forms of distress. As Nichter (1981) and
others (Alland 1970; Dunn 1976; Kleinman 1980, 1986; Kunstadter1978) have
pointed out (though from different theoretical vantage points), local eth-
nomedicines,even in contexts framedby rapidmodernizationand medicalplural-
ism, may have an adaptivevalue in constitutinga culturalarenain which particular
formsor idioms of distressmay be legitimatelyexpressed.One can conclude from
much of this work that modernitydoes not tend towardcompletion:as much as
ethnomedicineis subjectto nationalandglobal interests,local interestscontinueto
play a role in seizing upon or strugglingto maintainthe locally salientdimensions
of ethnomedicalknowledge and practice.Social ideologies, political power, and
global forces of capitalismand the like simultaneouslydeterminethe natureand
extent of change at local levels. The following questionsemerge as critical:What
aspects of ethnomedicine-symbolic, clinical, or social-are undersuch circum-
stances seen by local communitiesas essential,as worth strugglingfor, and why?
To whatdegreeare such strugglesrepresentativeor expressive of strugglesagainst
the dominantideology in general(e.g., Singer 1990:184)?

Methods
The datapresentedin this paperwere gatheredduringthe course of a research
projectconductedbetween 1988 and 1993 in centraland west-centralTibet, Tibet
AutonomousRegion (TAR), China.The researchwas designed to examinemulti-
ple linkages among local Tibetancommunities,Tibetanmedicine, and the wider
sociopoliticalcontext.To thisend, datawerecollectedon multiplelevels. A random
sample of 56 patients, stratifiedby age, presentingsymptoms, and institutional
locus of treatment,were interviewed;these patientswere drawnfrom an observa-
TIBETANMEDICINE 9

tional exercise in which 718 clinical encountersin Tibetanmedicalfacilities (both


ruraland urban)were recorded.Forty practitionersof Tibetanmedicine, selected
on thebasisof whenthey weretrainedandwheretheypracticeorpracticed(private,
governmentinstitution,ruralor urbansetting),providedtheir careerhistories and
trainingexperiences, and 20 key informants-including senior officials of the
Health Bureau of the TAR-provided data on health policy and how it was
implemented"on the ground"in Tibet. These individualsalso providedmuch of
the historical data presented below. In the spring of 1993, 42 case studies of
individualssufferingfrom rlung imbalance,a particularlyimportantpsychosocial
disorderthatwill be discussed at some length, were collected, and,wherepossible,
physicians were administeredfollow-up interviewsabout the rlung patients they
supervised.
The majorityof the researchwas undertakenin Lhasa,the capitaland largest
city the TAR, with a populationof about 125,000 (of which perhaps50,000 are
of
Tibetan).It is herethatthe majorTibetanmedicalhospitalsandtrainingcentersare
located. Although the majority of patients at the Tibetan medical facilities are
Lhasans,a significantnumberof patientstravelsome distanceto seek treatmentin
Lhasa, in which it is generally perceived are the best doctors, medicines, and
facilities. Lhasa Tibetans are quite diverse in socioeconomic characteristicsand
backgrounds,andthis diversitywas representedin the samplesof patientsobserved
and interviewedat the various Tibetanhospitals, and included well-heeled work
unitadministrators, entrepreneurs,powerfulgovernmentofficials, clericalworkers,
laborers,farmers,herders,and a large percentageof the unemployed,a significant
and growingproblemin Tibet (and, generally,acrossChina)with the acceleration
of economic reforms.
Researchactivities were also carriedout in both town and ruralsettings in
Shigatse and Tsethangprefectures(the prefectureis an administrativelevel above
thatof the county and below thatof the provinceor autonomousregion). Shigatse
and Tsethang are medium-sized towns that serve administrativeand economic
functionsto largely agriculturalhinterlands.
Physicians from each of the researchsettings were interviewed.All patient
case-historieswere takenin Lhasa,Gyantse(a ruralcountyseat nearShigatse),and
Tsethang;observationsand key-informantinterviews were conducted in Lhasa,
Tsethang,Shigatse, and three rural,agriculturalcounties in Shigatse and Lhasa
prefectures.
The descriptionsand analyses presentedhere pertainto government-funded
Tibetan medicine in the TAR and can probably be generalized to the Tibetan
medicine found in surroundingprovinces of China where there are substantial
Tibetan populations. No claims are made that the findings presented here are,
however, representativeof the Tibetan medicine found among the refugee and
exile communitiesin India or Nepal. The TibetanMedical Centrein Dharamsala,
India,has been active since its establishmentin research,training,and publishing,
andone mightspeculatethattherehas likely been divergencein theoryandmethod
from the Tibetanmedicine found and practicedin moder China.
10 MEDICAL ANTHROPOLOGY QUARTERLY

Medical Systems in Tibet

Historically,Tibetansociety has possessed a multilayeredmedical system,'


rangingfrom local, community-levelshamanicand folk Buddhistritualpractitio-
ners and practices to religious and secular practitionersof a professional and
scholarlytraditionof healthcarerootedin the naturalisticethnomedicinesof Asia,
Europe, and the Middle East. These latter practitionersderived their legitimacy
largely from the social formations of the feudal state (cf. Adams 1992). This
scholarlytraditionof medicineis today whatmost referto when they use the term
"traditionalTibetanmedicine."Manyresearchers,bothWesternandTibetan,trace
the core of this Tibetanmedicine to Sanskritworks of the fourth century A.D.
(Clifford 1984; Rechung 1973; Snellgrove and Richardson1968; Tsarong et al.
1981) or to a syncretism of Indian, Chinese, and Western (Persian-Greek,or
Galenic) systems of medical thought(Beckwith 1979; Stein 1972).2Common to
these systems of thoughtis a constructionof the body as a microcosmof the natural
universe. To this largely naturalisticsystem of theory and practice,early Tibetan
medical scholarsaddedBuddhistnotions of the mind or self, emotion,and the law
of karma, developing a theoreticalsystem in which the notion of a mental self
(sems) was constitutedas dominantover the objective, or grossly physical, body.
The etiology of all diseases may be, accordingto this classical Buddhistparadigm,
reducedto an understandingof the "NobleTruths,"thatis, all life is impermanent,
and impermanenceleads to suffering throughthe operationsor "attachments"of
the ego, or self (bdag 'dzin).Ego is manifestedin the formsof delusion,ignorance,
or confusion (gti mug). These, in turn,give rise to attachment,greed, and desire
('dod chags) and hatred,aversion, and aggression (zhe sdang; see Tsaronget al.
1981). The three poisons give rise to the three humors (or afflictions associated
with the humors):air(rlung);bile (mkhrispa); andphlegm (badkan),respectively.
Buddhisttraditionalso providesthe concretemethodsto removethese causes (the
"Eightfold Path").Thus, Buddhist medicine posits that the self (the "ego") is
ultimatelycausal of all suffering,includingthat of ill health. Althoughbody and
mind are seen to be fundamentallyintegratedin this system, it is the mind that is
problematizedandseen as primaryin facilitatingbothhealthandill health.As Lock
and Scheper-Hugheshave noted (1990), unlikeWesternconstructionsof the body,
where the mind is collapsed into the physical body, in classical Buddhistmedical
theorythe physical body is collapsed conceptuallyinto the sentientmind.
On a secondarylevel (Tibetanstendto use the terms"closer"or"moredistant"
in discussing pathogenesis),the humorsarelinked to the fundamentalelements of
materialexistence: earth(sa), water (chu), fire (me), air (rlung), and space (man
mkha).It is the maintenanceor restorationof the delicate balanceof humorsand
the forces or energiesthatunderliethemthatis the goal of Tibetanmedicalpractice.
At an immediatecausal level, this involves examining an individual'sdisorderin
relationshipto climate, time, unbalanceddiet, and improperbehavior (mental,
emotional,and physical).
ApplyingFoucault's(1980a) conceptof bio-power,Adams(1992) arguesthat
the Tibetan-Buddhistmedical tradition,in creating a subject-objectdualism in
which the self supercedes and controls the physical body and in linking the
technology of self-managementand control to the politically importantmonastic
institutions, was instrumentalin the development and expansion of the loose
TIBETANMEDICINE 11

Tibetanstate, which until the 20th centurylacked any kind of centralizedpolitical


authority(Samuel 1982). Adams notes that the discourse on the self and body,
emanatingfrom the politico-religiousinstitutionsof the feudal state, was superim-
posed upona systemof pre-Buddhistreligiousbeliefs thatemphasizedtheexistence
of multiple categories of deities, demons, and spirits and the importance of
shamanichealingpracticesdesignedto keep demonsat bay andkeep the individual
on favorableterms with protectivedeities. Producedout of kin-based systems of
exchange, such beliefs underscoredthe contingent, social nature of illness and
facilitated the reproductionof values of communalityand kinship. Over time,
Buddhistmedical ideology strove to supplantsociocentrictheorieswith individu-
alistic causal theories by wresting control over sickness and health from malign
deities, placing control of the suffering body in the hands of the sentient mind,
therebydesocializing explanationsof worldlysuffering.

Thediscourseof Buddhismaimedto producesubjectivity: where


individuality
therehadbeencollectiveidentities; wheretherehadbeencontrolby
self-control
peers; a bifurcatedself wheretherehad been a unified,social whole;and a
supercedence of conscious(mental)overphysicalbeing,whichultimatelymeant
constitutinga bodyas a non-socialobjectuponwhichself-strategies
couldbe put
intoeffectintheefforttoobtainself-perfection.
[Adams1992:161-162,emphases
in original]

Although the radicalsubjectivityof this scholarlyBuddhistmedicine may be


seen as supportingthe power structuresof pre-20th-centuryfeudal Tibet (see
Goldstein 1989), it was a perspective only partially accepted by the largely
uneducatedTibetanlaity.To this groupand,perhapsto some degree,to a proportion
of Tibetanphysicians, the ontological statusof the body is not problematic.The
body becomes sick, it suffers, and thoughsuch sufferingmay well stem from the
imperfectionsof the self (in this as well as previousexistences), Tibetansare well
able to construehealth as an ingredientof worldly happinessthat is producedby
phenomenaof this world,naturalas well as supernatural,operatingin parallelwith
or supplementalto the grand theoreticaland philosophical schemes of scholarly
Buddhism.Now, as in the past, sickness is constructedaccordingto social as well
as individualistideologies. Interviewswith a wide varietyof Tibetansfrom differ-
ent social and economic backgroundsshow thatthey express notions of causality
that mix notions of mind management,appropriatesocial behavior of self and
others, pollution or defilement, the actions of deities and demonic misfortune,
misfortune or bad luck, strong or "poisonous"emotion, diet, and weather (see
Lichter and Epstein 1983). These constructionsof causality may complement,
cooperatewith, or sometimesact apartfromthe law of karma.In interviews,many
lay Tibetansemphasizedthe socially contingentnatureof emotion, referring,for
example, to violated expectations, witnessing troubling events, or being disap-
pointed by children. This is not to say that Tibetans reject the basic tenets of
Buddhism;rather,they accept them, but with a sense that they explain only the
"grandcontingenciesandnot the littlejoys andsorrowsof life" (LichterandEpstein
1983:257).Ideasaboutdemonicmisfortuneandbadluck, for example,lead directly
to notions of this-worldly and unmeritedsuffering. It is precisely in the cultural
spaceopenedup by these notionsthatTibetansareable to constructsocioemotional
12 MEDICALANTHROPOLOGY
QUARTERLY

models of illness thatappear,on the surface,to runcounterto the theoryof karma


and the spiritualindividualismof TibetanBuddhism.
In the mixing of models of humansicknessas suffering,the natureof medical
pluralismin traditionalTibet emerges. Although most Tibetansaccepted in very
broadoutline what they knew aboutBuddhismand adheredto the moral scheme
of self-managementthatBuddhismstampedon the social landscape,they were also
able to admitinto discussions of sufferinga varietyof interpretiveschemas, each
of which emphasizeddifferentdimensionsof causality,therebydemandingmulti-
ple levels of intervention.In healing, this complexity contributedto a social
differentiationof local healersthattypically includedmonk-ritualists,lama-divin-
ers, tantricpractitioners,shamans,folk healersspecializingin treatingvariouskinds
of disorders, and itinerant scholar-physicians(see Finckh 1978; Norbu 1987;
Snellgrove and Richardson1968; Tucci 1967). As will be discussed, this tradi-
tional, pluralistichealing structurehas collapsed underthe weight of the Chinese
state into the formalinstitutionsof professionalTibetanmedicine. The laity have
consequentlybroughtpressureto bear on the institutionsof Tibetanmedicine to
incorporatethe more sociocentric models of now-forbidden folk religious or
shamanic healing.
Prior to the dramaticevents of the 20th century,the professional sector of
Tibetan medicine was quite heterogeneous.On the basis of my interviews with
elderly Tibetan physicians and a review of historical works (e.g., Norbu 1987;
Shakabpa1967; Snellgroveand Richardson1968; Tucci 1967), physicianscan be
sortedinto several groups accordingto theirtraining,practice,and theirrelation-
ships to the formal organs of government. The first category of physicians,
historicallyof the greatest antiquity,are those whose trainingand practice were
rooted in individualcontractualrelationships.Studentswere recruitedinto medi-
cine by a physician-relativeor would appealto well-knownphysiciansto be taken
on as novices. Upon completionof theirtraining,which may have takena decade
or more (often studentshad to leam to read and write Tibetanfirst), the students
would practiceprivately,exchangingservices for goods or fees. These "lineages"
of physicians were often seen as descending from one of the great historical
physicians of Tibetan medicine. Privately trained and practicing doctors were
primarily associated with the secular aristocracy in Tibet; that is, they were
membersof or attachedto landedestates.Therewas, however,significantvariation
in the socioeconomic backgroundand status of these physicians. Some were
itinerantherbalistswho made a regularroundof villages to peddlemedicines (e.g.,
Norbu 1987).3Otherspracticedmedicine as a sideline to other occupations,even
farming,and derivedrelativelylittle income from it.
Some well-known physicians who were in demand as teacherswould open
private(secular)academiesand accept small numbersof studentsto pass on their
knowledge more effectively and perhapsto enhancetheir incomes. There were at
least two such academiesoperatingin 1951, one in Lhasa and one in Shigatse.
In the monasteries,Tibetanmedicine was eventually acceptedas one of the
sciences in which one could pursue advanced training. It is unclear from the
literaturewhen the trainingwas legitimized,but it was certainlywell developedin
monastic institutionsby the end of the 17thcentury.Tibetanmedicine underwent
a greatexpansionat this time underthe governmentof the fifth Dalai Lamaand his
TIBETAN MEDICINE 13

minister, Sangye Gyatso (Sangs rgyas rgya mtsho). Sangye Gyatso founded the
ChagporiCollege of Medicineadjacentto the PotalaPalace in Lhasa.The teachers
were monks, mainly sent from other monasteriesin Tibet. In additionto medical
training,importancewas placedon liturgyand ritualpractice(Parfionovitchet al.,
1992). Chagporicontinuedto be one of the most importantof the religious-based
medical traininginstitutes,producingmost of the personalphysicians to the great
religio-politicalhierarchsof Tibet until it was destroyedby the Chinese in 1959.
Informantssuggested thatthe accomplishedmonk-physiciansin the greatmonas-
teries of Tibet (which had populationsin the thousands)provided their services
almostexclusively to othermonks.In ruralareas,however,the smallermonasteries
tendedto be more closely integratedwith the surroundingvillages, and it is likely
that they provided health services to villagers (see, for example, Snellgrove and
Richardson1968).
A final group of physicians,referredto inconsistentlyin the literature,were
those trainedeitherprivatelyor in monasteries,butwho wereuniqueinsofaras they
were in the employ, at least part-time,of the government.Adams (1992) suggests
thatpublicemploymentof physiciansdates to the 17thcentury(cf. Rechung1973).
Except for the employmentof personal physicians for various state dignitaries,
however, there is little mention of government-sponsoredhealth care or public
healthefforts until the early 20th century.
The heterogeneityof trainingand practicetended to producemultipletradi-
tions of medicine thatvariedaccordingto individualteacher-studentrelationships,
whichover timeproducedparticulargenealogies of knowledge (see Beckwith 1979
for some discussionof the earlyhistoryof these genealogies). Althoughall Tibetan
physicians subscribeto the authorityof the "fourroot tantras"(rgyudbzhi), which
date roughly to the eighth centuryA.D., the texts are open to multiple interpreta-
tions. Commentariesby eminent physicians have additionallybeen passed from
teacherto studentwithin particularphysician lineages. Medical heterogeneityis
also relatedto geographicallydistinct epidemiologic differences in Tibet. Tibet's
greatgeographicvariationresultsin ecological zones, rangingfromrelativelylow,
moist valleys in the east to high, aridplateausin the west and north.The distinct
epidemiologic profiles of these regions led to medical traditionsthatwere geared
toward treating the most common ailments found in each region. Even today,
physicians will note differences in "eastern"and "western"(or "northern"and
"southern")schools of Tibetanmedicine. Although the main variationin medical
training and practice is in the particularsof the materia medica, it has been
broadenedby regional variabilityand the developmentof distinct local traditions
and physician genealogies. The general features of Tibetan medicine remained
fairly constantover time and acrossregions, but applicationof the generalcorpus
of knowledgein particularlocales produceddistinct,local traditions.This variation
was a majorcasualty of the 20th-centuryshift towardinstitutionalmodernity.

The Expansion and Modernization of Professional Tibetan Medicine,


1913-1951
In the early 20th century, the government attempted to expand Tibetan
medicine throughstandardizedtrainingin a government-fundedinstitutiontied to
the seculararmof the government(kashag) ratherthanthe ecclesiastical.Though
14 MEDICALANTHROPOLOGY
QUARTERLY

it left the privateand monasticsectors essentially untouched,governmentpolicy


soughtto increasethe numberof physiciansfromnonmonasticsectorsof the society
and to recruit more physicians into governmentservice. The impetus for these
efforts is well describedby Goldstein(1989) in his detailedhistory of Tibet from
1913 to 1951. In brief, Tibet found itself in the midst of colonial conflicts among
Britain,Russia, and Chinaover the division of Asia. After fleeing first from the
British,and thenfrom the Chinese,the 13thDalai Lamareturnedto Lhasain 1913
with a small military force and expelled the last vestiges of a Chinese political
presencein Tibet. Perhapscognizantof the need to deal with these forces on their
own terms, the Dalai Lama attemptedto centralize his political authorityby
wresting some control from the ecclesiastical elite and turned his attentionto
buildinga militaryforce, institutingseculareducation,and reformingmedicineto
makeit morewidely availableto the averageTibetan.Althoughhe ultimatelyfailed
to overcome the entrenchedconservatism of the economically and politically
powerful monastic elite in most areas, the reforms did affect the institutionsof
Tibetanmedicine.
Influenced by his personal physician and concerned about the need for
expandedhealthcare, the Dalai Lamaauthorizedthe buildingof a secondmedical
college in Lhasa (sman rtsis khang; hereafter written as Mentsikhang), which was
completed by 1916, and later orderedthat the Tibetan army, monasteries,and
aristocraticfamilies each meet establishedquotasfor trainingnew Tibetandoctors.
For example,each monasteryin Tibet was orderedto send two studentsto studyat
the Mentsikhang,one to specialize in medicine per se, the other to specialize in
astrology.4These effortsat expandingtrainingwere accompaniedby minorreforms
in the practiceof medicine so as to provide greateraccess to medical care at all
levels of the class system. A public clinic, intendedprimarilyas a trainingfacility
for the new doctors, was establishedin Lhasa, and for about 15 years the govern-
mentorganizedwomen's andchildren'spublichealthprogramsthatsentmedicines
to pregnantwomen, new mothers,andinfantsthroughoutTibet.The few physicians
trainedduringthis period who are still alive reportthat doctors were assigned to
needy monasteries and communities, and many were given governmentrank.
Cassinelli and Ekvall (1969), for example, reportthat duringepidemics the gov-
ernmentin Lhasa would post additionalphysicians to the Sakya region, where
physicians possessing low-level governmenttitles were alreadyposted (see also
Shakabpa1967:258-259).
The well-known physician, KhenrabNorbu (mKhyenrab nor bu), was ap-
pointeddirectorof the Mentsikhang,and, as noted by a numberof informants,he
made efforts to standardizetraining in Tibetan medicine regarding texts, the
trainingof teachers,and enrollmentof studentsfrom the three groupsmentioned
above. The new Mentsikhangdid not supplantothertrainingcenters,includingthe
college at Chagpori,nor did it precludeprivatetraining.The diversity of training
arrangementscontinuedunfettereduntil the institutionof reformsby the Chinese
after 1959. Left to its own devices, the Mentsikhangwould have been unlikely to
pose a seriousthreatto monasticandprivatetraditionsof healing;it was simply an
additionalresourcefor careand training.
When the Chinese enteredTibet in 1951 and began their programof social
and economic transformationof Tibetan society, they confronted a pluralistic
TIBETANMEDICINE 15

medical system that,at its most formalandpowerfullevel, was well integratedinto


the peculiarinstitutionsof the Tibetanstate.Guidedby a policy thatacceptedsome
ethnic self-determinationbut a revolutionaryideology that demanded that the
feudal relations of productionbe transformedthroughdirect attackon the class
system and its ideological allies, in particularthe monasteries, China became
embroiledin political problemsin Tibet, as it did in many otherminorityregions.
An overt attemptto underminethe most significantculturalinstitutionswould risk
the wholesale alienationof the Tibetan populace. But the institutionshad to be
weakened if China was to follow throughon its guiding socialist ideology. A
symbolicallysecularTibetanmedicine,providingfree healthservices andtraining
people from the most socially significantand powerful sectorsof Tibetansociety,
was a convenientprop. It could be reconstitutedas a symbol of the socialist ethic
of serving the common good; at the same time, it could be used to demonstratea
fundamentalrespect for Tibet culture. A culturallyfamiliar institutioncould be
elaboratedandexpandedfor display to a populaceundergoingrapidsocial change,
providinga kindof ideologicalcover for the dismantlingof the feudalstate.(In this
case, the broad similarities between traditionalChinese and Tibetan medicine
providedthe Chinesewith, at the least, an institutionalmodel with which to work;
see Crozier 1968.) Furthermore,by legitimizing Tibetan medicine, the Chinese
could demonstratetheir concern for minority traditions and rights, a strategy
consistent with their "unitedfront"policy of co-opting resistanceand engaging
minorityleaders,if cooperative,in social reformefforts (Blum 1994;Dreyer1976).
From 1951 until the beginning of the Cultural Revolution, as the events
described below illustrate, Tibetan medicine as practiced in the Mentsikhang
dodged the antifeudalbullet, so to speak, and slowly consolidatedits position in
the newly introducedhealth bureaucracy,accepting, in the process, the Chinese
terms of its legitimacy.Tibetanmedicine, with its Buddhistorientationto mental
phenomena,began to move towarda more grossly physical medicine;the objecti-
fied body began to lose its sentientmind in official medical discourses.

Tibetan Medicine, 1951-1959: Consolidation

From 1951 to 1959, institutionsof Tibetanmedicine were generallytolerated


by the Chinese, who were more concerned with creatingconditionsfavorableto
the introductionof what they termed"democraticreforms."This involved efforts
at delegitimizing the religious aristocracythroughpublicizing abuses of power,
symbolically secularizinghigh offices in the Tibetan government,educating the
public to the wrongs of the class system, elevating "unclean"groups, such as
blacksmiths, to positions of leadership on new local councils, and impressing
Tibetans with the level of Han Chinese concern for their Tibetan compatriots
throughpublic worksprojectsand introductionof hospitals, schools, and agricul-
tural innovations (Burman 1979; Dreyer 1976). Yet as the decade progressed,
efforts to delegitimizeand suppresslocal medico-religiouspracticeswere intensi-
fied. Propagandaregarding"unhealthycustoms"and "feudalsuperstition"began
to appear,and much was made of exposing lamas as "parasiteson the peasant,"
nothing more than charlatansworking for the class interests of the old feudal
landlords(Burman1979).
16 MEDICAL ANTHROPOLOGY QUARTERLY

The Mentsikhangcontinuedto operateas a public facility underthe direction


of the seculararmof the Tibetangovernment.Little contactwas initiatedbetween
the importedhealth bureaucracyof the Chinese and that alreadyfunctioning in
Tibet, and nothingwas done to disruptthe day-to-dayactivitiesof physicians.No
overt political pressureswere broughtto bear at this time on the Mentsikhangto
increasetheir primaryhealth care services; however, doctors workingat the time
recall being encouragedto do so. Most Tibetans in Lhasa, unaccustomedto the
concept of a public clinic, remained committed to obtaining services from the
numerousprivatesecularand religious health specialists who were practicingin
the capital.
The influx of large numbersof cosmopolitanphysicians and the buildingof
clinics andhospitalsbroughtTibetanmedicineinto contactwith biomedicaltheory
and practicefor the first time and necessitated the creation of a bureaucracyto
administerthe rapidlydeveloping health care system. By 1954 several hospitals
had been built in majorpopulationcentersand a programto trainTibetancommu-
nity healthworkers(a predecessorto the "barefootdoctor")was established,with
1,300 such workerstrainedby 1961 (Burman 1979). There was an interest and
openness on the part of Mentsikhang professors to biomedicine, and several
studentswere sent to the militaryhospital to study a "little"biomedicine,particu-
larly trainingin basic infectiousdisease diagnosis and treatment.
The periodfrom 1951 to 1959 can thus be describedas a reasonablycomfort-
able one for leadershipin the Mentsikhangand other local facilities and medical
schools. Overtly,the Chinese demonstratedgreatrespectfor the integrity,"scien-
tific basis,"and socialist potentialof Tibetanmedicine. Overtureswere courteous,
and many of the physicians and students then practicing or studying in the
Mentsikhangwere mollified by the obvious respect given Tibetanmedicine by
visiting Han medicalexperts.Severalof these experts,in fact, undertookthe study
of Tibetanand participatedwith seniorphysicians in the study of Tibetanmateria
medica.This "unitedfront"strategywas successfully deployedin the healtharena,
and many Tibetanphysicians, including the presentdirectorof the Mentsikhang,
conceived of takingthe Mentsikhangin a new direction,orientedto public health
andlow-cost primaryhealthcare,andjoined with biomedicinein a new cooperative
enterprise.

Tibetan Medicine, 1959-1966: Cautious Growth


The reasonably smooth relations between the Chinese and Tibetans that
characterizedthe first partof the decade began to crumbleas economic hardship
caused by the influx of Han Chinese cadre,military,and refugees from Chinese-
imposed land reforms in eastern Tibet took their toll. A growing unease at the
prospectof futuresocioeconomic reformcontributedto a small resistancemove-
ment. As a result,in March1959, a ragtagforce of Tibetansstagedan unsuccessful
revolt againstthe Chinese.5The Chineserespondedharshly,andmanywho did not
flee to India or Nepal were imprisoned.Despite the harshness of their initial
response,the Chinesedid not rushto impose the economic reformsthatwere then
being imposed in the rest of China. Although the Chinese dissolved the Tibetan
government,Beijing, adhering,albeit tentatively,to the spirit of its nationalities
policy, determinedthat the local conditions were not favorableto communalism
TIBETANMEDICINE 17

and so adopteda more gradualistpolicy of bringingsocialism to Tibet (Goldstein


1991).6 The majorityof peasantand herdinghouseholds were allowed to keep the
fields and animals they owned, and economic decision making was left at the
household level. Virtually all monks were sent home from their monasteries,but
lay Tibetanswere officially permittedto practiceBuddhism(Burman1979; Gold-
stein 1991).
The Mentsikhangwas broughtunderthe directcontrolof the Chinese health
bureaucracy,in particularthe Lhasa City Health Bureau,and the majormonastic
medicalschool at Chagpori(in Lhasa)was closed (it was destroyedin theuprising).
All physicians at Chagporiand studentsin trainingthere were transferredto the
Mentsikhang,bringingthetotalnumberof staff to 80:25 studentsand55 physicians
and administrativestaff. The 25 studentsfrom Chagporiwere allowed to continue
theirtrainingat the Mentsikhang;15 graduatedin 1961, theremainderthefollowing
year. A new biomedical hospital, the Lhasa City Hospital, was built; this facility
became the sole public resourcefor biomedicine in Lhasa, and the Mentsikhang,
which had previously been primarilya trainingfacility, was orderedto open its
doors as a public outpatientclinic. All Tibetanphysicians were placed on a small
salary,but no funds were given to supportthe operationsof the hospital,including
the gatheringand preparationof medicines. This had to be accomplishedby the
physicians and studentsthemselves. By 1961 a few older physicians remainedin
the Mentsikhangto treatpatientson a daily basis; these patients numberedonly
30-50 per day as the public was, according to a doctor working at that time,
"unaware"of the availability of public Tibetan medical facilities that were not
intendedjust for the poor and staffedwith student-doctors.The remainingphysi-
cians were involved in politicalmeetings,raisingfood, collecting medicinalingre-
dients, and manufacturingmedicines.
The privatetrainingand practiceof Tibetanmedicine came to an abruptend
as land and social reformsbegan to take root throughoutTibet. Monk-physicians
were no longer permittedto practice,many being forced into menial laboror sent
backto theircommunitiesof originto be farmersor herders.Slowly, local traditions
of Tibetanmedicinebeganto die out as doctorsceased to practiceor wereprevented
from doing so. Many of the distinguishedlineages of Tibetanphysicians came to
an end. The depopulationof the monasteriesandthe official suppressionof "feudal
superstition"virtuallyeliminatedovert recourse to Buddhist healing rituals (sku
rims) and the divinatoryservices of lamas, oracles, and shamans.
Trainingin andpracticeof Tibetanmedicinerevertedentirelyto the institution
of the Mentsikhang,which was involved in its own struggles for survival in an
increasinglyhostile political environment.Several Han Chinese health officials
called for governmentsupportof Tibetanmedicine to be discontinuedor sharply
curtailed.Mountingcriticismfrom the health bureaucame to a head in late 1961,
with the governmentcalling a meeting to decide the futureof Tibetanmedicine.
On one side were those, primarilyHanChinese, who wished to restrictthe practice
of Tibetanmedicine andthe numbersof practicingphysicians.They envisionedan
attenuated,"combined"Tibetanmedicineandbiomedicinethatwould be practiced
in a departmentof an otherwisebiomedicalfacility. On the otherside of the issue
were those well-educated and previously influential Tibetans who argued that
Tibetan medicine ought to be able to develop separatelyalong its own course,
18 MEDICAL ANTHROPOLOGY QUARTERLY

althoughthey accepted the demandthat it become more "scientific"and widely


available.The thenquiteelderlyKhenrabNorbu,directorof the Mentsikhangsince
his appointmentby the Dalai Lamain 1916, was able to prevail againstthe critics
in the HealthBureau.The popularstory told these days is thathe manipulatedthe
supportof his "backdoor"contactswith several senior Chinese officials who had
been successfully ("miraculously")treatedwith Tibetanmedicines. After a series
of privatemeetings and some political machinations,the Mentsikhangemerged
from this conference as a fully legitimate medical institutionof the Lhasa City
HealthBureau,recognizedas a hospitalof LhasaCity,thoughwitha meagerannual
budget of approximatelyU.S. $7,000 (in 1961 dollars) for salaries and operating
costs.
When KhenrabNorbudied at the end of 1962, he was replacedby one of his
students,who today remainstitularhead of the Mentsikhang.This new director,a
former monk and the last member of one of the more distinguishedphysician
lineages in Tibet, was just 33 yearsold at the time of his appointmentbuthadheld
several significant political positions in the Chinese government.Understanding
the changedpolitical circumstances,possessing political legitimacy as far as the
Chinesegovernmentwas concerned,andhavinga traditionalmonasticandmedical
education,the new directorwas ableto steerthe Mentsikhangon a middleroadthat
formallyand publicly acknowledgedsocialist ideology while sustainingmuch of
its traditionalflavor. He looked to implementthree strategies:first, to create an
institutionthatparalleled,symbolicallyandin termsof the organizationof care,the
biomedicalinstitutionsthen presentin Lhasa;second, to increaseutilizationrates
in orderto demonstratethe populardemandfor services;andthird,to de-emphasize
those elements of Tibetan medicine that the government found objectionable,
particularlythe use of religiousconceptsandthe problematizingof the mindor self
in diagnosis and treatment.The director introduced to Tibetan medicine the
sociological idea of departmentalization, creatingspecialized departmentsof "in-
ternal medicine," "women's and children's medicine," "surgery,"and so forth.
Exemplary of his moderate approach,although the idea of specialization was
entirelynew to Tibetanmedicalpractice,the areasof specializationcorresponded
with the traditionalbranchesof medicine described in the root tantras.More
symbolic efforts were undertakento enhance the "modernand scientific"appear-
ance of Tibetanmedicine, for example, the requirementthat doctors wear white
coats and hats. Emphasis was placed on the stocking of a complete pharmacyof
Tibetanmedicines, and youngerdoctors were assigned the task of gatheringand
producingadequatesupplies of medicines, workingnearlyaroundthe clock to do
so. By extendinghours and takingsteps to ensurethatdoctors,particularlysenior
doctors, were availablefor patientconsultations,the numberof patientsseen per
day began to increaserapidly.
With these changes in place and the clientele of the Mentsikhangincreasing,
the directorthen appealedto the governmentto admita new class of studentsfor
trainingin Tibetanmedicine.The Mentsikhangwas given permissionto collect a
class of 45 studentsfor advancedtraining,as long as it madesurethatthose students
who were admittedcame from a variety of socioeconomic backgrounds.Those
fromthe lower classes of the"oldsociety,"not traditionallyeligible to seektraining
in medicine, were particularlyencouraged to apply. The doctors subsequently
TIBETAN MEDICINE 19

trainedhave become of increasingimportanceto the modem Mentsikhanginsofar


as they now occupy ranksimmediatelybelow the seniorranksin the hospital and
have become influentialpolitically.
This group of physicians is importantfor two additionalreasons. First, it is
the first group trainedin Tibetanmedicine for which efforts were made to ensure
thatrepresentationfrom all sectorsof society was equal.It includedlargenumbers
of women and top graduatesof the newly introducedChineseeducationalsystem.
Ten of the students,five men and five women, were recruitedfrom the new Lhasa
middleschool (equivalentto high school in the U.S. system).These were individu-
als of lower-class and peasantbackgroundswho had tested high in their Tibetan
languageabilities and who, in termsof theirpolitical affiliations,were considered
quite "red."The remainingstudents were from a varietyof social and economic
backgrounds.Second, we were told thatthe class of 1963 was also the firstto learn
in whatinformantstermed"modemways,"thatis, in classroomsettings, wherethe
method of teaching was by lecture and discussion with little in the way of
supervisedpractice,ratherthan by memorizationand one-on-one practicewith a
personalteacher.The length of trainingand the degree to which practicalskills
were integratedinto this trainingwere dictatedby the governmentand were thus
basedon those generallyused to instructmidlevel biomedicalphysiciansin China.7
The methods of recruiting students, training them in fixed time periods and
accordingto standardizedcurriculamodeledon those of biomedicine,testing them
for theirknowledge, and then certifying them for practicediverged sharplyfrom
the pre-1959 system of medical education.The "class of 1963" thus representsa
substantialconceptualbreakwith the traditionalmedicine of the pre-Chineseera.
It is in this class that one glimpses a transformationof causal theory and practice
to be more consistentwith those of state biomedicine.

Tibetan Medicine during the Cultural Revolution


The class of 1963 had finished memorizing the root tantrasand was just
beginningthe practicalportionof theirtraining,aboutone year away from gradu-
ation, when the CulturalRevolution swept into Tibet. The intent of revolutionary
activity in Tibet during this period, put simply, was to "destroythe social and
culturalfabric of Tibet's traditionalway of life" (Goldstein 1991:139). Tibetan
medicine was not, despite intense lobbying efforts on the partof the Mentsikhang
director,able to dodge the antifeudalbullet it had successfully avoided earlier:it
was definedin revolutionarydiscourseas one of the"fourolds"-old ideas, culture,
customs, and habits. Many Tibetanphysicians, particularlythe older doctors and
professors, were put into a group known as "gods, ghosts, and evil spirits," a
revolutionarypariahgroupsingled out for particularlyharshtreatment.Many were
sent to labor camps and ruralcommunes where they were forbiddento practice
medicine.Religious activitieswere proscribed,andlargenumbersof medicaltexts
were destroyed.Possession or use of the root tantraswas outlawed,and many of
the doctorsand studentswere forced to hide theirtexts.
Dependingon theirclass statusandpriorpoliticalactivities,manyof the class
of 1963 weresent to ruralcommunesandworkedas agriculturallaborersorherders.
As the radicalismof the CulturalRevolution began to subside in the late 1960s,
Mao introducedhis policy of "sendingdown" educatedyouth to the countryside.
20 MEDICAL ANTHROPOLOGY QUARTERLY

Severalof the young physicianswho had avoidedbeing orderedto ruralcommunes


duringthe CulturalRevolutionwere sent at this time. As word spreadamong the
local residentsthat they had some knowledge of Tibetanmedicine, theirservices
were subject to increasingdemand,although in some places, dependingon the
sentimentsof local officials, the doctors were forced to practicecovertly. By the
early 1970s, when the politicalclimatetendedtowardincreasingmoderation,many
of these young Tibetandoctorswere invited to join the staffs of ruralhealthcare
enterprisesas either "barefootdoctors"or assistantsin township or county-level
biomedical clinics. In these contexts, they learned some biomedicine, primarily
basic clinical skills such as giving injections, recognizing common infectious
diseases, and the like. When the Mentsikhangwas finally able to re-collect the
doctors who had been dispersedthroughoutTibet during this period, this group
formed the nucleus of the "combinedForeign and Tibetanmedicine"department
establishedin 1980.
By 1973 Tibetan medicine as an institutionhad virtually disappeared.The
Mentsikhanghad remainedopen during the CulturalRevolution years, but the
remainingstaff-most only marginallyqualifiedto practicemedicine-were more
involved in political "struggles"than in the practice of medicine. Beginning in
1974, however, local Health Bureau officials began to recognize, slowly but
reluctantly,the importanceof Tibetan medicine, if only as a traditionthat was
"culturallycompatible"with the needs of the population-particularlyruralcom-
munities-they were serving. At this time several county- and prefecture-level
health departmentsin the main population centers of west-central,central, and
easternTibetbeganto offer combinedor integratedtrainingin WesternandTibetan
medicinefor communityhealthworkers.This trainingwas basedon a modelsimilar
to thatused in Chinaduringand afterthe CulturalRevolution.That is, some very
basic elements of diagnosis and treatment,emphasizingherbalmedications,were
incorporatedinto a practical,biomedicallybasedpublichealthcurriculum.By 1976
the Health Bureau-supportedmedical schools in Shigatse and Lhasa, designed
originally to train nurses and communityhealth workersin clinical biomedicine
and public health, added independenttracks in Tibetan medicine and recruited
politicallyuntaintedTibetandoctorsto teach. Studentswere not permittedto study
fromtheroottantrasbecauseof theirreligious associationsbutinsteadstudiedfrom
hastilyprepared,secularizedtextbooks.The teacherswerepermittedto lecturefrom
the tantrasbut were forced to eliminateany overt referencesto Buddhistpsychol-
ogy, philosophy,andreligion.Studentswere also taughtbasic biomedicalanatomy,
physiology, and biochemistry.The doctors we interviewedwho were studentsat
this time referred to this training as nearly "worthless."Most had to relearn
significant portions of Tibetanmedicine at a later time. Several of the students
trainedduringthe mid-to-late1970s continue to work in the Mentsikhangand in
government clinics outside Lhasa, but their expertise is considered by other
physicians and the laity to be poor.Effortshave been made since 1980, with only
partialsuccess, to retrainthese individuals. The currentdirectorof the Tibetan
medical college claims, and this statementwas repeatedby bothjuniorand senior
physicians,thatmost of thedoctorstrainedbetween 1974 and 1980 arenotqualified
to practiceTibetanmedicine.Unfortunately,thoughestimatesvary,relativelylarge
numbersof these physicians(about10-20%) comprisethe medicalstaffsof county
TIBETAN MEDICINE 21

andprefecturefacilities. One of the currentstrugglesin the Mentsikhangconcerns


how to bringthe trainingof these physiciansup to some acceptablestandardwhile
at the same time limiting the potentiallynegative impactthey may have, by virtue
of rankand seniority,8on the futureof Tibetanmedicine.

Tibetan Medicine, 1980-Present: Legitimation and Expansion


The social changes thatswept throughChina with the rise of Deng Xiaoping
to power in 1976 did not result in significantpolicy changes in Tibet until 1980.
At this time, senior officials of the Beijing governmentstepped in to investigate
the impactof democraticand socialist reformson Tibet. Apparentlyled to believe
by the regionalleadershipthatreformsin Tibet had been enormouslysuccessful,
the Beijing government was greatly embarrassedwhen a delegation from the
government-in-exile,led by the present(14th) Dalai Lama's brother,was met in
Amdo (Qinghaiprovince)andLhasaby massive, emotionalcrowds.The delegation
subsequentlyreportedto the Chineseleadershipin Beijing thatthey were shocked
by the level of culturaldestructionand lack of materialprogress that had been
achievedin Tibet (Goldstein 1991). These criticismsled PremierHu Yaobangand
Vice Premier Wan Li to make their own investigatory trip to Tibet. The Han
Chinesesecretaryof the Communistpartyin Tibet was dismissed,andHu publicly
announceda numberof sweepingchangesin Tibetanpolicy. Privately,as Goldstein
reports,Hu is "saidto have equatedthe previous 20 years of Chineserule in Tibet
with Western colonial occupation"(1991:141). The resultingreformpolicy was
intendedto provide for improvementsin the standardof living, establish a social
and industrialbase for continuingeconomic development,allow more autonomy
for Tibetanswith respect to religious and culturalexpression, and reducethe Han
Chinese presence in Tibet. In one document issued by the central government,
Tibetan medicine was specifically singled out as a valuable contributionto the
"familyof Chinesetraditionalmedicines"andthehealthof theTibetanpeople(e.g.,
Cai 1982; Rao 1992). Governmentfinancial and political support for Tibetan
medicine was firmly and unambiguouslyestablished,bringinga flurryof changes
to the Mentsikhangand creatinga substantialniche for Tibetanmedicine within
the overall healthcare apparatusof the region.
A trainingprogramin Tibetan medicine was launched in Lhasa, followed
shortly thereafterby programsin Tsethang, Shigatse, and Chamdo (the major
prefecturalcapitals) under the administrationof the prefecturalhealth bureaus.9
Senior physicians, most of whom were trained before 1959, were recruitedto
instructthese new classes, andthey were permittedto reintroduceinto instruction
the four root tantras,althoughpartyattitudestowardthe religious contentof these
documents remained, and remains, ambivalent. The head of the Mentsikhang
launchedwhathe termedan "emergency"plan to find Tibetanphysicianswho had
been scatteredthroughoutTibetby the revolt of 1959, the CulturalRevolution,and
Mao's "sendingdown"policies. Efforts were also made at this time to collect the
physicians trainedduring the 1970s and put them through intensive retraining
programsand workshopsbasedon the root tantras.Immediateplans were made to
expand clinical facilities and increase rapidly the numbers of Tibetan medical
practitionersto staff these facilities.The strategyof the directorhad two parts:first,
an emergency"salvage"planto collect knowledgeableteachersandfind andobtain
22 MEDICAL ANTHROPOLOGY QUARTERLY

medicaltexts; andsecond,with this knowledgebase intact,expandtrainingrapidly


so that a complete and traditionallyauthoritativeTibetan medicine could be
integratedinto all sectorsof the healthcare system.
Governmentfunding was increasedtenfold. The Mentsikhang,a Lhasa city
hospital until September1980, was renameda regional-levelfacility, structurally
parallelto the regionalbiomedicalhospital,theTibetAutonomousRegionPeople's
Hospital. The directorof the Mentsikhangwas also given a state-leveltitle and a
vice-director'spositionin the TAR Bureauof Health.Buildingwas begunin Lhasa
on additionaloutpatientfacilities, andplansfor an inpatienthospitalwereapproved
and funds were appropriatedby the regional government;this hospital was com-
pleted in 1985. The capitalconstructioncosts alone between 1980 and 1992 total
well over 12.5 million Yuan.10A medicine factory was built for the exclusive
productionof Tibetanmedicines, producing60,000 kilogramsof 300 varieties of
Tibetan medicines by 1992. Patient demand for Tibetan medicine soared, from
32,400 visits in 1980 to over 260,000 in 1990.
In 1985 the Mentsikhanghad achievedsufficientpolitical strengthto consoli-
date its position as the truecenter of professionalismin Tibetanmedicine.It was
moved from the prefecturalto the "state" level and became an independent
sub-bureauof the Health Bureau of the TAR. Medical courses established in
Shigatse,Tsethang,andChamdowere all discontinuedby 1988 in favorof a single,
centralizedinstitutegovernedby the Mentsikhang,which now controlsthe state's
trainingof Tibetanphysicians.''The graduationof large numbersof youngTibetan
physicians since 1984 has permittedthe Mentsikhangto send adequatenumbersof
Tibetanphysiciansto staff nearlyall countyhospitals and clinics in ethnicTibetan
regions of the TAR, Qinghai,Sichuan,and Yunnanprovinces.Today, in the TAR
alone, thereare about1,200 practitionersof Tibetanmedicine workingat all levels
of the governmenthealthcare system. At present,the Mentsikhangin Lhasahas a
staff of 400 (includingadministrativeand nursing staff) with an annualbudget in
1992 of 3 million Yuan for operations(about U.S.$600,000). Approximately60
studentsper yearareadmittedfor trainingat eitherthe middle school or university
levels; the currentstudentpopulationnow stands at 323. New buildingsto house
the Tibetanmedicalcollege and middle school were finished in 1989.
With this as a generalframeworkfor understandingthe contemporaryhistory
of Tibetanmedicine,I now turnto a more detailedanalysis of the particularsocial
andculturalrelationsthatled to the transformationof Tibetanmedicine,the impact
of these on the structureof Tibetanmedicine, and the strugglesnow being waged
within the institutionsof medicine, as well as in Tibetansociety, to resist or seize
control of the course these transformationsare taking. My purposehere is best
served by attending to the following questions: What macroforces propelled
Tibetanmedicine into its presentexpansionistmode? What are the consequences
of this expansionandits termsfor patientcare,the physician'srole, andthe cultural
contentof the medicineitself? Whatrole has Tibetanmedicinecome to play in the
moder Sino-Tibetanstate, both in tacit supportof this state and in constitutinga
forum for the expression of ethnic conflict and political dissent? These will be
addressedin turn.
TIBETANMEDICINE 23

Tibetan Medicine and Chinese State Interests

Interviewswith senior healthofficials, particularlythose who have been part


of the Mentsikhangleadershipsince the 1960s, suggest thatthe underlyingmoti-
vations for the statelegitimizationand expansionof Tibetanmedicine are overde-
termined.It is clearfrom a generalreadingof the literatureon minoritygroups in
Chinathatthe periodsof culturalandeconomic liberalizationcoincide with efforts
in minority regions to show respect for local customs, language, and regional
autonomy (Blum 1994; Dreyer 1976). By 1980 the Chinese government had
become fully awarethat its optimism over integratingTibetansociety into China
throughsocial andeconomic reformwas ill foundedandthatattemptsto do so had
resultedin widespreadeconomic hardshipas well as a significantdegree of anger
toward,and distrustof, the centralgovernmentin Beijing. Unwilling to relinquish
close administrativecontrolof Tibet, the Chinese,in orderto ease social unrestand
make governanceof this troubledregioneasier,adopteda plan that,in effect, made
Tibeta moretruly"autonomous"regionin social andculturaltermsandat the same
time increasedeconomic opportunityfor Tibetans.Tibetanmedicine was at this
time explicitly identified in one detailed reform plan authoredby the central
governmentas being "worthyof development."It seems clearby the timing of this
plan and the level of economic andpolitical supportthatit was immediatelygiven
that the Beijing governmentconsideredTibetanmedicine to be an important,and
possibly useful, symbol of this new policy.
Several scholarsof Chinese minoritypolicy have noted thatthe toleranceor
supportof non-Hanculturalinstitutionsmay in fact be partof a larger effort to
co-opt minorityleadershipandthe contentof whatcountsas minorityculture(Blum
1994;Dreyer1976).Whetherandto whatdegreeTibetanmedicinewas partof such
an overt strategy of co-optation is a complex question. Certainly, the central
government,which by 1980 realizedthatits policies had createdferventresistance
to Han Chinese rule and to the presence in Tibet of a growingpopulationof Han,
was compelledto permitTibetansa degree of freedomfor culturalexpressionthat
they had not previouslyenjoyed.Tibetanmedicinelikely representeda reasonably
safe and apoliticalforum for doing so. By centralizingtrainingactivities and by
incorporatingclinical facilities and physicians into the health bureaucracy,the
government was able to bring Tibetan medicine and such related elements as
religioushealingandastrologyundersome control.The transformations of practice
thataccompaniedthe 1980s expansionof Tibetanmedicine-in particular,making
it widely availablethroughoutthe health care system-certainly had appealfor a
governmentquitedesperateto win over the heartsandmindsof the Tibetanpeople.
Here was one way, among many, to be sure, that the Chinese leadershipcould
demonstratetheirrespectfor an importantelement of Tibetanculturewhile at the
same time showing theirbenevolenceby making such medicine widely available.
The glowing hyperbolein state publicationssuggest that, at a minimum,Tibetan
medicinehaspropagandavalue. Studentsof ethnicminoritypolicy in Chinasuggest
that state legitimationof minority traditionsmay advance Chinese culturaland
political hegemony by making Chinese control appearnaturaland inevitable (cf.
Blum 1994; Gramsci1971).
This view is overly simplistic. Primaryhealth care in Tibet, in comparison
with that in Chinaproper,was woefully underdevelopedin 1980. Even now there
24 MEDICALANTHROPOLOGY
QUARTERLY

areseriouslyunderservedareas.A rapiddeploymentof traditionalpractitionersmet


a clear need. The fact that such services were popularand could be providedby
Tibetans at low cost certainly made their provision an attractivealternativeto
deployingandequippinghigh-costbiomedicalfacilities throughoutthis geographi-
cally remote region. The Chinese could draw on their own experience with
successfully developing traditionalChinesemedicine in ruralregions in the 1950s
and 1960s to guide the way in this regard(Crozier 1968). It should also be noted
that the governmentconsidersTibetanmedicine to possess effective remediesfor
many conditionsthatafflict those in ruralareas.Of particularinterestto the health
bureau,which has become increasinglydominatedby Tibetans,are treatmentsfor
arthritis,gall bladderdisease, chronicgastritis,and diarrhealdiseases. Combined
with an aggressive immunizationcampaign,Tibetanmedicine is today seen offi-
cially, thoughwith some internaldissension,as an inexpensiveandmoreefficiently
deployable system of health care than more expensive, principallybiomedical,
alternatives.

Biomedical Authority, Clinical Practice, and the "Making Social of


Sickness"
When Tibetanmedicine was formallyresanctionedin 1980, it was elevated
to a state-levelpositionin thehealthbureaucracy,given a liberalbudgetfor building
and day-to-dayoperations,and permittedto redevelop its curriculumalong more
"traditional"lines. This was a heady time for those physicians who had suffered
greatly during the CulturalRevolution, and among those young students who
enteredthe new medical school, a spiritof ethnic revivalismwas clearly evident.
Severalyoung doctorstold me, usingnearlythe samelanguage,thatafter1980 they
were "trainedlike the monks used to be trained,read and memorized the root
tantras,and learned from teacherstrainedduring the old society." These newly
trained young men and women clearly felt a connection with their past and
expresseda confidencethatthe futureof Tibetanmedicinewas indeeda brightone.
Yet the legitimationandrapidexpansionof Tibetanmedicinein the 1980s brought
it firmly into the modem healthbureaucracyand,thus,madeit increasinglysubject
to the potent culturalforces for modernitythat are inherentin this bureaucracy.'2
Although young studentsmay have felt themselves "one"with the monks of the
old society, the educationalpaths that eventually broughtthem to the study of
Tibetanmedicine,theirexposureto Tibetanhistory,literature,andreligion,the way
in which they studied, the institutionsin which they would practice, and the
political, social, and symbolic relationshipof these institutionsto the institutions
of biomedicinedivergedsharplyfrom the situationpriorto 1959.
Tibetanmedicine is becomingfully modem in its social structureandcultural
content;that is, to paraphraseGiddens(1990), it is becoming disembeddedfrom
local contexts of practice and reconstitutedas part of a centralized system of
technicalaccomplishmentandprofessionalexpertise,which in turnis expectedto
conform to the pervasive and powerfulculturalstandardsof rationalscience and
biomedicine (cf. Leslie 1980). As has been documentedelsewhere in the anthro-
pological literature,when ethnomedicinesare sanctioned and supportedby the
state, the resultingpluralismis orchestratedby institutionsand structuresbuiltout
of the cultureof biomedicine and, therefore,entails a transformationof medical
TIBETANMEDICINE 25

care and trainingso that it is consistent with the epistemological, symbolic, and
sociologic attributesof biomedicine (e.g., Lock 1990). The modernizationof
ethnomedicinesin such a fashion is representedby shifts in epistemology and
practice that favor a standardizedand radically materialisticperspectiveon the
body, an objectificationand thus desocialization(decontextualization)of disease;
and transformationsin the social relationsof healing thatput emphasison profes-
sionalism, contributeto asymmetriesof power in healing encounters,and objec-
tify/reify the patient (e.g., Comaroff 1982; Lock 1990; Scheper-Hughes 1990;
Scheper-HughesandLock 1987; Taussig 1980). The social and culturalforces of
modernityareplayedout on a numberof levels in Tibetanmedicine;here,I identify
two dimensionsin which the potentialfor theoreticalandclinical transformationis
clear:the trainingof Tibetanphysicians,and the constraintsplaced on traditional-
ism by the organizationalcultureof the state healthbureaucracy.

Trainingin TibetanMedicine
The Mentsikhangbegan a vocationally oriented middle-school course in
Tibetan medicine in 1980. In 1985 it established a university-level curriculum
within Tibet Universityin Lhasa. Studentsin the middle-school course are those
who have completed the first portion of middle school and have adequatetest
scores, particularlyin Tibetanlanguage.Most are 16 to 17 years of age and have
had eight years of formaleducationwhen they enter trainingat the Mentsikhang.
Middle school-level studentsare recruitedby the health bureau,which funds the
trainingand sets quotas for the numberof studentsto be trainedeach year. The
bureauattemptsto maintainequalrepresentationof studentsfromthemajorregions
of Tibet,andnearlyall will be sentbackto the areasfromwhich they wererecruited.
University students are admitted to Tibet University on the same basis that
universitystudentsare selected all over China:by examination,declaredinterest,
andquotasset by the educationbureaufor particularsubjectsor programsof study.
Severalof the universitystudentswith whom I spoke indicatedto me thattheirfirst
declaredpreferencewas biomedicaltraining,but they were unableto gain admis-
sion to a medical school given their mediocre test scores and the substantial
competitionfor places in the medical schools, which are currentlyall in China.
Once based on a didacticmodel of apprenticeshiptraining,particularlyin the
context of learningdiagnosticand treatmentroutines,trainingin Tibetanmedicine
has been standardizedto conform to the model used for trainingbiomedicaland
traditionalChinesemedicalspecialistsin China.Severalyearsof classroom-based,
lecture-orientedtrainingare followed by an internshipexperience of one year,
duringwhich time a studentrarelyworksclosely with a seniorphysicianbutrotates
through various clinics and is supervised by a number of teachers. University
studentstakea five-yearcourseof studythatincludesone yearof practicaltraining.
In theirfour years in the classroom,studentsspend a total of 4,120 hoursexposed
to formal lecture-basedinstruction.A little over half of the hours (51%, or 2,212
hours) are devoted to specific trainingin Tibetanmedicine. Forty percent(1,656
hours) are devoted to political study, physical education,and language,including
English, Chinese, andTibetan.Just before they are sent for theirpracticaltraining
experience,primarilyin largeTibetanmedicaldepartmentsin countiesandprefec-
turesoutside Lhasa,studentstake a small numberof courses in biomedicaltopics:
26 MEDICAL ANTHROPOLOGY QUARTERLY

anatomy, diagnosis, and emergency medicine. Middle-school students follow


essentially the same course of study in Tibetanmedicine but take fewer hours of
language,politics, and biomedicine.The course of studyis four years, includinga
one-yearpracticum.
Threebasic changesto the contentandorganizationof the modem curriculum
are significant insofar as they constitute new ways of conceptualizingTibetan
medical theory, disease entities accordingto that theory, and the relationshipof
medicine to Buddhist ideology. First, and most basic, perhaps, is the fact that
Tibetan physicians must, by necessity, arrive at some satisfactory means for
explainingTibetanmedicaltheoryin the contextof the currentpluralismof healing
traditions.In effect, the value, authority,and role of Tibetan medicine require
reconsiderationin a context that includes powerful, competing alternatives.Al-
though most of the instructorsthemselves have little experience with or formal
trainingin biomedicine,they are awarethathumoraltheorydiffers and, therefore,
expend some effort at identifying,explaining, andoccasionallyresolvingwhat are
to them the most significantdifferences.The tendencyundersuch circumstances,
particularlyfor these studentswho come out of Chinesepublic educationand for
many who wished to study biomedicine in the first place and are thus highly
motivatedby the prospectsof "modem"science, is to reducesignificantelements
of Tibetanmedicine to biomedicine or to try to resolve the epistemological and
ontological differences that divide them, typically privileging biomedical dis-
courses on anatomy,physiology, and nosology. I was asked pointedlyby several
studentswhetherI "believed"in Tibetanmedicine and,further,whetherI thought
thatthehumorsreallyexisted.The studentsthemselvesexpressedgraveuncertainty
aboutthe "truth"of Tibetanmedical theory, save for one young man who simply
asserted that the existence of the most significant of the humors, rlung, was a
"matterof religiousbelief,"to which he stridentlyadhered.They thenofferedtheir
own explanations,which although idiosyncratictended to reconstitutehumoral
theory as a system of metaphorsfor biomedical systems or functions (the "real
truth").As the object of such biomedicalized discourse, the humors themselves
become abstractsymbols of physiological functioning,often couched in religious
terms,ratherthan an authoritativesystem for describingthe integrationof natural
andmentalphenomena.Humoraltheorycan no longerbe takenfor granted;it must
be constantlyand vigilantly evaluatedin relationto competingsystems of truth.
Second, the modem Tibetan medical curriculumnow rests on presenting
knowledge of the body in terms of specific categories of illness-categories
organizedas to spatial locus and general cause. The organizationalscheme that
producesthis curriculumis the same as that underlyingthe peculiarsociology of
the modem hospitaland, as such, derives its authoritynot as much from humoral
theory as from modem epidemiological and biomedicalunderstandings.Classes,
for example,aretaughton the following subjects:infectiousdiseases, women's and
children's diseases, internaldiseases, emergency medicine, surgery,methods of
diagnosis, and so on. There are no courses on the actions of specific humorsor
particularcausal classifications that are based exclusively on Tibetan medical
theory.Forexample,studentslearnabout"diseasesof the gall bladder"ratherthan
about"illnessesresultingfrom an imbalanceof bile."Flowing naturallyfrom this
kind of instructionis an inclination,revealed in postgraduationpractice, to ap-
TIBETANMEDICINE 27

proachmedicine as simply a cataloging system of discretediseases and attendant


treatmentsratherthan one of identifying disorderson the basis of individually
specific social, emotional, and environmentalcharacteristics,a practicethat is the
hallmarkof humoraltheory (e.g., Lock 1990:44). An interestingexample of this
can be found in the mannerby which new physicianspresentlythinkaboutand use
thenotionof character(ranggshis), whichatone time was fundamentalto diagnosis
andtreatment.Accordingto the root tantras,an individual'snaturalpredisposition
is towardone or anotherhumor (or combinationthereof),and this predisposition
(or slight, but "natural,"imbalance)explains one's body type, behavior,personal-
ity, and emotionality. One's characternot only predicts what particularkind of
disorderone is at high risk of developing but is criticalto prescriptionsof specific
medicinesandothertreatments(Parfionovitchet al. 1992). At present,studentsand
recent graduates,although they are conversantwith charactertheory and how it
affects or is involved in humoral imbalance,find it difficult to apply and even
irrelevantin clinical practice.Characteris notedon inpatientcharts,but it does not
appearto figure prominentlyin either diagnosis or treatment.The individualized
and subjective notion of characterruns counterto the ways in which studentsare
now taughtto think aboutbodies, diseases, and medicines (Hosseini 1994).
Third, students receive little exposure to formal Buddhist thought in their
educationalexperience.They are,of course,exposed to the religiousmessages that
are integralto the root tantras,for example, the relationshipof ego attachmentsto
humoralimbalance,but they leam little else. They are certainlynot permittedto
apply this knowledge in clinical contexts. Studentscannot be requiredto learn
religion in medical school, and teacherscan teach it, but only on their own time;
students attend voluntarily and after normal class hours only. This does not
necessarilymean thatall studentshave become highly secularin theirapproaches,
but ratherthat they now base their approachesto medicine and healing on what
appearedto me to be idiosyncratic understandingsof how various aspects of
Buddhismpertainto healing. Due to the incompleteknowledgeof Tibetanmedical
practice prior to 1951, we cannot conclude that the fundamentalsof Buddhist
medicinehave been transformed,only thatat presentthe absence of instructionin
Buddhist thought has contributedto a great deal of heterogeneity in how the
relationshipof mind to body-and of the mind to family, society, and state-is
conceptualizedand applied in healing contexts. This will be addressed further
below.

TheImpactof the RationalBureaucracy


The conceptualpressuresthat are being broughtto bear on modem Tibetan
medicine, insofaras they underliethe organizationof all health care in Tibet and
China, flow into and constitute the structuralprinciples that order the social
relations of modem Tibetan healing. These principles tend to reinforce, in a
dialectical way, the theoreticaltransformationsof Tibetan medicine by placing
constraintson the patient-healerrelationshipand requiringnew technologies of
recordkeepinganddiseasereportingthatease theadoptionof biomedicalnosology.
In consequence,the diseases themselvesareseen increasinglyas standard,concrete
categoriesto which can be affixed standardtreatments(medicines) regardlessof
individualvariability(cf. Lock 1990).
28 MEDICAL ANTHROPOLOGY QUARTERLY

The moder medical bureaucracyimposes social organizationalconstraints


on tendenciesto taketime withpatients,to treatthemas individuals,andto explore
with them the social, emotional,and environmentalcorrelatesof their suffering.
Indeed,physicians reportedthatthe averagelength of consultationswith patients
was about three minutes. Conversationbetween doctors and patients rarely in-
cludedmore thansuperficialinquiriesaboutsymptomsandoccasionaldiscussions
aboutdiet. Under such conditions,the medicines themselves loom as the primary
productsof the clinical experience.Van der Geest and Whyte's (1989) important
argumentregarding the "charmof medicines" and how the symbolic value of
medicines increaseswith the objectificationof disease is applicablehere.
The drive to modernizeTibetanmedicine and bringit underthe controlof the
statehas by no meansreachedcompletion.Struggleswage in the Mentsikhangover
its futurecourse. Many youngerphysiciansfavor continuingalong a modem path,
bringingscientific methodsto bearon Tibetanmedicine and adoptingbiomedical
categories,medicines, and technology. Othersare becoming increasinglycritical
of the path takenby the Mentsikhangin rationalizingTibetanmedicine and have
become vocal in criticizingits relationshipto the government.One young college
student who graduatedlast year provided in his final paper a ratherextensive
exegesis of "psychologicalmedicine"andlauncheda bitterlycriticalattackon the
"weakening"of Tibetan medicine in the 20th century as a consequence of its
submission to biomedicineand the state. (It should be noted that the notion of a
psychological medicine is itself an artifactof the particularkind of mind-body
dualism introducedby modernbiomedicine and, as such, is foreign to classical
Tibetanmedicine.) Althoughthe most criticalremarkswere edited out of the final
draftby the directorin orderto avoid a confrontationwith HealthBureauofficials,
it is clearfrom ourinterviewsthatthe criticismresonatednot only with the director
but with large numbersof Tibetanphysicians. The directorof the Mentsikhang,
trainedin the "old society" and being himself the last representativeof a well-
known medical lineage, confidedthathe felt "torninto a numberof pieces; pulled
in a numberof directions."He believes that to maintainits legitimacyat the level
of the state, the institutionmust respondaffirmativelyto pressuresfor rationaliza-
tion-in form if not in content-if Tibetanmedicine is to continueto develop. On
the otherhand,he recognizesclearlythe real possibility thatTibetanmedicinewill
become biomedically dominated,impersonal,and fully materialistin its perspec-
tive, and has tried to soften the effects of the policies promulgatedby the Health
Bureauto do just that.'3
Today,the focus of institutionalandpersonalresistanceto biomedicalauthor-
ity and Chinese hegemonylies in what the young studentabove notedas "psycho-
logical medicine."It is in this area-where Buddhistmedical theoryunderscores
the fundamentalintegrationof mind and body and, moreover,the causal priority
of mentalphenomena-that classicalTibetanmedicinediffersmost markedlyfrom
contemporaryChinese medicineand biomedicine.Most important,the conceptof
ego, centralto Buddhist thoughtand Tibetanmedicine, has been transformedin
practice. Now, ratherthan seeing the attachmentsof the ego as ultimately or
exclusively problematic,physicians increasingly socialize the ego and, conse-
quently,socialize sickness.This is not a new configurationof pathogenesisper se,
but rather, under present social and political conditions, the acts of treatment
TIBETAN MEDICINE 29

undertakenby physicians-most important,behavioral changes and rest-are


occurringin a contextin which they may be interpretedas possiblepoliticaldissent.
The energy that drives this sociocentric agenda in contemporaryTibetan
medicine appearsto rest with the demands of the Tibetan people, who, having
experienced enormous social changes and dislocations and having personally
encounteredvery painful events, have reconstructedtheir metamedicalcultural
frameworksto include the pain, frustration,and sadness of social change as an
explanationfor this-worldlysuffering. With the demise of the great monasteries
and suppressionof religious and shamanichealing rites, Tibetanslost a significant
and symbolically salientportion of theirmedical system. It was in these contexts
thatmuch sufferingof a personaland social naturewas expressed,legitimized,and
contained(see, for example, descriptionsof medical pluralismin Sherpacommu-
nities by Adams 1988, 1992; see also Ortner1978). From the perspectiveof the
laity, the old pluralsystem of healing has collapsed into the institutionof profes-
sionalTibetanmedicine.Theexplosion of demandfor Tibetanmedicinethroughout
Tibet as it was legitimizedand expandedin the 1980s may have been drivenby its
value as a contextfor expressing these uniquelyTibetan"idiomsof distress,"that
is, wherethe physicalbody is used metaphoricallyto describepersonal,social, and
emotionalconflict (Lock 1989; Lock and Scheper-Hughes1990; Nichter 1981).
This is most evidentin the contextof rlung,or wind disorders.These illnesses,
given the generictermof rlung nad by physicians, arehighly elaboratedin the lay
or popularsectoras a consequenceof strongemotion thatin turnis typicallylinked
to social events. Although conceptualizationsof rlung disordersrequire more
extensive analysisthanis possible within the confines of this article,to appreciate
its potentialas a focus of resistanceit is helpful to review brieflythe contemporary
treatmentand perceptionsof rlung disordersby Tibetanphysicians.

"TheCorruptionsof Desire"-Wind Imbalancesand the Embodimentof Social


Conflict

According to classical Tibetan medical theory, the humor wind (rlung) is


consideredthe most importantof the threehumors;it animates,gives rise to action,
and bringslife to physical matter.Glossed simply, rlung might be defined as "life
force." It representsthe bridging of the multiple bodies recognized by Tibetans,
most significantly,the grossly materialbody of touch and sense and the inner or
"mental"bodiesof the sentientmindor consciousness (one componentof this body
is termed rlung, or "vibratorypower") (Adams 1992). The discrete symptom
clustersof rlungimbalancearerelatedto the spatialorientationof rlungin the body.
Symptomsthatderivefromdisordersof rlungin the brain,heart,andchest aremost
frequentlyexperienced.In the brain, rlung may disruptthe "life vein," causing
disorderedthinking,depression, and insanity. In less severe forms, rlung causes
dizziness, insomnia,dysphoria,fainting,ringing in the ears, and impairedsensory
perception.In the heart,rlungcontributesto palpations,"heartswings,"anda rapid,
fluttering heart beat. In the chest area, rlung causes shortness of breath and
symptoms of pain in the sternum that often goes through to the upper spine
(especially significantis pain between the sixth and seventh cervical vertebrae).
The most commonly diagnosed rlung imbalances are those that affect the heart
30 MEDICAL ANTHROPOLOGY QUARTERLY

(snying rlung), the circulationof blood (high, low, or "variable"blood pressure;


khrag rlung), and the life "vein"or nerve (srog rlung).
In Buddhist medical theory, rlung imbalance is linked most closely to the
mental poison of desire ('dod chags). When asked to discuss the relationshipof
desire to wind imbalance,the physicians I interviewedtended to provide opera-
tionaldefinitionsthathighlightedthe disjuncturebetweensocially legitimatehopes
and actualities.For example, one physiciandescribedhow desire manifests itself
amongaveragepeople andhow it may lead to an imbalanceof rlung:"Peoplewant
to have good living conditions,enoughfood, obedientchildren,peace in the family,
and so on. However, when they do not have these things thatthey desire, it leads
to mental agitations, and these in turn cause rlung imbalance."The linking of
"desirefor a betterlife" for oneself andothersto rlung imbalancelies at the root of
the contemporaryprofessionalmodelof rlung,andit is in thisbasiccausalstatement
thatmuch of a social, familial, andpolitical natureis incorporated.
Physicians tell us that the prevalence of rlung, though always high, has
increasedwith "moder social changes,"particularlyduringthe CulturalRevolu-
tion. My observations confirmed that rlung disorders are indeed common. In
observationsof 718 clinical exchangesconductedin 1991 and 1993, some form of
rlung imbalance was the most commonly given diagnosis (18.2%), followed
closely by the generalcategoriesof stomachailmentsand "infection"(17% each).
The proportionof rlung patientsseen is relatively consistent from one outpatient
context to the next, with higher proportionsof rlung found in urbanareas and
inpatienthospital settings. In 1993 we conducted two separatecensuses of the
Tibetan inpatienthospitals in Lhasa and Tsethang. Of all patients admitted,22
percenthad some form of rlungdiagnosis.The averagestay for all patientstreated
at the Mentsikhanginpatienthospitalis threemonths;our data showed thatrlung
patients stay approximatelytwo weeks longer than this. The higher numbersof
hospitalizedrlungpatientsand the longer averagestays of such patientsis consis-
tent with physicians' beliefs aboutthe seriousnessof rlung. Physicians generally
believe that patients who have a serious imbalance of rlung require long-term
hospital treatment.They gave two reasons for this: rlung is consideredthe most
importantof the humorsand, when imbalanced,poses a serious dangerto the rest
of the system;perhapseven moreimportant,physiciansbelieve thatbecauserlung
imbalancesare subjectto a host of social agents,hospitalizationprovidesa way to
protectpatients from these and release them, for months at a time, from normal
employmentand social obligations. We found in talking with both patients and
physiciansthathospitalizationis actively used as a legally sanctionedmethodfor
removingthe patientfrom difficult circumstancesof whateverorigin.'4
It might be arguedthat the medicalizationof rlung imbalancein the context
of the statehealthapparatusin fact desocializes it or defuses the potentialfor social
protestthatinheresin rlungnarratives.The tendencyfor physiciansto refrainfrom
overt discussion of social explanationsin clinical settings might be interpretedin
such a light. Indeed, physicians' approachesto and attitudesabout the political
salienceof rlungdiagnosesarequiteheterogeneous.A few adhere,atleast publicly,
to a model of rlungcausalitythatemphasizesindividualresponsibilityfor "closed
mindedness"or "failureto managethe mindproperly."In my systematicinterview-
ing of doctors regardingrlung in general and in discussing particularcases with
TIBETANMEDICINE 31

them, however, the majorityrecognizeclearly the sociopolitical salience of rlung


but avoid explicit political discussions that might put them or their patients in
danger.Forexample,nothingis evernotedon patientchartsaboutthe social context
of the sickness, but nearlyall the physicianswe talkedto aboutparticularpatients
were quite able to offer informal,andsomewhatdetailed,explanationsfor rlungin
which social or politicalevents figuredprominently.Physiciansalso recognizethat
explicitly legitimizing sociocentric models of rlung will have little effect on the
circumstancesof theirpatients'lives. They exercise whatpowersof resistancethey
possess by wielding their authorityto protectpatientsby releasing them from the
situationsthat arecausing them the greatestpersonaldistress.
Physicians,furthermore,are not blind to the statementsof dissent and disaf-
fection inherentin a rlung diagnosis. One middle-agedphysician who began his
trainingafterthe Chinese takeover,aftera long and detailedexposition of Tibetan
medical theoryregardingrlung and its causes, paused and noted, in response to a
questionconcerningthe modem prevalenceof rlung disorder,
Ofcourse,rlungmustbemorecommonnowadaysbecauseTibetis no longerfree.
The Chinesegovernmentis the government of rlung.The Chinesegovernment
makespeopleunhappy,andso rlungmustbe morecommon.... Tibetanshave
rlungbecausetheyarenotfree.

Summary and Conclusions


At the beginning of the 20th century,the Tibetan medical system could be
accuratelydescribed as a pluralisticstructureof ritual and healing practicesthat
addressednature,supernature,mind, and body along different symbolic dimen-
sions. Monks and lamas provided divinatory services to identify the sources,
demonic and otherwise, of harm and directed their clients to undertakevarious
rituals, merit-earningbehaviors, and proper thought, take medicines, and also
consult scholarphysicians and itinerantherbalists.They highlightedfor Tibetans
the natureof the Buddhist universe,populatedby demons and deities but, ulti-
mately,underthe controlof, most practically,the local lama and,morephilosophi-
cally, the sentientmind properlyequippedwith Buddhisttechniquesof self-disci-
pline. Shamanism,probablydisappearingfrom all but the frontiersand fringes of
Tibetansociety, invokedsupernaturalaid structuredby the sociocentricideologies
of an older, pre-Buddhistera and emphasizedreciprocalrelationshipswith local
demons and deities insteadof the relationsof dominancethatconstituteBuddhist
ritualstructure.At the apex of this pluralisticsystem stood the scholar-physician,
either a secular,privatelytrainedpersonageor a monk whose trainingwas rooted
in monasticdiscipline. Irrespectiveof trainingexperience, these physicians acted
in healing contexts structuredby the notion that the ailing, physical body was a
materialentity,closely linked with the naturalisticuniverseand its vicissitudesbut
responsive to the discipline of the sentientmind or corruptibleby the emotional
poisons caused by ego attachmentsto the phenomenalworld.
The early 20th century saw the movement of this scholarly traditionin the
directionof the secularandmodem. Physiciansbeganto providepublic healthand
maternal-childhealth care services; students were recruitedfrom a number of
sectors of Tibetan society; and this new kind of Tibetan medical institutionwas
brought formally into the secular bureaucracyof the Tibetan state. When the
32 MEDICAL ANTHROPOLOGY QUARTERLY

Chinesetook controlof the governmentof Tibet andsoughtto rootout anddestroy


the vestiges of the old feudal order,this relativelynew secularinstitutionemerged
as a legitimizedtraditionwithin the Chinese state but was held firmly in the sway
of its revolutionaryandmoder agenda.Althoughgrowthwas fitful,punctuatedas
it was by the radical paroxysms of modem Chinese political history, Tibetan
medicine was propelled into the highly rationalized health care bureaucracy,
leadingto therapiddeploymentof Tibetanphysiciansthroughouttheethnicregions
of Tibet. Guidedby the basic tenetsof socialist ideology, Tibetanmedicinemoved
rapidly from an institutionclosely linked with the old feudal elite to a widely
available health care resource. By 1985 Tibetan medicine had developed to the
point thatit was possible for the head of the Mentsikhangto note thatit had more
practitioners,more patients,producedmore medicines, and was markedlymore
accessible to the widely dispersedTibetanpopulationthan at any time in its long
history.
Yet the termsof its legitimationand expansion were as much rooted in the
interestsof the Chinese state to consolidate its control of the Tibetanpopulace as
in the service of the moral socialist agendato serve the common good. Not only
was it a useful symbol to Tibetansof Han Chinese intentionsto respectelements
of Tibetanculture,it had the potentialof being a constructiveemblemof cultural
tolerance to a world community that is becoming increasinglyvocal regarding
human rights in Tibet. The Chinese also used their legitimizingposition, under-
scored by socialist rhetoric,to transformtheory and practicein Tibetanmedicine
to bringit into conformitywith the interestsof the stateandmodemscience.Tibetan
medicine was reconstructedto be consistentwith the revolutionaryperspectiveon
health and health care:materialistconceptionsof the body were emphasizedand
elaboratedwhile the Buddhist substratewas suppressed.Efforts to objectify the
body and its partsfurtherso that Tibetan medicine could be enrichedthrougha
dialecticalencounterwith biomedicinewere begun. These efforts,combinedwith
the social organizationalconstraintsposed by the rationalbureaucracy,brought
Tibetanmedicineby the beginningof the 1990s to the verge of becominga shallow
herbalism,a state,as one older physician said with greatsadness,"no betterthan
traditionalChinesemedicine."
However pervasive the changes introducedby the Chinese state appear,it
would be inappropriateto suggest that they strictly determineTibetan medical
practice at all levels of the institution.It may be appropriatehere to employ the
metaphorof the "dialecticin the doublesense"appliedby Comaroffto thehistorical
analysis of Tshidi ritual:on one level there is the "interplayof socioculturalorder
and humanpractice;on the other, the historicalarticulationof systems dominant
and subordinate"(1985:252). Tibetanmedicine,once well integratedinto both the
secularandreligiousinstitutionsof the feudal state,was propelledin the early20th
century toward institutionalmodernityby colonial conflicts and the 13th Dalai
Lama's efforts to centralize his political control over what had been a highly
decentralizedsocial system. The resulting secularinstitutionof Tibetanmedicine
became the object of Chinese revolutionarydiscourses concerning,on one hand,
the provision of health services and, on the other, the appropriateconstructionof
the body. The conjunctureof Tibetanmedicine and the Chinese state became one
of mutualdependence,but a dependencein which the Chinese held the dominant
TIBETANMEDICINE 33

position. To some, though perhaps arguable,extent, the Chinese used Tibetan


medicine as partof its strategiesof ethnic co-optation.Tibetanmedicine was able
to some extent, however, although with limited power given its subordinationto
the interestsof the state, to seize upon this strategicposition to resist total social
and culturaltransformationinto a biomedicalizedsystem of healing.
On the other side of this "doubledialectic,"the Tibetanlaity has come, with
thedemise or attenuationof the nonscholarlyhealingsectors,to appropriateTibetan
medicine andconstituteit as an arenafor expressingthe sufferingthatcomes from
their experiencesin a rapidlychanging and highly polarizedethnic, political, and
economic context.These demandsplace Tibetanphysiciansin a peculiarinterven-
ing relationshipbetweentheirpatientsandthedominantbureaucraticapparatusthat
controlsthem.They have respondedby increasingtheirtacitrecognitionof social-
emotionalconstructsof illness, engaging with theirpatientsin a covert strategyof
legitimizing social distress and political dissent. Although it cannot be assumed
thatbasic theoriesof pathogenesishave been radicallytransformed,currentsocial
andpoliticalconditions,coupled with constraintson trainingandpractice,produce
a healing context in which both doctorand patientmay bringan enlargedperspec-
tive to sickness that implicates the state as a potentialcausal agent and brings a
new, potentiallypolitical meaning to the prescribedtreatment.It is now possible
for physicians and patientsalike to construethe social and political conditions of
modem life as the primarycausal elements in the corruptionsof desire.

NOTES

Acknowledgments.The researchupon which this articleis based was fundedin partby


a grant from the National Science Foundation, BNS-9005811, and Faculty Grant and
Fellowshipawardsfromthe Universityof Colorado-Denver.My colleague Loma G. Moore
was instrumentalin providingboth the encouragementandfinancialsupportrequiredto set
this projectup, given the complex politicalconditionsin Tibet.I acknowledgethe following
grants to Professor Moore: USARMDC 17-87-C-7202, NIH-HLBI 14895, and NSF
8919645. I wish to thank Vincanne Adams, Kitty K. Corbett, and the two anonymous
reviewers for their constructivecomments on earlierdraftsof this article. Last, but by no
meansleast, I acknowledgethe valuableassistanceof my studentsCherylReighter,Nawang
Sherap,and MahmoudHosseini in collecting the data upon which this articleis based.
Correspondencemay be addressedto the authorat the Departmentof Anthropology,
Universityof Colorado,P.O. Box 173364, Denver, CO 80217-3364.
1. Comparedwith other Asian medical systems, relativelyfew works on the history,
theory,and practiceof Tibetanmedicine are availablein English. Most notableare Clifford
1984, Finckh 1978, Parfionovitchet al. 1992, and Rechung 1973. In addition,the Tibetan
Medical Centrein Dharamsala,India, currentlypublishesa periodicalas well as a number
of topical publicationson various,primarilytheoretical,aspects of Tibetanmedicine. For a
good, generalintroduction,the readeris referredto Tsaronget al. 1981.
2. The history of Tibetanmedicine has been subjectto considerablerevision to serve
the changingculturalandpolitical agendasof the present.Some of the writingscoming out
of Tibetancommunitiesin Indiaand Nepal emphasize,perhapsin deferenceto the nation-
statesthathave grantedthem asylum,the Ayurvedicoriginsof Tibetanmedicine(especially
Clifford 1984; Rechung 1973; Tsaronget al. 1981). I have heardTibetansfrom India refer
to Tibetanmedicine as Ayurveda or, occasionally, Tibetan Ayurvedic medicine. Several
Europeanand American scholars, however, have emphasized that Tibetan medicine is
syncreticwith Ayurveda,Galenic-Persianmedicine,or Chinese medicine (Beckwith 1979;
34 MEDICALANTHROPOLOGY
QUARTERLY

Finckh 1978; Snellgrove and Richardson1968; Stein 1972; Tucci 1967). Today in Lhasa
the scholarsof Tibetanmedicineemphasizeits uniquehistoricaloriginsandhave suggested
that the core of Tibetan medical practice, in particularits materiamedica, stems from
pre-Buddhistsources. This is part of a larger and currentlycontroversialeffort to resist
Chinese attemptsto appropriateTibetan medicine as a "variant"of Chinese traditional
medicine.
3. Tibetansfrom "unclean"groups(blacksmiths,for example, who make implements
for killing andbutchering)were consideredunfit for medicalpractice.
4. Trainingin astrologygenerallyinvolved techniquesfor constructingand interpret-
ing calendarsin orderto determinethe most auspiciousdays for variousactivities,including
such things as death rituals, marriages,house building, and medical treatment.A very
complex system of thoughtand practice,it has traditionallybeen associatedwith Tibetan
medicine. To this day, though viewed with some skepticismby the government,astrology
is considered a "department"of Tibetan medicine. The well-known physician Khenrab
Norbu considered it helpful to have studentslearn astrology before medicine because it
"improvedthe memory."Astrology is a certainmoneymaker,especially in ruralareas,and
it is, and was, considereda lucrativesideline to medicine.
5. Land reforms along the eastern borders of Tibet coupled with a few bloody
confrontationsbetween the Chinese armyandTibetanBuddhistmonks in wester Sichuan
broughtan influx of disgruntledrefugees into Lhasabeginning in the mid-1950s. Reports
of Chinese excesses, combined with a growingunease on the partof the ecclesiasticalelite
that such reforms would soon be broughtto centralTibet, were the likely causes of this
rebellion(Burman1979; Goldstein 1991; Mullin andWangyal 1983).
6. For a more extensive discussion of Chinese minoritypolicy in general, and the
implementationof this policy in Tibet in particular,the reader is urged to consult the
following: Blum 1992, 1994; Dreyer 1976; Goldstein 1991; Heberer1989; and Mullin and
Wangyal 1983.
7. In Tibet today there are four traininglevels for physicians.The first is that of the
village doctor, trainedby county-level physicians for a very short period, averaging one
month. The second is the junior-level doctor,typically given about six months of training
by one of the prefecture-levelhealth bureaus.The thirdis the midlevel doctor, trainedfor
aboutthreeyears in China, with an additionalyear or two of practical,supervisedtraining.
The fourth,the fully qualifiedphysician,is trainedin Chinain one of the majoruniversities.
When trainingin Tibetanmedicine was first sanctionedby the Chinese government,it was
recognized that with the absence of a universityprogramin Tibet, the midlevel physician
trainingprogramsin Chinawere to be used as a model for trainingin Tibetanmedicine.The
universityprogramwas begun in 1993.
8. Tibetanphysiciansare assignedto four ranks,rangingfrom "qualifieddoctor,"the
lowest rank,to "professor,"the highest. Althoughthereis some notion thatrankis assigned
accordingto skill, and one can move up quickly with additionaltrainingor demonstrating
expertise in various aspects of Tibetanmedicine, most physicians move automaticallyup
the ranksystem with years of service or seniority.Rankis thus only loosely correlatedwith
skill.
9. There are six prefecturesin Tibet; the towns named here are centers of the more
populous.The remainingtwo prefecturesare in the east-centralregion (Khongpo) and the
far west (Ngari).
10. About U.S.$3.5 million, given exchange rates at the time various facilities were
built.
11. The Swiss Red Cross has recently established two additionalTibetan medicine
trainingcenters.Both areintendedto traindoctorsfor remoteregionsof Tibet.These doctors
will not be in the employ of the government,but ratherwill be expected to enter private
practice.
TIBETANMEDICINE 35

12. We must also keep in mindhere the degree to which the institutionsof the Chinese
socialist state, in particularthose relatedto health care and the redistributionof economic
resources,constitutemeans of control over the population(cf. Yang 1989). For example,
who gets free health care, who must pay out-of-pocket, and who may be reimbursedfor
expenses are criticaldecisions made by the work unit, social welfare offices, and so forth,
and, in turn, depend on the adherenceof the individual to various normalizing criteria:
numberof childrenin thefamily;class background;presentclass status;andso forth.Further,
within the Mentsikhang,itself a fairly large work unit, housing, rationsof grain, oil, and
kerosene are all dependenton a variety of social, political, and moral criteria.So when I
referhere to the HealthBureauandthe state,it mustbe rememberedthatin manyways these
are"totalinstitutions,"which arepowerfullydeterminantof individualbehaviorandpossess
ampletechniquesfor discipliningtheirminionsandassuringadherenceto a state-determined
moral standard.The power of the bureaucracyover Tibetanmedicine thus flows from its
abilityto structuresocial relations,disciplineworkers,assureconformityto partyandbureau
regulationsandpolitical-moralstandards,and,in fact, controlaccess to services on the part
of the population.
13. In early 1993, partlybecause of his adherenceto traditionalismand vocal opposi-
tion of policies intendedto modernizeTibetanmedicine, andpartlybecause of his powerful
political position in the Tibetanand Chinese governments,which was seen as a threatto
what is becomingan increasinglyassimilationistethics policy, this individualwas removed
from his position. He has been replacedby cadrewhose views are more in line with those
of the centralgovernmentin this regard.
14. In two interviewstudies,the firstconductedin late 1991, the second in early 1993,
we examinedhow rlung was conceptualizedamong 42 rlung patients(Janesand Reighter
1993). These patients,when comparedwith the general populationof clients we observed
or interviewed,were more likely to be employed andbe employed in clericalor government
settings(40.3%).Only 9.5 percentworkedin the agriculturalorpastoralsectors.Conversely,
the generalpopulationof patientswe saw were more likely to be unemployed(23.6%) or,
if employed, to be peasantfarmersor herders(34.3%).
The characteristicsof the patientsandthepathogenesisof theirsicknessaresummarized
briefly here.The individualswe interviewedwere primarilyurbandwellers, relativelywell
educated, and working in the governmentsector in clerical and administrativepositions.
Several were in the army or were police officers. All had firsthand,and in some cases
extensive, contact with Han Chinese in their day-to-day lives-as coworkers as well as
supervisors.The predominanttheme that patientsexpressed in these contexts was one of
overwhelmingimmobility.They felt stuckin untenablepositions andbelieved they hadfew
recoursesopen to themthatwould permitthemto changeor significantlyalterthe social and
economic conditions in which theirlives were perceived to be mired.Several cited racism
or politicalfactorsspecific to theirlife situationsas the reasonsfor theirimmobility.Unfair
treatmentson the job or job dissatisfactionwere also cited as causing or exacerbating
symptoms.

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