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ARTICLES
CRAIGR. JANES
Departmentof Anthropology
Universityof Coloradoat Denver
6
TIBETANMEDICINE 7
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
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.
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
NOTES
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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