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xt of Emerging Pathogens in China: The SARS Crisis and China's Health Care India's Foreign Policy Towards China: The NDA Experience Dominant Issues in Sino-Indian Relation Gender, Medicine, and Modernity: Childbirth in Tibet Today China's Control of Reproductive Choice Posted on January 28, 2006 by the Editor Jennifer Marie Chertow is a Ph.D. Candidate in the Department of Cultural and Social Anthropology at Stanford University. Chertow recently completed two years of dissertation fieldwork on childbirth practices in rural and urban Tibet, where she also researched state and non-state HIV/STI prevention for Han and Tibetan sex-worker populations in Lhasa. She returns to Stanford this year to complete her dissertation. Since Deng Xiaopeng opened Tibet to mainland China and the international community in the early 1980s, the press toward modernization in Tibet has been rapid. 1 Beijing has vigorously pursued a program of development and economic growth in its Western regions and tolerated an increasing number of international development schemes in the Tibetan Autonomous Region (TAR). Subject to these various modes of modernization, Tibetans consume, practice, and propagate both Chinese and Western forms of modernity. 2 At the same time, however, Tibetans are forging what might be called a distinct version of Tibetan modernity. 3 Moving between city life and rural landscapes; adopting new farming technologies while persisting in age-old methods of toiling the land; taking on Hong Kong-influenced styles of dress while continuing to wear sheepskin-lined woolen chubas ; and utilizing IV drips in conjunction with rilbu or Tibetan medicinal pills; Tibetans creatively and strategically adopt new standards of living. 4 In the TAR, formations of modernity reflect these uneven and fragmentary changes. Tibetans synthesize contradictory impulses to honor longstanding values and incorporate potentially advantageous innovations. Political, historical, and economic factors shape the contours of Tibets emergent modernity. For example, historical debates over the autonomy of Tibet influence Tibetans perception of Chinese resident populations as well as their relationship with the government of the Peoples Republic of China (PRC). On an economic and political level, government health bureaucracies control the packaging, marketing, educational institutions, and treatment centers for Tibetan medicine. In addition, multimillion-dollar international development agencies introduce new medical technologies such as ultrasound and fetal heart monitors into womens healthcare, while government-run population control measures influence Tibetan cultural-religious perceptions of reproduction and childbirth. In Tibetans eyes, incursions of top-down development projects, either governmental or non-governmental, often seem arbitrary, overwhelming, and beyond local villagers or city-dwellers control. Tibetans navigation of rapid and uneven changes serves as a marker of what might be called Tibetan modernity. 5 This modernity is mediated through Tibetan conceptual categories, values, and beliefs, even as the categories themselves shift and change. Tibetan pragmatism,

Buddhist values, shamanistic practices, and historical modes of legitimization of authority in Tibet strongly influence Tibetan understandings of their circumstances. 6 At the same time, modernization projects stemming from Beijing and the international community frequently ignore these understandings. The resulting present-day condition is the co-existence of multiple systems of authority, dominant and sub-dominant ideologies, and a myriad of institutional and noninstitutional structures. 7 Here, I will focus on the impact of these forces on womens health concerns, in particular those related to childbirth, and correspondingly ask what issues emerge for Tibetans in the context of childbirth today. As a primary domain of inquiry, childbirth practices offer a good way to map out a modernity that is neither Western nor Chinese, but distinctly Tibetan in its contours. Between Town and Country Within competing ideologies and practices, Tibetan women must strategically negotiate the terms of modernity in the uncertain terrain of government and non-government initiatives. Governmentsponsored construction projects often begin and never finish; roads are paved, then dynamited to accommodate new road projects; medical clinics are established, minimally utilized, and fall into disrepair. Furthermore, development projects often occur with little or no consultation among the populations they directly affect, regardless of whether the PRC government officials are ethnically Chinese or Tibetan. With relatively minimal consultation or forewarning about these projects, Tibetans must be creative and strategic about what they choose to incorporate, how they protect beliefs and practices they wish to maintain, and the manner in which they interpret, resist, or adapt to new life circumstances. Tibetan womens childbirth experiences reflect these concerns as women adjust to and reject different institutions, medicines, and epistemologies that comprise the shifting landscape of modernity. 8 Since the early 1990s, the door has opened for international non-governmental institutions (INGOs) to establish footholds in Tibet. 9 From this time onward, organizations have come and gone depending on government permission and local politics. Project agendas shift, personnel leave, and local staff are employed, trained, and then disbanded depending on organizational resources. Moreover, health projects for women and children are often attempted, not well conceived, perceived to be infeasible for monetary, environmental, or political reasons, and abandoned to other projects. 10 An overall sense of the tenuousness of the situation fed by fear and paranoia depending on shifts in leadership in Beijing and the Tibetan Autonomous Region (TAR) all factor into creating an unstable atmosphere for non-governmental agencies. The shifting and uneven contours of various projects of modernity, both governmental and nongovernmental, directly impact childbirth practices in Tibet. Despite Beijings goals to develop its Western regions and to dissolve certain traditions tied to historical modes of subsistence, village level medical practices are still central in childbirth today. Medicine, as historically understood in Tibet, consists of lay and non-literate, as well as institutional and highly literate, medical practices. These practices stem from pervasive and longstanding use of healing methods embedded in Tibetan medical understandings of the body, such as the bodys three humors and the proper balancing of these humors within the body. 11 Dating back to the eighth century, the literate Tibetan medical tradition includes practices such as pulse diagnosis, urine analysis, visual assessment, and palpation methods to determine the nature of disease. Practitioners trained in this tradition are referred to as amchis , and their methods of treatment include herbal, dietary, behavioral, and topical treatments such as moxibustion. Outside of medical practices by amchis , Tibetan healing practices include herbal remedies, folk knowledge, and regional understandings of the sacred landscape. Important and valued players in womens childbirth experiences, village healers can be barefoot doctors, spirit mediums, or lamas. At the village level, mothers and sisters also act as unofficial midwives for in-home birthing practices. In the context of village medical practices, Tibetan womens encounters with government hospitals and international non-governmental health projects contribute to the making of a new

Tibetan modernity. When women bleed onto concrete hospital floors that repel rather than absorb blood associated with drib , a Tibetan concept of pollution, they already enter a different modality for navigating old beliefs in new contexts. 12 In Tibetan households, dirt floors absorb the blood from childbirth, though recently pl astic tarps are sometimes laid down. The mingling of earth with childbirth blood create a powerful need to clear that space of spiritual pollution. What does it mean for a Tibetan woman to be able to wash away pollution rather than spiritually purify it? Shaped by forces past and present, women distrust certain government and non-government initiatives while adopting others. Likewise, women discard traditional practices that no longer seem relevant while maintaining those that appear beneficial. Tradition Meets Modernity Several issues emerge within the broad rubrics of tradition and modernity in the domain of childbirth and womens health within Tibet. On the one hand, Tibetans persist in village-based practices around childbirth. These include giving birth in the home with female relatives, taking herbal or dietary-based remedies for excessive cramping, circumambulating temples and walking over bridges in order to speed delivery. In addition, they engage in a variety of other practices that might be marked as traditional including the application of warm butter to the temples, fontanel, palms, and feet of a woman in labor. On the other hand, Tibetan women routinely encounter practices of the state and science, including reproductive counseling, contraceptive interventions, c-sections, and tubal ligations in city hospitals. They also accommodate the administration of pain medications via intravenous drips during labor in hospital settings. What makes this integration of old and new practices distinctly Tibetan are the ways Tibetan women position themselves vis--vis these practices. Tibetan notions of pragmatism as well as Tibetans commitment to their own ways of living despite communist Chinas best efforts to eradicate religion in previous decades and control its practice today give rise to a strategic admixture of tradition and modernity. The story of Drolma, a farmer from a village in Shigatse, represents one womans encounter with the shifting landscape of modernity. Tilling the land two seasons of the year in spring and fall, Drolma weaves wool and tends to domestic animals during the winter and summer months. In addition, she manages a household of twelve, who comprise her extended family. 13 At the age of 36, Drolma has had two miscarriages and five healthy children. Due to complications with her fourth and fifth child, she decided to deliver these children in the county hospital. While not her first choice, Drolma chose to go to the county hospital to deliver her fourth child due to the prolonged duration of her labor and the fact that she had been in pain for half a month prior to delivery. Though Drolma indicated that the hospital failed to make her experience of childbirth faster or more comfortable, she nonetheless valued its benefits which she believes led to the survival of her last two children. These benefits include biomedical expertise, technology, and trained personnel, all of which Tibetans are taught to understand as advancements in healthcare. Drolmas choice to give birth to her last two children in the hospital was not easy. Indeed, her initial decision to go to the hospital was made under duress, fearing the loss of her fourth child. 14 Factors that might be glossed as cultural likely influenced Drolmas decision to remain at home for her first three births. Tibetans perceive birthing as a family affair rather than a medical condition. Due to disease and concern over the disposal of bodily waste products, Tibetans perceive hospitals themselves as polluted places. Because rules for government-run hospitals do not permit religious activity on the premises, including purification rituals performed by lamas, these areas cannot be spiritually cleansed. In addition, women do not want to come in contact with strangers for fear that these strangers will bring harm or bad luck to the mother and child. 15 Chance meetings with acquaintances lead to village gossip, which women consider a source of harm. 16 Secrecy and privacy are important during pregnancy and delivery, though sometimes to ill effect if complications arise during these times. After a miscarriage or the death of an infant, women typically visit lamas and spirit mediums to ease pain and to obtain astrological advice ( tsi ) to prevent future miscarriages or deaths. Thus, village-level practices, spiritual figures, and

long-standing beliefs figure centrally into how Tibetan women understand their birthing experiences and thus, how they encounter government medicine. These beliefs influence womens preference to deliver their children at home. Structural Factors Shaping Choice Other factors affecting womens preference for home birth may be termed structural, including occupation, wealth, village politics, and education. In terms of occupation, women from nomadic families cannot readily access clinics because they graze their animals in mountainous areas away from roads and administrative centers. During winter months, these families avoid travel due to cold weather and snow. For farmers, variable degrees of wealth decrease the likelihood that poorer families will use government facilities that require up-front cash. Likewise, local politics within a village might affect usage of clinics and hospitals. For example, unless the wife of the village leader has used such a facility, other village women might avoid using these facilities because doing so might create problems for them at the village level. Finally, educated villagers tend to know more about external institutions and the purposes they serve. As a result, they may be more or less inclined to use these government medical facilities depending on the quality of the medical system outside of the village. Proximity to government health outlets has a direct influence on Tibetans incorporation into Beijings project of modernity. Villagers living closer to county seats tend to use clinics more frequently than villagers living in remote areas. In these administrative centers, there tend to be government schools where Chinese language, Chinese history, math, science, and politics are taught, thereby leading to quicker integration of Tibetan youth into nationalization and modernization efforts. Often, impediments in infrastructure have a decisive impact on womens choice to have a home birth. Yangkyi, a villager from a county just outside of Lhasa, described how she had given birth to her first child at the county hospital and her second child in the home. After her first experience of childbirth, she explained that the return ride home from the hospital on very bad roads in an exposed tractor bed was more painful and induced more bleeding than the birth itself. In addition, the doctors in the hospital scolded her for moving during the delivery. For these reasons, she decided to give birth to her second child at her village home, even though she had worried that her mother might not know what to do. 17 Here we see that infrastructural impediments had a strong influence on Yangkyis experience of hospital birth leading her to deliver her second child at home. In a 2001 Lhasa report by Save the Children, UK, Tibetan women reported that they did not deliver in hospitals due to paucity of transportation, bad road conditions, and lack of cash to cover the cost of giving birth in the hospital. All of these structural issues affected womens birthing choices. Families preferred to save their money for offerings to local lamas and monasteries in the event that the mother or child died during childbirth. 18 They did not believe that they would see the benefits of investment in an insurance plan and were reluctant to visit hospitals due to a general mistrust of biomedicine and strangers, including health personnel they did not know. Indeed, distances from clin ics, bad road conditions, lack of cash, and limited equipment and personnel in hospitals contributed to the external structuring of womens healthcare choices. In addition, government surveillance is another structural concern directly affecting womens birthing practices. Tibetans take government surveillance seriously since their religious practices and traditional modes of living have historically been considered a form of treason against the communist state. 19 By registering in the county hospital women are by default made more visible to the watchful eyes of the government. In the hospital, a womans name is recorded in hospital records, her health status reviewed, and the number of children she has had entered into health administrative logs a concern for Tibetans who have not strictly followed government reproductive control policies. 20 All of these issues affect women and the choices they make

about their healthcare and childbirth. 21 Through Mother and Child Health (MCH) initiatives, the government is able to monitor pregnancy, childbirth, pediatric care, and sexually transmitted infections across China and into Tibet. The stated goal of MCH initiatives is to reduce maternal and infant mortality rates with a secondary effect of introducing biomedical techniques and technologies into local birthing practices. Begun in the 1980s, MCH government hospitals now reach many rural areas of Tibet. Satellite departments and clinics actively operate in county seats and township clinics. Along with the introduction of biomedicine, the presence of MCH hospitals and clinics increases regulation, surveillance, documentation, enumeration, and governance over one of the most private and inaccessible domains of Tibetans lives, childbirth. 22 Government health policies encourage women to visit MCH clinics. As a result, increased visits by village women to city hospitals has led to the creation of a census register of rural populations who are otherwise difficult to quantify. In this way, the bodies of Tibetan women serve as the loci for the creation of new modes of governance into rural areas of Tibet. 23 The registration of villagers in county hospitals leads to better mechanisms of control over regions that normally lie beyond the reach of central governance. The government can more readily monitor the overall population in villages and regularly record maternal and child mortality rates, as well as birth rates. These numbers inform policies pertaining to population growth and directly affect government access to womens bodies, womens livelihoods and their modes of existence. Through the introduction of biomedicine, MCH hospitals collaborate in attempts to control Tibetan womens bodies as the ground for state governance. International NGOs unwittingly participate in modes of surveillance through practices of evaluation, documentation, and regulation under the paradigm of international development and Western forms of modernization. Combining Tibetan and Biomedical Practices Even in the midst of Chinas modernization efforts, the majority of births in Tibet occur in the home. On the whole, Tibetans consider birthing primarily a family affair rather than a medicalized condition. As mentioned above, women prefer to give birth in the home and consider the presence of strangers a risk to the mother and child. At the same time, village, township, and county level doctors do make visits to homes in the event of an emergency. Township doctors, in particular, may recommend a combination of biomedical treatments with traditional methods of diagnosis and treatment. If a doctor is present during home births, however, women often will not let the doctor perform the delivery unless the family already knows and trusts him or her. 24 Mothers, sisters, and even male family members assist the birth, rather than a doctor, who might look on from a distance. The medicalization of childbirth has yet to take a strong foothold in most parts of rural Tibet. Instead, biomedicine and birthing meet according to the needs of the pregnant woman. A woman might visit a biomedical clinic in the township for pre-natal checks and then deliver unassisted at home, only later receiving antibiotics for an infection from a village doctor. Biomedicine has primarily made inroads into Tibetan households in the form of intravenous (IV) drips and the rise in demand for injections. 25 The impact of this on birthing practices is found mainly in the prevention of infection with antibiotics before, during or after labor. IV drips are not commonly used outside of hospitals for birthing and postpartum periods, but at times they appear in village homes. Tibetans incorporate IV usage into the constellation of beliefs and practices associated with childbirth as an efficacious measure for preventing disease. 26 This acceptance of and utilization of modern medicine does not preclude lay healing practices. One such practice includes the blessing and application of warm butter to the delivering womans fontanel, temples, palms and feet to relieve pain. In villages, the mother or mother-in-law often apply warm butter to a woman during childbirth. 27 This practice is tied to traditional Tibetan medicine and the humoral element referred to as lung , or wind, which is associated with high

energy, nerves and stress. The practice calms the delivering woman, eases the pain of contractions, and evens out the flow of energy in her body. In the narratives of Tibetan women, numerous stories reflect womens ease in moving between both traditional and modern medical practices as they suit their needs. At times, womens needs during childbirth are related to the mundane (bleeding, labor pain, labor complications) and at times, the supra-mundane (ghosts, spirits, and demons). One woman describes how she was late to deliver and did all of the prescribed village measures to speed delivery. She walked the local bridge a symbolic passage perhaps between this life and the next, or for the baby, the previous life and this one and carried stones on her back in the manner of carrying a child. When all of these measures failed, she finally decided to visit the doctor who examined her and advised her to go to the county hospital to deliver. Whether or not a woman decides to deliver in the hospital, today Tibetan women use both biomedical and Tibetan medicine for childbirth. Villagers with lay experience in the domain of childbirth will use Tibetan massage and medicines to induce labor, contract the uterus, or change the position of the baby. However, Tibetan women might opt for biomedical drugs to ameliorate these conditions if indigenous techniques and medicines do not work. In addition, educational campaigns influence lay birthing practices with information about hygiene, maintaining body heat during delivery, breastfeeding techniques, and neonatal care. Tibetan women incorporate changes depending on the perceived benefit. They often consult a range of authorities in medical crises, including biomedical doctors, Tibetan medical doctors, spirit mediums, and lamas without regarding these domains to be mutually exclusive. Within certain parameters, a woman traverses these domains depending on whether she has cash, transportation, road access to clinics, official identity passes, and/or political or family ties to modern medical institutions. These conditions create a certain set of options for womens actions and choices, which factor into how Tibetan women strategically position themselves vis-vis family and state. Encounters With Biomedicine Tibetan women navigate a number of institutional and non-institutional medical resources, especially in the domain of c hildbirth. They face a myriad of constantly shifting health initiatives stemming from Beijing, such as new measures in safe motherhood, immunization efforts, and incentives to get pre- and postnatal checks. Women partake in new projects when new medicines or techniques appear beneficial rather than dangerous. Tibetan women, therefore, make pragmatic choices about their encounters with new health institutions and policies. Tensions emerge, however, when what Tibetans perceive as beneficial differs from what government or non-government agencies perceive as useful or necessary. In government-disseminated information about safe practices concerning childbirth, health practices associated with hygiene and childcare often differ from what Tibetans do in their own lives. For example, rural Tibetans consider washing bodily surfaces before birth superfluous and even dangerous in cold winter months. Similarly, they believe placing a small amount of butter in a newborns mouth facilitates digestion and feeding a child barley flour ( tsampa ) mixed with butter tea symbolically incorporates the child into the household lineage. From a biomedical perspective, these latter two practices are ostensibly unhealthy for newborns sensitive to oils causing diarrhea. One villager from the Lhasa area, Chodron, reported that she had done all of the prescribed ritually-correct things for her newborn, including giving it butter and feeding it tsampa with butter tea. She herself also drank lots of butter tea and ate fatty food, which was transferred to the child in her breast milk. Soon after delivery, her child began to have diarrhea and nearly died from dehydration. She brought the child to the township doctor, who told her that excess fat in her

breast milk was causing the diarrhea. Chodron changed her eating habits accordingly, and her child recuperated. 28 Chodrons tale reflects an ability by Tibetan women to incorporate new advice and behaviors. In the conflicting landscape of practices and beliefs around childbirth, Tibetans are pragmatic in choosing those methods that create the best outcomes for themselves and their children. Womens Bodies and the State Chinese modernity, understood in terms of nation-building projects and policies stemming from Beijing, shapes the contours of womens lives. In addition to MCH initiatives, an arena that directly impinges on the lives of Tibetan women is governmental concern about over-population. Chinas population control initiatives under the Chinese Communist Party (CCP) began in the 1950s, reached Tibet in the 1960s in a watered-down version, became codified across China as the One-Child Policy in the 1970s, and were re-invigorated in Tibet in 1983. Though not initially included, Tibetans and other national minorities of China were eventually compelled to conform to a two-child policy for urban settlers and three-child policy for farmers and villagers. If Tibetans do not comply, fines can be levied, and limits on access to education and healthcare can be imposed. In addition, residency permits allowing for travel and habitation as well as citizenship are not issued to any child born after the required limit. Government concern with over-population has brought reproductive education campaigns and clinics to the most rural parts of Tibet. Women figure centrally into the project for population control as a primary target for birth control and reproductive education. 29 Through these government policies, the bodies of Tibetan women become the ground upon which Beijings modernization projects take hold. However, Tibetan women actively negotiate their relationship to these policies, taking on certain aspects deemed beneficial to them while rejecting others whenever possible. Reproductive education campaigns teach Tibetan women to understand that their lives and the lives of their children will improve if they limit the number of children they have. 30 These campaigns inform women that with fewer children they can provide more for their families, especially if their farms are small. In addition, women learn that their children will have more opportunities to go to school, make money, and possibly get outside work, even in a government office. 31 In Tibet, women who participate in population control campaigns must compromise certain cultural-religious beliefs related to childbirth. Most Tibetans consider it natural for a woman to have many children and believe that terminating a pregnancy is sinful. 32 In addition, most Tibetans place a certain social valuation on fertile women, and a stigma exists against barren women. 33 In a chicken-and-egg manner, these stigmas are less accentuated than they once were since the institution of pervasive reproductive control measures in Tibet. Government campaigns put in place in order to dispel these ideas and reduce the rate of population growth have been largely successful. An overall shift in Tibetan womens attitude toward contraception and reproduction can be noted in everyday conversations about childbirth, family planning, and life goals. Many Tibetans no longer consider abortion to be a social stigma even in the context of a persistent belief that life begins from conception. While womens attitudes toward contraception are changing, deciding on a form of birth control remains a challenge. Confronted with an astonishing array of contraceptive measures, many women find new reproductive control methods confusing and impracticable in their everyday lives. Making monthly trips to township clinics to receive injections or new pill supplies can be costly and difficult depending on distances to clinics and availability of transportation. Likewise, women cannot easily accommodate health checks for IUD maintenance, infection, and other concerns related to their health. Many women live far from clinics and do not prioritize contraception in their lives especially since

they maintain beliefs that do not always accord with government health initiatives. Moreover, csections, surgical removal of uterine masses, tubal ligations, and intra-uterine devices (IUDs) often leave women with scars. Women cannot easily incorporate these changes into previous patterns of managing their health and their relationship to their bodies. As a way to deal with invasive or unwanted changes, Tibetan women learn to narrate their experiences of encounters with strange or foreign forms of medicine and technologies. Intrauterine devices (IUDs) have become part of common parlance amongst Tibetans, and stories range from the plaintive to the satirical. 34 Described as devices which at times float up and become embedded in the uterine wall or contraptions that have been poorly-fitted leading to pregnancies and unwanted abortions, many women consider IUDs to be the bane of their existence. 35 Other women report that their IUDs have simply fallen out or appeared on the top of babies heads after birth. Here, the use of humor and satire stand in as devices for critique of modern contraceptive devices and assist Tibetan womens processing of their encounters with the state. The story of Jamyang provides one picture regarding the implications of state reproductive control practices for women. Jamyang described how she elected to have an IUD put in after the birth of her second child. She and her husband wanted to provide a good education for their first two children. In addition, their farm was small, and they could not afford to have a large family. Unfortunately, the IUD failed, and Jamyang became pregnant again. At the time, the township doctor advised her to get an abortion in case there were complications with the IUD. She did so, but when she became pregnant yet again after the abortion, she decided to keep that child. Jamyang initially heeded the advice of government health workers to limit her family size for economic reasons and to give better life opportunities to her children. When her contraceptive device failed, the township doctor offered further medical advice to have to have an abortion, advice which happened to also fall in line with official state policy regarding birth quotas for townships and villages. 36 After having an abortion once, Jamyang decided to keep her third child and take the financial risks associated with an increased family size. When recounting her tale, she spoke with an air of frustration at the health system that had complicated her childbearing situation. In a sense, her decision to keep the last child was a defiant one. At the same time, she indicated that she would probably have a tubal ligation in the future to prevent further pregnancies. Jamyangs story highlights the tension for many Tibetan women who are willing to accommodate reproductive health changes introduced by the state but later regret their decisions due to the governments failure to provide practicable and safe technologies. These failures often compel women to make decisions which directly conflict with local beliefs and practices, in Jamyangs case involving abortion. Initially, Jamyang was inclined to accommodate her doctors advice, because she did not want a large family. 37 Nonetheless, the township doctors advice to abort her third child placed Jamyang in a difficult position. She would either have to be a good patient and get the abortion, or a good woman by carrying her pregnancy to term. Jamyang did not speak of an internal moral struggle. Pragmatism regarding her health and the survival of her children outweighed Buddhist moral codes or social stigmatization around abortion. Because the power of township authorities supersedes village authorities, Jamyang likely felt pressured to get the abortion. However, she also resisted state authority by deciding to keep her third child, though she indicates that she later wanted her tubes tied. Jamyangs case is not simple or straightforward. Initially, she was inclined to limit the number of children in her family, but later became frustrated that she was unable to do so without pain, invasive medical procedures, and difficulty to herself. Here, the problem appears to be one of adequate services, technologies and advice. Jamyang was ready to embrace modernity, but modernity as presented to Tibetans by the government failed to meet her expectations.

Pitfalls and Promises of INGOs Not only do state forms of governance affect womens childbirth practices, INGOs introduce another set of practices into local medicine through global capital and transnational forms of biomedicine. They offer, particularly to urban women, advanced technology such as baby heart monitors and sonic wave machines in addition to new, integrative medical methodologies. Certain INGOs have introduced therapies that combine Tibetan medical drugs to induce contractions with biomedical drugs like oxytocin and antibiotics. 38 The Tibetan Medical Hospital in Lhasa, for example, participates in integrative health measures by employing Tibetan medical treatments while also administering biomedical drugs. Other INGOs create integrative prenatal, delivery, and postpartum childbirth regimens, which incorporate Tibetan medical and folk methods of treatment and assessment into biomedical methods. Unfortunately, most women in Tibet do not have access to these new, integrative methods. Without adequate infrastructure, technologies and epistemologies offered by INGOs remain a distant and often daunting monolith. In addition, as we have noted above, womens willingness to utilize biomedicine also varies. Living at the edge of cash economies, many women frequently live out their lives in less than optimal health. As a result, they sometimes feel compelled to request free treatment for new forms of healthcare they are not entirely sure will be beneficial. Despite efforts to include women, 39 INGO investments in healthcare in Tibet frequently increase the influence of those who have power, namely government employees and institutions, and have little positive effect on those who do not have access to power, namely impoverished patients. A large percentage of international money goes toward increasing biomedical knowledge and techniques, which is mostly absorbed by government-run health institutions. On the whole, international development projects for womens health tend to remain biomedical in focus, allowing for local populations to selectively incorporate their own healing methods when they deem appropriate. As biomedicine becomes more lucrative with the infusion of new money from INGOs, women must find ways to navigate new medical resources while retaining ties to practices that give meaning to their childbirth experiences. In-Roads of Modernization The drive toward modernization links directly to nation-building projects in the name of One China. Through their participation in government health initiatives, Tibetan women figure as symbolic markers of and participants in Chinas nation-building project. 40 Government policy defines Tibetan women as central players in Chinas goal to rapidly modernize and industrialize its backwaters, including Tibet a project the government refers to as development of the Western regions. 41 More specifically, women hold a central place in development projects that aim to modernize the health care system. State initiatives to control the population and to reduce maternal and infant mortality during childbirth target women. Reproductive planning programs and maternal and child health initiatives are gender-specific components of the PRCs nation-building project. Willingly or not, Tibetan women must participate in these projects of modernity. In this context, the stakes remain high for Tibetans structured into this project since they do not want to give up certain traditions associated with Tibetan heritage and national identity in lieu of a dominant Chinese identity. When women participate in top-down ideologies of Chinese modernity, they do so to the degree that they perceive there are practical benefits to them. 42 Tibetan women accommodate those reproductive technologies that they see as beneficial. As with the case of Jamyang, who participated in reproductive control measures in order to limit her family size, many Tibetan women want to take more control over their reproductive lives. Ongoing governmental campaigns teach Tibetan women that having less children will increase the likelihood that their children will be well-fed, educated and have greater life opportunities in the

cities as well as the countryside. 43 In these ways, Chinas project of modernity inscribes itself on womens bodies. 44 At the same time, women interpret and forge modernity in local terms according to their own needs and perspectives. Historically nomadic and living in fairly isolated and transient conditions, Tibetans had many children in order to increase the productivity of their farming and to improve the chances of survival. 45 Seeing the changes and opportunities available in the cities and the benefits of having extra cash to purchase farm equipment, tractors, and trucks among other things, many Tibetan women today voluntarily participate in reproductive planning programs, particularly in farming communities. 46 Tibetan women embrace these changes for the same reasons that women in South America and Africa willingly comply with contraceptive plans to gain greater control over domestic finances, improve their childrens future, enrich their own work lives and take control of their reproductive capacity. Hospital encounters reflect different negotiations with the terms of modernity. In the accounts of Tibetan childbirth experiences given above, Chodron submitted to the clinical and foreign aspects of hospital birth under duress in order to insure the survival of her fourth and fifth children. In the case of Yangkyi, a disappointing hospital experience and a difficult journey home prompted her to deliver her second child at home. In both cases, as with many others, no single outcome toward or away from biomedicine arises. Women select health avenues according to experience, need, access, and ideological frameworks. In addition, cultural and structural factors influence womens birthing choices even as these factors shift over time. Health resources create daunting options and new incentives that influence womens decisions to participate in state and non-state health initiatives. Women obtain medical advice from a number of sources, including fellow villagers, governmental health workers, and INGO outreach workers. Furthermore, educational campaigns attempt to modernize childbirth practices, change reproductive activities, and influence womens decisions about whether to abort pregnancies. At the same time, both governmental and non-governmental agencies present new and different options for improving womens health. Education campaigns, health bureau officials, and INGO workers teach Tibetans at the village and township level when, how, and where to tap into new health resources such as biomedical clinics and hospitals. For better or worse, family relations provide the most salient avenue for receiving the benefits of biomedicine by creating ties to the wider community of health workers and institutions. Yet even with the assistance of family members, women find the institutional apparatuses of the modern health clinic to be cold, foreign, unfriendly, and intolerant of religious practices associated with childbirth and illness. The modernity emerging in childbirth practices might best be described in terms of womens strategic navigation of structural factors and religious-cultural concerns. Their choices are guided by pragmatic considerations in order to achieve the best birthing and reproductive outcomes for themselves and for their families. In search of the best outcomes, Tibetan women move between hospitals and the home for childbirth and between biomedicines and lay healing practices for treatment, while they also acquire varying attitudes toward reproduction. Both tensions and collaborations between Tibetan and biomedical practices factor into womens choices. As women navigate these choices, they tap into local knowledge in order to create, resist, and signify the current arc of motherhood and modernity in Tibet today. Endnotes 1 For productive intellectual engagements and kindhearted guidance, I would like to thank my advisors Vincanne Adams at UCSF, Akhil Gupta at Stanford, Matthew Kohrman at Stanford, and Sylvia Yanagisako at Stanford. My appreciation also goes to Jane and George Collier for visiting me in Tibet and providing critical input into grant proposals and research plans. Many thanks to the Tibetan Academy of Social Sciences and Tibet University in Lhasa for supporting my research while in Tibet.

Materials were collected for this paper stem from a two-year stay in Tibet, during summer 2001 to summer 2003. Thirty household level interviews were conducted on childbirth in counties outside of Lhasa while volunteering as an ethnographer for a midwife training project based in the US and funded by the NIH. During the summer of 2003, due to the SARS epidemic, I could not do village level research. Lhasa based research in hospitals was conducted at this time while a researcher from the Tibetan Academy of Social Sciences conducted the 51 interviews with women of reproductive age in Shigatse. Additional research includes 15 city level interviews with Lhasa health bureau officials and city health workers. These interviews plus extensive participantobservation in work, leisure, home, hospital, and pilgrimage contexts comprise the bulk of my independent research on childbirth. 2 The distinction between Western versus Chinese modernity might broadly be encompassed in a Maoist vision of classes applied to the peasant populace versus a liberal economic free market. Western modernity remains tied to capitalist modes of production, globalization, democratization, and neo-liberal forms of governance and economy. The underlying question in Tibet is one of economy such that Tibetan modernity emerges as an incremental and shifting admixture of economic forms specific to Tibet (for example, nomadic and farming communities, polyandrous marriage systems, and seasonal shifts in agriculture according to weather). Tibetan modernity is marked by changes introduced through commodities, technologies, movement between cites and shifts occurring with the infusion of new forms of capital into the economy combined with state regulated industries like pharmaceuticals from the Tibetan Medical College, road construction, transportation, health care delivery, education, communications, banking, insurance, armaments and certain modes of agricultural production servicing the Red Army. 3 The concept of modernities in the plural derives its inspiration from Lisa Rofel, Other Modernities: Gendered Yearnings in China after Socialism , (Berkeley: Berkeley University Press, 1999). In Rofels formulation modernity is not a monolithic concept that starts from the West and travels outward to other lands, like a juggernaut propelled by the force of its own weight. Rather, as Rofel points out through the lives of women factory workers, multiple modernities exist for lived peoples on the ground, and can begin in the most distant reaches of the world away from metropolises, factories, industries, department stores, shopping complexes, high rises, consumer culture and straightforward cash economies. 4 For discussion of everyday practice as a modality of ethnographic inquiry and the analysis of embodied forms of social enculturation as a tool for social inquiry, see Pierre Bourdieus The Logic of Practice , translated by Richard Nice, (Stanford, CA: Stanford University Press, 1990). Also see Arjun Appadurais discussion of local-global formations of modernity and cultural change in Modernity at Large: Cultural Dimensions of Globalization , (Minneapolis, MN: University of Minnesota Press, 1996). 5 Tibetan national formations outside of or in contrast to Chinese or other national formations may be traceable through this mechanism of analysis I am calling Tibetan modernity. However, the concept does not have bounded, restricted limits and might be applied to contexts beyond territorial Tibet as well as to non-Tibetan contexts. This paper does not address the question of Tibetan national formations since that question lies beyond the scope of this analysis. 6 Modes of legitimizing authority might broadly be said to be signified by the concept of nang (inside) versus chi (outside). I am basing this understanding of how Tibetans legitimize authority on the religious terminology used to describe a Buddhist practitioner in lay language, nang pa or nang ba , meaning insider versus the historical construction of the category for non-Buddhists or foreigners/outsiders, chi gyal gi mi (lit. foreign country people), during British colonial expeditions to Tibet during the first decade of the 20th century. I have not seen a discussion on this historical example in the literature on Tibet; however, likely sources are Melvyn Goldstein, A History of Modern Tibet: The Demise of the Lamaist State: 1913-1951 (Berkeley: U niversity of California Press, 1989), or David Snellgrove and Hugh Richardson, A Cultural History of Tibet , (New York: F. A. Praeger, 1968). While Westerners today are referred as chi gyal inside

Tibet, they are referred to as ingie (English), a marker of race, or alternatively kor che wa (tourists), a marker of social position, amongst exile communities in Nepal and India. Chinese living in Tibet are predominantly referred to as gya mi , or Chinese. These linguistic markers of difference serve as mechanisms of inclusion or exclusion depending on when and how they are employed by Tibetans. 7 See Frederic Jameson, Postmodernism,or,The Logic of Late Capitalism , (Durham: Duke University Press, 1991). Jameson attempts to outline a conceptual apparatus for mapping an ideological dominant against which the proletariat, interpolated into innumerable projects of capital, might be able to struggle. The descriptive passage above is meant to evoke a landscape of systems, both economic and governing, that are often contradictory and confusing and as such might be suggestive of Jamesons formulation of post-modernism. The context of communist state rule in Tibet troubles this formulation. Vincanne Adams addresses similar phenomena in the context of Tibet, although in a different manner, in her upcoming book on women and modernity. See Vincanne Adams and Stacy Leigh Pigg, eds, The Moral Object of Sex: Science, Sexuality and Development in Global Perspective (Durham, NC: Duke University Press, forthcoming). 8 See Santi Rozario and Geoffrey Samuels edited volume The Daughters of Hariti : Childbirth and Female Healers in South and Southeast Asia (London, New York: Routeledge, 2002). See also A.H. Maiden and E. Farwell, The Tibetan Art of Parenting: From Before Conception Through Early Childhood , (Boston: Wisdom Publications, 1997). See also K. S. Monro, Tibetan Mothers in India: Medical Pluralism and Cultural Identity, Ph.D. Thesis, Dept. of Sociology and Anthropology, University of Newcastle. Other sources include: Birth and Child Rearing in Zangskar, Himalayan Buddhist Villages: Environment, Resources, Society and Religious Life in Zangskar, Ladakh, edited by J. Crook and H. Osmaston (Bristol: University of Bristol, 1994); S. Pinto, Pregnancy and Childbirth in Tibetan Culture, Buddhist Women Across Cultures , edited by K. L. Tsomo (Albany, NY: State University of New York, 1999); Santi Rozario, Indian Medicine, drib, and the Politics of Identity in a Tibetan Refugee Settlement in North India, Presented at the International Workshop on Healing Powers and Modernity in Asia, held at Newcastle University. Revised Version at Australian Anthropological Society Conference, October 1998. 9 For recent discussion of the negotiated relationship between grantor and grantee as it relates to notions of sponsorship, charity and development in Tibet, see Ethan Goldings, No (Heart) Strings Attached: Misunderstanding the Meanings of Sponsorship, Charity and Development Practices in Contemporary Tibet, International Association of Tibetan Studies Conference Proceedings, 2003. 10 Multimillion dollar non-governmental initiatives incorporate new methodologies for reducing maternal mortality rates (NIH/OneHEART, US) and improving prenatal and neonatal care (Save the Children, UK). Other non-governmental organizations address health concerns specific to women and children (MSF, France; Swiss Red Cross, Kunde Foundation, US). Still others assess the problems associated with delivery at high altitude (Lorna Moore, University of Colorodo, US) and research pediatric diseases like stunted growth and big-bone disease (Terma Foundation, US). In addition, these international projects train health workers in integrative methodologies for pregnancy, midwifery, childbirth, and postnatal care (NIH/OneHEART, US; Save the Children, UK), and educate government officials in gender sensitive approaches to health care and development (Save the Children, UK). In light of these interventions, Tibetan women are subjected to research agendas, educational trainings, medical technologies and techniques, and new forms of medicine, which women at times absorb into everyday life and at times reject either tacitly or directly. Relevant citations include Lorna Moore, Tibetan protection from intrauterine growth restriction (IUGR) and reproductive loss at high altitude. American Journal of Human Biology 13:5 (2001): 635-44. Nancy Harris, P.B Crawford, et al Nutritional and Health Status of Tibetan Children Living at High Altitudes. New England Journal of Medicine , (Feb. 1, 2001):341347. Also see upcoming co-authored article with Vincanne Adams on cultural sensitivity in midwife trainings in Tibet.

11 The three humors in Tibetan medicine include lung or wind, tri pa or bile and bei gan or phlegm. Wind energies are associated with motility, movement, rapidity, stress, depression, and other psychological disorders. Bile is associated with stomach disorders, acidity, nausea, and distension. Phlegm is associated with viscosity, slowness, and infection. Tibetan healing methods involve balancing these three humors and creating equilibrium with the five elements of earth, water, fire, wind and ether, associated with different parts of the body. Dietary and behavioral recommendations constitute main treatment methods while pulse diagnosis, urine analysis, touch, and visual assessment comprise diagnosis. For detailed discussion, see Rechung Rinpoche, Tibetan Medicine , Translated by the Ven. Rechung Rinpoche Jampal Kunzang, (Berkeley: University of California Press, 1976, c1973). See also, Lobsang Rapgay, Tibetan Medicine, A Holistic Approach to Better Health , (Dharamsala, H.P. India: Lobsang Rapgay, 1985); Tsewang Drolkar Khangkar, Tibetan Medicine: The Buddhist Way of Healing , (New Delhi: Lustre Press, 1998). 12 For recent research on concepts of pollution on Tibetan communities in Dalhousie, India, see Santi Rozario and Geoffrey Samuels edited volume The Daughters of Hariti: Childbirth and Female Healers in South and Southeast Asia (London, New York: Routeledge, 2002). Also relevant are Mary Douglas discussion of the conceptual framework of pure and impure states for marking social inclusions and exclusions in socio-spatial contexts in Purity and Danger: An Analysis of the Concepts of Pollution and Taboo (London: Routledge & Kegan Paul, 1966). See also Lila Abu Lugods discussion of shame as a mechanism for surveilling womens sexuality in Veiled Sentiments: Honor and Poetry in a Bedouin Society , (Berkeley: University of California Press, 1986). 13 All names have been changed to protect the identity of interview participants. Drolmas extended family includes her mother-in-law, her mother-in-laws four sons to whom she is married, and her own five children. In Tibet, women will marry the brothers within one household in order to prevent the land from being divided through separate inheritance. Polyandrous marriage is a common form of marriage currently in practice today in Tibet. For detailed discussion of recent sociological research on polyandry, see Ben Jiao, Socio-Economic and Cultural Factors Underlying the Contemporary Revival of Fraternal Polyandry in Tibet , Dissertation (Ohio: Case Western Reserve University, 2001). Also see John Avery, Polyandry in India and Thibet, 4:1 (1881): 48-53. Ramesh Chandra, Report on the Project: Polyandry in a Himalayan Village, Bulletin of the Anthropological Survey of India Calcutta, 24:3-4, 1975, 54138. Pant, Rekha, The Changing Scenario of Polyandry Culture: A Case Study in Central Hi malaya, Man in India, 77:4 (1997): 345-353. 14 In the context of the interview conducted by a co-researcher from the Tibetan Academy of Social Sciences in Lhasa, Drolma incorporates her tale of birthing in the hospital on equal footing with her birthing experiences at home. However, she goes to great lengths to describe the amount of pain she was in and how this pain compelled her to go to the hospital. 15 In one interview, a woman explained that an astrologer had told her that her first child died because a dre mo , or female demon, residing in another woman attacked her baby when the two women came in contact. Shigatse, June 2003. 16 Another instance where Tibetans dislike encountering acquaintances is the case of sexually transmitted infection (STI) clinics established by the Swiss Red Cross in Shigatse. Local women refuse to visit STI clinics because the Tibetan doctors come from local communities and patients fear that they will acquire a bad reputation if seen by local doctors, especially since the clinics comprise a morally charged sphere of healthcare. Interviews collected from villages in the Shigatse prefecture by a co-researcher from the Tibetan Academy of Social Sciences in summer 2003. I conducted first round interviews in summer 2002 in villages surrounding Lhasa while conducting ethnographic research for an NIH sponsored midwife training.

17 Ideas about authority figure centrally in this example. Yangkyis grandmother advises Yangkyi to deliver in the hospital and values the government doctors knowledge over Yangkyis mothers knowledge for how to assist with birthing. Yet infra-structural issues lead Yangkyi to voice a vehement complaint against birthing in the hospital since the road and transportation conditions were more harmful to her than an otherwise safe hospital experience. Finally, Yangkyis unhappiness with the doctors yelling and her negative experience of post-hospital delivery point to fears related to institutional health practices, strangers, clinical settings, and larger infrastructural issues not taken into account when governments (and grandmothers) encourage women to give birth in hospitals. Field research conducted in villages around Lhasa summer of 2002. 18 Save the Children, UK mother and child health assessment of four counties in Lhasa prefecture, February 2002. 19 The PRC state rhetoric and political institutions including government health bureaus persist in this ideological construction of modern, forward thinking people versus traditional, backward thinking people. Tibetan cadre members use a particular term for the association of tradition with backwardness: ley pa nak po , or black brain, alluding to conservative thinking or a brain that has gone black with decay and degeneration. A milder, more common term which connotes the idea of conservative thinking amongst older generations is the term ley pa jang ku , or green brain, ostensibly a less degenerate form of this cerebral malady associated with conservatism. 20 See Goldstein et al, Fertility and Family Planning in Rural Tibet, The China Journal 47 (January 2002):19-39. The current reproductive control policy for minorities in China is one child for government workers, two children for non-government workers, and in Tibet, three children for villagers. Township health officials often visit villages and record these numbers as well, which are kept by the village leader. 21 Critical medical anthropologist Paul Farmer discusses structural economic and political factors affecting healthcare compliance for AIDS patients in Haiti, which bear a strong resemblance to the scope of issues affecting womens childbirth choices in Tibet. In the Haitian case, distances from clinics, bad road conditions, lack of cash, and the fact that hospitals would run out of costly treatments for patients in the middle of treatment plans all affected patient compliance, which had less to do with the individual and his or her health choices than with external factors structuring healthcare choices. See Paul Farmer, AIDS and Accusation: Haiti and the Geography of Blame (Berkeley: University of California Press, 1992). 22 The government did not create these epidemiological measures on its own. In the early 1990s, the World Health Organization did an evaluation of maternal and child healthcare delivery in Tibet. At that time, they introduced methods for creating statistics on maternal and infant mortality and morbidity using measures that included the number of infant deaths, maternal deaths, age of mother, age of child, number of women of reproductive age, and so on. These methods were adopted by counties and prefectures surrounding Lhasa and possibly other areas in Tibet. 23 For critical evaluation of institutionalized medicine, see Michel Foucaults The Birth of the Clinic: An Archaeology of Medical Perception ; translated from the French by A. M. Sheridan Smith, (New York: Vintage Books, 1994). 24 Some international agencies have found that women are willing to have a doctor assist with births if the doctor has acquired a good reputation based on trust. This assessment points to the issue of legitimacy at the local level and who Tibetans are willing to trust and why. Doctors from lineage based Tibetan medicine occurring within the framework of teacher-student relationships are the most trusted medical practitioners. If these modes of legitimization are mirrored in biomedical domains, trust of doctors in patients eyes will likewise also increase.

25 Since Deng Xiaopings liberalization of market economies in the 1980s, the usage of IV drips has expanded. Needles and intravenous drips have become a money making endeavor for entrepreneurially minded Tibetan doctors, who may or may not have formal training in biomedicine. 26 At the same time, an element of wonder is associated with intravenous drips, which is not transparent as a phenomenon. Cultural theorist Homi Bhabha describes how bibles introduced to local Indian communities during the British colonial period would take on an almost fantastical, divine quality. Intravenous drips may have acquired something of this mystical quality in medicinal terms for Tibetan patients. See Homi Bhabha, Signs Taken For Wonder, The Location of Culture , (New York: Routeledge, 1994). 27 Reported in 51 interviews with Tibetan women from the same village in Shigatse, summer 2003. 28 Chodron told her story with the zeal of one who had learned from her prior mistakes and had realized the benefits offered by township doctors, who are often trained in both biomedicine and Tibetan medicine. Tibetan medical prescriptions for nausea and diarrhea are similarly linked to dietary and behavioral measures. Most Tibetans are familiar with basic Tibetan medical methods of diagnosis and treatment. For this reason, it is likely that Chodron had little difficulty accommodating biomedical measures that did the same. 29 See Goldstein et al, Fertility and Family Planning in Rural Tibet, The China Journal 47 (January 2002):19-39. For a statistical overview of minority populations reproductive rates, see Jiann Hsieh, Chinas Nationalities Policy: Its Development and Problems, Anthropos 81:1-3 (1986):1-20. For analysis of the impact population control policies have on national minorities, see Mundigo, Axel I. Population and Abortion Policies in China: Their Impact on Minority Nationalities, Human Evolution 14(3) (1999). See also, The Moral Orgasm and Productive Sex: Tantrism Faces Fertility Control in Lhasa, Tibe t, China in Vincanne Adams and Stacy Leigh Pigg, eds, The Moral Object of Sex: Science, Sexuality and Development in Global Perspective (Durham, NC: Duke University Press, forthcoming). 30 Field research, summer 2002 and 2003. 31 The Tibetan researcher who conducted these interviews was herself highly educated, and she worked in a research office under the auspices of the government. It is likely that the village women who told her about their hopes for their children saw her as a model for someone who had made a good life for herself outside of the village. She herself had been from a village in the same area and was staying with relatives where she conducted these interviews. 32 While abortion raises ethical questions within Tibetan cosmologies, women in Tibet historically have been able to terminate pregnancies or induce miscarriages using Tibetan medical and lay methods. Before the introduction of biomedical contraceptive technologies by the Chinese state and even today, Tibetans used certain vegetable dyes that women would drink until they became sick. Tibetan medicines used today to prevent hemorrhage and contract the uterus have also been used in the past to induce miscarriage. The name of the medicine is shey ju chu chig - Shey Ju #11. Sources include Tibetan medical and pharmaceutical texts, or pey cha . 33 These stigmas are signified through the exclusion of barren women from weddings and purification rituals associated with birth ( pang sang ). Field research in Shigatse, summer 2003. 34 Medical anthropologist Michael Jackson describes how life-worlds are inter-subjective exchanges between individuals, their environment and their larger communities and social networks. These negotiated forms of inter-subjectivity shape how people understand their

position in the world. From this perspective, it is possible to see how Tibetan women might find ways to incorporate marks of state authority on their bodies into conceptual models of selfhood related to Buddhism, local beliefs, and village practices. See Michael Jackson, Paths Toward a Clearing: Radical Empiricism and Ethnographic Inquiry (Bloomington: University of Indiana Press, 1989): 1-18. 35 Reported by women during village level interviews, summer 2002 and summer 2003. 36 See Goldstein, Ben Jiao et al., Fertility and Family Planning in Rural Tibet, The China Journal 47 (January 2002):19-39. 37 Similar trends have been noted in South America and Africa where women accommodate non-governmental reproductive control interventions in order to better their life and those of their children. Taking control over reproductive decisions enables women to take control over the trajectory of their lives. See This Bridge Called My Back: Writings by Radical Women of Color , edited by Cherre L. Moraga and Gloria E. Anzalda; foreword by Toni Cade Bambara (Berkeley, CA: Third Woman Press, 2002). 38 This integrative method to delivery is being practiced at the Tibetan Medical Hospital ( Men Tsi Khang ). An international non-governmental organization currently operating in Lhasa is experimentally incorporating this methodology into trainings for health workers at the township level. Due to the directors wish for anonymity, I have omitted the name of this INGO. 39 For example, INGO outreach bolsters an education campaign by the Womens Federation. The Womens Federation is the ruling communist partys effort to include Tibetan women in its modernization efforts. It consists of a government work unit comprised of a collective of women from the villages and townships. These women disseminate government propaganda through education campaigns related to womens health topics, womens work topics, and political reeducation specifically geared toward women. According to the Swiss Red Cross 2002 handbook for maternal and child health, the Womens Federation is considered a more effective mechanism for disseminating new health messages to village women. 40 Under PRC governance, Tibetan women must represent and enact a communist vision of dialectical historical change. For discussion of the feminization of the minorities in China, see Louisa Schein, Minority Rules: The Miao and the Feminine in Chinas Cultural Politics (Durham: Duke University Press, 2000). See also Hjorleifur Jonsson, Yao Minority Identity and the Location of Difference in the South China Borderlands, Ethnos 65:1 (2000): 56-82. Ildiko, BellerHann Peasants and Officials in Southern Xinjiang: Subsistence, Supervision and Subversion Zeitschrift fur Ethnologie 124:1(1999): 1-32. 41 Jiang Zemin on the Three Represents (Beijing, China: Foreign Press, 2000). 42 For a discussion of governance through the State apparatus and disciplinarity at the level of the body, see respectively Louis Althusser, Lenin and Philosophy, trans. Ben Brewster (New York, NY: Monthly Review Press, 1971). Also see The Foucault Effect: Studies in Governmentality: With Two Lectures By and An Interview with Michel Foucault , edited by Graham Burchell, Colin Gordon, and Peter Miller (Chicago: University of Chicago Press, 1991). 43 See Goldstein et al, Fertility and Family Planning in Rural Tibet, The China Journal 47 (January 2002):19-39. 44 For a discussion of how the state disciplines women by way of reproduction while letting them stand in as iconic for the minority as sexual beings, see Globalization and Immorality: Selling Shoes, Sexuality and the Sacred in Lhasa, Tibet presented at the Global/Local conference, Department of Anthropology, Stanford University, May 1999, also Chapter 4 in Morality and Modernity: Saving Tibet in an Age of Desecration (book manuscript).

45 See David Snellgrove and Hugh Richardson, A Cultural History of Tibet (New York: F. A. Praeger, 1968). 46 Field research, summer 2002 and 2003. * HAQ share * Share * * Digg * Email * * Facebook * Print * * Reddit * StumbleUpon * * * This entry was posted in Uncategorized. Bookmark the permalink. Understanding the Context of Emerging Pathogens in China: The SARS Crisis and China's Health Care India's Foreign Policy Towards China: The NDA Experience Dominant Issues in Sino-Indian Relation Leave a Reply Cancel reply You must be logged in to post a comment. * Search for: * Archives o December 2010 o October 2008 o May 2008 o February 2008 o December 2006 o June 2006 o February 2006 o January 2006 * Meta o Log in HAQ Harvard Asia Quarterly Proudly powered by WordPress.