asian medicine 10 (2015) 221–248
brill.com/asme
The White Pill: Perceptions and Experiences of Efficacy of a Popular Tibetan Medicine in Multiethnic Rebgong
Nianggajia Qinghai Nationalities University, University of Oslo, Norway [email protected]
Abstract
In this paper, I address the local perceptions and experiences of efficacy among pro- ducers and patients of a popular Tibetan medicine in multiethnic Rebgong, a regional hub of Tibetan medicine in Qinghai Province, PRC. Known as the ‘White Pill’—Rikar in Tibetan, Jiebaiwan in Chinese—it is often taken directly without prescription for stomach and digestive disorders that are common among Tibetan, Han, and Hui patients. I will examine the White Pill’s classical formula and how different local pro- ducers in Rebgong explain what makes their own White Pill so effective and popu- lar. Based on interviews with patients of different cultural backgrounds, my research shows that the popularity of this Tibetan medicine is increasing among both Tibetans and non-Tibetans in Rebgong during the past decade. This is probably due to the new ways of producing the White Pill by specifically targeting common digestive disorders, which often and previously have been experienced as not being satisfactorily treated by Chinese biomedical pharmaceuticals. In particular, Rikar or Jiebaiwan is locally known and experienced to be simply the most effective treatment for stomach and digestive disorders without having side effects.
Keywords
Tibetan medicine – White Pill – Rikar – Jiebaiwan – multiethnic use – Rebgong (Tongren)
© koninklijke brill nv, leiden, ���6 | doi 10.1163/15734218-12341Downloaded352 from Brill.com09/25/2021 08:54:18PM via free access 222 Nianggajia
Rebgong—A Hub of Tibetan Medicine in Amdo
In the past decade ‘Tibetan medicine’ (Tib. bod sman) has become a wide- spread and popular healing option in China. Also known as Sowa Rigpa (Tib. gso ba rig pa),1 ‘the science of healing’, it has reached an unprecedented stage of development, commercialisation, and distribution. Many people from different cultural backgrounds have begun to use Tibetan medicines as a new measurement to complement their therapeutic treatment options.2 This phe- nomenon is also evident in the multiethnic Sino-Tibetan borderland of what Tibetans call Amdo (Tib. a mdo or mdo smad). Amdo is located in the north- eastern part of the Tibetan Plateau and belongs to Qinghai Province, with a major rural farming and nomadic Tibetan population sharing the space with other ethnic groups, in particular Han Chinese and Hui, who mostly live in urbanised centres.3 Rebgong (Tib. Reb gong; Ch. Tongren 同仁) is an important hub of Tibetan culture and medicine, yet academic research on the latter has hardly been undertaken.4 Rebgong is both the Tibetan name of the county and the county town of what in Chinese is called Tongren (同仁). Rebgong alias Tongren Town is also the prefectural capital of Malho Tibetan Autonomous Prefecture (Tib. Rma lho bod rigs rang skyong khul; Ch. Huangnan zangzu zizhizhou 黄南藏族自治州). In the past, many famous Tibetan physicians—generally known as menpa (Tib. sman pa) in Amdo and always ethnically Tibetan— came from Rebgong and they still do so today. Presently, Tongren Town has a specialised prefecture hospital of Tibetan medicine, of which we will hear more in detail, and many private clinics. The large Qinghai Province Tibetan Medical Hospital (Tib. Mtsho sngon zhing chen bod sman khang; Ch. Qinghai sheng zangyiyuan 青海省藏医院) in Xining City (西宁市) is in close proximity, about two hours drive by car. Before the 1950s, Rebgong County covered a much larger area than the present-day county boundaries delineate, and also included parts of today’s
1 I would like to extend my sincere gratitude to The Network for University Cooperation Tibet- Norway for funding my research, and Mona Schrempf and Heidi Fjeld for their constructive and invaluable comments on this paper. I also would like to thank all my informants who shall here remain anonymous. 2 See, for example, Craig and Adams 2008. 3 On historical aspects of Amdo, see Horlemann 2012, Tuttle 2013, Yangdon Dhondup 2011. On modern Amdo, social transformations, and economic development, see Huber 2002, Yangdon Dhondup 2011, and Fischer 2014. 4 On historical aspects of Rebgong, see Yangdon Dhondrub 2011. On health-seeking practices in the area of Rebgong, see Schrempf 2010.
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Chentsa County (Tib. Gcan tsa rdzong; Ch. Jianzha xian 尖扎县), Tsekhog County (Tib. Rtse khog rdzong; Ch. Zeku xian 泽库县), Malho County (Tib. Rma lho rdzong; Ch. Henan xian 河南县) and places to the north-west such as Trika County (Tib. Khri ka rdzong; Ch. Guide xian 贵德县) in Tsolho Prefecture (Tib. Mtsho lho khul; Ch. Hainan zhou 海南州), and Dobi Tibetan Township (Tib. Rdo sbis bod rigs zhang; Ch. Daowei zangzu xiang 道帏藏族乡) in Yadzi County (Tib. Ya rdzi rdzong; Ch. Xunhua xian 循化县).5 In this article, I am generally referring to present-day Rebgong County. This county has a total population of 89,654, with Tibetans as the predominant ethnic group making up 72.94%, Mongour 11.8%,6 Hui 3.86%, Salar 1.68%, Baoan 0.5%, Han 8.83%, Mongolian 0.18%, and other 0.21%.7 Rebgong is also known as ‘the city from which knowledge springs’ (Tib. rig pa ’byung ba’i grong khyer)8—a reference to famous Tibetan intellectual scholars born in this area. The most prominent are Chöjé Döndrup Rinchen (Chos rje Don grub rin chen, 1309–85) who was the teacher of Tsongkapa (Tsong kha pa, 1357–1419),9 Shar Kenden Gyamtso (Shar Skal ldan rgya mtso, 1606–77),10 and Zhapkar Tsokdruk Rangdröl (Zhabs dkar Tshogs drug rang grol, 1781–1851), a great tantric master.11 More recently, Rebgong was the home of Amdo Gendün Chömpel (Dge ’dun chos ’phel, 1903–51), probably the most famous modern Tibetan intellectual, philosopher, historian, and artist of the twentieth century, who until today has a lasting impact on Tibetan identity formation in this area. Less well-known is the fact that Rebgong is also a hub of Tibetan medical knowledge and practice in Amdo, historically connected with generations of ‘lineage physicians’ (Tib. sman rgyud) and the local Gelukpa (Tib. Dge lugs pa) monastery of Rongwo (Tib. Rong bo bde chen chos ’khor gling). Rongwo used to be one of the larger monasteries in Amdo, housing up to 2300 monks at its
5 Fischer 2014; Yangdon Dhondup 2011, p. 36. 6 Apart from language, Mongour communities and Tibetan communities in Rebgong share many common values and cultural attributes. Therefore, my research does not include Mongours as a separate group from Tibetans. 7 From the seventh census of Tongren County conducted in 2015 (prepublication data per- sonally conveyed to me). The Bureau of Statistics of Tongren County has not yet formally published the full results of the 2015 census. 8 Rig pa ’byung ba’i grong khyer is a popular eulogistic expression used among Tibetans in Rebgong. Local scholars often cite this expression in their writings to show that Rebgong is the birthplace of many prominent scholars. In addition, Rebgong is also famous for its Tibetan traditional arts, Thangkha painting in particular. 9 Tsongkhapa was the founder of the Gelukpa tradition of Tibetan Buddhism. 10 He was the first Shartsang, the head of Rongwo Monastery. 11 Yangdon Dhondup 2011, pp. 33–4.
asian medicine 10 (2015) 221–248 Downloaded from Brill.com09/25/2021 08:54:18PM via free access 224 Nianggajia peak and with 36 affiliated monasteries (Tib. dgon lag).12 Rongwo was also the historical centre of power of Rebgong ruled by the Nangso (Tib. Nang so) as political leader and the Shartsang (Tib. Shar tshang) as religious head.13 Today, Rongwo remains to be the old part of Rebgong town with Rongwo Monastery at its centre. Here, many famous Tibetan monk doctors were trained, such as Khenchen Gendün Gyamtso (Mkhan chen Dge ’dun rgya mtsho; 1679–1765), Jampel Tendzin (’Jam dpal bstan ’dzin; 1715–?), Gendün Tendzin (Dge ’dun bstan ’dzin; 1738–?), the fourth Kyamgön Rinpoché (Skyabs mgon rin po che; 1795–1843), and Drungyik Tsojé Gendün Trinlé Gyamtso (Drung yig ’tsho byed dge ’dun ’phrin las rgya mtsho; 1804–?).14 These scholar-physicians played an instrumental role in building up Rebgong as a centre for traditional Tibetan medicine in the late eighteenth and nineteenth centuries.15 In 1958, following political upheavals in the area, a public school comprised of four sections of history, art, language, and Tibetan medicine, was estab- lished for ‘re-educating’ (Tib. bsgyur bkod)16 local religious figures in align- ment with the new Chinese state policy in Rebgong. The school was primarily run by so-called ‘corrected religious figures’—basically the former intellectual monastic elite. The main medical teachers at the school were distinguished Tibetan physicians from Rongwo Monastery and affiliated monasteries, known as Ake Gyamtso alias Drungyik Gyamtso (Drung yig rgya mtsho),17 Ake Jikmé (’Jigs med), Ake Özer (’Od zer) and Ake Jamyang Yiknyen (’Jam dbyangs dbyig gnyen).18 In 1962, these prominent physicians set up a small clinic named Malho Tibetan Medical Treatment Clinic (Rma lho bod sman gso dpyad khang) staffed with several young physicians recruited from the public school with support from a local government leader. The young physicians acquired extensive experience in practising Tibetan medicine through rigorous training
12 See Sonam Tsering 2011; Yangdon Dhondup, Pagel, and Samuel (eds) 2013. 13 On the history of Rebgong, see Yangdon Dhondup 2011; Tuttle 2013. 14 Short biographies of famous doctors from Rongwo Monastery and affiliated monasteries can be found in the Rebgong Pilgrimage Annals (Reb gong gnas skor deb ther) compiled by Dorjégyal 2011, pp. 444–78, and in Research on the Art of Rebgong Culture (Reb gong rig gnas sgyu rtsal zhib ’jug) edited by Tsewang Dorjé 2009, pp. 421–59. On the history of Tibetan medicine at Rongwo Monastery, see Rong bo dgon chen gyi gdan rabs 1988, in particular the chapter on medicine Lha rje brag sna ba’i rgyud dang ’brel ba’i gso rig dang bzo rig dar tshul, pp. 778–806. See also Tongren County Gazetteer 2001, pp. 865–7. 15 A proper history of Tibetan medicine in the area of Rebgong remains to be written. 16 ‘Bsgyur bkod’ means the transformation of the old tradition to fit the new situation. 17 He systematically studied Tibetan medicine under the eminent physician and teacher, Drungyik Tsojé Gendün Trinlé Gyamtso. 18 Ake (a khu) is a respectful title for an older monk but also simply means ‘uncle’.
asian medicineDownloaded from 10 Brill.com09/25/2021(2015) 221–248 08:54:18PM via free access The White Pill 225 from the senior physicians and have subsequently become the cornerstones of the current Malho Prefecture Tibetan Medical Hospital (Tib. Rma lho khul bod sman khang, Ch. Huangnan zhou zangyiyuan 黃南州藏医院) in the prefectural town of Rebgong. The forerunner of this hospital was a small county Tibetan medical clinic set up in 1976, immediately after the Cultural Revolution. Then, seven years later, the clinic was expanded into the present Malho Prefecture Tibetan Medical Hospital (hereafter the ‘Malho Tibetan Hospital’). Among the senior monk physicians from Rongwo Monastery Ake Jamyang Yiknyen19 was also the teacher of many learned students who are now senior doctors working at the well-known Qinghai Province Tibetan Medical Hospital in Xining.20 Another former monk physician from Rongwo stands out, Jikmé Püntsok (’Jigs med phun tshogs). He is director of the large pharmaceutical factory for Tibetan medicine in Xining, the Qinghai Jiumei Tibetan Medical Co. Ltd. (Ch. Qinghai Jiumei zangyao yaoye youxian gongsi 青海久美藏药药 业有限公司), and of the Qinghai Jiumei Tibetan Hospital (Ch. Qinghai jiumei zangyiyuan 青海久美藏医院).21 His pharmaceutical factory and hospital are among the largest for Tibetan medicine in Xining, next to the Arura Tibetan Medicine Co. Ltd. (Ch. Qinghai Jinke zangyao gufen youxian gongsi 青海金诃 藏药股份有限公司) and the strongly government-supported Qinghai Province Tibetan Medical Hospital.22 Furthermore, the Tantric master from Rebgong Tamdringyel (Rta mgrin rgyal), both a well-known teacher of Tantric Tibetan Buddhism and a distin- guished professor emeritus of Tibetan medicine from Qinghai University, has taught many students who are now working at different Tibetan medical hos- pitals in Qinghai. In Rebgong, also local lineage physicians, many of whom are family-based and go back many generations, are well-known in this area and practise here to this day.23 Equally, the production of Tibetan medicine com- pounded by these private physicians themselves has a long history in Rebgong. The development of the Malho Tibetan Hospital into an important centre of Tibetan medicine is also due to the extended visit of probably the most famous teacher and physician of Tibetan medicine at the time, Khenpo Troru Tsenam (Mkhan po Khro ru tshe rnam, 1928–2005) in 1987. This highly-accomplished
19 Jamyang Yiknyen, a former monk, was first ordained at the age of six at Tsö (Gtsos) Monastery and moved to Rongwo Monastery at the age of 24. There he systematically studied Tibetan medicine. 20 Adams et al. 2010; Craig 2012; Saxer 2013. 21 Cf. Saxer 2013. 22 On these two pharmaceutical factories, see ibid. 23 Cf. Schrempf 2010.
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Tibetan medical practitioner—director of the famous Tibetan medical hospi- tal and school in Lhasa, the Mentsikhang (Sman rtsis khang)—had restored the elaborate mercury detoxification techniques thought to be on the verge of extinction in the early 1980s, following the Cultural Revolution. It is to his credit that he passed on this knowledge and practice also to the Tibetan doctors at the Malho Tibetan Hospital in Rebgong. Practitioners from other hospitals in Qinghai province joined his teachings at the time. Under Troru Tsenam’s aus- pices, the Malho Tibetan Hospital was able to make purified ‘mercury sulfide ash’ tsotel (Tib. btso thal) and used it to produce several ‘precious pills’ (Tib. rin chen ril bu), such as Mutik-70 (Mu tig bdun bcu), Rinchen Drangjor (Rin chen grang sbyor), and Rinchen Mangjor (Rin chen mang sbyor). Khenpo Troru Tsenam thereby succeeded in rekindling the fading embers of the knowledge of the ‘great mercury purification’ (Tib. dngul chu btso bkru chen mo) in this larger Tibetan area known as Amdo. This expertise of detoxifying mercury has ever since empowered Tibetan medical hospitals across Tibetan areas in Amdo and also beyond to produce a multitude of intricate precious pills. Well-known as being the most efficacious powerful pills of Tibetan medicine, the income generated by selling these pills also represents a major contribution to the eco- nomic survival of Malho Tibetan Hospital today.24 Four administrative levels of biomedical health care facilities are avail- able in Rebgong town, namely the Huangnan Prefecture Peoples’ Hospital (Ch. Huangnan zhou renmin yiyuan 黄南州人民医院), different hospitals of Tongren County,25 and several township and village level clinics. Before the second half of the twentieth century, the practice of biomedicine was basi- cally non-existent in Rebgong. The Tibetan term gyermen (Tib. rgya sman)— literally meaning ‘Chinese medicine’—illustrates clearly that biomedicine was probably not introduced here by Chinese physicians before the 1950s. According to the Tongren County Gazetteer (Ch. Tongren xian zhi 同仁县志), at that time only one public clinic and four private clinics existed in Rongwo. Of the four, two were biomedical clinics and the other two practiced traditional Chinese medicine.26 Today, biomedicine-based village and township clinics provide basic pre- ventive and curative services to the rural, mostly Tibetan population, such as
24 On the practice and importance of tsotel in Tibetan medicine, see Gerke 2013. 25 These are Xian jikong zhongxin 县疾控中心 (County Center for Disease Control and Prevention), Bo’ai yiyuan 博爱医院 (Bo’ai Hospital), Ziran fenmian zhongxin 自然分娩 中心 (The Center for Natural Childbirth), Regong fuchan yiyuan 热贡妇产医院 (Regong Hospital for Gynaecology and Childbirth). Except for the first governmental one, the other three hospitals are private. 26 Tongren County Gazetteer 2001, p. 859.
asian medicineDownloaded from 10 Brill.com09/25/2021(2015) 221–248 08:54:18PM via free access The White Pill 227 immunisation, maternal and child health care, family planning, and assistance in implementing health policies at these local levels. The Tibetan villagers I interviewed complained that biomedical health care workers stationed at the so-called ‘township health care centres’ (Ch. xiang weishengyuan 乡卫生院) were often absent and negligent of their responsibilities. When a disease can- not be prevented or cured by township doctors, patients are usually referred to the county and prefecture hospitals endowed with better facilities and equip- ment, and staffed with qualified doctors and nurses. However, according to the villagers, physicians of Tibetan medicine in local clinics were much more empathetic towards their patients and also more approachable after hours. Also, many non-Tibetan patients generally characterised Tibetan physicians as ‘kind’ and ‘patient’. The physicians whom I interviewed, senior ones in particu- lar, emphasised the importance of the ethical code of physicians of Tibetan medicine and their altruistic motive to benefit all patients indiscriminately. Although many young Tibetan physicians these days lack thorough training in Buddhist teachings traditionally required of medical practitioners, they also highlight this code of ethics as an indispensible moral asset.
Stomach Disorders—A Common Problem in Rebgong
In order to explore the use of Tibetan medicine among all three groups of Tibetans, Han, and Hui in Rebgong Town, I applied a combination of a quan- titative survey and qualitative interviews for data collection in 2014 and 2015 respectively. A questionnaire was distributed to 80 participants of Tibetan, Hui, and Han Chinese ethnicity respectively, amounting to 240 participants repre- senting a convenient sample. Ten respondents were selected from each ethnic group for follow-up, in-depth interviews. For the survey, I adopted a snowball sampling method to recruit informants based on participants’ previous or cur- rent experience of using Tibetan medicine. This I did through friends, acquain- tances, clinics, and hospitals. I would like to mention that it is possible that because I am a local Tibetan and because Tibetan medicine is mainly taken by Tibetans in this area—at least according to what physicians have to say at different levels—it was not that easy to find and approach enough Han and Hui patients to ask them about their use.27 The questionnaire survey was trans- lated both into Tibetan and Chinese language. However, some Hui participants
27 Generally speaking, the interethnic relationships between Han, Hui, and Tibetans in this multiethnic borderland are complex, and sometimes erupt at times of economic ten- sions. See, for example, Horlemann 2012.
asian medicine 10 (2015) 221–248 Downloaded from Brill.com09/25/2021 08:54:18PM via free access 228 Nianggajia were illiterate in both Tibetan and Chinese, hence these questionnaires were explained orally with deliberate slowness and detailed explanation. The primary objective of the survey was to find out about patients’ treat- ment choices as well as preferred Tibetan medical institutions or physicians. This was to gain a general overview of the ailments for which Tibetan medi- cine is used among the three ethnic groups. All health information is there- fore self-reported and happened outside of clinical contexts.28 To complement the quantitative survey with qualitative data, in-depth, face-to-face and semi- structured interviews were conducted with ten selected informants from each group, as well as Tibetan medical practitioners. Some participants withdrew during the course of the inquiry.29 However, most participants were willing to share with me their experiences and reasons for resorting to Tibetan medicine. Relatively speaking, many Tibetan patients as well as non-Tibetans reported that they often visited private physicians of Tibetan medicine at their clinics. They reasoned that Tibetan doctors were more experienced, learned, and eas- ily approachable. My own visits to such private clinics confirmed that many Tibetan doctors are indeed experienced senior physicians. They are either lineage-holders of previous prominent doctors or retired physicians from the Malho Tibetan Hospital. In turn, these retired senior doctors are recruited specifically for their presence as specialists at this hospital, so that based on their renown Malho Tibetan Hospital can attract more patients and offer bet- ter health services. So these physicians divide their time between the hospital and their own private clinics, spending one day at the hospital and the rest at their private clinics. I think it is because of this important circumstance—the renown and expe- rience of these senior physicians in effective treatment—that both private clinics and the Malho Tibetan Hospital were popular. Yet it seemed that gen- erally among patients the latter was preferred over private clinics. This could also have to do with the seriousness of the disease, leading the patient needing to stay as an in-patient rather than an out-patient, and the New Cooperative Medical Scheme (Tib. zhing sde’i mnyam las sman bcos; Ch. nongcun hezuo yiliao baoxian 农村合作医疗保险), a health insurance scheme to reduce the
28 We can therefore exclude any direct influence physicians of Tibetan medicine could have had on the patients if interviews would have been conducted in their clinics. 29 Since I had informed all participants at the outset of the survey of their right to with- draw from the study at any time without any explanation, some declined further in-depth interviews. I would attribute their rejection to the painful reminiscence of unpleasant illness experiences and to the disapproval from other family members. Potential infor- mants had to be recruited as substitutes to replace those who had declined.
asian medicineDownloaded from 10 Brill.com09/25/2021(2015) 221–248 08:54:18PM via free access The White Pill 229 risk of catastrophic health expenditures for rural residents.30 Furthermore, it is possible that additional biomedical facilities were offered at the Malho Tibetan Hospital. My ethnographic research data shows that stomach and digestion related problems were the most common disorders among patients, regardless of patients’ ethnic background;31 52% (n = 44) Han, 45% (n = 38) Hui, and 33% (n = 27) Tibetan respondents reported to have suffered from these. These con- ditions included both chronic and more acute conditions, such as chronic stomach inflammation (Ch. manxing weiyan 慢性胃炎), stomach ulcer (Ch. weikuiyang 胃溃疡), indigestion (Ch. xiaohua bu liang 消化不良), diarrhoea (Ch. fu xie 腹泻), and stomach problems (Tib. pho ka, literally ‘stomach’;32 weibing 胃病). Among 43% (n = 35 out of 44) of Han patients, the White Pill was specifically used to treat stomach ailments either with or with- out prescription. Also 31% (n = 25 out of 38) of Hui respondents confirmed this while Tibetan patients often did not remember what they had used as treatment for their stomach ailments because they did not know what their doctors had prescribed at the time. From interviews with Tibetan respondents and conversations with acquaintances, I learnt nevertheless that they also fre- quently took the White Pill. Compared with non-Tibetans, Tibetans had a variety of Tibetan medicines to choose from to treat their stomach aliments without prescription, such as Sendru Dangné (Se ’bru dwangs gnas). Also popular among Tibetans are the famous precious pills; for example, Rinchen Drangjor, Dashel Chenmo (Zla shel chen mo), Dashel Dütsi (Zla shel bdud rtsi), Rinchen Mangjor, Zhijé-29 (Zhi byed nyer dgu), and Dejé Nyomden (Bde byed snyoms ldan). Many Tibetans knew the names of frequently used medicines for correspond- ing conditions. This resulted from their previous experience and long-time interaction with menpas. It is a popular phenomenon in Rebgong that Tibetans have a tendency to take the White Pill to prevent potential stomach disorders ensuing from exces- sive intake of food or cold-natured food that is known to reduce the necessary digestive heat. While the White Pill among Chinese and Hui was primar- ily prescribed by physicians of Tibetan medicine related to the seriousness of their disease, Tibetan respondents seemed to take the White Pill without
30 This scheme only covers in-patient hospital expenses; cf. You 2008, pp. 1–9; Nianggajia 2011. 31 This finding coincides with what Bassini 2013 encountered as being a very common health issue in another area of Amdo populated by Tibetan pastoralists. 32 In the context of illness, Tibetans in Rebgong often use pho ka to refer to stomach problems.
asian medicine 10 (2015) 221–248 Downloaded from Brill.com09/25/2021 08:54:18PM via free access 230 Nianggajia prescription primarily as a digestive tonic; in particular, when they had eaten too much. However, some non-Tibetans also said that they take the White Pill without prescription. One female Chinese respondent in her forties, suffering from both gallstone and stomach problems, explained:
I think gallstones led to my stomach problem because I took Xiaoyan lidan pian33 very often. This medicine is a kind of traditional Chinese medicine for gallbladder problems. Frequent use of Xiaoyan lidan pian, I think, caused my stomach problem. I say so because I felt discomfort in my stomach every time I took it. Then, one of my colleagues recom- mended the White Pill to treat my stomach. As he advised, I went and bought the White Pill from Gartse Monastery Clinic34 directly. I guess I took three packages of Gartse White Pills. The White Pill, as my colleague said, was indeed good for my stomach. As far as I have noticed, it seems the White Pill does not have any side effects.35
When asked if his Hui friends know about the Tibetan White Pill, Wang, one of my Hui respondents in his forties, said the White Pill was widely used among his friends for stomach disorders. I probed further as to whether the White Pill was prescribed by Tibetan physicians or bought without valid prescription. The White Pill, he answered, was directly recommended by acquaintances during conversations about health problems. They bought it either from the private clinic of Gartse Monastery or the dispensary at Malho Tibetan Hospital. It can be concluded that the White Pill is widely used among the three ethnic groups in Rebgong to prevent and treat stomach problems. There is a general consensus among the majority of the respondents I inter- viewed—both patients and physicians—that the culprit of their stomach problems can be attributed to the frequent consumption of spicy food, con- stant use of Western medicine or biomedicine, skipping breakfast, and other unwholesome lifestyle habits.
33 Xiaoyan lidan pian (消炎利胆片) is a traditional Chinese patented medicine. 34 The full name is Gartse Monastery Tibetan Medicine Clinic (Tib. Mgar rtse dgon bod sman khang, Ch. Guashize si zangyiyuan 瓜什则寺藏医院), hereafter called abbre- viated Gartse Monastery Clinic; it is located in Gartse Township (Ch. Guashize xiang 瓜什则乡), Rebgong County. 35 From my fieldnotes collected in the summer of 2015.
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The White Pill alias Rikar alias Jiebaiwan
Tendzin, a young Tibetan physician, well versed in Tibetan medicine who worked at a private clinic, explained confidently:
In general, Rikar is good for bad kan [‘phlegm’] disorders. In particular, it is good for the stomach and indigestion.36 What I have found unique about Rikar is that it also cures bad kan ’byor byed [‘connecting phlegm’] disorder in the joints.37 If the fluid between joints dries up, it is impor- tant to cure bad kan disorder so that bad kan ’byor byed can be restored. [However] I guess there are probably no doctors these days who would prescribe Rikar for the joints disorder bad kan ’byor byed.38
As we have seen in the previous section of this article, Rikar—among Chinese- speakers known as Jiebaiwan, literally ‘the pristine white pill’—is a popular Tibetan medicine among both non-Tibetan and Tibetan patients in Rebgong for treatment of gastrointestinal conditions (Tib. pho rgyu’i nad; Ch. changwei bing 肠胃病). Rikar is also known among physicians of Tibetan medicine as a kind of panacea, the ‘Single Medicine for a Hundred Illnesses’ (Tib. nad brgya sman gcig). Based on the experiences of menpas as well as those of patients, this is most likely the case because digestive disorders are very common in this area and because digestion is so central to health in Tibetan medical under- standings. However, the Tibetan name Rikar is virtually unknown to non- Tibetan patients, as it is eclipsed by its Chinese name, Jiebaiwan. In addition, Rikar is also named after the place of production, like Gartse Rikar and Labrang Rikar, reflecting the fact that there are specifics of this pill related to distinct types of empirical local knowledge and place. In Rebgong, Gartse Rikar is particularly renown for its efficacy. Gartse Rikar does not neces- sarily have the same ingredients as Labrang Rikar and vice versa. The addition of more ingredients to the inceptive formula has led to the production of dif- ferent White Pills in different places, yet they are all labelled with indications for digestive problems. Because no biochemical tests have been conducted and the labelling of single ingredients is usually not complete, we cannot be sure what exactly is contained in a White Pill and whether one particular
36 Bad kan myag byed is one of the five types of ‘phlegm’ (Tib. bad kan) located in the stom- ach and responsible for breaking down food stuff properly. 37 Bad kan ’byor byed is one of the five types of ‘phlegm’ located in the joints and responsible for the movement in the joints. 38 From my fieldnotes collected in the summer of 2015.
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White Pill is more effective than the other. In any case, in Rebgong patients generally preferred the Gartse White Pill, which shows a perceived difference in local efficacy and renown connected to this monastery and place. Important questions relate to the fact that compounds produced by different pharma- ceutical entities, although following the same formula, usually do not procure the same therapeutic efficacy. This is unless they have the same ‘taste’ (Tib. ro) and therefore ‘effect’ or ‘potency’ (Tib. nus pa), according to Tibetan medical principles regarding the efficacy of materia medica.39 Among producers, the expertise of those involved and the freshness of the herbs are decisive compo- nents for efficacy.40 As one private physician, who also produces the White Pill himself, puts it:
I neither buy the White Pill from public hospitals nor from pharmaceuti- cal companies. I produce the White Pill myself and prescribe it accord- ing to the [individual] condition of my patients. These days, producers of medicine and doctors working at hospitals are practically independent of each other. Then the question arises, how much do the doctors know about the medicine produced by the producers? And how much do the producers know about Tibetan medicine? So there is a knowledge gap between the doctor and the medicine. The traditional way is that doctor and medicine are not two separate entities. In my case, I know how my medicine works and how I should prescribe it according to the condition of my patients. That is why medicines produced by senior private doctors are deemed more effective.41
Rikar is a formula said to be first compounded by the well-known Tibetan cul- ture hero Tangtong Gyelpo (Thang stong rgyal po, 1361–1485).42 The White Pill’s full Tibetan name is Druptop Rikar (Grub thob ril dkar), the ‘White Pill of an Accomplished One’. This formula will be introduced in the following section.
The Original Formula of Druptop Rikar Druptop Rikar is a formula said to be first compounded by the famous Tibetan culture hero and saint Tangtong Gyelpo. According to the Tibetan formula text Clarification of the White and Red Pills, the Single Medicine for a Hundred Illnesses, the Tradition of the Great Saint Tangtong Gyelpo (Grub chen thang stong rgyal po’í lungs kyi nad brgya sman gcig ril bu dkar kyi gzhung gsal byed
39 See, for example, Clark 1995, pp. 124–87. 40 See, for example, Saxer 2013, p. 96. 41 From my fieldnotes collected in the summer of 2015. 42 Stearns 2007, p. 23.
asian medicineDownloaded from 10 Brill.com09/25/2021(2015) 221–248 08:54:18PM via free access The White Pill 233 dang bcas pa)—hereafter called Clarification of the White and Red Pills—by Jamyang Khyentsé Wangpo (’Jam dbyangs mkhyen brtse’i dbang po; 1820–92),43 the classical formula Druptop Rikar has the following six core ingredients:44 1. arura (Tib. a ru ra; Lat. Terminalia chebula Retz) commonly known as chebulic myrobalan, 2. chongzhi (Tib. cong zhi; calcitum), 3. künjé gyelpo (Tib. kun byed rgyal po), 4. drakzhün (Tib. brag zhun; Lat. Trogoptrus xanthipes Milne-Edwards), and 5. pushkaramula (Tib. pusha ka ra mu la; Lat. Vladimiria Souliei (Franch) Ling). These five ingredients are compounded into a pill with ‘honey’ or drangtsi (Tib. sbrang rtsi). Jamyang Khyentsé Wangpo comments that the original text does not precisely clarify what künjé gyelpo actually is, but only briefly explains it is a herb. For this reason, the ‘Northern Tradition’ (Byang lugs) of Tibetan medicine identifies it as pangtsi dobo (Tib. spang rtsi do bo; Lat. Pterocephalus hookeri Hook)45 whereas the ‘Southern Tradition’ (Zur lugs) of Tibetan medicine recognises it as honglen (Tib. hong len; Lat. Picrorrhiza scrophulariaefolia pennell). At the same time, some even claim it is rékön (re skon; Lat. Corydalise nepalensis Kitamura).46 The Tibetan pharmacopoeia Gso rig zin tig yang tig, known in short as Zin tig, written by Kongtrul Yönten Gyamtso (Kong sprul yon tan rgya mtsho; 1813–92), records that the Druptop Rikar formula has honglen instead of pangtsi dobo and rékön.47 However, Deumar Tendzin Püntsok (De’u dmar bstan ’dzin phun tshog; 1672–17?) in his famous pharmacopoeia Shel gong shel phreng enumerates 20 different Tibetan names for pangtsi dobo, and künjé gyelpo is only one of them.48 As we can see, the core formula may have slightly changed over time due to the differ- ent interpretations of the original formula, probably also depending on local differences in nomenclature, identification, and availability of these plants. Despite the difference, Jamyang Khyentsé Wangpo argues that the change of ingredients does not really contradict anything if the all-over potency of the formula is established and if it is prescribed properly according to the nature
43 Jamyang Khyentsé Wangpo, born in Dilgo in Dergé (East Tibet) in 1820, was a major ‘trea- sure revealer’ (Tib. gter ston) reviving Tangtong Gyelpo’s treasure tradition. See Stearns 2007, p. 24. 44 The names of the following ingredients are given first in Tibetan. For details on the phar- macological names of ingredients, including Latin (when given), see Karma Chömpel 1993, pp. 23, 21, 147, 556. However, pharmacological names may refer to different plants within the same plant family; see also Clark 1995; Gawé Dorjé 1995. Since Latin names may not refer to the exact Tibetan medical ingredients, I suggest the emphasis should be placed on Tibetan terms in Tibetan medical contexts. 45 Karma Chömpel 1993, pp. 255, 413, 417. 46 Jamyang Khyentsé Wangpo 1997, pp. 590–601. 47 Kongtrul Yönten Gyamtso 2005, p. 313. 48 Deumar Tendzin Püntsok 2005, p. 349.
asian medicine 10 (2015) 221–248 Downloaded from Brill.com09/25/2021 08:54:18PM via free access 234 Nianggajia of illness(es) and imbalance of the patient. As I found during my fieldwork, Malho Hospital, Gartse Monastery Clinic, and private physicians I interviewed follow the Northern Tradition. Arura, one of the six core ingredients of the White Pill, is often called Menchok Gyelpo Arura (Sman mchog rgal po A ru ra, ‘Arura, the King of Medicines’). As documented in the classical and widely used pharmacopoeia Shel gong shel phreng, it is so-called because arura covers all six tastes, eight natural potencies, three post-digestive tastes, and seventeen qualities. Given its therapeutic qualities, arura is added to many compounds as one of the main ingredients. Chongzhi halts diarrhoea, and cures fever caused by ‘phlegm’ (Tib. bad kan) and hot disorders; pangtsi dowo cures infectious diseases and fever in the heart; drakzhün cures all kinds of fever and fevers of stomach, liver, and kidneys in particular. Pushkaramula cures ban kan fever. Finally, ‘honey’ or drangtsi, similar to an excipient in a biomedical sense, works primarily as menta (sman rta, literally ‘medicine horse’), i.e. as the vehicle to deliver the effect of the pill to the location of disorders.49 The six ingredients have more qualities and potencies than I have listed above. Above mentioned are only brief illustrations drawn from the Shel gong shel phreng.50 With the six ingredients as the core formula, more ingredients can be added on in relation to the cause and severity of the disorder of a particular patient. This practice of addition is called kha bsgyur, which literally means ‘direction change’. Adding a particular ingredient can direct the action of the formula to the predominant nyépa of the patient that causes the disease. As explained in the Clarification of the White and Red Pills, agaru or short agar (Tib. a ga ru, Lat. Aquilaria sinensis)51 and lishi (Tib. li shi; Lat. Eugenia caryophllata thunb)52 can be added if the disorder is caused predominately by the ‘fault’ or nyépa (Tib. nyes pa) of ‘wind’ (Tib. rlung); tikta (Tib. tig ta; Lat. Swertia chirata buch- ham) and ser metok (Tib. gser me tog; Lat. Herpetospermum pedonculosum (ser) Baill) are added for disorders caused by the nyépa of ‘gall’ (Tib. mkhris pa); and pomegranate or sendru (Tib. se ’bru; Lat. Punica granatum) and ser metok are added for treating ‘phlegm’ disorders. Bongnga (Tib. bong nga; Lat. aconitum) and latsi (Tib. gla rtsi) or ‘musk’ are additionally used for curing ‘inflammations’
49 In general, there are three menta functioning as vehicles of medicines. Honey usually serves as the carrier of medicines to cure ‘phlegm’ (bad kan) disorders. Sugar is used as the vehicle for medicines to cure ‘gall’ (mkhris pa) disorders while molasses or cane sugar for medicines is used to cure ‘wind’ (rlung) disorders. 50 Deumar Tendzin Püntsok 2005, pp. 112, 158, 163, 239, 349, 454. 51 Gawé Dorjé 1995, p. 164. 52 Karma Chömpel 1993, pp. 5, 7, 9, 11, 12, 14, 18, 50, 132, 163, 258, 259, 344, 346.
asian medicineDownloaded from 10 Brill.com09/25/2021(2015) 221–248 08:54:18PM via free access The White Pill 235
(Tib. gnyan tshad); bongkar (Tib. bong dkar; Lat. Aconitum naviculare Stapf ) and dzinpa (Tib. ’dzin pa; Lat. Aconitum flavum Hand-Mazz) for ‘infectious dis- eases’ (Tib. rims nad). The ‘six excellent substances’ (Tib. bzang bo drug)53 are used as add-ons for disorders of the five organs and the six hollow organs; more specifically dzati (Tib. dza ti; Lat. Myristica ficafragrans Hount) for the heart; lishi for ‘life channels’ (Tib. srog rtsa); chugang (Tib. cu gang; Lat. Bambusa textilis McClure, calciosinter or bamboo concretion) for lungs; gurgum (Tib. gur gum; Lat. Crocus sativus) for liver; kakola (Tib. ka ko la; Lat. Amomum tsao—ko Crev et Lemaire) for the spleen; sukmel (Tib. sug smel; Lat. Elettaria cardamomum) for kidneys; pomegranate sendru for the stomach; ser metok for gallbladder; dukmo nyung (Tib. dug mo nyung; Lat. Strophanthus wallichii A. DC) for intestines; wangpo lak (Tib. dbang po lag; Lat. Gymnadenia crassi- nervis Finet) for reproductive organs; gyatsa (Tib. rgya tshwa; Lat. Ammonium muriaticum, or Sal ammoniacum)54 for urinary bladder;55 batru (Tib. ba spru; Lat. Mirabilis himalaica) for uterus and vesicle; and finally ngülchu (Tib. dngul chu or ‘detoxified mercury’) and sengdeng (seng ldeng; Lat. Dalbergia sissoo Roxb) for lymph or serum disorders.56 Apart from latsi, bongkar, dukmo nyung, wangpo lak, gyatsa, batru, and ngülchu, all other added ingredients are used in many contemporary White Pill formulas produced by private doctors and hospitals with by Tangtong Gyelpo’s core formula as basis. According to the Clarification of the White and Red Pills, the White Pill pos- sesses high therapeutic potency or efficacy to cure all kinds of disorders aris- ing from an imbalance of the ‘three faults’ (Tib. nyes pa gsum). Thus Druptop Rikar is also known as the ‘Single Medicine for One Hundred Illnesses’ (Tib. Nad brgya sman gcig). The eulogistic expression implicitly denotes that the pill does not have any side effects as it has the efficacy to balance and cure all disor- ders indiscriminately of individual patients’ respective imbalances. In particu- lar, the White Pill cures ‘blood and bile’ (Tib. khrag mkhris), and beken kyamuk (Tib. bad kan skya smug) disorders, today often equated with stomach ulcer in a biomedical sense; i.e. acute and chronic stomach disorders, infectious dis- eases, and acute fevers. Jamyang Khyentsé Wangpo argues that, in addition to the fact that the knowledge that emanated from Tangtong Gyelpo is unbroken
53 The ‘six excellent substances’ are gurgum, chugang, lishi , dzati, sukmel, and kakola. 54 Karma Chömpel 1993, pp. 96, 171, 596. 55 The original sentence in the text reads ‘snang ba’i bzang po rgya tshwa yin’. I think the word snang ba is misspelled and it should be lgang ba (‘urinary bladder’), one of the six hollow organs. 56 Jamyang Khyentsé Wangpo 1997, pp. 590–601.
asian medicine 10 (2015) 221–248 Downloaded from Brill.com09/25/2021 08:54:18PM via free access 236 Nianggajia and transmitted by lineages for centuries, his own clinical experiences also prove that the core formula does not have any ‘side effects’ (Tib. zhor skyon).57
Present Producers and Users of Rikar in Rebgong
The White Pill from Malho Prefecture Tibetan Medical Hospital Malho Prefecture Tibetan Medical Hospital is a public hospital with 150 beds for in-patients and an outpatient ward. It also has 200 employees, of whom only 56 are on the state’s payroll, and the rest are ‘temporary employees’ (Ch. linshi gong 临时工) that need to be paid by income generated by the hospital itself. The latter circumstance is partly managed via the hospital’s own production of Tibetan medicines in the pharmaceutical department (Tib. sman sbyor tshan kang). Rikar is one of their best-selling products and prescribed to in- and out-patients—in particular for the locally common ail- ment of stomach disorders. As well as the pharmaceutical department, the hospital at present con- sists of seven specialised medical departments or units, including the hepatic department (Tib. mchin nad tshan khag), the gastrointestinal department (Tib. pho rgyu tshan khag), the department of internal medicine (Tib. kong nan tshan khag), the department of cardio-cerebrovascular diseases (Tib. glad snying tshan khag), the department of gynaecology (Tib. mo nad tshan khag), the department of external therapies (Tib. phyi bcos tshan khag), and the department of surgery (Tib. gshag bcos tshan khag). The department of surgery was recently launched by the head of the hospital who specialises in biomedi- cine. Since the appointment of new leadership in 2013, the use of biomedi- cine in this hospital has become more dominant; now minor surgeries, such as appendectomy and cholelithotomy, are also performed here. Generally speak- ing, however, biomedicine is only used when either the patients’ symptoms are very acute or certain illnesses fail to respond to Tibetan medicine. In most cases, all oral medications administered to in-patients are Tibetan medicines. Intravenous drips are primarily used for the amelioration of acute symptoms, while the simultaneous use of orally taken Tibetan and Chinese bio-medica- tions is usually avoided. This is due to fears that Tibetan medicine may not procure the predicted desired effect. The hospital has both the expertise and the facilities necessary to pro- duce Tibetan medicines in order to meet the demands of its patients. The
57 Jamyang Khyentsé Wangpo 1997, pp. 590–601.
asian medicineDownloaded from 10 Brill.com09/25/2021(2015) 221–248 08:54:18PM via free access The White Pill 237 pharmaceutical department produces around 200 different medicines with 129 registered at Qinghai Province Food and Drug Administration as medicines certified by ‘Good Pharmacy Practice’ (GPP).58 Tsering, a pharma- cist in his forties from the hospital, explained that GPP-certified medicines should be used only within the hospital and must be prescribed to in- and out-patients with a valid prescription. GPP-certified medicines are produced locally in relation to the clinical need at a hospital, and thus large-scale pro- duction is not allowed. In contrast, profit-oriented pharmaceutical companies produce Tibetan medicines for mass-consumption and a wider market based on GMP (Good Manufacturing Practices).59 Although large and technically far more advanced, the state-owned public Malho Tibetan Hospital does not produce more White Pills than private pro- ducers, such as Gartse Monastery Clinic, which I will discuss below. At Malho Tibetan Hospital, the annual production of the White Pill is about 225 kg used for both in- and out-patients depending on clinical demand and patients’ needs. When I asked Tsering why their relatively large hospital produced such a comparatively small amount of White Pills, he answered:
Our White Pill is for our own use only at the hospital and we can produce more when we are short of the pills. The provisions for private Tibetan health care providers are not as strictly implemented as they are for pub- lic Tibetan hospitals. For private Tibetan doctors, the sale of a large quan- tity of medicines like the popular White Pill at a lower price is one way to bring in more revenues. Our price is fixed no matter how many pills we sell or prescribe to patients.60
As I learnt from the patients I conversed with, the hospital also sells small quan- tities of the White Pill—for instance ten boxes with 150 pills at a time—relying on how much medicine a patient needs. The hospital’s White Pill box features indications, dosage, and administration precautions, as well as the hospital’s contact address in Tibetan. In Chinese, it additionally includes the registra- tion number, production, and expiration dates. Trying to correlate indications
58 GPP entails standards for pharmacy practice regulated by the Food and Drug Administration. The valid term of registration is three years. The hospital is obliged to apply for the renewal of registration of medicines prior to the expiry date to continue the production. 59 See Craig 2011; Saxer 2012. 60 From my fieldnotes collected in the summer of 2015.
asian medicine 10 (2015) 221–248 Downloaded from Brill.com09/25/2021 08:54:18PM via free access 238 Nianggajia written in Tibetan and in Chinese via English translations, the following would result:
1. mashuwa (Tib. ma zhu ba, ‘indigestion’)—Ch. qing weire 清胃热 (‘clear- ing away stomach-heat’)61 2. beken kyamuk (Tib. bad kan skya smug, ‘pale-white and brown bad kan’)62—Ch. pei gen mu bu 培根木布63 3. chin tri po tsé gyépa (Tib. mchin mkhris pho tshad rgyas pa, ‘liver, gallblad- der, and stomach inflammation or fever’)—Ch. manxing weiyan 慢性 胃炎 (‘chronic stomach inflammation’)64 4. dangga midewa (Tib. dang ga mi bde ba, ‘loss of appetite’)—Ch. wei tong 胃痛 (‘stomach pain’) 5. po kyur (Tib. pho skyur, ‘stomach acid’)—Ch. zhi suan 制酸 (‘stop hyperacidity’) 6. kyuk (Tib. skyugs, ‘vomiting’)—Ch. outu suanshui 呕吐酸水 (‘the throw- ing up of acid liquid’) 7. Tib. poné (pho nad, ‘stomach illnesses’)65—Ch. weibu yongse 胃部壅塞 (‘stomach congestion’)
As we can see from the above, the indications in Tibetan and Chinese slightly differ from each other. Despite the fact that the White Pill is known as the ‘Single Medicine for a Hundred Illnesses’ among Tibetan physicians, it seems the hospital is specifically focusing—in both Tibetan and Chinese indica- tions—on stomach related illnesses only. This specialisation of indications
61 ‘Indigestion’ (Tib. ma zhu ba) often starts with acid reflux if it is hot in nature. 62 Bad kan skya smug or bad kan smug po is often translated as ‘stomach ulcer’, even though this is only one aspect of this complex disease and its either hot or cold variants, that occurs in three to four main stages—acid reflux, liver impairment, ulcers, and impaired bowel movement. 63 This is simply a phonetic Chinese transcription of the Tibetan medical term bad kan smug po. Bad kan smug po is considered a combined digestive disease of an imbalance of all ‘three faults’ (Tib. nyes pa gsum), including as fourth important substance ‘blood’ (khrag) that is related to the liver. See chapter five of the Man ngag rgyud (The Oral Instruction Tantra) of the Gyüshi (Rgyud bzhi, or Four Tantras) by Yutok Yönten Gönpo 1992, pp. 133–46. 64 This correspondence is an example of an only partial translation of more complex Tibetan disease categories into just one of its aspects in Chinese. 65 Pho nad is a very general Tibetan term for any kind of stomach disease.
asian medicineDownloaded from 10 Brill.com09/25/2021(2015) 221–248 08:54:18PM via free access The White Pill 239 could also imply that a certain adaptation to biomedical disease foci is already on its way.66 As stated earlier, the White Pill is prescribed only with prescription to both in- and out-patients of the Malho Tibetan Hospital. Yet, while the White Pill is frequently prescribed at the hospital according to Dorjé, a Tibetan pharmacist working in the in-patient dispensary, it is not necessarily the only medicine more often prescribed when compared to other stomach medicines. Dorjé estimates conservatively that on a scale of one to ten, one being ‘often’ and ten being ‘seldom’, the White Pill was prescribed eight out of ten times. He reasons that usually doctors do not administer the White Pill individually to in- patients, but combine several different medicines to reinforce the efficacy of prescribed remedies for particular illnesses and in accordance with respective Tibetan medical principles and clinical experiences. In the context of Tibetan medicine, medicines are never prescribed only according to a specific disease but dosed and administered following a holistic diagnosis of each individual patient’s imbalance of the three ‘faults’. As Dorjé illustrates, there is no single case where only one type of medicine is used to treat patients. Since for in- patients the White Pill is only administered in combination with other Tibetan compounds, it is not given to them in the same amounts as it is to out-patients. Although the White Pill box explicates that the pill should be taken in the dose of one pill two or three times a day, doctors at the Malho Tibetan Hospital usu- ally administer only one pill a day and combine it with other compounds, as I will demonstrate in the example below. Combining an individualised treatment plan including the White Pill with several other formulas in one prescription complex for an in-patient diagnosed with ‘atrophic gastritis’ (Tib. pho rub), the patient was prescribed the follow- ing, with the aim of curing ‘inflammation’ (Tib. gnyan tshad) and restoring the patient’s digestive heat: • 5am: the precious pill Tsotrü Dashel (Btso bkru zla shel) was soaked over night in warm water; it is to be taken in the following morning on an empty stomach. • 7am before breakfast: Pagmo drupa (Phag mo grub pa) taken together with one Rikar (Ril dkar, White Pill). • 10am after breakfast: Yudril-13 (G.yu dril bcu gsum) and Khyungnga (Khyung lnga).
66 Further research would be necessary to clarify how the regulations of GPP-produced medicines impact on the way in which indications on packages have to be written.
asian medicine 10 (2015) 221–248 Downloaded from Brill.com09/25/2021 08:54:18PM via free access 240 Nianggajia • 1pm after lunch: Dütsi Sumjor (Bdud rtsi sum sbyor) and Tikta-8 (Tig ta brg- yad pa). • after dinner: Gurgum chokdün (Gur gum mchog bdun) and Tangchen-25 (Thang chen nyer lang).
By contrast, Tsering who works in the out-patient dispensary of the Malho Tibetan Hospital roughly estimated that the White Pill was the one drug prescribed most among the medicines for stomach disorders to out-patients regardless of ethnicity, yet to Tibetans in particular. Taking advantage of his daily interaction with out-patients, I probed to find out more specifically why the out-patient dispensary administered more White Pills than did the in- patient dispensary. Tsering replied:
In most cases, it is not the doctors who prescribe the White Pill, but rather it is the people themselves who ask doctors to prescribe the White Pill. I would say two-thirds of annual production of the White Pill is sold to out-patients while one third is administered to in-patients.67
Since gastrointestinal problems are common among Tibetans, Hui, and Han in Amdo,68 the White Pill has become indispensible and is often used for pre- venting and treating gastrointestinal disorders. The White Pill is also part of the important revenue for the Malho Tibetan Hospital to pay for its temporary employees. Similarly, private producers like the Gartse Monastery Clinic sus- tain themselves financially mainly by selling the White Pill as will be shown in the following.
The Gartse White Pill Gartse Monastery Clinic has made itself a name in the area of Rebgong and beyond with its production of the Gartse White Pill. Gartse Monastery (Tib. Mgar rtse gya sa dgon thub bstan chos ’khor gling), founded in 1610, is located approximately 44 kilometres east of Rebgong Town in Gartse Township, Rebgong County. This monastery, which accommodated up to 500 monks before 1958, reopened in 1981 after having been devastated and closed down during the Cultural Revolution. Since then it has undergone numerous res- torations and renovations. It now houses around 130 monks belonging to the Gelukpa School of Tibetan Buddhism. The income of the monastery mainly depends on private donations from its supporting local lay communities (Tib.
67 From my fieldnotes collected in the summer of 2015. 68 Cf. Bassini 2013.
asian medicineDownloaded from 10 Brill.com09/25/2021(2015) 221–248 08:54:18PM via free access The White Pill 241 lha sde) and pilgrims, and what is generated by the monastery’s small shop, a gas station and, in particular, its clinic. Gartse Monastery Clinic is a private institution and is staffed by seven monk doctors. The clinic also has a small pharmaceutical department with a dispen- sary offering medical treatment and medicines to patients. The Tibetan medi- cines produced here contribute a significant amount of revenue to the total annual monastic income, generating approximately 450,000 Rmb every year. Revenues from these sources usually fund monastic activities and supplement the livelihoods of the monks. Despite its limited financial means, in compari- son to the government institution and well-staffed larger prefectural Malho Tibetan Hospital and other hospitals in the area, it has made its own name, becoming famous for its White Pill. According to my informant, Gartse Monastery is not built on a historic tra- dition of a ‘monastic medical college’ (Tib. sman pa grwa tshang) such as the well-known Labrang Monastery (Tib. Bla brang bkra shis ’khyil, Ch. Labuleng si 拉卜楞寺) in Xiahe County (Ch. 夏河县) Gansu Province (Ch. Gansu sheng 甘肃省), for example. The opening of Gartse Monastery Clinic is quite recent, dating back only to the mid-1980s. Following Deng Xiaoping’s Economic Reforms and the revival of monastic life in the early 1980s, new policies for autonomous income generation among monasteries were implemented, and consequently Gartse Monastery was also obliged to seek sustainable ways for its own financial needs (Tib. rang ka rang gso, literally ‘feeding its own mouth’). The Gartse Monastery Clinic is relatively larger than other private clinics in Rebgong Town—indeed it could be called a small hospital.69 As is often the case with many other Tibetan clinics and hospitals, the Gartse Monastery Clinic also uses Chinese biomedicine together with Tibetan medicine to aug- ment its annual revenues. A Chinese woman in her early thirties from Rebgong Town recalls how the Gartse White Pill had cured her stomach problems. Her story reflects how more and more patients, no matter of which ethnic background, and in par- ticular the younger generation directly, take specific Tibetan pills for curing diseases that were previously diagnosed biomedically, i.e. without consulting a physician of Tibetan medicine. Stomach disorders are also a very common urban lifestyle problem in China, regardless of ethnicity:
69 Although it is a clinic, local people call it ‘hospital’ or ‘monastery hospital’. This clinic does not have any beds for in-patients. However, there are four rooms with six beds and bathtubs for menlum (Tib. sman lums, ‘medicinal bath therapy’). My informant from the clinic roughly estimated that they received around 20 out-patients every day.
asian medicine 10 (2015) 221–248 Downloaded from Brill.com09/25/2021 08:54:18PM via free access 242 Nianggajia
In 1996 I left my home for the first time to pursue higher education in Xining. It was also my first time ever to go to a big city. City life was not as easy, convenient, and comfortable as I had imagined, primarily because life was very expensive there. Since my family was not rich, the money my family sent every month was barely enough for my subsistence. Although food was not good at home, I was used to having always three daily meals. Yet, regular meals were not a priority at school and skipping meals became a lifestyle. It was not that I wanted to live such an unwholesome lifestyle; it was partly due to heavy schoolwork and partly to financial constraints. Cheap spicy instant noodles and food sold by fast-food street vendors were basically my daily diet. I guess this led to the stomach prob- lem I had two years later. The symptoms were so strong that I felt like throwing up, and in addi- tion it became painful to eat. My mother took me to the No. 2 Hospital in Xining70 for a gastroscopic examination. There I was diagnosed with stomach inflammation. I took the medicine prescribed by the doctor for several weeks and felt a little better. However, as a Chinese saying goes, ‘Once the wound is healed, the pain is forgotten’.71 I resumed my unwhole- some lifestyle and thus my stomach problem recurred. On the recommendation of a friend, my mother bought Jiebaiwan (White Pill) produced by Gartse Monastery from a shop72 in Rebgong. I took two pills every morning on an empty stomach for several months. It was indeed as effective as my mother’s friend had claimed. It was good for ‘stomach distention’ (Ch. wei zhang 胃胀), ‘stomach pain’ (Ch. wei tong 胃痛), and ‘stomach acid’ (Ch. wei suan 胃酸). I still take Jiebaiwan when I have stomach problems like indigestion. Apart from stomach problems, I think Jiebaiwan is also good for gallbladder problems. I say so because I know I have gallstones. Every time I have gallbladder pain, I have abdominal pain and feel some sort of air (pressure) moving up and down in my back. Jiebaiwan relieves the pain and the air (pressure) disappears.73
70 Qinghai University-Affiliated Hospital (Ch. Qinghai daxue fushu yiyuan 青海大学附属 医院), in short called ‘No.2 Hospital’ (Ch. Er yiyuan 二医院). This is known as the best biomedical hospital available in Xining, a city with approximately 1,267,600 inhabitants. 71 Ch. Haole shangba, wang le tong 好了伤疤, 忘了痛. 72 Some shop owners sometimes buy medicines from private hospitals like Gartse Monastery Tibetan Medicine Clinic and sell it to their customers to generate additional income. 73 From my fieldnotes collected in the summer of 2015.
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In Rebgong, Gartse Monastery is probably more famous for its White Pill than it is for its religious practice. Surrounded by larger and more famous Gelukpa monasteries, such as Labrang and Rongwo, Gartse Monastery is basi- cally known for its popular White Pill. Various stories revolving around Gartse White Pill’s efficacy are circulating among its users. For example, one story popular among Tibetans claims that the Gartse White Pill includes ingredi- ents of the removed gallstone of a famous local lama. Out of curiosity, I asked one of the doctors from the monastery, named Losang, if the stories spreading among consumers were true. He promptly negated all these stories, yet implic- itly admitted that Gartse White Pill included ‘special substances’ (Tib. rdzas khyad par can). However, I was not sure if he was referring to an ‘additional ingredient’ (Tib. kha tshar) of a formula or something else. Rumours fabricated by consumers coupled with doctors’ reluctance to reveal the secret about the actual ingredients in their formula bestow a mysterious aura on the Gartse White Pill, which makes it even more special and particularly efficacious, it seems, among consumers. ‘What is it that makes the Gartse White Pill so special?’, I asked Losang, the physician-cum-pharmacist from the dispensary of the Gartse Monastery Clinic. The following is a summary account of his explanation:
Every year we produce around 750 kg of Rikar, but 750 kg is hardly enough. Since producing more Rikar requires an extensive workforce and time for processing the ingredients, this is all we are able to approximately annually produce. We produce around 70 different types of medicines and Rikar is the one we produce most in relation to others. We collect locally available ingredients and buy those that are not. However, there are not many ingredients we can get hold of in our area. So we buy them from the herb market in Xining and ensure the freshness of ingredients or at least make sure they have not been stored for several years. Among the ingredients of Rikar, pangtsi dobo, drakzhün, and chongzhi are the only available ingredients in this area.74 Nonetheless, we collect pangtsi dowo and drakzhün only when time allows because pangtsi dowo grows far up in Henan County and collecting drakzhün in steep rocky mountains is a bit inconvenient and dangerous. We collect chongzhi every year, which is somewhere close to our mon- astery. Fearing over-exploitation and depletion of chongzhi, we usually don’t tell others where we collect it. Our chongzhi is uniquely different
74 See above, pangtsi dowo, (Lat. Pterocephalus hookeri Hook), drakzhün (Trogoptrus xanthipes Milne-Edwards), and chongzhi (calcitum).
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from those used by others because it has high efficacy. The type of chongzhi we use is po chong resembling broken horse-teeth. In addition to its efficacy, we have our exclusive ways of processing chongzhi and arura. We process ingredients with meticulous care and renew our medi- cine in due time. As Buddhist monks, we also perform the ‘medicine empowerment’ (Tib. sman sgrub) thoroughly. Additionally, we have our unique secret instructions (Tib. man ngags), which we have promised not to divulge to anyone in anyway. Considering all these key factors together, I believe our Rikar is relatively more effective (than that produced by oth- ers). The efficacy of our Rikar is acknowledged and acclaimed by many patients irrespective of ethnicity. Our Rikar is particularly good for com- mon powa mukpo (Tib. pho ba smug po) or beken kyamuk (‘indigestion’), liver, and gallbladder diseases.75
Although only nine ingredients are mentioned on the package leaflet of Gartse White Pill, the leaflet shows that the formula is made of 15 different ingredients. As is often the case with descriptions on packages of traditional medicines in China, producers do not detail all the ingredients as a way to protect their distinct formulas. Gartse Monastery Clinic generally adds its own additional ingredients that are kept secret from outsiders to the core common ingredients of known Tibetan formulas according to well-known Tibetan pharmacopoeias. As in the case of the White Pill from Malho Tibetan Hospital, the indications written on the package leaflet of the Gartse White Pill are both expressed in Tibetan medical terms and Chinese terms, making the indications intelligible to both Tibetan and non-Tibetan consumers. In comparison to the former, the Tibetan and Chinese indications for the Gartse White Pill are either cor- responding more closely with each other or at times no Chinese equivalent has been given to match the Tibetan term. The Gartse White Pill mainly cures the following indications:
1. mazhuwa (Tib. ma zhu ba, ‘indigestion’)—Ch. xiaohua bu liang 消化不良 (‘indigestion’) 2. beken kyamuk (Tib. bad kan skya smug, ‘pale-white and brown bad kan’)—Ch. wei kui yang 胃溃疡 ( ‘stomach ulcer’) 3. chin tri po tsé gyé pa (Tib. mchin mkhris pho tshad rgyas pa, ‘liver, gall- bladder, and stomach inflammations’)—Ch. ganyan 肝炎 (‘liver inflam- mation’), baogan 保肝 (‘protecting the liver’), dannang yan 胆囊炎 (‘gallbladder inflammation’), manxing weiyan 慢性胃炎 (‘chronic stom- ach inflammation’), chang yan 肠炎 (‘intestinal inflammation’)
75 From my fieldnotes collected in the summer of 2015.
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4. po kyur (Tib. pho skyur, ‘stomach acid’)76 5. kyuk (Tib. skyugs, ‘vomiting’), Ch. outu suanshui 呕吐酸水 (‘the throwing up of acid liquid’) 6. poné (Tib. pho nad, ‘stomach illnesses’)77
Despite the fact that Gartse White Pill, as well as many other Tibetan med- icines produced in Rebgong, does not have a drug registration number, it is widely used by patients of different ethnic backgrounds and prescribed by pri- vate doctors of Tibetan medicine. From a legal point of view of policy, the drug registration number is meant to ensure the safety of drugs. In reality, neither physicians of Tibetan medicine nor patients—regardless of ethnicity—make a distinction between registered and unregistered Tibetan medicines. This clearly shows that known therapeutic efficacy by experience or among family and friends takes precedence over a registration number.
Conclusion
Rebgong is a typical multiethnic region cradling six ethnic groups, the Tibetan being the largest. Rebgong is also a regional hub of Tibetan medicine with spe- cialised hospitals and many private clinics of Tibetan as well as Western medi- cine including mixed or combined types of medical practices, and with the urban city of Xining and provincial hospitals within close proximity. In recent years, non-Tibetans have also begun to use Tibetan medicine along with rapid development and commercialisation of Tibetan medicine. In 2014, I began my ethnographic research with Tibetan, Han, and Hui patients and physicians of Tibetan medicine. This was with the attempt to first find out which ailments are most common and for which ones Tibetan medicine is frequently used in Rebgong. I found that stomach and digestion related diseases were the most common, regardless of patients’ ethnic background. According to my findings, the White Pill, known as Druptop Rikar in Tibetan and Jiebaiwan in Chinese, was the most commonly used medicine which was locally produced and cir- culated in the region of Rebgong with indications written in both Tibetan and Chinese. Interestingly and in contrast to most industrialised Tibetan pharmaceuti- cals produced by large pharmaceutical factories solely for the Chinese market
76 Gartese White Pill package leaflets do not have a corresponding Chinese term for this indication. 77 Pho nad is a very general term for any kind of stomach disease.
asian medicine 10 (2015) 221–248 Downloaded from Brill.com09/25/2021 08:54:18PM via free access 246 Nianggajia with indications only written in Chinese, the indications written on the package leaflets of the White Pill from Malho Tibetan Hospital and Gartse Monastery Clinic are bilingual and predominantly derived from Tibetan medical principles and disease terms translated into Chinese. The White Pill is an interesting example as to how one particular formula is manufactured for a specifically targeted disease complex that is not primarily biomedically defined. It maintains, at least on the leaflet, the Tibetan medical indications, yet can be taken like a biomedicine with a fixed dosage and without prescrip- tion, for example as a prophylactic or after a heavy meal, as many Tibetans do. On the other hand, it is also popular and prescribed by physicians of Tibetan medicine in their private clinics as well as in the Malho Tibetan Hospital. While different producers manufacture their White Pill with slightly different ingredients keeping the core formula intact, patients have—independently of this—one preference over another based on their own experiences and trust in a particular producer. The White Pill is a perfect illustration of how Tibetan medicines are chang- ing from being prescribed in a complex detailed way by physicians of Tibetan medicine to over-the-counter (OTC) drugs taken for specific ailments. It seems this is without, however, turning into drugs with biomedical indications or los- ing their efficacy. Also more and more patients, regardless of ethnicity, seek medicines that they believe are both more efficacious than biomedicine; in particular, that have no side effects and are available for direct use, often with- out prescription. At the same time, producers benefit as well and adapt to the increasing demand, financing some of their much needed expenditures whether for their hospital or for their monastery.
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