Socio-Economic Dimensions of Tibetan Medicine in the Tibet Autonomous Region, China1 Part One

Asian Medicine 4 (2008) 174–200 www.brill.nl/asme

Th eresia Hofer

Abstract Th is article investigates some of the socio-economic dimensions of contemporary Tibetan healing practices in the rural areas of the Tibet Autonomous Region (TAR) in China. It sheds light on the workings and the eff ects the commodifi cation of the offi cial Chinese health care system, which started in the late 1990s, have had on Tibetan medicine and how these are related to the concurrent re-introduction of the Co-operative Medical Services (CMS) scheme throughout rural China. Th e contribution to this journal is divided into two parts. Part One predominantly deals with the medical practitioners and the practices within governmental health care in the TAR. Part Two, which will be printed in the next issue of the journal, deals with the private sector of Tibetan medicine. Both parts focus on the situation in the Tsang or Shigatse region of the western and central TAR, hence enabling there to be useful comparisons with medical practices in the capital Lhasa, most of the anthropological literature has focused on so far. Both contributions are based on extensive anthropological fi eldwork in Lhasa and the Tsang region of Tibet.

Keywords Tibetan medicine, Sowa Rigpa, Tibet Autonomous Region, health care reforms, Co-operative Medical Services, CMS, rural China

1 Th is article is based on 16 months of ethnographic fi eld research in summer 2001, summer 2003, and from September 2006 to September 2007 in the TAR. I wish to thank the University of Vienna, the Austrian Academy of Sciences, the Wellcome Trust and DDr. Mag. A. M. Hoeger for their generous fi nancial support. I also would like to thank Andrew Beattie, Hildegard Diem- berger, Andre Gingrich, Guntram Hazod and Vivienne Lo for their guidance before and during fi eldwork, Nandini Bhattacharya, Sienna Craig, Anna Lora-Wainwright, Th omas Shor and Geoff rey Samuel for comments on earlier drafts, and Dawn Collins for the many cups of tea and kind words that sustained me throughout my fi eldwork. Tibetan terms, such as names of Tibetan authors and Tibetan titles of books, have been transliterated here according to Wylie 1959. Exceptions are the often-used terms of amchi (doctor, A mchi), Mentsikhang (Medicine and Astrology Institute, sman rtsis khang), rinchen rilbu (precious pill or jewel pill, rin chen ril bu) and Sowa Rigpa (science or knowledge of healing, gso ba rig pa), which are rendered phonetically as are names of places and persons. Chinese terms are transliterated in Pinyin.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access T. Hofer / Asian Medicine 4 (2008) 174–200 175

Introduction

Tibetan medicine, the inheritor of what in Tibetan has been traditionally referred to as Sowa Rigpa or ‘Science of Healing’, is readily available through governmental and private medical practices in Lhasa, the capital of the Tibet Autonomous Region (TAR) in China. Th e Mentsikhang (established in 1916) is the foremost Lhasa–based institution for the practice of Tibetan medicine and astrology and provides medical care through a fl ourishing and centrally located out-patient department and a large in-patient department in the north of the city. In both locations, Sowa Rigpa practices are often combined with biomedical diagnostic and therapeutic techniques. Th ere is also a part pri- vately and part government owned medical factory, the ‘Tibetan Traditional Medicine Factory of the TAR’, where over 300 diff erent kinds of Tibetan medicines are currently produced and then dispensed through governmental and private institutions in the TAR and on national and global markets.2 In Lhasa there is also the Tibetan Medical College with over 300 students enrolled in undergraduate and graduate courses, who mostly go on to work in government positions. Additionally, there are several private Tibetan medical practitioners who, in some cases, have their own medical production facilities. Tibetan medical drugs and products, for example the famous ‘precious pills’ or rinchen rilbu among other more common medicinal drugs, are now also sold on a large scale as over-the-counter (OTC) drugs through various pharmacies and shops all over town, with buyers often not having had a prior clinical consultation. Th ese medicines may be produced by the TAR medical factory or in one of a growing number of private Tibetan medical factories in the country. Tibetans in the capital Lhasa use Tibetan medicine, which tends to be considered fi nancially and culturally3 a more attractive health care option than Chinese biomedicine, more readily than Tibetans in the rural areas.4 On the contrary, for Tibetans in the rural areas of the TAR it is hard to have access and to be able to aff ord Tibetan medicine, which is unequally reimbursed through a governmental medical insurance scheme.

2 Th is factory in their publicity advertises their uninterrupted existence of over 300 years. It claims to date back to the medical production section at Chagpori Medical College, established in 1696 by Desi Sangye Gyatso in Lhasa, despite this institute being totally destroyed by Chinese armed forces during the 1959 Tibetan uprising against communist Chinese occupation of Tibet. 3 Janes 1999. 4 Th e practices and ideas referred to here as Chinese biomedicine are what Tibetans call ‘out- sider medicine’ (Tib.: phyi lugs sman), ‘Chinese medicine’ (Tib.: rgya sman, Chin.: zhong yi) and ‘communist medicine’ (Tib.: tang sman). I am aware that the use of the term ‘biomedicine’ in this context is problematic, since its practices are not uniform across nations and, in fact, often bear little resemblance in diﬀ erent places. See Berg and Mol 1998.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access 176 T. Hofer / Asian Medicine 4 (2008) 174–200

Th is disparity in use and availability of Sowa Rigpa between the urban and the rural areas was of concern to some of the Tibetans I worked with during my stays in the TAR, and sparked off my interest to research further the question: ‘Who uses and has access to what kinds of Tibetan medical health care in the contemporary TAR?’ Th is question is part of my ongoing research, in which I consider a variety of historical, political, socio-economic and cultural forces that infl uence twentieth-century and current Tibetan medical practice in its incessant encounters with Chinese biomedicine and government policies. I have narrowed my focus in this article to some of the socio-economic dimensions and pressures that infl uence contemporary Tibetan healing practices in the rural areas, which have, so far, not been dealt with in its own right in the literature on Tibetan medicine.5 Anthropological research on contemporary Sowa Rigpa practices in TAR to date has largely focused on Government institutions for Tibetan medicine in Lhasa. For these, scholars describe and analyse the increasing secularisation and commercialisation of Sowa Rigpa,6 as well as shifts towards a ‘scientifi cation’ of Tibetan medical ideas, practices, theory and training.7 We also have one in-depth account of the radical changes taking place in the manufacturing of Tibetan pharmaceuticals following the introduction of Good Manufactur- ing Practice (GMP) in 2003 and increasing pressures for Tibetan medicine to perform in clinical trials.8 Although the changes described and analysed in the above literature infl u- ence Tibetan medical practice outside the capital and in Government institutions also, in particular because of sharp increases in costs of medicines, I aim to shed light on the workings and eff ects of the commodifi cation of the offi cial Chinese health care system and the impact of the re-introduction of the Co- operative Medical Services (CMS) on Sowa Rigpa practices in the rural areas in the late 1990s. In Part One, I will predominantly deal with governmental health care in the TAR and in Part Two, which will be printed in the next issue of Asian Medicine: Tradition and Modernity, I consider the private sector of Tibetan medicine, in both cases with focus on the Tsang or Shigatse region of western and central TAR. Before turning to the medical fi eld of this peripheral region, a brief vignette on Tibetan medicines in the capital Lhasa will illustrate some of the larger dynamics at play in the contemporary TAR. It shows a diff erent and far wealth- ier economy into which much Tibetan medical practice is increasingly drawn.

5 Only Craig in Schrempf (ed.) 2007, Schrempf (ed.) 2007 and TIN 2004 touch on some aspects of this. 6 Adams 1998, 2001, 2007, Adams and Li 2007. 7 Adams 2002, Adams et al. 2005 and Craig in Schrempf (ed.) 2007. 8 Craig 2006.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access T. Hofer / Asian Medicine 4 (2008) 174–200 177

Rinchen Rilbu for the Rich?

During my residence in Lhasa in the 12 months from September 2006 to September 2007, working on contemporary and twentieth-century transformations of Tibetan medicine, most of my regular visits to the main branch of the China Post Oﬃ ce on Beijing Lu passed a Chinese or a Tibetan customer packing up colourful boxes of rinchen rilbu to be sent home or abroad. In Lhasa’s specialised Tibetan medical pharmacies, rinchen rilbu boxes sit on the front shelves and catch the viewers eye (Figure 1). Several companies advertise on large posters and on television: Mutig 70, Rinchen Drangjor and Rinchen Mangjor are the names one usually sees written in Tibetan, Chinese, and roman characters.9 Chi- nese and biomedical pharmacies-cum-souvenir shops also stock these pills, especially around the tourist area of Lhasa between the Jhokhang (Lhasa’s main temple) and the Potala. Rinchen rilbu have, indeed, become what many urban Tibetans, Chinese, and foreign visitors to Tibet view as Tibetan medicine per se, paired with the impression that Tibetan medicine is alive and ‘developing’.

Fig. 1. Tibetan medical pharmacy stocked with boxes of rinchen rilbu, or precious pills in the Tibet Autonomous Region, China, 2003 (Image © Th eresia Hofer)

9 For a general introduction to precious pills, see Aschoﬀ and Tashigang 2001.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access 178 T. Hofer / Asian Medicine 4 (2008) 174–200

For rinchen rilbu to attract this more diverse national and potentially global clientele, various changes were made to their production process.10 Depending on the type, precious pills contain a number of purifi ed metals, minerals, herbs, and animal parts. However, many of these ingredients—mercury, for example—and the processing methods, which used to be passed on in oral and textual lines of transmission,11 did not conform with national and international standards of medical production. Hence their composition, ratios of ingredients and the processing methods had to be changed. In part, this was to follow the regulations and standards of the Good Manufacturing Practice (GMP) scheme for medical production that were implemented in TAR starting in 2003. Also, this standardisation underpins biomedical and clinical research trials that are becoming a prerequisite for obtaining registration numbers and patents for commercialised Tibetan formulae.12 Th e outcome of these eff orts are controversial. Together with a decrease in many medical raw materi- als due to increased production and export of Tibetan medicinals, along with national and international bans on the usage of certain endangered species, prices for rinchen rilbu have increased. Th is development is not only limited to rinchen rilbu, but is also the case for more widely used and more common Tibetan medicines that fall outside the category of rinchen rilbu. While it may be relatively easy for people living in the urban areas working for cash to aff ord more expensive medicines (because those areas have profi ted most from recent economic development in the TAR), this is not the case for the rural areas.

Costs of health care in the capital

Many Lhasa Tibetans still consider treatment with Tibetan medicine—except for rinchen rilbu—to be cheaper than biomedicine.13 Considerable numbers of my friends and interviewees recounted stories about how they spent a couple of hundred RMB14 in the biomedical ‘People’s Hospital’ (Tib.: mi dmangs sman khang, Chin.: Ren min yiyuan) or at a private clinic on minor complaints, running up bills of several thousands of RMB for treatment of more serious

10 Craig 2006. 11 Traditionally a student of medicine tended to gain access to medical knowledge only through initiation from a teacher, who could be a family member (in most cases one’s father or uncle) or possibly non-relatives (lay or religious teachers). Such initiations, also known as lung or dbang, give permission to the adept to study a particular medical text or introduces them to a particular teaching on a practical diagnostic, therapeutic or drug compounding method or technique. 12 Craig 2006. 13 Based on my interviews in Lhasa. Th is is also mentioned in Adams in Schrempf (ed.) 2007, p. 29. 14 Ten RMB are currently equivalent to 1.4 US dollars, 0.9 Euros and 0.7 GB pounds sterling [3 June 2008].

Downloaded from Brill.com09/25/2021 06:18:52AM via free access T. Hofer / Asian Medicine 4 (2008) 174–200 179 conditions, often leaving whole families in debt. A doctor at the Tibetan medical hospital or Mentsikhang in Lhasa or a private Tibetan medical practitioner costs much less, although courses of treatment with Tibetan medicine usually take longer than with biomedicine. In the cities of the TAR, no public insurance scheme is in place comparable to the CMS or Co-operative Medical Services scheme which exists in rural parts of China and Tibet. Only government employees and a few Tibetans who work for international non-governmental organisations (NGOs) in the cities have an insurance plan. Private health insurance coverage among Tibetans is virtually non-existent. Hence a majority of Lhasa Tibetans pay for medical expenses out of their own pockets, and, for them, Tibetan medicine is the ﬁ nancially, and often culturally more attractive health care option for certain ailments.15 Also, a wider variety of Tibetan medical care is available and more easily accessible in Lhasa, ranging from the large governmental Tibetan medical in- and out-patient hospitals to small private practices and an increasing number of pharmacies and shops where over-the-counter Tibetan medicines can be purchased without prior medical consultation.

Tibetan medicine in the rural areas

At the same time, in rural parts of the TAR, I found that skilled Tibetan medical practitioners, common Tibetan medical preparations, and a large variety of treatments mentioned in Sowa Rigpa’s core text, the Rgyud Bzhi, and its commentaries are out of reach of most people. Th is is even more the case for more expensive aspects of Sowa Rigpa, like the rinchen rilbu: I found few Tibetan medical doctors in rural areas who prescribe rinchen rilbu, few patients took them, and virtually no one who was producing them. Rinchen rilbu are considered too expensive for both doctors and patients. And indeed, they are diﬃ cult to produce. Some of the oral lines of transmission of knowledge

15 Contradictory to some Tibetan doctors’ views, there is a notion among patients that Tibetan medicine is particularly eﬀ ective for ‘old diseases’ (Tib.: na tsha rnying pa) while biomedicine is best for ‘new diseases’ (Tib.: na tsha gsar pa). Th ese categories have become simplisti- cally linked to the biomedical terms of ‘chronic’ and ‘acute’ disease. Th is link can be problematic when it comes to the allocation of health care funding for traditional vs. modern medicine in a society undergoing major health transition (cf. Janes 1999). In the towns and among Tibetan doctors it is also common to have it pointed out that Tibetan medicines have no side eﬀ ects and cure diseases from the root, while patients in the villages rarely mentioned this to me. By ‘culturally more attractive’, I refer to the situation that many Tibetans are drawn to the Mentsikhang because it is one of the few Government institutions that is left where Tibetan language is used more widely than Chinese and many of the concepts of disease and their causation tend to over- lap more readily with the beliefs of the patients themselves. I also found certain policies towards the practice of religion in Government institutions are less strictly enforced at the Mentsikhang, which then contributes to its distinct Tibetan-ness.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access 180 T. Hofer / Asian Medicine 4 (2008) 174–200 on the production of rinchen rilbu may have been interrupted following the Chinese Communist take-over of central Tibet in 1951. Even if they have not, there are limited fi nancial resources and facilities available in the rural areas for their long and labour-intense production process, often requiring more than a month. If there is an amchi, a practitioner of Sowa Rigpa, who has more common medicines in stock—whether purchased or, more rarely these days, self- made—more often than not patients consider these to be expensive, if not unaff ordable. Expenditure on Tibetan treatments consisting of a course of medicines is much higher than for Tibetan external treatments, such as moxibustion (Tib.: me brgyab), cauterisation (Tib.: me lcags), bloodletting (Tib.: khrag brgyab) and golden needle therapy (Tib.: gser brgyab), which require the purchase of no drugs by the patient or doctor and for which many traditional practitioners do not charge. Most often, however, patients choose fast-working and widespread biomedical intravenous injections and pills.16 Th ese are delivered inexpensively through private doctors and pharmacists, and through the diverse channels of the governmental health care system, funded in part by the CMS scheme. As another writer has pointed out, I agree that it is impossible to under- stand current Tibetan medical practices without considering the peculiar history of modern Tibet and the ways in which the People’s Republic of China has both classifi ed and controlled minority nationalities and valorised their ethno- medicines in diff erent ways.17 Th e following is a brief sketch of relevant aspects of late twentieth-century history spanning the revival of traditional Tibetan medicine in the 1970s and 1980s to the commodifi cation of health care starting in the mid-1990s to the transformation of Tibetan medicine into an increasingly secularised and commercial ‘product’ for the national and international market by the turn of the millennia, accompanied by the commodifi cation of the Chi- nese health care system and the reintroduction of the CMS scheme.

Th e wider context

Revival of traditional medicine

Although Tibetan medicine in the twentieth century never lost the oﬃ cial support of the Chinese Communist government in Tibet, strong and sustained

16 Cf. Neuenschwander 1989 and Hofer (forthcoming). 17 TIN 2004, p. 30.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access T. Hofer / Asian Medicine 4 (2008) 174–200 181 eﬀ orts by Tibetan physicians and the Chinese government itself, starting in the early 1970s, were necessary to recover as much as possible of what was left of Sowa Rigpa following the destructions commonly attributed to the ‘cultural revolution’ (1966–77).18 Tibetan doctors of the ‘old society’ (Tib.: spyi tshogs rnying pa), as Tibetans refer to pre-1959 Tibet, had often been part of the upper strata of Tibetan society, entirely restructured in the 1950s and 1960s. Sowa Rigpa had many institutional ties with the Tibetan Government and the mon- asteries, which stopped receiving any support from the new socialist Govern- ment. Also, since Sowa Rigpa shared many of its ideals with Tibetan Buddhism, there was not the same outright communist support for Tibetan medicine as given to ‘Traditional Chinese Medicine’.19 Finally, in the wake of the Red Guards’ attack on so-called revisionist and old-fashioned thinking, many Tibetan medical practitioners lost their lives, ended up in prisons and labour camps, or escaped to India and Nepal.20 Several famous medical lineages and the transmission of their knowledge were interrupted in Tibet proper.21 Some involved with the production of rinchen rilbu were among them. Some continued in exile, while many texts and medical and religious paraphernalia were lost forever. However, Tibetan medicine is considered to have emerged from the Cultural Revolution more intact than other aspects of Tibetan culture.22 Despite this, there was still a lot to be recovered, and much has been lost forever. One outstanding ﬁ gure in reviving Sowa Rigpa in late twentieth-century Tibet is the Lhasa-based scholar-physician Jampa Trinley (b. 1928). He had been a student of Khenrab Norbu (1883–1962), the personal physician to the Th irteenth Dalai Lama Th ubten Gyatso (1826–1933), under whose auspices the Mentsikhang, the ‘Tibetan Medicine and Astrology House’ in Lhasa had been established in 1916 as part of a larger modernisation project of Tibet. When the Chinese Communists annexed central Tibet in 1951, Jampa Trin- ley, as the director of the Mentsikhang, skilfully and diplomatically navigated a new path for Tibetan medicine under Chinese rule throughout the coming decades. Th is path neither entirely compromised Sowa Rigpa’s own founda- tions and values, nor did it completely surrender to the new regime, but it

18 For this section, I have drawn on the work of Craig Janes, who provided the most detailed description and analysis of the twentieth-century transformations of Tibetan medicine thus far (1995, 1999). Th is is complemented by information I have collected during oral history interviews with practitioners in the TAR and by drawing on histories recently published in Tibetan language in China (e.g. Byams pa ’phrin las 2004). 19 Taylor 2004. 20 Choedrak 1999, Hofer (forthcoming). 21 Th ere are at least six medical lineages in the areas where I worked whose members were executed or experienced severe punishment, of which I have ﬁ rst-hand accounts. 22 Janes 1995.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access 182 T. Hofer / Asian Medicine 4 (2008) 174–200 incorporated the new demands made on Tibetan medicine so as to become— in a western sense—a scientifi cally based ‘medical system’, to a large extent stripping away its theoretical ties to Buddhism. Th is was a vast, challenging and, at times, frustrating undertaking for the Tibetans involved.23 Its relative success, however, earned now senior physicians such as Jampa Trinley high respect from young and old Tibetans from all over the country. Th ey still come to pay their respects at his residence in the original Mentsikhang building in central Lhasa, off ering blessing scarves and prostrating, much as they would to a high religious fi gure. Many publications and conferences on Sowa Rigpa are to his credit, among them a workshop held in 1974 at which senior doctors of the Mentsikhang met to ‘recover, recollect and research what has been lost and disappeared during the Cultural Revolution’.24 He encouraged many elderly doctors to teach the younger generation their knowledge before it was lost. Towards the end of the Cultural Revolution, the government increased the funding of the Mentsikhang in Lhasa, which became the professional centre of Tibetan medicine, of teaching, practice, research, and production of Tibetan medicine in the TAR.25 As early as 1972 there were Tibetan medical classes incorporated into the Lhasa Health Care Middle School curriculum26 and later in the prefecture-level biomedical education, such as in Shigatse Voca- tional Health School.27 In 1984 a small Tibetan medical school was established in Lhasa, which was complemented by the Tibetan Medical College in 1989, off ering graduate courses of study, while less formal instruction continued at the Mentsikhang.28 Jampa Trinley also travelled the country in search of local medical traditions and practitioners, to facilitate their integration into the local government health care system or otherwise to ensure the continued transmission of their knowledge. In the 1980s, a considerable number of Tibetan medical out- patient sections in township as well as at county-level hospitals were established in rural areas.29 Often Tibetan medical practitioners trained in the old society had been off ered the chance to take government exams in order to

23 Tse brtan ’jigs med 2007. 24 Byams pa ’phrin las 2004, p. 134. 25 See the two chapters ‘Tibetan medical history since the establishment of New China’ (pp. 132–6) and ‘Th e development of Tibetan medicine after the policy change’ (pp. 136–43) in Jampa Trinley’s textbook on the history of Tibetan medicine (Byams pa ’phrin las 2004). 26 Ibid., p. 134. 27 Personal communication with teachers, Vocational Health School, Shigatse 2006. 28 Personal communication with graduates and teachers of these institutions, 2006 and 2007. 29 Byams pa ’phrin las, 2004, p. 137. For Shigatse prefecture, personal communications 2003, 2006 and 2007.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access T. Hofer / Asian Medicine 4 (2008) 174–200 183 obtain offi cial licences to practise within the state system. Th e 1980s was marked more generally by a revival of Tibetan scholarship, Tibetan language and a liberalisation of the practice of Tibetan Buddhism, following the visit of the Communist Party secretary, Hu Yaobang, to Tibet in 1980.30 Following a series of protests by Tibetans in Lhasa from 1987 to 1989,31 radical changes in Chinese policies towards Tibet took place, replacing the relatively culturally sensitive policies of the 1980s, and ‘entirely reversed the liberal policies of the 1980s’.32 A series of momentous events followed, including the appointment of Chen Kuiyan as Party Secretary of the Tibet Autono- mous Region in 1992,33 the ‘Th ird forum on work in Tibet’ in 1994, and Jiang Zemin’s ‘Great Western Development’ policy of 1999.34 Th ese events and the new policies aff ected Tibetan medical practice and theory and its role in health care provision in the TAR directly and indirectly. Under the umbrella of the policies referred to as ‘grasping with two hands’, the forum on work in Tibet developed two main goals for TAR: stability and development. Th ese policies included restrictions on the practice of religion, which manifested itself in the fi eld of Tibetan medicine. For instance, in 1995, there was a ban on the performance of the annual medicine empowerment performance at the Mentsikhang. Under the rubric of development, the specialised industries of Tibet, such as mining, tourism and Tibetan medicine, were singled out as one avenue to foster rapid economic development in the TAR.

Co-operative medical services in rural China and the commodiﬁ cation of health care

Th e CMS scheme was originally established under Mao Zedong in the late 1950s, along with the implementation of a three-tiered rural health care system (brigade, commune, and county level). During the Cultural Revolution, CMS was built into the people’s communes, accompanied by the famous ‘barefoot doctor’ campaign, which made China’s rural populations experience remarkable health improvements.35 However, since the implementation of the rural economic and administrative reforms of the late 1970s and early 1980s, the ﬁ nance and delivery of rural health care experienced dramatic change

30 Yao 1994. 31 Barnett in Barnett and Akiner (eds) 1994; Barnett 2007; Schwartz in Barnett and Akinger (eds) 1994. 32 Quote from a paper given at a conﬁ dential meeting in Cambridge held under the Chatham House Rules in April 2008. 33 Barnett in McKay (ed.) 2003, p. 231. 34 TIN 2000. 35 Liu et al. 1995, p. 1085.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access 184 T. Hofer / Asian Medicine 4 (2008) 174–200 in China.36 Government funding for health services decreased drastically, and the CMS scheme collapsed with the introduction of the household responsi- bility system,37 which shifted the fi nancing of health care to individuals, who then paid for all health care out of their own pockets.38 Patients’ expenses for health care increased,39 and as is the case in other developing countries many people, when ill, fall into what has become called a ‘medical poverty trap’.40 Th e WHO report of the Commission of Macroeconomics and Health for the year 2001 still singled out rural western China, along with rural north-eastern Brazil, as areas in the world where the poor are routinely denied essential health care.41 Th e World Bank continued to argue during this period that the introduction of user fees for medical services would improve poorer groups’ access and use of essential health services in developing countries.42 In Tibet, changes in the structure and fi nancing of health care started later than in inland China and became part of major health care reforms outlined for the ninth and tenth fi ve-year plans for the TAR (1996–2000, 2001–5).

Reforms and the Co-operative medical services scheme in the TAR

Although both the three-tiered rural health care system and the CMS scheme had also been introduced in Tibet in the 1960s, following its introduction in China in the 1950s, little is known about its development and working in Tibet. Based on my preliminary research on it in the TAR, it seems that the TAR was privileged over other Chinese provinces. Elderly doctors, who had worked in Ngamring County (Shigatse Prefecture) most of their lives, as well as several other local people I spoke to, clearly recalled the days of free health care in Tibet. Th ese lasted until the late 1990s, when the Government’s economic reforms led to severe cuts in subsidies, forcing clinics and hospitals to generate their own incomes. Th is was achieved primarily through the sale of drugs and expensive diagnostic tests, and through investing in businesses. One

36 Xueshan et al. 1995, pp. 1111–2. 37 Bloom and Jing 2003, p. 23. 38 Xueshan et al. 1995, p. 1111. 39 For instance, in a Canada Tibet Committee report on poverty and the economy in Tibet, Andrew Fisher reviewed and analysed national and regional price indexes. He stated that the costs of health care in the year 1998 increased by 17.2 per cent nationally, and by a much higher rate in one of the Tibetan provinces, e.g. 56 per cent in Qinghai, the traditional Amdo Region of Tibet. Fisher 2002, p. 54. 40 Cf. Whitehead et al. 2001, p. 833. 41 WHO 2004, p. 7. 42 World Bank report cited in Whitehead et al. 2001, p. 833.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access T. Hofer / Asian Medicine 4 (2008) 174–200 185 of my interviewees, a 69-year-old doctor originally from Ngamring, now resident in Lhasa, commented on this development: Nowadays the doctors have become like business people. Common people say they are businessmen in white, except for that you can’t bargain with them! Th ere is no bargaining with the doctors. In TV, hospitals advertise their doctors giving out free medicines, but this is only to give themselves a good name and a good reputation. In reality, they charge lots to everybody. I think medicines should be free for everyone, like it used to be when the communists fi rst arrived.43 Among other reasons, this is an interesting comment because of what it both says and does not say about the pre-1950s access to health care, of which we know so little, and about the changes in the post-reform era. Th e CMS scheme collapsed in the late 1970s and was re-launched in the late 1990s in the TAR, fi rst in one pilot district in each county in 1998 and later expanded to include the rest of the counties. Th e scheme is organised on the same level of the state health care system of village (former brigade), township (former commune), and county. Since its re-introduction, the CMS scheme has undergone many changes, including recent increases in input from the central authorities, but its success and working still diff er widely, even within counties. During my research in 2003, patients who joined the CMS scheme paid between four and ten RMB per person per year, depending on the rates set by the local township. Some people reported they were forced to join, although this contradicts recent government policy.44 Every member was entitled to a partial reimbursement of up-front expenditure on consultation, treatment, and medicine. Th e scale of the reimbursement varied according to the level of care used by patients, with higher reimbursement rates at village- and township-levels of care (between 60 and 80 per cent) and lower rates for more expensive in- and out-patient care in county- and prefecture-level health clinics (which could be as low as 30 per cent, but in one case was as high as 95 per cent). However, the problem was often that patients were unable to pay up front, but they also had to pay to travel great distances and on certain days of the week to the county health bureau to claim the reimbursement. I found that the success of CMS scheme also depended to a large extent on local man- agement, people’s knowledge of how the CMS and government institutions work and their trust in the people in charge, as well as their mobility. In 2003, I spoke with numerous patients in Ngamring county in diff erent clinical settings. Many hardly ever received reimbursement, despite having

43 Interview in Lhasa, 2007. 44 Bloom and Jing 2003, p. 24.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access 186 T. Hofer / Asian Medicine 4 (2008) 174–200 joined the CMS scheme.45 Th is was confi rmed by a doctor who was previously employed in a leading position in the governmental county ‘People’s Hospital’ in Ngamring. After his retirement, he started his own private practice in the same town, close to the main road and the bus stop. He wanted to provide a better service than the government hospital, which he considered to be too expensive and highly bureaucratic. Despite patients not receiving payment for his services from the CMS, many who had known him during his 21 years service to the hospital started to attend his clinic: it made little diff erence even if members of the CMS. He commented: ‘Previously, when I was the leader in the People’s Hospital, patients came and begged for treatment, now the doctors there have to beg for patients to came.’46 In the three months following the opening of his clinic, few continued to attend the People’s Hospital. Th is situation was diffi cult for the hospital, since it depended on income from the sales of drugs and fees for diagnostic tests. Soon, the hospital followed the retired doctor’s example and opened a small, less bureaucratic and less expensive out-patient department next to the doctor’s clinic. Since then, the People’s Hospital virtually stands empty, which I witnessed in 2003 and 2007. Most patients are now treated in the small clinic in the centre of Ngam- ring where members of hospital staff take turn on duty. Th is is ironic, since in 2003 an entirely new and much larger hospital was constructed with central government funds. Th e interlocutor at the private clinic considered the newly constructed People’s Hospital unnecessary, while its doctors lacked good training, and patients had to pay large sums for diagnosis and treatment: Just showing people that ‘now we have a new hospital’ is useless. It is like building a new monastery without statues in the lhakhang [the main temple room].47 I found a great deal of disappointment among both patients and doctors about the introduction of medical fees and the subsequent CMS scheme and, in 2003, I also considered the CMS’s implementation in this county to be a serious failure. However, I had also seen one exceptional township where people were satis- fi ed with the CMS scheme. Th e director of the township clinic had good connections with the local authorities, enjoyed the trust of the local people and seemingly was devoted to his profession. He also balanced his clinic’s accounts by encouraging the better-off people to make donations to the clinic. In his township clinic, the CMS scheme had even been reimbursing Tibetan

45 In Ngamring’s Health bureau, I found records showing an 80–90 per cent participation rate in the CMS scheme for the years 2000–3. 46 Interview in Ngamring, 2003. 47 Interview in Ngamring, 2003.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access T. Hofer / Asian Medicine 4 (2008) 174–200 187 medicine and Chinese acupuncture for one year (2003–4) which, according to the leaders of the counties’ health bureau, should have been the case every- where. People from other townships envied those living there and travelled long distances to be treated in this clinic. In Ngamring, out of 17 township clinics there were only two that kept Tibetan medicine in stock in 2003, and only one in 2007. Th e latter had a foreign sponsor who paid for the purchase of the Tibetan medicine. In 2006 and 2007, I extended my study of the workings of the CMS scheme to ﬁ ve counties of the Shigatse prefecture in TAR.48 Th e working of the CMS scheme seemed to have improved, which could be due to Government investing in making the CMS work. In 1996, China News Analysis aptly observed that health insurance in China has become ‘the next test of the legitimacy of the Party in the villages’.49 I would argue that this is even more important for the TAR and other Tibetan provinces. Tibetans’ suspicions of the communist leadership and government have faded little in the 50 or more years since China’s liberation/occupation of Tibet, as we have witnessed in a series of recent protests in March and April 2008. In 2006 and 2007, I observed that the CMS scheme had slightly changed. On payment of their annual fees to the CMS scheme, farmers and nomads received a booklet from the health bureau in which their and their household member’s contribution to the CMS (10 RMB per person) and all their medical expenditures were recorded (Figure 2). Every member was entitled to free medical care in villages and townships up to a certain amount, calculated from the individual CMS fee plus contributions from local, TAR and central gov- ernments (about 60 RMB per person). Household members usually have a common ‘account’ or booklet where the individual contributions are added. Th is money can then be used by whoever falls ill. When the account is depleted, patients pay all medical costs directly out of their own pockets or sometimes a percentage thereof. People interviewed again in 2006 and 2007 seemed a little more satisﬁ ed with the CMS scheme than in 2003. Th ey appreciated the absence of up-front payments when using out-patient care in townships and villages. In fact, I heard it said that Tibetans living in urban areas wished they had a similar scheme. In cities, all medical expenses were required to be paid out-of-pocket by the patient, unless oneself or one’s close relative is working for the Government or one of the few NGOs. However, the limited CMS funds can hardly cover

48 My study then included the counties of Gyantse, Lhatse, Ngamring, Rinpung and Sakya. Th ese were chosen owing to contacts established when I was working with the doctors from a Tibetan medical project funded by the Swiss Red Cross and due to private connections. 49 China News Analysis 1996.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access 188 T. Hofer / Asian Medicine 4 (2008) 174–200

Fig. 2. A CMS (Co-operative Medical Services) booklet recording medical expenditures in a rural township in the Tibet Autonomous region, China, 2007 (Image © Th eresia Hofer) medical costs at county- and prefecture-level hospitals, and the poor quality of medical training and the ill-informed prescribing of biomedical drugs in the rural areas remains a serious problem, as it does in inland China.50 Health sector oﬃ cials that I spoke to about the CMS scheme in 2006 and 2007 said that all kinds of treatments are now reimbursed by the CMS, which should include biomedical, Tibetan or Chinese medical treatment, whether at

50 Zhan et al. 1997. Th e liberal use of biomedical drugs has had negative physical conse- quences that are often recounted by those aﬀ ected, but which have not been investigated in the TAR. I will address these in future work. One example should suﬃ ce here to highlight the importance of such future research. It is very common to hear deaf or partly hearing-impaired people recount the story of how they acquired this impairment after having been given antibiotic injections when they were children (cf. for inland China, Callaway 2000, p. 56). Gentamycin and other ototoxic antibiotics (such as streptomycin, kanamycin, and neomycin), given in inap- propriate dosage to children are indeed considered to be the main human-made cause for deafness in Tibet (Personal communication with members of ‘Handicap International’, Lhasa, May 2007), and by comparison, accounts for 30 per cent of deafness in urban China (Callaway 2000, p. 56). Th e high usage of intravenous drugs is entirely supported by the various health bureaux. Th e poor training of health workers and doctors in rural Tibet may also be an important factor for other major public health problems, such as multi-drug resistant tuberculosis and a much higher than usual prevalence of hepatitis B in the TAR (TIN 2002, p. 33).

Downloaded from Brill.com09/25/2021 06:18:52AM via free access T. Hofer / Asian Medicine 4 (2008) 174–200 189 governmental or private level. As of September 2007, in practice this is not the case in the fi ve counties of Shigatse prefecture where I worked. More research is needed to explain this gap. On the contrary, the monetarisation of health care and the introduction of a reimbursement scheme that eff ectively only reimburses biomedicine expenditure has led to a situation where few township clinics exist where patients can receive Tibetan medical treatment at all, even if there is a fully trained Tibetan medical doctor there. He or she may be using Tibetan medical diagnosis,51 but with no Tibetan medicine in stock, they fall back on biomedicine or external treatments, such as moxibustion, cauterisation, bloodletting, golden needle therapy, or Chinese acupuncture. Many of the younger Tibetan medical doctors are not fully trained in the use of Tibetan medical external treatments, but most of them have a basic understanding of Chinese-style acupuncture and apply it regularly. In one particular county in the late 1990s, the government doctors from the county Tibetan medical hospital as well as a few township clinics were making Tibetan medicine freely available to their patients in both the county hospital and on their medical rounds, while only a small fee was charged for consultations with the senior doctors. Biomedicines were also free. After state-wide economic reforms in China in the 1980s, the state funding for clinics and hospitals started to diminish. For Tibet, this became more pro- nounced in the 1990s. Clinics and hospitals had to cover increasingly large portions of their running costs and doctors’ salaries. Rural Tibetan clinics achieved this more readily through sales of biomedicine rather than of Tibetan medicine, and virtually all the private pharmacies or clinics, which had started growing in small towns since the reforms, sell biomedicine. Ironically, health care reforms and the reduced funds from the Government for the running costs of hospitals and clinics and doctor’s salaries, are accompanied by a sub- stantial fi nancial input into the construction of new hospitals and clinics, as well as the purchase of high-tech diagnostic equipment, often purchased from bilateral development aid. Th e newly purchased equipment often remains unused due to lack of training of clinic staff , the lack of electricity and proper maintenance and repair. Today, in the rare case of the availability of Tibetan medicine in a township clinic, the CMS scheme hardly ever reimburses for it. Th is often makes Tibetan medicine in these government clinics an unattractive option for people who live largely outside the cash economy, especially when they can get the most commonly used biomedical treatments like antibiotics, injections and glucose drips fully reimbursed or very cheaply.

51 Th is counters the trend in Lhasa to incorporate more biomedical methods of diagnosis into Tibetan medicine practice.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access 190 T. Hofer / Asian Medicine 4 (2008) 174–200

Th e practice of Tibetan medicine in government institutions in Shigatse prefecture

County level

In the following ethnographic accounts, I introduce some of the places where I researched Tibetan medical practice. Th is will reveal some of the eff ects that the introduction of user fees and the CMS scheme had on Tibetan medical practitioners who work in and outside the governmental health care system, and on the populations they are meant to be serving in the rural areas. Th e eff ects on practitioners outside the offi cial government system will be dealt with in Part Two of this article, published in the next issue of this journal. However, these changes befalling contemporary Sowa Rigpa practitioners and their patients are by no means entirely new, nor of a solely top-down nature. People, ideas, and technologies circulate, change and are exchanged over time and place. Patients and doctors are active agents in making decisions and in their understanding health, illness, and healing, and they face the structural changes in creative and often unexpected ways. Th e county of Ngamring in rural Shigatse Prefecture is where a large part of my fi eldwork has been done. I observed medical practice and talked to doctors and patients at the Tibetan medical hospital, the People’s Hospital and in pharmacies in the county capital, as well as in many rural townships and villages. Ngamring is one of two counties in the TAR (Sog county in Naqchu prefecture is the second) that has a hospital solely devoted to the practice of Tibetan medicine in its county capital. Other counties might have a Tibetan medical section within the biomedical People’s Hospital.52 Ngamring’s Tibetan medical hospital began in 1974, when three Tibetan medical practitioners were invited by the Government to start the People’s Hos- pital’s Tibetan medical section. Th ey had studied Sowa Rigpa in the pre-1959 so-called ‘old society’ and continued to use Tibetan medicine to varying degrees afterwards. In their new position at the county hospital, these doctors diagnosed and treated patients predominantly using Tibetan methods enriched by sphyg- mometres and Chinese acupuncture, brought to the area in the early 1960s. Th ey collected materia medica in Ngamring that they exchanged for ready-made pills and powders from the medical factory of the Mentsikhang in Lhasa. No medical fees were collected, apart from a consultation fee for the two senior doctors.

52 Whereas it is common at prefecture-level to have independent institutions for biomedical and Tibetan medical practice, as in Shigatse (established in 1976), Naqchu, Ali and Shannan, at the county level it is not. Th is contradicts a 1999 publication by China Intercontinental Press which states otherwise (Yun 1999, p. 20).

Downloaded from Brill.com09/25/2021 06:18:52AM via free access T. Hofer / Asian Medicine 4 (2008) 174–200 191

In 1993, Jampa Trinley, the Lhasa-based scholar-physician, then director of the Mentsikhang in Lhasa, encouraged the establishment of a logistically and fi nancially independent Tibetan medical hospital in Ngamring. Th e reasons, he stated, were the extraordinary expertise of the doctors there, and the long history of Tibetan medicine in Ngamring, the homeland of the founder of byang lugs, a medical tradition that fl ourished in the region from the fi fteenth to the seventeenth centuries.53 In 1996 the hospital was extended by a small medical factory sponsored through a partnership with a city in inland China, and the staff increased over the years to fourteen. New recruits included younger doctors trained at the Mentsikhang and the Tibetan Medical College in Lhasa, who started to receive more in-depth practical training under the experienced elderly doctors working there. From 1996 until 2001 (when production stopped and the older doctors retired) they went on plant-collecting trips in the summer and the herbs they gathered were dried and made into 40 diff erent types of commonly used medicines. According to the two senior doctors, the quality of the medicines was good, but they regretted that they were not able to make precious pills, due to fi nancial restraints as well as to the ban on the usage of certain endangered species by the Government. However, they also had a small amount of rinchen rilbu from the Government factory in Lhasa, which were freely given to seriously ill patients. Two doctors were also well known for their skill in external treatments. From 1996 until 2002, the Tibetan hospital also provided some biomedicines, mainly antibiotic injections and intravenous drips delivered by the younger doctors, amounting to roughly 10 per cent of all treatments.54 In 2000, one of the senior doctors retired, followed by the other two in 2001, who moved to larger towns at lower altitudes. Highly revered by the local people as experienced practitioners, they had been the driving force behind the fundraising and running of the medical production unit and had trained many younger doctors. In 2003, two of the remaining eleven members of the staff diagnosed and treated patients at the hospital, while one acted as a pharmacist handing out the c. 100 medicines stored at the hospital’s pharmacy (Figure 3). One was on leave being further trained in biomedicine. Th ree graduates from the Tibetan Medical College lived in Ngamring, but were in more prestigious and better-paid government and administrative positions in the People’s Hospital and the Health Bureau and had stopped practicing as amchi altogether.

53 On this tradition, see Hofer 2007c. 54 Th is percentage is based on conﬁ dential data collected and kept in the county’s health bureau in Ngamring.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access 192 T. Hofer / Asian Medicine 4 (2008) 174–200

Fig. 3. Tibetan medical pharmacy with approximately one hundred diﬀ erent kinds of medicines in a county hospital in the Tibet Autonomous Region, 2003 (Image © Th eresia Hofer)

By the end of 2002, the Hospital started to provide exclusively Tibetan medicine, which I witnessed in 2003. I could not verify this upon my visit in 2007. In 2003 a new director started work at this hospital who told me he was keen on starting to use biomedicine, since he expected an increased income from their sale. Th is was also indicated by most of their staff receiving further biomedical training. Th e Tibetan medical hospital still had a relatively good reputation, but since the elderly doctors had retired its best days seemed to be fi nished and costs were an issue. I met people who preferred to travel to one of the townships where a retired doctor gave out Tibetan medicines at a dis- counted rate, purchased from his government pension. In 2003, the Hospital had between fi ve and twenty-fi ve patients per day, each paying a 0.5 RMB consultation fee in addition to the cost of the medicine. In most cases, these amounted to between 10 and 25 RMB per person for a seven-day course of treatment with common medicines and were not refunded under the CMS scheme. In comparison, a seven-day course of treatment for a common cold with pills from the biomedical private or governmental out-patient clinic could cost as little as 2 RMB. An intravenous drip was commonly delivered for a cold at these facilities, containing a glucose

Downloaded from Brill.com09/25/2021 06:18:52AM via free access T. Hofer / Asian Medicine 4 (2008) 174–200 193 solution and an antibiotic of varying make and dosage. Each drip cost about 10 RMB in the case of delivery through the government clinic, refundable by the CMS scheme. Based on data kept in the county government health bureau, records of the number of patient contacts in the People’s hospital could be compared with the Tibetan hospital for the period of 1999–2002. Th ere was no stark diff erence between them. Each institution recorded between 9,000 and 12,000 patients per year, with the People’s Hospital having recorded slightly fewer than the Tibetan Hospital. In 2002, following the retirement of the senior doctors and their own medicine production coming to an end, the People’s Hospital recorded for the fi rst time more patient contacts than the Tibetan medical hospital. Th is may well have been aff ected by the introduction of the CMS scheme in one pilot district in 1998 and the whole of Ngamring county in 1999 and 2000. In 1999, the township clinics also had fewer recorded cases of patients who were given Tibetan medicines (TM), rather than biomedicines (BM): 1,665 (TM) compared to 25,191 (BM). From 1999–2002, biomedical patient contacts in townships had almost doubled to 53,973, while the records for Tibetan medical patient contacts had shown a decrease by less than a half within the same period, from 1,800 to 700. On village level, between the years 2000–2, for each year between 12,366 and 20,000 patient contacts were reported. According to the records, all of those patients received biomedicine. Th ese fi gures exclude biomedical or Tibetan medical private practice, and should be used with caution since record-keeping is lax in rural Tibet. It may also be weighted for political reasons, especially in the records for births and maternal deaths during childbirth. However, even with caution, a relatively equal usage of Tibetan medicine and biomedicine in the county capital governmental health services can be seen, at least until 2002. On township level of the governmental system, there has been a much larger and increasing provision and usage of biomedicine than Tibetan medicine.55 Tibetan medicines were completely absent on the village level of the governmental health care system, although village doctors often ‘read’ a patient’s pulse in order to meet their patient’s expectation of an amchi—even if they had not learned pulse diagnosis. Th e decrease of Tibetan medical practice in governmental institutions in Ngamring, as suggested in these fi gures, is also confi rmed by doctors, health workers, and patients interviewed during my research. Although some elderly doctors retired, when we see the stark decrease, the heart of matter is that

55 Patients treated by one of the county doctors who went on medical rounds are included in the county hospital’s ﬁ gures, but not in the township-level ﬁ gures.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access 194 T. Hofer / Asian Medicine 4 (2008) 174–200

Tibetan medicines are usually no longer supplied to the clinics by the government even with a fully ﬂ edged Tibetan medical doctor there. If there are Tibetan medicines in stock, patients have to pay out of their own pockets and are rarely reimbursed by the CMS scheme. Th e diﬃ culties, social dynamics, and changes in medical practice brought about become apparent in many clinical encounters, which the next section will illustrate in the context of a township clinic.

Township level care

My co-researcher, from the Tibetan Academy of Social Sciences in Lhasa, and myself were visiting the township clinic of Kaga for a day, and spent the eve- ning at the doctor’s residence in the compound. Th e clinic was built in Tibetan style and consisted of two rooms: a medicine storeroom, where the shelves were mostly empty, and a consultation room with a table, chair, bench, bed, and a small cupboard containing some biomedical drugs. Th ere was a strong smell of antiseptic. A couple of empty intravenous drips were hanging from the joists of the ceiling and the walls were decorated with posters from the Red Cross on hygiene and childcare. One showed Jiang Zemin giving medicine to children and another showed the obligatory communist leader trinity of Mao, Deng, and Jiang Zemin which was decorated with a white Tibetan blessing scarf. Th e place looked like most of the township clinics I had seen before, although in 2007 many old township clinics had been replaced by new and larger concrete structures equipped with advanced medical technology such as X-ray machines, while many of them still lacked electricity, heating or running water. Th e doctor in charge of the clinic had trained at Lhasa’s Mentsikhang for four years followed by a few years of practical training under the senior doctors in Ngamring’s Tibetan medical hospital. Th ere was also a health worker there with a two-year training in basic biomedicine through the Swiss Red Cross in Shigatse.56 Working at the township clinic, the doctor mostly used Tibetan medical diagnostic techniques, referred to in Tibetan as ‘bltas regs

56 Th e ﬁ rst Delegates of the Swiss Red Cross (SRC) in Shigatse provided courses for existing rural Health Workers (1988–92), who had previously been trained for a maximum of six months to become ‘barefoot doctors’ or ‘village doctors’ in the Chinese system. Subsequently, these courses (both basic and refresher activities) were sub-contracted to the local vocational health school and prefecture hospitals (1992–2002). Th roughout this period, the SRC had supported the training of more than 700 health workers in Shigatse prefecture. Th is part of their project closed down in 2002, and SRC initiatives are now mainly devoted towards the provision of clean drinking water, hygiene and sanitation, and the prevention of transmitted diseases in Shigatse Prefecture. Th ey remain the only NGO working in this region to date.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access T. Hofer / Asian Medicine 4 (2008) 174–200 195 dris gsum’. Th e fi rst refers to visual observation of the patient (in particular, the inspection of urine and the tongue), the second to palpation of the pulse on the radial arteries and the third to questioning the patient. He also often took the patient’s blood pressure. Treatment tended to consist of biomedicine, except for the odd application of Tibetan external treatment. Th ere were no Tibetan medications available. Within the few minutes that a consultation lasted, the young doctor translated from one way of understanding the body/ mind and the patient’s ailment based on Sowa Rigpa to one based on biomedicine.57 Although he had received six months of biomedical training as part of his Sowa Rigpa education (as do all Tibetan medical doctors recently trained in state institutions), this was by no means his option of choice. Th e doctor tried to negotiate with the local township administration and the health bureau for Tibetan medicine, but was unsuccessful. His conviction was in the effi cacy of Tibetan medicine for many conditions and that he did not want to lose his practical expertise. Shigatse Health Bureau provided all township clinics with biomedicines only, and the rare clinic that had Tibetan medicine purchased them at one of the factories using donations from foreigners or from people’s CMS scheme contributions. If patients in this small township wanted or needed Tibetan medical treatment, they either went to the Tibetan medical hospital in the nearby county or, more often, they turned to the former and locally resident director of the township clinic. He had learned Tibetan medicine from his father and uncle as a young man, and after 1960 had worked as a barefoot doctor in a remote part of the nomadic areas of Ngamring, where he exchanged Sowa Rigpa knowledge with a local Bonpo practitioner, a follower of the pre-Buddhist religion of Tibet, who had also studied Sowa Rigpa. Even though the ex-township clinic director has retired, patients still come to his house to ask for a consultation and Tibetan medicines. His explanation of his choice to retire early is indicative of larger changes in the health care system that some Tibetan doctors have diffi culty in dealing with: I thought that towards the end of the life it was good to practise the Dharma (chos). [. . .] After 39 years of work all over the place, including years of visiting patients on horseback in remote areas, I wanted to stay here calmly and relax. Also, I couldn’t get used to charging people money for treatment. When I went on medical rounds to the countryside, I didn’t get payment for medicines from the people; I knew all of them—many were poor. I am a doctor, not a business- man, and I had never learned how to do business. However, I still had to give the

57 A detailed discussion of such ‘translations’ between medical systems can be found in Adams and Fei Fei Li 2007, looking at medical practice in an ‘integrated hospital’ in Lhasa where both biomedicine and Tibetan medicine are practised.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access 196 T. Hofer / Asian Medicine 4 (2008) 174–200

payment to the government, so I used the money from my own salary to pay it back to them. Actually I earned more than 2000 RMB (a month), but I gave lots of it back to the government where I got it from (he laughs . . .)58 Once a year, this doctor purchases Tibetan medicines in Lhasa, which he pays for from his pension and donations from relatives. To be honest out of the 4500 RMB I spend, I usually get back about half of it. Not all is in money—it also includes butter, meat and barley for making chang. Mostly I want the patients to keep their gifts, for one because I don’t need it—I am also a farmer—and on the other hand I don’t drink chang. [. . .] More importantly, I tell myself and them that ‘for this life it would be o.k. to accept these gifts, but it’s not good for the next life’. So I continue like that until this human life is over.59 Th ese statements indicate a diﬀ erent kind of economy of treatment prevailing among some Tibetan practitioners. Th ey know that they help their patients, but they also have an awareness that they are helping themselves on their own religious path through the accumulation of merit, both for this and the next life. It is generally acknowledged in Tibetan societies, that being a doctor is one of the professions most favoured for its intrinsic practice of the Dharma. An elderly Tibetan doctor in Shigatse also indicated this. I once asked him why he did not join his wife for her daily ’khor ra, or circumambulation around Tash- ilunpo monastery every morning, counting the beads of her rosary and spin- ning her prayer wheel. He replied that it was not necessary for his practice of chos, or Dharma. He said that seeing patients—provided it was done with a sems bzang po (a pure heart/mind)—essentially was the same as his wife’s circumambulations and religious practices.60 Th is resonates with what is expounded in the Rgyud Bzhi on the results of being a physician, where in the chapter on the ethics of a doctor, it is written that the practice of medicine may ultimately lead to enlightenment: Temporally in this life one will be endowed with happiness, prosperity, joy and bliss. One achieves these through the practice of Medicine [. . .]. Harmful people should be treated aﬀ ectionately [. . .]. By force of practising in this way, one will win merit and renown, and the food and possessions one wishes will appear. At these times one should be modest and apply [what one has learned]. When one is in demand one should accept food, money or measures (of grains etc.) [. . .]

58 Kaga, Ngamring County (TAR), summer 2003. 59 Ibid. 60 Shigatse, TAR, summer 2007.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access T. Hofer / Asian Medicine 4 (2008) 174–200 197

[. . .] with respect to ultimate results, a physician who has abandoned deceit and desire and who engages in healing will proceed to the unsurpassed state of Buddhahood.61 So, currently, there are doctors who follow such ethics as laid out in the classi- cal texts of this tradition and follow a diff erent kind of ‘economy of treatment’, in which the doctors’ concerns for the patient, whether rich or poor, and their professional and religious ideals, infl uenced by Tibetan Buddhism, can become paramount and may confl ict with the demands made by the offi cial system on them. Most often this applies to elderly doctors, who previously worked for Government institutions and can aff ord to embrace such ideals more thoroughly because they earn a government pension. A majority of the younger Tibetan medical doctors, inside and outside the governmental health care system, fi nd themselves in a fi nancially and legally more precarious situation that raises questions about the future development and the place of Tibetan medicine in more rural and remote areas of the TAR. Th is will also be explored in greater depth in Part Two.

Conclusion

While certain aspects of Tibetan medicine expand and become more widely available in urban settings in Tibet, China and abroad, it is increasingly diffi - cult for a doctor to practise solely Sowa Rigpa in the rural areas of the TAR, and to aff ord and access Tibetan medical treatment as a patient. Most younger and many older doctors are hybrid practitioners, whether they are trained in governmental or NGO-sponsored Tibetan medical schools, or whether they are private Tibetan amchi, who have acquired biomedical training through ‘barefoot doctor’ campaigns, subsequent training for rural health workers or self study. Biomedicine in Tibet has been systematically strengthened and supported since the Chinese communist’s arrival in Tibet,62 which was accompanied by a loss of local medical and cultural knowledge. Whatever the reasons for the contemporary dominance of biomedicine, its fast eff ect, especially those of intravenous antibiotic drips and injections, hold a certain attraction for many rural Tibetan patients and doctors. Th is goes as far as the Tibetan term khab being used in rural Tibet not only for IV drip and injection, but also for Chinese biomedicine as a practice (Tib.: khab brgyab) and for its practitioners (Tib.: khab brgyab mkhan, or ‘injectionist’).

61 Clark 1995, p. 232, my emphasis. 62 On the establishment of biomedicine prior to this, see McKay 2007.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access 198 T. Hofer / Asian Medicine 4 (2008) 174–200

Transportation and roads in TAR have improved and expanded over the last decade, enabling more goods and larger volumes of more sophisticated drugs, among them drips in glass bottles, to reach isolated places. However, taking into account historical, political and logistical developments, I consider that the CMS scheme, which is currently biased towards biomedicine, together with a steady increase in the price of Tibetan medicines, are leading factors for the current decline in the use of Sowa Rigpa by doctors and patients, at least in the rural fi ve counties of Shigatse prefecture where I have worked. Th is situation is aggravated with the immanent death of a generation that was more thoroughly trained in Sowa Rigpa and had considerable medical experience, which made them confi dent practitioners who garnered the patient’s trust. Few younger doctors had the luck to study under such doctors or to build up their confi dence in the power to heal with the means of Sowa Rigpa. Th e initial question of ‘Who uses and has access to what kinds of Tibetan medical health care in the contemporary TAR?’ then reveals an imbalance in the prevalence of Tibetan medical practice in urban and rural areas, and also along lines of income. Th ere are still a few Tibetan medical practitioners who treat patients who cannot participate in the now predominantly commodifi ed health care system. Th e urban-rural divide in the use of Tibetan medicine may to a certain extent also be linked with the question of Tibetan identity, an interesting avenue of further research. Tibetan culture, and the Tibetan language above all, is more obviously under threat in places like Lhasa, where a majority of the population is Chinese, and the practice of other aspects of Tibetan culture, such as religion or the arts, is more closely monitored. Tibetan medicine is, in part by virtue of being a more holistic understanding of the body/mind and since the Tibetan language is still at the core of its teaching and practice, an apt way to state one’s ‘Tibetan-ness’.

References

Adams V. 1998, ‘Suﬀ ering the winds of Lhasa: Politicized bodies, human rights, cultural diﬀ erence, and humanism in Tibet’, Medical Anthropology Quarterly, 12: 74–102. —— 2001, ‘Particularizing modernity: Tibetan medical theorizing of women’s health in Lhasa, Tibet’, in L. Connor and G. Samuel (eds), Healing Powers and Modernity: Traditional Medi- cine, Shamanism, and Science in Asian Societies, Westport, CT: Bergin and Harvey, 221–46. —— 2002, ‘Randomised controlled crime. Postcolonial sciences in alternative medicine research’, Social Studies of Science, 32: 1–32. —— 2007, ‘Integrating abstraction: Modernising medicine at the Lhasa’s Mentsikhang’, in M. Schrempf (ed.), Soundings in Tibetan Medicine: Anthropological and Historical Perspectives, Leiden: Brill, 29–43. Adams V. and Fei Fei Li 2007, ‘Integration or erasure?: Modernizing medicine at Lhasass Men- tsikhang’, in L. Pordié (ed.), Tibetan Medicine in the Contemporary World: Global Politics of Medical Knowledge and Practice, London: Routledge, 105–32.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access T. Hofer / Asian Medicine 4 (2008) 174–200 199

Adams V. and S. R. Craig 2008, ‘Global pharma in the land of snows: Tibetan medicines and identity across nations’, Asian Medicine: Tradition and Modernity, 4 (see this volume). Adams V., M. Varner, S. Miller, S. Craig, Sonam, Lhakpen 2005, ‘Th e challenge of cross-cultural clinical trials research: Case report from the Tibetan Autonomous Region, People’s Republic of China’, Medical Anthropology Quarterly, 19: 267–89. Akin J., N. Birdsall and D. Ferranti 1987, ‘Financing health services in developing countries: An agenda for reform’, Washington, DC: World Bank, www.popline.org/docs/0818/046618. html (accessed 10 May 2008). Aschoff J. C. and T. Y. Tashigang 2001, Tibetan ‘Precious Pills’ the Rinchen Medicine—A Tantric Healing System with Great Benefi ts, Some Problems and Many Secrets, Ulm/Donau: Fabr. Barnett R. 1994, ‘Symbols and protest: Th e iconography of demonstrations in Tibet, 1987–1990’, in R. Barnett and S. Akiner (eds), Resistance and Reform in Tibet, London: Hurst and Com- pany, 238–58. —— 2003, ‘Chen Kuiyuan and the marketisation of policy’, in A. McKay (ed.), Tibet and her Neighbours—A history, London: Hansjörg Mayer, 229–39. —— 2007, Lhasa: Streets with Memories, New York, NY: Columbia University Press. Berg M. and A. Mol 1998, Diff erences in Medicine: Unravelling Practices, Techniques and Bodies, Durham, NC: Duke University Press. Besch F. 2007, ‘Making a medical living’, in M. Schrempf (ed.), Soundings in Tibetan Medicine: Anthropological and Historical perspectives, Leiden: Brill, 155–70. Bloom G. and Fang Jing 2003, China’s Rural Health System in a Changing Institutional Context, IDS Working Paper 194, Brighton: Institute of Development Studies at the University of Sussex. Bod rang skyong ljongs sman tsi khang 2006, Tibetan–Chinese–English Catalogue of the Tibetan Traditional Medicine Books, Lhasa: People’s Publishing House. Byams pa ’phrin las 2004, gso rig lo rgyus (Textbook on the History of Tibetan Medicine), pe jin: mi rigs dpe skrun khang, Beijing: People’s Publishing House. Callaway A. 2000, Deaf Children in China, Washington, DC: Gallaudet University Press. China News Analysis 1996, ‘Health and Medical Insurance’, No. 1562, 15 June. Choedrak T. 1999, Der Palast des Regenbogens: Der Leibarzt des Dalai Lama erinnert sich, Frank- furt: Insel Verlag. Clark B. 1995, Th e Quintessence Tantras of Tibetan Medicine, Ithaca, NY: Snow Lion Publications. Craig S. R. 2006, On the ‘Science of Healing’: Effi cacy and the Metamorphosis of Tibetan Medicine, unpublished PhD dissertation, Cornell University. —— 2007, ‘A crisis in confi dence: A comparison between shifts in Tibetan medical education in Nepal and Tibet’, in M. Schrempf (ed.), Soundings in Tibetan Medicine: Anthropological and Historical perspectives, Leiden: Brill, 127–54. Fisher A. 2002, Poverty by Design: Th e Economics of Discrimination in Tibet, Montreal: Canada Tibet Committee. Heimsath K. 2004, Traditional Tibetan Medicine in Rural Tibet: Evaluation of the 1996 Graduates of SRC Pelshong, Shigatse, Internal Report, Swiss Red Cross. Hofer T. 2007a, Evaluation and Needs Assessment II. Th e 2003 Graduates from the Tibetan Medi- cal School, Shigatse, Tibet Autonomous Region, Internal Report, Swiss Red Cross. —— 2007b, Evaluation and Needs Assessment I. Th e 1996 Graduates from the Tibetan Medical School, Shigatse, Tibet Autonomous Region, Internal Report, Swiss Red Cross. —— 2007c, ‘Preliminary Investigations into New Oral and Textual Sources on Byang lugs— Th e “Northern School” of Tibetan Medicine’, in M. Schrempf (ed.), Soundings in Tibetan Medicine: Anthropological and Historical Perspectives, Leiden: Brill, 373–410. —— forthcoming, Tibetan Medicine in Ngamring, Tibet Autonomous Region: Historical and Anthropological Perspectives, Vienna: Wiener Studien zur Tibetologie und Buddhismuskunde. Janes C. R. 1995, ‘Th e transformations of Tibetan medicine’, Medical Anthropology Quarterly, 9: 6–39.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access 200 T. Hofer / Asian Medicine 4 (2008) 174–200

—— 1999, ‘Th e health transition, global modernity and the crisis of traditional medicine: Th e Tibetan case’, Social Science and Medicine, 48: 1803–20. —— 2001, ‘Tibetan medicine at the crossroads: Radical modernity and the social organization of traditional medicine in the Tibet Autonomous Region, China’, in L. Connor and G. Samuel (eds), Healing Powers and Modernity: Traditional Medicines, Shamanism, and Science in Asian Societies, Westport, CT: Bergin and Harvey, 197–221. Kloos S. in press, ‘Good Medicines, Bad Hearts: Th e social role of the amchi in a Buddhist Dard community’, in L. Pordié (ed.), Medicine at the Borders: Th e Social Life of Tibetan Medicine in India, Durham, NC: Duke University Press. Liu Y., William C. L., Hsiao Qing Li, Xingzhu Liu and Minghui Ren 1995, ‘Transformation of China’s rural health care fi nancing’, Social Science and Medicine, 41: 1085–93. Lora-Wainwright A. 2005, ‘Using local resources: Barefoot doctors and bone manipulation in rural Langzhong, Sichuan Province, PRC’, Asian Medicine: Tradition and Modernity, 1: 470–89. McKay A. 2007, Th eir Footprints Remain. Biomedical Beginnings across the Indo-Tibetan Frontier, Amsterdam: Amsterdam University Press. Meyer F. 1998, Report of the Missions in Tibet for the Swiss Red Cross, Paris. Neuenschwander J. 1989, Shigatse—One injection asks for more, documentary fi lm, 90 minutes, Switzerland. Schwartz R. D. 1994, ‘Th e anti-splittist campaign and Tibetan political consciousness’, in R. Barnett and S. Akiner (eds), Resistance and Reform in Tibet, London: Hurst and Company, 207–37. Schrempf M. (ed.) 2007, Soundings in Tibetan medicine: Anthropological and Historical Perspecti- ves, Leiden: Brill. Taylor K. 2004, Chinese Medicine in Early Communist China, 1945–1963. A Medicine of Revolu- tion, London and New York, NY: Routledge. Tibet Information Network (TIN) 2000, China’s Great Leap West, London: Tibet Information Network. TIN 2002, Delivery and Defi ciency: Health and Health Care in Tibet, London: Tibet Informa- tion Network. —— 2004, Tibetan Medicine in Contemporary Tibet: Health and Health Care in Tibet II, Lon- don: Tibet Information Network. Tse brtan ’jigs med, mkas dbang byams pa ’phrin las mchog gi bod lugs gso rig gi dran gsos gtam rna ba’i bcud len, pe jin: mi rigs dpe krun khang 2007, Beijing: People’s Publishing House. Whitehead M., G. Dahlgren and T. Evans 2001, ‘Equity and health sector reforms: Can low- income countries escape the medical poverty trap?’, Lancet, 358: 833–6. World Health Organization (WHO) 2004, Macroeconomics and Health: Investing in Health for Economic Development. Executive Summary, Geneva: WHO, http://www.who.int/macrohealth/ action/sintesis15novingles.pdf (accessed 3 July 2008). Wylie T. V. 1959, ‘A standard system of Tibetan transcription’, Harvard Journal of Asiatic Studies, 22: 261–76. Xueshan Feng, Tang Shenglan, G. Bloom, M. Segall and Gu Xingyuan 1995, ‘Cooperative medical schemes in contemporary rural China’, Social Science and Medicine, 41: 1111–18. Yao W. 1994, ‘Hu Yaobang’s visit to Tibet, May 22–31, 1980—An important development in the Chinese government’s Tibet policy’, in R. Barnett and S. Akiner (eds), Resistance and Reform in Tibet, London: Hurst and Company, 285–95. Yun Z. 1999, Medicare Service in Tibet, Beijing: China Intercontinental Press. Zhan S., S. Tang and Y. Guo 1997, ‘Drug prescription in rural health facilities in China: Impli- cations for service quality and cost’, Tropical Doctor, 28: 42–8.

Downloaded from Brill.com09/25/2021 06:18:52AM via free access