Asian Medicine 4 (2008) 492–514 brill.nl/asme Socio-Economic Dimensions of Tibetan Medicine in the Tibet Autonomous Region, China1 Part Two Th eresia Hofer Abstract Th is article investigates some of the socio-economic dimensions of contemporary Tibetan medi- cal practices in the rural areas of the Tibet Autonomous Region (TAR), China. Th e article is divided into two parts. Part One, printed in the last issue of the journal, deals with traditional medical practitioners and their medical practices within the governmental health care system in the TAR. It sheds light on the workings and the eff ects that the commodification of the offi cial health care system have had on its Tibetan medical practitioners, most of whom now work as hybrid practitioners and incorporate Chinese-style biomedicine into their practice. I argue that several historical, social and political factors have brought about unequal access and availability of Tibetan medicine as compared to Chinese style biomedical care in the rural areas. Special attention is given to the role of the re-introduction of the Co-operative Medical Services (CMS) scheme in the sidelining of Tibetan medical practices in the rural areas. Part Two describes the work of private Tibetan medical practitioners and explores some of the social dynamics and ethical dilemmas that have arisen for them due to the commodifi cation of the offi cial system and the re-introduction of the CMS. 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, where most of the anthropological literature has focused on so far. Both contributions are based on extensive anthropological fieldwork in Lhasa and the Tsang region of Tibet. Keywords Tibetan medicine, Sowa Riga, Tibet Autonomous Region, health care reforms, Co-operative Medical Services, CMS, rural China, private medicine, social change, NGOs 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. Höger for their generous fi nancial support and the Swiss Red Cross for allowing me to use data gathered during an evaluation and needs assessment I carried out on their behalf. I also would like to thank Andrew Beattie, Hildegard Diemberger, Andre Gingrich, Guntram Hazod and Vivienne Lo for their guidance before and during fi eldwork, my Tibetan friends, co-researchers and trans- lators, 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 latest period of fi eldwork. Tibetan terms, names of © Koninklijke Brill NV, Leiden, 2008 DOI: 10.1163/157342009X12526658783772 Downloaded from Brill.com09/30/2021 07:12:33PM via free access T. Hofer / Asian Medicine 4 (2008) 492–514 493 When you have crossed the river, you forget the bridge. When you have recovered from an illness, you forget the doctor. Tibetan saying Introduction Tibetan medicine, the inheritor of what in Tibetan has been traditionally referred to as Sowa Rigpa or ‘Science of Healing’, is readily available and acces- sible through governmental and private medical practitioners in Lhasa, the capital of the Tibet Autonomous Region (TAR). 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 in comparison to Chinese biomedicine is unevenly available, and unequally reimbursed through the governmental medical insur- ance scheme, the Co-operative Medical Services (CMS).2 Th is disparity of 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 ques- tion: ‘Who uses and has access to what kinds of Tibetan medical health care in the contemporary TAR?’. Part I described the processes of revitalisation of Tibetan medicine and the role it gained in government medical institutions following the Cultural Revolution (1966–77). By describing the kinds of ser- vices provided on diff erent levels of the governmental health care system, a contrasting picture of the situation of Tibetan medicine in Lhasa and in the rural parts of the Tsang region of the TAR arose. I concluded that certain aspects of Tibetan medicine have expanded and have become more widely available in commercial contexts and in, mostly, urban settings in Tibet, China and abroad, while it is increasingly diffi cult to fi nd a doctor who practises solely Sowa Rigpa in the rural areas of the TAR and to aff ord and access Tibetan medical treatments as a patient. I highlighted some of the challenges that doc- tors are facing at diff erent levels of medical care in the offi cial system. I explored how their medical ethics may be compromised due to demands arising with a Tibetan authors and Tibetan titles of books have been transliterated following the system as devised by Wylie 1959. Exceptions are the often-used terms 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. 2 Th e sets and ideas I refer to here as ‘Chinese biomedicine’ include what Tibetans generally call ‘outsider medicine’ (Tib.: phyi lugs sman Chin.: zang yi), ‘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. See Berg and Mol 1998. Downloaded from Brill.com09/30/2021 07:12:33PM via free access 494 T. Hofer / Asian Medicine 4 (2008) 492–514 commercialised paradigm in the offi cial medical system and when, on the other hand, their medical practices are not receiving nearly as much fi nancial, legal and ideological support as compared to Chinese-style biomedicine. I have indicated how, in particular, elderly and private practitioners are more readily able to adhere to traditional medical ethics. For example, in volunteer- ing to treat patients for free and perceiving medicine as a part of their religious practice. For younger doctors, both working in government and private set- tings, it is diffi cult to adhere to such practices and ideals. Th is part explores how private doctors from the Tsang region of the TAR perceive and negotiate social and economic change in their day-to-day medi- cal practices.3 Private practice—Buddhist ideals and complex realities Scholar and physician Doctors who wish to and can in fact aff ord to give medicine largely for free are mostly elderly practitioners in their 60s and 70s who went through many years of theoretical and practical medical training, often paired with in-depth studies of Tibetan language, astrology and Buddhism. Many previously worked in government institutions and live on a pension from the state. A close teacher and friend of mine, who now lives in Shigatse, has consulted and treated more than 10,000 people since his retirement in 2001, predominantly on this prin- ciple. Usually patients come to his private house where he treats them in his living room or the courtyard of the house. Occasionally he sees patients in their own homes if they are too ill to come to his house. At least once a year, he goes on medical rounds to remote and poor areas of Shigatse prefecture and combines those with visits to relatives. Generally he uses Tibetan medical diagnostic techniques, expounded in Sowa Rigpa’s core text rgyud bzhi and referred to in Tibetan as ‘bltas regs dris’. Th e fi rst Tibetan term 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. In many cases, he took the patient’s blood pressure. He is one of the few doctors who also regularly give a full physical examination. Although he can employ a large variety of Tibetan medical treat- ments, most commonly he prescribes medical formulae (pills and powders) 3 For a discussion of similar issues within the wider Tibetan cultural sphere, I would like to refer the reader to two excellent studies carried out in Ladakh (Kloos forthcoming) and Spiti (Besch 2007a, 2007b). Downloaded from Brill.com09/30/2021 07:12:33PM via free access T. Hofer / Asian Medicine 4 (2008) 492–514 495 Fig. 1. A retired doctor performing moxibustion on medical rounds to rural areas. Tibet Autonomous Region, 2007 © meinradphotography.com and applies moxibustion. (See Figure 1). Occasionally he also gives biomedical eye drops and painkillers, and advises patients to continue with a course of biomedical drugs in addition or on their own. What is of interest here is that a majority of his treatments are off ered with- out expecting payment in return. He pays for this from his pension and on two occasions through donations from foreign sponsors. Although he some- times accepts money when patients off er it, he never asks for it, even if patients could aff ord it. However, it is regularly the case that patients do give money, food or Tibetan tea in return, the latter two in particular when he goes on medical rounds to the countryside.