Equity of the Ineffable:

This paper has been prepared under the Global Health Equity Initiative project on "Foundations of Health Equity" based at the Harvard Center for Population and Development Studies.

GLOBAL HEALTH EQUITY INITIATIVE

The working papers in the series on "Foundations of Health Equity" arise from two workshops held at the Harvard Center for Population and Development Studies in 1998. The workshops were organized as part of the Global Health Equity Initiative (GHEI), a comprehensive project on health equity funded in part by the Rockefeller Foundation and SIDA. The GHEI is an interdisciplinary project which combines conceptual work on health equity with country-case studies. The foundational issues of health equity discussed at the two workshops form a part of the conceptual work, which addresses issues that cut across the case studies. Other cross-cutting topics include "measurement", "gender", and "social determinants". The papers in the "Foundations of Health Equity" series will appear in a volume provisionally entitled Health, Ethics, and Equity.

Abstract

Using the case of ethnomedicine in the Tibetan Autonomous Region of the People’s Republic of China, this essay illustrates the centrality of culture to health. It also argues for greater sensitivity to the ways that cultural politics affect health equity. In contemporary Lhasa, cultural freedoms are limited by the politicization of Buddhist religion and secular modernization. These policies are linked to historical public health efforts aimed at establishing equity by providing basic health care to all China’s citizens. But such policies have not eliminated all diseases, and in fact are thought today to directly produce women’s reproductive health problems. Moreover, the secularist nature of modernization is seen as producing health problems related to emotional distress, particularly problems diagnosed as "winds" and associated with unfulfilled desires tied to secularization. The author suggests that using Tibetan ethnomedical conceptions enables us to understand the links between culture and health, to see that religious freedoms are central to health, and that therefore we might consider the relevance of discussions over the equity of different ethnomedical approaches in the international community.

Introduction

My goal in this essay is to show that health can be first and foremost formulated in cultural terms--for everyone, not just for Tibetans, not just for cultural anthropologists. By this I mean not simply that the subjective experience of suffering is cultural-specific. It can also be taken to mean that health is a product of social, economic, political, and religious social structures that are themselves shaped and constituted culturally and in contested political terrain.

Recognizing the centrality of culture to health can, however, open up a Pandora’s box of problems for policy oriented work. In my experience, it seems as if culture is typically bracketed off and held apart, treated as an independent variable in policy discussions. When it is made central, it is generally with the goal of eliminating cultural views that are seen as obstacles to health reforms. Otherwise, it is left out. For although culture is recognized as important, it makes visible the ways in which groups of people become incomparable. Culture makes differences of opinion, experience, and even structure significant and forces tidy universalizing policies into the realm of the narrowly contingent and consensually unstable. But if health is recognized as a product of the fine tuning required of public policy in order to achieve equality, or even simply the optimal advantage of all members of a society, then it would seem that no social, political, economic policy and even policy on religion, would dare be considered without some attention to the health outcomes it would produce. To get this fine-tuning, I believe, attention needs to be paid to the cultural politics embedded in social policies and social institutions.

My case study offers an example of a non-Western socialist nation that laudably recognized the relationship between culture, basic social structure, and health, and that implemented social reforms to attend to health equity but then, because it limited cultural freedom, produced sicknesses. Sickness among Tibetans can in many cases be understood as a product of secularist reforms. However, understanding this, and understanding how to eliminate it, is problematically tied up in ideas about religion--specifically to ideas of the sacred--that are as "ineffable" in the world of modern medical science as they are in the secularist ideologies of the Chinese state. The problem of culture, in other words, is not just one that presents itself in the case of China, where it is politicized to achieve health for all. It is also a problem in health policy-making centers of the world wherein taking into account "culture" demands a level of specificity, particularity, and even "belief" that tend to make it unusable. But, I suggest here, to overlook culture is to overlook a cause of health and an extremely important basis upon which to design and theorize interventions to bring about health equity.

The materials I present here are based on research I have done over three visits to Tibet since 1993 at the women’s ward of the Traditional Tibetan Medical Hospital in Lhasa.¹ My placement in the women’s ward is deliberate in that my research goals have been to understand how modernization is worked out through women’s bodies and women’s health, but in ways that are theorized in unique ways by Tibetan medical doctors. This presentation and analysis should be read as initial rather than conclusory, and should not be taken to represent anything other than my own analysis and interpretation. In what follows, I first describe Tibetan medicine in the context of a history in which medical practices were first politicized and later, under Liberalization, depoliticized by being deemed "scientific" in this region of the People’s Republic of China (hereafter, China). In what follows, I first explore how Tibetan medical theories are being modified by political processes that valorize the secular over the religious. I then offer a Tibetan view of the healthy body based on Buddhist cultural foundations in which ideas about morality and the power of the sacred are tied to bodily well-being. I then discuss the influence of social environment on health as accounted for by Tibetan medicine, and the role of belief and the sacred in producing health through a few cases of women’s ill health. I then ask: when the moral is manifest as bodily health, following the Tibetan views, and efficacy is partly based on belief, how well can a secularized medicine respond to ill-health? I conclude by arguing that while efforts are underway to secularize the sacred in Tibetan medicine, we might also understand these processes as enabling science to speak to and about religious concerns.

Thus, the paper makes two linked arguments: one that shows how social policies lead to ill-health, as understood by Tibetan medicine, and one that shows how social policies affect Tibetan medicine in ways that reveal competing epistemologies in a world that continuously prioritizes biomedical science over all other medical theories. Thus concerns are raised about the links between cultural survival and health, as well as the idea of an equity of epistemology--about the way we theorize health and its causes--in international arenas. I suggest that these concerns, cumulatively, point to ineffable areas of ethics in health and health equity; because of their religious character, Tibetan medical theories and practices both resist description and quantifiability in a manner acceptable to secularist discourse but may nevertheless remain essential to health. To begin with, however, I first walk back over the terrain of health equity to explore the numerous ethical discourses that have become relevant to Tibet’s (that is the Tibetan Autonomous Region’s)² situation.

Health Equity and Ethical Discourses

Ratification of Alma Ata’s commitment to Health for All by the year 2000, occurring as recently as 1992, confirmed WHO’s commitment to the ethical proposition that it should be possible to help all people achieve "a level of health that would permit them to lead a socially and economically productive life" (WHO 1992). The obvious difficulty of uniformly defining what this level might be, let alone achieving it, has perhaps only been matched by the difficulty that soon became, and remains, apparent in trying to ensure this outcome by calling for political will on the part of participating nations. Placing issues of health equity on the health development map in this particular way has meant raising concerns about the need for political and social reforms as health priorities. But doing this has in many cases meant treating health itself as a political instrument and subjecting it to political agendas that actually subvert rather than promote health care (Morgan 1993, Ferguson 1994, Adams 1998).

Despite the overt ethical mandate of Alma Ata, in many ways the missing link in the discussions has been that of ethics. What ethical boundaries can be set in relation to universalist ideas about "complete" or even a minimum level of "adequate health?" What are the ethical ambiguities of using productivity (economic or social) as a basis for defining health? Is this definition shared as an ethical assumption cross-culturally? More specific to my discussion, what ethical measures might have been and can still be put in place to ensure that "political will" works in the best interests of health rather than vice-versa? Perhaps ethical discussions have been less visible than they might have been because of the difficulty in defining on what basis the discussion of ethics should be grounded: philosophical, religious, scientific?

Based on my own research experiences in the area of health development in Nepal and the Tibetan Autonomous Region of China, I would say that in the field of health the human rights discourse has become the place-holder for this ethical discussion. This may be because human rights offer a secularist and perhaps universalist ethical mandate that is seen as transcending particular political agendas in the same way that health is supposed to. The achievement of human rights, like health, may require political reform, but as goals, they are supposed to transcend particular political formations. The same might be said of their ability to transcend religious orientations. Human rights provide a powerful way to speak about ethics in a secular fashion. The benefit of this particular secular discussion of ethics, however, is not so much its ability to speak apolitically or even philosophically but rather its ability to speak scientifically. In medicine, I would say the language of science counts more than the language of philosophy or politics. Scientific languages enable universalist ethical claims that produce consensus and practical action partly at least because their terms of objectivity can be agreed upon (Adams 1998). The secularist vision of equality in health offered by the declaration of Alma Ata draws from the compatibility between the languages of science and of human rights. In this essay I question whether the secularist ethical discourse is the best way to promote health in all cases.

China has prided itself on meeting, better than most other nations, both mandates for the provision of health for all. It has done this by promoting a socialist ethics that prioritized material needs over spiritual ones, and prioritized meeting the basic needs of all over meeting the exhaustive health needs of a privileged few. In this essay, I want to illustrate how even when basic health care is provided universally, and even when a basic level of health for all is attained by deploying a highly secularized public health policy, certain ethical foundations of health, and hence health itself, can be compromised. The case of traditional Tibetan medicine points to the importance of bringing the non-secularist, i.e., the religious, back into discussions of health as a way of foregrounding ethical concerns and perhaps restoring health.³ Can Tibetan ethnomedical epistemology, because it emerges from religion, better attend to ethical concerns of Tibetans precisely because it sustains ideas of sacred as opposed to secular qualities of health, even if doing so requires the labeling of it as "science?"

Ethnomedicine in China’s Tibet: Politicization and "Scientization"⁴

It seems fitting to return to China in order to pursue the topic of health equity. China’s model of the barefoot doctor that came fully into existence during the Cultural Revolution was a source of inspiration for the primary health care movement and Alma Ata’s declaration of 1978 (Grant 1993). China tried to provide rudimentary health care "for all" as part of its larger socialist project to establish an equitable society based on Marxist-Leninist ideals of communism. In fact, achieving this was one of its primary successes, despite what many now perceive of as enormous political sacrifice to accomplish it. But China went beyond the universal provision of basic health services. Undertaking to incorporate and attend to the needs of what came to be 55 ethnic minority groups who collectively constituted the new Republic, China adopted aggressive policies that would identify and redress inequities in its multiculturalism.

In programs that designated and privileged its nationalities with special state benefits (Gladney 1994), health care was not overlooked. Not only were the nationalities (minzu) given access to training in basic biomedical health services, but attention was paid to making use of their existing traditional ethnomedical resources as well. The logic followed in minority regions was that a culturally-sensitive medicine works not only to reach more people, but it effectively demonstrates the benevolence of the state in caring for and accepting the diversity of all its nationalities. It is thus not surprising that one can still find state expressions of official forms of tolerance for cultural diversity in a robust medical pluralism in China (Farquhar 1994, Ots 1994). In China’s more remote minority regions, like Tibet, the tolerance for ethnomedical traditions must have played a significant role in arousing some loyalty and commitment to the socialist project in the early days.

This glowing picture of a tolerant and equitably oriented state can be, however, differently illuminated in consideration of the state’s growing and equally strong need to control cultural pluralism through medical institutions, particularly when such culture becomes a site for opposition to state ideology, or when it fuels national separatism. In medicine, as in other areas, the relationship was set in place whereby services were received from a benevolent state so long as unquestioned loyalty to its ideology was continuously shown, even when this meant retraining its practitioners and rewriting its theories (Farquhar 1987). Here, the idea that basic health care should be provided to all of China’s citizens became possible only by politicizing health care all the way down to its delivery of tinctures of iodine and referrals for tertiary care (New and New 1977). In a very literal sense, it "sutured" the public in all its cultural diversity to state party objectives that were presumed by the state to be uniformly desired (Anagnost 1997).

Unlike in other regions of the developing world, arousing "political will" was, if anything, not a problem in China; it was enforced. The model provided by Han majority’s emphasis on uses of zhongyi medical techniques and treatments in the training of the barefoot doctors during the Cultural Revolution is exemplary. Although traditional Chinese medicine was itself on the wane in the years before the Cultural revolution, it was revitalized during these years by being remade into a set of practices that served the socialist agenda and were considered ideologically unproblematic, e.g. not-elitist (New and New 1977), not religious, and materialist in orientation.

In the case of Tibet, the politicization of medicine and incorporation of indigenous traditions was enacted most profoundly in and through the problematizing of Tibetan medicine’s epistemological foundation in Buddhism (Janes 1995).⁵ As elsewhere in China, reforms during the Cultural Revolution focused on retaining those aspects of traditional medical systems that were deemed both practical and useful by the state.⁶ This meant trying to eliminate the superstitious and religious aspects of Tibetan medicine as part of a widespread persecution of religion during this period.⁷ It entailed ideological retraining of professionals to meet the needs of the revolution, including mandatory periods of service in the rural countryside by most of the medical system’s only qualified practitioners and teachers. It sometimes included imprisonment. Altogether, socialist reforms required all professionals and non-professionals alike to develop an acute sensibility about the legitimacy and illegitimacy of certain forms of traditional cultural practice. Knowing what was officially acceptable and what was not, especially in terms of religious practice, became not simply a strategy for successful delivery of health care, but a matter of individual survival.

The persecution of religion during the 1960s and early 70s marked the beginning of the period of secularist reforms that would be the greatest influence shaping the contemporary practices of Tibetan medicine and affecting Tibetan health. However, the terms of this influence have changed somewhat since the end of the Cultural Revolution and rise of the period of Liberalization. Two trends are worth noting as post Cultural Revolution reforms. The first is the marriage of an existing socialist materialism with an uncritical importation of Western-based scientific technologies believed to guarantee rapid and uniform modernization. This marriage was carried out as a political mandate within the health system. In contrast, the second trend has entailed efforts to revitalize specific traditional cultural practices, including selected religious practices that were no longer believed to threaten the materialist foundations of the nation.

The merging of these two trends in Tibet has led on the one hand to a great nostalgia and reverence for the minority cultures on the part of Han majorities and on the other hand to a fragile sense of security concerning the legitimacy of traditional cultural practices among Tibetans themselves. Increasingly, the minorities are seen as resources for recuperating the lost cultural treasures of the greater Chinese nation (Schein forthcoming), and even in Tibet medical practitioners are overtly compelled to join the effort to sustain and revitalize their traditional practices. At the same time, the terms of Tibetan involvement in this project are constantly sources of self-questioning because they are labeled as potential sites for political dissent.

It is not suprising that since religion was early on a site for the execution of political reforms within China, religion has remained an important site for political dissent in the years since the Cultural Revolution.⁸ One outcome is a situation in Tibet in which religion is frequently tied to official suspicions of Tibetan nationalist and separatist sentiment (Goldstein 1997, 1998). Despite overt official efforts to allow a certain amount of religious freedom in Tibet, the persecution of religion during the 1960s and 70s has given way to a politicization of it today. Government fears over national separatism tie religion to perceived desires for political independence and to exile Tibetan activism (and His Holiness, the Dalai Lama). Thus, because the state remains in a state of constant paranoia over the meaning of religious expression, efforts to support Tibetan cultural traditions have been undercut by state fears of these traditions when they are associated with religion. As fears of nationalist-separatism rise, the degree to which religion can be sanctioned, even in medicine, is raised as a sensitive issue, leading to enormous pressure to secularize traditions, especially medicine.

There are other forces of secularization in Tibetan medicine. Since the opening of the TAR (Tibetan Autonomous Region) to foreigners in the 1980s, urban Tibetan practitioners have been made aware of the international interest in their work, and in the fairly widespread attention already given to Tibetan medicine in the exile community. This interest is matched by the growing state interest in making the virtues of Tibetan medicine known throughout the rest of China. Practitioners, in turn, have become increasingly interested in assessing their work in the terms of medical legitimacy that have since the Cultural Revolution been put forward in the Chinese scientific arena. These are largely based on standards found in the international scientific community. The terms of both science and Chinese socialism insist on a radical materialism that separates religious "belief" from objective "facts" when it comes to health issues. The trend is of course applauded and supported by the government, not simply as a way of ensuring widespread recognition of the scientific efficacy of Tibetan medicine but also as a way of lessening the importance of its problematic religious aspects.

Because the religious foundations of Tibetan medicine have been politicized, and because, unlike earlier eras in China, Liberalization era reforms set science and scientific approaches in opposition to the political (Rofel 1999), Tibetan medical practitioners treat the religious foundations of their work as problematic by claiming that all of their traditional theories are scientific. This pressure is coupled to international pressures that call for efforts to document the scientific validity of their work in order to make it marketable in international domains. This has led to at least one trend that compels Tibetan practitioners to secularize the religious aspects of their practices by calling them scientific, transmuting the ethical and the sacred into socialist and scientific ways of providing for Tibetans’ health.

This point is worth pursuing because of the way in which China’s strategy resembles the one found in the terms of legitimate discourse in the international scientific world. Although religious tolerance is considered an important element of statecraft and a fundamental component of the condition of freedom in the "free world," the imperative to keep religious ideology in a category separate from that of science, including medicine, is, I would say, profound.⁹ The motivations for this may be similar in China. This state today wants to be seen as religiously tolerant, but it fears a loss of control and slippage in its modernization when its materialist ideology is threatened by rising nationalist separatisms tied to religious differences (for example among Muslims or Buddhists).

The secular materialism of Marx and Lenin became the foundation of the socialist state in China, but the materialism of Western science offered similar sorts of interventions in the secular humanism found in places like the United States and elsewhere. Both views maintain that an ability to distinguish fact from belief, the objective truth from the subjective experience--distinctions that are, I believe, deeply tied to historical developments in the production of the modern discourse of science (Shapin and Schaffer 1985)--has provided a foundation for the scientific knowledge and practice that has enabled enormous improvement in the quality of life not only in China but in the world in an ecumenical and universalist fashion. But this discursive development ensured that the edifice of scientific epistemology would hinge in some sense on not confusing, or worse yet substituting, subjective belief for objective fact in the same way that it would refrain from substituting religious ideology for scientific truths. Some would argue that to conflate them would be to open the floodgates of relativism that lead to culture wars, religious nationalisms, etc. It would destabilize epistemology. But what exactly is at stake in confusing these domains? In the next section, I explore the ways that traditional Tibetan medicine confounds belief with fact. I do this in order to elicit an understanding of both the ethics, benefits, and even the risks this may involve in Tibet and perhaps elsewhere.

Tibetan Medical Theories of Health and Ill-health

Tibetan conceptualizations of health and medicine are derived from Buddhism, among other sources.¹⁰ The Buddha’s insight on the four noble truths is the basis for understanding the nature of both health and all suffering (Dhonden and Kelsang 1983, Meyer et.al. 1992). Evidence for his claim that suffering was inevitable in life is found in his understanding that all suffering arises originally from the presence of the three poisons: desire, anger, and ignorance. At the time of conception, the presence of these poisons gives rise to the physical body in the form of three humors: wind, bile, and phlegm. Accordingly, the theory argues that the best remedy for suffering is taking refuge in the Buddha and devoting one’s life to achieving enlightenment by purifying oneself so as to eliminate the presence of the three poisons. It is thus not surprising that the opening chapters of the Tibetan medical texts, called the rGyu bShi (Four Tantras), are devoted to worshipping and making an offering, and to request the Bhaisyagyaguru, the medicine Buddha, Master of Remedies (or King of Medicine), for teachings on how to eliminate these poisons.

Beyond this, the basic Tibetan medical theory of anatomy links the worlds of materiality and spirituality in complicated relationships between the five elements that are phenomena believed to make up all phenomena and the forces of consciousness that enable these to take specific form in, say, a human body. Tibetan Buddhist and medical theory holds that all phenomena are made up of the five elements, singly or in combination. These are wind (responsible for movement), earth (giving substance), water (which holds things together), fire (which transforms or "cooks" things), and space (providing the place within which things can exist). The elements determine the properties of all substances--hot, cold, heavy, light, stable, unstable -- and all the tastes (Meyer 1992, Clifford 1984, Clarke 1995). It is believed that the presence of a variety of winds, operating on a subtle and coarse level, transform these elements into a human body, although not in an obvious way.

At the time of conception, the fetal entity is formed by a meeting of the combined regenerative fluids of the mother (red element) and father (white element). When these elements are without flaw, they become a suitable home for a sentient consciousness (sems) transmigrating from a past life. Located at a "supreme seminal point" (thig-le chenpo) in the middle of the heart, this consciousness and five elements combine into a life force (srog) that has the potential to form a human being. The emergence of a human form is contingent upon the type of winds circulating in this life-force--that is, its subtle winds of wisdom and karma. When unified by the winds of wisdom of emptiness (ye-shes-kyi rlung), the mind and its energy are conducive to enlightenment--a physical body does not necessarily materialize; but when activated by the vital energy of past deeds (las-kyi-rlung [karmic winds]), they are dispersed (paraphrase of Meyer 1992, see also Rechung 1973, Dhonden 1986, Dhonden and Kelsang 1983). The "dispersal" of this vital energy is what produces the body in a being who has not reached enlightenment.

From there, the subtle winds give rise to the three channels of the body called the uma, roma, and kyang ma (dbu-ma, ro-ma, and rkyang-ma) believed to oscillate as energy fields along the axis of the body: a central channel (the dbu-ma) a right channel (the roma) and a left channel (rkyang ma). These channels operate in tandem with the presence of ignorance, desire, and anger, respectively (Clifford 1984). Thus the places on the body where these energy channels intersect around the central channel (manifesting as ignorance)--that is when desire and anger are present--are known as chakras (kor-lo). The conceptualization of this movement is that it takes the form of circulating winds. The chakras are located at the crown of the head, the throat, the heart, the navel and the genitals. As the subtle winds operate upon the generative fluids, they set in motion the formation of a central channel (chags-pa’i rtsa) which extends from the navel upward to form the brain and the "white channels." It extends outward to create the black "channel of life" and the blood vessels. Finally, it extends downward from the navel to generate the genitals (Meyer 1992). From there, the quality of elements in the generative fluids also plays a role in the formation of the quality of body tissues. From the white fluids come bone tissue in the embryo and eventually semen and breast milk. From the red fluids comes blood, flesh and skin. Eventually all seven of the bodily constituents are produced: chyle, blood, flesh and muscle, fat, bones, marrow, and reproductive fluid.

Interactions of the elements constituting the internal world with those found in the world outside the body is constant. Therefore, the body is never in a permanent state, always changing in relation to the climate, the seasons, the foods we eat, the emotions we feel in relation to our perceptions of the world around us, and even by the demonic or other harmful forces we come in contact with, and the karmic effects of actions and intentions in past lives. What regulates the harmonious relationship between being and environment is the three humors: wind (rlung), bile (tiba) and phlegm (bad-kan). Again, associated with the presence of the three poisons of ignorance, desire and anger, the humors in the fully formed body are of a coarse nature (Clifford 1984). Each humor has five aspects. There are five winds, for example: one that regulates downward expelling motion, one that activates fire so that it pervades the body’s locations, one that is life-sustaining, etc. The coarse biles are associated with heat and are also five in number, as are the phlegms, associated with cold and cooling.

The optimal functioning of the human being is the subject of the second through 5th chapters of the first medical tantra (of four). When the humors are functioning well, the body’s waste products emerge in perspiration, feces, and urine. When the body sits well in its environment then the potential for material and spiritual well-being is achieved. These are depicted in a seated meditating figure at the heart of a lotus blossom, surrounded by fruits and flowers. The message here is the fact that we are not already enlightened is one indication that we have not achieved ultimate health. But we can optimize our chances for achieving enlightenment by optimizing our humoral functioning. How? By practices of morality that purify the humors. In other words, ultimate health is achieved by doing things that eliminate bad karma--doing or not doing things in order to transcend samsara.¹¹

If morality is the basis for achieving ultimate health, how does this morality manifest in bodies in relation to proximate health or in, as it is called, samsara’s body? In the normal person, desires (attractions) and anger (aversion) are always figuring in perceptions of the world. The trained mind, on the other hand, is believed capable of regulating these winds through meditative or other techniques that can help calm and focus the mind and thereby calm the movement of the inner winds. There is a link between inner subtle winds and outer coarser functioning of the humors and this is why it is believed the well-trained tantric practitioner can actually sustain great physical health. That is, the mental state of the person is believed to have a direct effect on his inner functioning. But in the average person, who may or may not be trained in tantric methods, the ability to control these subtle winds is basically nil. Rather, the average person is pushed and pulled by the mind’s wandering from one mood to the next, one desire to the next, one aversion to the next. As it moves, so too are the humors activated, creating imbalances that can result in ill-health.

Once any of the internal or external factors are set in motion to arouse imbalances, it becomes harder and harder to undertake a meditative life or renunciation, that is, the further one gets from ultimate health. For example, eating too many foods that are of a hot, fiery nature, either because one cannot control one’s desire for them or because one is forced to through other circumstances, can have the effect of agitating one’s bile humor. Bile, in turn, has effects on organs, fluids and functions through the theory of five elements, again. Each humor is associated with one or more of the elements such that when they are activated, they affect those elements present in the components of the body. But it is not simply material forces that affect the humors. Living with someone who constantly makes one angry can also increase bile activity. The two are interdependent; the more bilious one is, the more likely one will perceive of the external world as something over which to have aversion. The reverse is also true: the more anger one feels toward the outside world, the more likely one will crave and eat foods that aggravate the bile. Social conditions that are not conducive to eliminating the poisons are thus seen in this cultural system as pathological--as disease producing. By the same token, imbalances of the humors can arise from perceptions of socially hostile conditions which may or may not actually be hostile: a being who has too many desires (whose desires are perceived as being unfulfilled) likely has an imbalance of winds. A person who has great aversion (or anger) toward his or her social environment, or a person who is unaware of his or her ignorance (likened to the state of being asleep), is likely to have imbalances of bile and phlegm respectively. In this case it is not that the external situation is necessarily pathogenic, but that one’s perception of it makes it so. Either way, humoral imbalances result in an inability to digest food, think clearly, eat or even rest properly. Normally, substances enter the body and are refined into the elements which then nourish the seven body constituents, but when the humors are imbalanced, this process malfunctions.¹² The more malfunctioning, the less easy it is to be morally virtuous, (but also the more merit accrued if one does, despite these circumstances, engage in virtuous activities).

This model of health posits that morality is embodied. This is not simply in the sense of there being "sins of the flesh," as we might assume from Buddhism’s accounting of kleshas (disturbing mental states) resulting from unvirtuous deeds of the body (and speech, and mind) from past lives. It is rather in the way that the flesh itself becomes evidence of past virtues and "sins" as well as a site for the atonement and transcendance of them. People’s bodies are literally expressions of their accumulated virtue and non-virtue in relation to other sentient beings in past lives. Even sicknesses are an index of the body’s internal moral functioning--expressing non-virtuous behaviors in relation to others can reflect and create imbalances within the body, just as external conditions that cause imbalances give rise to tendencies to express more non-virtuous behaviors and thoughts. Here, the ethical domain, in so far as it is tied to morality, is not aggregated to the physical realm. It is constitutive of it. Moral qualities are assigned physiological character, again, by the logic of the five elements: bile is associated with fire, phlegm to water and earth, wind to wind. Understanding this is from a Tibetan medical perspective essential to understanding how to approach the task making people healthy.

Ill-Health Part I: Wind Disorders as Embodied Moralities and Degradations of the Social

In this section I first explore Tibetan ill-health as the sometimes embodied experiences of social discord tied to secularist modernization. In the second part, I explore how Tibetan approaches to healing resonate with Tibetan religious ideas about the sacred, and to assaults on the sacred in forms of secularization

Changes in the health of Lhasa Tibetans since the 1960s are directly tied to larger changes occurring within Tibetan society. Traditional practitioners in the women’s ward of the Mentsikhang, where I worked, felt that the health of urban women was in many ways worse now than historically. This was because of the rapid changes modernization had brought which, they believed, although they had made more basic health resources available, also had created a great deal of pathogenic situations. More varied diet and the consumption of too many imported foods, changes in behavior, especially among young sexually active women, new demands being placed on them for fertility control, and the presence of new disease agents (especially sexually transmitted agents) were all seen as being on the rise. Women suffered high rates of infertility which doctors associated with frequent abortions, rapid succession pregnancies, lack of sexual and feminine hygiene, too much sex, and reproductive tract infections.

In almost all cases, women’s complaints were seen as having a long history that spanned the period of modernization ushered in by communism. Current ill-health dated back to the years just before the Cultural Revolution when women recounted frequent miscarriages from heavy labor, arduous work conditions in regions unfavorable to patients’ constitutions, traumatic deaths of family members.¹³ In many cases, the diagnoses of these women included imbalances of the wind humors, rlung.

Dolma was a 56 year old woman who had kidney and heart trouble that she felt could be traced to her early reproductive years. At 17 years of age in the early 1960s, she was working as a laborer in the metalworks production unit outside of Lhasa. Workers there had to lift very heavy hammers for this work, and because of this, she said, she miscarried her first pregnancy. She then delivered a full-term boy who was pronounced dead upon his difficult delivery. She explained, "I am not the only one who suffered like this. There were many women in my area [of work] who worked and had miscarriages because they did very strenuous work that caused bleeding. Many women lost their babies. It was very common." Later, she was able to conceive again and gave birth to a baby girl who is still alive. She was later transferred to a road construction laborers unit and there got pregnant again but again because, as she said, of the hard work requirements for road building, she lost that baby. It began with a lot of bleeding. This time, she had to have surgery. This time, the baby that had died in her womb had to be removed and in the course of this she had to have "seven people’s blood put in her" through transfusions.

In 1975 she was sent to a different county during a time when "all of the laborers were divided and sent to remote places." The county she was sent to had no factory work and so she was given a job at the school. Because she told the administrator that she was weak from her enormous blood loss and could not handle manual/physical work, he gave her the job of ringing the school bells. This job, she said, suited her because she had developed a problem with her heart from both the blood loss and the exhaustion from years of heavy manual work. The symptoms bringing her into the hospital included pain in her kidneys, pains in her uterus, heart weakness. She said that her body had become very weak from all the blood she lost many years ago. Even if she works a little bit, she noted, her face starts to swell and she feels very tired and dizzy. She said that before "I was a very healthy young girl, but the job was just too hard, physically hard."

Dolma’s doctor explained that she had two problems, a kidney fever with arthritis and a heart-wind disorder (snying rlung). Her kidney and joint pains were related to the fact that the region where she was transferred was known as a damp place, and once there, she had to do a lot of washing in cold water (clothes, bathing, etc.). Cold water and cold climate both had an effect on her phlegm humor because phlegm is responsible for cold in the body. Since the kidneys process the cold water, its ingestion will have a cooling effect on them, slowing the phlegm in her body and eventually producing a "fever" from too much cold at the location of her kidneys. Weakened by all her blood loss, her heart was also disabled. The winds responsible for moving her blood through her body were involved with this. Because of the trauma of her hard work and difficult circumstances surrounding the deaths of her children, Dolma’s winds were weak. This added to her excessive blood loss. Here, unfavorable climate and onerous work conditions are linked to humoral imbalances that have a long-term effect on the body. Dolma stayed at the hospital two weeks until her kidney trouble subsided and then became an outpatient for several months while being treated for her snying rlung.

Yangki’s story showed similar physiological outcomes of harsh social policies.

In her mid-fifties now, Yangki was diagnosed with a growth in her uterus and a "wind" disorder. She explained that when she was young, she had three children and her husband died when they were all small. The doctor noted that generally a woman’s wind will become more easily agitated with age, but Yangki’s problems began when she lost her husband. Her periods were generally heavy, meaning she lost a lot of blood. Her winds were weakened by the sadness over losing her husband and stress of raising three children by herself. In particular, her thursel rlung (downward expelling wind) was unable to hold back the flow of blood from her body. Over the years, this wind problem had contributed to the growth of a tumor in her womb, but her condition was exacerbated by her current work situation. Yangki had a job in the government office that was responsible for monitoring religious activities in the Lhasa area. She told us that her job was stressful. She had to go from nunnery to nunnery to ostensibly provide government assistance with their management. Everyone knew, however, that this meant that she was supposed to monitor them for illegal political activities. She was essentially in the position of policing her fellow Tibetans’ religious behaviors. This meant sometimes limiting the number of enrolled nuns and undertaking cultural re-education programs that would ensure politically-correct readings of the historical feudal theocracy of Tibet. When asked to talk more about her work, she became quiet and agitated.

We had been told by the doctor that it was important to avoid talking about certain topics with patients who had wind disorders because getting them to think about their difficult life situations could exacerbate their conditions. Here again, difficult life conditions manifest themselves as physiological problems--excessive bleeding and tumor growth.

Patients in the women’s ward nearly always recounted their suffering in terms that linked social conditions over which they had little control to physical distress.

Yangchen was a 25 year old road construction worker who lived in Lhasa. She was diagnosed with an infection in her uterus (mngal-nad ti gyu). She explained that her problems began when she was 22 years old and aborted a child. At that time, neither she nor her husband had been living in their government work unit long enough to receive a pass for having a child. So she aborted. Some time later she applied for the pass and, after receiving one, got pregnant again. Looking back, Yangchen thought that her second pregnancy came too soon after her first. She had a complicated delivery at the People’s Biomedical Hospital and had an infection afterward that caused her to be told she could not yet contracept. So, she got pregnant again soon thereafter. By this time, she explained, she could not have the second child because she had already submitted her contract and received a pass to have only one child. Her work unit had provided incentives of money to her to have only one child, and they had also indicated strong disincentives, such as fines and job loss, were she to fail to keep to her contract. So she had to give up that child too by abortion. She spent two and a half months in the hospital as an inpatient before her health was fully restored.

Yangchen’s doctor explained that her infection came about because she failed to take enough rest after her pregnancies and delivery. Every time a pregnancy is finished the blood needs to be replenished. Again, the blood loss itself will cause the rlung to be weakened. In Yangchen’s case, her blood loss and worries over her infection caused her anxiety. But the doctor also suggested that Yangchen’s problems were related to her sexual appetites. Having too much sex can be a problem, she noted. She became pregnant in too rapid succession and never gave herself a chance to rest in between pregnancies. Her sexual appetites were themselves an indication of rlung imbalance, but now, the doctor noted, she had become depressed from her "whole life situation." Her nervousness and anxiety, in turn, meant that "rlung had been recruited and was supporting the bile activity in the infection. This would in turn lead to more bleeding." If it continued, Yangchen might be at risk of developing a more serious wind disorder called srog rlung (wind in the life-force channel) that can, if untreated, lead to madness and even death. The doctor made sure to note that when interviewing her, care must be taken not to get her thinking about the seriousness of her condition.

Here, onerous demands for fertility control and her own sexual appetites led to infections of the womb.

The idea that bodies can "wear" the signs of social discontent is found elsewhere in China (Kleinman 1981, 1985, Ots 1994), but the social conditions of distress were perhaps more oppressive in Lhasa given contemporary governmental political suspicions and the urgency with which they demanded modernization. Just as medical practitioners have had to develop an acute sensibility about the ideological implications of their actions and utterances, so too have all Tibetans, especially in the urban areas, had to develop this acute sensibility since the late 1950s.

The perception on the part of a great many urban Tibetans, though not all, was that matters of life and death were decided for them on the basis of their ability to utter speech and perform actions that were considered conforming to official ideology. They believed that the instruments the government had put in place to help ensure a productive and thriving society were in fact largely apparatuses of censorship and surveillance over their political speech and degree of loyalty to state agendas. These included, for example, neighborhood councils and weekly political meetings for confessing irregularities or suspicious behaviors, work units that paid managers to watch over public and private lives of employees, an enormous plainclothes police force that circulated the public zones of the city at all times in order to obtain information about possible separatist opposition. Again, among the most scrutinized zones, they felt, were those involving religious acts of worship (private and public) that could be construed as political.

These instruments of surveillance were backed by the perception of very real consequences: arrests and public trials preceding private executions of prisoners whose crimes were expressing open dissent to Chinese rule. The public’s witnessing of such enforcements of politically correct behaviors was ensured by mandatory attendance at these trials mobilized by work units and neighborhood councils. Altogether, the perception was that there was always a need to be cautious about what was being said, politically, by one’s behaviors.

The paranoia of the state in its perceptions of a potentially volatile Tibetan Autonomous Region trickled down to most of the citizens of the region and re-emerged in a variety of complaints, but, as I have shown, most prominently in wind disorders.¹⁴ Janes noted this stunningly in a quote of one Tibetan doctor saying: "Of course, rlung must be more common nowadays because Tibet is no longer free. The Chinese government is the government of rlung. The Chinese government makes people unhappy, and so rlung must be more common...Tibetans have rlung because they are not free" (Janes 1995:31).

In so far as ethics might be defined at least partly as one’s morality in relation to others, then the category of wind disorders might be thought of as a barometer of the ethical health of Tibetan society under Chinese control. The theory underlying winds provides us with an ability to read this logic. A person whose sickness arises because his or her desires are not fulfilled because social conditions prevent this, is something of a walking expression of social discord. The harm that results from people behaving unethically toward one another--that is in ways that hurt one another--is here inscribed on patient bodies in wind disorders. In a world that has become increasingly overrun by concerns for the practical, the political, and the productive as opposed to the sacred and especially the sacred that comes from associating with other people (and sentient beings) in virtuous ways--that is, in a world that is transforming in ways that many Tibetans perceive it--bodies themselves are being secularized. The particular forms of secularization in this region of China are contributing to ill health. Below, I will suggest that failing to see the body as sacred--because it is a repository for social relations-- makes it less possible for healing to occur.

Given the scenario in which religious repression is directly tied to physical health, it seemed prudent for some doctors to deploy a medical system that attends directly to the connections between ethical behaviors and physical health. A medical system that has built its theory around the idea that moral behaviors toward other people are a basis for a healthy body might also effectively engage methods of attending to the ethical health of society. At a minimum this sort of proposition might suggest fruitful discussion of the role of ethnomedical epistemologies in ethical mandates of health for all.

I want, however, to move to a slightly more subtle reading. It would be incomplete to merely read winds as a sign of social ill-health. A person can perceive of even the most paradisiacal of worlds as socially problematic because they have a wind imbalance. It is this fuller sense of wind disorders that helps clarify the importance of the sacred in Tibetan conceptions of health. Moreover, under the current conditions of political suspicion, it becomes impossible for Tibetans to speak about complaints of the government directly. Here, Tibetan ethnomedical diagnoses implicate politically repression as a source of ill-health, but making this sort of link obvious is not straightforward. In the next section, I will show how a logic of the sacred explains ill-health and healing.

Ill-Health Part Two: The Efficacy of Belief and Sacred Qualities of Health

Wind (rlung) imbalances reflect difficult social circumstances, but they can also generate the perception that one is in a difficult social circumstance even if ostensibly one is not. Winds are directly tied to perceptions. Once the wind is imbalanced by perception, its imbalanced functioning can further aggravate a perception of the world that seems, to the victim, threatening or problematic, and this may cause the victim to engage in behaviors that only exacerbate his or her condition. This can include a range of things including dietary cravings and overeating, too much sex or desire for it, (or in the case of the other humors) showing aversion or even open hostility toward people around oneself. The morality of one’s behaviors in relation to others is both regulated and revealed by the humors. Sometimes the aggravated anxiety can come from a patient’s perception that they have become sick from their anxiety. This additive pattern is typical of wind imbalance.

Because winds are bodily expressions of perceptions, they are mercurial. The wind humor is easily influenced by the two other humors, resulting in augmentation of the patient’s ill-health even when winds are not initially involved. And, once the wind humor is disrupted, it is easily able to augment the proper or improper functioning of the other humors. Doctors explained the wind’s character with a metaphor: together the three humors are like three fighter planes flying in unison. The rlung (wind) is the lead pilot who, when he detects small deviations in his flanking planes, moves toward them rather than keeping them on course himself. If one humor goes astray, the wind will follow it, eventually pulling the whole trio off course. In this image, the wind is in charge and the other humors are its protection, but it is also easily swayed by their movements. As a leader, it resembles something of a wanderlust. It isn’t always wandering, but already the most subtle of influences from outside may activate its potential.

Popular conceptions of wind also suggest this mercurial property Tibetans say that spring weather is like the wind humor--unpredictable and always changing. A person’s character can also be likened to rlung--fickle and mercurial--always turning toward the things it is most attracted to. Not coincidentally, the depiction of the rlung as driven by wanderlust is not very different from the view of the samsaric mind in Tibetan Buddhism--always getting distracted by the smallest little things, but most especially feelings of aversion or attraction (anger or desire) that form the basis upon which we make judgements, decide to perform actions, and then carry out these actions in ways that produce karmic effects. Were it not for these distractions, people would, from a religious perspective, be much more able to reach a state conducive to enlightenment, the theory goes.

It is not in some ways surprising that there is a similarity between wind and mind. The subtle winds that form the basis for the human body (wisdom and karma) and exist in the form of a sentient consciousness before birth also form a basis upon which the physical being emerges (Meyer 1992). The faculties of being, including consciousness and the senses enabling us to take form, discernment, etc. are all in some sense made actual--set in motion--by winds. The sentient consciousness is transported upon wind into its rebirth form, signaling desire is present, and revealing its aggregative tendencies, right from the start. The body that is formed from this initial desire (literally a transmigrating consciousness that sees his future parents copulating) is rarely, if ever, free from desires that just escalate therefrom.

The theory of winds gives us some insight about epistemology in Tibetan medicine. In theory, I was told, the perceptions one holds cannot be dissociated from the material world in which one exists (from the body out to the world around it). Winds are both constitutive and reflective of the sorts of relationships one has with others, and with the physical conditions of one’s life because they too are mediated by perceptions. Like the mind that has a wanderlust spirit, winds are easily swayed by influences around it. Perceptions change quickly and bodies, because they are made alive by winds, follow. Even small feelings of desire and anger, and the pervasiveness of ignorance draw one toward unvirtuous deeds. However, it is not Tibetan minds that bear witness to ethical concerns but bodies. Because winds are responsible for all movement in the body, the body’s normal functions are all related to healthy winds. Having a weak "downward expelling" wind manifests in loss of menstruation, or incontinence, and eventually growths in the uterus. A weak fire-permeating wind appears as poor digestion, weight loss and skin diseases. A weak "life-sustaining" wind expresses itself as heart palpitations, dizziness, madness, and even death.¹⁵ Here, Tibetans suggest that subtle changes in attitudes can have profound effects in their material beings. Here, "spirit"--insofar as it is a product of morally-based perceptions and actions--produces material reality; matters of belief produce matters of fact.

Doctors expressed their understanding of the subtle effects that a patient’s attitude had on their health when they described to me the basis upon which they believed Tibetan medicine was efficacious. Knowing, for example, that imbalanced winds could be further imbalanced by anxiety-producing conversations, made doctors aware of their need to enact therapeutic services rather than simply provide or prescribe them. When asked why patients came to the Mentsikhang as opposed to other hospitals for care, physicians and patients nearly uniformly claimed that their most significant distinction from available Sinicized biomedical services was the Tibetan "mind-training" in techniques of compassion, used at patient’s bedside and in such things as pulse diagnosis and making medicines. The idea of compassionate practice was an important part of their medical efficacy. One doctor explained it this way:

There is a part in the rgyu shi (Four Tantras) that talks about recovery of the patient, and in that there is a saying that is translated as "If the nag tsi, the talk of the doctor, if that is not gentle and smooth and soft for the patient, then no matter what medicines they give, it will not help." If for example she gives the patient not very strong medicine or even the most basic medicine, but she talks to this patient really gently and softly and in a really encouraging manner, then this patient will take that medicine and it will probably help this patient quite a bit because she is very pleased by the way that the doctor has spoken to her. She feels nice about that. So she will take the medicine. She will not avoid taking the medicine. But if the doctor is giving this patient very precious pills, the strongest, and most expensive medicine, but is scolding the patient like crazy and is really hurting the patient with her words, then this patient might not take this strong medicine, the precious pills. Or even if she takes it, the thought with which they take it might be very sad because they will feel, "Oh, this doctor just scolded me and I am such a bad patient." All the negative thoughts will probably make the medicine not work for this patient. It is in this book: gSo Byes thabs, recovery methods. In here is the saying: if the doctor’s words rings well to the ear of the patient, that patient will be in a state of happiness.

In her account, it is not just that patient compliance will be greater if the doctor is pleasing to the patient. It is that the medicines themselves will or will not work in the body on the basis of the attitude held by the patient. Setting the patient’s mind at ease was directly linked to enabling the patient’s body to respond to its treatments effectively. One detects in this sort of logic the idea emergent from Buddhist epistemology that posits relative truth on the basis of subjective experience.¹⁶ The effectiveness of medicines is not simply tied to its ingredients but to the sentiments associated with the experience of receiving them. Belief here has a direct and unmediated physical correlate in the body’s reaction. It is not just "in the mind." Again, I think what is being said in this system is that belief produces matters of fact.

I want to turn now to the idea of the sacred. In Tibetan Buddhism there are three levels of practice: inner, outer, and secret. These days, there is much discussion of the importance of keeping things "secret." The "secret" is used in Tibetan Buddhism to protect religious teachings by ensuring that only those who are given initiations for certain meditative practices actually receive the teachings. The idea is that this method will help ensure that the religious teachings remain intact--that only those who learn them completely and with proper motivations--learn them and are capable of passing them on to the next generation. This mechanism of the secret is a form of protecting the "sacredness" of religious knowledge. Keeping this knowledge secure in one’s mind serves as a means of rendering that knowledge sacred. Here, the idea is that one has to make something sacred in one’s mind in order for it to exist as a sacred thing. This technique is particularly useful under conditions of cultural or religious persecution (of which there is ample evidence in Tibet’s history (Germano 1998).

The logic underlying the sacred, for most Tibetans, is not far from the logic found in the relationship between mercurial winds and the efficacy of medical beliefs. The belief that the mind has some ability to effect the material world through more than just perception and resulting in more than just subjective experience is part of what "making" something sacred is all about. Unless a thing is "made" sacred in the minds of those who consecrate it, it doesn’t necessarily have the quality of being sacred. Tibetan medical theory makes the same epistemological claims about the role of belief in physical health. Unless the mind of the patient has faith in the medical practices they receive, they will not necessarily have the ability to cure them. This is partly because the winds circulating in the human body are so affected by perceptions. Where the wind goes, the mind is present, and where the mind goes, the body follows. Where the mind is influenced, the winds will respond in bodily processes augmenting humoral imbalances or remedying them.

What I am suggesting is that the logic of the sacred explains ill-health and healing in Tibetan medicine. It would be, of course, preposterous to interpret this to mean that this theory suggests belief alone creates material reality. Rather, it merely points to the incredibly powerful role that, according to this theory, perception plays in "making" bodies work. But this logic is, as I have said, problematic. At a time when it seems as if restorations of the sacred would be just the thing to "heal" Tibetans, the ability to effect this sort of social change is more remote than ever. At the same time that secularization threatens the sacred, the sacred becomes all the more important as a means of protecting domains of tradition and morality that many Tibetans feel are important for health and well-being.

So long as religiously devout Tibetans are being asked to participate in a world that prioritizes socialist materialism and secularism, the more aware they are of their need to refuse or at least self-censor the sacred dimensions of their everyday lives, especially in the worlds of work, school, medicine, politics, and even reproduction and sexuality. Here the particular brand of socialist modernization they are exposed to is seen by some Tibetans, certainly not all, as desecrating the sacred potential of the social. Problems of political repression for many of them are thought of as arising from treating the world as if it were not sacred by removing the imperative to behave in familiar morally virtuous ways with others.

This is not to suggest that there is not an ethical dimension to secularism. On the contrary, secular social formations have often offered powerful ethical critiques to those based on religions, and some Tibetans have wholly adopted this position. But for others, the perception is that modernization denies the ethical imperatives found in the worlds that were historically sustained by the logic of the sacred under Buddhism.

Also, this is not to suggest that ideas of the sacred and the moral imperatives they set in place, historically or ever, penetrated all aspects of everyday life, or that all Tibetans ever held uniform and uniformly-committed ideas about the sacred. Nor, finally, am I suggesting that Tibetan Buddhism is not without its ethically problematic areas. Certainly there were instruments of political terror in Tibet’s theocracy. Certainly there have always been uneven commitments to Buddhism, let alone to a religious life, in Tibet. Certainly there is ample evidence of debate over ethical fairness within the religion. But, for many Tibetans today who try to remain devout Buddhists, the perception is that many of the actions of soldiers and policement, of government officials, and many of the actions ordinary citizens are forced to undertake for the sake of socialist modernization are, in fact, deeply immoral (including mandated witnessing of public trials, not opposing executions of criminals, having abortions, abandoning their monks or nuns vows, erasing traces of religion from history). So, while the government remains convinced that it needs secularism to ensure equality of health--and sees this as an ethical imperative--the perception, among many Tibetans, is the opposite. It is possible to read wind disorders as arising from a perceived destruction of sacred logics in the public domain.

Many Tibetan medical scholars and practitioners recognize, I think, that if they view health as something that entails processes that are modeled after the manner of the sacred, that health is itself only possible when people are viewed as sacred as well--when they are viewed as fields for the practice of virtuous behaviors. In some sense, this means recognizing that the social conditions which give rise to health and ill-health might be seen, and treated, as either sacred or mundane, depending upon the type of world one wants to inhabit and, in a sense, produce. This, of course, is not unique to the present era but has rather always been true; there have always been desecrations of the sacred potentials of social life. But today the demand for these sorts of behaviors seems to many Tibetans to come as part of the mandate for modernization itself, as direct results of government policies, not simply as personal choices. Finally, the contemporary mandate for these doctors and scholars is to explain this logic in terms of the rational and scientific because making overt criticisms of failed government policy is too easily construed as criticism that asserts the need for Tibetan independence. What is at stake here?

Secularizing the Sacred or Sanctifying Science?

Medicine was early on in the Chinese socialist project politicized so that it would be configured in a manner that could serve the most people with the most good. Later politicizing of religion in Tibet resulted in demands that medicine conform more than ever to the terms of legitimacy of science. In the medical college and hospital, this has resulted in numerous attempts to make Tibetan medicine speak the language of science, while still attending to the project of seeing health in terms of religious practices and ideas. Scientizing medical theory has been a strategy to enable practitioners to participate in the great socialist modernization following the terms of Western science, while giving them a basis upon which to claim international recognition for their achievements. But there is another way to read the scientization under conditions of political instability. We might be able to read secularization as a source of physical disorders whether advanced through social policies, or through the moral stress they produce. Tibetan medical theory points to these links directly.

I have suggested that in many ways, the ideas found in Tibetan medicine are ineffable in the world of science and in the secularist discourse of the Chinese state. On an epistemological grid that would place bodies opposite minds in the same way that matter is placed opposite spirit, and objective facts opposite subjective beliefs, where do we place the wanderlust wind and its powerful effects on health?

The problem of the "ineffable" in Tibet forged an alliance between the government’s priorities for secularization and scientific methods, its fear of religion, and the religion’s own concerns over keeping some things secret in order to protect them. That is, Tibetan Buddhism itself proposes a mechanism for protecting religious teachings (a method of keeping them intact) based on the idea of a "secret" form of practice. At a time when the realms of the sacred were under assault by being politicized in the Tibetan Autonomous Region, it was the mechanism of the "secret" that was again being revitalized. A medical intern revealed this phenomenon clearly when she told me:

At the medical college, we didn’t learn much about the uma, roma, and kyang ma (the three tantric channels). In general, they try to avoid religious things, but they do talk about the white and red channels. But, anything that is religious--even the word, chos (dharma-religion)--is very contested. There are a lot of people who don’t believe anything to do with dharma is good. They think that is another affliction--being superstitious--something you can’t prove. They make fun of people who prostrate or who go around temples because they say, ‘How do they know that that is going to benefit them? How do they know? How can they prove it?" In fact, you can’t prove things like this. But I have a different view of dharma. For me, dharma is anything you do that is helpful to other people. You can look at it from a medical perspective. For instance, these people who go for prostrations, that is a very good form of exercize. It keeps the body healthy. And those who go for rounds, physically and mentally it is good for them. Those who do mani [prayers with a prayer bead or prayer wheel]... some people in our society who are against religion think that is really bad and should be prohibited. But for me, that exercize of the three fingers that connects directly to the channel that goes to the heart. So when you exercize the channel a lot you are exercizing your heart also. So that again is a physical benefit that comes out of this. You can look at it that way. There are some commoners who really devote themselves to doing things for other people, who always try to have very good things happen to other people. That is the same as dharma and that too keeps people healthy. But there are a lot of people who are anti-religious. Even talking about consciousness (rnam shes) is not something you can prove and they think this is very close to religion and so it is prohibited. It is very difficult to learn about these topics in college because many people will not talk about it. But I try to find as much as I can. It will probably never be physically proven, but if I can explain the stages of how consciousness [rnam shes] works then...

[I ask exactly what she means by prohibited?] It is sangwa- secret. It is not allowed to be talked about in public. Sangwa by nature because maybe there are only one or two people in this whole community who really know the rgyu bshi well. And so the rest of them can’t really speak about it in great knowledge and so it is secret. It is not because people are scared of anything but as in the old days knowledge was passed down orally, from one person to another and usually the teacher feels that if there is a bad hearted person (sems nagpo), they won’t teach it to that person. It will be kept secret to the person. If the person is good-hearted (sems dkarpo), then they will learn it. Not many people will be able to learn this in great detail anyway, so it will always be like a secret in the community.

[I ask about other senses of prohibition?] It is related to government prohibitions too. For example, the uma channel is not something you can see but it is the location of consciousness, and so a lot of people don’t believe in this. Because a lot of people don’t believe in this you aren’t allowed to show these things or talk about these things to people. For instance if you do something that is against the law or against what the majority thinks you should be doing, then you get into trouble. Similarly if you talk about sangwa things to everybody then you might get into trouble. You talk about these religious ideas to only a few people. You don’t talk about this to everybody. You can discuss these things but you can never say that there is rnam shes or uma if you can’t prove it. I believe in it but I cannot say that it exists without being able to prove it. That would be against the law. The thing is, if I am researching the topic, then I can discuss it and try to figure out how to prove it, but if I can’t prove it then I can’t claim openly that it exists. Like you can’t really say that the non-existent exists. It can be punishable. It will cause trouble for you. We have the freedom to speak about these things but I cannot claim that it exists and if I claimed that in the open then I would get into trouble.

[I ask if she can use the religious explanations to explain rnam shes?] We can use religion but in medicine one has to be able to identify from a physiological perspective how to establish the existence of it. Rnam shes is like rlung. People even argue about rlung. They say rlung exists but what is it like? They can see that it has effects on the body, but it can’t be seen itself. It has no character, how do you characterize rlung? These need to be proved and this goes into the religious part of the rgyu bshi where one needs to be taught about these things in order to argue them.

The oppositional demands to both speak the truth of the medical system and yet to protect the truth in the sense that it should remain sacred is perhaps overdetermined by the current cultural politics of Tibetan Autonomous Region. Of course, just when there is more need for religious education in the methods of the sacred from a health perspective, there is an even greater compulsion to protect it from the desecrations that secularist regime might subject it to. What is at stake for practitioners like this one, is figuring out how to make science speak the language of the sacred without desecrating it. On the one hand, this means revealing enough about the logic of the religious underpinnings to render the logic of their medical efficacy self-evident, but not exposing so much that they could be used to politically implicate those who revealed them.

Conclusion

The last half of the twentieth century has ushered in policies that require Tibetans to think of their religion as a distinct domain of life--something one can do on weekends and days off--as opposed to a culturally prescribed way of being, that imbues nearly all acts of everyday work and living. How successful this effort has been, is not entirely clear. Surely in the Tibetan Buddhist community and even among many immigrant Han and Muslim Chinese, there are still widespread commitments to religious ways of life. But Buddhist religious practices in the TAR are still heavily, perhaps even increasingly, scrutinized because they arouse government suspicions of national separatism. Secular forms of humanism in many nation-states are, I believe, seen as that which can protect religious freedom. But in China, a secular humanism pitched to ensure modernization has been effected through authoritarian policies that have variously deemed religions as problematic. At a minimum, modernization policies have tried to force a disaggregation of domains of ethnic identity, politics, and religion in order to forge new political allegiances, only to reunite them as an effect of governmental paranoia over state security.

In Tibetan medicine, this disaggregation has taken place along a slightly different axis, distinguishing between religion and science and then using the language of science to legitimize medical knowledge. By adopting a language of science, practitioners are able to confirm their commitment to the modernizing agendas of the state and the secular forms of practice the state considers acceptable. But I have raised questions here over what exactly this "science" is that some of them have adopted.

Studies of efficacy in Tibetan medicine conducted at the Mentsikhang point to one end of a continuum of "the scientific" in Tibet. These studies are modeled after the example of biomedicine, in which cohorts of patients taking different drugs are compared on the basis of treatment regimens and outcomes. Concerns over "beliefs" of patients are completely disregarded. Once these studies move beyond discussions of outcomes, however, there is confusion over what to do with things like the theory of five elements, the three channels, and the moral discourse underpinning the humors, for these don’t find comfortable homes in biomedical cosmology. This trend presents problems not simply in terms of theoretical misfit, but in terms of practical understandings of the need to make use of medical models that attend to contemporary Tibetan problems occurring on the social, emotional and physiological levels simultaneously. Tibetan medicine offered insights about the role of ideas about the sacred in health and health care, and they revealed that denials of basic cultural freedoms can be implicated as causes of ill-health.

One solution, at the other end of the continuum, is found among scholars who take the category of "science" to be much broader than that found in biomedicine or Western examples. Their concern is with establishing the validity of traditional theories, including five elements, three channels, the humors, but in a manner that conceals, or at least renders ambiguous, their religious foundations.17 One senior physician at the Mentsikhang expressed this when he told me:

"The five elements, the humors, the consciousness (rnam shes), all of this may seem very different to a Western scientific person, but desire, hatred and ignorance, these three, we consider these part of a scientific explanation. There are many people who have high esteem [are well respected] but they may completely ignore the fact that scientific explanations can be different in Tibetan medicine because they are so pro-Western medicine. All of these must be recognized as scientific ideas."

Physicians like this are looking for a way to legitimize religiously-based knowledge and theory under the rubric of science. They seek to establish the scientific legitimacy of ethical precepts and ultimately, they will have to confront the ways in which a logic of the sacred--for example, that explains the role of perception in healing--explains medical efficacy. These scholars believe this project is important not simply for the sake of establishing the historic value of Tibetan traditions, but also for establishing a basis for revealing Tibetan medicine’s great contribution and utility in the modern world today. In one sense, the benefit of this strategy is already found in its ability to depoliticize Tibetan medical practices. But the challenges this approach poses to us, as others who chose to respond to them are several. These return us to questions about the role of culture in health policy.

Recognizing that China’s restrictions of cultural freedom demonstrate the importance of culture to health, it would seem that calls for basic cultural liberties would be fundamental to policy discussions on health equity. But raising the question of cultural freedom in international arenas opens up other debates. For one, what does it mean to ensure cultural freedom and to bring cultural concerns into the policy arena at the same time? How does one guarantee cultural freedom while tying cultural forms to state or even international agendas? Doesn’t culture risk being put in the service of particular political agendas in the same way that health care is often forced into such a position when it is politicized by becoming attached to one political platform over another? Politicization here does not mean simply mobilizing a uniformly accepted idea about how to attend to the social good. Rather, it means privileging one set of political and cultural ideas that are forged through contestation into the position of being (usually temporarily) dominant, whether or not there is consensus. Government policies are in this sense seldom universally consensual, and one could ask whether international agendas can ever be as well. More often, they represent the winning side in political battles that compromise one set of agendas for another. Just as it is difficult to understand how health can avoid politicization once it is policy-bound, it is also hard to understand how culture can escape this fate once brought into the policy realm. Wouldn’t one end up doing just what China has done: picking and choosing cultural features for eradication and preservation on the basis of health priorities that are already politically determined? Ironically, it may be a blessing in disguise that we find it so hard to deal with culture on a policy level.

A second challenge raised by this case is this: all medical theories implicitly make ethical and moral claims, whether they are secular or religious (Foucault 1981, Bates 1995), but how do we reconcile those systems of knowledge that are explicitly religious with those that are not? In other words, in the international community, how do we determine standards of efficacy that accommodate non-secular, non-Western epistemological claims in a fair way? This raises questions of an equity of epistemology. The Tibetan medical perspective outlined here operates as both a theoretical tool and as source of medical intervention. That is, Tibetan medical theory reveals the centrality of cultural freedom to health, and the logic of the sacred is revealed as that which can explain its healing efficacy. Why shouldn’t we take this set of medical theories very seriously? Finally, when scientific languages are used to parse these concepts, how can we ensure that the full meanings of their content are understood in a manner that does not undermine their local significances?

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Endnotes

Foundation for Anthropological research, the National Science Foundation, and Princeton University for generous support of this research. I also wish to thank Dechen Tsering for her support as a research assistant and Tashi Tsering for his tireless help as liaison. I am indebted to the Mentsikhang, particularly the director and the head of the women’s ward and the staff in the women’s wards at both inpatient and outpatient wards in Lhasa. I also thank the Harvard Center for Population and Development Studies for inviting me to participate in their Health Equity Workshop. I alone take full responsibility for the presentation and analysis offered here.
The Tibetan Autonomous Region refers the region of U-Tsang or central Tibet that has slightly different governance than the former regions of cultural Tibet, including the Amdo and Kham regions which absorbed as part of Qinghai and Sichuan provinces.
Murmurings of the question of ethnomedicine were heard throughout the 1980s as health development programs confronted the matter of "indigenous healers" and most of the literature with which I am familiar suggests that the question of their involvement was largely shifted from the center to the periphery. Even when researchers did not advocate a complete dismissal of indigenous practices illustrations of their utility were nearly always calculated in terms of a presumed dominance of biomedicine. In sympathetic minds, their utility was tabulated in simple models of harmful versus beneficial health practices that could be seen as ineffective at best, dangerous at worst. In other cases it was thought that the best use of indigenous healers was in retraining them in the methods of scientific medicine, which usually meant undermining their own epistemological bases (Bastien 1992).
See Janes (1995) for my inspiration on this topic.
In Lhasa, Tibet, efforts to modernize Tibetan medicine actually began before the arrival of the People’s Liberation Army. In 1916, the great Khenrab Norbu, physician to the Thirteenth Dalai Lama, sponsored the construction of a secular college for Tibetan medicine and astrology, the Mentsikhang. At the time, there was only one other government college for medicine, the monastery at Chags-po-ri, or "Iron Mountain," built in 1694 by the medical visionary Desi Sangye Gyamtso, regent for the Fifth Dalai Lama. The medical college at Chags po ri was designed for monastic scholars who would, after learning the esoteric arts of medicine and tantrism, mostly remain in the monastery, serving the public as would other monk scholars and lamas. The Mentsikhang, in contrast, was designed as a college for "laypersons" who would, after receiving training, return to their rural areas for work as doctors and educators.

Although the modernization envisioned by the lama-physician Khenrab Norbu attended to concerns for the state’s interest in the public’s health, his project was carried out under the auspices of a theocracy. Thus the modernization of medicine was at this point not necessarily one that entailed secularization. Most of the students who were accepted for study at the Mentsikhang received training in religious fields prior to their arrival. In most cases, merely learning to read and write Tibetan script entailed religious study. Moreover, all of the ten fields of scholarship taught at the Mentsikhang, including grammar, logic, technology, medicine, religion, literature, rhetoric, drama and astrology, were based on religious teachings.

Prior to 1916, the only other way for Tibetans to learn the arts of medicine was by becoming apprentice to, or raised within, a family of practicing physicians. The history of family-based lineage practitioners probably dates back to the origins of Tibetan medicine in at least the 12th century, although even thereafter there was monastic tutoring in medicine (See Meyer 1992 for a nice summary of history). Lineage practitioners learned medicine through oral instruction and memorization of the four tantras. Although they were not always recognized as religious figures associated with one or another of Tibetan’s five Buddhist sects, they were taught the religious components of the tradition. One can surmise that from at least the 17th century this entailed receiving initiation and empowerment blessings of the ningje wong (nying rje dbang) or "empowerment of compassion." These teachings were meant to enable practitioners to use their own techniques of meditation as preparation for treating others.

Support for traditional Chinese medicine in other regions of China was on the wane (New and New 1977) due to the large influx of foreign medical services in the 1930s particularly.
For the early years of China’s control in Tibet support for traditional medicine was largely uninterrupted, reflecting the government’s strategy of "gradualism" in implementing communist reforms in this minority region (Janes 1995, Goldstein 1998). However, with the first signs of political dissent to Communist rule in Lhasa, things changed. In 1959, opposition activities were launched as rumors of threats to the Dalai Lama were circulated. Chags-po-ri medical college was destroyed and the Dalai Lama along with some 100,000 Tibetans fled from Tibet and from communist rule. The monk and lama scholars from Chags po ri were sent to the Mentsikhang where agendas for more rapid modernizing were already being implemented. For example, it was already clear that efforts to establish separate departments that were modeled after biomedical systems were in place by 1962 (e.g., creation of separate wards). Attempts to restore Tibetan medicine began during the Cultural Revolution (late 1960s, according to Meyer 1992), although the real resurgence seems to have followed the 1978 reforms.
By the last years of the 1970s, state efforts in Tibet to rebuild religious institutions, especially monasteries, were quickly compromised (though not abandoned) by unsuccessful negotiations with His Holiness the Fo

Equity of the Ineffable: Cultural and Political Constraints on Ethnomedicine as a Health Problem in Contemporary Tibet

Vincanne Adams Department of Anthropology Prineton Univiersity

http://www.hsph.harvard.edu/

Harvard Center for Population and Development Studies Working Paper Series Number 99.05

April 1999

Equity of the Ineffable:
Cultural and Political Constraints on Ethnomedicine
as a Health Problem in Contemporary Tibet

Vincanne Adams
Department of Anthropology
Prineton Univiersity

Harvard Center for Population and Development Studies
Working Paper Series
Number 99.05