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Mongolian medicine

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Mongolian medicine a modern tradition
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Hilliard, Casey
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148 leaves : ; 28 cm

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Traditional medicine -- Mongolia ( lcsh )
Medical care -- Mongolia ( lcsh )
Medical care ( fast )
Traditional medicine ( fast )
Mongolia ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Includes bibliographical references (leaves 143-148).
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Department of Anthropology
Statement of Responsibility:
by Casey Hilliard.

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Full Text
MONGOLIAN MEDICINE: A MODERN TRADITION
by
Casey Hilliard
B.S., Bucknell University, 1998
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts
Anthropology
2003
l
j
l


This thesis for the Master of Arts
degree by
has been approved
by
James Igoe
/7'I -oS
Date


Hilliard, Casey (M. A., Anthropology)
Mongolian Medicine: A Modern Tradition
Thesis directed by Professor Craig Janes
ABSTRACT
Over the past twelve years, Mongolia has undergone a dramatic transition from a
socialist, centralized state government to a democratic nation with a liberal free
market economy. The consequences of this radical change in Mongolias political
and economic environment are far-reaching. Mongolia has been thrust into the
global marketplace, has opened its borders to the influence of multinational
investment, and has undertaken radical reform in all sectors of Mongolian society.
Amidst these dramatic changes, Mongolia has developed a formal system of
traditional medicine after seventy-years of repression. Remarkably, in twelve short
years Mongolia has reconstituted a nearly lost system of traditional medicine
thoroughly integrating it into the nations fully modem health care system. This
thesis is based on a preliminary study of Mongolian Medicine, its development and
practice. It explores the articulation of global forces with Mongolias changing
sociopolitical context, the reasons for Mongolian Medicines reconstruction and the
nature of its content, practice, and integration.
This abstract accurately represents the content of the +i,d;o t
recommend its publication.
Signed
m


DEDICATION
I dedicate this thesis to my husband for his support and patience.


ACKNOWLEDGEMENT
My thanks to Dr. Janes for the opportunity to work with him in Mongolia and his
assistance throughout the writing process. I would also like to thank Dr. Corbett
and Dr. Igoe for their helpful suggestions and insights. Finally, a special thank you
to Kimberly Rak, Oyuntsetseg Chuluundoij, and Khulan Janchiv for their support
and input during my time in Mongolia.


CONTENTS
Figures.......................................................ix
Tables........................................................x
CHAPTER
1. INTRODUCTION................................................1
Mongolian Medicine........................................3
Data Collection...........................................5
2. LITERATURE REVIEW..........................................13
Medical Pluralism........................................20
Encounters with Biomedicine...........................22
Health Care Reform and the Integration of
Traditional Medicine..................................26
Traditional Medicine and the Market...................30
Cultural Nationalism and Traditional Medical
Revivalism............................................34
Summary........................................!.........36
3. TRADITIONAL MEDICINE IN MONGOLIA:
PAST AND PRESENT............................................38
History of Traditional Medicine in Mongolia..............39
Mongolias Socialist History and the Dismantling
of Traditional Medicine................................ 43
vi


The Post-Socialist Context...............................46
Mongolian Medicine Today: A General Overview.............49
4. THE NATURE OF MONGOLIAN MEDICINE..........................52
The Content of Mongolian Medicine...................... 52
Mongolias National Health Care System:
Its Structure and Distribution...........................58
Mongolian Medicine: Training and Practice................65
The School of Mongolian Traditional Medicine,
National Medical University of Mongolia..............66
NMUM Mongolian Medicine in Practice..................69
\
Summary..............................................78
Manba Datsan and the Buddhist Institution of
Mongolian Medicine...................................80
Summary of Mongolian Medical Practitioner Interviews ....87
5. PATIENTS AND THE GROWTH OF
MONGOLIAN MEDICINE.........................................93
Mongolian Medicine: Patient Interviews...................93
Discussion of Patient Themes and Health Seeking
Behavior.............................................. 105
The Prevalence of Mongolian Medicines Use..............110
Summary.................................................112
6. MAKING SENSE OF MONGOLIAN
MEDICINE..................................................113
Vll


The Modem Determinants of Mongolian
Medicine.................................................114
The Economic Crisis of the Early 1990s and the
Construction of Mongolian Medicine....................115
Health Care Reform and Mongolian
Medicine..............................................119
Cultural Revivalism and the Construction of
Mongolian Medicine....................................126
Summary...............................................129
Conclusion.................................................130
APPENDIX
A. Human Subjects Research Committee at the
University of Colorado at Denver Approval..................137
B. Practitioner and Patient Interviews.......................138
C. Description of Mongolian Medical Clinics..................140
REFERENCES.........................................................143
vrn


FIGURES
Figure
5.1 Mongolian Medical Patients Complaints.............................95
IX


TABLES
Table
1.1 Health Care Reform Study Activities and Methodology....................7
1.2 Mongolian Medicine Study Activities
and Methodology.........................................................9
4.1 Four Levels of Health Services in Mongolia............................58
4.2 Private Health Care Institutions in Mongolia, 1999....................62
4.3 Description of Practitioners Interviewed..............................87
5.1 Description of Patients Interviewed...................................94
5.2 Reasons Patients Chose Mongolian Medicine.............................97
5.3 Perceived Benefits of Mongolian Medicine.............................101
5.4 Perceived Disadvantages of Biomedicine...............................102
5.5 Patients Reasons for the Growth in Mongolian Medicine...............104
x


CHAPTER ONE
INTRODUCTION
A basic fact observed around the world is that despite biomedicines
hegemony, traditional medicine1 remains an important medical resource for a large
proportion of the worlds population. Historically, the continued survival of
traditional medicine in the face of biomedical hegemony was principally understood
as a consequence of biomedicines inequitable distribution in developing nations,
which created a large unmet demand for medical care among the poor and rural
population. However, in recent years our understanding of traditional medicine, its
use and importance, has expanded, along with a growing interest in traditional
medicine for practical and commercial purposes. Today, traditional medicines
survival is linked to global health care reform initiatives, inherent limitations in the
application of biomedicine, the growth in a free medical market, and from an
anthropological perspective, the metamedical functions of traditional medicine
1 Throughout my thesis I use the term traditional medicine to refer to non-Westem, indigenous
medical systems because it is a widely used and generally understood phrase. However, I recognize
that the term traditional medicine is problematic. Its use suggests that the medical systems in
question are products of the past, unchanged by modem influences. This is, of course, untrue. As I
discuss in chapter two, all medical systems are dynamic products of the current historical moment.
Therefore, my use of the term traditional medicine is not intended to imply that these medical
systems are stagnant but rather it is employed to distinguish these medical systems from the
biological sciences based, Western-origin medicine (which I will refer to as biomedicine) found
throughout the world.
1


resulting from its culturally salient beliefs and principles. The appreciation of
traditional medicines association with these modem exigencies reflects a more
nuanced and contextualized understanding of medicine developed by
anthropologists over the past twenty-five years.
Through their extended acquaintance with foreign cultures, involvement in
the development programs of the 1960s, and critical investigation of biomedical
knowledge in the West, anthropologists have developed a model of medicine that
recognizes the constitutive significance of the historical, social, cultural, and
political context in the determination of a medical systems fundamental principles,
beliefs, and values. The model defines medicine as a cultural system built out of the
meanings, values, and behavioral norms of a society (Kleinman, 1980). In this
view, medical systems are models of and for social reality; they simultaneously
reinforce the values and norms of society, create order and meaning, give plans for
purposive actions, and produce the conditions for their own perpetuation (Young
1982). As a consequence of this iterative relationship with culture and the
sociopolitical context, anthropologists understand that the content, effectiveness,
and relevance of a medical system are dramatically shaped by the macrolevel forces
acting within a particular historical moment. Therefore, it is not just traditional
medicines continued survival that is determined by the modem sociopolitical
context but its nature and meaning are also fundamentally shaped by the web of
forces in which it is embedded. In this thesis, I explore the integration and the
2


development of traditional medicine in Mongolia from this political economic
vantage point.
Mongolian Medicine2
Over the past twelve years, Mongolia has undergone a dramatic
transformation from a state controlled socialist nation to a democratic free market
society. The political economic transition was peaceful but its consequences were
far-reaching. Mongolia experienced an economic crisis that threatened to
destabilize the country, it was thrust into the global arena, and its western Soviet
identity built on the principles of centralized control, the collective good, and the
hegemony of the state was rendered irrelevant. Mongolia responded quickly to
these changes. It liberalized its economy, responded the introduction of global
discourses, undertook radical reforms in all sectors of society, and revived its
traditional culture as a symbol of the new democratic nation. Amidst these dramatic
events, a formal system of traditional medicine was constructed after seventy years
of socialist repression and biomedical dominance.
The system of medicine that grew out of the interaction of the powerful
forces reshaping the nation is a distinct blend of Mongolian, Tibetan, and East Asian
2 Although it is commonly accepted by Mongolians as Mongolian Traditional Medicine, I use the
term Mongolian Medicine to refer to Mongolias formal system of traditional medicine because the
phrase Mongolian Traditional Medicine is misleading. As I will discuss, Mongolian Medicine is a
modem construction, significantly determined by Mongolias changing sociopolitical context. It is
set in contrast to the countrys dominant biomedical system and associated with the nations ancient
heritage but the development and nature of Mongolia Medicine has been deeply influenced by
modem exigencies.
3


medicine. It has two distinctive schools of thought, one closely associated with
the biomedical community and one overtly linked to Tibetan Buddhist religious
practices. Both schools of thought are government supported and integrated into
the national health care system. Over the past several years, Mongolian Medicine
has rapidly grown in popularity and today, there are several government regulated
schools and a large number of public and private traditional medical practices
throughout Mongolia.
What is remarkable about Mongolian Medicine is that in 1990 when its
reconstruction began there was no cohesive system of indigenous medicine in
Mongolia. Therefore, its relationship with the modem context is quite salient. The
political and economic changes which have accompanied Mongolias post-socialist
experience are clear determinants of the nature and practice of Mongolian Medicine.
Focusing on the these political and economic changes, this thesis attempts to
discover and explain some of the unique qualities of Mongolian Medicine that have
been determined by the countrys socialist and post-socialist experience.
Specifically, the thesis looks at how the economic consequences and national
identity crisis caused by Mongolias political economic transition have led to the
development of a well-integrated system of traditional medicine that is designed to
complement rather than compete with biomedical care. It will also explore how
biomedicine retains a hegemonic position in the health care system, what factors
determine the distribution of Mongolian Medicine, and how the national political
4


agenda has provided for a distinctly religious (Buddhist) practice of Mongolian
medicine.
Data Collection
The thesis is based on fieldwork conducted in Mongolia between the months
of May and August 2002. Most of the research was completed in the capital city,
Ulaanbaatar, though I had the opportunity to interview a Mongolian Medical
practitioner and a caretaker of a private Mongolian Medical clinic in the rural aimag
(province), Hovsgol. The data collected consists of patient and practitioner
interviews, clinical observations in several Mongolian Medical clinics in
Ulaanbaatar, and household interviews conducted for a larger study on health care
reform in Mongolia. The data were supplemented with primary literature resources
provided by several practitioners. These resources enhanced the data collected on
the history, theory, and growth of Mongolian Medicine. All research was reviewed
and approved by the Human Subjects Research Committee at the University of
Colorado at Denver (Approval #800, Appendix A).
The research was conducted in the context of a larger investigation of health
care reform in post-transition Mongolia, funded by a U.S. Fulbright Program, 2001-
2002 New Century Scholars award to Professor Craig Janes. The larger study
consisted of a survey of urban and rural residents in low-income communities,
interviews with practitioners and health policy decision-makers, and clinical
5


observations in three family doctor practices in Ulaanbaatar. The centerpiece of the
investigation was a household survey designed to elicit the general populations
opinions of and experience with Mongolias reformed health care system. Table 1.1
outlines the methods and overall design of the larger investigation (see also Janes
2003 for further details).
6


Table 1.1: Health Care Reform Study Activities and Methodology
Activity Methodology Number Interviewed
1. Survey of Low- Income Households la. Quantitative survey of a random sample of urban and rural households lb. Elicitation of qualitative illness narratives for all persons reporting illness in last year or month and opinions about the various medical resources available in Mongolia. 91 household interviews; of these 83 reported illness in last year or month
2. Focus groups with family doctors 2. Narrative record of family doctors evaluation of the system, their practices, challenges faced, etc. 2 focus groups, each comprised of approximately 5 family physicians from 4 districts of Ulaanbaatar
3. Interviews and observation with family physicians 3 a. Qualitative interviews regarding specifics of a particular practice, experience of being a family doctor, funding issues, challenges 3b. Clinical observations with family doctors during morning office visits. Heads of 3 family group practices in Ulaanbaatar, 2 family group practices in Hovsgol aimag
4. Interviews with policy-level staff in the Ministry of Health, NGOS, donor organizations 4. Qualitative Interviews on the subjects of health reform, insurance, family doctor program 7 interviews


The interviews and observations with Mongolian Medical practitioners and
patients that occupy the central focus of this thesis were developed and conducted
independently, although the information collected as part of the larger investigation
provides important data on the general populations use and opinion of Mongolian
Medicine. Additionally, the data on health care reform and access to care were
particularly helpful for understanding the distribution and integration of Mongolian
Medicine into Mongolias heath care system.
The patient and Mongolian Medical practitioner interviews for my study of
Mongolian Medicine were semi-structured. The questions were open-ended,
encouraging patients and practitioners to express their opinions of traditional
medicine and biomedicine, reasons for using/studying Mongolian Medicine, and
general ideas about the growth and development of traditional medicine in
Mongolia (Appendix B). hi all, 33 patients and 22 Mongolian Medical practitioners
were interviewed in Mongolian Medical clinics throughout Ulaanbaatar.
In addition to patient and practitioner interviews, several hours of clinical
observation were performed. Patient doctor interactions were observed in the in-
and outpatient settings for several hours at five Mongolian Medical clinics. The
observations of the clinical encounters allowed me to develop a deeper
understanding of Mongolian Medicine in practice. I observed diagnostic
techniques, patient-doctor interactions, treatment prescriptions, and therapeutic
practices. Additionally, because the doctors commonly told me the patients
8


complaints, diagnosis, and treatment prescription, the clinical observations provided
a larger sample of patients from which a general picture of Mongolian Medicines
patient population could be constructed. Table 1.2 summarizes the study design and
methods.
Table 1.2: Mongolian Medicine Study Activities and Methodology
Activities Methodology Study Population
1. Mongolian Medical Practitioner Interviews Qualitative interviews regarding reasons practitioners chose to practice Mongolian Medicine, how they understood the causes and symptoms of disease, the benefits of Mongolian Medicine, its limitations, and opinions on its growth. 11 practitioners in private practice and 10 working in public health sector in Ulaanbaatar; 1 physician at aimag hospital in Hovsgol
2. Mongolian Medical Patients Qualitative interviews including questions pertaining to symptoms, reasons for consulting Mongolian Medicine, treatments, efficacy, and opinions on benefits and growing popularity of Mongolian Medicine. 33 patients in the in and outpatient setting in Ulaanbaatar
3. Clinical Observations with Mongolian Medical Practitioners Clinical observation of patient- practitioner interactions. Observed diagnostic techniques, prescription of treatments, and application of various therapies. Observations in Ulaanbaatar Mongolian Traditional Medical Hospital and four private outpatient clinics.
The clinics where the interviews and observations were conducted were
chosen by referral from those knowledgeable of Mongolian Medicine in
Ulaanbaatar. Two clinics, the Ulaanbaatar Mongolian Traditional Medical Hospital
9


and Manba Datsan, were identified by members of the research team investigating
health care reform as ideal starting points because of their national recognition.
These institutions are the largest, most well-known Mongolian Medical clinics in
Mongolia and they are associated with the countrys two primary schools of
traditional medicine. Thus, they are representative of the formal system of
Mongolian Medicine. Interviews and observations were completed at both these
institutions as well as four private hospitals and two district level public outpatient
clinics. The additional research sites were identified by patients and practitioners I
spoke with at the Ulaanbaatar Mongolian Traditional Medical Clinic and Manba
Datsan and one was discovered serendipitously while exploring the city.
The clinics represented a variety of government supported Mongolian
Medical practices ranging in size from outpatient-only facilities with three
physicians on staff to larger hospitals with 20 or more beds and six physicians.
Most clinics were staffed by practitioners trained in both biomedicine and
traditional medicine. Two clinics were run by monks trained only in traditional
medicine. All the clinics specialized in traditional medicine and offered no
biomedical treatments, despite many of the practitioners biomedical training.
Practices varied among the clinics but all offered traditional diagnosis, herbal
medicines, and manipulative therapies. Appendix C contains a more detailed
breakdown of the clinics in which the research was conducted.
10


The data collected were analyzed qualitatively to construct a general
description of Mongolian Medicine. Using an immersion and crystallization
approach3 (Borkan 1999) to analyze the interview material, patient and practitioner
themes on the reasons for use, benefits and drawbacks of Mongolian Medicine and
biomedicine, and growth in popularity of traditional medicine were identified. By
combining the themes with the descriptive data from observations, a comprehensive
picture of the practice and modem development of Mongolian Medicine emerged.
In the following chapters, I will illustrate how Mongolias socialist and post-
socialist history have shaped the Mongolian Medical System I observed. To
contextualize the discussion I provide a review of the relevant literature in chapter
two. The chapter outlines the theoretical perspective I have taken in my analysis of
Mongolian Medicine. In the third chapter, I include a brief history of traditional
medicine in Mongolia and a general overview of Mongolian Medicine today, which
illustrate the discontinuity between the pre-socialist and post-socialist reality of
traditional medicine in Mongolia. Chapter four presents the results of my research,
providing a summary of Mongolian Medicine, its practice, integration, distribution,
and practitioner discourses surrounding its use and growth. In chapters five and six,
I explore the determinants of medical pluralism in Mongolia. Specifically, chapter
five investigates the reasons patients are choosing to use traditional medicine and
3 The immersion crystallization approach described by Borkan (1999) is an organizing style
involving repeated engagement with the data, leading to insights, interpretations, and the
identification of general themes. Much of anthropological work is based on this type of analysis.
11


chapter six looks at how the articulation of macrolevel forces with the local
sociopolitical context has shaped the content, practice, and distribution of
Mongolian Medicine. Chapter six also offers some brief conclusions and
suggestions for future research.
12


CHAPTER TWO
LITERATURE REVIEW
Over the past twenty-five years, medical anthropologists have developed a
model of medicine that opens up new avenues for investigating the nature and
meaning of traditional medicine in the modem context. The anthropological model
of medicine moves beyond the dominant scientific gaze of the biomedical paradigm
to a more nuanced and contextualized understanding of medicine that defines all
medical systems, whether they be traditional or biomedical, as cultural systems built
out of the meanings, values, and behavioral norms of a society (Kleinman 1980).
This theoretical perspective is bom out of years of cross-cultural studies that
demonstrate the universal fact that all medical practices follow from and make
sense in terms of underlying medical beliefs, which are integral parts of culture
(Wellin 1977:49). In other words, medical systems are internally coherent products
of the cultural presuppositions and values embedded in the larger social and
historical context (Hahn 1996). Medical systems are models for and of a special
type of social reality; they simultaneously create order and meaning, give plans for
purposive action, and reproduce the condition for their own perpetuation (Young
13


1980). This observation has a number of important implications for the study of
medicine.
First, it reveals a very important fact about biomedicine, a system of
medicine that due to its hegemony is commonly accepted as a truth based,
acultural medical system with global applicability. The contextualized view of
medicine suggests that biomedicine, like any other medical system, is culturally
constructed. It is a product of the ideas, beliefs, and values of the cultural matrix in
which it resides. Its knowledge and practices are not privileged or apart from
culture, in fact, biomedicine is steeped in value-laden meaning. Biomedical
principles like the foundation of medical practices in science, a strong preference for
objective evidence, technological means of diagnosis and intervention, an
orientation towards curing disease, individualism, and a hierarchy of authoritative
knowledge are not universal, acultural values (Hahn 1996). They reflect a specific
cultural perspective that has a direct impact on the effectiveness and adaptability of
biomedicine in foreign contexts. Additionally, the hegemony of biomedicine has
led to the acceptance of these values as the standards for the validation of alternative
medical practices, leading to a narrowly focused valuation of traditional medicine
within the global health care arena. Through explication of the culturally
constructed, contextualized nature of biomedicine and the consequences of
biomedical dominance, anthropologists have contributed to a growing critique of
14


biomedicine and have offered useful evaluations of health care reform and health
promotion programs around the world.
Second, it provides a broader perspective through which the efficacy of
medical systems and health-seeking behavior of individuals can be investigated.
Because of the global dominance of biomedicine and the scientific paradigm, the
efficacy of medicine in general is typically validated by standards and practices
defined by these specific approaches to disease and healing. This limited evaluation
of alternative medical systems neglects a number of important functions of medicine
and, due to biomedicines focus on disease to the exclusion of the larger forces
shaping health and illness, it excludes the psychosocial aspects of the illness
experience that play a prominent role in patient health seeking behavior. The model
of medicine as a cultural system helps move beyond this narrow approach by
recognizing the importance of the overall illness experience, symbolic,
contextualized nature of medicine, and the relationship medicine shares with
everyday interpretations of the world.
This more inclusive understanding of medicine reflects the contextualized
nature of a medical system. As a cultural system, medicine is fundamentally
connected to the beliefs and values of the larger society and as a result, it is in the
unique position of linking the social and cultural world with the biological and
psychological reality of disease (Kleinman 1980). Due to its close association with
everyday interpretations of the world, medicine appears to do more than cure
15


disease; it gives deeper meaning to the illness experience by addressing the affective
and social dimensions that often surround the experience (Young 1976, Waldram
2000). Therefore, to simply evaluate a medical system based on its ability to cure
disease in scientifically verifiable terms, is to neglect a number of the critical
functions of medicine related to its culturally embedded nature. According to
Kleinman, such functions include the cultural construction of illness as a
psychosocial experience, the designation of criteria to guide the health seeking
behaviors of individuals, the determination of the communicative processes through
which sickness is managed, the provision of healing therapies and treatments, and
the negotiation and interpretation of therapeutic outcomes (1980). These features of
a medical system are particularly important for understanding both a medical
systems efficacy and the ways patients chose and employ medicine to address the
potentially disruptive illness experience.
It is a basic social fact that patients do not seek medical care due to the
biological reality of disease (Leslie 1980). They employ medicine to redress a
disruptive event that affects daily functioning, disrupts social relations and roles,
and psychologically challenges their ability to organize the world in a meaningful
way. Therefore, patient decision-making is driven by a pragmatic desire to heal the
biological, psychological, and social aspects of the illness experience. Medicines
meaning giving functions are critical to this process. As systems of symbolic
meaning, medical systems articulate illness and healing as socially constituted
16


experiences (Kleinman 1980). Through engagement with a particular medical
system, the meaning of the illness experience and its cure are negotiated. Thus,
despite what the hegemony of biomedicine implies, for patients it is not simply the
scientific validity or biological efficacy of a medical system that guides health-
seeking behavior.
A third consequence of the assertion that medical systems are internally
coherent products of the cultural matrix in which they reside is that the
categorization of medical systems in unequivocal terms becomes problematic.
Because all medical systems are culturally constructed, distinctions between
medical systems based on modem and tradition or science and religion are
untenable, revealing an ethnocentric bias in favor of Western medicine (Leslie
1976). Additionally, defined as systems of symbolic meaning that guide health-
promoting behavior, medical systems are not isolated to professional, standardized
formal institutions. In fact, a large portion of illnesses are managed in the popular
health sector by family and friends (Kleinman 1980).
Anthropologists have therefore, struggled to identify appropriate unbiased
and meaningful ways of classifying the various types of medical systems observed
in society. Some, like Kleinman who focuses on clinical realities, have argued that
there are three health care arenas within every societys health care system: the
popular, folk, and professional (1980). Others more interested in cross-cultural
comparisons, like Dunn, have defined medical systems based on their geographical
17


and cultural settings (Dunn 1976). According to Dunn there are local medical
systems, which include most folk and primitive systems; regional medical
systems, such as Chinese and Ayurvedic medicine; and the cosmopolitan medical
system, which refers to modem or biomedicine and its worldwide application
(1976). Still others distinguish medical systems based on professionalization, which
entails a self-conscious grouping of healers with defined criteria for membership
and control over certain esoteric knowledge (Last 1996). Last has argued that there
are three types of medical professions: the conventional, privileged, and scientific
medical profession, government and public supported alternative medicine, and
traditional medical systems that create distinct groups of practitioners for
government recognition (1996). This classification of medical systems is somewhat
restricted, it neglects many of the informal systems of medicine that exists within
every society, but it does elucidate an important distinction between some medical
systems. To date, a universally satisfactory system of classification has not been
achieved, although anthropologists have become cognizant of the deeper
implications of the categories they chose and seek to avoid ethnocentric biases.
For this thesis, I have chosen to use the terms traditional medicine and
biomedicine to refer to the two medical systems I investigate. I use the term
traditional to refer to nonwestem, indigenous medical systems because it is widely
understood. When referring to Mongolian Medicine, I use the phrase a formal
system of traditional medicine to emphasize the systems government backing,
18


scholarly, and standardized training. It also helps to distinguish Mongolian
Medicine from other informal medical beliefs and practices that may exist within
the country.
Finally, the model of medicine as a cultural system directs attention to the
social, cultural, and political forces that determine the shape and meaning of a
medical system in a particular historical moment. As in the case of biomedicine, the
contextual elements of a given historical moment are constitutively significant in
determining the continued use of and nature of every medical system. All medical
systems are dynamic, responsive to the various forces acting within a particular
sociopolitical environment. These forces operate at the global, national, and local
level to determine the content and practice of a medical system. Thus, an important
avenue for understanding medicine in the modem context is through a political
economic investigation of the factors that shape the nature of a medical system and
their consequences.
Taken together, these implications of the anthropological model of medicine
provide a valuable approach to the study of traditional medicine that allows for a
more balanced view of its efficacy, significance, and paradoxical position in todays
global health care arena. The broader perspective provided by the model of
medicine as a cultural system addresses the base of traditional medicines cultural
construction, its historically contingent contextualization, and the experiential
particularities surrounding medical pluralism in general (Morsy 1996). Employing
19


this model to investigate the nature of traditional medicine in the modem context,
anthropologists have uncovered a complex iterative relationship between traditional
medicine and the sociopolitical context, which dramatically influences its meaning,
content, and practice (Janes 1995, Leslie 1974, Lock 1980).
Medical Pluralism
To understand the nature of traditional medicine within the modem context,
an investigation of medical pluralism, its determinants and consequences, is
necessary. Medical pluralism is a prominent characteristic of all complex societies.
Due to the culturally constructed nature of medicine and the inequitable distribution
of medical care, within every complex society a diversity of medical practices
coexist (Baer 2001, Lock 1980, Unschuld 1980). This is true for developed and
developing nations. The fact is that despite biomedicines global hegemony, it has
not rendered the practice of traditional and alternative medicine obsolete. Instead,
as Lieban summarizes, modem medicine has been established around the world not
so much by displacing indigenous medicine as by increasing the medical options
available to the population (1977:27). However, medical plurality does not simply
reflect the simple coexistence of diverse medical practice; it is characterized by
struggle and compromise. It is a medium of encounter, negotiation, and
transformation between medical systems struggling for legitimacy, meaning, power,
and control over the course of development (Leslie 1974, White 2001). It is a
20


process of negotiation directly influenced by large-scale political, national, and
global interests. Thus, medical pluralism does not operate in isolation; its effects
are a product of the articulation of a complex array of macrolevel forces with the
local sociopolitical context and the medical practices themselves
For traditional medicine the consequences of the struggle and compromise
that surround medical pluralism are dramatic. Within medically plural societies,
traditional medical systems represent structures of compromise, transformed and
redefined by the forces and values of modernity, globalization, and cultural
nationalism that pervade the current historical moment. The pressures of the
modem context have led to dramatic changes in the content and practice of
traditional medicine. As a result, the traditional medical systems that exist today are
different from traditional cultural medicine (Leslie 1992). Their legitimacy and
identity are contingent on modem discourses that only make sense in light of
knowledge that is not authentically traditional (Giddens 1990).
Unfortunately, anthropological studies have shown that the transformation of
traditional medicine in the modem context is often a one-sided process that tends to
erode many of its distinctive and culturally salient features. The changes often
undermine traditional medicines unique theoretical perspectives, individualized
approach to health care, efficacy, and its accessibility to underserved populations
(Lock 1980, Janes 1999). Therefore, although traditional medicines continued
survival does not appear to be in jeopardy, its integrity, distinctiveness, and value is
21


threatened by the powerful transformative effects of the politics of medical
pluralism. To demonstrate this point and illustrate how traditional medicine has
been shaped by the modem context, I provide a brief review of the medical
anthropology literature, focusing on the impact of biomedicines global hegemony,
naively conceived health care reform initiatives, and the development of a free
medical market.
Encounters with Biomedicine
One of the most salient transformative powers impacting traditional
medicine today is the global dominance of biomedicine and the scientific paradigm.
Although biomedicine has not displaced the practice of traditional medicine around
the world, it is the unquestioned hegemonic system of medicine in most nations and
the dominant global paradigm. As a consequence, its standards of practice,
measures of validity, biological theoretical perspective, and technological resources
provide the lens through which all medicine is evaluated and legitimated within the
global medical arena. The privileged status of biomedicines scientific, analytico-
deductive approach to knowing has forced traditional medical systems to adopt new
forms of representation, resulting in the scientization and standardization of
traditional medical knowledge and practice. The process results in critical changes
in traditional medicines practice, theoretical perspectives, and professional
22


organization, all of which undermine its potentially valuable and novel contributions
to modem medical knowledge and care.
For instance, in the case of Traditional Chinese Medicine in China, the
nuanced and flexible approach to theory and practice has been eroded by pressures
to modernize along biomedical and scientific lines. According to anthropologists
studying the modernization of Traditional Chinese Medicine, the 20th century
intrusion of the West and its threat to the nations sovereignty led to an obsession
with building national strength through modernization (Croizier 1976). As a result,
China quickly adopted biomedicine and science as the standard by which all
medical systems in the country were evaluated. Traditional Chinese Medicine, a
well-developed scholarly system of medicine, was not displaced by this process but
its theoretical foundations and therapeutic practices were disrupted.
According to scholars of Traditional Chinese Medicine, there is a
fundamental distinction between the scientific approach to knowing and the one on
which Traditional Chinese Medicine is based (Unschuld 1992). Unlike
biomedicine, Traditional Chinese Medicine is a system of medicine characterized by
a plurality of practices and knowledge that does not possess a structural totality
(Farquhar 1987). It is based on an instrumental, patterned approach to knowing that
is grounded in personal experience and practice, which stands in stark contrast to
biomedicines analytico-deductive pursuit of a singular truth (Unschuld 1985,
1992). Contrary to the biomedical and scientific paradigm, Traditional Chinese
23


Medicine readily incorporates contradiction into the system for pragmatic reasons
(Unschuld 1985,1992). However, due to the active pursuit of modernization along
scientific lines, the experiential, individualized approach to theory and practice has
been disregarded in an effort to secure Traditional Chinese Medicines legitimacy in
a national health care system dominated by biomedical science. Consequently,
Traditional Chinese Medicine has been reformulated as a rationalized system of
medicine through the emphasis of its objective, empirical basis (Farquhar 1996).
Additionally, the pressure to scientize the tradition has led to the fixing of
elements to immutable signifying relations, as opposed to the more processual,
contingent approach to illness that once characterized the system (Farquhar 1987).
Similarly, in Tibet, Chinas privileging of biomedical and scientific
knowledge has led to notable transformations in Tibetan Medicine, a popular and
well-developed medical resource in the autonomous region. Along with the
pressures of biomedical dominance, Tibetan Medicine has come under Chinese
opposition to feudal and religious traditions in the autonomous region. In Tibet,
science not only represents the accepted means for the legitimization of Tibetan
Medicine, but it is also a tool in the process of contested signification, a political
strategy in the negotiation of Tibetan Medicines identity (Adams 2002). As a
result, Tibetan Medical practitioners have had to adopt new ways of thinking about
knowledge. They have been forced to invent categories of distinction between
religious and scientific knowledge, dissociating Tibetan Medicine from its Buddhist
24


theoretical foundations (Adams 2001b). Additionally, as in the case of Chinese
Traditional Medicine, the Tibetan Medical theoretical paradigms are being reduced
to explanations that fit comfortably within the biomedical paradigm. Diagnostic
strategies are being simplified, focusing on the identification of discrete diseases
and their corresponding treatments.
These examples are illustrative of how the dominance of biomedical and
scientific thinking has impacted traditional medicine within medically plural
societies. In most national health care systems, there is an unequal balance in favor
of biomedicine. As a consequence, biomedical diagnoses are given greater
legitimacy over traditional medical methods, traditional medical theory is generally
neglected, science is emphasized as the competitive edge in medicine, and
traditional medical diagnostic categories and treatments are reduced to standardized
therapeutic formulas that lack the individualized approach associated with
traditional medical care (Adams n.d., Janes 1995).
There is also another level at which biomedicine affects traditional medicine,
the level of professionalization. The bureaucratically ordered set of schools,
hospitals, clinics, medical associations, companies, and regulatory agencies that
characterize most national health care systems is a historically recent phenomenon
modeled on the Westernized and scientized profession of biomedicine (Leslie
1974,1980). The adoption of this model of professional medicine as the dominant
structural feature within national health care systems places additional pressures on
25


traditional medicine, forcing it to standardize the transmission of knowledge and
clinical practice. This too fundamentally impacts theory and practice. For example,
Hsu, in her study of the transmission of Chinese knowledge, observed that the
imposition of standardized approaches to learning and knowing Traditional Chinese
Medicine led to a body-centered medicine that reduced Chinese physiological
concepts to Marxist dialectics, Western scientific ideas, and biomedical conceptions
of the body and disease (1999). Thus, as a result of the structural and theoretical
dominance of science and biomedicine, traditional medicine has been transformed
both practically and theoretically.
Health Care Reform and the Integration of Traditional
Medicine and Biomedicine
In recent years, due to a growing interest in traditional medicine among
international health planers, governments, and individuals in Western developed
societies, the scope of medical anthropological investigations into the forces shaping
the nature of traditional medicine has expanded beyond the study of encounters with
biomedicine. One trend that has been particularly influential in the reconstruction
and development of traditional medicine is the global initiative to integrate
traditional medicine into national health care systems around the world.
Spearheaded by intergovernmental organizations like the World Bank and the
World Health Organization, health care reform efforts aimed at strengthening
primary health care and the private health care sector have begun to include the
26


development of traditional medical resources in their aims (WHO 2002). There are
a number of practical reasons for this.
First, the international health planning community has recognized the
continued importance of traditional medical care among a large portion of the
worlds impoverished and rural populations. Particularly, in Africa, Latin America,
and Southeast Asia, traditional medicine still represents a primary health care
resource (WHO 2002). In these regions, biomedical care is often limited in its
accessibility and quality. Therefore, reasoning that the high number of traditional
medical practitioners and their concentration among underserved populations can
increase the equitablity of health care in developing nations, the WHO has argued
for the incorporation of traditional medical practitioners with basic biomedical
knowledge and skills into primary health care delivery systems.
A second motivation for the development of traditional medicine is its
relative cost efficiency. In impoverished nations, the highly technological and
expensive system of biomedicine is often underfunded and reliant on foreign aid and
resources. The WHOs goal of Health for all by the Year 2000 is based on a
principal of universally accessible primary health care. Due to the cost of
biomedicine and the limited resources within many countries, universal coverage is
believed to be unattainable without the incorporation of local medical resources
(WHO 2002). Traditional medicine, which relies on local resources for the
production of medicines and a native workforce, is one cost effective approach to
27


this problem. Integration of traditional medical practitioners into the national
health care system of developing nations could ideally increase access to care and
improve the sustainability and self-reliance of the nations medical system.
A third reason the international health community has turned its attention to
traditional medicine is the health transition occurring around the world, which has
exposed the limitations of biomedical care in even the most developed nations.
Influenced by declining fertility rates, increased life spans, social inequality, and
urbanization, an epidemiological and demographic transition is creating new
demands on national health care systems (Janes 1999). The transition takes
different forms in different sociopolitical contexts but the general trend is an
increase in chronic illnesses and disabilities associated with growth in the modem
consumptive lifestyle and an increasing adult and elderly population. Although
infectious disease, perpetuated by inequality and crowded, unsanitary urban areas in
impoverished nations, continues to be a leading health problem, health care systems
are now challenged to address the growing demands of adult illnesses (Jamison and
Mosley, 1991). Biomedicine, with its narrow focus on treating infectious and acute
illnesses, is poorly suited to take on the demands of the epidemiological transition.
This fact is underscored by the growth in alternative and complementary medicine
in developed nations to a worldwide expenditure of $60 billion USD (WHO 2001).
The international health community has come to view traditional medical practices,
like acupuncture and massage, as effective and inexpensive treatments that can help
28


relieve the suffering of the growing number of chronically ill patients. Thus, they
have advocated the development and validation of such practices in almost every
medical context.
On the surface, the world health communitys interest in developing
traditional medicine as a complementary medical resource appears to be a well-
reasoned and promising initiative for addressing the needs of underserved
populations. Their concerns and observations are valid, but the programs designed
to integrate traditional medicine into national health care systems fail to
acknowledge obstacles like biomedicines monopoly of power and financial
resources in most nations, the need for a strong political will (the barefoot doctors
of China were a success because they had the complete backing of the state), and
challenges of regulating traditional medicine (Chi 1994). As a consequence,
integration initiatives have tended to create a policy of coexistence dominated by
biomedical standards and without the will to improve cooperation between the
medical systems in the country (Chi 1994). Additionally, the world health
communitys perspective on health and disease is grounded in the biomedical
paradigm, a standardized, reductionist view that serves to undermine many of the
beneficial features of traditional medicine that attract patients. In fact, the more
holistic approach to healing, strong patient-practitioner relationships, and natural
therapies associated with traditional medicine have been weakened with their
incorporation into national health care systems built on the biomedical model of
29


medicine and health care delivery (Lock 1980). To summarize Janes, the WHOs
1978 initiative to incorporate traditional medicine into national health care systems
around the world was a naive proposition that failed to take into consideration the
diversity of traditional medical theories and the heterogeneous sociopolitical
landscape in which the programs were to be implemented and as a result, the
WHOs and World Banks efforts to promote traditional medicine only served to
essentialize and disrupt the practice (2001).
With the backing of powerful intergovernmental organizations, the practical
resonance of their efforts, and the new health concerns growing throughout the
world, the development of traditional medicine as a complementary medical
resource within national health care systems is and will continue to be a major
pressure affecting the autonomy and integrity of traditional medicine. Thus, it is an
important consideration in anthropological investigations of the nature of traditional
medicine and its reconstitution within the modem context.
Traditional Medicine and the Market
Another force within the modem global context that has begun to
dramatically impact traditional medicine is the growth of a free and global medical
market. The medical market is an increasingly critical field of contestation between
medical systems. The privatization of health care is in large part a product of the
neoliberal policies associated with globalization. These policies are generally
30


designed with two principal aims: to remove the government from the economic
sphere and to maximize a nations integration into the global market (Lewellen
2002). Neoliberal health care reform, which is being carried out in countries around
the world, attempts to reduce public expenditure on health care services and
promote the development of a competitive private market for health care (Janes
2002). As a consequence of such reforms, traditional medicine has become engaged
in market competition with biomedicine and other medical resources, a competition
that is played out in the local and international marketplace. To increase its
competitive advantage, traditional medicine has pursued two distinct avenues for
demonstrating its worth. The first is associated with the global hegemony of science
in the medical marketplace. The second reflects a growing nostalgia for an
authentic, pure past.
The influence of scientific thinking and the biomedical model of medical
care has already been reviewed but the force of science carries over into the global
marketplace and places additional pressures on traditional medicine to adapt, even at
the local level. Anthropologists have demonstrated that in the local context, the use
of traditional medicine is often based on its perceived efficacy and practical
concerns about cost, availability, and time (Beals 1976, Nichter and Nichter 1996).
Accordingly, many argue that shared epistemology and scientific foundations are
relatively unimportant for individual health care decisions (Lock 1980, Unschuld
1980, Young 1976). As a result, at the local level, traditional medicine has been
31


able to position itself as a complementary and effective form of medicine that
addresses needs not met by the mainstream medical system (Farquhar 1996),
without recourse to scientific standardization. However, in the global market,
scientific validation is a necessary means for successful competition with other
medical commodities (Ferzacca 2002). The Western consumption of traditional
medicine is mediated by a system of validation based on the scientific model.
Therefore, to penetrate and compete in foreign markets, traditional medicine has
been encouraged to demonstrate the biological activity of its medicines and
therapies and standardize treatments for Western style consumption (Janes 2002).
Interestingly, in the global market traditional medicines association with the
past is also an avenue through which legitimacy is secured. As Adams explains,
modernity is often expressed as a sense of longing for something lost, a nostalgia for
the past, for the untouched, the whole (2001a). Many individuals in developed
nations seek to fulfill this longing by recapturing the past. Traditional medical
systems, due to their association with a deep and rich cultural heritage, have become
symbols of the lost past (Ferzacca 2002). They represent natural, holistic forms of
care that treat the whole body and mind. They appear to be the antithesis of modem
medicine with its chemical dependence and Cartesian dualism. Due to the nature of
the void created by modernity, the natural, holistic, and authentic features of
traditional medicine are valuable commodities in the global market place. So, for
example, as Janes argues in the case of Tibetan Medicine, for some groups in the
32


West, Tibet-as-Shangri-La is imagined as a threatened source of exceptional
disappearing knowledge for maintaining physical and spiritual health (2002:284).
Thus, nostalgia and longing are principal forces in the consumption of traditional
medicine around the world (Adams 2001a). The push and pull between the
scientific standards of the global market and the demand for alternative medicines
that represent a lost past creates a need for traditional medical systems to reconstruct
their identity in ways that strike a measured balance between these two extremes.
The result is often a standardized form of care, packaged as an organic product of
native genius.
The privatization of medical care and the introduction of market forces in the
health sector have also served to redistribute traditional medical resources.
Historically, traditional medicine was principally a form of care for underserved
populations who had limited access to biomedical services. It was a culturally
relevant form of medicine that drew on local resources to provide affordable
services to the masses. However, in many contexts, the creation of a competitive
medical market has caused the co-opting of traditional medical resources for the
consumption of urban elites and foreign markets (Janes 2002). The demand for
traditional medicine as an ancillary form of care among individuals with disposable
income has drawn traditional practitioners out of the primary health care arena and
many have moved into the private health sector where they offer specialized
traditional medical services at inflated costs. Similarly, the demand for traditional
33


medicine in Western markets is very attractive to practitioners, manufacturers, and
governments in impoverished nations because these markets are quite lucrative. As
a result, many of the locally available resources that keep traditional medicine
affordable and sustainable within a nation are being garnered for sale on the global
market. As Janes aptly summarizes whether traditional medicine is good medicine
or poor medicine, it is increasingly not for poor people (2002:285).
Cultural Nationalism and Traditional Medical Revivalism
There is one final factor that demands consideration in the political
economic investigation of traditional medicine: the dynamic relationship traditional
medicine shares with the construction of national identity in todays globalized
world. Unlike, the pressures of biomedicine and science, integration, and medical
privatization, the effects of this relationship do not necessarily undermine the
cultural saliency and significance of traditional medicine, in fact, it tends to
counteract these other pressures. However, the project of cultural nationalism is
transformative; it gives new meaning and significance to traditional medicine.
National identities are built on the sentiment of shared origins and culture
that distinguish the boundaries of one nation from another. They demarcate the
nations territory, economy, and polity and work to socialize its members as citizens
creating a social bond through shared values, symbols, and traditions (Smith 1991).
National identities like nations themselves, are constructions; though they seem to
34


invoke an origin in a historical past with which they continue to correspond, actually
identities are about questions of using the resources of history, language, and culture
in the process of becoming rather than being (Hall 1996:4). A prominent feature in
the construction of national identity is traditional culture and its icons. Thus,
traditional medicine is for some nations a prominent symbol of nationalism
(Croizier 1976, Ferzacca 2002, Leslie 1976).
This is especially true today. With increasing globalization and the invasion
of global markets, developing countries are seeking to articulate their distinctiveness
and meaning in new ways, pursuing what Yoshino terms a secondary nationalism.
Secondary nationalism, entails the reenhancement of national identity through the
construction of boundaries based on contemporary cultural differences that create an
other in an effort to redefine our own realm (Yoshino 1998,1999b). The project
of secondary nationalism is increasingly carried out in the marketplace because the
states reliance on culture for control has been reduced by the growing centrality of
the market in determining power and authority. Thus, nations are now in the
business of advertising themselves to the world and to its citizens. Identity is today
negotiated through a process of consumption that puts the nation in the hands of its
citizens and advertises the nations distinctive and competitive assets to the world
(Yoshino 1999a, Kemper 1999).
Traditional medicine is often employed in this process. For instance,
Ferzacca observed that the development and reorganization of post-traditional
35


medicine in Indonesia was tied to efforts to reproduce the identity of the nation-
state. As he states, situating traditional medicine with other veritable icons of
Javanese culture in order to establish their authenticity and cultural heritage imbues
medicine as both a medium and instrument of Indonesian political organization
(2002:41). Similarly, White, in his study of Naxi identities in China, argues that
the politics of therapeutic practices are inextricably linked to the politics of cultural
identities, and both are played out on a variety of levels within and between nation-
states (2001:190). These examples suggest that traditional medicine has become a
valuable asset in nationalist efforts to secure a competitive position in the global
marketplace and promote nationalist sentiments within the nation. The use of
traditional medicine as a tangible symbol of national identity not only encourages
traditional medicines continued existence but it also helps to preserve traditional
medicines distinctive qualities. Packaged as a symbol of native genius, cultural
heritage, and a peoples authenticity, traditional medicine is conferred legitimacy
and authority based on its culturally salient, unique, and indigenous features. Thus,
its association with cultural and national revivalism is an important balancing force
in the modem context.
Summary
The study of the development and practice of Mongolian Medicine that
follows employs the anthropological model of medicine as a cultural system, to
36


investigate the complex array of forces that have shaped the nature of the tradition
in recent years. Like other traditional medical systems in medically plural societies,
Mongolian Medicine has been subject to a wide array of dramatic changes at the
hands of powerful social, political, economic, and cultural forces. Over the past
twelve years in Mongolia, national politics, economic concerns, and the introduction
of global discourses have led to wide scale health care reform, the privatization of
medicine, and a deeply felt need to reconstruct the nations identity. Thus, in
Mongolia many of the factors reviewed here are important in understanding the
nature of Mongolian Medicine.
37


CHAPTER THREE
TRADITIONAL MEDICINE IN MONGOLIA:
PAST AND PRESENT
One of the distinctive features of Mongolian Medicines revival in the
modem context is the history of traditional medicine in Mongolia. Ancient
Mongolian Medicine is situated among the great traditions of Asia. Constructed
over the course of 2000 years through the exchange of ideas across the Asian
continent, ancient Mongolian Medicine was heavily influenced by Tibetan
Medicine, Traditional Chinese Medicine, and Ayurveda. Like the other Asian
medical systems, it was built around a formal system of scholarship and training.
However, in Mongolia, the scholarly tradition of medicine was not simply disrupted
or reorganized with the pursuit of development along modem technological lines, it
was effectively dismantled. Through violent campaigns, the ardent pursuit of
Soviet-style modernization, and establishment of a rationally distributed biomedical
health care system, Mongolias traditional medical system, which was associated
with the feudalist and religious leanings of the society, was actively repressed at the
hands of a strong, centralized government.
This distinctive history frames one of the principal arguments of this thesis:
Mongolian Medicine is a modem construction shaped and determined by the
38


exigencies of the current sociopolitical context. The socialist dismantling of
traditional medicine in Mongolia suggests that the revival of Mongolian Medicine
was accomplished through a process of construction and invention. Mongolian
Medicines ties to the past and current reality appear to be products of Mongolias
modem sociopolitical context and the discursive work of intellectuals and the state.
A review of traditional medicines pre-socialist and socialist experience in
Mongolia is thus an important starting point for the investigation of Mongolian
Medicine. It not only demonstrates the discontinuity between Mongolian Medicine
and Mongolias ancient system of medicine; it also elucidates how the history has
been redefined to emphasize ancient Mongolian Medicines distinctive contributions
to Asian medical traditions and provides insight into the foundations to which
Mongolian Medicine is moored. Additionally, by reviewing the history of
traditional medicine in Mongolia in juxtaposition to the modem reality of
Mongolian Medicine, a crucial question is raised: what are the features of the
modem context that led to the development and particular shape of Mongolian
Medicine?
History of Traditional Medicine in Mongolia
The following history of traditional medicine in Mongolia was constructed
from interviews with practitioners and patients and contemporary literature authored
by Mongolians invested in the current system of Mongolian Medicine. The authors
39


draw on ancient medical texts from Tibet, India, China, and Mongolia,
archeological evidence, and Mongolian history but, like any history, it has been
shaped by the desires and interests of its architects. Therefore, it also serves as an
illustration of how Mongolian Medicine is being constructed as a rich and vital
tradition, with distinctive and ancient Mongolian roots.
According to practitioners and scholars, Mongolian Medicine is a 2500-year-
old tradition built on shamanistic beliefs and the exchange of medical ideas across
Asia. For the early part of its history, Mongolian Medicine was an informal set of
practices and theories associated with the worship of the natural environment. As
stated by a leading traditional medical scholar, the fundamental theory of
traditional medicine is no doubt an intellectual property of Mongolian people
(Tumorbaatar 2002:10) developed from ancient shamanistic ideas about the origin
of the universe. The core theoretical paradigm he is referring to is arga and bilig or
Wisdom and Compassion, which represent the circulating energy that created the
universe and in Mongolian Medical theory the balance of qualities that determine
health and disease. The concepts of arga and bilig are akin to yin and yang in
Traditional Chinese Medicine and some Mongolian medical scholars go as far as
suggesting that the yin and yang paradigm originated in Mongolia (Tumorbaatar
2002).
The medical practices employed during the ancient period of Mongolian
Medicine included moxibustion, acupuncture, herbal medicines, bloodletting, mud
40


treatments, and bonesetting. According to Mongolian medical scholars, practices
like bloodletting, moxibustion, and bonesetting were developed independently in
Mongolia to address the needs of a nomadic population living in a harsh
environment (Tumorbaatar 2002, Ambaga and Bold 2002). One scholar associates
the development of Mongolian medical practices with the herding lifestyle, stating
that cattle breeding was once the institute of study of clinical, pharmaceutical, and
therapeutic traditional care (Tumorbaatar 2002:1). Authors of Mongolian
Medicines history cite references to Mongolian bloodletting and moxibustion in
2000-year old Chinese texts and century Tibetan medical texts and mention
artifacts from the Stone Age to substantiate the claim that certain widely used
practices are Mongolian in origin. Other practices were borrowed from East Asian
and Indian traditions and adapted to suit the demands of the Mongolian climate and
lifestyle. During this period, despite exchange with other Asian cultures, medicine
was primarily a folk practice passed on through oral tradition.
In the 13th century the tradition of Mongolian Medicine was infused with
Buddhist ideas and practices and the organization of the medical tradition became
more sophisticated and systematic. After the 13th century medical texts were
authored and special medical training was provided for body workers, surgeons, and
veterinarians. Advances in surgery for minor injuries were made and knowledge of
anatomy and physiology grew with postmortem studies. Also, trade along the Silk
41


Road allowed for an exchange of ideas with civilizations as far west as the
Mediterranean.
During this period, Mongolian Medicine developed into a thriving scholarly
tradition with a Tibetan Buddhist core. It was at this time that Mongolian Medical
theory was enriched by the five elements theory of white and black astrology that
was imported from India and China (Ambaga and Bold 2002:52). The white
astrology from Ayurvedic/Tibetan medicine is particularly important to Mongolian
medical scholars because along with the five elements earth, water, fire, wind,
and space it introduced one of the important theoretical precepts of contemporary
Mongolian Medicine, the three humors. The three humors, khii, shar and badgan or
wind, bile, and phlegm, respectively, were integrated into Mongolian Medical
theory as the primary determinants of disease and assimilated to the qualities of
arga and bilig.
In 1586, Buddhism was made the official state religion and the formal
development of Mongolian-Tibetan medicine flourished. Manba Datsans4, schools
of medicine, were established throughout Mongolia and Mongolian physicians
began to gain esteem throughout Asia. Between the 16 and 20 century, numerous
Tibetan medical texts were translated into Mongolian for study and over 200 books
and critiques on medicine were written in Tibetan (Mongolias scholarly language)
4 Manba Datsan is the Mongolian transliteration of the Tibetan term, Men-ba Dra-tsang, which
means, literally, college of medicine, where college refers to a particular (and peculiar) monastic
institution not college in our sense of the term.
42


by Mongolian doctors. This tradition of medicine thrived in Mongolia until the 20th
century.
This history is particularly telling in that it shows how Mongolian Medicine
is being positioned and represented today. It has been associated with the great
traditions of Asia, while at the same time Mongolias distinctive foundations and
contribution to the Asian medical tradition have been emphasized, even exaggerated
to demonstrate its association with a deep and valuable heritage. Ambaga and Bold
(2002) provide an excellent summary of what this history represents:
It is hardly necessary to emphasize that Mongolia is definitely not so
far behind, if not quite so up-to-date, in the modem medical sciences.
It is true that at present we lack good hospitals and the latest
equipment, due to financial problems after the collapse of socialism,
but it is not so long in the history of the world that Mongolia was at
the forefront of medical knowledge. Historically, when the entire
world was still backward in the field of medical science, the Mongols
had very advanced methods of composing medicine and healing
ailments. (25)
The reconstructed history of Mongolian Medicine stands as a symbol of
Mongolias former greatness and acts as a testament to the legitimacy and
authenticity of the tradition.
Mongolias Socialist History and the Dismantling of
Traditional Medicine
The history of traditional medicine in Mongolia takes a dramatic turn with
the countrys socialist experience. A loosely organized feudal state at the turn of the
20th century, Mongolia was in Marxist theoretical terms among the least likely
43


candidates for a socialist revolution. In 1924, however, they became the first
socialist state in Asia, and the worlds second socialist state after the Soviet Union.
This dramatic change in political philosophy and social organization was not, at the
outset, the consequence of Mongolias deep-seated commitment to revolutionary
values but a desperate political attempt to escape hated Chinese hegemony and
secure international recognition of their independence and sovereignty (Baabar
1999).
Initially, due to Mongolias largely rural, pastoral economy, and the
entrenched social and political power of the religious elite (40% of the male
population were reported to have been monks; Baabar 1999), socialist political and
economic reforms were moderate. Religious tolerance was the policy of the
government and indigenous medicine was not only tolerated but actively supported.
Although health workers from Czarist Russia began to develop private health
practices in Mongolia, Mongolian medicine remained an important component of
health care in Mongolia until the 1930s (Ambaga and Bold 2002). However, this
support came to an end with the Stalinist purges of the 1930s and 1940s, which
attempted to eradicate from Mongolia superstitious, religious, feudalist, and
traditional medical practices.
The Great Purges, begun in 1937 and designed to cleanse Mongolia of its
feudalist leanings, stand out as the harshest examples of the repressive Soviet era.
Over the course of seven years, the government executed over 30,000 Mongolian
44


men, mostly monks, and displaced many others. The terror campaign devastated the
traditional culture of Mongolia. Baabar, a Mongolian historian, writes, Through
the Great Purges, Stalin eliminated the heirs of 2000 years of Mongolian aristocratic
tradition, whose civilization, historic continuity, oral literary traditions, rules of
conduct, customs, and habits had been passed on from generation to generation
(1999:355). As a result of the purges, the religious institutions that had served to
integrate the dispersed Mongolian population were dismantled and the medical
system that had served the Mongolian population for centuries was driven to the
verge of extinction.
In the years that followed, a massive, Soviet-style socialist program of
modernization was undertaken. This program of technological development along
Western lines had dramatic social and economic effects. Mongolia moved rapidly
from a feudal state of loosely-organized nomadic groups to an industrial state
embracing high modernist (cf. Scott 1998) efforts to establish communal
agricultural enterprises, rationalize public education, promote science and
technology, and introduce Soviet-Western biomedicine to all sectors of the
population. As part of the campaign, traditional Mongolian medical practice was
rejected as a remnant of the feudal past and Mongolia established a fully modem
and technological health care system based on the Russian model, which
emphasized inpatient services, the building of hospitals, and a reliance on
biomedical diagnostic and therapeutic technology.
45


The effects of the socialist turn went to the very heart of the nation. Over
the course of seventy years Mongolia adopted a Western Soviet identity,
abandoning its traditional culture and denouncing its association with East Asian
culture (Bulag 1998). Unlike the response to the intrusion of modernizing forces
and political repression in China, Tibet, or India where traditional medicine was
embraced as a symbol of a cultural heritage threatened by uninvited, foreign
influences (Croizier 1976, Janes 1995, Leslie 1976a), Mongolia embraced their
modernity and shunned their traditional culture as a remnant of the feudalist past.
As a consequence, in Mongolia traditional medicine was effectively dismantled and
displaced. By 1990, when the socialist period in Mongolia came to an end, the
Mongolian-Tibetan system of medicine was mostly a historical curiosity. Only a
few practitioners trained in secret and a library of medicinal herbs and untranslated
texts at the Academy of Sciences remained and these few scattered resources did not
constitute a unified system of medicine.
The Post-Socialist Context
In 1990, the Mongolian Socialist Party undertook a peaceful transition to a
democratic parliamentary style government, effectively ending Mongolias
experiment with socialism and rapidly transforming the nation. Abandoning a
socialist, centralized government meant severing the countrys ties to the Soviet
Union, Mongolias longstanding ally and financial backer. Soviet aid, which
46


comprised 35% of Mongolias GDP (Pomfret 2000), was withdrawn and the country
experienced a severe economic crisis that threatened to destabilize the country. To
cope with the crisis the government turned to international lenders, shifting
Mongolias dependence from Soviet aid to institutions with a vested interest in the
neoliberal global agenda. Influenced by these lenders and inspired by the
democratic shift in government policy, Mongolia embraced a free market economy
pursuing decentralization and privatization in all sectors of the Mongolian economy.
The economic transition was swiftly enacted; within just a few short years Mongolia
went from a centralized, state controlled economy to one of the most liberal market
economies in the world (Ginsburg 1998). The reform and assistance have stabilized
the economy but Mongolia remains dependent on foreign aid. The consequences
have dramatically transformed the nation.
In the 1990s, Mongolia saw for the first time in 70 years a growth in
unemployment to a high of almost 20% of the Mongolian population in the year
2000 (UNDP 2000). The poverty index climbed rapidly in the early 1990s.
Although it has slowed, 870,000 of the 2.4 million population live below the
poverty line (UNDP 2000). Even more disturbing is the emerging and deepening
inequality. The GINI index, a measure of inequality, rose by 20% between 1995
and 2000 (Government of Mongolia 1999). The population recognizes the growing
inequality and unemployment as a threat to their communities; a notable proportion
(25%) believe that life was better before the transition (UNDP 2000). Education
47


enrollment levels, which were once close to 100%, have declined, along with the
literacy rate. Additionally, for the early part of the 1990s, the health of the nation
suffered; infant and maternal mortality rose and life expectancy was declined. The
changes, however, are not all negative. The private informal sector has grown,
providing individuals with opportunities and freedoms that were unheard of during
the socialist period. Mongolians are exploring the world, traveling to foreign
countries as entrepreneurs and students, and partnerships with foreign corporations
are bringing investors and new industries to the nation.
The political economic transition also created the opportunity for Mongolia
to develop a new national identity. After the democratic transition, the Soviet
Western identity that embraced technological modernization under centralized
control and emphasized three idealsequality, brotherhood, and cooperationno
longer resonated with Mongolias democratic capitalist orientation. Mongolia was
in need of a new identity, one that could address the concerns of a population in
transition, and provide them with a sense of community, pride, and worth after the
evaporation of an identity that defined the nation for seventy years. Additionally,
Mongolia, which had long suffered as a pawn in the power struggles between its
two powerful neighbors, China and Russia, was acutely aware of its vulnerable
geopolitical position. Eager to secure recognition of their continued sovereignty and
independence, the country strived to negotiate an identity that symbolized
Mongolias distinctiveness, value, and right to autonomy to the rest of the world.
48


As a consequence, Mongolia has sought to redefine its national identity through the
celebration of the countrys deep heritage and revival of Mongolian traditional
culture.
To accomplish this aim Mongolia has undertaken a far-reaching nationalist
movement that embraces the nations nomadic past and eulogizes the countryside as
a treasure chest of Mongolian heritage (Bulag 1998). The country has revived the
traditional culture that was once repressed and eschewed as a threat to national
interests. As part of the campaign, Mongolia has reestablished Buddhism as the
national religion, introduced Chinggis Khan as the national hero, begun the mass
production of the traditional costume, the deel, and rediscovered shamanism (Bruun
and Odgaard 1996). Through these efforts and others, Mongolia has been redefined
as an Asian nomadic nation with a deep, continuous, and vital history.
Mongolian Medicine Today: A General Overview
Among the dramatic political, economic, and cultural changes that have
taken place over the past twelve years a formal system of traditional medicine has
reemerged with the full backing of the state. Today in Mongolia, there is a
flourishing government supported system of Mongolian Medicine. Mongolia has 11
public Mongolian Medical hospitals, 35 public outpatient clinics (mostly associated
with district and provincial hospitals), and 65 private clinics (Ambaga and Bold
2002). In addition to the clinics, there are five public factories and four private
49


factories of traditional medicine in Mongolia. These companies produce over 270
types of traditional medicines with raw materials (herbs, minerals, and animal
products) primarily collected in the Mongolian countryside; a number of the
manufactured drugs are patented and licensed for sale in several Eastern European
countries.
There are also three colleges of traditional medicine. The primary training
facility for traditional medicine is the School of Mongolian Traditional Medicine at
the National Medical University (NMUM), which offers a 6-year training program
that licenses graduates as both biomedical and Mongolian Medical doctors. In
addition, there are two private Mongolian Medical colleges, Otoch Manramba
Institute at Manba Datsan and Monos College, offering 5-year training programs
with a heavier emphasis on the Buddhist foundations of the tradition. All programs
are licensed, regulated, and supported by the Mongolian government. To date,
approximately 400 individuals have graduated from these training programs and an
additional 1000 biomedical doctors have participated in 3-12 month postgraduate
courses in traditional medicine at NMUMs School of Mongolian Traditional
Medicine.
The government backing of this burgeoning medical system is significant, as
evidenced by the 1999 National Policy on the Development of Mongolian
Traditional Medicine. The policy advocates the strengthening of training programs,
improvement of research and practice, translation of ancient texts, and the
50


enhancement of pharmaceutical production enterprises. Revisions in 2001 included
the following aims: expansion and enhancement of Mongolian Medical training by
requiring all medical students to complete courses in traditional medicine at the
undergraduate and postgraduate levels; identification of the appropriate level of care
for traditional medicine (i.e. hospitals, primary care, etc.); the establishment of
policies and guidelines for the standardization and quality control of traditional
medicines.
Due to the socialist disruption of tradition in Mongolia, the existence of this
thriving, government-backed system of traditional medicine in Mongolia is
remarkable. Yet, in light of Mongolias dramatic post-socialist experience,
Mongolian Medicines rapid development is not inexplicable. The powerful
national and global forces that have reshaped the nation appear to be inextricably
linked to Mongolian Medicines reconstruction. The political, economic, and
cultural changes in Mongolia over the past twelve years have served as the impetus
for Mongolian Medicines development and the determinants of its content,
practice, and distribution. In the remainder of this thesis, I will explore how these
changes have interacted to shape the formal system of Mongolian Medicine I
observed.
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CHAPTER FOUR
THE NATURE OF MONGOLIAN MEDICINE
Before we can understand how Mongolian Medicine has been shaped by
Mongolias political economic transition, we must look at what Mongolian
Medicine is. The following is a detailed description of Mongolian Medicine drawn
from interviews and observations with patients and practitioners. The chapter
illustrates the nature of Mongolian Medicine, discusses its distribution and
integration into the national medical system, and offers some insight into how it is
understood and employed by Mongolian Medical practitioners.
The Content of Mongolian Medicine
The theoretical foundations of Mongolian Medicine are associated with
shamanistic conceptions of the natural environment and Tibetan medical ideas. The
core theoretical paradigm, according to practitioners and Mongolian medical
scholars, is bom out of the shamanistic story about the creation of the universe.
According to ancient Mongolian beliefs, prior to the origin of the universe there was
emptiness. As time progressed, a swirling dark and confused cloud of particle dust,
the khas (represented as an inverted swastika), formed (Tumorbaatar 2002).
Through its motion the four elements wind, water, earth, and fire were created. The
52


khas itself represents the core Mongolian Medical concept of Wisdom and
Compassion or arga and bilig. Like yin and yang in traditional Chinese medical
theory, arga and bilig represent the balance of nature. They are interdependent
opposites. One cannot exist without the other. They underlie everything in creation
and are the root source of life and death. Arga is the fire, heat, brightness, day, and
activeness. Bilig is water, coldness, darkness, night, and stillness. All components
of Mongolian Medical theory are understood with respect to this core theoretical
paradigm.
In the 16th century, the five elements, a scientific corpus of knowledge
(Ambaga and Bold 2000:65) based on Ayurvedic medical theory, were incorporated
into Mongolian medical theory. The five elements earth, water, fire, wind, and
space unite the universe as one material common to all things. Although the
concepts are abstract, according to Mongolian scholars they signify a reality of
quality and sense that explains structure and function (Ambaga and Bold 2000).
Mongolian medical scholars divide the four elements into arga and bilig qualities.
Fire is arga, earth and water are bilig, and wind has a dual quality, which provides
the power of motion. Space, the fifth element, is the context necessary for the other
elements existence.
Mongolian Medicine divides the body into two aspects, the subjective and
objective. The subjective aspects are wind, bile, and phlegm or khii, shar, and
bagdan. They are the bodys three humors and the principal determinants of health
53


and disease. These aspects represent the dynamic or arga function of the body,
which cause disease when imbalanced. Each humor or aspect is associated with an
arga or bilig quality. Bile, because it develops from the fire elements, is arga.
Phlegm is from earth and water and it is cold, thus it represents bilig. Wind is
dynamic; therefore it has a dual quality. According to Mongolian Medical theory,
the balance of these three humors determines health and disease. The objective
aspects are the seven constituents of the body, nutrients, fat, bone, regulatory fluids,
blood, marrow, and flesh. These constituents are the static condition, the bilig, and
they become diseased when the subjective aspects of the body are out of balance.
There are two causes of disease in Mongolian Medicine, external and
internal factors. The external causes of disease include diet, behavior, and the
seasons. These causes lead to the imbalance of the three humors, wind, bile, and
phlegm. This imbalance is the internal cause of disease that affects the seven
objective constituents of the body. To restore health, Mongolian Medicine aims to
restore balance. Identifying the cause of disease (i.e. excess arga or deficiency of
bilig) is critical for healing.
The traditional diagnostic techniques for identifying the internal and external
causes of disease include interrogation, observation, palpation, and pulse reading.
The interrogation entails an extended interview with the patient. A history of the
disease and the patients medical history are taken along with a comprehensive
history of the patients life. Ideally, questions about place of birth, family, children,
54


and work are included to provide a fuller understanding of the causes of disease.
Visual observation of the patients eyes, ears, and tongue is performed and an
inspection of urine, noting color and cloudiness, is conducted because, according to
Mongolian Medical theory, urine conveys a great deal about the health of the body.
Palpation of affected areas often accompanies a Mongolian Medical workup. The
final and most important means of diagnosis for the Mongolian Medical practitioner
is the pulse reading.
The theory that guides the taking of the pulse is based on the fourth tantra of
the Tibetan Four Root Tantras (Tib: Gyu-Shr). The pulse is the hallmark of
Mongolian Medical diagnosis. The pulse is viewed as the messenger between the
doctor and the condition of the disease and a practitioner, if experienced, can
accurately assess the health of the whole body with a single pulse reading.
However, in order for it to be effective and accurate, the patient and doctor must be
properly prepared. They must adhere to a healthy diet before the reading, the
doctors fingers must be clean and trim, and both the doctor and patient must be free
of stress, anger, and anxiety. Because the human body is intimately connected to
the universe, the environment also influences the pulse. Therefore, the pulse is
ideally taken at sunrise when the sun is not too high, encouraging hot elements, and
when the moon is not out, influencing the bodys cold elements.
The traditional pulse is taken with three fingers, the index finger, tson,
middle finger, gan, and the ring finger, cheg. The three fingers are placed one
55


knuckle length below the thumb pad along the middle tendon of the wrist. The
fingers should be placed close together with a distance the size of a grain of rice
between them. Each finger exerts a different pressure to feel the different pulses.
The tson exerts very light pressure, skin deep. The gan is a little harder, pressing
into the muscle. The cheg is the hardest pressing deep to the bone. For males the
pulse is taken first with the left wrist and for females the right wrist is observed first.
Each finger takes two pulses, the pulse of hot and cold (arga and bilig) disorders
and the pulse of the individual organs. Thus, both the imbalances that cause disease
and the diseased organs can be identified with the pulse.
Mongolian Medical treatments are a confounding mix of folk, traditional,
and peculiar practices. They are designed to restore balance and heal the root
causes of disease, but many appear to be employed based on their observed or
reputed ability to relieve symptoms regardless of their theoretical qualities.
Generally, the treatments include herbal medications and manipulative therapies.
Herbal medications represent Mongolian Medicines primary treatment modality.
Mongolia has over 600 herbal plants and produces over 270 types of herbal
medications. There are several factories for the production of herbal medicine but
many doctors collect and produce their own medicines. According to Mongolian
Medical theory, the preparation of multi-component drugs should be based on the
individual diagnosis, but due to increasing government regulation most traditional
drugs are mass produced based on recipes found in ancient medical texts. In
56


general, each medicine includes a component regulating the arga/bilig nature of the
disease. Ingredients are combined to balance the elements of the body. Almost
every patient of Mongolian Medicine receives a prescription for herbal medications.
In addition to traditional drug therapy, Mongolian Medical practice
incorporates a wide variety of manipulative practices. The most common are
acupuncture, moxibustion, massage, cupping, bloodletting, mud therapy, and
mineral baths. In the inpatient setting these treatments are liberally prescribed along
with herbal medications. Mongolian Medical practitioners also employ
nontraditional techniques. For example, ionic treatments, which use an electric
current to draw a medication to an injured area, are often used to treat joint and
muscle pain. I also observed the use of UV lights placed above painful areas for the
treatment of a cold disease. Additionally, in the medical practices more closely
associated with the Buddhist tradition of medicine, healing rituals and prayers are
commonly prescribed. Ostensibly, all treatments are prescribed based on the
traditional diagnosis, but it is not clear how they are reconciled to classical
Mongolian Medical theory since many are borrowed from other Asian traditions or
incorporated based on their ability to relieve symptoms. The result is an eclectic
mix of practices that reflect patients and practitioners perceptions of effectiveness.
57


Mongolias National Health Care System:
Its Structure and Distribution
In order to understand how Mongolian Medicine is being shaped by and
integrated into the national medical system, the structure of health care in Mongolia
and how Mongolian Medicine has been situated within it must be reviewed briefly.
Mongolia has an extensive and well-developed health care system, which, until
1990, was based on the Soviet model of strong central planning and highly
specialized hospital based services. Since 1990, there has been an effort to move
away from the expensive curative system of care to a system more reliant on
primary health care services. However, reform has not been entirely effective. The
number of hospital beds in Mongolia has decreased and the number of primary care
physicians has grown (WHO 1999). The population and medical community
remain committed to specialized hospital based care.
The basic structure of Mongolias national health care system has been
retained from the Soviet model. It includes four levels of service (Table 4.1, WHO
1999).
Table 4.1: Four Levels of Health Services In Mongolia____________________
N
Level 1 Bag Feldsher posts (Community health workers) 875
Level 2 Soum (County) Soum hospitals 345
Level 3 Aimag and city (Province and city) Aimag and city hospitals 33
Level 4 Central Specialized centers 11
Source: WHO 1999
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The first level consists of bag feldshers (physicians assistants) in rural
areas and family doctor posts in aimag centers (provincial capitals) and major cities.
This level of service encompasses Mongolias primary health care system.
Bag feldshers are the principal primary care providers in rural areas. They
are trained as physicians assistants and are equipped to provide basic medical
services. Each feldsher is assigned to a 20-80 kilometer area and is responsible for
an average of 50-100 families. The feldsher periodically visits local families to
provide simple curative treatments, preventive care, and health education.
Mongolia has begun to offer Mongolian Medical training to feldshers but in rural
areas, much of the population still relies on and prefers biomedicine. Aside from a
few bonesetters and herbalists scattered throughout the countryside, traditional
medicine has not really penetrated this level of care in rural areas (Carey 2002).
The family doctors, the primary care physicians for Mongolias urban areas,
are appointed to posts in aimag centers and outpatient clinics in city district
hospitals. The family doctor system has been developed over the past few years
with the assistance of international donors. Thus, they represent a relatively new
effort at strengthening primary health care in Mongolia. Each family doctor is
responsible for 1200 1500 individuals living within the community. In the
mornings the family doctors see patients in their office and in the afternoons they
travel to family homes. They provide patients with health promotion and prevention
59


advice and are trained to treat a wide range of illnesses. Unfortunately, these
physicians are unable to sell essential drugs, they have no access to basic biomedical
diagnostic tests, and thus are forced to refer most patients to the higher levels of care
(Janes 2003).
Family group practices are viewed as the ideal level for the integration of
Mongolian Medicine into the national health care system. Many of the Mongolian
Medical practitioners in Mongolia are trained in both biomedicine and traditional
medicine (see below) and therefore, they possess a wide range of diagnostic skills
and treatment modalities to address the general complaints of the population.
However, to date, as will be in discussed in detail later, the practice of Mongolian
Medicine has been concentrated at the secondary and tertiary levels of care.
The first referral level includes soum (county) hospitals in rural areas and
public health centers in aimag capitals and Ulaanbaatar. The soum hospitals in rural
areas are small facilities with at least one doctor and midwife on staff. The goal is
to have three physicians, two to four feldshers, three to four nurses, and a
pharmacist at each hospital but rarely is this aim achieved (WHO 1999). The soum
hospitals provide ambulatory, obstetric, family planning, inpatient, and health
promotion services to an average of 2,500 people within an 80-kilometer radius.
Mongolian Medicine appears to be a growing commodity in the soum
centers where there is often a shortfall in the availability of biomedical resources.
In two rural soums, visited as part of the larger health care reform investigation,
60


doctors at the soum hospital had taken an active interest in developing traditional
medicine. One practitioner, a dentist with a year of postgraduate training in
Mongolian Medicine at the National Medical University and the former director of
the soum hospital, had opened a private Mongolian Medical clinic adjacent to the
soum hospital. Its patient clientele were in large part an overflow of the soum
hospital where services and staff were limited. Similarly, in another soum a
biomedical physician was using a large portion of the funding he was provided for
the development of a surgical unit to subsidize the construction of a Mongolian
Medical wing. He hoped the Mongolian Medical services would attract revenues
for the soum.
The second level public health centers in the aimag capitals and Ulaanbaatar
consist primarily of district hospitals that provide outpatient services to patients
referred by family doctors. The district hospitals typically have a number of
specialists on staff including obstetrician/gynecologists, internal medicine
physicians, traditional practitioners, surgeons, and ophthalmologists. Because of
Mongolias historical emphasis on specialized care, many patients often choose to
bypass the primary care physicians and go directly to the soum and district
hospitals. Every district hospital in Ulaanbaatar has a Mongolian Medical
practitioner on staff offering outpatient services, including herbal medications,
massage, acupuncture, cupping, and moxibustion.
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The third level of care or second referral level comprises the general
hospitals in aimag centers and city districts. Each aimag has a general hospital with
250-400 beds that serves the local population and is a referral center for the rural
population. The hospitals are equipped to deliver laboratory and radiological
services, dental treatment, and emergency and surgical care. They also have a staff
of biomedical specialists offering outpatient and inpatient care. In Ulaanbaatar,
secondary referral services include four internal medicine hospitals, four pediatrics
hospitals, and three maternity homes. Most aimag hospitals have a department of
traditional medicine and 12 of these departments have inpatient services. In the
aimag hospital, I visited in Hovsgol, a department with inpatient services had been
recently established. However, the director complained that despite the patients
growing demand for Mongolian Medical care, the aimags Health Director was still
wary of traditional medicine and offered little financial support. As a result, the
department was underfunded and understaffed.
The fourth level of care is the national referral level, which consists of ten
hospitals offering tertiary care services in Ulaanbaatar. There are three clinical
hospitals, the Maternal and Child Center, and several specialized hospitals,
including the Traditional Medical Science, Technology, and Production
Corporation. These institutions serve the entire country. Unlike the other levels of
care, which are under local administration, the national institutions are subordinate
to the Ministry of Health and Social Welfare. The Ulaanbaatar Mongolian
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Traditional Medical Hospital visited as part of this study is a national referral level
hospital that treats patients from all over the country.
These four levels of care represent the basic structure of the public health
sector in Mongolia. Although the management and operation of these institutions
have been decentralized over the past several years, Mongolia still strives to
maintain a rational and equitable health care system for its population and thus, the
primary medical resources remain in the public sector. However, reforms have led
to the privatization of medical services and a growing private sector is emerging in
Mongolias cities. Encouraged by rapid decentralization and a liberal market
economy, the private sector has become involved in the delivery of curative
outpatient and inpatient services, production and distribution of pharmaceuticals
(Table 4.2, WHO 1999), hospital management, and supply of hospital equipment.
Table 4.2: Private Health Care Institutions in Mongolia, 1999
Types of Services Number in All Mongolia Number in Ulaanbaatar
Private hospitals with beds 75 45
Private pharmacies 320 184
Drug wholesale agencies 42 42
Dental clinics 148 83
Gynecological clinics (abortions and STI treatments) 60 43
Traditional medicine clinics 59 45
Source: WHO 1999
As Table 4.2 illustrates, Mongolian Medicine is one of the principal health care
services to penetrate the private medical market. Low overhead, sale of traditional
medicine that can be collected by the physicians themselves, and increasing demand
63


for alternative medical services have encouraged the growth of traditional medicine
as a private venture in Mongolia.
It is important to note that despite efforts to develop an equitable health care
system rationally distributed throughout the country, the majority of Mongolias
medical resources are concentrated in urban areas (see Table 4.2). Although there
are medical facilities widely dispersed throughout the country, many remain
understaffed and ill-equipped to serve the needs of the rural population. Only 12%
of physicians practice in rural hospitals (WHO 1999). The majority of physicians
choose to practice in public and private institutions in Ulaanbaatar, giving the city a
patient to doctor ratio that is three times higher than other aimags. This is true for
Mongolian Medical practitioners as well. Although some physicians in soum
centers and aimag capitals are recognizing that traditional medicine can be a
potentially lucrative business, most (45 of the 59 in 1999) private Mongolian
Medical practices are found in Ulaanbaatar. The situation has left the rural
population grossly underserved and undermines the rationality of Mongolias
national health care system.
As illustrated by this brief review, Mongolian Medicine has been integrated
into this system of health care at various levels. It has become an integral
component of public health care services and private Mongolian Medical clinics are
growing in popularity throughout the country, though services remain concentrated
in Ulaanbaatar. Because Mongolian Medicine was envisioned as a primary care
64


medical resource, the government is concerned about the disproportionate number
of Mongolian Medical practitioners practicing at higher referral levels. In its most
recent revision of its National Policy on the Development of Traditional Medicine,
the parliament indicated that determining where Mongolian Medical services fit
within the health care system was an important goal and therefore, reform of the
current distribution of Mongolian Medical practices can be expected.
Mongolian Medicine: Training and Practice
Mongolian Medicine is an eclectic system of medicine. It encompasses a
wide variety of blended theories and practices and two distinct schools of thought.
The first is closely associated with the biomedical community. It has been
developed over the past twelve years as a complement to biomedical care and is
taught at the School of Mongolian Traditional Medicine at the National Medical
University of Mongolia (NMUM). The School has trained the majority of
traditional practitioners in Mongolia. Graduates of the program are licensed to
practice both biomedicine and traditional medicine. The second school of thought
is represented by Manba Datsan, which operates the Otoch Manramba Institute for
the training of Mongolian Medical practitioners, an outpatient clinic, inpatient
hospital, and active monastery. The medicine taught at this institution and practiced
by its graduates emphasizes the Buddhist foundations of Mongolian Medicine.
Graduates of the program are not biomedical doctors; they practice only traditional
65


medicine. Together these two schools of thought are representative of the formal
system of traditional medicine in Mongolia. Both are modem constructions
supported and regulated by the Mongolian government and, despite their inherent
distinctions, they are united as Mongolian Medicine. The training and practice
characterized by these two schools of thought provides an inclusive illustration of
the nature of Mongolian Medicine.
The School of Mongolian Traditional Medicine,
National Medical University of Mongolia
The National Medical University of Mongolia (NMUM), the only university
for training physicians in the country, introduced a program in Mongolian Medicine
in 1986. The program was initially met with skepticism but with active government
support and the integration of Mongolian Medical courses into the overall medical
curriculum, awareness and interest in Mongolian Medicine grew quickly. By 1991
the program had grown into the School of Mongolian Traditional Medicine and
several of the top students from the medical universitys class of 1989 were
recruited into the program. To date, the school has had 250 graduates.
The School of Mongolian Traditional Medicine provides biomedical and
Mongolian Medical training. The six-year program offered at the school has a dual
emphasis. Students study biomedicine and Mongolian Medicine and graduates are
licensed as both biomedical general practitioners and Mongolian Medical doctors.
The curriculum places greater emphasis on modem medical theory (60%), although
66


a large portion of the students training focuses on traditional medicine (40%). The
first two years of the program are dedicated to the basic sciences. The curriculum is
similar to the first two years of biomedical training for family doctors, but it is
supplemented with coursework in Tibetan and Mongolian medical theory. In the
third year, clinical work begins and, as one professor stated, the process of applying
the two theories of medicine in practice helps the students reconcile the differences
between biomedical and Mongolian Medical theory. In their 4th and 5th years
students begin to devote themselves to Mongolian Medical practice and in their final
year, students intern in traditional medicine and general practice.
The Schools core texts for Mongolian Medical theory are the Tibetan Four
Medical Tantras (Tib: Gyii-Shi). The Gyii-Shi consists of four books or tantras:
the Root Tantra, the Explanatory Tantra, the Oral Instruction Tantra, and the Final
or Additional Tantra. Although it is hard to date, it was probably written around the
12th century; some elements are believed to be older (Samuel 2001). Some scholars
argue that it originates from a single Ayurvedic text, although there are distinct
Persian and Chinese contributions (Samuel 2001). The first two tantras contain
general Tibetan medical theory, while the last two provide practical guides for
diagnosis and treatment. Students at the School of Mongolian Traditional Medicine
are required to memorize the first of the four tantras, though they study all four.
Students are also taught the core theories of arga and bilig. Though students are
required to learn to read Tibetan because many of the ancient Mongolian medical
67


texts are written in this language, one graduate explained that few master the
language and thus, students are heavily reliant on professors lectures as the
principal resource for learning Mongolian Medical theory.
Graduates of the program are general practitioners licensed to practice
biomedicine and traditional medicine. Graduates may choose to practice in
Mongolian Medical clinics in Ulaanbaatar or establish general family practices
throughout the country. If they choose to specialize in traditional medicine and
work in a Mongolian Medical clinic in the city, practitioners must complete a two-
year residency under the supervision of an experienced practitioner before they can
practice independently. However, according to a recent graduate of the program,
the graduates who wish to establish general practices do not have to complete the
residency. In fact, practitioners in the countryside are free to do anything without
additional training or supervision. These traditionally trained practitioners perform
surgery, deliver babies, give herbal medicines, and provide acupuncture.
According to professors at the School, one motivation for the development
of such an integrated program of medicine at the National Medical University was a
desire to train primary care physicians with a broader knowledge so theywould be
equipped to address the needs of their patients in situations where expensive
biomedical resources are absent or inappropriate. The School operates on the belief
that biomedicine and traditional medicine are complementary; each medicine
addresses different aspects of the same problem. Practitioners described the
68


complementarity with the metaphor of looking through two windows at the same
object and as one stated, no science is 100% effective; using both is better.
According to the Schools philosophy, doctors trained in both medicines are at an
advantage because the effectiveness of medical care is increased. This is an
interesting and important approach to integrating traditional and biomedicine. By
incorporating the idea of complementarity as a fundamental tenet of Mongolian
Medical training, a great deal of competition and conflict between the two systems
of medicine has been avoided.
NMUM Mongolian Medicine in Practice
Although the graduates of the National Medical Universitys School of
Mongolian Traditional Medicine are trained as primary care physicians, most
traditional practitioners are found in private Mongolian Medical practices or
working as specialists at the higher referral levels in the public sector of the national
health system. In fact, a majority of the 1,250 NMUM School of Mongolian
Traditional Medicine graduates and doctors with postgraduate training work in the
public sector in district level Mongolian Medical outpatient clinics, aimag hospital
departments of Mongolian Medicine, and at the Ulaanbaatar Traditional Medical
Clinic, the national reference hospital for Mongolian Medical care (Tumorbaatar
2002). A large number of graduates have also traveled abroad to Eastern European
69


nations, where they have established lucrative private practices. Only a small
portion of graduates are practicing as general practitioners.
NMUM Traditional Medicine in the Public Sector: The Ulaanbaatar
Traditional Medical Clinic. The Ulaanbaatar Traditional Medical Clinic is run by
the government supported Science and Technical Corporation of Traditional
Medicine. The corporation also operates a traditional medicine manufacturing
company and research institute. The Clinic operates an ambulatory care unit,
inpatient facility, and sanatorium, an inpatient retreat in the countryside offering
Mongolian Medical treatments during the summer months.
The Ulaanbaatar inpatient hospital has 120 beds, with eight traditionally
trained treatment physicians, a feldsher for assisting with intake and filling
prescriptions, a masseuse, and a number of traditionally trained physicians serving
administrative roles. Due to its association with the National Medical Universitys
School of Mongolian Traditional Medicine and the Corporations research institute,
the hospital also serves as a teaching facility. The ambulatory unit is associated
with the Clinics admissions department, offering outpatient care and patient intake
on alternating days, although my observations suggested that few patients visit the
hospital for outpatient care. The admissions department and ambulatory unit are
staffed by a traditionally trained admitting/outpatient physician, a nurse, and several
biomedical specialists with Mongolian Medical training who provide diagnostic
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testing and assist treating physicians with designing treatment plans for special
cases.
For admission to the hospital, a referral from a family doctor or aimag
hospital is required for all patients from rural areas. Individuals from Ulaanbaatar
may receive outpatient services at the clinic without a referral, but one is required
from their family doctor for inpatient care. Proof of registration and insurance is
also required for all inpatients, unless the full cost of hospitalization, 47,000 togrogs
(about 47 US dollars) can be paid up front. Patients with insurance pay a 10%
copayment, except for elderly patients and other vulnerable groups, children,
students, women with young children, whose hospitalization is free. The hospital
stay is limited to two weeks, a limit determined by insurance laws rather than
medical need. For individuals who require further care, doctors provide regimens to
follow at home and, if necessary, instructions to return.
Patients seeking admission to the hospital must first be seen in the
ambulatory clinic where they are carefully screened by the admitting physician.
The hospital treats virtually all chronic illnesses from neurological disorders to
neuroses. However, there is a strict policy prohibiting patients with acute and
serious illnesses that require biomedical care and individuals with high blood
pressure. Thus, for all patients, four biomedical laboratory tests blood, urine,
ECG, and ultrasound -- are required. In addition, the admitting physician checks the
blood pressure and heart rate of all patients seeking admission. Patients who are
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diagnosed with an acute illness or high blood pressure are referred to a biomedical
specialist and not admitted until the problem is addressed.
The biomedical diagnosis arrived at through the laboratory tests and initial
consultation with the admitting physician is recorded in the patients records as the
primary diagnosis. However, this diagnosis is purportedly unimportant to a
patients therapy. The diagnosis is considered necessary for statistical reporting and
screening patients for admission, but the traditional diagnosis is the important
determinant for care at the hospital.
The admitting physician performs an initial traditional diagnosis in the
ambulatory clinic, utilizing a brief interrogation and examination of the pulse. The
diagnosis is recorded alongside the biomedical diagnosis in the patients records.
Notably, the admitting physician, who I observed, admitted to amending the
diagnosis arrived at with the pulse based on the lab results, stating that her original
diagnosis (arrived at using the pulse) is right 80% of the time. Thus, in this
situation biomedicine appeared to be the trump, the gold standard by which other
approaches were deemed right or wrong.
Both the biomedical and traditional diagnoses determined by the admitting
physician are largely disregarded subsequent to admission. At this time, the treating
physician undertakes a thorough consultation with the patient to arrive at the
particular diagnosis that will guide care. The consultation begins with an account of
the current complaints, physical observations, a pulse diagnosis, and palpations
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where necessary. A morbi or history of the disease is then taken. The doctor
seeks information about the disease, however remotely related, dating to the
patients childhood, if relevant. A life history is performed next with questions
about place of birth, family, work, et cetera. Finally, the doctor concludes the
interview by asking about prior diseases or conditions for which the patient has been
treated. The consultation takes up to 45 minutes. Both traditional and biomedical
diagnoses are recorded in the patients chart. The diagnoses are further revised with
information from a traditional urine analysis and, if necessary, consultations with
the specialists at the hospital. One physician also noted that the diagnosis remains
flexible throughout the patients stay because traditional diseases are known to
change with treatment.
It is the traditional diagnosis, not the biomedical one, arrived at by the
treating physician which determines the patients treatment plan. A wide variety of
traditional treatments are available at the hospital. Herbs are prescribed to all
inpatients and are considered by most practitioners at the clinic as the hallmark of
Mongolian Medicine. The hospital manufactures 80 types of herbal medications
and physicians regularly experiment with new herbs and formulae. Other therapies
provided at the hospital include bloodletting, massage, acupuncture, moxibustion,
mineral baths, mud treatment, and cupping. In addition, various peculiar treatments
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of unknown origin are offered, for example, ionic treatment5 and UV therapy.
Overall, the treatments are an eclectic mix of alternatives employed on a trial and
error basis with perceived effectiveness guiding their continued use.
Doctors choose among these numerous treatments based on the patients
particular ailment. All patients are entitled to a certain number of each of the
clinics manipulative treatments regardless of the nature of their illness, but the
physician customizes these therapies to suit each patients needs. For example,
during a 12-day stay at the hospital, every patient is provided five 25-minute full
body massages, eight mud treatments, several mineral baths, and five acupuncture
sessions, but a physician may choose to add more massages, concentrating on
pressure points, accompany acupuncture with moxibustion and cupping, and
prescribe fewer baths due to concerns with blood pressure. In addition to this suite
of treatments, the patient is also prescribed herbal medications according to the
traditional diagnosis. Thus, the hospitals care is holistic, designed to rejuvenate the
mind and body, while targeting the patients individual problems. As one patient
being treated at the hospital for only a short time summarized, Mongolian medicine
treats the whole body and mind so in general, I am already feeling better.
NMUM Traditional Medicine in Private Practice. Private practices are
flourishing in Ulaanbaatar and throughout Mongolia because, as one physician
5 An ionic medicated ointment, Baragshin, is applied to a cloth and then the affected area. An
electrical current is run from an electrode placed on either side of the injured area and the medicine is
pulled into the body to quicken the pace of healing. The treatment is believed to be very effective for
acute pain (Novocain added to the cloth), joint pain, arthritis, and thyroid deficiency.
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explained, They are easy to establish and relatively inexpensive to sustain. All of
the private practices I visited were able to rely on word-of-mouth advertising to
support their business. None engaged in media advertising: the reputation of the
clinics physicians and the effectiveness of their treatments attracted patients. For
instance, one clinic was established in an industrial district on the outskirts of town.
If it were not for the reputation of its director, few patients would be motivated to
seek it out. The director, a famous neurologist associated with the Ministry of
Health and National Medical University, and a leading Mongolian Medical scholar,
attracted patients from all over Mongolia. Indeed, a number of patients at this clinic
mentioned coming to the private hospital first because they knew of the doctor and
the clinics reputation for healing neurological disorders. Almost every patient
interviewed at these private clinics had chosen the clinic based on a
recommendation from a friend or family member.
Aside from the testimonials on effectiveness, the clinics were able to exploit
the disadvantages of biomedical care in Mongolia to attract patients. Because
biomedical doctors with traditional medical training established these private
practices, an appealing mix of biomedicine and Mongolian Medicine could be
offered to their patients. For many patients interviewed at these clinics, the use of
both medicines was attractive. Most patients were not entirely dissatisfied with
biomedicine; they were just discouraged by the lines, required referrals, expense,
and the inability of available biomedical care to cure their particular illness. In
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general, they trusted biomedicine and therefore, the medicine offered at these clinics
was perceived as a cheap and effective alternative that allowed them to avoid the
negative aspects of biomedicine but not sacrifice the advantages of biomedical care.
However, in practice, these clinics provided little-to-no biomedical care. The only
biomedicine in these clinics, as in the Ulaanbaatar Traditional Medical Clinic, was
employed for purposes of diagnosis.
The typical outpatient consultation at these private clinics included a pulse
diagnosis, interrogation, palpation, blood pressure monitoring, and auscultation.
One doctor also performed urine observation, even with his outpatients, but most
practitioners limited that practice to inpatient care. The same doctor also employed
an EKG in his practice. Private practitioners reported that the biomedical tests and
methods were only employed as back-ups to traditional diagnoses. According to
the physicians, biomedical methods were used to check the progress of patients
treated with traditional therapies and to broaden the doctors understanding of the
illness, but traditional diagnosis alone guided treatment choices.
Unlike the Ulaanbaatar Traditional Medical Clinic, the biomedical tests were
not employed as strict screens for excluding individuals with acute illnesses. The
clinics were equipped and willing to admit more severe patients, but generally the
patient population was similar: individuals with chronic illnesses who had been
unsatisfactorily treated with biomedicine. There were exceptions. For example, a
woman with herpes zoster was being treated at one clinic, several patients with
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severely high blood pressure were observed, and a few individuals with localized
paralysis were receiving Mongolian Medical care. However, patients with acute
illness that needed immediate attention were referred to biomedical specialists.
The private clinics varied in size, ranging from 10 to 20 inpatient beds. The
larger clinics had about six doctors on staff and the smallest clinic had three doctors.
All of the private hospitals had at the very least a supply of traditional medications
on hand, so that outpatient prescriptions could be filled at the clinic. One had its
own pharmacy, stocked with medicines collected by the hospitals staff and
imported from China and India. There were no nurses and the physicians performed
all treatments.
The treatments offered at these clinics were as diverse and eclectic as those
observed at the public institution. Massage, bloodletting, cupping, acupuncture, and
herbal medications were all commonly prescribed. However, the nature of the
practice varied among the practitioners. Some attached electrodes to the
acupuncture needles to increase effectiveness, some favored point massage, while
others spoke of the value of animal fats for full body massages. The tools for
therapy were also diverse. Cupping was typically performed with mason-type jars,
but a few practitioners employed suction cups specifically designed for the purpose.
Also, a number of practitioners used a heat lamp for moxibustion therapy, in lieu of
the traditional needles and burning herbs. One doctor said this was done because
some practitioners are allergic to the herbs. Another explained the difficulty of
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balancing the burning herbs on the end of a needle and the potential for burning the
patient.
Summary
The system of Mongolian Medicine associated with the National Medical
University of Mongolia is a distinctive approach to the development and practice of
traditional medicine. The establishment of a School of Mongolian Traditional
Medicine at the countrys only medical school has allowed for the
institutionalization of complementarity between biomedicine and traditional
medicine in Mongolia. Therefore, in practice, it appears that tension between
biomedicine and Mongolian Medicine is absent. The ingrained belief that the two
medicines are complementary, addressing the same problem from different angles,
allows for a mutual existence free of conflict. However, it is unclear whether or not
the theoretical perspectives that guide practice exist independently alongside one
another. Due to their dual training, graduates of the School of Mongolian
Traditional Medicine are challenged to reconcile the two theories and in other
contexts, reconciliation usually entails an unbalanced compromise accomplished
through metaphors or parallels drawn between the two medical systems (Adams
n.d., Janes 1995).
The use of biomedical diagnostic tests as back-ups to traditional diagnoses
suggests that the theories of medicine are being blended in some fashion. The
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ability to compare a Mongolian Medical diagnosis to a biomedical diagnosis based
on an entirely different theoretical paradigm means that the traditional diagnostic
categories are being understood with respect to biomedical explanations. Because
the biomedical laboratory tests are considered the measure of what is right and
wrong, the compromise between the two medical theories appears to be in favor of
biomedicine. Thus, the complementary perspective that guides medical practice
does not seem to carry over to the theoretical paradigms that define each medical
system. In Mongolia, biomedicine appears to be the standard by which traditional
medicine is measured.
The distribution and practice of Mongolian Medical practitioners in
Mongolia defy the underlying philosophy of the School. Although professors and
graduates suggest that Mongolian Medicine and biomedicine are best used together,
and though they are trained to practice both, few Mongolian Medical practitioners
employ biomedicine in their clinical practice. Most offer only very basic
biomedical diagnostic tests. Mongolian Medical physicians in Mongolia have
chosen to specialize in traditional medicine, offering only traditional treatments.
Thus, few physicians are fulfilling the role the program intended. Trained as
general practitioners equipped with a broad medical knowledge, these physicians
are ideal primary care physicians for rural areas. Few, however, have explored this
option.
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Manba Datsan and the Buddhist Institution of
Mongolian Medicine
Manba Datsans, centers for the training of Tibetan traditional medical
doctors, were introduced to Mongolia in the 16th century. During the period
between the 16th and 20th century, these schools flourished, providing the only
formal medical training in Mongolia. However, the Manba Datsans for Mongolian-
Tibetan medical training were destroyed during the socialist period. In 1990, at
about the same time Mongolian Medicine was being rediscovered by the biomedical
community, Manba Datsan, a new center for traditional healing and training was
established in Ulaanbaatar. Symbolically, Manba Datsan was built on the former
site of the Monastery of Medicine to Help People (Busdad Tuslahui Anagaah
Uhaani Khiid), a monastery that had been demolished by the socialist government
in 1937. The facility houses an outpatient clinic, hospital, college of Mongolian
Medicine, small pharmacy, and an active monastery. The monastery is a lively
place, home to 40 monks specially trained to provide healing rituals, ceremonies,
meditations, blessings, and prayers that repel misfortune and sickness. Their
activities are intended to create physical, emotional, and mental harmony for the
monasterys visitors and the clinics patients. Manba Datsans pharmacy produces
over one hundred different traditional medicines, each blessed in a special religious
ceremony. Thirty percent of the medicines are licensed for export and the center
holds several patents for herbal medicines.
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The Otoch Manramba Institute at Manba Datsan. The Otoch Manramba
Institute is the academic training center at Manba Datsan. It was established in
1991 and to date there have been 100 graduates from the program. Eight of the 25
teachers at the college are Otoch Manramba graduates. The rest are biomedical
doctors, scientists, and religious figures with advanced degrees in Buddhist
philosophy (many earned in Tibetan monastic colleges in India). For admission to
the program, students must be high school graduates. They are required to pass the
national chemistry and physics exams given annually throughout the country.
The curriculum is 70% Mongolian Medical topics, 25% western medical
subjects, and 5% general knowledge. Graduates describe the biomedical
curriculum as limited to the interpretation of biomedical diagnostic tests, which, as
in the case of the public university, are required in order to rule out an acute
biomedical disease prior to treatment. There are three levels of study. The first two
focus on basic coursework, including Tibetan language, Latin, English, traditional
Mongolian calligraphy, history of medicine, public health, computers, ethics, and
astrology. The second level incorporates professional training, shifting to a greater
emphasis on Mongolian Medical theory and practice. The third level involves
specialization in traditional medicine, focusing on diagnostic techniques, therapies,
and pharmacology. Throughout their course of study, the students are required to
memorize all four books of the Tibetan gyu-shi and study Buddhist philosophy.
Students are also taught how to perform Buddhist healing rituals.
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Graduates are not licensed to practice biomedicine; they receive a
baccalaureate degree in Mongolian Medicine. After graduation, graduates must
complete a three-year residency studying under and working with an experienced
traditional physician. After three years, Manba Datsan graduates can take a
licensing exam. Once they pass they are licensed to practice, teach, or conduct
basic research in Mongolian Medicine. Re-licensing exams are required every five
years for the length of a physicians career.
Manba Datsan Mongolian Medicine in Practice: The Khamba Lama. Dr.
Natsagdori. The outpatient clinic at Manba Datsan is a busy and bustling location.
Four doctors staff the outpatient clinic: the director and famous Khamba Lama6,
Natsagdoij, two young Manba Datsan trained physicians, and a biomedical doctor
employed to perform and interpret laboratory tests. Patients are free to see any of
the traditionally trained doctors. Most choose to see Natsagdoij, whose reputation
for healing attracts patients from all over Mongolia. Patients choose to wait to see
him rather than visit the two young doctors that also work in the outpatient clinic.
Natsagdoij is a Mongolian lama trained at the national Gandan Monastic
University. After graduating from the University in 1975, where he began his study
of Mongolian traditional medicine, Natsagdoij spent three years in India studying
Tibetan-style astrology. He says that he has expanded his medical knowledge
through deep meditation, which he has been pursuing since 1980. He is, in his
6 The highest rank at Manba Datsan monastery.
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words, an infertility specialist. He has traveled to several countries to aid infertile
couples conceive and is often called to local hospitals to help women at risk of
miscarriages. He says that his special tantras are guaranteed treatments. He
explains his effectiveness by saying simply I am a magic lama.
Although Natsagdoij does not begin seeing patients until 9AM, they begin to
line up at 8AM. On a typical day, Dr. Natsagdoij will treat forty outpatients before
1PM. The hallway where patients wait to see Natsagdorj is usually filled with
almost twenty patients before the office opens. There is an air of mystery and
spirituality at Manba Datsan, associated with the religious setting and Natsagdoijs
reputation. Patients appear eager to just catch a glimpse of the Khamba Lama,
peeking into the treatment room while waiting. The chanting and prayers of the
lamas in the monastery provide a spiritual soundtrack for the activities in the
outpatient clinic.
Manba Datsans patient population is quite diverse. The majority of
outpatients are elderly women seeking treatment for chronic illnesses that had been
unsatisfactorily treated with biomedicine. There is also a large segment of young
professionals visiting the clinic for treatment of more acute symptoms. Patients are
not screened for acute problems. The clinic treats all illnesses from sore throats to
cancer, but Natsagdoij refers patients to biomedical physicians when he feels it is
necessary. Notably, referrals are reciprocal. He mentioned being called to hospitals
83


to treat severely ill patients, and during my observations at the clinic, a pediatrician
brought her parents to see Natsagdoij.
No biomedical care is offered at the clinic, although they employ a
biomedical doctor for administering laboratory tests like, ECGs, x-rays, and
ultrasounds. The tests were viewed as back ups, providing confirmation of the
diagnosis arrived at through traditional methods. According to Natsagdoij, they
were also used to measure and identify the biological effectiveness of traditional
treatments. For example, an ultrasound could be used to monitor the reduction of a
cyst by traditional medications. The biomedical doctor at the clinic was emphatic
that he only provided this type of diagnostic advice, stating, Treatment is the
domain of the traditional medical practitioners [at the clinic].
Natsagdorj began each outpatient exam with a quick review of the patients
records and an interview about complaints. He then performed a pulse diagnosis.
The length of the reading varied by patient, but he was always quiet and meditative
while taking the pulse. Although each consultation only lasted 5-10 minutes, his
concentration and attentiveness to the patients concerns was notable. If the patient
brought biomedical tests or lab results, he reviewed them. On several occasions he
prescribed a medical test to confirm his diagnosis, but he did not provide any
biomedical diagnoses himself. Unlike the NMUM traditional practitioners, he never
performed auscultation or blood pressure monitoring.
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<1
For almost every patient, Natsagdoij prescribed three medications In
general herbal medications were all he prescribed, although the clinic offered a wide
variety of treatments. Acupuncture, bloodletting, cupping, massage, and
moxibustion were available but these were performed by the young doctors and
mostly restricted to inpatient care. In addition to these therapies, the clinic offered
ritual healing and astrological readings.
According to Natsagdorj, ritual healing is necessary because some illnesses
are associated with astrology and evil spirits and, therefore, cannot be cured with
medicine. In such cases, he will prescribe a mantra or tantra. According to
Natsagdorj, mantras are brief prayers that can be performed in the outpatient setting
by all Manba Datsan graduates. The tantras are long elaborate rituals that can only
be performed by experienced monks. At Manba Datsan, tantras were performed by
the monks at the monastery and, with a special appointment, by Natsagdoij himself.
The astrological readings available at the clinic consisted of general consultations
about health, the future, and major life events.
Summary. The traditional medicine practiced by Natsagdoij and graduates
of the Otoch Manramba Institute is distinct from the School of Mongolian
Traditional Medicine. The close association with the Buddhist tradition gives
Manba Datsan Mongolian Medicine a unique religious quality. The active
7 The prescription of three medications, one for the morning, one for midday, and one for the
evening, is the standard Tibetan practice. The prescription relates the qualities of the medicines to
the characteristics of hot and cold that vary in normal bodies from morning to night.
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integration of religious rituals, monastic practices, and spiritual healing sets it apart
from the more biomedically-guided system of traditional medicine practiced by
NMUM graduates. Practitioners are not trained biomedical physicians. They can
interpret biomedical diagnostic tests and refer patients to specialists when necessary
but rely more heavily on Mongolian Medical theory and Buddhist ideas.
In light of the experience of traditional medicine in other Asian contexts,
particularly Tibetan medicine in China, the government support and investment in
this overtly religious medical system is noteworthy. In Tibet, the political
environment and Chinese rule has led to the suppression of the spiritual foundations
of Tibetan medicine. The repression of religious and feudalist practices in Tibet has
forced traditional practitioners to redefine their medicine in scientific terms (Adams
2001b). In the Tibetan context, science is a political strategy employed to
distinguish Tibetan medicine from religion. In Mongolia, on the other hand, the
governments interest in reestablishing Buddhism as the state religion has led to the
active pursuit of a Mongolian Medical system with overt religious foundations.
Associated with the deep heritage that Mongolia is striving to recapture, Mongolian
Medicine has been encouraged to exhibit its distinct religious characteristics.
However, as the system becomes more entrenched and the influence of the global
market grows, scientific standardization may begin to affect this distinctly Buddhist
practice of Mongolian Medicine.
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Summary of Mongolian Medical Practitioner Interviews
Interviews with practitioners were an important component of this research
project. They informed the description of traditional medicine provided above and
they offered insight into how Mongolian Medicine is being understood and
employed by the practitioners themselves. The following is a brief summary of the
practitioner population interviewed and the themes that emerged from the interviews
that help elucidate the discourse surrounding traditional medicine in Mongolia.
The sample population of practitioners was drawn from various private and
public Mongolian Medical clinics throughout Ulaanbaatar and the northeastern
province, Hovsgol. Table 4.3 includes a description of the practitioners
interviewed.
Table 4.3: Description of Practitioners Interviewed
Sex N %
Male 7 32
Female 15 68
Training N %
Graduates of School of Mongolian Traditional Medicine 9 41
Biomedical doctors with at least one year postgraduate training in Mongolian Medicine 5 23
Biomedical physicians with foreign or secret traditional medical training 4 18
Manba Datsan graduates 3 14
Monastic graduates 1 4
Types of Mongolian Medical Practice N %
Private 14 64
Public 8 36
Experience N %
Recent Graduates 8 36
Experienced Physicians (10+ years clinical experience) 14 64
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As table 4.3 indicates, sixty eight percent of the Mongolian Medical practitioners
interviewed were female, which is reflective of the fact that the majority of
physicians in Mongolia are women. The majority of Mongolian Medical
practitioners were trained biomedical physicians (82%) and most of the practitioners
had 10 or more years of clinical experience. Also, 64% of the practitioners
o
interviewed were in private practice. All physicians but one were from
Ulaanbaatar.
The reasons practitioners had chosen to study traditional medicine differed
slightly between the more experienced physicians and recent graduates. For the
more experienced doctors, Mongolian Medicine was often a family tradition,
practiced by parents or grandparents, which fostered a childhood interest in and
early experience with traditional medicine. Also, many of these physicians
mentioned choosing Mongolian Medicine because they wanted a more effective
way to address their patients needs. As experienced biomedical doctors, many had
encountered the frustration of having patients they simply could not help with
biomedicine, and had thus pursued training in Mongolian Medicine to complement
their biomedical skills. Associated with this desire to better serve their patients was
the relative inexpensiveness of Mongolian Medicine, which was also attractive for
8 This physician was the director of the traditional medical department at the aimag hospital in
Moron, Hovsgol, a province in Northwest Mongolia. She is a graduate of the School of Mongolian
Traditional Medicine at the National Medical University.
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some physicians. This was especially the case for the one practitioner interviewed
in the countryside who mentioned the value of being able to use local resources.
For recent graduates, Mongolian Medicine was more of a curiosity
encouraged by its growing popularity and association with the positive aspects of
Mongolian heritage. These physicians valued the natural holistic approach to
medicine and appreciated Mongolian Medicines ability to promote self-healing.
However, three of the recent graduates did mention choosing to study Mongolian
Medicine by default. For two practitioners, the School of Mongolian Traditional
Medicine was chosen because the only other places available at the NMUM were in
pharmacology, dentistry, or public health and they wished to practice medicine.
The third physician was a Manba Datsan graduate and monk who had hoped to get
into the Mongolian Technical University but his test scores were too low. All stated
that they were now pleased with their decision to pursue Mongolian Medicine,
although one doctor still wished to pursue training in a biomedical specialty.
The majority of practitioners interviewed were traditionally trained
biomedical doctors who felt strongly that biomedicine and traditional medicine were
complementary, resulting in the greatest effectiveness when used together.
However, the only biomedicine they employed in practice were diagnostic methods.
Generally, Mongolian Medicine was perceived as a holistic (treats mind and body),
natural, and safe way to promote healing. Its effectiveness was heralded by many
physicians and was often illustrated by dramatic testimonies on its ability to cure.
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Biomedicine was described as good for emergencies, acute illnesses, and surgeries,
and its advanced technology and scientific foundations were viewed as advantages.
Most of what was said about the benefits or disadvantages of either medical
system was set in contrast to the other. For example, when physicians talked about
Mongolian Medicines ability to cure the root causes of disease, it was said with
respect to biomedicines ability to suppress and relieve acute symptoms but not cure
disease. Biomedicine was said to only provide temporary relief. Similarly, the
natural and safe qualities of Mongolian Medical treatments were contrasted with the
chemical and often harmful synthetic drugs of biomedicine. Also, the scientific and
advanced technology of biomedicine was compared to the abstract, untested nature
of Mongolian Medicine. This was especially true when it came to Mongolian
Medical diagnostic methods versus biomedical laboratory tests. Practitioners felt
that the greatest disadvantage of Mongolian Medicine was the potential for
misdiagnosis and, therefore, mistreatment. According to practitioners, the
subjectivity of the pulse diagnosis did not provide the concrete observable results of
biomedical testing; they stressed the importance of experience and vigilance when
practicing traditional medicine.
Practitioners explanations for Mongolian Medicines popularity were quite
similar to patients. The most common answer was that Mongolian Medicine was
effective and satisfied patients encouraged friends and family to try it, leading to a
growth in popularity. Practitioners also mentioned Mongolian Medicines
90