Conflict in the science of diagnosis

Material Information

Conflict in the science of diagnosis decline of intuition in modern Tibetan medicine
Hosseini Asheghabadi, Sayed Mahmoud
Place of Publication:
Denver, CO
University of Colorado Denver
Publication Date:
Physical Description:
iv, 105 leaves : ; 29 cm.

Thesis/Dissertation Information

Master's ( Master of Arts)
Degree Grantor:
University of Colorado Denver
Degree Divisions:
Department of Anthropology, CU Denver
Degree Disciplines:
Committee Chair:
Janes, Craig Robert
Committee Co-Chair:
Corbett, Kitty
Committee Members:
Curran-Everett, Linda


Subjects / Keywords:
Medicine, Tibetan ( lcsh )
Diagnosis ( lcsh )
Diagnosis ( fast )
Medicine, Tibetan ( fast )
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )


Thesis (M.A.)--University of Colorado at Denver, 1994.
Includes bibliographical references (leaves 99-105).
General Note:
Submitted in partial fulfillment of the requirements for the degree, Master of Arts, Anthropology
General Note:
Department of Anthropology
Statement of Responsibility:
by Sayed Mahmoud Hosseini Asheghabadi.

Record Information

Source Institution:
University of Colorado Denver
Holding Location:
|Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
31508802 ( OCLC )


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CONFLICT IN THE SCIENCE OF DIAGNOSIS: DECLINE OF INTUITION IN MODERN TIBETAN MEDICINE by Sayed Mahmoud Hosseini Asheghabadi B. A., University of Colorado at Denver, 1988 A thesis submitted to the Faculty of the Graduate School of the University of Colorado at Denver in partial fulfillment of the requirements for the degree of Master of Arts Anthropology 1994


This thesis for the Master of Arts degree by Sayed Mahmoud Hosseini Asheghabadi has been approved for the Department of Anthropology by Craig Robert Janes Linda Curran-Everett If Ju"( I?? Y Date -----Jrr:lrn _____________________ ..... __


CONTI:NTS CHAPTER 1. INTRODUCTION............................................................................................ 1 Methods ......................................................................................... 12 2. THE HISTORY OF TIBET AN MEDICINE .................................................. 1 7 Significant Elements of Tibetan Medicine .................... 2 0 Humors and Illness Related to lmbalance ...................... 2 2 Sub-types of Humors ............................................................... 2 5 Causes of lmbalance ................................................................ 28 Diagnostic Techniques .......................................................... 3 0 Treatment................................................................................... 3 3 Buddhist Dimensions of Healing ......................................... 3 6 Rang-bzhin ................................................................................... 4 0 3. TRAINING IN TIBETAN MEDICNE BEFORE 1959 .............................. 47 Classical Training .................................................................... 4 5 Apprenticeship and lntuition ............................................... 5 3 Case Studies ......................... ..................................................... 57 4. TRAINING IN TIBETAN MEDICINE SINCE 1959 ................................ 7 4 Case Studies ................................................ .............................. 7 7 The Contemporary Model of Tibetan Medicine .............. a 3 5. TIBETAN MEDICINE AND THE 'SOCIALIST FREE MARKET' ECONOMY .......................................................... 8 7 6. SUMMARY AND CONCLUSION .................................................................. 94 7. REFERENCES ................................................................................................. 9 9 iii


Hosseini Asheghabadi, Sayed Mahmoud (M.A., Anthropology) Conflict in the Science of Diagnosis: Decline of Intuition in Modern Tibetan Medicine Thesis directed by Professor Craig Robert Janes ABSTRACT The concept of rang-bzhin in Tibetan medicine will be shown to illustrate the importance of intuitive, subjective knowledge used by physicians in diagnosis and treatment. I will arg-ue that the use of rang-bzhin by Tibetan physicians is currently in decline, due to changes in the educational curriculum and in the training of doctors. These changes limit opportunities for a lengthy apprenticeship which is the key vehicle for the transmission of intuitive skills. With the introduction of the new market economy in China, the ancient healer's art is transformed into a mere specialization and Tibetan medicine has become commodified to meet the growing demands of the international markets for traditional medicines. This abstract accurately represents the content of the candidate's thesis. recommend its publication. Signed Craig Robert Janes v ------TrT'11"11 ________________________


Acknowledgment I would like to express my deepest gratitude to all individuals who supported me at each stage of producing this thesis. I would like to acknowledge all the Tibetan physicians and their patients who devoted their tlme for my quest. I would like to express my deepest appreciation to my academic advisor, Craig R. Janes, for his guidance, support and instruction in Tibet, and for his thoughtful editorial assistance. I would also like to express my sincerest to the two other members of my committee, Kitty K. Corbett and Linda S. Curran-Everett, and also to John Brett, for reading this thesis and providing me with helpful comments and questions. I owe especial thanks to Nawang Sherap, Chimay phuntsok and Tsedor la who assisted in interviewing physicians, and with translation. I especially would like to express my heart-felt appreciation to Cheryl A. Reighter, for introducing me to Tibet, for her love and encouragement throughout this work, and for her inspiring editorial assistance. iv


CHAPTER 1 INTRODUCTION Tibetan traditional medicine is a holistic approach to healing based on Buddhist foundations and is concerned with physical and spiritual balance. It views the cause of illness as imbalance in the natural order of the body/mind or due to diet, time, regimen, or as the action of demons. Tibetan medicine employs dietary and behavioral advjce, herbal, faunal and mineral remedies, herbal baths, acupuncture, moxibustion and other external treatments, as well as astrology, for restoring health. Tibetan medicine, with its Buddhist emphasis on the importance of compassion in healing, has combined spiritual and physical remedies to approach the patient's suffering from intellectual as well as somatic angles. Doctors traditionally were trained in teacher-appr.entice relationships, which placed emphasis on intuitive diagnostic approaches. In Buddhist philosophy the primary cause of all illness is "ignorance" as to the true nature ofreality, which leads to the three mental defilements of desire, hatred and delusion. Ignorance is referred to as improper thought and is considered in the Buddhist philosophy to be the-root cause of all human suffering. 1


The secondary causes of illness include improper diet or behavior, such as irregular eating or sleeping, or overindulgence in inappropriate foods or sexual activity. Since the individual is ultimately responsible for his own health, self-maintenance and close attention to the doctor's advice is important. Food is also a primary determinant of balancing the three humors in the body. Pulse reading is a complex system involving three finger spot pulse taking with eacli finger correlating to -particular organ (s) in the body (Donden, 1986:77-105). Since so much of Tibetan medicine depends on accurate pulse reading, apprenticeship with a highly respected senior physician becomes essential in doctor training. Also important in diagnosis, is urine analysis where the urine is whipped with a stick and evaluated for factors ::such sediment, size of bubble, color and odor. Diagnosis is through patient character type observation, pulse reading, and history ,_ (nutrition and behavior). Balancing the three humors is fundamental. to the concept of stable health", since all treatment is determined by one's character type. The doctor must learn the normal state or character type of the individual in order to detect imbalance. Therefore, rang-bzhin ("rang-bzhin") the Tibetan science of reading people's inherent nature, is of paramount importance in diagnosing and determining proper therapy. 2


Rang-bzhin is based on intuition. Intuition refers to the ability to see beyond the obvious and to make guesses based on one's "hunches" about the underlying nature of the patient's suffering. The ability to make accurate guesses improves with practice, due to the fact that the. doctor's storehouse of information is everincreasing. He develops archetypes for different combinations of the three humors from which he is able to_ assess each character type, the first step in the restoration of balance and harmony in the patient. Pulse taking, urinalysis, and character type reading are all highly subjective Tibetan medical diagnostic practices and typify the importance of developing intuitive skills. The concept of rang-bzhin or character type, because it is such a fundamental cqncept to Tibetan medicine, illuminates the problem of modernity and training in traditional medicine as it relates to the subjective, intuitive approaches. There are the three primary character types, associated with the three humors rLung {"Ioong"), mKhris-pa {"triba"), & Bad-Kan {"paigen"). Together they combine to produce the seven common combinations of character types {blends of the three humor) treated by the traditional doctors. The traditional style of training doctors placed greater emphasis on the use of intuition in treatment of the patients. 3


This was accomplished through the medium of long term apprenticeship with a master/guru, who transmitted his knowledge of healing, orally and by example, to his student. Apprenticeship enabled the student to observe his teacher using everyday in diagnosing patients, and to practice using his own intuition under the teacher's careful guidance. This has been discouraged in recent years by the classroom model of doctor training, which includes Chinese language and politics as well as the memorization of medical texts, but deemphacizes guided clinical experience. There is no opportunity for lengthy individual apprenticeship. Greater numbers of students compete for the teacher's attention in the classroom. Doctors have less time to spend with patients and with students because there are many more patients and not enough teachers and doctors. Today, medicine is taught at Tibet Medical College, in classes of forty students to one teacher and based on a standardized curriculum which is presented in lecture format. Moreover, students compete one another for class position, which dictates their future employment career paths: remote village, or Lhasa. Students learn the text of Tibetan medicine by memorization of the four medical tantras (rGuyd-bzh1), which takes a dedicated student four or five year to accomplish. They 4


are then assigned to a senior doctor for apprenticeship. Students actually do not become apprenticed to an experienced traditional doctor until they graduate from medical college. Then, they begin to really learn about traditional Tibetan medicine, and get clinical experience. This thesis will focus on the principle on rang-bzhin, in terms of examining how Chinese "modernity" has transformed Tibetan medicine. My research questions address the following .. issues: 1) what are the forces of modernity in Tibet and how are these forces affecting Tibetan medicine? 2) How are these forces transforming the training and practice of traditional Tibetan medicine in the science of rang-bzhin? 3) Do younger doctors use rang-bzhin in their diagnosis as much as older doctors? 4) How do Tibetan doctors view the future of Tibetan medicine in the struggle for holding on to the tradition? 5) Is a synthesis of traditional thinking arid modern testing possible? The introduction of public health and educational reform models in the early 1950's, .under the term "democratic reforms", today has given way to a new set of medical values that promotes technology over intuition. Most of teaching today is "reductionistic" in approach and more priority is given to modernization of Tibetan medicine. Students are taught to rely more on lab tests, blood samples, x-ray and other standard 5


methods of diagnosis to the neglect of the patient as one unique character in need of balance. Modern teaching identifies and deals with particular malfunctions of various organs through standardized techniques. The apprentice relationship is fundamental to the development of a doctor's intuitive skills and for the oral transmission of knowledge from teacher to student. Eliade has noted in Tibet the Buddhist masters emphasized the necessity of: an authoritative tradition of teaching, the validity of which was assured by direct chain of instruction transmitted from master to disciple (Eiiade, 1987:34). Most importantly, the apprentice learns that compassion is an important quality in a Buddhist physician and a quality not be gained by means of any normal training. How is intuition taught? Darling-Smith refers to "the wisdom traditions" that reach beyond physical body and the Tibetans of "opening the third eye" to see other realities beyond the visible matters. She criticizes Desecrates simplistic mind/body dualism which removes spirit from human body and argues that: Desecrates disjunction couldn't dispel the human intuition; that there are things besides mind and matter (Darling Smith, 1993:19). 6


She refers to the importance of rediscovering the .. regions of the self .. that the wisdom traditions such as Tibetan Buddhist, Hindu, and Persian Sufi scriptures allude to in their formulations of mind/body relationship. These are taught through yoga and awakening of the Chi energies to maximize health and happiness, and minimize human suffering. Although a teacher can not teach intuition directly, knowledge can be transferred to the students so that the intuitive knowledge can be discovered by the individual as he focus on his own insight in utilizing the power of the intelligence to deal with complicated situations without really understanding how it operates. Teacher or guru can only help the student to formulate his own logic by trial and error. Darling-Smith in her book .. Virtue Be Taught? .. argues that: students of behavior and learning are finding that when faced with exceptionally subtle tasks, people who 'feel' or intuit their ways through them are more creative than those who consciously try to do their way through the situations (Darling-Smith, 1993:23). Tibetan traditional medicine has a holistic approach to healing and in its own terms and within its own unique cultural context, can therefore be considered a .. rational .. system of diagnosis and treatment. 7


Rationality, as a concept in biomedicine, refers to the use of empirical, measurable tests to diagnose disease and is based on the idea that there is an invariant .. truth .. which can be determined through the right technology. The training of doctors is oriented toward materialist concepts of illness causation and organs are dissected as parts for location of the pathology. Both Western medicine and Tibetan traditional medicine have strong points in their explanation. of .. truth.. but are quiet different. Western medicine has developed surgical techniques with anti parasitic and anti-bacterial drugs which are quiet strong and able to combat epidemic diseases. However, most traditional medicines proven in their .. rational'' explanations show how sophisticated they are in treating most chronic diseases; those that western medicine can not cure. Studies done in medical tradition by Obeyesekere, indicate that the knowledge achieved through intuition must be highly regarded and that: it is indeed true that the most important source of knowledge in Buddhism ... is that of intuition and inspiration obtained generally by some form of religious and meditative trance, contrasted with abstract theoretical knowledge Obeyesekere, 1980:4-9). Obeyesekere states that, contrary to the popular view that intuitive knowledge can not be expressed in ordinary .. abstracted 8


theoretical'', or "rational" language, it is the mind/body connection, the lived experience associated with trial and error over time which makes it sound logical. The western view of development, which is based on science has its own rational language cross-culturally, and varies in the construction of "rationality". He proposes that Buddhist. "rationality" is of two types: metaphysical and theoretical. Metaphysical rationality, according to Obeyesekere (1980), is an "abstract and conceptual grasp of the nature of the man, the world, and the cosmos in its metaphysical dimension" (i.e., karma, nirvana, etc.). This however, has little or no empirical or observational basis, and is far removed from scientific theories, where abstract, rational and .conceptual language ideally helps us understand processes in nature and in man. The teaching of the great Buddhist philosopher near the first century B.C., Nagarjuna is primarily considered metaphysical. Obeyesekere defines theoretical rationality as that part of Buddhism which uses: abstract concepts to understand the nature of the man, the world and the cosmos. Although not exactly scientific, its form is parallel to theoretical explanations in science. Like notions. in contemporary physics, they are closer to formal logic and mathematics, rather than to statistical averages (Obeyesekere, 1980:8-9). 9


The modern Chinese/Western model seeks rapid intervention and quick cure. As a biomedical model, the rational system is not concerned with mind/body connection, spiritual liberation or individual character differences, thus it is not a holistic system. Disease is understood and cures are discovered through multiple tests and statistics involving a number of "cases", possessing a category of pathology. Therapy treats the. ailment, rather than individuals or character types. According to Margaret Lock in respect to holistic approach of healing in Japanese society: Buddhism teaches that intuitive understanding leads to insight, and it is considered to be .more refined and esthetic than rational, deductive, and verbal communication. A mother prides herself on her intuitive understanding of her baby; a good mother anticipates the needs of the child by being receptive to nonverbal indications of discomfort before the baby actually cries (Lock, 1980:219-20). When the Chinese came to Tibet, closing the monasteries and labeling monk/doctors as "superstitious", their intention, formed from a firm conviction in the social and economic benefits of modernization, was to modernize Tibet and upgrade the lifestyle of all countryside peoples in China. This would be accomplished, not just by replacing the "non-rational", "superstitious" aspects of Tibetan medicine with a more "scientific" domain, but also by establishing a new educational 1 0


curriculum where scientific approaches would be complemented by traditional remedies. The modernization of Tibetan medicine has resulted in a new order of medical curriculum which has .transformed the concept of humoral balance (rang-bzhin) of Tibetan traditional medicine towards the contemporary knowledge of biomedicine practiced in Chinese/Western hospitals; This transformation of ideas is rapidly changing attitudes and moral standards regarding treatment of. patients, and is threatening the values placed on the power of intuition in healing. Since doctors in modern settings are rewarded financially and in most cases are underpaid, they tend not to feel responsible for the total recovery of the patient. They seem not to have enough time to spend on rang-bzhin ideas and traditional beliefs in diagnosis and treatment. Therefore, doctors trained in modern style are unable to satisfy their patient's basic needs; providing compassion, care, and respe_ct. In regard to the consequences of modernity Anthony Giddens explores the world of modern institutions as they create abstract systems of ''impersonalized He describes how these new relations rapidly drain away the local power of traditional institutions, and how they transform with a chain of complex relations. According to Giddens abstract elements of 1 1 ------Jrf"lwn _______________________


modernity bring about a rupture in kinship ties and transform the sense ot' trust and intimacy with their complex technology and electronic information systems.. He says in the modern type, policies are forged and decisions taken which forces a concentration upon the self absorption; this is a result of the powerlessness most people feel {Giddens, 1990:122-3). According to Giddens, intimate relationships and trust are always ambivalent in the abstract systems of social existence which constantly demand a level of self-understanding and self expression. Everything is in the context of time and space that itself must be a source of psychological tension. {Giddens, 1990:140-4). This technical abstract system of communication and relationships is according to Giddens, the source of our anxieties. Methods I accompanied a research group from the University of Colorado, Denver, to Tibet to study the role t?f Tibetan medicine in the modern Chinese state in spring 1993. This thesis is an exploration of how the Chinese system affects the practice of Tibetan traditional medicine, especially those elements drawing heavily on the use of rang-bzhin and intuition in diagnosis and treatment. Data were drawn from a variety of sources, doctor-12


patient observation, physician interviews, and personal communication with my research group. Professor Craig Janes, the principal investigator, and Cheryl Reighter, research assistant in the study, had already worked in Tibet and for them this was a follow-up study. I went to Tibet, first of all, to learn how to do field work. I was also curious to see how "traditional medicine" operates in contrast to Western medicine and in a pluralistic setting. As a student in the field of anthropology I was interested to learn how Tibetan traditional medicine was functioning after the changes Chinese brought to Tibetan culture. In what ways has the Chinese presence and their "modernization plan" transformed traditional values regarding health and illness and the rituals evolving around the meaning of such values in healing practices. Several weeks into our work, I learned about the. diagnostic principle of rang-bzhin and realized it was similar to the tri dosha (three personality types} which is used in Ayurvedic medicine of India to determine individual character types. My interest in rang-bzhin system originates from the fact that this theory is fundamental to both systems; an underlying thought guiding both diagnosis and treatment. I was eager to learn more about Tibetan traditional medicine. 13


Tibetan doctors were interviewed in both in-patient and out-patient hospitals in Lhasa and TseThang regarding the use of traditional methods for the training of doctors in Tibetan medicine and the use of rang-bzhin methods according to the traditional root medical texts (rGyud-bzhl}, or "four tantras". Sample individuals chosen for interViews consisted of 16 doctors, male/female between the ages of 24 years and 70 years old. All interviews took place at the Tibetan traditional hospitals (Mentsikhang) in Lhasa, and Tse-Thang. Tibetan interpreters working at the Mentsikhang translated. In addition to physician interviews, a sample of 40 patient's charts was selected at random from various departments in the Lhasa Mentsikhang; such as Combined medicine, Internal medicine, women's and Children's, and External medicine departments to determine how rang-bzhin was -recorded and applied. Each chart reflected the patients' diagnosis and was based on the doctor's observations and questions, along with pulse taking, urine and tongue exam. By combining these methods, Tibetan doctors were able -to determine one's character type by looking at rang-bzhin as a part of a humoral system which relates mind and body inseparability in both diagnosis and treatment. Today, a younger generation of Tibetan doctors are trained to view body, disease and treatment mechanistically, leaving out 14


ones character type or rang-bzhin theory of diagnosis and treatment. These young doctors are not comfortable using their own intuition, and are having a hard time applying the principles of rang-bzhin in their diagnosis and treatment. They are more oriented towards Chinese/Western ideas of institutionalized centers where patients go there to be .. fixed .. rather .than balanced. The aim of this study was to investigate the shift in perspective towards the pathology of disease, training of doctors in the .. old society .. by means of apprenticeship, vs. ..modern society .. and classroom style, with an overall concern about the future of Tibetan Traditional Medicine. In chapter two, I will review the history of Tibetan medicine, including the debated origins of Tibetan medicine and the influence of indigenous beliefs on the imported system. Then I will discuss the significant elements of Tibetan medicine as these pertain to the five natural elements, the three humors and illnesses related to specific imbalances of. these humors. Causes of illness, both primary and secondary, will then be addressed, with diagnostic technique and treatment. I will also explore the distinctions between classical or. monastic Buddhism and folk or popular indig.enous healing. 15


Chapter three will study training in Tibetan medicine in this century, prior to 1959, including di.scussion of the Four Tantras or the original Tibetan medical texts, elemer:tts of classical training, and the importance of intuition in traditionalhealing. The concept of rang-bzhin will be discussed in detail through case studies. Chapter four concentrates on the training of doctors since 1959 and follows the changes in training style from 1959 to the present. I will also look at the irnpact of Chinese modernity on Tibetan traditional values and on the concepts of holism, rang bzhin and intuition. Case studies will augment this discussion. Chaptet five looks at the influence of the socialist free market economy on Tibetan culture, and with the commercialization of Tibetan medicine for market expansion and profit. It also looks at the ccmnection between the rationalization of Tibetan medicine and the increasing importance of the medicine itself. conclude in chapter six with a discussion and analysis of what these cultural changes mean to the future of Tibetan medicine and what other traditional medical systems can learn from observing the transformation of the concept of rang-bzhin in modern Tibetan medicine. 16


CHAPTER2 THE HISTORY OF TIBETAN MEDICINE Tibetan historians date the birth of Tibetan traditional medicine to the reign of king Songsten-Gongpo (Beckwith,1979) who invited three famous doctors to Tibet to perform their skills and exchange talents of medicine. From India was the tantric master Padmasambhava known in Tibet as Guru Rimpoche, the second Buddha Bharadhavadza (Beckwith,1979), who received teachings on the science of medicine from god lndra and introduced to Tibet the medicine of Buddha .. Bhaishajyaguru .. Shakyamuni Buddha. According to some historians (Parfionovitch,1992; Beckwith, 1979; Zysk,1991) in the eighth century, Viarocana had translated the text Astangahrdaya into the Tibetan language, during the same time that Yuthog the .. elder" also received it. Later it was hidden by Padmasambhava (Guru Rimpoche) in the Samye monastery. They were rediscovered in the 11th century by Dragpa Ngoshe and transmitted to Yuthog the .. younger," who probably amended it to suit the local conditions of Tibet (Parfionovitch, 1992). Some other historians believe that the rGyud-bzhi contains concepts foreign to India, since its origin, although rooted in a 17


"lost" Sanskrit text, was modified by the work of Tibetan authors, especially Yuthog the younger. However, the Tibetan Buddhist historian Bu-ston states that one of the principal texts used for the medical instruction was Vagbhata's Astangahrdava Samhita which was originally translated into Tibetan from Sanskrit (Zysk, 1991 :48-49). It also has been noted that Tibetan medicine was introduced into Tibet in the seventh century with the development of a written Tibetan language based on Sanskrit, and was a direct translation from the Ayurvedic texts Charaka Samhita the earlier Ayurvedic text, and now the "lost" version or Astangahrdava Samhita ("The Collection of the Essence of Eight Limbs") which has been translated into Tibetan from Sanskrit. (Clifford, 1990:37; Zysk, 1991 :48). The collection of the Physicians are among the collections translated fro'm Sanskrit to form the rGyud-bzhi libetan medical texts. Tibetan historians however, attribute Tibetan medicine mainly to Yuthog Nyingma Yongden Gongmpo the "elder" who is said to have lived during the seventh centuries, and later around twelfth century the knowledge has been transmitted to Yuthog Sarma Yonden Gogmpa, the "younger" (Parfionovitch et al., 1992) .. However, the rGyud-bzhi Tibetan medical text is not considered departed from the word of Buddha; since Yuthog himself is considered the manifestation of the "master of remedies". 1 8


Indian, Chinese, and Persian influences are believed to have nourished Tibetan medicine between the seventh and ninth centuries. From China came Hen-Wen Han-de (Heng et al. 1990; Norbu,1988) known supposedly as the author of the Nei ching. "InternalClassic", and from Iran was "Galenos" or Galen the Greek; the most famous physician throughout Persian and Muslim Middle ages (Beckwith, 1979). Among the diverse cultural contacts, the Indian influence seem to be the greatest in Tibetan medicine and Tibetan Buddhism for three centuries. The Tibetan Buddhist historian Bu-ston shows the chief medical texts used for medical instruction were several works of "Nagarjuna", the great Buddhist philosopher of the second century, and the AshtangahvdaYsamihita (Fundamental Ayurvedic Medical Treatise of India) that has been translated from Sanskrit to Tibetan agree_d to forrn _part of the rGyud-bzhi medical texts. (Beckwith 1979; Zysk, 1991 :48) Tibetan medicine and the Indian medical system, Ayurveda, from which Tibetan medicine extends, were passed down through a lineage of physicians who transmitted theiroral teachings and texts to their students by way of apprenticeship. Although Tibetan medicine is the unique result of the blending of Indian, Chinese and Persian medicines, and of Buddhism with local folk 19


remedies rooted in Bon (animistic) beliefs, the theoretical roots of the Tibetan texts are distinctly Indian. Significant Elements of Tibetan Medicine According to Buddhist philosophy, a human being is the product of the temporary conjunction of five constantly changing orders of phenomena: body, feelings, perceptions, impulses, and consciousness the locus of all, and is the "seat" of thought; underpinned by the subconscious conditioned by past acts transmitted from one life to next life. (Donden, 1986; Parfionovitch et. al., 1992). According to. the Tibetan medical teachings, all organic and inorganic matter results from combinations of the basic five elements: earth, water, fire, wind, and space (ether), in varying proportions. Each of these elements is perceived by one of the five senses. These five elements determine all properties of substances (hot, cold, stable, heavy, light, oily, sharp, coarse), the potencies of substances and different tastes. Everything in the universe is composed of these elements. Earth has the strong and stable quality and characterized as being pungent, rigid, and firm; it helps to balance the wind disorders. Water is the liquid matter, soft, cool, and heavy, and not stable. It lubricates the body system and helps to balance the bile disorders. Fire element 20


is associated with "heat" in the system, and can convert solid to liquid and gas, and vise versa. It gives complexion, and helps balance the phlegm and wind. humors. Wind (Air) is characterized as being cold, dry, light, unstable, and gaseous. It has no form and travels -throughout the body. It: helps the distribution of nutrition and movements of the limbs. Space (ether) has no physical form. It is "hollow and provides room for things to happen (i.e., wind or air needs space to move in the body, just as a tree a space to grow). "It exists only as distances which separate matter" (Clifford, 1990:120-1; Svoboda, 1989:17). These qualities generally serve as the agents of the physiological, pathogenic and therapeutic activities of substances found nature. The substances which nave the same quality, a given quality stimulates or increases that substance, and diminishes or inhibits every substance which has the opposite quality. The five elements are condensed to the three humors of Wind, bile and phlegm. Wind or rLung activates the nervous system, and controls body actions and it is understood as "vital current". Bile or Triba humor is referred to as "vital energy" which controls digestive energy and helps to maintain body stability and heat. Phlegm or paigen humor is the "potential 21


energy" or "vital force" which helps to maintain body stability and moisture. Humors and Illness Related To Specific Imbalances The balance of humors results in good health. Illness results from humoral imbalance, with one or more elements predominant in an individual character type. The rGyud-bzhi medical texts emphasizes humoral theory, in which the balance or imbalance of the three humors are inseparable from the other aspects of the body and the five elements, in the maintenance of stable health. Tibetan medicine is thus becomes necessarily holistic and is linked philosophically to Tibetan Buddhism. The following is a brief description of the specific disorders of the three humors, all caused by "ignorance", the state of mind, which gives rise to desire, hatred, obscuration; known as the "three mental poisons" or "three sins" (dug-gsum) (Oonden,1986). Depending on the nature of the imbalanced humor, an illness could have the nature of "heat" or "cold". Heat is associated with the "fire" element resulting in an increase in the "bile" humor. Illnesses with the cold nature are generally associated with "wind" and "phlegm" humors. 1) Wind disordersThere are 42 disorders associated with wind (rLung) humor which moves through bones, joints, ears, 22


pores, heart, and large intestine, and is common to all people. The humor of rLung in the body is associated with .. cold .. or .. heat .. caused by desire. In such cases, in order to bring the wind humor back to balance, a. physician generally follows these guidelines for treatment: Diet-Use warm oils, foods, and beverages of heavy nature with oily, gentle, and warming qualities. Leisure and activitiesStay in warm places; have pleasant friends around; sleep and wear warm clothes. Medication includes decoctions of mutton (broth), bone marr:ow derived from the ankle, coccyx, and shoulder blades, bone meat, butter, wine, ginger, rock salt, nutmeg, halite, ghee, garlic extract, and compounds with hot, oily potencies. External therapyMassage with hot oils (sesame oil, year old butter, etc.), and if the person is strong enough to handle it, moxibustion on the crown of the head, and other rLung points in the body, such as 1st and 7th vertebra. If a person with rLung character gets a rLung imbalance, the imbalanced humor must be treated first, and then the rLung type. 2) Bile (mkhris-pa) disordersBile humor is stored in small intestines and gallbladder, and is responsible for digestion, skin color, eye sight, and temperature. There are 33 bile disorders associated with .. heat .. and caused by hatred, jealousy, and pride. The pathways of bile disorders are through blood, 23


perspiration, and in the eyes, liver, and gallbladder. One needs cooling substances to reduce the "fire'' element. Curative diet includes fresh butter, fresh meat, fresh game, and fruits or vegetables with cooling qualities. The patient is advised to stay under shady trees and meadows where there is a cool breeze, and by the peaceful banks of rivers. Therapy consists of sweet tasting medicines or purgatives. 3) Phlegm (Bad-Kan) disordersPhlegm humor is a mucous in the stomach which dissolves solid foods and influences the formation of muscles, tissues, bones, and the sense of smell. There are 26 disorders related to phlegm. This humor is associated with 'cold' and is caused by confusion, and obscuration. Phlegm disorders require substances with 'hot' potencies to balance the disorder. Diet includes white or clover honey, and foods that are easy to digest and recommended activities include staying in warm, dry and sunlight areas; wearing warm clothing, a hard work-out and not sleeping during the day. Medication is a decoction of black pepper and rock salt, pomegranate fruit, and foods with sour and salty tastes which have light, harsh, and sharp potencies. Therapy consists of sharp and harsh emetics, moxibustion, blood letting, etc. 24


There are seven vital physical constituents; chyle, blood, flesh, fat, bone marrow, reproductive fluid, ahd residues (feces, urine, and sweat) which are also medically significant. I In Tibetan medicine, rLung (wind) humor manifests itself in the brain, respiratory breath and the sense of touch, and is responsible for speech, physical movements of the limbs, and mental activities. It has the quality of wind, subtle, light, dry, sharp, and cold. Wind is the "life force'' responsible for body function; it travels all throughout the body and "starts and finishes" all diseases. It is associated with "desire" one of the three mental defilements. It increases with mental and emotional strain, and by worrying too much about one's own problems. Sub-types. of the Three Humors Tibetan and Ayurvedic medicine have similar points of reference to the functions, main features, locations, and pathways of humors in the body. The following is a brief description of the "seat" of each humor, and their sub-types which constitute normal physiology; an imbalance results in pathology. Similar to Ayurvedic medicine, physical health is stable when the three humors are in harmonic balance. Illness 25


results from imbalance of the doshas (Sanskrit, .. faults .. or troubles). Each humor has five sub-types. rLung (wind), or Vata (air) is associated with sense organs, heart, and large intestine. Rising occasions of the 'wind' humor are-in old age, cold places, summer. midnight and early in the morning. The .. seat .. of illness is in lower part the body. These sub-types are described briefly below with Sanskrit and Tibetan names; showing the similarities between Tibetan and Ayurvedic medicine: 1) rog-'dzin or parana, .. sustaining breath .. : the. locus (seat) is in the brain and controls emotions, mental activities, and movement. 2) gyen-rgyu or udana; ascending rLung: associated with the vocal cord, locus is in the diaphragm and travels to nose and tongue. 3) Khyab-byed "pervasive wind" or vyana: it controls metabolism and musculature movements and its locus is in -the heart. 4) me-mnyam (fire accompanying wind), or amana: it controls digestion and its locus is in the small intestine. 5) thur-sel or apana: descending wind which helps with exertion and reproduction; locus in the colon. 26


The humor mkhris-pa (Bile), or pitts, is seated in the middle part of the body and moves through perspiration glands, eyes, liver, and gallbladder. Rising occasions of the 'bile' humor is in adult maturity, dry and hot places, autumn, and noon and midnight. 1) 'ju-byed (digestive bile), or pacaka: is seated in the intestine. 2) mdangs-sgyur (color transforming bile). or ranjaka resides in the liver. 3) sgrub-byed (energizing bile), or sadhaka: locus is in the gray matter, hair and head. 4)mthong-byed (vision producing bile), or alocaka: is located in the eyes. 5) mdog (complexion clearing bile), or gsalbhrajaka: the seat is in the skin. Humor bad-khan (Phlegm) or Kapha: the seat is in the upper part of the body. It moves through chyle, feces, urine, nose, lungs, stomach, chest, throat, semen, and bone marrow. There are 26 phlegm diseases with nature. of "cold". Rising occasions of the phlegm humor are in childhood, damp places, and spring. 1) rten-byed {supporting phlegm), or avalambaka: it prevents excessive thirst. The seat in the chest. 2) myag-byed (decomposing phlegm), or kledaka: it dissolves solid foods. The seat is in the upper part of the stomach. 27


3) myong-byed (gustatory phlegm), or bodhaka: it gives different flavors to food, and situated in the mouth and tongue. 4) tshim-byed (sensory stimulating phlegm), or trapaka: it develops the sense organs, eyes, nose, tongue, mouth. 5) 'byor-byed (adhesive phlegm), or slesaka it binds the joints in the body and controls movements and strength. Causes of Imbalance According to the teachings of Buddha, all diseases have primary and secondary causes. When visiting a patient, the physician pays attention to both primary and secondary causes of diseases; the character of each humoral imbalance; the dysfunction of sense organs and sense perceptions, body odors, age, seasori and time of the day, and the social factors. The ultimate cause of all diseases is understood to be "ignorance". According to Yeshi Donden, in the rGyud-bzhi Tibetan medical text propounded by Shakyamuni Buddha, there are 84,000 different types of afflictive emotions arising from the three mental defilements in humans, namely desire, hatred, and obscuration, known as the "three mental poisons". The 84,000 afflictions have been condensed to 1 ,016 types of disorders, and further reduced to 404 common illnesses. These illnesses are 28


classified in terms of their locations in the body, type, social and environmental factors. (Donden, 1986:15-26). According to the teachings of Tibetan medicine, the primary cause of all human suffering is rooted in the three mental defilements, desire, hatred, and delusion. Tibetan medicine views mind and body as one integrated entity. Unlike the "germ theory" that views all diseases are caused by germs and can be treated by means of particular drugs, Yeshi "Donden states that the primary cause of any disease is due to "the three mental poisons", the concept of bDag'-zin or ego which is manifested in the form of gTi-mug refers to human delusion, ignorance, and confusion. This in turn gives rise to 'Dod-chags attachment, greed, desire, and followed by Zhe-sdang or hatred, aversion, and aggression leading to illness (Donden, 1986:56). Among the secondary causes of diseases which bring about the imbalance in three humors are: diet, climate, environment, behavior, trauma, misfortune, and the actions of demons. With the exception of demons and trauma, the former four factors are said to be the main causes of disorders at the immediate level. That is, they could stimulate the humors by the respective effect of their identical or opposing qualities of hot and cold. Therefore, in order to restore health, different measures are undertaken to maintain equilibrium in the body. Food as medicine 29


and also an agent which causes disease, is an important measure in restoring the lost humoral balance in the body. Diagnostic Technigues Medical diagnosis is done through a series of empirical, logical, and intuitive operations traditionally performed by the Tibetan doctors. They are classified into three parts The first part of diagnostic method is visual, where doctors examine the body type, make observations of the tongue, and examination of urine sample. The second part of the diagnosis is palpation, or pulse taking through which, body heat/cold, irreguiarity and smoothness of the pulse is examined. Pulse taking is pne of the most important tools in diagnoses and treatment, since it informs the Tibetan doctors about the proper functioning of the body organs For the most part, the science of pulse taking as a diagnostic tool should be credited to Chinese medicine, rather than Ayurveda. Older doctors, who were trained in the old society, are famous for their intuitive knowledge of pulse taking methods associated with ''the number of heart beats in one breath ... Tibetan doctors use pulse diagnosis to discover which organ is not stable and the humor responsible for the diseased organ. 30


Locations and functions of the body organs in Tibetan medicine can not be equated with anatomically modern humans in Western Elisabeth Finckh points out in her observations of Tibetan doctors in Dharamsala, India, that: it is wrong to equate what we in the west understand of organs, with the functional scope of Tibetan 'organs. .. not identical with those of Western anatomical science. The Tibetans regard their organs not only as sub-strata, but also as reflections of their functions on the surface of the body. The area of invisible forces, vibrations, currents, wheels, life veins, etc. beyond the visible man and other uch concepts are to be explained in this way (Finckh, 1982:261-2). The third method of diagnosis is interrogation or questioning the patient. First doctors directly question the patient regarding the imbalance of humors, where the origin of disease, its stage, location and the ways in which the patient experiences the disease, are explored. The patient's rang-bzhin is thus established, determining diagnosis and therapy. Interrogation helps doctors to make a more accurate diagnosis. and also is important for establishing rangbzhin. The imbalance is traced by the doctor through all these methods. The doctor is looking for the cause of illness. by gathering as much information as possible about the diet and behavior of the patient that may be connected to the cause of the imbalance. 31


Often times relatives or friends will be questioned by the doctors, to gather more information on the history of illness. It is recommended not to rush the patients with too many questions at once, especially if the doctor sees the patient as a rLung character type with the rlung humor "out of whack". In this situation, one method for gathering more information regarding the illness would be to treat the. patient in a gentle manner and perhaps prescribe a small dose of herbal medicine which is good for general cleansing and for "relaxing" the patient. If the doctor is unsure of the diagnosis made based on the above classifications, he may attribute illness to the secondary causes of for example, the harmful influences of demons, or bad diet, until family members can provide more information regarding the illness. Doctors emphasized that it is very important not to ignore rlung disease in a rlung character type. Diagnosis ana treatment in Tibetan medicine is similar to that of India's Ayurvedic medicine. Ayurveda has its roots in Indian Buddhist tradition, classifying the internal. organs into five solid and six hallow viscera. The eight branches of medicine in Tibetan Buddhism however, differ in a few tenets with that of Ayurvedic medicine due to their locality. For example, the 32


Buddhist philosophy prohibits an extensive dissection (surgery) as mutilation or violent intervention of the body. The eight branches of medicine are, the body (internal medicine), children's diseases, women's diseases, diseases caused by evil spirits, healing of the wounds caused by external objects (weapons), poison treatment, rejuvenation, and reproductive organs. As I mentioned earlier, in Ayurvedic medicine the eight branches of medicine are similar to Tibetan medicine, with the exception of surgery, which was banned in Tibet after a heart operation on the queen failed, and King Muni Tsen-Po (799-804 A.D.) banned its practice (Norbu, 1988:44). Tibetan medicine also resembles that of the Chinese traditional medicine where examination of pulse and moxibustion are used frequently. What marks Tibetan medicine as unique is its combination of different medical systems under the umbrella of Buddhist psychology and supernaturalism. Treatment During the reign of Srong-tSan sGampo in the seventh century Tibetan doctors were aware of the physiology of human body, and able to communicate with the outside world to enrich their medical knowledge, and find cures for the .,84000 33


afflictions of humans .. attributed to rlung, Triba, and Piagen and caused by supernatural figures. After medical diagnosis is established depending on the nature of the imbalance, the doctor prescribes two kinds of treatments, anabolic and catabolic. Based on the .. hot" or "cold ... nature of all disorder, a herbal mixtures for hot and cold diseases are prescribed. Anabolic medicine is prescribed when .. wind .. humor is in excess and .. phlegm .. and .. bile" are low (Parfionovitch et al., 1992). Anabolic medicine results in energy rising up for constructive metabolism where food changes into living tissue, behavioral adjustment, and.. happiness of the mind". Certain types of food and drink are prescribed for each of the three humors depending on the hot and cold qualities of the foods and the effects they may have on individual character type. The same principle is applied to the medicines prescribed. For instance, sweet, sour, and salty medications for rlung (wind) types; bitter, astringent, and sweet for Triba (bile) types; and pungent, and astringent for Paigen (phlegm) character types. The second type of medicine prescribed is characterized as catabolic medicine or cleansing remedies are used to stimulate the process of living tissue, changing it into energy and waste 34


product. Catabolic medicines are prescribed when 'wind' is low and 'phlegm' and 'bile' are in excess. Catabolic medicine prescribes specific internal medication, for example enema or oily medicine for rLung types, purgatives for Triba types, emetics for Paigen types, etc.}. With careful consideration of the physical and mental stability of the patient, external therapy (cauterization, physiotherapy and massage for rLung types; blood-letting for Triba type; moxibustion for Paigen type, etc.} is performed if necessary to remove the morbid humor. Moderation in diet and medicine prescription is the key word in treatment of the patients, and physicians must avoid excess in their treatment. If excessive treatment of anabolic medicine occurs, it may result in obesity, lethargy, and accumulation of phlegm in the system. Similarly, if catabolic medicine is it may result in depletion of the physical constituents, thin muscle tissues, insomnia and excess of rLung (wind) in the patient's system. Therefore, symptoms should not be taken lightly or confused with one's inherent character type, and must be examined very carefully in order to avoid any negative consequences. Normally doctors write three prescriptions for a day; morning noon and night. It also depends on the underlying cause 35


of the illness. For example, depending on the "hot" or ".cold" qualities of the medicine, a prescription is g.iven at a particular time of the day; cold medicines in the heat of the day, and so on. There are several kinds of medicines for a particular disorder, which, depending on cause and imbalance, may be difficult to diagnose without proper;. attention to character type. Buddhist Dimensions of Healing Folk and classical Buddhism has always been a part of Tibetan culture and witches and sorcerers constitute or control those powers which can interfere in human life and cause illness or death. These healing and potentially malign forces represent a mixture of Bon and Buddhism. Similar to other traditional medical systems (Unani, Ayurveda, Chinese medicine), Tibetan medicine has long integrated religion into its healing practices, believing that a characteristic of all humans is suffering in the way to enlightenment. Furthermore, in classical Buddhism the doctor-patient relationship is based on care with compassion as an integral part of Buddhism that has always been exercised in treatment. Karma as the result of one's actions in earlier lives leads to sorrow, fear, imbalance of humors and illness. Karma in Tibetan life, according to Geoffrey Samuel (1993:208-9), constitutes the 36


proper behavior to one's fellow humans which is recognized as "virtuous action", qualities attributed to the "Buddha-nature" in all living beings. One must practice mental training to get rid of "negative emotions, hate and craving" which leads to imbalance of the humors and thus to illness. In Tibetan folk Buddhism, accumulating merits in the hope of some kind of balance through proper behavior towards fellow beings leads to reduction of one's anxiety over "death and possible -rebirth", and happiness of the mind. Folk or traditional healing practices in modern Tibet are derived from the Bon religion of old Tibet and are still being practiced, such as the using of amulets and charms for many illnesses. According to Nik Douglas (1978:119-120) there are Buddhist charms against women's diseases, stillbirth, and the complications of childbirth symbolized with the fish, which is the early phase of pregnancy. This charm is ink stamped on a paper which could be worn on the body or eaten by the patient. There are all kinds of amulets and charms against smallpox, worms, syphilis, plague, and a host of other diseases as well as amulets for wealth, and prosperity. The pre-Buddhist religion (Bon) which has undergone enormous changes since the spread of Buddhism in Tibet is now being practiced as a "parent sect" of Tibetan Buddhism. Lamas 37 ______ Tr,nru _______________________


and monks trained in medicine were able to convert the spirits which cause harm and sickness into Buddhism by their what is now known as witchcraft or "black magic". Black magic may still be a part of healing rituals in folk healings tied with Bon religion of old Tibet. According to Downs: it is the Bon priests who are considered to be wizards or able to be wizards, although even they no longer perform what Tibetans call black magic (1972:76) The common greeting, that of sticking out one's tongue derives from the custom of showing one's tongue wasn't black; the sign of a sorcerer. Downs argues that the learned Buddhist teachers had greater power over these wizards, and were able to perform greater miracles and thus convert the wizards witches, and sorcerers to Buddhism (Downs, 1972:79). The writing of the mantras on prayer flags and food offerings to the spirits and local gods were "to maintain a workable relationship with these powers" for bringing good luck and good fortune (Samuel, 1993:173). These rituals in healing aimed to scare away the spirits, witches, and sorcerers who possess the power to inflict death or cause damage, although this tradition of combating illness may seem to be abolished, but still exists among the folk populace of Tibet in villages and nomadic areas. Most Tibetan Buddhists carry a prayer wheel, rosaries, 38


prayer beads, sacred amulets, statues of Buddha or other holy things, many for protection from harmful spirits. This form of communication with the sp'irits practiced by the lay people of Tibet, by means of spirit possession, constituted what Bonpo scholars called it .. the Bon of Cause .. (gyui-bon) classified into twelve kinds of knowledge. These rituals and techniques of divination and medical diagnosis, along with burning of incense to please; overcome or replace the local gods continued into recent times constituting a mixture of .. folk religious, and of rituals involving the lamas .. in healing practices (Samuel, 1993:177-198). After the Chinese invaded Tibet the use of divination and ideas about possession and cosmology in folk traditional healing were radically oppressed. Lamas and monk practitioners were discouraged and persecuted from such practices. Qualities of a Tibetan Doctor Early Buddhist healing traditions depict four qualities desired of every physician and patient in respect to their relationship to each other. Those of a physician are compassion and excellence in medical knowledge, extensive practical experience and good knowledge of symbols, dexterity and cleanness. Among the qualities attributed to the patient are 39


memory, obedience, fearlessness, and "confession," or giving complete information about the disease (Zysk, 1991 :38-49). In an interview with a traditional Ayurvedic physician asked what distinguishes an Ayurevedic doctor from a Western doctor? She replied that a physician has certain characteristics and qualifications, and the desire to remove people's troubles and sorrows. A physician may or may not have the qualifications of an ideal doctor such as excellent skills and excellent knowledge of medicine, but nothing can be accomplished without love and compassion, the main characteristic of a physician. Being a physician is not only having the desire to remove people's physical and emotional ailments, but also the desire for their spiritual liberation through balance (personal communication, Alakananda:1991 ). Rang-bzhin in Tibetan Medicine Rang-bzhin is described in the rGyud-bzhi as the foundation for bringing together the mind, body and soul, as one entity independent and related to other enti.ties in an individual person. The individual human personality therefore, encompasses the whole being with certain conduct and behavior, which is molded at birth to form one's natural constitution or character type. 40


Rang-bzhin in Tibetan terminology refers to one's natural constitution, or character type and part of the humoral system. The three primary or "pure" rang-bzhin types (rLung, mKhris-pa, & Bad-Kan) in Tibetan medicine are in practice, combined to produce seven common character types ideally used by Tibetan doctors to aid in diagnosis and treatment. The seven character types are: loong(rLung), triba (mKhrispa ), Paigen (Bad-Kan ), rlung-triba, paigen-triba, paigenrlung, and the "duba" which would be the combination of all three: rlung, triba, and paigen. The three pure rang-bzhin types of rLung, triba, and paigen or the three character types (nyes pa ) in Tibetan medicine are similar to those of the Greek humoral system, and can be equated roughly with the three doshas (personality types) in Ayurvedic medicine; referring to the qualities and attributions of the three humors, wind, bile, and phlegm, with specific qualities given to each humor and represented in every individual. Similar to Ayurvedic medicine, rang-bzhin roughly equates to the Ayurvedic concept of Parakruti, or ones "natural constitution". This is believed to be determined at birth, being molded while still in the mother's womb. One of the primary factors contributing to the formation of one's rang-bzhin, is the "total" mother's behavior and conduct, before and during 41


pregnancy. This includes her diet and nutrition, drug and alcohol use, and her general physical and mental health while pregnant. Doctor Kungga, a processor in medical college explained the process of character type molding while a fetus in mother's womb as follow: A baby will have the nature of rLung if the mother eats rLung causing foods and engages in rlung causing behavior while pregnant. When the baby gets more "wind" (air) element in the womb, it will be a rLung nature baby. If the baby gets more I "earth" element when in the womb, it will be a baby with Bad-Kan nature. If the baby gets more of the "fire" element when in the womb, it will be a baby with mkhris-pa nature. In addition to the factors contributing in the transmission of a particular feature or character of the mother to the child, are astrological knowledge calculated by the lunar and solar cycles and used to inform astrological questions about one's birth and death (based on particular year, season, and time of the day a person is born or dies). The character type is also affected by the nature of food and the behavior of the mother. It is rare to find a person with just rlung character type. Most people have the nature of combination of two. The best nature is one who has the balance of the three. If the elements are evenly present, it is the best 42


case. According to one doctor, a person with rLung nature is thin, hunched over, talkative and physically weak. If the patient is fat, then the Bad-Kan nature is suspected. A person with rLung nature is thin, dark in complexion, light sleeper and nervous. The vulture and the crow symbolize rLung nature. A person with mkhris-pa nature is smart, with more tenancy to be jealous and passionate, and the tiger is the animal symbol for that nature. A person with Bad-Kan nature likes cool temperatures and is fat with fair complexion. The elephant represents that nature. In order to determine a person's nature, all the conditions should be considered. A person cannot be identified as having rLung nature just because he is thin and has a dark complexion. Most people are a combination of two natures. Very few people have the nature of just one of the three humors. Acording to doctor Kungga-la the father is not related to the nature of the baby. The nature of the baby depends on what the mother eats and how she behaves while pregnant. Only some doctors would choose to have their babies some particular nature. Because doctors know what to eat and how to behave to have a baby with a certain nature. If the mother has the nature of rLung, she eats rLung foods, she lives in a rLung prone land and behaves in rLung related activities, then she will have a baby with rLung nature. If she avoids rLung foods and behavior, then the baby will 43


not have the nature of rlung. An example of rlung prone land is the northern plain where it is very cold. Most nomadic lands are susceptible to rlung. Not having willow trees and having cold weather are characteristics of a rlung prone land. Consensus of physician interviews and the patient's chart readings on rangbzhin as character type revealed the following profiles: rLung types are of slouched back with poor posture, slouched shoulders, bluish. skin, thin body posture, are always talking fast and get easily distracted. They have wind in their joints, which make popping sounds, are generally slim with a weak body and dry and rough skin, are unable to achieve prosperity and tend to have short life span. Triba (mkhris-pa)types are always very thirsty, often run high fevers and have large appetites. The hair and skin are yellowish. They are clever, intelligent have good memories, are easy to anger, and fight like a "mad" person. Generally, they have average body height, shape, and strength. They tend to sweat a lot and their sweat has a "strange odor". If they eat greasy foods, they suffer bursts of dizziness and nausea. If a character with Triba nature gets a "triba disease", it will be more serious {as with rlung disease for those with rlung nature). Fever usually brings about symptoms of liver and gallbladder diseases in Triba types. 44


Paigen (Bad-Khan)types are usually heavy individuals; fat and puffy, with white and soft skin. It is often hard to see the knuckles of the hands. They have a straight body with good posture, are very tolerant of hard work and suffering. They are prone to "cold" diseases (cold kidney, cold stomach). They like quiet places and are quite even-tempered. Duba types are considered to be a rare type which contains an equal collection of all the humors with no single one predominating. When asked which of the three humor types was first in the Duba type, one doctor answered that he has never seen anyone that has had these three evenly distributed, but has only read about it in the tantras. If a doctor ever sees such a combination, the one humor that seems to be the highest is treated as indicative of character, and thus is used in making treatment decisions. Rang-bzhin is an important part of traditional medical teaching. Students learn in their first year the theory of rangbzhin associated with the three humors and the five natural elements of space, wind, fire, water, and earth. In the second year, rang-bzhin becomes a reference point for medical students to determine how the patient's character type influences his relationship to the elements and his predisposition to particular 45


illnesses. Students also learn the fundamentals of natural laws of balance. In an interview with a doctor regarding the seven common character types, he noted that rang-bzhin shows how essential it is to spend time with patients and learn about their character types, in order to know more about both their physical as well as mental predispositions. As a fundamental part of the diagnostic procedures in traditional medicine, rang-zbhin will help us to investigate the impact of Chinese-Western medicine on the over all transformation and the practice of Tibetan traditional medicine in the post-invasion era, since 1959. 46


CHAPTERS TRAINING IN TIBETAN MEDICINE BEFORE 1959 Prior to the Chinese invasion in Tibet in early 1950, Tibetan doctors were primarily trained in the private monastic tradition by a physician relative or a famous Lama doctor who took on apprentices. The monasteries served asthe main educational centers for learning Tibetan language and religion, as well as training centers for medicine, social and political activities {Goldstein, 1989; Janes, 1994;). The lineage of medical teachings in Tibet has been in a continuous form, learned and practiced in the monasteries, and private sectors, since the time of rSong-Sang Gong-po in the seventh century. In an effort to preserve this tradition, Tibetans learned to integrate local medicine with Buddhist religious ideas as practiced in everyday life. In the expansion of Tibetan medicine the building of the Chagpori college has been one of the great contributions to training and practice of medicine in Lhasa since the Fifth Dalai Lama reign (1617-1682). From that time on, Chagpori college of medicine became a center for training novice monks from the monasteries in throughout Tibet. Some students, upon graduation, 47


which could take as long as ten years, returned to their monasteries to practice or their own villages to help the many sick people there (Rechung, 1973). Studies done on Tibetan traditional medicine by Craig Janes indicatethat the training and practice of Tibetan medicine has been pluralistic in character, and this heterogeneity of training and practice varied among groups and their relationships to the elements of the government. Each group had followed its own unique voice related to a particular lineage of knowledge which was passed on by a well known physician to his relatives or other students. Students were recruited to medicine by a physician relative and accepted as an apprentice through a "contractual teacher-student relationship" (Janes, 1994). This form of "private teachings" and practice of medicine has been regarded as very "noble" by Tibetans and highly supported by the elite class of the society who had invested in the medical enterprises, and building of big business centers (Janes, 1994:7-8). As a part of the expansion in training doctors, students now were recruited from the monasteries, the army and the elite class in society (aristocracy) in Tibet to get training in astrology and medical subjects (Rechung, 1973; Janes, 1994). New novices who came to Chagpori had to learn all Tibetan grammar, reading, writing and chanting mantras (Sk., Sutras) as a part of the ritual 48


of the medicine Buddha (Rechung, 1973). Learning was through memorization and reciting the verses. Less advanced students were encouraged to start with learning astronomy in order to develop a better cognitive capacity for memorization of the teachings of the rGyud-bzhi medical text. Moreover, all students were required to learn the art of discussion and debate in explanations of medical and astronomical subjects. All students had to pray to the "Bodhisattva of Wisdom", the "Lineage" of the medical teachings two times a day; early in the morning and in the evening (Rechung, 1973). Training and practice of the medicine required individuals who were willing to commit to learning. the teachings of the rGyud-bzhi. The rGyud-bzhi medical text or "Tantra of Secret Instructions on the Eight Branches", are collectively referred to as "Four Tantras" which translated as "lineage". One of the reasons for being referred to as "secret" is because it was taught only to those who were ideally free from the three mental poisons of desire, hatred, and delusion. rGyud-bzhi is the original Tibetan medical text and is attributed to. the word of Shakyamuni Buddha, who transmitted his knowledge may be in the above described manner (oral teaching) to Youth Nyingma Yonden Gongpo "the elder" (A.D. 708833). In the eleventh century this knowledge was transmitted to 49


Yuthog SarmaYonden Gongpo "the younger" (Parfionovitch et al., 1992; Yeshi & Russell, 1991:170). The rGyud-bzhi today comprises "the four tantras"; four separate treatises, each of which deals with causation, diagnosis and treatment, pharmacopoeia and spirituality. According to Yeshi and Russell the 'four tantra' were down to more than 5400 verses with the ink of lapis lazuli on sheets of gold (Yeshi & Russell, 1991 :169). I summarize an outline of the contents of these four primary medical textbooks below: The Root Tantra (Tsa-rgyud) is referred to as the "Buddha mind" and is used to teach the basic elements of medicine, using simple metaphors for describing parts of the body and illnesses, including illness causation, diagnosis, and treatment. According to Yeshi Donden, this part is referred to as "the healthy body''; where the three humors are in a state of balance, not imbalanced (Donden, 1986:23-4). The teachings of the root tantra consist of six sections mainly treating the three humors and their sub types, and the activities of the five natural elements. The root tantra is where the fundamentals of medicine are compiled, and where three other tantras are briefly introduced. This part is studied in the first year of medical college. The Exegetical or Explanatory Tantra (bShad-rgyud), is referred to as the "Buddha-body" of Bhaisajyaguru, the medicine 50


Buddha, and it teaches details of anatomy, physiology, patho physiology and treatment. This text takes us through the formation of life from conception and birth, to old age and death. It also discusses the balance and imbalance of the three humors, causes, conditions, and classifications of diseases {Donden, 1986:24). The Instructional Oral Tradition Tantra (Man-ngag-rgyud) is a corpus of detailed treatments of speCific illnesses. It is used principally as a reference text for methods and instruction, and although studied, is not memorized like the other tantras. It talks about the one hundred and one specific disorders of the three humors, and the causes, symptoms, and treatment of these disorders. The Subsequent or Last Tantra (Phyi-ma-rgyud) is known as the ''enlightenment activities of Buddha" and deals with diagnosis and therapeutic activities of the healers such as pulse taking, urinalysis, and talking to the patient regarding the cause of illness. It also deals with the preparation of medicines and their dosage and usage, and with other accessory medications such as purgatives, emetics, moxibustion, acupuncture and catheterization (Donden, 1986). There are eight branches of Tibetan medicine described in detail in the rGyud-bzhi: general healing of the body, the 51


treatment of women's ailments, children's ailments, disorders caused by spirits, healing of wounds, using minor surgery, treatment for poisoning, problems of old age and treatment to bring about fertility and a long, happy life (Donden & Kelsang, 1983). Classical Training According to Clifford, in the 14th century Tibetan medicine was divided into two main schools; the Jangpa (Tib. Byang-pa ) and the Zurkarpa (Tib. Zur-mkar-pa). The difference between the two schools is founded in regional differences (north and south) and rooted in variation as to the location of points of intervention in the body. The identification of some herbal remedies is unique to local climate and geographical conditions; both illnesses and herbal treatments are said to be region-specific. Tradition has it that the two schools of north and south combined their knowledge in the 17 century, when Tibetan culture and medicine were reunified under the central government led by the Fifth Dalai Lama, and subsequently are considered to have gained great maturity in theory and practice (Clifford, 1984:59). The Fifth Dalai Lama's minister, Desi Sanggye Gyatso, who himself was a physician, contributed greatly to the renaissance of Tibetan medicine at this time. 52


In 1696 the Chagpori College was founded on "Iron Hill" in Lhasa. It was the first institution to specialize in medical teachings, and was under the direction of Desi Sangye Gyatso (1653-1705). After Yuthog Yongden-Gamgpo (A.D. 708-833), Desi Sangye Gyatso was the second most influential figure in the history of Tibetan medicine. Before the Chinese invasion of Tibet students and teachers at the Chagpori college were all monks from various Gelugpa ("Yellow Hat") monasteries. At Chagpori college students were taught the Gyud-bzhi. The course of study was six to seven years, followed by oral examinations consisting of reciting the fundamentals of the medical and philosophical texts by heart. Monk-physicians (geshes) were then awarded the degree of doctor of medicine. Medicine was one of the developed curricula for advanced training in the larger monasteries. In 1916, the Thirteenth Dalai Lama founded the largely secular Tibetan Traditional Hospital (Mentsikhang), "the school of medicine and astrology", a teaching hospital if you will, which gave a new impetus to medical learning and the practice of medicine in the modern era. Apprenticeship and Intuition 53


Before the Chinese invasion to Tibet in 1959, Amchis or traditional Tibetan doctors were taught medicine by way of apprenticeship, where training was done in the monasteries or within the family. Medical knowledge was passed down from Lamas to monks, father to son, uncle to nephews, and in rare cases where there was no son in the family, father to daughter. Monasteries not only served as centers for spiritual practices, but as havens where people could find refuge in times of illness. These centers later became local medical colleges and principal locations for medical studies. Health needs among the monks and the staff in the monasteries resulted in monk-healers who could provide spiritual guidance as well as herbal medicine to their lay devotees and to the local community. This was done out of compassion and as a devotional practice as part of their duty to reduce all human suffering. Doctors also charged a fee for their services, especially for services given to the public sector. Such monastic establishments also received funding largely through gifts of wealthy merchants who found such establishments a convenient resting place to receive spiritual guidance as well as medical care (Zysk, 1991 :44). lt. was not until the 17th century, when the Fifth DalaiLama supported the reunification of Tibetan medicine, that the 54


first medical school called Chagpori was founded in 1696 in Lhasa. Chagpori monastic medical school had classes for basic instruction for the monks who were selected to serve in this monastery. Popular doctors accepted students for training in clinical care on a lengthy apprenticeship base on a contractual relationship. Doctors were ranked by their background and the nature of their training, or their association with the elite families and particular lineages of physicians. Chagpori medical college was one of the popular institutions to specialize in medical teachings, astrology, divination to monks who were sent to this monastic school from other monasteries. It was a teaching hospital for pharmacopoeia (herbal, faunal, mineral) and clinical experience. It In the 18th century the model of Chagpori medical college was taken up by other larger monasteries in Eastern and Central Tibet. In the 19th century the thirteenth Dalai-Lama founded the Mentsikhang which became the training center for traditional Tibetan doctors and functions up to the present time (Parfionovitch et al., 1992). Students sent to monastic medical colleges or to the Mentsikhang for training were normally selected from other monasteries, the Tibetan army and from elite families, who had .. clean bone .. a character which made them suitable candidates to study 55


medicine. This selectivity reflects the class structure of traditional Tibetan society. According to Mircea Eliade, in training, the authoritative figure of the Lama served as a necessary element in the transmission of knowledge from master to disciple. Such direct transmission of knowledge by the Lamas, referred to as the "second diffusion of teaching," was encouraged as an expression of compassion and became paramount in the development of a doctor's spiritual guidance in healing (Eiiade,1987:35). In Tibetan Buddhist philosophy, Karma, the result of past and the present action in someone's life, plays an important role in one's health and "happiness of the mind". Learning the teachings and practice of medicine in Tibetan Buddhism has always been considered as the most noble way of reducing human suffering. In Buddhism helping the sick results in making others happy, therefore, accumulating "good karma" for the happiness of the mind. This tradition of healing continued to nourish Tibetan medicine until the -Chinese sanctioned religious institutions in 1959. Today the elderly individuals who remained to their teachers in preserving Tibetan traditional medicine are comprising the doctors who were trained in the "monastic" 56


tradition and cautiously continue teaching and practicing the rGyud-bzhi medical text in schools and privately. Case Studies Case One Jampa Trinly is a Tibetan physician and the principal of the Mentsikhang. Jampa's grandfather and father were both well known doctors. His grandfather was the teacher of the famous Tibetan physician Khenrab Norbu, the first director of the Mentsikhang. Jampa Trinley's parents had one son and one daughter and as a child Jampa has been brought up in a very dear way. When he was six years old he started school, and at seven years of age, he became a monk in Drepung monastery, and remained a monk until a year after he was graduated from the Mentsikhang in 1950. Jampa was thirteen when he lost his father, and shortly thereafter, with the help of his mother, he became a personal student of his famous uncle, Khenrab Norbu. Jampa feels he was selected by his uncle, Khenrab Norbu "with a happy mind" as his personal student. In the "family tree" of medicine and the genealogy of training based on the individual-teacher relationships, Jampa's grandfather had been Norbu's teacher {a greatuncle/nephew apprenticeship). Khenrab Norbu believed 57


that Jampa Trinley was the reincarnation of this individual, his great uncle and teacher. Jampa was a very clever student, finishing Tibetan language school at the age of twelve. By being around his fathers' medical books, he also developed a good background and interest in medicine. Under Norbu's training he was advised to study astrology first in order to "help develop intelligence", and then begin the study of medicine. He said the text he memorized during his training numbered some 25 million He says that at that time, students would come from different backgrounds to the Mentsikhang to study medicine. A few were "private" volunteers like himself. Many had a hard life while in the program, but he didn't, since came from a wealthy merchant family. Norbu kept. Jampa with him for three years as a personal aid and apprentice. He studied for a total of 9 years, and graduated in 1950 from the Mentsikhang. After graduation, he did not go back to his monastery, and decided to work elsewhere privately. Later in 1951, he met a nun, left the monk-hood, fell in love, grew his hair long and married. In 1951, the Chinese brought Chinese/Western doctors to Tibet who talked about "not taking fees and treating patients kindly". Jampa thought that if he learned about Chinese medicine, 58


he could help even more people and "have liberation in the next life," so he took up the study of the Chinese language in order to study medicine and help all suffering people, not just Tibetans. Jampa worked as a Tibetan teacher in a school started by the Chinese for two years, and then was sent tour to China in 1953-55. Upon his return he was appointed as the organizer for the Tibetan Youth Committee until the Chinese invaded Tibet in 1959 and recruited Norbu and Jampa to work to protect and organize the medical texts in the Mentsikhang, which at that time was more of a training center, than hospital with an out-patient facilities. When Jampa's teacher Khenrab Norbu died in 1962, he continued working in the Mentsikhang until the Cultural Revolution in 1966, when he was sent to the country side to work with the peasant farmers. He was forced to do manual labor for a decade until 1974 when the Lhasa medical school was established and Jampa was recalled to compile the texts for students. Jampa accepted the offer with great enthusiasm to develop to save what remained of traditional Tibetan medicine during such emergency times, when Tibetan medicine was at the brink of extinction. Jampa's effort to compile new medical texts for students has been one of the fruitful contributions to the survival of Tibetan medicine. He was forced to retire from his position as the "first 59


principal .. of the Mentsikhang in 1993, leaving him in despair by not being able to fulfill his duties. Jampa's passion is to be able to work in the Mentsikhang so long that he lives. Perhaps, appoint another doctor as his successor to carry on the teaching and practicing of medicine according to the .. lineage of medicine Buddha .. in the struggle to preserve Tibetan medicine. Case Two Kungga Phuntsok like many other Tibetan doctors is a very gentle. loving, and a humble man who teaches at Lhasa medical school. When we met doctor Kungga, he was preparing himself for a journey to a monastery; a two months .. religious studies and meditation... He was interviewed in 1993 in Lhasa, and Nawang Sherap translated the interview in its entirety. When I was a small boy, I went to the Tse-Labdra in Shegatse. This was a school where students were trained to become government officials someday. In 1963 the government recruited students to be trained as traditional Tibetan doctors. They used three sources to recruit the students, monasteries, middle schools upper class families who didn't participate in the uprising. He said he was selected from the third category. 60


In the medical school students had to memorize the rTsa rGyud and oShad-rGyud, and then study from the teacher. The standard of education is very different today than then. In the old time students were taught only sDe-Srid Sngs-rGys rGy-mTso's commentary on the rTsa-rGyud. Today, they are taught using and comparing many other commentaries by different scholars. Today, the standards of education is much higher. Doctor Kungga taught at the traditional college for three years. Most of his time was spent teaching and sometimes preparing the teaching material. For the last three years his responsibilities has been to compile texts books, printing the text books and other liaison work between the medical college and the heads of the traditional medical college. Facilities at the medical college have to work eight hours a day which is the standard work hour set forth by the government. But sometimes when they don't have anything to do, they read newspapers and drink water. During the first year in the college, the students are taught six chapters of the rTsa-rGyud and 31 chapters of the bShadrGyud. Two chapters out of the 31 chapters of the bShad-rGyud deal with Rang-bZhin. It is not very long. In the 27 chapters of the bShad-rgyud, there is a little about Rang-bZhin too. It also talks about how to treat different Rang-bZhin. 61


According to doctor Kungga, a person's Rang-bZhin is not too important. Yet, it is not good not to be aware of them either. A person's Rang-bZhin can be slightly understood just by examining the person's physical build. Chapters 27, 28 and 29 of the bShad rGyud talk about Rang-bZhin. One chapter talks about the treatments. That one chapter talks about how a doctor treats a patient and the absolute treatment. There are two kinds of treatments. There is this. thing called the "nine ways of treating a patient". Doctor gave us a simple analogy to demonstrate the importance of "right treatment. According to Kungga, Yak's burden for yak and sheep's burden for sheep; treating a patient should be such. If you make a sheep carry a yak's burden, it would be too heavy for the sheep. If you make a yak carry a sheep's burden, it would be too light for the yak. A doctor should be able to treat a patient appropriately like the above analogy. If a person with rLung nature comes down with a rLung (Ioong) problem, it is more severe than if a person with a Bad-kan (paigen) or mKris-pa (tirba) nature comes down with a rLung problem. If you don't know about Rang-bZhin, the treatment will not be accurate. It would be as if you don't know how heavy a burden the yak should carry. If you don't know how to load the yak and sheep appropriately, it would be a problem. Likewise, in 62


medicine if you don't know the patient's nature, the treatment will be inappropriate. It is important. According to Kungga a person has 10 Rang-bzhin. Place, time, food and age are just a few of them. If a person has 6 out of 1 0 of the Rang-bZhin circumstances, we consider that the person has a considerable rLung problem. If the person has 4 or 5, the problem is not severe. And it is a very small problem, if the patient has only one or two of the circumstances. A person with all ten of the rLung circumstances is in severe condition. If a person suffers from a rLung problem, in a rLung prone land, at a rLung prone time, then the person has a considerable rLung problem. All in all if a person has more than six conditions. A person has a severe case of rLung if he is in old age, lives in a rLung prone land or place, and the time is rLung prone. Such a person needs strong treatment. If you don't know that a person has a rLung nature, you won't be able to treat him right. There are three reasons why Tibetan doctors have to be careful when treating a patient. First, is the danger of under medication, two is the danger of over-medication and three is the danger of wrong medication. The patient's life is in danger if you prescribe the wrong medication. If you undermedicate, it will not be effective and if you overmedicate, there will be side effects. How a doctor should treat his patients is emphasized when 63


teaching the students. I don't know if all of the teachers do the same. Most of the teachers do that. it is in the medical book. As the yak's burden is to the yak and the sheep's burden is to the sheep, likewise, treating patient's should be appropriate. How much the student learns depends on the teacher. If the teacher emphasizes too much Western medicine, the student will be likewise. For myself, as an example, I teach that Tibetan medicine is very important. I don't know anything about Western medicine. I make sure that students believe that Tibetan medicine is good medicine. But all teachers are not the same. study medicine with a great deal of belief. Besides, I don't know anything .about Western medicine. Some teachers teach that if one doesn't know anything about Western medicine, that it will be a. problem when one goes to a village area. It depends on the nature of the society, how people think. These days people talk about how Western medicine is advancing and how Tibetan medicine is having a problem keeping the pace. It is true. I don't know Tibetan medicine that well. What I know is just a tiny fraction of what the scholars in the past time knew. If we knew Tibetan medicine as much as the scholars of the past time, we would not have to depend on anything. We believe that Tibetan medicine is taught by Lord Buddha. Scholars have said that the god named who has a hundred eyes 64


cannot see all of the diseases on the three lands; Upper Heaven, Middle Human and the Underland. There is not a single disease that is not included on these three lands. Right now, all we do is check pulse and do urinalysis. We don't know everything. It is easy to believe what other people say {the criticism of Tibetan medicine) when you don't know what you're supposed to know, when you don't know your field that well; other people are telling you something else and the times support the new ways. If you know Tibetan medicine well, everything is there. The difference between the scholars in the past time and the medical practitioners today is like the difference between the sky and the earth. sDe-Sriad Sngas-rGyas rGa-mTso, for example, has written many books including The Blue Lapis Lazulis in a short time. Today when a person composes ten pages, he thinks of himself as a great person. There is no way we can compete with the scholars of the past. We just say that Tibetan medicine is very deep, but we don't study much. If I were to tell you why there is a big difference between the past time and today, I'd have to do that through the religious point of view. If you have the habitual pattern of studying in our past lives, it is much easier to learn things in this lifetime. If you don't have the habitual pattern of the past lives, no matter how much you study in this lifetime, it is difficult to master. 65


You have the habitual pattern of past lives, you are intelligent now, and you are very studious. That is a good circumstance to become a scholar. The great scholar of Sakya mastered many languages and wrote many holy books. When he was a little boy, all his teachers had to do was show him how to write and read and he learned them instantly. In Tibet there has not been a scholar like him. One needs tenancy as well as perseverance to become a scholar. Yuthok went to India three times and went everywhere else to seek teachings. He studied from many scholars in Tibet and he ate only tsampa (roasted barley flower) and water. Today, all we do is go to school for a few years and then we are done. Perseverance is very important. We have a saying that a man with perseverance can make a hole in the rock. It takes a very persistent person to make a hole in a rock because it takes a very long time and its very boring too. The best country in the world, America, is paying attention to what we are doing. I am very happy for that. We will do the best we can. You are paying attention and that is good. We also will not fail you. American people are smart and we are nothing. Our Lord Buddha knows past, present and future. I think America is similar. 66


Case Three Jam-Den, 57 years old traditional Tibetan doctor who began studying the Tibetan language at the age of five, in preparation for studding medicine and becoming a practitioner. He is a doctor in the out-patient Mentsikhang, where many patients rather wait in line to see him everyday. He has a great sense of humor and jokes with his patients constantly, especially with the Han Chinese patients. His father and his teacher were both well-known doctors. His father's teacher was a classmate of Khenrab Norbu's. At the age of eight he studied for one year at the Mentsikhang, in preparation for the study of the rGyud-bzhi. When he was nine years old, he entered Tashi Lhunpo monastery. In 1951 he returned to the Mentsikhang and studied until 1956. Because he was from a famous family, he entered at the highest level and therefore had to memorize all of the chapters (one hundred and twenty one) of the rGyud-bzhi. In 1956, he passed oral exams in front of Khenrab Norbu. Doctor Jam Den is very famous for his intuitive knowledge and pulse reading. He noted that before the Chinese come to Tibet, some famous doctors could read the pulses of the patient's parents and relatives without them being presented. Learning and teaching such skills is impossible today he said, adding that 67


younger students lack the individually oriented, apprenticeship based clinical experiences. They are more oriented toward "rational" based education: referring to modern diagnostic methods (elctrocardiograph, x-ray machines, etc.} which aid doctors to diagnose health problems. This rational education may eventually replace the intuitive knowledge of pulse taking and creative ability of doctors in diagnosis and treatment. The more young doctors rely on modern diagnostic devices, the more they will distance themselves from intuition, emotions, compassion, or traditional values in medicine. Making the practice of medicine so highly technical will consequently result in more distant and adversarial relationship between the doctors and their patients. According to Jam Den, training in the "old society" was much harder than now, and students didn't have the many "advantages they have now": access to textbooks, electricity, desks and chairs, etc. Despite all advantages of the modern life, however, Jam Den says that in the old society doctors paid more attention to the individual patient, and students learned better than today. Because of the increase in number of patients and a shortage of doctors, there is not enough time to use the methods of rang-bzhin in diagnosis and treatment, in the out-patient Mentsikhang. He said, there are so many patients who come to 68


Mentsikhang everyday and it is impossible to use Rang-bZhin methods to determine character type or body type in each diagnosis. He says, if he is not too busy he uses a little character type in his diagnosis by just observing the patient to see whether or not there is change in skin and hair color, or when he examines the patient's tongue for color coatings. In this way, if he also notices that the patient has an angry disposition when answering questions, then he knows that this is an example of a mKris-Pa (triba) person. Then, he may ask other questions to verify his diagnosis. Case Four Interview with doctor Lobsang Tar-Chi, of the Surgery department, a 70 year old male who comes from Chon-gyel village in the Lhoka region. Doctor Tar-Chi said he was a monk in a monastery near his village and was selected to go to the Mentsikhang when the government recruited students from all over Tibet to be trained as doctors under the direction of Khenrab Norbu. He studied for 12 years in Lhasa and was sent back to Lhoka and his monastery to practice medicine in 1955. Tar-Chi was selected to become a doctor, not on the basis of examinations or demonstrated skill, but because of his wealthy family background. 69


During the course of his studies he had to memorize the rGyud-bzhi, plus another "very thick religious book" called "Cho Cho." After he completed the memorization, and before he actually was considered qualified to engage in any medical practice, he had to practice in front of his personal teacher Khenrab Norbu, practicing urinalysis and pulse diagnosis. DoctorTar-Chi emphasized that the same methods used in the past must be used today; there is no other way to teach medicine. When he returned to Lhoka he began practicing medicine in his monastery and for the public for four years. Upon leaving the Mentsikhang for Lhoka, he would bring with him a supply of medicines, along with an apprentice, and when the supply ran out, they either would gather herbs and prepare medicines, or return to Lhasa to buy more. He said this was a hard thing to do, especially if you had no financial support; Tar Chi received no salary for his services. Fortunately, he was supported by his wealthy family, and the monastery which sponsored his work. The monastery was in turn supported by the nearby wealthier families and the government of Tibet. It was also his duty, he said, to "nurture" another student who accompanied him during his time of apprenticeship. 70


As a result of the uprising against the Chinese in Tibet in 1959, a lot of people were injured and fled to Lhoka, where he was one of the only doctors who could help the injured. After being labeled as an activist in the revolution by the Chinese; he was sent to Lhasa and imprisoned for 7 years, being released in 1966. This being the Cultural Revolution period in Tibet, he was sent near Sera monastery to do "community service" for the "Fifth Prison", tending pigs, growing vegetables and cleaning toilets. Tar-Chi said that community service was no different from prison. He finished community service in 1974 and became the official doctor in the prison to help the many, many sick people there. In 1988, he was assigned to the Mentsikhang, where there was an effort to collect all of the direct students (of Khenrab Norbu in order to practice and teach traditional Tibetan medicine at the Mentsikhang. Among the ideal qualities of a doctor: Tar-Chi possesses many. He is famous for being gentle, polite and loving with patients. This he says is a special skill he credits his teacher Khenrab Norbu for giving him. He knows nothing of the practice of Chinese/Western medicine, or a word of Chinese. The method of teaching is different now, he said. 71


As a teacher, he has worked with 25 students in a practical context. Most spend just 15-30 days with him and other doctors. Patients are referred to him by word of mouth, when for example they hear "there is an old doctor .... who gives good medicine, advice, and diet", everyone then wants to see him. This is a problem today facing older Tibetan doctors. The reward for being famous is a day crowded with patients, (the pay does not change) where the younger doctors' rooms are relatively empty. A busy doctor has no time to use complete Rang-bzhin methods in his diagnosis. The average patient visit observed in Lhasa in 1991 (n=300) was about three minutes (Janes, 1994). He sees a lot of Chinese patients and foreigners for treatment, due to his stature as an "old" doctor. When he was asked "why do so many people, when they are treated by you, cry?" He responded: "because their disease is relieved and they cry tears of joy. Others cry because he practices with a very kind heart". As his teacher taught him, he treats his patients gently. He said "when you treat patients in this way, the treatment is much more effective". Some diseases and the disposition of certain symptoms make sense only to the members of that particular culture; the values and customs shared by the same people. Tibetans say that the Chinese are unable to relate to their problems and that they 72


don't understand the relationships of mind, body, and the soul. According doctor Tar-Chi, Tibetan medicine is a "complete" medical system if taught in the "right" way. Then, Western medicine can be a great compliment to its expansion. Most religious bo.oks (Pecha)' :were taught by knowledgeable teachers who had to supervise their young novices on the individual bases to make sure they learn the proper way. The study of Pecha (holly books) is no longer a major priority of medical teachings. Instead, more emphasis is paced specialization and the use of modern techniques. There are a few knowledgeable doctors in Tibetan medicine who are still alive, and are trying hard to preserve Tibetan medicine through their teachings and their practice. They believe, Tibetan medicine must be preserved, before it completely disappears in the Chinese markets. They are worried that today's younger doctors know only a small fraction of the Tibetan medicine, and the teachings of the "lineage" of medicine Buddha is in danger, due to the Chinese overall control over school curriculums and policies in Tibet. 73


CHAPTER4 TRAINING IN TIBETAN MEDICINE SINCE 1959 Tibetan medicine has been subject to officially sanctioned selection of medical students and censorship in official textbooks. The first sanction was in 1959 when the Chinese took over Tibet and turned the Mentsikhang into a school with out patient facilities for training students until 1961. Then it was transformed into a hospital with Khenrab Norbu as the first principle ( Yon-Kran) and Jampa Trinley as the second principal. At this time there were about 70 doctors practicing and teaching in the Mentsikhang. There were two classes of students, one of 19 and one of 25, trained in 1961-62. There was another class of 45 who entered in 1963 and graduated in 1966. This class was the last class trained until after the Cultural Revolution. Teachers and doctors were sent to the countryside to do manual labor. No more students graduated until 1978. In August of 1966 the Cultural Revolution reached Tibet and older doctors were .. brought down .. from their positions, labeled as belonging to the .. four olds .. superstition, gods, ghosts, and evil spirits.. or labeled for practicing .. old customs, old habits, old religion, or old culture .. (Heng et al., 1984). These doctors were 74


accused of belonging to the elite class of society the Dalai Lama's government and were sent to the country side for manual work and "re-education". According to senior doctors in the Mentsikhang, during the Cultural Revolution all "intellectual medicine" suffered drastically. Only the medicine of barefoot doctors was elevated; referring to Mao's proclamation that all doctors be sent to rural areas to help peasants. According to one senior doctor, in the classrooms, students had no respect for teachers; they "stood on their desks and did not listen". For almost a decade Tibetan medicine was "underground" and was either taught in secret or practiced in the Chinese prisons, where in some cases doctors were ordered to treat fellow inmates. Others did so secretly. In 197 4, a program of training in Tibetan medicine at the Lhasa medical school was established. This was the first such training offered since the beginning of the Cultural Revolution. Two classes of Tibetan students were recruited, mostly from the villages. Jampa Trinley was asked to compile new texts for teaching the rGyud-bzhi to these students. Under Chinese orders, he had to eliminate Buddhist aspects of Tibetan medicine in these new editions, yet he took great joy in making these texts, in order to: "save whatever portion of Tibetan medicine he could". Fortunately, these works were only used for a few years. In 75


1980, the use of the original rGyud-bzhi was again permitted, but students have a fraction of the time in school, for it competes with Chinese history, language and politics, as well as biomedical training. The Mentsikhang Middle School was established in 1984; the first Tibetan medical school "dedicated" after the Cultural Revolution. Students (men and women) were collected from lower social class background, monasteries and the elite families who did not have any political affiliations with the former government. In 1990 the university-level Tibetan medical college was established. Those students who have finished upper middle school (equivalent to high school in the U.S. system) study medicine for 5 years, while students who have only finished the lower middle school (about 9th grade in the U.S. system) study medicine for three years of formal classroom training, with one year of supervised training (internship) in the hospital. The college students have a higher salary when they graduate. There are four training levels for doctors in modern Tibet (Janes, 1994). The first level is the "village" doctors who are trained by county-level physicians for about one month. The second level is the "junior-level" doctors who are trained for about three to six months by the health bureaus. The third level is the "mid-level" doctors who study for three 76


years in a classroom style in China, with an additional year or two of practical training under supervision. The last level of training is the .. fully qualified .. doctors who study for five or more years in one of the major universities in China. Although there are o,ver two thousands Tibetan doctors practicing medicine in Tibet, but the teaching and practice of I medicine according to the doctors has become .. weak .. with only a surface-level understanding of diagnosis and healing. Most doctors know very little of the teachings of the .. four tantras ... They learn only simple methods of diagnosis and treatment through pulse taking and testing urine samples, with less time spent in learning the Buddhist aspects of Tibetan medicine. The following case studies illustrate the problems and difficulties Tibetan medicine has experienced as a result of the Chinese modernization plan. Case Five Doctor Norbu decided to become a doctor because he considered it a good thing to do, both for this life and the next. Before he was sent to primary school in 1959, he used to be a monk. In 1962, he was selected to study medicine under Khenrab Norbu, the head of the Mentsikhang. He began memorizing the rGyud-bzhi in 1963 and graduated in 1966. He was then put under 77


apprenticeship with two other older doctors for three years for further training (private In 1970 the Cultural Revolution forced him and seven others to go to the country side, a remote area in east central Tibet called Khongpo to be a farmer. After one year he joined the staff of a -local hospital in a remote county with a population of only 2,700. He served for 8 years both as a doctor and teacher for younger doctors who came for training in the hospital. He also received two years of training by the doctors from the interior of China, who came to the hospital to teach Tibetan doctors ChineseWestern medicine. In 1979 he came to Lhasa and worked in the research department of the Mentsikhang until 1987, when he became the physician in charge of the internal medicine department When asked about the training of doctors and the experiences of his classmates compared with those of the present day students, he said that he did not have a chance to apprentice. He worked only three years with older doctors before he was sent to countryside to practice. Like others of the same generation, doctor Norbu had to make the best of what was available to him. He had to learn how to diagnose diseases he saw, be able to identify plants, and to make his own medicines. These days, he said, students only read about these things in the books. They don't have the opportunity 78


to learn the practical skills of plant identification and medical production. Now students specialize in only a small range of diseases and are not aware of the types of diseases prevalent in the countryside. Nowadays, it is very difficult to teach students all of these skills, they have a limited knowledge of medicines. Since the medicine factory is separate from the Mentsikhang, students are seldom exposed to the identification and production of medicines. They only learn the name of herbs and what they are good for on annual plant gathering excursions in the late summer. Doctor Norbu said that he sees this as a big problem for research in Tibetan medicine and for its expansion. Another problem facing Tibetan medicine is that younger doctors lack the proper training in religious healing. He said that according to the rGyud-bzhi, there are 2000 different diseases, out of which 400 require both medical as well as religious treatments. Younger doctors cannot provide such religious treatments. When asked about the differences between his class {19631966) and the younger doctors today, he replied that new medical students are not well trained; that they depend on their teachers a lot. They don't know medicines well and don't know how to make them. He said the members of his class were more self-79


trained and had to learn on their own. "Today's doctors are becoming more specialized and they don't have to perform so many tasks", he said, adding that it would be very difficult to train new doctors as in the old times (before 1959), as training in the Tibetan classical language is now discouraged. Patients' charts were in fragmented Chinese and Tibetan. We overheard doctors make fun of young doctors' "illiteracy". Case Six Nima is a 46 year old Tibetan doctor. She was among the first group of females who were selected by the health departments of Lhasa to study medicine. After Nima graduated from middle school (about 1Oth grade), she attended the Mentsikhang from 1963 to 1966. During this time she learned medicine by memorizing the rGyud-bzhi (the edited version), and in the summer, going along with older doctors to the mountains to collect herbal plants for identification and medicine production. According to doctor Nima, these days there are specialized teachers who teach only one particular subject, but she "had just a single teacher who taught everything". She said that Tibetan medicine encompasses all aspects of medical practice and in the times when she was a doctor in the village, she had to be midwife and also treat women's diseases. 80


When she was asked if she uses the method of rang-bzhin in diagnosis, she replied that first she relies on the traditional methods of observation, touching and talking to the patients. Secondly, if the first method fails to work, she may use modern techniques, such as blood test and chemical urinalyses to diagnose. Doctor Nima said that the intuitive approach of rang-bzhin and the use of traditional methods of diagnosis should give doctors a clue as to what the appropriate medicine should be. Expressing her preference for modernity, she said that learning methods in those days were "less sophisticated", with no Chinese or Western medical training. Case Seven Doctor Tenzing was born in 1944, and when he was 8 years old he became a monk in a monastery in the Shigatse area. He was among the two who were selected by the government from his monastery to study medicine. At the age of 17 he went to Lhasa to study medicine. He studied the rGyud-bzhi, memorizing the four tantras in 8 years, then stayed in the Lhasa Mentsikhang to help out there. He said that young doctors "had to work hard and do everything" during those days and so did he. 81


Unlike other doctors who were sent to countryside to do manual labor or practice medicine, he stayed at the Lhasa Mentsikhang and only occasionally visited patients in the countryside. But his home remained in Lhasa and he said he did not suffer too much like some other doctors during the Cultural Revolution. He was from a poor family, and thus was considered from a political stand point, one of those to be elevated in need of little reeducation. Doctor Ten-zing thinks that the separation of the Mentsikhang and the medicine factory is not really a problem for new students, as some other doctors may perceive. Ten-zing thinks specialization is an advantage in "modern Tibetan medicine", and medicine manufacturing is a specialization by itself. He says that the environment in which the students study and get their training in medicine these days is much better than in his time. In his time "life was very poor" and they had to work very hard. Of course, he said that made them learn better. but these days, students don't have to worry about living in poor conditions, they need only concentrate on their studies. Unlike some other doctors who see medicine manufacture as an important part of doctor training, he thinks "it is different now than in the past", some people have to work in the medicine factory to make drugs, and some just study to become doctors and 82


treat patients. One can not learn everything. He seems to enjoy the idea of .. specialization .. as a basic improvement that has been introduced into Tibetan medical practice. Doctor Ten-Zing has specialized in Women's and Children's Diseases, and has worked in this department since 1966. The Contemporary Model of Tibetan Medicine Tibetan medicine is being transformed as a result of modernity and rapid culture change. By training a new generation of doctors with Chinese methods, in classroom versus apprenticeship model, students learn advancement depends on competing with one another rather than following one older respected doctor, a devoted monk doctor, or a geshe Today younger Tibetan doctors learn about treating kinds or categories of cases or diseases, rather than learning about the unique individual constitution of each patient; a hallmark of humoral medicine. They learn a new set of medical values that include technology over tradition, trusting lab results over their own intuition, and desiring quick results in favor of slow. They rely more on lab tests, blood samples, x-rays and other Western methods of diagnosis and less of unique individual intuition. In Tibet today, specialization and departmentalization demonstrate rationality model and emphasis on modernity, the 83


change in thinking. In general the older doctors believe that specialization is a big problem facing the traditional holistic view of Tibetan medicine, and even though specialized doctors may be good at treating a certain part of the body. they lack the necessary knowledge for treating other parts of the body affected as a result of the illness. One older doctor felt that since specialization requires a knowledge of science and technology, younger doctors tend to know more about certain medical devices and their usage, therefore they may be better than older doctors. Specialization enables younger doctors who are trained under the Chinese Western model to compete with each other to make higher salaries (regulated salary} and having modern lifestyles. The reconstruction of Tibetan medicine within the Chinese state has filtered Buddhism from the supplementary medical texts, renamed landmarks previously associated with deities, and sternly discouraged folk Buddhist practices as .. superstitious ... During the Cultural Revolution Tibetan doctors were .. brought down.. from their positions. by being labeled as .. superstitious .. and belonging to the group of ''gods, ghosts, and evil spirits .. or of the .. four olds". After many years of hard labor in camps or in the countryside, senior doctors were finally brought back to practice Tibetan medicine under .new Chinese orders in the early 1980's. 84


However, the Chinese government remains reluctant to introduce religion fully into Tibetan medicine. Some fundamental aspects of Tibetan medicine are still labeled as "old fashioned" by doctors who were trained during the Cultural Revolution, since they were. considered a part of the "old society". An interview with an older Tibetan physician trained in the "old society" indicates that "during the mid to late 70s, and mid 80s, the government demanded that training in Tibetan medicine be done without mention of religion. This was impossible and the teachers found themselves without much to teach. They had to stop where any religion was included, saying ... and ... and ... and ... and so on. These words were actually used by the informants to show the degree of confusion and difficulties in teaching the original tantra scriptures. The only way to allow teaching of Tibetan medicine has been for teachers to censor its core Buddhist essence. In the process of transforming from the traditional to the modern many monasteries where closed or destroyed during the Cultural Revolution and folk religious healing practices which has been an inseparable part of the Tibetan medicine were banned. Older doctors in the Mentsikhang were sent to the countryside to learn from farmers and peasants. During the Cultural Revolution students were trained for a short time (one to 85


six months) as "barefoot doctors" and sent to the villages to provide health care services to the farmers and workers. For immunizations, the older doctors were trained in Western medicine (injections) and worked with barefoot doctors in the prevention of epidemic diseases. Students were basic science, biomedical anatomy, physiology, chemistry, and the fundamentals of the materialist language in medicine which teach the mind-body separation. 86


CHAPTERS TIBETAN MEDICINE AND THE "SOCIALIST FREE MARKET" ECONOMY The introduction of the new socialist free market economy to Tibet has resulted in a new economic context which continues to drive the rationalization of Tibetan medicine, as it seeks to compete in a pluralistic medical setting. The idea of "Socialist Market Economy" was first enacted in 1982 and later, in 1988 was amended in the new version of the constitution. The idea was to encourage people in various profit making activities, and to find ways "to justify the existence and development of private economies and the transfer of land use rights" (China Daily, March 26, 1993). Chinese equated this idea of market economy with Capitalist mode of production where private ownership will provides more autonomy and free exchange. Under the "planned economy" which was established in 1954, China committed to provide free health care for everyone. All funding and allotments had to be appropriated by the Central Government and then distributed to the regional and county hospitals for practice and training. 87


Today the "planned economy" is still regarded as the first priority the "Four Cardinal Principles of Communist Party of China: the socialist road, people's democratic dictatorship and Marxism, Leninism and Mao-Zedong as the dominant ideology that must remain intact (China Daily, March 26, 1993:4). The new market economy is ranked as the "second priority" to the "planned economy". In the new market economy, doctors are encouraged to invest in store-fronts and newly constructed restaurants near hospitals and in private clinics to supplement their income, due to inadequate allotments for the Mentsikhang and other facilities in Tibet. Economic pressures, induced by a ten percent reduction in state funding for the annual operating budget of the Lhasa Mentsikhang since 1990, have prompted doctors to "invest in a variety of income producing activities", (Janes, 1994) to supplement both personal and hospital income. Doctors are paid a monthly salary through their work unit, in this case, the Mentsikhang. Being a doctor is classified as a trade in China, like being a carpenter, so doctors earn what they describe as an "average salary" and they were amazed to hear about the large incomes of American doctors. Although a Tibetan doctor's salary is not comparable to doctor's incomes in the west, some other benefits are provided by 88


the government. These benefits include housing, monthly allotments of basic foods and kerosene, and new .. profit sharing .. programs in restaurants and store front rentals. Other important sources of income for doctors are clinics, such as the one in. Chengdu built in 1987, and the one at the Lhasa Holiday Inn, which serves tourists. The average visit to the Holiday Inn clinic costs the equivalent of fifty U.S. dollars. This is private income, a .. second shift .. in the evening for a few chosen. The clinic job at the Holiday Inn has recently become very popular. Private clinics on the Barkhor afford doctors an alternative to public practice at the Mentsikhang. Several doctors said they planned to take early retirement from the Mentsikhang and open private clinics. According to one senior doctor, these clinics, which usually employ three to five doctors, have gross incomes of as much as ten to twelve thousand yuan per month. Private .. biomedical .. doctors (giving injections, glucose I.Vs. and vitamins) averaged incomes of 1000 yuan (Chinese currency) per month, while the average salary for a physician at the Mentsikhang, a government work unit, is 250-350 yuan per month depending on rank and seniority. Today the medicine factory sells medicines to private doctors in Tibet and has recently expanded its market to include 89


clinics in China, Nepal and India. While this market is still small, it is growing rapidly with the social reforms like the socialist market. These reforms have not only necessitated "other" sources of personal funding, but also the allocation of health care services in general. The money that the central government allocates for. each region is not nearly enough and doctors are faced with shortages of medicines and supplies, especially in rural areas. The consequences of these reforms are higher prices and shortages of medicine in the rural areas. A 72 year old female Tibetan doctor who lived in TseThang prefecture, claimed that, not only did she not have medicine for her patients, but there was no medicine to treat even her own illness. It was mid April and she had not yet received her yearly allotment of money to purchase medicines. Though this elderly doctor is too old now to gather her own medicines, and though the medicine factory is of great benefit, in that it can provide this service for her, she must pay for all medicines. As the doctor of a poor rural region, she gets most funding from the government. But if government funding doesn't reach her region, because it has been diverted to foreign markets, or to those who can afford to pay "the market price," then the people of a large rural area are without adequate health 90


care. Because of the competition introduced by market reforms, those areas most able to afford medicine will get medicine, which leaves China's commitment to rural health largely unfulfilled in Tibet. As I stated earlier, before the Chinese took over Tibet, the medicine factory was inseparable from the hospital and doctors used to gather and prepare their own medicines. Now the medicine factory is a separate work unit with a separate physical location, separate operating budget, and the Mentsikhang is now one of its customers. Thus, doctors no longer have sole claim to .. the expert knowledge .. of medicine-making. The medicine thus becomes a commodity, rather than a part of the physician's art. One doctor said that many medicines appear to be less effective now than in the old days, and that due to the high standard of living and the availability of many medical resources, one must boost the effectiveness of the drugs by prescribing stronger medicines, or in greater quantities than previously. This is not in accordance with the teachings of the rGyud-bzhi which says that treatment starts with small dosages of .. ordinary .. medicine and gradually increases the amount if necessary .. Precious pills", said the doctor, used to be really .. precious ... but now people use them all the time. Thus, they become .. ordinary .. medicines and less effective. 91


Today, many of the older doctors are concerned about the future of Tibetan medicine, saying that Tibetan medicine is not like what it used to be before the Cultural Revolution. They believe the new generation of young qoctors trained in the new classroom style, don't spend enough time on religious aspects of medicine and no longer gather their own medicinal herbs like they used to. They basically learn about the properties and identification of herbal plants in books and displays, with occasional field trips in the course of training to identify plants. Today, the main task of gathering medicinal herbs is left to peasant farmers, who collect them after the rainy season and sell them to the medicine factory. This, coupled with the tremendous pressures on the doctors as they are required to work faster, has resulted in a three minutes ineffective doctor-patient interactions and therapy. According to senior doctor Karma-la from the research department, Tibetan herbal medicine needs improvement in its standardization, packaging and labeling for export to Western countries. He is concerned about the future of Tibetan herbal and mineral products in the free market economy. Doctor Karma Ia has a long history of healing and has written a two volume compendium on Tibetan medicine under the direction of the 92


Mentsikhang research department. He has been the head of several successful research projects using the funds of the government for research and expansion of Tibetan medical products. Currently he is conducting research to .improve Tibetan medicine and expand its foreign market. Among the research projects at hand, is Srolomarbo, a refreshing drink that inhibits the symptoms of high altitude sickness and also is good as a sports drink. The research department of the Mentsikhang is currently working to register the patent for Srolomarbo. They applied in 1989 to the China Health Bureau and have not yet heard if they will win patent on its contents. Today, while the patent to this Tibetan medicinal product is "undetermined" and doctors and researchers at the Mentsikhang are suffering funding shortages for research and development of Tibetan medicines, Srolomarbo is being sold all over China by a Han company in Chengdu. The Chinese government is rapidly pushing to modernize the Tibetan health care system by commodifying medicine for local and international markets. This could serve as an avenue for profit in the hands of the Chinese government, which has by now, realized that the world's demands for herbal medications and pharmaceuticals are expanding. 93


CHAPTERS SUMMARY AND CONCLUSIONS The process of modernization and change has fragmented Tibetan cultural, political Identity, religion and language. Rapid migration of many Han into Tibet in recent years, particularly asso"ciated with the military presence, presents difficulties for both groups. Tibetans have increased health risks from poor sanitation and overpopulation. For the Chinese in Tibet, isolation from family, poverty, altitude sickness and a higher risk of infant mortality are among the difficulties many face (Moore, 1989). Tibetans have been isolated from their language in schools and in the work place, and many twenty year olds cannot read or write Tibetan. Access to a good job comes only with fluency in Chinese, arid ability to demonstrate loyalty to .. the party ... Upwardly mobile Tibetans dream of sending their children to China, knowing that is the only way to compete in its market. Young Tibetans who are educated in the big cities in China, now are reluctant to go to the country-side to practice medicine. And while rural areas of Tibet are suffering from sporadic shortages of medicine, modern clinics of traditional medicines in big cities are becoming the center of attraction for tourists and those seeking alternative health care. 94

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The religious aspects of Tibetan medicine have .been greatly disrupted by the Chinese government's modernization plan. Buddhist healing involves spiritual, medicinal, and personal elements. Tibetans still practice religious rituals in healing in private and still travel long distances to get to the Mentsikhang to be treated by an "older" doctor; one who was trained prior to 1959. Pilgrims who come to Lhasa as the "Mecca" of Buddhism in Tibet, come mainly for three reasons: to build merit through circumambulation and offerings; to seek divination for their illness and to seek Buddhist medicine at Mentsikhang. The popularity of the Mentsikhang means that doctors in the out-patient hospital in Lhasa had an average of only three minutes for each patient, as they see in excess of one hundred patients in a day. Generally the older doctors in the out-patient hospital are too busy to use the principles of rang-bzhin with their patients. Instead, doctors now rely more on the information their patients provide them through specific complaints. The increase in the number of patients could be viewed in one of two ways. Either, that this is a sign of growth in Tibetan medicine, where today it can provide medical help to the majority of the people who come from remote areas to the Mentsikhang, or that the increase in the number of patients is a reflection of the difficult conditions and stresses of social life in Lhasa. 95

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The general concern of the .. older .. doctors is that Tibetan medicine are no longer able to use the full potential of Tibetan medicine to respond to the increasing demands of their patients. Due to overcrowding, they no longer are able to use rang-bzhin in their practices. Younger doctors who learned Tibetan medicine in the classroom style with Chinese language and Chinese values of modernity, do not practice Tib7tan medicine with a full faith; they doubt the inherent value of intuition and want to embrace all things modern. They want to incorporate into their practice what they perceive as a superior approach, the science and technology of biomedicine. According to Tarchin from the research department, one characteristic of Tibetan medicine is that doctors can make medicines according to individuals illness. That is an important aspect of Tibetan medicine. Now, he says that the medical facility is very big and the old practice of making medicine is not .. practical... Doctor Kungga from the Lhasa Medical College claims that: It is also a reflection of the nature of today's society. In the old days we learned everything from our teachers. They would give us hands on training in how to treat diseases and how to make medicines. They taught us where medicinal herbs grew and all the details. These days, the younger generation will give you medicine from anywhere, and if 96

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they can not find out the problem, they will use x-ray and cardiogram techniques {personal communication, 1993). Tibetan senior doctors are indeed fascinated by technology and its impact on people's lives and they want technology to complement Tibetan medicine, rather than to replace its traditional diagnostic methods. They stress the need for science and technology to be taught in Tibetan. But in 1993, the Chinese government failed to keep its commitment to develop Tibetan language in the instruction sciences, based on terminology borrowed from India and Nepal. In this thesis I have shown how the intuitive aspects of Tibetan medicine are threatened from several directions. Modern training methods made the transfer of traditional intuitive knowledge virtually impossible because the apprenticeship with older doctors is no longer practiced and because classroom style teaching replaced the teacher-apprenticeship system of training. Buddhist philosophy, the foundation upon which Tibetan medicine is built, has been dismantled through religious oppression. The forces of modernity in Tibet, including the introduction of biomedicine, in which young doctors learn to value lab tests over intuitive knowledge, have had profound impact on the training and practice of the traditional Tibetan medicine. The state health bureaucracy and the classroom model of training, with its standardized curriculum, has replaced the 97

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apprentice-like relationship and has resulted in the viewing and describing of the humoral theory of illness in light of science and in relation to alternative systems of .. truth... The new training places greater emphasis on the disease model and mind/body separation, than on the subjective art of rang-bzhin in diagnosis and treatment, pulse and urinalysis. Ironically, in the process of modernization, the market economy, by enabling private clinics to develop, may also be providing the only environment in which can continue to be practiced. Although apprenticeship opportunities are greatly diminished in official schooling, we are told that this relationship does still exist in private, within certain lineages of knowledge. Doctors still come to the Mentsikhang from a long line of doctors and training in the home is possible. If the subjective intuitive and religious aspects of Tibetan medicine are to survive, it will be in this context. .98

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>am, V., Eva 1991 The Magic Life of Mi!arepa Tibet Great Yogi. Shambhla. Boston & London. >arling-Smith, Barbara. 1993 Can Virtue Be taught? University of Notre Dame. Notre Dame, Indiana. >ommer, Tom 1988 )onden, Yeshi 1986 Tibetan Medjcjne; And other Holistic Health Care Systems. Foreword by His Holiness Dalai Lama. Routeledge Inc. London & New York. Health Through Balance: An Introduction to Tibetan Medicine. Snow Lion Pub. Ithaca, New York. londen, Yeshi, & Jhampa, Kelsang 1983 "Tibetan Medicine". Library of Tibetan works and Archives. Series No. 6. louglas, Nik 1978 )owns, F., James 1972 liade, Mircea 1987 Tibetan Tantrjc Charms and Amulets. Dover Pub., Inc., New York. Lhassa of Tibet. Human Relations Area Files, Inc. New Haven, Connecticut. PP. 76-79. The Encyclopedia of Reljgjon. Macmillan Pub. Co. New York. vol. 13, P. 34. 100

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an, C., Michael and Praag, V., Walt 1986 Population Transfer and the Survival of the Tibetan Identity. Special Report Series. Pubs. The U.S. Tibet Committee. New York. eshi, Padron; Russell, Jeremy 1991 Cho-Yang: The Voice of Tibetan Religion and Culture. Dharamsala, India. vsk, G., Kenneth 1991 Asceticism and Healing in Ancient India: Medicine jn Buddhist Monastery. Oxford Univ. Press. New York, Oxford. 105 -------..'.. .. ----------------------