REVIVING TIBETAN MEDICINE, INTEGRATING BIOMEDICINE
Tibetan medicine should improve relations between the nationalities and develop the economy and the culture of [minority] nationality areas.
—Short History of Ngamring Dzong Tibetan Medical Hospital
A SMALL place for Tibetan medical practice, publishing, and teaching had opened up after 1974, and the first classic texts were soon republished, albeit with “religious elements” cut out. Following the Third Plenum of the Eleventh CCP Central Committee in Beijing in December 1978, which ushered in religious freedom alongside economic and other reforms, Tibetan medicine was able to expand more fully. State policies allowed Tibetan medical doctors to revive the tradition’s own epistemologies in government clinics and schools, paid them salaries, and recruited new students. Doctors tried to revive and adapt their practices to the new circumstances over the ensuing two decades. During the 1980s and 1990s, state-sponsored Tibetan medical infrastructure and personnel grew rapidly in urban centers, expanding in county hospitals. Tibetan medicine was practiced in selected township clinics, which took in former barefoot doctors who had benefited from exposure to simple Tibetan medical techniques. The former three-tier primary care system of brigade health stations, commune health center, and county hospital was reorganized along the lines of the new administrative units, changing to the three tiers of village-level health worker, township clinic, and county-level hospital. Following decollectivization and the (re)introduction of the “household responsibility system” in 1981–83, the commune-based Cooperative Medical Services (CMS) scheme, on which the lowest level of care had depended for income, collapsed. The barefoot doctors in many cases became village health workers but had great difficulty sustaining their work and stocking medicines.
STATE-SPONSORED REVITALIZATION OF TIBETAN MEDICINE
Fundamental to government support for and expansion of Tibetan medicine in the 1980s were what Janes calls “Chinese State interests” (1995: 23). We need to place these in a wider context of growing freedom in social, cultural, and religious practices paired with increasing market-driven economic development fostered throughout China under Deng Xiaoping, and in the TAR through a six-point plan announced by party secretary Hu Yaobang in May 1980.1 Chinese state interests were, according to Janes, primarily concerned with Tibetan medicine as an arena where the state could show overt respect for a select aspect of local culture and customs (23–24), with the added benefit of providing locally appropriate primary health care for rural populations. Both interests contributed to central government efforts to relegitimate itself after the devastation wrought during the preceding years and to help counter the ongoing challenges posed by the reluctantly participant minority populations. In renewed attempts to co-opt minority populations, “Tibetan medicine likely represented a reasonably safe and apolitical forum” (Janes 1995: 23).
Janes has shown in detail how the state, through central, regional, and local governing mechanisms, orchestrated the expansion of Tibetan medicine—for instance, by setting up higher-level education in Tibetan medicine at Tibet University, and later establishing an independent Tibetan Medical College. Most contemporary Tibetan and Chinese works on Tibetan medicine published in the PRC in the postreform period necessarily highlight the role of the state in promoting Tibetan medicine.2 Such state-led imperatives, like those that created traditional Chinese medicine (TCM), would seem to lend themselves to analysis through the “invention of tradition” theory (Hobsbawm and Ranger 1983). Janes and Hilliard (2008) employ this line of analysis for Mongolia, where after seventy years of persecution, traditional medicine needed to be “reinvented” when democracy was established in 1990. There were no longer any practitioners to transmit and revive medical practices.
For the TAR in the 1980s and 1990s, due to the shorter period of attacks on Tibetan medical practitioners, Janes and Hilliard speak instead of a “revival” of Tibetan medicine: by the mid-1980s, “the institutions of Tibetan medicine—the hospitals, clinics and medicine factories—had been restored to their formerly integral position in Tibetan society” (35). In fact, Tibetan amchi established frameworks and institutions for Tibetan medicine that had not existed previously. The state was not interested in rebuilding destroyed Medical Houses or funding practitioners in their homes or monasteries. They wanted Tibetan medicine to fit into the recently built-up health infrastructure, and thus at least partially integrate it with biomedicine. Thus the theorizing, practice, and funding of Tibetan medicine had to change.
From the 1980s onward, new laws regulated and legitimated what was variously called nationality or ethnic medicine and pharmaceuticals (minzu yiyao), in ways similar to Chinese medicine. The latter was enshrined in the constitution of the PRC in 1982–83, precipitating a host of “nationality medicine”–specific regulations and laws on national and regional levels.3 In marginal areas such as Ngamring in Tsang, TAR-specific policies were thus easily promoted and enacted. A cohort of government servants and local cadres at the county level in Ngamring, for example, firmly established Tibetan medicine in government facilities. Some of them were at the forefront of Tibetan medicine’s local revitalization but avoided challenging the hegemony of the post-Mao PRC state and party line.
At the same time, a range of private amchi in Tsang pursued their own projects and actively sought to reestablish meaningful social and medical networks and practices. Some of these did not overlap with those the state was eager to promote in government clinics and colleges, where a tendency to standardize knowledge transmission and practice was inevitable, as was the integration with biomedicine. Multiple advocates and initiatives emerged in and across two main currents of Tibetan medical revitalization during the 1980s and 1990s: that led by the state and that embodied by local private amchi.
The first current of Tibetan medical revitalization was promoted through government cadres and institutions in urban settings and to some extent in the rural primary health care system. High levels of financial and often personal investment persisted here until 1994, when new market-led health reforms began to be implemented in the TAR in earnest, almost twenty years after the rest of rural China. Reforms eliminated much of the funding previously available for building Tibetan medical institutions and providing rural primary health care. The second current, which began later and continues today, has been the revival of Tibetan medicine in private family homes, clinics, and schools, as well as monasteries—at times with the support of international nongovernmental organizations (NGOs). Some of these initiatives aimed to fill gaps in primary care provision that persisted or became apparent in the wake of medical privatization after 1994 for poor rural patients.
The lives of some of the actors encountered in this chapter straddle governmental and private medical domains, as well as the pre- and postreform periods, which experienced radically different forms of sociality and politics.4 How did private initiatives and practitioners relate to state-funded Tibetan medical institutions and initiatives? Where and how did private amchi reestablish their work? In what ways did their practices differ from amchi who trained in the state system, not least in relation to the continuously reshaped government policies regarding the integration of Western and Tibetan medicine? What was the role of women amchi in the postreform era?
The parallel development of state and local medical institutions and practices resembles similar processes in Chinese medicine during the same period. The CCP’s endeavor to abstract, standardize, and fully institutionalize Chinese medicine as TCM was far from complete (Scheid 2007). This was despite prominent CCP involvement in the creation and use of TCM in revolutionary discourse and health work in the 1950s and early 1960s (Taylor 2005), the barefoot doctor campaign (Fang 2012), and the postreform period (Farquhar 1994, 1996; Hsu 1999; Scheid 2002, 2007).
Through accounts of attempts to reestablish Tsang’s Tibetan Medical Houses, revive medical work among Buddhist monks and nuns, and establish a private Tibetan medical school, this chapter analyses revitalization of Tibetan medical cultures and the ways these operated outside of governmental Tibetan medicine institutions and state-sponsored initiatives.
As we have seen, Tibetan medicine’s authority as well as the social and physical aspects of the lay Medical Houses were successively dismantled during socialist and Communist reforms and campaigns in Ngamring and Sakya. In the postreform period, with its more open political context, to what extent could Medical Houses be rebuilt? Could private medical practice be revitalized?
Rebuilding the Mentrong
For the first half of the twentieth century, the Mentrong was a gerpa household with landholdings and several yokpo (servants). Its high social standing and economic and ritual power derived from family connections to the western Tibetan Ruthog kings and the royal and medical lineages of Ngamring’s past rulers. This position also conferred ritual responsibilities from the local monastery. Classified in 1959–60 by Communist work teams as “serf owners” and “exploiters,” members of the Mentrong were punished harshly during the successive reforms and campaigns. Despite its initial loss of most of its material wealth and its almost complete destruction near the beginning of the Cultural Revolution, parts of the physical building survived for another three years. Rinchen Wangyal and his wife continued to live in a ground-floor room with a makeshift roof. This accommodation was porous to the summer rains, but the couple had nowhere else to go.
These remnants of the house were finally destroyed in 1969, when it became, according to Rinchen Wangyal, a casualty of the government’s crackdown on widespread local protests.5 Rinchen Wangyal and his wife then moved to a one-room shed, where they lived for the next thirteen years, under no better circumstances. They were later permitted to join the commune and subsisted largely on official barley and butter rations calculated on the basis of their labor contributions to the local production team. They were given land in early 1980–81, when the newly introduced Household Responsibility System (gentshang lamlug) was implemented in Ngamring. This system redistributed previously communalized land. The amount depended on the kind of land available and the number of household members above a certain age.6
With no surviving children, Rinchen Wangyal and his wife had adopted her younger brother, Kunsang. He was apparently too young to be eligible for consideration in the system, so the family received a very small plot on which they could barely subsist. When Kunsang came of age, he started a small business, and in the late 1980s, the Mentrong began to earn a modest livelihood. Kunsang married Yeshe Wangmo of the Nyingkhang around 1984, and they produced three children, two boys and a girl. Once Kunsang’s business became profitable and the family had enough money, they constructed a small single-story house on the new land. By 2001, this had been extended to two stories. The house was not as large as the previous one, but it was hard won. The newly rebuilt Mentrong featured few aspects of what had previously made it a medical house. The family established an elaborate altar room, but otherwise it looked much like other two-story houses in the area.
These circumstances made it impossible for Rinchen Wangyal to recover his medical practice and work again as an amchi. Substantial means (financial and temporal) were required to obtain the medical raw materials necessary to an amchi’s work. Furthermore, practitioners had to depend to varying extents on family wealth and tax benefits rather than income from seeing patients, and that family wealth was no longer there. Rinchen Wangyal had to take up farming to feed his family. Due to his class background, he had never been considered for training as a barefoot doctor, which would have not only helped with the family’s material situation but probably enabled him to maintain at least some of his medical skill. Nevertheless, he attempted to reinvigorate symbolic, social, and occupational features of the Mentrong.
In 1982, Jampa Trinlé, by then reinstated as director of the Lhasa Mentsikhang, visited Lhünding to conduct historical research and search for medical classics to restock the Mentsikhang library. To everyone’s disappointment, not a single book from the Mentrong library remained. Rinchen Wangyal, in the meantime, had recovered a large medical bag that he had given to the Nyémo Lama in anticipation of Democratic Reforms. The Mentsikhang representatives asked if it could be displayed in Lhasa, and Rinchen Wangyal agreed to donate it. In gratitude to the historical Jang and Lhünding medical traditions, Jampa Trinlé arranged for a statue of its founder, Jangpa Namgyel Drazang, to be made for the Mentrong. The gilded statue was presented to the family and installed in the their new chökhang. It forms the centerpiece of their altar in the (now expanded) Mentrong House (figure 5.1), the only reminder of the Jang medical tradition with which the Mentrong had been so intimately linked. In the 1940s, the material items kept in the Mentrong’s menkhang and chökhang, along with Rinchen Wangyal’s training in Phuntsoling, had made possible the reestablishment, however brief, of the Mentrong.
When I visited in 2003, I heard hopes that members of the Mentrong could restart the practice of medicine. It was, therefore, a happy surprise to hear from Rinchen Wangyal in 2007 that the youngest grandson, then twelve, had been sent to Lhasa to apprentice with a close disciple of Jampa Trinlé, who was then retired. In the capital, the boy benefited from extended family, including Kunsang’s retired uncle and aunt, Ngawang Dorjé and Ani Payang of the Nyingkhang, Ngawang Dorjé having kept up his medical practice at his new Lhasa home.
Rinchen Wangyal commented, “Now the inheritance of the bone lineage7 entirely depends on the boy,” his face expressing both hope and anticipation. That he used the expression bone lineage testifies again to the emphasis and value placed on the rhetoric of patrilineal descent in the transmission and continuity of Medical Houses. The erstwhile amchi clearly considered his adopted son Kunsang, from his late wife’s side of the family, to hold the “bones” of the Mentrong’s patrilineage by virtue of membership in the house. This was a way to make up for their lack of biological children, which was possibly related to the harsh circumstances in which Rinchen and his wife had spent the years of intense reform.
Memorizing the “Communist Gyüshi”: The Ruthog Amchi
These recent efforts to return some of the old medical authority to the Mentrong differ significantly from what happened to the village amchi in Ruthog, a slightly lower-lying farming village by the Tokshung River in southern Ngamring. Here Tibetan medical practice did not entirely stop, yet due to changed socioeconomic circumstances, the practice has of late not been easy to maintain.
Tsewang was known as the Ruthog village amchi and practiced in the fourth generation. During my first fieldwork in 2003 he was in his seventies. His son Pema (b. 1964) had succeeded him in the family occupation. Another son, Lobsang (b. 1969), had also been taught medicine, but after taking orders as a monk at Ngamring Gonpa in 1987, he stopped his medical training. The continuity of the medical tradition in the practice of Tsewang and Pema was the result of fortuitous circumstances and timing, not least that Tsewang and his wife had seven children who had survived into adulthood and that classical Tibetan medical works were accessible.
Tsewang was already an experienced doctor when the Democratic Reforms began in Ruthog, and his trelpa household (which was similar in status to Yonten Tsering’s Térap) was labeled “middle-off farmers”8—between rich and poor categories. Like Yonten Tsering, they had lost almost everything during the land reforms. Their wooden medicine box, the medicine bags and instruments, and books that had been passed down the generations were at first kept in the house while the family moved to the ground floor. At the start of the Cultural Revolution, these items were said to be “poisonous roots of the landlords,”9 as Pema’s seventy-year-old mother recalled. She described how the people throwing things out of their home were undecided about burning the bags and boxes and wondered whether they could find any “safe” use for such “poisonous roots.” They finally decided to use the bags and boxes for salt and other household goods, but there was no doubt that the books had to be destroyed. Pema’s mother recalled feeling sorrow at what was happening, her wish being for the family medical tradition to continue. She managed, at great personal risk, to hide two of their Tibetan medical books and thus saved them from being thrown in the river. One of the texts was a print edition of the Four Treatises, the other a family medical compounding book (menjordeb) where previous generations had added their own recipes and annotations (figure 5.2). The family subsequently moved to other accommodation and the house was locked, then finally destroyed.
Tsewang had by then been recruited to work as a secretary for the new government owing to his literacy. He hardly ever applied his medical skills beyond his own family during the early reforms and almost completely stopped during the Cultural Revolution. Saved to some extent by his secretarial role, the most severe beatings were endured by his mother-in-law, Pema’s grandmother, whose family was related to the royal family of Ruthog in western Tibet. Despite these difficult circumstances, Tsewang managed to homeschool Pema in the early 1970s by practicing Tibetan letters using coal on a wooden board. Tsewang decided Pema and his baby brother would stay at home and become amchi, while the older brothers and sisters would be married out. He was often criticized for not sending Pema to the government school, where only Chairman Mao’s works and songs were taught and the sole textbook was the Quotations.10 Others accused the family of keeping the children out of school so they could earn more work points, called karma. It was in 1976, Pema recalled, that he began memorizing the Gyüshi; he also attended school by that time, where other books had slowly started to reappear: “There were two lessons: one in the morning and one in the afternoon. At lunchtime when I came home. I did not do homework; I just studied and memorized the Four Treatises. In the evenings too, I kept on studying the Four Treatises. I didn’t do well in school, but I learned the Four Treatises by heart!”
Pema did not memorize the Gyüshi from the printed peja that had been saved by his mother. He explained that its lettering was much harder to read than what the family referred to as “the Communist Gyüshi” (Tangi Gyüshi).11 I subsequently discovered that this 1976 Communist Gyüshi was the first modern, European-style printing of what was mainly the content of the Gyüshi, but it had been thoroughly reedited under duress by Jampa Trinlé in 1974 and then published as a Tibetan medical textbook. Yet the family considered this close enough to call it the Gyüshi. The printing, possession, or teaching of classical block-printed works was considered one of the Four Olds, and only a very few books with Tibetan medical content had been published in the previous decade, by revolutionary committees and under the heavy influence of Maoist thought.
In this 1976 edition of the Communist Gyüshi, all references to the Medicine Buddha had been edited out, including the story of the origin of the medical teachings. Also gone were the formal requests of the student to the teacher of the Gyüshi, found prior to 1976 at the beginning and end of each volume and each chapter of the work, which gave the text its typical dialogic format and Buddhist authority. Pema continued to memorize that work during the coming years. At the same time he learned diagnostic and therapeutic techniques from his father and assisted him with patients. The family did not acquire later reprints of the Four Treatises (which reincorporated sections on the Medicine Buddha). Yet they clearly considered the Communist Gyüshi the teaching of the Medicine Buddha, whom they revered highly, placing his statue in the family’s current altar room.
While his father used the family-owned medical compounding manuscript in traditional Tibetan book format, Pema did not. Again, citing easier legibility, he studied what he referred to as the Sorig Zintig, a reprint of work by the nineteenth-century Rimé master Jamgon Kongtrul Yonten Gyatso,12 republished in Xining in April 1976 (Yonten Gyatso 1976).13 In most cases, however, he followed his father’s practical approach and his compounding methods and techniques, only later studying the family compounding work, more out of interest than necessity.
While Pema still practices, as the only amchi in the village, the Ruthog amchi’s medical techniques, especially moxibustion and bloodletting, as well as the family medical compounding, the Medical House could not be fully reestablished in the postreform era. When the family reacquired land in the early 1980s, they could only afford to construct a single-story house. Their absolute reliance on farming and the lack of extra cash income made the family medical practice financially precarious, to the point that the house has never been extended. Tsewang, who once assisted with the Ngamring Dzong’s Tibetan medical doctors’ herb collection trips and kept up good relations with the county civil servants, never entered government service, as it would have left the village without a doctor. Thus the household did its best to maintain an active medical practice, although the physical house was effectively no different from most other farmhouses in the village.
Here the uninterrupted medical practice in the bone lineage, that is, its social continuity, was made possible by the fortunate situation of Tsewang and his wife having had several surviving children and their somewhat lighter punishment compared to those in the Mentrong (Tsewang, for example, had not been banned from working for the Communists). This allowed them slightly better material circumstances, and meant that Tsewang could secretly maintain some of his medical knowledge and skill, which he also taught to his sons at home.
Medical Practice: The Ruthog Amchi
The Ruthog amchi’s rebuilt home, though simple, has become the site of medical practice once again, the days of covert practice having ended in 1974. Upon my visits, I found books, instruments, and medicines kept in the altar room,14 and patients consulted in the kitchen-cum-living room, where medicines were ground and compounded as the need arose.15 On average, Amchi Pema saw a couple of patients every day while continuing to work the fields and perform a variety of other jobs in the household. Although people called Pema a private amchi or a gergyi amchi,16 his home was very much a public space, and family members were frequently called to assist in consultations and treatment. This was particularly the case for his daughter, then his only child, as Pema hoped she would become an amchi herself. Whether he would have the same willingness if he had sons, I am not sure.
Although Amchi Pema compounded medicines, he did not collect the necessary medicinal herbs or other materials. This was largely because collecting herbs required longer absences from home. He relied on people bringing plants and minerals from nomadic areas or, when raw materials could not be found in his area, purchased them from traders in Lhasa. Amchi Pema spent considerable money on medical substances, especially those collected in high mountain locations that are rare or difficult to find and those imported from India or Nepal. Some patients offered raw medical materials in exchange for treatment. Whatever the source, all the medicines he gave to his patients were prepared in front of their eyes, sometimes with their assistance, freshly ground on a large stone and prescribed as fine powder (figure 5.3). The patients were instructed to take them with boiled water, as he believed medicines prepared this way to be more effective. Because each was compounded in accordance with a particular diagnosis, a medical prescription was never repeated precisely, which probably accounts for his vague answer to my question about how many different medicinal compounds he typically made.
Because of Pema’s method of producing medicines, the family spent a lot of money on raw materials but received hardly any remuneration for the medicines and consultations. “Being an amchi today means losing money,” Pema said repeatedly. He seemed uncomfortable with the idea of charging for his services: “This has not been the tradition in our family. To start it now is very difficult—people have become used to it.” His mother added, “If people had a feeling of shame [ngo tsha yod pa], they would give something anyway, but most people these days are shameless [ngo tsha med pa].” These comments illustrate the social role of amchi (cf. Kloos 2004) as well as social dynamics in the village that prohibit Pema from asking for or receiving payment.
One of our conversations was interrupted by a patient who had sprained his ankle a few days earlier. Amchi Pema prepared some dried artemisia, forming cones for moxibustion, a kind of mégyap practice, meaning literally to “apply fire.” After inquiring about and feeling the location of the pain, he placed a poultice of wet barley grain on a specific point of the patient’s ankle with the moxa on top. Everyone was quiet as the moxa cones burned slowly toward the skin before making a popping sound, after which the leftover ashes were brushed off the skin. Following this short consultation and a chat, the patient left. Amchi Pema then picked up our conversation about the remuneration of his practice:
We have a saying in Tibet: “When you have crossed the river, you forget the bridge; and when you have recovered from an illness, you forget the doctor.” That’s how I feel when I treat my patients these days. When they recover from their illness, they don’t need me anymore and they forget me. Then later they might tell me, “You have really helped me,” and give me a cup of chang—that’s all. They always say, “I will give you money,” but never act. They forget and instead I get a cup of chang and that’s it. I lost lots of money like this.
Despite radically changed social and economic circumstances, making medicine and treating people is still a not-for-profit enterprise, an approach to medicine that, in the words of members of this household, makes a “real amchi” (amchi ngönné). In our conversations Amchi Pema and his mother used this term to distinguish him and his father from the government “amchi,” in fact the local village health worker and largely an “injectionist” (khap gyapnyen) who uses exclusively Chinese biomedicines, especially injected ones. But I also take his use of “real amchi” to refer to an amchi who embodies an alternative economy and morality of treatment, and does not ask for payment due to religious considerations. The fact that this amchi continues to compound his own medicine, as they have done in his lineage for generations, has exacerbated his precarious financial situation, but his approach is related to ideas of medical work procuring religious merit.
The Dispersal of Térap
The Térap building survives to this day in Gye Village, its menkhang and signature medical mural intact (see figure 1.3). The social, symbolic, and occupational aspects of the Medical House, however, only partially survived into the postreform era. Its material and immaterial wealth, its medical instruments, bags, and books and a member’s medical knowledge and skill, have been dispersed over time. Yet hopes to reunite at least some aspects of its pre-Communist assemblage were high. Plans to restore the Térap’s physical building and transform it into a Tibetan medical clinic, a new kind of Tibetan medical institution, for the village and the valley’s population, were well underway in the summer of 2007. In the meantime, the building was used by villagers to make and store the tsatsa that were being prepared to be interred in a new stupa built in the village (figure 5.4).
Before turning to other aspects of the dispersed legacies of Térap in the postreform period, we shall briefly revisit what happened after 1959, when it was taken away from Yonten Tsering’s family during the land reform. Four previously landless farmers’ and servants’ families were given deeds to the house, moved in, and divided the doctor’s belongings. The amchi himself, along with his parents and his wife, moved to a shed. The medical equipment and library of Térap were transferred to a downstairs room. After initial loss of access, Yonten Tsering was then allowed to use that room as a “clinic space,” in addition to his work as a secretary for the local government. He managed to preserve books from destruction by the Red Guards, who left the building itself unscathed. After moving briefly into another home in Gye, Yonten Tsering finally relocated to Ngamring town in 1974, having gained a permanent position in the Tibetan medicine section of Ngamring’s People’s Hospital.
Despite having taken up residence there, between 1980 and 1982 he and his wife reacquired farmland in Gye and built a small house in the location where they had last lived in the village. With the new policies, each of the four families who were living in the Térap building also received farmland at that time. Eventually they established new homes in other parts of the village and sold their shares to Tashi’s father, Gyatso. Gyatso owns the house, but during my 2006–7 fieldwork he no longer lived there. With the exception of the medical mural and the ground-floor room belonging to Yonten Tsering, which he visited from time to time, the Térap had long ceased to be a Medical House.
Like Rinchen Wangyal and his wife, Yonten Tsering and Yeshe Lhamo had no surviving children. This is perhaps striking, given their knowledge of medicine, particularly maternal and child-related medicine, and the continued emphasis on bone lineage, at least rhetorically posited as the ideal for medical lineage transmission. Yeshe Lhamo, Yontan Tsering’s wife, told me in a private conversation many years after my main fieldwork, when I asked her specifically, that she was unable to become pregnant because they did not have enough to eat and had to work so hard. This clearly hints at a challenging situation even for this family during the Democratic Reforms, when they lived in the shed, and all the years afterward, despite very different accounts given by her husband.
They eventually adopted Tenpa, one of the sons of Yonten Tsering’s younger sister, who had married and lived in Phuntsoling. Tenpa attended regular school in Ngamring and, since he showed no special interest in medicine, did not apprentice with his father. Instead, Yonten Tsering taught students from other backgrounds according to the various governmental health campaigns: first, in the 1970s and 1980s, the barefoot doctors and village and township health workers; and later, in the 1980s and 1990s, younger colleagues who had graduated from Lhasa Mentsikhang and the Tibetan Medicine College but had little practical skill. The techniques in which he trained younger doctors included pulse and urine diagnosis, pharmacological and external treatment methods, and importantly, the compounding of medicines. Most of the medicines were produced at the Tibetan Medicine Section of Ngamring’s People’s Hospital, using medical materials jointly collected in the summer months, thus keeping medicine quality high and expenditures low.
Yonten Tsering did not pass on his medical knowledge and skill within the bone lineage or the Térap, nor in classical teaching lineages (lobgyü) with one or all of the three core aspects of traditional learning (wang, lung, and tri). However, he eagerly shared his knowledge with numerous groups of students, amounting over his lifetime to several hundred individuals. Only in special cases did his teachings take on the qualities of what were known as teaching lineages. For instance, one doctor from Tobé township stayed with him for some months, and similarly, after Yonten Tsering had retired, two teenage boys lived with him and his wife for three years, with him teaching them medicine and giving them the lung to study the Four Treatises prior to memorization.
Whether mere serendipity, the influence of Yonten Tsering, or any of the remaining powers of the Térap in which he grew up, Tashi Tsering, the youngest son born there to Gyatso’s wife, as a teenager developed an interest in Tibetan medicine, for which he had the strong support of his parents. Tashi Tsering was admitted to the Tibetan Medical College in Lhasa in 2004, and in 2008 was due to graduate and embark on the usual year of practical training and internship at a Tibetan medical and biomedical government hospital. He spent his holidays as a volunteer at the Tashilhunpo Monastery clinic, helping to give injections, make Tibetan medicines, and hand them out at the pharmacy.
As things stood in 2007, it was the elders’ plan that Tashi Tsering would start a private medical clinic in the Térap building after completing his training. He would be married locally and work with another young amchi graduate from the village, who had been to Pelshung and then the Lhasa Medical College. An international donor was close to agreeing to pay for the renovation and expansion of the house as well as an initial stock of medicines. During the first months after the clinic opened and summers thereafter, Yonten Tsering would further instruct the young amchi, focusing on the therapeutic specialties of his family medical tradition. Patient fees could, it was estimated, be kept low through on-site medicine collection and compounding, potentially supported by local and international donations I would raise. Yonten Tsering vowed to donate to the new clinic in the Térap building his collection of medical equipment, including a wooden box for medical materials, the grinding stones, medical bags, and his precious medical texts and thankas.
Other Medical Houses and Monastic Amchi
Other medical houses had also been only partially reestablished, their transmission as yet unsecured. One of these was Sonam Drölma’s Nyékhang. Though its rich collection of medical texts had been saved from destruction and the building partly rebuilt, her practice remained very limited and exceedingly difficult after the Cultural Revolution. Her training with her grandfather had been cut short by his death and attacks on the Four Olds, and in the 1980s it was hard to extract any surplus from subsistence farming. For her medical work, mainly for the people of the local villages, she relied on local medical resources, yet had limited time to collect and prepare them, and her family lacked financial resources. At the same time, she was bringing up children, running the household, and doing farmwork. Despite her hope that her son might become an amchi, the household’s continued poverty and her son’s middle school education limited this prospect. As of 2006–7 this level of education was no longer enough to enter the Tibetan Medical College in Lhasa without passing extra exams. The entry requirements in Chinese language had been raised, disadvantaging graduates from rural primary and middle schools, like her son, where Tibetan was still the medium of instruction. Yet government-approved institutional licenses were increasingly necessary to work in a government clinic—or to be permitted to work at all. The continued practice, however limited, of this long-standing household lineage (khyimtsang gyü) and the possibility of its transmission were therefore uncertain. Lack of funds was clearly a major obstacle, compounded by Sonam Drölma lacking government or monastic support, living in a poor area, and having to do all the things expected from a lay woman.
Some private amchis managed to start independent private practices even without previous family history in medicine, particularly those who either had a foot in the government bureaucracy or were connected to the newly reestablished monasteries and nunneries. This was the case with the former Bon monk Rabgyal, who had served as resident health worker at Tsatsé township clinic for almost fifteen years.
Rabgyal left the clinic in 1975 and, with his wife, set up a new home in the extremely remote pastoral Nyingu township. There they lived with their children, Rabgyal practicing as an amchi among pastoralists and teaching medicine to two of his sons. A repayment of several thousand Chinese yuan (CNY) from the government had enabled this move. The sum, paid after he obtained an official license and the Tibetan medical degree of rabchampa, made up for what he successfully argued had been underpayment in earlier years. After initially relying on the pastoral economy, Rabgyal began to make a substantial income from his medical practice and soon was widely sought out in the area, as many already knew him from his days at the Tsatsé township clinic. With the help of family members, they compounded all the medicines used in his practice, and by the time of my fieldwork the sons were practicing independently in a nearby township in Nyima County, Nagchu Prefecture. They all charged considerable fees for their medicines but were still sought out by many people in the area. Cheaper and also very desired was cauterization, another kind of mégyap, or “fire” treatment, particularly suited to treat the many “cold” diseases common in this windy and cool high-plateau environment of the Changthang.
What of the monastic medical practitioners? Could they restart their medical work once Buddhist practice was again officially allowed? Many of the monks and nuns mentioned in chapter 2 returned to a more open and complete medical practice once the CCP congress of 1978 had introduced limited freedom of religious practice. Tutop, the abbot of the Nyingma Chaug Gonpa, was one of the first to resume medical practice, training a monk in the late 1970s. He had kept up some of his practice while riding out the harshest reforms by basing himself in a remote cave. There patients sometimes came to him for treatment and in exchange brought medical plants.17 At the time of my research, patients often sought him out for healing rituals as well as medicines, the balance tipping more and more toward ritual treatments rather than medicine as he grew old and had difficulty picking plants and the monk he had trained in medicine was no longer there to help.
The nun Ani Pema Lhamo was valued for her treatment skills, often sought out by lay patients in the valley and the older monks at Pangyul, some of whom had learned to make simple medicines and upon her death inherited her text and medicine collection. She had tried to reestablish Dewachen Nunnery, above the monks’ monastery at Pangyul, but in 1983 moved to Thölung, near Lhasa.
Ani Ngawang, the student of Khyemen Rinpoche, rebuilt the Chiu Tekcholing nunnery in Nyémo, where she passed on her teacher’s medical legacy—including the preparation of tsotel for simple rinchen rilbu—to several nuns and monks. Ani Ngawang and her nunnery were highly regarded for an eye medicine compounded there, which according to her main disciple contained homemade tsotel.
Extensive rebuilding of the monasteries in Ngamring only started in the mid to late 1980s, proceeding initially in small stages. Some were never reestablished, and some villages and hamlets are still saving up to rebuild the stupas and lhakhangs torn down through revolutionary fervor or violent political pressure. As of 2016, none of the local monasteries in Ngamring County had started any formalized clinic arrangements. Those monks and nuns with medical knowledge simply treated patients from their residences, sometimes combining, as was the case with Tutop, medical treatment with healing rituals and Buddhist prayers. The great exception in the wider region was Tashilhunpo in Shigatse.
The laborious and often painful process of trying to reunite the violently dispersed parts of Medical Houses and monastic medical practice is ongoing, with long-term viability uncertain. This contrasts with what Janes and Hilliard assert was by the mid-1980s a “restoration of the institutions of Tibetan medicine—the hospitals, clinics and medicine factories—to their formerly integral position in Tibetan society” (2008: 35). Neither the Medical Houses nor the monasteries had at that point been truly recovered, yet amchi from Medical Houses and monasteries had constituted the majority of medical practitioners prior to the reforms. They had a much harder time restoring and securing the continuity of medical practice on their own terms and under new socioeconomic conditions. After the early 1980s, they had exactly as much land as everyone else and received no tax exemptions in recognition of their work.
State-funded institutions set up in the postreform era, by contrast, typically established Tibetan medical institutions as partial replicas of biomedical institutions, and in such cases received impressive state funding (Janes 1995; Trinlé 2004, 2006). In total these new places for Tibetan medical practice far exceeded the previously formalized governmental Tibetan medical institutions, spreading Tibetan medicine funded by the government to counties and even townships. In the process, they replaced many of the diverse practices of Medical Houses and monasteries that had been the institutions of Tibetan medical practice on the margins. Following Janes and Hilliard’s logic, it seems to me that only the Mentsikhang in Lhasa, as a traditional Tibetan medicine institution, had truly been reinstated to its “formerly integral position in Tibetan society”—at least in outer appearance, if not with its earlier ethos of practice and teaching. Otherwise, Tibetan medicine in government facilities was established within new institutional, social, and medical frameworks.
In the oft-heralded integration of Tibetan medical and biomedical institutions and practices, which was happening everywhere in the 1980s except perhaps at the Lhasa Mentsikhang, governmental Tibetan amchi had to develop entirely new frameworks for Tibetan medicine. This may explain why some amchi were not content to participate in this process; instead they envisioned a less “diluted” version of Tibetan medicine, characterized by continued production of their own medicines (Pema and Rabgyal mainly), integration of certain Buddhist elements in healing (Tutop), and application of manual techniques not routinely learned or applied in state colleges and clinics (Rabgyal, Pema, and Sonam Drölma). Although the last years of the Cultural Revolution allowed for small expressions of Tibetan medical practice, this most extreme phase of modern Tibetan history had taken a huge toll on the continuity of the Tibetan medical tradition. In many cases it has taken years to make up for the damage, economic impoverishment, gaps in the transmission of medical knowledge—and even the lack of progeny—that resulted.
A prominent initiative aimed at restoring some of the losses due to the Cultural Revolution in Tsang, which strove to complement the limited and largely biomedical government primary health care in the area, was the establishment of Pelshung Tibetan Medicine School.18
PELSHUNG TIBETAN MEDICAL SCHOOL, THE SWISS RED CROSS, AND THE STATE
Following the Tenth Panchen Lama’s release from prison in 1978, he became a figure of great importance for Tibetans striving to reestablish Tibetan cultural and Buddhist institutions in the 1980s. He worked actively to support the limited freedoms regained through the creation of government laws, policies, and commitments that he hoped would give Tibetans and other nationalities lasting institutional guarantees for the survival of their culture, religion, language, and to some degree, a genuine regional autonomy (Barnett 1997: xii). Among the Panchen Lama’s activities was the start of Tibet Development Fund (TDF). The first modern charitable organization in Tibet, it was specifically designed to attract and manage foreign aid for development projects (Barnett 1997: xiii).19 In 1986 the Panchen Lama officially invited the Swiss Red Cross (SRC) to Tibet as the first international aid organization there.
The Panchen Lama’s wish had been for the SRC to open a biomedical hospital in Shigatse, but the organization’s International Cooperation Department (ICD) proposed instead to support the rural health care system, which it considered to be in poor shape.20 Between 1988 and 1992 the first delegates from the SRC provided basic biomedical training for newly recruited Tibetan students and refresher courses for rural medical personnel with prior biomedical training, such as township doctors and village health workers. This instruction was subsequently subcontracted to the local Vocational Health School and county hospitals (1992–2002).21 Shigatse Health Bureau then made a formal request to the SRC to establish a school of Tibetan medicine. The charity agreed, and the school was inaugurated in 1991 in Pelshung, about ten kilometers outside of Shigatse Town, on land previously donated by the Panchen Lama but otherwise wholly funded by the SRC (Swiss Red Cross 2005).
A main aim of the training at the Pelshung Tibetan Medicine School, according to SRC documents, “was to contribute to the improvement of the health care situation of poor communities in remote parts of Tibet via the comprehensive training of young men (women were not yet admitted) to become traditional Tibetan doctors” (SRC 2001). A later document introduced a range of SRC programs and activities, including what is here termed Traditional Tibetan Medicine (TTM):
At the request of the late Panchen Rinpoche, SRC agreed in 1991 to support the creation of a private school for TTM. Students are selected in remote and underserved villages of the 19 counties; the studies last five years and are entirely free. The first batch graduated in 1996, and the second batch will finish its studies at the school proper in 2003. The graduates will then take another year at the Shigatse Health School, in order to learn elements of Western Medicine, Obstetrics, Pediatrics, Nutrition, Health Education, Sterilization and Hygiene, etc. (Swiss Red Cross 2003: 9)
That support for TTM fitted well within the World Health Organization’s guidelines for supporting primary health care through inclusion of traditional medicine practitioners, as pronounced in the seminal Declaration of Alma-Ata from 1978, as well as other SRC documents. One SRC document written by a long-term delegate to Tibet asserts that “what concerns Public Health [is that] there currently exists a pluralistic system. Western medicine and Tibetan medicine can benefit each other…. Therefore, we contribute not only to the survival of a culture threatened with extinction, but also equally improve long-term health care in rural areas” (Swiss Red Cross 1998: 6). In addition to Tibetan medicine supporting primary health care for rural areas, the support for TTM is also thought to counter cultural decline.
SRC partnered in the Pelshung School project with Jampa Trinlé, the local senior amchi, who was behind the Shigatse Health Bureau’s official proposal for the Pelshung Tibetan Medicine School. He was a rehabilitated doctor and graduate of the Tashilhunpo’s Kikinaka School, later head of the Shigatse Mentsikhang Hospital. To distinguish him from Lhasa’s Mentsikhang director, who incidentally has the same name, I will refer to him as Shigatse Jampa Trinlé.
The timing of the opening of the Pelshung School is relevant, as it shows how all three parties involved—SRC, the Shigatse Health Bureau, and rural medical students—considered Tibetan medicine an important part of the health care system for the rural TAR. This view shifted dramatically with the introduction of the New Cooperative Medical Services (NCMS) scheme, an updated rural medical insurance scheme aimed to reduce rural populations’ healthcare costs that began in a few pilot townships in Tsang in 1998 and was implemented in the entire region in 2003 (Janes 2002; Hofer 2008a, 2008b).
Shigatse Jampa Trinlé’s personal motivation and influence regarding the ethos and curriculum of the Pelshung School should not be underestimated. Initially a monk at a monastery in his home district, Namling, in 1954 he enrolled at Kikinaka Medical School (alongside Yonten Tsering and Ngawang Dorjé). Following his final exams during the Democratic Reforms, Jampa Trinlé left the order to work as a farmer, secretly continuing his medical practice. In the 1970s he was officially reinstated as a health worker, gradually climbing the ladder of health-related civil service while continuing to see patients on a daily basis (Trinlé 2000). In 1982 he became director of the new Shigatse Mentsikhang Hospital, a facility that attracted several thousand patients every year. Like the Lhasa Mentsikhang, it shifted toward providing “integrated care,” offering both “Chinese” (the local term for biomedical) and Tibetan medical treatment. Since the mid-1990s, more patients received biomedicines than Tibetan medical treatments at this hospital.22 Shigatse Jampa Trinlé’s support for the Pelshung School, given his official position and local influence as well as support from the prefecture-level Health Bureau (led by Dr. Puntsok, a former student at Kikinaka), must not be overlooked. He was, for instance, crucial in defending the choice to invite only male students to the school, a policy the Swiss Red Cross accepted only with great reluctance.
Medical Training at Pelshung and Making a Living Back Home
After Shigatse Health Bureau had sent an invitation to rural communities to bring forward male candidates for the Tibetan medical training at Pelshung, Jampa Trinlé traveled the prefecture visiting and interviewing those who seemed most promising and had good written Tibetan. He also recruited monks from distant monasteries and a few from Tashilhunpo Monastery. There the monks had wanted to add Tibetan medicine to their existing clinic, which since the early 1980s had been providing Chinesestyle biomedicine and TCM acupuncture, its last Tibetan medical practitioners (who returned after the Cultural Revolution) in the meantime having passed away. Jampa Trinlé also selected a few boys from either active or historical Medical Houses.
When this first cohort of thirty-eight students joined the school, they were in their early teens and had received, in most cases, a basic primary school education, though a few had some additional monastic or family-related medical training. Upon entry, students were obliged to take three vows to their teacher: to go back and practice as an amchi in their home village or home monastery after graduation; to work as a private amchi and not join government service; and to not change profession (Heimsath 2003: 4–5). The thirty-eight young men received what could best be described as a monastic-style education. The day began with prayers to the Medicine Buddha and Manjushri, the bodhisattva of transcendental wisdom. A large part of the day was devoted to memorization of the Four Treatises (figure 5.5) and study of the Moon Jewel of the Body’s Measurements,23 the Essence of Medical Compounding by Khyenrap Norbu,24 and some popular commentaries on the Four Treatises. There was also some classroom teaching and practical instruction in medicine making. The students learned about diagnosis and a wide range of therapeutic techniques, including external therapies25 and bonesetting (albeit mostly theory only) as well as how to recognize Tibetan materia medica—both wild and dried forms—and how to compound some basic Tibetan medicines. They had no exposure to biomedical ideas, as a result of insistence by the school’s director and the SRC’s attempt to be culturally sensitive.
After graduation, this first group returned home with a certificate from the school, medical instruments, and a bag of 90, 100, or 150 types of Tibetan rilbu, depending on the student’s final grade. The SRC and Jampa Trinlé thought of these medicines as the young doctors’ start-up capital, from which they could make their initial income, allowing them to thereafter replenish their stocks of materia medica. When planning the project, the idea was that the graduates would enhance the economic viability of their practice by making their own medicines.
The reality encountered by the first group of doctors, once they returned home, proved to be different—and difficult. The doctors had limited practical training in Tibetan medicine; their own and others’ confidence in their ability to heal was minimal (cf. Craig 2007). They were in their late teens and early twenties, whereas Tibetans generally trust older, more experienced doctors. The idea of the power and trustworthiness of doctors coming from a medical lineage or a Medical House was still strong, and only a few of the first cohort had such a family background.
Furthermore, like Pema and Sonam Drölma, they were confronted with predominantly subsistence economies in their remote nomad and farming areas. Jampa Trinlé had advised his student doctors to set a price of ¥1 for three doses of Tibetan medicine taken three times a day. His students soon found that payments generally came in kind, if they received remuneration at all (none came from poor people or relatives). They sold whatever goods they received to have cash and replenish their stock of medicinals, but in most cases they were unable to fully replenish their stock.26 In addition, most graduates had to balance their medical practice with work as a farmer or nomad. In a first evaluation of the program, the external consultant to the SRC, Professor Meyer, wrote that “only one of the graduates visited in 1998 could make some profit from his medical skill.”27
Meyer found that many of the doctors had started to administer biomedical treatments. Given the widespread use of biomedical drugs in rural Tibet, in particular injected ones or those administered through intravenous drips by doctors and village health workers in clinics, it is hardly surprising that rural patients would ask the Pelshung doctors for similar kinds of treatment in their homes as well. As one did not absolutely need a medical license to sell or purchase biomedical drugs, the doctors could easily stock these. If they did not have them, at least they could deliver medicines people had bought. This saved their patients the delivery charges in the newly part-privatized rural health care facilities.
Meyer’s recommendations included that the Pelshung amchi be given biomedical training to reduce the risk of medical malpractice—a very real risk given their insufficient training. The first group of students was called back to Pelshung in 1999 for a six-week intensive course in basic biomedicine, including lessons in hygiene, sanitation, mother and child health care, and the safe use of injections.
That same year, in October, a second cohort of fifty-six students (again exclusively male and selected by Jampa Trinlé) started training. Forty-two of them hailed from rural backgrounds, their studies financially covered by the SRC, while twelve were from more affluent families, including some from urban areas who could pay their own costs. The training was shortened to four years, and the school’s headmaster, Jampa Trinlé, was the primary teacher, with some teaching support from previous graduates.
Compared with the first graduates, the second group received a more realistic training. After four years of Tibetan medical education (and following the closure of the school), the SRC sponsored three-month internships for them at the Mentsikhang in Lhasa and its branch in Lhoka Prefecture. Here they often came in contact with biomedicines, despite the fact that these are nominally Tibetan medical institutions (cf. Adams and Li 2008). Then they all attended the Vocational Health School in Shigatse for nine months’ biomedical training, with fees and subsistence paid by the SRC. It was more common for doctors among the second intake to speak and write Chinese, knowledge they had acquired in primary school, at the vocational school, or since graduating.
In 2003, a second evaluation of the first cohort of students was carried out in their home villages, which showed the adverse effects of the vows students had taken to remain private Tibetan medical doctors in their home villages or monasteries.28 Later, when the vows were lifted, doctors of both cohorts were free to set up clinics and practice in places other than their home regions, to join government service, and even to change their profession. This development left them better equipped to make decisions in the midst of the challenges of practicing Tibetan medicine in remote areas, at a time when rural health care provision was beginning to change radically. Since the second batch began training in October 1999, the NCMS rural insurance scheme had been introduced, later spreading throughout Tsang. Tibetan medical care, which was not reimbursed under this scheme, almost completely ceased to be provided through government channels, and people increasingly chose the reimbursed biomedical therapies (cf. Hofer 2012: 176–80; Hofer 2008a, 2008b). Although the majority of graduates from both cohorts have remained private amchi, some have chosen to join government service, including a larger percentage of the second group.29 Some saw government service as an opportunity to see patients more regularly, some to have an ongoing exchange with biomedical health workers and learn new skills, some for the status of working in a government institution, and some because they found it difficult to continue to practice at home. The majority, however, joined because they were granted a small but stable income of on average ¥200 a month. Despite having undergone shorter training, their biomedically trained colleagues in the township clinics usually earned substantially more than the Pelshung graduates, accounted for by the fact that they had official graduation certificates from a government school.
The lack of official recognition of the Pelshung degrees by the Shigatse Health Bureau, which, as we should recall here, had proposed establishing Pelshung School, contributed to the decision to close the school in 2003. One report cited a long-term delegate who had coordinated the activities of the school, who attributed the school’s problems and long-term viability to three factors: “A section for TTM has opened at the vocational school in Shigatse, which trains 40 TTM doctors a year,” offering students an official government-approved certificate30 while TTM Pelshung school diplomas were not recognized by the official health care bureaucracy; and he considered that “TTM was incapable of tackling the major public health problems” in the prefecture.31 Why this change of attitude toward TTM’s capacity to make a difference in primary rural health care provision?
The assessment of the SRC delegate questioned one of the two main project aims for the establishment of the Pelshung Tibetan Medicine School: the support of the rural health care system through TTM. TTM’s inability to tackle major public health problems should be understood in the context of the dominant biomedical health care paradigm that pervades both primary and public international health care initiatives and which has abandoned efforts to incorporate traditional medicine practitioners based on the Declaration of Alma-Ata. The move toward biomedical interventions rather than reliance on indigenous medicine also represents attitudes that are now more prevalent, especially among biomedically trained development workers and international NGO delegates, not just in Tibet. The Health Bureau’s unwillingness to provide official certificates, on the other hand, reflects the state’s changing outlook on Tibetan medicine in primary rural health care and state control over the legitimacy and authority of private Tibetan medicine practitioners and private education more broadly in Tibet.
TIBETAN MEDICINE, RURAL PRIMARY CARE, AND NATIONALITY POLICY ON THE MARGINS
At the same time as these private initiatives were taking place, Tibetan medical care was being incorporated into PRC-government institutions, as discussed by Janes and others. In Ngamring, this current of revitalization mainly comprised the establishment of a Tibetan medicine section at the biomedical People’s Hospital in 1974 and then the independent Tibetan Medicine Hospital, established between 1993 and 1996.
Wangnam’s Short History of Ngamring Dzong Tibetan Medical Hospital, written in 1999, reports on both developments in tightly confined political rhetoric and structured mainly by two nationally important events.32 The first is the Third Plenum of the Eleventh CCP Central Committee in 1978, which, according to the author, writing on behalf of the senior physicians, “inspired us to further expand medical services to people living in remote rural areas.” This was achieved, as the report quotes expanding patient numbers between 1974 and 1988. Intimately linked to this growth, the report states, was a structure in which most medicine production was carried out locally with medical materials picked by doctors and health workers during the summer months. The senior doctors offered courses in Tibetan medicine to barefoot doctors, village health workers (as barefoot doctors were called after 1983), and township-level health workers, whose workforce added to the efficacy and volume of medicines collected in the wild.
Tibetan medical work in Ngamring is then said to have substantially expanded in 1993, when the three senior doctors of the Tibetan medical section of the People’s Hospital managed to secure extra funds from Lhasa and from a sponsor from China proper to establish the separate Ngamring Tibetan Medicine Hospital. The substantial building—featuring a reception and pharmacy area and several treatment rooms—was completed in 1994.33 The facility increased its staff, keeping the three senior doctors and adding three graduates from the Lhasa Mentsikhang and Tibetan Medical College. Only one was a woman.
Both the Short History and doctors’ accounts of this period clearly show that the work of Ngamring Tibetan Medicine Hospital in many ways was a continuation of the Maoist call to “stress medical work in the rural areas,” with traditional medicine playing a significant role in this endeavor. Rural patients using the Tibetan medicine facility increased, and the thirty medicines they prepared were considerably more complex than the Tibetan Medical Manual’s recipes of the barefoot doctor era. For instance, they made Agar 8 and traded locally collected ingredients for foreign ingredients that the Lhasa Mentsikhang imported in bulk.
The second political event structuring the Short History is the Third Forum on Work in Tibet, held in Beijing in 1994, which, according to Barnett, entirely reversed the liberal policies of the 1980s (Barnett 2003). In 1992 hard-liner Chen Kuiyan became party secretary of Tibet after condemning the 1980s liberalization as a failure, claiming it had indirectly fueled the large-scale protests in Lhasa between 1987 and 1989 (Barnett 1994). In line with the usual requirements for political reports, the Short History describes the Third Forum on Work in Tibet as a wonderful milestone opening up new opportunities. It repeats the newly emerging government discourse regarding Tibetan medicine: that it would “improve relations between the nationalities.” The report further describes Tibetan medicine as a means to “develop the economy and the culture of nationality areas.” In so doing, “Tibetan medical treatments have to fit the market economy as well as fundamental Communist principles” (Wangnam 1999). This indicated how significantly Tibetan medicine was now to depart from its main mission of providing primary health care through low-cost local means.
The Short History clearly demonstrates the changing nature of “Chinese state interests” in the wake of the 1994 forum (cf. Janes 1999, 2002). While economic liberalization had already started in the rest of the PRC during the 1980s, such measures were delayed for the TAR—partly due to major protests of 1987–89. After the Third Forum they were implemented in the TAR, in what Barnett (2003) termed a “marketization of politics,” with at their core Chen Kuiyan’s “grasping with two hands” of “economic development” and “security.” Under the umbrella of these policies came restrictions on the practice of religion, which also manifested in the field of Tibetan medicine—for instance, in 1995 a ban on the performance of the annual medicine empowerment ritual that the Lhasa Mentsikhang had revived in the 1980s. Under the rubric of development, specialized industries were singled out as “pillar industries” for the TAR, including mining, tourism, and Tibetan medicine (Barnett 2003).
Despite these developments and the financial cuts that came with the following five-year health plans, the cohort of older government servants and local cadres in Ngamring managed to challenge financial cuts by the health bureau and kept patients’ expenditures for health care as low as possible. They were able to minimize the impact of Chinese state interests and maintain the socialist-cum-Buddhist health care ethos that they had upheld for two decades.
The reemergence of private Tibetan medical practice in rural Tsang, despite long odds and substantial growth in governmental Tibetan medicine institutions, shows that in addition to the state-led policies and support for Chinese and Tibetan medicine between the 1970s and the mid-1990s, an alternative sphere reopened for the practice and teaching of Tibetan medicine. Here much medical, if not economic, power remained in the hands of those who possessed lineage affiliations, the associated medical techniques, and increasingly, international networks. Some senior amchi actively drew on these to foster the revival and transmission of Tibetan medicine knowledge in rural areas. Internationally sponsored schools were established, such as the Kailash Projects School in Darchen in Ngari and the NYIMA Foundation–sponsored school in Lhundrub.
Sometimes these initiatives, although sanctioned by the state and even carried out in addition to government jobs by senior cadres, can be read as a partial resistance to the wholesale co-opting of traditional medicine practitioners by Chinese state interests, especially the pharmaceutical commercialization that was to follow. To (re)establish or continue private practice in rural Tsang was, however, often a precarious undertaking. Through the postreform period, the region remained the “poorest relation” of the TAR. The few new government job opportunities in Tibetan medicine and biomedicine were highly desired and in many ways socially prestigious.
Rural private amchi, whether trained prior to 1959 or in the Pelshung School in the 1990s, often lacked the means and social standing characteristic of many urban practitioners, both in Lhasa and in other parts of the PRC among Chinese medicine physicians (Scheid 2007). The socioeconomic order in which Tibetan Medical Houses and monasteries had functioned and flourished in the pre-Communist period was gone forever. During the introduction of the household responsibility system in the TAR, nothing in the land and benefit allocations benefited amchi practitioners who provided the medical care for their local communities.
After government health care was privatized beginning in the mid-1990s (Janes 1999, 2002), rural amchi were sought out, especially by poor patients, but therefore often faced severe economic challenges in keeping up their practice, as these patients were unable to pay for services. When the newly introduced NCMS did not reimburse Tibetan medicines in the early 2000s, these medicines, though available in government clinics and hospitals, became more expensive and had to be paid out of pocket (Hofer 2008a, 2008b). Many private initiatives to revitalize medicine in the private domain, like the Pelshung School and home training for amchis, had completely disappeared by the early years of the new millennium. Those from Tsang desiring to study Tibetan medicine, like Gyatso’s son Tashi, now had to take courses at Lhasa Tibetan Medical College. However, access, educational, and financial requirements were usually beyond the means and local possibilities of many rural Tibetans who were interested in pursuing this career, as we saw for Sonam Drölma’s son.
Those who wanted a medical career of sorts were often forced to enroll in the Shigatse Health Vocational School, as only a middle school leaving certificate was required. This school offered a few Tibetan medicine modules, but in effect produced biomedically trained health workers and nurses. These courses were often chosen by women who would have liked to study Tibetan medicine but for various reasons could not attend the Tibetan Medical College in Lhasa.
The revival of private medical work between the mid-1970s and the mid-1990s was much slower and more limited than medical work funded and promoted by the state in governmental institutions. When the state began to pull back its funding for the rural provision of Tibetan medicine in the 1990s, and in 2000 excluded it from reimbursement through the NCMS, this seriously threatened the Tibetan medical practice of both governmental and private amchi in rural areas. It also further consolidated the hegemony of Chinese-biomedical pharmaceuticals in the Tibetan villages and pastoral townships, a process that had begun with the barefoot doctor campaign, as Fang (2012) has argued.
The shift toward government training provoked by various legal and economic factors (cf. Hofer 2011d) means that newly standardized Tibetan medical diagnostic and therapeutic techniques spread more widely, leaving little room for the diverse medical cultures that were embodied and transmitted in private and monastic domains. Government training and practice openly embrace the integration of Sowa Rigpa with biomedical ideas, standards, and practices.
One of the main differences between private and governmental Tibetan medicine practitioners, even in the younger generation, is the former’s ability and confidence in Tibetan medical diagnostic and therapeutic methods, as well as their capacity to prepare at least some of their own Tibetan medicines. By contrast, government Tibetan medicine practitioners trained in the Tibetan Medical College in Lhasa rely to a greater extent on Chinese biomedical pharmaceuticals and almost exclusively on manufactured Tibetan medicines. They are in the process losing some of their Tibetan medical clinical and pharmacological skills and knowledge, and this inevitably weakens the sustainability and efficacy of Tibetan medicine.