A review of Tibetan Medicine in Exile: The Ethics, Politics and Science of Cultural Survival, by Stephan Kloos.
This dissertation offers the first comprehensive ethnographic and historical study of Tibetan medicine in Indian exile, with a special focus on the Dharamsala Men-Tsee-Khang (Tibetan Medical and Astro Institute). This institute is one of a handful of large semi-governmental Tibetan medical institutions in Asia with increasingly global reach. Kloos’ work is situated within the field of critical studies of science and alternative modernities, more particularly drawing on the theoretical concept of “global assemblages” (Aihwa Ong and Stephen Collier eds., Global Assemblages: Technology, Politics, and Ethics as Anthropological Problems. Oxford: Blackwell Publishing, 2005). His excellent dissertation is also the first study that directly analyzes the crucial role of Tibetan medicine in the (exile) Tibetan nationalist struggle, thereby responding to existing works on modern Tibetan nationalism more broadly, exile, transnational Tibetan medicine, as well as Asian medicines in the context of regimes of governmentality, capitalism and globalization.
Following the failed Tibetan uprising against Chinese Communist forces in Lhasa during March 1959, thousands of Tibetans escaped together with His Holiness the Dalai Lama into Indian exile, many to Dharamsala. Since then at least 100,000 more have come. The Men-Tsee-Khang was one of the first Tibetan institutions to be “re-established” in exile. The original institute — established in Lhasa in 1916 — continues there, yet for obvious political reasons has no official links to the one in India. Over the past half century the Dharamsala institute has developed from initially humble beginnings (one hut, three doctors, and virtually no funding) into the largest and most profitable secular Tibetan institution in exile. At the time of the writing of Kloos’ dissertation, it had 120 doctors and several hundred staff caring for members of the Tibetan community, their Indian host populations, and a number of foreigners in fifty branch clinics throughout India and Nepal. The Dharamsala institution itself consists of a network of outpatient clinics, and inpatient department, research departments, and importantly, an associated medical college and a large pharmaceutical factory. Beyond the main tasks of practicing, producing and transmitting Tibetan medicine, Kloos brings to our attention other significant functions and duties of the Men-Tsee-Khang, such as that of “preserving Tibetan culture” and “helping the world.” How Tibetan doctors working there navigate the challenges of these multiple and constantly changing tasks lies at the heart of his dissertation.
Kloos’ account begins with a brief prologue offering some background to the place and people where the research was carried out, and to its author’s main research methods and concerns.
The Introduction (Chapter 1) serves to situate the thesis within existing studies of Tibetan identity and nationalism in exile. It invites the reader on a fascinating journey, enquiring how and why the Men-Tsee-Khang as an institution comes to be so prominently involved not only with re-creating and shaping Tibetan medical traditions — thereby keeping them relevant and effective for their patients (something one would naturally expect) — but also how the role of Tibetan medicine practiced there comes to be defined and used for upholding “socio-political values of Tibet” and serving as an avenue that “establishes and finely molds the Tibetan nation and culture,” to quote from one of the Dalai Lama’s speeches at the Men-Tsee-Khang in 1994 (p. 14). While medical institutions before 1959 in Tibet were not considered equal in status or importance with large monastic centers, in exile the Men-Tsee-Khang increasingly has come to serve important political and cultural functions not unlike those of monastic Buddhist institutions. The Chapter also offers an introduction to core foundations of Tibetan medical theory and practice, and clearly states how the author intends to “contribute to a more adequate conceptual and analytic framework for understanding the political and ethical problems of the twenty-first century” (p. 30).
The Chapter also contains a fresh appraisal of other scholarly studies of Tibetan identity and nationalism. Attention is drawn to how Tibetan medicine continues to be both an ethical and a political practice within the context of “Buddhist modernism” (pp. 39-41). This position overcomes traditional dichotomies in the study of the ethical and political domains and is thus imperative in offering more adequate understandings of Tibetan nationalism and Buddhism. Such assertions are themselves inspired by wider scholarship on governmentality, for example by Nikolas Rose, who diagnoses contemporary modes of power as “ethico-politics,” concerned as they are with “self-techniques necessary for responsible self-government and the relations between one’s obligations to oneself and one’s obligation to others” (Nikolas Rose, Powers of Freedom: Reframing Political Thought. Cambridge: Cambridge University Press, 1999, p. 188; quoted in Kloos, p. 50; emphases in original).
Chapter 2 provides a historical background to the reestablishment of Tibetan medical institutions in exile, and the Men-Tsee-Khang’s trajectory and success story in particular. The argument made here is that the unique confluence of culture, Buddhist ethics, body politic and medical need that converged in the Men-Tsee-Khang has fostered its remarkable development and its role in the expansion of Tibetan medicine as a global “alternative medicine.” In its projects, the institution has consistently received explicit backing from His Holiness the Fourteenth Dalai Lama, whose support for Tibetan medicine is well known. This work, however, makes clear how such support is intimately and strategically linked to the spiritual leader’s unwavering support for Tibetan culture and his nation’s survival in exile.
Kloos then turns attention to how both exile and globalization are fostering profound changes in Tibetan medical practices and production at the Men-Tsee-Khang. Chapter 3 concerns the Men-Tsee-Khang’s struggle to preserve the traditional link between ethics and politics. This Kloos demonstrates through examples of the sustained practice of certain medico-religious traditions. One such is the ritual blessing of medicinal substances, which are imbued with mantras of compassion by the Tibetan lay and medical community of Dharamsala as well as by the Dalai Lama, and are subsequently used in regular medical pills and powders and distributed throughout the world. At the same time, however, a redefinition of what it means to be ethical for the Men-Tsee-Khang and its doctors is also taking place, for example by not being overtly political, and through the provision of free health care for certain sectors of society. In addition, the Chapter also explores how various ethical practices double as political ones, joining the self-interest of cultural survival among the Tibetan community in exile with altruistic concern for others, both at home and abroad.
Not unlike the case of Ayurveda in early twentieth-century India and to some extent more recently (Jean M. Langford, Fluent Bodies – Ayurvedic Remedies for Postcolonial Imbalance. Durham and London: Duke University Press, 2002), Kloos suggests that one of the crucial functions of the Men-Tsee-Khang and of “traditional Tibetan medicines” for the exile community turns out to be providing a cure for the split personality of the Tibetan nation, the painful separation of its modern and traditional selves, the Tibetan people and their territory, and ultimately the “nation” and its “state.”
In Chapter 4 the focus shifts to the link between ethics and business. Addressed here are the Men-Tsee-Khang’s attempts to combine financial survival, which it manages well despite an almost complete lack of government funding, with cultural survival in a context where capitalism is perceived as undesirable, yet unavoidable. Profit, the sole underlying aim of business according to capitalist logic, is perceived to go against Tibetan medical doctors’ ideal motivation of serving the best interests of a patient over and above everything else. Financial benefits for oneself or in this case for one’s institution should come, if at all, as a side effect. That said, Tibetans have engaged in trade and business for centuries; moreover, ethical codes of Tibetan medical doctors as found in medical texts also appear to have endorsed seemingly less “self-less practices” to ensure material survival and sustainability of their medical work (Janet Gyatso, The Way of Humans in a Buddhist World: An Intellectual History of Medicine in Early Modern Tibet. Forthcoming). It is, therefore, interesting to note the current ambivalence towards earning money through Tibetan medicine that Kloos documents among Tibetan doctors at the Men-Tsee-Khang. What emerges is that this ambivalence relates to expectations of the Tibetan community as a (Tibetan Buddhist) “moral community” and as such, is intimately linked to Tibetans’ cultural survival, which has already been shown to be one of Men-Tsee-Khang’s crucial functions.
Men-Tsee-Khang doctors perceive their institute’s ways of engaging in the “business of altruism” to be ethically diametrically opposed to those of private Tibetan medical doctors. Although usually graduates and previous colleagues of Men-Tsee-Khang practitioners, private doctors are seen by them not only as greedy for forsaking proper ethical conduct for profit, but also as guilty of abandoning the Men-Tsee-Khang and its noble struggle for the future of the Tibetan nation and culture. That this would only be a part of the story is clear, as on the other hand private doctors have a host of reasons for their decision to leave the Men-Tsee-Khang. Prominent among these are the structural and administrative shortfalls within the institution, with some going as far as to state that they are able to preserve more “authentic” medical practices through the combination of clinical and pharmaceutical work, as well as transmissions to students — domains that have become clearly separated in most medical institutions today.
Chapter 5 relates the struggle of the Men-Tsee-Khang in regard to their legal and political status as the official guardian of Tibetan medicine in exile and in consequence its “cultural preservation” and worldwide expansion. It shows how as a first step, diverse strands of knowledge, experience, texts, practice and transmission had to become regulated and standardized to become a clearly demarcated “medical system” that could become a legal entity. This was to be achieved through the establishment and work of the Central Council of Tibetan Medicine (CCTM), with whom doctors would register and in turn be inspected to ensure a degree of professionalism and patient safety in their practice. Due to lack of funds and power, the actual work of the council (meetings, conferences, etc.) became in fact a platform for debates about the future of cultural, intellectual, economic and political ownership over Sowa Rigpa (the Tibetan “science of healing”), in addition to being an internal regulator of medical practice. The dynamics within the early years of CCTM speak volumes about the relationship between Men-Tsee-Khang doctors and private doctors — in particular the “Himalayan” amchi (Tibetan medical doctor), who tended to be portrayed as backward practitioners in comparison with their more sophisticated colleagues at the Men-Tsee-Khang.
Chapter 6 considers the legal recognition in 2010 of Tibetan medicine — under the name of “Sowa Rigpa” — as one of the “Indian Systems of Medicine” regulated by the Indian AYUSH Department. This development took place just before Kloos finished writing the thesis, but it had been one of the core aims of CCTM during his fieldwork and its dynamics are hence traced in detail. Here the Ladakhi “Himalayan” amchi resurface as an important and rival group of (Tibetan) medical practitioners in India, who semi-independently yet also as part of CCTM lobbied for government regulation. This they did through a strategy that represented Tibetan medicine as strongly resembling Ayurveda, having been initially taught by the Buddha in India. In contrast, the Men-Tsee-Khang had focused more strongly on the Tibetan — even pre-Buddhist — roots of Sowa Rigpa while at the same time also stressing its “scientific” basis rooted in both its own practitioners’ scholarship as well as modern clinical trials.
Chapter 7 reports on the Men-Tsee-Khang’s engagements with Western “science” with which they pursue various aims, including the support this would lend to the legal recognition of Tibetan medicine by the Indian government, as well as attracting western audiences and patients. This Chapter discusses the clinical studies that have been carried out at the Men-Tsee-Khang, analyzing how, on the way, its practitioners are both reconfiguring Tibetan traditions as well as remedying the scientific reductionism of global modernities and their intricate link to unwanted (from their perspective) capitalism and epistemological superiority. The employment of Western science here emerges not so much as an avenue for making new discoveries, but rather as a way of documenting and establishing proof of something that already works, i.e. as an “ornament for traditional knowledge” (p. 310).
Modern scientific methods and technologies, however, have made the most substantial inroads into the Men-Tsee-Khang’s pharmaceutical production. As most ingredients are no longer picked and sourced on the ground by Men-Tsee-Khang staff and students, but purchased through traders from all over India and also abroad, a sole reliance on traditional methods of quality control had to be abandoned — not least so they could provide consistent batches of medicines for patients and scientific trials. It is on this sustained efficacy of pills and powders, Kloos argues, that continued trust in and growth of Tibetan medicine will rest in the long term.
A brief conclusion at the end ties up loose ends of the argument, which is clearly about how Tibetan medicine “‘preserves’ Tibetan culture and produces a modern Tibetan nation by instantiating, materializing and validating Tibetan Buddhist ethics — and thus Tibetan culture and nation — in its medical knowledge, its institutions, doctors, pills, and efficacy” (p. 336). The thesis also urges us to re-think traditional notions of nation and nationalism, studying them as “shifting assemblages of practices, discourses, norms and values” (p. 339, citing Ong and Collier eds., Global Assemblages). The outcome of the many and often contradictory demands made on Tibetan medicine in exile and Tibetan medical doctors’ responses to them remains open, but as this thesis shows they are continually emerging, negotiated and re-negotiated once again.
When published this dissertation will offer a significant contribution to the study of the Tibetan diaspora and the globalization of Tibetan medicine in the context of growing interests in both “alternative medicine” as well as (Tibetan) Buddhism and associated Tibet support movements. One of its main contributions will be a better and more nuanced understanding of the ongoing work of Tibetans in building, sustaining and working their nation as a “moral community” in exile — an endeavor that has so far in academia rarely been described with as much genuine sympathy, despite its obvious contradictions and shortcomings, as well as a critical stance.
With nations increasingly moving away from being clearly demarcated entities in the context of migration and globalization, the work will certainly also be of interest for comparative studies of other groups around the world, who due to one reason or another are seeking to preserve their culture, language, and medical traditions under changed circumstances and in new political, legal, socio-economic, and environmental spaces.
Institute of Health and Society
University of Oslo
Ethnographic fieldwork at the Dharamsala Men-Tsee-Khang and with private Tibetan medical doctors and health administrators in India
Statements and speeches of leading figures in Tibetan exile community and the Men-Tsee-Khang
Materials drawn from the Tibetan exile media
University of California, Berkeley. 2010. 368 pp. Primary Advisor: Vincanne Adams.
Image: Photographs taken by SebGeo in collaboration with Stephan Kloos.