Humanitarianism from Below: Sowa Rigpa, the Traditional Pharmaceutical Industry, and Global Health

ABSTRACT

In this article I explore, for the first time, the relationship between Sowa Rigpa (Tibetan medicine) and global health, tracing “the global” in ethical discourses and pharmaceutical innovation practices of Tibetan medical practitioners. I argue that Sowa Rigpa’s engagement with the world and its global health activities outside China can be understood as a form of “humanitarianism from below,” while its industrialization in China aligns with global health in different ways. In providing new insights into recent developments of Sowa Rigpa, I aim to decenter the notion of humanitarianism and contribute to a broader understanding of global health.

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KEYWORDS:

• Asian medical industries
• global health
• globalization
• humanitarianism
• Sowa Rigpa
• Tibetan medicine

As the world was reimagined in terms of a singular “global” reference point over the past three decades, global health and humanitarianism emerged as new forms of intervention and governance, ostensibly concerned with the welfare of humanity as a whole. At the same time, medical anthropologists and the WHO began to pay increasing attention to traditional medicine, the former noting the gradual process of globalization of especially traditional Asian medicines since the 1980s (e.g. Alter 2005; Connor and Samuel 2001; Wujastyk and Smith 2008), and the latter passing several resolutions and policy documents related to these medicines (e.g. WHO 2002, 2008, 2013). Three distinct trends can therefore be observed to coincide during this period: 1) the emergence of global health and humanitarianism as new modes of intervention; 2) the globalization and industrialization of traditional Asian medicines; and 3) a renewed and more serious WHO focus on non-biomedical health resources, first stated at its 1978 Alma Ata conference. This coincidence is striking, and raises the question whether – and if so, how – these three trends might be connected. In this article, I address this question from the perspective of one of these developments, namely the globalization and industrialization of Sowa Rigpa, also known as Tibetan medicine.¹ By critically engaging the worlding (Zhan 2009) of a formerly little-known regional health tradition, I trace the emergence of the notion of “the global” in regard to health and medicine among Tibetan doctors outside China, and some of the consequences thereof. I argue that Sowa Rigpa’s worlding is strongly rooted in, and connected with, an exile Tibetan “humanitarianism from below,” which in many ways mirrors the logics and discourses of global health from a subaltern position. Supplementing the article’s main focus on the Tibetan exile community and its particular ethico-political agenda, the Sowa Rigpa industry in China suggests further parallels with global health. While the similar trajectories of Sowa Rigpa in- and outside of China and global health since the 1980s and ‘90s indicate a gradual convergence that has real health-care, political, and economic consequences, they nevertheless constitute distinct domains with their own character and dynamics. A critical exploration of their complex and evolving relationship appears an important element in efforts to better understand the role and development of contemporary Asian medicine and to broaden our perspective on global health and humanitarianism more generally.

Global health and traditional Asian medicine have more in common than is suggested by popular associations of a well-funded, globally operating modern biomedical apparatus on the one hand, and a range of ill-organized and under-funded local health traditions on the other. To begin with, while neither “world health” nor Asian medical traditions are new, both “global health” and “traditional Asian medicines” began to emerge as distinct fields of engagement, discourse, and inquiry in the late 1970s and 1980s, gathered momentum in the 1990s, and fully established themselves on a global stage from the 2000s onwards. Thus, Jean-Paul Gaudillière (2014) traces a number of trends concerning intervention techniques and their targets since the mid-1980s that marked a shift from “international public health” to “global health” as a new, market-driven regime increasingly concerned with risk management, pandemics, and chronic diseases.² Similarly, in the wake of Charles Leslie’s seminal reframing of traditional Asian medicines as Asian Medical Systems (Leslie 1976), sustained medical anthropological scholarship from the 1980s onwards solidified the status of Ayurveda, TCM, and Greco-Persian medicine as globally relevant professional entities (e.g. Bates 1995; Connor and Samuel 2001; Leslie and Young 1992). Secondly, the rise of both global health and traditional Asian medicines is directly connected to a worldwide trend of pharmaceuticalization (cf. Gaudillière 2014; Kadetz 2015:145; Kloos 2017b), whereby medicine and health interventions are increasingly reduced to the material object of the drug and its delivery (Banerjee 2009; Biehl 2007; Farmer 2001). This, thirdly, led to the growth of “traditional” pharmaceutical industries especially in Asia (e.g. Kloos 2017b; Pordié and Gaudillière 2014; Saxer 2013; Zhan 2009), which could then be included in the WHO’s Traditional Medicine Strategies (WHO 2002, 2013) as a primary target of regulation, effectively reducing the wide and heterogeneous field of “traditional medicine” to its recently developed pharmaceutical sector. In short, global health and the segments of traditional Asian medicines most visible to it both participate in the same framework of pharmaceuticalized, market-based health economics.

Sowa Rigpa is a good example for the co-emergence and growing alignment of traditional Asian medicines (or substantial sections thereof) and global health. Sowa Rigpa’s gradual globalization began in the early 1980s in India, when the Tibetan exile community – notably doctors – started to increasingly engage the world after two decades of medical, sociocultural, and political reconstruction efforts.³ Thus, in the 1980s, English language publications and conferences on Tibetan medicine first addressed lay and scholarly Western audiences, the first interactions with modern science took place, and Tibetan medicine for the first time attracted more non-Tibetan than Tibetan patients (Kloos 2017a). During the 1980s and ‘90s, Sowa Rigpa also began to grow exponentially in the Tibetan areas of China as its cultural and commercial value became apparent in a post-socialist world, while exile Tibetan doctors traveled or settled all around the globe. In the early 2000s, Sowa Rigpa’s ongoing commercialization, pharmaceuticalization, and globalization in China, India, Mongolia, and Bhutan led to the emergence of a transnational Sowa Rigpa pharmaceutical industry (Kloos 2017b) that, while still much smaller than the Ayurveda or TCM industries, is rapidly gaining momentum, global scope and market value. Like global health, this industry constitutes a particular regime of governance, driven by both capitalist market logic and humanitarian ethics, that actively connects health and development by specifically targeting underserved populations, chronic diseases, and occasionally also infectious pandemics or natural disasters on a transnational scale. While such commonalities need not be interpreted as evidence for Sowa Rigpa’s active participation in global health, they provide a starting point to investigate their relationship and partial convergence.

Engaging the world

Tibet’s persistent image of geographical, cultural and political isolation belies the cosmopolitan nature of its history and cultural heritage, including Sowa Rigpa. As the most important symbol of Tibet’s national identity today besides Tibetan Buddhism (Janes 2001; Kapstein 2000), Sowa Rigpa was originally assembled from Indian, Chinese, Persian and Central Asian scriptures and experts from the seventh century onwards (cf. Kilty 2010; Yang Ga 2014). After it had been fully institutionalized as Tibet’s own unique science, Sowa Rigpa was re-exported throughout Inner Asia and the Himalayas, playing an important role in the expansion of Tibet’s sphere of cultural influence (Schaeffer 2003) that partly still exists today (Kloos 2017a). Sowa Rigpa’s Mahayana Buddhist ethical claim to work for “the benefit of all sentient beings” (Tib. ‘gro phan) was particularly useful in the Ganden Phodrang government’s political and economic agenda (Gyatso 2004), articulating a universalist vision that potentially included the whole world. In practice, however, the extent of Sowa Rigpa’s world of “all sentient beings” remained limited to the Central Tibetan sphere of hegemonic ambition (including Himalayan areas like Ladakh and Bhutan, as well as Mongolia and Buryatia) until the mid-twentieth century, when Tibet’s occupation by China and the Fourteenth Dalai Lama’s subsequent flight to India in 1959 forced major changes upon the Tibetan world. It was only in exile that Sowa Rigpa’s and the Tibetan community’s ethical, political, and economic vision expanded to include, in the notion of “all sentient beings,” the world in a global sense (cf. Huber 2001; Kauffmann 2015; Roemer 2008).

Rooted in its pan-Asian origins, its universalist Buddhist framework, and its historical development until the twentieth century, Sowa Rigpa’s contemporary globalization was a gradual process. During the first two decades in exile (Kloos 2008), as much as during the Cultural Revolution in China (Hofer 2018; Janes 1995), Sowa Rigpa’s ethics was certainly to “benefit all sentient beings” just as it had been for centuries, but its immediate concern was one of sheer survival: its own survival as a central part of Tibetan culture, and also the physical survival of its Tibetan patients, who were dying in large numbers due to the violent reforms in Tibet, and the unfamiliar climate, poor sanitary conditions, and inadequate biomedical care in India. It was only in 1982 that several events – the first successful production of tsotel (mercury sulfide ash) in exile,⁴ the organization of a popular “Tibetan medicine week” in New Delhi, and the first international conference devoted to Tibetan medicine in the United States – enabled exile Tibetan Sowa Rigpa practitioners to broaden their vision and begin to engage with the world at large (Kloos 2012, 2017a). This coincided with a shift in the Tibetan exile government’s political strategy, which led to an active reframing of Tibetan culture as consubstantial with the Mahayana Buddhist ethics of altruism and compassion (cf. Lopez 1998). Manifested most clearly by Tibetan Buddhism and medicine, these universal values enabled the portrayal of Tibetan culture in terms of a threatened common good worthy of the world’s protection and support (Barnett 2001). For this, its value to the world had to be demonstrated, leading the Dalai Lama for the first time to explicitly include, in a 1982 speech to Tibetan doctors and medical students, Indians and foreigners as Sowa Rigpa’s beneficiaries, pointing out that “the more benefit and service Tibetan medicine renders to humanity, the more it is of service to Tibetan culture. We must understand that this holds strategic importance.” (Dalai Lama 2007:17) In later speeches, he noted a “growing global interest in Tibetan medicine,” and reiterated repeatedly that Sowa Rigpa should not remain limited to Tibetan society.

In China, too, Sowa Rigpa’s popularity began to grow exponentially in the 1980s, as new political and economic policies led to its integration into the official health care system, improving its availability for local Tibetan populations. This growth accelerated in the 1990s, when liberal market reforms forced Sowa Rigpa to enter the commercial pharmaceutical market catering to wealthy urban Tibetans and increasing numbers of Han Chinese, further expanding its reach (Hofer 2018; Janes 1995; Saxer 2013). If up to this point, Sowa Rigpa’s role and function in both China and India had largely been restricted to primary health care for local or refugee Tibetans with little access to other health resources, from the 1990s onwards it began to systematically specialize on common, chronic, complicated, or untreatable biomedically-defined diseases of urban, often non-Tibetan upper and middle classes.

The prime institution of Tibetan medicine in India, the Dharamsala Men-Tsee-Khang, serves as a good example for Sowa Rigpa’s expanding scope. In several key meetings and a conference in the mid-1990s, the institute decided to strategically focus its clinical research activities on hepatitis, a major health issue especially among the exile Tibetan community; diabetes and asthma, health problems of epidemic proportions in India; and cancer, a cure for which would guarantee international attention (cf. Czaja 2011). Also in the early 1990s, the then Men-Tsee-Khang director and a senior physician publicly claimed in the US that Tibetan medicine could, at least in principle, cure AIDS. The results of such activities were mixed: while the Men-Tsee-Khang team had to cut short its US tour to avoid a lawsuit, Tibetan clinics opened all over South Asia – and doctors traveled and settled throughout the world – not for their primary health benefits, but their seemingly miraculous cures for problems like asthma, diabetes, arteriosclerosis, or cancer. In fact, almost all Men-Tsee-Khang branch clinics in metropolitan India – Mumbai, Chennai, Bangalore, Ahmedabad, Secunderabad – were established upon the initiative and sponsorship of enthusiastic local Indians who owed their (or their family members’) lives to Tibetan medical intervention. Similarly, Sowa Rigpa’s accelerating spread in other parts of Asia and the rest of the world is largely sustained by its reputation of efficacy in treating complicated chronic diseases and dramatically improving patients’ quality of life.

Sowa Rigpa’s worlding, that is, its re-envisioning of the global as a singular reference point through multiple, transformative relations with the world (Zhan 2009:7), was best summarized by one Tibetan physician in India who told me: “Although we are refugees, through Tibetan medicine we can help the world.” This doctor’s sentiment, which was shared by most exile Tibetan physicians I talked to, is doubly revealing. For not only does it point to the extent to which the world has become an integral, defining feature of exile Tibetan medicine, but it also articulates an exile Tibetan “politics of compassion” that can be understood as a particular kind of humanitarianism (e.g. Bornstein and Redfield 2010; Fassin 2012; Ticktin 2014). Commonly defined as a “way to ‘do good’ or to improve aspects of the human condition by focusing on suffering and saving lives in times of crisis or emergency” (Ticktin 2014:274), humanitarianism accords moral sentiments such as altruism and compassion a central place in the realm of politics and governance. As Didier Fassin (2012) reminds us, this involves an uncomfortable combination of genuine ethical motivations with political or economic self-interest and power inequalities, without one necessarily invalidating the other. The exile Tibetan case constitutes precisely such an introduction of moral values like altruism and compassion into the political sphere of nationalism (Fassin 2010:269) and market competition, via the ostensibly apolitical non-governmental institution of Sowa Rigpa (Kloos 2017a). Like humanitarianism elsewhere (Ticktin 2006; Redfield and Bornstein 2010:6), it also reframes (Tibetan) medical expertise as an important vehicle of such moral engagement, and thus as a crucial mode of governing.

The particularity of the exile Tibetans’ politics of compassion lies in its subaltern nature: instead of large, well-funded humanitarian organizations or rich states of the Global North, in this case it is poor, often stateless refugees who set out to “help the world” with their unique medicine. Craig, Gerke and Sheldon’s (forthcoming) ethnographic study of Sowa Rigpa medical camps in India and Nepal provides an illustrative case in point. Lacking official recognition outside a small number of countries, Sowa Rigpa remains invisible to large global health institutions like the WHO or the World Bank, and technically illegal in most of the world. Contrary to the global politics of compassion of the North, carried out by an army of NGOs and large international organizations, the Tibetan version thus largely remains an unofficial (or even clandestine) operation. The relationship of inequality inherent in humanitarianism’s usual flow of aid and intervention (Fassin 2012) – from above to below, from the powerful to the weaker – is thus turned on its head. However, just like the humanitarian agents from the privileged countries of the Global North, exile Tibetans are keenly aware of not only the moral, but also the political and economic capital to be earned by helping others. In the Tibetan historical context, this model was known as the “patron-priest” relationship (Tib: mchod yon), in which Tibet would provide spiritual/religious guidance in return for foreign political or military patronage (Goldstein 1999; Kapstein 2006). Today, as Tibetan religious and medical experts offer their services around the world, what is at stake are global, regional, and professional hegemonic ambitions, just as occurs in Western humanitarianism. They involve the representation of Tibetan identity and history on the global stage (Kloos 2012), the perpetuation of a Tibetan cultural/religious hegemony in Inner Asia (Kloos 2017a), and the control over (parts of) the transnational Sowa Rigpa industry – all legitimized by the genuine intention to help. Sowa Rigpa’s development in exile, then, not only testifies to an extraordinary process of globalization, but also constitutes a subaltern politics of compassion – or, in other words, a particular kind of humanitarianism from below.

The Sowa Rigpa industry

If Sowa Rigpa’s expansion and reorientation towards the global within the framework of a subaltern humanitarianism originated in the Tibetan exile community, from the 1980s the Tibetan areas in China took the lead in terms of its commercialization and modernization. By the early to mid-2000s, these developments – which also took place in Mongolia (Gerke 2004; Janes and Hilliard 2008) and Bhutan (Wangchuk 2008) – culminated in the emergence of a transnational, and rapidly growing, Sowa Rigpa industry (Kloos 2017b). Based on pharmaceutical mass production to supply burgeoning domestic and international markets for traditional medicines, this industry quickly established itself as an integral part of Asia’s innovative knowledge sector, officially proclaimed as one of Tibet’s “pillar industries” and constituting an important factor for economic growth throughout the region.⁵ Although traditional medicine is rarely portrayed in terms of an industry by the WHO, it is clearly its economic value as a pharmaceutical industry that has attracted the WHO’s attention,⁶ and that provided it with a concrete target for its global health agenda (Kadetz 2015:145). Thus, its Traditional Medicine Strategy from 2013 observes that traditional and complementary medicine “has growing economic importance,” and “plays a significant role in the economic development of a number of countries” (WHO 2013:18).

Nevertheless, the greatest difference between global health and traditional medicine – particularly Sowa Rigpa – remains their respective size, power and legitimacy. In the 2000s, as Sowa Rigpa became increasingly exposed to competitive domestic and global markets for complementary medicines, Tibetan practitioners and administrators began to seek greater legitimacy through recognition, regulation, and representation. In China, this mainly took the form of implementing Good Manufacturing Practices (GMP) and drug registration laws to fully integrate Sowa Rigpa into the national health care system and pharmaceutical industry (Craig 2011, 2012; Saxer 2012, 2013). In India, both exile Tibetan and Indian Himalayan physicians began to lobby for official recognition, leading first to Sowa Rigpa’s increasing regulation and standardization at the level of the exile Tibetan government (Kloos 2013), and finally to its formal recognition by the Government of India in 2010 (Blaikie 2016; Kloos 2016). Along with legal status and, at least in principle, access to the vast Indian market for traditional medicines, this also initiated the gradual introduction of modern quality control regimes in the domain of Sowa Rigpa’s pharmaceutical production (Kloos 2015), albeit on a much lower level than in China. These developments closely reflected the WHO’s first Traditional Medicine Strategy published around the same time (WHO 2002), which advocated the establishment of regulations and quality standards in order to integrate traditional medicines into national health care systems and thereby ensure or increase their availability, safety, quality, and efficacy.

Mirroring well-known calls by the WHO (2000, 2002, 2013) and international NGOs for an evaluation of traditional medicines from a biomedical standpoint in order to enroll them in their global health agenda, the Dalai Lama repeatedly suggested to assess other medical traditions (particularly biomedicine but also Ayurveda and TCM) in order to harness their knowledge to further improve and globalize Sowa Rigpa (Dalai Lama 2007). Although Tibetan medical institutions tend to be conservative regarding the integration of biomedicine, they did begin to address epidemics and even global pandemics and natural disasters, something hitherto associated only with biomedical global health interventions. Thus, the Men-Tsee-Khang first began to produce and sell special herbal pills, medicinal incense and amulets in 1994 to prevent contagion in the context of the Indian plague outbreak that year. During the 2003 SARS crisis, demand for Sowa Rigpa products skyrocketed especially in China (Craig and Adams 2008), and later during the same decade, similar patterns could be observed in both India and China related to the avian and swine flu pandemics. This is illustrated well by an announcement of Men-Tsee-Khang director Dr. Dawa in 2009 during the swine flu outbreak:

Tibetan Medicine has a history of some thousand years. The fundamental text of Tibetan Medicine, the Gyud-shi … outlines … various means of protecting oneself and others from the contagious viral infections … One convenient means is the use of the herbal compound called ‘Rim Sung Gu Jor’ (Nine Compound for the protection of contagious infection). Instruction: … During the prevalence of viral infection, sniff the pill in the mornings on an empty stomach, when concerned about the viral outbreak, when coming in contact with an affected patient and while traveling around. If implemented properly, this protection pill can safeguard one and all from dreadful contagious infections. (Men-Tsee-Khang 2009)

Dr. Dawa’s reference to “viral infections,” which are not mentioned as such in the Gyud-shi, indicates a development comparable to Ayurveda’s response to the Indian Chikungunya epidemic in 2005–06 (e.g. CCRAS 2009). That is, Tibetan doctors in both China and India increasingly translated older metaphysical etiologies of epidemics, like demons and spirits, as modern viruses and bacteria (cf. Czaja 2011:270–272),⁷ and ancient herbal compounds as instruments of pandemic risk management (cf. Phayul.com 2003). On a more fundamental level, such attempts to acquire relevance in a biomedicine-dominated world involved the pharmaceuticalization and individualization of earlier communal ritual or spiritual measures to appease aggravated demons and spirits.

In other domains, Sowa Rigpa’s economic and political stakeholders became increasingly vocal in proclaiming its value and potential to global health. For example, the main focus of a 2008 conference in Dharamsala, intended to lobby for Sowa Rigpa’s official recognition, was remarkably less on Sowa Rigpa’s contributions to Indian health care (despite its long tradition of providing free medical care to poor and remote communities, including Indians) than on its potential to address global health problems (Blaikie 2016). Throughout the conference, the presenters displayed a clear awareness of global health concerns and positioned Sowa Rigpa in relation to them, rather than to the specific health problems of exile Tibetans or Indians. Thus, Dr. Tenzin Namdul from Men-Tsee-Khang spoke about Sowa Rigpa’s efficacy in the treatment of type-2 diabetes and its global applicability, while Milan-based Dr. Pasang Yonten Arya gave an eloquent presentation on Sowa Rigpa treatments for Western chronic and lifestyle ailments such as Crohn’s disease. More recently, the Men-Tsee-Khang observed the WHO’s 2014 World Diabetes Day and the 2016 World Health Day by organizing large and well-attended public health events in India. Besides diabetes, the Men-Tsee-Khang has also come to pay increasing attention to the global mental health crisis, leading to the foundation of a new Body, Mind and Life Department with the aim “to provide optimum mental health care services to humanity” (Men-Tsee-Khang 2016).

The focus on mental health shows that while Sowa Rigpa’s humanitarian and global health agenda is crucially connected to its emerging pharmaceutical industry, it is by no means limited to it. Counterbalancing its industrial upgradation and urbanization, in the 1990s and 2000s Sowa Rigpa practitioners and institutions began to consciously reach out to medically underserved communities in Tibet and the Himalayas (Craig 2007; Craig, Gerke and Sheldon forthcoming; Hofer 2018; Pordié and Kloos forthcoming), often employing the rhetoric of development agencies (Kloos 2017a). On a more global level, Dr. Nida Chenagtsang, founder and director of the Germany-based non-profit foundation Sorig Khang International (SKI), presented “Sorig Aid” as “An Integrative Health Care Model for Our Underserved International Community” at a 2018 conference at Stanford. He emphasized that while “Sorig Aid” was created in response to the 2015 Nepal earthquake (where SKI and local associations offered free Tibetan medicine to the victims), its vision grew out of 15 years of rural health care in highland Asia to now provide “accessible, low-cost, sustainable, and effective therapies with low side effects” also to “the underserved international community” in developed countries, including “communities of color, undocumented migrants, and victims of abuse”. As far as global health was concerned, Dr. Nida concluded, Sowa Rigpa might actually offer more sustainable humanitarian aid than Doctors Without Borders or the Red Cross. His speech ended with the slogan, “Together we create happier and healthier societies worldwide.”⁸

There are, of course, critical voices regarding SKI’s activities especially in post-earthquake Nepal (cf. Craig and Gerke 2016), and about Sowa Rigpa’s global spread more generally. As Hofer (2018) shows in rural Tibet, when some institutions acquire the power and scope to provide and represent Sowa Rigpa on the national and international level, village practitioners and their local knowledge may end up ignored, silenced, or even disenfranchised. Similarly, Sowa Rigpa’s emerging global humanitarianism is accompanied by its ongoing commercialization, which large sections of the profession see as problematic. Dr. Namgyal Qusar, who runs a private clinic and pharmacy near Dharamsala, for example, agreed that Tibetan medicine should “help the world,” but contested the connection of this ethics with globalization. While it was important to treat every individual the same, regardless of their background, he argued that “I’m not in favor of spreading Tibetan medicine. Just increasing medicine production doesn’t mean one is helping others. If you mass-produce Tibetan medicine, then you can’t focus on the individual patient, you need to raise the prices, you lose touch… Commercialization is not helping. We have to help the local people first, and also think of the local practitioners.” While Dr. Qusar’s critical stance vis-à-vis Sowa Rigpa’s commercialization and industrialization was widely shared among practitioners both in exile and in Tibet, the uncomfortable connections between these trends and Tibetan medicine’s worlding often remained unproblematized.

Anti-commercialization sentiments notwithstanding, over the past two decades, Sowa Rigpa’s general ethico-political idea of “helping all sentient beings” has gradually solidified in the framework of an industry – largely but not exclusively pharmaceutical – that actively seeks to participate in the contemporary humanitarianism of global health in order to gain not only moral but also economic and political capital. Sharing important features with the field of global health, including the aspiration to operate on a global scale, a strong reliance on humanitarian rhetoric, an increasing adoption of capitalist market logic, and a strong focus on pharmaceutical interventions as well as chronic diseases and mental health, this industry makes Sowa Rigpa legible not only for states (Kloos 2016) but also global health. The fact that traditional pharmaceuticals can be portrayed as simultaneously humanitarian-ethical and capitalist-political – at once affordable to the poor and profitable for investors, culturally embedded in local communities and amenable to regulation or appropriation by (trans-)national elites – makes them attractive to organizations like the WHO. Nothing illustrates this development and its implications better than the Sowa Rigpa pills, powders, tonics, and teas that are produced and reformulated in the attempt to make them “global.”

From regional medicines to global products

On a recent, high-profile outreach flyer, the Dharamsala Men-Tsee-Khang noted that “the world today is undoubtedly facing a severe health crisis which has significant impacts on community health, loss of lives, and on economy [sic].” The text went on to argue that Sowa Rigpa had an important role to play in addressing this crisis, particularly given the Men-Tsee-Khang’s “tremendous development” in terms of a “creative invention of more medicines and herbal products” (Men-Tsee-Khang 2015:5). Despite its conservative role of “preserving Tibetan medicine” in as pure a form as possible, the Men-Tsee-Khang has been remarkably flexible and innovative in adapting Sowa Rigpa to new contexts and requirements from its very beginnings (cf. Kloos 2017a). As with its counterpart in Lhasa and other Sowa Rigpa institutions in India and Tibet, this not only includes the representation and translation of Tibetan medicine to both Tibetan and global audiences to preserve its relevance in a modern, globalized world, but also the adaptation and adjustment of its pharmaceutical practices and formulas. Thus, we can observe a significant increase of innovation practices over the past two to three decades, which more often than not seem to be driven by market and/or global health considerations.

On the one hand, these practices involve the invention of new over-the-counter products and the rebranding of rinchen rilbu (precious pills) as tonics, partially doing away with the need for individual diagnosis and prescription and thus facilitating Sowa Rigpa’s global spread. While the marketing of rinchen rilbu – traditionally considered the most potent medicine available in Sowa Rigpa’s formulary – as tonics and souvenirs from Tibet is especially prevalent in China, where these pills cost up to ten times more than in India, exile Tibetan institutions dominate the field in terms of newly developed Sowa Rigpa “herbal products”. In 1994 the Men-Tsee-Khang founded its Herbal Products Research Department (HPRD) to create a commercially oriented “Sorig” line that today includes some 50 products sold throughout the world. Besides some purely cosmetic items like beauty creams, most of them are herbal health supplements based on Sowa Rigpa’s materia medica and the successive HPRD head doctors’ clinical experience: oils for arthritis or nervous disorders; teas against headaches, diabetes, hypertension, or gynecological disorders; tonics for increasing the intelligence of children, the stamina of men, or the life span of the elderly. Other producers in India, Bhutan, China, and Mongolia followed the Men-Tsee-Khang’s example, making such herbal products the fastest growing sector of the Sowa Rigpa industry overall. Although lacking any direct global health impact, they serve two important functions in terms of Sowa Rigpa’s larger aim of establishing itself as a global health resource. Firstly, they generate profits that can be invested in expanding the Sowa Rigpa pharmaceutical industry, or used to cross-subsidize prescription medicine prices in order to ensure accessible and affordable health care to local populations. Secondly, they play a significant role in creating international awareness of Sowa Rigpa and its efficacy, thus helping Sowa Rigpa help the world. As Ugyen Tsewang, the head of the Men-Tsee-Khang’s Export Department, explained: “It’s to educate people around the world about Tibetan medicine and its efficacy. When we sell our herbal products, customers ask whether we also have products for certain diseases, and then we refer them to our doctors. So Herbal Products Exports is a tool to help Tibetan medicine.”

On the other hand, Sowa Rigpa’s expanding scope has been accompanied by the innovation and reformulation of prescription medicines. Innovation in this context can roughly be classified into two categories. One is the production of “new” medicines, whose novelty lies in the fact that they have not been part of a given doctor’s or institution’s contemporary repertoire of drugs. As one pharmacy doctor at Men-Tsee-Khang told me in 2015, “We have more than 2000 formulas in our texts. Of these, [at the Men-Tsee-Khang] we only use about 170. So when we say that we produce a ‘new’ medicine, it’s new for us but actually it’s an old formula.” The other category concerns the “creation” of new medicines by adding ingredients to old formulas, usually in response to clinical demand. Since at the pharmacy level, such individual, case-by-case admixtures have become mostly impracticable in today’s context of industrial mass production of pills, the Men-Tsee-Khang has adopted an altered system, in which it collects public health information (morbidity rates, etc.) as well as feedback on the efficacy of its medicines during its annual assembly of clinic doctors. This feedback is evaluated by a High-Level Council consisting of senior experts, which may then instruct the Pharmacy Department to expand or include certain formulas. Once a small experimental batch of a new formula is produced, it is distributed as a trial to select clinics, which then send back reports on the new pills’ indications and effectiveness. Based on these reports, the High-Level Council decides whether and how to include these medicines in the Men-Tsee-Khang’s repertoire of pharmaceutical treatments. According to the current head of the pharmacy, Dr. Jamyang Tashi, the Men-Tsee-Khang “created,” through the addition of new ingredients to old formulas, about 18 new medicines since the 1980s, mostly for various kinds of chronic and acute stomach and liver disorders, prostate problems, and different types of cancer. While this institutional set-up is unique, the creation of “new” medicines through admixture and experimentation has been common practice among Sowa Rigpa producers throughout the region (Blaikie 2013, 2018; Gerke 2018).

Similarly, throughout Sowa Rigpa’s history, classical formulas have been adapted to new environmental, climatic, social, and more recently also public health and legal contexts, and different constitutions of new patient groups (e.g. Blaikie 2018; Bold 2009). In India, for example, Tibetan recipes were significantly altered in the 1980s to account for the different physical constitution of Indian patients, who during that decade became the most numerous patient group of Tibetan medicine in exile. For example, Dr. Penpa Tsering, a highly respected private manufacturer in the Dharamsala area, remarked about one popular formula: “In the old texts, the quantity of aconite⁹ in the formula for Khyunga is very high. Now, here in India, we use much less, otherwise the patients will faint. Indians get dizzy more easily than Tibetans because of their diet, and since most clinics serve mainly Indian patients, we have to take that into account. So we can’t use the old texts just like that.” Also, whereas it used to be common to adjust the quantity of aconite depending on its potency or toxicity, which could vary depending on its source and condition, contemporary pharmaceutical mass-production requires the use of ingredients from many different sources and subspecies simultaneously (as one Delhi-based doctor told me, recently even African aconite has appeared on Indian herb markets), making such adjustments impossible. Hence, besides reducing the actual quantity of aconite in the formula, the Men-Tsee-Khang pharmacy has begun to detoxify it as a standard practice during the 1980s, regardless of its relative potency.

Leaving aside medicines with toxic ingredients, even regular pharmaceuticals required adjustment due to Sowa Rigpa’s industrialization and globalization. Again, the beginning of this trend can be located in the 1980s, when the Men-Tsee-Khang opened more branch clinics in metropolitan and South India, attracting predominantly non-Tibetan, non-Himalayan patients with different lifestyles, diets, and health care needs. Around the same time, it became clear that Sowa Rigpa’s classical medicines – originally formulated for a population of sturdy meat-eaters living on the cold, dry Tibetan plateau – required adaptations even for Tibetans, who were forced to settle in India’s hot climate and had adopted an Indian preference for spicy food and sweet tea. Thus, exile Tibetan pharmacists began to reduce the quantities of ingredients with warm potency, like pomegranate seeds (Tib: se ‘bru), and increase the amount of cooling ingredients like safflower (Tib: gur gum) in order to address different climatic and bodily conditions. As Sowa Rigpa further globalized during the 1990s and especially the 2000s, and its mass produced pills were increasingly consumed by patients from around the world, the need for generalizing Sowa Rigpa’s formulas to some kind of global “average” became even more apparent. As Dr. Penpa Tsering explained:

The use of medicines is changing today. Earlier, we adjusted the formulas according to the individual patient, according to age, health, and constitution, even the weather and the season. Some places are very hot, some very cold. If we put too many warm or cold ingredients in, then there’s a problem. So when deciding what quantity of ingredients to use, whereas before we adjusted to the individual, or the place, now we have to use an average. Of course, for special patients, we can still adjust or even change the formula. But normally, one medicine goes to the whole world. Nowadays, we have to think ‘general’.

Exile Tibetan doctors and patients regard this transformation of previously potent and context specific medicines into generic global pills with mixed feelings: the more their pills “help the world,” the less effective – and available – they seem to become as a primary health resource for their own community. Any adjustment of formulas towards a global average inevitably means making them less suited to any particular need or locale. This is true as much for the relative quantities of cooling and warming ingredients, as for the use of toxic – but highly potent – herbs like aconite. Besides such reformulation practices, the sheer up-scaling of Sowa Rigpa’s pharmaceutical practices to industrial mass production, and the new regulations and safety standards that come with it (e.g. Adams 2002; Craig 2011; Saxer 2013), not only drive up medicine prices, moving them out of reach for poor rural populations (e.g. Hofer 2018), but are also perceived to negatively affect the efficacy of Sowa Rigpa medicines, be it in China or India. As several Sowa Rigpa practitioners told me: “Medicines are like food. They are best when prepared in small quantity, by hand. When produced in big quantity in factories, even if they follow the best standards, they are not as tasty, not as potent.” But, the consensus goes, global demand, national regulations, and the Sowa Rigpa communities’ political and economic agendas, leave producers with little choice but to participate, however carefully, in the global traditional and complementary medicine industry.

Conclusion

I have tried to trace Sowa Rigpa’s transformation from a local primary health provider struggling for survival to a global alternative health resource specialized in the emerging chronic disease pandemic. This transformation was first triggered by a radical change in the geopolitical situation, which relocated Sowa Rigpa from the center of the Tibetan world to the margins of the international community. As its old ethical imperative “to help all sentient beings” gained a new global scope and political purpose in exile in the 1980s, and Chinese economic reforms created a profit-oriented market for Tibetan medicines in the 1990s, a transnational Sowa Rigpa pharmaceutical industry began to emerge in tandem with global health and other humanitarian modes of global governance. Sowa Rigpa’s industrialization, regulation, and standardization during the 2000s, especially in China, closely mirrored the WHO policies and resolutions concerning traditional medicine that were published during the same decade. Similarly, both the Dalai Lama’s and exile Tibetan practitioners’ discourses, and concrete pharmaceutical reformulation and innovation practices since the 1980s, suggest a gradual reorientation of Sowa Rigpa’s focus towards the global in general, and global health agendas in particular. Vice versa, WHO documents indicate an increasing recognition of traditional medicine – or, at least, its commercially operating pharmaceutical industry – as playing an important role in global health.

Both sides – Sowa Rigpa and global health – are connected by a common rhetoric of humanitarianism, in which political and economic interests are conflated with the genuine moral imperative to help others. While this humanitarian logic was a central element of Tibetan foreign policy for centuries, ensuring both Sowa Rigpa and Tibetan Buddhism an important place in Central Tibetan governance, from the 1980s onwards it was consistently applied in a modern, global, capitalist context. Contrary to Tibet’s earlier, powerful position in Inner Asia, Sowa Rigpa’s modern humanitarianism does not come from a position of strength, but of weakness: it has to be exercised not from above, as in its usual Western form, but from below. As Tibetan refugees consciously began “helping the world” from a marginal, subaltern position, and China integrated Tibetan doctors into its health care infrastructure, Sowa Rigpa’s economic, political, and humanitarian potential quickly became clear, eventually giving rise to a Sowa Rigpa pharmaceutical industry that consciously positions itself within the field of global health. Without postulating any linear relationship between these two fields, which each have their own complex history and dynamics, it is clear that global health is sensitive to the emergence of a strong and innovative traditional pharmaceutical industry in Asia, just as this industry is in continuous dialogue with WHO policies and the broader concerns and orientation of the field of global health. Sowa Rigpa’s industrialization, as a case in point, serves to make this Tibetan medical tradition visible, recognizable, and relevant to global health regimes, as both sides increasingly share a common ground of economic and geopolitical interests couched in humanitarian reason.

There remains the question about the consequences of this rapprochement and the Sowa Rigpa industry legitimated by it. My aim in this article was to draw explicit attention to, and begin to explore, the relationship between Sowa Rigpa and global health/humanitarianism. Yet much ethnographic work remains to be done on how this relationship plays out in local Tibetan, Himalayan, and Mongolian communities, and in the policies of states and large global health organizations. Even as Sowa Rigpa today provides relief and hope for more patients in more places than ever before, Namgyal Qusar’s and Penpa Tsering’s comments above hint at troubling ethical questions that arise from Tibetan medicine’s global humanitarian focus. What is the moral value of “helping the world” if it comes at the expense of effective and affordable health care for local Tibetan and Himalayan communities that depend on Sowa Rigpa? Should – or can – the Sowa Rigpa industry continue to expand on a global scale, given its limited natural resources of wildcrafted mountain and steppe plants, which have come under increasing pressure as practitioners and producers seek to create and fulfill rising demands (Kloos 2017b)? What would be the terms of Sowa Rigpa’s – or other Asian medicines’ – official inclusion and participation in global health policies, who would benefit, and who would bear the costs? It is questions like these that scholars and practitioners of Sowa Rigpa, other Asian medicines, and global health need to address, collectively and individually, as previously local or regional health traditions seek to engage the world.

Acknowledgments

A first draft of this article was presented at the 2015 “GlobHealth” ERC Advanced Grant Conference “From International to Global: Knowledge, Diseases and the Postwar Government of Health” at CNRS/INSERM/CERMES3 in Paris. I am indebted to Jean-Paul Gaudillière and Laurent Pordié for their invitation and inspiration, and to Didier Fassin, Vincanne Adams, Calum Blaikie, Sienna Craig, Barbara Gerke, and three anonymous reviewers for helpful suggestions and feedback. This research would not have been possible without the long-term cooperation and support of the Dharamsala Men-Tsee-Khang and Tibetan doctors in India, China, and abroad.

Additional information

Funding

This research was funded by the European Research Council (ERC) Starting Grant RATIMED (336932).

Notes on contributors

Stephan Kloos

Stephan Kloos is senior researcher at the Austrian Academy of Sciences’ Institute for Social Anthropology. His recent publications include The Pharmaceutical Assemblage (Current Anthropology 2017) and The Politics of Preservation and Loss (EASTS 2017). See stephankloos.org for more information.

Notes

1. The term “Sowa Rigpa” (Tib: gso ba rig pa – “the science of healing”) is used here according to recent scholarly practice (cf. Craig and Gerke 2016). For stylistic reasons, however, I occasionally also use “Tibetan medicine.”

2. While there exists a broad consensus regarding the general trajectory of “global health” in the literature (e.g. Adams 2016; Basilico et al. 2013; Chorev 2012), a range of different (but largely compatible) perspectives besides Gaudillière’s emphasize its focus on human rights and social justice (Farmer et al. 2013), or on metrics-based evidence (Adams 2016).

3. No other professional Sowa Rigpa community – in Tibet, Mongolia, Bhutan, Nepal, or the Indian Himalayas – was able to do this at that time for a variety of political, economic, and other reasons. For decades, Tibetan medicine in exile (i.e. based in India) thus led the field as far as Sowa Rigpa’s global image and spread were concerned.

4. Tsotel (Tib: btso thal, “cooked ash”) is a complex compound of detoxified and purified mercury, and other metal, mineral, and herbal ingredients. It counts as the pinnacle of Tibetan pharmacology. See Gerke (2013) for more details.

5. Capital for this industrial development came from different sources, including government and bank loans, private or corporate investments, institutional savings, donations, and in one case even funding from the European Commission. This indicates official support as well as the perception of Sowa Rigpa as not only a culturally, but also economically valuable resource.

6. For example, an article on herbal medicine and global health in the Bulletin of the WHO begins with the following sentence: “Traditional herbal medicines are naturally occurring, plant-derived substances with minimal or no industrial processing that have been used to treat illness within local or regional healing practices” (Tilburt and Kaptchuk 2008:594). The authors, one of whom is a specialist on TCM and directly involved in the TCM industry, thus portray traditional medicine as a non-industrial, heterogeneous array of local or regional healing practices, before going on to quote multi-billion dollar figures in terms of their annual sales value.

7. For example, srin or srin bu (translated in classical Tibetan dictionaries as “insect,” “worm,” “tiny being,” but also as “parasite,” “ghost,” or “spirit”) are equated with viruses and bacteria. The “poisonous breath of mamo demons” and other supernatural beings – through which these srin bu enter human bodies and thus cause epidemics – has been related to environmental pollution and chemically contaminated food (Czaja 2011:271).

8. I would like to thank Dr. Nida Chenagtsang for kindly providing me the Powerpoint presentation of his speech at the 2018 Stanford Annual Symposium on Western and Tibetan Medicine, from which the above direct and paraphrased quotes were taken. I am also grateful to Tawni Tidwell for sharing her more detailed notes on the event.

9. Aconite (aconitum sp. and related species) is a highly toxic plant, commonly used in Asian medical traditions. In Sowa Rigpa, its detoxified roots are used in a number of formulas, most notably Khyunga (Garuda-5).