Introduction: Medicine and Healing in Tibetan Societies

Abstract

This introduction to the special issue of EASTS begins with a survey of recent social scientific work on medicine and healing in Tibetan and Himalayan societies. The author considers the specificity of the Tibetan encounter with biomedicine in comparison with that experienced by other traditions of Asian medicine and introduces both the traditional Tibetan medical system (Sowa Rigpa) and the wider context of approaches to healing of which it forms part. He discusses the significance of Sowa Rigpa's religious dimension and its techniques of pulse and urine examination, suggesting that these open up important questions for medicine in general regarding the relationship between “subjective” and “objective” aspects of the healing process. The political economy of Sowa Rigpa is considered, including questions of access, of the production of medicines, and the impact of new regulatory regimes. The article ends with an introduction to the remaining articles in the special issue.

Keywords:

• Tibetan medicine
• Sowa Rigpa
• Himalayas
• yoga

The articles in this special issue of EASTS derive from papers presented at an international workshop on contemporary issues in the Tibetan medical tradition of Sowa Rigpa, which was held in early 2011 as part of a project funded by the Leverhulme Trust. ¹ The participants were mainly anthropologists but also included historians of medicine, along with Tibetan and Ladakhi practitioners of traditional medicine (Sowa Rigpa). This opening article is intended to serve as an introduction to the special issue as a whole, as well as to present some of my own views about the present state of work on Sowa Rigpa within the wider field of the social scientific study of contemporary medical knowledge and scientific practice.

Sowa Rigpa is the medical tradition of culturally Tibetan regions. In origin it is a synthesis of major Asian medical scholarly traditions (Ayurvedic, Greco-Arabic, Chinese) with indigenous knowledge of materia medica and healing techniques, and it was developed over many centuries by local medical practitioners (amchi, menpa). It has been referred to variously by Western scholars as Tibetan medicine, amchi medicine, and Gyüshi ² medicine, as well as by the term we use here, Sowa Rigpa, which is Tibetan for the science or art of healing. ³

While there was already a significant body of research on Sowa Rigpa before the year 2000, as one can see from Jürgen Aschoff's quite substantial bibliography (1996), very little of this work involved social scientific approaches. Much of the research was of an applied nature, concerning the pharmacological action of materia medica used in Sowa Rigpa. There was also the beginnings of a literature on the medical system itself and its history. The main contributions by social scientists were a couple of early pieces by Craig Janes (e.g., 1995) and Vincanne Adams (e.g., 1998), along with Alice Kuhn's Ladakh study (1988). Around 2000, however, things started to change quite quickly, as the successive conferences of the International Association of Tibetan Studies (IATS) demonstrate. The 2000 Leiden IATS conference had only one or two scattered papers on medical topics. The 2003 IATS conference in Oxford had a Tibetan medicine panel with nearly twenty papers; it was the largest single panel in the conference. It already included a considerable range of anthropological contributions, along with some Western historical studies and a number of contributions by Tibetan scholars. The 2006 Bonn IATS conference was to have had an even larger panel, but it was so unwieldy that it was split into two, eventually combined into a single volume for publication (Schrempf et al. 2010). The majority of contributors on the Western side were anthropologists, with some historians; there were also a number of Tibetans, with interests in part in history and in part in contemporary practice. ⁴ The 2009 International Conference on Traditional Asian Medicine in Bhutan had an even larger contingent of studies in Tibetan medicine, again dominated by anthropologists. ⁵ Over this same period, Sowa Rigpa also began to establish itself as a significant presence within the complementary and alternative medical field in Europe, North America, and the more developed Asian societies.

Publications in the social scientific study of Sowa Rigpa started to appear with increasing rapidity from 2007 onward. These included edited volumes, special journal issues consisting wholly or in large part of social scientific studies of Sowa Rigpa, and recently, several significant monographs. All this work, along with numerous further individual articles and book chapters by the now quite numerous scholarly community working in this area, has meant that our picture of Sowa Rigpa as a body of practice within contemporary societies is much fuller and more detailed than only a few years ago. There is thus by now a substantial social scientific literature on Sowa Rigpa; but what can we learn from it, and what are the problems and issues that might guide research in this area in coming years? ⁶

The Cardiff workshop was planned to give an overview of the present state of research, and many of the principal people from Europe working in the field were present and contributed papers. This special issue of EASTS includes versions of eight of the papers given at the workshop, in most cases substantially revised, along with an afterword by Elisabeth Hsu, who also took part in the workshop. It therefore offers an excellent opportunity for a wider readership to become acquainted with this significant body of work, so far not widely known outside the Tibetan studies context. ⁷

1 The Specificity of the Tibetan Encounter with Biomedicine

The encounter in recent years between the Tibetan medical tradition of Sowa Rigpa and contemporary Western science has similarities to the interactions with biomedicine of Chinese medicine, Ayurveda, and other Asian medical traditions with premodern roots. The Tibetan encounter, however, has a specificity that has led to studies of particular interest, with the potential to illuminate many of questions in the wider field of the modernization and globalization of Asian medical traditions.

One specific feature of the Tibetan encounter is the relative recentness of Tibetan acquaintance with biomedicine; Sowa Rigpa continued to operate very much on its own terms until the mid-twentieth century. While the incorporation of most ethnically Tibetan regions into the People's Republic of China from 1949 onward led to the modernizing of Tibetan medical curricula within Chinese-controlled Tibet (Janes 1995), Tibetan medical schools and family traditions outside China maintained much of the premodern structure of Tibetan medical knowledge (see, e.g., Millard 2002; Smanla and Millard this issue). All this has led to a historical trajectory substantially different from that of “traditional” medicine in China proper or in India. Sowa Rigpa practitioners who were trained in an essentially unreconstructed tradition of premodern medical knowledge are now agents within a global market for complementary and alternative medicine. Healing rituals from a living tradition of Tantric Buddhism remain an active part of medical practice for many Sowa Rigpa practitioners while making little or no sense within newer, biomedically influenced approaches to Tibetan medical knowledge.

Other critical issues relate to pharmacology: What happens when alchemical recipes from medieval India are evaluated by twenty-first-century pharmaceutical standards? How does a relatively small-scale, preindustrial medical tradition dependent on rare, wild-crafted ingredients respond to rapidly growing market demand and increasingly restrictive regulatory regimes for pharmaceuticals? The distance between premodern Tibetan medicine and the regimes of contemporary science and technology with which it is now contending makes the study of these and similar questions particularly illuminating. Aspects of all of these and other issues are discussed in the articles in this special issue.

The remainder of this essay looks at two main sets of issues before briefly introducing the articles in the collection. I begin with a series of issues regarding the nature of Tibetan healing. Here I ask what is going on within various Tibetan healing modalities, and how we might understand it. The second set of issues concern the social context, the politics, and the political economy of Tibetan healing. Who gets access to Tibetan medicine, and in what forms? How are practitioners trained, and how is that training transforming as it interacts with biomedicine and other modernizing and globalizing forces? What happens to the production and availability of Sowa Rigpa medicines as the scale of use increases massively and as medicines produced according to traditional production techniques become subject to the regulatory mechanisms of the contemporary state?

2 Sowa Rigpa, Tibetan Medicine, and the Art of Healing

It is worth beginning with the term Sowa Rigpa used as the name for the medical tradition under discussion here. This is the term of choice among most Asian practitioners and has been increasingly adopted by Western scholars as well (e.g., Adams et al. 2011).

The choice of Sowa Rigpa over Tibetan medicine is not arbitrary. One issue with the term Tibetan medicine is that the healing tradition considered here is practiced among a wide range of culturally Tibetan people both within and outside the Tibetan regions of the People's Republic of China. Many of these practitioners, particularly those outside China and Tibetan refugee contexts, do not regard themselves as Tibetan and prefer not to use the term Tibetan medicine. Another is that Tibetan medicine tends to suggest a narrower delineation of the object of study, as a medical system in a conventional Western sense, whereas Sowa Rigpa points toward a wider approach, as an art of healing. Studies of “Tibetan medicine” have frequently taken it as equivalent in practical terms to the medical tradition described in the Buddhist canonical medical text, the Gyüshi (Four Tantras or Four Treatises), or its Bon equivalent, the Bumshi (Four Collections). ⁸ Sowa Rigpa is the Tibetan term for the science or art of healing, and it is also the standard translation for medicine and healing as one of the fields of study in the ancient monastic universities of Buddhist India, so it may reasonably be applied to the Gyüshi tradition. But if Sowa Rigpa means the science of healing, it presumably includes anything that is used to heal, and this could include many things beyond the mostly pharmacologically based medicine of the Gyüshi.

One can consider here a range that commences with the standard medical compounds, based on plant, mineral, and some animal-derived ingredients, along with therapies such as cupping and gold-needle moxibustion, and related diagnostic modes of pulse and urine examination. These approaches are typical of Gyüshi-based practice, and we would, I think, have no problem in defining all of these as part of “Tibetan medicine.” We could move on to the famous rinchen rilbu, or precious pills, based on processed mercury and other heavy metals (see Aschoff and Tashigang 2004; Sallon et al. 2006). Most scholars would probably include these within “Tibetan medicine,” and there is some reference to them in the Gyüshi, the principal text of the tradition, but while rinchen rilbu, like the Gyüshi, are clearly of Indian origin, they come from a context different from that of the Gyüshi. The Gyüshi's Indian affinities are with the classic Ayurvedic texts such as that of Vāgbhata, ⁹ while the rinchen rilbu derive from the Indian tantric and alchemical (rasāyana) tradition (see Millard and Samuel 2009; Samuel 2010a).

We might move on to the performance of ritual in medical contexts. The Medicine Buddha (Bhaisajyaguru in Sanskrit, Menla in Tibetan) is central to the origin myth of the Gyüshi, and rituals to Menla are important for many Tibetan medical practitioners. The longevity practices associated with deities such as White Tārā or Amitāyus are, however, also used both to obtain health and long life and to empower medical substances. Their origins, again, are quite separate from those of the Tibetan medical tradition, and on the whole they are practiced today by lamas and yogins, not by doctors (see Samuel 2010b, 2012; Cantwell and Samuel forthcoming). In fact, these techniques form part of a wide range of healing practices employed by Tibetan lamas in various contexts. Sometimes, today, they are employed directly to treat patients in hospitals or other explicitly medical contexts. I am not sure how far we would consider this either “Tibetan medicine” or even Sowa Rigpa, but it is certainly part of the wider field of Tibetan healing practices. So are the healing practices of village spirit mediums or shamans, variously called lhawa, pawo, khandroma, and other names (see, e.g., Day 1989; Schenk 1993; Diemberger 2005). In fact, both spirit mediums and lamas play an important role in diagnosis (see Samuel 1999, 2001, forthcoming).

Another mode of Tibetan religious practice that has received some attention for its therapeutic possibilities in recent years, especially through the very interesting work of Alejandro Chaoul (e.g., 2007a, 2007b, 2011, 2013), is constituted by the tsalung and trülkor exercises that are an important part of advanced Tantric practice. These are breathing and physical exercises, also involving internal visualizations, which are historically related to the Indian yogic practices from which modern postural yoga developed in the twentieth century (see Alter 2004; de Michelis 2005). However, as in the older Indian tradition, these practices are mostly restricted in the Tibetan tradition to the specific contexts of Tantric and Dzogchen practice (Loseries-Leick 1997; Baker 2013). Does it make sense to understand these practices as a healing tradition, and if so, how do we relate them to Sowa Rigpa?

What needs to be appreciated is that this whole spectrum of practices both belongs together, in some senses, and does not, in others. This is in part a historical question of origins, but more important, it is also a question of contemporary practice, and of how those working within the tradition of Sowa Rigpa today define what they are and what they are doing. In fact, very few Sowa Rigpa practitioners, even in the People's Republic of China, would exclude Buddhist or Bonpo ritual entirely from medical practice, but opinions clearly vary extensively about how far we are dealing with an empirical or even scientific tradition of medicine, and how far we are dealing with a holistic practice of healing (see, e.g., Craig 2011a).

Nevertheless, it seems to me that Sowa Rigpa in its narrow sense, whether defined in terms of the Gyüshi or in terms of the practice taught in the medical colleges in Lhasa, Xining, Dharamsala, or Thimphu today, is clearly not a holistic practice of healing, if that term implies the idealized holistic treatment of body, mind, and spirit envisioned by Western consumers of holistic medicine. There has been considerable effort devoted in recent years to presenting it as such a holistic tradition. ¹⁰ We might look here at the frequent translation of the term nyépa (corresponding to Sanskrit dosa) as “humor” and the associated presentation of the three nyépa in terms of balance and equilibrium (e.g., in Dhonden 1986; Clark 1995; see Samuel forthcoming). The question of how much importance is given to elements such as the linkage between the three nyépa and the three roots of samsāra (desire, hatred, and delusion) is also significant in this connection. ¹¹ I would not deny that there are elements of holism in the Tibetan medical tradition, but they are arguably overstated and selectively emphasized in many Western presentations.

However, Tibetan culture as a whole undoubtedly includes most or all of the resources that a holistic system of healing might require or involve. The point is more that they are located in a variety of different places within Tibetan culture and are not necessarily understood by traditional Tibetan teachers, whether medical or spiritual, as belonging together as part of a holistic healing practice.

3 Religious Aspects of Sowa Rigpa

A question of particular significance here is that of the spiritual or religious component of Sowa Rigpa. I have already mentioned the cult of sajyaguru. Another important issue here is the Yuthog Nyingthig tradition, a set of Tantric and Dzogchen teachings, which is traced back to Yuthog Yonten Gonpo, the presumed author of the Gyüshi and a major founding figure of the medical tradition. The Yuthog Nyingthig has been studied in recent years by Franz-Karl Ehrhard (2007) and Frances Garrett (2009). It seems clear that for many medical practitioners in the past, particularly perhaps in the tradition associated with the Chagpori, the medical school at Lhasa founded in the seventeenth century (Meyer 2003), the Yuthog Nyingthig was a key part of medical practice. It remained a significant part of training within the reformed and modernized curriculum of the Lhasa Mentsikhang college, founded in 1916. While the Yuthog Nyingthig has not been completely dropped from medical practice, even at the contemporary Lhasa Mentsikhang, it is clearly less important for many contemporary practitioners. What, however, does this change imply for the nature of medical practice?

Some might say, not very much. Many contemporary people would not regard the religious commitment of a biomedical doctor as relevant to his or her medical practice. The situation with the Yuthog Nyingthig is rather different, however, since this is a tradition of Tantric practice that is explicitly and consciously linked to Sowa Rigpa. Garrett notes that this “little-studied link” between Sowa Rigpa and Nyingma Buddhism “is not a marginal feature of Tibetan medicine but rather one that has a significant shaping factor on each tradition throughout history” (2009: 209). Her focus in that article is primarily on the question of mendrub, “accomplishing medicine” in her translation, the ritual preparation of medicine from various esoteric ingredients. Versions of these practices, which first came to light in the twelfth century, at the time of Yuthog Yonten Gonpo, are shared by many Tibetan ritual traditions, but the Yuthog Nyingthig provides the most common set used by Tibetan doctors. These practices are still widely used for the ritual empowerment of medicine, a process that continues to take place alongside increasingly modernized methods of preparation (see below). Calum Blaikie's contribution to the workshop, included in this issue, looks at empowerment in the context of pharmaceutical preparation, giving a revealing picture of the continuing significance of these ritual elements of Sowa Rigpa in Ladakh.

The Yuthog Nyingthig cycle, Garrett notes, also provides “a complete contemplative-yogic curriculum for the Tibetan doctor” (2009: 223). All this implies that, for at least some Sowa Rigpa practitioners and their patients, the process of healing is not just a question of pharmacological or other physical remedies but includes spiritual transformation of those physical substances, and perhaps also of the spiritual development and abilities of the practitioner. Here we might also consider the various sets of ritual prescriptions for different Tibetan ailments codified by lama-doctors such as Jamyang Khyentse Ongpo (1820–92) or Ju Mipam (1846–1912). ¹²

There is considerable variety, as I have tried to suggest, in how significant these various components are and in how far they are emphasized within the various contexts of contemporary practice of Sowa Rigpa. This whole area of the interplay between medical and spiritual aspects of healing has received little attention so far, with the partial exception of the question of spirit causation of illness, which has received some attention in recent years (see Samuel 1999, 2001, 2007, 2010b; see also Millard 2006).

4 Pulse and Urine Examination

Somewhat similar issues are raised by the question of medical diagnosis. As far as I know, there has been little reflection so far in the literature on Sowa Rigpa on what actually might be going on in pulse and urine examination, those key elements of Tibetan medical diagnosis (e.g., Meyer 1990; Rapgay 1994a, 1994b). Most scholars appear to have assumed rather straightforwardly that what is going on is parallel to the process of biomedical diagnosis, in that clear physical indications are being used as markers of organically based diseases and syndromes. In fact, many mysteries remain unclear even in relation to biomedical diagnosis (see, e.g., Featherstone and Atkinson 2011), but, leaving that aside for the present, one does not have to look very closely at either pulse or urine examination to appreciate that there is much here that could use a closer investigation. Certainly, it makes sense to assume that both pulse and urine may be affected by the condition of the body and so may serve as signs of the inner condition of the body. However, what do we make of such procedures as the ngotsar tsardün, the “seven wondrous pulses”? Through reading these pulses, one can detect the situation within a family by observing the pulse of a senior member, discover whether a traveler about to visit the family has left home and how his or her journey is proceeding, or discover the medical condition of another member of the family. Those aspects of urine diagnosis that are concerned with discovering the activities of evil spirits by studying patterns appearing in the various sectors of the examination bowl are also hard to reconcile with a purely physiological interpretation of the diagnostic process.

All this can be embarrassing for a medical tradition that, like other non-Western medical traditions, is constantly at risk of being devalued and dismissed by the powerful and authoritative voices of biomedicine, so it is understandable that little has been written or said about these issues. However, my aim here is not to accuse Sowa Rigpa of being unscientific. If anything, I would prefer to turn the tables on some of the claims of biomedicine in this regard. The point is, rather, to ask whether we can arrive at a meaningful understanding of the relationship between objective examination and intuitive, participatory engagement in Tibetan medical practice.

This question was opened up for the somewhat related tradition of Siddha medicine in South India in a classic article on pulse reading by Valentine Daniel (1984). Daniel emphasized the cultivation of a direct, experiential sensitivity to the patient's condition as a key component of the diagnostic process in Siddha medicine. Elisabeth Hsu has explored related themes in the Chinese context in some of her own work (e.g., 2005) and has also pointed to the close relationship between Tibetan and Chinese pulse examination techniques (2008). The inner workings of Tibetan pulse examination, however, have remained largely unstudied. ¹³

All this leads in the direction of a more general set of questions that address the relationship between “objective” and “subjective” factors in illness and healing and the possibilities of developing an analytic frame that might be able to integrate them into a single mode of analysis. That has been one of my own long-term interests, and it has been particularly aroused by working on Tibetan longevity practices (see, e.g., Samuel 2010b, 2012, forthcoming). However, rather than pursuing this direction further at the moment, I simply leave it as an outer frame, a potential horizon in relation to which, I would hope, a future social science of Tibetan medicine might more naturally be able to phrase its endeavors.

5 The Political Economy of Tibetan Medicine

Another large set of issues for the social scientific study of Sowa Rigpa is constituted by what we might call the political economy of Sowa Rigpa. ¹⁴ It is here that many of the key contributions of recent years have taken place. While many of the questions that arise are not specific to Sowa Rigpa, and apply in some form to any health system, they take on specific forms in relation to Sowa Rigpa.

Sowa Rigpa is practiced in a wide variety of contexts, varying from remote Tibetan agricultural and pastoral communities to urban medical centers and large cities, but we can distinguish between two substantially different sets of locations: (1) among Tibetan populations (mainly) in China, India, and Bhutan, where Sowa Rigpa is a “traditional” mode of medical practice, and (2) among elite populations in the West (also China, India) where Sowa Rigpa is an “alternative” mode of healing. Having said this, the availability of Sowa Rigpa among contemporary Tibetan populations is far from uniform. In many areas some form of biomedical provision is also present and may be easier to access than Sowa Rigpa for local populations (see, e.g., Hofer 2008). Many Tibetan populations, however, especially outside larger towns, are dealing with a situation where available health resources, whether biomedical or Sowa Rigpa, are limited and inadequate, and the choice of Sowa Rigpa over biomedicine (or of using both in combination) is made within this context (see, e.g., Gerke 2010). For elite Western, urban Chinese, or Indian populations, good biomedical provision is generally readily available, so the choice of Sowa Rigpa as an alternative therapy is likely to be made for other reasons.

6 Access to Sowa Rigpa

An important set of questions here concerns who has access to health care and how much access they have. There is a historical problem here, regarding how far Sowa Rigpa was available to the Tibetan population as a whole in premodern times, and how far it was primarily an elite tradition. This problem has, as far as I know, been largely ignored in the study of “Tibetan medicine,” although there are indications that the availability of Sowa Rigpa in many areas was quite limited. However, here I am concerned less with the inequalities of the past than with those of the present day. There have been a number of important contributions in this area, including the work of Janes, who opened up many of these questions (1995, 1999, 2000, 2002), and more recently that of Resi Hofer (2008, 2011). However, almost everyone who has done research with Sowa Rigpa among Tibetan populations in China, Nepal, or India has been confronted with some of these questions. Both biomedical provision and Sowa Rigpa may be expensive options for people with limited financial resources. Sowa Rigpa practitioners may be few in number and not available locally. Government policy may discourage the use of Sowa Rigpa (e.g., state insurance schemes may fail to support its use), or Sowa Rigpa practitioners may have to spend much of their time on income-generating ventures away from their home institutions in order to generate enough funding to maintain some degree of local provision.

Patrizia Bassini's contribution in this issue is particularly valuable, since it gives a picture of how issues of health and well-being are understood by ordinary Tibetans without specialist knowledge of Sowa Rigpa. There has been very little work of this kind so far, and Bassini's article gives an important and highly relevant insight into the background of ideas within which choices about healing modalities are made.

7 Training of Sowa Rigpa Practitioners

Another set of questions concerns the training of practitioners in Sowa Rigpa. Sowa Rigpa initially developed in the context of an apprenticeship system, in which students were trained individually or in small numbers. Since medical expertise was frequently handed down within a family lineage, this training was often carried out by senior family members. The introduction of medical colleges created an alternative context of teaching. The Chagpori school in Lhasa (Meyer 1990) was followed by medical colleges in a number of large Eastern Tibetan monasteries and by the Lhasa Mentsikhang in the early twentieth century (Janes 1995: 14). The teaching of substantial numbers of students on the basis of a standardized curriculum progressively developed, with the study and memorization of the Gyüshi generally taking a central place. The founding of the Lhasa Mentsikhang in 1916 followed on the thirteenth Dalai Lama's visit to Calcutta in 1910 and his encounter with the British public health systems in India, and appears to have been inspired in part by that encounter.

The imposition of Chinese control over Tibet in the 1950s led to partial suppression of the Sowa Rigpa tradition, followed by the development of new Sowa Rigpa curricula strongly influenced by biomedicine from the 1980s onward (Janes 1995; Hofer 2008, 2011). Meanwhile, the Tibetan government in exile at Dharamsala gradually created its own medical training institution, the Men-Tsee-Khang (Kloos 2008; see also Kloos this issue), and other Sowa Rigpa colleges and training programs developed in India, Nepal, and Bhutan (Jork 1997). The first training programs in Sowa Rigpa are also beginning to be set up in Europe and the United States (e.g., Millard 2008). All of this has led to progressive changes in medical training. These varied from place to place but typically included the reduction of the emphasis on memorization of the Gyüshi, further influence from biomedicine, the dropping of pharmacology and medicine preparation as an essential part of the curriculum, and so on. Colin Millard (2002) has provided a detailed description of a relatively “traditional” training context; his article in the present issue, along with the biographical accounts by two Tibetan amchi, Lobsang Soktsang and Tsewang Smanla, provides insight into the wide-ranging transformations undergone by Tibetan medical education in recent years.

A related set of questions concerns who authorizes practitioners and where and how they are allowed to practice. These questions address not only national and international (European Union, etc.) legislation (see Millard 2007, 2008; Soktsang and Millard this issue), but also the internal issues surrounding the Dharamsala Men-Tsee-Khang's attempts to establish its authority over the certification of Sowa Rigpa practitioners. Laurent Pordié's 2008 volume, Tibetan Medicine in the Contemporary World, opened up many of these issues. Stephan Kloos's contribution in this volume provides a revealing insight into developments in India, where Sowa Rigpa has very recently been recognized as an authorized medical system under Indian government legislation originally designed to regulate Ayurveda, Unani, and other widely practiced nonbiomedical healing modalities.

8 Pharmacology, Medicine Production, and Global Expansion

A further important area where issues of economics and of political economy impinge on Sowa Rigpa is that of pharmacology and the production of medicines. What are the implications for the production and availability of Sowa Rigpa medicines, often derived from relatively rare plants collected from the wild, and of the massive increase in scale of the use of Sowa Rigpa and change from small-scale and local production techniques? How can plant resources be preserved and sustainability ensured when overharvesting provides one of the few sources of income for local populations? These issues have been explored in some detail in the recent collection by Sienna Craig and Denise Glover (2009). Mingji Cuomu's article in the present issue adds the significant perspective of a contemporary Tibetan medical practitioner who has also studied in the West on these issues.

The impact of regulatory regimes such as good manufacturing practice (GMP) on Sowa Rigpa was explored in Martin Saxer's paper from the workshop, published elsewhere (Saxer 2012; see also Craig 2011b). Saxer suggests that the problems caused by GMP for Tibetan medical production resulted less from conflict between contrasting epistemologies than from the imposition of GMP in a way that was inconsistent and poorly thought out. Blaikie's article in the present issue demonstrates ways in which key aspects of premodern medicine production may be maintained in the contemporary context. There nevertheless are fundamental conflicts between the regime of evidence-based medicine and that of premodern medical knowledge as represented by a tradition such as Sowa Rigpa (see Adams 2002, 2010–11), and these have already led to heavy restrictions on the practice of Sowa Rigpa in Western countries, for example, in the United Kingdom, where most Sowa Rigpa medication is not officially approved.

The growing practice of Sowa Rigpa in non-Western societies is a matter of considerable interest in its own right and is addressed directly in Lobsang Soktsang and Colin Millard's article in this issue. It is clear that there is a demand for Sowa Rigpa in the West, if on a fairly small scale so far, and that this tradition of medical practice is going to develop further in this new context. But the shift to the Western context foregrounds the question of what Sowa Rigpa actually is. Is there a core to this system of practice that remains the same between these very different contexts? What do Westerners (and other “elite user groups”) want of Tibetan medicine?

9 The Articles in This Issue

It remains to give a brief survey of the articles in this issue. Colin Millard's article, which follows immediately after this introduction, looks at the changing values among Tibetan medical practitioners. Millard is particularly concerned with the increasing secularization of Sowa Rigpa and the related transformations in its teaching. He discusses the lesser-known Bon tradition of Sowa Rigpa, its relationship to the Buddhist medical tradition, and how it is faring among Tibetans today, both in China and in Nepal. This article presents initial findings from a three-year Leverhulme Trust–funded project undertaken by Millard, which focused in particular on the career of the distinguished early twentieth-century Bonpo lama and medical scholar Khyungtrul Jigme Namkhai Dorje (1897–1955). ¹⁵

Stephan Kloos's article, which follows, concerns Sowa Rigpa as practiced among the Tibetan refugee community. Kloos notes that Sowa Rigpa received little attention in early work on Asian medical systems, in part because it was not perceived as a “system” on the same basis as Ayurveda or Chinese traditional medicine. Today, Sowa Rigpa is undoubtedly recognized as a medical “system,” both within and outside the People's Republic of China. Kloos focuses on the politics of the recognition of Sowa Rigpa (and/or “Tibetan medicine”) in India, including the role of the Central Council for Tibetan Medicine at Dharamsala. Ironically, Sowa Rigpa's recognition has been accompanied by an increasing variety and fluidity of modes of medical practice and a weakening of the dominant role of Dharamsala in defining the nature and identity of “Tibetan medicine.”

Mingji Cuomu's article provides a contemporary Tibetan perspective on a significant aspect of Sowa Rigpa, its pharmacology, and the consequences of increasing demand for drugs and the unplanned exploitation of the wild species that form much of the basis for Sowa Rigpa remedies. Her case studies provide a revealing glimpse of the on-the-ground situations in several parts of Tibet. She emphasizes the need to develop a respectful approach to plant exploitation, based on the long-established principles of Sowa Rigpa pharmacological knowledge.

Calum Blaikie's article also focuses on pharmaceutical production, in this case in Ladakh, an area politically within India where family and lineage traditions of Sowa Rigpa have retained considerable strength. Blaikie's use of assemblage theory allows for a flexible and inclusive approach, allowing us to see medicine production and empowerment as sites of complex interaction between local actors and wider Ladakhi and state networks.

Patrizia Bassini's work on gastric and gallbladder disorders in Amdo (northeastern Tibet) moves us away from Sowa Rigpa to the wider cultural, social, and ecological context within which illness takes place and is experienced. Food is not merely sustenance; it is deeply implicated in social relations, including gender relations. Vernacular notions of heat, cold, illness, and karma echo textual understandings but have their own integrity and logic, which link food consumption to the wider sociocultural milieu. Bassini suggests that the associated dietary practices both generate specific forms of illness and militate against their effective treatment.

Then follow two autobiographical accounts of the lives of two Sowa Rigpa practitioners, both of whom participated in the conference. We are particularly happy to include these two accounts, written in conjunction with Colin Millard, since they provide a rich sense of the environments within which Sowa Rigpa has operated and the dramatically different environments within which it often functions today, as well as the rapidly changing contexts of Sowa Rigpa training.

Lobsang Soktsang studied Sowa Rigpa in Lhasa, first with his uncle, who had studied at Chagpori, and then at Lhasa Medical College. He has practiced as a doctor for more than twenty years in Tibet, in India, and eventually in Scotland. His account incorporates illuminating reflections on the nature of Sowa Rigpa practice in these various environments. Tsewang Smanla comes from a hereditary Ladakhi medical lineage, was trained by his father, and was recognized as an amchi (Sowa Rigpa practitioner) at a traditional public community-based examination. Yet his career, too, has been shaped by modernity. Smanla worked for many years alongside biomedical staff as chief amchi to a Ladakh-based nongovernmental organization, the Leh Nutrition Project, and makes regular visits to Germany and the United Kingdom for consultations with his patients in Europe. He sees the recent recognition of Sowa Rigpa as an approved healing modality by the Indian government, which resulted mainly from the efforts of Ladakhi amchi, as an important advance. However, the viability of old-style, village-based amchi practice seems increasingly questionable.

Reading these two practitioner's accounts, we can perhaps be confident that Sowa Rigpa in some form will continue well into the future. It is evident, though, that Sowa Rigpa's encounters with biomedicine and state regulation, the disappearance of its old social base, and the growth of a new global clientele are all bringing about radical transformations in what is practiced under the label of Sowa Rigpa, and how it is perceived by both practitioners and patients.

The issue closes with an afterword by Elisabeth Hsu, whose presence at the conference, as a senior scholar with expertise in a range of cognate fields, was greatly appreciated by all the participants. Her afterword, like her contributions in Cardiff, helps greatly to place our subject matter in an illuminating wider context.

10 Conclusion

The rich and illuminating material in the present issue hardly exhausts the areas that have been explored by social scientists looking at Sowa Rigpa in recent years, but I hope that it will serve as a useful introduction to scholars dealing with other aspects of the complex interaction between Asian knowledge and technical practices and modernizing and globalizing forces such as those associated with biomedicine. I have suggested that the relative isolation of Sowa Rigpa and its consequent maintenance of many premodern features well into the late twentieth century have meant that Sowa Rigpa's encounter with modernity has taken place in circumstances different from those of many other Asian practices and give the case studies in this issue particular interest and significance. Readers familiar with social scientific writing on Sowa Rigpa will also find that the articles in this issue complement and extend the existing literature on this topic in useful ways. I hope, too, that some of my own remarks may help direct the scholarly community toward considering what might be productive and useful directions for future research.^{Table 1}

Table 1  Phonetic and Wylie Spellings of Tibetan Terms

Phonetic spelling	Wylie spelling
Amchi	a mchi
Bumshi	’Bum bzhi
Gyüshi	Rgyud bzhi
Jamyang Khyentse Ongpo	’Jam dbyangs mkhyen brtse'i dbang po
Ju Mipam	’Ju Mi pham
Menpa	sman pa
Ngotsar tsardün	ngo mtshar rtsa bdun
Nyépa	nyes pa
rinchen rilbu	rin chen ril bu
Sowa Rigpa	gso ba rig pa
Yuthog Nyingthig	G.yu thog snying thig
Yuthog Yonten Gonpo	G.yu thog Yon tan mgon po

Notes

1 The conference, titled Issues in the Anthropology of Tibetan Medicine, took place at St. Michaels College, Llandaff, Cardiff, on 21–22 January 2011, as part of the project titled Tradition and Modernity in a Bonpo Medical School and Hospital in Western Tibet, funded by the Leverhulme Trust.

2 The term Gyüshi (Wylie rgyud bzhi) refers to the Four Tantras (or Four Treatises), the most important textual source for this tradition (see, e.g., Clark 1995). Tibetan terms are given here in phonetic transcription; for Wylie transliteration, see Table 1.

3 The term Sowa Rigpa (see below, section 2) originates as a Tibetan translation for medicine and healing as one of the fields of study in the ancient monastic universities of Buddhist India.

4 See Samuel 2011 for the divergences between Western and Tibetan participants that were revealed on that occasion.

5 No doubt because many people had chosen to go to the 2009 International Conference on Traditional Asian Medicine conference instead, the 2010 Vancouver IATS conference had fewer papers on Tibetan medicine, but it had a panel on ritual and healing organized by Colin Millard and myself and a number of papers in other sessions.

6 Edited volumes include Schrempf 2007; Pordié 2008, forthcoming; Schrempf et al. 2010; and Adams, Schrempf, and Craig 2011. Special journal issues include Craig and Glover 2009 and Fjeld and Hofer 2010–11. For significant monographs, see Craig 2012, Gerke 2012, and Hofer 2012.

7 Two further papers from the conference have been published elsewhere: Garrett 2010–11 and Saxer 2012.

8 The Gyüshi was probably compiled in the twelfth century by Yuthog Yonten Gonpo (1126–1202; see Yang Ga 2010) and is generally studied in whole or part by practitioners as part of their medical training. The Bumshi is the equivalent text in the Bon medical tradition, associated with the Tibetan non-Buddhist religion of Bon (see Millard this issue). The two texts are closely related, and one is clearly based on the other. The Bon tradition claims that the Gyüshi was based on the Bumshi, and certain internal features of the text suggest that this may in fact be the case (Millard and Samuel forthcoming; Blezer 2012).

9 I am not suggesting that the Gyüshi and the Bonpo equivalent, the Bumshi, are entirely derivative from the Indian Ayurvedic tradition. Leaving aside their mythological origins as Tantric revelation in one case and the teachings of Tönpa Shenrab in the other, this is clearly not the case. While Ronald Emmerick (1977) and others have demonstrated conclusively that substantial parts of the Gyüshi are directly based on Vāgbhata's writings, other parts would seem to be almost certainly derived from China or the Greco-Arab tradition or to represent local Tibetan developments (see Yang Ga 2010).

10 These efforts may even succeed some day in re-creating Sowa Rigpa in the Western context as a holistic tradition, but that is not my topic here.

11 This connection is stated in chapter 8 of the Shégyü (Explanatory Tantra), the second part of the Gyüshi, and is often emphasized in popular Western presentations of “Tibetan medicine.” My impression is that it is not generally significant in relation to medical practice but has become increasingly important in Western contexts, where it reinforces the sense of Sowa Rigpa as a specifically Buddhist practice.

12 See, for example, the texts by these and other authors included in Chenagtsang 2004. Dr. Nida Chenagtsang's International Academy for Traditional Tibetan Medicine is now teaching mantra healing practices widely in Europe, North America, and Australia (see http://www.iattm.net).

13 See Millard this issue on possible conflicts with UK and similar legislation for complementary and alternative medicine. Many of the same problems arise in relation to pulse examination techniques in Chinese and Indian medicine.

14 Similar questions might be asked in relation to the political economy of long life practice and of spirit mediums, though these topics are not pursued here.

15 The project was titled Tradition and Modernity in a Bonpo Medical School and Hospital in West Tibet and directed by Geoffrey Samuel in 2008–11.