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Efficacy and the Social Ecologies of Tibetan Medicine
By Sienna R. Craig
UNIVERSITY OF CALIFORNIA PRESSCopyright © 2012 The Regents of the University of California
All rights reserved.
Portrait of a Himalayan Healer
We have weathered so many journeys, and so many forms of love. Would it have been the same, we ask one another, had we stayed still, in the mill with the water running under us. There is no way of knowing.
—Alastair Reid, Whereabouts: Notes on Being a Foreigner
It is early September 2008. The high-altitude air is tinged with autumn. I walk through the alleys of Lo Monthang, the largest settlement in northern Mustang District, Nepal. This is the time before animals have been let out to graze, before children have gone off to the new local day care, to school, or to help gather dung and tend animals. I pass whitewashed homes decorated with protective door hangings above the threshold: colored yarn webs holding sheep skulls, repelling nefarious spirits and gossip. I hear the muffled sounds of cymbals, bells, and the resonant drone of Tibetan Buddhist monks calling forth another day.
As I make my way through Lo Monthang, I am conscious of borders. This is Nepal's northern edge, where the Indian subcontinent is subducted under the Tibetan Plateau. Mustang lies in the Himalayan rain shadow; it is mostly high-altitude desert, abutting the Tibet Autonomous Region, China. Jomsom, the district's headquarters, is linked to Pokhara, the nearest city, by flights from a small airport and by trails. No all-season motor road connects the district to any urban center, although this reality is changing swiftly. Seasonal unpaved roads have been constructed over the past decade and are passable with tractors, jeeps, and motorcycles. Mustang is encompassed by the Annapurna Conservation Area, Nepal's largest protected area. The district is home to approximately 14,000 individuals (2001 Nepal census), whose households and property are partitioned into sixteen village development committees. Upper Mustang, at the center of which sits Lo Monthang, is home to Tibetan speakers, tsampa eaters, and practitioners of Buddhism and Bön, indigenous religious practices of the Tibetan plateau (Snellgrove 1981; Samuel 1993). These moral cosmologies lend structure and meaning to life here, along with what Charles Ramble (2008) calls a "civil religion," which prescribes social norms and governs natural resource use, further defining the region's cultural and natural landscape.
Mustang's Kali Gandaki River and settlements situated along its banks have been a locus of trans-Himalayan trade for centuries, including the exchange of lowland grains for Tibetan salt. The people of Mustang have relied on agriculture, animal husbandry, and trade to wrest survival and even prosperity from the area for centuries. Mustang was incorporated into the nation-state of Nepal in the eighteenth century, though the area has maintained cultural, economic, and political alliances with Tibet (Ramble 2008). The most significant and enduring of these connections is the lineage of kings, descendants of western Tibetan nobility who, since the fourteenth century, have wielded influence over the region, particularly in upper Mustang, or what is known as the Kingdom of Lo (Dhungel 2002). Jigme Palbar Bista, the twenty-fifth in the lineage of Lo kings (T. gyalpo, N. raja), still lives in a looming whitewashed palace at the heart of Lo Monthang. His wife, the queen (T. gyalmo, N. rani), hails from Shigatse, the second largest city in the TAR. Tibetan Resistance forces occupied Mustang from 1960 to 1974, as they waged guerrilla war against the Chinese People's Liberation Army (Knauss 1998; McGranahan 2010). A permanent Tibetan refugee settlement has existed in southern Mustang since the 1970s.
Due in part to this sensitive political history, foreign access to upper Mustang was prohibited until 1991. Travel to the region is now allowed on a restricted basis, requiring a permit that costs $50 per person, per day. In contrast, villages in lower Mustang are part of the Annapurna trekking circuit and have been a mainstay of Nepal tourism since the late 1970s. Lower Mustang is also more accessible to roads and regional markets. These distinctions have real-world effects with respect to economic opportunities and the provision of government services, including health care. Many from the region spend the winters engaged in small business in northern India, Pokhara, or Kathmandu. During Nepal's decade-long (1996–2006) conflict between Maoist forces and the state's army and armed police, Mustang remained the only district in the country that did not see active combat. Yet this conflict—along with the chance to earn social and economic capital by working abroad—has propelled many people to leave Mustang (Craig 2002, 2004, 2011b).
On this crisp September morning, I round the corner past Thubchen, a fifteenth-century monastery that has been restored recently (Lo Bue 2011). I walk past a row of reliquaries (T. chöten, Skt. stupa) and stop before the wood-and–corrugated metal door leading to a school. A window, rimmed in black and red paint, rests above the door. Between window and door hangs a trilingual signboard. There is an arc of English—"Lo-Kunphen Traditional Herbal Medicine Clinic and School"—under which is written an approximation of the same, first in Tibetan and then in Nepali. The Tibetan reads Lo Kunphen Mentsikhang Lobdra. The Nepali reads Lo Kunphen Aamchi Aaushadhyalaya Skul. My friends and colleagues, Gyatso and Tenzin Bista, run this small institution.
Many elements of meaning are lost and gained across the two-dimensionality of this sign. As mentioned in the Introduction, the term mentsikhang means "house of medicine and astrology." In its generic sense, this is a place where Sowa Rigpa is practiced. It is also the name given to major state institutions of Tibetan medicine in China and India. It becomes, simply,"clinic" in English. In Nepali aamchi aaushadhyalaya skul is an amalgam of language and history. The first term is a Nepali approximation of amchi, itself a Mongolian word long ago loaned to Tibetan, which means "healer" or "doctor." Aaushadhylaya connotes a medical establishment. It is formal, Sanskritized, the type of word most people from Mustang—though citizens of Nepal—would have trouble using in common speech. The word might conjure memories of failed School Leaving Certificate (SLC) examinations, and it would probably feel more foreign than the English word clinic. Finally, skul is a Devanagari approximation of the English term school.
I have passed this sign many times. This morning it stops me short. I realize that, in Nepali, there is nothing Tibetan about this place. In Tibetan, centuries of interconnected history between Mustang and centers of Sowa Rigpa in Lhasa, Dharamsala, and beyond are implicit in the choice of names given to this institution. In English, the deceptively simple signifier "traditional herbal medicine" supplants regionally and culturally specific understandings of medicine and heath care.
Nestled between the arc of English, Tibetan, and Nepali are the words "Estd. 2056." This is a reference to the Nepali calendar. No Gregorian or Tibetan lunar year is given, though it would have been 1999–2000 or the cusp of the Iron Dragon year of 2126, respectively. This detail on a sign—a tableau of identification, where space is limited—speaks to the struggle for recognition and legitimacy in which Gyatso, Tenzin, and other amchi in Nepal have been engaged for nearly two decades. It is easy to imagine "Estd. 2056" stamped on registration papers Gyatso and Tenzin filed with district and national authorities to start this institution: a vermillion mark soaking into the thick, uneven warp and weft of Nepali lokta paper.
The only other element on the sign is, in a sense, its heart: a small rendering of Sangye Menla, the Medicine Buddha, his offering bowl brimming with arura, the fruit of the myrobalan tree and the "king of medicines." This sign is a mosaic, an assemblage of meaning. To understand only one of these languages is to miss the negotiations of culture and identity wrapped up in my interlocutors' efforts toward increasing the social efficacy of their practice in a new age. To see this sign simply as a handmade entrance to a marginal institution in far away place is to miss the point. Certainly this is a remote locale. But it is a place connected to regimes of value and patterns of social change that stretch out from the Himalaya and Tibetan Plateau, down the Indian subcontinent, across the world, and back again.
Filled with these thoughts about identity and belonging, language and culture, tradition and contemporary life, I walk through the door and enter the courtyard of Lo Kunphen. Several students cluster around a water spigot, brushing their teeth. Older students ready the simple dining hall for breakfast, after prayers and before classes. I greet them and head toward the back door of Lo Kunphen, which lets me out beyond Lo Monthang's city wall, in front of Gyatso and Tenzin's home, the lower floor of which is devoted to an herbarium and small Sowa Rigpa museum. I climb the stairs and call out a greeting. Gyatso's familiar voice answers, inviting me in.
MANTRAS, IVS, AND MORNING TEA: 7:30 A.M.
Gyatso is seated on low cushions in the main room, drinking salt-butter tea. The brothers' infirm mother directs morning traffic. Two generations of this family's women perform chores as seamlessly as if playing a symphony. Gyatso's wife loads the stove with sheep and goat dung, blows embers awake, pours water into a kettle, and sets it to boil. She then breaks grassy clumps of brick tea into this tepid water and metes out a pinch of Tibetan salt. Her eldest niece carves a slab of butter from a block with the swiftness of a potter slicing clay. She tosses it into the tea churner. These acts mark a day's beginning here: art, routine, discipline each in its own right. This place would not run without its women.
A stack of notebooks sits on a wooden table in the corner, nestled between divans laid with Tibetan carpets. Some of these books are tea-stained and once or twice soaked through by rain. Their pages contain all manner of notations, written mostly in Tibetan, at times in Nepali, or in approximations of English, sounded out. They bespeak these doctors' networks: prescription notes, names of tourists who might become school sponsors, lists of plants and other raw materials to buy in Etum Bahal or Indra Chowk, old Kathmandu neighborhoods where herb traders hawk and bargain. Beside these notebooks are religious texts wrapped in cloth, a Tibetan-English medical dictionary, and a binder whose plastic sheaves protect stacks of receipts for school expenses. These pieces of paper must be carried to Jomsom in saddlebags, then on to Kathmandu in Chinese-made totes embossed with NGO insignia, gifts from academic conferences and conservation-development workshops these brothers have attended. In Kathmandu these recollections of rupees spent are presented to a Nepali accountant who reconciles the books and sends them to British, German, and U.S. charities that help to support the school. This institution is an experiment in bridging the gaps between Gyatso and Tenzin's father's generation and the worlds their children will inherit.
Tenzin comes into the room carrying a glass bottle of a glucose and saline solution, a splice of IV tubing, and a still sterile hypodermic needle. The glucose is Nepali made, though nearly every other commercial item in this house was manufactured in China: thermoses, blankets, solar panels that charge their satellite telephone. Tenzin moves toward his mother. This woman has been unable to walk for years and has, in a sense, been waiting to die ever since her husband passed away, in 1996. For all her despondency, she is still the center of this home, the voice to which everyone defers.
Tenzin calls his niece, a senior student at Lo Kunphen. They prop up the old woman so she can receive this IV infusion. I ask Tenzin why he has chosen to give this biomedical treatment to his mother. "It gives her strength, since she struggles to eat," he responds. The old woman seems calm until Tenzin produces the needle. Then she wriggles, moans, covers her eyes. The niece struggles to still her grandmother.
Seeing the task will not be easy, Tenzin calls for Gyatso. These sons reassure their mother. Then, deftly, Gyatso pins down her forearm as Tenzin inserts the needle past layers of weathered mountain skin into the river of a bluish vein. Tenzin tapes the needle in place, attaches it to the tubing, and hangs the glass bottle from a hook fitted to the ceiling above the old woman's perch. All the while one of the youngest members of the extended family looks on with fascination, nestled beside her great-grandmother, enfolded in layers of wool.
This simple act—needle into vein and the slow, steady infusion of sugars, salts, and water into this old woman—reminds me there are no easy ways to parse this world of healing. Neither the terms tradition and modernity nor a presumed ideological divide between Tibetan medicine and biomedicine makes much sense here (Samuel 2006). These Buddhist amchi have given a biomedical anodyne with tenderness to their ailing mother. They do so in great part because empiricism has brought them here. They know it works because their mother's cheeks flush after such infusions. Just the same, a different empiricism instructs them to conduct long-life rituals and wear protection amulets. Ultimately they will face their mother's death as part of sentient existence: one karmic turning of the wheel of life.
MASTERS OF THE GIFT: 9:00 A.M.
Gyatso, Tenzin, and I move into the school's chapel (chökhang) and library. The phrase "someone who wears many hats" works in both English and Tibetan. This is often how I feel about these brothers. In addition to his responsibility as principal of Lo Kunphen, Tenzin is also a senior monk at Chöde Monastery, a sakya Tibetan Buddhist institution in Lo Monthang. Yesterday he spent half the day performing a ritual in the household of someone who had recently died. Gyatso, like his father before him, is the householder-priest (nakpa) and doctor to the royal family of Lo. Since 2003 he has also been the chairman of the Himalayan Amchi Association.
Yesterday, despite our plans to review clinic records and write a funding proposal, Gyatso was called to the palace to greet officials from across the border in the TAR. They had driven to Lo Monthang in a Chinese land cruiser to discuss trade relations. The "road" they drove in on is relatively new, but cross-border exchange is at once an old and an increasingly common phenomenon. Many obstacles to such exchange occurred this year, 2008. Lhasa erupted in riots in March, followed by continued unrest and repression across Tibetan areas of the PRC. The Beijing Olympics resulted in further clampdowns. The closure of Tibet to foreign tourists meant more had ventured to upper Mustang. However, geopolitical problems also curtailed the flow of goods between this part of Nepal and the TAR, commodities on which the people of Mustang have come to depend. And so, when the Tibetan officials arrived, Gyatso was called to serve his king, as this traditional leader negotiated the terms of cross-border trade. To some in Mustang, such visits are welcome. To others, they bespeak unwanted Chinese influence in Nepali territory.
As is often the case, Gyatso was asked to read the pulse of these TAR visitors and give them medicines. I could imagine him rolling up the sleeves of a Tibetan official's dusty polyester blazer, reaching for the right hand and then the left, and, reading pulsations both deep and shallow, auguring a bile-related disorder or a chest infection. These officials, like the Tibetan constituents they represent, rely on Gyatso and Tenzin's medicines as they did their father's before them, maintaining netsang, relations of fictive kin and trading partners, with people across the border. Geopolitical boundaries and social ecologies do not always align. In parts of the TAR it can be difficult to access locally made Tibetan medicines such as those Gyatso make here. Some of Gyatso's Tibetan patients have been eating medicines made by his family for years, and they prefer them to the more expensive manufactured formulas trucked in from Lhasa.
Yesterday's unexpected visit put off our work on the grant proposal until this morning. Gyatso and Tenzin begin by reiterating to me their need for money. They struggle to raise sufficient funds to maintain this school of thirty to forty students, along with their "factory" and small branch clinics. Our current task is to craft a proposal for a London-based foundation that has normally supported only Tibetan refugees. On occasion it will accept applications from "Tibetan border peoples" such as those from Mustang.
Excerpted from Healing Elements by Sienna R. Craig. Copyright © 2012 The Regents of the University of California. Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
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