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EastAsianScience,TechnologyandSociety:AnInternationalJournal(2013)7:381–395 DOI10.1215/18752160-2333653 How Tibetan Medicine in Exile Became a “Medical System” StephanKloos Received:26September2011/Accepted:29November2012 qNationalScienceCouncil,Taiwan2013 Abstract TibetanmedicineorSowaRigpawaslargelyignoredinclassicpublications on“Asianmedicalsystems.”Thisarticlecontendsthatoneimportantreasonforthis oversight was that Tibetan medicine had not yet managed to establish itself as a recognizablemedicalsystematthattime.Thishaschangedonlyrecentlywithongoing politicalandeconomicprocessesthroughwhichTibetanmedicineinexilehasbeen transformed,sincethe1990s,fromaregionalhealthtraditionintoagloballyrecog- nizableandclearlydefinedanddelimitedmedicalsystem.Aftersomereflectiononthe notionofmedicalsystems,thisarticlefocusesontheeventsandintereststhatledtothe establishmentoftheCentralCouncilofTibetanMedicineinearly2004,whichcanbe regarded astheofficialestablishmentofSowa Rigpa asamedical system.Thedis- cussionthenmovesontotheconsequencesofthisdevelopmentforTibetanmedicine in exile at large, and for its most powerful institution, the Men-Tsee-Khang, in particular. The outcome of wider exile Tibetan political aspirations, Sowa Rigpa’s “embodiment”asamedicalsystemalsohasdirectmedicalandpharmaceuticaldimen- sions,manifestingmostimportantlyineffortstoregulateandstandardizeitssyllabi, clinicalpractice,andpharmaceuticalproduction.Thearticlegivesin-depthinsights intosomeofthemostimportantrecentdevelopmentsinTibetanmedicineinexile,its economicandpoliticalorganization,andtheroleofitsmaininstitutions. Keywords Tibetanmedicine(cid:1)SowaRigpa(cid:1)Tibetanexile(cid:1)Asianmedicalsystems Acknowledgments Theresearchandwritingofthisarticlewasfunded,atdifferentstages,byaWenner Grendissertationfieldworkgrant,theAustrianScienceFund(FWFprojectP20589-G15),andaMarieCurie InternationalIncomingFellowship(PIIF-GA-2010-275832).IamgratefultotheBody,HealthandReligion ResearchGroup(BAHAR)forenablingmetoparticipateonitsinternationalworkshoponTibetanmedicine inCardiff.SpecialthanksareduetoGeoffreySamuel,ElisabethHsu,MonaSchrempf,BarbaraGerke,Colin Millard, and the other workshop participants, as well as Me´lanie Vandenhelsken and two anonymous reviewers,fortheirinsightfulcommentsandsuggestions.Finally,IamindebtedtotheCCTM,itsexecutive members,andstafffortheircollaborationandsupportovertheyears,withoutwhichthisresearchwouldnot havebeenpossible. S.Kloos(*) Institute for Social Anthropology, Austrian Academy of Sciences, Apostelgasse 23, A-1030, Vienna, Austria e-mail:[email protected] 382 S.Kloos ThepublicationofAsianMedicalSystems(Leslie1976)wassomethingofafounding event for the anthropology of Asian medicines. Identifying Ayurveda, Unani, and Chinese medicine as intellectually coherent, rational, and professionally organized “systemsofmedicine,”CharlesLeslieandhiscolleaguesshapedthethennascentfield ofmedical anthropologyfor decadesto come.In their work, they defined “medical systems”ascharacterizedbyahighdegreeofcomplexityandprofessionalization,a longhistoryofsystematicempiricismandtheorization,internalcoherencemanifested incoreclassicaltexts,andadistinctidentityresultingfromclearexternalboundaries vis-a`-vis other medical systems. While not denying the existence of syncretism, internal heterogeneity, or exchange between plural medical systems, Leslie’s focus onsystems ofmedicinesoonforegroundedthese phenomena asmedicalanthropol- ogy’scoreproblems,whichcanbetracedthroughmuchofmedicalanthropological literatureduringthe1980sand1990s. Besides this immediate impact on the discipline,the work of Leslie and his col- leaguesalsohadlargertheoreticalandpoliticalconsequencesforthestudyofmedical traditions around the world. Rather than collecting bits of apparently incoherent or irrationallocalbeliefsandknowledgeforthepotentialuseofpublichealthspecialists eagertoovercome“culturalobstacles”tomoderndevelopment(seeLeslieandYoung 1992:7),ashadbeenthepervasiveapproach,medicalanthropologistsbegantofollow LeslieinrecognizingAsianmedicinesascivilizationalprocessesandepistemicsys- temsthatneededtobeplacedinthecontextofhistoryandpolitics.Inshort,Leslie articulated an analytic framework that saw Asia’s “great medical traditions” (see Redfield1956)asimportantmarkersof“civilization,”thatis,asmanifestationsofa people’santiquity,scientificgenius,andculturalindependence.1 InallthesestudiesofAsia’sgreatmedicaltraditions,however,Tibetanmedicine wasconspicuousbyitsabsence.NeitherAsianMedicalSystemsnorits1992sequel, PathstoAsianMedicalKnowledge(LeslieandYoung1992),andlatervolumesonthe topic (e.g., Bates 1995) so much as mentioned it in passing,2 let alone devoted a chapteroranentiresectiontoit(seePordie´2008b:3).ItisnotthatTibetanmedicine does not meet Leslie’s criteria for “medical systems” outlined above, as a growing numberofrecentscholarlyandlaypublicationsdocument(e.g.,Meyer1981;Donden 1986;Janes1995;Adams2002;Schrempf2007;Pordie´ 2008a;Adamsetal.2011). Tibetan medicine notonly possesses morethan fourteen hundred years ofrecorded history and a classical textual core (the rgyud bzhi) displaying a high degree of complexity and intellectual coherence, but it also has clear external boundaries distinguishing it from Ayurveda, Unani, or Chinese medicine, not to mention a well-established institutional apparatus in contemporary Tibet and the Tibetan exile.Sowhatarethereasonsforthis—inretrospectquitemonumental—oversight? One important reason is to be found in Asia’s colonial history: while Western scholarlyattentionhaslongfocusedonIndiaandChinainconnectionwithEuropean (and later also American) political and economic interests there, Tibet remained 1 ThisframeworkreflectsthediscoursesofnationalistmovementsinIndia,China,andelsewheresincethe nineteenthcentury,whichusedmedicaltraditionsasameanstolegitimatetheirpoliticalclaimsforinde- pendence(seePrakash1999;Chatterjee1993;Langford2002;Kloos2010). 2 TheonlyindirectreferencetoTibetinLeslie1976occursonpage3,intheintroductiontoAsianmedical systems,whereLesliementionsAyurveda’s“markedinfluenceinTibet”andotherareas. HowTibetanMedicineinExileBecamea“MedicalSystem” 383 largely inaccessible—a situation that was only reinforced with China’s annexation and subsequent isolation of Tibet in the 1950s. Thus, when Tibetan medicine first begantoattractseriousscholarlyinterestintheWestinthelate1960sand1970s—at thattimelimitedtoafewhistoricalandtextualstudies(e.g.,Rechung1973;Finckh 1975; Dash 1976; Norbu 1976; Donden and Kelsang 1977; Meyer 1977; Beckwith 1979)—it was from the Tibetan exiles in India and Nepal. In the Indian town of Dharamsala, the Central Tibetan Administration (CTA) had founded, upon the Dalai Lama’s advice, a small Tibetan medical center in 1961, which in 1967 was officiallynamed“DrophenMen-Tsee-Khang”(’grophansmanrtsiskhang:institute formedicineandastrologyforthebenefitofallbeings).Whiletheexplicitpurposeof thiscenterwas,fromthebeginning,to“preserveTibetanculture,”itsdailyworkcon- sistedincompoundingmedicines,treatingpatients,andtrainingstudentsinTibetan medicine andastrology.Lacking everythingfromhumanandfinancial resourcesto specializedmedicaltextsandeventhelanguageskillsnecessarytooperateinIndia,it tooktheMen-Tsee-Khanguntiltheearly1980stogainsomesortofstability,anduntil the mid-1990s to achieve its present status as the most prestigious, profitable, and successfulsecularinstitutionintheTibetanexile(Kloos2008).Foralongtime,the Men-Tsee-Khang—whichpracticallywasTibetanmedicineinexileuntilthe1990s— remained occupied with internal problems and was thus barely visible outside the Tibetanexilecommunity.Similarly,theTibetanmedicalestablishmentinsideTibet, whichstruggledwithproblemsofitsown(Janes1995),remainedclosedtotheinter- nationalcommunityuntilthe1990s.Inshort,Tibetanmedicinehadnotmanagedto attractthesamescholarlyattentionasotherAsianmedicinesbythetimeAsianMedi- calSystemsandPathstoAsianMedicalKnowledgewerewritten.Atleastasfarasthe academicrealmwasconcerned,Tibetanmedicinehadnotyetestablisheditselfasa “medicalsystem”initsownright. Ofcourse,givenmorerecentcritiquesof“medicalsystems”asananalyticconcept, thequestionarises:whyshouldit?AsJeanLangford(2002)andJosephAlterpoint out,“ThereareseriousproblemsinlookingattraditionslikeAyurveda—oranyother formofmedicine—asanintrinsicallyunified,organicallycoherent‘system’ofknowl- edge and practice” (Alter 2008: 1167). Volker Scheid (2002: 9) makes a similar observationinthecontextofChinesemedicine,whileLawrenceCohen(1995:320) arguesmoregenerallythat“theformalism,coherence,andsynchronicityofasystem donotseemtomapwellontomedicalknowledgeandpracticeinsitu.”Tobefair, muchofthiswascleartoLesliefromthebeginning,causinghimtodistinguishamong classicaltextual,syncretic,contemporaryprofessional,andfolkvariantsofmedicine inIndia(1976:358–61).Still,thenotionofthe“system”thatLesliehadintroduced required,inCohen’swords,“isolat[ing]thatwhichappearsmoststructuredandcoher- ent as the epistemology of the thing and trace it backwards and forwards to give ourselves back time” (1995: 358). Indeed, we find a strong focus on epistemology andknowledgeinmostmedicalanthropologicalworkonAsianmedicinesduringthe 1980s and 1990s (e.g., Leslie and Young 1992; Bates 1995). However, this Bour- dieuianattempttocombinestructuralistandhistoricalanalysisrequiredarrestingthe historicity of medical knowledge in a classical past, thus separating it analytically fromitscontinuallychangingpracticeandpolitics.Theresultwas—againstLeslie’s ownethnographicinsights—aproblematicdualismbetweenknowledgeandpractice, 384 S.Kloos between an inner (coherent, stable, etc.) essence of a medical system and its outer historicalmanifestations(seeLatour1999;Adams2005). Yet,evenwhiletheconceptofmedicalsystemshasoutliveditsanalyticusefulness, it continues to be seen as an effective political strategy. Thus, the essentializing function of systematization, especially in the realm of “traditional medicine,” was successfullydeployedbyAsiannationaliststryingtoreclaimtheir“culturalessence” inordertoimagineandlegitimizetheirnation(Langford2002;Spivak1988).More recently and under (geo)political circumstances vastly different from Asia’s anti- colonial movements in the early twentieth century, the Tibetan exile community has lookedtoIndian nationalism—as the closest exampleathand—forguidance in their own nationalist struggle for a “Free Tibet.” Thus, from the 1990s onward, it becamecleartoTibetanmedicinepractitioners(calledamchi)inexilethattheconcept of“medicalsystems”waswellestablishedinIndia’shealthpolicies,whichofficially recognize,promote, and subsidize“Indian systems ofmedicine” (ISM).In order to receive government funds, political representation, and regular access to the tra- ditional health market, therefore, Tibetan medicine needed to be recognized by the government of India as a “medical system.” What is more, the notion of a medical system was attractive to the exile Tibetans for the same reasons as it was for other Asiannationalistsbeforethem:throughitsstrongconnectiontotherelatednotionof “civilization,”itconnotesculturalgreatness,historicalantiquity,intellectualgenius, andpoliticalself-determination.3 Itisinthispoliticalrationale(againstChina’sopposingclaims)ratherthaninmore superficial—thoughalsoimportant—financialconsiderationsthattheexileTibetans’ realinterestinremakingTibetanmedicineintoa“medicalsystem”lies.Theethical andpoliticalimperativeforTibetanmedicineinexileto“preserve”Tibetanculture neatlycoincideswiththeideathathavingone’sownmedicalsystemsignifiesone’s statusasa“culture,”asa“civilization,”andconsequentlyasanation.Indeed,forexile Tibetans,therecognitionofTibetanmedicineasamedicalsystemdoublesasarec- ognitionofTibetasanation.Basedontwentymonthsofmultisitedfieldworkinthe SouthAsianTibetandiasporabetween2005and2012,thisarticleexploreshowand whyTibetanmedicineinexilecametobeconceptualizedasa“medicalsystem”and tracestheearlieststagesofthedevelopmentthatfinallyledtoitsofficialrecognitionby thegovernmentofIndiaasan“Indiansystemofmedicine”in2010.Whiletheevents moredirectlyconnectedtothiswatershedeventwillbethesubjectofanotherarticle, the following pages provide a more general study of Tibetan medicine’s “embodi- ment” as a medical system that in turn embodies the nation, and of the interplay betweenpoliticsandmedicineintheTibetanexile. 3 RobertRedfield,fromwhosewritingsLeslieetal.borrow,usesthetermcivilizationasasynonymfor “greattraditions,”inordertopointtothecomplexity,historicity,andlargerconnectionsbetweenwhatwas previouslystudiedasboundedlocalculturesor“smalltraditions.”Inlightofitsmodernconnotationasthe oppositeofbarbarism(theexistenceofoneassumingandnecessitatingtheother),itsuseasanideological justificationofcolonialismandSamuelHuntington’s(1996)thesisofa“clashofcivilizations,”thetermis deeplyproblematic(hencetheuseofquotationmarksinthisarticle).IntheexileTibetancase,however,both meaningsoftheterm—assynonymouswithcultureandastheoppositeofbarbarism—convenientlycon- vergeinthefightforculturalsurvival,politicalsovereignty,andresistancetocommonChineseclaimsthat Tibetanswere“barbaric.” HowTibetanMedicineinExileBecamea“MedicalSystem” 385 1 ABodyforTibetanMedicine Nationalism’scentralthemeistobringintobeingaclearlydemarcated,unifiednation, forwhichitrelied,inthe(post)colonialcontextsofAsia,oncultureandspiritualityas itssovereigndomainthatborethecommunity’sessentialmarkersofdifferencevis-a`- vis the colonial power (Nandy 1983; Norbu 1992; Chatterjee 1993; Prakash 1999). Giventheirlonghistoriesas“nativesciences”andtheirundeniableeffectivenessin clinicalpractice,suchmedicaltraditionsasAyurveda,Chinesemedicine,andTibetan medicineemergedasidealmanifestationsofanotherwiseintangiblecultureor“civi- lization.” But in order to do so, they needed a “body,” so to speak, that could be preserved,defended,andsovereignlygoverned,onethatwasimmediatelyrecogniz- ableandmarketableas“Tibetan”(or“Indian”or“Chinese”).Theconceptofa“medi- calsystem”—withitsinternalcoherenceandclearboundaries,itsdistinctidentityand self-governing, self-policing institutional structure—provided exactly the body that bothnationalistsandmedicalpractitionerswerelookingfor.Inotherwords,totrans- formarangeofmoreorlessheterogeneousmedicaltraditionsthatfollowedsimilar epistemologicalprinciplesintoaunitary“medicalsystem”was,andcontinuestobe,a politicalactofnationalism. IntheexileTibetancase,whereTibetanmedicineiswidelybelievedtosymbolize thegreatnessoftheTibetan“civilization”andthusmanifestTibet’snationalidentity, the“preservation”ofTibetancultureisdirectlylinkedtothetransformationofTibetan medicineintoamedicalsystem.InordertogiveTibetanmedicineanewbodypro- videdbytheconceptofamedicalsystem,exactlythecriteriaoutlinedbyLeslieandhis colleaguesandusedbyIndianofficials—uniquehistoricalorigins,aclassicaltextual core, internal homogeneity, and clear external boundaries—needed to be demon- strated, highlighted, and, if necessary, created. But before going into the details of theseeffortsandaskinghow,exactly,Tibetanamchiinexiletransformedtheir—until recently relatively obscure—medical tradition into a clearly defined “system,” it is worth considering their timing. Why, in other words, did exile Tibetan medicine’s preservationandsurvivalbecomesuchanurgentissueduringthelate1990sandearly 2000s—a time when it was actually thriving and its survival seemed, at long last, secured? For all practical purposes, Tibetan medicine was consubstantial with the Men- Tsee-Khang’sinstitutionalbodyduringthefirstdecadesinexile,forthesimplereason thatnootherinstitutions—orasignificantnumberofprivatepractitioners—ofTibetan medicineexistedinexile.However,bytheearly1990s,thisequationbecameprob- lematic as Tibetan medicine gradually grew larger, healthier, and stronger; other Tibetanmedicalinstitutionswerefounded;andincreasingnumbersofamchiestab- lished their private, independent clinics and pharmacies or traveled and practiced abroad.OnecouldsaythattheboundariesofTibetanmedicineinexileincreasingly outgrewthoseoftheMen-Tsee-Khang’sinstitutionalbody.Thissituationwasaggra- vated bygrowingtensionsbetweenthe Men-Tsee-Khangandprivateamchi, which hadalreadybeguninthe1960sand1970swiththeresignationofseveralsenioramchi from the Men-Tsee-Khang and the dismissal of the popular chief physician at that time, Dr. Lobsang Dolma, amid allegations of unethical conduct (Josayma and Dhondup1990: 5;Tsering 2005:183; Kloos 2008: 23–24).Inthe 1980s, theMen- Tsee-Khang decided to stop selling its medicines to private amchi in an attempt to 386 S.Kloos discourage the establishment of private clinics, which was widely perceived as a hostilegestureagainstthem.Duringthe1990s,astheeconomicpotentialofTibetan medicinebecameincreasinglyapparent,thesheernumberofnewlyestablishedpri- vatedoctors(mostofthemoriginallyfromtheMen-Tsee-Khang)begantochallenge not only the Men-Tsee-Khang’s market dominance but also its political power to representTibetanmedicine. Uptothatpoint,Tibetanmedicineinexilepracticallyfunctionedwithoutanykind of regulation or control whatsoever. The CTA did not have a single law regarding Tibetanmedicine,oranyinstitutionalstructurestooverseeitspracticeanddevelop- mentbesidesthelargelyautonomousMen-Tsee-Khang.Similarly,althoughthegov- ernmentofIndiahadtoleratedthepracticeofTibetanmedicineonitssoilsince1964 (ChoeloThar2000:52;Kloos2008:18–19),itwasnotofficiallyrecognizedandthus remained outside Indian legal regulatory purview. Until the 1990s, this was not a problem, since Tibetan medicine in exile was largely consubstantial with the Men- Tsee-Khang,andthefewpractitionersthatpracticedindependentlywereallserious senior doctors. But during the 1990s, three other Tibetan medical institutions were founded(Kloos2008:30–33),andthenumbersofprivateamchiincreaseddramati- cally. Consequently, concerns arose at the Men-Tsee-Khang about these doctors’ ability and motivation to practice and represent Tibetan medicine in a proper way. The clandestine spread of counterfeit precious pills (rinchen rilbu) and impostors pretending to be fully qualified amchi in the West—both widely discussed in exile Tibetanmedia—onlyservedtojustifytheMen-Tsee-Khang’sconcernsinthepublic andingovernmentcircles.Tibetanmedicinegrew—quiteliterally—outofcontrol. TheabsenceofanyregulationwasathreatnotonlytotheMen-Tsee-Khangand Tibetan medicine but also to exile Tibetan ethical and political aspirations. One of themostcommonstatementsIencounteredamongexileTibetanamchiwasthateven asrefugees,throughTibetanmedicinetheycouldhelptheworld.Inordertodoso, however,theyneededtoensureTibetanmedicine’sefficacyandthepatients’trustin it, both of which seemed endangered by unqualified or unscrupulous medical prac- titioners.Inotherwords,Tibetanmedicineneededtobe“preserved”—thatis,regu- latedandcontrolled—forthebenefitofitspatients.Whilethismedicalmanifestation ofaTibetanethicsofaltruismandcompassionisagenuinesentimentandshouldbyno means be interpreted as mere “self-marketing” (Huber 2001: 367), it does have an importantpoliticalaspect,insofarasexileTibetanstodaylocatemuchoftheircultural andpoliticalidentityinexactlythisMahayanaBuddhistethics(Kloos2010,2011). Byvirtueoftheclassical—butnewlyreformulated—Tibetandefinitionofmedical practiceinethicaltermsanditsrecentgrowthinpopularity,Tibetanmedicinehad,by the1990s,becomeanincreasinglypowerfulvehicletotransportacertainculturaland politicalidentitybothamongthediasporapopulationandtheworld.Thus,theabsence ofanyregulationforTibetanmedicineinexilewasproblematicnotonlyintermsof theprofession’sclinicalandethicalresponsibilitytowarditspatientsbutalsointerms oftheCTA’spoliticalagenda,inwhichtheMen-Tsee-Khangplayedanunofficialand indirect, but nevertheless central, role (Kloos 2012). Indeed, it was the Men-Tsee- Khang’sambiguousstatusbothasamedicalinstitutionwithhegemonicambitionsand asaquasi-governmentalentitywithjustifiedethicalandpoliticalconcernsthatlayat therootofvirtuallyalltensionssurroundingit.Whenthemillenniumdrewtoaclose withaninternaluproarabouttheCongressonTibetanMedicineinWashington,DC HowTibetanMedicineinExileBecamea“MedicalSystem” 387 (wheretheMen-Tsee-Khangfeltslightedinitsself-perceivedroleasthesolelegiti- mate representative of Tibetan medicine outside China); negative press in Europe regarding toxic Tibetan pills (for which the Men-Tsee-Khang blamed unqualified privatedoctors);andincreasinglywidespreadconcernsamongexileTibetandoctors andofficialsaboutthedeteriorationofTibetanmedicineduetocommercialexploi- tation,atippingpointwasreached. 2 ConflictingInterests Inearly2000,theMen-Tsee-Khang’sdirectoratthetime,PemaDamdulArya,sub- mitted a draft law to be passed by the Assembly of Tibetan People’s Deputies (the Tibetanparliamentinexile,oftensimplycalledtheAssembly).Thislawwasintended to regulate Tibetan medical practice and pharmaceutical production by bringing Tibetan medicine in exile under the Men-Tsee-Khang’s official control—or, in other words, of expanding the Men-Tsee-Khang’s institutional body and power. Notsurprisingly,giventhetenseclimateofmutualsuspicionsandaccusations,this decisionwasmetwithvigorousoppositionfromotherquartersinthefieldofTibetan medicine,notablytheprivatepractitioners,andsetinmotionanearlyfour-year-long showdown, with political battlesandheatedconfrontations betweenthe Men-Tsee- Khangandprivateamchi.TheAssemblyrejectedtheMen-Tsee-Khang’sproposal— notleastbecauseofnumerousspellingmistakesintheTibetanoriginal(anindication ofthehasteinwhichitwaswritten)—butinsteadpassedaresolutionon27September 2000callingfortheestablishmentofaCentralCouncilofTibetanMedicine(CCTM). Both the idea and the CCTM’s name indicate an important reference point for Tibetan medicine outside the exile community. It was not only Tibetan medicine’s dramaticexpansionandeconomicsuccess—coupledwiththeeventsjustdescribed— thatledtoagrowingconsensusamongexileTibetansabouttheneedofsomesortof regulation, but also the developments in the Indian health care context. In 1970, thegovernmentofIndiahadestablishedtheCentralCouncilofIndianMedicinesto recognize the so-called Indian systems of medicine (ISM): Ayurveda, Unani, and Siddha.4 In 1979, it amended the Indian Drugs and Cosmetics Act toinclude regu- lationsforthecommercialproductionof“Indian”medicines,andin1995itbrought ISM-H under the Indian Ministry of Health and Family Welfare in the form of a separate Department of ISM-H, which was renamed the Department of AYUSH in 2003.5EspeciallythelatterdevelopmentconstitutedamajorboostforISM,providing themwithahighlevelofpoliticalrepresentationandaccesstobillionsofrupeesof governmentfunding.AlthoughtheexileTibetanamchitendtoregardespeciallythe developmentofAyurvedaverycritically,allofthisconstitutedapowerfulexamplefor “embodying”Tibetanmedicineintheformofa“system.” AsafirststepintheestablishmentoftheCCTM,acommitteeconsistingofmem- bers from the CTA Health Department and the Men-Tsee-Khang was formed in November 2000. This committee met in December to draft a legal code for the 4 Later,yogaandnaturopathywereadded,aswellashomeopathy(thelatterindicatedbythe“H”inISM-H). 5 AYUSHstandsforAyurveda,YogaandNaturopathy,Unani,Siddha,andHomeopathy.InSanskrit,a¯yus (commonlypronounced“ayush”)means“health”or“longlife.” 388 S.Kloos CCTM,whichwasthenpresentedtothehealthdepartment.Consideringthemakeup ofthecommittee(withthehealthdepartmentatthattimeclearlysidingwiththeMen- Tsee-Khang), it is hardly surprising that the result was, in its main ideas, not very differentfromPemaDamdulArya’soriginalproposal.Itcontainedtwosetsofrules andregulations,oneforTibetandoctorsandoneforTibetanpharmacistsinexile.Each setwastobeoverseenandimplementedbyacouncilheavilydominatedbyMen-Tsee- Khang representatives and members of the health department. Most important, the rulesstipulatedthatanyTibetanmedicalinstitute,privatepractitioner,orpharmacist mustberegisteredunder—andcontrolledby—theMen-Tsee-Khangandmustfollow thelatter’srules,ranks,normsofpromotion,andexamspecifications. Forexample,Article18stated:“SincetheMen-Tsee-Khangisrecognizedasthe standard center for the study of Tibetan medicine, the institute is endowed with the responsibility and authority to regulate registration, conduct training programs andexaminations,andissuecertificates.”Regardingpharmaceuticalproduction,the CCTM’sabove-mentionedcommitteewastoinvestigateanyoneproducingmedicines and“take anappropriatedecisionandimmediately reportthe matter tothegovern- ment.” Furthermore, “Any Tibetan lineage doctor planning to start pharmaceutical practicemustobtainpriorpermission[fromtheMen-Tsee-Khang]andgetregistered under the Tibetan government in exile. No Tibetan doctor can engage in Tibetan pharmaceuticalpractices[forcommercialpurposes]withoutpriorregistration.”The documentcontinuedwithacallforagovernmentpharmaceuticalinvestigator—again explicitly from the Men-Tsee-Khang—to check whether any private amchi’s phar- maceuticalproductionwas“atvariancewiththeTibetanmedicalsystem,whetherthe ingredientsareinstandardproportion,”whetherhygienicconditionswerekept,andif there were any signs of adulteration. Finally, in order to keep medicine prices af- fordableforthepoor,Article30concluded:“Thegovernmenthasthepowertocontrol andfixpricesforsaleaswellasexportofthemedicinestakingintoconsiderationthe costprice.Thegovernmentalsoreservesthepowertoreducethepricesorrepealthe registrationcertificateincaseofmedicinesalessolelyforpersonalgains.” Thesedraftrules—andthestrongrepresentationoftheMen-Tsee-Khangandthe CTAontheCCTM—demonstratetheconcernsofallthreepartiesinvolved.Theexile government’s interest in controlling one of its most valuable cultural and political assetswouldbeensured,andthewell-knownanti-commercializationstanceofSam- dhongRinpoche(whowouldbeelectedprimeministerthenextyear)isclearlyvisible inthelastrule.TheMen-Tsee-Khangwouldhavefinallyobtainedtheofficialpower tocarryoutwhatitsawasitsmainresponsibility,thatis,toprotectand“preserve” Tibetanmedicinebyensuringthequalityofitseducation,clinicalpractice,andphar- maceuticalproducts.Atthesametime,theseplansonlyconfirmedtheprivatedoctors’ worstsuspicions,namely,thattheMen-Tsee-Khangwanted tomonopolize Tibetan medicine,marginalizeprivatepractitionersasmuchaspossible,anduseitspolitical powertodistortthemarketofTibetanmedicinetoitsownadvantage.LiketheMen- Tsee-Khang’sownconcerns,thesesuspicionswerepartlyjustifiedandpartlyaprod- uctoftheescalatingtensionswithinTibetanmedicineinexile. UnfortunatelyfortheMen-Tsee-Khang,itsdreamsofalmostabsolutepowerand controlwerenottocometrue.Therewasanothermeetingtodiscussandamendthis draft code in March 2001, where both Men-Tsee-Khang and private amchi were invited. While private physicians were up in arms against the proposed regulations HowTibetanMedicineinExileBecamea“MedicalSystem” 389 andturnedoutinlargenumbers,mostMen-Tsee-Khangdoctorsatthattimeshowed littleinterestinsuchpoliticalissues,whichallowedtheprivatedoctorstochangethe proposalintheirfavor.Whenthechangedproposalwaspresentedtothehealthmin- isterandtoPemaDamdulArya,theMen-Tsee-Khangdirectorstronglyopposedthe newversionbutultimatelyhadtoagreetosubmitittotheAssembly.However,this was in July 2001, and the entire exile government was in transition after the first general election, so it was not presented to the new parliament before January 2002. Again, however, the code did not pass the parliamentary vote, this time due toobjectionsbyaBonpodeputy,whoinsistedonastrongeremphasisonBoninflu- ences in Tibetan medicine.6 Yet another committee was formed, and changes were madetothedraft,including,mostsignificantly,strongreferencestothe’bumbzhi(the Bonversionofthergyudbzhi)andaBonpomemberontheCCTM’sgoverningboard. Theresult—Document13,alsoknownastheExileTibetanDoctor’sAssociationAct, orsimplytheCCTMAct—wasthenreadbythehealthministerduringthefifthsession ofthethirteenthAssembly,passedunanimouslyinMarch2003,andapprovedbythe DalaiLamaalittlelater.Onthebasisofthisact,theCCTM(btsanbyolbodmi’ibod kyigsobarigpa’ichesmtho’ismanpa’ilhantshogs,orChe-thoeMen-paeLhen-tsog) wasofficiallyestablishedasan“apexbody”undertheCTAon5January2004,during theFirstConferenceofSorigPractitionersinDharamsala. 3 TheCentralCouncilofTibetanMedicine After more than forty years in exile, Tibetan medicine was thus finally born as a “medical system.” That is, for the first time in its history, there existed a legal body—separate from any particular medical institution—with the sole purpose to regulate,standardize,andcontrolTibetanmedicineinordertomakeitintoaclearly demarcated“system”ofmedicalandpharmaceuticalknowledgeandpractice,which could in turn define the larger contours of an exile Tibetan cultural and political subjectivity. This body—no doubt weak and dependent for now, but also full of promise—was the CCTM. As it turned out, however, its shape—the result of four years of intense political battles—was hardly what had been envisioned at its con- ceptionin2000. AccordingtotheofficialtenoratthatFirstConferenceofSorigPractitioners,the CCTM’smissionseemedtobeclear:tocontrolandgovernTibetanmedicineinexile inordertopreventitscommercialexploitationanddegradation.Buttherealitybehind thepoliticians’loftyspeechesspokeadifferentlanguage.Whilethefirstdraftcodefor theCCTMin2001stillcontainedanexplicitstatementthatTibetanmedicinehadto remainaffordabletothepoor,andgavetheexilegovernmentthepowertoregulatethe pricesofTibetanmedicinesaccordingly,thereremainednotraceofsuchrulesinthe finalCCTMact.Notonlythat,butinsteadofestablishinggovernmentaloversightover 6 Bonisusuallyconsideredtorefertopre-BuddhistreligioustraditionsofTibet,whicharestillpracticedby apartoftheTibetanpopulationandrecognizedbythefourteenthDalaiLamaasoneofsixTibetanreligious schools(Kvaerne1995).ThehistoriccompetitionbetweenBonandBuddhismextendstocontemporary Tibetanmedicineintheformofdebatesoveritsorigins,whicharelocatedeitherintheBuddha’steachings orintheBontradition.SeealsoColinMillard’scontributiontothisissue. 390 S.Kloos Tibetanmedicine’spreservationanddevelopment,theCCTM’sgoverningboardnow consistedofonlyonegovernmentappointee(abiomedicaldoctor,notapolitician), three Men-Tsee-Khang representatives, and four private amchi. In other words, the exilegovernmentwasleftwithnodirectpoliticalcontroloverTibetanmedicineatall, andtheMen-Tsee-KhangonlyhadaminorityofvotesintheCCTM’sdecisions.Both PemaDamdulArya’sandthecabinet’s(andpartsoftheAssembly’s)initialplanto countertheperceivedthreatofprivatepractitionersandbringTibetanmedicineunder thegovernment’sandtheMen-Tsee-Khang’scontrolhadthusbackfireddramatically. TheMen-Tsee-KhangwasdemotedtoanequalstatusasanyotherTibetanmedical institutionorprivatedoctorsregisteredundertheCCTM,whilethefledglingCCTM itselfwascharged,intheMen-Tsee-Khang’sstead,withthegovernmentalresponsi- bilityofpreserving,regulating,andrepresentingTibetanmedicineinexile. TheCCTM’slegalcode, as itstandstoday,explicitly states asits objectives the registration,regulation,standardization,andcontrolofTibetanmedicalcolleges,phar- maceuticalunits,clinics,doctors,andnewlydevelopedpharmaceuticalformulations. Itsjurisdictionappliesto“alltraditionalTibetanphysiciansundertheexileTibetan government,andtothosepractitionersofTibetanmedicinewhovoluntarilyrespect andacceptitslegalcode”(CTAHealthDepartment2003).Inotherwords,whilenon- Tibetan, Himalayanamchi—for example,Ladakhi,Sherpa,orMonpa—can choose whethertheywishtocomeundertheCCTM’sjurisdictionornot,Tibetannationals havetoacceptitsrulesaspartoftheirgovernment’slaws.EspeciallytheMen-Tsee- KhangdoctorsbutalsosomeofthemoreestablishedindependentTibetanamchiwere lessthanamusedbythisturnofeventsandprivatelygrumbledaboutthisimposednew authority. Most Himalayan amchi, on the other hand, were attracted by the status conferredbytheCCTM’sregistrationcertificates,aswellastheregularconferences, workshops,andhigh-profileempowermentsorganizedbytheCCTM.Thus,atpresent 425 practitioners of Tibetan medicine in South Asia, Europe, North America, Aus- tralia,andIsraelareregisteredundertheCCTM(CentralCouncilofTibetanMedicine 2013),7whichrepresentsthevastmajorityofTibetanmedicinepractitionerstrained andpracticingoutsideTibet,Bhutan,andMongolia. While the CCTM’s most visible activities since 2004 consisted of registering doctorsandaccreditingthefourmainTibetanmedicalcollegesinIndia,standardizing syllabi,compilinglistsofrecognizedclassicaltexts,andorganizingthejust-mentioned conferences and workshops—thus establishing a hitherto nonexistent platform of communicationandexchangeamongmostactorsinthefieldofTibetanmedicinein exile—this is not its main objective. As Dr. Dorjee Rabten, CCTM chairman from 2007to2010, repeatedlystressed both inpublic speeches andinprivateinterviews with me, the CCTM’s real mission is to control, regulate, and represent Tibetan medicine in exile as its sole legitimate authority and thereby claim “the authority andownershipoftheTibetans”(Chukora2007:16)overTibetanmedicine.AsTibet- an medicine is growing into a multimillion dollar market on a global scale, exile TibetanauthoritiesareclearlyconcernedtoreasserttheircontrolnotonlyoverTibetan 7 TheCCTMdistinguishesbetweentwokindsofregistration:“qualifiedmedicalpractitioners,”whopos- sessgraduationcertificatesfromTibetanmedicalcollegesrecognizedbytheCCTM;and“registeredmedi- calpractitioners,”whoaremostlyHimalayanamchitrainedinthetraditionalteacher-apprenticesystem(and thuslackinganyofficialcertificates).
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