A book review by Stephan Kloos (in Somatosphere, 2013).
Healing Elements: Efficacy and the Social Ecologies of Tibetan Medicine
by Sienna R. Craig
Berkeley, University of California Press, 2012, 344 pp.
This review by Stephan Kloos has been published on February 1st 2013, in Somatosphere.
It is a truism that the world we live in today is increasingly interconnected. Yet, when it comes to medicine – and particularly "traditional" or alternative medicine – the tendency is often to delimit its study along disciplinary lines, or simply reduce it to the pragmatic question of patients the world over: does it work? Sienna Craig's new book on Tibetan medicine is, above everything else, an attempt to go beyond such reductions and make visible the multiple elements and connections that make up contemporary Tibetan medicine (also known as Sowa Rigpa). What do George W. Bush's neo-conservative policies, Himalayan mountain gods, climate change, and the Coca Cola company have to do with Tibetan herbal remedies? How do Sowa Rigpa practitioners create or negotiate connections between randomized controlled trials and tantric empowerments, and between the conflicting moral imperatives to conserve the environment and to help the patient? Tracing such unlikely connections and encounters across nations and continents, Sienna Craig's Healing Elements offers a refreshing, lightly written yet erudite introduction into the world of contemporary Tibetan Medicine.
The book is based on Craig's extensive engagement – as an anthropologist, grant writer, translator, fundraiser, co-investigator, and coauthor among other roles – with Tibetan and Himalayan practitioners of Sowa Rigpa over two decades. In particular, the book draws from ethnographic data collected in the Tibetan regions of China, in Nepal, Bhutan and the US between 2001 and 2012. As the title suggests, its main argument is framed by the central problem of efficacy: what does it mean to say that a medicine "works"? How is efficacy determined? What is at stake in these determinations? Rather than focus solely on the domain of pharmaceutical production (which is usually taken as the most pertinent to this issue – e.g. Craig & Adams 2008; Craig 2011), Craig expands the notion of efficacy to refer to the capacity to produce desired outcomes, whether through herbs, clinical encounters, project proposals or research methodologies. Efficacy therefore resides not only in clinical and pharmaceutical interventions, but also in socio-cultural, environmental, political, economic, epistemological and historical factors, at the confluence of which Tibetan medicine's healing powers are constituted.
This is an important, if not altogether novel approach in anthropology (e.g. Nichter 1987; van der Geest et al. 1996; Whyte et al. 2002), which derives its brilliance here from Craig's ethnographic prose illustrating this multitude of "healing elements" and their complex interconnections with deceptive ease, clarity and elegance. Tibetan medicine and the manifold domains of its efficacy can be fruitfully analyzed, the author argues, as social ecologies, a concept borrowed and expanded from public health, epidemiology and parts of medical anthropology. Thus, social ecologies refer to interdependent and mutually constituted relationships between human beings and their environments (p. 5), demanding a holistic approach to the study of health and healing resonating with that of Tibetan medicine itself. In Healing Elements, this approach takes the form of a wide-ranging, multi-sited exploration of Tibetan medicine's various engagements – on part of its practitioners, patients and administrators – with biomedicine, clinical research, environmental conservation-development projects, regimes of governance, commodification and identity politics.
The book is organized in seven chapters (not including the introduction and brief conclusion, a glossary and the usual bibliography and index), which proceed from a focus on the practitioners of Tibetan medicine (chapters 1-3), through their patients' experiences (chapter 4), to an exploration of Tibetan medicine's products and materia medica (chapters 5-7). Each chapter contains a wealth of ethnographic encounters, observations and theoretical discussions, which together form an intriguing mosaic of the dynamics and diversity of contemporary Sowa Rigpa. Due to the sheer amount and diversity of the book's material, the following discussion is limited to necessarily incomplete outlines of each chapter's contents and arguments.
After an introduction of the central concerns, analytic framework and ethnographic context, chapters 1 and 2 chronicle a day each in the study's main ethnographic sites, that is, Mustang in Nepal and Qinghai in Eastern Tibet respectively. Although mainly descriptive in their content and thus serving as an extended introduction in terms of situating the book's narrative, each of these chapters takes up core issues of contemporary Sowa Rigpa. Thus, in chapter 1 we learn about the social ecology of Tibetan medicine in Mustang, where the amchi – the practitioners of Sowa Rigpa – find themselves enmeshed in a web of regional and global ideas, practices, goods, services and values, which poses both challenges and opportunities for them. Following two amchi brothers through their daily routine of treating patients, teaching students, compounding medicines, keeping medical records, and securing funding for all of this by engaging with foreign conservation-development organizations, Craig offers a good sense of the structural parameters that shape Tibetan medicine in this Himalayan border region.
As a point of contrast, chapter 2 describes a day at the Arura Tibetan Medical Group in Xining, the capital of Qinghai province. This is one of China's largest Tibetan medical establishments, comprised of a hospital, a research institute, a medical college, a Tibetan cultural museum, and a pharmaceutical company. In this highly institutionalized, modern urban context, Sowa Rigpa is scaled up to a massive commercial enterprise. Yet, despite the evident commodification of Tibetan culture, Arura is also invested in "preserving" this culture through "strategic innovation" (p. 51) aimed at legitimating and transforming Tibetan medicine within China's political and economic system. As in Mustang, here too Sowa Rigpa is tied to global regimes of governance like development agendas, technoscience and global pharma (cf. Craig & Adams 2008), and needs to articulate – indeed, produce – its efficacy both in biopsychosocial and political-economic ways, within specific social ecologies.
Chapter 3 discusses the issue of Tibetan medicine's legitimacy in relation to lineage, gender, morality and the state in Kathmandu, Lhasa and Mustang. In particular, we learn about the efforts of Nepali amchi to gain official state recognition for their medicine, which – unlike in China, Bhutan, Mongolia and more recently also India – remains elusive. As these amchi forge strategies to make Tibetan medicine both legible to the state (cf. Scott 1998) and retain its traditional knowledge and efficacy, it becomes clear that official and professional legitimacy do not always overlap, and need to be actively reconciled. In this context, belonging to an amchi lineage can be both an asset and a liability, much in the same way as Nepali amchi as a group are regarded, within the professional field, as both valuable in their authenticity and marginal to contemporary Tibetan medicine. A vivid description of a meeting of the Himalayan Amchi Association (The Inner Life of an Association, p. 101ff) illustrates well the various personal, social, cultural, economic, political and moral issues at play in the amchi's quest for legitimacy and the preservation of their knowledge.
Switching perspective, chapter 4 focuses on the social ecologies of illness and healing as experienced by patients. As they navigate diverse settings of medical pluralism in the Tibetan-speaking world (here: Kathmandu, rural Qinghai and Mustang), Craig describes how they carefully evaluate their options considering factors such as cost, trust, language, and the diversity of available treatments. As Craig shows, in such contexts the language of Tibetan medicine often also serves as social and political commentary, linking family relations, the supernatural world, government programs, geography, building materials, morality, Tibetan medical concepts and biomedical notions together into a larger cartography of life and suffering in particular locales.
Chapter 5, together with chapter 7 the book's most profound in terms of ethnography and analysis, uses ethnographic material collected between 2002 and 2010 at three important Tibetan medical factories in the TAR and Qinghai (Mentsikhang, Shongpalhachu, Arura) to explore the industrial production of Tibetan medicines, and particularly the implementation of Good Manufacturing Practices (GMP). Showing how global and national regulatory agendas impact local social and pharmaceutical practices, Craig argues that the Chinese SFDA's implementation of GMP in Tibetan medicine needs to be understood in the context of global pharmaceutical governance of Traditional Medicines (most notably by the WHO) and the international market for Complementary and Alternative Medicines.
While agreeing with Saxer (2010) that GMP rarely conflict directly with traditional pharmaceutical practices, this chapter focuses on the powerful and problematic indirect effects of such biomedically-oriented regimes of governance. The indirect effects of GMP include price increases for drugs, the closure of non-GMP factories, discontinued use of the local labor force, and a decrease in medical skill and knowledge among younger doctors (p. 161). While not mentioned by Craig, one wonders whether changes and innovations in actual pharmaceutical formulas and practices might not constitute another (direct or indirect) effect of GMP implementation. Importantly, however, the author does point out that GMP also serve as a way for the Chinese state to render Tibetan medicine "legible" (and thus governable and exploitable), inevitably mandating its standardization and commodification. As a consequence, Tibetan medicine in China is today increasingly defined by its exchange value (making profits) rather than its use value (healing patients), potentially occluding other Tibetan ways of healing people, stewarding landscapes, and articulating their identities (p. 180). However, Craig notes, of late the widespread fetishization of GMP has given way to disillusion and a more pragmatic approach, which has even led to efforts to re-create non-GMP facilities.
Chapter 6, titled "Cultivating the Wilds," refers less to actual medicinal plant cultivation projects than to the ways in which various stakeholders "cultivate" wildness in the attempt to simultaneously exploit and conserve Tibetan medicine's wild resources. As Sowa Rigpa depends on the ready availability of wildcrafted herbs, the problem of overharvesting and environmental degradation – exacerbated by the rapid growth of the industry – is an existential one. Yet, as wildness itself is considered a source of pharmaceutical potency, even conservation-minded amchi often give priority to their patients' health rather than the environment, preferring rare, wildcrafted herbs to less endangered or cultivated substitutes. Discussing various models and notions of conservation, Craig links medical anthropology and political ecology here to explore the links between conservation-development projects and the commodification of nature and culture in regard to Sowa Rigpa.
Chapter 7, finally, explores the "social life" of zhije 11, a Tibetan medicine commonly known as the "birth helping pill." Created, according to legend, by a 13th century female adept, this pill is today used to help aid and speed delivery and stop bleeding after birth. As a team of NIH researchers decide to conduct a double-blind randomized controlled trial (RCT) at the Lhasa Mentsikhang to compare its efficacy to that of the biomedical drug misoprostol, Craig – who was a member of that team – uses her unique access to document this mutual engagement between two medical systems. In particular, the account of zhije 11's reformulation leading up to the trial stands out as an interesting case of pharmaceutical innovation, tying in with ongoing work on reformulation regimes (Pordié & Gaudillière in press), while the account of the ritual empowerment of these newly formulated medicines raises important questions about ethics and commensurability. Over all, this chapter illustrates both the creativity and agency of Tibetan doctors in their interactions with modern science, and their increasing reliance on modern science as a tool to validate their knowledge.
Reading Healing Elements, it quickly becomes clear that Craig is an experienced author (her voice is distinct and consistent throughout the book), and that this book is written with the explicit aim of providing a serious yet accessible introduction to the field of contemporary Tibetan medicine. Its tone and style is both personal and didactic, often directly addressing the reader, with summary sections at the end of each chapter rehearsing the main arguments ("In this chapter, you have learned..."). Using the tools of creative non-fiction, Craig narrates ethnographic data largely through dialogues and personal observations – travelogue style – rather than dry descriptions. Theory, for its part, is presented concisely and in easily digestible chunks throughout the book, and serves to discuss the material at hand as much as to introduce the reader to the relevant literature. All of this makes this book an ideal, and so far missing, teaching resource on Sowa Rigpa, "traditional medicine," and the problem of efficacy more generally.
Even though Healing Elements most explicitly addresses undergraduate and graduate students in medical anthropology, international health and development studies, this is an ambitious book that also aims to contribute to cutting edge scholarship on Tibetan medicine. It is no small achievement that Craig succeeds in both endeavors: her many, well-chosen ethnographic encounters, dialogues, observations and theoretical reflections not only serve as an engaging introduction to newcomers to the field, but also form, like pieces of a mosaic, a bigger picture that reveals, better than any single article or monograph on the topic so far, the complex interconnections that shape Tibetan medicine today. In short, this is an outstanding and long-overdue book that will doubtlessly serve as the standard monograph on Tibetan medicine for years to come.
Craig, Sienna. 2011 "Good" Manufacturing by Whose Standards? Remaking Quality, Safety, and Value in the Production of Tibetan Pharmaceuticals. Anthropological Quarterly 84(2): 331-378.
Craig, Sienna, and Vincanne Adams. 2008 Global Pharma in the Land of Snows: Tibetan Medicines, SARS, and Identity Politics Across Nations. Asian Medicine 4: 1-28.
Pordié, Laurent, and Jean-Paul Gaudillière. In press The Reformulation Regime in Drug Discovery: Revisiting Polyherbals and Property Rights in the Ayurvedic Industry. East Asian Science, Technology and Society.
Nichter, Mark. 1987 Kyasanur Forest Disease: An Ethnography of a Disease of Development. Medical Anthropology Quarterly 1(4): 406-423.
Saxer, Martin. 2010 Manufacturing Tibetan Medicine: The Creation of an Industry and the Moral Economy of Tibetanness, PhD Dissertation, Institute of Social and Cultural Anthropology, University of Oxford. Forthcoming at Berghahn Books.
Scott, James C. 1998 Seeing Like a State: How Certain Schemes to Improve the Human Condition Have Failed. New Haven, CT: Yale University Press.
van der Geest, Sjaak, Susan Reynolds Whyte, and Susan Hardon. 1996 The Anthropology of Pharmaceuticals: A Biographical Approach. Annual Review of Anthropology 25: 153-178.
Whyte, Susan Reynolds, Sjaak van der Geest, and Anita Hardon. 2002 Social Lives of Medicines. Cambridge: Cambridge University Press.
Stephan Kloos received his PhD in Medical Anthropology from UC San Francisco and Berkeley in 2010, and currently works as a Marie Curie Fellow at the Austrian Academy of Sciences. Stephan has authored a book as well as several journal articles and book chapters, their topics ranging from the socio-economic transition of health care in Ladakh, the engagement of Tibetan medicine with modern science, to exile Tibetan nationalism, medical history and postcolonial theory. For more information see www.stephankloos.org.