Introduction

Ethnomedicine was pioneered as a subfield of cultural anthropology by scholars like Horatio Fabrega, and mapped in discipline-defining collections by David Landy (1977) and by Lola Romanucci-Ross, Daniel E. Moerman, and Laurence R. Tancredi (1991) among others. Implicitly pursued in the rich ethnographic traditions of E. E. Evans Pritchard and Victor Turner, and explicitlyin the work of George Foster, Fred Dunn, Arthur Rubel, and Charles Leslie, the study of indigenous practices of health and healing have occupied a small but important place in the history of medical anthropology – some would argue as a foundational concern.

There are many possible genealogies of ethnomedicine in anthropology but, for me, these early ethnographic commitments explored indigenous healing systems, cross-cultural notions of health and disease, and transcultural conundrums like culture-bound syndromes. All of these topics drove theorizing in the larger discipline of anthropology. Early efforts to map the limits of relativism; cultural ecologies; relationships between culture and personality; and boundaries between science and religion, symbol and empirical fact inspired generations of anthropologists. These early interests gave way to interrogating how medical systems opened up insights into larger phenomena such as political and economic infrastructures, colonialism, development, modernization, socialist reform, and psychological and social suffering. Work by Byron Good, Margaret Lock, Arthur Kleinman, Jean Comaroff, Peter Guarnaccia, Mark Nichter, Judith Farquhar, Deborah Gordon, and Jean Langford, among many others, inherited the sense of possibility that came from taking up the study of ethnomedicine, including the study of biomedicine as an ethnomedicine.

Some of us would also trace in this work the birth of an early anthropology of science.Research such as that of Leslie’s (1976) explorations of Ayurveda or Farquhar’s (1994) early studies of Chinese medicine, brought together epistemological questions about bodies and technologies to interrogate efficacy, postcolonial forms of statecraft, the micropolitics of subjugation, and the globalization of medical practices. These works are also inspiration for (and inspired by) others’ works that I would label ‘ethnomedical’, such as Ashis Nandy, Frederique Marglin, Sjaak van der Geest, and Mei Zhan as well as scholars such as Annemarie Mol and Vinh-Kim Nguyen who have posed alternative routes to theories of ontology.

Although some might argue that in casting my net so widely I have lost distinctions between ethnomedicine studies and medical anthropology in toto, my point is the opposite. I want to remind us that at the heart of much of what we do in medical anthropology is a fundamental set of concerns about how people attempt to heal, how they define disease and health, how they make claims about the legitimacy of their culture in and through medicine, and how medical systems reflect basic cultural claims (even about nature and the body). What has been missing in the ethnomedical repertoire lately, I would say, is a focus on this last topic: how medical systems have a way of speaking for whole nations and their collective anxieties about existential survival. It makes sense that this would be a topic of late. Medical phenomena everywhere take up more and more economic, political, and cultural space. As Nikolas Rose, Didier Fassin, and others note, life itself is medicalized through regimes of humanitarianism, development, social welfare, and the psy- disciplinary regimes we live by (and pharmaceuticalize ourselves with). These are global phenomena. So, it makes sense that when we feel collective anxieties about precarity or existential erasure, these fears become visible in medical ways.

This collection of essays returns us powerfully to these concerns in possibly one of their more interesting sites in the world today: that of Tibet and its medical traditions. What, then, do these contemporary efforts to report on ethnomedicine contribute to our knowledge of not only Tibetan anxieties but also about how to do ethnography in medical worlds?

I want to applaud the careful scholarship here that reveals the broad reach of ethnography. Making use of historical and linguistic material; event-based participation and interviews; and insightful powers of observation, these essays illuminate complex microcosms of debate over what Tibetan medicine should be called. Craig and Gerke’s multisited essay details this debate; Kloos’s analysis of the politics of state recognition in India shows that the debate over naming is simultaneously a debate over recognition; and Blaikie’s ethnographic analysis further explicates how this debating plays out. These debates are of huge socioeconomic and affective significance – and they are issues that have not been taken up in anthropology with regard to medical traditions, but have rather been focused on the somewhat distinct cases of indigenous rights and related political movements.

One of the reasons naming matters so much today, as shown in these papers and the larger corpus of work by these authors, is that the rewards proffered by specific names are not just articulated in terms of cultural or nationalist survival; they also surface in the form of financial gains, access to markets, and legal protection by governments and states. In Kloos’s essay we see how tactics of recognition are renegotiated and fought over, under the guise of ‘protection’, ownership, and control (political, economic, and cultural). Kloos’s larger overview of this process is complemented by Blaikie’s in-depth ethnography of several key moments in it, revealing just how much language and discursive practices matter. These issues are relevant worldwide and directly connect with larger anthropological concerns that trace how, and with what effects, previously inalienable traditions, knowledge, and aspects of culture/identity are incorporated into the global economic system. These papers remind us of what is at stake as ‘traditional’ medicines and their underlying knowledge systems get commercialized while they are simultaneously being ‘protected’ – but only under certain circumstances, when different interests (states, markets, local communities, etc.) can be aligned. All three articles trace distinct aspects of how these changes are being negotiated within contemporary Tibetan medicine across transnational domains, in ways that speak far beyond Tibetan studies.

It turns out, though, that naming Tibetan medicine as a scholarly field of inquiry, not to mention a set of empirical therapeutic practices, is not easy, as Craig and Gerke show. The name ‘Tibetan medicine’, used widely today across local and global registers, refers at least in some part to a set of practices that are known and used by a variety of people sometimes in direct connection with (and other times not) the foundational text called the Gyüshi (rgyud bzhi) or Four Treatises that emerged during the twelfth century in central Tibet. This name, however, is not suitable to those who do not necessarily call themselves Tibetan, even if they hail from geographic regions that have been highly influenced by, if not arguably part of, the larger Tibetan cultural area. In fact, Craig and Gerke note, medicine is always just medicine until it needs to be named as different in relation to an awareness of some sort of rupture of ideology, geography, and national identity, including (as the other authors show) political recognition and/or threats to cultural survival under the dual pressures of modernization and diaspora.

Today, we are faced with a swirl of shifting names and meanings when it comes to this medical system, each of which attends to but also cuts across what Blaikie identifies as particular ‘discourse coalitions’, and each of which has specific intentions in regards to recognition, as both he and Kloos map out. The term ‘Sowa Rigpa’(gso ba rig pa), for instance, uses Tibetan language to talk about Tibetan medicine in India and in many other countries outside of Tibet. It gets translated as ‘science of healing’ or ‘knowledge of healing’ but has etymological roots that are multiple and blurry. As all three of these contributions note in different yet complementary ethnographic ways, this name matters enormously because of its ability to perform acts of inclusion and exclusion in the contemporary efforts among practitioners to legitimize their practices in India and beyond. As the contributions by Blaikie and Craig and Gerke show, Sowa Rigpa can make Ladakhi and Nepali practitioners feel included and protected, even while requiring it to appear as a subset of Ayurveda in order to gain political legitimacy and legal protection. This particular name, though, simultaneously undermines efforts on the part of the Tibetan exile community in India and Tibetans in China to use Bod kyi sman, literally ‘Tibetan medicine’, as a gesture of cultural identity and survival even though this name probably arose as a modern invention. To erase the Tibetan assignation is to instigate fears over another type of erasure, as Kloos notes, as practitioners feel it strips the medicine of its national origins much in the same way that the exile community collectively feels it has been stripped of its homeland.

Craig and Gerke offer a useful analytic for making sense of the swirl here, reminding us that these naming practices are simultaneously constructive and destructive, requiring both invention and forgetting. One even wonders whether debates arise over whether Sowa Rigpa could be a direct translation of Ayurveda (which is often translated from Sanskrit into English as ‘knowledge of life’ or ‘nourishment’). This is a claim that contemporary debates among Ayurvedic practitioners would likely support, but one that clearly erases a millennium of historical progress and transformation, and the unique origination in Tibet proper. Craig and Gerke astutely call upon Paul Connerton’s analytical notion of collective memory and forgetting, arising as a contingency of modernity itself. Thus even though the term ‘amchi’ refers to the name ascribed to Tibetan healers by Mongolian elites centuries ago, it has only been in modern times that such names have mattered so much, as a tactic of inclusion that transcends geographic boundaries and claims of origin and requires forgetting a past when such distinctions didn’t matter. These authors also note that the name ‘Tibetan medicine’ appears to have become newly important only after non-Tibetan-speaking researchers appeared on the scene, and as Tibetan practitioners were confronted with other forms of healing attached to political and economic institutions that challenged their own – in other words, it appeared at the time when Tibet itself was called into question enough to warrant a sense of nationalism. Contact with foreigners for whom Tibet meant something altogether different from the related regional cultures that surround it (in China, Nepal, Bhutan, India, for instance) entailed turning medicine into ‘Tibetan medicine’.

This might seem ironic, given the historical and multicultural origins of the Four Treatises and its inclusion of knowledge from a wide geographic reach. Modernity breeds this kind of irony. Take the fact that these medical practices (or at least some historic form of them) travelled initially from India and, in Tibet, were put in contact with medical practices from elsewhere, including China and Persia. Today it is the return of Tibetan experts of this medicine to India, their interactions with practitioners who share this system but don’t define themselves as ‘Tibetan’, and the increasingly global reach of this medicine that has created so much concern and contestation over ownership and the right to its naming. What specific names accomplish for different actors reveals the contemporary situations of diaspora for more than Tibetans, although among Tibetans in exile and, differently, those in China, the terms of this conversation are tied to existential crisis. The names used to talk about Tibetan medical experts today have multiple meanings associated with the political work these names accomplish, and in each case this often requires a type of singular forgetting – even of a time when this question of ‘what to call it’ may not have mattered. Or maybe it did.

Names enable some claims about cultural ownership, national belonging, and forms of scientific legitimacy and not others. They are used by specific groups, in specific places, to establish a basis for recognition and legitimacy by states, ethnic groups, and markets. As markets for Tibetan pharmaceuticals grow, naming and recognition go hand in hand. Narratives of legitimacy must navigate their terms of empiricism, and these terms are at once cultural, political, and scientific. These narratives sometimes pit one kind of practitioner against another, one set of empirical claims against another, even one vision of efficacy against another – even between healers who ascribe to the same healing traditions. What we know is that systems of healing are always dually invested: in bodies and in efficacies that spill far beyond the body. As biomedical science industries impinge on Tibetan pharmaceutical opportunities by calling for ‘good manufacturing practices’, randomized controlled trials, and the standardization of formulas – not to mention production circuits that require vast material resources – and as clinical trials research demand an evidence base derived from expensive and sometimes incommensurable experimental models, these questions of naming, ownership, and state legitimacy matter even more as arbiters of, and rubrics for, protocol and epistemology.

The ethnographic and analytical nuggets in these essays speak to processes far beyond the Tibetan case. Take the parallel case of biomedicine itself. The 1910 Carnegie Foundation-funded Flexner Report and the 1962 Kefauver Amendment (for mandatory drug safety testing) in the United States might be comparable instances of discursive coalition forming in and around the inclusion and exclusion of certain kinds of clinical specialists in the United States. These regulatory practices are not simply about facts and efficacy (or even health versus harm). They are about the terms and conditions that enable or disable different kinds of healing acts in a field of great potential financial reward. Just consider what happened to homeopathy in the United States after Flexner (Harris Coulter’s 1982 Divided Legacy shows this well). The criminalization of practices that fall outside of the new state-backed norms greatly raises the stakes for practitioners here and there. Charles Leslie set an important medical anthropological trajectory by tracing many of these efforts in India in and around Ayurveda. His work reminds us that despite the Indian government’s inclusivity when it comes to traditional healing systems, in the wake of colonial policies that destabilized and even criminalized them, these efforts reach a certain kind of limit in the Tibetan case. Who gets to tax, profit from, regulate, and practice these healing modalities makes the state’s interest all the more profound and troubling.

There are other ways Tibetan medicine serves as a microcosm of the trends seen in ethnomedicines in other places, including in biomedicine. I am thinking here of the emphasis on pharmaceutical use over other kinds of therapies, the clash between theoretical versus practical forms of knowledge, and the sense of urgency to resolve new health problems that are associated with modernity. Ironically, this last trend often appears as a claim that traditional medicines can do something modern medicines cannot, such as curing ‘modernity’s ills’ (as Jean Langford shows in her 2002 ethnography Fluent Bodies). Some of the specific negotiations over legitimizing knowledge in Tibetan Medicine are unique to the Tibetan case, while others are worldwide trends tied to modernization, global capitalism, and the spread of government and juridical surveillance over medical things. Sometimes they are more simply tied to the desires of patients and consumers to opt for choices that are distinctly not biomedical.

This brings me to a related, final point about these essays. Although these papers are focused on medical politics outside of Tibet proper, there are many ways in which the work could inform our understanding of what goes on inside Tibet too. Consider the parallels: In India, Tibetan doctors worry about legislation that makes Tibetan medicine a subfield of Ayurveda (as Kloos and Blaikie deftly show). In Tibet, Tibetan doctors worry about legislation that will make Tibetan medicine a subfield of Traditional Chinese Medicine. The recent adoption by Lhasa’s medical scholars of the English transliteration for Men Tsee Khang (close to and derived from that used in India, Men-tsee-khang) deserves some note here, just as an example that suggests that these debates are as important inside Tibet as they are outside, that they are indeed interdependent and reflect Tibetan medicine’s engagement with English-speaking observers, including myself and the authors of these essays. Similar efforts to negotiate the terms of scientific research, ownership of pharmaceutical industries, and protection and support from the legal infrastructures of the state are being played out in Tibet too.

Reading through the essays here as a group, I am reminded of the rich reward that comes from focusing on ethnomedicine. What can local debates over the languages of medicine and medical systems tell us about how marginalized and diasporic groups navigate their membership in states, nations, and global industries in and through indigenous techniques of healing? What are local methods of establishing efficacy, determining potency, and even legitimizing diseases if they have no purchase outside their unique cultural sphere? How might the histories of political dialogue and the discursive coalitions that form in their wake remind us that recognition and self-determination in and through medicine happen all over the world, and in biomedicine as well? These accounts remind us that healing is far more than a set of empirical claims about bodies and health and empirical things that are used in practices of state-making and perceptions of cultural survival. Who might have guessed that with a focus on an ethnographic field that seems so specific, we can come to see much larger anthropological themes play out and be pushed theoretically? Even the narrowly focused ethnographic lens can shed light on phenomena that are anthropologically quite large indeed.

About the author

Vincanne Adams, PhD is Professor and Vice Chair in the Department of Anthropology, History and Social Medicine at the University of California, San Francisco. She is coeditor of the Duke University Press book series: Critical Global Health: Evidence, Efficacy, Ethnography. She is also the editor of Metrics: What Counts in Global Health (Duke University Press, 2016) and author of Markets of Sorrow, Labors of Faith (Duke University Press, 2013) as well as other ethnographies. She is currently working on several other projects, including one on pesticides and pediatric health in the United States and another on Tibet and science.

References

Coulter, Harris L. 1982. Divided Legacy, vol. 3, The Conflict Between Homeopathy and the American Medical Association, Science and Ethics in American Medicine 1800–1910. Berkeley, CA: North Atlantic Books.

Farquhar, Judith. 1994. Knowing Practice: The Clinical Encounter of Chinese Medicine. Boulder, CO: Westview Press.

Landy, David, ed. 1977. Culture, Disease and Healing: Studies in Medical Anthropology. London: Colliers Macmillan.

Langford, Jean. 2002. Fluent Bodies: Ayurvedic Remedies for Postcolonial Imbalance. Durham, NC: Duke University Press.

Leslie, Charles Miller. 1976. Asian Medical Systems: A Comparative Study. Berkeley: University of California Press.

Romanucci-Ross, Lola, Daniel E. Moerman, and Laurence R. Tancredi, eds. 1991. The Anthropology of Medicine: From Culture to Method. Westport, CT: Bergin & Garvey.