1December 2008

2Among traditional Asian medicine based on a written corpus, Tibetan medicine was late in establishing its recognition outside of its cultural framework. Research on the Tibetan “science of healing” (gso-ba rig-pa) only developed from the middle of the 20^th century onwards, especially with the influx of refugees in the south who were escaping from the army of the young Chinese People’s Republic, which had taken control of the Tibetan Plateau. At the same time, teachings were spreading throughout the world thanks to the religious leaders of the diaspora, as well as the activism of Tibetan defence groups, or the promotion of alternative medicine, the development of tourism in areas of the Tibetan culture and a certain craze for media coverage, which have all, to some extent, illustrated the existence of this type of medicine and possibly its resources to the general public. In recent decades, Tibetan medicine has become increasingly institutionalised in many regions of its traditional geographic area, where it now faces local avatars in the field of globalised biomedicine. Additionally, it has been collaborating with NGOs in local programmes in promoting primary healthcare or even environmental protection, and in certain cases, Tibetan medicine, has been incorporated into the national health systems in many ways.

3If we restrict our discussion to scholarly Tibetan medicine, it should be emphasised that the majority of native health practices depended – and continues to depend, in many remote areas – on registers that were not strictly medical. These include therapeutic practices, formal acts whose aims are to gain merit (donating to poor or religious organisations, freeing an animal that was to be slaughtered, sponsoring the reading of religious texts), visiting sacred places, pilgrimages, receiving blessings from great religious figures, wearing protective charms, using divinatory and astrological calculations, exorcism, longevity or recovery rituals, receiving diagnosis or treatment carried out by a medium possessed by a god.

4The development of scholarly Tibetan medicine was intimately linked to its culture, and therefore to Buddhism, which has strongly influenced all of its aspects. Buddhism has close affinities with medicine on several levels. As a doctrine and path to salvation, recovery from illness has become a metaphor for the ultimate liberation from enslavement to the endless cycle of re-births. Moreover, and more specifically, the problem of suffering has always remained at the heart of its soteriology. Finally, this Buddhist affinity to medicine was further strengthened at the beginning of our era, with the doctrinal development of the Mahayana and its new idea of the Bodhisattva, “dedication to Enlightenment”, for which the healing of wounded bodies is both the opportunity for perfecting compassion, giving, and a clever way to convert people. Medical science itself was thus open about being part of the syllabus for Buddhist studies, especially in monasteries. At around the same time, the Buddhist place of worship was enriched with figures of therapy. Among these, the Buddha, Master of Medicine, (Bhaisajyaguru) was worshipped with great devotion in Central Asia, then in the Far East, and later in Tibet.

5Classical Tibetan historiography places the origins of the medical tradition in the 7^th century, when Tibet formed a unified empire for the first time and came into contact with ancient neighbouring civilisations including India, China, Central Asia and the Iranian world. Having acquired a style of writing borrowed from India, Tibet was able to access a large number of texts (especially Buddhist), including medical books. The variety of influences, notably, Indian and Chinese, probably even Greco-Arab, which according to Tibetan historians, marked the origins of medicine in their culture, is confirmed by ancient Tibetan documents and by the traces of these influences that can be found in the medical treatises that are still used today. Over the centuries, some of these influences were abandoned, while others were incorporated into a coherent body of knowledge and specialised practices, along with the legacy of native therapeutics. The treatise called, “The Fourfold Tantra” (rGyud-bzhi), became the body of reference for Tibetan practitioners, in a vast collection of medical literature, which still remains relatively unknown.

6Medical teaching, texts as well as oral instructions and practical techniques, often together with religious teachings, were passed down, not to specific institutions, but from master to student, often in a monastic setting, or from father to son within the family lineage. Traditionally, this teaching was not acknowledged by formal accreditation, and the medical practice did not require any recognition by any civil or religious authority, which would have required a standard level of theoretical knowledge or technical expertise. Moreover, Tibetan practitioners have never been a well-defined socio-professional group, and many had other professions particularly religious ones. At the end of the 17^th century, the first monastic establishment that was specifically devoted to medical teaching was founded on the Iron Hill (Lcags-po-ri) near Lhasa. Later it was used as a model for other similar establishments in eastern Tibet, Beijing and Mongolia. Finally, Tibetan medical science earned itself newfound popularity when the Tibetan Astro-Medical Institute (sMan-rtsis-khang) was founded by the Thirteenth Dalai Lama in 1916 at the heart of Lhasa that was clerically orientated. Alongside these centres of institutionalised medical teachings that were accredited by exams, medical tradition continued to be passed on, like it was in the past, outside all official control, by individual practitioners, in family lineages or otherwise, at various levels of knowledge and practices. Certain women thus received a medical education, usually through their fathers.

7Tibetan science of healing, as it is presented in its reference treatise, The Fourfold Tantra, supposedly taught by the Buddha, Master of Medicine, is not empirical medicine. On the contrary, it was deliberately developed as a sophisticated system in which all parts, whether they involve empirical experiments or theoretical speculation, are integrated into a coherent body bound by epistemological rules and formal logic based on a certain number of natural laws.

8For Tibetan medicine, as for the Indian Ayurvedhic medicine, from which it borrowed the basic theoretical essentials relating to physiology, pathology and therapy, the living body is made up of an organic substrate in which three humeral fluids, pneuma, bile and phlegm ensure the body’s different vital functions. These humours, blood and other organic fluids flow through the body in channels forming a network. Although these humours provide the body with life and health as long as they remain in harmony, the state of the illness is nothing but the pathological symptoms of these very humours in an imbalanced state, under the influence of food, lifestyle, seasons, etc.

9Medical diagnosis is seen as the outcome of a process of logical inference during which the doctor should ideally compare clinical signs that are obtained by questioning the patient, palpation of pulses, and visual examination, especially of the tongue and urine. Diagnostic examination is often limited to taking the pulse, according to a technique that was clearly borrowed from China.

10The treatment involves four types of therapies that are supposedly increasingly drastic in the following order: healthy lifestyle, diet, remedies and external therapeutic procedures. Generally, this involves comparing excessive humours to qualities that are the opposite them and, if necessary, discharging them from the body. Among the sensitive qualities attributed to food and drugs, their flavours and whether they are hot or cold, are taken into account. The remedies combine elements of a rich medical material, in various forms (mainly powders, decoctions or pills) of which the majority are plant-based products. The external therapeutic procedures include frequent moxibustion, possibly fomentations and medicinal baths, anointment, bleeding, and minor surgery.

11For three decades now, Tibetan medicine has undergone major changes in all areas where it was traditionally practised, as much in the Tibetan regions of China, the Himalayan regions or in the Diaspora. In China, Tibetan medicine was a victim of major upheavals that followed the Dalai Lama’s escape into exile in 1959, then of the extreme political violence of the Cultural Revolution. With the period of relative liberalisation that started around 1980, Tibetan medicine, nevertheless, emerged as one of the cultural heritage elements to have best survived. It owes this no doubt to several factors including the recognition of traditional medicine in China itself, its local availability at a low cost, its pragmatism with a touch of rationality that is to be encouraged at the expense of its religious aspects, its aptitude, the fact that it is easily monitored and its use as an iconic image of a Chinese policy that seeks to promote both the well-being and cultural heritage of Tibetans. Tibetan medicine has thus been incorporated into the health system of the Tibetan regions of China at the expense of an evolution that has borrowed certain traits from a biomedical model such as institutional education accredited by degrees, and therefore an evolution towards a relative standardisation of knowledge and practices. This includes secularisation, professionalisation, more exclusive focus on the somatic nature of illnesses to the detriment of their psycho-emotional or social aspects, more impersonal consultation of patients in a formal setting of a small clinic, a pharmacy or hospital, re-evaluation of certain concepts or practices with reference to modern science, and practitioners giving up on preparing medicine to make way for pharmaceutical companies with increasing commercial goals, as well as resorting to certain diagnostic or therapeutic biomedical techniques. Some of these traits also mark, in varying degrees, the evolution of Tibetan medicine outside of Chinese borders under the influence of so-called development programmes, local processes of state integration, or even the demands of the exile community. Finally, Tibetan medicine, which is also the subject of identity issues, can be found today in the globalised market of alternative medicines. The practitioners affected have found a way to adjust to this by changing the way in which they think and practise, which, in turn, is echoed in the areas that they come from.