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Chapter 6 examines how <i>amchi</i> interact with conservation-development practitioners, policies, and projects. The chapter draws on fieldwork from Yunnan Province, China—a region actually called “Shangri-La”—as well as ethnography from Nepal and Bhutan. Perhaps surprisingly, insights about the nature of health and illness, the social lives of medicines, and the political-economic possibilities and constraints for meeting global health needs rarely intersect with insights gleaned from political ecology. Much of what exists in both academic and popular literature tends to focus on the interface between ethnobotany and biomedicine, specifically around bioprospecting or biopiracy: namely, the search for “magic bullet” plants and the well-founded fears that indigenous knowledge will be appropriated and commodified without sufficient forethought or compensation. Some work has focused on the ways plant knowledge is also social knowledge—the sense that herbal remedies are biocultural phenomena whose meanings and value are at once medical and social. Other points of convergence have occurred around issues of environmental health and the bio-psycho-social effects of conservation-induced displacement, natural disasters, or otherwise environmentally prompted migrations on local populations. This chapter links medical anthropology and political ecology by examining connections between the commodification of nature and culture in the context of <i>amchi</i> involvement with conservation-development projects, and how this relates to their role as healthcare providers and transmitters of Tibetan medical knowledge.
Chapter 5 presents ethnography conducted in the Tibet Autonomous Region and Qinghai Province, China. This chapter focuses on the implementation of Good Manufacturing Practices (GMP) and related regulations on the commercial production of Tibetan medicines. GMP are regimes of pharmaceutical governance that define the conditions under which raw materials are evaluated and processed and medicines are produced. When combined with Chinese drug administration regulations, including the practice of applying for registration numbers to produce Tibetan formulas, such regulations bear on how products are marketed and sold, as well as at what price and to whom. Chinese state implementation of GMP for commercial production of Tibetan medicines must be understood within the context of global pharmaceutical governance of traditional medicine, as the WHO defines it, and within expanding international markets for CAM therapies. In addition, Chinese reconfigurations of international biomedically oriented policies have cultural and political effects when connected to a minority nationality such as Tibetans. Not only are the parameters by which the quality, safety, and efficacy of Tibetan medicines are determined at stake; so, too, is the future of Tibetan science, cultural identity, and environmental stewardship, given the expertise and resources upon which Tibetan pharmacology depends. Tibetans involved in the industry are themselves divided about the impacts of such regulations and the process of commoditizing and standardizing Tibetan formulas.
Chapter 4 draws primarily on fieldwork from Kathmandu and Mustang, Nepal, and Qinghai Province, China, focusing on the types of therapeutic encounters that occur in small, private clinics, and how individuals narrate their experiences of illness. Illness narratives introduce readers to an array of concerns regarding access to and affordability of health care in culturally Tibetan areas. One witnesses how and where Tibetan medicine fits into complex patterns of resort, issues of mistrust that surface with respect to biomedicine and state healthcare options, and the association between material and cosmological or spiritual understandings of illness causality. Next, the chapter discusses how social ecologies are at once maintained and transformed through migration and experiences of modernity, including the circulation of medicines between people from Nepal and China now living in the United States and their relatives back home. The final sections of this chapter discuss issues related to illness causality and how specific diseases and patterns of illness experience are linked to material, cosmological, and place-based understandings of the causes and conditions giving rise to health problems. One sees how medicine is a dynamic engagement between the oft-polarized extremes of science and religion.
Chapter 2 presents a very different world of Tibetan medicine, operating in an urban Chinese context, within distinct governance structures and possibilities for efficacious practice. This chapter takes place at the Arura Group, a major Tibetan medical institution in Qinghai Province, China. Located in central Xining, Qinghai’s capital, Arura’s hospital serves a large and diverse patient base. In addition to clinical practice, Arura also runs a research institution, a Tibetan pharmaceutical factory, and a major cultural museum; Arura also supports the Tibetan Medical College within Qinghai’s medical school. In contrast with the single individuals fulfilling multiple social roles described in chapter 1, in chapter 2 one moves between departments within Arura, revealing distinct domains of expertise and professional jurisdiction. One witnesses translations across medical systems—Tibetan medicine, Chinese medicine, biomedicine—as well as a certain level of standardization of practice and greater economic investments in Tibetan medicine here than in a rural community in the Nepal Himalaya. Chapter 2 illustrates multiple levels of engagement between Tibetan medicine, the biomedical sciences, and commercial pharmaceutical production.
The introduction begins with an ethnographic vignette that evokes the central questions of this book: How is efficacy determined? What is at stake in these transactions across science, culture, and meaning? This multi-sited ethnography focuses on the question of what it means to say that a medicine “works.” The author’s research on Tibetan medicine in Nepal and China suggests the issue of efficacy needs to be addressed in far broader terms than solely experiential or clinical perspectives on “what works” allows. Answers to these central questions—<i>What makes a medicine “work”? How are such assertions made, by whom, and to what ends?</i>—hinge on the varied social ecologies in which therapies are made and evaluated, practitioners are trained, and patients are treated. The introduction elaborates on these questions and concepts; provides background information on the field sites in question (Nepal and Tibetan regions in the People’s Republic of China) and the history and status of Tibetan medicine in these contexts; discusses the author’s research methodologies; and provides a chapter-by-chapter précis. The first three chapters focus on practitioners and Tibetan medicine as a <i>process</i>. Chapter 4 links ethnography that highlights Tibetan medicine as <i>process</i> to Tibetan medicines as <i>products.</i> The last three chapters focus on medicines and <i>materia medica—</i>their circulation as objects of sociocultural, medical, and economic value.
Chapters 1 and 2 describe one day in two ethnographic sites. They show the scope of this ethnography and introduce key characters. They exemplify the book’s central arguments: that efficacy is a biophysical, socioeconomic, and political concept, articulated in specific social ecologies, and that modern “traditional medicine” is tied to global regimes of governance (conservation-development agendas, biomedicine, technoscience, and global pharma) and to localized <i>materia medica</i> and forms of practice. These chapters reveal that it is best to speak of Tibetan medicines (plural, not singular); there is too much diversity in the practices and perspectives to do otherwise. The ethnographic realities presented are distinct but also deeply interconnected. Chapter 1 tracks one day of an <i>amchi</i>, a practitioner of Tibetan medicine. Witnessing an <i>amchi</i> at home and at work shows how social ecologies shape experiences of efficacy and the healing life in a rural place. It also shows how simple dichotomies—tradition/modernity, rural/urban, local/global—are inadequate to describe the lifework of <i>amchi</i> and their patients. Although the protagonists travel only several miles, they move through many worlds and occupy many social and medical roles. This chapter analyzes the ways Tibetan medicine is practiced and supported within a national context that has not officially recognized this healing system. Chapter 1 emphasizes themes including identity, knowledge transmission, and interactions with conservation-development agendas.
Chapter 3 uses the concepts of lineage and legitimacy to describe how forms of cultural and economic capital are produced through learning Tibetan medicine and through state support and recognition of this practice. Standardized regulations of all sorts—from moral precepts about the behavior of healer-physicians to state-approved curricula to medical licenses—emerge from particular social ecologies, rooted in particular political histories and environments. This chapter and chapter 5 explore how “Traditional Medicine” (TM) and “Complementary and Alternative Medicine” (CAM), as globalized frames of reference, shape Tibetan medicine in Nepal and China. In this chapter, the relationship between TM/CAM and more localized understandings of legitimacy are highlighted. What makes an <i>amchi</i> legitimate in the context of a village or within a government-supported institution of Tibetan medicine? Are the sources of legitimacy the same? How important is lineage <i>(menpé gyü)</i> to garnering legitimacy? What does it means to seek government recognition in Nepal, where Tibetanness is associated with cultural backwardness and political sensitivity? How does this contrast with Chinese healthcare policies that seek to capitalize on minority nationality medicines, and to subsume all non-biomedical practices under the banner of state-supported Traditional Chinese Medicine (TCM). How do contemporary Tibetan medical practitioners in Nepal and China navigate the personal and professional channels available to them, as means of legitimating and enabling their practice?