Dancing the Canadian Chinese mining two-step

Tibet, Congo or Papua New Guinea

When, in 2012, I wrote a book about mining in Tibet, it seemed China’s appetite for minerals was insatiable, having survived the great global recession of 2009 onwards with hardly a blip in demand. By then the global commodity boom had been rolling on nonstop for a decade and nothing, it seemed, could slow it, not even a global financial crisis. And all the long term predictions, based on assuming China can, must and will achieve the same  consumption levels of the richest countries, cheerfully forecast decades more of rising mineral extraction worldwide to meet China’s needs.

How wrong we all were. The unstoppable Chinese demand, in the aftermath of the global crash, was fuelled by endless stimulus money pumped in by China’s central authorities, ostensibly for infrastructure construction, which uses up lots of metals and other basic commodities. Much of that money was diverted, often by local governments, to much more profitable real estate ventures, constructing all those tower blocks and ghost cities of empty apartment blocks in the desert. They too needed lots of copper, steel and other metals.

Then the music finally stopped, just after the book, Spoiling Tibet: China and Resource Nationalism on the Roof of the World was launched in October 2013. As well as empty apartment towers, all that stimulus had built many more smelters and refineries than China, or the world market, actually needed, and suddenly the big new problem was oversupply.

Now, in mid-2015, that problem is bigger than ever, so big that a major driver of China’s New Silk Road project is to establish export markets in neighbouring Asian countries for all the excess supply. But prices have fallen sharply, and have now remained low for years, and show no sign in the short term of recovering, even if the long term pundits are right that there is still a long way to go before China uses copper and other metals as intensively as the US.

Until the recent over supply crisis, China’s mining companies, nearly all state-owned, pursued an aggressive strategy of mergers and acquisitions worldwide to get hold of more raw materials, as well as expanding rapidly into Tibet, notably the big copper/gold deposits at Shetongmon near Shigatse, at Kham Yulong between Chamdo and Derge, and Gyama upstream from Lhasa.

Two companies stand out in this rush: Jinchuan and Zijin. Jinchuan has long dominated nickel supply in China. Its home base is far inland, in Gansu,  close to the main rail line connecting China and Tibet, placing Jinchuan in the ideal position to be the smelter for the first big copper mine to get under way in Tibet, at Shetongmon. The Canadian company Continental, part of the Hunter Dickinson Group, did much of the work of quantifying the size of the deposit and the most profitable strategy for extracting the copper, gold and silver there. Then Jinchuan bought out not only Continental’s interest in Shetongmon, aided by China’s national rule forbidding foreign investors from actually mining molybdenum (one of Shetongmon’s minerals). Jinchuan went one further and bought Continental, which is now a subsidiary of Jinchuan.

Jinchuan also pressed ahead with constructing a big new copper smelter, just as the prices started tumbling. By April 2014, Jinchuan’s  oversupply problems became so acute, they reneged on contracts with their suppliers in far away Chile, relying on the concept of force majeure, meaning uncontrollable disaster, to cancel contracts for Chilean copper concentrates. Jinchuan announced a problem with oxygen supply to the main Gansu smelter, a problem so severe it would knock out all production for as much as four months, giving Jinchuan a breather.

This occurred just as China, at great expense, completed the rail extension from Lhasa to Shigatse, well to the west, leaving only 80kms to the Shetongmon mine. So Tibetan copper, in big quantities, became available, along with supplies from Chile and elsewhere, at exactly the time demand tanked.

That’s a major reason we don’t hear so much about mining it Tibet these days. From the perspective of China’s major mining companies, access to capital isn’t a problem, especially since the stock markets are again booming, and investors are keen to get a slice of the action, despite the overall economic slowdown. The problem is where to invest, where to get the best bang for the renminbi. Tibet doesn’t cut it, compared to the available alternatives.

This brings us to the other company with a major slice of Shetongmon, Zijin Mining, based in eastern China, its fortune built on gold. In 2011 Jinchuan sold a 45 per cent stake in Shetongmon to Zijin, a big company with a strong history of going global. In May 2015 Zijin acquired half of the troubled Porgera copper/gold mine in Papua New Guinea, from a heavily indebted Canadian miner, Barrick. At the same time, Zijin also announced it had bought almost half the Kamoa copper/gold mine in Democratic Republic of Congo from another Canadian miner, Ivanhoe.

Zijin has also acquired mines in Inner Mongolia, Xinjiang, Tuva (the most Tibetan part of Russia) and Kyrgyzstan, a literal embarrassment of riches.

Why, at a time of over supply, depressed prices and force majeure, would  Chinese miners want to buy mineral deposits in difficult places like PNG and Congo? This tells us much that is relevant to Tibet. Remarkable as it may seem, mining projects ready to roll, in remote Congo and PNG are actually less remote, less difficult than mining in Tibet, building it all from scratch.  Tibet is actually harder.

Much of this is because the Tibetan Plateau is huge, and mineral deposits are often in areas difficult to access. China has spent decades building infrastructure, but there is still so much to be done, especially before the massive copper/gold deposits at Yulong, in precipitous Kham, are ever to be mined, concentrated, smelted and shipped out to lowland Chinese industries.

But there is another reason why Tibet is harder than PNG or Congo: the Tibetans. Although Tibetans feel disempowered by authorities declaring protests to be criminally splittist, they persist in protesting against mining, often taking care to quote Xi Jinping’s environmental pronouncements in the biggest possible banner headings. As the eminent Tibetanist scholar Gray Tuttle pointed out recently in article in Foreign Affairs, it takes a state with 1.3 billion population to hold down the Tibetans. That is how Tibetans see it.

While small scale mining is rampant across Tibet, the much more publicly visible, capital-intensive large scale mines in Tibet are taking a long time to develop, longer than one might expect if all those Five-Year Plan announcements of mining as Tibet’s “pillar industry” were to be believed. It is certainly taking longer than I expected when I wrote that 2013 book on mining.

Longer is not never. Demand may yet rebound, mining is highly cyclical. If China is serious about adopting the American life style and American consumption, the minerals of Tibet will be in demand, especially as China’s biggest manufacturers move far inland, close to Tibet. But not just yet.

When the minerals cycle ticks up again, as it will, Tibetans may need friends worldwide. But because China reserves the mining of Tibet for itself, with very little international investment, what traction do Tibet’s friends worldwide have?

Here again things have moved on since that 2013 book. Not only are Chinese and Canadian miners doing deals to take over each other’s assets, so too the global minerals commodity traders are buying into a slice of the action in China. Specifically, the Swiss commodities trader Trafigura has bought 30 per cent ownership of Jinchuan’s new copper smelter –Jinchuan’s other smelter, the one that didn’t have the oxygen problem and the four months of force majeure repudiation of contracts. Jinchuan would like to believe it has done Trafigura a favour by giving it access to Chinese markets, but, given chronic over supply, it is Trafigura, able to sell the new smelter’s output into other Asian countries, that is helping out Jinchuan. That new smelter, a big one, is also in a minority nationality area, in Guangxi province.

Jinchuan, the owner of the Shetongmon mine near Shigatse, may also hope that its connection with Trafigura gives it (and China) entrée to the world of commodities futures, hedging, arbitraging and financialisation of minerals. China wants to get into the big league worldwide.

Trafigura, however,  probably knows how much reputation affects stock prices, and how much a brand can be damaged by hanging out with the wrong crowd.

Posted in China, Tibet | Leave a comment



The mastiff guard dogs of the Tibetan pastoralists preceded their owners into modernity. Early this century China discovered an utterly modern fashion for Tibetan mastiffs, traditionally used to guard the black yak hair tents, and the few possessions of pastoralists, while the herders were out with their herds.

These fearsome dogs are utterly loyal to their owner, and ferocious towards anyone else, kept from attacking by rope and a stake driven into the ground. This attribute perfectly displayed the worldview of the new class of urban Chinese bosses, the laoban, who dominate modernity with Chinese characteristics. The laoban’s mastiff exemplified the qualities the boss required of his staff: total loyalty to the boss and a predatory attitude to everyone else.

The mastiff craze reached extraordinary heights, and Tibetans who knew their dogs went into business to supply the trade, investing in this new market. In 2006, at the peak, China’s Foreign Language Press published in English a glossy 98 page paean to the mastiff, opening with this poem: “The Tibetan mastiff lives in Tibet,/ the most mysterious snowy plateau in the world./ Boasting ferocity rivalling that of lions and tigers,/ aristocratic aloofness and elegance,/ unquestionable loyalty,/ and an amazingly high degree of intelligence,/ the Tibetan Mastiff deserves/ the honour of being titled ‘the Holy Dog.’”[1]

In Xi Jinping’s China, ostentatious laoban displays of wealth and power are now frowned on, and the bottom has dropped out of the mastiff market. The New York Times reports: “Mary Peng, the founder and chief executive of the International Center for Veterinary Services, said ‘Ten years ago, it was German shepherds, then golden retrievers, then Dalmatians and then huskies. But given the crazy prices we were seeing a few years ago, I never thought I’d see a Tibetan mastiff on the back of a meat truck.

“At the peak of the mastiff mania, some breeders pumped their studs with silicone to make them look more powerful; in early 2013, the owner of one promising moneymaker sued a Beijing animal clinic for $140,000 after his dog died on the operating table during face-lift surgery. ‘If my dog looks better, female dog owners will pay a higher price when they want to mate their dog with mine,’ the owner told the state-run Global Times newspaper, explaining why he had asked surgeons to alter the dog’s saggy mien. Li Qun, a professor at Nanjing Agricultural University and an expert on Tibetan mastiffs, said speculators were partly to blame for sabotaging what had been a healthy market. But also, as prices spiraled upward, unscrupulous breeders began mating pure Tibetan mastiffs with other dogs, diluting the perceived value of the breed and turning off would-be customers.

“These days, those mastiff breeders left in the business are suffering from overcapacity, as it were. Buyers have largely disappeared, and prices have fallen to a small fraction of their peak. The average asking price for desirable dogs — those with lionlike manes and thick limbs — is hovering around $2,000, though many desperate breeders are willing to go far lower. ‘If I had other opportunities, I’d quit this business,’ said Gombo, a veteran breeder in China’s northwestern province of Qinghai. ‘The pressure we’re under is huge,’ he said. Since 2013, about half the 95 breeders in Tibet have gone under, according to the Tibetan Mastiff Association, and the once-flourishing Pure Breed Mastiff Fair in Chengdu, in the southwestern province of Sichuan, has been turned into a pet and aquarium expo.  In some ways, the cooling passion for Tibetan mastiffs reflects the fickleness of a consuming class that adopts and discards new products with abandon.”[2]

Those who live in modernity know well this boom and bust cycle. It is new to Tibetan pastoralists who see at first the promise of a better life, aided by propaganda posters on the grasslands depicting the promised new resettlement housing looking like apartments on a village green. But the peri-urban cinderblock is not the destination. From there, China expects the exnomads to reinvent themselves as factory workers or as feedlot ranch hands forking barley and soybean meal into troughs for cattle fattening prior to industrialised slaughter. This is the plan.

Mastiff Rock Dog book cover

Can you believe, in today’s China, the biggest hit movie is based on the writings of a Tiananmen dissident gaoled for years for his views; the movie version directed by the Frenchman who directed Seven Years in Tibet?

On the face of it, Wolf Totem, 狼图腾,first the book and now the hit movie, would seem to contradict everything we know about Xi Jinping’s China, especially the insistence on rigid ideological conformity and the strict, swift machinery of censorship.

This movie will no doubt be championed in the west as an environmental pic showing how the Chinese can learn to love nature, notably the wolves of Inner Mongolia, and maybe the Mongols too. Given western yearnings, we’d like to believe China can embrace wild nature and ethnic minorities, so that approach will be good marketing.

But in China, both the book and the movie have quite different meanings. The book, by “Jian Rong”, pseudonym for political scientist and former Tiananmen protester Lu Jiamin, was an enormous hit when it first came out, selling in China an amazing 25 million copies. Only Mao’s Little Red Book beats that.

Lu Jiamin has reinvented himself more than once, as one must in today’s China. A profile of him in The Guardian in 2007, when the English translation of the 2004 Chinese original won the Man Asian Literary Prize, starts with Lu as a fervent revolutionary Red Guard: “ In the fervid early months of the Cultural Revolution, in 1966-67, Jiang Rong was in a Red Guard gang that ransacked homes in Beijing, confiscating and burning any books deemed counter-revolutionary. Western novels and Chinese classics were condemned as equally evil. These works were seen as promoting bourgeois decadence, imperialism and old thinking. Like all good Maoists, Jiang knew his duty: he should turn the words into ashes.”

Lu Jiamin/Jiang Rong embraced Mao’s slogan that “It is Right to  Rebel,” have been born to a family of rebels who took power. The Guardian says: “He was born in 1946 in Jiangsu province to a politically red-blooded family. His parents were former Red Army soldiers, heroes of the war against Japan. The author’s biggest influence was his mother. In the 1920s and 30s, she had been an underground member of the communist party in Shanghai. After Mao took power in 1949, she moved into education, working for the women’s federation and running the Jiangsu provincial nursery school. Jiang’s father – a bureau chief in the ministry of health – was denounced [in the Cultural Revolution] as a ‘black gang capitalist-roader’. Even though he was a disabled veteran who had fought the Japanese, his persecutors beat him so badly that he nearly died.” The former rebels had become the new class, the power elite, and were in turn rebelled against by the Red Guard. Lu’s response was to join the Red Guards himself: “He rounded on his accusers, joined the student Red Guard and rose to become deputy head of the revolutionary core group in his college. Didn’t he feel torn, after what happened to his father? ‘Yes, there was a confusion in my mind. But I thought things would improve,’ he says. ‘There was a conflict within me between Mao’s theories and western liberal theories. There were plenty of bad things. I was against the beatings, the arson and seizures of possessions,’ Jiang recalls. ‘I took part in some of them. But in the depths of my heart I was against violence and mob activity. It was against my character.’”

He obeyed Mao’s call for educated youth to go live in the countryside with the masses. Rather than waiting to be sent down, he went voluntarily, to Inner Mongolia and it was in his years there that he met the Mongols, who were fast being outnumbered by waves of poor Han Chinese peasants ploughing the grasslands –the direct cause of today’s dust storms that envelop Beijing. In Inner Mongolia he also learned about wolves, and they became his central metaphor, for what is wrong with China, and how China can save itself, by becoming more wolfish.

Twenty years later, in neoliberal capitalist China he joined the Tiananmen protesters voicing their patriotic dismay at the corruption that came with China’s opening and reform. He was gaoled for at least a year –some reports say two years- for again being seen as a rebel.

Then Lu Jiamin turned to writing, in the vein of so many Chinese intellectuals, fixated on the endless mission of saving China, not only from outside threats, but from itself. Wolf Totem was written as a polemic, an exhortation to the Han nation of sheep, as he calls them, to learn to become wolves.

What Lu means by this is made plain in a 64-page afterlude to the Chinese original, omitted in the translations into 30 other languages.  Just in case Han Chinese readers didn’t get this autobiographical novel’s message, Lu’s “Rational Exploration: A Lecture and Dialogue on the Wolf Totem” unrolls a fullscale ideological program for saving China in a hostile world. William A. Callahan, professor of international relations at London School of Economics explains:

“While Chinese people generally fear wolves as forces of savage violence, Wolf Totem praises their ferocity, strength, and violence. Rather than seeing wolves as a problem that needs to be exterminated from the Mongolian grasslands, Jiang examines –in detail- how cultivating ‘wolf nature’ can aid China’s future development. Jiang tells us that the Chinese people have been weakened over the centuries by a Confucian culture that only teaches them to be followers. He argues that the nomads’ wolf-nature is the best model for China’s national character. China risks being a ‘plump lamb’ that militant countries might gobble up. Because Han are soft and weak, Jiang explains, outsiders prey on them –just as wolves prey on sheep.”

This is the rant of a man of almost 70, still a rebel. Far from being an environmentalist, or liberal rebellion, Chinese writers have accused him of being a fascist. He is certainly a racist, not only about the wolfish nature of the Mongols, but the Europeans too are descended from wolves, which is how they were able to humiliate China. Prof Callahan again: “What Jiang calls the ‘Western race’ was able to dominate China and become the most advanced civilisation in the world. Europeans are ferocious, he explains, because they have wolves’ blood from the same Inner Asian sources: Huns, Turks and Mongols also attacked Europe. The Europeans wolf-nature was then used to conquer Asia. He argues that mixing wolf’s and sheep’s blood will produce the ‘modern Chinese civilised wolf’. In this racial struggle for the survival of the fittest, wolf-nature is worshipped for its strength, ferocity and violence. The story’s popularity in China comes from more than its nostalgic description of an exotic past; businesses and the military use Wolf Totem to train managers and officers in strategies for success in today’s world of life-or-death struggles, and the Politburo has studied the book as a ‘significant work.’”

So making it into a movie seemed a good move, bringing the super-patriotic rebel Lu Jiamin’s racist imaginary to an even wider audience. But who could make such a movie? That turned out to be difficult, not least because the plot requires the young hero, Lu Jiamin’s alter ego central character to befriend a young wolf, with lots of intimate close-ups.

If the movie was ever to be made, it needed a director who knows how to work with animals, and how to film them lyrically. Peter Jackson was meant to do a Lord of the Rings meets wolfman version, but nothing happened. The Chinese state-owned China Film Group finally settled on Jean-Jacques Annaud, maker of The Bear, but also maker of the 1997 hit Seven Years in Tibet, in which the saintly, other-worldly Tibetans seem to spend more time saving worms from the spade than anything else. With Brad Pitt in the lead it did much to make 1997 the peak year of the Tibet movement. Yet 10 years later, according to The Economist, “representatives of the Beijing Forbidden City Film Corporation visited him in Paris to ask him to make the film. Chinese producers wanted a foreign director for the project. Mr Annaud was an Academy Award winner with successful experience of working with animals (in his film “The Bear”). What about his Tibet film, he asked? They said the past was the past, he says. No apology would be necessary. In late December 2009, however, months after his hiring had been announced, Mr Annaud did apologise.”

Even a renowned bear-wrangler such as Annaud had much difficulty making the movie, not least because many in China were unimpressed by Lu Jiamin, and by the hiring of a Frenchman to make a movie meant to be quintessentially Chinese. Then there was the problem of actually training a young wolf to be camera-ready.

And there was the problem of trying to find a romantically unspoiled corner of Inner Mongolia where there is still grassland, since almost anywhere in this heavily industrialised province there are coal mines, petrochemical plants, power pylons, big cities, and tens of millions of Han Chinese settlers. They did finally find a filmshoot location in a remote corner of Xilingol.

So is Wolf Totem, the book and/or the movie, a lyrical pastorale, a paean to nature and an elegy for the Mongol nomads who have lost their pastures and livelihoods? Certainly the Man Prize committee thought so. You be the judge: thanks to Alibaba, it will soon be on a screen near you.

Lu himself, when talking to the wolfish westerners, including the Financial Times, seems to know what we want to hear: “’I never thought this movie could be made,’ said Jiang Rong, the author, who spent 11 years in the open grasslands of Xilin Gol during the Cultural Revolution as a ‘sent down youth’ and fell in love with the romance of nomadic Mongols and the wolves they worshipped and fought. Like the main character, he tried to raise a captive wolf cub that becomes a metaphor for a free spirit unwilling to submit to captivity. ‘I cried and cried writing about him. I soaked two towels,’ he said. Wolf Totem documents the end of both nomads and wolves due to China’s policies of converting open pastureland into farms for settlers — policies that have proven disastrous in Inner Mongolia as the region’s thin soil gives way to desert.”

Han man bonds with nature and the oppressed ethnic minorities?  Or a fascist vision for a wolfish China in the making? Go see for yourself, it should be on soon, and of course the trailer is up now.


[1] China’s Tibetan Mastiff, Foreign Languages Press, 2006

[2] Andrew Jacobs, As China’s mastiff mania dims, dogs are discarded, International New York Times Asia Edition, April 20, 2015

Posted in China, Tibet | Leave a comment




It is 18 months since my book on mining in Tibet came out, over two years since I finished writing. What a lot has changed, in directions I did not foresee. Those changes mean a lot for the future of Tibet.

While writing Spoiling Tibet: China and Resource Nationalism on the Roof of the World, China’s insatiable demand for raw materials seemed inexorable, and forever escalating into a worldwide search to source just about any commodity you could think of. Not even the sharp global recession of 2008 dented China’s global demand for raw feedstocks of minerals, oil, gas, and many food crops. Just about the only commodity that couldn’t be shipped to China was water, but it too was (and is) in short supply in the industrial provinces and the major manufacturing cities.

Not surprisingly, Tibet loomed large in China’s plans for access to raw materials, especially minerals, electricity and water. That all of these would be exploited for lowland China’s industrial hubs seemed obvious. If anything, what needed explanation was why it was taking China so long to fully exploit the  massive Tibetan deposits of copper, gold, silver, molybdenum, lead, zinc, salt and other minerals; and dam all the rivers, both to export electricity to the coast, and divert the rivers to dry northern China.

Only two years ago China’s demand for every natural resource had run nonstop for a decade, a decade that had come to be known as the supercycle of high prices that just kept going up and up, seemingly immune from the usual boom and crash cycles that have always afflicted mining. Several analysts, confident that China still has far to go before it is as rich as those it aims to emulate, confidently predicted a new law of economics, in which demand and prices ever rise, and not fall back.

How things have changed. The supercycle was unusually long, but it did end. As we all know, just about any commodity, from oil and gas and coal to copper and almost any metal, is now at far lower prices, and look to stay that way for the foreseeable future. In part, this is because the wheels on China’s developmentalist state model are wobbling, and there is no longer any way this can be fixed, as in 2009, by pouring massive stimulus funding into the economy to build yet more railways, tollways, cities and megaprojects.

The collapse of prices for the raw inputs of manufacturing –economists call them producer goods- at first seemed just a blip. Sure, it was obvious China was producing much more steel than Chinese buyers wanted to buy; and provincial governments, protective of their local champion corporations, resisted Beijing’s demand that the bloated state-owned steel furnaces merge, which also meant closing the more polluting and least efficient ones. But few foresaw that the weakening of demand would ripple right through the economy, at a time when global demand for China’s manufactured stuff remains weak.

Many causes and conditions have ripened at once. Europe’s austerity-driven weakness has affected China’s export industries; likewise America’s gradual recovery. The willingness of the Saudis to keep pumping oil to the max, despite low prices, was a surprise, a long term gamble to drive out of business the newer players, such as American shale oil producers and the Russians, whose energy industries remain profitable only if prices stay high.

But what the Saudis did, other big players have now done, in other key raw resource industries. Iron ore, the primary ingredient of steel making, is dominated by a few giant global corporations who made a similar calculation to the Saudis, that they could remain profitable even on low iron ore prices, while newer entrants to the global iron ore traffic, with loan finance to service, had higher costs, and would be driven out. We are in a different world, where the powerful are willing to endure a period of pain to maintain their oligopolies.

Is China an onlooker in all this? Not so. China has been playing the same game, in which there are only two options: get big or get out. China took full advantage of its near-monopoly in production of rare earths, a range of elemental metals that have innumerable high-tech uses. China worked especially hard to dominate the global market in manufacturing aluminium, building huge smelters dependant on massive amounts of electricity, usually provided by coal-fired power stations. In recent years, as coastal city citizens get fed up with smelter pollution, the new smelters are being built far inland, in Xinjiang, which also makes a troubled frontier region more Chinese, with more employment for standard Chinese speaking industrial workers.

China has taken advantage of low prices to increase its stockpiles of strategic metals, enabling smart warehouse managers to use the assets under their management as leverage to finance access to capital, sometimes using the same piled ingots over and over as collateral on multiple loans. Many have benefited from the collapse of the supercycle, and the end of the mining boom.

But in the longer term, the Chinese model is in trouble. There is too much hot money, concentrated in real estate, often money creamed off from urgent stimulus spending that was meant to build productive infrastructure. There is too much bad debt, to be rolled over and over in the hope that eventually, as the next up cycle ramps up, it will pay itself off out of new profits. Maybe.

China is no longer the lowest cost factory, with the cheapest labour. China is now a middle income country. Manufacturers are shifting to Vietnam, Cambodia, Bangladesh and of course, far inland to Xinjiang and the foot of the Tibetan Plateau, in Sichuan and Chongqing. That move was gathering momentum as I wrote the mining book, and has gathered pace. I predicted that this would increase demand for the minerals, water and hydroelectricity of Tibet, because it makes little sense to buy minerals from overseas and then get them far inland, largely because the grand vision of the Three Gorges Dam as a new inland waterway for big ships, as far in as Chongqing, never worked and probably never will. So the global brands that now manufacture their high tech in Chengdu and Chongqing will increasingly need Tibet as a source of raw materials. That part of my argument may yet turn out to be true, but it is taking time.

A major reason for my counter-intuitive argument, in the 2013 book, that Tibet is not yet spoiled, was that the mining and damming are exclusively done by state-owned corporations that are restricted in how much profit they can make, by their party-state owner, which deliberately discriminates in favour of manufacturers, and uses its political power to hold down the prices of raw materials, water and electricity. That is still so today. Large scale exploitation of Tibet seems imminent, but it has seemed imminent for as long as China’s central planners have announced mining Tibet as a “pillar industry”, which is decades.


That’s the backstory. Then along came Xi Jinping.

Xi’s extraordinary centralisation of power came with announcements that private enterprise would be allowed to play the “decisive” role in the economy, and that rigid price controls on water, electricity and minerals would be relaxed. There would be reforms of the state-owned enterprises, a crackdown on corruption and the “China Dream” would materialise.

Much of this came to pass, and much is turning out to be not at all what was expected. The corruption crackdown has exposed the oil, gas and minerals industries as major corruption opportunities, including in Qinghai (Amdo in Tibetan) where the Western Mining Corporation, which was involved in almost every major mine in Tibet, became a special focus of the party’s corruption inspections.

But the relaxation of commodity price controls is moving slowly, and there is less sign than ever of private corporations playing a decisive role. In March 2015 came an announcement that took everyone by surprise: far from downsizing the state-owned corporations (SOEs), they are to be upsized, by a state-driven policy of mergers and acquisitions, to become even bigger. This is what economists call agglomeration, an unlovely word that means what it says.

Not so long ago, when reformist premier Zhu Rongji was inclined to listen to the World Bank and neoliberal orthodoxy, the SOEs were trimmed, downsized, demerged, forced to compete with each other. It began to look like China might follow the prescribed path of market economics.

That is now decisively over.  Once again, in today’s world, big is better, biggest is best. China is determined to be globally competitive, notably in what it sells to the world, but also in what it buys. The agglomerations are initially concentrated in industries where China can sell its heavy manufactures, such as railway construction and nuclear power stations. Shipbuilding is another industry due for a shotgun wedding, and maybe even the oil industry, which has for decades extracted two million tons a year of Tibetan oil from Amdo Tsaidam.

For Tibet, it’s a mixed picture, at least in the short term. So far, there has been no announcement of compulsory state-driven mergers in the mineral extraction industry, or in the hydroelectric dam builders who jointly dominate the new economy of the Tibetan Plateau. Competition may be narrowing, behemoths building.  Will the dam builders, all state-owned, also be agglomerated? If export competitiveness is to be the trigger for industry consolidation, they do qualify, as dam building expertise, hard won in the steep valleys of Tibet, is a highly exportable capability.

The logic of this new policy of agglomeration is to make China more competitive in foreign markets. For China, operating in Tibet is very much like operating in a foreign market: the distances are great, infrastructure is not there, supply lines are long, markets are far away, everything is different. The SOE mineral extraction corporations, and hydropower SOEs are already used to operating worldwide, and, in the boardroom, the real world decision is whether the next copper mine will be in Peru or Congo or Tibet.

Xi Jinping’s centralisation of power, agglomeration of SOEs and (so far) reluctance to allow the metals and water extractors the freedom to set prices, add up to a centralisation of exploitation of Tibet. Xi’s regime is clearly out to do what it takes to revitalise the profitability and export success of China’s manufacturers. If that means bigger and more powerful SOEs, that is a familiar formula, that takes us back to the 1970s and 1980s. If bigger profits for the world’s factory, now relocating to Chongqing and Chengdu, also mean suppressing prices of the raw materials Tibet provides, so be it.

Official control over the price miners and  electricity generators can charge for what they produce may lead the big SOEs in these sectors to look for better places than Tibet for their capital. Yet it is part of the new official policy that newly agglomerated SOEs must become more profitable, and hand over a bigger proportion of those profits to the central government, which, in turn, keeps the centre supplied with the fiscal means to invest in more infrastructure in Tibet.

So in the immediate future, the SOE mining companies have few prospects for making much money from exploiting Tibet, but as demand picks up, and agglomeration grows, they will be in a stronger position, especially if, as is the case at the Shetongmon copper  and gold mine near Shigatse, the SOE mine owner is itself a major smelter company, eligible for much official favouritism.

This may mean the exploitation of Tibet will continue to intensify, as predicted in Spoiling Tibet in 2013. It also means the electricity producers, miners and dam builders will have to put up with slender margins, an incentive for them to ignore frivolous expenses such as compliance with environmental laws, or worker health and safety.

The Saudi oil producers, the Brazilian and Australian iron ore miners, the coal diggers all remain confident that China, even if it slows, will still need their raw materials, in huge quantities, for a long time to come, to make manifest the China Dream of a city apartment for all.

This period of low prices, low profits and suppressed environmental compliance will end, and we will be back to the world of Spoiling Tibet, a world where demand once more exceeds supply. By the time the next cycle kicks in, incentivising the SOEs to accelerate extraction from Tibet, China and the world will be dominated even more than now by the biggest of multinational corporations, and China will have its national champion SOEs in the big league.

All of the above affects the big state owned corporations that, with high visibility, and maximum propaganda coverage, build and extract on a big scale. Almost none of the above affects the smaller mining companies proliferating all over Tibet, who have a single, simple agenda: to make as much money, as fast as possible, ripping out of the ground as much stuff as they can, with no heed for environmental consequences or impact on nearby Tibetan communities. Because they operate outside the gaze of the state –usually because local governments are paid to look the other way- none of the above complex and contradictory agenda applies to them.  They  do not have to invest but keep profits low. They do not have to be concerned about occupational health and safety, or environmental impacts.

But if they are too successful in their singular pursuit of profit, they may become big enough to get caught up in the coming compulsory round of mergers. And they do, for the time being, have to accept prices that are lower than a few years ago. However, the primary attraction of resource exploitation, all over Tibet, remains gold. The price of gold does fluctuate, but not as sharply as other minerals.

The reason is simple. Eminent China-watcher David Shambaugh recently predicted: “The endgame of Chinese communist rule has now begun, I believe, and it has progressed further than many think.” How did he reach this  conclusion?  “Consider five telling indications of the regime’s vulnerability and the party’s systemic weaknesses. First, China’s economic elites have one foot out the door, and they are ready to flee en masse if the system really begins to crumble. In 2014, Shanghai’s Hurun Research Institute, which studies China’s wealthy, found that 64% of the “high net worth individuals” whom it polled—393 millionaires and billionaires—were either emigrating or planning to do so.  Meanwhile, Beijing is trying to extradite back to China a large number of alleged financial fugitives living abroad. When a country’s elites—many of them party members—flee in such large numbers, it is a telling sign of lack of confidence in the regime and the country’s future.”

The discreet fungibility and portability of gold is at the heart of this flight of capital. This is what drives mining in Tibet, much more than high level pronouncements of agglomerations.





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Butter Lamp


Tibetans in exile, and their supporters, chronically politicise everything they learn about what is happening inside Tibet; maybe they forget there are other lenses.

However, there are other ways of approaching reality, and in today’s China those approaches can occasionally come from Chinese film-makers taking a fresh look at situations that usually seem mired in right vs wrong, good vs bad.

That’s the case with the wry, surprising, confronting, gentle and humorous mocko-doco Butter Lamp, that got as far as an Oscar nomination.

When National Public Radio in the US discovered this whimsical play on China’s visual clichés of Tibet, and of China’s modernity, it could only see politics, leaving until the very last line a gentle warning from its French producer Jean Feret: “’It’s a tricky subject,’ Feret admits. ‘And we always have to fight for the idea that this is a non-political film and that it’s artistic.’”

This isn’t just a producer playing dumb, denying the political message so as to avoid censorship in China, where it was shot by a Beijing-based director Hu Wei, and has already collected 70 awards around the world for its playful sensibility.

All we see initially is groups of ordinary Tibetans, against various iconic backdrops, being bundled into frame by an unseen photographer, just as in today’s world of mass tourism Tibet, with its Chinese characteristics, folks get their pictures done with Tiananmen, or a busy Hong Kong shopping street, or the Potala as backdrop. Or the sort of European mansion China’s new rich love to build; or the Great Wall. Clearly these are regular Tibetan villagers, unused to composing themselves for the camera. Only at the end do we see what is beyond the backcloth, what Tibetans see every day. To say more would be a spoiler. See the trailer for yourself.

When Feret insists this is art, he is right. It is our categories, in the minds of the audience, that are being played with, our buttons that are being pressed. That’s more than just politics.

This short film has won awards in China, and that tells us that China is no longer such a cut-and-dried, right-and-wrong place, that new perceptions of Tibet and the Tibetans are emerging; as the Dalai Lama has long said would happen.

Director Hu Wei is a face of the new China. He told South China Morning Post:  I majored in film at Beijing Normal University. While I was a student, I travelled to Tibet. When I got to Litang (in western Sichuan province), I stayed with a nomad family on the grasslands. There were about 20 families living there. That was 2004. I had a camera with me so I took lots of photos of them and promised the families I would send them the pictures. The following year I went back to those grasslands, but only 10 of the families were still there. The others had been relocated by a government programme.

“Changes are very stark in Tibet. That’s why I made Butter Lamp in Tibet, and not in Peru, for example. I don’t know if these changes are good or bad, but I wanted to use this film to get people thinking about these changes, and how they are changing us. Where are we headed? I chose to feature a picture of the controversial Panchen Lama in Butter Lamp because I don’t want us to forget him as our world changes. I’m trying to record facts, objective truths, that may one day be forgotten in the stream of history. I won an award (for Butter Lamp) last year in Shenzhen at the China International New Media Short Film Festival, which is run by the State Administration of Press, Publication, Radio, Film and Television.”

Yes, it is indeed remarkable that the only photo of the disappeared child Panchen Lama appears, in the hands of an elderly Tibetan, in this Butter Lamp film. Yes, that does make it political.

But that’s one moment in a film that, by its structure, confronts us, the viewers worldwide, with our preconceptions about what Tibet is, and can be. And the prize it won in China tells us much we need to know about how China is changing. To see this charmer as only political reduces it to either/or: the disappeared Panchen appears, so that’s a slap in the face for China, a win for the Tibetan cause. To reduce everything to simplistic dualisms is puerile, as the Buddhists have always said.

And if you think this is just a random accident, see if your nearest Chinatown bookshop still stocks a copy of the October 2014 issue of Chinese National Geography magazine.

For less than $4, you get 400 pages of the glossiest supersaturated colour pix of central Tibet, not only the marvellous landscapes, but also the same ordinary Tibetans who file into shot in Butter Lamp, in everyday dress, not just decked in traditional costume like ethnic dolls. Every romantic trope of Tibet as a magical Shangri-la, originating in the projections of the European gaze, is lavishly reproduced in this Chinese language publication for Chinese consumers. This is a glossy devoted entirely to the sumptuously colourful landscapes, architecture, ordinary people and charismatic lamas of Tibet. There are respectful photo-essays on seven “living Buddhas” scattered through the  volume.  In the entire magazine, the only other content is the ads, full-colour double page spreads for the latest models of Mercedes,  BMW, Jeep, Cadillac etc.  Audi and Landrover each has an eight-page spread. Yaks drinking at a lake shore adorn the cover.[1]

China, especially the urban new rich, is starting to recognise Tibet in new ways. That’s what Chinese readers now want: high-end consumption and the fantasy of a pure land where you can get away from the ratrace. They want pure air and a quiet mind, a reminder of what life is for, just like we do.


[1] Chinese National Geography #10, 2014 ISSN 1009-6377  http://hk.dili360.com/

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from a small book of essays, poetry and art on the Soil and the Earth, edited by  Vandana Shiva, celebrating the International Year of Soils, 2015


That the soils of the Tibetan Plateau exist at all is remarkable. This vast island in the sky is, in planetary history, so new, so high and still rising skyward, so unconsolidated and prone to quake, so raked by gales and blizzards, it is a miracle that soil exists.

Yet the soils of the Tibetan Plateau sustain huge herds of migrating gazelles and antelopes, millions of yaks, sheep and goats cared for by nomadic pastoralists, and an entire Tibetan civilisation. Not only does a rich soil sustain life, the hardy grasses and sedges of the vast plateau pasture lands in turn protect the soils from the powerfully erosive forces of wind, snowstorms and intense cold. Neither permafrost below nor the sudden hailstorms from above disturb those soils, aerated by burrowing mammals, held together by the biomass of living plants, most of which is underground.

Tibetans have long known and respected the earth, and its innumerable local gods and spirits, which can cause earthquakes, landslides and floods if not treated with respect. Offerings are made daily to these local protectors, starting with a sprig of juniper put onto the morning fire to produce fragrant smoke.

The entire plateau is at an average altitude of 5000 metres in upper Tibet, in the arid west, and 4000 metres in the forested and wetter east; with the mountain ranges that enclose the plateau soaring far above. It is only on the mountain slopes that there is little or no soil, above the snowline. In Tibet the snowline is at 5000 metres, sometimes as much as 6000 metres, much higher than elsewhere, because Lhasa is no further from the equator than Shanghai, Mecca, Johannesburg, Tehran or Houston. Intense sun, intense inner continental winds, intense summer heating and winter cooling make for intensive erosion, so great that the entire yellow earths and Yellow River of northern China are the result of a Tibetan Plateau that erodes as fast as it uplifts. Yet despite these elemental forces, the soils sustain verdant alpine meadows for wild and domestic herds alike, and the millions of nomadic pastoralists who annually gather what nature provides.

Those soils regulate the flow of the great rivers of Asia, from Pakistan’s Indus, through Southeast Asia’s Mekong, to the Yangtze and Yellow of China. They absorb the summer monsoons and the icemelt from the glaciers in the snowmountain  peaks, acting as a sponge that both soaks up and releases water through the year.

Across northernTibet there are no big rivers. This is a land of lakes, abodes of goddesses, slowly shrinking over recent millennia as the entire plateau becomes drier, only to start rising again very recently, due to climate change accelerating the melting of the glaciers.

Wetland soils are common, great peaty marshlands where migratory birds nest and feed, reeds grow thickly and yaks tread delicately tussock to tussock, fattening on the rich herbage. Hard ungulate hoofs seldom compact these springy soils, because the nomadic pastoralists know well that grazing must be done with a light touch, always moving the herd on well before the grass is exhausted. A mobile civilisation was guarantor of healthy soil and the protective plant cover.

Why the switch to past tense? The encroachment of modernity onto the Tibetan Plateau, over the past 65 years, has failed to understand any of the above. The modernisers, from intensively-cultivated lowland China, insisted the Tibetan Plateau could be made more productive, and that started with making the nomads build walls, of soil, of upturned sod, cutting the living turf to make fences running up and down hillsides, for “scientific management” of livestock. Further cutting into the soil was required to build highways, cities, hydro dams, power pylons, pipelines, railways, and to experiment with ploughing the grassland for crops. Herd sizes grew greatly, beyond the capacity of the soil to sustain them, while the pastoralists were allocated fixed lands, restricting their mobility, intensifying the impact of hooves and teeth on tightly fenced plots.

The result is widespread land degradation and even desertification. When the soil is stripped bare, Chinese scientists call it “black beach”, for which there is no cure, short of waiting thousands of years for soil to form naturally all over again. Bare rock is the final stage of a tragedy that need not have happened, a tragedy intensified by blaming the pastoralists themselves for recklessly overstocking and overgrazing, as if they are ignorant, unskilled herdsmen with no knowledge and no concern for the consequences of their actions. The victims of foolish policies designed in distant cities take the blame, and now must leave their ancestral lands and soils, to live in concrete peri-urban dependence on official handouts.

Scientists also declared war on the burrowing rodents of the grasslands, the pika and marmots which aerate the soil, keystone species which in turn feed many predators of the air and land. They have been poisoned en masse, blamed for soil degradation, although their population explosions are more the result than the cause of degradation.

Now China faces a major decision, whether to drown the water meadows of Dzoge, where the Chinese provinces of Qinghai, Sichuan and Gansu meet, under a torrent of water diverted from the upper Yangtze River, in a grand canal scheme intended to deliver water to northern China. The Dzoge wetland is on the great bend of the Yellow River as it rounds the sacred Amnye Machen mountain range. It is at last recovering from  misguided attempts to modernise it by digging drainage ditches everywhere, drying wetland into fire-prone peatland that starves the grasses of the water they need. It was these water meadows that gave the People’s Liberation Army its worst moments, in the Long March of 1935, as soldiers, unfamiliar with the marshy soils, failed to step only on tussocks, got mired and died. Ever since, Dzoge (Ru’ergai in Chinese) has been seen as treacherous, to be tamed, initially by drying it out. Now the plan is to blast tunnels and canals across eastern Tibet, capturing several major tributaries of the Yangtze River (Dri Chu in Tibetan) to be poured into the Yellow River at Dzoge, inundating the water meadows. As the International Year of Soils ends, China’s 13th Five-Year Plan is due to begin, in 2016. It is during the Year of Soils that the decision on this megaproject will be finalised.

Tibet’s soils have sustained the barley farmers of the valleys and the pastoralists of the open grasslands for thousands of years, because the Tibetans practiced eco-agriculture, with a light touch. They understood that highland soils are readily disturbed, and once the steppe is broken, the soils quickly erode. They always moved on, not lingering. That customary wisdom has been supplanted by a modern insistence on extremes: firstly on intensive meat production that overused the land and soil; now on grazing bans to somehow conserve watersheds.

Modernist intensive land use is unsuitable for the soils and the livelihoods of Tibet; while the traditional extensive land use, spread out across the landscape, respected the upland soils and the local gods.


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China’s completion of the two routes channelling water from the Yangtze far to the north, to water deficit northern China, sets the scene for one of the biggest decisions China will make in the coming year.

The decision facing China’s leaders in 2015 is whether to now go ahead with the planned third canal –through Tibet- from the Yangtze in the south to the Yellow River in the north.

From the outset, the plan was for three canals, one far downriver and now in operation, the second in midriver, now in operation; and the third up in the Tibetan mountains, traversing troubled Ngawa and Kandze prefectures. All along, the plan was that first the two lowland canals would be dug and blasted, then the entire engineering team would be switched to Tibet, starting in the 13th Five-Year Plan period that starts in 2016. That’s the decision that must be made this year, as the next Five-Year Plan is finalised.

If the Ngawa Kandze route goes ahead, it will mean a massive influx of engineers, heavy equipment and a huge workforce, perhaps taking over a decade, certainly more than one Five-Year Plan to complete, as there is a lot of tunnelling through mountains and probably massive pumping stations, as well as the canal itself winding round mountain sides.

Since it has long been exactly those two Tibetan prefectures that have been most troubled, where most of the public suicide protests have occurred, such a massive encroachment will have major impacts.

However, much has happened in China’s domestic politics since this grandiose  Three Canal South-to-North Water Transfer project was first announced.

For starters, users of the Yangtze River, all the way down to Shanghai and the sea, are increasingly protective of their river, and don’t want any more of it diverted, and the downstream provinces carry enormous clout.

Critics in China rightly point to China’s insistent focus on increasing supply, rather than on moderating demand. As northern China is undoubtedly short of water, it remains amazing that rural users pay so little, and squander so much water. Inner Mongolia, largely dryland but with massive coal mines and electricity power stations, is especially hungry for water.[1] The huge coal mines of Inner Mongolia use vast quantities of precious Yellow River water to wash coal and suppress dust. Heavy industry still treats the Yellow River as a sewer for dumping toxics, even though the Environment Protection Ministry is at last getting some teeth. There are many reports showing in detail how demand management instead of increased supply could be a far cheaper way of dealing with the problem.

Another reason against this third canal ever being built is that the water, after flooding the richest wetland meadow pasture in Tibet, at Dzoge, will flow through the upper Yellow River, with water available to upper river provinces such as Gansu and Ningxia, maybe as far downstream as Inner Mongolia. But they will grab all the benefits, there won’t be enough flow for  the more politically powerful provinces further downriver, including the heartland of China’s coal and coal-fired electricity industry, plus Beijing itself.

Until very recently, this seemed to add up to a compelling argument that, for purely domestic reasons, the third canal might quietly fade away.

Now there is a new factor, which is the fast pace of heavy industrialisation of Xinjiang, directly to the north of the Tibetan Plateau, and equally unhappy at Han domination. China’s policy for long-term solving all ethnic unrest is development. That strategy works patchily in Tibet, but in Xinjiang a new wave of industrialisation is gathering pace. Many aluminium smelters are being built, reliant on electricity generated by new coal and gas burning power stations using the abundant fuel supplies of Xinjiang and which China imports, via Xinjiang, from Kazakhstan to the west.

There is only one thing missing in Xinjiang, and that is water. Much of Xinjiang is desert, its towns traditionally clustered around oases. Coal fired power stations need cooling towers that use a lot of water, likewise aluminium smelting and other major heavy industries under construction in Xinjiang will all need lots of water.

This could tip the balance towards the third canal which, if big enough, could divert water not only eastwards to Gansu and further down the Yellow River, but also north and west in Xinjiang.

Another change that has happened since the 3-canal scheme was first announced, is that in today’s China there is and will be a semi-public debate about the various options.[2] We will be able to track it, and if we are skilful, contribute to it. So throughout 2015 we should be alert to this ongoing debate, which is likely to intensify.

China’s hydrologists and engineers have revealed not only the route of the Ngawa/Kandze route but also some alarming basic statistics on the design, most of which suggest it may never be built, despite having been announced over a decade ago as part of a grand package of three south-to-north canals.

In eastern Tibet, the upper reaches of the Yangtze and Yellow Rivers look tantalisingly close, much closer than the downstream locations of the two great canals just constructed. But that’s where it stops looking easy. There are few locations where the two rives are reasonably close, and also at roughly the same altitude. Even the chosen location, driven by the lie of the land, actually requires that water be pumped uphill, in fact almost up by half a kilometre, 458 meters up to be precise. Even if the rivers to be dammed have extremely high dam walls (as planned), that is still a lot of pumping, in fact the engineers estimate is 7.1 billion kilowatt hours (KwH) of electricity will be consumed pumping water uphill. That’s approximately the same amount of hydroelectricity generated by the entire province of Henan, or Shaanxi, or Xinjiang, all of them middling provinces on China’s hydro league table.[3] That means a lot of hydro dams to be built as well, in eastern Tibet just to push against gravity. You can seldom use the same dam to divert water away from where it wants to go, and use that water to generate electricity by letting it drop, so that’s many more dams.

Then there is the minor inconvenience of the Bayan Har mountain range that intervenes between the valleys of the Yangtze tributaries to be dammed. That will have to be tunnelled; a long tunnel in a seismically active area where some of the very strongest earthquakes, of magnitude 8 and even 9, are known to occur.

But, for China, the clincher is that, for all that effort, the volume of water that can be diverted to the Yellow River is a maximum of 20 billion cubic meters a year, most of it in the wet summer months. That is just not enough to reach the lower Yellow River, let alone flush it out. The whole attraction of these megahydraulic projects is the idea of recharging the Yellow River all the way to the sea. The more the Yellow River is over-used, the slower and weaker it gets, dropping its load of sediment first picked up in Tibet, dumping it in the lower reaches where the river is already above ground level in many areas, having been built up by labour-intensive embankments over many decades as a flood control measure. A sluggish Yellow River that in some winters fails to reach the sea at all is also a major flood danger in the summer peak flow months, if the bed is raised by extra sediment.

These statistics come from Zhao Hongliang’s 2014 book Centennial Hydraulic Project: South-North Water Diversion,[4] which enthusiastically praises the canals built downriver, but is much more cautious about the western route, and its 300 kms of tunnels. Zhao points out that even if this project does go ahead, it will not be complete until 2040. But if it is to go ahead, the 13th Five-Year Plan period, of 2016 to 2020 is when it will be listed, with funding allocated.

Dynasties throughout Chinese history have risen and fallen, depending on whether they controlled the waters, or were controlled by rising floods, and lost their legitimacy. Zhao Hongliang reminds us China needs to get this right: “Those who are sophisticated in running a country also pay great attention to water control. Success and failure of water control also decides to a great extent the rise and fall of a country or nation, which is true at all times and in all lands.”

In the New York Times David Barboza recently noted that “Such enormous infrastructure projects are a Chinese tradition. From the Great Wall to the Grand Canal and the Three Gorges Dam, this nation for centuries has used colossal public-works projects to showcase its engineering prowess and project its economic might. Now, as doubts emerge about the country’s three-decade boom, China’s leaders are moving even more aggressively, doubling down on mega-infrastructure. ‘China has always had this history of mega-projects,’ said Huang Yukon, an economist and senior associate at the Carnegie Endowment for International Peace, a think tank based in Washington.’It’s part of the blood, the culture, the nature of its society. To have an impact on the country, they’ve got to be big.’ Whether China really needs this much big infrastructure — or can even afford it — is a contentious issue. The infrastructure plans run counter to Beijing’s commitment to reduce its heavy reliance on government-led investment to fuel growth. And some economists worry that the country might eventually be mired in enormous debt.”

Traditionally, the Yellow River has been called “China’s sorrow” for the frequency of devastating floods, and increasingly frequent droughts. China has time to consider carefully whether the depleted state of this great river becomes the cause of Tibetan sorrow in Ngawa and Kandze.


[1] Troy Sternberg, Caitlin Werrell and Francesco Femia, Inner Mongolia: Coal heaven, water hell, China Environment Series #12, Woodrow Wilson Center, 2013

[2] Scott Moore, Hydro-politics and inter-jurisdictional relationships in China: the pursuit of localised preferences in a centralised system, China Quarterly #219, 2014, 760-780

[3] China Energy Statistical Yearbook 2011, table 3-10

[4] China Intercontinental Press, Beijing, 2014

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Why is it “inefficient” to save the lives of mothers?

This is the first in a series of four blogposts on why so many women in Tibet die in childbirth, usually alone, bleeding to death.

As with almost anything to do with Tibet, even the basic facts are contested. As we rapidly approach the fulfilment date for the Millennium Development Goals, including the universally agreed responsibility to reduce maternal mortality by three-quarters, by 2015,            China claims credit for being the exemplary developing country, with a far better record than any in the developing world.

So this first blog seeks to establish some basic ground truths: is it true that the maternal mortality rate (MMR) in Tibet is one of the worst in the world? Is that inevitable, due to the scatter of nomads across a vast landscape, or is this due to state failure? Is it asking too much of China to extend effective health services to remote nomadic pasturelands; or is that by definition inefficient, even impossible? Or is the MMR in Tibet a failure of Tibetan civilisation, of entrenched sexism and complicated pollution taboos that condemn women to give birth alone, in unsanitary conditions?

In the second blog, we look more deeply into Tibetan culture to see what it can offer. In the last two blogs, we look at fresh approaches, and fresh solutions.

This Rukor blog first looked at maternal mortality back in 2011, and a lot has changed since. That’s why the fourth and last blog in this series, despite the appalling statistics, ends on an optimistic note, that things are starting to change, on the ground, in quite remote areas of Tibet. New lessons are being learned, new, decentralised ways of helping pregnant women are being trialled, and taken up by the official public health bureaus.


 To die while bringing fresh life into the world, giving a new human rebirth a chance to live, is shocking. The maternal mortality rate in Tibet is approximately 400, perhaps even 500, per 100,000 children born live, every year. Yet the rate in China is 45 per 100,000. Why is so little done to help Tibetan women, when most of these deaths are unnecessary, and can be prevented inexpensively?

Why do so many Tibetan women bleed to death? Mobile populations need accessible, mobile health care, which traditional Tibetan healers, or amchis, continue to provide. But sometimes, in an emergency, preventive and restorative medicine is not enough. Maternal mortality in Tibet is among the highest worldwide, and has not been reduced by China’s  urban-centric, user-pays health care delivery system; which fails to meet the needs of a widely dispersed Tibetan pastoral population making skilful use of one quarter of China’s land area. Extensive dryland users’ worldwide need highly decentralised health services, especially for timely access to emergency care when pregnancy complications occur.

In an emergency, not only are existing clinics too far to reach, accessible on roads impassably muddy in summer, but the clinics are also ill-equipped, understaffed, and rely on presales of the most expensive intravenous medicines to make a profit. Upfront payment is necessary before a patient is allowed in the door remains the norm, despite recent reforms. China’s  Rural Cooperative Medical Scheme (RCMS) has reduced outpatient costs for the poor, but remains less effective than planned. Because of the expense, and the need for the right “connections”, women expecting a normal pregnancy are nowhere near a clinic until it is too late. Recorded journey times to reach a maternity clinic in Tibet may be several days.

Over recent decades China’s health system has shunned taking responsibility, having downshifted health care to local levels, making users pay, and leaving poor counties with poor health services. Although recent reforms have ameliorated the situation in some parts of the region, they have not been effective in the poorest and remote areas, including rural Tibet. The RCMS covers the costs of basic medicines, but doctors still have incentives to over-prescribe expensive medicines from which they can profit.

Small-scale pilot projects have shown it is possible to educate community health workers (CHWs) as skilled birth attendants, even in very remote areas of the Tibetan Plateau, who are capable of identifying complications within sufficient time to evacuate to a biomedical clinic when necessary. However China has been reluctant do this sort of community work, instead relying on women to come to hospitals, and blaming them when they do not.

This chapter argues for alternatives to the maternal mortality situation in Tibet, one based on strengthening deeply embedded capacities within Tibetan culture and its sciences of healing; another on upscaling the successful pilot projects training CHW interventions.

Contemporary Tibet is a classic test of the capacity of the modern state to extend its reach into remote areas and deliver the services inherent to modernity, including timely interventions to prevent maternal mortality.

The maternal mortality Millennium Development Goal  (MDG) of the United Nations, set in the year 2000 and culminating in 2015 as the target date for completion, is a specific, deliverable goal well within the capacity of a middle income country such as China, with its strong tradition of social engineering, resource allocation, state intervention and many aspects of dirigiste planning still intact.

What do we know about the maternal mortality ratio (MMR) in Tibet? Few official statistics are available that span the five provinces that constitute the Tibetan Plateau. China claims overall success in meeting the MDG target 5A of a three-quarters reduction  in the Tibetan MMR between 1990 and 2015. And yet:  “The maternal mortality ratio (MMR) for rural Tibet was reported to be as high as 400–500/100,000 in some areas, and infant mortality within the first 12 months was reported to be as high as 20%–30% in some areas.”[1]

In China, the maternal death rate has decreased to 45 per 100,000 births. Senior Chinese health administrators have stated:  “Progress in reducing maternal mortality in China has been impressive; the MMR decreased from 95 deaths per 100,000 live births in 1990 to 45 deaths in 2005, a remarkable success given the size and diversity of the country.”[2]  China takes pride in this achievement that began not just in year 2000, when China pledged to fulfil the MDGs, but goes back to the 1980 Safe Motherhood global conference in Nairobi. But has 35 years of effort made much difference in Tibet?

Using auto-regressive statistical methods, Chinese scientists predict that by the year 2020, China’s MMR will drop to 22 per 100,000 live births,[3] a figure that is comparable to the rate in the USA. While China is confident it will soon be the equal of the US, the maternal death rate in Tibet remains statistically similar to such resource-poor nations as Cambodia, Benin, Gambia, Ivory Coast, Kenya, Madagascar, Senegal, Uganda or Zambia.

In Tibet, the women often die alone. Government hospitals are too far away, and too expensive. International aid agencies have been required to cease working in Tibet. Few now look into Tibet from the outside. Very few reproductive health agencies, multilateral development banks, or health NGOs from around the world are any longer on the ground in Tibet.

In 2015 China has been hailed as a great MDG success story, and as an example to the rest of the developing world, in achieving almost all goals. Yet if the Tibetan Plateau – representing one quarter of China’s area – is disaggregated from national statistics, the available evidence suggests the maternal mortality rate (MMR) remains alarmingly high, at levels found only in the poorest of countries. China now ranks in the middle of countries worldwide assessed by the annual State of the World’s Mothers.[4]   Officially, “In Tibet, the death rate of women in childbirth dropped to 174.78 per 100,000, or nearly six times of the national level in 2010.”[5]

Yet an in depth survey of women in a remote area of eastern Tibet reports the deaths of three women over a 19 month period, in which there were 103 live births, suggesting a far higher MMR. The investigators, a large team from Johns Hopkins University in the United States, and many Tibetans, conclude that: “The majority of women in Surmang were very worried about dying in childbirth, and the report of 3 recent maternal deaths in this small population suggests exceedingly high maternal mortality in this region. Facility delivery rates <1% in Surmang in the 5 years between 1999 and 2004 can be compared with facility delivery rates of 92% for China overall.” [6]

Although this report is from a small study population, and is too anecdotal, to make generalizations (as the authors point out), there are almost no other comparable studies. International health NGOs active in Tibetan areas, mindful that embarrassing statistics represent “loss of face”  for local officials who have power to deny ongoing access to Tibet, are understandingly reluctant to publish their data.

The few other village level studies in Tibet report similarly: “Maternal and child health findings were alarming with high rates of miscarriage and infant loss, with no traditional midwives to assist in pregnancy and delivery. A quarter of all infants born after 7 months of pregnancy in the previous 5 years died. On the other hand, during the same period, none of the pregnant women died, in either township, at any time in pregnancy or within 6 weeks after delivery. In 18 percent of the pregnancies women were reported to have suffered severe swelling of ankles and legs, 12 percent had postpartum haemorrhage (PPH) immediately after birth and 12 percent within a few days of birth, and 37 percent had a fever within a few days of birth. In the focus groups, however, some women described knowledge of maternal death from childbirth—some in first degree relatives.” [7]

In summary, Tibet has one of the highest maternal mortality rates in the world. The alarming statistics of maternal death in Tibet are concealed by the routine aggregation of Tibetan data into large corpus of Chinese national statistics. Comparable rates are found in post-conflict countries recovering from war, but in those nations the data are available for all who care to see. If an extraordinary proportion of Tibetan women haemorrhage and die during or shortly after giving birth, we need to ask why. Several plausible explanations come readily.

Tibet has been isolated more than ever in recent years from global scrutiny.  We can not only ask, but partially answer, the key question of how this shocking death rate of mothers and their infants has occurred.  Although fieldwork surveys and experimental interventions to reduce MMR in Tibet are rare, there is enough known to define the aetiology of this ongoing crisis.

The purpose of seeking the origins of the crisis is not to apportion blame or responsibility.  What needs clarifying is whether the problem is a state failure, a failure of traditional Tibetan culture, or both. Those are the options canvassed in the existing debate, and the answers which investigators reach deeply influence the design of projects intended to improve the situation. Thus, it matters greatly which of the dominant discourses: of state failure or Tibetan culture failure, is to be believed.

This chapter explores both master narratives, finding them both plausible, internally consistent and logical; yet both are seriously flawed. The conclusion is that we need a fresh approach.  Two new approaches are discussed.


China promotes what could be called the efficiency argument. The six million Tibetans occupy a plateau the size of Western Europe, scattered extensively across a vast area; and not even the wealthiest state can possibly extend health services to small and remote communities. The logic of efficient resource allocation for service delivery requires centralising clinical services in county seats, of which there are 150 in the Tibetan Plateau, in five Chinese provinces. It is thus unreasonable to expect China to extend the reach of the state beyond the county capital, and pastoral nomads should realise that effective clinical treatment for complications of pregnancy is just one of a package of benefits available by abandoning mobile pastoralism for peri-urban settlement. Only when nomads cease wandering will the MMR decline, along with access to general health care, schooling and electricity. The efficiency argument is a familiar one, and worldwide.

Over recent decades China’s health system has shunned taking responsibility, having downshifted health care to local levels, making users pay, and leaving poor Tibetan counties with poor health services. China continues to be largely a user-pays system that favours the rich, privileged and urban, leaving the rural and poor to fend for themselves, with upfront fees payable in advance before anyone can even come through the door of a hospital. China’s maternal mortality surveillance system reports that “Income-related inequalities in institutional births increased in rural areas between 1993 and 2003,”[8] which means that when rural women do get to a hospital, the gap between the poor and the rich who can afford upfront fees for treatment is widening.

Slowly, rural health insurance schemes are extending into remote areas, but Tibet remains too remote, after decades of neglect, and health post staff having to earn most of their incomes by selling expensive medicines. The Rural Cooperative Medical Scheme (RCMS) has gradually increased its scope, yet RCMS: “had little impact on reducing its participants’ out-of-pocket payments for outpatient services.”[9]

China, it seems, has science and statistics on its side. Giving birth in Tibet is inherently risky, Chinese scientists say, because of the high altitude, and made riskier by primitive beliefs in spirits that are offended by the messiness of birth. The state can do only so much in the face of such superstitious attitudes.



A different argument shifts the focus to Tibetan tradition. This argument, sometimes advanced by NGOs active in Tibet, notes the absence in Tibetan culture of skilled traditional birth attendants (TBAs or SBAs), women in the community known for their capacity to support pregnant women and identify complications early enough to ensure emergency medical help is accessible when needed. This TBA argument is, like the efficiency argument, plausible and based on worldwide experience in more densely settled areas of the developing world, where community health workers (CHWs) with TBA experience are common. This argument sometimes goes a step further, suggesting the Tibetan traditional healing system of sowa rigpa, being a branch of Buddhism, is largely delivered by male practitioners who have neither the knowledge nor understanding of the urgent circumstances in which a pregnant woman can bleed to death. Traditional pollution taboos force women to give birth alone, in unsanitary places.

Taken together, the efficiency and TBA arguments are complementary, and seem to encompass a full, if depressing, explanation of why MMR in Tibet remains alarmingly high. The conclusion is grim – the modern state has failed, and so has Tibetan tradition. Only eventual urbanisation offers a long term prospect of reducing MMR. At best, China may outgrow its urban-centred clinic model and employ community health workers.



Plausible as these two arguments are, they require critical evaluation to discover their many assumptions, which may not be applicable to the actuality of being a Tibetan woman about to give birth. Starting over, we might seek a different approach, utilising the strengths of sowa rigpa traditional healing, and the global TBA movement, and the capacity of modern states to extend their reach (using new technologies) into even the remotest communities. Instead of seeking whom to blame, this alternative approach seeks solutions that build on existing capacities.

Unless and until all Tibetans acquiesce to China’s plans for urbanization as the solution to all problems of development, MMR included, viable alternatives are needed. The CHW/TBA midwifery approach has worked all over the world, and  in Tibet, where low population densities mean little scope for vocational specialisations of any sort, small scale NGO projects have experimented with training skilled birth attendants. This seems a very promising strategy, in that it provides early warning of pregnancy complications, allowing women in danger time to get to a centralised clinic or hospital in a county capital. In Tibet, widespread rural poverty and bad, potentially unpassable, roads, especially in the wet summer months, can mean a trip of days, or even a week, to get to a hospital. Thus, early detection of pregnancy complications is essential to bridge the gap between decentralised populations and centralised biomedicine.

However, small scale experimental training and support programs for birth attendants seem hard to replicate, and to subsequently expand to cover the entire Tibetan Plateau, unless integrated into the existing, decentralised, trusted rural health service provided by the Buddhist sowa rigpa healers, or amchis.  Some programs import a western feminist model that lacks a basis in Tibetan tradition, as well as lacking support from official health delivery ministries, though that is beginning to change. Implementation of such a programme depends on international NGOs whose presence in Tibetan areas within China is precarious in a state preoccupied with threats to stability, and wary of foreign agencies. They may yet succeed in persuading local governments to embrace the CHW approach.

Proponents of the CHW/SBA movement are quick to relegate Tibetan culture to irrelevance, on the basis that there is no such customary profession in which independent, self-actualising, empowered women earn their living as specialist professionals exclusively providing birthing services. Tibetan culture and Tibetan Buddhism are said to be silent, or even inimical, to this global movement which is now blossoming in Tibet into a wider feminist challenge to traditional patriarchy. The CHW/SBA movement and clinic-based biomedicine are alike in their impatience with Tibetan tradition. The complex choices faced by Tibetan women – where and how to seek help – are seldom noticed. One exception is anthropologist Kim Gutschow, whose fieldwork in the Indian part of upper Tibet, Zanskar, offers a fine-grained depiction from the perspective of the new mother.

Because hospitals choose institutionally to be wilfully ignorant of traditional rituals to protect mother, baby and the community from the dangers of childbirth, the hospital has no idea of what is occurring in the mind of the mother of a newborn. How can I get back home with my baby without crossing streams where the water spirits will be offended if I cross before I can ritually purify? How can I tread the mountain paths home without going too close to a shrine, polluting it and angering the protector deities? “When a new mother returns home from the hospital, she puts herself and her child in danger, as her unpurified presence angers household, village, regional, and monastic protectors whose shrines she passes on the way home, “ Gutschow says.[10]

Because the hospital chooses to ignore such complexities, many Zanskari women feel uncomfortable giving birth in the presence of strangers, Gutschow reports. Because hospital staff are seen as arrogant and aloof, women delay going to hospital unless and until medical intervention is a necessity, for which they are scolded by staff. To the staff, this is further proof of the superstitious, primitive mentality of pregnant women; to the pregnant women it is further evidence that the hospital refuses to be part of the community. What is true of Zanskar and Ladakh is more so in Tibet, where there is a stronger assumption that Tibetan women are, as is often said,  cai (stupid bumpkins), mian gua (idiots), and ruo zhi (dull witted).

Hospitals are temples of scientific modernity and reductive simplification, Gutschow argues, which choose to ignore the traditional Tibetan complexities of drib (ritual pollution) caused by birth, and the behavioural taboos that go with the woman taking care to minimize any offence that might be taken by local spirits of earth and water. Hospitals insist on radical dualism; confident that they alone have the technologies to reduce maternal and infant deaths.

Tibetan women, in such circumstances, face difficult choices. A woman who mixes customary and modern healthy behaviours soon finds that: “Her body became the ground upon which modern subject-citizen making took place.”[11]


A version of this blog series will be published in 2015 by Nova Science Publishers, in a global textbook called ‘‘Maternal Mortality: Risk Factors, Anthropolo​gical Perspectiv​es, Prevalence in Developing Countries and Preventive Strategies for Pregnancy-​Related Death”, edited by David Schwartz.




[1] Vincanne Adams, Suellen Miller, Jennifer Chertow, Sienna Craig, Arlene Samen and Michael Varner, Having a “safe delivery”: Conflicting views from Tibet; Health Care for Women International, 2005, 29 [9], 821-851

[2] Feng X, Zhu J, Zhang L, Song L, Hipgrave D, Guo S, Ronsmans C, Guo Y, Yang Q.; Socio-economic disparities in maternal mortality in China between 1996 and 2006; British Journal of Obstetrics and Gynaecology, 2010, 117, 1527-1536

Juan Liang., Xiaohong Li., Li Dai, Weiyue Zeng, Qi Li1, Mingrong Li, Rong Zhou, Chunhua He, Yanping Wang, Jun Zhu; The Changes in maternal mortality in 1000 counties in mid-western China by a government-initiated intervention, PloSOne, May 2012 | Volume 7 | Issue 5

Beibei Yuan, Xu Qian and Sarah Thomsen; Disadvantaged populations in maternal health in China: who and why? Global Health Action 2013, 6: 19542

Qing Du, Oyvind Nass, Per Bergsjo, Bernadette Nirmal; Kumar determinants for high maternal mortality in multiethnic populations in western China; Health Care for Women International, 2009, 30:957–970,

[3] Ren Zhenghong, Forecast of the indicators on maternal and child health of China in 2020; Health Sciences Journal of Peking University, 2010, 42 [2], 221-224

[4] State of the World’s Mothers 2014: Saving Mothers and Children in Humanitarian Crises; Save the Children 2014

[5] Life expectancy in Tibet nearly doubled over last six decades: white paper; Xinhua, 11 July 2011, http://news.xinhuanet.com/english2010/china/2011-07/11/c_13978305.htm accessed 7 December 2014

[6] Mary Wellhoner, Anne CC Lee, Karen Deutsch, Mariette Wiebenga, Maria Freytsis, Sonam Drogha,

et al., Maternal and child health in Yushu, Qinghai Province, China; International Journal for Equity in Health 2011, 10:42 http://www.equityhealthj.com/content/10/1/42

[7] Peter M. Foggin, Marion E. Torrance, Drashi Dorje, Wenzha Xuri, J. Marc Foggin, Jane Torrance; Assessment of the health status and risk factors of Kham Tibetan pastoralists in the alpine grasslands of the Tibetan plateau, Social Science & Medicine; 2006,  63, 2512–2532

[8] Feng at al., Socio-economic Disparities op cit.

[9] Wei Yang and Xun Wu; Paying for Outpatient care I Rural China; Cost escalation under China’s New Co-operative Medical Scheme, Health Policy and Planning, 28 Jan 2014

[10] Kim Gutschow, From Home to hospital: the extension of obstetrics in Ladakh; ch 8 in Vincanne Adams, Mona Schrempf and Sienna Craig eds., Medicine between science and religion, London, Berghahn, 2010

[11] Jennifer Chertow, Gender, Power, Space: transnational bodies and the cultures of health in contemporary Tibet, PhD dissertation, Stanford University, 2007, 94

Posted in Tibet | 1 Comment


Traditional Tibetan sciences of healing, and Community Health Workers

Second in a series of four blogs on why so many Tibetan women die in childbirth, and what fresh solutions may be possible.

The first in this series canvassed the conventional explanations, which both reach the pessimistic conclusion that as long as Tibetan nomads occupy remote rangelands,  it will never be economically efficient to extend effective prenatal health checks, that can pick up early signs of pregnancy complications, and help a women to get to a clinic or hospital, if necessary, in time.

The first blog also canvassed the view,  commonly found among NGOs and international development agencies, that the absence of professional birth attendants, or community health workers (CHWs) trained in providing health checks in remote areas, Tibetan culture has nothing to offer, and Tibetan women will continue to die.

But, if we take a deeper look at Tibetan culture, what are its relevant strengths?



In the projects, statistics and published literature regarding maternal mortality in Tibet there is little advocacy for approaches grounded in Tibetan culture, that is, until very recently. It is time to reintroduce core Tibetan values, and to examine them to see if they are suited to an active effort to reduce MMR.

Demographers and anthropologists argue that the fertility transition evident worldwide is now also occurring in Tibet, as women are choosing to have fewer children.[1]  Tibetans, however, are acutely aware of being utterly outnumbered by Han Chinese, and are strongly pronatalist.  China has a policy of allowing two or more children in ethnic minority families. The strong expectation that Tibetan women should have more than two children is due, in part, to the ongoing high MMR, and in part to nationalism. However, it is also because, from a Buddhist viewpoint, to give a sentient being, in the limbo between exiting one life and entering the next, a chance of human birth, is an act of great compassion. Tibetan women feel strongly that one of the most deeply compassionate things they can do in life is to create another precious human rebirth.

This is a reminder of how pervasive Buddhism is in shaping the Tibetan culture, including the Tibetan sciences of healing. The healing sciences, sowa rigpa in Tibetan, are embedded in the monastic curriculum of comprehensive training in wisdom and active compassion, in understanding the nature of reality, and how to liberate others from their sufferings. Sowa rigpa has medicines specifically for women giving birth, although this is seldom acknowledged in the MMR literature. Among them is a “precious pill”, or rilbu in Tibetan, specifically for postpartum haemorrhage, called zhijé 11, which contracts the uterus and controls bleeding. It has been known and used for centuries, and has long been widely available throughout rural Tibet as an inexpensive treatment. Zhijé 11   can be bought well in advance, in areas where doctors and clinics are far distant, for a women giving birth to self-administer.

Zhijé 11 is now well-documented, with an English language biography of it as a medicine, a medical anthropology account of its contemporary use, and a clinical investigation of its efficacy.[2] Its ingredients are well-known, and their action well-documented. The most recent review article concludes that: “Our analysis supports ZB11’s [zhijé 11] safety and effectiveness as a uterotonic with the potential to decrease the risk of PPH, particularly in low-resource settings, where current allopathic uterotonics face significant barriers to use. ZB11 has several qualities that make it an attractive uterotonic for prevention and/or treatment of PPH at the home or community level in Tibet. With over 700 years of history, it is widely culturally accepted by birthing women, Tibetan healers, and family members in Tibet. At the same time, it is highly affordable (USD 0.04 per dose) widely available, does not require electricity or technology for effective storage, and requires minimal training for administration. Its safety profile is similar to misoprostol, the current standard of care. In places where access to a steady supply of “Western” medication may be limited, this offers an important, less costly alternative.” [3]

Although many English language sources state that there is no Tibetan tradition of skilled birth attendants, and that giving birth is considered polluting, classic sowa rigpa instructional paintings do show women giving birth attended by several helpers.[4]

In Tibetan Buddhism, at an early stage of the path, the practitioner learns what constitutes active compassion, on three levels. The first but least effective kindness  to pacify the suffering of others is to offer them material assistance that alleviates the situation temporarily. This is to be done without thought of reward. The second kind of generosity is to offer refuge, or shelter, to those in danger to their lives; again to be done without expectation of reciprocity. The third, and most effective way of cultivating and enacting generosity is to enable others to access the nature of mind, which is the only lasting and reliable source of alleviating suffering.

Medicines to alleviate postpartum haemorrhage are part of this holistic approach, in which temporary interventions are needed, but in the longer term, what is most beneficial is to understand the cause of suffering and the path that ends suffering, through awakening to the nature of mind. Zhijé connotes pacification of suffering, a term used both for specific medicines, and for one of the many Buddhist lineages. Sowa rigpa has a comprehensive discourse of the entire cycle of birth, ageing and death,[5] with a detailed embryology, as seen from the perspective of the foetus.[6] Rather than atomistically isolating childbirth as the basis of a stand-alone mode of medical intervention, sowa rigpa understands birth as part of a cycle that repeats over generations. This healing system is usually termed (outside of Tibet) Traditional Tibetan Medicine (TTM), as if its herb and mineral pills are its sole mode of treatment.

However, sowa rigpa’s strength is in its diagnostics, which frequently detect incipient problems well ahead of the appearance of overt symptoms detectable instrumentally. Diagnosis is usually followed by behavioural advice, and suggestions about adopting a constructive mental attitude, as one might expect of an integrated mind-body therapeutic grounded in Buddhism. Only after proposing dietary, behavioural and mental changes does the amchi prescribe medicines. Early diagnosis of pregnancy complications is the key to MMR reduction, and early diagnosis of somatic imbalances are the great strength of the skilled amchi.

Whence this strength? The authors of a recent anthropological book call it a science of healing, a phrase chosen not only as a meaningful translation, but because “sowa rigpa is epistemologically subtle, crossing as it does the boundary between science and creative practice, between knowledge and experience. A sowa rigpa sensibility is efficacious both in its coherence and its permeability.” [7] This openness to the empirical, coherence and permeability enable sowa rigpa to be effective, and to adapt to new circumstances, even to its present constriction under modern state control as a technology stripped of its religious psychophysiology.

While sowa rigpa has its diagnostic categories, its mapping of the human body/mind and theories of aetiology and course of diseases, it also counsels a receptive mental quietude in the physician as an essential preliminary to effective diagnosis. The root text of the whole sowa rigpa system, in the section on skilful diagnosis, advises: “Taking one’s time refers to sitting near the patient for a while, during which time one should carefully listen to each word of the patient without being distracted by one’s own mind and speech.”[8]

Developing the capacity to put aside ego and its ideations is a skill specifically taught, as an aspect of the mind training that is part of learning to be an amchi. Each morning, before clinical practice begins, it is customary for all clinical staff to jointly recite a text such as the 21 Praises of Tara, to renew a selfless, altruistic state of mind.

The classic texts on pulse diagnosis methods are highly visual, in a densely packed series of 79 thangka paintings, each of which may contain dozens of instructions, scenarios and prescriptions.  Much of the key thangkas depicting the precise methods of pulse diagnosis are reproduced in a 50 page section of a recent catalogue (and translation) of sowa rigpa paintings.[9]

The pulse diagnosis for which sowa rigpa is known is an intersubjective encounter of doctor and patient in which the doctor has been trained in putting the self aside, an encounter of equal sentient beings, not a transaction driven by desire to profit from unequal power.

Diagnosis is best done early in the morning, when the pulse is not perturbed by the day’s activities, mental or physical. The Tibetan texts use a rich terminology for the many different pulses to be identified, starting with the baseline pulse, which itself varies with the seasons. A normal summer time pulse, for example, should be full and robust, like the call of the cuckoo. The autumn harvest season pulse is short and rough like a redheaded Tibetan bird; the winter pulse is retarded, soft and gentle, like the singing of the gull. The spring pulse should be tense, like the song of the skylark. When it comes to further pulses, overlaying these baselines, indicative of disease, the Tibetan training manuals use a wide vocabulary, such as floating, sunken, full, fine, large, small, slippery, puckering, solid, void, retarded, rapid, mild, tense, weak, rough, hard, soft, flat, slow, intermittent.[10]

The result is that not one but several pulses are detected, leading to a specific diagnosis and treatment. Amchis are remarkably consistent in their diagnoses, especially of chronic conditions that enable comparisons across time and between practitioners. They have a capacity to diagnose signs of imbalance well before overt signals detectable by instruments are manifest.

As a branch of Buddhist practice, sowa rigpa trains its practitioners to eschew personal competitive advantage in the healing encounter. This  is inbuilt in the mind training slogans widely memorised in Tibet among lay and monastic Buddhist practitioners: Don’t put an exchange value on things. As one exegete explains: “This slogan is about the need for sincerity and honesty in our spiritual pursuits. We should never use spiritual activities to further our own dubious and self-centred motivations. We are trying to manipulate a situation to our own advantage so that we don’t have to relinquish our egoistic domain, like adopting a trader’s mentality to spirituality.”[11] This extends the Marxist argument for a use economy as preferable to an exchange economy, into the personal sphere, as a standard for interpersonal behaviour as well as economic behaviour.

The cultural maintenance of active compassion as the driver of healing practitioner behaviour is embedded in the emphasis on continuity of transmission in sowa rigpa tradition, not only of technical knowledge but of cultivating the proper mental outlook. Even though this means the training of an amchi is much more demanding than that of a biomedicine practitioner, making sowa rigpa uncompetitive in a newly competitive world, the teachers of sowa rigpa are trying to maintain that continuity of inner motivation training.[12] A conference at Oxford in 2014 on sowa rigpa transmission was led by amchi  Mingji Cuomu of the Tibetan Medical College in Lhasa, who argued that “based on the fieldwork funded by the Wellcome Trust between 2011-13 in three provinces of China (Tibet Autonomous Region, Qinghai and Gansu), Dr Cuomu found that receiving a ‘sacred transmission’ involves incorporation into a living lineage (rgyud) and becoming part of its trajectory of medical transmission. This learning comprises acquisition of knowledge, ethics, practical skills and a sense of care and commitment not only to the patients but also to the lineage and its future.”[13]

This renewed emphasis on medical knowledge as sacred and profoundly liberating is all the more remarkable at a time when the commodification of sowa rigpa reduces the practitioner to a dispenser of formulaic pills manufactured on a huge scale, as the fame of sowa rigpa now encompasses markets among the Han Chinese and other nationalities. The institutions providing sowa rigpa training are caught between neoliberal China’s commodification, and  China’s ongoing apprehension that institutionalised Buddhism competes with the state for popular loyalties. These forces have greatly constrained initiatives to maintain sowa rigpa as a central aspect of modern Tibetan life.

Most Tibetans are rural, although urbanization is accelerating.  The sowa rigpa amchi is a familiar, trusted part of local rural communities. Tibetan culture is not a monolith, although it may seem so when viewed from afar through the lens of both the efficiency and the SBA arguments. One abiding contested fault line entrenched in rural Tibetan society is a widespread fear of the evil eye and malevolent spirits. One of the most careful and sensitive surveys of such beliefs shows that they greatly inhibit nomad and farming women from going for help, or accepting the interventions of strangers, for fear of attracting pollution and danger.[14]


The amchi, often the most literate person in a remote community, has the potential to be part of the solution, overcoming the barriers to eliciting timely care. Tibetan women know that they, and their babies, are vulnerable. They vividly imagine “that spirits can be brought into the home by strangers. The spirits ride ‘piggy-back’ on a person entering the home, without them knowing it. Infants are particularly vulnerable to spirit attacks. If the baby cries just before the arrival of a guest, this can mean that the infant ‘sees’ or intuits the arrival of some spirit beings. If the baby cries a lot when the guest arrives, this too can be taken as a sign that the baby’s own ‘soul’ or ‘essence’ (bla) is uncomfortable with the visitor, for reasons of spiritual incompatibility.”[15]

This recourse to local spirits as causative agents of illness is pervasive. Anthropologist Stan Mumford tells a story of his landlady: “When her daughter had a toothache, she concluded that it was the goddess of water (chu-gi lha-mo) living in the stream who had caused the affliction. She seized a stone in the stream and tied a string around it, gradually pulling it out of the water and saying, ‘If you feel this pain, then don’t send pain!’ Nyima Drolma [the landlady] interpreted this to mean, ‘If the water goddess agrees to stop causing the toothache, we will stop doing the same to her,’ using the model of reciprocity in negative form. The model was dramatized by hanging the stone over the hearth (to feel heat) and wrapping prickly leaves around it. After a few days the goddess seemed to get the message: the toothache subsided, and the stone was put back into the stream.”[16]

A standard scientific response to such stories, which keep women from seeking help when giving birth, is to smile at the “superstitious” explanation of toothache. But “religion” and “science” are very modern concepts, as is their supposed mutual exclusivity. In the nineteenth century Japanese, subsequently Chinese, and then Tibetan languages had to come up with neologisms to convey each of these imported categories which modernity treats as natural.[17] There is no traditional Tibetan word for Buddhist, other than “one who goes within.”

The amchi, having trained in not only medical arts but also in a Buddhist understanding that all phenomena are empty of substance, is aware that traditional Tibetan beliefs in earth and water spirits is just a story. But, having also trained in active compassion, the amchi refrains from denouncing the water goddess aetiology of toothache as nonsense. The amchi is in and of the local community, yet also apart.

The local amchi, having trained for many years in a Buddhist monastery, is aware that these easily offended local spirits are creations of the mind, and not to be taken too seriously. These spirits are personifications of human jealousies and anger projected onto rivers, rocks, trees and mountains. Far from bluntly contradicting the villagers and camp-dwellers, the amchis participate in rituals to placate, tame and subdue these ghosts and demons, but they also do what they can to loosen their hold on fearful minds.



In these situations, the familiar amchi can ease the entry into modernity, and add to the value of prenatal health checks by visiting health workers. The amchi is a bridge between tradition and modernity; and need not be dismissed as another brick in the androcentric wall of Tibetan tradition, necessitating the invention of an entirely new CHW profession. The amchi is both insider and outsider, accepting of conventional realities and of transcendant ultimate meanings. This is the epistemological subtlety, the coherence and permeability of sowa rigpa. Even though sowa rigpa has not yet had much to offer a woman in imminent danger of postpartum haemorrhage, and even has some distaste for the polluting blood of birth, it is adaptable, available and widely trusted.

The all-encompassing sowa rigpa system has obvious potential to go beyond its customary role in the management of chronic conditions, to also detect signs that a woman nearing term is likely to experience complications that necessitate quick emergency access to clinical care. Rather than inventing a totally new vocational specialisation of skilled birth attendant, the amchis could train in prenatal diagnostics. Given the scatter of Tibetan population, its low fertility rate and declining population growth rate in recent years, it is hard to see how professional birth attendants could make a living, unless they travelled far from home regularly, which undermines the whole concept of the TBA as part of the local community.

     Sowa rigpa, although banned altogether during China’s revolutionary era, has revived, and ethnographers have observed close collaboration between amchis and biomedicine practitioners in the leading Lhasa sowa rigpa institute: “In the women’s division, a biomedically trained physician worked alongside Tibetan doctors. Among these doctors we observed an easy mapping of one set of names for disorders onto others. For example, of the nine types of growth in women’s reproductive tract, there were seven that corresponded to known biomedical conditions: cervical cancer, fibroids, ovarian cyst, endometriosis, polyps, ectopic pregnancy, and molar pregnancy. The non-matched diseases were considered so rare that they were largely ignored.”[18] However, this compatibility of disease categorization is predicated on a unidirectional logic, of sowa rigpa adapting to fit with biomedicine, in keeping with the anti-religious bias of both the ruling party-state and of science. Tibetan sowa ripgpa tradition is acceptable insofar as it conforms to the categories of biomedicine, and downplays its origins as a tantra of liberating the mind. As the anthropologist Vincanne Adams notes: “the direction of transfer was almost always toward use of biomedical knowledge to expand Tibetan understanding…. forcing Tibetan medicine to conform to biomedical standards rather than the reverse, even while publicly advocating and advertising the ‘alternative’ qualities of Tibetan medicine.”[19]


A version of this blog series will be published in 2015 by Nova Science Publishers, in a global textbook called ‘‘Maternal Mortality: Risk Factors, Anthropolo​gical Perspectiv​es, Prevalence in Developing Countries and Preventive Strategies for Pregnancy-​Related Death”, edited by David Schwartz.

[1] Geoff Childs,  Tibetan fertility transitions: comparisons with Europe, China, and India; Journal of the International Association for Tibetan Studies, December 2008,  no. 4 http://www.thlib.org/collections/texts/jiats/#!jiats=/04/childs/#ixzz3HbRXv5NH

Geoff Childs; Tibetan Transitions: Historical and contemporary perspectives on fertility, family planning, and demographic change; Leiden, Brill, 2008

[2] Sienna R. Craig, Healing Elements: Efficacy and the Social ecologies of Tibetan medicine, Los Angeles, University of California Press, 2012, 215-252

Rebecca Lynn Coelius, Amy Stenson, Jessica L. Morris, Mingji Cuomu, Carrie Tudor and Suellen Miller;  The Tibetan Uterotonic Zhi Byed 11: Mechanisms of action, efficacy, and historical use for postpartum hemorrhage; Evidence-Based Complementary and Alternative Medicine; Volume 2012, 1-9

[3] Rebecca Lynn Coelius et al., op cit

  1. Miller, C. Tudor, V. Thorsten et al., Randomized double masked trial of Zhi Byed 11, a Tibetan traditional medicine, versus misoprostol to prevent postpartum hemorrhage in Lhasa, Tibet, Journal of Midwifery and Women’s Health, vol. 54, no. 2, pp. 133–141, 2009.

[4] Romio Shrestha and Ian A. Baker, The Tibetan Art of Healing, San Francisco, Chronicle Books, 1997, 40-1

[5] Tsering Thakchoe Drungtso, Tibetan Medicine: The Healing Science of Tibet; Drungtso Publications, Dharamsala, 2004, 80, 113, 140, 182-192

[6] Frances Garrett, Narratives of Embryology: Becoming Human in Tibetan Literature, PhD dissertation, University of Virginia, 2004

Frances Garrett,  Religion, Medicine and the human embryo in Tibet, London, Routledge, 2008

Laila Williamson ed., Body & Spirit: Tibetan medical paintings, New York, American Museum of Natural History, 2009,  29-30

[7] Vincanne Adams, Mona Schrempf and Sienna Craig; Introduction: Medicine in Translation between Science and Religion; in Vincanne Adams, Mona Schrempf and Sienna Craig eds., Medicine between Science and Religion, London,  Berghahn, 2010, 5

[8] Yuthok Yonten Gonpo, The Root Tantra and the Explanatory Tantra, From the Secret Quintessential Instructions on the Eight Branches of the Ambrosia Essence Tantra, Dharamsala, Men-Tsee-Khang Publications, 2008, 247

[9] Laila Williamson and Serinity Young eds., Body and Spirit: Tibetan Medical Paintings, American Museum of Natural History and University of Washington Press, 2009, 153-202

[10] Zhen Yan and Cai Jingfeng, China’s Tibetan Medicine, Beijing, Foreign Languages Press, 2005, 73

[11] Traleg Kyabgon, The Practice of Lojong: Cultivating Compassion through Training the Mind, Boston, Shambhala, 2007, 191

[12] Tibetan Medicine in Contemporary Tibet, Tibet Information Network, London, 2004

[13] The Transmission of Tibetan Medicine: Spiritual Growth, Questions of Method and Contemporary Practice, Oxford University, http://www.isca.ox.ac.uk/fileadmin/ISCA/LATEST_EVENTS_SEMINARS_CONFERENCES/Argo-SacredTransmission-abstracts-22_5_14.pdf  Accessed 7 Dec 2014.

[14] Vincanne Adams, Suellen Miller, Jennifer Chertow, Sienna Craig, Arlene Samen and Michael Varner; Having a “Safe Delivery”: conflicting views from Tibet; Health Care for Women International, 2005, 26, 821-851

[15] “Safe Delivery” in Tibet, op cit. 827

[16] Stan Royal Mumford; Himalayan Dialogue: Tibetan Lamas and Gurung Shamans in Nepal, Madison, University of Wisconsin Press, 1989, 94-5

[17] Isomae Jun’ichi The conceptual formation of the category “religion” in modern Japan: Religion, State, Shintō; Journal of Religion in Japan 2012,  1, 226-245

Wang Hui, Scientific Worldview, culture debates, and the reclassification of knowledge in twentieth-century China, 2008, boundary 2 35:2 (

[18] Vincanne Adams and Fei-fei Li; Integration or erasure? Lhasa’s Mentsikhang, 105-131 in Laurent Pordié ed., Tibetan medicine in the contemporary world: global politics of medical knowledge and practice, Routledge, 2008, 113

[19] Ibid, 115, 110

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Reaching out to remote women:

Sciences of healing, Sowa Rigpa and Community Health Workers

In the first two blogs, we asked why it is that well into the 21st century, on the eve of declaring China the great success story of the Millennium Development Goals, so many Tibetan women still bleed alone to death as they give birth to a new precious human rebirth.

Conventional wisdom is that if Tibetans persist in spreading across a vast plateau the size of Western Europe, not even a rich state could afford to provide them with effective health care (blog one) and Tibetan culture has also failed the women of Tibet, although Tibet’s traditional sciences of healing, or sowa rigpa, actually have a lot to offer, both in a crisis, and in the long term.

All along the third alternative, of trained midwives and birth attendants, employed as community health workers (CHWs) has been tried on a small scale, with good results. Is it now time to scale up those pilot projects? Are there signs that, at last, Tibetan women might get accessible, affordable, timely health checks that pick up early signs of pregnancy complications, and save lives, of both mothers and babies?

Despite the negativity of the first two blogs, is this a story with a happier ending in sight?



In the MMR debate, in developing countries the new normal is the CHW skilled birth attendant, who embodies both traditional roles and modern biomedical training. Much of the reporting on MMR in Tibet highlights the absence of traditional birth attendants; and some go further, suggesting that the largely male practitioners of sowa rigpa have little interest or understanding of women’s problems around birthing. There is much evidence of an androcentric bias in Tibetan culture and Tibetan religious institutions.[1]

Does this mean the only solution is to invent a new specialised vocation, because Tibetan tradition cannot adapt? Specialised division of labour is inherent to modernity. Proponents of efficiency often call it the engine of economic growth. Well-intentioned interventions in Tibet often propose occupational specialisation as an essential step in raising productivity; for example, by persuading pastoral nomads to also become farmers – fencing, ploughing, sowing, weeding, harvesting and storing fodder crops as winter animal feed. Similarly, the invention of the CHW/SBA has obvious appeal, as a new profession of women for women, but it ignores the widespread Tibetan reality of scarcity of labour, and limited opportunity for specialisation.

There are now signs that the patient work of international health NGOs in Tibet, running pilot projects on a local scale, have had an exemplary effect, and that at prefectural level in largely Tibetan areas, local Public Health Bureaus are increasingly interested in training community health workers to fill the gap between a scattered population of mobile women pastoralists and the sedentary, urban-based health care system.



Amchis are still common throughout Tibet, both in rural and urban areas. Can they also be trained to provide the four prenatal  diagnostic checkups that worldwide achieve so much in reducing MMR? This should not be too difficult.

The attraction of this, as an alternative and more effective strategy than the statist centralized clinical model, or the heroic invention of a pan-Tibetan cohort of CHW/SBAs, is that it is practical and likely to succeed in reducing MMR. Further, it provides an integrated mind/body approach, avoids medicalizing pregnancy except in emergencies where biomedical intervention is essential, and provides helpful advice on maternal mental attitude choices conducive to successful pregnancy and delivery.

What is striking is that, despite the ongoing high rate of maternal deaths in Tibet, no-one has proposed strengthening sowa rigpa as a solution. The state now supports “Tibetan medicine” but remains suspicious of its positioning as one of the classic sciences of Tibetan Buddhism. “These elements were thought to be residual features of a feudalistic social order and not an essential part of medical efficacy. Such policies resulted in efforts to simplify Tibetan medicine into simple disease and treatment lists, and either to ignore theory altogether or to strip it of any of its ‘superstitious’ features, including references to karma.”[2] A recent  360 page textbook on sowa rigpa manages to say almost nothing about Buddhism, other than to suggest that the sowa rigpa root text “had the appearance of a Buddhist catechism, because contemporary people readily accepted the Buddhist canon and instructions from a god.”[3]

However, immediately adjacent to upper Tibet, in the uplands and empty plains of Ladakh, in India, the women of the Association of Traditional Tibetan Medicine are out in the remote villages, training local midwives in how to diagnose and treat early signs of a difficult pregnancy, using the herbs and minerals of sowa rigpa. This new generation of Tibetan midwives also trains in diagnosing those uncommon circumstances that do require hospitalisation, in time for a medical evacuation, by helicopter if necessary, to a hospital.

Tibetan amchis by now are quite familiar with biomedicine and its strengths in dramatic interventions in obstetrical emergencies. The adaptability of amchis, as they negotiate between incommensurate bodies, between the psychophysical energy flows of the Tibetan body and the nervous system of the biomedicine body, is well established. For example, the common, chronic gastritis problems of Tibetan monks in exile, traditionally explained as untreatable, now respond well to standard treatments for Helicobacter pylori infection; and biomedical treatments are now standard.[4] This is “a tremendous adaptability to local environments, cultural differences, spiritual and practical resources for practitioners and patients.”[5]

A third alternative exists – it is a revitalised, modernised Tibetan sowa rigpa system, drawing on the existing network of thousands of amchis across Tibet, building on existing strengths in prevention and early diagnosis, to embrace new capacities, especially emergency interventions to treat post-partum haemorrhages.

What is missing is active participation by the amchis of the sowa rigpa system, through the established training colleges such as the Mentsikhang in Lhasa in expanding the curriculum to more fully meet the maternal health challenge. Faced with official hostility to religion, sowa rigpa struggles to assert a new role in what the state defines as the exclusive domain of biomedicine; which has become the norm, to which sowa rigpa must adapt. At most, sowa rigpa medicines may find an accepted place in the pharmacopeia of biomedicine, but can claim no more.

This third way is to build on the strengths of existing Tibetan culture, in contrast to both the efficiency model and the CHW/SBA model, which tend to bypass and ignore the sciences of healing deeply embedded in Tibetan life. This putative third way, however, is an aspiration with few active advocates. Sowa rigpa exists in a subordinate and even subaltern position in China. The basis of sowa rigpa as a spiritual understanding of the nature of body/mind is seen as a superstitious intrusion of religion into the objective science of biomedicine. The religiosity of the Tibetans, as well as the central role of Buddhism in Tibetan culture, remain at the heart of official fears and apprehensions. The manifest loyalty of the Tibetans to their lamas, amchis, sciences of mind and of healing continues to be seen from afar as a failure to trust or even show the required gratitude to the modern nation-state. If sowa rigpa is intrinsic to the Buddhism of Tibet, it too is suspect, and is restricted to its role as a pill manufactory.

There is thus little opportunity for the sowa rigpa medical colleges to initiate new roles, in treatment of emergencies such as postpartum haemorrhage. Such possibilities cannot be publicly discussed in a public sphere dominated by official discourse.




A version of this blog series will be published in 2015 by Nova Science Publishers, in a global textbook called ‘‘Maternal Mortality: Risk Factors, Anthropolo​gical Perspectiv​es, Prevalence in Developing Countries and Preventive Strategies for Pregnancy-​Related Death”, edited by David Schwartz.

[1] Kim Gutschow, from home to hospital: the extension of obstetrics in Ladakh, ch 8 in Vincanne Adams, Mona Schrempf and Sienna Craig eds., Medicine Between Science and Religion, Berghahn, 2010

[2] Adams, Integration or Erasure,  op cit., 108

[3] Zhen Yan and Cai Jingfeng, China’s Tibetan Medicine, Foreign Languages Press, Beijing, 2005, 19

[4] http://www.youtube.com/watch?v=2hgyS6gjo28  Accessed 10 December 2014

[5] Adams, Integration op cit.,Introduction, 6

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New hope for the women of Tibet:

Sciences of healing, Sowa Rigpa and Community Health Workers

This is the fourth of four blogs on the number of Tibetan women dying in childbirth, at a rate equivalent to some of the poorest places on earth, and what can be done.

The first blog took up two common arguments why little can be done. The “efficiency argument” of the economists is that a developing country such as China can at best afford centralised, urban health services, not extension services in remote areas. The first and second blogs looked more closely at strengths and weaknesses of traditional Tibetan attitudes to women, birth, death, cleanliness and pollution; to ask if these are the obstacles to improving the  appalling maternal mortality rate (MMR).


The other master narrative that warrants a fresh look is the efficiency argument, which on economic grounds, concentrates investment in centralised locations where factor endowments are concentrated. In this argument, it will never be economically viable to deliver effective health care outside an urban hub, not only because of economies of scale but also because of the scarcity of trained staff, who are unwilling to work in remote areas.

This standard argument needs unpacking, partly because new technologies can overcome the spoke-and-hub logic of centralisation; and because the modern exchange economy is not the only way of working in Tibet.

The key to reducing MMR is by reducing post-partum haemorrhage (PPH), which can often be risk-assessed well in advance of labour, and the danger period for PPH. There is opportunity for alternative approaches that emphasize prevention, early diagnosis and remedial measures that do not require routine medicalization of pregnancy, or hospitalization as the default setting for delivery. Tibetan culture is a use economy, not an exchange economy. Sowa rigpa practitioners are usually not paid for diagnosis, dietary, behavioural and mental advice, because sowa rigpa is intrinsic to Buddhism, one of the tantras. Buddhist mind training exhorts practitioners to heal for the sake of healing, not for personal advantage or profit. A classic slogan of the lojong cycle of mind training is: “Don’t put exchange value on things.”

It is part of Buddhist tradition to emphasize not only acting compassionately, but also with a motivation uninflected by self-interest.[1] Intention matters greatly. China’s for-profit medical clinics distort treatment options, skewing doctor’s behaviour towards overuse of expensive and unnecessary antibiotics, injectable medications, and other biomedicines that may be unnecessary or actually harmful.

From the perspective of Tibetan patients, the institutional pressure on professionals to make money from patients means replacing trust in the disinterested advice of the amchi with a sceptical questioning of the concealed agendas of the clinician. The transition in Tibet from amchi to clinic doctor; from use economy to exchange economy; from generosity to calculation; introduces complexity, ambiguity and distortion, with many perverse iatrogenic outcomes.

The Rural Cooperative Medical Scheme (RCMS) was meant to reduce costs of both inpatient and outpatient treatment, especially the catastrophic costs of catastrophic illness, and the recent successes of RCMS, as it has become more comprehensive in quite remote areas, has also done much to restore trust. However, recent reviews of how this scheme functions in practice suggest that government financing of the RCMS does little to reduce costs to users, and that most of the reimbursement is offset by a rapid rise in medical expenses.[2] There is also consistent evidence that the availability of reimbursements by the RCMS has greatly increased the rate of Caesarian section births, whether or not they were medically necessary.[3] This intensifies the medicalization of pregnancy, and further marginalises sowa rigpa and its amchi practitioners.

Traditional Tibetan doctors, especially the female minority, can be trained in early diagnosis, and as birth attendants, building on their skills in early diagnosis of imbalances, through direct intersubjective pulse readings , without the mediation of instruments. This seems a more promising prospect than creating a new vocation of birth attendants, as if Tibetan tradition has no strengths to build on. Rural Tibetans continue to trust their amchis, who are often the only healers who are accessible.  However, biomedicine is alluringly new, even in remote areas of Tibet.[4] It is not only physical distance from an urban clinic that makes the amchi the preferred source of health services. Even with the funding newly available under the RCMS, urban hospitals still raise much of their funding and staff salaries from patients, which heavily skews treatment towards injections and the overprescribing of the most powerful of biomedicines, whether this is in the patient’s interests or not. Further, cost-recovery and profit-making clinics and hospitals usually require upfront payment even before admitting a patient to the ward; and common prejudices about “dirty nomads” make it hard for a prospective patient to even get in the door unless one has “connections”. For these reasons rural Tibetans are reluctant to go near a hospital unless absolutely necessary.



Because of these constraints, the few small scale NGO initiatives to reduce MMR have not only trained community health workers as skilled birth attendants, but  have also operated a clinic functioning not as an exchange value for-profit, but as a use-value service that took care to avoid excessive reliance on biomedicines of doubtful relevance.  These experiments have  demonstrated that doctors also need incentivisation to refrain from over-prescribing. While the results of this pilot project are impressive, this model is hard to replicate or upscale, unless it is adopted officially, as it requires of staff a high level of dedication, and considerable external support. Fortunately, official adoption of this incentivised model may come soon.

This trial, over nine operational years in the remote Surmang area, did demonstrate many of the less evident reasons why MMR in Tibet remains so stubbornly high. Even if clinics and hospitals were closer to where Tibetans live, other obstacles remain, and are hard to overcome in the current neoliberal model with Chinese characteristics. This is clear in the assessment of the experimental Surmang clinic by researchers from the Institute of Population Studies at prestigious Peking University. The Surmang model paid medical staff well enough to live without having to make money from prescribing and administering expensive drugs. Health service provision was free, undistorted by the need to overprescribe as a primary source of income.

The Peking University assessors report: “A number of community health workers trained by Surmang charity clinic have become a vital force in providing health services to the local community. While providing free health care services, Surmang charity clinic actively set up a practical operating model in line with the reality in the remote areas, such as practical and feasible management model, methods for training health care staff, and health education for local residents, which has achieved positive effect. “

     ”The survey discovered that therapeutic methods used by Surmang charity clinic are largely different from those used in public, primary medical institutions, by Tibetan doctors and village-doctors.  Doctors in Surmang charity clinic generally resort to the fewest medical measures. Around 40% of the visiting patients are given just health education instead of drugs. The principle for drug use is: minimize the use of multi-drugs, and avoid intravenous injection when possible. In public, primary medical institution, after inquiry about the symptoms, doctors usually prescribe medication as treatment. In using western drugs, over half are injections, of which 90% are intravenous injections. Doctors sometimes sell drugs without any analysis.”

     “In medical services, doctors are both the agents of patients and the ones to maximize their own interests. The interests of patients may conflict with those interests of doctors. If the providers are profitable, there will certainly be conflicts between the two groups. The reason for doctors in Surmang charity clinic to achieve high efficiency and good effects in this non-profit clinic lies in the stimulation to win good reputation. Doctors of the clinic accumulate a wealth of experience by serving local patients and win good reputation. Moreover, they don’t need to consider how to compete in the market for patients. All of these factors encourage the doctors to choose the best treatment programs according to the specific conditions of patients, so as to maximally avoid irrational and nonstandard behaviors.” [5]

The Surmang clinic saw itself as a replicable prototype that could be done elsewhere in Tibet. It could be an exemplary benchmark if the source of its’ strengths are understood. The Beijing-based evaluators have little to say about the core values on which the prototype was built, which are distinctively Tibetan Buddhist. The Tibetan doctors and staff shared with their international project inception team a shared experience of the inner strength generated my mind training in the Tibetan tradition. One aspect of that is what Tibetans call “sacred outlook”, which holds all others in positive regard. The ethos of community service, and a use value economy, pervades the Surmang model, which motivated its staff not with foreign-funded high salaries, but with a classic Tibetan Buddhist cultivation of active compassion for all.

While this use-value model remains deeply embedded in Tibetan culture, where it is widely-recognised and respected, is it practically able to achieve results in reducing maternal mortality? A 2013 review of the Surmang model suggests that, once it focussed specifically on MMR, by training community health workers (CHWs), much was achieved: “The CHW program represented a shift in focus for the Surmang Foundation from an ambulatory clinic operation largely serving male patients to a community-based care model supporting and recognizing the maternal and child health care needs of area women. The primary goal for the CHW program since its inception in 2006 has been to reduce both maternal and infant mortality rates in the Surmang Township catchment area of Qinghai Province, China. the CHWs are interviewed each summer to determine the number of antenatal visits, numbers and nature of births attended, referrals to clinic for pre/postnatal care, referrals to hospital for childbirth, complications, rescues and morbidity/mortality of women and children. The CHWs are paid each summer according to the number of births attended, antenatal care, referrals to the clinic for ultrasound and well-baby checks. Since 2009, the timely hospital referral for complicated and high-risk pregnancy has risen as more CHWs are recognizing warning signs.” The result has been a sharp decrease in MMR, although infant mortality remains worrisome.

The efficiency argument assumes factor endowment in remote areas is so low that it can never be economic to extend such community health services beyond urban hubs.  Recent interest by Yushu Prefecture Public Health Bureau in taking up the challenge of training and employing CHWs may overcome the centripetal tendencies of the current system. New technologies may also help. The crucial importance of ultrasound technologies in timely diagnosis, and cold-chain-controlled availability of oxytocin to stop obstetrical haemorrhage, remain for the moment powerful arguments for ongoing centralised hospitals and clinics. However, technology is changing. It may not be long before oxytocin will no longer need a refrigeration chain, and could be available to birth attendants in remote areas, for oral delivery. Ultrasound no longer means bulky apparatus installed in a clinic, as hand-held, battery-powered ultrasound is now available.

Mobile pastoralists of Tibet do have mobile phones, so maternal health initiatives in China could provide essential prenatal health checks that often identify problem deliveries in advance. Mobile ultrasound devices connected to mobile phones are a promising idea.  However, current m-health (health delivered by mobile phone) in China is solely for those literate in Chinese language, which is very seldom spoken or read by Tibetan nomad women.




Maternal mortality in Tibet remains high, official statements notwithstanding. Until recently, this seemed inevitable, since Tibet has neither a tradition of skilled birth attendants, nor affordable and accessible clinics or hospitals.   The women of Tibet remain caught between two models – the efficiency model and the SBA model – both of which condemn them to giving birth alone and without access to help. Both models perceive the land, the people and the culture of Tibet negatively, defined by what is lacking. From the standpoint of the efficiency model, Tibet lacks, scale, density, concentration, and critical mass. The answer from efficiency model standpoint is urbanization. From the CHW/SBA standpoint, Tibet lacks a tradition of birth attendants; its healing system is male dominated and androcentric. The answer in the CHW/SBA school of thought is to train a new breed of SBA community health workers empowered to challenge the male bias of sowa rigpa. Unfortunately, neither model has the will or capacity to significantly alter the realities of maternal health care in the foreseeable future.

Having dwelt at length on obstacles to reducing the MMR, we may conclude with two promising prospects. One is for a revitalised role of the amchis, if they can be recognised by official health care bureaus as having a more constructive role to play.

The other hopeful development is the prospect of scaling up small-scale projects targeting MMR,  initiated by NGOs, and suffused with traditional Buddhist beliefs of having positive regard for others. They show that active compassion, relevant skills training and new technologies can greatly reduce MMR. This new approach means creating a new profession of community health worker birth attendants.

Much can be achieved, yet China remains wedded to the standard efficiency model of restricting resource allocation to urban hospitals and clinics, and has little inclination to decentralise. However, those centralised services are beginning to trial the training and deployment of outreach staff, as community health workers. In four townships of Yushu Prefecture, CHWs will bring the mothers to the clinic for ante-natal and post-natal exams, and well baby exams in addition to birthing. This project has built-in triple incentivization: incentivization of the mother, the community health worker and the doctor. The method relies initially on training by highly skilled foreign doctors in the four township hospitals. The training is selective and somewhat competitive, unlike the mass lecture training given by UN WHO or the use of the Advanced Life Support in Obstetrics instructional materials. A health policy goal of this training is to reduce the salaries of the trained doctors and introduce a system of incentivization, so that when their performance increases, so does their income.  The measured criteria for increasing the pay of staff is patient numbers, amount of medications prescribed, live births, return visits, referral from village providers, referrals to County or Prefecture Hospitals.

Right now, Tibetan women remain at risk and will continue to experience one of the highest maternal mortality rates in the world. Hopefully, that will change.


A version of this blog series will be published in 2015 by Nova Science Publishers, in a global textbook called ‘‘Maternal Mortality: Risk Factors, Anthropolo​gical Perspectiv​es, Prevalence in Developing Countries and Preventive Strategies for Pregnancy-​Related Death”, edited by David Schwartz.


[1] http://www.rinpoche.com/teachings/paramitas.htm Acessed 7 Dec 2014

[2] Xiaoyun Liang, Hong Guo, Chenggan Jin, Xiaoxia Peng, Xiulan Zhang; The Effect of New Cooperative Medical Scheme on health outcome and alleviating catastrophic health expenditure in China: A systematic review; PLoS One, 2012, 7 #8,

Wei Yang, China’s new cooperative medical scheme and equity in access to health care: evidence from a longitudinal household survey; International Journal for Equity in Health, 12, 2013, 20

[3] Qian Long, Reija Klemetti, Yang Wang, Fangbiao Tao, Hong Yan and Elina Hemminki; High caesarean section rate in rural China: Is it related to health insurance (New Co-operative Medical Scheme)? Social Science and Medicine, 2012, 75, 733-7

Kun Huang, Fangbiao Tao, Lennart Bogg and Shenlan Tang; Impact of alternative reimbursement strategies in the new cooperative medical scheme on caesarean delivery rates: a mixed-method study in rural China; BMC Health Services Research, 12, 2012,  217-228

[4] Tibetan Medicine in Contemporary Tibet, Tibet Information Network, London, 2004, 86-7

[5] Tan Ling-Fang, Huang Cheng-Li,      Yang Cun, et al.;  Physician behavior analysis under a free health care system: an empirical research on Surmang Charity Clinic in Qinghai Tibetan Area, Chinese health economics, Oct 2011, Peking University Institute of Population Studies, http://surmang.org/cms/PKU%20assessment.pdf  accessed 7 Dec 2014

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