MATERNAL MORTALITY IN TIBET: 2 of 4

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?

 

A THIRD ALTERNATIVE:  CONTINUITY OF CULTURAL TRANSMISSION

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 AS COMMUNITY HEALTH WORKER

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.

 

NEW ALTERNATIVES ONE: MODERN MOBILE AMCHIS

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]

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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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