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?
NEW ALTERNATIVES TWO: TRAINING COMMUNITY HEALTH WORKERS
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.
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.” 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.”
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. This is “a tremendous adaptability to local environments, cultural differences, spiritual and practical resources for practitioners and patients.”
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, Anthropological Perspectives, Prevalence in Developing Countries and Preventive Strategies for Pregnancy-Related Death”, edited by David Schwartz.
 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
 Adams, Integration or Erasure, op cit., 108
 Zhen Yan and Cai Jingfeng, China’s Tibetan Medicine, Foreign Languages Press, Beijing, 2005, 19
 Adams, Integration op cit.,Introduction, 6