Final Report Summary - TIBETANMEDICA (Women Practitioners of Tibetan Medicine and the Modernisation of Health Care) Women Doctors in Tibetan Medicine and the Modernisation of Health Care Background to the Project and Overview of resultsAmong rural Tibetan woman untreated, severe complications and maternal and child deaths during pregnancy, childbirth and in the post-natal period are still extremely common today. Several governmental and international NGO institutional and community-based initiatives have tried to address this huge problem as it persists across Tibetan areas of the People’s Republic of China (PRC). Although maternal and child deaths are being reduced overall and especially in urban areas, in remote rural areas the positive results have been more limited. A variety of reasons has been discussed in the literature and relate, among others, to generally low socio-economic status and formal education of rural Tibetan women, limited health care facilities, difficulty of access to them and/or affordability, as well as presence or absence of, distance to and/or quality of pre-natal checkups and home based, clinical and/or emergency care for pregnant women and their children. All of these issues commonly persist in and among rural parts and poor social groups around the globe. While these major challenges and activities to overcome them have been researched by anthropologists and public health experts in some rural and poor communities in Inner Asia and in Tibet (Adams et al. 2005, Craig 2009, 2010, Janes and Chuluudorj 2004) and despite WHO endorsed support for traditional medicine (2001), the actual and potential contribution made by indigenous professional Tibetan medical doctors had so far been neglected and it has not been investigated and evaluated in earnest. Tibetans have a recorded history of about 800 years of an indigenous, empirical medical tradition, within which considerable knowledge has been gained, transmitted and applied by diverse practitioners, including the so-called amchi and/or menpa. These practitioners past and present receive several years of theoretical and practical training in medical families, Buddhist monasteries or dedicated traditional or modern medical colleges, the latter today being a part of the China-wide governmental university system. Two of the main eight clinical fields in the Tibetan medicine literature are gynaecology (moné) and paediatrics (chipané), which cover a wide range of medical conditions and treatment options for complications in reproduction. The practical application of this knowledge by amchi has however been poorly understood by anthropologists and public health experts, and it is far from clear to what extent and how amchi in rural areas and outside of the established modern medical institutions in urban centres apply and act on this textual knowledge base. Yet such medical practitioners due to their often combining medical and other work, or practicing in monasteries, are more frequently found in-situ in rural areas and among Tibetan communities. (Bio)medical, governmental facilities are often more distant and bureaucratic to use, and in the case of childbirth considered “polluted” and “polluting”. An important development framing such local and regional situations of maternal and child health care, is a strong revival of traditional medicine since the 1980s, to which was added most recently the large scale commercialisation of Tibetan pharmaceuticals in domestic and international markets. A so far academically neglected, but noteworthy phenomena within these processes of revitalisation and modernisation have been the stark increase of the number and the expertise of female Tibetan medical doctors, when before the 1980s Tibetan medicine was largely practiced by men, and among them often monks. Given limitations in the extant literature and in the empirical understanding of Tibetan medical practice in the field of maternal and child health, the main two objectives of the project have been stated: a.) To document and analyse the life stories and medical work of female amchi in contemporary Tibetan medical practice and in the context of its rapid modernisation. b.) To study and analyse the effect of amchi’s gender on patients and overall community health and in particular how an increase of female Tibetan medicine practitioners might have opened up the practice of women’s and maternal and child health by Tibetan medicine practitioners (amchi). Based on a review and study of the extant anthropological and Tibetan medical literature in European and Tibetan languages on the topic of Tibetan medical gynaecology and obstetrics, the researcher’s ethnographic fieldwork in Eastern and Central Tibet (using methods of participant observation and interviews), a more nuanced understanding has been reached with regard to Tibetan medicine practitioners’ contribution and engagement with maternal and child health. The most important results are here briefly summarized. Main results1. Textual knowledge as well as practical, clinical treatment of gynaecological disorders, pregnancy complications and assistance in childbirth is commonly found among both male and female Tibetan medicine practitioners of all generations and of both genders, but the range and depth of the practical application of this knowledge and clinical work in this field differs vastly. 2. Their diagnosis and treatment of diseases and complications for mothers and children are based on core medical ideas of Sowa Rigpa, such as clinical gynaecological and paediatric conditions discussed in the foundational Four Tantras work, its commentaries and a widely-used specialised modern college textbook (Byams pa sgrol dkar 2011). In some cases practitioners and specialised hospital departments in urban areas have started to incorporate considerable western (bio)medical knowledge and practice with Tibetan medical approaches, for instance the use of ultra-sound technology, (pap)smears, use of antibiotics and/or referral of women to mainstream biomedical obstetrics hospitals or departments. 3. There are active debates among Tibetan medical doctors and administrative staff whether more specialised knowledge in the field of Tibetan medical gynaecology and paediatrics should be promoted, that is specialisation be increased further within the tradition, or whether training and knowledge of maternal and child health should be increased among amchi in general. Due to costs of training and only one Tibetan hospital across all five provinces having also an obstetrics wards (in addition to a gynaecology ward), it would be unlikely that both paths to improving the level of understanding and practical expertise in maternal and child health could be achieved. 4. Tibetan medical doctors treat a wide range of genealogical disorders with Tibetan medicines. Tibetan medicines, such as Shi che 11, Shiche 6, Agar 8 and others are commonly given for the birth of children and the placenta, as well as to calm women during labour and stop haemorrhaging during and after birth. In rural areas amchi regularly give such medicines to women in preparation for birth at home and older female relatives usually know at what stage these should be taken. In urban areas the use of Tibetan medicines during or after birth is not common any longer as most women give birth in biomedical obstetric facilities.5. The increase of women among Tibetan medical students and doctors since the 1980s as well as the creation of specialised gynaecological departments in hospitals and dedicated medical college courses in moné have meant that the practice of Tibetan medical gynaecology and paediatrics has become more visible to patients and also more developed among amchi, improving their knowledge and practice in this field. However I have also found male doctors without any specialised training in moné, who were working in general Tibetan medical clinics and were having substantial knowledge as well as regular clinical applications in treating moné. This was even the case with several monks who are also amchi.6. Five interviews with older female Tibetan amchi who have lived through the wide-ranging Communist reform period since the 1950s as well as the study of the seminal (auto)biography of the Buddhist teacher and medical doctor Do Dasel Wangmo from Kham (in Eastern Tibet), demonstrate starkly different ways of learning of female and male amchi before the start of the modern educational set up in the 1980s. While many male amchis’ learning was grounded in textual learning and scholarship (especially in monastic contexts), clinical experience was gathered at later stages in the training and during practice. Female amchi, however, did not have easy and open access to textual learning, but were often engaged in the very practical tasks of plant collection and learning about treatments by close observation and practice, at times without any substantial study of even the foundational medical text Four Tantras.OutlookResults from the latest field research stay in Eastern and Central Tibet are currently written up in two more peer reviewed journal articles and will be sent off to high-profile journals by the beginning of May 2015. Future work should also include Bhutan (permissions forthcoming) and Ladakh in a study on Tibetan medical maternal and child health, as there have been concerted efforts to upgrade traditional medicine practitioners to involve them in rural maternal and child health care activities. This would serve as useful comparison with the materials gathered during the project in Tibet. Due to the of closure of most international NGOs in Tibetan areas of the PRC, and a trend towards the use of biomedicines through the public health care system, Tibetan medical amchi will most likely be further marginalised in rural areas, and whatever limited contributions they have made to rural maternal and child health be further limited. A promising new domain for the work of professional, female Tibetan amchi is the Arura Hospital in Xining, which has the largest specialised Tibetan medical gynaecology department. Dissemination ActivitiesDetailed discussion and analyses of the results and findings, as well as on topics closely or loosely related to the project, are found in several already published and several immanently forthcoming publications. Among these is a special issue of the Asian Medicine Journal on the topic “Women and Gender in Tibetan Medicine” (co-edited with Dr. H. Fjeld, published by Brill). This volume includes an introductory essay by the co-editors that reviews gendered productions, transmissions and practices of Tibetan medicine; the representation of women in medical literature and illustrations; and Tibetan medicine and reproductive health. The special issue contains five specialist articles by leading scholars in the field, and is available in print and though open access online. Results from the project have also entered my Tibetan Medicine on the Margins monograph, especially in the chapter titled “Beyond Medical Houses: Monks and Nuns as amchi and the limited Reach of the Tibetan State”, forthomcing with the University of Washington Press (2015). I have furthermore given 4 invited lectures and presentations at international workshops and/or departmental and public lecture series, and given 6 papers at international conferences and workshops some of which have become chapters in the conference proceedings. My work has featured prominently in the media, for instance in 2014 there were 6 major articles, among them one feature article in the New York Times, about an exhibition on Bodies in Balance: The Art of Tibetan medicine that I curated and organised for the Rubin Museum of Art in New York (open March to September 2014). The exhibition was seen by almost 40.000 visitors and was accompanied by an peer-reviewed book of the same title with a total print run of 2500. I have also helped organise one international scholarly conference and one local workshop, as well as co-organised and raised funds for the Oslo Buddhist Studies Forum to hold regular lectures by international academic guest speakers (Sept 2012 – Dec 2014), here at the University of Oslo. I have also for one year run a reading group on Asian Medicine at my host department, at the Section for Medical Anthropology and participated in several departmental and interdisciplinary seminar series in medical anthropology, medical history, and Tibetan studies.