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Department of Anthropology University of Colorado at Denver

Imagined Lives, Suffering, and the Work of Culture: The Embodied Discourses of Conflict in Modern Tibet
This article explores the cultural epidemiology 0/rlung ("loong") disorder among Tibetans living in the cities and towns of the modern Chinese state of Tibet. Rlung, glossed as air or wind, is the most important of the three humors of the classical Tibetan ethnomedical system. Considered by Tibetans to be contingent upon multiple social, emotional, and religious phenomena, rlung disorders are fertile ground for the development of etiological discourses that incorporate the social and political crises that are part of the rapidly changing Tibetan plateau. In this essay I locate rlung disorder in a confluence of Tibetan ethnomedical constructions of the mind-body-universe linkage, in which rlung stands as the chief symbolic mediator, with ethnic conflict, rapid economic development, and the localization of global debates over Tibetan suffering and human rights. [Tibet, ethnomedicine, politics, economic development]

The Chinese have been destroyed by suspicion; the Tibetans have been destroyed by hope. Common saying, Lhasa, 1991 If Tibet had to be conquered by a foreign invader, why couldn't it have been a rich country like America or England? Then at least we'd have improvements like water and electricity, and maybe even color televisions. Why did it have to be by one of the poorest countries in the world, one that only takes our resources? Tibetan laborer, 1991


lung (pronounced "loong") is the Tibetan term for wind or air and in medico-religious contexts is related to the "life force."1 If rlung is out of balance in the body, or if it is too slow or too quick in its circulation, a variety of sometimes serious symptoms result, ranging from dizziness to high blood pressure,

Medical Anthropology Quarterly 13(4):391-412. Copyright© 1999, American Anthropological Association. 391



heart palpitations, dysphoria, and, ultimately, insanity. It is the most commonly diagnosed humoral disorder in Tibet today. In this article I examine the cultural epidemiology of rlung disorder in modern Tibet. I also consider the degree to which popular Tibetan conceptualizations of rlung disorder, that is, rlung discourses, have been widened to admit the politics of the cosmopolitan, Chinese, and Tibetan engagements over Tibetan autonomy, independence, and human rights. The starting points for this analysis are the different but, I argue, complementary theoretical perspectives on the nature of culture and its relationship to experience offered first by Obeyesekere (1985) and later by Appadurai (1991). In what has become an influential essay on the relationship of culture to depression, Obeyesekere introduced the concept of work to assist an understanding of the processes by which Buddhist culture normalizes depressive affect:
The work of culture is the process whereby painful motives and affects such as those occurring in depression are transformed into publicly accepted sets of meaning and symbols . . . the constellation of affects . . . can, through the work of culture, be transformed in a variety of directions—into Buddhism and spirit attack and no doubt into other symbolic forms also. [1985:147-148]

In such fashion, Obeyesekere argues, depressive affect in Buddhist cultures is contextualized as insightful appraisal that the world apprehended through the senses is impermanent, illusory, and unworthy of ego-involvement (i.e., attachment). The work of culture in this sense is to elevate the pain and suffering of an individual nature to an occasion of reflection on Buddhist ontology, thereby, presumably, muting and even transforming it into an opportunity for revelation. With this perspective, the task for people becomes not how to avoid suffering or how to recoverfromit, but rather, how to suffer gracefully, employing and manipulating the symbolic devices available for doing so. The idea of cultural "work" directs attention to the constructed nature of reality as it pertains to affect and psychic suffering. For the anthropologist, this perspective nicely articulates the constructed, predominately social nature of emotion, now the generally accepted orientation in psychological anthropology (e.g., Lutz 1985; O'Nell 1996), and a perspective increasingly acknowledged by psychiatric epidemiologists to explain cross-cultural differences in psychopathology (e.g., Weissman et al. 1996). The challenge in studing of the meaning of suffering is to identify and describe how, and the avenues by which, culture works to transform painful feelings into publicly acceptable sets of symbols or, alternatively, to examine how individuals seize upon and manipulate these symbols to articulate their distress in locally meaningful terms. My emphasis is on the development of Tibetan medicine in interplay with the transnational flows of people, information, and public symbols that affect day-to-day life in the heavily touristed and rapidly changing Chinese-Tibetan cities of the Tibetan Plateau. Appadurai's (1991) comments are particularly apt in this regard. He suggests that the study of cultural dynamics must include reference to the phenomenon of deterritorialization: the character of modernity whereby ethnic groups and communities, among other social formations, operate according to principles that transcend territorial boundaries and identities. Most importantly, a deterritorialized world, crosscut by currents generated by mass media, tourism, migration, and capital, allows people in what were once

rapid economic development. I locate rlung disorder in a confluence of Tibetan ethnomedical constructions of the mind-body-universe linkage—in which rlung stands as the chief symbolic mediator—with ethnic conflict. Tibetan Buddhism. but often as the ironic compromise between what they could imagine. Most importantly. in the torture and imprisonment of its citizens. Tibet. and Tibetan suffering on the one hand. .. Prisoners of conscience. What are the stakes held by the West for constructing the kind of suffering in Tibet paraded in the international media. Western fascination with Tibetan Buddhism. and a growing Western-spawned outcry over "human rights" are part of the total context in which Tibetans bring new meanings to the pain and suffering expressed in rlung discourses. women who toil in the fields and factories of the world.3 Here I summarize the nature of the Tibetan medical system. thus. 1996b)? Growing world-wide debate over the Tibet question between the West and China. and expressive processes of cultural work. Appadurai writes: More persons throughout the world see their lives through the prisms of the possible lives offered by mass media in all their forms. and what social life will permit The biographies of ordinary people. and others whose lot is harsh no longer see their lives as mere outcomes of the givenness of things. are constructions (or fabrications) in which the imagination plays an important role. it enters. fantasy is now a social practice. what stakes compel Tibetans to accept or respond to such constructions (see Adams 1996a. I argue that the determinants of rlung disorder can be found in the social facts of structural discrimination and related economic injustice.. touristed Lhasa may deflect attention from these facts in favor of a principally Western-based framing of Tibetan suffering which locates it in the destruction of Tibetan religious culture. [1991:198] Suffering. and the realities of Chinese modernity on the other. Contemporary Tibetan cultural patterns must therefore be seen as developing within a context in which an ironic compromise is apprehended. subject to the definitional. with particular reference to disorders of the humor rlung. child laborers. the harshest of lived inequalities is now open to the play of the imagination. and provide a brief description of the Tibetan medical system as it is presently organized and deployed within the Tibet Autonomous Region (TAR) of China. and in state oppression (Adams 1996c). and conversely. a compromise between cosmopolitan ideas about the natures of Tibet. and the localization of the global debate over Tibetan suffering and human rights. may itself be partly fabricated out of the imagined lives and possible social existences to which Tibetans compare their own. principally urban. In the essay that follows I present a cultural-epidemiologic analysis of rlung disorders in central. in a host of ways into the fabrication of social lives for many people in many societies What is implied is that even the meanest and most hopeless of lives.SUFFERING AND THE WORK OF CULTURE IN MODERN TIBET 393 circumscribed local communities to now envisage and imagine possible alternative lives.2 Tibetan Medicine and Rlung Disorders I have provided a general cultural outline and modern history of contemporary Tibetan medicine elsewhere (Janes 1995). the particular modes of its expression and representation in modern. Tibetanness. the most brutal and dehumanizing of circumstances. transformative.

rlung contributes to palpitations. etc. Illness experiences are matters of diverse origin. For example. In Tibetan medical theory. "heart swings. and humors within the body that have gone out of equilibrium due to "improper" thought and behavior. in the stomach and intestines. and in the genitals. the standard practice these days (see Janes 1995)—described it in this way: "When one eats food. fainting. fluttering heart beat. Healing is approached on three levels: the spiritual or dharmic.'dzin-rlung) empowers the senses. In the heart. lightness. it causes the transformation of food into energy. dryness. the affected parts reflect the mapping of different "kinds" or "levels" of rlung on particular ethnoanatomical systems. the heat or fire of the stomach digests it. A young Tibetan physician—educated in basic biomedicine as well as Tibetan medicine. Although a classically naturalistic humoral system quite similar to Ayurveda. and supernatural forces. in the heart. but also heavy/slow or quick.) lead to dysfunctions in these ethnoanatomic regions. insomnia. substances. geographic. suggests a complex subjectivity that integrates the mind-body with the social and natural universes in a host of ways. Tibetan physicians often describe rlung metaphorically as the "king" or "integrating principle" of the mind-body. Rlung is what allows the food to enter the organs and muscles of the body and become the energy one needs to walk or think. rlung compels the heart muscle to beat and the blood to circulate. even among state-educated Lhasans. dysphoria.394 MEDICAL ANTHROPOLOGY QUARTERLY Classical Tibetan medicine combines South Asian and Middle Eastern naturalistic humoral theory with Buddhist principles and tantric practice. bladder. depression." Rlung imbalances may affect different parts of the body. tantric healing is intended to align the vital energies (rlung) within the body which connect it to its phenomenal existence. as well as the actions of supernatural beings aroused in the course of social events and personal behaviors. gives rise to action. rlung causes shortness . The three humors of Tibetan medicine—phlegm (bad kan). and the somatic or humoral (Clifford 1984. cognition. Dharmic healing is a spiritual practice aimed toward enlightenment. at remote causal levels Tibetan medical theory invokes the different modes of Tibetan Buddhism (Samuel 1993). In classical Tibetan medical theory. Rechung 1973). and insanity. dizziness. rlung is the integrator of such manifold forces. But the digested food cannot nourish without adequate rlung. and chest. quick moving. in the chest. and emotion. from diet and climate to emotion or mental agitations. and wind or air (rlung)—represent the confluence of climatic. heart. rlung causes disordered thinking. in the brain. and brings sentience to physical matter. the subtle (vital) or tantric. Imbalances of rlung and changes to the character of rlung (slow moving. bile (mkris pa). in less severe forms. it gives rise to respiration and speech. and colon. rlung may not only be high or low. In the brain. the humor rlung is that which animates. For example. Common symptoms are those that derivefromdisorders of rlung in the brain.ringingin the ears. rlung (as srog. In the chest area. dietary." and a rapid. spiritual. breaks it down. Imbalances have their own particular characteristics that determine which symptoms will appear and which will be the most troublesome. The pervasiveness of multiple modes of ethnomedical thought among Tibetans today. social-behavioral. and humoral medicine—the material elements of healing that constitute the most visible aspect of the tradition—balances elements. it empowers reproduction and elimination. and impaired sensory perception.

this life principle is subject to the actions of deities and often involves ideas about good or bad fortune and polluting places and activities. behavioral. Rlung is also believed to be the force that maintains the movement of blood through the body. Inborn levels of rlung can be influenced by a number of things. at least not in government medical clinics. and the life force (called srog-rlung) are more common. Severe and irremediable srog-rlung is synonymous with insanity. and lessons . rlung is polysemantic. Treatments for rlung are largely similar to treatments for the other humoral imbalances: herbal medicines. insertion of small gold needles into the top of the scalp. Rlung varies naturally between people and within an individual over one's lifespan. The amount of rlung one has is an inborn trait. as I will discuss in detail below. Rlung is central to a set of body-mind principles whereby culture "works" to push painful affect and bodily dis-ease along several significant cultural paths: Buddhist lessons about impermanence and the suffering created by attachment and desire. Both physicians and patients. In its cultural productions and social manifestations. dietary pre. social lessons about kin reciprocity. elements of tantric practice.SUFFERING AND THE WORK OF CULTURE IN MODERN TIBET 395 of breath and pain in the sternum. Intertwined in the classical medical texts—the rgyud-bzhi (the four tantras) and related commentary—with the essential Buddhist teachings regarding the inevitable suffering that derives from attachments to the world. but rarely practiced these days in Tibetan clinics). ranging from karma to the behavior of the mother. for older people and women to manifest. multiple modes of thought: classical Buddhist principles. and a host of lay theories of this-worldly misfortune (Janes 1995. It is "natural. hence. hence. called khrag-rlung). disorders of such movement. often simultaneously. which often goes through to the upper spine (pain is especially significant between the sixth and seventh thoracic vertebrae). the problems associated with rlung imbalance. On rare occasions rlung sufferers may be offered some simple. in the context of otherwise shared social. or "variable" blood pressure. simple behavioral advice. are attributed to rlung imbalance. rlung also refers to the "life" principle or consciousness (the subtle or "vibratory" body) that is manipulated through tantric practice. Rlung discourses thus invoke. are well aware of the social salience of rlung.and proscriptions. what we recognize as clinical psychoses or depression are consistently identified as severe srog-rlung by Tibetan physicians and laypeople alike. but this does not appear to be an explicitly recognized feature of rlung diagnosis and treatment. Lichter and Epstein 1983)." according to Tibetan medical theory. low." Rlung is also thought to increase naturally as one ages. is considered superior. in this case through desire ('dod-chags). One of the sources for concern among contemporary Tibetan physicians is the degree to which rates of rlung imbalance are increasing in younger people of both genders. the circulation of blood (high. or environmental "insults. and Chinese-style acupuncture are most commonly prescribed (Tibetanstyle acupuncture. high or low blood pressure (the latter producing fainting. One's essential character may be predisposed toward or protectedfromrlung imbalance and. Rlung imbalances that affect the heart (called snying-rlung). In lay Tibetan terms. to an unequal degree. lessons about proper mind and thought management. for example. part of one's essential character. rlung disorder. and to affect women more than men. or "losing the power of the body"). formulaic advice about "quieting one's thoughts" or managing or avoiding conflict with family members or coworkers.

Nearly every county medical facility and many townships have one (or more) traditionally trained Tibetan physician. but. a comparable group of individuals attending Tibetan medical clinics who did not have a rlung diagnosis. Rlung disorders are among the most common brought to Tibetan medical practitioners. disappointments. and a small group of Tibetan physicians considered to be experts in rlung diagnosis and treatment (see endnote 2). Centered in Lhasa. Qinghai. rlung stems from the corruptions of desire for that which is considered culturally valued. which was largely consistent with physicians' views of rlung etiology and distribution. both secularized and "scientized. The Tibetan Medicine Hospital in Lhasa now boasts more Tibetan physicians practicing in Tibet than at any time in Tibetan history. The extent to which rlung discourses have been opened up to admit purely political sentiments was investigated through interviews with rlung sufferers. I direct attention specifically to the sometimes subtle differences that emerge when comparing the epidemiological view constructed through systematic interviewing and analysis. and the view of rlung as a diagnostic category articulated by Tibetan lay people. spirits. that is. to some extent. The training is. the Tibetan medical college and the provincial Tibetan Medicine Hospital of the TAR have trained thousands of Tibetan physicians. The potential for the explicit politicizing of rlung illness here is a potent one. more subtly in some . What follows is a mix of quantitative and qualitative findings. and Yunnan provinces. Western desires for a certain kind of suffering Tibet. physicians and their patients bring quite variable understandings to the sources of rlung imbalance. and cherished (Janes 1995). and dashed expectations. I begin here with a description of the epidemiology of rlung in modern Tibet and then turn to a discussion of the meaning of rlung as articulated by these different groups. Interview results coincided with physicians' perceptions in locating the greatest number of rlung cases among those with more formal state education and correspondingly demanding jobs in large government work units." particularly as Tibetan medicine struggles to maintain legitimacy in the face of the powerftil impetus to adopt Western science and biomedicine now characterizing medical traditions in China. Accordingly. and good or bad luck.4 Since 1980 there has been a rapid development of Tibetan medicine in China (see Janes 1995). although it remains to a degree rooted in the traditional tantras and related commentaries that date in "modern" form to the early 18th century. Sichuan. "Like Trying to Lift the Sky with One Finger": Cultural Epidemiologies of Rlung The polysemantic quality of rlung makes it an effective means to respond to and articulate the impacts of modernity of the Chinese variety or. Contemporary and largely secular interpretations of rlung tend to focus on social and personal disjunctures. in a kind of inversion of classical Buddhist thought.396 MEDICAL ANTHROPOLOGY QUARTERLY about the inherent vagaries of demons. A recurring theme here was not only the demanding nature of the positions. the majority of whom are employed in government hospitals and clinics throughout the TAR and in Tibetan counties and prefectures principally in Xinjiang. appropriate. ranging from narrowly framed ideas about ego attachments and "mismanaging thoughts" to articulations of profound personal and social crises. I begin with a presentation of the qualitative material. increasingly and ironically.

Tsering is a 42-year-old worker in a foodstuffs factory in Lhasa. her head aches almost constantly. underscored by strong emotion: she is dizzy. extensive contact with Han Chinese in their day-to-day working lives. Promotions in his company have been awarded on the basis of personal networks established with senior. Tsering attributes his symptoms to his work situation. has quite literally found himself situated between Tibetan sentiments and Chinese interests: . Dawa (age 54) launches immediately into a rapidly spoken litany of complaints. patients often expressed overwhelming feelings of immobility. feeling as if it were swinging wildly in her chest. which he terms khrag-rlung. subject to some loathing on the part of the Tibetan populace: Clearly anxious and agitated when she sees the doctor. When we interviewed him. is "unhappy. "As long as you keep working your problem will continue. she says. they felt stuck in untenable positions. had substantial contact with the Chinese. It turns out that he has been in the same work unit for 25 years and has not achieved a promotion that he feels he deserves." Tenzing. Many had been sent to China to work or study. They. principally Chinese. Dawa is an important government official in the regional TAR office that sets commodity prices. Later in the interview he talks at some length about the injustices and discrimination he has experienced at work. He is in a managerial position. She is diagnosed with snying-rlung. experiencing systematic discrimination at the hands of Chinese supervisors. his salary has remained low. she is frightened by her heart.SUFFERING AND THE WORK OF CULTURE IN MODERN TIBET 397 cases. Passed over for promotions. The physicians we interviewed directed us to another group of rlung-sufferers who. Tsering is typical of a large number of rlung cases in that the demands of employment and difficulties with Chinese supervisors are the main themes of his narrative. like those above. which the doctor tells her is very serious. Despite their sometimes quite high positions in work units and government offices. management. which he admits creates some worry for him. an imbalance affecting the heart. she dreams of her father who died several years ago. difficult day-to-day contact with Han Chinese. as a consequence. perceiving themselves to be both exploited and unfairly deprived of access to promotion and salary increases. and. in some cases. were relatively well educated. and worked in the government sector in clerical and administrative positions." Her job is difficult and causes her much worry and anxiety. he reported symptoms of upper back pain and frequent insomnia. Some were obviously struggling to maintain the identity of the ideal "minority" celebrated in Chinese propaganda literature. She needs to be hospitalized as soon as a bed opens up. All had firsthand and. Despite his long years of service. most of the rlung sufferers we interviewed were principally urban dwellers. many of whom wield power over the Tibetan staff. Like Tsering. and had few (if any) available avenues for changing the social context of their work lives. and this in turn has placed significant economic pressure on his family. a policeman. She has trouble sleeping and when she does. and snying-rlung. were often angry. a controversial office. Her body. He has a history of high blood pressure. expressed a conflict at being caught between Tibetan and Chinese interests in one way or another. The doctor tells her. however.

physicians. dry mouth.). his younger sister. that they did not finish school or were unemployed. and he had to travel to his home village. Second. chest and back pain. to take care of affairs.398 MEDICAL ANTHROPOLOGY QUARTERLY We spoke to Tenzing (age 53) in the hospital where he had been an inpatient for a total of three months. It was at this time that he first noticed the ringing in his ears. fracturing his skull. place of residence. anything that causes him to be nervous or anxious will intensify his symptoms. schooling. . Drinking problems and unemployment were the two most commonly articulated themes. As with the sufferers of neurasthenia described by Kleinman (1986). which made him very nervous. He considered this unfair. insomnia. and Tibetan laypeople in general often reference what they call "family troubles" in discussing the probable remote causes of rlung illness. Overt references to social or political conditions in the narratives of rlung sufferers was relatively rare when compared to discussions of employment. was sent to far western Tibet. or economic problems. over 400 km south of his home town of Tsedan. about 50 kilometers southwest of Lhasa. pressures from family members to live a life they did not particularly want to live (in terms of work. He traces the onset of his symptoms to the previous year when he had "many bad family problems. a disruption of peace in the family. particularly for women. He is very clear about the causes of his rlung. In narratives of rlung sufferers. particularly taking care of their elderly mother. The anger often brings on dizzy spells. he has had many arguments with hisfiance*e. ticking them off on his fingers as he speaks. He links the onset of these symptoms to the beginning of "troubles" in Lhasa between Tibetans and Chinese which put him "in the middle. Finally. anxiety. He ruminates on all of these problems. he struck his head when he fell to the ground. He's hoping to be able to be released from work until he can retire. it makes him incredibly angry." which caused him to become dizzy. for example. with whom he is close and who studied at a prestigious banking school in China. Every time he thinks about it. Third. unhappiness. The last time he fainted. serious demonstrations began in early 1987 and continued sporadically through March 1988. Currently. dizziness." which keeps this sister from tending to family obligations. We talked with him at the Tibetan medical hospital in Tsethang. presentation of family problems took three forms. there was nothing they could do about it. his mother died. family troubles. with frequent arguments. The second source of family problems had to do with the behavior of a spouse.causing the couple to separate and call off their marriage. Rlung sufferers. Thefirsthad to do with disappointments or concerns over children's lack of success. and a cold sensation in his lower back. when martial law was imposed). When he returned to Lhasa he said things seemed very chaotic and that there were a lot of "sounds" in the city. but because his family does not have "backdoor" contacts. he says. etc. discussion of social changes and political factors were sometimes invoked to explain current economic difficulties." He described the following series of events: About six years ago (this would make it about 1987-88. occasionally fainting. his other sister is married to a "very bad man. People were yelling and screaming and there were sounds of gunfire all over the city. First. particularly when he joins his work unit. informants sometimes characterized their family life as conflicted. and. is a clerical worker for a public security office in south-central Tibet. Phuntsok. He's particularly sensitive to the insults he receives when he is on duty in the Barkhor (central market and circumambulation route of old Lhasa). His symptoms of rlung began four years ago and include chronic headache. age 25.

She has not been able to avoid thinking about it since. Family problems. and she had her livelihood. Theriskincreases over two-fold for those with a "professional" occupation or those who mentioned in their interviews that they had serious economic problems. accompanied by insomnia and bad dreams. the monk was dragged into a waiting van and driven off. Table 2 presents the results of a simple and straightforward epidemiologic analysis of the themes presented in the case studies above. and both now survive through begging.5 Physicians' interpretations of rlung etiology and epidemiologic distribution are. About a quarter of the rlung sufferers related their condition explicitly to political issues." thinking over and over about this obviously distressing event. she was not permitted to work. They have sold all of their remaining possessions and are now desperately poor. political events witnessed or experienced personally are related explicitly by informants to the onset of their symptoms. especially problems with children. or personal experiences with state discipline or terror. the usual forms of socioeconomic security promised by the socialist state are not available to this family. Proximate causes related to strong emotions and/or failure to manage such emotions were cited as significant by 27 percent. while always high. and reportedly died of starvation with his compatriots sometime later. it is possible to appreciate the nature and potency of the social and economic risks that arise in segments of the Tibetan population by virtue of Chinese modernization programs (discussed further below). For political reasons largely outside of their control. three weeks before the visit when she looked out her apartment window and witnessed a monk being beaten by police. recognized as a reincarnate lama. She has been subjected to a series of punishments and humiliations since that time: she was given housing next to the toilet. as noted. often consistent with the epidemiologic perspective presented here. has increased with "modern social changes. In a few cases. framed principally as Chinese oppression and loss of Tibetan autonomy. the alcoholism of a family member. confiscated and given to a work unit. In comparing rlung sufferers to a non-rlung suffering clinical sample matched by age and gender. of the supervisory positions. Her husband was part of the Khampa resistance in eastern Tibet. Her symptoms began. Physicians tell us that the prevalence of rlung. where she herself eventually went to work. and chronic unemployment of family members were presented as determinants of rlung symptoms by 37 percent. a young student at Tibet University. witnessing beatings and demonstrations. Drolma. Her son has not been allowed to join a monastery. Her father was involved in the Tibetan uprising of 1959 and died in prison several years ago. and her mind "seems out of control.SUFFERING AND THE WORK OF CULTURE IN MODERN TIBET 399 Nyima is a 68-year-old mother of four with no education who lives with her 38year-old son. an old sewing machine imported from India by her late husband. After being knocked bloody and senseless. which she was not allowed to use." Many cite the turmoil of*the cultural revolution as . she says. Table 1 summarizes the quantitative data on these rlung cases and a matched comparison group. The odds of having a rlung diagnosis in this particular study increase more than four-fold for those who have had experiences in China or who are working in settings where Han Chinese hold many. if not most. but was captured and imprisoned in 1957. is such a case: Drolma (age 22) presents symptoms of dizziness and headaches.

1991-1993.6 Other physicians expressed models of causality that emphasized Buddhist principles regarding the suffering that derives from attachment. who in effect cannot cope. fright. unit administrative work Experiences in China. and grief.400 MEDICAL ANTHROPOLOGY QUARTERLY TABLE 1 Characteristics of individuals diagnosed with rlung imbalance." That is. sadness. Characteristics rLung Cases (N = 41) Controls (N = 38) Men Women Mean Age Marital status Married Single Widowed/divorced Mean years of state education More than 6 years of education Primary rlung diagnosis sNying-rlung Srog-rlung Trak-rlung Other rlung Chronicity of primary diagnosis One year or less More than one year Government or high-level work. disappointments with children and other family members. and arguments and fights in the family. Some noted that rlung imbalance is a problem related to "narrow mindedness" or failure to "control the mind properly." Lhasa. anger and frustration over the current political situation. job problems or frustrations stemmingfromcareer immobility. people who are inflexible. the trauma of the Cultural Revolution and similar events. in predominately Chinese work-unit Unemployed Economic problems 20 21 46 19% 19% 41% 68% 21% 11% 2 18% 68% 17% 15% 4 38% 42% 20% 22% 16% 32% 68% 29% 46% 10% 27% N/A 42% 58% 13% 16% 11% 16% having produced a near epidemic of rlung illness in the late 1960s and early 1970s. are most likely to develop flung. . The following factors were the most frequently cited: rapid social change. compared with "controls. These were explanations that emphasized individual psychological/emotional states that produced the bodily symptoms of rlung such as anger. in Army. poverty or money worries. About one-half of the physicians identified social causation as primary to rlung disorder.

71 2. With lines of patients snaking out the door. it is striking to note the apparent trivializing by physicians of the concerns expressed by patients.2 percent) followed closely by the general categories of stomach ailments and "infection" (17 percent each).32 . the physician can do little except focus on the immediate and individualized problem and apply the material "magic" of the medicines (van der Geest and Whyte 1989). and rest (Scheper-Hughes 1994). herbal medications.64-6. The higher numbers of hospitalized rlung patients and the longer average stays of such patients is consistent with physicians' beliefs about the seriousness of rlung. In the rlung cases we observed in both in. taken from interviews with physicians and Tibetan lay people (non-sufferers of rlung): . some form of rlung imbalance was the most commonly given diagnosis (18.14* .78-9. physicians barely have time to get beyond the most superficial level of interaction. The proportions of rlung patients seen were relatively consistent from one outpatient context to the next. This raises the problem of "medicalization. Yet there is widespread sentiment among lay people and physicians that rlung is.71 . The average stay for all patients treated at the Mentsikhang inpatient hospital is three months. indeed listening intently to the encounter.96 2. where quantitative aspects of patient encounters loom ever larger as justifications for state support and legitimacy. In this highly rationalized medical bureaucracy. Controls = 38 (matched by gender).SUFFERING AND THE WORK OF CULTURE IN MODERN TIBET 401 TABLE 2 Epidemiology of rlung: case-control analyses. a political consequent. lack of advancement At least a lower middle school education Government or work-unit administrative position * Statistically significant Odds Ratio 4. and many witnessing. with slightly higher proportions of rlung found in urban areas and inpatient hospital settings.61 1.86-10.73 95% Confidence Intervals 1. at least in some form. Consider the following statements. Of all the patients admitted. Characteristics Extensive experience in China or with Chinese in work situations Significant economic stress." the transformation of problematic emotions and social disorders into simple individualized problems containable by diet.and outpatient settings.44-16. 22 percent had some form of rlung diagnosis. our data showed that rlung patients stay a bit longer than this.99 In observations of 718 clinical exchanges conducted in 1991 and 1993. In 1993 we conducted two separate censuses of the Tibetan inpatient hospitals in Lhasa and Tsethang. The complex of proximate and remote causes specific to an individual narrative seems easily transferable in general discussion to political discourses of how Chinese political hegemony causes Tibetans to suffer. Cases = 41.

Lhasa] Rlung [is] more common nowadays because Tibet is no longer free. It is most common in the city. [35-year-old male bureaucrat. increasing awareness of the outside world. These are very tumultuous times. with increasing education. They are more likely to develop a rlung imbalance.402 MEDICAL ANTHROPOLOGY QUARTERLY Rlung is caused by the social situation..One person can't do anything. Lhasa] Great sadness and anger will cause rlung. To assume that all Tibetans are alike is to dissolve these multiple divisions into a unitary subject and thereby miss the complexity that characterizes Tibetan responses to their current political and economic situation. If you see an official beating up local people. They also have little education. worries. and increasing contact with cosmopolitan representations of the. because there is nothing you can do about it. and so rlung must be more common. I suggest that Tibetans. particularly with non- . the complexity and multiple layering of rlung etiologies in popular as well as professional discourse. young and old. but of those attempting. Rlung used to be found only among old people. as the subaltern Other in this context. and yet people are not free to do anything about it. [46-year-old male physician. many of which are class-based and predate Chinese contact. and so they get pain in their body. they only think about immediate things. and an epidemiologic profile suggesting that it is not necessarily those with the least power who experience rlung argue against such a simplistic position. I direct the reader's attention to the details of the epidemiologic distribution of rlung: it is a disorder not of the weak. so now everyone. the highly flexible and fertile symbolic ground provided by rlung in a purely Tibetan cultural sense. Internal divisions and tensions in Tibetan society exist. are not a unitary group.. Rlung in an epidemiologic sense is about the denial of justice to some in a social and economic context that champions social equality. [36-year-old male carpenter. has rlung. Lhasa] It is tempting to read these statements as revealing rlung as a "medical weapon of the weak" (Scheper-Hughes 1994. Education improves one's awareness of the world. and so forth. Following Ortner (1995).. to be upwardly mobile. cited in Janes 1995:31] Rlung is common today because of the many changes in society and ways of life. However. Yet what can we make of statements made by physicians and lay people alike that certainly have the potential for politicizing rlung? One clue may be found in the remarks of one of the physicians cited above: Tibetans. People in the countryside do not think about the future or the larger picture. It is not fair or balanced. It is a result of social immobility and frustration arising from no freedom of movement. All Tibetans have problems with rlung because they are not able to move about freely. It is like trying to lift the sky with onefinger. Now it is everywhere. The Chinese government makes people unhappy. It is not dissimilar to so-called disorders of social change or "modernization" found worldwide (Christakis et al. The Chinese government is the government of rlung. in many cases. It was quite clear in many of our interviews. As an alternative. [56-year-old male physician. it causes pain. It is not a matter of political oppression as much as it is the denial of proffered equal rights to participate in China's rapid economic modernization on the basis of ethnicity. desires. are opened to new images of themselves. 1994). Tibet question. Scott 1985). Seeing the big picture opens up people to attachments. Lhasa. Tibetans have rlung because they are not free. Most people today have rlung because of the nature of society.

who have a certain stake in maintaining an exotically religious Tibetan Other. I turn to a consideration of the modern politicization of everyday life in Tibet. however. and Body Politics There are a number of cultural players on the scene in modern Tibet. it is probably best to distinguish rlung imbalance as a diagnostic category. This Westernized version of Tibet is often adopted and exploited by the exile government in Dharamsala. largely non-Tibetan representational interests. Tibetan refugee communities and the Tibetan government-in-exile. anthropologists. On the one hand are the various institutions of the Chinese state that have exercised direct control over Tibet since the 1950s. to talk about personal or individual freedom. but increasingly important. Popular rlung discourses. from popular rlung discourses. rlung represents the unsuccessful outcome of these struggles. and a block of right-wing Western political ideologues who see in a certain kind of Tibetan suffering a useful way to demonize China. and organizations on the global scene that exert a far more diffuse. particularly in touristed Lhasa. with a particular set of epidemiologic characteristics. and. in the most simple terms. To fully understand the multiple meanings and the political implications of rlung. As our epidemiologic analysis shows. in many ways a consequence of the wider. rlung discourses are an articulation of imagined lives made palpable by the now pervasive cosmopolitan representations of a suffering Tibet. Each deploys a distinctive representation of Tibet and Tibetans. however.7 Held firmly in the sway of these lines of interest and power are the Tibetans. To examine the sources of this contradiction. influence over Tibetan life and cultural identity. the stake is apparently in preserving aculturally distinct and "authentic" Tibet untainted by the socialist modernity proffered by China (Adams 1996b). is. and to articulate such descriptions in the language of oppression is part and parcel of the Western-Tibetan engagement—that is. In 1995. and. Epidemiologically. On the other are the multitude of individuals. tend to frame rlung disorder as oppression by the socialist demon. each with a stake in constructing a different kind of Tibet and proposing a certain kind of Tibetan.SUFFERING AND THE WORK OF CULTURE IN MODERN TIBET 403 sufferers. of course. In this mix are Western tourists. Such discourses shape the polysemantic character of rlung in such a way as to incorporate political ideas. to the West at least. who find in Western exotic yearnings a voice for their own political agenda. rlung is best characterized ironically as a disorder that stems from the failure of the socialist promise. hardly a homogeneous lot. ostensibly a matter with little real political importance. Often filled with anti-Chinese and pro-independence rhetoric. India. the exile government in Dharamsala and the Communist Party leadership in Beijing engaged in a heated debate over the reincarnation of the . who may struggle at a more fundamental. that many Tibetans describe rlung in social and political terms. Western concern with the "Tibet Question" has revolved principally around religious and cultural expression. A particularly illustrative example can be found in the conflict several years ago over the recognition of the reincarnation of a senior religious figure. poorly understood level for economic and social justice. interest groups. Chinese Modernity. Ironic Compromises: Dharma Bums. How it is interpreted and represented by patients. physicians. and each has a certain power to affect the local contexts in which daily life is conducted.

and the popularity of the Nobel Prize-winning Dalai Lama. which is conflated by many Westerners with humanrightsand social justice. the decision to repudiate formally and publicly the Dalai Lama's cultural authority is indicative of China's bristling sensitivity to an increasingly vocal international community that is strongly invested in a culturally "authentic" Tibetan autonomy. a principal of the Chinese Communist Party. failing economic reforms.10 The Chinese have likewise maintained an interest in Tibetan religion. and a shrill and escalating argument with the West over humanrights(Goldstein and Beall 1991. residual fascination with the "ShangriLa" myth (Bishop 1989). This latter argument has driven issues of economic and social justice. were it not for the dire human consequences that such action portends. Visits to what remains of the great monasteries around Tibet. and sites of the most grievous humanrightsviolations. and which. to the margins of the debate. humanrightsactivists. now primarily state museums. as I demonstrate. thus represents deeper and more fundamental representational conflicts over the status of Tibetan culture. It is the most critical signal to date. but this is an interest driven principally by the desire to package and commodify elements of Tibetan culture for sale to Westerners (Adams 1996b). Mullin and Wangyal 1983). resistance. wise charm that plays well in the West. that Beijing has chosen to abandon the reform policy and promises of autonomy it made to Tibetans in 1980 and to turn back to the heavy-handed domestic policies it had promulgated in Tibet in the post-Cultural Revolution decade. uncertainties created by the rapidly shifting sands of China's ethnic policy. a figure with charisma and a quiet. would be a delicious piece of post-modern irony.8 Why the state intervention? The political events surrounding the selection of the Panchen Lama are a culmination of recent efforts to repudiate the governmentin-exile and attack the most internationally visible elements of Tibetan culture. the Party aggressively repudiated the Dalai Lama's role in this affair and named its own reincarnation.9 Western visitors to Tibet regard the monasteries as the font of traditionalism. an autonomy that for most—travelers. has been thrust by these events into the role of Tibet's senior religious authority. but the culmination of half a century of troubled Han Chinese and Tibetan relations. are part .404 MEDICAL ANTHROPOLOGY QUARTERLY Panchen Lama. the selection of the new Panchen Lama was subject to the final approval of the state council and the personal endorsement of Li Peng. Tibetan culture. Thus a thoroughly atheistic. Playing politics with six-year-old boys is not just a capricious response of a paranoid regime (although this adjective may be appropriately applied in this case). and anthropologists alike—is exemplified principally in the practice of Buddhism. In the end. a matter which to all appearances has little real political significance. comprise the modern epidemiologic determinants of rlung disorder. Marxist leader. more importantly. Reportedly. a groundswell of support from the West (Goldstein and Beall 1991). just the problems that Tibetans articulate on a day-to-day basis. The growing popularity of Buddhism among the middle and upper classes in Europe and North America. Arguments over who has the authority to validate a reincarnation. Most significantly. associated by the West with the violent suppression of the Tiananmen uprising and in setting China's hard-line domestic policy. the political role of religion and religious institutions in Tibet has been largely sustained by the increasing stature of the government-inexile and. in fact. In fact. which. has resulted in a crystallization of world opinion around issues of religious freedom in Tibet.

several writers have acknowledged that a substantial portion of these subsidies were invested in losing propositions (Sharlho 1992). and occasionally documents related to government policy are passed on for conveyance to Dharamsala and the West. Tax relief and private ownership programs initiated at this time resulted in short-term increases in real income. pressing: lack of employment. The fact that. these advances have proven to be largely unsustainable. agricultural sector. for many Tibetans. The interplay of Western touristed desires around religion. The strong position it took on the reincarnation of the Panchen Lama is evidence of the current approach. invariably pro-Dalai Lama. however. are discussed with great relish. independence. Furthermore. Western desires for an authentically religious Tibet recognized and exploited by the Chinese for economic and political benefit create the potential for a Tibetan religious participation in which nationalist resistance is just as great a motivation as is the earning of Buddhist merit. Because a large number of the employees of state enterprises are Chinese. and nights filled with karaoke as they are to speak of dharma. freedom of religion. when permitted. not lost on the more independent young European and North American travelers. perceived discrimination.SUFFERING AND THE WORK OF CULTURE IN MODERN TIBET 405 of the standard package tour. The past several years have seen China recognize this problem and take a number of steps to deal with it directly. if not more. and the Dalai Lama (Adams 1996b). Among this group. who stay. photos. The Chinese duplicated in Tibet the governmental structures they had implemented in the more densely populated center of China." They fulfill in a direct way the desire for a Tibetan authenticity which rests within its once great religious institutions. rather than the rural. are equally. where letters. Two other factors impede economic development in Tibet. with everyone feeling (with some naive delight. they remain a locus of nationalist sentiment is. Beyond the Western gaze. Subsidies to raise output initially focused on state enterprises. and Tibetan resistance results in a relative lack of engagement with those local issues that.11 Such exchanges are the stuff of evening meetings in hotel courtyards and small Tibetan restaurants. benefiting the Chinese cadre and immigrants who are disproportionately represented in such enterprises. conspiratorial visits to monks and monasteries. resulting in a per capita greater number of government staff at all levels of the bureaucracy than anywhere else in China.12 Perhaps ironically. in the Tibetan hotels in downtown Lhasa. A heavy burden of administrative costs for the bureaucracy has siphoned off substantial portions of state funds that otherwise might have gone into subsidized rural projects. a massive subsidization in the form of extra benefits and wages is required to keep them in Tibet. These dollars. Even more money has been spent on what is termed Capital Construction Investment. however. although the state has tried to control the monasteries. intended in part to aid development of transportation and . and excessive government control over aspects of everyday life. religious expression might not have become so politically contentious if the economic reforms initiated in 1980 in Tibet by Chinese Premier Hu Yaobang had been sustained. young Tibetans may be just as likely to articulate desires for landcruisers. as well as for a desired engagement with an Other that is suffering at the hands of a state bent on expunging the influence of religion from daily life. corruption of Han officials. I suspect) part of "the resistance. cellular telephones.

In only three months in 1985 alone. Today. demand for consumer goods. A photo of the Dalai Lama. sometimes poor command of the Chinese language. The solution to these top-heavy impediments is. The extent of political reforms in Tibet were window dressing appointments of "rehabilitated" former Tibetan government officials to non-Party government positions. and they would either need to be absorbed into the underdeveloped local. With a burgeoning Chinese population. Today in Lhasa. may be purchased in front of the important Jokhang temple in Lhasa for approximately 25 cents from a merchant who is almost certain to be a Han immigrant.406 MEDICAL ANTHROPOLOGY QUARTERLY communication infrastructures. The present local government has been loathe to intervene in the economy in a fashion that would open up access to jobs and other opportunities for Tibetans. Lhasa has office and meeting space on a per-bureaucrat basis that exceeds the rest of China (Sharlho 1992). and services far outstripped supply. and building programs tended to favor the Chinese. or repatriated back to China. the trade in Tibetan traditional ceremonial scarves and other ceremonial paraphernalia is controlled by Chinese merchants. and subject to continuing ethnic discrimination by Chinese officials and employers. the infusion of subsidies into bureaucracy. creating the economic incentive for a wave of volunteer migration to serve immigrant Han needs (Goldstein and Beall 1991). industrial sector. created the conditions for the rapid immigration of thousands of Han Chinese into Tibet between 1985 and the present. Bureaucracies are always difficult to dismantle.000 official Chinese workers entered Tibet (Sharlho 1992). Since 1985 the majority of these funds have gone into nonproductive construction of office and government buildings in Lhasa. particularly the TAR People's Political . and indeed. but he was never trusted or supported by those below him. problematic. and could thus never fully implement Beijing's policies. in Tibet this is doubly the case because the majority of government officials and office staff are Chinese. Chinese food. has brought a huge influx of entrepreneurs and "penny capitalists" into Tibet from all over China. considered ironically by Western travelers to be a political symbol of a "free Tibet" and therefore carried into Tibet and given surreptitiously to monks in the monasteries. unfortunately. composed principally of a military and pro-Chinese Tibetan cadre who rose through Party ranks during the Cultural Revolution. more than 60. attempts to bring down officials appointed during the Mao era were sabotaged by the entrenched local leadership. While the development of rural agricultural and urban industrial sectors would have provided opportunities for the Tibetan population. In 1985 a minority leader (from the Yi nationality) was appointed to lead the Party in Tibet. are virtually shut out of the subsidy-stimulated consumer economy. with limited entrepreneurial skills. are also used for the construction of public buildings. Because much of the business is controlled by networks of socially affiliated Chinese. there were no Tibetans that Beijing trusted that could be appointed to Party leadership (Sharlho 1992). coupled with reforms to the household registration policy and various government incentives designed to facilitate migration and small business development. After 1980. Tibetans. A friend and colleague in Lhasa who has monitored this situation for years estimates that between 75 and 90 percent of all new business licenses are issued to Han immigrants. This demand. already Chinese-run enterprises. Local leadership could not be replaced. Tibetans have not been well positioned to take advantage of these entrepreneurial activities.

through the language of the body. in an epidemiologic sense. It is also a useful means for articulating the ironic compromises between the life they experience and that which is held out to them as possible by China. though not necessarily. With no access to economic opportunity and little chance for meaningful political participation. turn their gaze on medicine? What then will be the potential of medicine to safely contain such sentiments? Rlung. But what happens when the West. dissatisfactions over modern life that are not interpreted as signs of nationalism. Rlung provides an idiom for expressing the distress that might otherwise be seen as political resistance. via the productive work of culture. medicine may remain the only institution in which Tibetans can articulate. In the ironic spaces opened up by Chinese and Western modernities. are subject to causal constructions that foreground a number of principally social factors. Evidence from studies in India suggests that disorders of the humor rlung. given its centrality to Tibetan constructions of the integrated principle of mind. offer. body. It is developed. While Tibetans may respect the public positions these non-Party leaders may take on certain issues. of course. including Western anthropologists. anthropologists. with its polysemantic and fundamental tantric Buddhist attributes. Tibetans are becoming increasingly marginalized. in effect.SUFFERING AND THE WORK OF CULTURE IN MODERN TIBET 407 Consultative Conference and the TAR People's Congress. this identity develops in part out of a sense of ironic compromise. The politicization of rlung is likely. With increasingly strident Chinese rhetoric on religion as a source of "splittism. At present. Lack of access to social and economic opportunity places Tibetans. and the recent appropriation of reincarnation politics by the Party." moves to more directly control the monasteries and monastic education. in essence forced to articulate their needs and their resistance to Chinese policies in the context of those Tibetan institutions that remain functioning: religion and medicine. they are not generally respected by the people. an apprehension that day-to-day experience corresponds poorly with both Western and Chinese representations of what Tibet and Tibetans are or should be. rlungrepresentsmore than lessons about the suffering that stems from a failure to appreciate impermanence. Conclusions: Whose Corruptions? Rlung is an idiom of distress (Nichter 1981). a contemporary act. To lay people. it is a political statement about the Chinese corruptions of legitimate desire. all indications are that the TAR administration. supported by an increasingly conservative and hostile leadership in Beijing. and society. is in many ways a perfect vehicle for expressing the suffering that some Tibetans certainly experience under the conditions sketched out above. The physicians and institutions of Tibetan medicine. at risk. What is happening in Lhasa today is simply an expansion of this particular tendency using a language that reflects the realities of . Western tourists and dharma bums. and are seen as handmaidens of Chinese policy. and. as a statement of personal and social suffering that reflects a mix of classical Buddhist ontology with the modern politics of Tibetan identity. is resorting to some of the more severe political and economic means to suppress "splittist" attitudes in Tibet since the Cultural Revolution. off the main stages of political conflict. safe havens to those who suffer rlung. a dangerous play to a suspicious audience in these most dangerous of times.

the consequences of China's social and economic program on the plateau. is he playing to the Western anthropologist. . may join with the cosmopolitan cultural representations of modern Tibet in a kind of radical ethnomedicalization to deflect and channel social criticism away from its roots in day-to-day economic injustice. structural discrimination. that is." is he articulating common ethnomedical discourse. appear in the process of being shaped by the cosmopolitan representations of a suffering Tibet. and the global politics of humanrightscoalesce in a culturalist portrayal of suffering that may overlook. traditionally aligned with classical Buddhist principles regarding suffering. indeed mystify. As rlung discourses become more aligned with Western perspectives on humanrightsin China. or is he. participating in the reshaping of rlung etiology so that it reflects transnational desires? This latter possibility brings forth two important and related questions: to what extent do Western desires for a Tibetan Otherness. appropriate such desires in constructing their suffering. that issues of religious freedom or cultural autonomy must not stand in the way of social advancement through economic development. including some physicians. are palpable aspects of day-to-day life. rooted principally inrepresentationsof Buddhist spirituality. for us. provides an opportunity for some individuals. The Chinese response to Western critics of humanrightsin China is simply that individual rights must be secondary to the primary principle of economic equality. Tibetan medicine's shaping of rlung as a political disorder. they will deflect criticism from the critical economic issues that are precisely the most important and sensitive to Tibetans and Chinese alike. torture. equally.framedin Buddhist terms. Tibetans. through the processes of cultural work in this radicalized context. a desire for a certain kind and shape of Tibetan suffering? To what extent do Tibetans. caught unquestionably in a situation of ethnic and social conflict. When a prominent physician pronounces that the "Chinese government is the government of rlung. A Tibetan medical system. it will be a critical development. and an absence of economic justice. fantasies of Shangri-La.408 MEDICAL ANTHROPOLOGY QUARTERLY modern Tibetan life and of Tibetan encounters with Chinese attempts at social and economic transformation. as being rooted in the lack of individual freedoms and suppression of free religious expression. but it is also a language which incorporates Western ideas about Tibetan suffering. the Westerners. but who are rooted in ethnic conflict. the discourses of Western human rights. But the embodiment of suffering in this highly politicized context suggests that there is currently in process the hatching of a highly ironic subplot to Tibetan medical pluralism. In this confluence of transnational cultural forces and Tibetan suffering emerges an imagined life that is crystallized in stories about rlung. to articulate such suffering in forms thatrepresentonly minimal challenges to a state that is only too willing to resort to violence and imprisonment. where suffering derives most vividly from a demonized Chinese state that fails to permit practice of religion and free cultural expression and resorts to imprisonment. and other forms of bodily suffering to enforce its will. the anthropologists interested in things cultural? Rlung discourses. for whom state oppression. and even imprisonment and torture. create. a legitimate and highly rationalized branch of the Chinese social service bureaucracy. If this process is completed. In these stories. may seize on cosmopolitan constructions as one way to give some voice to their suffering.

1988. I am particularly grateful for the valuable assistance of Cheryl Reighter. presenting symptoms. currently publishes a periodical as well as a number of topical publications on various. Additional in-depth interviews with ten Tibetan medical practitioners considered "experts" on rlung were also completed. consult Clifford (1984). (1992). the history of Tibetan medicine more generally. Parfionovitch et al. Although the majority of the patients at the Tibetan medical facilities are Lhasans. A random sample of 56 patients stratified by age. Lhasans are also exposed with greater intensity to the rapid social changes occurring in the region and are more likely to articulate these as causal forces in their lay explanatory models of rlung disorder. with lung.. The remaining four were collected in Tsethang. The research was sponsored by the Tibetan Medical Hospital in Lhasa. In the context of the more general ethnographic project. rather than alternatives (e. 3. Kitty K. interviews with Tibetan physicians and government (Health Bureau) officials. 1994. nearly every county has a few "celebrated" practitioners who operate outside of the government sphere. Forty practitioners of Tibetan medicine provided their career histories and training experience. 2. these patients were drawn from an observational exercise in which 718 clinical encounters in Tibetan medical facilities (rural and urban) were recorded. Most of the interview data on rlung illness were collected between July and November of 1991.000). less directly. rlung emerged as an important category of sickness that individuals. BNS-9005811. and institutional locus of treatment were interviewed. primarily theoretical. and Mahmoud Hosseini in collecting the data upon which this paper is based. and observations of clinical interactions. In addition. The research upon which this article is based was funded in part by a grant from the National Science Foundation. Nawang Sherap. the English term for an anatomical organ). aspects of Tibetan medicine. 1. were eager to talk about. Finckh (1978). and 20 key informants. Susan Blum.. For a good. particularly practitioners. provided information on health policy. The rlung case studies presented here were collected in the towns Lhasa and Tsethang.g. and Geoffrey Samuel for their constructive comments on earlier drafts of this paper. the reader is referred to the work by Tsarong et al. Follow-up interviews and case studies were developed at this point with 42 individuals who were diagnosed by the formal medical system as suffering from rlung. Lhasa is the capital and largest city of the TAR. a substantial number of patients travel some distance to seek treatment in Lhasa. 4. and the professional explanatory model of rlung causation and treatment. principally senior officials in the Health Bureau. The research design included case studies of individuals seeking treatment at Tibetan medical facilities. For general materials on Tibetan medicine. and August. Samuel 1993) for the simple reason that it is perhaps less confusing to nonspecialist readers (e. the Tibetan hospital. Corbett. The primary goal of the research was to conduct ethnographic research on Tibetan medicine as it was then being practiced in the Chinese political and economic context. the ethnomedical category. It is here that the major Tibetan medical hospitals and training centers are located. India.g. and March and April of 1993. (1981). southeast of Lhasa in the Yarlung valley. There has been some reappearance of physicians in private practice. by the Tibet Autonomous Region Health Bureau. a small town and capital of Lhoka prefecture (Tibetan population of about 25.000. and the Tibetan Medical College. general introduction. I have chosen to use here the classical transliteration system proposed by Wylie (1959). Thirty-four of the 42 rlung cases collected were from the Lhasa area. which provided housing and logistic support. and Faculty Grant and Fellowship awards from the University of Colorado-Denver. . and. I wish to thank Vincanne Adams. and Rechung (1973). The research project upon which this paper is based was carried out over several field periods in the Tibetan Autonomous Region (TAR) of China in the roughly six years between October.SUFFERING AND THE WORK OF CULTURE IN MODERN TIBET 409 NOTES Acknowledgments. with a Tibetan population of about 50. the Tibetan Medical Centre in Dharamsala. confusing rlung.

. "If only we had a 'Dalai Lama' on the outside like you do. The Tibet issue has attracted a number of conservative politicians in the United States and undoubtedly elsewhere. can be found crowding the sweet tea shops in central Lhasa. has espoused the views of the Dalai Lama's government-in-exile. Uighur. 11. A review. Recently. 7. be able to practice without government inputs. which has lasted for more than 30 years. As day shifts into evening. the unity of various nationalities. As the confidence intervals indicate. and the unification of the country. monks. hurt the people's interests. . or violate the state law.. ideally. women. world opinion. some people in the world are using the Dalai Lama as a tool for opposing China and interfering in China's internal affairs in order to achieve . the drinking of sweet tea shifts to cheap chang (Tibetan beer) and arak (distilled liquor). noting that "Buddhism must conform to socialism. fellow Mongolian. we should point out that the Dalai Lama merely relies on his religious influence. and so on—is statistically significant. It should be noted that family problems. which makes it distinct from the issues faced by other minority nationalities. and violence. 9. In the November 13. 12. The Party newspaper. the government called for "large-scale" reforms of existing religious policy in Tibet. Alcoholism is becoming a serious problem. but cannot be assumed to reflect anything other than the chance introduced by the small sample. The sample size here is rather small. only the first variable—contact with Han Chinese. purportedly tortured. or who have died in prison. The existence of an internationally prominent exile government brings a new dimension to the Tibet question. Renmin Ribao (People's Daily). of the human rights information put out electronically by the Office of the Government in Exile in London typically features lists of monks and nuns that have been arrested. for example. The Colorado Friends of Tibet organization is led by a conservative American lawyer. this struggle is a continuation of our struggle against the Dalai Lama clique. particularly Tibetan youth just out of school. the Tibet Information Network in London published a translation of a document regarding the mandatory "reeducation of Sera monks. for example. and Kazak students would often say.1996 issue of the official Tibet Daily. . 10. however.410 MEDICAL ANTHROPOLOGY QUARTERLY The Swiss Red Cross operation in Shigatse (Xigaze) is also involved in training traditional physicians and sending them to remote areas of the TAR (and elsewhere) where they will. alcoholism. to a lesser extent. and nuns must "conscientiously accept" the leadership of the government and party at all levels (World Tibet Network News 1996). has acknowledged the relationship between religion. Senator Jesse Helms of North Carolina. Sharlho reports that." The signed article stressed that all temples. and Tibetan nationalism: Centering on the work of searching for and confirming a reincarnated child for the Panchen Lama." presumably passed by a monk to a foreign visitor and smuggled out of Tibet. The remaining odds ratios show positive trends. we have waged a serious political struggle against the Dalai Lama. the Dalai Lama created various obstacles to the work of searching from the beginning. The essence of the struggle is whether one should protect the dignity of the law. 6. and sabotage the unification of the motherland. notable for his social conservatism. Supported by certain foreign forces. 5. create splits among people of different nationalities. 8. After repeated failures. in particular unemployment of youth. too" (Sharlho 1992:48). not socialism to Buddhism. still cautious on the subject of the Dalai Lama. he risked everything in a single venture and publicly and arbitrarily announced that he had confirmed a "soul boy" . are linked by Tibetans to the current economic situation where there are few opportunities for Tibetans. Many of these unemployed young men and. then Beijing would care about us. while he was a student at the Central Nationalities Institute. the interests of the people. The control of religious institutions and expression by China has continued to accelerate.

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