Healing Powers and Modernity: Traditional Medicine, Shamanism, and Science in Asian Societies 9780313002762, 9780897897150

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Healing Powers and Modernity Traditional Medicine, Shamanism, and Science in Asian Societies Edited by Linda H. Connor and Geoffrey Samuel

BERGIN & GARVEY Westport, Connecticut • London

Library of Congress Cataloging-in-Publication Data Healing powers and modernity : traditional medicine, shamanism, and science in Asian societies / edited by Linda H. Connor and Geoffrey Samuel. p. cm. Includes bibliographical references and index. ISBN 0–89789–715–3 (alk. paper) 1. Healing—Asia. 2. Social medicine—Asia. 3. Traditional medicine—Asia. 4. Shamanism—Asia. I. Connor, Linda, 1950– II. Samuel, Geoffrey. RA418.3.A78H43 2001 615.5'095—dc21 00–029256 British Library Cataloguing in Publication Data is available. Copyright  2001 by Linda H. Connor and Geoffrey Samuel All rights reserved. No portion of this book may be reproduced, by any process or technique, without the express written consent of the publisher. Library of Congress Catalog Card Number: 00–029256 ISBN: 0–89789–715–3 First published in 2001 Bergin & Garvey, 88 Post Road West, Westport, CT 06881 An imprint of Greenwood Publishing Group, Inc. www.greenwood.com Printed in the United States of America TM

The paper used in this book complies with the Permanent Paper Standard issued by the National Information Standards Organization (Z39.48–1984). 10 9 8 7

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Contents

Illustrations Acknowledgments A Note on Tibetan Spelling Introduction 1

Healing Powers in Contemporary Asia LINDA H. CONNOR

vii ix xi 1 3

Part I. Healing in the Modern State: Korea, Malaysia, and India 2

The Cultural Politics of “Superstition” in the Korean Shaman World: Modernity Constructs Its Other LAUREL KENDALL

25

3

Tradition and Change in Malay Healing CAROL LADERMAN

4

Modernity and the Midwife: Contestations Over a Subaltern Figure, South India KALPANA RAM

64

The Political Ecology of Health in India: Indigestion as Sign and Symptom of Defective Modernization MARK NICHTER

85

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42

vi

Contents

Part II. Healing on the Margins: Malaysia, Indonesia, and China 6

Engaging the Spirits of Modernity: The Temiars MARINA ROSEMAN

7

Presence, Efficacy, and Politics in Healing Among the Iban of Sarawak AMANDA HARRIS

130

Sorcery and Science as Competing Models of Explanation in a Sasak Village CYNTHIA L. HUNTER

152

Medicines and Modernities in Socialist China: Medical Pluralism, the State, and Naxi Identities in the Lijiang Basin SYDNEY D. WHITE

171

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9

109

Part III. Healing, Power, and Identity in Tibetan Societies 10

11

12

Tibetan Medicine at the Crossroads: Radical Modernity and the Social Organization of Traditional Medicine in the Tibet Autonomous Region, China CRAIG R. JANES Particularizing Modernity: Tibetan Medical Theorizing of Women’s Health in Lhasa, Tibet VINCANNE ADAMS Tibetan Medicine in Contemporary India: Theory and Practice GEOFFREY SAMUEL

Glossary of Tibetan Terms Index About the Editors and Contributors

197

222

247

269 275 281

Illustrations

FIGURES 2.1

A shaman balances on knife blades

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2.2

Shaman exorcizing a couple outside the rented room of a public shrine

36

3.1

Pak Long and his minduk

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3.2

Cik Su

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4.1

Cover of Mantrajalam Daktarlada Mantrasanulada and sketch from Na Shariram Nadhi

73

4.2

Sketches of woman’s body by health project staff and women from Dalit and “tribal” backgrounds

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5.1

A vaidya consults with patients, as his wife stands by his side

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6.1

A medium sings as the chorus, playing bamboo-tube stampers, responds

115

Shredded plastic bags shimmer, mixed with a few fresh leaves to form the in Bihaay

125

6.2 7.1

An Iban longhouse in Pakan subdistrict

133

7.2

The organization of space in an Iban longhouse

135

7.3

Ruai of an Iban longhouse, daytime

136

8.1

A belian (Sasak indigenous healer)

156

8.2

Sasak women working together preparing food

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Illustrations

9.1 9.2

A Lijiang basin family takes in a public poster message on “hygiene and civilization” A hospital in the Lijiang area

186 187

10.1 10.2

Lhasa Outpatient Mentsik’ang from Jok’ang Temple Consultation, Women’s and Children’s Department, Lhasa

200 205

12.1 12.2

Men-Tsee-Khang Clinic, Dalhousie Dispensary of the Men-Tsee-Khang Clinic

249 251

MAPS 1 2 6.1 7.1 10.1

South and Southeast Asia with Study Locations

xii

Southeast and East Asia with Study Locations State Boundaries and Orang Asli Ethnic Divisions in Peninsular Malaysia Sarawak

xiii 112 132

The Tibet Autonomous Region

201

TABLES 10.1 10.2 10.3 10.4 10.5 10.6 10.7 12.1

Number of Physicians and Inpatient Beds by Selected Counties, Central Tibet Autonomous Region Prefectures Illnesses Most Frequently Cited by Mentsik’ang Patients Mentsik’ang Patients’ Explanatory Models for Common Illnesses Illness Case Studies: Diagnostic Categories of Individuals Interviewed Explanatory Models: Illness Case Studies Patterns of Resort Reported by Case-Study Sample Decision-Making Patterns Reported by Case-Study Sample A Sample of Adult Patients at the Dalhousie Clinic, July–August 1996

202 210 212 213 214 215 216 254

Acknowledgments

The chapters in this book, with the exception of the contribution by Sydney White, are selected and revised from invited papers presented at an International Research Workshop at the University of Newcastle, New South Wales, Australia, in December 1996, entitled Healing Powers and Modernity in Asian Societies. This meeting brought together a group of anthropologists who have in recent years been involved in researching issues of medicine, modernity, and healing in Asia. The workshop provided an opportunity for participants to discuss their work in a broader comparative framework, stimulated by their diverse perspectives on healing and modernity. We wish to thank all the participants in the workshop for their lively discussion of the ideas that have contributed to the chapters in this volume. We are grateful to Sydney White, who was not present at the workshop but who later kindly agreed to contribute a chapter in order to expand the geographical and comparative scope of the volume. Research by the convenors of the workshop, Linda Connor and Geoffrey Samuel, was supported by an Australian Research Council Project Grant (“Creative Synthesis in the Therapeutic Process: An Ethnographic Study of Tibetan Healing and Biomedicine,” 1994–1997), and it was this research that originally inspired the idea for the meeting. Funding for the workshop was provided by the Faculty of Arts and Social Science and the Department of Sociology and Anthropology, University of Newcastle. We wish to thank Janette Howell for her administrative assistance in organizing the workshop. Carol Laderman’s chapter is a revised version of an article titled “The Limits of Magic,” which was published in American Anthropologist 99(2): 333–341. We wish to thank K. Lalitha, and Sabala and Kranti, for the illustrations provided in Kalpana Ram’s chapter from their publications which are, respec-

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Acknowledgments

tively, Mantrajalam Daktarlada Mantrasanulada, 1993, and Na Shariram Nadhi (My Body Is Mine), 1995. We would like to thank Stephen Dick, who drafted the maps, for his careful work and his patience with our all-too-frequent rethinking. We are also grateful for the assistance of Rozanne Spouse, Karen McLeod, and especially Patricia Dobinson, who assisted at the many stages of the preparation of the manuscript. We gratefully acknowledge the suggestions made by the reviewer for Greenwood Publishing Group, and the work of our editor, Jane Garry. We also thank our copyeditor, Katie Chase, for her thorough and careful correction of the manuscript.

A Note on Tibetan Spelling

In Chapters 10 to 12, Tibetan words are given in an approximate phonetic transcription (e.g., Gyu¨ Shi for Wylie-system rGyud bZhi). The Glossary of Tibetan Terms at the end of the book gives correct Wylie-system spellings and brief definitions. To avoid overloading the Glossary, the disease categories in Table 10.2 and some terms in the notes to Chapters 10 and 12 are given in Wylie spellings, indicated by W.

Map 1. South and Southeast Asia with Study Locations xii

Map 2. Southeast and East Asia with Study Locations xiii

INTRODUCTION

1

Healing Powers in Contemporary Asia Linda H. Connor

The subject of this book is the state of healing practices in contemporary Asian societies. In what ways is indigenous healing being reconstituted through processes of transnational modernity? How is the praxis of healing being transformed by the politics of health within modern nation-states and by the processes of commodification of both healers and their therapies? What is the significance of indigenous healing in the construction of new discourses of cultural identity and new nationalisms? How do patients in Asian societies engage with the plurality of healing practices that are themselves shaped by wider relations of power? How is modernity experienced through the embodied senses and the suffering body? These are large and complex questions, especially since South, Southeast, and East Asian societies present many different facets of the encounter between “local,” “indigenous,” or “traditional” healing1 and modernity. “Healing” as used in this volume generally refers to therapeutic practices that are embedded in local social relations and forms of embodied experience. The term is a counterpoint to “health,” which is generally used to refer to a biomedically defined state, the absence of disease. Clearly these terms belong to different discursive frameworks that are of significance for the anthropological research undertaken by contributors to this volume. In this book we explore the present state of a range of healing practices in their Asian locales. The peoples involved include minority and majority populations. By minority we mean reasonably distinct, small populations living within the peripheries of larger nation-states such as the Naxi of the Lijiang Basin in the People’s Republic of China, the Temiar of peninsular Malaysia and

4

Introduction

the Iban of Sarawak in Malaysia, as well as Sasak people on Lombok in Indonesia. The geographical scope of the book also encompasses rural South Indians and Malays, the people of South Korea’s industrial cities, and Tibetans both in Chinese-controlled Tibet as well as in the refugee settlements of North India. Among these different peoples we find many types of healing, including shamanic ritual and herbal medicine, as well as formalized literate traditions such as Ayurveda, Chinese, and Tibetan medicine. We observe the conflicts as well as the blurred boundaries between indigenous therapies and biomedicine (also commonly referred to as allopathic or cosmopolitan medicine),2 which, in its many manifestations, is the dominant form of medicine supported by national governments, and is emblematic of the modernity to which they aspire. The studies presented in this volume draw on the specific strengths of ethnographic research into healing. The authors, all of whom are anthropologists with extensive research experience in Asian societies, acknowledge the multiple healing resources available to patients in these societies. However, they question the commonly deployed paradigm of pluralism in medical anthropology, which privileges the patient and support group as agents freely choosing “options” from among the available array. The studies in this book emphasize the ways in which the state legitimizes and transforms certain healing systems, and thus how institutional power relations shape healing in local contexts, but never totally define it. Another central theme is the importance of processes of representation in the struggles over healing power. Some of the medical traditions discussed, such as the formalized herbalhumoral systems of Tibetan medicine and Ayurveda, are becoming well known in the West, through both scholarly study and their increasing popularity with Western patients interested in their healing potential. The ethnographic approach of the studies presented here privileges the interaction between healing practice and textual knowledge, rather than exegesis of the latter. The chapters covering aspects of Tibetan medicine, in particular, provide an important new dimension on this subject, which up to now has been heavily oriented to traditional textual material rather than observations of practice. Other contributors to this volume have studied less formalized healing practices, such as shamanism in Malaysia (Laderman 1991) and Korea (Kendall 1985) for many years. They emphasize the value of an anthropological approach to lived practices in cultures where indigenous healing has long been subjected to a powerful reifying process through “folklore studies,” a disinterment of “pure” cultural forms through the use of aging informants and the salvage of various forms of material culture. Folklore studies of shamanism, as Laurel Kendall points out in Chapter 2, may retrospectively valorize ancient practices as expressive of a distinct national spirit, while contemporary practices are constructed as debased survivals. Korea’s “folklore revival” in the 1960s and 1970s can be seen as a nostalgic longing for a premodern world from the vantage point of an industrialized, urbanized, and Westernized existence. The chapters in this

Healing Powers in Contemporary Asia

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book focus on the more interesting and fruitful analyses that anthropological study of contemporary shamanism and other healing practices can provide. Two earlier works provide benchmarks in the comparative study of “Asian medical systems.” Asian Medical Systems: A Comparative Study, edited by Charles Leslie (1976), defined a whole new field of study for the emerging subdisciplinary area of medical anthropology and demonstrated the dependence of this field of study on interdisciplinary knowledge from historians, philosophers, practitioners, and others. The volume focused on the “great traditions” of Hindu, Arabic, and Chinese medicine, their transformations over space and time, and their relationship to cosmopolitan medicine; but local healing practices and indigenous healers also received attention.3 Another volume, Paths to Asian Medical Knowledge, edited by Charles Leslie and Allan Young (1992), continued the agenda of comparative study of the three formal traditions of Asian medicine and their interactions with cosmopolitan medicine and local knowledge. In both volumes, Asian medical systems were studied as cultural systems, and the framework of inquiry was the logic of knowledge of practitioners and patients. “Asia” was defined, implicitly, through particular forms of interpenetration and syncretism of three great traditions of medicine that had also spread from and to other parts of the globe. Since Edward Said’s groundbreaking work Orientalism was published in 1978, unifying constructs such as “Asia” have been seen to be deeply implicated in the processes of colonial domination by the West. What can permit us, two decades later, to speak of “Asian societies” as an intellectually viable boundary for study? In one sense the possible scope of Asia is so vast that no volume could embrace the diversity, and the present book does not claim to do so. In another, pragmatic, sense, the reference to Asia stakes out a broad field of scholarly interest and intellectual exchange that crosses narrower regional boundaries, and acknowledges the nexus of geography and history. Characteristics of precolonial state formations, political ecology, experiences of colonialism and nationalist struggles, the subjugation of ethnic minorities, patterns of migration, and displacement of populations, all give substance to the notion of Asia while recognizing its political and historical constructedness and its dependence on certain forms of cultural representation. The linkages, both historical and contemporary, of Asian societies to many others, including Western societies, should alert us also to the arbitrariness of boundary making in many contexts. For example, Sydney White in Chapter 9 details the dominance of Western medicine in the Republican period (1927–1949) in the People’s Republic of China (PRC). Carol Laderman describes in Chapter 3 how Islamic orthodoxy (ultimately connected to contemporary Middle Eastern political movements) validates a contemporary Malay shaman’s practice. Geoffrey Samuel unravels some of the relationships between Indian Ayurvedic medicine, Western idealizations, and traditional Tibetan medicine, in Chapter 12.

6

Introduction

This book is organized, not on the basis of the great medical traditions, but rather in terms of the articulation of healing, power, and modernity in a selection of societies of varying type and scale from South, Southeast, and East Asia. There are three parts to the book, structured thematically around transformations of traditional healing in modern states (Part I), healing among cultural minorities (Part II), and the role of healing in contemporary Tibetan societies (Part III). In the four chapters of Part I, we look at the significance of traditional healing modalities among populations that are integrated into modern nation states. In Chapter 2, Korean shamanism, dismissed as “superstition” by the biomedical establishment, is imbued with other forms of legitimacy in the context of an urbanized, industrialized state. In Chapter 3, among the majority Malay population of Malaysia, a female shaman finds a successful answer to the twin challenges of modernity and Islamic orthodoxy. Midwives in Tamil Nadu, South India, threatened with marginalization or incorporation by biomedical institutions, evolve a flexible response through the use of both traditional and modern cultural resources (Chapter 4). In Karnataka state, South India, Ayurvedic ideas about diet are used to articulate a critique of modernity and its effects (Chapter 5). In Part II, we explore indigenous healing traditions among four minority groups within nation-states, the Temiar and Iban of Malaysia, the Sasak of Indonesia, and the Naxi in the People’s Republic of China. Temiar shamans of the Malaysian rainforest use traditional techniques of trance and music to engage the dramatic changes their society is undergoing (Chapter 6), drawing power from elements of new social realities that simultaneously oppress them. The Iban community of Sarawak studied by Amanda Harris draws on indigenous knowledge and forms of sociality to maintain the vitality of community spiritbased healing procedures against the biomedical approaches that would undermine, not just healing practices, but the worth of Iban identity (Chapter 7). Sasak villagers of East Lombok similarly maintain local understandings of illness against biomedical hegemony (Chapter 8). Therapeutic practices have been particularly significant in the narratives of modernity that have framed the Naxi minority’s relations with the Chinese state over three political periods (Chapter 9). The three chapters on Tibetan societies in Part III bring together scholars who are currently engaged in anthropological research on medicine and healing among Tibetans, in both the People’s Republic of China, where Tibetans form a subjugated minority, and in India. As Craig Janes (Chapter 10) and Vincanne Adams (Chapter 11) discuss, traditional Tibetan medicine in Tibet has become, among other things, a mode of articulating and dealing with the stresses of life under Chinese domination, as well as a way of expressing a particularly Tibetan version of modernity that is not subsumed by PRC state narratives. Among the refugees in North India (Chapter 12), Tibetan medicine is a resource for dealing with ailments and troubles for which biomedicine as locally delivered can do

Healing Powers in Contemporary Asia

7

little, as well as a resource in efforts for international recognition of the Tibetan political struggle against the Chinese. MEDICINE AND GLOBAL MODERNITIES Contributors to the volume have characterized modernity in a variety of ways. They draw on the social science understanding of modernity as an epoch that began with the emergence of capitalism, industrialism, rational-legal bureaucracies, and state control of military power and surveillance (Giddens 1990; King 1995; Therborn 1995). The cultural dimensions of modernity include discourses of rationality, scientism, and progress through economic development. Contributors are also concerned to analyze the contours of modernity as a “structure of feeling” or mode of apprehending the world. Here, the epochal character of modernity and its implied spatial connectedness with Europe give way to what Homi Bhabha has called its “ambivalent temporality,” by which he means that the sense of the “modern” as opposed to the recent past is universal (everyone can have this experience) while each “enunciation of the sign of modernity” is culturally and historically specific (cited in King 1995, 113). The experience of modernity, broadly defined as a consciousness of being part of a changing world with an open future, is everywhere. Some anthropologists have argued that modernity has always been a global phenomenon, with the European colonization of the world being a necessary condition for its emergence (e.g., see Wolf 1982; Friedman 1995). There are many experiences of modernity in contemporary Asian societies. While contributors to this volume have drawn on recent cultural and critical theory in the humanities and social sciences that engages with emergent realities, they have been more concerned to understand the transformations and interactions of Asian modernities than to debate about the usefulness of conceptualizing these processes as “postmodern.” The radical and global character of modernity demands careful examination in specific contexts before we can go on to envisage possible futures. Postcolonial states, postnational movements, and global economic interdependence need to be understood in relation to modernity, rather than as usurpations of it. The people of Asia, just as much as people elsewhere, are active agents in the creation of “global modernities.”4 One of the ways in which modernity has laid a claim on people’s lives is through biomedicine’s expansion around the globe. In virtually every social situation considered in this volume, biomedicine has become a metonym for modernity in the domain of healing. It has been placed there by national governments intent on their own modernist projects of “development,” implying notions of social progress and economic improvement for the nation’s citizens. While agencies such as the World Health Organization (WHO) and United Nations International Childrens’ Emergency Fund (UNICEF) have exerted a unifying influence on international health policy and planning, their agendas

8

Introduction

have always had to come to terms with varying national visions of modernity, many of which have explicitly anti-Western elements. National visions of modernity, in turn, articulate in various ways with communities whose aspirations may point to quite different possibilities, particularly where minorities in authoritarian states perceive themselves as marginalized. The technologies of biomedical science cannot be deployed in a space devoid of cultural values and specific forms of social organization; their use is shaped by the political context in which they occur. As Mark Nichter discusses in Chapter 5, Mahatma Gandhi was one of the earliest critics of state-sponsored biomedicine, which he viewed as merely ameliorating the ills engendered by industrial capitalism, without challenging the unethical, exploitative characteristics that he held to be intrinsic to this manifestation of modernity. Vincanne Adams, in Chapter 11, analyzes how biomedical technologies are recommended by the author of a contemporary Tibetan text on women’s health as a means of validating the scientific truth of traditional Tibetan medicine—as in the use of ultrasound machines to diagnose womb disorders caused by blocked “channels,” or the use of microscopes to see the “bug” that causes a “feverish womb.” Here, the politics bears on minority struggles against an authoritarian state; in the case of Gandhi the resistance to biomedicine was part of his resistance to Western domination at many levels. The political embeddness of biomedicine is not confined to any one kind of politics. Anthropologists trace these conflicts and displacements from the international and national arena to their expression in local communities. Sydney White’s Chapter 9 provides an overview of the way systems of healing knowledge developed and changed in mainland China, over three historical periods beginning in the Republican period (1927–1949) and continuing through the Maoist and post–Mao governments. During the Republican period, “Western medicine” was promoted as the goal of a progressive state despite limited access to treatment. In the Maoist period, “Chinese medicine” was officially approved (in a standardized, simplified, and scientized form), and became a “critical icon of national identity in the PRC narrative of modernity.” During the 1960s Cultural Revolution, Chinese medicine became a key element of “integrated medicine,” which incorporated Western, Chinese, and state-authorized “folk” medicine. Post–Mao, the vision of a distinctively Chinese socialist version of modernity has persisted but in keeping with the state’s embrace of global capitalism, Chinese medicine, while still valorized, has become both increasingly commodified and marginalized in relation to “Western medicine” (see also Smith, 1993, and Janes, Chapter 10 this volume). White discusses how the Naxi of the Lijiang Basin, an officially recognized “national minority,” have created their own distinctive narratives of modernity through their strategic engagement with the state, enacting a politics of identity through their therapeutic practices as well as other domains of life. In the contemporary post–Mao era, minority nationalities have been reinvented (and have reinvented themselves) through the discourse of a more culturally pluralist state. In this context, Lijiang Basin Naxi

Healing Powers in Contemporary Asia

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have been empowered to valorize cultural difference (vis-a`-vis Han Chinese) in a way that was not possible in the Maoist period. Fortune-telling, gu witchcraft, and the cultivation and collection of local herbal remedies are the therapeutic elements of this cultural “revitalization.” However the main Naxi therapeutic option in the villages and town where White conducted her study remains “integrated medicine,” which has always been shaped by local practices. Biomedicine as a set of institutions occupies a dominant position in all nationally supported health systems in Asia. Yet state policy with regard to the status of traditional therapies shows some marked differences between countries as governments of varying political hue contend with the degree of formalization, political influence and popular utilization in different contexts.5 Even where the state has formally recognized the therapeutic value of other medical traditions, such as revived and reinvented Ayurvedic and Yunani traditions in India (Leslie 1976) and a standardized, simplified and secularized “traditional Chinese medicine” in the PRC (Crozier 1976; Adams, Chapter 11, Janes, Chapter 10, and White, Chapter 9 this volume), this has not necessarily translated into a meaningful allocation of the national health budget.6 Healing practices that are not based on formal literate knowledge applied by high-status (usually male) members of the politically dominant cultural group are less likely to receive any state recognition at all. Rather, they are likely to be defined as dangerous relics of the past, clung to by “backward” populations out of ignorance and superstition. Laurel Kendall’s Chapter 2 well documents the latter stance with regard to Korean shamans’ healing capacities since the nineteenth century, while Carol Laderman (Chapter 3) discusses the effect of state-supported Islamic orthodoxy on rural Malay shamans, many of whom no longer practice. Indigenous healing among cultural minorities of Southeast Asia, such as the Iban of Sarawak (Amanda Harris’s Chapter 7) and Sasak of Lombok (Cynthia Hunter’s Chapter 8), may not be officially prohibited but has achieved no significant role in national health policy, and indeed is clearly constructed in antagonistic terms to modernity in state discourse. Power relations are intrinsic to the operation of healing modalities in every society discussed in this volume. The diversity of healing practices may be constituted as much by class and gender relations as by cultural identities or other dimensions of difference/inequality. These inequalities have long preceded the advent of biomedicine as the dominant healing modality supported by postcolonial Asian states. In Chapter 4, Kalpana Ram points to the “hierarchy of knowledges in India, where textualized forms of knowledge are given the highest prestige and value.” In South India, for example, Ayurvedic and Siddha medicine based on textual knowledge and transmission through males in hereditary high-caste lineages have always enjoyed more social power and prestige than forms of spirit possession and midwifery practices among women of castes placed low in the social hierarchy in agricultural laboring communities.7 As indigenous healing practices come under the purview of policy-makers in postcolonial states (who are answerable to providers of international develop-

10

Introduction

ment funding), preexisting inequalities are reproduced and intensified as lowstatus, less-articulated healing modalities come to be seen as expressions of a primordialism which is incompatible with the modern state’s vision of itself. High-status, politically organized practitioners, such as Ayurvedic practitioners in India, are able to maintain and even enhance their legitimacy and access to state resources in the discursive construction of “complementary” care, traditional and biomedical. Nationalist discourse is another sustaining element of traditional healing in postcolonial states, whose leaders endeavor to counterbalance the negative effects of Westernization with valorization of state-authorized forms of “indigenous culture.” There are a variety of ways in which the universalizing knowledge claims of biomedicine, as a discursive construction, create a “growth of ignorance” (Hobart 1993) whereby local knowledge is of marginal or negative utility. The value of indigenous healing modalities for local people may not depend on their identification with highly systematized and discursively elaborated bodies of formal knowledge. Healing practices that rely for their efficacy on embodied dispositions and orientations, on “habitus” in Bourdieu’s (1992) terms, may be antithetical to the state projects of normalization of citizens through techniques of hygiene, hospitalization, pharmaceutical treatments, and the like. The significance of what de Certeau (1988) termed “minor practices” (see discussion of the concept in Ram’s Chapter 4) is explored by a number of contributors to this volume. For example, Cynthia Hunter describes the ways in which Sasak villagers on the island of Lombok, Indonesia, experience the tensions between modernity and the customary practices of their rural community when Henryati, the young daughter of a local schoolteacher, dies after a long illness. Relatives seeking treatment through the village clinics and district hospital of the state health system were mystified and alienated by the practices they encountered and the failure to achieve any meaningful explanation of illness or treatment from medical staff. The resolution of the moral and epistemological problem of the girl’s death came through the diagnosis of sorcery, made by all the indigenous healers (belian) consulted by Henryati’s parents, even while they persevered with biomedical treatments. This sorcery diagnosis was given force and strength, particularly for Henryati’s mother and paternal aunt (who did not share the father’s formal education or modernist ideals), through the locally embedded discourse of kin and neighbors, articulated through presence and talk in the cooperative gatherings, especially women’s gatherings, of daily life in the village. Sasak villagers do not accept the negative valuation of their practical knowledge by functionaries of the state health system. They attribute meaning to illness and death within an alternative framework of experience that is sustained by local social relations and embodied practices, despite deployments of state power and knowledge through the hierarchical organization of hospitals, health centers, and village health posts. In postcolonial states, citizens’ affiliation to the state is cultivated through new forms of social association—in formal institutions such as schools and

Healing Powers in Contemporary Asia

11

clinics, as well as in the public culture of the nation (anniversaries, commemorations, and celebrations). Indigenous healing is both sustained by and sustains forms of social relationship that bring into question the primacy of people’s identity as citizens. This is another context in which people, and their healing practices, are likely to be challenged by the state, with mixed results. In Chapter 7 Amanda Harris argues that social relations in Iban longhouse communities in Sarawak are central to the satisfactory enactment of healing work. Biomedical hierarchies of knowledge sever the biological from the social, and biomedical institutions construct the social relations of healing through bureaucratic practices, thus combining to deny many facets of Iban experience. Harris chooses case studies that show how contested the meaning of illness and death may be. In Gana’s case, as in the case of Henryati documented by Cynthia Hunter, the diagnosis of shaman and longhouse residents had explanatory force that biomedical diagnoses lacked. Gana was widely understood to have died from a spirit attack brought on by a breach of customary law that the patient had ignored. Powerful healing ceremonies performed by a shaman (manang) of high repute failed to save him. The shaman himself had expressed doubt about the possibility of a cure, but had responded to pressure from Gana’s longhouse community to perform further ceremonies. Gana was not taken to hospital, although the means to do so was available, because the consensus of opinion among kin and neighbors was that hospital treatment was useless in this case. He died in the longhouse where more than a hundred people had gathered to lend their support. The prevailing opinion among those involved was that Gana had died of a spirit attack too powerful for any shaman’s ministrations. By contrast, the schoolgirl Nita’s death was less confidently explained. She died in the hospital and was brought back to the longhouse where her “spirit” aspect (semangat) ominously appeared to relatives several weeks after her funeral, which increased people’s disquiet about her death. There was a widely held opinion that Nita had succumbed to a “new illness” (dengue fever), biomedically defined, that resisted any ready translation into Iban illness categories. The sense of vulnerability and confusion engendered by Nita’s death undermined people’s confidence in the indigenous theories and practices that had failed to cure her. The experience of Iban longhouse residents suggests that people are compelled to think about modernity through the suffering body. New illnesses connected with changes to the physical and social environment alter the foundations of indigenous knowledge, even while this knowledge remains an important political resource for groups being drawn into the lower levels of an emerging class structure. Part of biomedicine’s claim to modernity is the place it occupies in nationalist discourses of progress and prosperity. But primordialism and cosmopolitanism are two sides of the nationalist coin. Primordial elements are co-opted into the construction of distinctive nationalisms that Asian governments counterpose to Eurocentric “universalist” rhetoric (Kahn 1998, 19–20). Local healing practices can become implicated in the politics of representation of nation-states. In be-

12

Introduction

coming a signifier of cultural identity, healing may be transformed in fundamental ways. Laurel Kendall’s Chapter 2 documents the mutations of modernity in Korea from the early twentieth century to the present, elucidating the processes whereby shamanism has been rehabilitated from the dark place of “superstition” and therapeutic malpractice, onto the more appreciative public stage of “national culture” and an authentic Korean “religion.” These mutations are associated with a nostalgia for a preindustrial past among Koreans who experience the constraints (as well as the delights) of an urban, industrialized, consumerist society. By the 1980s, Korea’s economic prosperity and international recognition encouraged new ways of thinking about the past. Shamanism revived became a signifier of a modern but distinctively Korean cultural identity. Selected shamanic ceremonies since the early 1980s have been officially designated as “Intangible National Treasures,” while the carefully chosen shamans who perform them are “Human Cultural Treasures.” Shamans themselves organize staged events to showcase the more spectacular aspects of their performances to large urban audiences who are placed in the role of passive spectators. However, shamanism’s role in the rites of nationhood has not subsumed other practices and meanings that it has for shamans and their clients. Kendall finds that shamans are consulted for the same reasons now as twenty years ago when she first began her ethnographic study. Ceremonies for urban clients are now scheduled around the demands of industrial time and are held in rented shrines far away from apartment-dwelling neighbors who would complain about the noise. Shamans respond to clients’ perceptions of ongoing misfortune and affliction— medical, financial, social—that are attributed to disturbed relations of the household with ancestors and gods. In this sense, then, the narrative of shamanism in contemporary Korea is an open-ended one. The ways in which the dialectic of shamanism and the imperatives of modernity can create new opportunities for practitioners themselves is explored in Carol Laderman’s Chapter 3, which details the rise of a young woman shaman on the east coast of Malaysia, whose unorthodox methods of therapy simultaneously attracted a new category of affluent, urban clients, while alienating her village neighbors. Laderman describes the transformation of Cik Su’s practice over almost a decade, as she selectively shed some of the traditional elements of Malay seances that were unappealing to her urban clients (including their lengthiness) while playing up certain theatrical elements. She drew in a new partner in her performances, a male government official, who reworked traditional Malay medical theory into a simplified modern idiom and combined it with elements of Islamic doctrine. Cik Su and her partner combined “antiquity and modernity, magic and religious orthodoxy” in ways that appealed to both the Islamic piety of clients as well as their attraction to a reconstructed “authentic” Malay identity. The politics of national identity may foster the revival of indigenous cultural forms in ways that commodify and decontextualize them, for purposes of state power, as in the Korean example. But innovations, as

Healing Powers in Contemporary Asia

13

Laderman’s chapter suggests, are not entirely in the control of the state. Shamans and their patients engage the processes of modernity in ways that maintain their value and utility for a range of social groups. The experience of modernity is inevitably gendered, although there is no necessary relationship between gender and other dimensions of difference. In postcolonial Asia, while men are frequently seen to formulate and implement national agendas, and occupy the more favorable niches in the modern economy, women are more likely to be associated with primordial values, and are often relegated to the most exploitative forms of labor (Sen and Grown 1987; Mohanty, Russo, and Torres 1991). However, these images must be tempered with others: powerful women politicians (such as Benazir Bhutto, Indira Gandhi, Cory Aquino, Imelda Marcos, and Megawati Sukarnoputri) have drawn on class connections that have facilitated their influence on the nation-state through a diversity of political ideologies. These women, and educated middle-class women like the reform-minded Indian doctors discussed in Kalpana Ram’s chapter, are likely to “identify with the workings of modernity and not see themselves as all that marginal.”8 They may thereby become participants in national and international policies of development of which poor women are often the targets. Critical feminist scholarship has impressively documented how development programs involve particular forms of gender bias with the result that traditional areas of female autonomy and strength are undermined (for example, see Rogers 1980; Sen and Grown 1987; Kabeer 1994). The positioning of women in postcolonial Asian states in relation to the values, policies, and practices of biomedicine, as an icon of modernity, is worthy of attention. Women as patients, particularly as childbearers, have been subjected to intense forms of biomedical rationality through state-sponsored health systems. Indices of fertility, morbidity, and mortality rates of infants and mothers have become deeply invested with political meanings of progress, so that women become the target of invasive forms of surveillance and control instituted by the “social welfare” arm of modern Asian states (Yuval-Davis 1997; Ram and Jolly 1998). As healers, women’s expertise is rendered valueless or even dangerous and should yield to the superior capacities of biomedicine. “Traditional” birth attendants (TBAs) have been especially subjected to these constructions, and have been discriminated against in many ways despite the continued patronage and respect they receive from many women. They have often been designated untrainable, or have received inappropriate and poor-quality training in programs sponsored by international agencies such as UNICEF (e.g., see Rozario 1998). Articulations of gender with other forms of marginality is a subject that merits close anthropological analysis, as it is in the conduct of everyday life that the complexity of social domination emerges. Kalpana Ram takes up the struggles around midwifery in South India as a way of revealing the internal complexities of modernity as a postcolonial phenomenon and the significance of continuities with the past. Ram combines historical and ethnographic analysis to show how reform of childbirth in the Indian colonial context became a cause that endowed

14

Introduction

British colonialist women with racial power, and was tied to broader critiques of Indian culture. After Independence, the cause of reform was continued by middle-class Indian women, securing them key positions in the national health system. These reformist initiatives persist into the present in discourses around the dai or indigenous midwife. Indigenous midwives resist their integration into the biomedical health system in a variety of ways. Their stories of attending childbirths valorize their practical knowledge, despite its low status in the Indian hierarchy of male-dominated, textualized knowledges. They come to their vocation in response to the needs of women in their communities, and learn through “immersion” in the birth milieu by watching, talking, and doing. Their practices may include negotiating relationships with biomedical authorities on behalf of their patients, despite their frequent rejection by staff in hospitals and clinics. Ram argues that the midwife is “located at the intersection of diverse relations of power,” including the relations of the home where most rural births still take place, as well as the clinic. The midwife by virtue of her multiple marginalities—of class, gender, postcoloniality, and often, caste9 —develops a range of “tactics” (in de Certeau’s terms). These tactics, such as ingenious manipulations of the foetal position to facilitate birth, or the use of locally available herbal medicines, empower the midwife in ways that might not be available to her Western counterpart. At the same time, midwives’ knowledge of the spirit world and use of ritual techniques render them “irrevocably Other and subaltern to the agents of modernity.”10 Ram suggests that the situation of the South Indian midwife thus allows us to contemplate a more “complex and comparative” (and, one might add, gendered) acount of modernity. ARTICULATIONS OF GLOBAL AND LOCAL Globalization is usually fairly loosely characterized as the movements, connections, and processes that link people, information, and commodities around the world. While globalization is often represented as a causal process, it is more productive to think of it as a descriptive term for many interrelated phenomena that require theoretical analysis. The debates around globalization have tended to focus on the arguments of those who identify universal processes in globalization (referred to by Roland Robertson [1995] as the “homogenizers”), and those (the “heterogenizers”) who emphasize the divergence of processes and epistemologies that can be described as global. In the sphere of economic theory, the term has been used to imply the demise of the nation-state or national economies. However, economic globalization theories of this type have been disputed by theorists such as Hirst and Thompson (1996), who argue that an integrated international economy, in which nation-states remain important units, is a more accurate picture of the current and future global economic order. Anthropologists are perhaps less concerned with the efforts of sociological

Healing Powers in Contemporary Asia

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theory to “internationalize” itself through various forms of globalization theory, as with the articulations of the “global” and the “local” from the perspective of the local. For anthropologists, the local may refer to the traditional units of study—small-scale communities in which kinship relations are still an important ordering principle of social life. But it may also refer to groups which are “minorities” in nation-states, to displaced persons who are members of “imagined communities,” or to categories of social association, such as that of shamans and their clients. The local is also a form of representation, in which, for example, cultural idioms and commodities are brought into relationship through institutions such as advertising. All these approaches to the local can be found in this volume, and permit us to escape from the too simplistic dichotomies of some overgeneralized and often Eurocentric globalization theory that Goran Therborn has recently suggested threatens a return to the unifying theory of “sociological master narratives” (1995, 124). The chapters in this book explore the articulation of the local and the global in Asian societies with the purpose of yielding comparative insights into specific social and cultural processes that are part of modernity. Healing is a site of transaction and transformation between global and local. Commodification of medicines and therapies, for example, works in many different directions, not just as a transfer of “global” biomedicine to “local” societies. In Karnataka, South India, Mark Nichter (Chapter 5) documents the ambivalence that patients and healers express about modernity in their “double-voiced” commentaries on the benefits of progress and the ills of urban-industrial society. Patients seek solutions to the negative health effects of modern life (including the iatrogenic effects of biomedicine) in the “ecological” approach of Ayurvedic medicine, whose theory links a common problem, indigestion, to capitalism’s exploitation of people and environment. This potentially radical critique of modernity, which leads some patients, at least, to a cure, has in important respects been co-opted by the manufacturers of the plethora of commercial Ayurvedic products that now flood the market. As healers themselves are aware, misuse of Ayurvedic medicine has become as problematic as misuse of allopathic medicine, and both point to the larger process of “defective modernization.” In a study that highlights quite different transformative powers of global and local Marina Roseman (Chapter 6) has documented how the Temiars of Malaysia harness the power of commodities and other icons of transnational modernity in their healing ceremonies. Temiar forest dwellers are confronted with the devastation of their natural environment by the encroachment of logging companies. A people who have long interacted with “outforester” others, they are now challenged by the destruction of the environment that provides them with sustenance. Spirit guides provide shamans with new dream songs: from airplanes (that have historically brought food drops as well as bombs); dried fish (a new staple that replaces dwindling forest foods); and a foreign woman from the marketplace of the downstream town where Temiars now trade on disadvantageous terms with the transnational economy. Strips of plastic bags replace shred-

16

Introduction

ded forest leaves (now in short supply) in the shimmering moments that “disassemble the visual field” during healing ceremonies. The particular genres in which each new song is received enable Temiars to map their experiences of modernity at the site of the sensory and the embodied. Such innovations bear potent testimony to the engagement of the Temiar with global processes in ways that are continuous with past experiences of the new and the strange. Rather than interpreting these improvisations as a capitulation to the overwhelming forces of change, Roseman argues that they are part of a local politics of survival that provides the Temiar with “a technology for maintaining personal and social integrity in the face of nearly overwhelming odds.” Rather than commodities being an expropriation of power from local knowledge systems, as the Ayurvedic healers discussed by Nichter understood to be happening, the Temiar appropriate the power of commodities into local knowledge systems in order to fortify themselves against their emergence as part of the underclass in Malaysia’s capitalist economy. Indigenous healing may be drawn into the global flow of ideas and commodities by linkage with the political struggles of minorities. The situation of Tibetan medicine in both the Tibet Autonomous Region (TAR) of the PRC, and among exiles in North India, illustrates this process. In Chapter 10 Craig Janes studies the social organization of Tibetan medicine in the TAR, focussing on its transformations since the implementation of “socialist market economy” policies in the mid-1980s. Throughout the vicissitudes of policy changes, Tibetan medicine has continued to enjoy a state-endorsed legitimacy as part of the “family of Chinese medicines” since the integration of Tibet into the PRC in 1959. In this respect, Tibetan medicine is not different from the other government-sanctioned “traditional medicines” that were discussed by Sydney White. Janes documents the explosion in demand for Tibetan medicine, in urban areas as well as rural, arguing that there are a number of reasons why Tibetan medicine has flourished, even in the current phase of socialist market-economic policy whereby state subsidies of the health system have declined, and rural cooperatives (which funded local clinics in the past) are no longer strongly supported by the state. Patients do not see biomedicine as providing adequate treatment for chronic conditions. Moreover, other elements of Tibetans’ formerly highly pluralistic system, particularly more overtly “religious” elements (such as divination by lamas), have declined as they did not meet state-defined criteria of health care. Another reason of particular relevance to the arguments here is that Tibetan medicine provides a context in which people can express their distress in their own cultural idioms as a vulnerable and disenfranchised minority in the PRC, subjected to forms of racism that are also documented by Vincanne Adams Chapter 11. The pressure on doctors, clinics, and medicine manufacturers to make profit out of Tibetan medicine by commodification of services and remedies in the new market economy means that it is becoming less accessible to poorer, rural sectors of the population, who now have to compete with more affluent urban

Healing Powers in Contemporary Asia

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and international consumers. This responsiveness to the market (and to the cultural authority of biomedical science in terms of which Tibetan medicine is trying to justify itself) is transforming the practice of Tibetan medicine. It compromises the quality of local practitioners and medicines (as the priority services and products go to consumers who can pay the highest prices), and threatens to transform it into a “superficial herbalism.” The increasingly transnational character of Tibetan medicine’s appeal, linked as it is to foreign interest in Buddhism and Tibetan culture more generally, may threaten its accessibility as a resource for the disempowered Tibetan minority in the PRC. Vincanne Adams’ chapter explores the dialectic of past and present knowledges in her study of Tibetan medical theorizing about women’s health in Lhasa. Doctors trained in traditional Tibetan medicine have an ambivalent relationship to past knowledge, an ambivalence conditioned by the political situation in the PRC. Elements of the wisdom of the past that can be dissociated from socialist ideologies of “feudalism” and backwardness are celebrated but need recuperating and validating in modern scientific terms so that Tibetan medicine will continue to progress. Adams discusses a modern Tibetan medical text on women’s health for what it reveals about a particular apprehension of modernity that is conditioned by its author’s location as a Tibetan minority intellectual in the Chinese socialist state. The text, conforming to the dictates of liberalizationera reforms, affirms both the reality of gender discrimination in the Tibetan past but also the seeds of gender equality that can be found there. These seeds can now be cultivated by combining the wisdom of traditional sages and healers with biomedical science, toward the end of improving women’s health. Modern science can improve the practice of Tibetan medicine, and indeed in Adams’ ethnographic research in the women’s ward at the main traditional medicine hospital in Lhasa, she found that biomedical technologies such as ultrasound were frequently incorporated into diagnosis and treatment. However, from many practitioners’ point of view, these innovations confirm and refine traditional knowledge, rather than undermining its epistemological foundations. From the point of view of the patient who consults a traditional Tibetan healer, she does not necessarily experience herself as medicalized, objectified, and alienated, even where biomedical techniques are applied, as a Western patient might do, because these practices are contextualized within a different epistemological framework. In other words, Adams argues that appropriations of modernity should not be taken as a capitulation to its terms. Tibetans in Lhasa may draw on the power of biomedicine to strengthen their traditional knowledge and practices. When we turn to the situation of a social group displaced from their homeland, as in the Tibetans of North India studied by Geoffrey Samuel in Chapter 12, the terms of understanding must take account of their multiple marginalities: as Tibetans originating from a disenfranchised minority in the PRC, and as exiles, persons without place or citizenship in their new location. The “perception of loss,” inherent in the modern experience that is canvassed by Adams in

18

Introduction

relation to Lhasan Tibetans, is acute for the exiles who are physically separated from their homeland, even if freer to practice their religion and maintain their culture than their relatives in Tibet. Samuel explores the ways in which the practice of traditional Tibetan medicine in two North Indian refugee settlements diverges from both textual accounts and popular Western interpretations. The theory of humoral imbalance, which is emphasized in books for Western readers, was rather attenuated in the Tibetan clinics described in the chapter, as was the reliance on diagnostic techniques such as urine analysis. Pulse reading was the main diagnostic tool, supplemented frequently by blood pressure readings taken with a sphygmomanometer. Diagnostic categories and procedures showed some marked variance with categories in the relevant Gyu¨ Shi texts and their commentaries. An attenuation of more “supernatural” categories, an attribute also remarked on by Janes for TAR practice, was evident. Samuel locates the discrepancies between the pragmatically oriented practices of Tibetan doctors and the representations of their work in two related but separate processes: the long-standing relationship with biomedicine that is part of the practice of Tibetan medicine in India as well as the TAR; and the Western romanticization of Tibetan religion and culture that has included healing. If Tibetan medicine in North India is being reconstituted by processes of modernity, then it is not a one-dimensional or unidirectional process. Like Tibetan practitioners in Lhasa, those in control of Tibetan medicine through the Department of Health in Dharamsala endeavor to legitimate its efficacy in biomedical terms. Patients, already familiar with common concepts and treatments of biomedicine as it is practiced in North India, exert further pressures toward a more pragmatic version of practice. As for Tibetans in Lhasa, traditional healing is a valued cultural resource that is idenitified with struggles over national identity. For exiles also, Tibetan medicine is an important economic resource as medicines are a commodity that is increasingly in demand by consumers in many parts of the world. While Tibetan patients have a fairly pragmatic orientation to traditional medicine, the demand from international patients is created by what can only be described as the imposition of the more spiritualized interpretation of Tibetan healing that accords with the general interest in Tibetan Buddhism internationally. The exoticizing of Tibetan culture, a process in which Tibetans themselves actively participate, has important ramifications for the practice of healing. Tibetan exiles, while a disempowered minority in many respects, actively build on the cultural capital at their disposal—their medicine’s efficacy and its holism—in ways that serve the purposes of cultural identity struggles as well as health care. CONCLUSION It seems imperative for anthropologists to use their particular skills and knowledge to further our understanding of the ways in which social groups engage with global forces of change. Transformations are felt just as much in

Healing Powers in Contemporary Asia

19

the arena of healing as in other areas of social life. If we take “healing” to be a process that is embedded in a spectrum of interconnected social relations, embodied dispositions, and diverse modes of knowing, then we have to question whether healing is compatible with modernity, or whether “health,” a biomedically defined and achieved goal, will be the limit of human aspiration in the future. Much of the recent innovative work by anthropologists working in Asian societies has focussed on the ways in which healing has become a contested and deeply politicized area of modern life. Global modernities, from a “health” perspective, are characterized not only by “wonder drugs” and the proliferation of new biomedical technology, but also by new epidemics, mass violence, political repression, population displacements, endemic disease, and environmental degradation, all of which can be related to global relations of power at many levels. The anthropological studies in this volume render “healing” visible as a vital process in any praxis of change that reaches for better global futures. ACKNOWLEDGMENTS I am grateful for thoughtful comments on earlier drafts of this chapter by Laurel Kendall, Kalpana Ram, Santi Rozario, and Geoffrey Samuel. NOTES 1. None of these three terms satisfactorily delimits the scope of healing practices in Asia. All healing, including biomedicine, has “local” specificities; it is difficult to describe widely used healing systems with a long-documented history of syncretism, such as Ayurveda or Chinese medicine, as “indigenous”; and “traditional” implies a rigidity and resistance to change that is not characteristic of healing, whether in Asia or anywhere else. In this book, contributors have used whichever term seems most appropriate to the context of discussion. 2. See Leslie (1976, 6–8) for a discussion of these and other usages. The term “cosmopolitan” seems particularly dismissive of the complex history of global interconnectedness that characterizes the formal, literate traditions of medicine practiced in Asia. Leslie (1976, 8) favored this term because he thought it best summarized the scientific and professionalizing processes of biomedicine. 3. See, for example, the chapters by M. A. Jaspan and Alan Beals. 4. This useful term was coined by Featherstone, Lash, and Robertson (1995) as the title of their recent book. 5. There has been great variability historically as well, as many of the chapters in this book document. 6. As Janes points out in Chapter 10, Maoist-era China is one exception to this. 7. I am grateful to Kalpana Ram for providing me with this example (personal communication, 7th September 1999). 8. Kalpana Ram, personal communication, 7th September 1999. 9. Ram makes the point that among coastal communities of Tamil Nadu where she worked, where there are many converts to Catholicism, midwifery is not necessarily associated with pollution or low status.

20

Introduction

10. Laurel Kendall in Chapter 2 makes the same point with regard to shamans in Korea.

REFERENCES Bourdieu, Pierre. 1992. Outline of a theory of practice. Cambridge: Cambridge University Press. Crozier, R. C. 1976. The ideology of medical revivalism in modern China. In Asian medical systems: a comparative study, edited by Charles Leslie. Berkeley: University of California Press. de Certeau, Michel. 1988. The practice of everyday life. Berkeley: University of California Press. Featherstone, M., S. Lash, and R. Robertson, eds. 1995. Global modernities. London: Sage. Friedman, J. 1995. Global system, globalization, and the parameters of modernity. In Global modernities, edited by M. Featherstone, S. Lash, and R. Robertson. London: Sage. Giddens, Anthony. 1990. The consequences of modernity. Cambridge: Polity Press. Hirst, P. and G. Thompson. 1996. Globalization in question: the international economy and the possibilities of governance. Cambridge: Polity Press. Hobart, Mark, ed. 1993. An anthropological critique of development: the growth of ignorance. London: Routledge. Kabeer, Naila. 1994. Reversed realities: gender hierarchies in development thought. New Delhi: Kali for Women. Kahn, Joel S., ed. 1998. Southeast Asian identities: culture and the politics of representation in Indonesia, Malaysia, Singapore, and Thailand. Singapore: Institute of Southeast Asian Studies. Kendall, Laurel. 1985. Shamans, housewives, and other restless spirits: women in Korean ritual life. Honolulu: University of Hawaii. King, A. D. 1995. The times and spaces of modernity (or who needs post-modernism?). In Global modernities, edited by M. Featherstone, S. Lash, and R. Robertson. London: Sage. Laderman, Carol. 1991. Taming the wind of desire: psychology, medicine, and aesthetics in Malay shamanistic performance. Berkeley: University of California Press. Leslie, Charles, ed. 1976. Asian medical systems: a comparative study. Berkeley: University of California Press. Leslie, C. and A. Young, eds. 1992. Paths to Asian medical knowledge. Berkeley: University of California Press. Mohanty, C. T., A. Russo, and L. Torres, eds. 1991. Third World women and politics of feminism. Bloomington: Indiana University Press. Ram, Kalpana and Margaret Jolly, eds. 1998. Maternities and modernities: colonial and post-colonial experiences in Asia and the Pacific. Cambridge: Cambridge University Press. Robertson, R. 1995. Glocalization: time-space and homogeneity-heterogeneity. In Global modernities, edited by M. Featherstone, S. Lash, and R. Robertson. London: Sage. Rogers, B. 1980. The domestication of women: discrimination in developing societies. London: Tavistock.

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Rozario, Santi. 1998. The dai and the doctor: discourses on women’s reproductive health in rural Bangladesh. In Maternities and modernities: colonial and post-colonial experiences in Asia and the Pacific, edited by Kalpana Ram and Margaret Jolly. Cambridge: Cambridge University Press. Said, Edward. 1978. Orientalism. New York: Pantheon. Sen, Gita and Caren Grown. 1987. Development, crises, and alternative visions: Third World women’s perspectives. New York: Monthly Review Press. Smith, Christopher J. 1993. (Over)eating success: the health consequences of the restoration of capitalism in rural China. Social Science and Medicine, 37(6): 761–770. Therborn, G. 1995. Routes to/through modernity. In Global modernities, edited by M. Featherstone, S. Lash, and R. Robertson. London: Sage. Wolf, Eric. 1982. Europe and the people without history. Berkeley: University of California Press. Yuval-Davis, N. 1997. Gender and nation. London: Sage Publications.

PART I

HEALING IN THE MODERN STATE: KOREA, MALAYSIA, AND INDIA

2

The Cultural Politics of “Superstition” in the Korean Shaman World: Modernity Constructs Its Other Laurel Kendall

What was not transportable, or not yet transported, into the new areas of progress appeared as “superstition.” de Certeau, The Practice of Everyday Life, 1984.

su.per.sti.tion 1a: a belief or practice resulting from ignorance, fear of the unknown, trust in magic or chance, or a false conception of causation b: an irrational abject attitude of mind toward the supernatural, nature, or God resulting from superstition Merriam-Webster’s Collegiate Dictionary, electronic edition, c. 1994–1995.

⫽bewitched, deluded, false. sin Superstition: misin, mi Chinese: mixin, Vietnamese: me tin

⫽belief

When we consider “modernity” not as an inevitable and unidirectional process, but rather, in Baudrillard’s (1987) sense, as something like a viral ideology that has infected most of the globe but mutated, waxed, and sometimes waned in local settings (Rofel 1992), then new questions can be asked. “Superstition” may, with “modernity,” be interrogated as a historically contingent ideological construct, the potent dark side against which modernities take shape and measure themselves. For a century or more, Korean intellectuals and reformers have regarded shamanic practices as the target of a Manichean struggle between “mo-

26

Healing in the Modern State

dernity” and “superstition,” “rationality” and “magic.” From the modernizers’ perspective, this conflict has been about medicine and healing, it has been perceived and experienced as a contestation between rational science on the one hand, and charlatanry and peasant credulity on the other. These attitudes were very much alive in Korea when I began my first fieldwork in the late 1970s. In this chapter, I examine the local history of a potent and well-traveled concept, considering the stakes with which “superstition” was originally invested in Korea, for whom, and in what relation to the shamans upon whom its stigma was cast. Even as the onus of “superstition” is eclipsed by more recent Korean celebrations of shamanic rituals as “national culture,” these new public discourses are similarly detached from the perceptions and experiences of those who enact, sponsor, and participate in shamanic rituals and have similarly invested in the ideological baggage of modernity. THE CONFRONTATION On a cold, dark night in the early spring of 1977, I attend a kut for a family that had suffered multiple afflictions. Some months before this kut, the mother of the family was shot near her heart by a stray bullet as she tended her fields near a military installation. She did not know what had hit her. Because this was a sudden and mysterious affliction, her family called in the local shaman who performed a small exorcism. They also took the mother to a small clinic in Righteous Town and then to the branch of a major hospital on the outskirts of Seoul. No one could say what was wrong with her until the family, in desperation, took her to St. Mary’s General Hospital in downtown Seoul. There, she finally did receive effective treatment, but her cure took several months and was expensive. The family sold their cow and pig—most of their liquid assets— and spent money that they had been saving for the youngest daughter’s wedding.1 With rightful claims to compensation money, they tried to find the person who had fired the gun, but it was a futile search. And then the eldest son injured his leg. After visiting several doctors, he still walks with a limp. The strained expression on his face suggests constant pain. The daughter, who relates all of this to me when I ask her, “Why is your family holding this kut?” adds that even before her mother’s accident, things had not been going well. Their regular shaman advised them to tend their restless ancestors with a kut, but because their resources were pinched, they had made only a minor offering to exorcise ominous ancestral influences (p
udakkoˆ ri). Within months of this insufficient gesture, the mother had been hit by the stray bullet and the family fortunes continued to plummet. By 10.30 P.M., the shamans are well into the kut. A policeman from the district office appears at the gate and shouts his insistence that they cease their drumming and dancing. He complains that this sort of activity is precisely why the New Village Movement has not advanced in Enduring Pine Village. He denounces the shamans for dancing and shaking their hips to the drum rhythm in

Superstition in the Korean Shaman World

27

front of schoolboys. This greatly amuses the shamans, but the elderly couple who are sponsoring the kut are irate at the policeman’s intrusion. The old woman shouts at him with great fervor, “My son is ill. There is no help for it.” “If your son is ill, you should go to the hospital.” “We’ve been to hospitals.” Urged by the crowd to calm down and go away, the policeman threatens to imprison the shamans for a month if he finds them still drumming and dancing when he returns. The old man, the master of the house, declares that the kut is his responsibility and that if the shamans are to be arrested, then the policeman must arrest him as well. The policeman stalks away and does not return. It is generally assumed that this defender of local morality and social progress had been mollified with an envelope of “cigarette money” for his trouble.2 The drumming and dancing resumes and continues well into the next morning. AN IDEOLOGY OF AFFLICTION This interrupted kut, and many others that proceeded smoothly to completion, taught me that far more is at stake in shamanic rituals than a one-shot cure for an individual illness. This was not a simple exercise in “health-seeking behavior,” a privileging of “sacred medicine” over the “cosmopolitan” variety, a visit to the shaman in preference to a visit to the hospital. Indeed, the family had consulted a variety of hospitals and doctors and the mother had received a satisfactory biomedical cure. The shaman was not a stand-in for the doctor. The kut addressed not the specific illness, neither the mother’s nor the son’s, but rather a pervasive climate of family affliction in which accidents and injuries could occur, where an injury might not heal despite repeated medical treatment, and where ruinous medical expenses had grave consequences for other members of the household. Although the mother told the policeman that she was holding the kut because her son was ill, when she importuned the spirits who spoke through the shamans, she seemed equally concerned about her youngest daughter’s marriage prospects, anxious because she had spent her daughter’s marriage money on her own medical treatment. Generalizing from many kut like this one, I would describe an “ideology of affliction” wherein all manner of problems—medical, financial, and social—are symptomatic of a household’s troubled relations with its ancestors and gods (Kendall 1985, esp. Ch. 5). In all of these kut, the entire household and the full sum of the problems and aspirations of all of its inhabitants become the subject of healing. The idiom of healing is a series of reconciliations between the living members of the household and their gods and ancestors who appear in sequence in the person of costumed shamans (Kendall 1977; 1985, esp. Ch. 1).3 The policeman, of course, saw things differently. People who ought to be visiting doctors were spending money on “irrational” ritual practices. In my early work I found it necessary to confound these notions of “either/or,” “medicine or magic” with a view from within the world of shamans, clients, and kut where

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Healing in the Modern State

there was no contradiction between visiting a doctor and consulting a shaman. In my own thinking, I elided any distinction between the policeman’s critique and commonsensical attitudes encountered closer to home. Ethnography would triumph over all by illuminating the internal logic of shamanic practice. I failed to recognize that the policeman also inhabited my ethnographic field even as slogans advocating “development” (paltal) and “enlightenment” (kyemyoˆ nghwa) were inscribed on the walls of public buildings. Belatedly, I would acknowledge the policeman as a social actor within the rural Korean world of the 1970s, a product of both that time and place and nearly a century’s history of Korean “modernity.” This particular confrontation between the policeman, the shamans, and the elderly couple took place during the most enthusiastic years of the New Village Movement (Saemauˆ l Undong), initiated by the Park Chung-hee regime in the early 1970s as a mass mobilization campaign involving local communities in a variety of public works projects. Under the movement banner and with official encouragement, local leaders also attacked extravagant rituals and “superstitious” practices that were seen as detrimental to the economies of time and money necessary for national development. In these years, the Movement to Overthrow Superstition (Misin T’ap’a Undong) countenanced the destruction of village shrines and the fining or imprisonment of shamans for holding kut (Ch’oe 1974). “Superstition” (misin) is a term with powerful ideological content in Korea. Its genealogy is bound up with that of modern Korean history. KOREA GETS SUPERSTITION Confucian officials in dynastic times disdained shamans as practitioners of unclean and improper rituals and as potential charlatans. The Confucian worldview did not deny the existence of spirits so much as it asserted that there were better, more proper, less socially deleterious ways to honor them than by employing shamans. Local magistrates attempted periodically to transform shamanic rituals at local shrines into rites performed according to Confucian rules of ritual propriety. Some officials challenged the efficacy of specific spirits honored in particular local shrines, but only in rare instances of intellectual speculation was the very existence of spirits called into question (Walraven 1996; Yi 1976). The labeling of popular religious practices as “superstition” demands a profound cognitive break with the ambiguity and ambivalence of Confucians past. Rendered in Sino-Korean ideographs as misin, the term literally means “deluded” or “false” belief. It proclaims that there are no spirits, that the gods and ancestors do not and can not affect human fortune. The term came to Korea in the late nineteenth century via Japan where words had been feverishly coined to express in ideographs new social, political, and philosophical concepts contained in Western books, the newly minted vocabulary of modernity that was assaulting East Asia (Ch’oe 1974; Cohen 1993). “Superstition” had already en-

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joyed a long currency in the West. With subtle shifts in meaning over time and space, it had originally connoted improper, transgressive, or false beliefs in contrast to better, more orthodox religious ideas and practices. With the Enlightenment, superstition acquired its “modern” meaning as not merely “bad religion” but “bad science,” “misplaced assumptions about causality stemming from a faulty understanding of nature” (O’Neil 1987, 165). The Japanese translator captured this gloss precisely in his choice of ideographs. In East Asia, as in the post-Enlightenment West, “superstition” would serve forever after as modernity’s dark alter ego, the realm of unacceptable practices, of things irrational, invalid, and consequently harmful.4 But why—if we no longer accept the inevitability of modernity’s grand narrative—should Korean intellectuals have accepted the terms of this language and incorporated them into their own view of the world? To pursue the viral analogy introduced at the beginning of this chapter, late nineteenth and early twentieth-century Korean nationalists were highly susceptible to infection, humiliated by Korea’s slide into the colonial orbit of the Japanese Empire in 1910 and willing to blame native traditions for the nation’s weakness and humiliation. Historian Michael Robinson characterizes progressive Korean intellectuals of the early twentieth century as “quick to point out Korea’s failings, contrasting their own tradition with their understanding of what was modern, progressive, and scientific” (Robinson 1988, 35). They criticized Confucianism for fostering oppressive gerontocratic mores and empty ritualism (ch. 1). Buddhism would be reformed along “modern, scientific lines” (Buswell 1992, 26) as in Thailand (Keyes 1989) and Sri Lanka (Obeyesekere 1991; Swearer 1991, 637–638). Shamans, accused of deluding the people and fostering “irrational” beliefs, were to be extirpated as in China (Anagnost 1987; Duara 1991; Luo 1991), Siberia (Balzer 1993, 1996; Vitebsky 1995) and many other places. Many early progressives marked their rejection of the Korean past by becoming Christian. Indeed, Korea is Protestant Christianity’s unique success story in Asia, and Christian concepts of religion have had great bearing on how many Korean intellectuals view indigenous practice. Protestant Christianity sunk deep roots in Korea in the 1890s, bearing schools for Western education and hospitals, the institutional accoutrements of enlightenment and science (Clark 1986, Ch. 2). According to Robinson, many prominent intellectuals “linked in their own minds Western social and political institutions with Christianity” (Robinson 1988, 35).5 In the pages of The Independent (Tongnip Sinmun), an early progressive newspaper published bilingually with missionary support in the twilight years of the Chosoˆ n dynasty, concerned nationalists railed against deceptive shamans and inept practitioners of Chinese medicine. This, in de Certeau’s terms, is the “cleavage” that “organizes modernity,” the imperative that “science” would conquer the “irrational” hinterland of the human imagination, imposing its own words and categories upon it (de Certeau 1984, 6). “Modernity,” as a self-conscious ideology, shaped the identity of the small group of first-generation professionals and entrepreneurs that appeared in the

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cities of the colonial period (1910–1945) (Robinson 1988; Eckert 1991, Ch. 2). Disdain for shamans and “superstition” became a naturalized attribute of this new class as it distinguished itself from a seemingly “backward” rural populace. We have seen this process elsewhere. Keith Thomas describes how in England, by the seventeenth century, new intellectual developments deepened the gulf between the educated urban classes and the “superstitious” lower strata of the rural population who became the objects of “folklore” (Thomas 1971, 666). A similar split has come to exist in China where, from the end of the last century, the traditions of vast rural populations have been “derided as backward and actively suppressed by China’s modern political and intellectual elites, whose views on other matters range across the political spectrum from extremes of the Left and the Right” (Cohen 1991, 113). Both Argyrou (1993, 266), writing of Cyprus, and Kapferer (1983, 18, 29), writing of Sri Lanka, describe the middle class’s identification with “science” or with more “rational”-seeming religious practices as a means of asserting and naturalizing class domination. In urban India, middle-class households adopt new “rationalized” devotional practices that disassociate them from rural “superstition” (Babb 1990). In rural Nepal, those whose occupations define them as agents of “development” are most likely to reject shamanic practices as a way of asserting their own claims to “modernity” (Pigg 1996). Stacey Pigg’s observation that “the idea of the modern generates a sense of difference while at the same time holding out the promise of inclusion in a global cosmopolitan culture” (165) has a wide application beyond the site of her Nepalese fieldwork. The point here is not that the new elites’ posture toward popular religion is an inevitable consequence of “modernity” so much as it represents the self-conscious inhabiting of new class positions. In Korea, by the 1930s, the logic of these associations—modernity, middle class respectability, and disdain for shamans and “superstition”—would be taken up by ambitious migrants to the colonial city as an affirmation of their new aspirations and a measure of their disassociation from the countryside. In Pak Wansoˆ ’s (1991) autobiographical novella, Mother’s Stake 1 (Ommauˆ i Malttuk), a young widow turns her back on village life to eke out a marginal livelihood in Seoul in the hope of educating her son and transforming her daughter into a “new woman.”6 The widow sees her husband’s early death as a tragic consequence of rural backwardness. When the doctor of Chinese medicine could not cure her husband’s sudden and severe bellyache, she had gone with her motherin-law to consult a shaman who set an auspicious date for a healing kut. Her husband had died even before she returned from the shaman’s house. The neighbors attributed his death to ominous forces stirred up by the construction of a new house, a common ascription for sudden and often fatal illness. The widow thought otherwise. Pak writes from the young daughter’s perspective: Mother didn’t agree with them. She . . . had relatives in cities, and had tasted civilization before marriage, so she knew that the disease Father had died of could have been cured,

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as simply and easily as an operation on an infected finger. If only he had seen a doctor trained in Western medicine! From that moment on, Mother began to dream of an exodus to the city. (Pak 1991, 178)

This is modernity’s either/or logic (Tambiah 1990, 20–21), the logic of the rural policemen a few decades later. Acute appendicitis cannot be cured with Chinese medicine or a visit to a shaman; the patient was doomed. The young man died of ignorance, an onus cast equally upon the bad science of Chinese medicine and the irrationality of shamanic practice. A doctor of Western medicine could have saved him; tradition killed him. The “modern” widow knew better and escaped to the colonial city; in de Certeau’s terms, she turned her back on the “rural hinterland of the imagination.” But this is not the logic of Korean popular religion whose palimpsest can just barely be discerned in the story. Ominous spirits, stirred up by moving earth or erecting a new structure without proper ritual precautions, wreak havoc upon a particularly vulnerable family member; symptoms of a problematic and ominous spiritual condition are made manifest in a medical crisis,7 an interpretation that does not preclude the recognition of medical necessity. The rural family of Pak’s story summoned a doctor of Chinese medicine for their afflicted son, a parallel of actions taken by that other rural family in 1977 who, though cognizant of restless ancestors, brought their afflicted mother and son to clinics and hospitals. The spirits would be dealt with, but in their fashion. By modernity’s logic, however, the shaman is a dangerous instrument of ignorance, an agent of deluded and backward social practices that have tragic consequences, just as in Enduring Pine Village, several decades later, the policeman blames the shamans for the village’s lackluster participation in the New Community Movement that will bring progress and prosperity to the village. In his eyes, the shamans are both a source and a symptom of backwardness. That Korean shamans have been commonsensically perceived as agents against modernity has provoked periodic campaigns of active suppression. In 1896, cheered on by reformist elements, the Seoul police arrested shamans and destroyed shrines (Walraven 1995, 110–111).8 Between 1919 and 1945, Korea’s Japanese colonizers were similarly bent upon effacing “superstition,” having already mounted this campaign at home (Robinson 1988; Hardacre 1989 for Japan). In Korea, shamanic practices were discouraged by the strong arm of the colonial police (Ch’oe 1974). In the 1970s, when, in the name of “development” (paltal), the Park Chung-hee regime initiated “antisuperstition” (misin t’ap’a) campaigns, folklorists anxious to defend local custom noted the wry parallel between this movement and earlier Japanese colonial efforts (Ch’oe 1974). In the 1990s, this history of suppression by the Japanese is evoked to enhance the nationalist luster of shamanic revivals,9 but aging shamans recall how they were routinely harassed and sometimes arrested by the police of a newly independent Korean nation under Syngman Rhee.

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“SUPERSTITION” BECOMES “CULTURE” While this agonistic play of “modernity” versus “superstition” has a nearglobal resonance, familiarity should not obscure the historical specificity of each local realization. “Superstition” and “modernity” are not immutable constructs. “Modernities” do not inevitably vanquish “superstitions,” although this tenet is intrinsic to modernity’s worldview, and those who are invested in “modernity” have every incentive to tell linear narratives about themselves. “The shamans have all died out.” “Perhaps you might find one or two in the deep country.” “There aren’t so many kut anymore.” For more than twenty years, these pronouncements have been offered to me by well-intentioned Korean interlocutors in flat contradiction of ethnographic reality. In the 1990s, commercial shrines on the periphery of Seoul are filled with kut, and the shrines seem to be a growth industry. The shamans claim that more new shamans are being initiated now than ever before (they do not universally consider this to be a good thing) (Kendall 1996b, c). Twenty years after the irate policeman disrupted the kut in Enduring Pine Village and ordered the sponsors to visit a doctor, medicalized perceptions of Korean shamanship as “superstition” are yielding ground to discussions of shaman rituals as “religion” (chonggyo) and “national culture” (minjok munhwa). These borrowed concepts have their own genealogies in the history of Korean modernity and are invested with different but still problematic stakes for the shamans and their clients. Just as well-born collectors of popular folklore in seventeenth-century England fed a growing sense that the citizens of town and country inhabited different mental worlds (Thomas 1971, 666), the rise of modern folklore studies in early twentieth-century Korea was both sign and signification of the distinction between “modern” Korean urbanites and their “traditional” past. If the countryside was a place of backwardness and superstition, by the very act of imposing distance, it became for the new middle class a homeland of nostalgic longing, as in other places “alternately seductive and dangerous, unique, lost” (de Certeau 1984, 132), a site of ambiguous imagining and emotional resonance, simultaneously backward and bucolic (Williams 1973). As elsewhere, the development of Korean folklore studies was about the politics of culture as defined by new middle-class intellectuals and mingled with early nationalist agendas in the belief that the defining essence of a “people” was to be found in their folk traditions (Bauman 1989, cited in Bauman and Sawin 1990, 288; Burke 1978, Ch. 1; Linke 1990). But early Korean folklorists were also fired by the longings of a colonized people (I. H. Choi 1987; Janelli 1986; Robinson 1988). In the manner of Confucian officials who saw themselves as empowered to distinguish between “good and rich” custom and harmful practices (Deuchler 1992), the cultural nationalists saw themselves as sifting the pure stuff of national tradition from the dross of superstition (Janelli 1986, 30–31; Robinson 1988, 32).10 In crypto-Confucian dress, Korean cultural nationalists

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performed the culture work of new elites who, in de Certeau’s (1984, esp. Ch. 4) characterization, “normalize” popular practices into modernity’s new intellectual regime by observing, recording, and inscribing them as folklore. The folklorist, historian, and nationalist Ch’oe Namsoˆ n linked contemporary shaman practices to myths of the culture hero Tan’gun, as recorded in (highly ambiguous) ancient texts, and precipitated an intellectual tradition that regards “shamanism” as a unique spiritual force infusing the Korean people (Janelli 1986; Allen 1990; Walraven 1993).11 These writings moved “shamanism” from the jaws of “superstition” to the embrace of “religion” and “culture” within Korean intellectual discourse. Linked to Tan’gun, ancient shamanic practices were infused, retrospectively, with nationalist spirituality, a theme that has been taken up again with the revival of interest in Korean folklore since the 1970s (Janelli 1986; Walraven 1993). This operation necessarily constructs contemporary practices as debased “survivals.” Scholars value shamans and their rituals as evidence of ancient and enduring national traditions, while the observers maintain their intellectual distance, as learned men and modern progressives, from the unlettered and superstitious-seeming women who maintain these practices in the twentieth century. Thus modernity preserves its disdain of “superstition” while embracing “tradition” and rendering it safely in the past tense. The folklore revival of the 1960s and 1970s was prompted by a nostalgic reaction against rapid industrialization, booming urbanization, and a massive influx of Western popular culture. With the growth and popularization of folklore studies, many well-read Koreans began to regard shamanship as a pure Korean tradition alive on the peninsula since before the arrival of Buddhism and Confucianism. Shamans and their rituals were acceptable where they could be historicized; the middle class could begin to approach them as the subjects of folklore, the lingering relics of a dying tradition (See Figure 2.1). The decade of the 1980s was a critical watermark for Korean thinking about the past. Memories of national humiliation and economic hardship were now bracketed by Korea’s entrance into the ranks of the Newly Developed Nations and by the selection of Seoul as the site of the 1988 Olympics. Viewed from a distance, attributes of “tradition” could be safely enjoyed. In the early 1980s, the Ministry of Culture designated three shamanic rituals as “Intangible National Treasures” (muhyang munhwaje). Carefully selected shamans were appointed to perform them as “Human Cultural Treasures” (ingan munhwaje), and more would follow. These staged performances, celebrating ritual activities as folk art and reconstructed history, deny the persistence of lived belief and practice. Chungmoo Choi has described some delicious ironies as shamans vie for an official status that enhances their popularity with clients (C. Choi 1987, Ch. 2; 1991). The 1980s would see a profound shift in the regard accorded traditional elite versus popular culture. The 1980s were a decade of debate, argument, and sometimes violent protest, baptized in the blood of the Kwangju Insurrection and culminating in the torrent of popular dissent, labor strikes, and grass-roots move-

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Figure 2.1. A shaman balances on knife blades at a cultural event in downtown Seoul. Photo by Laurel Kendall, 1994.

ments that ushered out the Chun Doo Hwan government in 1987. Things Korean came to be cast in opposition to things Western (Kendall 1996a, Ch. 3). Nativistic impulses that had fueled Korean folklore scholarship in the 1920s and 1930s and a revival of interest on university campuses in the 1970s (Janelli 1986; Robinson 1988) now blossomed into a broad-based popular culture that drew its idioms from the traditions of downtrodden peasants and outcast shamans (the minjung or “masses”) (Abelmann 1993; C. Choi 1987, 1991, 1995; Kim 1994). Intellectual enthusiasm for popular religion mushroomed with performances of kut on university campuses (including Christian universities), the publication of attractively illustrated books on folk traditions, and television appearances by a well-known shaman. In the summer of 1991, the first conference of the International Society for Shamanistic Research was held in Seoul, and Korean delegates proudly suggested that Korea boasted the most vital living shamanic tradition in the world. The process had come full circle from denial, through nostalgic celebration, to recognition as an intangible national resource.

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GOING PUBLIC Let me briefly describe a large public kut held in a satellite city of Seoul in the spring of 1992.12 These kut are organized by the several associations that now claim to speak for and defend the professional interests of shamans, but are primarily financed by the shamans themselves who are also expected to invest tremendous sums in identical costumes for the occasion. Many shamans consider their participation in these events to be an honor, an opportunity for recognition in the manner of national treasure shamans. At this particular event, space and time were organized in the manner of a cultural festival rather than a shaman ritual; indeed the members of the organizing committee consistently referred to it as a haengsa, “an event,” rather than a shaman’s kut, or even a “festival” (che).13 It began with a taped recording of the national anthem, for which members of the audience stood and placed their hands over their hearts. A master of ceremonies introduced members of the festival committee (all men but for one) and distinguished guests (including myself, pinned with a distinguished guest’s boutonniere). We sat in a special section where a reviewing stand, a table covered with a banner, had been improvised for the chairman and the committee members. The chairman’s remarks echoed the sentiments expressed in the printed program, that the influence of foreign cultures has harmed Korea’s own distinct traditions and that this event was being held to keep the memory of such practices alive. The original local Tano Kut, it was claimed, had disappeared during the colonial period. Once the introductory formalities were complete, the committee and members of the local shaman’s association gathered for a commemorative photograph. The kut itself was performed on an open-air stage beside a large apartment complex. As on similar occasions, the stage relegated the spectators to the role of a passive audience while a small group of women from the association, all wearing identical Korean dresses, received the gods’ divinations and bowed in unison. The sense of separation, of watching rather than doing, was enhanced by the presence of a loud-voiced man with a microphone who announced each segment, explained its significance, named the participating shamans, and sometimes offered running commentary which, in the climactic moments of a shaman’s balancing on knife blades, resembled the frenzied pitch of a football announcer. This ambience could not be more different from the intimate atmosphere of a country kut, like the one that I visited at the start of this chapter, where the spirits vest with authority and humor things already known among the community, sentiments and family stories that clients, neighbors, and kin may have already revealed to the shamans before the start of the ritual (C. Choi 1987; Kendall 1977). These kut are about life as women live it, with tears and laughter. In contemporary Korea, the ground has shifted, and clients living in anonymous apartment blocks hold their kut in the more private settings of isolated rented shrines where the sound of the drum and cymbals will not disturb the neigh-

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Figure 2.2. Shaman exorcizing a couple outside the rented room of a public shrine. The couple was anxious about the fate of their business. Photo by Laurel Kendall.

borhood (see Figure 2.2). These kut are held far away from neighbors and supportive kinswomen, and they are usually held within the frame of industrial time, condensed to permit shamans and clients to return home at sunset. With these adjustments, shamans, clients, and spirits continue to share tales of wayward children, drunken spouses, and financial misadventures. If the event is condensed in time, it has also become more intense as the shamans and spirits directly engage the client, or the client’s immediate family, for the entire ritual. When kut are translated into large public performances, they necessarily become something else. They address not a gathering of concerned participants, family, and neighbors, but a larger and largely anonymous public: the residents of the sponsoring town or ward, the television-viewing nation, or, on the occasion of the first conference of the International Society for Shamanistic Research, scholars of the world. The personal issues discussed in more intimate kut are not only less compelling to a broad spectrum of strangers, these potentially embarrassing revelations from the private realm are inappropriate for public display. A large public kut thus showcases feats, spectacle, and photo opportunities while the shamans offer innocuous prognostications for good fortune. Personal stories are swallowed up in a larger national story, idealized, theatrical, an icon of bygone days. By the process of designating nationaltreasure teams and “reviving” local rituals with microphone commentary, sha-

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man rituals have come to be about the history of a people, about Korea, in an authorizing process whose dominant voices are almost inevitably educated men. CONCLUSION A public kut is not a fair measure of what shamanic practices have become in the 1990s. It does not represent the end point in a process. Shamans continue to perform kut in their own practices and apart from public displays (although some shamans might also participate in these). As living practices, shamanic rituals are also changing practices, adjusting to the spatial constraints of urban life, the temporal constraints of industrial time, and above all, to the particular vicissitudes of Korean life in the 1990s (Kendall 1996b). The staged kut does not find its counterpoint in the country kut described at the start of this chapter, but rather in the performance of the rural policeman who attempted to disrupt it. Both would deny the instrumentality of kut as a ritual of affliction: the one in the name of “superstition,” the other in the construction of a palatable cultural text. The culturalist response, no less than the denigration of these same practices as “superstition,” must be understood as a part of the unfolding story of modernity that Korea tells about itself. In this chapter, I have drawn on Michel de Certeau’s notion of how “modernity” discourses inscribe social practice, and have cast sideways glances to the work of historians and anthropologists who write of other places to suggest how the study of “superstition”—the inscription and not the thing inscribed— can enhance a critical understanding of “modernity.” Shamans, so often cast as the “shock absorbers of history” in Michael Taussig’s (1987, 237) apt phrase, are an excellent flash point for these discussions. But intertextual resonances should not suggest inevitable processes. Korean shamans and their rituals will likely survive romanticization even as they have survived antisuperstition campaigns. I have tried to suggest that the oscillating ascendancy of “superstitious” and “culturalist” labels for shamanic practices have been linked to specific politicohistorical developments within Korea. I have also hoped to suggest—although perhaps less explicitly here than in some other writing—that Korean shamans and their clients, rather than simply being “inscribed” with the discourses of modernity, have engaged and continue to engage these processes. The kut went on, despite the policeman’s intervention. NOTES 1. Because weddings were both a major expense and a prime parental responsibility, mothers in Enduring Pine Village would begin to save toward their daughters’ weddings by investing in informal credit associations years in advance of the event and usually long before a prospective groom had been identified. In this period, most village daughters worked. Where family circumstances permitted, substantial chunks of their earnings were invested as marriage money (see Kendall 1996a, Ch. 6).

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2. A local shaman, not involved in this kut, blandly stated that the way to deal with the police was to provide them with their cigarette money in advance to thank them for their trouble in looking out for the household during the forthcoming “big event.” The team that performed this kut came from the town of Suwoˆ n where they were registered with a local association that protected them from police harassment. They may have been innocent of local practices. 3. The kut described above was not described by the shamans as an uhwan (affliction) kut (usually translated as a “healing kut”) but rather a siyang kut (better known as chinogi kut) intended to send restless and troublesome ancestors to paradise to address the problematic condition that was the root cause of affliction. See Kendall (1985, Ch. 1) for a detailed description of a kut. 4. See Keith Thomas’ (1971) description of a post-Reformation English world attempting to distinguish “religion” from unacceptable folk and papist practices. 5. Because the missionaries were not of the same nation as the colonizers, the Christian community gave early nationalists a space in which to define themselves against both a failed tradition and the colonial presence that had supplanted it (Clark 1986, Ch. 2). 6. I am indebted to Kyeong-hee Choi both for introducing me to this work and for her insightful interpretation of it (Choi 1996). 7. See Kendall (1985, 97–99) and the general discussion of affliction in Chapter 5. 8. Walraven notes that the persecution of shamans was practiced in dynastic times (Walraven 1995, 109), but this would have been the first of many persecutions carried out in the name of “modernity” and “enlightenment.” 9. Chungmoo Choi (1995) notes how the salience of the notion of “colonial erasure” fired the enthusiasm of student groups in the early days of the Popular Culture Movement and became a key rationale for the military government’s cultural policy. 10. See also Linke (1990). 11. Ch’oe Namsoˆ n was not the first to describe Tan’gun as the progenitor of contemporary shamans. Boudewijn Walraven notes that the Mudang Naeryoˆ k (History of the Mudang), dated to 1885, already makes this link while it disparages then-contemporary shaman practices (Walraven 1993, 10). 12. For a more complete account and analysis of this particular performance, see Kendall (1998). 13. The banner draped over the performance area proclaimed the “First Sacrifice to the Spirit of X Mountain and Tano Festival.”

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Babb, Lawrence A. 1990. New media and religious change. Items 44/4: 72–76. Balzer, Marjorie Mandelstam. 1993. Dilemmas of the spirit: religion and atheism in the Yakut-Sakha Republic. In Religious policy in the Soviet Union, edited by S. Ramet. Cambridge: Cambridge University Press. ———. 1996. Flights of the sacred: symbolism and theory in Siberian shamanism. American Anthropologist 98: 305–318. Baudrillard, Jean. 1987. Modernity. Canadian Journal of Political and Social Theory 11: 63–73. Bauman, Richard. 1989. Folklore. In International encyclopedia of communications, edited by E. Burnouw. Oxford: Oxford University Press. Bauman, Richard and Patricia Sawin. 1990. The politics of participation in folklife festivals. In Exhibiting cultures: the poetics and politics of museum display, edited by I. Karp and S. Lavine. Washington, DC: Smithsonian Institution Press. Burke, Peter. 1978. Popular culture in early modern Europe. London: Temple Smith. Buswell, Robert E. 1992. The Zen monastic experience. Princeton, NJ: Princeton University Press. Ch’oe Kil-soˆ ng [Kil Seong Choi]. 1974. Misin t’ap’ae taehan ilgoch’al. (A study on the destruction of superstition.) Han’guk Minsokhak (Korean Folklore) 7: 39–54. Choi, Chungmoo. 1987. The competence of Korean shamans as performers of folklore. PhD. dissertation, Indiana University. ———. 1991. Nami, Oksun, and Ch’ae: superstar shamans in Korea. In Shamans of the twentieth century, edited by R. Heinze. New York: Irvington. ———. 1995. Minjung culture movement and the construction of popular culture in Korea. In South Korea’s Minjung movement: the culture and politics of dissidence, edited by K. M. Wells. Honolulu: University of Hawaii Press. Choi, In-Hak. 1987. Non-academic factors in the development of Korean and Japanese folklore scholarship. Paper presented to the Annual Meeting of the American Anthropological Association, Chicago, November 1987. Choi, Kyeong-hee. 1996. The making of the “new woman” in Pak Wansoˆ ’s “Mother’s Stake 1.” Paper presented to the Conference on Gender and Korean Culture: Literature, Television, and Oral Narrative, Korean Studies Institute, University of Southern California, October 18–20, 1996. Clark, Donald N. 1986. Christianity in modern Korea. Lanham, MD: University Press of America for the Asia Society. Cohen, Myron L. 1991. Being Chinese: the peripheralization of traditional identity. In The living tree: the changing meaning of being Chinese today. Special issue of Daedalus 120 (2): 113–133. ———. 1993. Cultural and political inventions in modern China: the case of the Chinese “peasant.” Daedalus 122 (Spring): 151–170. de Certeau, Michel. 1984. The practice of everyday life. Berkeley: University of California Press. Deuchler, Martina. 1992. The Confucian transformation of Korea: a study of society and ideology. Cambridge, MA: Distributed by Harvard University Press for Council on East Asian Studies, Harvard University. Duara, Prasenjit. 1991. Knowledge and power in the discourse of modernity: the campaigns against popular religion in early twentieth-century China. Journal of Asian Studies 50: 67–83.

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Eckert, Carter J. 1991. Offspring of empire: the Koch’ang Kims and the colonial origins of Korean capitalism 1876–1945. Seattle: University of Washington Press. Hardacre, Helen. 1989. Shinto and the state 1868–1988. Princeton, NJ: Princeton University Press. Janelli, Roger L. 1986. The origins of Korean folklore scholarship. Journal of American Folklore 99(391): 24–49. Kapferer, Bruce. 1983. A celebration of demons: exorcism and the aesthetics of healing in Sri Lanka. Bloomington: Indiana University Press. Kendall, Laurel. 1977. Caught between ancestors and spirits: a field report of a Korean mansin’s healing kut. Korea Journal 17(8): 8–24. ———. 1985. Shamans, housewives, and other restless spirits: women in Korean ritual life. Honolulu, University of Hawaii Press. ———. 1996a. Getting married in Korea: of gender, morality, and modernity. Berkeley: University of California Press. ———. 1996b. Korean shamans and the spirits of capitalism. American Anthropologist 98: 512–527. ———. 1996c. Initiating performance: the story of Chini, an apprentice Korean shaman. In The performance of healing, edited by C. Laderman and M. Roseman. New York: Routledge. ———. 1998. Who speaks for Korean shamans when shamans speak of the nation? In Configuring minority and making majorities: composing the nation in Japan, China, Korea, Fiji, Malaysia, Turkey, and the United States, edited by D. Gladney. Stanford, CA: Stanford University Press. Keyes, Charles F. 1989. Buddhist politics and their revolutionary origins in Thailand. International Political Science Review 10(2): 126. Kim, Kwang-ok. 1994. Rituals of resistance: the manipulation of shamanism in contemporary Korea. In Asian visions of authority: religion and the modern states of East and Southeast Asia, edited by C. F. Keyes, L. Kendall, and H. Hardacre. Honolulu: University of Hawaii Press. Linke, Uli. 1990. Folklore, anthropology, and the government of social life. Comparative Studies of Society and History 32: 117–148 Luo Zhufeng, ed. 1991. Religion under socialism in China. Translated by D. E. MacInnis and Zheng Xi’an. Armonk, NY: M. E. Sharpe, Inc. Obeyesekere, Gananath. 1991. Buddhism and conscience: an exploratory essay. Special Issue on Religion and Politics. Daedalus (Summer): 219–239. O’Neil, Mary R. 1987. Superstition. In The Encyclopedia of religion. Edited by M. Eliade. Vol. 14. New York: Macmillan. Pak Wansoˆ . 1991. Mother’s Stake 1. In Poˆ nyoˆ kiran muoˆ singa? (What is translation?), Yu Yoˆ ngnan, author and trans. Seoul: T’aehaksa. Pigg, Stacy Leigh. 1996. The credible and the credulous: the question of “villagers’ beliefs” in Nepal. Cultural Anthropology 11 (2): 160–201. Robinson, Michael E. 1988. Cultural nationalism in colonial Korea, 1920–1925. Seattle: University of Washington Press. Rofel, Lisa. 1992. Rethinking modernity: space and factory discipline in China. Cultural Anthropology 7 (1): 92–114. Swearer, Donald K. 1991. Fundamentalistic movements in Theravada Buddhism. In Fundamentalists observed, edited by Martin E. Marty and R. Scott Appleby. Chicago: University of Chicago Press.

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Tambiah, Stanley Jeyaraja. 1990. Magic, science, religion, and the scope of rationality. Cambridge: Cambridge University Press. Taussig, Michael. 1987. Shamanism, colonialism, and the wild man: a study in terror and healing. Chicago: University of Chicago Press. Thomas, Keith. 1971. Religion and the decline of magic. New York: Scribner. Vitebsky, Piers. 1995. From cosmology to environmentalism: shamanism as local knowledge in a global setting. In Counterworks: managing the diversity of knowledge, edited by R. Fardon. London: Routledge. Walraven, Boudewijn. 1993. Our shamanistic past: the Korean Government, shamans, and shamanism. Copenhagen Papers in East and Southeast Asian Studies 8/93: 5–25. ———. 1995. Shamans and popular religion around 1900. In Religions in traditional Korea, Proceedings of the 1992 AKSE/SBS Symposium, edited by Henrik H. Sorensen. SBS Monographs Number 3: 107–129. ———. 1996. Shamanism in a Confucian society: past and present. Lecture presentation made to The Hahn Moo-Sook Colloquium on the Korean Humanities, George Washington University, October 26, 1996. Williams, Raymond. 1973. The country and the city. New York: Oxford University Press. Yi Nung-hwa. 1976 [1927]. Chosoˆ n musok ko (Reflections on Korean shamanism). Modern Korean translation of the 1927 edition by Yi Chae-gon. Seoul: Paengnuk.

3

Tradition and Change in Malay Healing Carol Laderman

How can we explain a seeming paradox—the failure of a long-established and respected village shaman and success of a young shaman whose lack of training and use of unorthodox healing methods made her colleagues disdain and neighbors fear her? It can be seen as a conflict between tradition as custom incorporating flexibility but compatible with precedent, and the “modernity of tradition” (Rudolph and Rudolph 1967), as an essentially recent construct, rather than a survival untouched by modernization. Many “traditions” are recent in origin, invented with a purpose and invested with spurious ancestry (Hobsbawm and Ranger 1983, 1). Kessler speaks of the “eternal yesterday” of traditional societies in which the past continues to shape the present unproblematically (Kessler 1992), a state of affairs that Malaysian Prime Minister Mahathir bin Mohamad criticizes as an inability to find and correct the faults within a society. Mahathir recommends the urbanization of Malays as essential to the economic and political growth of Malaysia. The value concepts of Islam in Malaysia, he feels, are adversely affected by remnants of much older Malay faiths, particularly animism which runs counter to Islam, especially in rural areas. He criticizes Malay custom (adat) as conservative and rural and states that “by and large, the Malay value system and code of ethics are impediments to their progress” (Mahathir 1970, 173). Mahathir’s philosophy has been extremely influential to Malaysia’s development. During the decades from the 1970s to the present we have witnessed ongoing urbanization and growth of a new Malay middle class. The time was ripe for “the invention of tradition.” It is only when the eternal yesterday “ceases

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Figure 3.1. Pak Long (on the left) and his minduk. Photo by Carol Laderman.

to exert its pervasive guidance of social life” that parts of the past become prized and cherished by virtue of their “pastness” (Kessler 1992, 134). The failure of the elderly shaman’s usually successful treatment when applied to an urbanized Malay population and the success of the young woman’s practice, composed almost entirely of city Malays, were a result of ongoing changes in Malay society and culture, the growth of a new middle class, and the reflection of a concern to reconstruct Malay identity through the symbols of a traditional, village-based Malay culture (Kahn 1988–89, 8). PAK LONG’S FAILURE At the time of Pak Long Awang’s problematic seance, I had been studying with the bomoh (healer) for more than a year and a half, witnessing his successful treatments of patients suffering from afflictions caused by disembodied spirits, and lack or overabundance of elements of the Malay self (see Figure 3.1). His seances (Main Peteri) were easily recognizable as variations of other shamans’ seances I attended in Trengganu and Kelantan, and similar to those described by foreign writers who had witnessed them a hundred years ago in many states of what is now Malaysia (see Map 6.1). Maxwell wrote about songs and dances of a shaman during a seance held in Perak (1881, 1883). Annandale described shamanistic ceremonies in Patani (1903), Zainal-Abidin wrote about one in Negri Sembilan (1922), Kloss spoke of shamans’ activities in Johore

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(1908), and Gimlette wrote about shamanism in Pahang and Kelantan (1913). Skeat recorded an eyewitness account of a seance held in Selangor and described another in Perak which cured the sultan of a grievous illness (1898, 1972 [1900], 436–449). Even the movements performed by shamans during seances I attended were similar in form and meaning to those shown in photographs included in Cuisinier’s book (1936). I had come to Pak Long’s home one evening to find him talking to a man I didn’t recognize. He asked Pak Long to treat a woman married to the manager of a city hotel, visiting her parents in a nearby village. It was important to treat her right away, he said, because she was three months’ pregnant, had a stomach ache, and hadn’t moved her bowels for five days. Pak Long agreed to come, although it was unusual to give a shaman such short notice. At the patient’s home, Pak Long met Awang Jalal, one of his ritual partners (minduk, who do not trance but engage in dialogues and duets with the shaman as he assumes the personae of spirits), who had come to assist in the treatment. Pak Long asked if the patient had been to the hospital. She had, her father said. They had also called eight bomoh, but none were able to cure her. Pak Long felt his patient’s pulse in her wrist, ankle, and throat. He found it was fast in her throat, a sign of spirit attack. He asked for some boiled rice and a boiled egg, part of the usual offering for familiar spirits, and sat patiently waiting for their preparation. Seances in Malaysia ordinarily are preceded by a meal presented to the healers, but no food was forthcoming. Pak Long’s clients were unaware of the steps involved in conducting a seance. Besides the boiled rice and egg, he had to ask for dry popped rice (to attract the fiery, airy spirits), incense, perfumed water, and an areca palm branch (to use in exorcism). It seemed as though these people had never witnessed a seance before. Every time Pak Long shook his head rapidly in trance when changing persona in the seance, a serious moment for all who understand its meaning, the patient’s kin laughed. Pak Long, unused to such treatment, nevertheless conducted the seance with the variety, care, and length he consistently used. First he placed a spirit offering of coins, raw rice, betel-pepper leaf, a cigarette, and a string in one dish, and boiled rice and a boiled egg, with the top shell removed, in another dish, and hung them from the rafters after reciting an incantation. Then he rubbed the palm branch with “neutralizing rice paste” (ground rice mixed with water, whose earthy and watery characteristics protect against fiery, airy spirits), and censed the branch and himself. He put popped rice under a pillow and in his sash, then he held up the branch as he and his partner threw raw rice while reciting spells. The branch began to shake, and so did Pak Long’s head as he took on the persona of Awang Mindung Pengasuh, one of the body’s internal protective forces. The second persona to arrive was Wak Kedi Bomoh, the ancient healer who divines cause and prognosis, using popped rice counted in pairs. Each pair is assigned in turn to earth, air, fire, or water, and the diagnosis depends upon

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which of the four elements ends the counting of three piles. The divination revealed earth, air, and earth again, strongly pointing to spirits of the earth as culprits. Pak Long recited a spell over the popped rice and gave it to his patient to eat. He said that in the middle of the night she was startled by a spirit. Her husband affirmed that she had had a nightmare. Pak Long shook the branch over his patient, then touched her mouth and feet, making casting-away motions with his hands. He went once more into trance and took on the persona of an earth spirit, who told the audience that a human had hired him to bother the patient but hadn’t as yet paid for the service. The next persona was the genie of the crossroads who agreed to help for a price. If the patient recovers, he will be paid. The next five personae were familiar spirits of Pak Long who sang, danced, and made jokes that the audience and patient clearly enjoyed. Next came the Yellow Genie, who admitted he was torturing the woman but agreed to cast out his noxious elements. He was followed by another familiar spirit, who said it was “heavy indeed,” as he examined the flame of a beeswax candle. Pak Long explained to me later that “heavy indeed” meant the flame revealed someone was working strong magic on her, wanting her to die. The next spirit to appear was Sir Oil, notorious for being able to take on human form and rape or kill. He held up his fingers and toes to show the amount he demanded to leave the patient. After a session of bargaining, Pak Long’s partner promised him the offering. At the close of the seance, Pak Long recited a spell and massaged the patient’s abdomen. He waited a while before leaving, thinking perhaps the meal usually preceding the seance was instead to follow. At least the healers expected coffee and cakes. The host brought out some slices of watermelon, selling for five cents a pound at every market. He handed Pak Long two dollars to share with Awang Jalal, an insultingly meager fee. He said he would let Pak Long know if his daughter wanted another treatment. Pak Long made no comment; he was furious, but Malay medical ethics forbid specifying the amount expected for a treatment. A healer graciously accepts what is offered, but this was the only time Pak Long or his minduk ever experienced such a combination of rudeness, ignorance, and stinginess. Pak Long never heard again from the patient or her family, but the day after the seance her family asked me to drive her to a physician in the state capital. Shortly after, the patient recovered, but her recovery was attributed to the skill of the physician, rather than the work of Pak Long. The family threw a feast to celebrate, but Pak Long was not invited. Several days later, my son and a group of children came running down the hill from Pak Long’s hamlet to tell me that he was very sick; he was calling for me and needed me to come right away. As I hurried up the hill I saw crowds of people standing around Pak Long, who lay on the grass gasping for breath. They urged me to do something, fast—Pak Long was dying. He appeared to be in great pain, unable to move, and clutching at his chest. Several neighbors helped him into my car, and we drove to the hospital in the state capital. Since it was Friday, the Islamic Sabbath, the hospital had only a skeleton staff on

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duty. A resident examined him but failed to discover the source of his pain. No one was available to perform more sophisticated tests. The symptoms, including pains that traveled throughout Pak Long’s body (usually associated by rural Malays with illnesses that have some degree of spirit involvement), didn’t add up to any syndrome recognized by the resident. He gave Pak Long an injection of vitamin B, a popular procedure in the hospital and at local private clinics when nothing else comes to the medical mind. It is given, and works, primarily as a placebo. Pak Long did appear to feel better after the shot. The doctor suggested he stay overnight and be subjected to laboratory tests the following morning, but said that if he preferred he could go home and come back the next day. Pak Long chose to go home. Night was falling as we drove back. After we left the capital Pak Long’s sense of well-being began to diminish and his pains returned. The closer we got to home, the more intense were his pains. When we got as far as the hamlet in which Pak Long’s regular minduk, Pak Daud, lived, he asked me urgently to stop and pick up his friend and ritual partner. When we reached Pak Long’s home, he seemed almost as ill as when we left. Pak Daud recited spells for forty minutes, and when Pak Long didn’t respond, the minduk said it was time to have an emergency seance. My assistant drove to Kampung Gong Balai, the hamlet in which Pak Long and Awang Jalal had recently tried to heal the pregnant woman, and woke Awang from his sleep. It was midnight when the company assembled in Pak Long’s house: Awang Jalal as shaman, Pak Daud as minduk, two neighbors playing drum and floor gong. The audience was very small for this impromptu seance: only Pak Long’s wife, my assistant, and myself. A divination revealed Pak Long’s illness was caused by earth spirits, angered when offerings promised to them during the seance at Gong Balai had not been forthcoming. One explained he attacked Pak Long because he considered it the shaman’s responsibility to see the offerings were made. The minduk explained that Pak Long was only acting as intermediary for the patient and her family. He was joined by members of the audience, who advised the spirit to seek redress from the family in Gong Balai. When Pak Long heard the divination and the earth spirit’s explanation of his illness, he sat up, his pale face became suffused with color and his eyes lost their dull heaviness. When the next spirit arrived, Pak Long felt strong enough to try to persuade him to follow the first to Gong Balai. When the seance was over, Pak Long rose from his mat and stuffed several bills into Awang Jalal’s and Pak Daud’s pockets, despite their protestations. He, for one, would see that decency and decorum prevailed and that his physicians were paid their due. Pak Long’s pains were gone. We did not return to the hospital the next day; in fact, Pak Long was able to resume work in his tobacco garden. The reason for the failure of his seance and its consequences for his health was revealed in a manner that satisfied the dignity of the shaman and the integrity of the traditional Malay medical system, but Pak Long began to worry about

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the future. He was getting old and soon would be unable to perform as he had for many years. He, Pak Daud, and Awang Jalal decided to hold classes in the arts of shaman and minduk, and I was invited to attend. What was particularly important, it turned out, was my contribution to the school: driving participants to the classes during the two months before my research period ended. I wondered how the school would fare after I left Malaysia. CIK SU When I first met her in 1975, Cik Su was in an equivocal position in her village. She was unusual in many ways, including her acquisition of healing powers. Typically, Malays are reluctant to assume such responsibilities until a loved one is afflicted and they find themselves standing by, powerless to help. Appalled by their impotence, they may apprentice themselves to a master bomoh, and later, if they have shown the proper talent and drive, be inducted into the profession. Although bomoh who specialize in seances must have the stamina to deal with denizens of the spirit world until the small hours of the morning, they are not expected to exhibit their spiritual power by a show of physical strength. Cik Su, however, knew she had received supernatural power when her husband’s former wife arrived at her home, intending to deliver her usual harangue against husband-stealing. Cik Su felt a surge of unusual strength flow through her. The next thing she knew, her rival lay at her feet, knocked unconscious by a blow of Cik Su’s fist. After this episode of physical violence (quite unusual in the life of a Malay woman), which Cik Su attributed to an influx of spiritual strength, she went on to treat a variety of conditions, giving advice to people who had trouble walking, or who suffered from dizziness or “internal fevers” and other complaints that hospitals do not recognize. Although she did not specify a fee and accepted whatever was offered, she told me she preferred to treat rich people from the city. Her neighbors rarely called on her for healing. Her anomalous practices did not cast doubt upon their belief system, but neither did they convince her fellows that she was destined to become a great shaman. While her neighbors did not deny she had powers, many suspected she used them to harm others. Cik Su was one of the few female healers who not only knew how to recite spells, prescribe medicines, and give massages, but also performed seances. She often spoke of the dangers presented by envious people who “planted” magical objects, or purchased blood of murder victims to sprinkle on enemies’ doorsteps. Although her neighbors spoke about her sinister qualities behind her back, she claimed to be a pious woman who never envied anyone. For instance, although I was clearly a rich American, owning one of the only cars in the area, she assured me she would never try to harm me. I should be aware, however, she remarked with a smile, that there was a good possibility that a dragon lurked in my well, but she would do her best to protect me from it since I was so generous in sharing my hospital medicines. The most lucrative aspect of her

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profession, she said, was her performance of lengthy seances. Some day she would invite me to attend one. About a year later Cik Su invited me to witness a seance. By that time I had studied with several bomoh. I had been apprenticed to Pak Long and Pak Daud, a ritual pair who specialized in the Main Peteri shamanic ritual, and had been present at performances of a variety of healing forms. The ritual pair to whom I was apprenticed were unrelated men, but, although Malay shamans and their partners are most often male, there are respected female healers, including midwives (almost always women), bomoh whose treatments include materia medica and spells, and female shamanic performers. Shamanic performances, typically starting at dark and lasting well into the morning, were never exactly the same. They changed with actors and circumstances, calling on different spirits and featuring different tunes and turns of phrase. Despite their differences, however, they were all variations on an underlying theme, expressing common belief in a multiplicity of etiologies for human ills and their treatments. To accomplish their goal of healing, Malay shamans and minduk perform in ritual dramas, complete with audience, plot, props, and players, both seen and unseen. The invisible entities that speak through the shaman include hostile spirits, familiar spirit-guides, noble dewa (demigods from the Hindu pantheon of Malaysia’s pre-Islamic past, preserved in shadow plays and dance dramas), characters from Malay folk legends, and personified forces of the human body. The performance incorporates instrumental music, song, and dance, and combines poetry and philosophy with colloquial language and humor, often coarse and obscene, that alternate with scenes of awe and terror (Laderman 1991; Laderman and Roseman 1996). MALAY MEDICAL THEORY I learned that Malays, rather than dividing illnesses into those of “natural” or “supernatural” origin, speak of “usual” (biasa) and “unusual” (luar biasa) ailments. The distinction is based on incidence, not suspected etiology. “Usual” health problems may be attributed to a number of causes, such as accidents, poor hygiene, a bad diet, overwork, or worry. The most prevalent are considered due to humoral imbalance and treated with herbal remedies, dietary adjustments, and thermal treatments, all calculated to restore patients to a normal, harmonious state (Laderman 1983). Illnesses can also arise from a lack or overabundance of certain components of the Self. At birth all humans possess Inner Winds (angin) which determine personality, drives, and talents. Their presence, type, and quality can be deduced from the behavior of their possessor, but they are palpable neither to observers nor to their owner, except during trance, when they are felt as actual presences: winds blowing within the breast which vary in power from a mild breeze to hurricane strength. If expressed appropriately in daily life, possessors of strong winds may be leaders in their communities. If, however, the winds are stifled

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by life’s circumstances, they accumulate within the bosom, causing suffering and affliction (Laderman 1991). All God’s creatures must inhale the Breath of Life (nyawa) at birth, if they are to live. Nyawa, containing the elements of air and fire, animates the watery, earthy animal body: without it the body must die. It drives blood in its course; its effects are felt within the body and its presence is obvious to observers when it emerges as breath, just as the presence of a breeze, though itself invisible, is signalled by rustling of leaves and the feeling it gives as it blows on the skin. Semangat (Spirit of Life), another component part of the Self, is not limited to animals. It permeates the universe, dwelling in man, beast, plant, and rock (Endicott 1970). The universe teems with life: the life of a fire is swift and soon burns out; a rock’s life is slow, long, and dreamlike. Semangat strengthens its dwelling place, whether the human body or a stalk of rice, and maintains its health and integrity. A newborn baby’s semangat is soft and vulnerable. This is why a baby may be at risk from spirit attacks while her parents are not. Devils can startle the baby, causing her semangat to flee, leaving the protective “gates” of her body wide open (Laderman 1991). As the baby matures, its semangat hardens (Massard 1988). Illnesses can come from disembodied spirits acting on their own behalf, angry at the trampling of their invisible abodes or the flow of human urine on their invisible heads, or because they were sent by an enemy. Their attacks can range in virulence from merely greeting a victim and startling him; to blowing on his back and making him sick, by upsetting his humoral balance with their airy, fiery elements; to actually striking the victim, causing him to become seriously ill or even die. Besides bribing, threatening, and exorcising external spirits, Malay shamans heal patients by attending to their inner problems: lack of semangat and overabundance of unexpressed Wind. The bulk of most shamans’ practices, in fact, is treatment of the Inner Winds rather than merely exorcism of disembodied spirits. The diagnosis of illness and discovery of its causes are arrived at, typically, through a divination whose interpretation leaves the shaman leeway to incorporate his intuition and knowledge concerning his patient’s life circumstances. Treatments range from dealing with external spirits, to attracting lost semangat, to expelling accumulated Inner Winds. Patients suffering from Wind Sickness, for example, are placed in trance and encouraged to act out portions of their personality denied in everyday life and, in so doing, release the unexpressed Winds that have caused their suffering. CIK SU’S PERFORMANCE OF HEALING Cik Su’s seance followed neither the form nor content of performances of other east coast Malay shamans. When I met her at the doorway of her patient’s home (a woman in her sixth month of pregnancy who had been bleeding), she whispered to me that the next-door neighbor caused the illness. The patient had already been to the hospital where her condition improved, but it worsened when

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Figure 3.2. Cik Su. Photo by Carol Laderman.

she came home, a sure sign that magic was involved and village medicine was essential. Cik Su was the fourth bomoh called in. The preceding three had divined that the sickness was due, in part, to “someone” sending spirits against the pregnant woman, but they declined to say who, following proper Malay medical etiquette. Cik Su scorned the performance of another divination, usually done with the spiritual aid of the Ancient Bomoh whose persona is assumed by the divining shaman. She knew who had done the deed through her own powers, and didn’t hesitate to name names. Before the seance could take place, certain preparations had to be completed. Cik Su’s husband, Ali, who acted as her assistant, put charcoal and benzoin in a dish to be lit for incense. He cut two long pieces of bamboo and tied them together with strips of white cloth to form a wand. White cloths were torn into rectangles about 8" by 16" and long narrow strips about 1⁄2" wide. The cloths were rubbed with turmeric root which colored them yellow, the royal color of Malaysia, signifying the performers were acting as subjects of the sultan of Trengganu, a purported descendant of King Solomon who had authority over spirits and genies. The cloths were placed on a tray which also held coconut oil, raw rice mixed with pieces of turmeric, “neutralizing rice paste,” and the bamboo wand. Cik Su changed her clothing, as do all Malay shamans before a seance, but rather than merely donning a clean sarong and tying it tightly around the waist with sashes, she wore long pants, a tunic, and a short sarong, all made of black cloth with white stitching, a costume which, she explained, was like that of the heroes of old (see Figure 3.2). After passing a black cloth over the

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smoking incense, she tied it around her head in the manner of a master of the martial arts. When I asked about the significance of her costume, she replied that her spirit-guide, an ancient man from the state of Kelantan, insisted on it. He had also told her that once the seance began the doors of the house had to be locked. No one would be allowed to enter or leave, no one in the audience would be allowed to speak, no one would be allowed to walk about. None of these activities was prohibited by other shamans in any of the dozens of seances I attended. People regularly move about during seances and speak to their neighbors; children cry and are put to sleep on floor mats; audiences respond to the performance by laughing, voicing approval, and even addressing the spirits. Cik Su underlined the authenticity of her Kelantanese spirit-guide and the authority of his masculinity by speaking in a Kelantanese accent whenever she was possessed by him, and by smoking a cigarette, a rare activity for a woman from Trengganu but universal among east coast Malay men. Her spirit-guide was said to speak Chinese, Tamil, and English. During the seance, Cik Su called my name and said something I found unintelligible. The spirit-guide, furious, told the assembled company that I didn’t understand perfectly good English because I was a heathen, a non-Muslim who didn’t deserve further instruction. She called up a dog spirit, who revealed it was sent by the next-door neighbor to kill the pregnant woman so the neighbor could marry her husband. The spirit also added bits of juicy gossip: someone was studying evil magic, someone else was unfaithful. Ali took out one of the white rectangles, placed it on the floor, and sprinkled it with raw rice and diced turmeric to make it even more antithetical to the spirits. Still in the persona of the dog spirit, Cik Su lifted the bamboo wand and struck herself on the shoulders to gather the spirit into the wand. She shook it and thrust it into the cloth, screaming. Quickly, Ali and a friend bound up the cloth, knotting it and tying it with turmeric-smeared strips. He tossed the packet to one side and recited the Arabic words that guard one against the devil (“I take refuge in Allah from Satan the Stoned One”). Another spirit arrived crying and spitting. Once again, Cik Su thrust her wand into a cloth, which Ali tied and put aside with the first. At each change of persona, Cik Su threw handfuls of raw rice, fruit of the earth grown in water, around the room, to neutralize the airy, fiery spirits. Finally, Cik Su instructed her patient to loosen her hair so no evil influences could get tangled in it, and to sit with feet pointing away from the audience. Sickness leaves through the toes so a path must be cleared for its exit. Cik Su noticed that a bit of my shadow was cast on the patient’s body, and remarked that this might already have interfered with the cure. She touched the patient with her bamboo wand, clutched the woman’s head, pulled her hair, and gave her a couple of hard smacks on the bottom. Then she motioned for the sister and brother-in-law of the patient, who had complained respectively of general malaise and dizziness, plus hornet stings, to sit before her and receive the same treatment. Cik Su assured them that someone was working magic against them. She warned everyone against touching the cloths containing spirits; they were

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too dangerous now for anyone but Ali, with her help, to handle. He would bury them under the next-door neighbor’s house. Cik Su prepared cleansing water by squeezing into it limes prepared by passing them over the incense while reciting spells. She washed her hands and face, ending the seance, and announced it would continue the following evening. The second night, I was met at the door by Ali, who told me the neighbor had moved that day, having been made hot and uncomfortable by the devils buried under her house. He said it was useless for me to come there that night since there were no more devils left to catch; in other words, I might as well go home. Since he hadn’t actually asked me to leave, I hung around and witnessed the finale. Cik Su once again prepared herself for the seance, which was to be shorter but more violent and frightening than the first. Again, there was none of the humor, usually typical of Malay performances, to relieve the tension that accompanies dealing with danger. At one point a snake spirit arrived, causing Cik Su to fall to the floor, writhing and hissing. Although she tried to exorcise it, it refused to leave, throwing her violently against the spectators and terrifying the children. Finally it was captured by the wand, placed in a cloth packet, and tossed into a metal can. Once more possessed by her Kelantanese spirit-guide, Cik Su smoked a cigarette, prepared limes for the water, and gave the patient a tumeric-smeared cloth to tie on her arm. Everyone who was treated the night before was again struck by the wand, followed by a handful of rice thrown by Cik Su against their bodies. Now she also brushed them with leaves to remove all trace of noxious spiritual influences. Ali ended the seance by reciting spells over Cik Su. He said he had no power except whatever she granted to him. I recorded these seances, as I did every seance I witnessed. When I played the tapes to Pak Long, my shaman-mentor, he commented that Cik Su was certainly clever but definitely not to be trusted. It was wrong to point out culprits and name names, and it was impossible that so many problems were caused by people working evil magic. In his experience, this was rare. Although he had captured and buried spirits in his time, he found that most problems were caused by disharmonies within the Self, not by malevolent people. Where was her treatment of the loss of vital spirit and why did she not consider the possibility that some illnesses were caused, at least in part, by the stifling of Inner Winds, rather than by magic alone? Pak Daud, the minduk, was amused and appalled by Cik Su’s prohibitions against people entering or exiting during her seance. What would happen if someone needed to piss or shit, he asked? They advised me to throw away my tapes as worthless. Calling Cik Su, in their opinion, was worse than calling no bomoh at all. Not only was she incapable of curing anyone, but people’s conditions could deteriorate since the spirits would laugh at her incompetence and get angry at her patient. Their negative opinion of Cik Su’s treatments was not based on regional prejudice: I had witnessed dozens of Main Peteri in Trengganu and Kelantan and found little difference in the philosophy or performance of healing between these east coast

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states. Their opinion was not based on rivalries between shamans. Although my teachers had accompanied me to many other performances, they had never criticized healers as dangerous or ignorant. It is true that much of what Cik Su did was drawn from the stock of Malay shamanistic practices, however, her colleagues believed her concentration on evil and magic as primary causes of illness and neglect of other aspects of traditional Malay medicine limited her diagnosis, treatment, and prognosis, placing her patients in peril. Cik Su’s performance had not cast doubt upon the belief system underlying Malay medicine, but, rather, upon her own competence. She had narrowed and rigidified its theoretical basis by ascribing most problems to envy and magic, and had shown disregard for traditional values by controlling the behavior of patients and audiences used to more flexibility and self-determination than she would allow. Her performance was a star turn, denying equality to her husband, who acted in a severely attenuated role; it was a drama of awe and terror that omitted the music, dance, poetry, and humor of the traditional healing ceremony. Even the invisible actors were scaled down to one spirit-guide and a few hostile spirits. There were no noble demigods, no sustaining guardians of the body. Cik Su’s control extended to treatment of the unseen. She did not rely upon divination to tell her the cause of her patient’s ills; without the help of the persona of the Ancient Bomoh assumed by other shamans to point the way, she arrived at a diagnosis through her own powers. She did not entertain agreements with spirits or promise them offerings in return for their withdrawal, but, instead, violently captured and imprisoned them. In her daily life, too, Cik Su did not fit the usual pattern. Although ideally Malay women should be decorous and retiring, it was obvious she held the reins in her family. Her husband worked at odd jobs and his household contributions were minimal. Within the seance, she was leader and he follower. Her achievement of supernatural power was heralded by violence, and her seances continued this theme. Her ceremonial costume was that of a man, her spirit-guide was masculine, and her cigarette-smoking behavior and expressions of fury under his influence were far from normal for a female bomoh. Other female shamans danced in the manner of princesses in the Malay dance-drama during their performances, rather than strutting around like a male warrior, as she did. They did not rely upon masculine props to shore up authority, nor insist upon obedience from patients and audiences. The control Cik Su exerted was unusual in a culture where flexibility is stressed. When I left Malaysia in 1977, Cik Su was able to supplement her husband’s income by sporadic treatment of out-of-town patients, but she was far from being a success. CIK SU AND YUSSOF When I returned to Malaysia in 1982 and called on my former neighbors, I was sorry to learn that Pak Daud had suffered a stroke and retired from per-

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forming as minduk. Pak Long’s health had also worsened and he no longer had the strength to sing and dance for hours in a healing seance. The school for shamans had not lasted after I had left—none of the students had become a practicing shaman. Both healers and laypeople commented on the decline in traditional healing. They said it no longer paid well and there were many more paths to a satisfying livelihood these days than had been available in the past. But, although this seemed to be the case in many hamlets on the east coast of Malaysia, something new had been added to the picture. When I visited Cik Su, I was surprised to find her house doubled in size and thoroughly renovated. Electricity had been installed where previously oil lamps had cast the only light. A large refrigerator and electric fan, linoleum on the floor, and several new pieces of furniture attested to increased wealth, but nothing was so striking as the multitude of gold jewelry adorning Cik Su and her daughters. Gold jewelry is the first line of defense for Malay women in a world where husbands can leave merely by saying “I divorce you,” after which they are obliged to provide support for their wives for only three months. Jewelry remains the property of the wife, who can sell or pawn it to maintain herself. Cik Su did not appear to be in any danger of divorce, however. Ali, sleek and prosperous in his new clothes, had given up odd jobs in favor of helping his wife. Cik Su showed me her new possessions with pride and invited me to dinner and a healing ceremony to take place that night. At dinner, I was introduced to Yussof, a well-dressed educated man who worked in the District Office of the county seat, about twenty-five miles away. He was Cik Su’s partner, and the husband of four wives. Yussof smiled with pride as he told me his marital status. Four at a time is the total number of wives allowed in Islam, but only a handful of Malay men have more than one. Keeping two women happy and satisfied in obedience to the Koranic injunction of dealing equally with multiple wives is considered a sign of unusual masculine talent, almost certainly supplemented by magic. In our village of over 2,000, only three men had two wives each. Yussof was the only man of my acquaintance to have four at once. Three times a week Yussof drove to Cik Su’s home to participate in healing sessions. After dinner, Ali prepared for the seance. He spread new floor mats and readied the tray and its ingredients. Cik Su and Yussof greeted patients as they parked their cars. After turning off electricity and lighting oil lamps, she changed into her costume, the black outfit of a hero of olden times. As the patients watched in silence, Cik Su performed an abbreviated version of her seance, lasting less than an hour. She seemed to be almost entirely “speaking in tongues,” incomprehensible both to me and the native Malay speakers present. Her performance was unremittingly frightening; when I played a tape of it for a village friend, his wife and children soon left the house and he asked me to turn it off shortly thereafter. After she purified herself with lime water and sprinkled some on those assembled, Cik Su changed into a blouse and sarong. Oil lamps were extinguished and electricity turned on. Now it was Yussof’s turn. The patients and their

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relatives sat in a semicircle before Yussof, who explained his method of treatment as follows: I would like to tell you the facts about my medical treatment before I let you know the cause of your illness. All illness has three possible causes. Many people know this, but let me tell this to those who are not aware of it. When I tell you the cause of your illness, please don’t think your illness is caused by somebody’s magic, treachery, or spell. What I mean is that all illness is created by God. I’m trying to make you well, and this also depends upon His mercy and will. Don’t take this for granted. Do you think I handle this with any magic or spell? No, I cannot. I’m begging Him. Don’t think I have any hidden magical power. I do not. Yes, we must bear in mind the reasons for illness, the three causes. Let me tell you about them. The first one is Kifarat, God’s revenge. Please don’t say that God is cruel. No, He is not. It is a punishment, the punishment for our carelessness in piety and prayer, in forgetting His name, in neglecting to give thanks. For example, the Koran tells us that the poor can become rich and the rich can become poor. When a man is poor, he asks God to give him wealth, but when he becomes rich, he forgets the Almighty, never giving Him thanks. Then God curses him, causing all his wealth to disappear. The second cause is penyakit cari ambil sendiri [illness that seeks to come by itself, sickness that people cause themselves], like having a contest with God. For example, you may be beautiful and yet want to be even prettier, so you go to a bomoh and learn how to charm your husband, to prevent him from running away or marrying another woman. This is called penyakit cari ambil sendiri. It goes against God’s decision about which men and women should be matched. The thing we learn will finally destroy us. For example, we study and learn about magic oil, to brighten the face. People who do this will be cursed by God, they will become like the hantu [disembodied spirits]. The third cause is hikmat orang [spells cast by people]. If somebody wants to put some magic on us, there must be reasons. Or, sometimes the magic is badly aimed so that it hits a person it isn’t meant for and misses its target. It’s your bad luck if you get it, but that’s the cause.

Yussof’s explanation of the causes of illness is an amalgam of traditional and nontraditional Malay etiologies. Denial of personal power and attribution of ultimate cure to God is typical of Malay healers. Yussof’s statement that God punishes people for lack of piety by afflicting them with sickness is not typical. Other healers point out that both saints and sinners are heir to illness. He is ambiguous about the ability of magic to cause illness. First he denies that magic can either cause or cure illness. As he speaks, however, he warns against the possible consequences of attempting to improve one’s life by magical means. Although many Malays have acquired spells to increase personal attractiveness and luck, there is a strong injunction in Malay society against thwarting God’s will by attempting to escape one’s assigned status in life. Behavior inappropriate to one’s station has been discouraged by Malay law and custom. Love magic, widely practiced in Malay villages, is considered unfair to its victims and dangerous to others: for instance, the familiar spirits (pelesit) some women harbor to increase their attractiveness to men also frighten children and cause them to

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cry and fret. Finally, Yussof admits the possibility of sorcery as a cause of sickness, but claims that “there must be reasons” why someone has fallen victim to magic. On the whole, Yussof’s explanations for illness blame the victim. However, in the dialogues that follow, the onus for illness-causing behavior is more often put on patients’ relatives. Patient One (a middle-aged woman): Y: Now, what’s your problem? P: My body is very hot. I have serban. [Serban has several meanings. In this case it refers to pains, often in the joints, sometimes in the head.] Y: Serban of the head? P: Everywhere. Y: Some people have serban of the head. OK, the cause of this illness . . . sometimes serban is caused by blood, lack of vitamins, but I can’t tell you what kind of vitamin you must take. How long have you had this serban? P: A long time already, fourteen years or so. First I got it in the knees, now I have it everywhere. Y: What’s your name? P: Bunga [flower]. Y: [laughs] Oh, she’s not a fruit yet. No offense, I’m just joking. In this matter, I’m really concerned. Your illness hasn’t any connection with the three causes. No magic . . . if it has a connection, then only . . . P: Pakaian? [The common meaning of this word is “clothing” but here it refers to “spells.”] Y: I don’t know yet, I’m not very sure yet. Do you think you have “pakaian”? P: I don’t know. Y: What do you mean you don’t have pakaian? You have your baju [blouse] and sarong, haven’t you? P: Ohhh. That kind of pakaian I have. Y: Talking about pakaian—you can study and learn about fatwa [here, this refers to instruction in astrology], but don’t go overboard, don’t go beyond the limits. For example, if you are beautiful and you want to be still more beautiful, you shouldn’t do it; God has decided everything, and we shouldn’t go beyond it. But here, in this astrology, shines a clue. Let me ask you, do you live near a river? P: Yes, very close. Y: What’s the connection between lesung [mortar] and tumbuk padi [pounding rice to remove the husk]? P: I’ve pounded rice in the fields . . . Y: If you remember it, good. Do you know the definition of “lesung”? By the way, do you have children? a husband? P: Yes, my husband made the lesung.

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Y: What are you saying about your husband? Your lesung hides a story. Do you have any other lesung? P: I just got a new one . . . Y: I don’t mean that kind of lesung! Here is a lesung [he points to a woman]; was there one more? [Lesung in slang means woman; alu, or pestle, stands for man. The sexual allusion is obvious.] P: Oh, that sort of lesung, yes, there was one more. Y: So now there are two lesung? P: No, now one only. Y: It’s the same old story: two lesung quarrel, the alu runs away. I have to study this matter deeply. It’s not painful for the leg only. There’s also trouble in the heart. But don’t worry, it can be cured. Do you have anything to ask? No? Sit down and relax, I’ll call you afterward. This is just an interview; I’ll give you the medicine later. [He turns toward the audience.] Do you understand what I’m talking about? I’m talking in Trengganu dialect.

In his opening speech, Yussof ascribed all illness to three causes; here he introduces another etiology. This patient’s pain was brought on by the suffering to her self-esteem at having to share her husband with a second wife. Patient Two (an elderly woman): Y: What is your name? P: Halimah. Y: What is your problem? P: Benggung [confusion]. I’m mixed up in my mind, even when I’m saying my prayers. Y: How is your appetite? P: I don’t eat much. Nothing tastes right. Y: You are floating in the River of Sadness. To whom do you owe your sadness? P: No one. Y: You have problems, problems that cause you sadness. You have inherited problems. They worry you so much that you get a heart attack. I have no medicine to cure you, only advice. You can’t take Malay medicine because I’m afraid you won’t take it properly. Have you seen a doctor? No? Are you afraid of injections? Yes? You must see a doctor. Diabetes, kidney trouble, and high blood pressure are very difficult to cure; sometimes there is no hope at all. But your heart weakness, insyaallah [if God so wills], can be cured. I have no medicine now; for the time being I will give you air tawar and limau [“neutralizing water,” treated with cooling limes and incantations to counteract noxious influences]. Your soul is disturbed and your spirit has fled, so the way to cure you is also by spiritual means. Who brought this patient here? Okay, please tell her children to take good care of her, be nice to her, don’t treat her cruelly or she will go out of her mind. Yes, if her children and her relatives want to see her get back to normal,

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please treat her kindly. Okay, if you aren’t satisfied, come and see me again in two weeks.

With this patient, Yussof has introduced another etiology for illness, the loss of semangat, the vital spirit. The patient’s spirit has fled because of shock at her children’s unkind treatment. Although Yussof suggests a visit to the doctor, his advice is traditional: the use of “neutralizing water,” to cool down her body and make it a pleasant receptacle for semangat. To guard against further spirit loss, he advises her children to be loving towards the old woman. Patient Three (a middle-aged man): Y: What’s the matter? P: Serban . . . I can’t lift up my hand. [Here serban refers to numbness or paralysis.] It feels very heavy. It will swell up if I lift it. Y: This case also has no connection with magic. You feel it now but actually this illness has been with you for quite some time already. You didn’t suffer because you are still young and strong. Your blood is good to fight this illness, you have energy. This illness we Malays call pirai [pain in the joints, like gout or rheumatism, often attributed to shock and therefore connected with loss of semangat; see Gimlette and Thomson 1971, 187]. It’s not the work of magic. You’d better go have your shoulders massaged; don’t worry about the swelling. Then get the gall of haruan [snakehead, a freshwater fish] . . . I don’t mean beruang [a bear], that’s haram [food forbidden to Muslims]. [laughs] You must take black pepper and put it in the gall, and allow it to dry in the sun. You cut the gall into eight pieces and put a peppercorn in each slice. When the gall is dried, please eat it.

Yussof has diagnosed this illness as humorally caused and recommended a humoral cure: massage breaks up the clots of “cold” phlegm in the body, allowing the “hot” blood to flow unobstructed, thus alleviating the pain. The internal medicine prescribed is humorally “very hot.” Patient Four (an elderly woman): Y: What is your problem? P: I’m always very tired. Y: How long has this been going on? P: For seven months. Y: Have you seen a doctor? P: Yes, I did, once, but he told me I was all right. I took the medicine he gave me but it made me feel even worse. Then I went to a bomoh. He did spells, but I got a fever again. Y: The treatment was not in harmony with your blood. Did you bring limes? P: No, I didn’t.

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Y: What’s the use of tiup-jampi [bomoh’s act of blowing on a patient’s back with magically supercooled breath to counteract hot breath of spirits], if it makes you go from bad to worse? P: Last night I asked my granddaughter to massage me. She did it with all her might; my body even turned black and blue but I felt nothing, it didn’t hurt me. I couldn’t get up strength to say my prayers. I was shivering, my heart was beating very fast. Y: It’s penyakit angin sesat [Inner Winds which have gone astray]. The trouble is that the Winds have no way to escape, no door to exit. P: Is it because I’m already old? Y: You’re not old, you’ve just been around a long time [laughs]. The trouble is that the Winds in your body cannot blow freely. P: This part is swollen, but sometimes it is normal. Y: Can you take hot medicines like maajun [generic name for herbal remedies]? P: I never have. Y: Do you want to take them or not? P: Yes, I want to be well. Y: Write this down: kulit rambai [bark of a fruit tree, Baccaurea Motelyana, used to treat sore eyes], onion, jintan hitam [black cumin seeds, used as paste for swelling], sirih [leaf of Piper betel vine used to reduce swellings], daun pelaga [cardamom leaf, used in poultices]. Pound them hard together and put the paste into a cloth. Apply the compress to the affected part of your body to lessen the pain. Now, what about your appetite? P: I don’t feel hungry, I can’t sleep, it hurts everywhere. [These are common symptoms of sickness due to accumulated Inner Winds.] Y: If you don’t want to use it as a compress, you can use it as a bandage. P: How can I have a bandage? Every part of my body hurts. Y: Okay, apply it as a compress. [Turning to the assembled patients and relatives] Any questions? Now, here is the treatment: Can you say Fatihah [first chapter of the Koran]? Now, one by one, come to me. Say Fatihah three times, give praise to the Almighty. Do it with full concentration. Don’t listen to the cars, don’t look at other people, meditate. Let’s say that our hearts are facing Mecca, in other words, we are at the Kaabah. Our mouths praise God, our hearts are at the Kaabah [mulut berzikir, hati di kaabah]. Close your eyes. Remember when I call you to come forth: say Fatihah three times and praise God over and over again until the end of the treatment. During the treatment you must not speak or ask anything. If you want to say something, please do so now.

ARCHAISM AND MODERNITY IN MALAY HEALING Why do city patients accept Cik Su’s unorthodox methods while neighbors avoid employing her as a healer? A reader of a manuscript I had submitted to a journal wrote that “one would expect educated Malays to be skeptical of all ritual curing.” This ignores the many instances worldwide of “sophisticated” urbanites resorting to medical treatments whose philosophies and practices lie outside hospital-based medicine. In Malaysia, during the 1970s and continuing

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to the present time, “jet set” Malay healers advertising their expertise come from the very traditional and primarily agricultural state of Kelantan to heal inhabitants of Kuala Lumpur, the modern capital of Malaysia, where hospital-based medicine is readily available. Cik Su and Yussof’s patients were members of a growing urban Malay middle class, of civil servants, educators, and professionals. This group ranges from government clerks, teachers, and middle-level civil servants, through academics, employees of the media, employees of state-owned enterprises, and a smaller number of white-collar workers and businesspeople in the private sector (Kahn 1992, 164). The urban middle class is known for its concern to reconstruct Malay identity through symbols of a traditional, village-based Malay culture (see Kahn 1988–89, 8). Members of this group are inclined to romanticize the culture of the village. The 1980s witnessed a rediscovery of Malay “traditions,” including increased attention paid to traditional medicine. The State Museum in Kuala Trengganu embarked on a plan to grow and catalog plants used by Malay healers. The Malaysian Association of Traditional Malay Medical Practitioners was reported in the New Straits Times (Malaysia’s main government-controlled Englishlanguage newspaper) to have recommended traditional Malay medicine to treat AIDS victims, commenting that AIDS was not a modern disease but had afflicted mankind since Biblical times (Kahn 1992, 166). In a world of rapid change, tradition provides some grounding of personal authenticity and identity—it has power to confer legitimacy. The past, authentically ancient or recently invented, can seem to be rooted in remotest antiquity and yet be available for combining with the uses of modernity (Hobsbawm and Ranger 1983; Kessler 1992), exactly as demonstrated by the methods of Cik Su and Yussof. Urban people around the world are employing openings to medical archaism combined with modernity. New York City is a home to Santeria, called the fastest growing religion in the region. A three-part series on Santeria beliefs, practices, and healing, presented by the American Museum of Natural History in 1988, began with a panel discussion featuring psychiatrists and psychologists who work with santeros (adepts of Santeria) and santeros themselves, including one who combines mastery of Santeria healing with a Ph.D. in psychology. The first session was held in a small auditorium, but the overflow audience was convincing proof of the necessity of changing the venue of following meetings to the museum’s largest auditorium. The last meeting was standing-room only. Citing alleged skepticism of educated urban people in regard to alternative medicine ignores the fact that billions of dollars are spent annually in the United States on unorthodox healing methods (Kolata 1996a, b). The partnership of Cik Su and Yussof was a winning combination. Cik Su’s performance, in its unalloyed evocation of terror, awe, and ancient ways, authenticated the night’s treatments for patients and their families, urban Malays with little previous acquaintance with shamanistic ceremonies. Played in dark-

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ness, spoken in incomprehensible “tongues” punctuated by shrieks, Cik Su’s seance prepared them to be receptive to Yussof’s diagnoses and advice which, by themselves, would not have carried the same force. She was still the star turn, but now she made no accusations and named no names. By itself, Cik Su’s performance would have terrified her patients, but combined with Yussof’s contributions, the pair’s treatment resonated with a picture of authenticity which their urban clients, looking for cures of disturbing ailments not healed by physicians but unaware of the nature of traditional Malay medicine, could accept. Yussof supplied comic relief with his wordplay. He restored calmness, reason, and light to an atmosphere that had been marked by darkness and chaos. He widened the scope of performance of healing by restoring much of the traditional causation theory, including loss of semangat, accumulation of Inner Winds, and imbalance of humors, that Cik Su had ignored. Magic no longer reigned supreme; human problems were also due to inappropriate behavior, unkind treatment, loss of self-esteem, and stifling of personality and creativity. Solutions could be found in applications of herbal remedies and love, rather than violence toward spirits and revenge against sorcerers. Cik Su’s neighbors now combined suspicion with a healthy dose of respect for her success, but her practice continued to be composed almost entirely of clients from outside her community. Her colleagues, traditional village healers, still did not approve of her ways. But she was becoming a wealthy woman while they were performing seances less and less often, attacked on one flank by Islamic authorities who disapproved of their evocation of non-Islamic demigods, and on the other by old age and the ills to which mankind is heir. Cik Su did not cure her patients because she had become a great shaman; in fact, she never overcame her limitations. As a soloist, she was limited by her lack of training, insistence on control, and reliance upon magical explanations and treatments. The traditional Malay medical system recognizes multiple etiologies including disharmonies of the universal elements of earth, air, fire, and water in the human microcosm or cosmic macrocosm, and lack or excess of components of the Self, as well as attacks of disembodied spirits sent by enemies or acting on their own volition. Cik Su’s explanation of most illness as caused by malevolent magic did not reflect the view of the universe upon which the Malay medical system is based. Her performance as Yussof’s partner, however, was indispensable, persuading patients of the value of the night’s treatments in a way that his “common sense” advice by itself never could. While she conveyed feelings of awe and the presence of unseen powers, he expanded the limits of magic by restoring elements of traditional Malay belief that she discarded, restructuring them into a modern-sounding approach which impressed patients with its aura of education and urbanity. Yussof’s admonitions concerning piety, prayer, and devotion to Islam protected their healing treatments from criticism directed at more traditional shamans’ seances. This innovative combination of antiquity and modernity, magic and religious orthodoxy succeeded in making Cik Su and Yussof wealthy at a time when traditional Malay shamanism, pri-

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marily based in agrarian communities, as had been practiced by Pak Long, was on the wane; and the shared resonance of Cik Su’s and Yussof’s treatments with the beliefs and expectations of urbanized clients allowed them to perform cures together that neither could have accomplished alone. REFERENCES Annandale, Nelson. 1903. Primitive beliefs and customs of the Patani fisherman. In Fasciculi Malayensis, I, edited by N. Annandale and H. C. Robinson. Liverpool: Liverpool University Press. Cuisinier, Jeanne. 1936. Danses magiques de Kelantan [Magic dances of Kelantan]. Travaux et Memoires de l’Institut d’Ethnologie de l’Universite de Paris, 22. Endicott, Kirk M. 1970. An analysis of Malay magic. London: Oxford University Press. Gimlette, John D. 1913. Some superstitious beliefs occurring in the theory and practice of Malay medicine. Journal of the Royal Asiatic Society, Straits Branch 65: 29– 35. Gimlette, John D. and H. W. Thomson. [1915] 1971. A dictionary of Malayan medicine. Kuala Lumpur: Oxford University Press. Hobsbawm, Eric and Terence Ranger, eds. 1983. The invention of tradition. Cambridge: Cambridge University Press. Kahn, Joel S. 1988–89. Constructing Malaysian identity: a view from Australia. Ilmu Masyarakat 14: 6–8. ———. 1992. Class, ethnicity and diversity: some remarks on Malay culture in Malaysia. In Fragmented vision: culture and politics in contemporary Malaysia, edited by Joel S. Kahn and Francis Loh Kok Wah. Honolulu: University of Hawaii Press. Kessler, Clive. 1992. Archaism and modernity: contemporary Malay political cultures. In Fragmented vision: culture and politics in contemporary Malaysia, edited by Joel S. Kahn and Francis Loh Kok Wah. Honolulu: University of Hawaii Press. Kloss, C. Boden. 1908. Some ethnological notes. Journal of the Royal Asiatic Society, Straits Branch 50: 73–77. Kolata, Gina. 1996a. On fringes of health care, untested therapies thrive. New York Times, 17 June, A1, B6. ———. 1996b. In quests outside mainstream, medical projects rewrite rules. New York Times, 18 June, A1, B7. Laderman, Carol. 1983. Wives and midwives: childbirth and nutrition in rural Malaysia. Berkeley: University of California Press. ———. 1991. Taming the wind of desire: psychology, medicine, and aesthetics in Malay shamanistic performance. Berkeley: University of California Press. Laderman, Carol and Marina Roseman, eds. 1996. The performance of healing. New York: Routledge. Mahathir bin Mohamad. 1970. The Malay dilemma. Singapore: Asia Pacific Press. Massard, Josiane. 1988. Doctoring by go-between: aspects of health care for Malay children. Social Science and Medicine 27 (8): 789–798. Maxwell, W. E. 1881. Folklore of Malays. Journal of the Royal Asiatic Society, Straits Branch 7: 11–29. ———. 1883. Shamanism in Perak. Journal of the Royal Asiatic Society, Straits Branch 12: 222–232.

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Rudolph, L. I. and S. H. Rudolph. 1967. The modernity of tradition: political development in India. Chicago: University of Chicago Press. Skeat, W. W. 1898. Some records of Malay magic by an eye-witness. Journal of the Royal Asiatic Society, Straits Branch 31: 1–61. ———. 1972. [1900]. Malay magic: being an introduction to the folklore and popular religion of the Malay Peninsula. New York: Benjamin Blom, Inc. Zainal-Abidin bin Ahmad. 1922. The tiger-breed families. Journal of the Royal Asiatic Society, Straits Branch 85: 36–39.

4

Modernity and the Midwife: Contestations Over a Subaltern Figure, South India Kalpana Ram

INTRODUCTION The figure of the midwife is so deeply embroiled in the contestations internal to modernity that it is virtually impossible to strike any ethnographic attitude that is not already overdetermined by a rich political history. If we limit ourselves initially—and somewhat artificially—to modernity as this is commonly understood within a Western context, the midwife is located at the intersection of at least two competing views of modernity. The first view emanates from modern medicine, which has played a central role in representing modernity as the progressive realization of the capacity of reason and science to improve human welfare. Improvements in maternal mortality and infant morbidity occupy a special place within this general set of claims. In this account, the midwife becomes rendered as the main vector of dirt, lack of hygiene, and superstition (Radcliffe 1967). This interpretation of modernity marks its ascendance by establishing a strict hierarchy between male surgeons and midwives, or more brutally, by simply replacing the female midwives. The rationalizing of birth and health includes the elaborate system of examination, certification, registration, and regulation that Foucault has explored as typical of the diffuse and therefore pervasive system of surveillance and power in modernity (Foucault 1973, 1977). Contesting this medical view of birth is the feminist critique (Ehrenreich and English 1978; Rich 1977; Donnison 1988; Oakley 1980). In this view, the marginalization of the midwife has been a means by which men could make incursions into, and control, one of the few areas of social life that was entirely the domain of women in Europe. The result of this male encroachment, initially linked with the invention of the forceps, has been, in this view, the reduction

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of birth to a purely mechanistic and physiological process. Further, the woman’s body is not only seen as a machine, but as a machine poorly constructed, intrinsically prone to mishap (Martin 1987). Little or no confidence is placed in the birthing capacities of the woman (Oakley 1980; Rich 1977). Although the extent of the medicalization of birth varies in different Western metropoles, with the United States representing the most extreme case (Jordan 1993), the feminist critique turns our attention back to the figure of the midwife. The suspicion of the midwife now becomes reinterpreted as a result of professional rivalry, the fact that she was, as Perkins puts it in her account of a French seventeenthcentury court midwife, “to all intents and purposes, a member of a closed community, holding ‘secrets’ associated with her work” (Perkins 1996, 12). Perkins, like other feminist historians, concludes that “it is plain that midwives were the target for abuse and criticism in the late sixteenth and early seventeenth century” (12). As a result of feminist critiques, the view of modernity as unsullied progress has been considerably complicated. Modernity involves more direct forms of patriarchal control in the sphere of birth. As Perkins puts it succintly, we move into “a time when, technically safe but apprehensive and ignorant, the parturient woman gives birth in subservience to the domination of a (male) professional” (9). Even if the medical professional happens to be female, the woman giving birth no longer has access to a separate world of women, but must give birth under the direct gaze of, and on the terrain organized by, representatives of modern science. However, both of these conflicting views of midwives must be regarded as occurring within the broad horizon of modernity. Feminist critiques of the technological definition of birth, and in some versions of feminist critique, a correspondingly high valuation of the skills and knowledge of the midwife, are themselves part of a wider reaction to large-scale industrialization that goes back to its very inception. In the Romantic idealization of nature that we find in the poetry of Wordsworth or Shelley, or in the arts and crafts movement of William Morris, we find a new production of Nature and of the preindustrial past which, in its very resistance to industrialism, must be regarded as necessarily born out of that same set of social relations. Whether we honor the midwife for her skills, or highlight the inadequacies of her practice, our orientation as ethnographers will have been prefigured. Rather than viewing the preemptiveness of this discursive prehistory as an epistemological obstacle, this chapter attempts to utilize the contested history of midwifery for what it can tell us about the internal complexities of modernity, both in metropoles and in colonies. MULTIPLE MODERNITIES An inquiry into the status of the midwife in contemporary India presents particularly productive prospects for insights into the nature of modernity as this is defined, not simply in Western metropolitan debates, but in the more complex

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world of postcolonial societies in Asia. The simple version of feminist critiques of modern birth, as a male takeover of a female sphere, cannot be sustained in the face of the politics of race and colonialism. In India, indigenous midwives were displaced, not by men, but by white women doctors. In time, the place of white women was taken over by the Indian middle class, in which women again played an important role as medical professionals. Much has been written about the importance of colonial medicine in representing colonialism as a civilizing mission (Manderson 1997; Arnold 1989, 1993). However, there are colonial specificities to be considered. Colonial health policy in India did not concern itself particularly with the health of women and children. According to Arnold (1989), the colonial state’s health measures were centered on the priorities of conquest and mercantilism: the barracks, the urban centers, the industrial estates, and plantations. The rural areas and the majority of population were ignored, and even toward the close of the nineteenth century, when a more comprehensive system of interventions was adopted with census operations, vaccination campaigns, and primary school education, the health of women and children remained a “domestic” matter, distinct from and less important than the “public” projects of sanitation and control of epidemic disease (Arnold 1989). It was left to white women doctors to highlight the plight of indigenous women. In an important paper on the colonial construction of midwifery and gynecology, Shetty (1994) points out that the genuine concern felt by white women for indigenous women was shaped as much by the politics of race and class as of gender, insofar as it allowed the former to carve out a professional niche for themselves in the colonies. Obstetrics and gynecology in the colonies would bring these women less prestige than the fields of sanitation, epidemiology, and tropical disease research. Neverthless, it provided a sphere of professional expertise unavailable to women doctors in the colonial metropoles of England and America where obstetrics and gynecology remained fully under male jurisdiction. Depictions of the atrocious conditions governing “native birth” endowed these women with racial power that was in excess of the class-based authority available to them back in Britain, where as “lady doctors” they could pay “home visits” and patrol the maternal practices of women in the working classes (Davin 1978; Marks 1996). Shetty documents the “obsessive” gaze these colonial women turned on the indigenous midwife or dai. In 1901 the editors of the Census commissioned a special inquiry into the methods of indigenous midwives and reported on “the curious information” collected. As Engels (1996) points out, these practices were in fact not very different from contemporary European folk practices, and indeed, before 1900, “midwives in Europe interfered with the process of giving birth to a greater extent than Bengali midwives” (Engels 1996, 129). Evidently, what was at stake in India was not a simple project of modernity as reform, but reform as redefined by the politics of colonialism itself. Criticisms of childbearing practices were tied to much more extensive critiques of indigenous culture as a whole. Strictly

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medical and scientific criteria such as lack of hygiene were used to criticize the Indian home and the purdah system, particularly by white women doctors (Shetty 1994, 210ff). All the gender practices singled out for colonial contestation—sex segregation, prepubertal female betrothal, and consummation immediately after menarche (Uberoi 1996)—were not simple emanations of “Hindu culture,” as it was generally represented, but were elite practices. Medical condemnations of these practices were central to recasting colonial contestations with indigenous elites in a scientific light. Engels (1996) documents an intensification of reform efforts from the end of the nineteenth century onward, linked with British anxieties about maintaining a competitive army and workforce (cf. Davin 1978). The colonial discourse of white women doctors evoked equally vociferous male nationalist responses to initiatives such as the British establishment of maternity hospitals and baby clinics such as the Dufferin Fund (Engels 1996; Shetty 1994). Male nationalists explained maternal and infant mortality in quite different ways, by having recourse to the inequities of the colonial economy. In doing so they highlighted the Eurocentrism and imperialist nature of the reforms. However, Indian nationalism also absorbed colonial discourses and reworked them for its own purposes (Chatterjee 1986). Reform itself became as much a part of nationalism as it was part of a colonially imposed agenda; and by the 1920s, Indian middle-class women had already made both the agenda of reform and the feminist language of bodily autonomy and rights their own (Ram 1998b). The first all-India women’s organization, the Women’s Indian Association (WIA), was started in 1917 by women who displayed the mix of nationalist and colonialist discourses while seeking to infuse them with a specifically womanoriented agenda. They sought to combine the spiritual superiority of Indian mothers with a modernization of child-rearing practices, and they promoted hygiene, first aid, biology, and science, as well as needlework and embroidery (Whitehead 1996, 196). The first female medical graduate of Madras Presidency was Dr. Muthulakshmi Reddy, who was also the second president of the WIA. She strenuously advocated reform of female seclusion and propagated education in order to “teach women how to look after themselves during labour and how to bring up healthy children” (Whitehead 1996, 196). CONTEMPORARY POLICIES ON THE DAI: NATIONAL AND INTERNATIONAL The colonial history surveyed previously continues to shape contemporary discourses on the dai. What remains constant from the colonial to the postcolonial era is the attempt by the state to reshape the dai, but to simultaneously use her as intermediary into the world that is inaccessible to the programs of modernity. In the British era, this world of rural women was termed the world of purdah or zenana. Today, it is more likely to be characterized in terms of

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underdevelopment, and, as one might expect from a state that came to power on the crest of a nationalist movement, the degree of intervention attempted is greater. Dai chosen for training continue to be addressed in ways that makes abundantly clear the class distance between the carriers of modernity and those who must be reformed by this discourse. I have described elsewhere the predicament of dai who accompany birthing women to hospitals (Ram 1994, 1998a). Studies have found that the training is conducted in language that is inaccessible to the women (Narayana and Acharya 1980; Kumar et al. 1982, cited in Jeffery 1988). Although the course is three months long, what is understood by the dai is a very generalized message of stressing hygiene. Most studies report that “dais receive little supervision and support after training, and frequently have little contact with ‘their’ MPWF [Multipurpose Worker Female]” (Heaver 1989). Very few receive the kits or the incentive payments which are their entitlements for attending the program. There are other marked continuities to be observed between the colonial period and the present version of modernity. The colonial period produced a proliferation of “new positions . . . in various stages of approximation to full-fledged obstetrical legitimacy” (Shetty 1994, 294). In a similar fashion, the contemporary state health system in India continues to produce a hierarchy of categorizations of health workers in rural areas. The hierarchy of the staff that work in the primary health center (PHC) is determined not only by approximation to biomedical expertise, but by gender and class. Thus male health staff have been predominantly employed in single-disease campaigns, while female staff have been seen as suitable only for “women’s issues” of maternal and child health, and family planning (Jeffery 1988). Female staff are further categorized by a hierarchy in which Auxiliary Nurse Midwives (ANMs) and Lady Health Visitors occupy the upper rungs of the family planning and maternal/infant health staff ladder. These two categories of medical women have been redesignated since the 1970s. They are now “Multipurpose Health Worker Females.” However, their ascendance over village-based health personnel continues to be clear-cut: they are responsible for recruitment and supervision of “community health workers.” The recruitment and deployment of these village-level workers in turn reflects the hierarchy of gender. Community health workers are nominated by the upper-caste, male village leadership, and they usually select young males with some education. Dai, on the other hand, are selected for training by the female health workers themselves (Jeffery 1988). Despite these overwhelming continuities, the precise nature of the state’s agendas for rural women has shifted. The Indian postcolonial state has pursued a program of family planning from its very inception (see Ram in press). The program is invidious in its attitudes toward rural women as well as toward rural health workers. Female health workers in the primary health care system have found themselves principally deployed to recruit women for sterilizations. Hospital births and hospital abortions are now advocated not only as sites of more hygienic treatment, but because they allow medical staff to conduct sterilizations

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or, at the very least, to insert intrauterine devices—often without the knowledge of the women (Ram forthcoming). In a series of vivid interviews conducted with poor peasants in the southern state of Karnataka by Rao (1994), the women complained: The nurse is hostile to people of our caste. So is the doctor. She only comes to our house because I am a case for her. For the first two pregnancies she did not bother. She started coming to give injection only for the third. I agreed to be sterilized. But I want a boy. I had the baby at home, the dai delivered it. Sister got angry that I wouldn’t get sterilized. (3)

Once the women do undergo sterilization, the attention of the PHC staff dwindles: “Now the Sister does not even want to talk to me. She only comes to write on the wall [to indicate that she has done her house visit] when she knows I have gone out to work” (6). The dai is once again at the center of these tensions between women and state policies. The very access that dai have to women renders them valuable as an intermediary that will lead the PHC staff “to find prenatal or potential family planning cases” (Jeffery 1988, 276). At the international level, organizations such as the World Health Organization have moved from decrying the indigenous midwives as “mostly having no training at all in midwifery, but . . . usually well versed in folklore” (WHO 1966), to viewing the midwife in an instrumental fashion, valuable solely as intermediaries, “because they are often part of the community, culture, and traditions, and continue to have high social standing in many places, exerting considerable influence on local health practice” (WHO 1978, 63; also WHO 1979). As Saunders (1989) points out in her overview of WHO policies, the imperative to integrate the midwife into the biomedical health system also threatens to divest the midwife of her instrumental value as “cultural broker” between modernity and tradition. Nor is there any awareness that the predicaments and internal tensions of this discourse have also been prefigured by colonial history. At this point, I move to examine the ways in which the dai herself renegotiates her status and presents herself in dialogic encounters with her modern interlocutors. My own role as the Westernized Indian anthropologist and interlocutor evidently partakes of the much longer genealogy of figures produced by colonial modernity.1 THE SPEECH OF THE SUBALTERN In contrast to powerful edicts that have been issued on the virtual impossibility of the subaltern’s speech (Spivak 1988; but see Ram 1993), I wish to suggest that there is no necessary reason why we should be obliged to locate our analysis of speech entirely from the perspective of discourse analysis. I take inspiration

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here from the work of de Certeau, who is the advocate, methodologically, of shifting from an exclusive concentration on the discourses that shape the speaking subject, to that of the speaking subject herself: “By adopting the point of view of enunciation, . . . we privilege the act of speaking: according to that point of view, speaking operates within the field of a linguistic system; it effects an appropriation, or reappropriation, of language by its speakers” De Certeau (1988, xiii). De Certeau suggests that this technique “poses questions at once analogous and contrary to those dealt with in Foucault’s book” (xiv; the reference is to Foucault 1977). The questions are analogous in that they train us to perceive and analyze the micropolitics of technocratic structures. They are contrary to Foucault’s questions in that “the goal is not to make clearer how the violence of order is transmuted into a disciplinary technology, but rather to bring to light the clandestine forms taken by the dispersed, tactical and makeshift creativity of groups or individuals already caught in the nets of ‘discipline’ ” (xiv–xv). De Certeau’s thesis, itself a creative mediation between Foucault’s historiography of discourse and Bourdieu’s ethnography of practice (de Certeau 1988, 45–76), captures something of the complexity I seek to represent here. India provides a rich base for exploring what de Certeau describes as “minor” practices. These practices, unlike the “dominant type of procedures,” are “always there but not organizing discourses and preserving the beginnings or remains of different (institutional, scientific) hypotheses for that society or for others” (de Certeau 1988, 48). In India, the textualized and formalized ideology of Sanskritic Brahmanism was unambiguous in viewing the physical business of giving birth as polluting, even though maternity itself was auspicious, particularly if boys were produced. Such an ideology was capable of shaping practices among upper castes, so that the threat of this pollution was dealt with through ritual ablutions for the mother as well as the employment of an entirely different, lower caste of women to attend on upper caste women as midwives, and in effect, to act as removers of impurities like the function of a sweeper, also a polluting task. However, the reach and sway of this Sanskritic ideology has historically been extremely uneven and incomplete. As Sangari characterizes this diversity, the coexistence of tribal and agricultural modes of production, of matrilineal and patrilineal systems, and their articulation with regional histories, allows “multiple patriarchies” to exist in the one social formation (Sangari 1995, 3381). De Certeau’s notion of “minor practices” can therefore be conceived of as fragments and mixtures of entirely different ways of organizing social relations. This unevenness provides not only dai and birthing women, but occasionally entire communities, with alternative ways of conceptualizing their experiences and identities. Such alternatives are particularly well-documented for those on the margins of caste society—the so-called tribal social formations in India, generally regarded as predating both “Dravidian” and “Aryan” civilizations.2 Among these groups, the gender ideology of caste society is recast along less

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rigid lines, while birth is structured by valuations more favourable towards the maternal body (Vitebsky 1993, 47ff; Chawla and Pinto forthcoming). Alternative ideologies are also present within caste society itself. The Tamilspeaking region where my fieldwork is located is particularly rich in accounts of alternative ideologies of caste and power (Mines 1984; Bayly 1989; Dirks 1987; Price 1996). The consensus that emerges from this body of work is that the region has historically accorded an equal position, if not dominance, to nonBrahmanic castes defined by the values of kingship. The ethnography of the region records a more complete and positive valuation of the fertile female body among these non-Brahman castes than exists in the north of India. Girls in nonBrahman communities, for example, enjoy an elaborate celebration of menarche, which is celebrated like a small-scale wedding (Good 1991; Kapadia 1995). Such celebrations are absent in the north of India, and are extremely attenuated among the Brahman castes of the south. Similarly, the term for the midwife in Tamil Nadu is not dai, but marutuva˚cc˚ i whose etymology was explained to me early in fieldwork as “she who applies medicine” (maruntu vaikkyaradu). In addition, there exists in Tamil Nadu an entire bloc of castes once termed the “left hand” bloc, which include mercantile and trade-based communities. These groups have enjoyed a greater autonomy from the caste hierarchy than the castes based on agrarian land-based relations (Mines 1984). In my ethnography of the Mukkuvar, coastal fisherpeople in Kanyakumari District, Tamil Nadu, who rely on their sea-based and trade-based relations for economic survival, I have described how the Mukkuvars view themselves as skilled and martial, rather than as polluted or low in status (Ram 1991). Their conversion to Catholicism in the sixteenth century has consolidated this cultural autonomy from Hinduism, while their popular Catholicism also exhibits a very selective and partial absorption of the ideologies of caste (Ram 1991). In particular, although notions of danger attend the points of transition in the female life cycle, and indeed, in the cycle of fishing itself, the ideology of pollution exists only in a minimal fashion. In birth, precautions are taken for protecting the birthing woman against ghosts and demons with iron objects, with the employment of ka¯ val japam or Christian prayers of protection, without attribution of pollution to the midwife or the mother. Menstruation does not, for example, preclude church attendance, even though the first menstruation is attended by ritual seclusion. Many of these caste groups, including castes low in the agricultural hierarchy such as shepherds and potters as well as fisherpeople and hunters, have been able to produce stringent critiques of Sanskritic ideology. The following verses come from around the ninth century AD: It is the monthly cycle (tumai) Is it not the tumai [menses], [which] When it stops, shapes into a body? . . . You take bath daily in the river

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These verses comes from a body of literature produced by mystics drawn from nonelite castes such as shepherds, fishermen and hunters (K. Meenakski 1996, 112). Collectively, they were known as the Tamil Siddhas (Cittar in Tamil). They may have been part of a wider subcontinental movement known as Tantrism, but they were most certainly central to the establishment of a south Indian branch of medicine named after them as Cittavaittiyam or “Siddha medicine.” Such traditions have provided a scathing counterdiscourse to the ideology of pollution, and have influenced the wider practices around childbirth and the female body. In her examination of maternal and child health interventions in Madras, Van Hollen has generalized for the Tamil-speaking region as a whole: “in Tamil Nadu, there is much more concern with the ways in which blood, food and water interact to ensure a healthy mother and baby during the postpartum period than with the “polluting” nature of the theetu [postpartum outflow]” (Van Hollen forthcoming). Unlike the relatively articulate counterdiscourses of Siddha medicine, which is organized through male lineage and textualized palm-leaf manuscripts, the world of the rural midwives is shadowy. It is a measure of the additional powerlessness of being female as well as low caste that their knowledge is not only situated much lower in the indigenous medical hierarchy than the male practitioners of Siddha medicine, but they lack the formalized modes of transmission that are characteristic of the Siddha tradition. Instead, the knowledge of the midwife is a form of learning on the job, a classic example of what Bourdieu and de Certeau would describe as practical knowledge (cf. Jordan 1993) (see Figure 4.1). Such forms of learning occupy a low status in the hierarchy of knowledge in India, where textualized forms of knowledge are given the highest prestige and value.3 Despite this, midwives derive pride from the process of acquiring competence in a complex and skilled task over a period of time. A midwife’s self-representation is therefore that of someone who has mastered a cultural practice—that is, as Bourdieu (1992) describes it, one who knows when to introduce specific moves and maneuvers in order to outwit practical destiny. The speech of the midwife is typically peppered with tales of such outwitting: Kalyani: Let me tell you about a special delivery case. It was a kurukku position [breech presentation]. I waited, but no babe came. I recommended they go to hospital. But the family was poor, and I felt sorry for them. Cleaning my hands in hot water, I put my hand right in to ascertain the position. There were signs of the child’s distress [she means meconium]. I could also feel the buttocks and genitals of the baby—it was a boy. I then found the leg, and with the leg I turned it around so that the leg came out. I then straightened the arms so that the legs came through, and I delivered the baby head last.

Figure 4.1 Indian modernity is in fact even more complex than can be conveyed in this chapter. Representations such as these are indicative of efforts by Indian feminists to reverse and question some of the historic legacies of colonial modernity, and to bring a newly positive, but not uncritical, evaluation of rural midwives. Middle-class, urban feminists have often developed strong connections with rural women in campaigns over health, access to land, water facilities, and so on. Both the above representations are taken from feminist health publications. The first is from the cover of a Telugu-language publication entitled Mantrajalam Daktarlada Mantrasanulada (translatable as “Maze of Scientific Experience”), edited by K. Lalitha, 1993. The second is a sketch used in the English-language manual of health practices, Na Shariram Nadhi: My Body Is Mine, by Sabala and Kranti, 1995.

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I mockingly abused the child, Mayire, ni ca¯ kavillaiya? [You little pubic hair, aren’t you dead yet?]. I had had to put my arm in nearly up to my elbow to do this . . . (Field notes 1991) Bayamma: Once I was faced with a hand peeping out of the opening. I was in a fix about what to do, and felt very nervous. I thought for a while, until I had an idea. I lit a match-stick, blew it out, and touched the tip to the baby’s hand. At once, the baby took its hand back in. After that, I was able to slowly turn the baby, and helped the woman to give birth normally. (Sabala and Kranti 1995, 126)

In addition to these practical routes to knowledge, midwives draw on forms of knowledge that have traditionally existed alongside the male monopoly over medicine, without ever actually posing a challenge to that monopoly. Every one of the midwives was able to give me detailed accounts of herbs and plant extracts used during labor for relaxation. Some had recipes for increasing the rate of contractions, for the postpartum period, for cleansing the uterus after the delivery of placenta or in case of spontaneous abortion, for cleaning vaginal tears, and for adding to the hot water in which the woman should bathe for one month after delivery. Q: What do you give the woman at the time of labor? Kalyani: To ease the pain and relax the body, I give seven or eight cloves of garlic, boiled in one glass of water till it reduces to half a glass. I then beat an egg into it and give it to the woman. For two months before delivery, it is advisable to take the green leaf of the katali [plantain], the root of the a¯ malakum [the phyllanthus emblica, the nut from which oil is extracted], coriander, onion, cı¯ra [cumin]. Boil it all in water, and give the water to the pregnant woman. In case of spontaneous abortions, to clear the uterus, take the pith of the leaves of the drumstick tree, mix with jaggery [unrefined brown sugar] and give it to her. It will bring out any remnants. Another remedy for the same problem: take tenkai pu [coconut flower], 1⁄2 kilo of pac˚ c˚ ai arici [raw rice], a whole coconut, and 10 grams of cı¯ra [cumin]. Pound them together until they are flour-like, and the whole thing looks red like sand. Add karupet˚t˚ i [Travancore term for jaggery] and give. The woman can eat this whenever she pleases, as much of it as she wishes.

When I investigated the way in which these women came to function as midwives, I found that the routes to midwifery far exceeded the simple, colonially derived dichotomy employed by the Indian state, between “hereditary dai” (defined exclusively by the ideology of purity and pollution), and “trained dai” who are beneficiaries of exposure to biomedical norms. Midwives in the Mukkuvar community are created as much by the needs of local women and the random distribution of skills and aptitude among other local women, as they are by hereditary transmission. In the Mukkuvar coastal community, midwives attend on the women of their own community. They are not to be distinguished

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from other women of the village by caste or even by their specialization. As a result midwives are simply elderly women who have either some skills in the family, or else have won their place through being able to impart confidence and calmness in the birthing woman. Many midwives are fish traders, a feature which places them under the immediate censure of hospitals. The midwife Kirtina of Kadalkarai Uuru, where I lived in coastal Kanyakumari, worked as a fish trader. Kirtina [Kristina] regards herself as responding to the need of women around her for her services, rather than as a hereditary expert. “One feels obliged to help when called,” she says. Rural midwives cannot be simply viewed as either representatives of a pure, indigenous tradition of knowledge or as scientifically trained. Instead, midwives imbibe the different kinds of practices that are now current. These may include both hospital birth and village birth. Kirtina began by sitting with women during childbirth, being a companion, to give them courage. She did this for ten years, during which she observed the work of nurses in hospitals, and another village midwife, helping out the latter occasionally: “I then found myself delivering a child in hospital one day when I kept calling the nurse, and nobody responded. The nurses kept putting me off, saying there was time yet. Finally, the baby was on its way, and I delivered the child.” Ponamma, a midwife working in a landless agricultural laboring caste in Chengalpattu district of Tamil Nadu, learned her skills in part from working for one month with an Auxiliary Nurse Midwife in a hospital. At the same time, one also still encounters midwives who have learned skills entirely outside the context of biomedicine. Kalyani of Manjalamoodu, a different region of Kanyakumari, comes from a Hindu agricultural family with some land holdings. Her son supplements their income by tapping rubber. Kalyani’s mode of entry into midwifery is based on a female hereditary lineage. Kalyani’s mother was a midwife, and so was her grandmother. Of the various midwives discussed here, Kalyani had the strongest sense of being custodian of specialized and secret knowledge which she calls toril irakaciyam or secrets of the trade. She urgently requested us (myself, the coordinator of a nongovernment women’s organization, and the nursing sister from the local convent) for a house and two assistants to train so that she could pass her skills on before her death. The great dividing line bequeathed by modernity is between physiologically oriented medicines, and the world of spirits and religion on the other. It is belief in the spirit world, more than any other feature, which marks the midwives as irrevocably Other and subaltern to the agents of modernity. During fieldwork I came across several nongovernment organizations, as well as nuns in convent hospitals and medically trained personnel, who were genuinely interested in the herbal remedies and cures of the midwives. None were prepared to incorporate the ritual techniques employed by midwives, which were regarded as “superstition.”

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While this may sound like a consistent secular rationalist opposition between science and religion, in reality the opposition is broken up by finely graded distinctions based on class and colonial practices. Christianity and biomedicine, although the sites of many conflicts in European history, formed a single integral mission in the colonies. A peculiarly colonial conjunction brought the Bible and the medical clinic together as part of the same historical moment (Ram 1996; Shetty 1994). This legacy continues to be used in order to define the rituals and beliefs of rural midwives and villagers in general, as superstition. The impact of this legacy is apparent among Christian midwives. They make a sharp distinction between dealing with the “good spirits” and “bad” or demonic spirits, invoking the help of the former with Christian japam (catechism), praying to the saints, but eschewing any request to exorcize demonic spirits (cf. Rozario forthcoming, on Christian midwives in Bangladesh). Yet at the same time, there are few middle-class or professional people in India who would not engage in practices such as attending temples, undertaking religious vows when a family member is sick or dying, or in situations such as childlessness. The labelling of particular religious practices as “superstition” must therefore be understood as part of ongoing practices of class distinction, akin to the aesthetic distinctions of “taste” that Bourdieu (1996) has analyzed in relation to Western class formation. (See Figure 4.2 for a striking instance of the way education conveys middle-class norms of representation and embodiment.) Not all midwives have entirely grasped, let alone internalized, this class-based evaluation of their practice. Thus Kalyani goes without a break from telling us the herbs for spontaneous abortions, to discussing specially difficult cases that are caused by the spirit world: But I can size up a delivery, and I know if the delivery is going to be difficult. Sometimes it means that a pe¯ y [evil spirit] is involved. Typically, the pattern is one of a labor that eludes one. Delivery looks imminent, but then it becomes prolonged. For this I have special mantras. I pray to my special god. The pe¯ ys are usually of people who have died young, through suicide, and my mantras drive them away. There is genuine improvement after this. But I cannot divulge the nature of these mantras.

NEW CONTEXTS FOR MINOR PRACTICES These minor systems of knowledge are now deployed in a new context, one where “doctors” who may or may not possess biomedical qualification enjoy overwhelming authority and status. As Rozario (forthcoming) has argued for rural Bangladesh, the range of skills at the disposal of rural midwives becomes an important part of their negotiations with biomedical authority. In rural Tamil Nadu, midwives tended to present their approach as primary, adequate for the majority of cases they deal with, while hospitals exist as a further point of referral for complicated cases. The first example comes from Kirtina [Kristina]:

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The first delivery I did at home was my own daughter’s first child. I have attended some complicated cases, such as the birth of twins. In another case, the water [amniotic fluid] had come out two days before labor. However, I prefer to send complicated cases to the government hospital or to Nirmala [a private hospital]. But when I take women there they do not realize who I am and shoo me out of the ward. The nursing sisters at Presentation Convent are more accepting of me.

Figure 4.2. The two sketches above were done by two groups of women, both of whom were involved in an innovative health project in the state of Andhra Pradesh. The project attempted not only to improve health practices, but also to shift the politics of knowledge across class divisions. Two groups of women were asked to sketch their perceptions of their own bodies. The sketch on the right was done by project staff, mainly from a rural background but all literate. The sketch on the left was done by illiterate women who were wage laborers from Dalit and “tribal” backgrounds. The contrast in representations is striking. The project staff clothed the female body, and added purses and earrings. Project staff were hesitant, attempting to recall their school text diagrams, and drawing rigid body outlines before trying to fill them in with breasts, vaginas, and rib cages. The women from agricultural laboring classes, on the other hand, drew bold and colorful drawings, giving importance to the heart (gunde) and brain (medhadu), but also to the vulva-and-vagina (yo¯ ni). Ribs were pronounced, which the women traced to hunger and poverty of their children. (For details, see Sabala and Kranti 1995, 57–58.)

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The midwife Kalyani I have described as having a strong sense of professional pride. Yet she readily refers difficult cases to hospitals, only taking them on when the families concerned are too poor to afford a hospital: There was a case, four years ago. It was Onam [a Kerala festival]. I went for a delivery and found mother and child in a critical condition. I told them again and again, go to the hospital. But it was Onam, everyone was drunk. I had to see to the birth—but it was a tragedy. The mother and twin babies all died. I think they blamed me for that. (Field notes)

The same relationship which midwives treat as one of referral from one service to another, is interpreted by hospitals as so many instances of midwife incompetence. Hospitals typically see the midwives as coming too late, as displaying their ignorance of the need for proper medical care for the birthing woman. Both midwives and birthing women recount the abuse they get from hospital staff. The words below occur in so many accounts separated by place (cf. Kapadia 1995, 169) that they must be regarded as part of a generic “scolding” discourse through which hospital staff address rural populations: Having used your quackery, have you brought her here to die? Have you brought this woman here to tie her death around our necks? The authority of the hospital system leaves a mark on midwives, who feel they have to be able to report some degree of incorporation of biomedical practice into their repertoire. The degree of incorporation varies. According to the few studies that have been done of the results of the training received by the dai, there have been few changes in their everyday practices after training: In Uttar Pradesh, trained dais are more likely to encourage pregnant women to be immunized against tetanus, to get some protection against anemia, and to report following more hygienic practices. But on some simple indicators (the percentage washing their hands with soap or boiling the instrument used to cut the umbilical cord), many of the trained dais reported practices little different from those of the untrained dais. (Jeffery 1988, citing Kumar et al. 1982, 276)

All of the midwives I interviewed had changed some of their practices. Kirtina now encourages delivery in the lithotomy position, lying on the back. In the course of our conversation she more than once expressed a desire to have rubber gloves since she needs to keep her nails long for the fish trading business, but then makes a quick transition to midwifery. She cuts the kod˚ i or umbilical cord with a shaving blade. Another midwife, Ponamma, from a landless agricultural laborer caste in Chengalpattu, worked with an Auxiliary Nurse Midwife for one month in a hospital. Although she continues to walk birthing women through their labor, she was at pains to assure me that at the point of delivery she has

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the woman lie down and uses a razor blade for cutting the cord instead of the aruval or sickle. According to Chawla in her study of urban slums in Delhi, “many urban dais, themselves, now feel they must come equipped with syringe and drugs because the women often request them. ‘Magic’ rituals involving atta and Baimata are being uncritically replaced by the ‘scientific’ ones of syringe and pharmaceuticals” (Chawla 1993, 75). Such partial incorporations are a more general characteristic of the spread of biomedicine in the rural areas: By now, in the rural areas nearly everyone has seen local quack-doctors and ANMs using pitocin and [intravenous] glucose injections. City and small-town clinics promote ultrasonography and amniocentesis tests during pregnancy, often to tell the sex of the foetus so females can be aborted. (Sabala and Kranti, 1995, 125; Cf. Rozario 1997)

CONCLUSION: “TACTICS” OR “STRATEGIES” OF RESISTANCE? REVISITING COMPARATIVE QUESTIONS In his work on popular cultural practices, de Certeau makes a strong distinction between “strategies” and “tactics.” The former belong to subjects (including institutional subjects) that can claim a place of their own, a base from which relations with an exterior target or threat can be managed (1988, 36). Tactics on the other hand have no space of their own—they operate on the terrain of the other, and must therefore operate in isolated actions, taking advantage of opportunities. How may we characterize the responses of the rural Indian midwife to biomedical authority in terms of this distinction? The question links us back to the comparative study of modernities metropolitan and colonial, with which I began this chapter. Modernity in India continues to present us with a different picture to characterizations of modernity in the West. As sketched by de Certeau, modernity in the West entails the maneuvrings undertaken by an increasingly marginalized population. He tells of a situation where the majority have been reduced to the status of only consuming culture, not producing it (de Certeau 1988, xvii). The woman giving birth in a modern Western hospital could certainly be described in the terms supplied by de Certeau—that is, as a consumer rather than a producer of culture. Her creativity, in this instance, resembles more the fragmentary “tactics” of someone placed in an alien terrain, that of the hospital. These tactics may take the form of an insistence (perhaps born of alternative discourses such as active birth, expounded in prenatal classes and popularized books) on being able to move around during labor, or on not being routinely shaved before delivery. The Indian rural midwife also resembles this figure of the consumer on alien territory when placed in the terrain of a modern hospital. However, she has, in addition, recourse to alternative terrains, both physical (the home of the birthing

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woman) and discursive. Neither of these terrains may be romanticized as “woman-centered” spaces, but they do continue to coexist along with the space of the modern hospital. This very complexity of being located at the intersection of diverse relations of power allows subaltern populations to develop critical perspectives. Midwives avail themselves of their location at the intersection of different systems of knowledge in order to express criticisms not only of certain aspects of hospital birth, but of the effects of hospitals on the expectations of village women themselves: Women themselves are impatient today. They rush to hospital instead of waiting. They want the child to be born quickly and without pain. There are also a lot of women who go to hospital so they can have the sterilization operation afterwards. Hospitals have saved a lot of babies, but have also increased the amount of to t tu vya¯ tikal [which I ˚˚ translate as infectious diseases].

Kalyani of Manjalamoodu says: Home delivery is better for the woman. The girl gets looked after personally, one person devoted to her. I usually banish the relatives from the scene [at home births], otherwise there are too many conflicting opinions. But in hospitals it is quite a c˚ inna ku¯ t˚ am [a small mob]—a young, often inexperienced doctor, nurses, ANMs. It makes the woman quite uneasy.

Current political trends in India such as that of Hindu nationalism identify modernity as the artificial problem of a “secular intelligentsia” alienated from the religious spirit of their own country. This evidence presented in this chapter does not allow such a convenient separation of modern and nonmodern enclaves. The challenge is to develop a more complex and comparative account of modernity itself.

ACKNOWLEDGMENTS I wish to thank the Australian Research Council for funding this research and the Department of Anthropology, Macquarie University as the host institution. My thanks also to K. Lalitha (1993), as well as Sabala and Kranti (1995), for their generous permission to reproduce illustrations from their publications. This chapter has benefitted from its evolution through various presentations, and my thanks to Linda Connor for her editorial comments. The transliteration of Tamil words follows the conventions of the Tamil Lexicon (1988), unless widely known in their conventional English spelling, as with words such as purdah.

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NOTES 1. No account of Indian modernity in relation to contemporary discourses on women’s bodies is in fact complete without a discussion of the women’s health movement. I am unable to elaborate in this chapter, but see Ram 1998b. 2. Categories such as tribal, Aryan, and Dravidian are evidently not simply objective categories of classification, derived as they are from colonial discourses of race and ethnology. The general point about the historical priority of these now-marginal “tribal” formations, however, remains valid. 3. Unlike Christianity and Islam, Hinduism does not refer to any singular text such as the Bible or the Koran as the authenticating moment. The transmission of knowledge even of a relatively central epic such as the Ramayana is far more complex, entailing oral, performative, and textualized elements (cf. Richman 1992), while seemingly oral “folk” traditions entail textual elements (Blackburn 1988). Nevertheless, even the orally transmitted, recited collection of hymns, the Vedas, receive their greater authority from having been textualized as early as between c.1500 and 600 BC (Roy 1996, 10).

REFERENCES Arnold, David, ed. 1989. Imperial medicine and indigenous societies. Delhi: Oxford University Press. ———. 1993. Colonising the body: state medicine and epidemic disease in nineteenthcentury India. Delhi: Oxford University Press. Bayly, Susan. 1989. Saints, goddesses and kings. Muslims and Christians in South Indian society, 1700–1900. Cambridge: Cambridge University Press. Blackburn, Stuart. 1988. Singing of birth and death, texts in performance. Philadelphia: University of Pennsylvania Press. Bourdieu, Pierre. 1986. Distinction: a social critique of the judgement of taste. London: Routledge and Kegan Paul. ———. 1992. Outline of a theory of practice. Cambridge: Cambridge University Press. Chatterjee, Partha. 1986. Nationalist thought and the colonial world. Delhi: Oxford University Press. Chawla, Janet. 1993. A woman-centred revisioning of the traditional Indian midwife. Research paper for Masters of Theology Degree, Vidyajyoti Insititute of Religious Studies, Delhi. Chawla, Janet and Sara Pinto. forthcoming. The female body as battleground of meaning. In Perspectives: women in mental distress. Edited by Bhargavi Davar. New Delhi: Sage. Davin, Anna. 1978. Motherhood and imperialism. History Workshop Journal 5: 9–57. de Certeau, Michel. 1988. The practice of everyday life. Berkeley: University of California Press. Donnison, Jean. 1988. Midwives and medical men: a history of the struggle for the control of childbirth, 2nd ed. London: Historical Publications Ltd. Dirks, Nicholas. 1987. The hollow crown: ethnohistory of an Indian kingdom. Cambridge: Cambridge University Press. Ehrenreich, Barbara and Deirdre English. 1978. For her own good: 150 years of experts’ advice to women. New York: Doubleday.

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Engels, Dagmar. 1996. Beyond purdah? women in Bengal, 1890–1939. Delhi: Oxford University Press. Foucault, Michel. 1973. The birth of the clinic: an archaeology of medical perception. Translated by A. M. Sheridan. London: Tavistock. ———. 1977. Discipline and punish. Translated by A. M Sheridan. New York: Pantheon. Good, Anthony. 1991. The female bridegroom: a comparative study of life-crisis rituals in South India and Sri Lanka. Oxford: Clarendon Press. Heaver, Richard. 1989. Improving family planning, health, and nutrition outreach in India: experience from some World Bank-assisted programs. Washington, DC: World Bank Discussion Papers, No. 59. Jeffery, Roger. 1988. The politics of health in India. Berkeley: University of California Press. Jordan, Brigitte. 1993. Birth in four cultures: a crosscultural investigation of childbirth in Yucatan, Holland, Sweden and the United States, 4th ed. Prospect Heights, IL: Waveland Press Inc. Kapadia, Karin. 1995. Siva and her sisters: gender, caste, and class in rural South India. Boulder, CO: Westview Press. Kumar, A., A. S. Chauhan, and S. K. Pandey. 1982. Report of evaluation of traditional birth attendants (dais) in the State of Uttar Pradesh. Lucknow: Population Centre. Lalitha, K. 1993. Mantraja¯ lam D ˚ aktarlada¯ Mantrasa¯ nula¯ da. Hyderabad: Charita Prachuran˚ alu. Manderson, Lenore. 1997. Shaping reproduction: maternity in early twentieth-century Malaya. In Maternities and modernities, edited by Kalpana Ram and Margaret Jolly. Cambridge: Cambridge University Press. Marks, Lara. 1996. Metropolitan maternity: maternal and infant welfare services in early twentieth century London. Amsterdam: Editions Rodopi B.V. Martin, Emily. 1987. The woman in the body: a cultural analysis of reproduction. Boston: Beacon Press. Meenakshi, K. 1996. The Siddhas of Tamil Nadu: a voice of dissent. In Tradition, dissent and ideology, essays in honour of Romila Thapar, edited by Radha Champakalakshmi and Siddha Gopal. Delhi: Oxford University Press. Mines, Mattison. 1984. The warrior merchants: textiles, trade and territory in South India. Cambridge: Cambridge University Press. Narayana, G. and J. Acharya. 1981. Problems of field workers: study of eight primary health centres in four States. Hyderabad: Administrative Staff College of India. Oakley, Anne. 1980. Women confined: towards a sociology of childbirth. New York: Schocken. Perkins, Wendy. 1996. Midwifery and medicine in early modern France: Louise Bourgeois. Exeter: University of Exeter Press. Price, Pamela. 1996. Kingship and political practice in colonial India. Cambridge: Cambridge University Press. Radcliffe, Walter. 1967. Milestones in midwifery. Bristol: Wright. Ram, Kalpana. 1991. Mukkuvar women: gender, hegemony and capitalist transformation in a South Indian fishing community. Sydney: Allen and Unwin. ———. 1993. “Too traditional once again”: some post-structuralists on the aspirations of the immigrant/ third world female subject. In Australian Feminist Studies 17: 5–28.

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———. 1994. Medical management and giving birth: responses of coastal women, Tamil Nadu. In Reproductive Health Matters (Special Issue, Motherhood, fatherhood and fertility) 4: 20–6. ———. 1996. Rationalism, cultural nationalism and the reform of body politics: minority intellectuals of the Tamil Catholic community. In Social reform, sexuality and the state, edited by Patricia Uberoi. New Delhi: Sage Publications. ———. 1998a. Maternity and the story of enlightenment in the colonies: Tamil coastal women, South India. In Maternities and modernities: colonial and postcolonial experiences in Asia and the Pacific, edited by Kalpana Ram and Margaret Jolly. Cambridge: Cambridge University Press. ———. 1998b. Na¯ shariram na¯ dhi, “my body is mine”: the urban women’s health movement in India, and its negotiation of modernity. International Women’s Studies Forum. (Special Issue, Migrating feminisms, edited by Kalpana Ram and Kehaulani J. Kauanui.) 21: 617–621. ———. forthcoming. Rationalising fecund bodies: family planning policy and the modern Indian nation-state. In Borders of being: citizenship, fertility and sexuality in Asia and the Pacific, edited by Margaret Jolly and Kalpana Ram. Ann Arbor: University of Michigan Press. Rao, Mohan. 1994. Voices from the wilderness. Voices 1(2): 3–9 Rich, Adrienne. 1977. Of woman born: motherhood as experience and institution. London: The Women’s Press. Richman, Paula. 1992. Many Ramayanas: the diversity of a narrative tradition in South Asia. Delhi: Oxford University Press. Roy, KumKum. 1996. Vedic cosmogonies: conceiving/controlling creation. In Tradition, dissent and ideology: essays in honour of Romila Thapar, edited by Radha Champakalashmi and Siddha Gopal. Delhi: Oxford University Press. Rozario, Santi. 1997. The dai and the doctor: discourses on women’s reproductive health in rural Bangladesh. In Maternities and modernities: colonial and postcolonial experiences in Asia and the Pacific, edited by Kalpana Ram and Margaret Jolly. Cambridge: Cambridge University Press. ———. forthcoming. The healer on the margin. In The daughters of Hariti. birth and female healers in South and Southeast Asia, edited by Santi Rozario and Geoffrey Samuel. New York: Gordon and Breach. Sabala and Kranti. 1995. Na¯ shariram na¯ dhi: my body is mine. Pune: Saptahik Mudran. Sangari, KumKum. 1995. Politics of diversity: religious communities and multiple patriarchies. In Economic and Political Weekly, pp. 3287–3310 (December 23, 1995) and pp. 3381–3389 (December 30, 1995). Saunders, Penelope. 1989. Midwives and modernization: a feminist analysis of the World Health Organization’s suggestion that indigenous midwives be incorporated into primary health care programmes. BA Hons. Thesis, Women’s Studies Program, Australian National University. Shetty, Sandhya. 1994. (Dis)locating gender space. In Eroticism and containment: notes from the flood plain, edited by Carol Siegel and Ann Kibbey. New York: New York University Press. Spivak, Gayatri. 1988. Can the subaltern speak? In Marxism and the interpretation of culture, edited by Cary Nelson and Larry Grossberg. Urbana: University of Illinois Press. The Tamil Lexicon. 1988. Madras: University of Madras Press.

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Uberoi, Patricia, ed. 1996. Social reform, sexuality and the state. New Delhi: Sage Publications. Van Hollen, Cecilia. forthcoming. “Baby friendly” hospitals and bad mothers: manoeuvering development in the postpartum period in Tamilnadu, South India. In The daughters of Hariti: birth and female healers in South and Southeast Asia, edited by Santi Rozario and Geoffrey Samuel. New York: Gordon and Breach. Vitebsky, Piers. 1993. Dialogues with the dead: the discussion of mortality among the Sora of Eastern India. Cambridge: Cambridge University Press. Whitehead, Judith. 1996. Modernising the motherhood archetype: public health models and the Child Marriage Restraint Act of 1929. In Social reform, sexuality and the state, edited by Patricia Uberoi. New Delhi, Sage Publications. World Health Organization [WHO]. 1966. The midwife in maternity care: report of a WHO expert committee. (WHO Technical Report Series, 30). ———. 1978. Primary health care: report of the International Conference on Primary Health Care, Alma Ata, USSR. Geneva: WHO. ———. 1979. Traditional birth attendants. Geneva: WHO.

5

The Political Ecology of Health in India: Indigestion as Sign and Symptom of Defective Modernization Mark Nichter

An individual’s experience of health is visceral as well as psychosocial, environmentally conditioned as well as culturally mediated, subject to the idiosyncrasies of one’s individual habits as well as to the dictates of routine practices, and judged in relation to one’s ability to enjoy life’s pleasures and experience happiness—however defined—as well as in relation to social roles and work demands. Health is experienced as an absence of worries, socially devalued states, and uncomfortable symptoms, but also as a positive source of vitality, be this expressed in terms of beauty or spirituality, inner strength or ritual purity, resistance, or immunity. One’s experience of health is ecological, in the sense that the body is situated, interactive, and relational. The individual body does not exist in a vacuum. One’s biorhythms and consumption patterns, tastes and desires, are interconnected to larger social and political-economic processes (the social body and body politic) which shape them. Flexible, but far from being a docile medium, the body as agent communicates needs, desires, thoughts, and feelings in multiple ways to other members of a community who share common dispositions. Individual bodies are trained (disciplined, socialized, etc.) to fit the dictates of particular worlds. At the same time, the health and well-being of individuals impact on the workings of larger social formations and physical environments. The body out of control, the frightened, sick, dislocated, or unsettled body contributes to the greater malaise of the physical environment, the household environment, and society at large. No one was more acutely aware of the political ecology of health and the micropolitics of the body than Mahatma Gandhi. Viewing the advance of modernity (industrialism and globalization) with trepidation, Gandhi saw the po-

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tential impact of capitalism on the body as both a health and a moral issue. His recommendations that Indians should return to a simpler life was a return to an ecological sense of health—a sense of health responsive to one’s microecology (household, neighborhood, village), known through the careful monitoring and regulation of bodily processes (especially diet, elimination, hygiene), and achieved as a moral duty to oneself and the nation. The result of modernity, according to Gandhi, was colonization at the site of the body: the creation of a consumer body which would be a slave to ever-increasing appetites which could only to be met by industry. This would, in turn, render the body unhealthy and in need of constant repair by a state medical system which would strip individuals of their autonomy and divert attention away from the fact that many of their ailments were self-inflicted and fostered by state-sponsored hedonism. As noted by several scholars (Alter 1996; Arnold 1993; Nandy and Visvanathan 1990), Gandhi’s fight against modern medicine was an act of resistance to an urban-industrial civilization, which he fundamentally held to be unethical. His experimentation with vegetarianism and naturopathy was an attempt to provide living truth that an alternative ecological science better fit rural Indian culture. While Gandhi was skeptical of what might be termed “bourgeois Ayurveda,”1 the biomoral science which he advocated shared with Ayurveda: (1) the call for a situational diagnosis of the individual patient and not just “disease” as entity, and (2) a critique of Western medicine’s fetishism for germs as the cause of disease while overlooking those underlying conditions which provided the soil and internal climatic conditions necessary for such seeds of misfortune to flourish. In this chapter, I will explore whether an ecological model of health, espoused by Ayurvedic pundits and embraced by Gandhi, is deemed relevant by Indians today as a means of understanding their experience of modernity. Alternatively, has Ayurvedic reasoning lost ground and is Ayurvedic medicine increasingly utilized to mask the ill effects of defective modernization, a role Gandhi had envisioned for modern allopathic medicine? If people do resort to Ayurvedic medicine as an antidote for the ills of modernity, how do practitioners respond to patients having treatment agendas which stand in contrast to the principles of Ayurveda? In considering these questions it is necessary to bear in mind the changing Indian scene. Fifty years after independence, both change and continuity characterize rural India. Satellite dishes bring both modern soap operas and traditional folk dramas into the home, fast food and buffet marriage receptions coexist with traditional meal formats subject to folk dietetic principles, and tremendous growth is reported in both the commercial Ayurvedic and allopathic (biomedical) medicine markets. Given a scenario of rising consumerism and health commodification (Nichter 1996), both an Ayurvedic and allopathic pill seems available for every ill. Indians, at once, applaud the wonders of modernity (better communication and transportation, the greater availability of a larger array of products, more accessible health care facilities) as well as decry the

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fact that the infrastructure cannot cope with increasing demands, the environment is polluted, and the food is adulterated. Double-voiced commentary on life is commonplace. One minute the voice of progress speaks and the next minute the voice of nostalgia reminisces about how food used to taste so much better, before the advent of chemical fertilizers. In this chapter, I juxtapose four case studies which capture this play of doublethink and illustrate how the impact of modernity is thought about in terms of health. These case studies will serve to illustrate how three experienced Ayurvedic practitioners apply an ecological model while treating patients complaining of indigestion, a symptom which they diagnose in relation to defective modernization. In each case, the vaidya (Ayurvedic practitioner) is met by a patient having a different agenda for consulting them. The first two case histories are highly nuanced and illustrate the multidimensionality of illness experiences. Each patient is caught in a web of social relations which has affected their health-care-seeking behavior and illness experience. As these rural patients were familiar to me, I was able to collect detailed histories from them and discuss the vaidya’s treatment strategy. In the latter two cases, the vaidya were known to me, but the patients were not. Each had migrated out of the region and now lived in an urban area. The first two case studies were collected in 1989–1990 and the second two in 1996–1997. Data were gathered during patient consultations with three vaidya at their homes in South Kanara District, Karnataka State, India, a region where I have been conducting fieldwork for over two decades (see Figure 5.1). All cases involve members of the Havik Brahman caste, who have lived a significant portion of their lives in the areca nut growing belt in the southern region of the district, which borders on Kerala State. This district has a strong reputation for the practice of both Ayurvedic medicine and biomedicine. Over the last two decades, there has been a proliferation of biomedical doctors, clinics, and pharmacies in the district. The growing prosperity of the areca nut belt has led to improved transportation which links the region to the district’s capital, Mangalore, a city renowned for its medical college, hospitals, and diagnostic testing facilities. BRIEF OVERVIEW OF RURAL HAVIK LIFESTYLE: TOTA JEEVANA (GARDEN LIFE) The life of Havik Brahmins who engage in areca nut garden management is highly routinized, organized around the performance of repetitive tasks (from work to rituals), and the consumption of a fairly uniform staple diet (rice, coconut, pickle, and buttermilk). This diet is supplemented by seasonal foods partly eaten for taste and availability, but also strategically consumed for their medicinal properties in order to counterbalance seasonal excesses, assist digestion and the elimination of wastes, and increase vitality. One effect of adhering to this lifestyle is an internal clock literally calibrated to food transit time (hun-

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Figure 5.1. A vaidya consults with patients, as his wife stands by his side. Photo by Mark Nichter.

ger, defecation patterns) and activity-rest patterns. Deviation from this pattern is a cause of concern as are body signs (taste, feces, urine, sweat, smell) considered out of the ordinary, which are interpreted in relation to humoral imbalance, blocks of flows, and the like. Speaking to the importance of “somatic states of attention,” Csordas (1993) has noted the importance of considering culturally elaborated ways of attending to and with one’s body in surroundings that include the embodied presence of others. Bodily functions are closely monitored by Haviks and the gut is listened to attentively. Its rumblings are discussed as part of everyday conversation and responded to with a well-developed set of folk dietetic practices. Sensory relations (gut relations) are as fundamental to social relations in Havik society as verbal communication. Local reading of the body, or what Ots (1991) has referred to as the “emergent objectification of bodily experience,” entails an ad hoc process of translating phenomenological experience into cultural “common sense.” People apply familiar frameworks (hot/cold, body humors) when constructing a passing theory of illness and practice home care until it is recognized that a problem warrants the treatment of vaidya or doctor. In everyday discourse, food and digestion are common reference points among Brahmans. A common Kannada greeting in South Kanara inquires as to whether one has finished one’s meals (oota aiytu?). This constitutes an invitation to talk about visesha—happenings in one’s house related to special food preparations. Among Brahmans, it also constitutes an opportunity to talk about one’s

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appetite, digestion, pathya (dietary restrictions), and participation in social events—all spoken about in relation to food consumption. Through observation and overt discussion about foods eaten and not eaten, interlocutors learn much about the quality of life in each others’ households. Pathya and complaints of indigestion (ajirna) invite speculation about and draw attention to multiple domains of life. Indigestion may be the result of improper eating habits or the consumption of adulterated foods, may indicate one’s inability to adjust to a new or existing environment, or index the hardships of living and working in that environment. Indigestion is both associated with the activity of gastric worms and recognized to be caused by such varied emotional states as anger, worry, fear, and anticipation; it is read by others as a telltale sign of pregnancy as well as recognized to be a visceral response to upsetting social relations which literally spoil one’s appetite. In a context where social relations are articulated through the sharing of meals, full participation in social life is suspended by the inability to share and digest common fare. Refusing food calls attention to one’s bodily sense of social affiliation. I have argued elsewhere (Nichter 1981) that among groups where maintenance of bodily rhythms is directly related to the perception of health, and social surveillance of the body is high, somatic complaints constitute an evocative idiom for conveying psychosocial distress.2 My previous study of Havik women revealed that complaints of symptoms indicative of imbalance and blocks of flow within the physical body were understood by other Haviks to be metonymic (not merely metaphoric) of such disruptions of flow and balance in the social body (e.g., the household, kin relations). In this chapter, I want to further suggest that the experience of somatic complaints such as indigestion invites reflection on how modernity has affected the quality of life and social relations within and beyond the household. I will argue that somatic idioms of distress and commentary on political ecology play off one another. CASE ONE: TREATING THE STOMACH TO HEAL THE MIND OF ITS DESIRE FOR TABLETS AS THE ANSWER TO LIFE’S PROBLEMS The first case involves Raja, a Brahman patient who consulted Krishna Vaidya after having been diagnosed as having “BP” (a local term used for either high or low blood pressure as well as anxiety) by an allopathic doctor at a private clinic. Raja reported that he had been treated for two years with tablets, which I eventually learned were a minor tranquilizer and an antacid. He claimed that the tablets had been effective until recently, but that they no longer provided him relief. Raja suffered from indigestion, poor appetite, and gas in addition to tension, mental weakness, and poor sleep. He requested that Krishna give him a herbal decoction (kashaya) to improve his digestion, so that his body could once again digest the tablets which the doctor gave him. This would enable him to feel better.

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Directly prior to his consultation, I had a chance to interview Raja as he waited to see Krishna Vaidya. Raja believed that his BP was due to his blood becoming spoiled as a result of his mental worries. His worries were tied to economic pressures associated with compounding bank loans taken for fertilizers and pesticides, which could not be paid off due to several years of poor crops. He had to continue to invest in his garden and refinance his loans by borrowing money against his land. Raja spoke of needing his BP tablets to control his worries and most important, to enable him to sleep. At the same time he worried that taking strong allopathic tablets for a long time was not good for his health. His digestion was poor and he had no taste for food. He suspected that taking tablets daily exacerbated his weak digestive capacity. What I remember most about the interview was Raja’s reasoning about why his tablets were no longer effective. Rather than thinking that he had built up tolerance to the medications, Raja believed that his body had literally lost its capacity to digest them. He wished to resume taking the doctor’s medicines once he had increased his digestive capacity. During Raja’s consultation, Krishna spent over half an hour collecting the details of Raja’s dietary and defecation habits as well as those worries which prevented him from sleeping. During this discussion, Raja revealed several other life problems he had not mentioned to me: two unmarried daughters already over twenty years old (how could he afford to marry them?) and a son who roamed about and was irresponsible with money. Raja was angry with his son, but felt he was powerless to do anything about his behavior. Krishna listened to Raja’s complaints and told him that the tablets prescribed by the doctor had indeed weakened his digestion and dulled his mind. It was necessary for him to take purification medicines, medicines to stimulate his digestion, and medicines to replenish his dhatu—a bodily essence contained in semen, distributed throughout the body and responsible for mind-body control. Raja was placed on a strict pathya, devoid of stimulants of any kind (such as onions or garlic). Krishna’s recommended course of therapy would take three months, during which time Raja was advised not to take his allopathic tablets. After Raja left, I asked Krishna if he thought that the patient’s economic problems had led to his mental weakness, and whether or not his health could be restored without a change in the social and economic affairs of his family. Krishna replied by asking me whether in my country such patients would be sent to a psychiatrist? Before I could reply, he stated: This is where our thinking differs, in the way each of us diagnoses the roots of the problem. [I had come to represent the West.] You look for roots in the mind and dig into memories and social affairs, we look for root causes in the stomach. Thinking too much causes anxiety [tali bisi] and affects a man’s digestion as heat is diverted from the stomach to the brain. To break the cycle of undigested food and undigested, uncontrolled thoughts, I must first treat the stomach. This is the root cause of the problems. If a branch of a tree is unhealthy and you treat only the branch does the tree become healthy? The

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roots provide nourishment for the entire tree. Nourish the roots, correct the problem at the roots, and new buds will appear on once lifeless branches. If it were not for the patient’s poor digestion, his mind would not be so weak that his worries would overwhelm him to the point that he is not ready to meet life’s challenges. Correct his digestion and new ways of solving his problems will emerge. To reduce tali bisi, the patient requires proper practices, abhyasasatmya, as well as proper medicines. Following pathya and doing puja [daily rituals for the gods] will give him a correct path. Let him first achieve good digestion, then his relations within the family will improve.

On another occasion, Krishna spoke to me further about Raja’s “fear of movement” and his anger, and how these emotions were related to his digestion, not just external events. Given the circumstances, Raja’s feelings were warranted. It was his inability to reason and act which was impeded. His indigestion had unbalanced his humors leading to a form of vata-pitta dosha (literally wind-heat principle trouble) and dhatu deficiency, making it difficult for him to focus on any one subject. His mind wandered and this caused him to be fearful. What I saw in terms of psychological problems was in fact a humoral imbalance. Where I looked to social relations to understand Raja’s problems, it was humoral relations which I needed to better understand. Krishna drew an analogy between my present attempt to understand Raja and an attempt I had made fifteen years before to understand kinship relations before looking to see how kin relations were influenced by land issues. I had needed to literally “ground” my thinking. The same was true in this case. To understand Raja’s mental state, I needed to think ecologically and in terms of physiogomy, not somatization.3 Krishna explained BP to me to illustrate his diagnostic reasoning. BP (Raja’s blood pressure was never discussed in terms of numbers) was symptomatic of impurities which had built up in the patient’s blood leading to a feeling of pressure within his body’s many channels (nara: a term used for channels carrying blood as well as nerves). Raja complained that he was often constipated and had gas, which was further evidence of ama (undigested food) blocking his system. Gas disturbed the mind, and an imbalance of the humor vata (wind) manifested itself as mental distress in the form of a desire to run rather than face life’s problems. BP medicines offered by the doctor acted like “a silencer on a motorcycle.” Just as sound continued to be produced by the motorcycle’s engine, but was muffled by a silencer, the patient’s imbalance and desire to run from his problems remained, but was dulled by the tablets. Now that the tablets were not being digested properly, the patient’s fears were amplified. Silencing his mind with medicines could only last so long, stated Krishna, because “medicines which dull the mind, dull the digestion, and lead to larger problems (dosha).” According to Krishna, Raja’s desire for doctor’s tablets as a means of controlling his emotions was “a hunger expressed by the disease, just as a diabetic’s craving for sweets was a hunger expressed by disease.” Raja’s request to enhance his digestion so he could continue taking tablets was symptomatic not

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only of his own illness, Krishna noted rather philosophically, but a larger sickness facing humanity. This sickness was a growing desire for short-term solutions for life’s problems. This desire for such so-called solutions was diagnostic of a problem ailing not just Raja, but humanity-at-large in modern times. The theme of the “danger of short-term fixes” is taken up in the next case study. But before moving on to it, let me briefly report on Krishna’s treatment strategy and how Raja responded to it. Krishna’s approach to assisting Raja gain control of his life began with establishing control at the site of the body. He advocated working from the stomach outward. Medicines were provided to clean out his system, improve his digestion, balance his humors, and restore a sense of rhythm in his life.4 Achieving good digestion would lead to better thinking capacity, self-control, a more balanced emotional state, and self-confidence; all of which would result in improved social relations in his household. Raja was encouraged to focus on his own health concerns before trying to solve larger life problems. He was provided a sick role which involved more than the swallowing of tablets. He was instructed to engage in close personal surveillance of his body, so that his medicines could be better tailored to his needs. Following a special diet directly involved both Raja and his wife in his illness experience. I followed this case with interest. Raja ended up taking Krishna’s medicine for approximately two months (one month short of what had been advised). He reported to me that the medicine had improved his appetite, but that he still felt “tension” and had problems sleeping. He went back to taking his tablets which he reported now assisted him about half as much as they had earlier. A relative suggested that he consult another doctor who in turn recommended that Raja see a specialist. The specialist suggested that he get a “heart scan” in Mangalore.5 His relatives expressed concern and encouraged him to take rest and not worry so much about his problems. His wayward son returned home to manage the garden. The scan revealed no serious disease, but Raja’s new doctor gave him medicines and told him to take rest. His illness identity shifted from someone having indigestion to someone having a heart problem (if not a heart disease). An astrologer was consulted a few months later who indicated that the fortunes of his household would improve after some time, this being a period of problematic planetary conjunctions. As things turned out, areca nut prices rose as did the yield of Raja’s garden, his debts were paid off, and his elder daughter was married—all in a three-year period! The last time I spoke with him, three years ago, Raja was no longer taking heart or BP pills, but he does go for checkups every six months. He occasionally visits Krishna Vaidya for Ayurvedic medicines for indigestion, and has had a second heart scan. Nothing serious was reported, but family members continue to speak of Raja as a heart patient.

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CASE TWO: IDENTITY POLITICS, THE STOMACH, AND THE LAND Background During the past three generations, there have been marked changes in areca nut garden management. The grandparents of present generation Havik agriculturalists in South Kanara (SK) were migrants to the district from the neighboring district of Shimoga. In order to introduce areca nut as a plantation crop in this hilly region of SK, they literally transformed the landscape by leveling slopes for gardens. During the 1960s, the next generation participated in the intensification of modern agriculture and enjoyed a significant rise in the market price of areca. While the previous generation had domesticated the forest and leveled the land, the next generation made a name for itself by modernizing agriculture through the use of chemical pesticides and fertilizers in an effort to increase crop yields. Members of the current generation now question the wisdom of such innovations. There is rising concern about the diminishing fertility of the land and falling crop production among those unable to invest in “sufficient levels” of chemical fertilizers. An ecological movement championed by young agriculturists has emerged. Intergenerational tension is endemic within the Havik community. Those sons who remain at home to assist with the day-to-day management of the areca nut garden have to wait for their father to relinquish power and control over the land before they can come into their own. Sons often wait until the death or infirmity of their father before dividing up the land among themselves. The tensions which mount in the household are as much related to issues of identity as property. The Case of Govinda At age 30, Govinda’s parents were anxious for him to marry and yet he appeared disinterested. His father had a sizable areca nut garden which was prosperous. An only son, it was Govinda’s duty to manage the garden and take care of his parents in their old age. Despite his age and the fact that he was chronically ill with diabetes, Govinda’s father continued to make all major decisions about the garden and the sale of the areca crop. Govinda managed the daily operations of the garden and attended to details. A continual source of disagreement between father and son was the father’s extensive use of chemical fertilizers in the garden. Govinda was involved in the growing ecology movement being spearheaded by young Brahmans in the district, and wanted to use natural fertilizer in at least one section of the family’s areca garden. Govinda’s father, who had modernized the garden over the last two decades, was not interested in doing so and was extremely proud of the high yield of his garden. Govinda argued that although the garden’s current yield was high, it might not

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remain so in the future (his future). Govinda’s mother pleaded with Govinda not to upset his father because his health was not good. Govinda’s father’s health was a central source of concern in the household. Govinda’s mother was renowned for her preparations of sweets and fried snack foods (tindi) and Govinda’s father was fond of entertaining guests. While instructed by his doctor not to eat these foods, Govinda’s father attempted to do so despite the watchful eye of his wife and son. While Govinda’s father ate too well and suffered the consequences, Govinda did not eat well to the chagrin of his mother, and he complained of indigestion. The chronicity of his indigestion is what brought Govinda to Krishna Vaidya. Govinda’s father had heard impressive things about Krishna and Govinda consulted the vaidya more to appease his parents than because he had any particular interest in doing so. His interest in seeing Krishna, however, soon changed. During his consultation, Krishna asked Govinda a number of questions about both his symptoms and his eating habits, including how often he ate at tea hotels and his consumption of snack foods in and out of his home. This proved to be a nonstarter, because Govinda was not in the habit of regularly visiting such establishments. Krishna then asked Govinda where his family purchased its rice and how often they purchased vegetables from the market in a nearby town. Krishna also asked Govinda about his family’s water source and areca garden. After receiving answers to these questions, Krishna diagnosed Govinda as having “gastritis.” As a diagnostic category, Krishna’s use of the term gastritis differed from his use of the term indigestion (ajirna). Gastritis was a humoral disorder manifesting as indigestion, but specifically caused by the chemical adulteration of food and water. This diagnosis interested Govinda and led to a half-hour discussion. I had heard Krishna’s discourse on gastritis several times before, but rarely to a more interested audience. Krishna began with a question: As an agriculturalist, had Govinda noticed how few earthworms there now were in the soil? When Govinda nodded, Krishna stated that the reason for this was the amount of chemicals put into the soil by agriculturalists. “Earthworms,” he noted, “are not so different from man’s intestines. If earthworms cannot survive in the soil, then is it not reasonable to assume that people would also have trouble surviving off of the vegetables grown in this soil?” Krishna went on to point out that mushrooms did not grow abundantly on paddy straw as they once did. This was also evidence of the contamination of plants. He then noted that the soil had become hot as a result of the chemicals. Crops did not grow well unless chemicals were added in increasing measure. Like the tonic which people drank to regain strength, the effect of the chemical fertilizer was short-lived. Like the allopathic medicines they took, short-term benefits were paid for by long-term negative effects on the body and the soil. Farmers, he pointed out, were forced to use more and more chemicals to compensate for weak soil. As a result, harvested crops had become increasingly toxic. Future generations would suffer as a result of the agricultural practices of the present generation.

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Govinda was quite taken with Krishna’s discourse on health because it both broadened and reconfirmed his own convictions. Indeed, Krishna’s discourse gave new legitimacy to Govinda’s interest in ecology. What was more, it was based on Ayurvedic wisdom which his ailing father respected. What transpired? Govinda returned home, speaking highly to his parents of the treatment he had received from Krishna. They were delighted that he was finally paying more attention to his health and diet. Govinda religiously took the herbal medicines which Krishna had prescribed, followed the pathya which he recommended, and returned to talk to him as well as have his treatment adjusted. Govinda’s mother was all too happy to find a new way of expressing her concern for her son through food, and prepared his special diet attentively. The household’s vegetable patch was expanded and fertilized in the “old ways,” so that the household could supply itself with most of its vegetable needs. Govinda tested the soil purity of the vegetable patches with earthworms which he obtained from the forest. Govinda’s strict following of pathya was respected as a sign of control and self-discipline by his parents. His self-discipline stood in stark contrast to that of his father. I have followed Govinda’s case for the past ten years, stopping in to see him during periodic trips to South Kanara. Over time, Govinda gained permission to fertilize part of his family’s areca garden with organic fertilizers and the garden’s yield remained high. Govinda carried out several experiments in his garden using different mixes of organic fertilizers (e.g., neem cake, ash, cow dung), and testing ways of rendering traditional fertilizers more efficient. He discovered that wild pigs would not eat the roots of areca trees manured with neem and that tobacco could be used as an insecticide. Several other farmers and an agriculture research station scientist began visiting Govinda to see his areca garden and to exchange ideas. This became a source of status for his family. Govinda’s father spoke to visitors with pride about his son’s interest in ecology and his experiments with traditional agricultural methods. In a sense, Govinda had become a bridge between his grandfather’s and father’s generations. He reclaimed a fund of traditional knowledge and (re)legitimized it using present day scientific thinking. What about Govinda’s indigestion? While his physical symptoms did not continue, his discourse about indigestion and gastritis lived on. In fact, Govinda’s discourse on gastritis has grown more elaborate over the years. He entered local politics and on one occasion I heard him make the following analogy while talking to a group of fellow agriculturists about corruption: Just as artificial fertilizers increase yield but later lead to decline in soil fertility and digestive problems in those who consume these crops, so political favors doled out before elections make the party look strong and prosperous, but weaken it afterwards. Such practices spoil politics, adulterate the political system, and lead only to corruption, not sustained growth.

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Govinda embraced a political ecology that Gandhi would have applauded. CASE THREE: INDIGESTION AS AN OPPORTUNITY COST OF URBAN TRANSPLANTATION I encountered Ravi for the first time when he was consulting Ramesh, a vaidya whom I had not seen for some years. Ramesh attended to patients on his verandah, and I was invited to sit and observe him as he went about his business. Ravi was a 33-year-old professional who had left South Kanara seven years prior to take up a job in Bombay for a private company. He returned to his native place twice a year. Educated and well dressed, Ravi initially presented his complaint as two patches of itchy, inflamed, thick skin. When asked if he had received treatment for the problem, Ravi reported that he had taken allopathic medication from several doctors. In each instance, the prescribed medicine had cleared up the problem for several weeks, but the skin problem had later returned. He presented a medicine package insert to Ramesh (presumably from his last treatment) who passed it on to me as if I were the resident expert on English medicines! (The medication turned out to contain a potent steroid.) Without prompting, Ravi asked Ramesh whether his problem could be related to indigestion. Ramesh replied that it could be and questioned him about his indigestion and diet. Ravi proceeded to relate a short narrative. He had been suffering from diarrhea and constipation off and on for some time. He felt that this was related to the hygiene and the poor quality of food available in the city. It was his habit to eat most of his meals at local restaurants due to the time pressures of his job and his living situation. Ravi was unmarried, lived alone, and rarely cooked for himself. Because he felt his diet was lacking, he augmented it by drinking Horlicks (an “energy” drink) and eating eggs once a week. Ravi spoke of having no taste for food and an inability to relish even special meals when he went to more expensive restaurants with his friends. He occasionally took tablets for his diarrhea, but he also consumed a well-known brand of Ayurvedic aristha (fermented wine), which had been recommended to him by an allopathic doctor whom he had consulted about his skin disease. Returning to the subject of food, Ramesh asked Ravi about his daily dietary habits. Did he regularly eat rice or wheat (chapatis, bread)? Ravi’s answer suggested a mix. The timings and content of his meals depended on his work schedule which was not fixed. He consumed five or six cups of tea or coffee a day and asked Ramesh if this was an excessive amount which might be harmful to his health. Ramesh inquired about how Ravi’s appetite had been while he lived at home and as a student in the hostel when he was at college. Ravi reported that his health had been good. Ramesh asked Ravi a few questions about the color and smell of his stool, and whether his skin patches just itched or both itched and burned. He then proceeded to give him advice about medicines. In the middle of doing so, he spoke to Ravi about his lifestyle and how it contributed to his problem:

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You are a man who is uprooted [he used the English term]. You have not actually been able to settle in the city. You eat, but your food does not digest. This is because of food adulteration and because you do not have a proper system of eating as you did when you were at home and in the hostel. The situation is made worse by taking medicines, which only control the symptoms and do not get at the source of the problem. Your body desires to push out undigested matter and this process is stopped by the medicines you are taking. No matter whether these medicines are English or Ayurvedic by name. Ayurvedic medicines cannot be used like English medicines. Also, the quality is not there in these commercial medicines. I do not recommend company Ayurvedic aristhas to my patients. Who knows what is in them nowadays! By attempting to stop diarrhea instead of attending to your digestion, you have further spoiled your health. When wastes can not come out of the body, the tridosha [body humors] are disturbed. Ama [undigested food] accumulates in the blood and causes skin diseases. When you apply medicine to one patch, the problem raises up elsewhere. If the imbalance of the tridosha is left untreated, a more severe form of this problem is experienced. Allopathic medicines have side effects. Your skin disease may be caused by this as well.

Ramesh returned to his medicine prescribing. He recommended a purgative, a medicine to clean the blood (rakta shudhi), and a medicine to restore digestion, as well as an easily digestible and simple diet for him to follow while at his mother’s house. As Ravi was standing up to leave, Ramesh turned to him and said, “See this foreign gentleman, he has learned about Ayurveda. His work leads him to travel from place to place, from one climate to another, one diet to another. Ask him what the key to good health is?” Placed on the spot, I knew what the expected answer was, “Routine,” I said, “keeping some form of routine in one’s life, routine diet, sleep, exercise.” “Routine which matches the place,” Ramesh added. Once invited to speak, I could not resist following up on what I perceived to be Ravi’s dilemma. “What does one do when one lives in the city,” I asked Ramesh, “what habits fit the city?” Ramesh reflected for a moment. “The city is not a healthy place, but it is a place where there are employment opportunities for the young. This is the situation today. But even in the city one must put down roots and learn to bend with the wind.” That was all Ramesh had to say, nothing more. Ramesh went inside to take a bath before meals and Ravi turned to walk down the hill and catch a bus. I only had time for one fast question. “So what do you think?” I blurted out in English. “I think I had better get married like my mother has been encouraging me to do,” Ravi laughed. “Then, I will let my wife take care of my food and my health.” I nodded and he continued: What this vaidya has said is correct. Allopathic medicine has not cured my problem and it may well have made it worse. There are plenty of articles in the newspapers nowadays about such things. And I do feel healthier in the village. But my future is in the city. The costs of living there are high on both your health and your purse. Garden life is

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ideal as long as you have no ambition and are content to sit and eat and wait for your crop. You pay a price for having ambition.

“And you pay a price for having no ambition,” I added after a moment of reflection. “That is also there,” Ravi replied. Asking the time and admiring my watch, he told me he had two cousins in Chicago and New Jersey before hurrying down the hill to catch the bus.

CASE FOUR: MODERNIZATION AND THE MEDICALIZATION OF YOUTH Background In India, competition is fierce for a very limited number of merit places in desirable profession-oriented college programs (medical and engineering). Given scheduled caste/tribe reservations for a proportion of seats, competition for admission among Brahmans is particularly keen. It is common in India for a children’s parents to decide their career paths. Adolescents have little voice in such decisions and are expected to dutifully live up to their parents’ expectations the best they can. The political economy of education in India has led to an active tutorial market. Many public schoolteachers earn most of their income from tutorials after hours and are not motivated to deliver high-quality lectures in the classroom. The growing demand for examination preparation classes among the middle class has led to the emergence of competitive tutorial programs which are both costly and demanding. Students often begin attending private tutorials prior to their first public examination (10th standard) and continue for three years until their university entrance exams. It is not unusual for them to spend most of their waking hours outside school jumping between a series of five to eight different tuition classes. Many parents literally schedule their lives in order to ferry their children between classes and coach them through lessons. Much of students’ training involves “mugging up,” learning to memorize lists of key facts, figures, and equations, as distinct from being encouraged to critically examine or reflect on the subject which they are studying. If students do not do well in a tutorial program, they may be asked to leave as the placement record for each program is known. Poor students detract from the prestige of competitive programs. Little research exists on the psychological impact of testing pressure (both before and after exams) on students in India, but a rising number of “student suicides” have been reported in the newspaper. Adolescent depression among students facing academic pressures is no doubt rampant.

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The Case of Ashok Case Four was observed in the home of Vishnu, a vaidya who was a retired schoolmaster and Sanskrit teacher. A father, mother, and teenage son (Ashok) consulted Vishnu about the boy’s poor appetite and inability to concentrate on his studies. They worried that Ashok’s marks would not be high enough to secure a place in a dental college, the vocation his parents had chosen for him. The family lived in Mysore city (five hours’ drive away) and were visiting their native place for a death anniversary ceremony. Beginning his examination of Ashok, Vishnu felt the boy’s pulse and asked to see his tongue. The boy’s mother volunteered that she had been giving Ashok a commercial Ayurvedic brain stimulant named Mega Mind Two Plus which contained Brahmi, a herb believed to improve memory power. Vishnu made no comment and asked Ashok about his digestion and if he preferred any particular taste. He inquired about the boy’s bowel movements and asked him to supply a urine sample in a glass. While Ashok was complying, Vishnu asked the parents about the boy’s eating habits and education. Ashok’s mother noted that he was a poor eater. With regard to his schooling, Ashok attended a series of seven different tutorials after school and on Saturdays. The mother complained that her son was easily distracted and was having problems retaining facts he had memorized just days before. Facts she remembered, but he did not! And he wanted to sleep too much. Not only did he want to go to bed early, but once asleep it was hard to wake him in the morning. A friend had suggested that she bring the boy to a vaidya before she took him to a doctor to check for any mental defect. Vishnu concluded that a major cause of the boy’s problem was indigestion. Ashok’s poor digestion reduced his ability to think properly, and his study habits suffered. One could not think properly if his bowels were not “clean” and if his food was not properly digested. He recommended a course of Ayurvedic medicine and a pathya which the boy was to follow for some weeks. Vishnu went on to explain the boy’s condition in a manner which I found particularly clever. He told the parents that “just as digestion required heat to be in the stomach, so thinking required heat to be in the brain.” Both processes, he noted, required proper digestion. After all, “was not studying the digestion of facts, and memory their proper assimilation?” If their son was always thinking and worried about his studies both before and after meals, he would have little appetite and would not be able to digest his food properly. Following a meal, heat was required in the stomach, not the brain. When food was undigested, the body’s attention was directed to the intestines not the brain. This caused the boy to appear dull and was the reason he had no appetite. Vishnu’s recommendation was free time for the boy before and after the evening meal and after all meals eaten at home on the weekend. Vishnu’s prescription of free time was an antidote for the time pressure which Ashok faced, and provided a medical explanation which had legitimacy for his obsessive parents.

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After a few moments, Ashok returned holding his urine in the glass, a bit embarrassed. Vishnu held it up to the light and placed a drop of oil on the surface. Taking the boy aside, he had a small chat with him, which I was not privy to hear. They returned, and Vishnu briefly mentioned traces of albumin in the boy’s urine, which needed to be corrected, but was not considered serious. The family was served tea and Vishnu discussed the costs of tuition fees with them. Packets of herbal medicine prepared by an assistant were given to the boy’s father who in turn handed them over to his wife. After Ashok and his parents left, I spoke to Vishnu about the case. His assessment was that the boy was probably an average student, but his parents had high hopes for him. The boy was worried about displeasing his parents, as he was their only son. He also masturbated, something I gather Vishnu discussed with the boy when speaking to him about his urine. The boy had been instructed not to masturbate while undergoing treatment, and was told that resisting the urge to do so would help him increase his level of dhatu which would in turn increase his memory power. Later that afternoon, Vishnu brought up the case once again in the course of a conversation about changing times. He noted that it was very difficult to be a student at present for several reasons. First, in days past, a son followed his father’s vocation if he had the capacity to do so. If the child’s vasana (inborn talents) were recognized to lie elsewhere, the child was sent to a guru who would guide the boy’s education according to his capacity. Nowadays, however, education was a matter of prestige for parents. Parents did not consider where the talents of their child lay, but desired that their child study to enter one of a few high-status professions. Students had to study many different subjects “by heart” in a short time. “This is actually not education,” stated Vishnu. “Education requires that one digest what one has taken in and assimilate it.” I turned the conversation to examinations. Weren’t examinations necessary in India, given the degree of corruption? Vishnu agreed that examinations were necessary, both to provide opportunities for intelligent children and to keep standards high. The side effect was rising competition due to both increases in population and the rising desire of parents to see their sons and daughters enter into a limited number of prestigious occupations for which their children may not be suited. The following discussion ensued: Vishnu: Competition in education is a social problem, like rising dowry. Both are social practices which started with good intentions and have now become like a cancer.6 Both have become a business actually. We wring our hands about them and write about them in the newspapers, but feel helpless to do anything about them. Social pressure is there and so we go on against our better judgment. Mark: And in the end? Vishnu: The health of society is spoiled Mark: And is there a cure for this cancer?

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Vishnu: The problems of a place have to be solved in that place. Ayurveda teaches us that all of the medicines needed to solve one’s problems are in that place. That is the God’s blessing. One must only know how to use these medicines wisely. This requires discovering what suits each person, what is a medicine for them, what is a proper vocation, who is a proper marriage partner. People must learn how to adjust to life in a healthy way. Mark: So what do you suggest? Vishnu: People must learn to be satisfied with life’s simple pleasures and to value all things, all works. Marriage and one’s karma (work) must be seen as sacred and not a business. When medicine becomes a business, the side effects of medicine will cause disease. When education becomes a business, competition will cause disease. Is this not the case with this boy who cannot enjoy or digest his food, who studies but can not remember his lessons?

As I was thinking about Vishnu’s words, my eye was drawn to a bank calendar hanging near Vishnu’s desk depicting Gandhi reading a book in dim light. The juxtaposition of the bank’s name in big black and gold embossed letters, and the softness of Gandhi’s face led me to reflect further on co-option. CONCLUSION I began this chapter by talking about the experience of health in broad terms to bring to mind the many ways in which health is evaluated by different people. Attention was then directed to a political ecological theory of health embraced by Gandhi and consistent with many of the tenets of Ayurvedic medicine. I raised a series of questions. Was this mode of reasoning applied in India today as a means of understanding the experience of modernity? If applied by Ayurvedic vaidya, how was their passing theory responded to by patients attempting to cope with modernity? What did patients want from Ayurvedic medicine given the exigencies of modern life? Had the practice of Ayurvedic medicine been co-opted in the service of “modernity,” a role Gandhi had envisioned for allopathic medicine? These are complicated questions which invite broad-based inquiry. What I have attempted to do through the presentation of four case studies is to ground this inquiry in modern day reality. The cases involve contemporary life problems which face members of India’s growing middle class: the anxieties of economic uncertainty resulting from fluctuations in market prices, intergenerational power struggles and identity politics, the opportunity costs of work migration to urban areas, and unhealthy competition among youth for scarce educational and work opportunities. The Havik Brahmans involved in these cases were all exposed to ecological reasoning about health during their youth through an elaborate system of dietary and self-care practices. In each case, a rural Ayurvedic vaidya steeped in Brahmanic tradition was consulted. And in all cases, patients received from the vaidya not only medicines and dietary advice, but also a dose of ecological

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reasoning about the underlying nature of their problem. In each case, indigestion was diagnosed as central to the patient’s illness experience. What emerges from these four case studies is that for the vaidya featured, indigestion is both a central trope for defective modernization, as well as a bodily response to environmental (physical as well as social) degradation and change. Indigestion is a symptom of those problems which upset one’s basic capacity to assimilate food, sustain the body, and derive flavor from life, which in turn impedes all other aspects of health. In this sense, indigestion constitutes a final common pathway (Carr and Vitaliano 1982) through which distress is both experienced viscerally and communicated to those with whom one shares cultivated dispositions. Indigestion is also a sign. In the four cases presented, vaidya link indigestion to the ills of capitalist extraction: overproduction of the soil at the cost of sustainable agriculture; unhealthy competition leading to mental fatigue at the cost of healthy child development; and an overreliance on shortterm fixes which mask problems of modernity which become less visible opportunity costs. In Case One, the patient blames indigestion for his inability to digest medications upon which he has become dependent for a feeling of well-being. Paradoxically, indigestion is a side effect of these very medications. The patient’s BP medications turn out to be tranquilizers and the folk illness BP turns out to be an illness of “tension” and “pressure,” in this case related to the patient’s financial problems and anger toward a wayward son. Offered an ecological model for his problems, medicine to improve his digestion, and a sick role enabling him to slowly regain control of his life, Raja only has interest in the medication. Once indigestion is treated by Ayurvedic medicine, he returns to his pills. Over time, a heart scan proves to be a far more effective idiom of distress for this man than digestive complaints! In Case Two, indigestion is closely tied to the inability of the patient to “come into his own.” Govinda’s inability to savor food is linked to his unhappiness at not being able to express his individuality and sense of agency. Govinda embraces Krishna Vaidya’s ecological model of gastritis because it validates his environmental activism and enables him to express his individuality in a culturally acceptable manner. As Mines (1994) has observed, individuality in India often takes the form of assuming responsibility for others as distinct from achieving autonomy from others. Govinda’s individuality is achieved through assuming responsibility for the future of his household’s land. In Case Three, the patient’s indigestion is related to food adulteration, lack of a routine diet, and the side effects of allopathic medicine used for short-term palliative relief from symptoms. The city is a place of both job opportunities and opportunity costs for one’s health. Ravi’s skin rashes are a visible sign of internal imbalances which medicinal creams have not been able to suppress for long. Ramesh Vaidya advises him to put down roots and bend with the wind, settle and adapt to the city the best he can by developing a sense of routine. For Ravi, this means getting married and letting his wife assume the role of

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domestic health manager. It is she who will create a household environment (ecological niche) in which his good health may be maintained. Case Four highlights the impact of competition on society’s most vulnerable members, children. Education is a form of symbolic capital as well as an investment in human capital. Exposed to a high-pressure examination system, a mediocre student is in the process of becoming medicalized by his parents who are in search of a cure for his poor academic performance. Vishnu Vaidya, himself a former teacher, identifies the child’s physical and social problems. He treats the boy’s indigestion and dhatu loss and at the same time uses Ayurvedic medical reasoning to provide the student legitimate time out in a high-pressure exam-cramming environment so that he can at least relax and digest his food. The case leads Vishnu to reflect on defective modernization as it is related to prestige politics as well as a lack of respect for each person’s unique talents and bodily constitution. He bemoans the fact that all that is sacred, including medicine, has been turned into a business. Medicine and education have both become distorted and complicit in producing dis-ease. All three vaidya have in their own way applied and extended political ecological reasoning in their practice of Ayurveda. While they largely advocate a strategy of accommodation, their diagnosis of illness is embedded within a larger critique of sickness (Young 1982) and environmental degradation associated with defective modernization.7 Where did they acquire their ideas? From numerous places: ancient Sanskrit texts and pamphlets of environmental nongovernmental organizations, newspaper articles, TV broadcasts and their own empirical observations. The political ecological theory, crystallized and embodied by Gandhi, is alive and well in India, today evolving through creative acts of analogical reasoning and appropriation.8 To the question I posed initially— “Is this reasoning relevant in India today?”—I would answer both yes and no. From my field experience in various corners of India over the last twenty-five years, I have come across many individuals who subscribe to the passing theories presented by these three vaidya. One commonly hears comparisons between Ayurvedic and allopathic medicine which index aspects of this reasoning.9 One is routinely told, for example, that Ayurveda has no side effects and that allopathy provides fast relief of acute problems, but is not suitable for long-term therapy because “it” is hard on the body. While general consensus about this juxtaposition of medical systems holds up on the level of representation, in practice it often falls apart. Many chronically ill patients subscribing to Ayurvedic reasoning find allopathic medicines a godsend and praise them during times of need. On the other hand, most young middle-class people that I know (aside from those in the environmental movement), do not think in terms of political ecology. They embrace modernity even if they use the odd Ayurvedic product for troubling symptoms related to indigestion. And when they do use Ayurvedic products, they are likely to have English names (Nichter 1996). Their concerns about the harmful effects of environmental degradation are more often directed toward beauty work than health. Though they have the habit of pur-

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chasing over-the-counter allopathic medicines for fast relief from coughs and colds, they purchase Ayurvedic beauty products to restore that “healthy vitality that environmental pollution has spoiled.” The critique of modernity offered by the three vaidya featured in this chapter both exists in its own right and has been co-opted. It has been capitalized on by the manufacturers of commercial Ayurvedic and health-food products. Creative marketers have played on the collective anxieties of local populations. These anxieties range from spots which mar one’s beauty to diseases like cancer linked to adulteration, pesticides, and chemical fertilizers; weakness associated with overuse of allopathic medicines to the need for food supplements and digestive aids. In India today, there has been a proliferation of commercial herbal remedies marketed as an antidote for the ills of modernity. As noted by Ramesh Vaidya, misuse of such “solutions” has become as much a part of the problem of defective modernization as misuse of allopathic medicine. Does the public recognize this? This question invites further investigation. Let me close with a personal reflection, an analogy which struck me just after leaving Vishnu’s office when I observed Gandhi’s face on the bank calendar. Just as Gandhi’s image is featured on bank calendars to celebrate nationalism and give an aura of legitimacy to business as usual, so the image of sages adorn medicine bottles with English names promising relief from the ills of modernity. NOTES 1. Gandhi’s approach to a moral science of the body drew little from Ayurvedic doctrine and largely from a reading of Western advocates of vegetarianism, naturopathy, and hydropathy. His critical attitude toward Ayurveda as an elite and tradition bound science softened over time (Alter 1996). 2. Indigestion (ajirna) is a bodily state of dis-ease often used as a somatic idiom of distress in Brahmanic culture (Nichter 1981). So too are complaints associated with indigestion: blood impurity (rakta dosha), “BP” (the folk illness “blood pressure”), nerve trouble (nara dosha), poor sleep, and lack of mental concentration. In North India, a popular idiom of distress connoting that one is “out of sorts” is the complaint that one has not defecated satisfactorily (Hindi: khul ke nahin aata hai, literally open, no comes out). This phrase does not indicate constipation, but rather the feeling that “what has come out has not come out the way it should, one gets no satisfaction from having had a bowel movement.” 3. On the difference between physiogomy and somatization, see Ohnuki-Tierney (1984) 4. According to Krishna, the regaining of body rhythm, signaled by routine hunger, food transit timing, and sleep were basic to the patient attaining health. The medicines which Krishna offered enabled this process to take place by “preparing the body to receive food,” while the diet he prescribed provided food appropriate to the patient’s humoral disposition. Using a series of music analogies, Krishna spoke of “retuning” the patient’s body so that he could live a more harmonious life. Only then could he engage in harmonious interplay with others and be able to solve social problems.

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5. The term “scan” like the term “heart patient” connotes something serious. The use of diagnostic tests as an idiom of distress is a focus of my current research. 6. See Trawick (1992), for another example of an Ayurvedic practitioner who used “cancer” in a metamedical way to comment on rising levels of ill health related to modernization and social transformation. 7. Ayurveda contains an elaborate ecological model which moves back and forth between the macrocosm (brahamanda) and microcosm (pindanda), but lacks a political dimension. Patients are instructed how to adjust to circumstance, not change socialpolitical conditions in order to engender better health. 8. On the ethnopoetics and ecological reasoning inherent in Ayurveda, see Zimmerman (1987). On the appropriation and creative integration of ideas into an ever-invented tradition (and the politics of doing so), see Nandy (1987). 9. Comparisons of Ayurveda and allopathy are common at the level of representation. In postcolonial India, discussions of Ayurveda assume the presence of allopathy. The word, as Bakhtin (1981) has noted, does not exist in isolation, it is addressed to the presence of an audience, which may or may not be physically present.

REFERENCES Alter, J. S. 1966. Gandhi’s body, Gandhi’s truth: nonviolence and the biomoral imperative of public health. Journal of Asian Studies 55: 301–322. Arnold, D. 1993. Colonializing the body: state medicine and epidemic disease in nineteenth-century India. Berkeley: University of California Press. Bakhtin, M. 1981. The dialogical imagination. Austin: University of Texas. Carr, J. and P. Vitaliano. 1982. Depression and the culture bound syndromes: an ethnobehavioral view. Paper presented at the American Anthropological Association Conference, Washington, DC. Csordas, T. 1993. Somatic modes of attention. Cultural Anthropology 8: 135–156. Mines, M. 1994. Public faces, private voices. Berkeley: University of California Press. Nandy, A. 1987. Cultural frames for social transformation: a credo. Alternatives 12: 113– 123. Nandy, A. and Visvanathan, S. 1990. Modern medicine and its non-modern critics: a study in discourse in dominating knowledge. New Delhi: Oxford University Press. Nichter, M. 1981 Idioms of distress: alternatives in the expression of psychosocial distress: a case study from South India. Culture, Medicine and Psychiatry 5: 379– 408. ———. 1996. Pharmaceuticals, the commodification of health, and the health caremedicine use transition. In Anthropology and international health: Asian case studies, edited by Mark and Mimi Nichter, pp. 265–328. Amsterdam: Gordon and Breach. Ohnuki-Tierney, E. 1984. Illness and culture in contemporary Japan: an anthropological view. Cambridge: Cambridge University Press. Ots, T. 1991. Phenomenology of the body: the subject-object problem in psychosomatic medicine and the role of traditional medical systems. In Anthropologies of Medicine: A Colloquium on West European and North American Prespectives, edited by Beatrix Pfleiderer and Gilles Bibeau. Special edition of Curare 7: 43–58. Trawick, M. 1992. An Ayurvedic theory of cancer. In An anthropological approach to ethnomedicine, edited by Mark Nichter. New York: Gordon and Breach.

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Young, A. 1982. The anthropologies of illness and sickness. Annual Review of Anthropology 11: 257–285. Zimmerman, F. 1987. The jungle and the aroma of meats: an ecological theme in Indian medicine. Berkeley: University of California Press.

PART II

HEALING ON THE MARGINS: MALAYSIA, INDONESIA, AND CHINA

6

Engaging the Spirits of Modernity: The Temiars Marina Roseman

In a Chinese logging camp at the edge of the forest in Kelantan, Malaysia, piles of logs await pickup for their final journey out of the jungle and into the global economy. The camp complex, constructed out of wood and covered with the zinc roofing common to hastily built, commercial forest enterprises, includes dormitories for predominantly Chinese timber workers and truck drivers, kitchen, cafe, and grocery store. Forest-dwelling Temiars drop in periodically to buy food and sundries. Logging trucks roll in, emptying their loads, and the jungle’s spoils accumulate like jewels in a dragon’s lair. Back behind the living quarters, the runoff from bathing structures and latrines fouls a small rivulet emerging from a limestone outcropping about ten feet upstream. The limestone cliff is pocketed with caves worn by falling water, so soon to be polluted by the effluvia just downstream. From the spirit of this waterfall, the Temiar shaman and headman Ading Kerah received a song during his dreams. The spirit emerged in the shape of a young Chinese woman, who stepped out of the cab of a passing logging truck, stylishly dressed in a miniskirt. The stench, filth, and—from the viewpoint of a Temiar forest dweller rather than a timber company executive—devastation of the logging industry are concentrated in the camp’s gathering of workers and products. Yet from this site, arising like a phoenix out of dung, came the Logging Camp Cave’s spirit. Her song will be used in ceremonies for help in healing—or for the many other uses to which dream song ceremonies are directed: to mark important moments in the agricultural cycle; to welcome or send off travelers; to mark a mourning period’s end; or to celebrate the experience of dancing, trancing, and singing with the spirits.

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The mini-skirted Chinese Lumber Camp Cave spirit, with her gift of song for use in healing, comprises one of many instances in which Temiars engage the spirits of modernity for their own purposes. Spirit practices—these imaginative realms of dream and song—are critical sites for the engagement of local peoples with global processes. Spirit songs sung to effect individual healings address, as well, the health of a social group traumatized by loss of land and resources. Over the last twenty years I’ve charted the effects of deforestation, land alienation, and Islamic evangelism upon Temiar self and society. Ading Kerah’s dream song is a striking instance of ways in which I have seen Temiars draw the spirits into history through the power of expressive culture. Animated signs absorb the crash of disjunctured pasts and presents in Temiar ceremonial performance. Community members exploit motions and odors, musical sounds and glimmering colors to cross temporal and ontological boundaries, transcend geographic and cosmological space, polyphonically signal multiple-layered identities, and phenomenologically resituate experience.1 On the one hand, I am impressed by the resilience of Temiar ethnopsychology and cosmology, which is able to engage the spirits of foreign things and peo, “those who come from beyond the ple—whom they call “outforesters” forest”—within an indigenous discursive system of power and knowledge, thereby retaining agency. On the other hand, I am concerned that such shamanistic incorporation of the Outforest Other might presage an ideological acceptance of material disenfranchisement, as Temiars focus upon the flash of a spirit guide’s beauty, rather than mobilizing to resist their material losses. Yet I have come to see this grasping of a spirit’s healing song from those people, things, and technologies that have so thoroughly assaulted their material resource base as an act of social suturing, an art of survival, a technology for maintaining personal and social integrity in the face of nearly overwhelming odds. Dream songs have long provided Temiars a site for mediating encounters with their forest environment (Roseman 1991). The realm of songs, dreams, and spirit-mediumship provides a space for Temiars to incorporate the knowledge and power of “outforester” peoples and commodities, as well. Temiar dreamsong receipt is based in an ethnopsychology that posits multiple soul components that may become detached and animated as “spirit”; these include the head soul (r@waay), locus of expression and vocalization; the heart/breath soul (hup), locus of stored thoughts, feelings, and memory; the shadow soul , a reflective , a composite of things eaten and transported emanation; and odor soul by a person. During dreams, usually the head- and sometimes the heart-soul component of both dreamer, and the beings he or she might encounter become temporarily detached. Taking imaginal form as miniature human beings, dreamer, and spirit proceed to communicate. A song taught to a dreamer, as soul-component vocalized, becomes a channel for reestablishing contact with that spirit during nighttime, housebound ceremonies. The spirit may also designate certain fra-

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grant leaves (implicating odor souls), dance steps, and other performance parameters that will be recreated ceremonially to activate its presence in the human realm. The spirit, Temiars say, is able to see far above the forest canopy; made present in the shaman’s song, it brings its extensive knowledge and perspective to bear upon human illnesses. Activated spirit, when temporally and contextually bounded in dream and ceremony, infuses power and knowledge into a medium, who is thereby empowered to heal. But when spirit is excessively animated outside the bounds of dream and ceremony, illnesses of spirit intrusion or soul loss may result. In such cases, mediums call upon their spirit guides to seek out the source of the illness. Through singing and trance-dancing, mediums move ceremonially into the realm of detached spirit to extract, replace, or resituate spirit components in patient and cosmos. Some mediums specify particular spirit guides for assistance with specific illness complexes; others say that whatever spirit guide arrives can deal with an illness by virtue of its paramount status as animated spirit. Spirit guides make themselves known primarily through their songs and dance movements. Indeed, music packs its boundary-crossing power via its detachability, as sound resonates from its source through space, whether crossing social boundaries of natal and affinal affiliation as in Suya shout songs (Seeger 1988), through temporal zones of generational kin as in Mapuche tayil (Robertson 1979), or across cosmological categories of bound soul and unbound spirit in Temiar dream songs. If, as Attali suggests, music is prophetic, a herald of times to come (1985:4), then the increased potential for detachability and reproducibility initiated by recording technologies in the late 1800s, heralding what has come to be called the schizophonic realm of separable and reassemblable sounds, are the audible signs of the transnational era. “Music,” Attali continues, “makes mutations audible. It obliges us to invent categories and new dynamics to regenerate social theory.” Temiar ontology and epistemology suggest a level of comfort with multiplicity and detachability which they call upon, in dream songs and healing ceremonies, as they respond to disjunctures between local and the global that increasingly impinge on forest life. THE POLITICS OF SPACE The dense jungle constitutes both refuge and sustenance for Temiars, and holds within it powers both benevolent and malevolent. Temiars tap into this circuit of power, rendering the unknown known, in their dream songs, received from the sprits of the landscape, its flora and fauna. Temiars negotiate their geopolitical terrain with a double vision that responds simultaneously to spiritual and material presences. The forest’s edge, porous boundary between forest and outforest, and the river, flowing between the domains of deeper upstream forest and downriver marketplace, link forest and nonforest domains. The space above the forest canopy, and the long-distance vision it affords, constitutes another

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Map 6.1. State Boundaries and Orang Asli Ethnic Divisions in Peninsular Malaysia

realm of fantasy and fear. Home in its highest reaches to the thunder and light, feared for the floods and storms he unleashes, it is also ning diety home in its lower reaches to things of the “above ground,” like birds. Temiar hunter-horticulturalists refer to themselves as , “people of the forest,” in their Austroasiatic Mon-Khmer language. They are one among a number of peninsular Malaysia’s aboriginal peoples, termed “Orang Asli” or “Original Peoples” in contemporary Malay and the anthropological literature (see Map 6.1). Temiars have long engaged with peoples and things . The term is qualified according to from beyond the forest, whom they call the perceived ethnicity of the outforester person or item: m@layu for the

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Austronesian-speaking Malays who now constitute the nation’s mainstream Isputih or “white foreigners” for the British colonials and lamic population; other Euro-Americans who preceded and followed them; cina and for the Chinese and Tamil workers brought to work British tin mines j@pun for the Japanese occupiers during World War and rubber plantations; II. Songs sung during Temiar healing rituals now include those received from the spirits of the tunnels built by the Japanese, as well as those from market goods arriving from downriver Malay settlements. Rivers and footpaths, red dirt military and logging roads that came later, and the asphalt roads that followed them, wind their way out of, into, and through the jungle, connecting Temiars with “upstream” (teh) and “downstream” In an indigenous musical terminology rich with metaphors of movement through the landscape, Temiar songs are conceived of as “paths” bestowed during dreams by spirit guides, who have the knowledge and vision to see through and soar above the density of the jungle scene and forest canopy. “Upstream” is traditionally associated with things of the deeper jungle, including both benevolent spirit guides and malevolent illness agents. “Downstream”—the direction of the marketplace, big towns, and nonaboriginal Others penetrating into forest territory—is also a realm of things, people, and experiences both positively and negatively charged. The dense forest once provided a refuge for Temiars from intercultural interactions.2 These included symbiotic economic and cultural exchanges among forest peoples with peasants and petty entrepreneurs linked to transoceanic trade routes. Jungle products such as sandalwood, resin, rattan, medicinal herbs, and fruit were exchanged for “outforester” items such as salt, iron, and cotton cloth in earlier times—batteries, gym shorts and T-shirts, or cash nowadays.3 The interpenetrable distinctions offered by forest’s edge—while always porous— have become increasingly jumbled in the transnational era. Temiars currently face their cosmology gone wild: “market” (k@dey “town,” “shop”) illnesses now come from Chinese and Malay logging camps upstream, from whence only forest illnesses once emerged. Temiar healing ceremonies draw on songs received from Malay, Chinese, and forest spirit guides to grapple with the diversity of illness sources. THE SENSORY EXPERIENCE OF MODERNITY: THE AIRPLANE SONG To soar like a bird is a spirit’s privilege: to see long distances, returning visions and knowledge through the conduit of song. From that airspace above the rain forest canopy, the spirit space of cool winds and liquid mists, of entranced head souls flying, and spirits’ long-range vision, Temiars now receive dream songs from airplanes and parachute drops as they do from birds, from wristwatches as well as pulsing insects. Foreign peoples and things are socialized in dreams, brought into kinship relations as spirit familiar “child” to the Temiar

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dreamer as “parent.” Strange people, things, and technologies become humanized, even Temiarized, their potentially disruptive foreign presence now tapped for use as a spirit familiar in Temiar ceremonies. Hi-tech phenomena arriving with colonialism and postcolonialism, such as airplanes, bring mixed blessings: parachute-loads of food during the rainy season, when subsistence travels can be harder to perform, were dropped from the sky by British colonials, and later by the Malay Department of Aboriginal Affairs. But planes, which in Temiar memory date to the Japanese Occupation of 1941 to 1945, also brought bombs that strafed Communists hiding in the jungle during the Malaysian “Emergency” (1948–1965). Desire and destruction coalesce in the airplane as it brings foodstuffs on the one hand, and death on the other. While I was recording a nighttime housebound singing ceremony in the settlement of Lambok, in the area of Kuala Betis, Ulu Kelantan in 1981, Busu , Old Man Busu), sang a song received from the Airplane Puteh (or, Spirit. Old Man Busu had strong kinship ties to the Betis and to the Perolak River valleys, an area in the heart of the Kelantan known for the origination and genre. His father was from Perias, near continuation of songs in the the origination point of another important Kelantan Temiar genre, . He sang various songs received by spirits, some from his own dreams and others given to him through ceremonializing together with song-receiving relatives. genre, received from things “above ground” Amidst the songs of the like birds, mammals, and flowers, and his repertoire, received from the waterserpent of the “underground,” he sang the song his grandfather had received from an airplane spirit during the 1940s and 1950s. Busu Puteh’s grandfather received the Airplane Song in the genre, characterized by melodies that begin with a relatively flat melodic contour opening out slightly into a narrow range of tones constituting the melodic core that, compared with other Temiar vocal genres, remains relatively restricted. This from the Perolak and Betis constraint is particularly noticeable in River Valleys, where Lambok is situated. The tone row may be expanded by the periodic insertion of a jεnhook phrase, which begins on a pitch higher than those forming the melodic core, and descends, often reaching the tonal center. Temiar dream songs are constructed of verses formed from two or three song phrases, alternated in variable patterns, with the periodic insertion of a phrase. The song phrase melodies are repeated, while song text is varied extemporaneously. Each phrase sung by the initial singer is repeated heterophonically or, using Feld’s term (Keil and Feld 1994:118), in “echo polyphony” by a female chorus (see Figure 6.1). As is characteristic of , the Airplane Song’s first song phrase begins with a flat melodic contour, rhythmically elaborating the tonal center of E. Through most of the song, the first song phrase is repeated twice, then followed by a second song phrase, which expands the melody to include a whole tone above the tonal center (F#). In addition to their relatively flat melodic contour and restricted melodic range, songs of the genre exhibit a characteristic use of repeated one-

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Figure 6.1. A medium sings as the chorus, playing bamboo-tube stampers, responds. Fresh leaves suspended from the welcome forest spirits. Photo by Marina Roseman.

syllable vocables such as “ ,” “nah nah.” In the Airplane Song, the vocables “bom bom bom” render Japanese Occupation and British Air Force bombs cognate with the deathly shocking rumbles and pops of the ferocious . This period, and the “Emergency” that folTemiar Thunder diety, lowed, were a horrifying time for Temiars as the jungle became contested territory. Conflicting parties threatened aborigines’ lives as they vied for Temiar allegiance. The song text describes the actions and visions of the Airplane Spirit , the country of Japan: from 1–1

I alight

1–2

Bomb, bomb, bomb [trailing behind] me

2–1a

I sing in [entranced] forgetfulness

2–1b

A person from long ago

2–2

Here, me here, for all time

3–1a

Flying across from the country of Japan

3–1b

Many types

3–2

I throw out here

4–1a

I arrive with wooden planks, see young women not yet having born children

4–1b

In which house shall I descend?

4–2

Bomb, bomb, bomb, here with the childless young women

5–1a

I am a Siamese boss

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5–1b

I am a Japanese boss

5–1c

We ask your blessings

5–2

Bomb, bomb, bomb, to me here.

The song weaves a narrative of disconnected images reflecting upon the destructive power of this flying being, embodying the experience of a forest people caught in the whirl of global forces. The flat melodic contour, restricted tonal range, and jεnhook-phrase vocables of the Airplane Song exhibit stylistic markers of the genre, the ur-genre of Kelantan, received from “things above ground” (like the birds), but not quite as high as the “top of the sky” where thunder lives. Busu Puteh’s grandfather musically charts his experience of the Other, placing the Airplane Spirit with other beings from above ground. In musical genres, then, Temiars map their experiential universe, locating that which is Other within reach of the self. This musical rendering is comparable to cartographic acts whereby European explorers and emerging nation-states traced the changing surfaces of their experience of the world in geopolitical maps (Winichakul 1994; Mignolo 1994). Temiar genres link parameters of musical structure with particular compositional sources or “spirit guides” from which those genres are received, thereby constructing a musical map of the universe.4 Temiar mediums engage the tiger’s ferocious power in the musico-ceremonial , tapping genre Panooh (Mamuug), and that of Lightning in the genre these energies for their own devices as a “technology of healing.” So too, engages the dangerous power of deathly Japanese bombers with his Airplane Song. Busu Puteh’s grandfather may not be able to affect the global forces impinging upon his forest refuge, but by incorporating the tumultous events of history into musical structure, and then performing it, he situates himself as an active agent rather than passive participant. How is modernity experienced at the site of the body? Temiars often discuss it as shocking, startling, shaking you up, precipitating pathological detachment of the head soul. Instead of a raft on the river, now you’re in a Land Rover bumping over logging roads and getting shaken up. The assault upon the senses is not necessarily experienced in terms of a primitivist to modern linear progression—from soothing to startling times, for example. Rather, the sensory assault of loud engines, sudden noises, jerky rides is grafted onto previous categories of startling phenomena. Temiars recognize sensory experiences that can be harmful to health in their autochthonous forest environment: the sudden flash of lightning followed by a clap of thunder can startle a person’s head soul into sudden detachment, leading to the illness of soul loss (rεywaay). Preventive treatment, whether addressing indigenous or modern precipitating events, is drawn from therapeutic resources long brought into play to avoid the debilitating consequences of startle. Children, whose souls are less firmly attached, are more vulnerable to soul loss; following

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the warning flash of lightning, adults and older children hurriedly place their hands over younger childrens’ ears to guard them from the potential startle of the thunderclap. During trance, another time when head souls are more labile, participants will call out from the sidelines “Kεg, c@wok! Be aware of the dogs!” reminding trancers to maintain some level of awareness to guard against the startle of a sudden dog bark. The continual duple rhythm of the bamboo tubes, rhythmic ostinato to the changing melodies throughout a healing and trancing ceremony, provides the ongoing familiarity of sound to cushion against startle. The urban-bound traveler might present himself to a medium or an elder who will blow into, shape, and strengthen head and heart soul, making sure they are firmly situated to withstand the assaults to come. The guns and bombs of World War II and the Emergency are an extreme example of the assaulting sensory experiences Temiars were to experience. Busu Puteh’s grandfather dreamt the spirit of the airplane, taming the strange and the horrific by transforming its essential being into a spirit guide. The words and melody given by the enspirited airplane are nested within the rhythm of the bamboo tubes, symbolically embedded within the familiar pulsation of the rain forest soundscape and the human heart beat (Roseman 1991: 168ff). The Temiar world was dramatically transformed during the Japanese Occupation and Emergency, yet subsequent musical “change” is not necessarily found in the transformation of formal musical parameters of healing songs, in this case. Rather, it is found in the intentional use of traditional discursive structures to encompass altered circumstances. Temiars cushion the shock of the “uncanny” by embedding new phenomena in a familar dynamic processes of dream-song composition, performance practice, instrumentation, and musical structure. The strangeness is in the familiarity. —THE WOMAN OF THE MARKETPLACE On a tributary of the Plus River in the Perak hinterlands in the settlement of lives Latip, a shaman in his early thirties. is a satellite village of the Malaysian resettlement project, Post Legap. Islamic prayer houses sponsored by the Malaysian government’s Office of Religious Affairs dot each settlement. The government has converted the surrounding forest to palm oil plantations— while expediently harvesting the trees—in its efforts to sedentarize the aboriginal peoples. Despite these obstacles, Latip continues to hunt, fish, gather fruits from the forest, and plant swidden fields of rice, making a livelihood for his extended family through traditional Temiar subsistence technologies as best he can in the 1990s. Latip receives many of his spirit songs in the genres Pεnh@@y, , received from the received from the Perah fruit tree of the forest, and chrysanthemum flower. His vibrancy as a medium, singer, and healer is well known throughout the area. Following a trip downstream to the cosmopolitan frontier market town of Sungei Siput, where Perak Temiars visibly interact with the transnational econ-

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omy, Latip received a song from the spirit of the “Woman of the Marketplace.” Such frontier towns are the borderlines where global meets local; here the overlay of Malay peasantry and Chinese town merchant is complexified by the everincreasing penetration of global capital. The two ends of the Temiar cosmological continuum—“upstream” forest and “downstream” town—meet here at the crossroads of histories and cultures in a dizzying convergence of place and disjuncture of time. Temiars once engaged in the circumspect practice of “silent trade”: items left by peasants, traders, missionaries, or colonists were exchanged in absentia for forest goods. They rightfully feared the aboriginal enslavement common on the peninsula until the early twentieth century. Now they openly sell rattan, forest fruits, incense, and other products, and buy the latest clothes, foods, and commodities that reach the jungle’s edge. After one such trip, Latip returned home to sleep and dream: The Spirit of the Marketplace. A woman. I went to the new marketplace, and then I dreamt the Spirit of the Marketplace. She said to me she would help people. If children were sick, if their spirits were jarred, if they had fever and chills, we—she and I—could help them.

A spirit gives a set melody in her dream, along with some central images, vocabulary, and lyrics. But the singer extemporaneously expands upon the text in performance. The Spirit of the Woman of the Marketplace draws upon stock images central to Temiar musical performance: wafting fragrance of flowers, buds blossoming, expansive views, cool liquid spirit-fluids spraying the participants and alighting in their souls. But the source of the cool spirit-liquid kahyεk is remarkable. The spirit sings: “The liquid threads its way from far-away Sungei Siput market/ . . . From a distance, the fluid spirit arcs to its end here in the flowers.” In song, the Spirit of the Woman of the Marketplace describes her flight from the faraway Malaysian national capital Kuala Lumpur, to the Perak state capital of Ipoh, to the nearest local marketplace in Sungei Siput, and to the site of the ceremony in this Temiar settlement of . As she flies, omniscient, she incorporates this landscape into the Temiar realm. From downstream, at the river’s mouth, she comes, alights, spans the distance, brings the liquid of the spirits into the forested ceremonial space of song, dance, flowers, and leaves—and then returns home, leaving wistful longing in her wake. “I return home, into the distance, toward Kuala Lumpur/ . . . Mothers [women of the chorus], I return home into the distance, with a strolling dance step, my father [Latip, the singing medium]/ Into the distance, and you’ll be left with longing until whenever.” As an indigenous minority living on the final forest-frontier of global capital, Temiars live under the threat of displacement and disenfranchisement common to marginalized peoples in the industrialized world. In dream, song, and ritual, Temiars personalize and politicize this encounter, infusing their settlements and forests with the power of the marketplace. But that power is expressed in their

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own terms. Naming in her song text the towns and cities outside the forest— Sungei Siput, Ipoh, Kuala Lumpur—the singing Spirit of the Marketplace brings these places into the purview of this forest people, resituating the outforester periphery into the center of their forest mandala. The Market Spirit comes transformed into a forest thing, infusing Temiar people and foliage with her cool refreshing liquid song. During a healing ceremony, a patient will be brought before a singing medium. The medium, now imbued with the voice and vision of the spirit guide, is able to seek out lost souls as the spirit guide soars above the forest canopy. Then, in healing ministrations, the medium blows the patient’s wandering head soul back into his body, and fortifies the patient by blowing and singing over the patient. He infuses the patient with the healing liquid kahyεk that flows, with song, from spirit through medium to patient. He might also suck intruding objects out from patient’s body—either foods improperly consumed whose souls have “come alive” inside the patient’s body, or bits of forest and ritual paraphernalia that may have found their way into the patient’s body during improper trance behavior. For a period following such a treatment, the patient may have food restrictions. These might include restrictions related to the medium’s spirit guide, or to game considered “strong smelling.” The more recent (and less trusted) additions to the Temiar diet—canned goods, canned milk, curry—are also often restricted during this time. Thus it is particularly interesting to find the marketplace, source of these strange new additions to the Temiar diet, become a source of healing power. Yet Temiar philosophy counters like with like, responding to spirit-derived illnesses with spirit guides’ songs. This cultural logic is elaborated by many mediums who draw upon market spirits to fight those illnesses which might be associated with the ingestion of market goods, visits to the marketplace, or historically recent diseases such as tuberculosis and malaria, considered to be associated with a colonial and postcolonial presence. Latip’s Song of the Woman of the Marketplace is but one example of dream songs emerging from spirits of new commodities, peoples, places, and concepts. In this song, as in others, Temiars strive to counter the shifting balance of power between forest and marketplace by musically reconfiguring these new presences as spirits of their landscape. Through songs such as that of the Woman of the Marketplace, Temiars ease the strange and unfamiliar into their lives, situating the “new” within a previously encoded musical cosmology. Through the composition and performance of such songs, Temiars grapple with the incursion of outforesters, even as the forest is felled from underneath them. They valiantly attempt to reconstitute their multiple and corporate selves in the face of unrelentingly self-possessed Others. Market goods have established a unique position within Temiar systems of economic exchange, often undermining traditional practices of generalized reciprocity. The influx of new commodities promotes increasingly restricted networks of distribution. In contrast, Temiar musical performance diffuses sound through the initial dreamer-singer into the group, represented by the interactive

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chorus, thereby expressing and reinforcing the cultural logic of generalized reciprocity (Roseman 1984). Drawn into this performance format, “spirits” of commodities and peoples entering Temiar society are diffused throughout the social group. Spiritualizing new technologies and commodities in song, what Lipsitz (1994:33) calls the “capture of the colonizer” is accomplished through such transformative musical structures embodied and envoiced by performance participants. SPIRITUALIZING COMMODITIES: THE DRIED FISH SONG Low population density and a seminomadic settlement pattern constitute some of the survival techniques that Temiars historically developed in relation to their forest ecology. In small settlements along the tributaries of major rivers, they were dispersed geographically and demographically so as not to overtax the forest resources, including fish, game, water, and land. Yet in the interests of “national security,” “national integration,” and “development,” many Orang Asli have been relocated into large, permanent regroupment settlements (Dentan et al. 1997). Gradually losing their indigenous subsistence base, they have become increasingly dependent on their participation in the cash economy. The economic base they are encouraged to redevelop, usually as arboriculturalists, peasants, or rubber smallholders, is undermined by their landlessness. Under Malay constitutional law, the aboriginal peoples of the peninsula are not allowed to own land; they are corporate tenants on lands that can be granted or removed from aboriginal reserve status. Even as they try to restructure economically in new circumstances, regroupment projects may be moved again, and their efforts at reestablishing themselves come to naught. Given the concentrated populations and low acreage of government-sponsored aboriginal regroupment projects, rivers quickly become overfished, game depleted. Temiars deem these crowded resettlement areas and radical forest clearings “hot” and consider them prone to causing illness; the forest, in contrast, is “cool” and refreshing. Forest resources like rattan and the bεltop used to thatch roofs are gathered more quickly than they can be replenished. Those fish that do survive the effects of population densification struggle in waters polluted by deforestation processes. Increasingly, Temiars augment their diets with foods bought in the marketplace downstream, or from petty entrepreneurs who brave the logging roads with their four-wheel-drive vehicles, selling the new staples of Temiar life: tea, sugar, canned milk, canned sardines, dried noodles, dried fish. Upstream toward the source of the Betis River I heard a song received by from the Dried Fish and Canned Sardine Spirit. , also known by his Malay name Angah Busu, was the “representative headman” in Barong, one of several closely located renegade settlements formed by Temiars who had thus far refused to join regroupment projects. As he sings, his spirit guide expresses its desires. It doesn’t desire the things behind it, in the past. It doesn’t

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request the forest leaves or root incense that a forest spirit guide might call for. Rather, it requests market goods, singing: “I don’t want those behind me/I call, call, call, calling for canned sardines/I call, calling for dried fish/Don’t lag behind me.” The catchy tune and contemporary subject matter combined to produce a hit, and I often heard younger singers throughout the area singing this song. Angah Busu’s Dried Fish Spirit arrived in the musical genre , associated with the spirit of a chrysanthemum flower species that grows in clearings around Temiar houses. These flowers, tended as “flowers of field and settlement,” are taxonomically juxtaposed with “flowers of the jungle.” The Dried Fish Spirit arrived in this form, rather than singing with the voice of a forest spirit such as Pεnh@@y, associated with the fruit trees that signify the essence of the Temiar relationship to the forest. announces its presence musically in the form of an initial song phrase with a melodic contour similar to a jεnhook, starting with a recitation tone on the highest pitch in the tone row and descending to the tonal center. Either a second or third phrase includes a dip down to the tone below the tonal center (a minor third below), thereby defining the tonal center from above and below. The Dried Fish Song follows this model: the first song phrase rhythmically reiterates the song text vocable “lil” at a pitch a major third above the tonal center, then descends to the tonal center. The second phrase replays melodic motion between the major third above and the tonal center. The third and final song phrase begins a minor third below, swinging up to and a major second beyond the tonal center. Despite their differential beginnings, all three song phrases conclude by rocking back and forth from a whole step above to the tonal center. The healing powers of the Dried Fish and Canned Sardine Spirit are thus given a place within the Temiar social and spatial universe, marked by genre associated not with the jungle, but with “the their arrival in the settlement.” I do not intend to posit an unmediated Temiar “local” self against which the global is experienced. Rather, in the imaginary space of dreams and healing ceremonies, Temiars have developed cultural frames of reference for interpolating themselves in relation to ever-expanding spheres of “otherness”: from other Temiars, to forest, and to nonforest entities. Dream songs constitute a site for mediating the interpenetration of difference and similarity fundamental to Temiar cultural productions of personal and social identities, be they delineated along the axes of human/nonhuman, forest/outforester, male/female, above ground/below ground. These sites have been called upon as Temiar incorporate ever wider spheres of influence, maintaining their position as agents transforming the world even as they are transformed by it. Increasingly, I am coming to believe that Temiars project that which they both fear and desire onto their spirit guide song-givers, in a classic act of what is called “introjection” in the psychological literature. Temiars project the cultural possibilities and coveted things outforester Others carry onto spirit famil-

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iars, who are often imaged as cross-sexual objects of desire: women dream of spirits arriving as handsome young men, men dream of shapely female adolescents and children. Spirit figures appear as miniatures, homunculi, small enough to be intimate but not intimidating. And they give songs which empower the dreamer-composer with long-range vision, geographic mobility, and knowledge to counter the illness and misfortune brought into the forest from Other exotic places: the “marketplace” downstream, as well as the “deeper jungle” upstream. Through this complex interpolation of fear, fantasy, desire, and mutuality, Temiars deal with their Others. Through shamanistic mediation, intrusive technological and economic transformations of the modern age are musically resituated within the Temiar map of the universe. Schizophonic displacement is transmuted by a Temiar poetics , for of emplacement. Thus, the airplane is incorporated into the genre things “above ground.” A song received from dried fish and canned sardines, store-bought from the downstream marketplace, is absorbed into a genre associated with flowers of the field and settlement area, as juxtaposed with those genres associated with upstream and mountain areas. Through such musical mediations, Temiars appropriate the aura of the commodity, turning it toward their own utilitarian and aesthetic goals. Yet are they not also thereby being appropriated, through the powerful mechanisms of their own imaginary world, by the very system they subvert? Are they being seduced to “join the Pepsi generation” by the same imaginary power so successfully employed in capitalist economies by the musical jingles and moving images of commercials? Is the Dried Fish and Canned Sardine Spirit cognate with the animated figures of commodity logos (like Tony the Tiger of Kellogg’s Frosted Flakes, or the Toucan of Fruit Loops cereals), persuading Temiar dreamers and singers to accept, even to desire, the products of an economic system that will ultimately transform their ecology and economy? Evolutionary anthropologists once called these figures “cultural survivals,” suggesting that such images percolated through into modern society from haunts prior on the evolutionary scale. Ruth Benedict, in what remains a landmark article on “Animism” in the 1930s edition of the International Encyclopedia of the Social Sciences, suggested that such animistic formulations in modern society were less an evolutionary survival from earlier sociographic strata, than evidence of the continual need for a magical realm in all types of social formations. Conjoining the magical and the imaginary in the spiritualization of intrusive commodities and technologies, Temiars simultaneously disinscribe themselves from “outforester” agendas, and are reinscribed in outforester visions of the future. Contemplating a similar contradiction in the The Conquest of Mexico: The Incorporation of Indian Societies into the Western World, 16th18th Centuries, Serge Gruzinski observes: Styles and techniques of expression, memory, perceptions of time and space, the imaginaire, thus provide material for exploring the confusion of borrowings, the assimilation

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of European characteristics and their distortion, the dialectics of misunderstanding, appropriation and alienation. At the same time, one must not lose sight of the political and social stakes involved, which meant that a reinterpreted feature, a concept, a practice, could strengthen a threatened identity while in the long term it was likely to bring about a slow dissolution or a complete reorganization of the group that welcomed it. That is how I envisage coming to grips with the dynamics of the cultural entities that the Indians of New Spain ceaselessly rework. (1993:3, italics added)

Temiars of peninsular Malaysia responded to an influx of foreign goods and instruments of war by incorporating them into a mythologizing system that was already in place: the dream-song mediation of their landscape and its inhabitants. Through interwoven processes of mimesis and alterity enacted in imaginary images, musical sounds, and bodily motions, the spirit of the outforester Other is incorporated into individual and collective Temiar bodies. Temiar dreamers’ and singers’ incorporation of new technologies into their mythological system is reminiscent of the ecocybernetic model that Donna Haraway (1991) sees emerging in the postindustrial world, where human-machine interfaces blur the boundaries between thing and person. Is the fluctuating boundary between person and thing, self and alter, a “cultural survival”? Or, like the magical space that Benedict sees as necessary in some form among members of all social formations, is this the borderline space in which societies, in varied expressive forms and cultural configurations, play with (or worry over) difference? SHIMMER, SHUDDER, AND SWIRL Shamanistic discourse entangles the empirically observable with the magically real, a world of multiple realities in which even “things” of outforester Others— airplanes and canned sardines—participate. During healing ceremonies, the moment when the interpenetration of self and alter, human and spirit occurs is aesthetically marked by “shimmering” in the visual, kinetic, tactile, and auditory channels. The glimmer of hearth-fire lights on shredded leaves of ritual ornaments, in its simultaneous presence and absence, disassembles the visual field. Shimmering things, combining movement and light, exist at the fuzzy boundary between the visual and the kinetic. Among Temiars, flashing and glittering items like mirrors, trees with white trunks, or the anthropologist’s glossy paper are handled carefully during potentially dangerous moments such as illness, the time prior to ceremonies, or when working in clearings where refracting light might attract the attention of the thunder deities. Temiars say they don’t just “see” the shimmer of the leaves, they experience a sympathetic shivering—in their hearts, they say, the Temiar locus for emotion and memory. When a nighttime, house-bound singing and trance-dancing ceremony is in progress beneath the shimmering leaves, the movements of the dancers lead from a gentle sway into periodic shudders which replicate the shimmer in the kinetic realm. These moments of quickening and destabli-

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zation mark the onset of the transformative experience of trance. The female chorus accompanying the dancers with bamboo-tube percussion watches for the dancers’ shudders, speeding up its tempo and subdividing the beat. The starker clarity of the oscillating duple rhythms, high-low, high-low, becomes densified , “crowded”), fuzzing the boundaries between sound and si(Temiar lence high-high low-low, high-high low-low, in acoustic sympathy with the visual shimmer, kinetic shudder, and experiential shiver. In performance, then, Temiars employ a variety of tools that “beg the difference” between sound and silence (densification of the bamboo tube percussion ), one tone and another (vibrato, melisma, melodies that wind and ⫽ tug like a river ⫽ ), light and darkness (shimmer, sparkle ⫽ biyug), one bodily position and another (shudder ⫽ Dancing on the edge of the gap, they encounter and embody the people, things, and places that surround them. In a paradox of adaptation and resistance, they expropriate power and knowledge from the commodities that simultaneously link them ever more securely into the lowest social classes of mercantile and postindustrial capitalism. Healing is performed by shamans engaged themselves and surrounded by dancers involved in the performative transformation of trance. Entranced, Temiars move from a position of the relatively distinct subject in relation to the Other, through the visual glimmer, acoustic densification, and kinetic shudder that “begs the difference,” to an experience they describe as a sensation of internal (and sometimes external) “swirling.” In the swirl of trance, trancers momentarily move beyond difference, then slowly reawaken to the world of distinctions. In this space of difference stated and undermined, patients are moved from illness to health. One of the central ornaments transforming a house into a ceremonial space is the . In its simplest form, the is a leaf whisk, suspended from the rafters by vine or rope, to hang just above the heads of standing participants (see Figure 6.1). This is the place where spirits first alight on their arrival into the ceremonial space. From here, their healing songs and fluids are dispersed through medium and chorus into patients and other participants. This, too, is the most potent place for healing ministrations to occur; patients, if they are well enough to be moved, are often seated below the . Spirits, when giving their songs during dreams to Temiar mediums, elaborate upon the shape and types of leaves to be incorporated into the , the simplest being a rattan hoop strung with leaves, the more elaborate including multitiered hoops. Often, leaves are strung at head height from ropes or vines to produce a square shape demarcating the outer perimeter of the ceremonial are the long, space. One of the commonest leaves to find in the slender, light-colored leaves of shredded palm known as k@war (Malay, palas; Licuala species). The fragrance of fresh forest leaves and flowers adds to the ritual sensorium, and their sap literally and metaphorically brings the presence of visiting spirit guides flowing into the bodies of ceremonial participants. In the Temiar community of Bihaay, I came across an astounding sight. This

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.

Figure 6.2. Shredded plastic bags shimmer, mixed with a few fresh leaves to form the in Bihaay. Photo by Marina Roseman.

Temiar settlement was once surrounded by the dense green growth of the forest; now, in 1992, the forest was denuded. In the headman’s house, ceremonial paraphernalia hung from the rafters, a sign of recent healing and singing sessions. The elaborate was formed of multitiered hoops, decreasing in size as they ascended—like a layered cake. Additional ornaments included the square shape demarcating the outer perimeter of the ceremonial space. But this was not strewn with long, wavy strands of shredded k@war leaves. Instead, the was made from shredded plastic bags (See Figure 6.2). These bags, in which Temiars carry home market-bought produce to replace the forest foods no longer there to hunt or gather, had become a replacement for ceremonial leaves now too far or scarce to find. Wondering what type of spirit would feel at home among the shredded plastic, I asked: “What kind of spirit guide requested these leaves?” “As long as they shimmer,” answered the headman’s wife, implying that these plastic “leaves” retained a quality essential for attracting and activating the spirits. Her answer led me to rethink what, in a pared-down world, was absolutely necessary to make a Temiar ceremonial performance happen, and what the need for these shining shreds implied about ceremonial intent.

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“Is it still possible to heal, can the cool liquid still flow through these ‘leaves’?” The headman’s wife pointed to the few c@baay leaves mixed in with the shredded plastic bags, pointing out that forest leaves still maintained their presence within these newfangled ornaments. “Yes,” she replied, “we can still suck out the illness, and replace it with the healing liquids of the spirits. We can still dance, swaying gracefully, shuddering into trance, swirling in our hearts, as the bamboo tubes beat. As long as they shimmer.” If performativity entails constructing our take on the material world (or, in a more radical stance, constitutes that world), then Temiar healers, faced with the deforestation of their physical and spiritual environment, with the jagged realignments of social relations as they move from a resource-sufficient subsistence technology to the economic deprivations of landless peasantry, are calling upon the imaginative resources of music, imagery, and movement to mark their place within the nation-state and the global economy. They may be forced to eat canned sardines instead of freshwater fish, but they can dream and sing the power of the Dried Fish and Canned Sardine Spirit. Is this an illusory inversion of disempowerment and mastery, an example of false consciousness in which, between the beats, Temiars conceal their own fate from themselves? Or is it in the virtual world of healing performances that they will find the power to creatively engage their would-be masters? “It is the trope of our times to locate the question of culture in the realm of the beyond,” Homi Bhabha (1994:1) writes. Beginnings and endings may be the sustaining myths of the middle years; but in the fin de sie`cle, we find ourselves in the moment of transit where space and time cross to produce complex figures of difference and identity, past and present, inside and outside, inclusion and exclusion. For there is a sense of disorientation, a disturbance of direction, in the “beyond”: an exploratory, restless movement caught so well in the French rendition of the words au-dela`—here and there, on all sides, fort/da, hither and thither, back and forth.

For Temiars, this is : upstream, downstream, the river that both cuts a path through the dense foliage, and situates Temiars along the way between deeper forest upstream, and the realm beyond the forest, the marketplace downstream. When Aweng of Lambok first listened in 1981 to my recordings of Temiar song ceremonies through headphones, he commented: “hεwh@ya:w, it’s far away and deep inside, the sound of longing, like the voice of the spirits from the mountainsides heard deep within when listening and singing.” Temiars have always lived in a world of strangely dislocated simultaneity; like Aweng listening through audio headphones, they graft their experience of the disjunctures between modern and traditional lifeways, between

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forest and outforester presences, onto expressive techniques and performance practices addressed toward healing spirits. ACKNOWLEDGMENTS This chapter arose from presentations associated with the Centennial Conference of the School of Music, University of Melbourne, June 1995 (Cathy Falk, ethnomusicology organizer); the conference Healing Powers and Modernity in Asian Societies, University of Newcastle, Australia, December 1996 (Linda Connor and Geoffrey Samuel, organizers); the panel “Shamans Dancing on the Edge of the Millenium” (Laurel Kendall, organizer and chair), American Anthropological Association Annual Meetings, November 1996; and the conference Tribal Communities in the Malay World sponsored by the International Institute for Asian Studies and the Institute of Southeast Asian Studies, Singapore, March 1997 (Cynthia Chou and Geoffrey Benjamin, organizers). Contributions of conference participants and travel funds from conference sponsors are gratefully acknowledged. Field research with Temiars of Kelantan and Perak in 1981–1982, 1991, 1992, and 1995, has been conducted under the auspices of the Social Science Research Foundation, Asian Cultural Council, Wenner-Gren Foundation for Anthropological Research (Grant No. 4064), National Science Foundation (BNS81–02784), and Research Foundation of the University of Pennsylvania, with additional travel funds provided by Universiti Sains Malaysia and Malaysian Air Lines (1991). Analysis and writing were furthered by a Guggenheim Foundation Fellowship (1996–1997) and a Professional in Residence Fellowship from the Annenberg School for Communications at University of Pennsylvania (1996– 1997). My gratitude to these institutions; to my sponsors at the Cultural Centre of Universiti Malaya, Universiti Kebangsaan Malaysia, and the Muzium Negara (National Museum, Kuala Lumpur); and to the Orang Asli Broadcast Unit at Radio-TV Malaysia, whose staff shared their extensive knowledge with me. Temiars and other Orang Asli have been wise and patient teachers, hosts, and friends; so too, several Malaysian families have provided urban home bases. NOTES 1. A growing literature addresses the ways in which expressive culture expands to encompass the often disconcerting experiences of modernity; see, for example, Comaroff and Comaroff (1993), Ferzacca (1996), Roseman (1996). 2. Dentan (1992) discusses the historical significance of an intact forest refuge for the development of unique Senoi cultural characteristics such as nonviolence. 3. Gianno (1990), for example, charts the history of the resin trade among the Semelai, another Orang Asli group. 4. Recordings of a number of Temiar spirit song genres, as well as instrumental music,

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can be found on the compact disc Dream songs and healing sounds: in the rainforests of Malaysia. Smithsonian/Folkways Recordings SF CD 40417 (Roseman 1995).

REFERENCES Attali, Jacques. 1985. Noise: the political economy of music. Minneapolis: University of Minnesota. Benedict, Ruth. 1930–35. Animism. In International encyclopedia of the social sciences, edited by Edwin R. A. Seligman and Alvin Johnson. New York: Macmillan. Bhabha, Homi K. 1994. The location of culture. New York: Routledge. Comaroff, Jean and John Comaroff, eds. 1993. Modernity and its malcontents: ritual and power in postcolonial Africa. Chicago: University of Chicago. Dentan, Robert K. 1992. The rise, maintenance, and destruction of a peaceable polity: a preliminary essay in political ecology. In Aggression and peacefulness in humans and other primates, edited by J. Silverberg and J. P. Gray. New York: Oxford University Press. Dentan, R. K., K. Endicott, A. Gomes, and M. B. Hooker. 1997. Malaysia and the original people: a case study of the impact of development on indigenous peoples. Boston: Allyn and Bacon. Ferzacca, Steve. 1996. In this pocket of the universe: healing the modern in a central Javanese city. Ph.D. dissertation, Department of Anthropology, University of Wisconsin, Madison. Gianno, Rosemary. 1990. Semelai culture and resin technology. New Haven: The Connecticut Academy of Arts and Sciences. Gruzinski, Serge. 1993. The conquest of Mexico: the incorporation of Indian societies into the Western world, 16th-18th centuries, trans. Eileen Corrigan. Cambridge: Polity Press. Haraway, Donna. 1991. A cyborg manifesto: science, technology, and socialist-feminism in the late twentieth century. In Donna Haraway, Simians, cyborgs and women: the reinvention of nature. New York: Routledge; London: Free Association Books. Keil, Charles and Steven Feld. 1994. Music grooves: essays and dialogues. Chicago: University of Chicago. Lipsitz, George. 1994. Dangerous crossroads. London: Verso. Mignolo, Walter D. 1994. The moveable center: geographical discourses and territoriality during the expansion of the Spanish empire. In Coded encounters, edited by Francisco Javier Cevallos-Candaual et al. Amherst: University of Massachusetts. Robertson, Carol. 1979. “Pulling the ancestors”: performance practice and praxis in Mapuche ordering. Ethnomusicology 23: 395–416. Roseman, Marina. 1984. The social structuring of sound: the Temiar of Peninsular Malaysia. Ethnomusicology 28: 411–445. ———. 1991. Healing sounds from the Malaysian rainforest: Temiar music and medicine. Los Angeles: University of California Press. ———. 1995. Dream songs and healing sounds: in the rainforests of Malaysia. Washington, DC: Smithsonian/Folkways Recordings SF CD 40417 (compact disc and descriptive notes). ———. 1996. “Pure products go crazy”: rainforest healing in a nation-state. In The

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performance of healing, edited by Carol Laderman and Marina Roseman. New York: Routledge. Seeger, Anthony. 1988. Why Suya sing: a musical ethnography of an Amazonian people. Cambridge: Cambridge University Press. Winichakul, Thongchai. 1994. Siam mapped: a history of the geo-body of a nation. Honolulu: University of Hawaii Press.

7

Presence, Efficacy, and Politics in Healing Among the Iban of Sarawak Amanda Harris

SHAMAN AS BACKGROUND As an antithesis to modernity, the melding of the Bornean jungle and the Iban shaman (manang) has proved a tenacious image in the Western anthropological imagination. In the study of illness and healing among the Iban of Sarawak,1 East Malaysia, shamanic practice has continued to take center stage. It has been presented as a cultural domain par excellence that stands in juxtaposition to the everyday world and practical reason, a domain where cosmic boundaries are crossed with ease, action transcends normal time, and social actors transcend mundane states of mind. Earlier commentators, who first set foot on Bornean shores around the middle of the last century, wrote extensively on status and grades of manang, giving particular attention to the reputedly transvestite manang, or manang bali.2 Later researchers have been concerned with the centrality of deception and fraud in the practice of manang, or their personality characteristics, often analyzed through psychoanalytical frameworks.3 Others have given attention to the nature of “trance” states (Perham 1887; Freeman 1967), initiation rites and the shamanic career, symbolic analyses of the structure and substantive elements of shamanic practice, and the ritual language of the pelian chant.4 More recent analyses have addressed the manang in sociocultural context (e.g., Jensen 1972–73, 1974; Freeman 1967; Graham 1994), yet for the most part this context remains one of a bounded cultural order in pursuit of the explication of an Iban “cultural logic” (Graham 1994, 1). Although rich in historical and ethnographic analysis, the manang in these accounts bear little relationship to external social, economic, and political realities. The privileged position of ritual and the ritual specialist in representations of Iban healing reflects a history of Western anthropological concerns rather than

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local social realities. The literature pertaining to shamanism has been exemplary in this regard. An anthropological emphasis of ritual can be traced to the Durkheimian analysis of ritual as a site of social and cultural reproduction. “It was through the enactment of rituals of various kinds that actors were seen as coming to be wedded to the norms and values of their culture, and/or to be purged, at least temporarily, of whatever dissident sentiments they might harbor” (Ortner 1984, 154). The ritual focus gained even greater momentum in subsequent decades with symbolic anthropologists, for their part, analyzing ritual as a site for the reproduction of consciousness (Ortner 1984, 154). Later perceptions of ritual as routes to social reproduction yielded to the recognition of ritual as also a site of transformation and negotiation of wider social realities. A conception and representation of ritual as social praxis, self-contained and detached from the everyday, “the mere reflection of a transcendent ‘tradition’ ” (Comaroff and Comaroff 1993, xvi), became unsatisfactory and unsustainable. The emphasis in the literature attending to Iban healing on ritual, and the portrayal of the work of the manang as occurring within a realm that somehow transcends and exists in isolation from a broader context of social action, has been addressed more recently by the work of Barrett. He has argued for the need to extend concepts of performance and effectiveness in relation to healing performances by viewing them as discursive categories, so as to “fully integrate talk about ritual with performance of ritual acts” (1993, 235). Barrett has also addressed the pelian (healing chant) as a site of encounter and transformation among people of the Saribas district, in which the manang is able “to incorporate social and political themes . . . and express some of the major contradictions within Iban society, particularly the contradiction between modern medicine and shamanic healing” (1993, 266). I suggest that healing as a context of engagement with wider social conditions can be explored even further through a decentering of the manang in the analysis of illness and healing among Iban people. Among residents of longhouses in the Pakan Subdistrict (See Map 7.1), where this research was conducted over twelve months spanning 1995 and 1996, Iban manang are more appropriately refigured as one, albeit central, nonbiomedical resource that people bring to bear in their attempts to understand illness and secure healing efficacy. In order to do justice to the range of the therapeutic possibilities available to people of Pakan, and the diversity of social actors involved in their mobilization, it may be useful to reconceive ritual in a more expansive sense, “taking it down from its hallowed pedestal and putting it to work in the everyday world” (Comaroff and Comaroff 1993, xvi; see also Bell 1992). It may be expedient to replace “Ritual” with “ritual,” thus “detaching it from the sacred,” and to see ritual as “a vital element in the processes that make and remake social facts and collective identities” (Comaroff and Comaroff 1993, xvi, xviii). However, in completely erasing the line whereby we distinguish that which is ritual from that which is not, one runs the risk, as Comaroff and

Map 7.1. Sarawak

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Figure 7.1. An Iban longhouse in Pakan subdistrict. Photo by Amanda Harris.

Comaroff point out, of sacrificing all explanatory rigor. But in attempting to understand the broader implications of healing in an Iban longhouse, a degree of imprecision and flexibility in the positioning of this divide may be more reflective of lived experience. The pursuit of the extraordinary and the sacred in the healing rituals of the Iban has marginalized the community within which healing rituals proceed as well as the broader sociopolitical reality that impinges on the lives of rural Iban people. Also obscured is much of the work and experiences of women in the community, who have effectively been denied their pivotal role as carers most intimately associated with the physical, emotional, and mental suffering of the afflicted individual. One of the aims of this chapter is to step back from the manang and the action that proceeds around the ritual shrine, or pagar api, to take a “wider shot” of healing in an Iban longhouse (see Figure 7.1). I explore the social context of the longhouse community in which this action is embedded and from which much of its meaning and efficacy is derived. I suggest that this view, in which the practice of the manang proceeds as one element of a multiplicity of activities aimed toward achieving cure, enables an understanding more reflective of Iban sociality. Moreover, this shift in perspective facilitates an understanding of illness and healing work as sites where Iban people engage with change in their broader social environment. It signifies a move away from a search for the “cultural order” of the Other and an understanding of divergent rationalities, including ritual, which has been typified by Abu-Lughod as “that communal practice for

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which time seems to have such a different, perhaps cyclical, meaning, that kind of practice which in anthropological discourse so perfectly marks the (exotic, primitive) cultural other as different” (1991, 156). As Abu-Lughod (and Barrett in addressing the Iban) has noted, ritual “turns out to be particular and anything but timeless” (1991, 156). However, as I discuss in this chapter, a conception of ritual as a site of encounter, dialogue, and transformation takes a paradoxical turn in the longhouses of Pakan as people respond to their life circumstances by valorising essentialisms and timelessness in the work of manang. This chapter argues that the longhouse community has a role beyond merely that of a support system that provides mutual care in times of need, or a collectivity that derives benefit as a participating audience in ritual performance, or even, as some commentators have suggested, a group that derives benefit from the healing ritual as performance possibly at the expense of the patient (e.g., Hoskins 1996). Community members are critical in the passage, generation, and successful implementation of healing power. My concern is with action rather than text (by which I mean here the language of the pelian chant)—the action emerging from the community in the healing context as well as that of the ritual specialist. The various participants in the healing event—community members, ritual specialist(s), patient and nonsentient beings—are more meaningfully understood within a wider domain of interconnected action. In refiguring the healing event, it is necessary to alter the conception of Iban sociality away from restrictive notions of community based on structure and Western-derived notions of corporatism that have informed much of the research on Bornean sociality. It is more useful to examine what Helliwell, in relation to longhouse communities in West Kalimantan, has insightfully described as the more fluid and seamless character of social relations (1996, 131). Iban longhouse space is released from rigid compartmentalizations that have become axiomatic in literature on the Iban, and replaced by a representation of the lived space of everyday life that is more reflective of social relations as they are discussed here.5 Attending to these processes also unveils cohesive forces within Iban longhouse communities evident in the healing context, thereby counterbalancing the emphasis in the literature that has been given to more centrifugal movement in growing urban migration and dispersion of longhouse members (e.g. Austin 1977; Chalmers 1996; Kedit 1980, 1993; King and Parnwell 1990; Sutlive 1978). As explored in this chapter, ethnically defined medical knowledge and practice becomes the substance for the construction of boundaries, the forging of alliances, the creation of groups, and the inversion of hierarchies. An increasing ethnic identification evident in the valorization of Iban medical theory and practice in the longhouses of Pakan offers a framework for a political critique, and also needs to be seen as part of a broader trend in postindependence Sarawak politics (Jawan 1994). Adequate attention to this latter point, however, is beyond the scope of this paper (see Harris 1999a, 1999b).

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Figure 7.2. The organization of space in an Iban longhouse.

MULTIPLE HANDS MAKE POTENT HEALING In an Iban longhouse individual bilik apartments are distinguishable from the continuous open space of the ruai that runs the length of the longhouse (see Figure 7.2). Bilik are situated side by side and constitute the more private, domestic domain of each family unit. Doors, usually kept closed, allow passage between ruai and bilik. Partitions of varying degrees of solidity and permeability distinguish one bilik from the next and bespeak the nature of relations between members of different bilik. The ruai space directly in front of a bilik is owned and maintained by that bilik family, and everyday work and periods of rest generally occur in one’s own ruai space or that of one’s more intimate kin. The ruai is also the space where community meetings and formal parts of ceremonies are held, funerals and weddings proceed, and visiting state representatives are received. As the formality of an occasion increases so does the degree to which the ruai becomes more explicitly a public male domain and the bilik private and female. Some (e.g. Barrett 1993, 250; Mashman 1993), however, have proposed a more rigid dichotomization of longhouse space as male or female than I would suggest is actually articulated by the healing event. Although the social organization of longhouse space is made particularly explicit through the course of healing ministrations and pelian,6 there is also a dimension of fluidity that characterizes these “spaces” in longhouse sociality, tempering a view of rigid dichotomizations of male/female, public/private and ruai/bilik (see Figure 7.3). In the healing context the ruai is not the only, nor necessarily the preeminent,

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Figure 7.3. Ruai of an Iban longhouse, daytime. Photo by Linda Connor.

site of action and the bilik is not merely the site of the mundane, the private, and the female. Moreover, other community members are brought into focus in this reconception of longhouse healing space and the manang becomes one focus of action among many. The cases of Gana7 and Impan’s baby are illustrative. Gana Gana, a lean, strong man in his mid-sixties, lay writhing on the floor in the center of his bilik by the time I arrived at this upriver longhouse in the company of Manang Ipoi. Unable to walk or talk, black marks continued to appear over his torso and feet and his entire right side progressively succumbed to paralysis. A quiet debate continued among the people gathered over the nature of the illness: Was it the result of “high blood” or a type of spirit attack known as pansa utai? The room was hot and airless and a pressure lamp burned above Gana. To his right sat his wife and myself, and to his left his daughter and niece. The rest of the room was filled by about eighteen women with the occasional man moving in and out from the ruai. From this crowded bilik scene the chant of the manang emanating from the ruai was barely audible and the pagar api, or ritual center around which the manang worked, was obscured from view beyond the closed door. Those around Gana reached out hands to monitor temperature fluctuations on his limbs, forehead, and torso and symptoms were continually discussed and compared with past cases. As part of the ongoing action in this space, a woman entered the bilik carrying

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a pucau8 remedy scribbled on a piece of paper that had been passed on to her by a friend upriver. People sprang into action to gather the six botanical ingredients from around the longhouse. Leaves were flamed then pounded together in water by Gana’s niece. Her husband, Itam, then took over, moving closer to his ailing uncle whose eyes kept darting frantically from person to person. He began by applying the appropriate mark using saliva-moistened lime paste around the back of Gana’s ear, the site where it was suspected his invisible aspect, or semengat, had been struck by one of the largest and most ferocious types of spirit, an antu gerasi. Itam then took the bowl of pucau water and proceeded to apply it slowly and gently to Gana’s arms, legs, forehead, and torso. He then called for the longhouse headman to perform a second application, and after him another close male kinsmen of the patient came forward to repeat the procedure. Itam then looked around the room full of people, “Ngiga jari unsut!” he cried, announcing a search for hands to apply the pucau to the body of their kinsmen. He called up a woman sitting nearby to be the fourth individual to apply the cool liquid to Gana writhing on the floor. Then one by one others came forward to offer their hands to administer the remedy. In this event, the application of medicine (ubat) became a collective pursuit in which healing power did not derive from ubat alone, but a combination of ubat and people. Meanwhile on the longhouse ruai Manang Ipoi continued to summon his assisting spirits (yang) and other celestial manang to his aid, and through the words of the pelian chant the search for the errant semengat began. But in a sense this became background to the bustle of healing work in the bilik, where ministrations continued in intimate association with visible and affective dimensions of the patient. Impan’s Baby The importance of collective presence and action was also illustrated in the affliction of Impan’s baby, who was struck quite suddenly one afternoon with severe breathing difficulties and loss of consciousness. Impan had rushed out of their bilik with her child in her arms and within minutes a group of twenty or more had gathered around, joined shortly thereafter by another group from a longhouse upriver that had been alerted immediately. In this case those who did not have any ubat to offer, such as myself, were considered with some disdain. Concern centered not only on the nature of ubat, their specificity and power, but on the quantity, range, and number of people supplying and administering them. The child became the object of multiple ministrations and was quickly covered in and surrounded by a range of remedies. People and ubat in a sense functioned synergistically, to imbue each other with power. A need for cool air to reach the infant was acknowledged by those present but was not allowed to diminish the human presence that crowded closely around. A piece of cardboard was handed around instead as people took turns using it to fan the infant. Hands reached out constantly to massage the small torso and monitor temperature

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changes in limbs. Through this affliction the longhouse was defined as a comprehensive source of therapeutic possibilities and the ubiquity of healing knowledge and skill among longhouse members other than manang, and in particular women, was underscored. Resituating the manang as background to other more immediate healing ministrations also involves questioning conclusions reached in recent analyses of healing as performance which suggest, for instance, that, “if healing is to be effective or successful, the senses must be engaged” (Laderman and Roseman 1996, 4). An assertion such as this dismisses prior ethnographies that report efficacy as occurring without the engagement or presence of the patient. For example, Atkinson reports that among the Wana of Sulawesi “the role of the patient . . . is a totally passive one . . . no active role [is taken] in the ritual nor are signs of psychic or physical transformation expected from them” (1987, 344). Barrett (1993) also observed that Iban patients may reside in an entirely separate room, visually and aurally disengaged from the action of the manang. Considering the lack of patient engagement or presence during the pelian chant and action around the pagar api that I observed, efficacy of the work of the manang cannot be explained in terms of abreaction or transference along the lines of Le´ vi-Strauss’s argument (1963) in relation to Cuna ritual.9 The notion of healing as performance in which the practitioner manipulates culturally salient symbolic referents for the afflicted disregards local phenomenological conceptions of the person. As Barrett (1993) points out, the Iban patient is present by virtue of their errant semengat, which is in fact the focus of shamanic activity. “Ultimately [the Iban],” says Barrett, “contend that ritual directly affects a patient’s body, soul [semengat] and plant.10 It has no indirect effect on the patient’s mind by changing his perceptions. It does not work because we are moved by it; rather we are moved by what works” (Barrett 1993, 269). The question of efficacy is explored further below. EFFICACY AND “AUDIENCE” People enter and leave the bilik of the afflicted as their everyday work necessitates—the preparation of meals, caring for children, feeding of animals— but also to divide their presence between patient and manang on the ruai. Barrett’s description of the audience to the pelian performance in the Saribas district is one of a transfixed and attentive collective. The pelian chant proceeds “quietly at first so that it is drowned out by the chatter of men sitting nearby, then in a gradual crescendo that emerges out of the conversation and finally dominates and suppresses it” (Barrett 1993, 257). However, a scenario such as this would apply to only a fraction of over thirty pelian I observed, for in most cases, the chatter of the crowd continued in almost total disregard for the efforts of the manang, only dying out when revellers sank to the floor in sleep. Atkinson (1987) reports a comparable scene among the Wana during the mabolong healing ritual. During the Iban pelian performances in Pakan, what was often so

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striking was the total disregard for the manang as he performed. People continued their jokes, their conversations, and their shouting in competition with the words of the chant. On many occasions there was little point in continuing in my endeavors to record the language of the pelian chant because the noise of a radio blaring and the raucous conversations between those around me had become most assuredly the main “act.” However, while those attending the event often achieve a domination of the scene in this way, it would be erroneous to conclude that they are not participants in the healing effort. Rather, engagement exists as simply presence. Efficacy does not demand the audience’s sensory engagement and the manang is usually not a focus of people’s attention. As the performance of the pelian proceeds, individuals come and go, but there remains a collectivity of supporters throughout the event. As the pelian moves further into the night, pillows are brought out, hammocks strung, and sarongs pulled up around bodies as the members of the “audience” fall into sleep. The manang meanwhile continues his chant, his confrontation with antu and retrieval of semengat on many occasions largely unobserved and unheard. The longhouse community shares the job collectively of providing presence, gauging as they pass by the pagar api whether they are needed. Lack of such a gathering is not only an embarrassment to the bilik concerned, it also poses a threat to the efficacy of the work of the manang. The importance of this communal presence is explained by Iban people as eliciting the goodwill of the manang’s yang, or spirit familiars, and other celestial beings. If the manang is not seen to have support from the community, his yang will be less likely to bestow their assistance on the manang. Barrett reports that Iban people claim the true source of healing power is located in the yang of the manang (1993, 266). And indeed, a manang’s reputation around Pakan is highly dependent upon the nature and number of yang that he has. The more powerful the contingent of yang at a manang’s side, the greater the power of the manang to retrieve lost semengat from increasingly precarious and dangerous situations. Yang are also raised by manang as points of comparison between each other, as grounds on which to lay claim to superior healing power. Manang Ipoi was well known around the region for his yang—one female and two male antu gerasi—which made a particularly impressive trio and enabled him to earn the reputation of manang tuai berani (senior and brave) and manang cucun (accurate and precise). Being able to work with such potentially fickle and threatening antu as these was also indexical of his own bravery and skill. For, in addition to their yang, characteristics of the manang himself are also determinants of healing potential. Manang are judged in their communities by their work output, the energy they expel, and the risks they take in engaging invisible assailants. In one way Iban people do view these factors as important in a dramaturgical sense. However, to reduce therapeutic work to performance runs the risk of defining those present as mere audience to an entertainment or of construing the event as more

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for the benefit of community members other than the patient. On the contrary, those present are, as already noted, frequently disengaged from the action. A range of other practices, to which their attention is often turned, proceed concurrently with the work of the manang. Analysis of healing as performance also devalues the explanations of longhouse residents themselves. Those who make the effort to carry out the more difficult and dangerous pelian are considered far more powerful by virtue of the fact that such observable practice is engagement with antu. Healing efficacy is thus explicable in terms of a triadic relationship. Manang, their yang and other noncorporeal beings, and community members work interdependently to realize the power needed to combat the causative agents of illness. The importance of community presence in regard to the relationship between manang and yang is further evidenced in the immediate post-pelian period. The manang will always sleep beside the pagar api at night after performing a pelian, and in the Pakan area it is important to have a small kerosene lamp burning continuously so that the yang can see the manang in order that their cooperative efforts may continue. It is also important that several others sleep on the ruai at night with the manang to increase the likelihood of the yang’s assistance, and care is always taken to ensure that a few men do this. The community thus participates in this regard, as active interlocutors smoothing the passage of healing power between yang, manang, and patient. People say that noncorporeal beings must bear witness to the embeddedness of the manang in community for their effective engagement in healing. The significance of community members in therapeutic work is further evident in those relatively brief but critical moments during which presence does give way to undivided participation as those around assist the manang in his retrieval of semengat and the outwitting of antu. The more serious the affliction, the stronger the hold of antu over the semengat and, hence, the more dangerous the action within the pelian and the more attentive and participatory the audience become. During these climactic moments, manang and community members act in the visible realm to execute effects in the invisible, thus traversing these two coextensive realms. While people in the bilik continue to monitor symptoms and administer multiple treatments to the patient, those on the ruai become increasingly caught up in the frenzy and danger of the work of the manang. While the patient remains emotionally, visually, and aurally removed from this action, other members of the community become transfixed and terrified agents in the attempted retrieval of semengat and realization of healing power. Gana’s grave condition called for serious measures to be taken, and in several of the pelian performed that night members of the audience were central players in the forward movement of healing work. Gana, Continued Four distinct pelian were performed over an eight-hour period for Gana, each entailing a particular strategy designed to retrieve his semengat. In the reality

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of the pelian kara (“fig tree,” Ficus spp.) (Richards 1981, 139), Manang Ipoi called upon his skill and agility to outwit the implicated antu by ascending the tree in order to retrieve the captured semengat of Gana. Three large hardwood pestles used by women for pounding rice and other grains were joined together by a rope to form a tripod over an upturned mortar on the ruai. As symbolic referents in the pelian, the three pestles, according to some of those present, enable the manang to ascend the fig tree and the mortar exists as a hill which he ascends in order to “scan the landscape.” For others the pestles themselves were the fig tree. Ipoi rose from his sitting position at the base of the pagar api and began to move rhythmically around the structure in an anticlockwise direction. A large blanket woven by a female ancestor of Gana’s was draped over his right shoulder, held out in front with a hand on either side, and waved in time with his movements. One foot forward, the other brought up to meet it, then a sweep around to the side, and two steps forward again. A woman next to me was impressed by the action, and commented on how rare it was these days to find a manang that bothers to move like this during a pelian. With each rounding of the fig tree Ipoi kicked the mortar out a little further from underneath the pestles as the tension in those around mounted. Men raised themselves to their feet and stood by ready to spring into action. A few more circumambulations, each time moving a little further up the mortar, and Ipoi reached its highest point, quickly snatching the semengat from the antu’s lair. Immediately, a group of men rushed forward and released the structure to prevent the antu from pursuing the manang as he fled with his catch. The men yelled loudly and confidently: “Be well and healthy, at peace and content! Cease being ill! Be well, be well!” The healing event allowed community members to participate in achieving healing efficacy in various ways—as passive, sensorily disengaged people who facilitate the relationship between manang and noncorporeal assistants, as active players themselves risking proximity to beings of the invisible realm, or by contributing to the generation of healing power through more direct help to the patient. Healing becomes a collective process and a collective responsibility. The energies of the community are expended in the search for a cure until death finally ensues, for much of the weight of responsibility for Gana’s death will be on their collective shoulders if they fail to explore all possible therapeutic options. Healing efforts continue regardless of the fact that many at this stage may privately feel that further efforts are pointless. Although the Iban manang holds the power to announce terminality, such a prognosis is by no means taken as a fait accompli by the patient, family, or wider community. After the third pelian in the early hours of the morning, Ipoi called a meeting and pronounced to the inner circle of male kin that nothing more could be done to save Gana. The antu, he explained, was too powerful. Gana and his kin had hesitated too long before summoning him after a foreboding dream that Gana had experienced four days previously and a breach (puni) in customary law, or adat, by Gana, that had been ignored.

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The response from the community was a decision to call upon yet another manang. This was despite the fact that a four-wheel-drive vehicle sat just meters away and the driver who could have taken Gana to a hospital in two and a half hours had been in the longhouse since Gana fell ill. It was midnight when two men set off on a motorbike to fetch Manang Igat from his longhouse only ten minutes’ ride downriver. Over an hour later they returned alone only to announce that Igat did not wish to attempt to outwit this antu. The immediate longhouse community and those who had come to give support from surrounding communities turned again to Ipoi, beseeching him to try once more, to perform another final pelian. Kinship ties, a sense of responsibility as a selfproclaimed “carer of the Iban,” and the excruciatingly high demand placed upon him by those he cares for, precluded any possibility of refusal. Around two A.M. Ipoi began the chant of a pelian berancang which involved a final violent charge, armed with a burning log, at the antu. Thus, the impetus for further healing work came from the community, even when healers refused to continue and expressed their view of the futility of further attempts. Regardless of how futile people may feel their efforts are, or the efforts of those around them, an external public demeanor of hope and encouragement is considered imperative. Those who fail in this endeavor risk criticism from others as having threatened the efficacy of all healing work. Although there may not be a community-wide consensus of opinion on either diagnosis or curative strategy, the expression of a difference of opinion is strictly confined to the privacy of a bilik, a quiet moment apart from the crowd by the river, or brief interlude alone on the ruai. Only then are dissenting opinions aired in carefully minded but emphatic whispers. In the rear of a bilik late into the night, one woman, for instance, had grabbed my arm, saying, “There’s no point trying to help him any more, not when his semengat is caught like that.” The disruption of harmonious and orderly social relations potentially fosters a disturbed, heated, disorderly, or angat, condition. Such a state is one of increased vulnerability to outside dangers, and is contrary to a cool and calm, or celap, environment that is associated with health, healing and order. The part played by community members in ensuring healing efficacy may continue for several days after a pelian. This is a crucial fortifying period for the work that has gone before. The entire community may be implicated, depending on the severity of the illness and the strength of the causative agents identified by the manang. The observance of certain restrictions (pemali) prescribed by the manang enables the therapeutic effects of his work to be fully realized. The returned semengat of the patient is able to reconstitute itself in relation to its physical counterpart. This process is protected by the barriers erected by the manang to protect the patient who is rendered invisible to the malevolent antu. Failure to comply with the restrictions is invariably invoked retroactively to explain a recurrence or continuation of illness. Less serious cases will have pemali that apply only to the patient or bilik concerned, while others will encompass the entire longhouse. Most commonly

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these involve a cessation of movement. Other longhouse residents, for instance, may be restricted from entering the bilik of the afflicted, people from other communities may not enter the longhouse at all, or those who are residents may be required to return by late afternoon. Barriers are maintained, the longhouse community is “calmed,” and resistance to outside threats is reinstated through the stilling of potentially dispersive elements. In the case of a teenage girl, two men who chose not to heed such a restriction returned to their jobs in a logging camp the day following a pelian, and as a result of this act were later implicated in her death. Remaining still, minimizing movement, and acting to oppose dispersive tendencies at the level of community reflect commonly held principles that underlie the maintenance of health and well-being in the individual. If, for instance, a person feels ill at ease, discontented, unsettled, or lacking focus— expressed in phrases such as enda lantang or enda senang—it is common that they will decide to diau, or stay within the safe confines of the longhouse for a day to regain their sense of well-being and to reconstitute the self. These principles, reflected in community responsibilities in healing work, demonstrate the strength of the connection that ties the individual into his or her community and the community to the well-being of each individual. CONSTRUCTING BOUNDARIES, INVERTING HIERARCHIES The morning after the pelian were performed for Gana I walked downriver with his niece, Indai Jessi, to their longhouse to replace the clothes we had been wearing for the past few days. She had asked me how many people were present around the ill in my country and what our adat was in the event of illness. If the person was not in hospital, I had replied, usually members of the immediate family and some friends were present, but not all at the same time. Furthermore, the sick person was commonly in a separate room where it was quiet and restful. She had seemed pleased with my answer, as it provided an opportune moment for her to draw attention to the fact that among the Iban many people left their work and travelled far to come and assist. The alliances she valued and which emerged in the event of grave illness correspond closely to what Sutlive has termed “one brotherhood,” inclusive of “members of longhouses which are geographically close to one another,” who “eat together” and visit one another on ceremonial occasions (1978, 58). As Gana’s condition worsened, relatives and friends from surrounding longhouses continued to flow in until the longhouse became host to over a hundred people. Contained within my companion’s comment was an implicit assertion of a hierarchy of adat (in this sense, “custom”) in which Iban adat took a superior position to the adat of the Westerner. To Indai Jessi, the widespread support throughout the immediate and wider community, including several surrounding longhouses, was an important marker of ethnic difference. Its occurrence presented an opportunity to invert the usual hierarchies embedded in

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dominant discourse wherein Iban frequently emerge as socially and culturally inferior to their urban and other ethnic counterparts. Similar themes revolving around the assertion of a superior Iban adat in comparison to that of other ethnic groups frequently emerge in longhouse medical dialogue. Here I wish to draw attention to the way this discourse incorporates debate on alternative medical theories and modalities espoused by doctors, clinic staff, Christians, Chinese, and Westerners. In the midst of longhouse healing ministrations, the qualities of various therapeutic options are criticized, laughed at, and applauded. Frequently, the manang moves in and out of the discussions that proceed around him, occasionally interrupting the pelian chant to interject, as he shifts his attention between the movements of celestial manang and the direction of medical opinion among his clientele. Attention to this discourse reveals much about Iban people’s agency in the broader social and political environment. As the central ritual apparatus was being erected on the ruai during Gana’s illness, I joined a group of men gathered nearby sharing a bottle of rice wine. They were discussing theories of illness that they had heard from some Chinese and Christians and laughing at them light-heartedly. These theories included the assertion that illness can result from pork that isn’t cooked properly, and that the veins in the head can break, releasing blood into the brain. This was the same theory that I had just suggested to some people in the privacy of their bilik when they asked me if I knew what Gana’s illness might be. In dialogue among longhouse residents that took place during Gana’s illness, Christian and Chinese theories became the butt of jokes, and Iban medical knowledge was extolled as containing a far greater insight. Through the conviviality of laughter and drinking, alliances were formed on the ruai that invigorated Iban medical theories and were disparaging, even ridiculing, of others (cf. Crandon-Malamud 1991). Boundaries between ethnically and religiously defined groups were sharpened and medicine became the basis upon which Iban who followed Iban adat and heeded Iban medical knowledge were created as the knowledgable “ingroup,” while others—Chinese, Christians, and myself as the Westerner—were created as the ignorant “out-group.” My ignorance was also indexical of the ignorance of the biomedical profession as the modality with which I was associated. A dominant theme emerging in medical discussions in the longhouse involves the assertion of greater diagnostic powers possessed by Iban manang than those of the biomedical profession. This is attributed to the former’s more expansive knowledge of causative agents, their ability to see what other practitioners cannot, and their skills to deal with the illnesses that these agents cause. Among Pakan manang a trend in self-representation is evident as they turn toward the adat of past manang. Manang in the Pakan area present themselves to those around them as manang asal (original manang), as the embodiment of this more powerful Iban adat. By implication, they also construct themselves as closely allied with antu, the primary source of this knowledge, and thus further embel-

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lish their own individual claims to healing power. Manang thus essentialize their particular adat as untainted, pure and original. Such “strategic claims to essence . . . have important political effects, allowing for self-naming and other-naming in the mapping of antagonisms” (Smith 1994, 173). Through such claims manang express a competitiveness that often underlies their relations with one another. Allied kin and friends also take up this concern and engage each other in debates over which therapeutic practices are the most asal and which manang are the most accomplished. In requesting the services of a manang, clients often explain their choice in terms of a manang’s reputation as a practitioner of adat asal. Younger manang are criticized by older manang and other community members alike for their laziness in not learning the more difficult pelian, and pelian become admired for their content of “language of the past” (jako lama).11 Despite their internal rivalries, as practitioners who collectively valorize that which is considered essentially Iban, manang differentiate their knowledge and expertise from practitioners of other ethnic groups. Rather than actively incorporating aspects of other medical theories and methods, Iban practitioners consciously resist or deny such syncretism. This trend is in contrast to that observed by Barrett (1993), who discusses the pelian as a site of incorporation and transformation, and also, in an ironic sense, challenges Abu-Lughod’s (1991) assertion that ritual is a context for innovation and “anything but timeless.” To those Pakan residents who search for a manang asal to treat their afflictions and expound their healing efficacy to others, who underscore this “essence-claim” (Smith 1994, 173), medical knowledge becomes a crucial marker of their Iban identity. Manang become a medium for the shaping of a collective identity that has at its core the valorization of something precolonization and preindependence.12 Healing, at a time when rural Iban communities are experiencing significant economic and political disempowerment (King and Jawan 1996), may be providing a psychological link back to an “Iban power” located somewhere in the past. Indeed, a rhetoric of diminishing power pervades the longhouses of Pakan. Iban people assert that as an ethnic group they have experienced a gradual loss of “power” since migrating into Sarawak from the Kapuas basin in West Kalimantan around sixteen generations ago (Sandin 1967). According to numerous residents of the Pakan region, there are only a couple of “powerful” longhouses remaining in the Pakan area but there still exists, somewhere within the forest of Indonesia, “Iban power” in an original and more potent form. Not surprisingly, such processes are most apparent in the longhouses that have not been the beneficiaries of significant government subsidies.13 Deprived of a modern identity that builds on the economic fruits of “development” and an advantageous political affiliation, these people struggle to construct and assert a viable alternative. In many ways, this type of response to one’s life conditions is “less a matter of individual volition than of social situation” (Comaroff 1981, 374). As the material conditions of life, the construction of societal boundaries,

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and culture intersect, it is hardly surprising that constructions of identity among these less economically and politically favored communities become more emphatically antithetical to the state, and the medical modality with which it is associated. However, whether such “essence-claims” will prove beneficial to Pakan people and emerge in future practice as vital and dynamic dimensions of their own constructions of Ibanness in which Iban medical practice perpetuates and flourishes is another question. A contrast to the diagnostic certainty in Gana’s illness is the case of Nita, a thirteen-year-old girl whose death in the same longhouse community was marked by a lack of confidence in the ability of those concerned to understand the affliction. Nita’s illness and death were surrounded by confusion, conflicting opinions, and a widespread sense of unease and frustration (see Harris 1999a). The origin of the illness, blame, and responsibility were more disparately conceived and the public summation of the event during her funeral emphasized a biomedical interpretation, deprecating Iban medical knowledge. Consequently the large group of people that came together on this occasion was not availed of the chance to collectively invigorate Iban medical knowledge. Deprived of this opportunity, a sense of vulnerability to “new illnesses” and an inability to determine one’s own well-being was augmented. The disquiet associated with this illness and death was further underscored by the appearance of Nita’s semengat to several of her close kin some weeks after the funeral. Illness events such as that of Nita threaten to undermine the hopes of some longhouse residents that Iban medical knowledge can gain legitimacy as an efficacious lived practice in a social environment inclusive of other ethnic groups and other medical modalities, thereby persisting as an important part of Iban identity. Furthermore, indigenous categories of illness and etiological beliefs are constantly adjusting, incorporating, or yielding to the advent of “new illnesses,” such as Nita’s “dengue,” or new interpretations of illness. Thus claims that indigenous theories and practices constitute privileged arenas of knowledge and insight are further undermined in that they emerge out of a transforming illness environment, and in some senses, diminishing scope of therapeutic application for Iban medical practice. CENTRIFUGAL SOCIALITY This representation of Iban communities as, in part, socially inward turning is at variance with the image of rural Iban communities emerging in much of the literature, which has emphasized Iban people as outwardly focused, ambitious, competitive, and opportunistic (e.g. Chalmers 1996; Freeman 1992; Graham 1994; Kedit 1980; Sandin 1967; Sutlive 1978). Indeed, the impressive migratory history of the Iban, through the culturally institutionalized practice of bejalai, in which young men (and with increasing frequency, women) travel in search of work and new experience often for years at a time, provides ample evidence for such a representation. Yet this emphasis needs to be tempered by

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addressing contrasting social processes. Often the final destination of such outward movement among the younger generation is the longhouse, as people choose to eventually return to their own community and land where strong ties to home and place remain. In the four longhouses that I moved between, only three bilik were empty, and for all this was a temporary situation. In 1955 Freeman concluded, “a longhouse community is a serial aggregation of bilek-families, confederated by cognatic kinship. Moreover, it is an open, and not a closed group, for bilek-families are entitled to leave and join at will” (1992, 104). Freeman’s image of the longhouse was one of a collectivity of family units loosely joined and tending toward dispersion rather than cohesion, a conclusion which may lie in his conception of a longhouse community in structural terms as little more than a group of separate households, or bilik, which have come in Bornean ethnography to be conceived as the basic corporate group and building unit of larger communities. Helliwell has drawn attention to this trend to reduce sociality to discrete pieces or groups that can be represented in visualspatial terms as resulting in “a tendency both to overlook altogether more fluid and unstructured forms of sociality” (1996, 131). Thus, Freeman (1992) sought evidence for the longhouse as a corporate group in patterns of landownership, only to find that all land was owned separately by each bilik. There was no equivalent to a “village green” and only the graveyard was used by all longhouse members. In terms of collective ownership of property, only the main stairway formed out of a notched log was owned corporately and no great sense of responsibility for its upkeep was evident. Inasmuch as a corporate identity does exist, concluded Freeman dismissively, “it stems from ritual concepts” (1992, 104). Yet his summation of corporativity through ritual emphasizes the self-interest of each bilik group in reaping the benefits from this effort. Similarly, Freeman found that other aspects of cooperation within the longhouse are founded on strict principles of reciprocity, a view that underscores the insularity of bilik groups and obscures their interdependence. Freeman acknowledges the extensive kinship links that can connect a person to a large number of other longhouses, and Sutlive notes a “felt need and desire expressed to maintain social ties over a greater area [than the ‘brotherhood’]” (1978, 58). Sutlive also considers it noteworthy that “to a majority of Iban the longhouse still is the settlement pattern that is most meaningful culturally” (1978, 184). Yet Freeman’s portrayal of Iban kindred in this wider context as “an uncircumscribed grouping, extending indefinitely outwards” is again one that evokes a centrifugal movement concurrent with diminishing ties (1992, 67). In a similar manner, and as noted earlier, Sutlive tempers his discussions of alliances with references to more powerful and increasing tendencies to dispersal. In contrast to these representations of wider kin groups as radiating and migrating increasingly outward, crisis events such as illness and healing reveal the existence of counterbalancing tendencies that indicate a coherence underling such networks. More elusive and fluid aspects of sociality, conceived in terms of relationships between people and antu, and the generation, passage, and main-

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tenance of power in healing, fortify people’s sense of place, home, and collective identity. The context of healing work reveals a collectivity of people bound together in a multiplicity of ways, and an environment in which protective groups and boundaries are constructed. They are constructed, that is, according to principles that resonate with culturally salient ideas of resilience and wellbeing at the level of the individual, the bilik, or the longhouse community, but in response to newer threats of modernity. CONCLUSION I have argued that it is necessary to reconceptualize the study of healing and illness in Iban longhouses by decentering the ritual specialist, and shifting attention toward more “fluid and seamless” forms of sociality. Thus the healing context emerges as a crucial site where people negotiate economic and political realities through the strengthening of alliances, the essentialization of knowledge, and the construction of differences. The Iban manang and the pelian chant are refigured as merely one site of action in a more complex and diffuse therapeutic environment in which longhouse community members also play crucial roles in the generation and passage of healing power. To many rural Iban the longhouse is an efficacious healing environment, a perception that stands in opposition to portrayals of these residences as a disease-fostering domain by some health workers, medical department officials, and researchers (e.g. Chen 1988; Kedit 1989, 10–11): the degree of communicability of tuberculosis depends on the number of bacilli discharged, the virulence of the bacilli and opportunities for their aerosolisation by coughing, sneezing or singing, all of which are increased in the event of prolonged and intense social contact of the kind that occurs in the longhouse situation. (Chen 1988, 1077)

It is among those longhouse communities with relatively limited economic opportunities, particularly those not classified as “model longhouses,” that the incorporation of indigenous medical knowledge into constructions of identity is most strongly enunciated. Such constructions emphasize distinctions between Iban people who live according to an Iban adat, religiously and ethnically defined others, and those affiliated with government institutions. As I have discussed elsewhere (Harris 1999b), parallels with trends toward increasing ethnic identification in postindependence Sarawak (Jawan 1994) further underscore the politically embedded nature of these processes. The construction of difference between social groups through medical knowledge is also informed by principles that resonate with culturally salient ideas of resilience and well-being at the level of the individual, the bilik, or the longhouse community. The discursive boundaries emerging in medical dialogue could be conceived as barriers that protect the inner vulnerable Iban collectivity against encroaching economic and

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political forces, a means by which Iban people resist their progression into the lower ranks of an emerging class structure. NOTES 1. In 1990 the Iban constituted 29.5% of Sarawak’s population. Chinese comprised 28.9%, Malay 20.8%, Melanau 5.8%, Bidayuh 8.4% and other indigenous 5.5% (Annual Statistics Bulletin, Sarawak, 1993, 9). 2. For example, Hose and McDougall (1912); Howell and Bailey (1900); St. John (1974); Gomes (1911). 3. For example, Perham (1887); Wilken (1887) as cited in Graham (1994); Freeman (1967); Sutlive (1978). 4. For example, Freeman (1967); Perham (1887); Richards (1981); Sandin (1978); Sather (1996); Uchibori (1978) as cited in Graham (1994). 5. For a discussion of the relationship between space and social relations, see Moore (1986). 6. Barrett (1993), Barrett and Lucas (1993), and Sather (1993) identified the significance of these movements between bilik, ruai, and tanjo (outer uncovered verandah), during the healing work of the manang and the performance of pelian as crucial transitions in ritual space that mark the movements of the action occurring in the invisible realm. 7. Pseudonyms have been used throughout. 8. The term pucau is usually used in reference to a diversity of “spells” primarily of Malay origin. Knowledge of pucau is widespread among Iban people and not confined to manang. 9. This is not to dismiss the array of healing situations in which efficacy does involve somatic modes of attention and an engagement of the senses. 10. It is widely held among Iban people that each individual possesses a botanical aspect. 11. Similarly, Barrett also notes that archaic words and phrases (jako lama) in pelian are “associated with the origins of the Iban people, and therefore regarded as ‘powerful’ (bisa)” (1993, 574). 12. See Taussig’s (1980) analysis of the use of devil imagery by Bolivian tin miners. 13. Certain longhouses are chosen by government departments to be designated “model communities,” and as such they receive a disproportionate share of rural development funding and small-scale projects. These communities are selected on the basis of road access for government vehicles and the ability of the community to demonstrate adequate cooperative abilities to ensure the likely success of government initiatives.

REFERENCES Abu-Lughod, L. 1991. Writing against culture. In Recapturing anthropology: working in the present, edited by G. Fox. Santa Fe: School of American Research Press. Atkinson, J. M. 1987. The effectiveness of shamans in Indonesian ritual. American Anthropologist 89 (2): 342–355. Austin, R. F. 1977. Iban migration: patterns of mobility and employment in the twentieth century. Ph.D. diss., University of Michigan.

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Barrett, R. 1993. Performance, effectiveness and the Iban Manang. In The seen and the unseen: shamanism, mediumship and possession in Borneo, edited by R. L. Winzeler, Borneo Research Council Monographs, vol. 2. Williamsburg: Borneo Research Council Inc. Barrett, R. and R. Lucas. 1993. The skulls are cold, the house is hot: interpreting depths of meaning in Iban therapy. Man (N.S.) 28: 573–596. Bell, C. 1992. Ritual theory, ritual practice. New York: Oxford University Press. Biesle, M. and R. Davis-Floyd. 1996. Dying as medical performance: the oncologist as Charon. In The performance of healing, edited by C. Laderman and M. Roseman. New York: Routledge. Chalmers, J. 1996. Ethical questions raised by the politicising of Iban lives. Journal of Contemporary Asia 26 (1): 221–235. Chen, P. 1988. Longhouse dwelling, social contact and the prevalence of leprosy and tuberculosis among native tribes of Sarawak. Social Science and Medicine 6 (10): 1073–1077. Comaroff, J. 1981. Healing and cultural transformation: the Tswana of Southern Africa [1]. Social Science and Medicine 15B: 367–378. Comaroff, J. and J. Comaroff, eds. 1993. Modernity and its malcontents: ritual and power in postcolonial Africa. Chicago: University of Chicago Press. Crandon-Malamud, L.1991. From the fat of our souls: social change, political process, and medical pluralism in Bolivia. Berkeley: University of California Press. Freeman, D. 1967. Shaman and incubus. Psychoanalytic Study of Society 4: 315–343. ———. 1992. The Iban of Borneo. Kuala Lumpur: S. Abdul Majeed and Co., in association with Athlone Press. (London School of Economics Monographs on Social Anthropology, 41.) Gomes, E. H. 1911. Seventeen years among the Sea Dyaks of Borneo. London: Seeley Press. Graham, P. 1994. Iban shamanism: an analysis of the ethnographic literature. Canberra: Australian National University. Harris, A. 1999a. Healing knowledge, healing power: the agency of well-being among Iban communities, Sarawak. Ph.D. diss., University of Newcastle, N.S.W., Australia. Harris, A. 1999b. Remedy for an ailing “race”: elite agendas and shamanic visions. Review of Indonesian and Malaysian Affairs 33 (1): 125–156. Helliwell, C. 1996. Space and sociality in a Dayak longhouse. In Things as they are: new directions in phenomenological anthropology, edited by M. Jackson. Bloomington and Indianopolis: Indiana University Press. Hose, C. and W. McDougall. 1912. The pagan tribes of Borneo, 2 vols. London: Macmillan. Hoskins, J. 1996. From diagnosis to performance: medical practice and the politics of exchange in Kodi, West Sumba. In The performance of healing, edited by C. Laderman and M. Roseman. New York: Routledge. Howell, W. and D. Bailey. 1900. A Sea-Dyak dictionary. Singapore: American Mission Press. Jawan, J. A. 1994. Iban politics and economic development: their patterns and change. Bangi, Malaysia: Penerbit Universiti Kebangsaan Malaysia. Jensen, E. 1972/73. Sickness and the Iban manang. Folk 14–15: 93–102. ———. 1974. The Iban and their religion. Oxford: Clarendon Press.

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Kedit, P. 1980. Modernization among the Iban of Sarawak. Kuala Lumpur: Dewan Bahasa dan Pustaka. ———. 1989. Iban cultural heritage: an overview of Iban traditional cultural values and social norms, and their implictions for contemporary Sarawak. Sarawak Museum Journal, 61 (4): 1–14. ———. 1993. “Meanwhile, Back Home . . .”: Bejalai and Their Effects on Iban Men and Women. In Female and male in Borneo: contributions and challenges to gender studies, Borneo Research Council Monograph Series, vol. 1., edited by V. H. Sutlive Jr. Williamsburg: Borneo Research Council Inc. King, V. and J. Jawan. 1996. The Ibans of Sarawak, Malaysia: ethnicity, marginalization and development. In Ethnicity and development: geographical perspectives, edited by D. Dwyer and D. Drakakis-Smith. Chichester: John Wiley and Sons. King, V. and M. Parnwell, eds. 1990. Introduction. In Margins and minorities: the peripheral areas and peoples of Malaysia. Hull: Hull University Press. Laderman, C. and M. Roseman, eds. 1996. Introduction. In The performance of healing. New York: Routledge. Le´ vi-Strauss, C. 1963. Structural anthropology 1. London: Peregrine Books. Mashman, V. 1993. Warriors and weavers: a study of gender relations among the Iban of Sarawak. In Female and male in Borneo: contributions and challenges to gender studies, edited by V. Sutlive, Jr., Borneo Research Council Monograph Series, vol. 1. Williamsburg: Borneo Research Council Inc. Moore, H. 1986. Space, text and gender: an anthropological study of the Marakwet of Kenya. Cambridge: Cambridge University Press. Ortner, S. 1989. Theory in anthropology since the sixties. Comparative Studies in Society and History 26: 126–166. Perham, J. 1887. Manangism in Borneo. Journal of the Royal Asiatic Society (Straits Branch) 19: 87–103. Richards, A. J. N. 1981. An Iban-English dictionary. Oxford: Clarendon Press. Sandin, B. 1967. The Sea Dayaks of Borneo. London: Macmillan. ———. 1978. The pelian bejereki: Iban rite of spiritually fencing an expectant mother. Sarawak Museum Journal 26: 57–80. Sather, C. 1993. Shaman and fool: representation of the shaman in Iban fables. In The seen and the unseen: Shamanism, mediumship and possession in Borneo, edited by R. L. Winzeler. Borneo Research Council Monographs. Williamsburg: Borneo Research Council Inc. ———. 1996. Pelian texts of Iban shaman, vols. 1 and 2. Kuching: The Tun Jugah Foundation in cooperation with the Borneo Research Council. Smith, A. 1994. Rastafari as resistance and the ambiguities of essentialism in the “new social movements.” In The making of political identities, edited by E. Laclau. London: Verso. St. John, S. 1974. Life in the forests of the Far East. London: Oxford University Press. Sutlive, V. H. Jr. 1978. The Iban of Sarawak. Arlington Heights, IL: AHM Publishing Corporation. Taussig, M. 1980. The Devil and Commodity Fetishism in South America. Chapel Hill: University of North Carolina Press.

8

Sorcery and Science as Competing Models of Explanation in a Sasak Village Cynthia L. Hunter

INTRODUCTION One of the defining features of the concept of modernity, as it is presented in the literature, is its constitution of issues, dimensions, and aspects of ways of life which are set apart from those of an earlier period. Whether the development of Western Europe or of Asian societies is being discussed, modernity is linked to discontinuities and therefore is set apart from and opposed to tradition (Giddens 1990, 1). Anthony Giddens’ (1990, 3) conceptualization of modernity originates in a “discontinuist” interpretation of modern social development in which modern institutions are distinct and separate in form from traditional types. These discontinuities are identified by three features: rapid change; social transformation through global interconnectedness, and the historical specificity of many modern institutions (Giddens 1990, 6). For Giddens the two significant institutional complexes of modernity are industrial capitalism and the nationstate. Rationalism and commitment to progress are their main philosphical underpinnings. Some scholars argue that modernity is a Western project but one that has a global dimension. Giddens (1990, 1), for example, states that “ ‘modernity’ refers to modes of social life or organisation which emerged in Europe from about the seventeenth century onwards and which subsequently became more or less worldwide in their influence.” Scholars who examine Asian societies acknowledge the emergence of modernity as a Western project, but they are quick to point out that Asian modernity is not identical with Westernization. The nature

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of modernity involves the emergence of, in some areas at least, secularization, industrialization, and Islamic fundamentalism (Gomes 1994, 9–10). A common theme of discussions of modernity in Asian societies is its association with the role of discourse in the construction of cultural identity (Kahn and Loh 1992; Gomes 1994; Brenner 1996; Hefner and Harvatich 1997; Kahn 1998). This appears to emerge with a hegemonic modernity in the form of a development discourse and people’s resistance to it. Development discourses are promulgated by modern nation-states as the government rationale for modus operandi. The rhetoric is inevitably followed by policy and planning and the implementation of new sets of practices. However, because of the strong rhetoric and the time and space gap between policy and implementation, the ideas have symbolic value for rural populations well before the practices become embedded in the minds and everyday lives of villagers (e.g., see Pigg 1995). These issues are pertinent to my focus on modernity in the context of the relations between the village and the Indonesian state. In the construction of cultural identity, the relations between the local and modern are significant, as very often the official discourses of nation-states exhort their varying ethnic, regional, and rural populations to conform, with little or no sensitivity to the cultural specificities of identity and local custom. In this chapter I demonstrate some of the complexities of the concept of modernity in relation to healing as it affects rural villagers in northeast Lombok, in the province of West Nusa Tenggara in Indonesia. I draw on a detailed case study of a health quest that I argue has relevance to understanding articulations of the local in other Asian societies. I argue that the government’s development discourse, based on a scientific, hegemonic, and global rationality, can be subverted by village discourses of healing. Local social and cultural contexts and the establishment of personal relations between healer and patient are of paramount importance in the realization of alternative rationalities. BACKGROUND AND CONTEXT Lombok is an island that lies to the east of Bali in the Indonesian archipelago. Historically Lombok was subjugated to Bali for over one and a half centuries. Today the Hindu Balinese form a sizable minority in West Lombok. In comparison, the Sasak, who are the focus of my study, are Muslims. They are the indigenous inhabitants, they form the majority of the population, and they live throughout the island. Lombok is a largely agriculture-based society that economically, politically, and culturally has not yet emerged as significant in national terms. There are no national heroes, politicians, or matters of consequence (except perhaps in religious terms) in comparison to Javanese, Balinese, and the major ethnic groups of the other main Indonesian islands. Lombok is considered something of a backwater by other Indonesians; the Sasak are considered to be kasar ([Indo-

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nesian, hereafter “I”]: uncivilized) and also as fanatik ([I]: strictly adhering to religion) because of the local variant of fundamentalist Islam the majority of people now follow. In particular, in the district of East Lombok, where I worked, the fundamentalist Islamic faith, the waktu lima [Sasak, hereafter “S”] has recently come to overshadow the pantheistic Hindu-Buddhist and animist waktu telu [S] style of Islam of former times. One of the leaders of waktu lima, Tuan Guru Haji Zainuddin Abdul Majid, who died in 1997, was probably the most significant figure to come to the attention of outsiders in recent times. Tuan guru ([S/I] great respected teacher) are the intellectual leaders of waktu lima associations (Hunter 2000). INDONESIAN ISLAM AND LOCAL IDEOLOGIES Islam is the dominant religion in Indonesia, taking a variety of discursive and organizational forms depending on whose voice, which locale, and what context is being represented. In the national context one can distinguish broadly between national pan-Indonesian organizations with regional and provincial branches— for example, Muhammadiyah and Nahdlatul Ulama—and regional or ethnic variants of Islam which are contained within geographical and local boundaries— for example, waktu telu and waktu lima. Muhammadiyah is an intellectual Muslim and social welfare organization aimed at improving the quality of education, including in its curriculum both religious and secular subjects. Muhammadiyah has been at the forefront of modern trends in Indonesia, but over the years a wide gap has developed between the traditional Islamic organizations such as Nahdlatul Ulama, and Muhammadiyah (Federspiel 1995; Geertz 1960; Noer 1973). The tensions which emerge through the traditionalist/modernist dichotomy at the state level are also found at the regional and/or local levels. Most villagers in Lombok follow the local variant, waktu lima, which they consider to be modern, while the waktu telu variant is considered traditional. The tuan guru have replaced the traditional leaders of waktu telu as the new intellectual leaders of the Sasak people. But in urban centers waktu lima and Muhammadiyah compete with each other for followers. The community of Elah, where I undertook field research in 1991 and 1992, is situated over 400 meters above sea level on the volcanic slopes of Mount Rinjani. The population of around five thousand people is homogeneously Sasak. The main income is derived from garlic and wet-rice agriculture, with the majority of landowners owning small plots of approximately half a hectare. Landlessness and unemployment among youth is becoming more visible than ever before. Elah is a market village that serves several villages in its vicinity. Sasak villagers distinguish and identify the waktu telu villages from those that are waktu lima.1 Elah is considered a waktu lima village and is therefore modern in Lombok terms. Villagers say “Those who follow adat (custom) follow waktu telu, those who follow agama (religion) follow waktu lima. We used to follow adat but now we follow agama.”

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To be modern in village terms means to be a follower of waktu lima. In East Lombok, the waktu lima variant is represented by three separate religious associations.2 Each association has established networks of Islamic schools (madrasah [S/I] and pesantren [I]) in the villages. All three waktu lima associations are represented in Elah village.3 Furthermore, the other modern religious organizations represented on Lombok, such as Muhammadiyah, also have a network of educational institutions. This situation demonstrates the complexity within the arena of contestations. There are two frames of reference: the local and modern, and the state and village. HEALING POWERS Healing powers in Indonesia constitute a broad field that incorporates two medical systems: biomedicine and indigenous medicine. In theory, Elah villagers have access to both. The field of indigenous healing consists of a body of customary medical knowledge and curing practices performed by numerous and variously skilled belian ([S]: indigenous healers). Belian and their curing practices originated in the waktu telu religion. There are at least thirty-seven belian in Elah, both men and women, most in their forties or older, each of whom has his or her own area of expertise (see Figure 8.1). They cure a wide range of diseases and illnesses, and as well they treat teeth, use massage for an endless list of ailments, deliver babies, produce love magic and sorcery. Some healing practices incorporate Sasak cosmology, related to the four cardinal points and the positioning of Mt. Rinjani, the holy mountain that dominates Lombok. Much of the belian’s pharmacopoeia consists of natural products (plants, herbs, and seeds) which come from the gardens and nearby jungle. Other items are bought, in fresh or dried form, at the market as jamu-jamuan [S/Javanese, hereafter “Jv”].4 Some belian acknowledge the potency of modern drugs such as aspirin or paracetemol and they are quick to direct patients with acute illnesses such as cholera or diarrhea to the subclinic. When treatment is given by a belian, it is usual for each cure to be accompanied by jampi (recitation of a mantra) and prayer. Belian are an integral part of daily life and villagers consult belian for whatever ails them. They might call those nearest to them, go to a special friend in another kampung ([S/I]: subhamlet), or visit a famous belian known through kin and social networks in neighboring villages. For sicknesses which are prolonged or more debilitating, a villager may seek cures from a number of belian as well as visit the health aid post. Belian are recompensed with material items for daily use rather than any substantial amounts of cash, and most engage in other economic activities of village life. Rarely is healing a full-time or lucrative occupation. There is no formal institutionalized structure to indigenous curing. Belian are not legitimized by the state, with the exception of belian ranak (midwives) who have received some formal training. Furthermore, the fact that belian are found

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Figure 8.1. A belian (Sasak indigenous healer). Photo by Cynthia Hunter.

in the waktu lima villages is proof of continuing practices involving the nonmanifest spirit realm and indicates something of the complexity and embeddedness of local village cultural practices in everyday life. Belian transcend the traditional/modern categories because they maintain their popularity with most villagers. The new intellectuals (tuan guru) do not appear to discourage this. The national health system, one of several state institutions that link the village world through vertical integration to the Indonesian state, is represented by the subclinic (puskesmas pembantu or pustu [I]) and the integrated services post (posyandu [I]) both of which come under the administrative jurisdiction of a subdistrict level clinic (puskesmas [I]) located about fifteen kilometers away. These health services form the first point of contact for rural villagers with the national health system. The local-level clinics represent one institutional form of the “expert systems” of modern nation-states which Giddens defines as “systems of technical accomplishment or professional expertise that organise large areas of the material and social environments” (1990, 27). They are part of the state governmentality’s control and protection of its population. The national health system, grounded in scientific paradigms of care, is a quintessentially modern institution. Medical,

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nursing, and paramedical practices adopt the clinical focus: educational and training curricula are based on Western models and there is a spectacular lack of indigenous medical knowledges. The health system is constituted at the central government, but with input, in very fundamental ways, from another social space, the international arena of the multilateral health agencies such as the World Health Organization and the United Nations International Children’s Emergency Fund. Biomedical institutions and the state bureaucracies develop their own cultures in the course of their activities. Bureaucratic functionaries working in the lower echelons of the hierarchy may be culturally distant from the local communities the government aims to serve. The tensions which are created through the different discourses of state and village, local and modern, emerge through the narrative of a health quest where science and sorcery emerge as a further dichotomy by which local experience can be understood in relation to the imperatives of modernity. THE HEALTH QUEST This narrative examines the tensions which develop between close kin when religious differences and differential distributions of knowledge affect decisionmaking and so the ultimate outcome of a health quest. The quest begins when Henryati, a fourteen-year-old schoolgirl, is forced to stay home from school with an immobilizing illness. The Persons Involved Henryati: a fourteen-year-old schoolgirl Pak Sudikin: father of Henryati Inaq Sudikin: mother of Henryati Ibu Rumiah: paternal aunt of Henryati Pak Husni: paternal grandfather of Henryati Inaq Huriah: sixth wife of Pak Husni and stepgrandmother of Henryati Dr Naati: internist/physician (spesialis penyakit dalam, [I]) at the district hospital Rizal: paramedic in Elah subclinic Women workers and neighbors

The Course of Events One evening I went to visit a friend, Ibu Rumiah. She was not at home, but at her brother’s house, where a group of women was preparing the garlic crop for drying before selling. Inaq Huriah (Ibu Rumiah’s stepmother) and daughter invited me to accompany them because they were going to work too. They explained that Ibu Rumiah had been there since early morning, helping in the

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household because one of the children was sick. The houseyard was full of women, most of whom were sitting working around a very large pile of freshly gathered garlic plants. I was led into the central reception room by Ibu Rumiah to meet her brother the household head, Pak Sudikin, and his wife, Inaq Sudikin, and take coffee and snacks with them, after which we (Ibu Rumiah and I) returned to the yard to work with the other women. After some time the conversation turned to Henryati, the sick daughter of the family. She is a fourteenyear-old schoolgirl who is in class two of junior high school at Nahdlatul Wathan, one of the two religious waktu lima schools in the village. I was told she had been sick on and off for about five months. Her parents were mystified by her condition. Ibu Rumiah and one or two others suggested I come back into the house to see her. I was ushered into a dark room that contained a double bed, a table, and a wardrobe. The double bed was empty but on the floor lay a mattress covered with a woven mat and a pile of pillows. Henryati, a pretty young girl, lay resting there; still and quiet, she appeared to wear a powder face mask.5 Her body was covered with two sarongs. Her parents explained to me that her health status fluctuated; she would get better and play normally for a few days and then become immobilized again. Her body would swell up starting with her head, neck, and shoulders and gradually the swelling would move down to her legs and feet. Inaq Sudikin pushed aside Henryati’s sarong for me to see her thigh and lower leg. It looked edematous and felt taut to touch. Her ankles and feet were swollen. She did not appear to have a temperature, but occasionally she gave a small cough. She was listless, and did not take much notice of me or any of the others present. Diagnosis and Treatment At her request Henryati had spent eight days in the district hospital in Selong. There, the internist/physician told her parents she had a “heart defect” (kelainan jantung [I]), identified as a ventricle septal defect or hole in the heart. Inaq Sudikin also told me the physician said Henryati had beri-beri basah (I).6 Treatment in the hospital consisted of a series of injections and an infusion. Henryati’s condition improved and she returned home with tablets and six phials of an infusion called Lasix, a diuretic. I questioned the family about the six phials, but they neither knew the drug’s intended use nor how it was to be administered. They had been advised to buy the medicines from the pharmacy across the road from the hospital, but it was not made clear to them that they needed the services of the local paramedic to administer the drug. The doctor also had informed the family that Henryati’s heart condition could be fixed by an operation at a hospital in Surabaya, East Java at a cost of about Rp. 6,000,000.7 Another diagnosis of Henryati’s condition had come from Rizal, the local paramedic. “She’s often sick, she has always been thin and it isn’t

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only a heart condition she suffers,” he said. “There’s also something wrong with her lungs, perhaps TB [tuberculosis].” As well as taking her to the hospital, the family had called upon six belian oat ([S]: curers who use medicines), some from Elah, such as Amaq Rusni, some from other villages nearby. The last belian, a Javanese, gave Henryati jamu ([Jv]: a medicinal herbal tonic) with a raw chicken egg. Others used various medicines together with exorcism rituals to drive out the offending jin or evil spirit. All the consulted belian had agreed on the diagnosis: penyakit seher ([S]: sorcery). Pak and Inaq Sudikin, speaking in hushed tones, told me they agreed with this diagnosis. Henryati remained ill for the next three weeks and family members continued to nurse her rather than taking her back to the district hospital. Indigenous nursing and curing practices were administered, including massage to her swollen limbs (one of the most common therapeutic techniques used throughout Indonesia8). Her father burnt cendana ([S/I]: yellow sandalwood) which his son had brought him. Sandalwood grows in Timor, and is a very powerful aromatic and prophylactic in Sasak medicine. The ash was also used to massage Henryati’s swollen feet and legs. According to Ibu Rumiah, two other belian were called during these weeks. One diagnosed Henryati’s illness as being caused by someone who hates her. The eighth curer, a Sasak woman from a nearby town, had brought with her oat sekur,9 a large leaf which is classified as “cold,” and pills made from rice and cooking spices. She gave the leaves to Henryati to eat, and massaged her legs with betel leaves mixed with lime and water. Henryati was allowed to eat “cool” foods (for example, mangosteen), but not mango which is classified as “hot.” Ibu Rumiah and I discussed Henryati’s condition on another occasion as we were working together in the ricefields. She talked about her brother’s ambivalence. “The family has sufficient money for the operation, although the expense and distance from Lombok is considerable,” she said. Her brother, however, was frightened because he didn’t fully believe what the doctor said nor what the belian said. Pak Sudikin himself told me: “I only half believe the doctor and half believe the belian. Inaq, on the other hand, believes the belian.” According to Ibu Rumiah, Inaq Sudikin was the one who still strongly believed in belian. “She’s a coarse and cruel woman. I’ve spent a lot of time cooking in the household and she is a person who would rather turn to outsiders for help before her family. Possibly, it would be better if Henryati died because people are spending so much time and effort nursing her when there is other work which must be done.” If a jin had caused the illness this could be related to the hatred people feel for her father. Some villagers had illegally taken water from the water pipes near Pak Sudikin’s house until he put a stop to this. It could be this action which resulted in an act of sorcery being performed on the family, according to Ibu Rumiah. A few days after my talk with Ibu Rumiah, Henryati died in the hospital

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where she had requested to be taken once again. Her body was brought back to Elah soon after, and two family members were sent on a mission to inform the relatives in other parts of the island. The funeral took place, and the wake (selamatan [S/I]) nine days later was a lavish affair by village standards. THE VILLAGE ARENA AND THE FIELD OF KIN Ibu Rumiah’s account reveals the tensions between family members and the complexity of decision-making when there is a differential knowledge distribution. Pak Sudikin is a primary schoolteacher whose family has a tradition in this occupation. Henryati’s deceased great-uncle (FFB), her grandfather’s elder brother (kakaq [S]), Haji Abdullah Marif, was principal of the first government primary school in Elah in 1933, and Pak Husni, her grandfather, also held this position from 1956 until 1970 when he retired on the government pension. Another great-uncle, her grandfather’s younger brother (adiq, [S]) is a teacher of religion in the Nahdlatul Wathan school which Henryati attended, and her great aunt (FFS) is head of the Education and Culture Department’s subdistrict office. Pak Sudikin is a member of Muhammadiyah. He and his father, Pak Husni, are said to be the only two members of the organization in Elah, whereas the neighboring town of Pohgading is considered a center. Muhammadiyah followers are said to utilize clinics and other health department services for their health problems. They do not practice the customary ways, such as calling on indigenous healers when they are ill. According to Pak Husni, “These attitudes are considered kolot ([S/I]: old fashioned).” In Henryati’s case, the actions of close family members demonstrate otherwise. The significance of the family tradition as teachers is twofold. Few people in the village have achieved this level of education. What is important here is the commitment to the idea, embodied in the formal education system, that rational thinking is modern. Thus biomedicine is accepted because it represents rational and modern forms of authoritative knowledge. This acceptance places Henryati’s family apart as villagers who have invested in education as cultural capital, compared with a number of villagers who have invested in social, symbolic, and religious capital (by undertaking the pilgrimage to Mecca), and the rest, who have not been able to invest in either. These educational and religious dimensions are allied in representing a modern strand of rural village life, though a minority one in Elah. Pak Sudikin is an influential man of high status, a man distinguished from the majority of villagers. He is therefore a target of envy and jealousy and a suitable target of sorcery should relations sour between him and his neighbors. Villagers with greater economic and social resources at their disposal recognize they have more choices: whether to go to the health clinic or not, to outlay a greater economic sum or not. Pak Sudikin is also a farmer with enough land

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to need outside help at certain times of the year. This was one of those times and many women had come together in his houseyard to prepare the garlic bundles for drying and sale. There were more than the usual number of women to help with cooking, provide coffee and snacks for the workers, or look after the sick. It is significant that Henryati’s illness occurred at such a busy time in the agricultural cycle, a difficult time for a wealthy farmer to leave his household or village to embark on an unknown quest such as medical and surgical intervention on another Indonesian island. INAQ SUDIKIN In contrast to her husband, Inaq Sudikin is a village woman with little education, and she does not speak the national language, Bahasa Indonesia, well. Inaq Sudikin is a waktu lima follower like her women neighbors and the majority of villagers in East Lombok. On the whole, women are subordinate to men in Sasak society. The group to whom she turns for emotional, social, and spiritual support are her neighbors and close women friends who live nearby. Pak Sudikin’s position emphasizes the tension between the relations of education and modernity which represent the state, on the one hand, and rural life and the embeddedness of customary practices which represent the local, on the other. He appears to hold two contradictory positions regarding his daughter’s diagnosis and oscillates between the two. The religious tension manifested is not the usual traditionalist/modernist positions of waktu telu and waktu lima in village Lombok, but pan-Indonesian Islamic tensions between conservative and modern positions of the national and village dimension. In this arena of contestation, the waktu lima is considered conservative compared with Muhammadiyah, which is modern. The couple’s differing affiliations represent these contrasted positions. The significance of the modern alliance of education and religious affiliation is best described in Giddens’ notion of time-space distanciation—“the conditions under which time and space are organized so as to connect presence and absence” (Giddens 1990, 14). In premodern situations time and space were located together so that in many instances social activity was situated in geographically circumscribed locales. Modernity sunders space and place by fostering relations with “absent” others (Giddens 1990, 18). The strained relations between husband and wife are expressed in Henryati’s affliction. Her parents follow different religious practices, have different levels of education, and have access to different types of knowledge and power. Inaq Sudikin is an insider, a village women like her neighbors. Pak Sudikin is an outsider in terms of social, cultural, and economic capital. His act of chastising other community members for water tapping is the action of an officious private individual. Henryati was caught between the two.

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Figure 8.2. Sasak women working together preparing food. Photo by Cynthia Hunter.

THE STRENGTH AND FORCE OF EMBEDDED PRACTICE Because of the close-knit relations of kin and neighbors at the village level, the women working in Pak Sudikin’s houseyard are part of a “community of suffering,” a term Victor Turner used to define the set of regular coparticipants in rites of affliction—a community of neighbors who live together over a number of years in the same space (1970, 142–4) (see Figure 8.2). In Elah, the women have years of experience in coping with illness and are well-versed in a Sasak logic of pragmatic existence. They occasionally ventured to the health subclinic for ailments, to receive oral drugs or injections for the quick cure offered by biomedicine, but many maintained a distance and reluctance based on skepticism of the services offered. They gossiped about the nature and cause of Henryati’s illness, gossip that included rumors about the human agent responsible. Some would know the suspect as a neighbor or a relative. The views readily exchanged in this work situation form along the lines of friendship, kinship, and acquaintance, become strengthened and solidified, and create an “effective network” of gossip (Hannerz 1980, 186–187). The place and strength of gossip not only underscores the general animosity felt by villagers toward Pak Sudikin over his efforts to stop the water tapping, but also reveals a meaningful and convincing explanation for Henryati’s misfortune: a human agent has attempted to perpetrate sorcery on her father. Notions of sorcery among village men and women are strengthened by authority when a well-known and respected village curer gives her or his diagnosis. The belian Amaq Rusni was such a

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person. The persuading force of numbers and the embeddedness of Sasak cultural values highlights the social dimension of sickness in this instance. The confluence of close relations, the same cultural practices, and overlapping social fields creates a strong social network through which knowledge flows. Nevertheless, as Ibu Rumiah’s statements expressed, prolonged care of the sick is a drain on most household economies. Her opinion was reiterated by the women working in the houseyard. Villagers feel morally bound to help care for the sick, but over a period of time the effort impinges on labor allocation. It is significant that this health quest was at a peak labor time, since this intensified the competing demands of care of the sick and economic production. The community of sufferers is a loyal and supportive group but time allocation is crucial. This is not just an allocation of time in terms of economic rationality. Individual women laborers must make decisions about production and also about caring. Among poor people, work is an economic necessity for survival. An economic morality or a moral economy becomes the measure by which individuals weigh up their social obligations and responsibilities. A tension between discourses emerges as part of the polar relationship of traditionalism and modernity. In the village arena little credence is given to the modern, intellectual ideas of a remote, nonindigenous (to Lombok) Islamic organization like Muhammadiyah. Pak Sudikin’s modernist orientation is not part of a context constituted by the proximity of the spirit world. The educated minority are distanced culturally and intellectually from those who are not, their cultural capital neither realized nor appreciated. The dominant and prevailing attitudes are those of the close-knit villagers, a reversal of what is found at the Indonesian state level. SORCERY Sorcery is not culture-specific to the Sasak or, indeed, to Indonesian or Islamic populations in particular. It is well entrenched among Islamic and non-Islamic groups throughout Indonesia (Atkinson 1989; Jordaan 1985; Lovric 1987; Wikan 1990; Woodward 1985). Among the Wana in Central Sulawesi, Jane Atkinson asserts that sorcery is considered “a predictable way to vent anger or hurt feelings. To provoke such feelings in others is to invite sorcery in retaliation” (1989, 61). Though not a “pronouncement of death,” a diagnosis of sorcery is good reason to enlist a powerful shaman to perform countersorcery. Furthermore, acts of sorcery are not publicly proclaimed, either to the victim or the community (1989, 61). On Java, “Sorcery is most commonly used against relatives, neighbours or business partners” (Woodward 1985, 1014). Sasak theories of sickness causation encompass ideas about the state of social relationships, between living beings and also ancestors. Marwick’s (1982, 300– 301) concept of “the social strain-gauge” is appropriate in this context. In Marwick’s view, especially for the African material, sorcery occurs between persons linked by close social bonds. The relationships between sorcerer and victim are

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not only close but also strained, and reflect tensions within the community. Sasak customary practice incorporates the use of sorcery against strong and powerful persons such as Pak Sudikin. People say that sorcery destined for one member of a family can be successfully resisted through personal power and strength and be deflected onto another member less able to fight it. Henryati’s was not the only case of sorcery deflection I encountered. Sorcery is a socially based explanation of sickness that takes into account the strength of the (social) positions of the individuals concerned. Inaq Sudikin’s strength resides in the authority of the majority religious orientation in the community. That is why the explanation of sorcery eventually dominates the biomedical, and why Pak Sudikin finds himself taking up two oscillating positions. He represents the modernity of the state but lives in the village. The power of the state is located on the periphery and marginalized by the local community in this case. SCIENCE AND SORCERY AS COMPETING MODELS There are two main diagnoses of Henryati’s illness: a medical diagnosis and a social diagnosis. One offers a modern solution to a congenital malfunctioning of the body by way of surgery and drug treatment according to biomedical procedures. This solution is based on the readings of an analysis of bodily signs and symptoms by way of angiography and other medical technologies. These techniques, asserts Vasseleu (1991, 55–57), have genealogies that can be traced to the dissecting anatomical gaze of Vesalius (1543) and the nineteenth-century medicine described by Foucault (1973). The development in medical imaging techniques together with computer and video technology allows the body to be viewed from a screened image—an image that becomes a “spatial metaphor for flesh” (Vasseleu 1991, 57). The other, the social diagnosis, is cathartic, requiring an exorcism of evil from the body, caused by the actions of a human agent. The body is considered polluted by evil as a result of tensions and conflicts in social relationships. Sorcery must be treated by countersorcery. The power of one belian is deployed to vanquish the power of another. If countersorcery is unsuccessful the patient usually dies. Sasak constructions of illness incorporate appropriate therapies and prophylaxis as well as the performances which bind medicine and religion together. There is complementarity between the two sets of diagnoses and treatments. Neither impinges on the other. From the doctor’s point of view, one is based on objective criteria, the other subjective. But tensions exist because of the state ideology that creates a juxtaposition of indigenous and modern medicine. In this objective discourse, drawing on Foucault’s notion of governmentality (1979) and the apical positioning of biomedicine, indigenous practices (with the exception of indigenous midwifery) are neither recognized nor legitimated by the state.

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The legitimation of indigenous practices is in local hands, those of Sasak villagers who request the services of belian. The contrast between the two diagnoses marks the disjunctions between two social spheres, and between several sets of relations. In the social sphere characterized by biomedical explanations, treatment requires surgical intervention to repair a defective body part. This procedure in Henryati’s case could only take place on Java, an even more distant and remote social sphere, and could only be performed by a doctor who is ethnically and socially distant. Alternatively, short-term relief was available if drugs could be administered regularly and constantly by paramedics. The only pharmacy from which to buy the drugs was near the hospital, more than forty kilometers from the village. There was no attempt made by hospital medical personnel to communicate to the local village paramedic the necessity of his services to administer the drug to Henryati. There is little or no attention given to the patient as a person, or to the logistics of acquiring the drugs or their administration. In this diagnostic and treatment procedure the illness has been objectified and reified (Taussig 1980). In the social sphere of village life, by consulting belian the family members are using the treatments which are part of villagers’ everyday practices. Social relations, favorable or unfavorable, are always at the core of human agency in this construction of events. Both the biomedical and the village diagnoses and treatments are socially and culturally embedded, but in different systems and different social spheres. DISEMBEDDED TIME AND SPACE Disembedding, defined by Giddens (1990, 21) as “the ‘lifting out’ of social relations from local contexts of interaction and their restructuring across indefinite spans of time-space” provides a salient framework of analysis for Henryati’s health quest. A consultation with the doctor at the district hospital is an example of removing social relations from local contexts of interaction because the hospital is locationally distant from any given situation of face-to-face interaction for most villagers. The doctor’s procedures of examination, the instruments he relies upon for diagnosis and treatment, and the hospital organization and bureaucratic structure are part of expert systems, which are “ ‘disembedding mechanisms’ because . . . they remove social relations from the immediacies of context” (Giddens 1990, 28). Health personnel have an occupational identity based on educational achievement and specialization. This identity is accompanied by elevated social status and the opportunity for upward mobility. Their loyalty is to a professional code of ethics. They participate in modernity as employees in expert systems of medical-bureaucratic institutions. Like other salaried bureaucrats, hospital doctors are required to perform and administer services according to the state’s

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demands. In the professional sense, if a patient dies, the doctor is not required to take personal responsibility. She or he does not contract personal relations with patients. Health personnel represent social distance because their concerns are with maintaining social difference in order to maintain their professional standing. As a result, services to the rural population—those they aim to target but who happen to be socially different—remain largely inaccessible. For most villagers the district hospital and the doctors are in a space and place alien to them. Even though modernity has come to the village in the form of the lowest level of the modern health care system—the subclinic—the villagers do not base their health care decisions on knowledge from this site. Belian, unlike bureaucrats, are embedded in the community. They represent the familiar and their credibility and power lies in their embeddedness. They display loyalty to their clients and have a greater responsibility to “get it right” because more is at stake. Belian do not have professional organizations and their approach to clients is informal and relaxed. Decisions about treatment proceed according to the close relations between the fields of kin and indigenous healing. The distance between informal social relationships and formal bureaucratic structures is accentuated in Henryati’s health quest because of the multiplicity of recourses villagers practiced. Unless health personnel cultivate close social relations with members of the rural population and are able and willing to share their knowledge with patients, the latter, particularly in moments of crisis, resort to familiar therapies that are embedded in the social field of the village. The local microcosm of social relations in this health quest extends from the village arena and its social fields of kinship, economic relations, and indigenous health practices to the realm of the state, and the field of health care provided at the district hospital level. The alignment of faith in varying diagnoses— indigenous and “modern”—divides better-educated men from women in the village. A man such as Pak Sudikin voices a preference for hospital practice, in keeping with political and religious orientations, but his faith in the hospital doctor is half-hearted. The division also emphasizes the distance between social and spatial spheres. Village women’s positions are incorporated in a Sasak body of explanations that are reiterated by the various belian who are called and who give the same or a similar diagnosis: penyakit seher, or sickness caused through evil spirits. Agency and personal relations are important elements because of the social proximity of belian to their clients. Sorcery, the ultimate diagnosis given by the villagers for Henryati’s illness and death, is prohibited by modernist Islam. On Lombok, followers of either of the local variants of Islam, waktu telu or waktu lima, think in terms of sorcery. Adherence to Muhammadiyah implies an eschewing of syncretism and, therefore, an adherence to modern medicine. This is an instance of tensions not only between subjective religious positions but also between the state and village.

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CONCLUSION Henryati’s story, which is particularly compelling in showing the contested relationships between tradition and modernity, has been discussed in terms of three frames of analysis: the state and the village; the local and the modern; and science and sorcery. The institutional form and disembedding mechanisms of modernity that are instantiated in the state health system require rural people to make a “leap of faith” which they resist. An examination of the hospital admission records bears this out. The number of patients from Elah for the three-year period 1989–1991 was very small. It appears that people from the village consider the state system a poor alternative (Hunter 1997, 264–268). As long as villagers have an indigenous system of healing embedded in everyday cultural practices, or unless the alternative can demonstrate beyond reasonable doubt that there are advantages in making the “leap of faith,” why would they want to take the risk? The case study alerts us to the significance of the immediacy of the social context in which meaning is constituted. Villagers cannot relate to the social and cultural milieu of sophisticated technology unless it is more fully part of their immediate context. In terms of power and knowledge the social fields of national health care and the government bureaucracy operate at the state level. Their discourses are bureaucratic, biomedical, and modern; their knowledges are formed by the institutionalized structures of governmentality and biomedical rationality. Furthermore, modern rationality has an accompanying political discourse which implicitly or explicitly states that science is about real things. The Indonesian state and at least some other Asian states perpetuate a positivist rhetoric in which “scientific” and “modern” are catchwords aimed at seducing citizens into political and cultural acquiescence. This partially explains why villagers are willing to try biomedical procedures that represent modern methods of curing, but also why they resist them. The social meaning of sickness is significant because it characterizes the differences between distinct rationalities. In the village, the knowledges formed in the social fields of kin, religion, economic relations, and indigenous medicine are based on different religious and educational orientations and the specialized knowledge of indigenous medicine as practiced by the belian. There is a microcosm of power firmly embedded in the knowledge and practices of the belian and supported by the majority of villagers. Pak Sudikin’s position represented authority in terms of education and economic and cultural capital. But he is almost alone in the village context. Henryati was a young female who had not reached maturity and who may not have been able to have children. There was the sense that nothing else could be done to save Henryati, and that her fate was the will of Allah. The quest illustrates the oscillatory nature or multiplicity of resort in cure seeking and the importance of immediacies of context and personal relations in

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decision-making about treatment. Henryati returned to hospital and died there. Does this show vacillation on the part of her carers? Or are people trying to make the most of both systems in a pluralistic setting? The relations between gender, power, and modernity are also represented. What is of interest in the hospital records is that those most likely to present are men (Hunter 1997, 200). They outnumber the young, babies, women, and the old as patients. Men, who are the most mobile in the village world, and are better-educated than women, are most likely it seems to move beyond the therapeutic resources of the village and align themselves more resolutely with the institutions of modernity promoted by a patriarchal Indonesian state. The entry of the national health system into villagers’ lives in recent decades has generated a range of options hitherto unknown, but the decision-making process with regard to treatment remains within an immediate context of close social relations. The meaning of sickness is still largely constituted through social relations that have persisted from one generation to the next. Sorcery has a continuity of meaning from pre-Islamic times to the present because it has always provided an explanatory link between illness and ever-present strains in village social relationships. From the villagers’ point of view, local variants of biomedicine are part of state-promoted modernist discourse. Until such time as a different engagement with the state evolves through redistributions of power and knowledge, rural people will continue to favor those healing resources which are embedded in the social field of the village. NOTES 1. In other contexts I have described waktu telu and waktu lima as cultural ideologies rather than Islamic variants because of political and cultural implications pertinent to a study of Lombok but not an issue in this chapter. 2. The largest association, Nahdlatul Wathan, was established in Pancor, East Lombok by Tuan Guru Haji Zainuddin Abdul Majid, still active until his death as a very old man in 1997. Tuan Guru Haji Zainuddin Arsyad was the founder of the Maraqittaqlimat association in Mamben, and the other main association, Jamaluddin, was also founded in East Lombok. 3. Approximately 50% of villagers in Elah belong to Nahdlatul Wathan, 30% to Maragittaqlimat, and the remaining 20% to Jamaluddin. 4. There are other types of medicines sold in markets by medicine sellers, such as Chinese patented preparations. 5. Indonesian women from all over the archipelago use commercial cosmetic face masks or make their own from natural products to cleanse and beautify the skin, in much the same way women in Western cultures use cosmetic face masks. 6. Beri-beri basah (I) is the disease beri beri, caused by a deficiency of vitamin B1 and the added symptom of swollen body parts due to the retention of body fluids. 7. This information was confirmed by the doctor when I visited him subsequently. Six million rupiah would at that time have been more than $4,000, a huge expenditure for the household.

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8. Cf. Connor, Asch, and Asch (1996, 159–189); Jordaan (1985, 191); Wikan (1990, 230–264); Geertz (1960, 93). 9. This is the spice galingale (kaempferia galanga). It is similar to ginger (sekuh, sekur [S] ⫽ kencur [I]).

REFERENCES Atkinson, J. M. 1989. The art and politics of Wana shamanship. Berkeley: University of California Press. Brenner, S. 1996. Reconstructing self and society: Javanese Muslim women and “the veil.” American Anthropologist 23(4): 673–697. Connor, Linda H., P. Asch, and T. Asch. 1996. Jero Tapakan: Balinese healer, 2nd ed. Los Angeles: Ethnographics Press. Federspiel, H. M. 1995. A dictionary of Indonesian Islam. Ohio: Center for International Studies, Ohio University. Foucault, Michel. 1973. The birth of the clinic: an archaeology of medical perception. Translated by A. M. Sheridan-Smith. New York: Tavistock Publications. ———. 1979. On governmentality. Ideology and Consciousness 6: 5–21. Geertz, C. 1960. The religion of Java. Chicago: University of Chicago Press. Giddens, Anthony. 1990. The consequences of modernity. Cambridge: Polity Press. Gomes, Alberto, ed. 1994. Modernity and identity: Asian illustrations. Melbourne: La Trobe University Press. Hannerz, U. 1980. Exploring the city. New York: Columbia University Press. Hefner, R. and P. Horvatich, eds. 1997. Islam in an era of nation-states. Honolulu: University of Hawaii Press. Hunter, Cynthia. 1997. Sasak identity and the reconstitution of health: medical pluralism in a Lombok village. Ph.D. diss., University of Newcastle, N.S.W. Australia. Hunter, Cynthia L. 2000. Tradisi and moderen, village and state: emergent tensions in a Sasak health quest. The Australian Journal of Anthropology 11(2): 155–173. Jordaan, R. 1985. Folk medicine in Madura (Indonesia). Leiden: State University of Amsterdam Press. Kahn, J. S., ed. 1998. Southeast Asian identities: culture and the politics of representation in Indonesia, Malaysia, Singapore, and Thailand. Singapore: Institute of Southeast Asian Studies. Kahn, J. S. and Francis Kok Wah Loh, eds. 1992. Fragmented vision: culture and politics in contemporary Malaysia. Sydney: Allen and Unwin. (Asian Studies Association of Australia Publication no. 22.) Lovric, B. 1987. Rhetoric and reality: the hidden nightmare. Ph.D. diss., University of Sydney. Marwick, M., ed. 1982. Witchcraft and sorcery, 2nd ed. Harmondsworth: Penguin Books. Noer, D. 1973. The modernist Muslim movement in Indonesia 1900–1942. Oxford: Oxford University Press. Pigg, Stacey. 1995. The social symbolism of healing in Nepal. Ethnology 34(1): 17–36. Taussig, M. 1980. Reification and the consciousness of the patient. Social Science and Medicine 14B: 3–13. Turner, Victor. 1970. The forest of symbols. Ithaca, NY: Cornell University Press.

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Vasseleu, C. 1991. Life itself. In Cartographies, edited by R. Diprose and R. Ferrell. Sydney: Allen and Unwin. Wikan, U. 1990. Managing turbulent hearts: a Balinese formula for living. Chicago: University of Chicago Press. Woodward, M. 1985. Healing and morality: a Javanese example. Social Science and Medicine 21(9): 1007–1021.

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Medicines and Modernities in Socialist China: Medical Pluralism, the State, and Naxi Identities in the Lijiang Basin Sydney D. White

INTRODUCTION This chapter explores the usefulness of the concept of modernity in general and of distinctive narratives of modernity in particular for contemporary understandings of medical pluralism in the People’s Republic of China.1 The case study presented here focuses on the shifts in therapeutic practices2 of one particular corner of southwest China—Yunnan Province’s Lijiang basin—over the past five decades since the 1949 Chinese Communist Revolution. The Lijiang basin has historically been the political heartland of Naxi people. Contemporary Naxi trace their ancestry to Tibetan peoples who migrated to the Lijiang area from the Qinghai plateau more than a millennium ago, and are currently state- and self-identified as a “minority nationality.” However, Lijiang basin Naxi (in some contrast to Naxi who reside in more remote parts of the Naxi area) have for many centuries been greatly influenced by Chinese state policies and popular culture. Therapeutic practices, along with kinship, marriage, and many other ritual practices, all constitute arenas of basin Naxi culture that have particularly reflected this influence. The socialist (i.e., post-1949) Chinese state has had at least as great an influence on basin therapeutic practices as previous imperial (206 B.C.–1911) and Republican (1912–1949) forms of the Chinese state. I argue that the shifting contours of medical pluralism (or plural therapeutic practices) in the Lijiang basin since 1949 reveal two distinctive narratives of modernity: a narrative of modernity that basin Naxi have themselves shaped in their relationship with the socialist Chinese state, and a larger state narrative of modernity that the People’s Republic of China (PRC) has created during both

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the Maoist (1949–1979) and post–Mao (1979–present) periods. The basin Naxi experience further reveals that the larger PRC narrative of modernity itself has not only been shaped with respect to “Western” and other narratives of modernity, but also with respect to the socialist Chinese state’s “civilizing project” (Harrell 1995) vis-a`-vis its “minority nationality” and other subaltern constituencies. The chapter begins by providing some background on the theoretical problem and on basin Naxi. The core of the analysis is then presented in three subsequent sections in which I address the key shifts in state and basin Naxi narratives of modernity on the one hand, and in state and basin Naxi therapeutic practices on the other. These are each explored during three specific historical periods: just prior to the 1949 revolution, during the Maoist period, and from the beginning of the post–Mao period in 1979 through 1990—the year that marks the “ethnographic present” for this chapter.3 I conclude with a discussion of what shifting Lijiang basin therapeutic practices reveal about a distinctive basin Naxi narrative of modernity which itself is negotiated with respect to a distinctive socialist Chinese narrative of modernity. THE PROBLEM Medical pluralism is, in essence, the politics of therapeutic practices—that is, how relationships of power and meaning are played out between diverse therapeutic practices in a given context and how they shift over time. As such, medical pluralism is integrally linked to the politics of cultural identities. Both identity politics and the politics of therapeutic practices are played out on a variety of levels within and between nation-states, as well as in the transnational spaces that transcend nation-states. The anthropology of modernity4 that has emerged over the past two decades in response to influences from both poststructuralist theory and critical theory provides an exceptionally useful framework for understanding the closely interconnected politics of identity and of therapeutic practices, both of which are embedded within the fabric of the nation-state. While different anthropologists have different working definitions of what constitutes “modernity,” they generally share with scholars of other disciplinary persuasions a definition that encompasses both global capitalist forms of domination and state technologies that normalize citizens (Rofel 1999). For the most part, however, anthropologists have progressively pushed the boundaries of a concept of modernity informed by European experience toward an understanding of modernities in the plural, whether conceived of as “multiple modernities” (Pred and Watts 1992), “alternative modernities” (Appadurai 1996; Ong 1996, 1997, 1999; Rofel 1992), or “other modernities” (Rofel 1999). Some particularly useful reframings of the concept of modernity have come out of anthropological work on the PRC, where the state has played a powerful

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role in shaping the everyday experiences of citizens, and where modernity has perhaps been the key trope influencing both state narratives and the narratives of citizens. Aihwa Ong (1996, 1997, 1999) refers to “imaginaries of modernity” and utilizes the concept of “alternative modernities” to outline several different projects of Chinese modernity, including Maoist and post–Mao shifts in the official PRC state project, a regional project in southeastern China, and an “Overseas Chinese” project of transnational capitalism. Lisa Rofel (1999) uses the term “other modernities” to additionally define modernity as a narrated imaginary—“a story that people tell themselves about themselves in relation to others” (p. 13). Making the critical point that modernity is such a powerful narrative precisely because the nation-state organizes the body politic around it (p. 13), Rofel focuses on the divergent narratives of modernity expressed and experienced by three generationally-distinct cohorts of female silk factory workers in Hangzhou. Ann Anagnost (1997) examines state, intellectual, and popular levels of discourse at various historical junctures during post–Mao, Maoist, and Republican eras in order to develop an understanding of how modern Chinese subjectivities are constituted vis-a`-vis the nation-state in the contemporary PRC. Taken together, these PRC-based studies suggest an approach that takes modernity as a set of discursive practices that are historically contingent, rooted in shifting socialist and capitalist social formations, and frequently contested and renegotiated.5 In the context of the PRC, narratives of modernity are produced at a multiplicity of sites, encompassing (at a minimum) discourses generated by partyand government-produced state policies, the collective discourses of PRC intellectuals, and the popular discourses of various citizens who engage with state narratives from the perspectives of their own positionalities and life experiences. An understanding of the distinctive post–1949 basin Naxi narrative of modernity must take into consideration all of these levels of discourse production.6 THE CONTEXT Geographically, the Lijiang basin and the dramatic Jade Dragon Snow Mountain (at 18,000⫹ feet) that towers above it are part of northwest Yunnan’s Himalayan sweep toward Tibet. The 7,200-foot basin is located at the center of the Lijiang Naxi Nationality’s Autonomous County, with the town of Dayanzhen (referred to as Lijiang by outsiders) in turn located at the center of the basin. Dayanzhen serves as the seat for both the county and the larger Lijiang Prefecture, and as of 1990 had a population of approximately 60,000. Numerous villages are distributed throughout the basin surrounding Dayanzhen. Naxi are the predominant “nationality” (minzu) in the basin itself and constitute approximately 250,000 of the county’s 300,000 residents. The first language of most basin Naxi residents is Naxi-hua, a Tibeto-Burman language, although most basin Naxi also speak the Yunnan dialect of Mandarin. A detailed exploration of basin Naxi history and cultural identities would

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unfortunately take us well beyond the allowable length for this chapter.7 However, it is important for understanding the particular distinctiveness of the basin Naxi narrative of modernity to note here that basin Naxi have historically tended to appropriate the politics of the Chinese state (in its respective imperial, Republican, and socialist forms) in playing out power struggles within their own society. Additionally, basin Naxi men in particular have consistently sought to achieve the statuses that the Chinese state has associated with “culture” (wenhua). Under the imperial state, they embraced the Chinese literati model of classical Confucian education as an ideal and as the potential key to attaining an official position in the Chinese bureaucracy via the imperial examinations. Under both the Republican and socialist states, education and positions in government bureaucracies have continued to be sought-after goals. Since the founding of the PRC, party membership has been regarded as an important avenue to political and economic success by basin Naxi men especially, and many have served as cadres for the state in various government work units throughout Yunnan and the rest of the country. It is also important to note here, however, that despite their endeavors to acquire the symbolic capital that associates them with Chinese “culture,” basin Naxi have maintained a strong, positively imbued consciousness of their own difference beyond—and in many instances despite—the form of difference that the post–1949 state conferred upon them with its designation of the Naxi as a “minority nationality” (shaoshu minzu).8 The following section provides an examination of the relationship between basin Naxi and the Chinese state just prior to 1949. PRE–1949 STATE AND BASIN NAXI EMERGENT NARRATIVES OF MODERNITY There were many discursive strands that informed the various imperial and then Republican “civilizing projects” of the Chinese state. The most salient strand of this project for basin Naxi prior to 1949 was the ideology of “cultural universalism” that lay at the core of the “Confucian civilizing project” (Harrell 1995). Premised on the long-standing discourse of (locale-based) “social customs” (fengsu xiguan), peoples who were targeted to be incorporated into the Chinese empire as well as individuals who were already part of the empire were given leeway to engage in distinctive practices along ethnic, regional, or other lines, so long as they subscribed to a critical core of Chinese cultural practices. Naxi could thus acquire “culture”—in the eyes of the state—by adopting these practices, which encompassed specific therapeutic practices. While in some ways the Republican period Nationalist government (1927– 1949) represented a continuity of the “Confucian civilizing project,” the Nationalists were primarily engaged in a new state project—one of forging a modern nation-state. The larger context was one of national crisis wrought by a post–World War I renewed threat of Western imperialism, internal national strife

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with both warlords and the nascent Communist Party, and Japan’s invasion of China. Debates about Chinese national identity frequently juxtaposed concepts of Chinese “tradition” (chuantong) against a vision of “modernity” (xiandaihua) that was informed by Japanese and various “Western” national models. A state/ intellectual level discussion in which pro-modernism Chinese intellectuals called into question the relative validity of “Chinese medicine” (zhongyi)9 with respect to “Western medicine” (xiyi)10 was a central part of these debates (see especially Croizier 1968). The form of “Western medicine” supported by the Nationalists was then-stateof-the-art biomedicine taught in medical schools set up in China by elite, foreign medical institutions such as Yale, Harvard, and Johns Hopkins. This medical care, however, was based in hospitals in major cities and generally only available to a select (usually urban elite) few. Thus, while Nationalists and Communists alike (at this particular historical juncture) were generally strong proponents of “Western medicine”—which they associated with science, progress, and modernity—and opposed to “Chinese medicine”—which they associated with “tradition”—the overwhelming majority of the population relied on both classical Chinese medicine and other Chinese therapeutic practices. It appears that this was also the case for most basin Naxi. Historically, Naxi culture has been influenced by both Tibet and China. “Bon” (indigenous, pre-Buddhist) practices from Tibet, Tibetan Buddhism, Chinese Buddhism, Daoism, Confucianism, and Chinese popular culture have all informed Naxi therapeutic practices in various forms in diverse parts of the Naxi area at different historical moments. In addition to having been shaped by these external cultural influences, Naxi therapeutic practices have also historically encompassed two distinctive types of ritual practitioners which contemporary Naxi identify as indigenous: dongba (ritual priests) and sanyi (shamans). Indeed, this multifaceted historical legacy was the original reason I selected the Lijiang basin to examine the relationship between medical pluralism and Naxi cultural identities. However, my interviews with basin Naxi informants who came of age before 1949 have indicated that the two primary strategies of therapeutic resort in the basin just prior to 1949 were “self treatment” (ziji zhiliao), based upon household knowledge, and “senior Chinese medicine doctors” (laozhongyi—following Farquhar’s translation, 1995), who were themselves Naxi. Based upon older basin Naxi informants’ descriptions of the types of household practices their own families drew upon before 1949, and the nature of the encounters that they had with practitioners of Chinese medicine, it appears that the primary epistemology11 informing both of these practices was the particular legacy from Chinese therapeutic practices of the “medicine of systematic correspondence” (Unschuld 1985). This was reflected in informants’ etiologies of most afflictions, and represented the underlying logic according to which informants selected the herbal remedies that served as the primary forms of treatment for these afflictions. Informants referred to these herbal remedies as encompassing the post–

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1949 categories of both “Chinese herbal medicine” (zhongcaoyao) and “Naxi folk herbal medicine” (Naxi minjian caoyao). The medicine of systematic correspondence has evolved over the past two millenia, and has integral links to Confucianism and the official culture of the imperial Chinese state (Unschuld 1985). Yin/yang dualisms in physiological, humoral (e.g., hot/cold, dry/wet, etc.), and other arenas parallel the dyadic relationships upon which Confucianism is premised. “Five phase” (wu xing) relationships between bodily organs and a variety of other substances parallel the emphasis on the complex network of relationships intrinsic to the bureaucratic structures of the (imperial) Chinese state. These dyadic and quinary relationships are replicated at the levels of the individual body/self, the local level society/ environment, and the state/cosmos. The “Chinese medicine” informed by the medicine of systematic correspondence was practiced in the pre–1949 basin in much the same way it was practiced (by most accounts) in other parts of China at that time. Basin Naxi practitioners of Chinese medicine were virtually all male, and had either acquired their knowledge as apprentices of their fathers or other older male relatives, or through an apprenticeship with a nonrelated practitioner usually arranged by their parents. They started as young boys and gradually developed expertise over the years through learning from their masters, reading the classic texts of Chinese medicine, and learning through personal experience. While the medicine of systematic correspondence, combined with herbal medicine therapies, appears to have been the prevailing epistemology informing pre– 1949 basin Naxi understandings of affliction and therapeutic practice, informant and scholarly accounts (see especially Goullart 1955) indicate that some other therapeutic practices existed in the basin as well. These practices—as described by informants—for the most part corresponded with popular therapeutic practices in other (Han) parts of Yunnan and China in general. They encompassed fortune telling (suan ming), the exorcism of ghosts or demons (chu gui), the retrieval of lost souls (zhao linghun), and gu witchcraft (see Unschuld 1985; White 1993, 1999). Rituals associated with Buddhist and Daoist voluntary associations also factored into basin Naxi therapeutic practices. It appears, however, that (indigenous) dongba and sanyi practitioners did not play a significant role in shaping basin Naxi therapeutic practices just prior to 1949 (Goullart 1955; White 1993; Chao 1995, 1996). Additionally, neither “Tibetan medicine” (zangyi) nor “Western medicine” apparently played a significant role (White 1993). In short, Chinese therapeutic practices, particularly what had come to be called Chinese medicine (i.e., the medicine of systematic correspondence combined with herbal medicine remedies) but also therapeutic practices from Chinese popular culture, constituted the primary influence on basin Naxi therapeutic practices for at least the several decades prior to 1949. Given the Confucian agendas embedded in the medicine of systematic correspondence in particular,

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it is possible that basin Naxi adopted Chinese medicine along with other Confucianism-informed Chinese practices, and that this perhaps became particularly widespread from the time of the 1723 (Qing dynasty) incorporation of Lijiang into the Chinese empire. While such speculation is difficult to substantiate based on existing historical records, the prevalence and predominance of Chinese medicine and other Chinese therapeutic epistemologies in informing pre-1949 basin Naxi therapeutic practices does suggest that Chinese therapeutic practices were very much a part of the Chinese civilizing project with respect to basin Naxi. The subscription to Chinese medicine in particular and other Chinese therapeutic practices in general on the parts of basin Naxi in the pre– 1949 context can best be understood, I suggest, as an integral part of a larger negotiation of their identities by basin Naxi with respect to the civilizing agendas of the Chinese state. The medicine of systematic correspondence/Chinese medicine was to become the core of the socialist Chinese state’s formulation of “(Traditional) Chinese medicine” and, I will argue, an implicit (if not explicit) part of the PRC’s own “civilizing project.” MAOIST PERIOD STATE AND BASIN NAXI NARRATIVES OF MODERNITY The establishment of the socialist Chinese state with the 1949 revolution marked the creation of a narrative of modernity that contrasted with the previous Republican state’s juxtaposition of Chinese “tradition” and Western “modernity.” The Maoist narrative of modernity drew primarily—at least initially—from the Soviet Union’s model. It encompassed both a discourse of socialist modernity (as distinct from Western bourgeois capitalist modernity), and a unilinear social evolutionary discourse of history derived from Friedrich Engels’ adaptation of Lewis Henry Morgan’s late nineteenth-century scheme. It also reworked and carried forward many long-standing “culture” agendas of the Chinese state from the various imperial and Republican civilizing projects. (See also Gladney 1991; White 1993, 1997; Harrell 1995; McKhann 1995.) According to Mao Zedong’s vision, the PRC’s socialist narrative of modernity was to encompass science and technology, which were associated with “progress” (fazhan), but not the less desirable aspects of bourgeois Western capitalist society. Furthermore, “revolutionary tradition” (geming chuantong), which included the “good” parts of Chinese “tradition” deemed to be close to the “simple life” of “the people,” was to be incorporated into this modernity project. “Revolutionary tradition” was in turn juxtaposed against the “bad” parts of Chinese “tradition” from the “old society” (jiu shehui) that were deemed to reflect “feudal superstition” (fengjian mixin) and “backwardness” (luohou) and were banned by the time of the Cultural Revolution (1965–75). This distinction between “good tradition” and “bad tradition” was played out in the PRC state distinction be-

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tween “official” (guanfang) and “unofficial” (fei guanfang) practices (Link et al. 1989). The long-standing state discourse of “culture” thus took on new meanings encompassing this distinction for Naxi as it did for other Chinese citizens. It was the unilinear social evolutionary discourse of history, however, that had the greatest implications for Naxi and other citizens of the PRC who had become newly designated as “minority nationalities.” While this discourse took on different implications for Naxi and other minorities during different political movements in the Maoist period, for the most part minorities became categorized as “relatively less advanced” (bijiao luohou) on the social evolutionary scale than Han, and consequently were perceived of as more “backward” in terms of social and especially “cultural” development. Thus, while Naxi were distinguished from most other minorities as “relatively advanced” (bijiao fada) by the state (since the scripts associated with dongba practitioners endowed the Naxi with a status of “being literate”—you wenhua), they were technically (i.e., according to state ethnological criteria) still not as “advanced” as the Han. This Maoist discourse of backwardness (in terms of social evolutionism and socialist modernity) was directed not only to “borderland minority nationality areas” (bianjiang shaoshu minzu diqu) but also to “peasants” (nongmin) and “the countryside” (nongcun). The party imbued the urban-based areas of the PRC with an image of Chinese socialist modernity that set a standard for a (Han) Chinese cultural nationalism. The mission of urban work teams and youth work teams during the Cultural Revolution, for example, was to develop the “backward” minority and rural areas. This unilinear social evolutionist view of Chinese history combined with an urban-centric perspective also served to reframe the long-standing state discourse of “culture.” In keeping with their historical modus operandi, however, basin Naxi (including officials, scholars/intellectuals, and “the people” in general) attempted to negotiate these new state policies, discourses, and practices in a manner that placed them in the most advantageous position possible (at least in terms of symbolic capital) for any given political movement. Thus, Naxi did indeed acquire a new status as an officially designated minority nationality (which was recorded on their residence and other identification cards), and were indeed classified in an economic, social, and cultural evolutionary slot that was more “backward” than the Han in the new official discourse of “cultural development” (albeit “relatively advanced” compared to other minorities). Basin Naxi, however, mediated and appropriated these new discourses just as they did earlier civilizing discourses of the Chinese state (see White 1997, 1998a). Throughout the Maoist period, the vast majority of basin Naxi were active supporters of state policies and vigilant adherents to every political movement. Given the prevailing antidifference and assimilationist tenor of the Maoist period (despite the minority nationality form of difference that the Maoist state had itself imposed upon them), Naxi themselves tended to downplay their difference and go along with state agendas. Nonetheless, they maintained a distinctive insider versus outsider consciousness.

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Therapeutic Practices Both the emergent Maoist period narrative of socialist Chinese modernity and basin Naxi negotiations of it had implications for therapeutic practices in the basin. The distinction established in the early 1950s between “official” and “unofficial” practices very much reflected the new contours of the PRC narrative of socialist modernity. Selective aspects of Chinese medicine were sanctioned as official and seen as integral to the PRC modernity project, while other aspects were designated as unofficial and antithetical to this project. Therapeutic practices designated as official during the Maoist period—in the basin as well as throughout the PRC—included “Chinese medicine,” “Western medicine,” “integrated Chinese and Western medicine” (zhongxiyi jiehe), and “folk medicine” (minjian yixue). Only these therapeutic practices were technically designated as “medicine” (yixue), and became associated with the public health discourse of “hygiene” (weisheng)12 in the socialist modernity project. All other types of therapeutic practices were relegated to unofficial status on the grounds that they were “unscientific” (bu kexue), “backward,” and reflective of the “feudal superstition” associated with the “old society” prior to 1949. For basin Naxi, this meant that fortune-telling, exorcism of ghosts and demons, retrieval of lost souls, and gu witchcraft were no longer etiologies that could be openly acknowledged or strategies of therapeutic resort in which citizens could be openly engaged. It also meant that other ritual practices engaged in by various members of basin Naxi society, such as those associated with Tibetan Buddhism, Chinese Buddhism, Daoism, Confucianism, and/or other aspects of Chinese/Naxi popular culture, were also banned. The primary epistemology informing etiologies and strategies of therapeutic resort in the basin—that is, the medicine of systematic correspondence—was not as directly affected by the Maoist banning of unofficial practices as were other popular therapeutic practices in the basin. The medicine of systematic correspondence was, however, very much influenced by the new Maoist configuration of official medical practices. “(Traditional) Chinese medicine” (hereafter referred to as TCM),13 the official PRC practice of Chinese medicine, reflected a reformulated medical practice whereby the medicine of systematic correspondence, the pharmaceutical canon, and a variety of techniques such as acupuncture, moxibustion, and acupressure were standardized and “scientized” (see Croizier 1968; Farquhar 1994). The medicine of systematic correspondence, for example, was essentially “sanitized” of “feudal superstition” by the deletion of the more abstract, elaborate cosmologies from the classical texts. A heavy emphasis was placed on the practical, the material, and the scientific, a process which entailed the simplification of all “systematic correspondence” relationships—including yin/yang relationships, five-phase relationships, and concepts of bodily substances and bodily flows. In the Maoist narrative of socialist Chinese modernity, this was the way in which the “good tradition” (i.e., “revolutionary tradition”) aspects of Chinese medicine

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could be distinguished and salvaged from those “feudal supersition” aspects of Chinese medicine that were to be exorcised. Through this process, Chinese medicine (albeit of a reinvented vintage) was reclaimed as a critical icon of national identity in the PRC narrative of modernity, in stark contrast to its vilification during the Republican period. The official PRC practice of biomedicine, designated as “Western medicine” and hereafter referred to as WM, was also a Maoist-period creation. In the 1950s, Mao broke with physicians who had been trained during the Republican era in an elite-focussed, urban-based, hospital-centered practice of biomedicine. It was at this juncture that Mao declared TCM a “national treasurehouse,” and that biomedicine was reenvisioned, reformulated, and reorganized to enable the new, more pragmatic, broad-based, public-health-oriented practice of WM. In keeping with other national practices of biomedicine (see Lock 1993), biomedicine in the PRC developed its own distinctive characteristics as a practice. Integrated Chinese and Western medicine (hereafter referred to as integrated medicine) emerged as a consciously formulated hybrid medical practice that was introduced by Mao during the Cultural Revolution as the cornerstone of national health policy (see White 1998b, 1999). It was originally envisioned as the epistemological handmaiden of the “cooperative health care system” (hezuo yiliao— of barefoot doctor fame). Ideally, it was to represent a synthesis of the best of TCM and of WM (see Revolutionary Health Committee, A Barefoot Doctor’s Manual, 1977). And although it was initially implemented in both urban and rural areas, it was in fact geared toward the health care needs of the rural PRC in particular. It emphasized primary health care, specifically preventive care and treatment of basic health problems and health emergencies. In integrated medicine, the body became understood according to both WM criteria of anatomy and physiology and TCM criteria of the “five viscera” (wu zhuang) and “six bowels” (liu fu). WM diagnostic and treatment techniques were utilized along with TCM techniques, with a heavy (and pragmatic) emphasis on the use of herbal medicine. “Folk medicine” was the official category established during the Maoist period to acknowledge medical practices other than Chinese and Western medicine. It came to encompass aspects of folk and popular Chinese therapeutic practices that were perceived of as more “scientific” (kexue) and therefore as more legitimate (i.e., than those that had been designated as feudal superstition)—particularly local and/or regional herbal medicine remedies that were not part of the formal pharmaceutical canon of Chinese medicine. It also came to encompass some “minority nationality” medical practices such as Tibetan medicine and Yi medicine, which were seen as discrete practices in terms of “theory,” “techniques,” and “materia medica” (see below). In the Lijiang basin, “Naxi folk herbal medicine” was recognized as a form of folk medicine, albeit one described in basin Naxi and state public health discourses alike as “without [its own] theory” (mei you lilun—i.e., no theory distinguishable from TCM theory) informing the pharmaceutical usage of its materia medica.

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The Maoist period establishment and implementation of these four official practices through public health policies and institutions reshaped the contours of the previously existing Chinese medicine and other Chinese therapeutic practice informed discourses and practices in the basin. In Dayanzhen, where most of the public health bureaus, hospitals, and clinics were established beginning in the 1950s, the newly reformulated practices of TCM and WM became the epistemologies with which town residents engaged when they sought health care. As was the case elsewhere during the 1950s and early 1960s in the PRC, Dayanzhen medical institutions operated according to an epistemological and institutional division of labor between TCM and WM. The Prefectural Hospital and the County Hospital each maintained separate WM and TCM departments that mutually engaged in cross-referrals, but maintained no other detailed coordination. There was additionally the County Chinese Medicine Hospital that engaged solely in the practice of TCM. For the duration of the Cultural Revolution, all three institutions shifted to the revolutionary practice of integrated medicine (indeed, it was counterrevolutionary to do otherwise), but returned to their former epistemological/institutional division of labor arrangement as soon as the Cultural Revolution began to wind down. In contrast, in basin brigades (now villages) integrated medicine became thoroughly institutionalized as the prevailing therapeutic practice starting from its implementation in the late 1960s. Rural residents engaged with this new practice that endeavored to combine TCM and WM when they sought out treatment from brigade cooperative health care practitioners. I have argued in detail elsewhere (see White 1999) that, notwithstanding integrated medicine’s ostensibly hybrid approach to the Maoist reformulated practices of WM and TCM, the Chinese medicine legacy of the medicine of systematic correspondence persisted—albeit reframed by post–1949 TCM influences—as the primary logic informing the practice of integrated medicine in the rural Lijiang basin. I have further argued that integrated medicine is likely the official medical practice (of the four outlined above) that was most shaped by popular culture influences (or the culture of “the masses”) given the local license in interpreting state policy engaged in by brigade practitioners and lay rural residents alike—at least in the case of the rural Lijiang basin. (For basin Naxi, of course, this meant primarily Han Chinese popular culture influences.) Both rural and urban basin residents were vigilant adherents to the Cultural Revolution policy encouraging the widespread collection and utilization of herbal medicine—“Chinese herbal medicine” and “Naxi folk herbal medicine” alike. An important characteristic of all four official medical practices was that— on policy, clinical, and popular levels—an analytical distinction was made between the “medical theory” (yixue lilun), the “medical techniques” (yixue jishu), and the “materia medica” (yixue yaowu)—or pharmaceuticals—associated with any given practice. Theory, techniques, and pharmaceutical substances associated with one practice could thus be “detached” and incorporated into another practice without there being a perception that the integrity of a given practice

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(as determined by any one of these domains) had been violated. Thus, for example, injections of antibiotics were viewed as an integral part of all four official practices. This was true throughout the PRC as well as in the basin, and was itself an artifact of the “scientizing” legacy of the Maoist period. In other words, the critical issue was not whether a practice was associated with biomedicine/ WM, Chinese therapeutic practices/TCM, or Naxi therapeutic practices, but whether it was viewed as science or feudal superstition, and consequently whether it could be construed as part of the Maoist project of Chinese socialist modernity (see also Croizier 1968). This is a legacy that has continued into the post–Mao period, to which I will now turn. POST–MAO STATE AND BASIN NAXI NARRATIVES OF MODERNITY There have been significant transformations in the PRC narrative of socialist modernity in the post–Mao period, beginning with Deng Xiaoping’s leadership. Like Mao, Deng’s vision was one of “socialism with Chinese characteristics” (jiyou Zhongguo tese de shehuizhuyi) and encompassed a distinctively Chinese socialist vision of modernity. Unlike Mao, however, his vision of the “Four Modernizations” (sige xiandaihua—industry, agriculture, science and technology, and national defense) that were to be the salvation of the PRC entailed “opening” China to the world capitalist economic system and the nonsocialist world in general. This led to a reframed post–Mao narrative of modernity that has also been played out on the levels of state, intellectual, and popular discourses. In particular, there was a significant shift in the discourse of “backwardness” between the Maoist and the post–Mao periods. During the post–Mao period, the discourse on backwardness formerly confined to minorities, peasants, and specific locales was extended to whole regions of China (i.e., those less economically and culturally “developed”) and even to major urban/cosmopolitan centers of China itself as juxtaposed against the West and Japan. Nonetheless, Maoist legacies have continued to influence this post–Mao narrative of modernity— particularly in terms of the concepts of “progress” and “history” rooted in socialist modernity and in unilinear social evolutionism. Along with the all-pervasive post–Mao discourse of progress and backwardness, the state also overtly fostered a strong sense of cultural nationalism that most Chinese citizens have come to share. This post–Mao vision of cultural nationalism has been imagined by the state and citizens alike both in terms of China’s potential for soon-to-be-realized economic ascendancy and in terms of China’s cultural capital, rooted in its “ancient culture” (gulao wenhua) and “twothousand years of history” (liang qian nian de lishi). In this way, the discourse of “culture,” so long associated with the Chinese civilizing project, has been reworked in this particular historical moment using the trope of “Chinese traditional culture” (Zhongguo chuantong wenhua). Furthermore, although the

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post–Mao narrative of modernity has emerged through an engagement (albeit state-controlled) with the world capitalist economic system, the PRC has turned for both economic and nation-building practices primarily to other East Asian models of modernity rather than to Western models (see Ong 1996, 1997, 1999). In the post–Mao period, another official discourse has emerged that valorizes specific forms of difference—including certain “minority nationality,” “local place,” “folk,” and “regional” cultural practices. This valorization of aspects of difference has in some respects contradicted and in some respects been consistent with the broadened post–Mao discourse of backwardness. With respect to minority nationalities, this new discourse valorizing difference has created contradictions that have been played out both in terms of state minority policies and the state and popular discourses they have generated, and in terms of various minority responses to these policies. After Deng came to power in 1978, the PRC began to strongly promote the representation of China as a “multinationalitied country” (duaominzu guojia) that was formulated during the Maoist period. Whereas most Maoist period depictions of minorities were generally directed toward the goal of demonstrating the unity of the masses in supporting class struggle with the aim of attaining a truly socialist society, during the post–Mao period minority difference in general and certain minority cultural practices in particular have become reified, fetishized, reinvented, and even created. This has been the case both with respect to the representation of minorities in state and popular culture and with respect to the active participation of minorities themselves in this process for their own agendas (Blum 1992, 1994; Schein 1993; White 1993, 1997, 1998a; Gladney 1994; Chao 1995, 1996; Walsh 1997). Just as certain dimensions of minority difference have become icons of the post–Mao Chinese socialist state, so have dimensions of rural, local place, folk, and regional difference become icons of the state. The “reemergence of tradition” (both in terms of life-cycle and annual-cycle rituals) associated with the post–Mao period in the rural PRC has reflected the revitalization (Potter and Potter 1990) and/or the (re)invention (Siu 1989) of pre–1949 cultural practices. This has been considerably facilitated by the post–Mao government’s “softening,” to a degree, of the distinction between official and unofficial practices. While this distinction still exists, many practices formerly (i.e., during the Maoist period) designated as “unofficial” have become officially tolerated, if not sanctioned, as part of an emergent “popular culture.” The long-standing Chinese discourse of “social customs” has been revived in the current post–Mao period to encompass lines of “minority nationality,” “local place,” “folk,” and/or “regional” difference. All of these types of difference have played into a discourse of national internal difference that, on one hand, has celebrated difference for its “colorfulness,” but, on another hand, has used difference as a gauge of relative “backwardness.” Not unlike the U.S. multiculturalism project (see Goode and Schneider 1994), this discourse has enabled the celebration of cultural difference in the PRC without an engagement with the structural and historical

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implications of this difference along lines of rural/urban residence, ethnicity/ race, gender, and class. Not surprisingly, basin Naxi have drawn upon all of these often contradictory post–Mao state, intellectual, and popular discourses of difference to position themselves in the best light possible in situationally specific circumstances (see White 1997, 1998a). When positioning themselves with respect to discourses of socialist modernity, social evolutionism, and “culture” (as it has been redefined in the post–Mao period), basin Naxi have aligned themselves as closely as possible to Han Chinese norms (as opposed to actual Han people). Individual basin Naxi would state, for example, that Naxi were pretty much the same as Han, and that, indeed, certain Naxi were Han since many could trace their patrilineages back to Han ancestors who came to the basin in the Ming or Qing dynasties. Basin Naxi would also state that, while Naxi were “not as advanced” as Han (a statement usually prefaced with “although” and made quickly in a dismissive way), Naxi were “relatively advanced” compared to other minorities, since they had a “written language” (you wenzi), an “ancient history” (lishi hen gulao), and a “relatively high level of culture” (wenhua shuiping bijiao gao—i.e., as gauged by Naxi education levels and sociocultural practices in alignment with Han norms). On the other hand, when positioning themselves with respect to post–Mao discourses that valorize difference—particularly minority difference—Naxi have emphasized their uniqueness vis-a`-vis Han. They have outlined certain “Naxi social customs” (e.g., their “dongba culture,” Naxi herbal medicine, certain annual cycle rituals, and their gender system) that distinguish them from other “nationalities” (including Han). And, in some circumstances, in what I have referred to elsewhere (White 1997) as a discourse of “Naxi greatness,” Naxi have emphasized their superiority over Han and, indeed, their rightful preeminent position in the world. This particular state discourse of minority difference and basin Naxi appropriations of it to form a discourse of Naxi exceptionalism have served basin Naxi well in terms of promoting tourism (international and domestic), international development projects, and economic development in general in the Lijiang basin (see also Swain 1990). Therapeutic Practices The shifts in the post–Mao narrative of modernity and basin Naxi responses to it have had implications for basin therapeutic practices as well. Specifically, the relationships between the official medical practices of the Maoist period have been reconfigured—particularly the relationship between TCM and WM. Additionally, the “softening” of the distinction between official and unofficial practices and the “reemergence of tradition” have recast the status of certain pre– 1949 basin therapeutic practices that were labeled as “feudal superstition” during the Maoist period. As was the case during the Maoist period, the four officially recognized therapeutic practices—TCM, WM, integrated medicine, and folk medicine—have

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continued to be the only therapeutic practices technically regarded as “medicine” in the PRC. While medicine, “hygiene,” and public health have remained centerpieces of ongoing PRC discourses of socialist modernity and “culture” (see Figure 9.1), all four official practices have become more professionalized, “scientized” (in a manner different than the Maoist period), and commoditized in the post–Mao period. The post–Mao reestablishment of longer periods of training, more stringent standards, and a deepened sense of hierarchy in medical schools, as well as the implementation of certification procedures for alreadypracticing medical practitioners, are all factors that have contributed to the reprofessionalization of medicine. The centralization, privatization, and commoditization of health care have made comprehensive health care increasingly more inaccessible and unaffordable for rural residents and ever-larger numbers of urban residents. TCM has continued to be an icon of PRC national identity, but in a somewhat different fashion than during the Maoist period. As outlined earlier, Mao’s vision of TCM reflected the incorporation of “good (Chinese) tradition” into the scientific, practice-oriented, revolutionary agendas of the Chinese socialist modernity project. In the post–Mao discourse of modernity, the “scientization” of TCM as an official practice has indeed continued to be emphasized, but from a more commoditized perspective that stresses extensive phytochemistry research on active properties of herbal medicines and actively seeks out the investment of international funds to support its research and international markets to purchase its products. From another perspective, the Maoist “national treasurehouse” iconicity of TCM has been reshaped to conform to the contours of the emergent post–Mao discourse of “Chinese traditional culture.” On both official and popular levels, TCM has been construed as part of China’s “two thousand year history” and as integral to the post–Mao discourse of cultural nationalism. Its supremacy to WM (on the basis of its ability to “cure the root” of an affliction, its slow, gradual manner of healing, and its lack of side effects) has become a litany in this constantly reiterated state and popular discourse. In the post–Mao institutional division of labor between TCM and WM, the relationship between the two has been separate but perhaps not as equal as it was (in theory, at least) during much of the Maoist period. In terms of state funding for research and development, WM appears to have become prioritized over TCM. One manifestation of this has been the extensive purchase of expensive, “hi-tech” medical equipment that is perceived of as an important form of symbolic capital in the post–Mao modernity project far beyond its actual medical uses. Despite these transformations, biomedicine in the PRC has continued to reflect a distinctive national practice. In the post–Mao town context of Dayanzhen, most Naxi residents have had the option of choosing TCM or WM as institutionally segregated forms of treatment in clinics or hospitals (see Figure 9.2). On a popular level in Dayanzhen, however, as elsewhere in the basin and probably throughout the PRC, the prevailing epistemology that has informed understandings of affliction has been the

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Figure 9.1. A Lijiang basin family takes in a public poster message on “hygiene and civilization,” strategically located on a major thoroughfare in the “new city” part of Dayanzhen. Photo by Sydney White.

medicine of systematic correspondence/Chinese medicine in its reshaped Maoist and post–Mao forms. Lay etiologies for the most common afflictions of Dayanzhen lay (town) residents have thus been quite similar to the perspectives of lay basin villagers. In the villages of the Lijiang basin, and probably throughout much of the rural PRC, integrated medicine has persisted as the primary form of therapeutic resort. This has been the case despite the dismantling of cooperative health care with post–Mao decollectivization, and despite the privatization and professionalization of rural health care practitioners (which in the basin really only involved nominal examinations in either TCM or WM that had no bearing on whether or not a practitioner could continue to practice). I have argued elsewhere (White 1999) that this has been due both to the fact that the state never replaced integrated medicine with any other initiative, and to the fact that integrated medicine as a practice was particularly influenced by popular discourses of therapeutic practice. As outlined earlier, for basin villagers these popular discourses were rooted in the prevailing epistemology of the pre–1949 medicine of systematic correspondence influenced practice of Chinese medicine. The medicine of systematic correspondence/Chinese medicine that was reshaped in its Maoist engagement with TCM and WM in the rural practice of integrated medicine has continued to be the primary epistemology informing village etiologies of most afflictions in the post–Mao period.

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Figure 9.2. Like most PRC hospitals, this hospital contains both Western medicine and Chinese medicine departments and is an icon of socialist Chinese modernity. Photo by Sydney White.

Folk medicine has also continued to be state-sanctioned, but emphasis has been placed on researching aspects of folk pharmaceuticals—especially folk/ minority nationality herbal medicines—believed to have medicinal or economic value. Herbal medicine in general has become big business for domestic and international markets, and Yunnan specialists estimate that 50% of the PRC’s herbal medicine supply is produced in Yunnan Province. Basin Naxi have become actively engaged in the booming post–Mao herbal medicine market, both as cultivators and collectors. While epistemologies deriving from the medicine of systematic correspondence have predominated in both town and village contexts of the basin, in keeping with other parts of the PRC there has been a post–Mao “reemergence” of certain practices formerly banned as unofficial into the officially tolerated (if not sanctioned) arena of “popular culture.” Most prominent among these practices have been fortune-telling and, in basin villages, gu witchcraft (see White 1993, 1999)—both of which reflect long-standing Chinese popular culture legacies. Basin informants have also said that shamanism (focused on exorcistic rituals) began to be practiced covertly in some basin villages by individuals whom they referred to as sanyi, but that this was not very common (indeed, I found no informants who had heard of any specific instances).14 Much of the post–Mao “revitalization” of “tradition” in the basin has taken the forms of elaborate life-cycle ritual celebrations (especially weddings, funerals, and first-

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month baby parties) and an intensive focus on the building of newer and more ornate houses. CONCLUSIONS That Lijiang basin Naxi understandings of affliction in the post–1949 period have essentially continued to be dominated by the medicine of systematic correspondence/Chinese medicine epistemology—rather than by indigenous Naxi narratives of affliction or WM narratives of affliction—is revealing of two distinctive narratives of modernity. On one level it reveals a socialist Chinese state narrative that has spanned both the Maoist and post–Mao periods; on another level it reveals a basin Naxi narrative that reflects how basin Naxi have positioned their identities as PRC citizens with respect to the state. Both narratives of modernity have incorporated discourses of “culture” and of difference rooted in earlier forms of the Chinese state. The basin Naxi experience suggests that the medicine of systematic correspondence-informed practice of Chinese medicine in particular has been a significant technology not only for the civilizing project agendas of the imperial Chinese state, but also—in the form of TCM—for the civilizing project agendas of the Maoist and post–Mao incarnations of the socialist Chinese state. The peoples that occupy the symbolic and often geographic margins of the Chinese state have long played an important role in how the state has defined itself, and “minority nationalities” have certainly been writ large in the ongoing post-Mao project of socialist modernity. This is not to say that borderland/minority peoples have been the only citizens of the Chinese state subjected to the civilizing agendas of Chinese medicine in particular and therapeutic practices in general. All therapeutic practices embody potent, coded social messages, including messages related to social control. Under the socialist Chinese state, powerful messages of citizenship and social control have been explicitly and implicitly imparted through therapeutic practices. The state’s designation of certain therapeutic practices as “unofficial” has been as much a part of this as has been its formulation and deployment of specific “medical practices” as “official.” Discourses of hygiene, science, medicine, and technology have played an integral role in both Maoist and post–Mao narratives of modernity. “Peasants” (Han and non-Han), like minority nationalities, have been particularly targeted for PRC discourses of hygiene given their “backward” cultural status. Notwithstanding the powerful role that Chinese medicine/TCM has arguably played historically in shaping Naxi citizens as subjects of the Chinese state, nor the degree to which basin Naxi have accommodated these and other Chinese cultural practices, basin Naxi have also historically appropriated state and popular discourses and practices to position their individual and collective identities to the best advantage. Prior to 1949, this entailed acquiring core Chinese cultural practices (including, I suggest, the medicine of systematic correspondence) nec-

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essary to establish themselves as part of a “cultured” Chinese state arena. During the Maoist period, despite the socialist state-imposed discourse of “minority nationality” difference and its intrinsic positioning of the Naxi as social evolutionarily “backward” vis-a`-vis the Han, basin Naxi nonetheless maneuvered to position themselves as “relatively advanced” vis-a`-vis other minorities, and as powerful constituents of the Chinese Communist Party and advocates of the revolutionary agendas of the state. The enthusiastic adoption of official Chinese medical practices by basin Naxi and their vigilant eschewing of unofficial therapeutic practices were integral to this endeavor. And since the beginning of the post–Mao period, Naxi have positioned themselves optimally both with respect to the state’s more hierarchical discourses of socialist modernity, social evolutionism, and “culture,” and with respect to the state’s more recent discourses valorizing difference—notwithstanding the obvious contradictions between these two particular sets of discourses. In representing this distinctive basin Naxi narrative of modernity, it is important to understand basin Naxi as historically having maintained a consistently strong sense of a special identity—regardless of whether that identity has been variably premised on place-based, ethnicity-based, or even class-based difference. The particular narrative of modernity that basin Naxi have created under the Chinese socialist state has not been merely reactive to the state’s shifting narrative of modernity. Naxi have actively appropriated state discourses in very distinctive ways on an ongoing basis. The post–1949 basin Naxi experience with respect to therapeutic practices is quite revealing of the Chinese socialist state’s shifting narrative of modernity with respect to discourses of internal difference. It is equally revealing of the PRC’s distinctive narrative of modernity with respect to “Western” and other narratives of modernity. Therapeutic practices have played an integral role in Republican, Maoist, and post–Mao framings of Chinese modernity. I have argued here that, with respect to therapeutic practices, the Republican juxtaposition of “[Chinese] tradition” against “[Western] modernity” was reframed by the Maoist narrative of Chinese socialist modernity that aligned “[good] revolutionary tradition” with science, progress, and technology, and juxtaposed this against “backward feudal superstition.” Post–Mao framings of PRC modernity have perpetuated this vision to a degree, but, given China’s reengagement with the nonsocialist world, “Chinese traditional culture” (including TCM) is sometimes an integral part of Chinese socialist modernity, and sometimes located in an ambiguous space betwixt and between scientific socialist modernity and backward feudal superstition (see also Yang 1996). As has been argued by Ong (1996, 1997, 1999), Rofel (1999), and others, it is important to acknowledge the agency of different constituencies that have engaged in shaping specific narratives of modernity. Like the basin Naxi narrative of modernity, the PRC narrative of modernity is not merely reactive to Western and other narratives of modernity. Rather, it is very much informed by China’s own distinctive historical experience and by China’s emergent senses

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of national identity. The shifting relationship between the PRC medical practices of TCM and WM have played a central role in shaping this narrative of modernity, but both medical practices must be understood as distinctive PRC practices in and of themselves, with contours that are constantly being reshaped. In closing, I suggest that the concept of distinctive narratives of modernity can be extremely useful for contemporary understandings of medical pluralism in the PRC.15 As outlined earlier, the politics of therapeutic practices are inextricably linked to the politics of cultural identities, and both are played out on a variety of levels within and between nation-states. In the contemporary PRC, modernity is an all-encompassing state narrative that permeates all facets of everyday experience for virtually all citizens. Various constituencies of the Chinese socialist state—whether along minority nationality, rural/urban residence, and/or other lines of difference—in turn negotiate their own narratives of modernity vis-a`-vis the state and their own respective experiences. Medical discourses and therapeutic practices are an integral part of this process. NOTES 1. For research funding, I am indebted to the Committee on Scholarly Communication with the People’s Republic of China (CSCPRC—now CSCC), the Wenner-Gren Foundation for Anthropological Research, Sigma Xi, a UC Berkeley Humanities Grant, a UCB Department of Anthropology Lowie Scholarship, and a summer research grant from the Temple University Center for East Asian Studies. I am also indebted to the Kunming Institute of Botany for their tremendous support as my host institution in the PRC. A study leave from Temple University has greatly facilitated the writing of this chapter. I am especially grateful to Donna Goldstein for her invaluable critical feedback on an earlier draft. Special thanks to Linda Connor for her wonderful support and suggestions throughout the writing, and to Geoffrey Samuel for his excellent critical comments and editorial suggestions on the final draft. Responsibility for any errors or misrepresentations made here is mine alone. 2. Throughout this chapter, I use “therapeutic practices” as a generic term of reference for healing strategies in an effort to avoid some of the assumptions embedded in the term “medical” (see Worsley 1982). I use the term “medical” when referring to therapeutic practices designated by the socialist Chinese state as official medical practices. 3. Findings presented here are based on eighteen months of comparative fieldwork research on therapeutic practices and cultural identities in village and town contexts of the Lijiang basin, primarily during 1989 and 1990. 4. See Lisa Rofel’s (1999) excellent overview of this literature. 5. See also Mayfair Yang’s (1994) important discussion on Chinese modernity. 6. I draw upon the intersections between the anthropology of modernity and the anthropology of modern China in my usages of the terms “projects,” “agendas,” “narratives,” and “discourses.” Throughout this chapter, the “projects” to which I refer and their associated “agendas” are those of the Chinese state, and include the projects of the imperial state as well as those of the modern nation-state (see Harrell 1995; Ong 1996, 1997, 1999); as Ong has demonstrated, however, constituencies other than the state (e.g.,

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transnational “Overseas Chinese” constituencies or regional constituencies within the PRC) can also have projects and agendas. My usage of “narratives” and “discourses” is of course very much indebted to the understandings of modernity and governmentality that Michel Foucault has linked to the rise of the nation-state, with specific reference to how the institutions that constitute the nation-state generate discourses that themselves embody power/ knowledge formations (1977a, 1977b). As a China scholar, I of course find Foucault’s European-experience-informed conceptualizations of modernity and governmentality simultaneously extremely useful and extremely problematic for understanding China. I follow work outlined above by Rofel (1999) and Ong (1999) in my specific use of the term “narratives” in the context of China, especially because of the sense of agency and dynamism it can potentially provide to ethnographic endeavors. For purposes of expediency—and to avoid a confusion of “orders”—I refer to a variety of historically specific “discourses” as constituting larger “narratives” of modernity, though certainly these terms are used interchangeably by many scholars. 7. See McKhann (1992, 1995), White (1993, 1997, 1998a), and Chao (1995, 1996) for recent ethnographic work on Lijiang Naxi based on long-term fieldwork research. 8. For an analysis of how gender constructions inform contemporary basin Naxi identities, see White (1993, 1997). 9. The term “Chinese medicine” is itself an artifact of the late Qing dynasty/nineteenth century that was created by its discursive juxtaposition to “Western medicine” (see Croizier 1968, 1976; Unschuld 1985, 1992; Sivin 1987). Since that time, the Chinese state, Chinese intellectuals, and English-language speakers have come to use the term “Chinese medicine” to refer to the scholarly, classical text-based, Confucian stateassociated, and diversely interpreted therapeutic practice that Paul Unschuld (1985) has glossed as “the medicine of systematic correspondence.” This was in fact but one of a panoply of therapeutic practices that emerged from varied social contexts at different historical moments in China (see Unschuld 1985). In this chapter, I use the term “Chinese therapeutic practices” to invoke an all-encompassing sense of this diverse legacy of practices, particularly with respect to how they have come to influence popular practices in the PRC. 10. “Western medicine” is the literal translation of the term used in most Chinese societies to refer to biomedicine. During the Republican period, it also encompassed the legacy of “missionary medicine” introduced to China by Western missionaries beginning in the late nineteenth century. 11. In using the terms “epistemology” and “epistemological” throughout this chapter, I invoke the important contribution made by anthropologists in their understandings of epistemologies and knowledges as “how people know what they know” (Crandon 1987; Farquhar 1987; Leslie and Young 1992; and Worsley 1997). Michel Foucault’s concept of power/knowledge (1977b) and Donna Haraway’s concept of situated knowledges (1991) also represent important contributions to reformulated anthropological understandings of epistemologies and knowledges. 12. I would argue that the discourse of “hygiene” is more pervasive in PRC state policies than the discourse of “medicine.” Whereas “medicine” is perhaps much more neatly associated with the science and technology agendas of the socialist modernity project, “hygiene” is imbued with many of the Confucian civilizing project “culture” agendas that have carried over into the “Communist civilizing project” (Harrell 1995). Stevan Harrell has drawn attention to the links between discourses of hygiene and discourses of minority nationality “backwardness” in the PRC (1995). “Public health”

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(gonggong weisheng), which refers more to the public health infrastructure, is one component of the larger PRC discourse on hygiene. 13. Deferring to the prevailing English-language scholarly convention, I use the term “TCM” to refer to this post–1949, official, state-sanctioned therapeutic practice (see Furth 1999). It should be noted, however, that the Chinese term for TCM literally translates as “Chinese medicine,” with no reference to the term “traditional.” See Judith Farquhar’s (1994, 1995) and Elisabeth Hsu’s (1992) excellent ethnographic analyses of TCM as an institutional practice in the PRC. See also Nathan Sivin’s (1987) important analysis and translation of a PRC key TCM textbook. 14. Emily Chao (1995, 1996) states that such practitioners in the contemporary basin tend to be Bai or Han rather than Naxi. 15. See also Vincanne Adams’ and Craig Janes’ important contributions in this volume (Chapter 11 and 10, respectively). See also Adams’ (1996) important work theorizing the relationship between medical practices and the anthropology of modernity in Nepal.

REFERENCES Adams, Vincanne. 1996. Tigers of the snow and other virtual Sherpas: an ethnography of Himalayan encounters. Princeton, NJ: Princeton University Press. Anagnost, Ann. 1997. National past-times: narrative, representation, and power in modern China. Durham, NC: Duke University Press. Appadurai, Arjun. 1996. Modernity at large: cultural dimensions of globalization. Minneapolis: University of Minnesota Press. Blum, Susan D. 1992. Ethnic diversity in Southwest China: perceptions of self and other. Ethnic Groups 9: 267–279. ———. 1994. Han and the Chinese other: The language of identity and difference in southwest China. Ph.D. diss., University of Michigan. Chao, Emily Kay. 1995. Depictions of difference: history, gender, ritual and state discourse among the Naxi of Southwest China. Ph.D. diss., University of Michigan. ———. 1996. Hegemony, agency, and re-presenting the past: the invention of Dongba culture among the Naxi of Southwest China. In Negotiating ethnicities in China and Taiwan, edited by Melissa J. Brown. Berkeley: Center for Chinese Studies and Institute of East Asian Studies. Crandon, Libbet. 1987. Introduction, Symposium on the Cultural Epistemology of Medical Systems. Social Science and Medicine 24: 1011–1012. Croizier, Ralph C. 1968. Traditional medicine in modern China: science, nationalism, and the tensions of culture change. Cambridge, MA: Harvard University Press. ———. 1976. The ideology of medical revivalism in modern China. In Asian medical systems: a comparative study, edited by Charles Leslie. Berkeley: University of California Press. Farquhar, Judith. 1987. Problems of knowledge in contemporary Chinese medical discourse. Social Science and Medicine 24: 1013–1021. ———. 1994. Knowing practice: the clinical encounter of Chinese Medicine. Boulder, CO: Westview Press. ———. 1995. Re-writing traditional medicine in Post-Maoist China. In Knowledge and the scholarly medical traditions, edited by Don Bates. Cambridge: Cambridge University Press.

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Foucault, Michel. 1977a. The archaeology of knowledge. London: Tavistock. ———. 1977b. Discipline and punish: the birth of the prison. London: Penguin. Furth, Charlotte. 1999. A flourishing yin: gender in China’s medical history, 960–1665. Berkeley: University of California Press. Gladney, Dru. 1991. Muslim Chinese: ethnic nationalism in the People’s Republic. Cambridge, MA: Harvard University Press. ———. 1994. Representing nationality in China: refiguring majority/minority identities. Journal of Asian Studies 53: 92–123. Goode, Judith and Jo Anne Schneider. 1994. Reshaping ethnic and racial relations in Philadelphia: immigrants in a divided city. Philadelphia: Temple University Press. Goullart, Peter. 1955. Forgotten kingdom. London: John Murray. Haraway, Donna. 1991. Situated knowledges: the science question in feminism and the privilege of partial perspective. In Simians, cyborgs, and women: the reinvention of nature. London: Routledge. Harrell, Stevan. 1995. Introduction: civilizing projects and the reaction to them. In Cultural encounters on China’s ethnic frontiers, edited by Stevan Harrell. Seattle: University of Washington Press. Hsu, Elisabeth. 1992. Transmission of knowledge, texts, and treatment in Chinese medicine and Qigong: three settings in Kunming City, P.R.C. Ph.D. diss., Cambridge University. Leslie, Charles and Allan Young. 1992. Introduction. In Paths to Asian medical knowledge, edited by Charles Leslie and Allan Young. Berkeley: University of California Press. Link, Perry, Richard Madsen, and Paul G. Pickowicz, eds. 1989. Unofficial China: popular culture and thought in the People’s Republic. Boulder, CO: Westview Press. Lock, Margaret. 1993. Encounters with aging: mythologies of menopause in Japan and North America. Berkeley: University of California Press. McKhann, Charles F. 1992. Fleshing out the bones: kinship and cosmology in Naxi religion, Volume One. Ph.D. diss., University of Chicago. ———. 1995. The Naxi and the nationalities question. In Cultural encounters on China’s ethnic frontiers, edited by Stevan Harrell. Seattle: University of Washington Press. Ong, Aihwa. 1996. Anthropology, China and modernities: the geopolitics of cultural knowledge. In The Future of anthropological knowledge, edited by Henrietta L. Moore. New York: Routledge. ———. 1997. Chinese modernities: narratives of nation and of capitalism. In Ungrounded empires: the cultural politics of modern Chinese transnationalism, edited by Aihwa Ong and Donald Nonini. New York: Routledge. ———. 1999. Flexible citizenship: the cultural logics of transnationality. Durham, NC: Duke University Press. Potter, Sulamith Heins and Jack M. Potter. 1990. China’s peasants: the anthropology of a revolution. Cambridge: Cambridge University Press. Pred, Allan and Michael John Watts. 1992. Reworking modernity: capitalisms and symbolic discontent. New Brunswick, NJ: Rutgers University Press. The Revolutionary Health Committee of Hunan Province. 1977. A barefoot doctor’s manual. Seattle: Cloudburst Press.

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Rofel, Lisa. 1992. Rethinking modernity: space and factory discipline in China. Cultural Anthropology 7: 93–114. ———. 1999. Other modernities: gendered yearnings in China after socialism. Berkeley: University of California Press. Schein, Louisa. 1993. Popular culture and the production of difference: the Miao and China. Ph.D. diss., University of California at Berkeley. Siu, Helen. 1989. Recycling rituals: politics and popular culture in contemporary rural China. In Unofficial China: popular culture and thought in the People’s Republic, edited by Perry Link, Richard Madsen, and Paul G. Pickowicz. Boulder, CO: Westview, Press. Sivin, Nathan. 1987. Traditional medicine in contemporary China. Ann Arbor: Center for Chinese Studies, University of Michigan. Swain, Margaret. 1990. Commoditizing ethnicity in Southwest China. Cultural Survival Quarterly 14 (1): 26–29. Unschuld, Paul U. 1985. Medicine in China: a history of ideas. Berkeley: University of California Press. ———. 1992. Epistemological issues and changing legitimation: traditional medicine in the twentieth century. In Paths to Asian medical knowledge, edited by Charles Leslie and Allan Young. Berkeley: University of California Press. Walsh, Eileen Rose. 1997. Ethnic imaginations: images of Chinese ethnic minority women. Paper presented at the American Anthropological Association Annual Meeting, November, Washington, DC. White, Sydney D. 1993. Medical discourses, Naxi identities, and the state: transformations in socialist China. Ph.D. diss., University of California at Berkeley. ———. 1997. Fame and sacrifice: the gendered construction of Naxi identities. Modern China 23 (3): 298–327. ———. 1998a. State discourses, minority policies, and the politics of identity in the Lijiang Naxi People’s Autonomous County. Nationalism and Ethnic Politics 4 (1&2): 9–27. ———. 1998b. From “barefoot doctor” to “village doctor” in Tiger Springs Village: a case study of rural health care transformations in socialist China. Human Organization 57: 480–490. ———. 1999. Deciphering “integrated Western and Chinese medicine” in the rural Lijiang basin: state policy and local practice(s) in socialist China. Social Science and Medicine 49: 1333–1347. Worsley, Peter. 1982. Non-western medical systems. Annual Review of Anthropology 11: 315–348. ———. 1997. Knowledges: culture, counterculture, subculture. New York: The New Press. Yang, Mayfair Mei-hui. 1994. Gifts, favors, and banquets: the art of social relationships in China. Ithaca, NY: Cornell University Press. ———. 1996. Tradition, travelling theory, anthropology and the discourse of modernity in China. In The future of anthropological knowledge, edited by Henrietta L. Moore. New York: Routledge.

PART III

HEALING, POWER, AND IDENTITY IN TIBETAN SOCIETIES

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Tibetan Medicine at the Crossroads: Radical Modernity and the Social Organization of Traditional Medicine in the Tibet Autonomous Region, China Craig R. Janes

INTRODUCTION: THE HEALTH TRANSITION AND ASIAN MEDICAL SYSTEMS In Asia, the collision of radical, transnational modernity with indigenous medical systems has transformed the nature of local healing practices. In the past three decades, recognition of the potential utility of indigenous medicines to public health, and, in some cases, the demand-induced profitability of traditional pharmaceuticals, has resulted in an accelerated pace of change. Perhaps the most significant historical event for indigenous medicines in the late twentieth century was the World Health Organization’s recommendation in 1978 that traditional medicine be integrated into national health care systems (WHO 1978). From an anthropological standpoint the proposal was naı¨ve, uncritical, did not acknowledge the complexities involved in assessing efficacy, and was not cognizant of the difficulties posed by uniting medical systems widely divergent in their theoretical systems under the banner of modern science (e.g., Leslie 1980; Lock 1990; Singer 1988). What appears in World Bank and WHO reports is an essentialized traditional medicine; a kind of voluntary community health network that can under some circumstances be harnessed to deliver basic biomedical services ranging from drug dispensing to midwifery (World Bank 1993, 129). Despite what can surely be termed an abundance of anthropological critique of the international assumption of the pragmatic utility of indigenous medicines, there has been little change in this viewpoint. Indeed, worldwide changes in epidemiologic patterns now seem to be propelling nonorthodox medicines again

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onto center stage. The last decade has seen increasing attention given to the positive functions of nonorthodox medicines for addressing the complex health concerns of those suffering chronic disease in developed countries where biomedicine has achieved substantial structural and cultural dominance over health policy. The paradox of the epidemiologic transition is that the basic social and economic principles that likely propelled (but may not sustain) the transition— global modernity and the cultural dominance of Western science—have invariably led to the rationalization and “scientification” of alternative medicines. The organizational, political, and cultural dominance of scientific biomedicine, although it creates the demand for alternatives, also means that such indigenous medicines struggle for greater social and cultural legitimacy by acknowledging or strengthening the scientific basis of their practices, skills, and medications, and deemphasizing their often radically different epistemologies (Janes 1995, 1999a; Lee 1982; Chi et al. 1996; Chi 1994). Ethnic and nationalist sentiment continues, and will continue, to keep some aspects of indigenous medicines from a complete surrender to biomedical epistemology; however, the central theoretical and practical question in the study of indigenous medical systems is to understand how they transform themselves in response to these aspects of radical, transnational modernity. Tibetan medicine as it is organized and practiced in China offers an important case study of how indigenous medicines both adapt and respond to the changing structural and cultural conditions of global modernity. China, more than perhaps any other country, has remained committed to the development and sustainability of a large indigenous component to its primary health care system. Although pressure from the dominant scientific paradigm, combined with the organizational transformations of traditional medicines, has had an impact on Tibetan medicine, it has not eroded its theoretical or epistemological basis to any great degree. Yet Tibetan medicine has had to and must continue to respond to a shifting array of economic, structural, and political influences. This chapter explores the complex intersection of global modernity and local cultural and body politics in contemporary Tibet. In the following pages I examine three topics: (1) the organization and practice of Tibetan medicine in contemporary China (as of 1993); (2) the political and economic forces that have transformed both the role of Tibetan medicine in the primary health care system of the Tibet Autonomous Region (TAR), and the way in which it is practiced; and (3) the perspectives and behaviors of the users of Tibetan medicine. The chapter extends my previously published analyses (Janes 1995, 1999a, b) of Tibetan medicine.1 TIBETAN MEDICINE IN MODERN CHINA An important element of health care policy in postrevolutionary China is the incorporation of indigenous medicine into the primary health care system (Cro-

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zier 1968; Lee 1982). Tibetan medicine, already partly integrated into the structures of the Tibetan government prior to the Chinese takeover in 1951, was favorably poised for official recognition by Chinese health authorities (Janes 1995). The 1950s saw several important scholarly exchanges between Tibetan and Chinese medical scholars, and the Tibetan medical hospital in Lhasa and its medical staff were formally recognized as providing important services to the Tibetan people. Tibetan medicine was thus defined early on as a fully developed and respected member of the “family” of Chinese medicines. In 1959, when, subsequent to a failed uprising against the Chinese by Tibetan resistance groups, Beijing took direct control of the Tibetan government, the hospital and college of Tibetan medicine were fully legitimized and provided modest government subsidies. Although the Cultural Revolution was to have a substantial and largely negative impact on Tibetan medicine, as it did on Tibetan society and culture as a whole, at no time did Tibetan medicine lose its state legitimacy. When the reforms of the Deng Xiao-ping era took hold in Tibet after 1980, Tibetan medicine went through a period of significant state-sponsored growth. Most important, the main Tibetan medical hospital became an autonomous unit of the Tibet Autonomous Region Health Bureau, and the Tibetan medical college was formally integrated into the educational bureaucracy through affiliation with the new regional Tibet University in Lhasa. The main hospital, the Lhasa Mentsik’ang,2 and the affiliated medical college, are now the authoritative center of state Tibetan medicine in China, establishing policy throughout the region, and supervising the training of all new doctors (see Figure 10.1). Thus, from a strictly institutional and organizational perspective, Tibetan medicine weathered successfully the revolutionary vicissitudes of late twentieth-century China. By 1993, state Tibetan medicine was distributed throughout Tibetan regions of China in the same fashion as were public health and biomedicine-based primary health care services (see, for example, Hsiao and Liu 1996; M. Young 1989). It is commonplace to speak of China’s “three-tiered” system of primary care, referring to county-level, township, and village facilities. In the TAR and other Tibetan regions it is useful to add what is commonly termed the “prefecture” level to any discussion of health services. The prefecture is an administrative unit below that of the Autonomous Region (province), and above that of the county (see Map 10.1). In the TAR there are six prefectures, each of which has a health department and Tibetan medical hospital.3 Since 1985 Tibetan medicine has been rapidly integrated into the top three tiers of the system. By 1993, Tibetan medicine had been successfully deployed to the county level, and in some areas to the township level, in the three prefectures we surveyed (Lhasa, Shannan, and Xigazeˆ ). Village health stations do not generally possess a formally trained Tibetan medicine physician, though village health workers may have some practical knowledge of Tibetan medicine. In 1991 the Lhasa Mentsik’ang director reported that the health bureaus throughout the ethnic Tibetan regions of West and Southwestern China, including the TAR, employed 1,553 Tibetan medicine physicians. Table 10.1 shows the num-

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Figure 10.1. Lhasa Outpatient Mentsik’ang from Jok’ang Temple. Photo by Craig Janes.

ber of doctors of Tibetan and Chinese biomedicine for selected counties in the Central Tibetan prefectures, in 1991.4 The table also shows the ratio of physicians to population. The ratio of biomedical physicians to population in these rural counties is 1:1,094, approximately the same as for China generally, while the ratio of Tibetan medicine physicians to population (1:4817) is higher than the ratio of traditional practitioners to population in China as a whole (M. Young 1989; Jamison et al. 1984). Demand for Tibetan medicine in rural areas, combined with the rapid deployment of young Tibetan physicians to the countryside, suggest that the ratio of Tibetan medicine doctors to population will be reduced substantially, though health reform efforts will have a negative impact on physician numbers in poor, rural areas (see below). In townships and counties, Tibetan medical doctors practice alongside those trained in, as the Tibetans term it, “foreign” or “Chinese-Western medicine.” In most counties Tibetan doctors have been provided separate office, examination, and pharmacy space, though in some, pharmacies remain combined. Under such circumstances, biomedical and Tibetan medicine practitioners each come to learn a great deal about the other’s medicine, and some integration at the clinical level subsequently occurs. Despite their smaller numbers, Tibetan medicine physicians will treat as many, if not more, patients than their biomedicine-trained colleagues. At the county level and below, Tibetan-trained physicians are subject to the direct authority of the county hospital and health bureau director. Unlike the

Map 10.1. The Tibet Autonomous Region

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Table 10.1 Number of Physicians and Inpatient Beds by Selected Counties, Central Tibet Autonomous Region Prefectures

practice of Tibetan medicine in the prefecture or Lhasa Mentsik’angs, where individual practice patterns are not subject to close scrutiny by those outside the institution, rural Tibetan doctors are required to be responsive to county medical directors. Medical directors, while in most cases Tibetan and interested in maintaining Tibetan medicine, are nevertheless trained in biomedicine, and thus bring a highly practical, Western scientific perspective to organizing health services in their counties. In Gyangzeˆ (Gyantse) county in Xigazeˆ prefecture, for example, the medical director in 1993 insisted that Tibetan doctors confine their practice to conditions that he views as responsive to, or especially responsive to, Tibetan medicine: chronic ailments of all kinds, particularly gastrointestinal disorders, arthritis-like conditions, high blood pressure, and disorders he defined as “mental” in origin. Above the level of the county, Tibetan medicine continues to remain administratively, if not socially, a distinct institution, and this is reflected in practice styles, age, and experience of practitioners, and the degree to which the tradition of Tibetan medicine is more overtly articulated and defended. In the three prefectures where we collected data (Lhasa, Xigazeˆ , and Shannan), all had administratively and physically separate Tibetan medical hospitals which in 1993 included clinical facilities, medicine factories, and residences for staff. Each also received independent budget appropriations from the prefectural health bureau and from the traditional medicine bureaus of the TAR as well as Beijing. So, while at the regional level Tibetan medicine maintains a singular institutional

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identity, each prefecture has the freedom to develop Tibetan medicine within the general policy guidelines established by the regional health bureau and the Lhasa Mentsik’ang. The specific policies and ideologies of a Mentsik’ang director and Communist Party secretary5 may have an impact on a specific hospital: who is hired, how doctors practice, and so forth. Furthermore, as will be discussed later, each of the Mentsik’ang work units, under the present climate of economic reform, is expected to devise strategies for generating income supplementary to the state’s rapidly declining appropriations. THE POLITICAL ECONOMY OF PRIMARY HEALTH CARE IN THE TIBET AUTONOMOUS REGION Mao Zedong considered universal access to health care to be among the first goals of socialist reform (Tang et al. 1994). The government invested, in the context of its then undeveloped economy, a tremendous level of human and financial resources in public health and health care. The investment paid off handsomely in terms of reduced mortality and increased life expectancy (by 1990 the infant mortality had fallen to 31 per 1,000 births, and life expectancy had increased to 69 years [Hsiao 1995, 1047]). As a consequence of these quite remarkable achievements, China’s health care system became a model for other developing countries (Jamison 1985), and for the primary health care strategies adopted by the WHO-Alma Alta convention of 1978 (Jamison et al. 1984; M. Young 1989). Despite celebratory discourse in the West over its achievements, health care in China has been subject to serious internal conflicts since the revolution, and these conflicts have greatly accelerated under the modernization programs launched by Mao’s successors (Hsiao 1995; Tang et al. 1994). As Chen (1989) and Crozier (1968) observed (see also Chapter 9 by Sydney White in this volume), there is a history of conflict over health policy between urban and rural sectors, and between biomedicine and “traditional medicine.” Health policy has vacillated significantly between a commitment to universal access and more restricted financing policies, and between a celebration of traditional or integrated traditional-modern medicine and a commitment to the dominance of biomedicine (Chen 1989). Beginning in the 1980s, China’s health policy began to undertake marketoriented reforms. In particular, a number of changes to health care financing were undertaken in order to reduce government investment in, and control over, the health care sector. These reforms have substantially changed the manner in which health care and medicines are distributed, and have eroded the right to universal access so highly touted during the early postrevolutionary period. Public funding of health care has been reduced, and local hospitals, clinics, and work units have been invited to undertake several market-based activities to generate additional income to replace lost government revenues. As a result, local institutions rely increasingly on fee-for-service financing mechanisms. Fur-

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thermore, provincial and regional governments in China have largely shifted control of health department budgets to county and township hospitals and clinics. Last, government has greatly relaxed the rules and regulations that governed private practice (Hsiao 1995). Health development is thus restricted to the more affluent sectors of China’s rapidly growing market economy. As Hsiao and Liu (1996) predict, under this system, increasing scarcity and inequity will come to characterize health care in regions at the margins of China’s rapidly growing economy. The Tibet Autonomous Region is clearly one of these marginal regions. Although Beijing has undertaken several market-based economic reforms to “develop” the economy of the region, most reforms have bypassed ethnic Tibetans in favor of Han (ethnic Chinese) immigrants (Goldstein 1997; Janes 1999a, b; Sharlho 1992). Economic reforms have, if anything, exacerbated the ethnic conflict that has characterized the TAR since 1951, and, in particular, have failed to erase Tibetan recollections of the overt racism of the Cultural Revolution period (Sharlho 1992). Ethnic conflict, fuelled both by failed economic reforms and experienced discrimination at the hands of ethnic Chinese, largely defines the metamedical social and political context within which Tibetan medicine is both practiced and sought (Janes 1999a, b). Of particular importance here is the degree to which Tibetan medicine provides an important and politically “safe” setting for the expression of Tibetan identity, and, as well, a forum for articulating a rejection of the development discourses of modern China (see Janes 1999a). Unlike the institutions of religion, which not only symbolize to Beijing the feudal past but have become closely identified with resistance to Chinese sovereignty (Goldstein 1997), Tibetan medicine has been considered by Beijing to be politically nonthreatening, and has since the 1980s carefully maintained an ethic of service that is easily reconcilable with socialist ideology (see Figure 10.2). Well off the main stage of ethnic conflict, Tibetan medicine is thus an important and potentially revitalizing element of modern Tibetan culture (as it exists in the TAR). Tibetan medicine is seen as encompassing the genius of Tibetan culture, and may represent one of the last public contexts where Tibetan ideas about the body-mind, social ethics, and the consequences of modernity can be freely and legitimately expressed. It is thus unsurprising that Tibetan medicine offers for Tibetans multiple idioms for expressing the loss of cultural identity, conflicts arising from rapid economic modernization, and ethnic/racial discrimination (Janes 1995, 1999b). Despite occupying such a central social and cultural role in modern Tibetan society, however, Tibetan medicine must also respond to the policy environment which defines the terms under which all medical systems in China must operate. Of particular concern here is the extent of market reforms to primary health care in China and the degree to which such reforms presently affect the practice of Tibetan medicine. As described above, health reforms in China have involved a change in fi-

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Figure 10.2. Consultation, Women’s and Children’s Department, Lhasa. Photo by Craig Janes.

nancing mechanisms, a decentralizing of budget control, and an overall significant reduction in state subsidies for all forms of official medical practice. The impact of these reforms on Tibetan medicine has been significant. State subsidies of Tibetan medicine on all levels has declined rapidly, with financing increasingly provided by individual patients and a small number of enterprise and laborbased insurance plans. In poor rural areas, the lack of cash has precipitated a decay of the overall health system, and has clearly constrained the number and quality of services provided by Tibetan medicine doctors. Of particular importance here is the decline in budgets for medicines. Supplies of Western, as well as Tibetan, medicines have dwindled significantly in township and county clinics. Given its relatively lower cost, greater accessibility, and the high levels of patient demand, Tibetan medicine has not suffered nearly so much from declining budgets as have some of the biomedicine-based facilities. However, Tibetan hospitals and doctors have been forced to engage in a number of budget-enhancing activities that have diverted health care resources from unprofitable rural areas. For example, hospitals and clinics that once received most of their operating revenues from the TAR Health Bureau, now receive somewhere between a third and quarter of revenues from this source, having to make the balance up either directly from patients and the sale of medicines, by engaging in non-health-related business enterprises, or by relying on special supplementary funds from government offices in Lhasa and Beijing whose area of interest is “traditional medicine.”

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Medicine manufacture and sales have become big business. The main medicine factory in Lhasa, producing the largest numbers and volume of Tibetan medicines (over 60,000 kg of 400 different varieties in 1992), has become an independent fiscal entity, encouraged to produce for profit. It in turn sells drugs at above cost to Tibetan facilities throughout the region, and, increasingly, internationally. Given increasing demand for Tibetan medicines throughout China, Nepal, and India, and a growing demand in the West, the incentive to produce for non-Tibetan markets is now placing enormous pressures on supplies as well as production standards. Within Tibet, Tibetan medicine-selling shops have sprung up in a number of towns and cities, often operated by the governmentsubsidized hospitals and clinics. These shops sell medicines, particularly the highly valued “precious pills,” directly to the public, often with substantial markup. Rural areas, where most Tibetans live, are being increasingly bypassed in the rush to provide medicines for more well-heeled consumers. Additionally, the regional Mentsik’ang in Lhasa, and many of the prefecturelevel Tibetan medicine hospitals have begun to comply with government encouragement to engage in profit-making enterprises (Xizang Ribao [People’s Daily of the TAR], Feb. 2, 1994). Many of these activities are clearly unrelated to medical practice, and often take doctors away from their main business of seeing patients. Hospitals we studied invest in local real estate, build and manage shop space, open and operate restaurants, and, increasingly, are establishing private, for-profit facilities, staffed by the most experienced physicians and stocked with the highest quality medicines. High-priced (in the context of China) specialty clinics have been opened by TAR-based Tibetan medicine facilities in Chengdu, Xian, and Beijing. A clinic for foreigners was established in 1991 at the Lhasa Holiday Inn. In early 1993, Lhasa Mentsik’ang staff were being encouraged to invest a portion of their salaries in an investment fund. At the time no decision had been made as to the purpose of the fund, but staff were told it would be used to invest “in business,” presumably to return an investment that would substantially supplement their regular salaries. In summary, the organization of Tibetan medical services is determined in large part by the nature of its relationship to the formal health bureaucracy of the Tibet Autonomous Region, and the international political-economic forces that drive health reform throughout China. As a significant player in the delivery of basic primary health care services, it is constrained both by formal regulatory processes and by a range of economic factors. Tibetan medicine must now be at least partially responsive to market forces, which means orienting elements of practice to populations willing to pay fees, and, of course, placing an increased emphasis on producing services and medicines as commodities for profit-oriented exchange. In the short term the practical consequences of these forces on Tibetan medicine are threefold. First, the decline of state subsidies has and will continue to have a substantial impact on the availability of doctors and medicines in the rural areas already marginalized in China’s program of modernization. The variety of medicines

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and the seniority of physicians will decline as experienced physicians and a wider array of popular medicines are reserved for distribution to urban populations in Tibet and elsewhere. Second, transnational fascinations with Buddhism generally, and with Tibetan culture more specifically, will further propel the production of an “authentic” Tibetan medicine for world consumption. Although Tibetan medicine as it is practiced in the exile communities is better-positioned to exploit such transnational interest, it is clear that the Mentsik’angs of the TAR have taken advantage of the interest in Tibet to open clinics for foreigners and Chinese in many of the major cities of China. In these clinics the white coats and hats that symbolize for Lhasans “scientific” state Tibetan medicine are exchanged for traditional garb and thangka-bedecked consultation rooms. Ironically these symbolic accouterments of native Tibetan genius found outside China, represent in Tibet, at least according to formal Chinese political discourse, superstition and feudal backwardness. Third, the market potential of Tibetan medicine is one of the factors that drives a program of modernization within the Mentsik’ang in Lhasa. Cognizant of the market potential for Tibetan pharmaceuticals, particularly if they can be advertised as “effective” according to the terms of conventional Western science, the Mentsik’ang and the main medicine factory have embarked upon a series of research projects designed to both develop and evaluate a select number of Tibetan drugs. MAKING TIBETAN MEDICINE “SCIENTIFIC” Despite reluctance by many physicians to embrace the epistemology of Western science, Tibetan medicine, like many Asian medical systems, has not been able to fully avoid pressures to become more “modern” (Janes 1995; Lee 1982). Biomedicine has in China achieved the cultural authority to define what constitutes disease, and alternative systems must grapple with and at least acknowledge this authority. In Tibet this means accepting the legitimacy of multiple ways of viewing the body, and for Tibetan practitioners, reconciling classical epistemology and nosology with the Chinese variant of biomedicine (see Janes 1995). As Adams (Chapter 11, this volume) argues, this may not necessarily result in a complete acceptance of biomedical epistemology; it does however require that Tibetan medicine accept the cultural authority of science in its production of a “modern” Tibetan medicine. As a consequence, there has been a self-conscious effort on the part of the Lhasa Mentsik’ang leadership to engage in what they call “research.” This activity largely involves subjecting the products of classical scholarship—therapeutic procedures and medicinal compounds—to systematic scientific research. A research department was established in 1973, and physicians with a special interest in research, generally defined as an interest and expertise in Tibetan pharmaceuticals, have been assigned to work in this department. Work in the

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research department has proceeded in two directions: evaluating Tibetan pharmaceuticals using standard clinical trials methodology (usually in conjunction with the regional biomedical hospital or the Army hospital), and compiling textbooks and monographs on particular elements of Tibetan medicine. It is as yet difficult to assess the impact such activities may have on Tibetan medicine. In 1993 the research department was inactive. Despite lots of talk about building laboratories and working with biomedical researchers, the level of ongoing scientific activity appeared to be quite modest. It is likely that Tibetan medicine will endeavor to “modernize” in some fashion in order to maintain its official standing in the region. The extent and degree to which the leadership of the Lhasa Mentsik’ang accepts rather than resists cosmopolitan, scientific domination will have a significant impact on the provision of recognizable health care services to a Tibetan community that is itself changing very rapidly. As Adams (Chapter 11, this volume) suggests, the continued development of a viable and distinct Tibetan tradition will rest in the abilities of Mentsik’ang physicians and scholars to navigate a complex social and cultural situation and produce knowledge that remains rooted in Tibetan cultural understandings of sickness, while at the same time acknowledging to some degree the legitimacy of cosmopolitan alternatives. Adams’ discussion of how women’s reproductive health care has provided a strategically important avenue to revitalize Tibetan medicine as being neither traditional or biomedicalized is a positive example. Whether Tibetan medicine can become central to a process of cultural revitalization will rest on the success of these and similar efforts, particularly as these efforts respond to and integrate contemporary Tibetan articulations of distress and suffering. TIBETAN PERCEPTIONS OF THE BODY, ILLNESS, AND CAUSALITY The users of Tibetan medicine play a strategic role in the contemporary rapid development and official legitimization of Tibetan medicine. The explosion of demand for services, particularly in the rural sectors of the region, has been the dominant force driving the deployment of government-trained and -funded physicians down to the township level. Without such demand, the shape and form of Tibetan medicine, the extent to which it is subject to the authority of the state, the level of its present political power, and the particular position it holds in China’s implementation of its ethnic policy in Tibet would be quite different. In order to understand the nature of this demand, and the motivations of users, it is necessary to consider the following interrelated topics: nonspecialist views of illness and the body, dominant folk etiologies, and patterns of resort. In addition, Chinese social, political, and economic policies have driven Tibetans to take their illnesses to Tibetan physicians, and in so doing have not only increased numerical demand, itself significant in a bureaucratic society, but

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have subjected Tibetan medicine to appropriation by a lay public concerned with expressing peculiarly Tibetan distresses (Nichter 1981). There are few historical sources that report directly on Tibetan ethnoanatomy, folk etiology, or idioms of distress. Some information can be gleaned from sources that mention healing in passing (e.g., Tucci 1967; Snellgrove and Richardson 1968), or from personal accounts of pre-Chinese Tibet. Of these, probably the most useful is a reflection of life growing up in the Sakya region of south-central Tibet (Norbu 1987). Last, the anthropological literature, now ample, on the Tibetan-Sherpa of Nepal can be assumed, with caution, to apply to pre-1951 Tibet. Most important with respect to healing are the published works of Adams (1992, 1996) and Ortner (1978). Together these sources paint a picture of a system of knowledge and behavior that is highly complex, comprised as it is of Buddhist, shamanic, and humoral constructs of the mind-body and the misfortunes and suffering to which it is susceptible. Corresponding in some sense to differing levels of explanation, these various components produced a pluralistic medical system with an array of folk, religious, and secular healers, each approaching illness in a particularly distinctive way.6 Case study and key informant interviews collected between 1991 and 1993 show that in large part this cultural system of healing, as a corpus of knowledge and belief, remains intact (Janes 1995). However, the Chinese government, acting in accordance with the tenets of its socialist policy, has over time suppressed sectors of the health system to which these knowledge and beliefs corresponded. Until very recently (1991 according to Lhasans), divination was expressly forbidden. Concomitant with the decline of divination as a health care seeking strategy, other elements of the healing system, for example, tantric rites (skurim), went “underground,” and have reappeared only recently. Generally, the informants we spoke with acknowledged that such activities continue, but pointed out that fear of government reprisals made people reticent to speak of them. In our case study interviews, most individuals questioned suggested that divination, particularly in the case of a persistent illness, was desirable, as were certain religious rituals (mostly the reading of texts by monks) designed to both prevent and treat illness. Thus while traditional medical pluralism continues to be seen, its shape, scope, and the availability of certain kinds of services has since 1951 been substantially transformed. It might be argued, in fact, that this traditional pluralism has largely collapsed into the public and private institutions of scholarly Tibetan medicine. This system, however, is not accustomed by the nature of its knowledge and activities, by the training of its physicians, nor by the policies of the health bureau, to respond to inquiries, demands, or offer explanations of an overtly religious nature. Most physicians, in the government system at least, were loath to address religious matters, claiming that such was expressly forbidden. However, a few older physicians, well-known to the public, did actively

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Table 10.2 Illnesses Most Frequently Cited by Mentsik’ang Patients (from a free-listing exercise, Lhasa, 1992)

Note that “lung” (1) in this table has its normal English meaning, while “lung” (2) refers to the nye´ pa or humor (W rlung).

suggest alternatives of a religious nature. Of course, private practitioners,7 under less governmental scrutiny, were more active in this area. Most important, however, Tibetan physicians appear to be increasingly tolerant of explanations for illness that draw upon wider social and environmental factors, including political oppression, job immobility, family conflict, and so forth (Janes 1999b). In case study and key informant interviews we sought to determine how Tibetans thought of health and illness as these are manifested in the workings of their body-minds, and how illnesses are categorized. We asked individuals to “free-list” all the illnesses they could think of, recording Tibetan terms for each. We then asked them to discuss the causes of the listed complaints (cf. Bernard 1994, 239–242; Trotter 1981). These data are summarized in Tables 10.28 and 10.3. From the perspective of reporting and describing illness, the body is seen as a system of linked organs. Each organ system is susceptible to a distinct pathophysiology, and corresponds to particular clusters of symptoms. The elaboration of organs is overlaid by humoral theory, most commonly notions of hot and cold, with coldness being particularly emphasized. The characteristics of “heat” and “cold” are associated with the proper functioning of the organ systems. “Fire” or heat, for example, is essential for proper digestion and operation of the liver and spleen; in order to function correctly the kidneys require a

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balancing of heat and cold, with coldness upsetting kidney function most seriously. While reference to organ systems is the most common way to categorize symptoms (e.g., “liver problems” refers to a syndrome of liver pain, dizziness, nausea, and headaches), occasionally the formal humoral terms are adopted by the lay public to denote particular kinds of symptoms. For example, the term for the humor bile, tr’ipa, is used in lay contexts interchangeably with “liver problems.” Lung, which has been discussed in depth elsewhere (Janes 1995, 1999b), refers to a cluster of somatic-emotional complaints, particularly dizziness, headaches, back and neck pain accompanied by insomnia, dysphoria, anger, or frustration. Table 10.39 lists the most frequently cited causes that correspond to the illnesses listed in Table 10.2. Sickness is frequently described as having multiple causes, which are in turn often presented by laypeople as having proximate as well as remote levels. The table demonstrates the generally multifactorial nature of causation in this cultural setting: most typical explanations emphasize diet and hot/cold imbalances, and less often will explicitly reference social, emotional, religious and ethical factors. In order to examine the issue of causality in a more in-depth way, in 1991 we collected 56 illness case studies from patients seeking care at the Lhasa Mentsik’ang outpatient facility. We asked individuals to reflect on the causes of their problem as well as on those things, such as behavior or food, that seemed to exacerbate the most troublesome of their symptoms. Tables 10.4 and 10.5 summarize this analysis. Table 10.410 lists the general diagnostic category into which the individuals’ particular illnesses fell. Table 10.5 summarizes the full range of explanatory models offered us. The humoral and distinctively Tibetan moral-religious nature of explaining illness in part explains the high use of Tibetan medical resources. Our informants repeatedly told us that their expectations regarding dietary and behavioral advice were only met in the context of their visits to a Mentsik’ang, and that this increased their confidence in the care they received. Regardless of nature and severity of an individual’s symptoms, it might be surmised that in the context of the regulated, generally oppressive, and constrained social atmosphere of modern, urban Tibet, the particular context of Tibetan medicine, especially now that it is so widely available, may represent a setting in which personal dissent, dissatisfaction, or alienation may be freely and fearlessly articulated, and with some expectation that these factors will be seen as relevant to diagnosis and treatment (Janes 1999b; Nichter 1981). Tibetan conceptions of sickness, given their sensitivity to social and emotional context, have appropriated more modern notions of ethnic conflict, politicized suffering, and lack of economic opportunity (Janes 1995, 1999b). Upsets of the humor lung, a humor which is associated with ideas of life force and karma, for example, are often attributed to such factors. Tibetans also use their models of hot/cold imbalance and dietary causation to further underscore the socialpolitical origins of Tibetan suffering. Many of the foods now identified as being

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Table 10.3 Mentsik’ang Patients’ Explanatory Models for Common Illnesses

Note that cold foods (1) in this table are cold in temperature, “cold” foods (2) are cold in humoral terms.

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Table 10.4 Illness Case Studies: Diagnostic Categories of Individuals Interviewed (N⫽56)

associated with arthritis and gastric disturbances are also foods that Tibetans either did not traditionally eat, or which are associated with introduction through the immigrant Han Chinese population. For example, pork and chicken are considered to be cooling foods and, especially in the case of pork, are considered to be both rich and sweet. Excessive pork consumption is thought be particularly problematic. Tibetans also did not traditionally eat fish; Han conceptions of a complete meal, however, often involve multiple meats and ideally include some form of fish or seafood. As anthropologists well know, food preferences are commonly used to symbolize ethnic differences and demarcate ethnic/cultural boundaries. In the Tibetan case, and under current political conditions, people also use dietary differences to signal more widely how the presence of Chinese in their society causes them to suffer. When, during my research, I was asked to a formal banquet at one or another of the Chinese restaurants in town, it became a bit of a joke to note that the Chinese style was to “eat the three kleshas” (the obscurations of desire, hatred, and ignorance that hold people in samsara, the cycle of death and rebirth). The kleshas are commonly symbolized in temple paintings by a cock, a serpent (a scaled creature, and thus similar to a fish), and a pig. That these are preferred Chinese foods is a fact not lost on Tibetans, nor is their association with a host of bodily disorders, nor is what they symbolize, which is the full extent of human suffering. Use of Tibetan medicine is not only determined by its symbolic-political salience, however. Tibetans are, like most people, interested in the pragmatic issue of relieving symptoms. Toward this end they use a variety of health care resources according to their understanding of what resources best address what symptom, and an understanding of how the nature of the illness, its onset and duration, dictates how it should be handled. Our case study analysis focused primarily on the issue of patterns of resort. In Tables 10.611 and 10.712 the particular pattern of resort followed by the patients we interviewed, and the reasons offered retrospectively for their behavior, are summarized. These tables

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Table 10.5 Explanatory Models: Illness Case Studies

show unsurprisingly that Tibetan medicine is used to treat chronic conditions or those disorders considered untreatable by other, principally biomedical, resources (e.g., J. Young 1981; Colson 1971). Furthermore, Tibetans evince greater satisfaction with Tibetan medicine by virtue of its resonance with their own expectations and explanations, and its basis in a common language and tradition. Why is it that demand for Tibetan medicine has increased in such an extraordinary fashion in the past twenty years, and how is Tibetan medicine integrated, at the level of the patient, with other resources? The research reported here suggests that the answer includes three interrelated elements. First, since 1959 the availability of an array of folk-sector services has largely disappeared under official discouragement by the government and health bureau. This factor has collapsed the traditional Tibetan sector of healing into a primarily governmentfunded Tibetan medicine (Janes 1995). It is here where individuals find healers with whom they can speak; healers who address the cause and treatment of disease using a commonly understood language of mind-body attributes and processes. As in other humoral systems, this language underscores the interrelation of the body-mind with natural and supernatural worlds, positing a close

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Table 10.6 Patterns of Resort Reported by Case-Study Sample (N⫽56)

correlation between balance in one world and balance in the other. Second, Tibetans believe that “old,” chronic, and hard-to-remediate symptoms are most appropriately treated by Tibetan medicines that, while slow acting, are considered to “root out” the problem. Third, Tibetan medicine provides a context in which people can express, through illness idioms, the particular kind of distress that they associate with the current social and political climate, or the disruptive aspects of social change more generally (Janes 1995; 1999b). CONCLUSION: THE FUTURE OF TIBETAN MEDICINE The attempt by Beijing to integrate Tibet into the Chinese state, and to modernize Tibet, initially along the lines of the socialist reform programs implemented by the Mao regime, and more recently according to capitalist-based market reforms, has had a number of important consequences for Tibetan medicine. Tibetan medicine has been completely disembedded from the local social networks of community and monastery, it has been transformed into a rationally deployed segment of the primary care system, and elements of its practice incompatible with materialist ideology have been largely suppressed, though not entirely removed. As a sector of the primary health care system, Tibetan medicine is increasingly subject to health policy initiatives promulgated by Beijing, which in turn has implemented an array of reforms to social and health service work units that correspond with internationally based, neoliberal economic principles. Consistent with present global, neoliberal economic policy, Beijing is now seeking to reduce spending on social programs, including health care. Tibetan medicine, fully integrated into the regional health care bureaucracy, has had no choice but to respond to these wider environmental contingencies which further threaten its viability as a resource for Tibetans outside of the market centers of the region. The forcible integration of Tibet into the Chinese state has many other social and cultural dimensions, most of which are beyond the scope of this chapter. However, it is important to note that two aspects of modernity in Tibet are partially determinative of the status of Tibetan medicine in the region. First, the

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Table 10.7 Decision-Making Patterns Reported by Case-Study Sample

social vulnerability of Tibetans—as a result both of failed ethnic policy and market-based reforms that have tended to marginalize Tibetans in the region— has brought Tibetan medicine into the conflict over the Tibet question. Tibetan medicine remains among the few viable, distinctively Tibetan traditions that remain functionally sound. Religion and religious institutions have become increasingly subject to state control, and most of the great monasteries have been transformed into what are essentially state museums: displays of architecture, religious iconography, and “feudal superstition.” Tibetan medicine, however, having firmly consolidated its position in the primary health care system, is now a survivor of nearly fifty years of Chinese cultural and political hegemony. In an atmosphere where things traditionally Tibetan are apt to be, or to have been, labeled as backward, primitive, feudal, and superstitious, it has weathered these five decades reasonably untainted. This is not an insignificant historical fact, and, from the perspective of Tibetan ethnicity, cultural identity, cultural revitalization, and even nationalism, is a matter of strategic importance to Tibetans. Its very existence symbolizes a classical Tibetan culture, a native genius. Quite beyond the pragmatic considerations of symptom amelioration, its use is an act of demonstration. And, as I have suggested elsewhere, Tibetan laypeople and physicians alike are quite aware of this potential (Janes 1999a). The question remains, however, as to whether Tibetan medicine can steer clear of the shoals upon which so many traditional medical systems have foundered: a surrender to the principles by which its services can be most easily commoditized, in particular the evaluative authority of Western science. Rationalization processes will continue to be transformative as a consequence of state policy, though the

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shape of future changes will depend on whether Tibetans can devise a strategy for “modernizing” Tibetan medicine without turning it into a superficial herbalism. Adams’ writing to this effect suggest that particularly in the strategic area of women’s reproductive health, such a strategy may have been found (Adams, Chapter 11, this volume). Second, Tibetans are not the only players on this stage. Tibet has been, and continues to be, an object of fascination, not only to the West, but increasingly to other countries in Asia. Even within China (and Hong Kong and Taiwan) one sees an increased fascination with things Tibetan. Tibetan medicine is an object of transnational concern, a concern that both celebrates traditional Tibetan culture, yet at the same time creates the conditions for its exploitation through capitalist appropriation (e.g., travel, marketing of artifacts, art, medicines). As Tibetan medicine responds to the market, it is increasingly subject to packaging itself as a product for consumption outside Tibet. This packaging responds to transnational images of Tibetan supernaturalism, Shangri-la, and within China, to Han ideas of the curious and magical ethnic other (Blum 1992; Lopez 1998). A commercialized Tibetan medicine will likely lead to the erosion of services within Tibet, particularly outside the towns and cities, as, in classic modern fashion, Tibetan medicine is increasingly oriented to and prepared for the major markets of China and the West. Although anthropologists may view this particular ethnomedical system and this historical context as an example of how medicine and medical systems fit larger metamedical social, cultural, and political agendas, it is useful to also consider Tibetan medicine from the perspective of health services and public health—that is, as a health resource of considerable practical value. As I have shown here, Tibetan medicine is used heavily, and it is used principally (as in the case of other indigenous medicines), to address a host of chronic complaints in a familiar setting, and according to commonly understood and accepted cultural principles. Issues of efficacy aside (a difficult subject and beyond the scope of this chapter), Tibetan medicine provides an avenue for Tibetans to receive long-term treatment of conditions that are not likely to be treated or even recognized in biomedical facilities, which, as in the case of other developing countries, are oriented to short-term therapeutic responses to maternal and child health, acute infectious diseases, and trauma. This particular role, as a resource for treating chronic illness, will become increasingly important over the next several decades, for the population of Tibet is in the midst of an epidemiologic transition; a transformation of the causes of death from one of infectious disease striking individuals at a young age, to the chronic and degenerative disease of mid- to older adulthood. The speed of this transition varies; rural areas still lag far behind the urban areas in rates of infant mortality and life expectancy, for example. Yet, with continued commitments to public health, it is likely that Tibetans will experience the same kinds of positive health changes that have occurred throughout much of the rest of China. It is at this point, when the chronic diseases of adulthood, particularly the un-

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treatable cancers and cardiovascular diseases, become a pressing concern to the medical system, that the need for a functioning alternative medical system will increase. It is not likely that China will devote medical resources to treating these diseases; they are simply too expensive to treat (see Jamison and Mosely 1991). As is the case in Japan (Lock 1990), Tibetan medicine may become increasingly central to health care if it can continue to modernize and develop without losing the depth of its classical scholarly base, the integrity of its theoretically rich explanatory system, or the principles of its nonmaterialist, Buddhist epistemology. NOTES 1. For a fuller discussion of methods, please refer to Janes (1995). The research on which this chapter is based was conducted between October 1988 and April 1993 in the Tibet Autonomous Region of Southwestern China. The research was done in the context of the traditional Tibetan medical hospital of the region, the “Mentsik’ang” (or “Center for Medicine and Astrology”). Research focussed on the most densely settled districts (termed “prefectures”) of central Tibet—Lhasa, Shannan (Lhok’a), and Xigazeˆ (Shigatse)—and included observation of rural, as well as town- or city-based health care settings. The interview-based data presented were gathered in the period of 1991–1993. 2. I will use the term mentsik’ang to refer to institutions (hospitals and outpatient clinics) dedicated to the provision of Tibetan medicine. The term encompasses both medicine (men) and astrology (tsi). Astrology is not discussed in this chapter; see Janes 1995 for a brief discussion of this aspect of healing. The Lhasa Mentsik’ang is the largest Tibetan medical facility in China. In 1993 it had a staff of 400 physicians and administrative staff. Since 1985, between 50 and 60 new students per year have been admitted for formal training in Tibetan medicine. 3. The prefecture is an administrative unit not, to my knowledge, found outside of minority areas of China. In the TAR, prefectures are largely consistent with pre-Chinese political and social divisions. The prefectures are, from West to East: Ngari (Ali in Pinyin), Shigatse (Xigazeˆ ), Nagch’u (Nagqu), Lhasa, Lhok’a (Shannan), and Ch’amdo (Qamdo). 4. The village “doctors” in the right-hand column of Table 10.1 are community health workers who have been given about six months of basic medical and public health training, including, in some cases, training in Tibetan medicine. The ratios for China as a whole are from data cited in M. Young (1989, 29). 5. In 1993, each government work unit had a senior cadre—that is, a member of the Chinese Communist Party—who served as a senior official insuring that party policies were implemented. In the case of the Tibetan medicine work units, most of the party secretaries have a medical background, though not necessarily in Tibetan medicine. All of those I met and interviewed were ethnically Tibetan, however. 6. See, for example, Norbu’s (1987) description of events leading to his father’s death. 7. Under the terms of market-oriented reform, the government has liberalized many of its policies governing fee-for-service private medical practice. Hence, private practice of Tibetan, Chinese, and biomedicine is becoming more noticeable in the towns and

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cities. There is some private practice of Tibetan medicine by part-time practitioners in the countryside as well. 8. Arthritis (Wylie grum bu’i na tsha) is commonly associated with the kidney. In free-listing, informants would sometimes use the term kidney problem (mkhal nad) to refer to arthritis, otherwise the more specific term for arthritis was used. Arthritis is the more restricted category, referring specifically to joint swelling and pain. Kidney problems include a whole syndrome of complaints, including lower body edema, back pain, coldness about the waist, and stiffness of the joints. Listings are exactly as the informant stated them. If the categories are combined, kidney-arthritis is the top-ranked category of disorder. Lung “problem” (W. glo nad) is also the term used for lung “infection” (e.g. TB). The term is today used rather generally for a number of problems, and does not always reflect an underlying belief in germ theory. It is sometimes implies “inflammation”; at others it conflates contagion with the religious notion of “defilement” (or sin). Bum (Wylie ’bam) is a term for a constellation of symptoms of arthritis and lower extremity edema. Bum primarily affects the legs. They swell, become hard and discolored, and walking becomes quite painful. It is a relatively common complaint seen and treated in outpatient settings. “Blood abnormality” (W khrag shed na tsha) refers usually to abnormalities of blood pressure: “high” or “low” blood. In professional contexts, heart and blood pressure problems are seen as a consequence of lung (W. rlung) imbalance. 9. “Cold foods” in relation to stomach problems means cold in terms of temperature. “Heat” or “fire” is considered essential to the proper digestion of food. Food that may quell this heat—uncooked or cold food—may lead to problems. Also, becoming chilled, especially around the waist, is thought to disrupt the fire needed for digestion. In all other cases in this table (kidney, arthritis, and lung disorders) “cold” foods implies cold in its humoral or metaphorical sense. In Tibet, this generally refers to foods which are sweet and, in the case of meat, rich or “sweet tasting.” Lung imbalance was studied intensively, so the causal categories indicated are rather more detailed than for the other illnesses and the number of informants greater (Janes 1995; Janes 1999a). 10. Individuals interviewed may have as many as three diagnoses. “Blood abnormality” is usually called high or low blood (i.e. pressure). “Heart abnormality” is usually associated with lung. Yama is similar to a severe sinus infection. 11. Some categories are not mutually exclusive, thus the total N exceeds 56. For example, use of private doctors and folk healers will overlap with other patterns. 12. Again, note that categories are not exclusive, since individuals may cite more than one reason for choosing Tibetan medicine.

REFERENCES Adams, Vincanne. 1992. The production of self and body in Sherpa-Tibetan society. In Anthropological approaches to the study of ethnomedicine, edited by Mark Nichter. Amsterdam: Gordon and Breach Science Publishers. ———. 1996. Tigers of the snow and other virtual Sherpas. Princeton, NJ: Princeton University Press. Bernard, H. Russell. 1994. Research methods in anthropology, 2nd ed. Thousand Oaks, CA: Sage. Blum, Susan D. 1992. Ethnic diversity in southwest China: perceptions of self and other. Ethnic Studies 9: 267–279.

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Chen, C.C. 1989. Medicine in rural China. Berkeley: University of California Press. Chi, Chunhuei. 1994. Integrating traditional medicine into modern health care systems: examining the role of Chinese medicine in Taiwan. Social Science and Medicine 39: 307–321. Chi, Chunhuei, Jwo-Leun Lee, Jim-Shoung Lai, Chin-Yin Chen, Shu-Kuei Chang, and Shih-Chien Chen. 1996. The practice of Chinese medicine in Taiwan. Social Science and Medicine 43: 1329–1348. Colson, Anthony. 1971. The differential use of medical resources in developing countries. Journal of Health and Social Behavior 12: 226–237. Crozier, Ralph. 1968. Traditional medicine in modern China. Cambridge, MA: Harvard University Press. Goldstein, Melvyn. 1997. The snow lion and the dragon: China, Tibet and the Dalai Lama. Berkeley: University of California Press. Hsiao, William C. L. 1995. The Chinese health care system: lessons for other nations. Social Science and Medicine 41: 1047–1055. Hsiao, William C. L. and Yuanli Liu. 1996. Economic reform and health: lessons from China. New England Journal of Medicine 335: 430–431. Jamison, Dean. 1985. China’s health care system: policies, organization, inputs and “finance.” In Good health at low cost, edited by S. B. Halstead, J. A. Walsh, and K. S. Warren. New York: Rockefeller Foundation. Jamison, Dean T., John R. Evans, Timothy King, Ian Porter, Nicholas Prescott, and Andre Prost. 1984. China: the health sector. Washington, DC: The World Bank. Jamison, Dean and Henry Mosley. 1991. Disease control priorities in developing countries: health policy responses to epidemiological change. American Journal of Public Health 81: 15–22. Janes, Craig R. 1995. The transformations of Tibetan Medicine. Medical Anthropology Quarterly 9: 6–39. ——— 1999a. The health transition and the crisis of traditional medicine: The case of Tibet. Social Science and Medicine 48: 1803–1820. ——— 1999b. Imagined lives, suffering and the work of culture: The embodied discourses of conflict in modern Tibet. Medical Anthropology Quarterly 13: 391– 412. Leslie, Charles. 1980. Medical pluralism in world perspective. Social Science and Medicine 14B: 191–195. Lock, Margaret. 1990. Rationalization of Japanese herbal medication: the hegemony of orchestrated pluralism. Human Organization 49: 41–47. Lopez, Donald S. 1998. Prisoners of Shangri-La: Tibetan Buddhism and the West. Chicago: University of Chicago Press. Nichter, Mark. 1981. Idioms of distress, alternatives in the expression of psychosocial distress: a case study from South India. Culture, Medicine and Psychiatry 5: 379– 408. Norbu, Dawa. 1987. Red star over Tibet. New York: Envoy Press. Ortner, Sherry. 1978. Sherpas through their rituals. Cambridge: Cambridge University Press. Sharlho, Tseten Wangchuk. 1992. China’s reforms in Tibet: issues and dilemmas. Journal of Contemporary China 1: 34–60. Singer, Philip. 1988. Two gods that are failing for medical anthropologists. Anthropology Newsletter 29: 9–10.

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Snellgrove, David and Hugh G. Richardson. 1968. A cultural history of Tibet. Boston: Shambhala. Tang, S. L., G. Bloom, X. S. Feng, H. Lucas, X. Y. Gu, and M. Segall. 1994. Financing health services in China: adapting to economic reform. Brighton: Institute of Development Studies (IDS Research Report 26). Trotter, Robert T. III. 1981. Remedios caseros: Mexican-American home remedies and community health problems. Social Science and Medicine 15B: 107–114. Tucci, Giuseppe. 1967. Tibet, land of snows. New York: Stein and Day. World Bank. 1993. Investing in health: world development report 1993. Washington DC: The World Bank. World Health Organization. 1978. The promotion and development of traditional medicine. Geneva: WHO (WHO Technical Report Series No. 622). Young, James. 1981. Medical choice in a Mexican village. New Brunswick, NJ: Rutgers. Young, Mary E. 1989. Impact of the rural reform on financing rural health services in China. Health Policy 11 (1989): 27–42.

11

Particularizing Modernity: Tibetan Medical Theorizing of Women’s Health in Lhasa, Tibet Vincanne Adams

MODERNITY For many popular social theorists, modernity implies the perception of loss. This seems as true for theorists today as for those who wrote during an earlier century in the contexts of Europe, America, Britain, and their colonies. We can find this sense of loss in Emile Durkheim and later Marcel Mauss and their shared perception of modernity as the loss of certain kinds of trust, the kind that brings about mechanical solidarity and social reciprocity as the “glue” holding society together; in Karl Marx and his insight that modernity entails a loss of fundamental subjectivity, particularly the alienation of self in the labor process; in Max Weber, for whom modernity always entailed the potential for a loss of the sacred self in its iron cages of bureaucratic rationality; and even in Rabindranath Tagore, who wrote about European modernity: “Take away man from his natural surroundings, from the fullness of his communal life, with all its living associations of beauty and love and social obligations, and you will be able to turn him into so many fragments of a machine for the production of wealth on a gigantic scale. Turn a tree into a log and it will burn for you, but it will never bear living flowers and fruit” (1992 [1917], 69–70). In these most popular accounts from an earlier era, moderns understood their loss as lack. A loss of something once present in an earlier mode of social life but now gone forever was transformed into lack—into something felt on an emotional, physical, social level as missing or incomplete. Turning to contemporary theorizing, lack is again seen as pivotal in the experience of modernity: lack is internalized by the subject, where it produces endless perceptions of selfneed (Foucault 1978, 1988; Deleuze and Guattari 1983; Kracauer 1995; Harvey

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1989; Giddens 1991). Foucault has argued that moderns are disciplined by this lack. It stands at the center of our being as a definitive feature of our subjectivity, an internal panopticon always looking to tell us what we are missing, what it is necessary to purchase, to experience, to consume in order to satisfy the needs it generates. One also finds that in some accounts the void produced by perceptions of lack can, under conditions of modernity, never totally be filled because it emerges from an objectification of the self. It arises from being able to see ourselves not just as subjects, but as objects—objects that can be fixed and improved upon with a little help from more money, better work, better therapy, better pharmaceuticals, more time, and so on. The lack/void is seen, in some fundamental sense, as being generated by the separation of self into both subject and object. This, Foucault (1973) suspects, is a particular accomplishment of European Enlightenment: needs arise in that interstitial moment of objective recognition that the self can be improved upon. Needs become visible when they are perceived objectively, as from a position outside the self. This objectification is tied to the emergence of rationalist scientific knowledge and methods. Thus, modernity’s double-bind: we moderns objectify ourselves in order to most effectively know our needs, but objectified, we are made to feel incomplete. The hope for completion and fulfilment is then constituted as the hope for restoring our subjectivity completely. Objectification of the self demarcates one’s modernity, but so too does the search for its transcendence in attempts to recapture an earlier, more complete way of being. Turning to consumption in the endless attempt to recuperate that which is held up as having once been available as cultural, social, visceral experience in sociological visions of the past, it is suggested that modernity provokes a sense of nostalgia about the past and hopeful idealism about the future (Kracauer 1995). Modernity’s progress is mapped out in this movement between past and future, its promise of movement toward something “better,” and its “emptying” the present of the ability to generate fulfillment on its own. Sometimes, the past that is thought to hold what the modern lacks is located in cultural Others (Fabian 1983), in those societies whose perceived differences both deny them status as “moderns” and render them consumable by moderns in their search for self-fulfillment (Root 1996). That said, I would take us momentarily to the Tibetan plateau, to a place often historically considered an exemplary resource—a Shangri-la of a resource—for modern European, British, and American projects of selfcompletion (Bishop 1989; Lopez 1998). In this chapter I explore Lhasa Tibetan experiences of modernity and modern science, but not in order to find the cultural materials with which to complete a “Western” modern sense of loss. Rather, I do so to explore the particular forms of modernity that become evident under historical conditions that were and are somewhat different from those in the Western world. My goal is not to point to the novelty of critiquing nineteenth- and twentieth-century “Western” social theorists of modernity, for

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indeed most of twentieth-century cultural anthropology has undertaken to show these limitations. Rather, it is to see whether one can parse Tibetan experiences of modernity from particular vantage points situated in Tibet with different particular ethnographic and theoretical specificity than those shown and argued for Western experiences of modernity. My exploration is inspired by anthropologists who have generated insights on ethnographic methodology by way of the study of ethnomedicine, such as Rivers (1924), Evans-Pritchard (1976 [1937]), Turner (1961, 1968), Comaroff (1981, 1982, 1985), and Young (1976, 1978, 1981a, b, 1982), who have noted that it is in the medical domain that fundamental conceptualizations of body, subjectivity, social structure, and epistemology are visible. Their works evidence the centrality of medical anthropological concerns to anthropological ways of knowing more generally. I, too, assume that medical theories and practices contain epistemology—theories about ways of knowing—and that studying how a culture deals with suffering and its remedies can also reveal insights about how to undertake an epistemologically sensitive ethnography.1 In addition, my inquiry is focused upon ethnomedical concerns of and about women, their sexuality, and the inscription of social agendas on their bodies (following the work of Martin 1987; Comaroff 1985; Scheper-Hughes 1992; Farquhar 1991; DelVecchio Good 1980). I note that since female sexuality is a site upon which modernist state and national projects are often launched, studying local theories about these bodies and their ailments is one way to learn about larger state projects and thus the particularity of the modern.2 Thus I am interested in what Tibetan medical theories about women’s health can teach us about the cultural specificity of how we theorize modernity. Although I have been conducting ethnographic research at the Mentsik’ang in Lhasa, Tibet, since 1993,3 I rely principally on one text in this analysis, only supplementing it with information taken from observations and interviews at the hospital. In the first part of this chapter, I explore the configuration of Tibetan modernity depicted in a Tibetan doctor’s writings about women’s health. I argue that a familiar modernity can also look particular in this locale. In the second part, I show that modernity can be seen in Tibetan medical apprehensions of biomedicine. Here, I argue that this apprehension does not suggest a universal modernity contingent on objectification but rather reveals, again, its particularity in this locale. This leads to the suggestion that we might rethink our theorizing of modernity through Tibetan medical approaches. I conclude that we might expand our understanding of modernity through Tibetan medical approaches that do not theorize the subject, or object, in quite the same way as Western social theorists. MODERNITY IN THE FIGURE OF THE HEALER When I first inquired about women’s health under conditions of modernization in Lhasa, a Tibetan physician began to describe the problem of infections or

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inflammations of the uterine region, generically called nyenk’a, inflammation, the most common forms of which are bile-related infections of the uterus (ngelne´ tr’igyu). She then gave me a copy of (at that time) a manuscript, telling me that I would find the answer to my questions therein. The text was entitled “Health Measures for Commonly Seen Sicknesses of Women” (Bud med gyi rgyun mthong nad gzhi’i ’phrod bsten) written by Amchi (doctor) Trinlay. It has since that time been published as a handbook for distribution to patients and practitioners throughout the Tibetan Autonomous Region (Trinlay 1998). Amchi Trinlay works at Lhasa’s formidable new Mentsik’ang, the College of Medicine and Astrology, or what is translated in official publications as The Tibet Autonomous Region’s Traditional Medical Hospital, “praised as a bright pearl on the plateau.” One of the first things noticeable about contemporary Tibetan medicine in Lhasa is that although it was at least partially managed as a state bureaucracy in the years prior to the rise of the Communist government in the 1950s, it has since that time been subjected to dramatic state-controlled regulations which have variously suppressed or rehabilitated it. Janes (1995) has offered a clear and concise account of the history of state demands on the practices of Tibetan medicine from the turn of the century to the late 1980s.4 He suggests that the trend toward biomedicalization is one of the most obvious outcomes of these demands, although it has not completely undermined the traditional system. In his account and in some of those found among Mentsik’ang scholars, modernization becomes almost synonymous with efforts to incorporate elements of biomedicine and “modern science” into their practices. I elaborate on the contemporary versions of these processes here. One of my goals is to further our understanding of the complexity of modernization in this context in order to avoid suggesting a straightforward trend toward biomedical hegemony. In fact, I argue, modernization in this medical system has also come to mean establishing the scientific legitimacy of the traditional system, even by use of biomedical technologies. Thus, I argue, modernization there might be seen as in some ways similar to the forms of modernity identified by Western social theorists, but we might also turn our attention to the ways that Lhasa modernity is made different by not only different historical and socio-political factors but also different ways of theorizing subjects and human suffering. Several trends are worth noting in Amchi Trinlay’s text: (1) his commitment to a form of modernity that, by defining its losses, oscillates between past and future; (2) his illustration of the presence of state ideological interests in his theory; and (3) his ability to redefine the terms of modernity by naming Tibetan medicine as a science while proposing a theory of the subject quite different from that theorized as universal in the West. CONDEMNING AND RECUPERATING THE PAST AS A CONDITION OF TIBET’S MODERNITY Amchi Trinlay opens his text with an exemplary case of modern anxiety: he is worried that “the present” state of affairs in Tibetan medicine reveals an

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“incompleteness,” that the future promises more because of its scientific methods, and yet feels that the past may actually have resources for solving modern problems. On the basis of the life-work of great scholars of the Land of Snows [Tibet], who gradually perfected the five branches of knowledge through burning, cutting and polishing, as [one would perfect and test the quality of] gold, the thousand light-rays of knowledge have grown greatly.5 As the five branches of knowledge have grown, the banner of the medical knowledge [sowa rigpa] of Tibet has also, from ancient times until the present, fluttered in the sky of the inner and outer countries, throughout all regions. However, if we contemporary people stay satisfied with the works of the scholars of the past, then all clearly know that Western medical knowledge and the medical knowledge of other peoples, like a horse encouraged with a whip, will, as it were, pass us on the broad upwards road of progress. Therefore, if we modern people do not carry out extensive study and research into Tibetan medicine in accordance with modern science, then it will come about that everyone will say that Tibetan medicine is not able to sit in the company of developed countries. [Thus,] on the basis of work I have carried out over eight years in the Division of Female Illnesses at the Province’s Mentsik’ang [College of Medicine and Astrology], including carrying out treatment of and research into the common illnesses of women in the course of my career, and with help and instruction from knowledgeable doctors [lharje]6 from special fields in the hospital and from other doctors who have had contact with the medical systems of other countries and developed practices, and relying on wind, bile and phlegm [lung tr’i pe´ ken], the foundation of the life-tree of our own Tibetan treatises of medical science, I have composed this book. (Trinlay 1998, 1–2; page numbers in this and later citations refer to the unpublished version)

Amchi Trinlay’s repeated concern about the urgent need to modernize belies the fact that he has confirmed that Tibetans are already modern in his opening paragraph. Suggesting that Tibetan medicine needs to improve itself through modern science discloses that this scholar already participates in a thoroughly modern project: the perpetual search for self-completion by pursuing a “better” future, in part by recruiting from a recuperable past. To make the case about a better future, he must first convince his readers that all is not well in this Tibetan modernity: it is incomplete. But here is where particular forms of Tibetan modernity become visible. His ability to recuperate from the past and set a course for the future is constrained by state demands that Tibetans problematize their past in order to legitimize the gains made by Communist liberation, ensuring the latter’s continued presence in Tibet’s future. Thus, the first twenty-one of this scholar’s one hundred pages offer evidence of the Tibetan need to reject elements of their feudal past for the sake of Chinese forms of modernization. In this text, the bedeviled past takes the form of gender discrimination. In a section on “The Condition of Women” he notes that “it is said about women that all women are the source of calamity, and that just as the peacock has beautiful feathers but weak wings, women have long hair but shallow minds. People who use these sayings in the world show a biased atti-

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tude” (4). The following section discusses the “status of women according to those who are enchained by old views”: “Old views” here means the attitude to women held in the feudal system. Thus according to old sayings, “Women won’t leave an enjoyable place, nanny-goats won’t leave a comfortable place” [i.e. women and nanny-goats are too attached to comfort] and “Birds and daughters have no ears, dogs and daughters cannot be trusted.” According to these sayings women are less important than men, their abilities are held down and they are regarded as inferior beings. Many other such proverbial sayings have been collected. In general, if you are a human being, you may or may not have the qualities of being modest and being trustworthy. Now how could it be that all those not to be trusted should be women and nanny-goats, and how could it be that all men and other animals should be able to leave enjoyable and comfortable places and should be trustworthy? (5– 6) . . . Even in this modern era in which we see the dramatic increase of the spectacle of traditional knowledge and modern science, there are some who still hold prejudiced views towards women because of the karmic imprint [p’agch’ak] of old traditions. (13)

Confirming his commitment to state-directed rhetorics of modernization as a solution to Tibet’s feudalistic tragedy, initially at least, the author suggests that the flaws arising from his nation’s contaminated past can be eradicated through the future promised by the adoption of communist versions of dialectical materialism. In his next section, called, “The Status of Women Under Progress” one even finds the ambiguity, characteristic of Chinese versions of Communist social theory, over whether this dialectic that will bring completion to the present is driven by material forces of production and relations or whether it is driven by ideology: With the progress of people’s opinions and of society and the onward development of knowledge and the economy, then attitudes and ways of thinking will also change. As the policy of equality of men and women spreads through all countries, inside and outside [⫽ in Tibet and abroad], the status of women has also been raised and continues to be raised higher. From within the developing social life, literature arises and being confronted through this literature recognition [of these views] and education come about. Through their favorable reception, the power to transform society emerges. (10–11)

Writing under conditions of Chinese socialist modernity in the 1990s, Amchi Trinlay has to accomplish several things. Even before he gets to the main body of his medical text on women’s disorders, he has had to write against backward traditions of Tibetans configured as such by the Communist Party. Women suffer from poor health, he notes, because they suffer from low social status produced during Tibet’s feudalistic past. This may be a distinctive feature of Tibet’s modernity, though consistent with other regions of China: truths about the subject are always visibly and legitimately organized around official government interests. In other words, the truth of the subject is always generated in a visibly intervening official political field.

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Amchi Trinlay attends to state concerns in other ways as well. The idea of marrying politics to medicine is a characteristic of Tibet’s experience of modernity. Even the World Health Organization and UNICEF’s Alma Ata Declaration along with its attendant models for primary health care were derived in large part from China’s model of the barefoot doctors, although we shouldn’t forget that there is a long history of European medicine that advocates politicization of health care. Amchi Trinlay’s attentiveness to being politically correct, as shown by his desire to explain the links between the social status of women and their health, is characteristic of Chinese modernity. He asks them to reject their nonsocialist past as a political and medical effort. Again, this need to render his political stance highly visible at the outset might be understood as a more uniform feature of professional life in contemporary China. Anagnost (1994, 148), clarifies this by noting that China’s citizens are seldom offered “alternatives to participating in the party’s socialist realist fictions about its role as the true representative of the popular will.” But Amchi Trinlay’s ability to confirm China’s rhetorical presence in Tibetan modernity is coupled with his interest in actually recuperating elements of Tibet’s past for use in solving modernity’s problems. Soon after criticizing his nation’s past for its feudalistic attitudes, Amchi Trinlay returns to a different version of that past in order to eradicate women’s modern suffering. Reading further in his introduction, we learn that the seeds for gender equality are actually found in Tibet’s pre-Communist Tibetan culture. He offers examples of historical female figures whose works and accomplishments are considered extraordinary as exemplars for modern society! He begins with a quote from the early twentieth-century scholar Gedu¨ n Ch’o¨ p’el:7 Great Tibetan scholars, coming one after the other, have praised women and produced many literary works. [From Gedu¨ n Ch’o¨ p’el:] “This broad world is like a great plain of sorrow; beings who carry the burden of many karmic deeds will certainly suffer. [But] a woman playmate who can bring joy to the mind is like a magical apparition brought through karma. She is the Goddess of Form [one of the Offering Goddesses of Tantric ritual], seeing her brings joy; she is the field which can bring forth a good lineage. She is the beautiful nurse who cares for you when sick; she is the poet consoling the mind when you are sad. She is the mistress who does all the household work. She is a true friend who takes care of you with joy and play throughout your life.”8 Also, “Like spring to the eye, her form is beautiful, the playfulness and joy of her smile is like the radiance from a jewel ornament. . . .” Through these and many other such literary compositions which describe the nature of women and their fate, many people have been encouraged to think about and improve the social status of women (12–13). . . . As everyone well knows, we people of the Land of Snow, like many other people, also have a long, glorious and very extensive history, shining with splendid rays of light. However, through the power of the firmly ensconced view that men are superior and women inferior, there are very few histories and annals of the women who have lived in the distant times during and around the dynasty of the Tsenpo kings [up to 9th centuries C.E.]. We write only on the basis of what has been remembered. We know some traces of their accomplish-

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ments in the political sphere of Tibet. Thus for example, there are the Five Great Queens, Mongsa Tr’icham, Tsu¨ nmo Drosa Tr’imalo¨ d, and many other distinguished and famous women, including King Songtsen Gampo’s younger sister Semakar, as well as the more recent Togde´ Lhomo¨ Po¨ nmo, and so on, and many distinguished and famous po¨ nmo [women estate-heads or local rulers]. These Five Great Queens and others, through constructing walls and buildings and making extensions to them, made a permanent contribution. Tsenmo Semakar can be considered among the early great women literary poets of Tibet. [He also refers to great female agrarianists, veterinarians, religious, and literary figures.] Also, in the realm of medicine, in recent times, everyone knows of the skilled physician Yangchen Lhamo, whose skill was inconceivable. If I were to describe further the countless women of ability among all the other peoples and states of the world and the ability that they exerted and exert to develop and improve human society, would we not again realise that women, being half the sky, require a sympathetic evaluation? (20–23)

In the end, Amchi Trinlay even establishes that Tibet’s Buddhist religion can serve as a basis for legitimating women’s high status, again referring to the work of the intellectual Gedu¨ n Ch’o¨ p’el. It is also established by Gedu¨ n Ch’o¨ p’el’s passage, “Whether for one’s own welfare or the general welfare of the country, for the king’s purposes of state or for a beggar’s livelihood, whatever the undertaking, small or large, women are indispensable” (19).9 Also, explaining from the point of view of the Dharma [Buddhist teachings], it is stated in many Tantric texts that if you denigrate women as a whole you incur a Tantric transgression which is one of the fourteen root Tantric transgressions. Also, it is said in certain Tantras, “The Father is spoken of as possessing the great Means [t’ap], the mother as Wisdom [sherap], the object [of ultimate wisdom] is emptiness [tongbanyi].” Following this, from among Means, Wisdom, and the Union of the two, women symbolize Wisdom. (14–15)

In order to make the case that women should be revered rather than treated as lowly beings, he again invokes an extraordinarily literal (though not necessarily secular) reading of a Buddhist prayer, praising the figure of the mother— the same mother who is generally taken in Buddhism to mean conceivably any living being (including nonhumans) to make the point that Tibetans have always revered women: “Lama Chenrezig [Guru Avalokitesvara], in your compassion, take care of this kindly mother, this great kind mother who carried lovingly to the tenth month this solid mass of flesh and blood which had come forth from her body’s container” (16). Amchi Trinlay’s efforts to find a recuperable culture from within Tibet’s past “feudal” theocracy does not, however, reveal a resistance to state agendas. Official discourses that demonize Tibet’s feudal past have changed over the years. Liberalization era reforms ask the minorities throughout China to applaud state condemnations of backward traditions while also appealing to them to retain elements of their traditional cultures as evidence of China’s commitment to national pluralism (Schein 2000). In this region, however, expressions of na-

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tionalism (especially those tied to religion) are considered problematic because official views tie them to nationalist resistance to the Chinese state—that is, to desires for Tibetan independence. Thus, local scholars must be very careful how they reveal their support for traditional culture. Accordingly, Amchi Trinlay legitimizes a Tibetan past as a part of Tibet’s more modern future by packaging this argument in rhetoric about the horrors of that feudalistic era from which Tibet was saved by Chinese Liberation. By doing so, he is able to argue that that past worth saving may provide a key to true socialist gender equality. Thus far Amchi Trinlay’s text provides useful insights on one way that Tibetan modernity is experienced. Like modernist projects elsewhere, Tibet’s moderns are asked to question their ontological status in the present by recognizing the incompleteness of their present state of being, by holding onto the promise of a better future, and by looking to the past to find elements of traditional culture that can serve as an antidote to modernity’s problems. In this oscillation between past and future, Tibet’s moderns are also forced to reveal their ideological commitment to Chinese versions of modernity by problematizing their relationship to their own past in order to carve out space in their present for the Chinese state. Here, recuperations of historic forms of knowledge and practice are only legitimized by the presence of a counter-discourse that persistently renders traditional culture potentially suspicious when it is not either deplored or overtly applauded by the state. Amchi Trinlay is able to fold elements of Tibetan historical culture into the state’s plans for a more modern future in ways that carefully transmute that past into forms that the state considers acceptable. This generally entails transforming religious cultural pasts into secular socialist futures, but in medicine it also involves transforming religious cultural pasts into socialistically acceptable pasts—that is, into secular and scientific pasts. This occurs in the context of swift modernization programs that compel Tibetan doctors and scholars to appropriate and incorporate elements of biomedical science and knowledge into their work while at the same time claiming that their own medical past was scientific. This topic introduces the second point of analysis available in Amchi Trinlay’s text that demonstrates a particularizing of Tibetan modernity: the great willingness for incorporating scientific biomedical techniques into Tibetan medical practices (which, in and of itself, is not unique [Lock 1980]) in order to confirm that Tibetan medicine’s own traditional knowledge is scientific, as opposed to undermining it by the greater force of a foreign scientific medicine. I suggest that the particularizing of modernity emerges in the peculiar contribution of this theory to understanding modern subjects. THE PLACE OF THE “SCIENTIFIC” IN TIBETAN MEDICINE In his opening paragraph and throughout Amchi Trinlay’s text, he makes reference to the need to improve Tibetan medicine through modern science.

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Here, signs of a “better” future, are drawn from the “foreign” as techniques that might be efficacious aggregates to traditional practice, officially promoted by the state, and signifying a bright and promising “modern” future. What sorts of practices are these? Amchi Trinlay refers enthusiastically, for example, to the use of ultrasound machines to diagnose womb infections: This kind of illness may be caused and menstruation may cease [for various reasons:] through [the condition called] nyents’e increasing within the womb, or by a growth in the two ovaries [samse’u] or the two great channels [Fallopian tubes], or by a birth control operation, also if the womb-channel [ngel tsa] is stretched after a child is born, so that the lesser channels become blocked. [This may also happen] by the power of the t’ursel lung [“downwards-expelling lung,” the form of lung involved in elimination of waste from the body, including menstrual blood] degenerating so that it is unable to open the mouth of the womb [to release the blood]. Treatment: in order to recognise the nature of the underlying illness, if there is a hospital, it is best if one can establish what the underlying illness is through examining the abdomen with ultrasound or the like. If there is a growth in either of the ovaries, there will be a sharp pain in the part of the abdomen where the growth is, and it will get stronger if pressed. If the growth has become large, the patient herself or the doctor will also be able to feel it. If there is a growth in either of the two great channels, there will be a sharp pain in the part of the abdomen where the growth is, and it will get stronger if pressed. (28–29)

Later in his text, Amchi Trinlay refers to the need to ascertain blood pressure (for which use of sphygmomanometers is normal). In a section on pregnancy and fetal development, he writes: During the 30th week of the seventh month, the 35th week of the eighth month, the 38th week of the 9th month, during these three months, you should go to the hospital to be examined to determine which way the fetus is situated inside the womb. During the examination, you should definitely check the following: whether the strength-giving blood [sungtr’ak] and blood pressure [tr’agshe´ ] are normal, the strength of the movement of the fetus and the pulse of the heart. For weak movement of the fetus or weak pulse, you should apply to the abdomen a hot mixture of cumin and ground nutmeg mixed in butter. Having done that, you should sit in the sun or by a fire to warm yourself and then the movement and the pulse should increase. (34–35)

Dr. Trinlay also refers to the improvements in Tibetan medicine that are possible through the use of microscopes, speculums, and sterile cloths in order to see the disorder caused by the agitation of a “womb bug” (ngelgi bu) called marutse which can produce fever, and also in order to evaluate the quality of semen in relation to problems of fertility and conception. The symptoms: According to the Blue Lapis commentary on the Gyu¨ Shi, “The abdomen and genitals itch, the breasts swell, the mind is agitated and [the patient] doesn’t sleep. She desires to move and her libido is increased, the skin is dry and the female genitals

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give off a strong odor.” If you are uncertain of the presence of the womb bug, you should certainly examine under a microscope. Before examining, be careful that the patient should not have had intercourse for a period of 24 to 28 hours before, that the outside of the vagina is wiped only with sterilized cotton, and that you should not investigate in the vagina with your fingers. You must be careful of this since otherwise impure bacteria [tr’ap’ung] will enter into the vagina. The method of testing: drop warm growing liquid onto the flat glass [slide]. Then, using a speculum to reach the back of the cervix, take some secretions from the sides. After mixing them with the growing liquid, place the slide quickly under the microscope and search for the bug [sinbu]. The bug is shaped like a pear, with the back part pointed. (80–81)

In relation to infertility, he writes: Having checked for any illness that has caused defects in the woman’s red element, cure that disease. While I have explained above the signs of defects in the man’s semen, since the doctor cannot tell simply by looking at the semen, if you examine with a microscope you can see the proportion of live to dead sperm [tr’ap’ung], also whether the sperm are abnormal, including whether the heads of the sperm are large and the tails small. If the sperm in the semen are abnormal, then although they are not dead, even if semen is sprayed into the birth canal, they will not have enough power to go via the cervix to the womb. The main treatment is to remedy and restore the kidney’s power. Tsawa nge´ menmar, dachi chusum, sendru nyikyil, and lhalung [names of medicines] should all be given. If [various] types of nutritious food are taken, the amount of semen will increase, and the number of live sperm in the semen will also increase. Once the abnormal sperm has become normal, it becomes the seed for pregnancy. (61–62)

Elsewhere in his text, he reveals the presence of biomedical techniques and knowledge in Tibetan medical practice when he notes that unsterile insertions of intrauterine devices can cause cervical infections, and that biomedical surgeries are the best treatment for some conditions that can’t be remedied by traditional treatments. In my research at the women’s ward of the Mentsik’ang, I found ample evidence of use of particular technologies of biomedicine. Use of ultrasound machines for diagnosing growths in the reproductive tract was common, as was use of intravenous drips of multivitamins, glucose, and antibiotics for treatment of even the most minor of illnesses. Doctors made referrals to various biomedical facilities specializing in certain services that were not available at the Mentsik’ang, such as treatment for tuberculosis and childbirth. Janes (1995) also reports dramatic evidence of the “biomedicalization” of Tibetan medicine under the direction of state Sinicization programs, leading to an overall “accession to institutional modernity.” He points to three trends in medical training that reveal the increasing influence of biomedicine (I summarize): (1) the incorporation of biomedical models in the training process, resulting in a perceived need among students to evaluate Tibetan humoral theory in relation to competing systems of (biomedical) truth, rather than taking the former for granted; (2) the use of

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diagnostic strategies which do not organize knowledge around the humors (and their myriad illnesses, respectively), nor around the intuitively perceived dominant humoral “character” (rangshi) of the patient, but rather around discrete diseases and their attendant treatments; (3) the apparent lack of training in Buddhism or its use in healing practices (Janes 1995, 26–27). These trends, Janes argues, entail greater accommodation of biomedical theories at the expense of this tradition’s religious foundations and are a direct outcome of state-directed modernization. I believe that in so far as Amchi Trinlay’s primary interests are with the health of his patients, his embrace of foreign technologies might be seen as stemming largely from a committed empirical spirit—to a medically “scientific” desire to seek efficacy no matter from where it arises. One would not want to overlook the pragmatism of his position. At the same time, it would be a mistake to assume that his pragmatism, or his empiricism, are not nested within a field of sometimes competing, overlapping, and complementary sociological, political, cultural, and epistemological agendas. Evidence from elsewhere in China is compelling here and makes for a useful comparative case, given the similar sociological status of traditional Chinese (zhongyi) and traditional Tibetan (Gyu¨ Shi) medicine within China. Farquhar (1987) studied the infusion of political agendas into medical epistemologies as found in medical practices and literature among China’s urban Han majority. Farquhar found that, in zhongyi, as practitioners explained the utility of traditional medicine to a communist society, Maoist renditions of a Taoist-inflectedMarxist dialectical materialism found their way into practitioners’ explanations of the fundamental ideas of yinyang. She also found that as biomedical epistemologies of diseases find their way into contemporary, liberalization-era China, practitioners interpret their practices in a manner that accommodates biomedical categories. These adjustments, like many of those undertaken by Tibetan medical practitioners, are successful in that they reveal a political acquiescence to a form of modernization mandated by the state (often an amalgam of imported and indigenous ideas), but they do not always undermine traditional epistemologies. The need to modernize accompanies officially sanctioned support for traditional medicine. Thus, rather than an acquiescence to biomedicine, many practitioners explain biomedical theories in terms of Chinese epistemologies and approaches to healing. Farquhar notes this is particularly true regarding zhongyi’s bases for authoritative knowledge and conceptualizations of the body, anatomy, and function.10 Amchi Trinlay’s concerns with political correctness and with incorporating biomedicine are at least partially mandated by the Chinese state. Little can be written in this, or any, government work unit in Lhasa, that is not attentive to official agendas and their justifications, whether or not these agendas accord with the author’s own ideas about empirical efficacy in relation to improving women’s health. At the same time, it would also be wrong to assume his text is attentive to only these issues. Just as with some zhongyi practitioners, Amchi

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Trinlay is also interested in reassuring readers of traditional Tibetan medical theory’s ability to serve as antidote to modernity’s loss and as promise of modernity’s “better” future. Rather than seeing the incorporation of biomedical forms of knowledge and practice as contributing to a hegemony of biomedicine at the expense of traditional practices, many Tibetan doctors feel that biomedicine validates traditional forms of knowledge and practice under new political and ideological circumstances. Examine again, for example, the uses of ultrasound machines to ascertain the type and location of growths in the woman’s womb. Although it may be possible to decipher the biomedical correlates of these growths, the intention of the Tibetan doctors is not to do this but rather to confirm Tibetan diagnoses that are found in the root tantras. Even the etiology referred to here and in practices in the Mentsik’ang relate to Tibetan medical concepts that have no equivalent in biomedicine. One of the causes of growths in the uterus, for example, is degenerated “downward-expelling winds.” If the t’ursel lung is deficient, then blood will accumulate in the uterus, and over time it can cause a type of growth referred to as a blood growth. Women generally suffer from declining wind strength as they get older, but other factors can affect the strength of the downward expelling winds. One patient I met was diagnosed with growths in her uterus. She developed growths because of a wind condition she incurred many years earlier, during the time just before the Cultural Revolution. She had been sent to work as a laborer in a metalworks factory and because of the conditions of heavy labor there had lost two children successively (one at birth and one shortly thereafter). When asked about the deaths of the children, one doctor explained that, according to the Gyu¨ Shi, if the red fluid of the mother and white fluid of the father do not match properly, the fetus may be unviable, or the child may be born with major health problems. One way to determine the suitability of the match between a husband and wife is by consulting a medical astrologer (tsipa). He can see from the parents’ time of birth what constituents of each parent’s generative fluid are present, and what their situation is in relation to each other. The quality of the parents’ elements (present in the generative fluids) is partly determined by the state of health of the parents, and partly by what they are born with themselves—that is, their own past lives. I was told that these factors also affect the health of children. A child’s health will be determined by its own karma as well as by the quality of the match between the father and mother. In the case of the patient we were talking about, the doctors involved in the case commented that her children’s deaths could also have been because of the heavy labor that she was subjected to. The patient herself felt that this was a reason, stating: “Many women like me lost their children because the metalworking was too hard. We had a lot of heavy lifting and were exhausted all the time. We didn’t have good food either.” The doctors also noted that the only surviving child of this patient, her third, was also not in good health. Again, this could be from the fact that the match between hus-

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band and wife was not good—their elements did not match—or from the other conditions prevailing during her birth and life. The doctors then explained that, for all these reasons, the loss of two children in a row had coincided with the onset of menstrual problems for this patient. For many years, she had had blood clots and much pain during menstruation. This was partly because of the disruption of the wind (lung) from depression over the loss of her children, but also because she was living in a cold and damp climate where she was not physically comfortable. Such conditions slow the movement of the winds in the body and also lead to excess production of phlegm substances (especially in the joints). After losing two children, she began to drink ch’ang (beer) regularly and they considered her level of consumption to be more than was healthy. Finally, they explained that her normal “character” (humoral character), taking into account her age, was that of wind-bile (lungtr’ipa). All of this pointed to serious wind imbalances that began early in her life and developed into chronic health imbalances that eventually contributed to growths in her uterus. Weakened downward-expelling wind (t’ursel lung) coupled with the dampness and increased phlegm led to stagnated, clotting menstrual blood and, eventually, blood growths, which were confirmed by ultrasound. How are we to make sense of the various factors brought to bear on this patient’s case? Tibetan doctors understand that the function of the downward-expelling wind is connected to the other four types of bodily winds, which are in turn related to all physiological processes associated with movement. But the deeper we go into Tibetan theory of the causes of these growths, the more we find ourselves in domains of theory that would seem, to some, dramatically “unscientific” from a biomedical perspective. Winds, for example, are originally produced from the presence of desire at the time of conception, when a transmigrating consciousness finds its way into a copulating couple by perceiving and desiring that orgasmic moment. From there, the presence of desire gives rise to the features of the physical body that enable it to function, which in the case of winds means the capability of movement. The relationship between desire (or attachment) and movement is fundamental: desire sets in motion causes that produce actions. Similarly, bile activity is related to the coarse emotion of anger or aversion. This too is fundamental: sentiments of aversion are related to the production of transformations produced by heat. Phlegm can also be parsed in relation to problems of ignorance or “obstructions and cold disorders.” The link between emotional distress and physiological dysfunction is clearly mapped out in Tibetan theory: in the case of winds, experiences of great emotional loss or stress (or merely the perception of unfulfilled desires) can weaken the body’s ability to function by disrupting its ability to move things around properly. Although not always explicit in clinical encounters, these theories explain both the role of karma in one’s health and the effects of deleterious social conditions which, by the power of perception, result in ill-health.

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Herein one finds legitimacy in Tibetan claims to a scientific approach in Tibetan medicine. The link between emotional or perceptual states and physiology is at the core of Tibetan medical theory: it assigns elemental properties to what are essential moral characteristics. Winds are associated with desires or attachments, bile with anger or aversion, and phlegm with ignorance or lack of clarity about the way things truly are. These links are established through the Tibetan theory of the development of the human body at the time of conception—the presence of the three poisons of greed, anger, and ignorance here give rise to the three channels from which all the body’s organs and systems arise coincident with the presence of these perceptual phenomena in the form of the humors.11 How? By the fact that each of the body’s humors/poisons is associated with one or more of the five elements that constitute all phenomena: bile with fire, phlegm with earth and water, wind with wind (space being the domain within which all are able to exist). This set of relationships explains how Tibetan medical theories of etiology can encompass such a wide range of interconnected factors: from climate and diet and sociological conditions to states of mind. External factors that the person comes in contact with have an effect on the internal functioning of the body because the elements inside the body are essentially the same as those outside. What is significant here is that at least at the level of theory, morality is what ties all the causal factors together. Morality, in the sense of the quality of relations between beings, is what ensures that climatic, social, political, dietary, bodily, and perceptual processes are all connected. In the Tibetan medical approach, domains of phenomena are seen as interdependent. Perceptions of loss (of a child, for example) are as disruptive to the body as major climatic or dietary changes, or natural phenomena such as aging; they are capable of producing the same effects. Simultaneously, all of these phenomena are recognized as sites for the expression of moral fallibility. Perceiving things like climate or political policies as problems or experiencing their deleterious effects (from discomfort of labor to the loss of children), which can, in turn, alter one’s perception of self, life, country, and the like are all expressions of very basic causes of suffering arising from moral fallibility, wherein this refers to the spiritual/ethical quality of relations between beings. But these ideas are seldom articulated in the daily clinical practices of Tibetan medicine. What is articulated, however, is their end product, in diagnoses such as growths in the uterus, imbalances of wind, and the like. These disorders are recognized as caused by the mutual interaction of perception and objective conditions that arouse states of anger, desire, ignorance (moral fallibility), hence imbalances of the humors (the physical expression of moral fallibility), and ultimately diseases. Although only articulated in discussions of theory, these are the principles at the root of Tibetan medical science. The closer one gets to the theoretical explanations of Tibetan diagnoses, the closer one gets to fundamentally religious ideas that explain such things as the relationship between perception and physical process which is mediated by mo-

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rality. Tibetan medical theory contains Buddhist presuppositions about the nature of suffering and the ultimate causes of all disorders in the human condition. Thus, the patient from the metalworks factory was presented to me as a patient who had suffered a great deal in the past, and who was in special need of therapies that could attend to her fragile mental state as a part of her treatment of uterine growths. I was told to avoid talking with her at great length about her past, for fear that it would rekindle her perceptions of loss and exacerbate her disease. With this in mind, one might ask about the nature of subjectivity found herein, and about whether it would be appropriate to talk about it as objectified by conditions of modernity. What sort of objectification could accommodate these external/internal moral permeations—since morality is by nature relational—and by the simultaneously objectively physical and subjectively perceptual quality of all health phenomena? With an eye upon the ways in which biomedical instruments like ultrasound are used, and upon the plethora of concepts to which its diagnoses refer, it is possible to see how Tibetan medical theories are, at least in some cases, being reinforced even with borrowings from foreign science. The Tibetan method of diagnosis is emphatically tied to humoral classifications as is the prognosis of disease and its symptomology. One might think, for example, from reading the table of contents of Amchi Trinlay’s text, that the biomedical disease model has come to play a more important role in classification of diseases than humoral theories. His contents lists the following chapters: sicknesses related to menstruation; sicknesses of pregnancy (including determining the position of the fetus, calculating delivery dates, and delivery); blood loss after delivery; protrusion of the uterus; the problem of having too many abortions; infections of the uterus; infertility; sicknesses of the breast; disorders of the anus; irregularities of the lining of the cervix; womb bugs. In fact, the method of medical investigation and writing has since the time of the Gyu¨ Shi’s initial writing included attempts to list diseases in this way. Once these diseases are listed, it becomes clear that their categorization follows humoral theory quite closely, and the same is true, I found, in clinical practices, where disease classifications generally followed humoral theory in order to ascertain appropriate treatments. At a more esoteric level, the discursive frameworks within which the doctors work still make implicit connections between humoral constitution and the moral qualities of relationships that underlie pathological histories and pathological physiologies, even if doctors seldom enter into explicitly moral discussions with patients. Convergences in discursive style and even to some extent in epistemology between Tibetan and biomedical approaches should not necessarily be taken as a sign of corruptions of the Tibetan system. Other examples also show this. The use of microscopes to ascertain the presence of the womb bug marutse, for example, might be seen as evidence of the penetration of biomedical theories of sexually transmitted diseases in Tibetan medicine. But Amchi Trinlay is concerned with this possible reading, and so refers at the outset to the presence of these diagnoses in a historical Tibetan text, the Blue Lapis medical commentary,

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written in the seventeenth century and in the Gyu¨ Shi, the primary medical tantras. It is also worth noting the classification of this disease of marutse as a “hot fever” type, which in Tibetan medicine means that the bile (pe´ ken) humor is activated, and fire is agitated, as part of this disease. Again, because Tibetan medical theory assigns connections between the five elements and the humors, which are in turn related to emotional dispositions (perceptions and attitudes), it becomes possible to understand how central the classification of the disease is to its symptomology. Amchi Trinlay lists the symptoms: “The abdomen and genitals itch, the breasts swell, the mind is agitated and [the patient] doesn’t sleep. She desires to move and her libido is increased, the skin is dry and the female genitals give off a strong odor.” The symptoms for this disease12 also include mood changes not directly related to anger or its bile equivalent but rather to perceptual states associated with the wind (lung) humor (agitation and insomnia). This is because the wind humor, most closely associated with the sentient consciousness (sem), is mercurial and is easily disrupted by the other humors. Once the bile is agitated, it recruits the wind and this increases the activity of both. Because bile is associated with heat (fire, which cooks or transforms things) and wind is related to movement (elemental forms of wind), their combined activity can lead to physiological changes such as dry skin, swollen breasts, and itchiness as reactions to the presence of this parasite. And in reference to the other symptoms, we see again that the humors are at once both physiological and psychological phenomena. Once again, the ability to “see” through a microscope the bug that causes these actions in the body and mind is, from the Tibetan medical perspective, not something that undermines traditional theoretical assumptions. Rather, it confirms the validity of them and the contemporary relevance of this medical system’s early scholars. To the extent that biomedical theories and practices are making their way into Tibetan medicine, it is worth asking questions about the epistemological effects they have had. If, for example, one of the hallmarks of biomedicine is its ability to objectify patients in the same way it objectifies knowledge (Taussig 1980; Comaroff 1982; Foucault 1973),13 there is some evidence of this sort of process in Tibetan practices. So long, however, as theories about humoral function continue implicitly to make associations between the elements that constitute both external and internal states and the morally based theory of three poisons (which ultimately refer to the ethical quality of social relations between living beings), then objectification processes remain constrained. Tibetan medical approaches to the suffering patient do, for example, conceptualize health problems of the patient in terms of methods of containment, wherein a series of connected disruptions that link together climate, diet, behavior, social circumstances, perceptions, and more, are felt to be manageable at the site of the body where they can be temporarily contained. But these strategies point less to an objectification of the patient than to the patient’s visible expressions of a universe that is all connected, ultimately, by morality. Although Tibetans are em-

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bracing forms of modernity that resemble those seen in the Euro-American context, whether in attempts to make claims about science, in borrowing biomedical techniques, or in describing their experiences of modernity in terms that resemble Western universalist ideas about lost pasts and hopeful futures, the ontological status of the suffering Tibetan patient is not necessarily equivalent to that of the Western modern. An objectified Western self through whom modernity is organized by processes of medicalization, clinical reductionism, and alienation, is simply not present in the same way among Tibetans.14 Modern biomedical practices (even in their Sinicized form) work with theories of knowing that separate the social from the biological, even when such theories make half-hearted attempts to bridge these domains. Durkheim and others recognized this as a hallmark of our modernity—the act of recognizing our existence as social beings who could function above and beyond our biological natures. This act of recognition is at once intellectual and embodied. It becomes an embodied reality, a way of knowing the world through our theories about the world (Latour 1990). Herein, subject-object dualism as ontology and epistemology became a paramount achievement of modernity. This dualism is seen as an imperative for effective medical interventions as well as for liberatory critiques of modernity. Those who recognize the ultimate sense of loss it produces ask for a return to a former, more complete, mode of being as a hopedfor future that will transcend the dilemmas of modern life. In modern Lhasa, ideas about suffering are theorized by Tibetan doctors in ways that do not make this distinction, in the same way pointing to a different sort of modern experience, subject, and set of liberatory agendas to deal with modernity’s losses. If we return then to the question of modernity and its losses among Lhasa Tibetans, the question of appropriate epistemology might be raised. One is tempted to deploy various methodologies emergent from within Western social science in order to attend to the project of identifying the relevant concerns and experiences of Tibetan modernity and contemplating a liberatory position from which to write about them.15 When considering an epistemological starting point that foregrounds the ways that Tibetan theories inform their experiences of modernization, then one place to look for this is in the religious texts, and in the medical texts that theorize suffering and modernity as problems of greed, anger, and ignorance in a universe held together by—in fact, produced from—moral comportment. These theories today might show some similarities to those experiences mapped out by social theorists like Durkheim, Marx, Weber, Tagore, as well they should considering the impact of these theorists, especially Marx, on Chinese socialist forms of modernization. But they might also show divergences. CONCLUSION It would be a mistake to attribute too much traditionalism and/or religious devotion to scholars like Amchi Trinlay, for surely his goal is to undertake an

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updating and refashioning of Tibetan medicine that will legitimize it in a climate that increasingly demands scientific explanations as opposed to religious ones, and that presents biomedical knowledge, technologies, and treatments as unproblematically viable alternatives for upgrading traditional practices. This process began seriously in 1916 under the reign of the thirteenth Dalai Lama with the construction of a college for higher education for nonmonastic students (children of elites mostly) called the College of Medicine and Astrology (Mentsik’ang). Since then, efforts to modernize by focusing on the scientific logic of Tibetan medical theory have been rapidly pursued. But the last forty years have radically increased the pace and terms of this engagement. When these modernization demands are put in place by a state that establishes its presence through the use of force and terror, alongside some democratic processes, the ability to avoid incorporating and attending to those ideologies valorized by the state (or to avoid taking them seriously) is limited, to say the least. And so, there is a tendency among scholars to claim that despite its origins in religious epistemology, Tibetan medicine is now and always has been a science. It is even useful to consider why, if Tibetan medical theories are so rooted in religious presuppositions about the nature of reality (from the five elements to the moral basis for the creation of the human body), more of these explicitly religious discussions do not appear in contemporary medical writings. One answer is that they do,16 but as with many Tibetan literary genres, knowledge about the nature of the universe, like the laws of karma, or the basis for morality, is taken as implicit—as part of a cultural worldview—and so the idea of naming these as “religious” is considered unnecessary. On top of this, scientific language is now depoliticized as strongly and pervasively as religion is politicized. In this context, it becomes safe to speak of Tibetan medicine in terms of science rather than religion, but the process also reveals how religion and science are taking on new meanings.17 If upon first inspection, it is easy to see how similar modernity looks because of the transnational linkages which enabled not only socioeconomic but also ideological convergences between nations far apart but brought close through the movement of theories and through geopolitical contacts, then it is not surprising that Tibetan medical scholars think about modernity at least partially in similar terms to scholars of Europe and America—that is, in terms of its losses. Modernity’s ability to create a sense of incompleteness around the subject who is constantly looking to recover something that was lost from the past in order to produce a better future is found among Tibetans, where it is coupled to a rhetorical commitment to a language of science to which is imputed the power to fulfill or erase these losses. In the case of China’s Tibet, this project gets interwoven with problems of internal hegemony and nationalist resistance, which are articulated in terms of a problematizing and valorizing of Tibetan history and religion. A closer look at the medical domain, however, suggests that there may be more to the experience of modernity among Lhasa Tibetans than simple state

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or foreign hegemony. In fact, elements of modernity found in those features of knowledge and theory that are not visible—that are simply known in implicit cultural knowledge about the relationship, for example, between morality and health—may be more significant forces shaping Tibetan modernity even though they are not immediately visible. With this in mind, it becomes possible to read overt commitments to forms of scientific modernization as indications of the particularity of Tibetan modernity. Whereas it may look like they represent a shift toward more biomedical forms of knowledge and practice, including a potential trend toward objectification, this may be not be the only reading of these things. These overt tendencies may in fact be strategies for confirming and legitimizing traditional knowledge and practices, even, perhaps, ending in a critique of objectification as it is typically known to social theorists popular in the European and American contexts. ACKNOWLEDGMENTS I wish to acknowledge research funding support from Princeton University, the Wenner-Gren Foundation for Anthropological Research, and the National Science Foundation. I thank the organizers Linda Connor and Geoffrey Samuel for the conference on Healing Powers and Modernity. I gratefully acknowledge comments from Laurel Kendall, Mark Nichter, Elisabeth Stutchbury, Geoffrey Samuel, and other participants at the conference, with particular thanks to Craig Janes. The translated portions of Dr. Trinlay’s work are taken from the manuscript version of his text received in 1995. Dr. Trinlay read and approved the translation used here in 1998. However, Dr. Trinlay should not be held responsible for any of the interpretations of the text which are offered in this chapter. These are entirely the author’s. Finally, I thank the physicians, nurses, and medical students at the Mentsik’ang who enabled me to conduct this research. I alone take full responsibility for the ideas presented here. NOTES 1. Examples of ethnomedical studies that assume that a culture’s fundamental epistemes can be read from its medical theories and practices are plentiful (Zimmerman 1982, 1992; Leslie 1992; Good 1977, 1994; Unschuld 1985, 1992; Farquhar 1987, 1992, 1994a, b). Anthropologists have shown that medical knowledge attends to fundamental problems emergent from the normative social structure (Turner 1961, 1968; Comaroff 1982, 1985; Frankenberg 1980, 1981, 1986; Good 1994) and that theories of healing are oriented to both clinical and extraclinical domains. For example, it has been argued that biomedicine reproduces the ontological dilemmas of modernity which cause medical problems, such as in Cartesian dualism, reductionism, and reification (Comaroff 1982; Taussig 1980), but also that biomedicine, whether successful or not, positions itself to remedy such modern problems through a wide variety of treatments (Scheper-Hughes and Lock 1987; Lock and Scheper-Hughes 1991; Scheper-Hughes 1992; Kaufman 1988). 2. Like Ivy (1995) I argue that the ethnographic pursuit should attend not only to

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the way our informants behave culturally, but also to the way they theorize about their behavior and their social practices. 3. I began research in the women’s ward of the Lhasa Mentsik’ang (inpatient and outpatient wards) in 1993, and I returned for another summer research visit in 1995. I then undertook four and a half months of research in 1998. I want to acknowledge with great appreciation the help of Art Engle of Howell, NJ, and Geoffrey Samuel in translating the medical text I use here. 4. Janes (1995) notes this, and specifically that Tibetan medicine became most dramatically restructured to meet the needs of the modernizing socialist regime—a regime already committed to some biomedical techniques—in the years after 1959. I refer readers to his article. 5. The analogy is to testing the quality of gold before buying or using it. The same image is used in relation to testing the quality of a Buddhist teacher before studying with him. 6. This term, literally meaning “divine lord[s],” is said to have been given as an honorary title by the ninth-century Tibetan king Tr’isong Detsen. 7. Gedu¨ n Ch’o¨ p’el is a controversial figure from early twentieth-century Tibet who was seen as something of a heretic by Gelukpa officials (Stoddard 1988). He is the author of a Tibetan treatise on passion (translated as Tibetan Arts of Love, Ch’o¨ p’el 1992). Goldstein (1989, 453) offers insight on why this particular Buddhist historian might have been considered an acceptable source for this amchi, for Gedu¨ n Ch’o¨ p’el was himself a student of Marxist-Leninist political philosophy: He was an erudite but somewhat wild Amdo monk who had been born in 1905. After becoming a monk, he stayed at Tashikhil monastery in Amdo until he was twenty-two or twenty-three, when he enrolled in Gomang college, Lumbum khamtsen, in Drepung monastery. When he was about thirty he went to India for a stay of twelve years during which he learned English and Sanskrit and translated and composed a wide variety of texts. While in India he became enamored of MarxistLeninist political philosophy and anti-colonialist ideology and came to believe that major reforms or a revolution in Tibet was necessary. He favored giving the monks salaries instead of estates and requiring them to study instead of engaging in business. He is also said to have favored land and legal reforms, and democracy. For all his brilliance, however, Gendun Chompel [sic] was hopelessly degenerate for a monk. He was a womanizer, a chain smoker, a user of opium and liquor, and physically unkempt.

8. Compare Ch’o¨ p’el (1992, 182). 9. Compare Ch’o¨ p’el (1992, 182). 10. Farquhar (1987) notes that following the traditional system, authoritative truth still arises largely from multiple points of view legitimated by lineages of practitioners and by a commitment to a nonanatomical, functional, and outcomes-oriented perspective on the body. This contrasts with a system in which authoritative truths arise from objectified and standardized knowledge shared as professional epistemology, and with a system in which fixed anatomical objects serve as the basis for standardized bodily functioning. Here, efforts to modernize by incorporating biomedical knowledge and techniques are not necessarily effective in undermining traditional Chinese epistemologies. Strategies for incorporating biomedical theory and practice are themselves multiple and often contested among Chinese practitioners, and the degree to which such strategies accommodate or contest officially sanctioned programs for socialist modernization is not uniform, even if the latter are ever present.

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11. On one level, the physical being is, in the Tibetan theory, created as a result of the moral actions and intentions from past lives that left “traces”—that is, that created karma—which determine the quality and strength of the humors. At the time of conception, the fetal entity is formed by meeting of the combined regenerative fluids of the mother (red element) and father (white element). When these elements are without flaw they become a suitable home for a sentient consciousness (sem) transmigrating from a past life. Located at a point (t’igle ch’enpo) in what will be the middle of the heart, this consciousness and five elements is associated with a life force called the sog—a potentiality. The emergence of a human form is contingent upon the type of winds circulating in this life-force—that is, its subtle winds of wisdom and karma. Meyer (1992) explains it this way: when unified by the winds of wisdom of emptiness (yesheki lung), the mind and its energy are conducive to enlightenment—a physical body does not necessarily materialize; but when activated by the vital energy of past deeds (le´ ki lung [karmic winds]), they are dispersed (paraphrased from Meyer 1992; see also Rechung 1973; Dhonden 1986; Dhonden and Kelsang 1983 for parts of this description). The “dispersal” of this vital energy is what produces the body in a being who has not reached enlightenment. 12. “Disease” is an inadequate translation of ne´ because it does not capture the “syndrome”-like quality of named diagnoses in Tibetan medicine—syndrome-like in the sense that they refer to a set of system disruptions, not a single, bounded entity or state. 13. I would add that this assumption has to be made in order to make an argument about medicalization, for medicalization presupposes the ability to differentiate between the sociological contexts and causes of disorders and their bodily, biological manifestations. 14. I am not suggesting this is entirely unique to Tibetans, since it resembles that found among many people in the world, although neither am I suggesting it is universalizable as “premodern.” 15. See Goldstein (1989) and Stoddard (1988) for histories attending to Chinese and Euro-American involvement in Tibet. 16. See, for example, the lama-amchi Tsultrim Gyantse’s text: “Explanation of the System of Channels (Nervous System) as Illustrated in the Medical Thangkas” published in the “Collection of Talks Given at the Seminar on Higher Studies of Tibetan Medical Research of China,” compiled by the Tibetan Autonomous Region Mentsik’ang, 1996. 17. Another reason for this lack of its presence in the medical texts that I am pursuing elsewhere concerns the nature of certain religious knowledge that must be kept secret (sangwa).

REFERENCES Anagnost, Ann. 1994. The politicized body. In Body, subject, and power in China, edited by Tani E. Barlow and Angela Zito. Chicago: University of Chicago Press. Bishop, Peter. 1989. The myth of Shangri-La: Tibet, travel writing and the Western creation of sacred landscape. Berkeley: University of California Press. Ch’o¨ p’el, Gedu¨ n. 1992. Tibetan arts of love. Introduced and translated by Jeffrey Hopkins with Dorje Yudon Yuthok. Ithaca, NY: Snow Lion Publications. Comaroff, Jean. 1981. Healing and cultural transformation: the Tswana of Southern Africa. Social Science and Medicine 15B: 367–378.

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———. 1982. Medicine: symbol and ideology. In The problem of medical knowledge, edited by P. Wright and A. Treacher. Edinburgh: Edinburgh University Press. ———. 1985. Body of power, spirit of resistance. Chicago: University of Chicago Press. Deleuze, Gilles and Fe´ lix Guattari. 1983. Anti-Oedipus: capitalism and schizophrenia. Minneapolis: University of Minnesota Press. DelVecchio Good, Mary Jo. 1980. Of blood and babies: the relationship of popular Islamic physiology to fertility. Social Science and Medicine 14B: 147–156. Dhonden, Yeshi. 1986. Health through balance: an introduction to Tibetan medicine. Translated by Jeffrey Hopkins. Ithaca, NY: Snow Lion Publications. Dhonden, Yeshi and Jampel Kelsang. 1983. The ambrosia heart tantra. Tibetan Medicine 6. Dharamsala: Library of Tibetan Works and Archives. Evans-Pritchard, Edward E. 1976 [1937]. Witchcraft, oracles, and magic among the Azande. Oxford: Clarendon Press. Fabian, Johannes. 1983. Time and the other: how anthropology makes its object. New York: Columbia University Press. Farquhar, Judith. 1987. Problems of knowledge in contemporary Chinese medical discourse. Social Science and Medicine 24: 1013–1021. ———. 1991. Objects, processes, and female infertility in Chinese medicine. Medical Anthropology Quarterly 5: 370–399. ———. 1992. Time and text: approaching Chinese medical practice through analysis of a published case. In Paths to Asian medical knowledge, edited by C. Leslie and A. Young. Berkeley: University of California Press. ———. 1994a. Multiplicity, point of view, and responsibility in traditional Chinese healing. In Body, subject and power in China, edited by A. Zito and T. Barlow. Chicago: Chicago University Press. ———. 1994b. Knowing practice: the clinical encounter of Chinese medicine. Boulder: Westview Press. Foucault, Michel. 1973. The birth of the clinic. New York: Vintage Books. ———. 1978. History of sexuality. Volume One. New York: Vintage Books. ———. 1988. Technologies of the self. In Technologies of the self, edited by L. H. Martin, H. Gutman, and P. H. Hutton. Amherst: University of Massachusetts Press. Frankenberg, Ronnie. 1980. Medical anthropology and development: a theoretical perspective. Social Science and Medicine 14B: 197–207. ———. 1981. Allopathic medicine, profession, and capitalist ideology in India. Social Science and Medicine 15A: 11–125. ———. 1986. Sickness as cultural performance: drama, trajectory, and pilgrimage, root metaphors and the making social of disease. International Journal of Health Services 16: 603–626. Giddens, Anthony. 1991. Modernity and self-identity: self and society in the late modern age. Stanford: Stanford University Press. Goldstein, Melvyn C. 1989. A modern history of Tibet: the demise of the Lamaist state. Berkeley: University of California Press. Good, Byron. 1977. The heart of what’s the matter: the semantics of illness in Iran. Culture, Medicine, and Psychiatry 1: 25–58. ———. 1994. Medicine, rationality, and experience. New York: Cambridge University Press. Harvey, David. 1989. The condition of postmodernity. Oxford: Basil Blackwell.

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Ivy, Marilyn. 1995. Discourses of the vanishing: modernity, phantasm, Japan. Chicago: Chicago University Press. Janes, Craig. 1995. The transformations of Tibetan medicine. Medical Anthropology Quarterly 9: 6–39. Kaufman, Sharon. 1988. Toward a phenomenology of boundaries in medicine: chronic illness experience in the case of stroke. Medical Anthropology Quarterly 2: 338– 354. Kracauer, Siegfried. 1995. The mass ornament: the Weimar essays, translated and edited by Thomas Levine. Cambridge, MA: Harvard University Press. Latour, Bruno. 1990. Postmodern? no, simply amodern! steps towards an anthropology of science. Essay review. Studies in History and Philosophy of Science 21: 145– 171. Leslie, Charles. 1992. Interpretations of illness: syncretism in modern Ayurveda. In Paths to Asian medical knowledge, edited by C. Leslie and A. Young. Berkeley: University of California Press. Lock, Margaret M. 1980. East Asian medicine in urban Japan: varieties of medical experience. Berkeley: University of California Press. Lock, Margaret M. and Nancy Scheper-Hughes. 1991. The message in the bottle: illness and the micropolitics of resistance. Journal of Psychohistory 18: 409–432. Lopez, Donald S. 1998. Prisoners of Shangri-La: Tibetan Buddhism and the West. Chicago: University of Chicago Press. Martin, Emily. 1987. The woman in the body. Boston: Beacon Press. Meyer, Fernand. 1992. Introduction: the medical paintings of Tibet. In Tibetan medical paintings: illustrations to the Blue Beryl treatise of Sangye Gyamtso (1653–1705), edited by Y. Parfionovitch, G. Dorje, and F. Meyer. New York: Harry N. Abrams, Inc. Rechung, Rinpoche. 1973. Tibetan medicine. Berkeley: University of California Press. Rivers, W. H. R. 1924. Medicine, magic and religion. London: Kegan and Paul. Root, Deborah. 1996. Cannibal culture: art, appropriation and the commodification of difference. Boulder: Westview Press. Schein, Louisa. 2000. Minority rules: the Miao and the feminine in China’s cultural politics. Chapel Hill, NC: Duke University Press. Scheper-Hughes, Nancy. 1992. Death without weeping: the violence of everyday life in Brazil. Berkeley: University of California Press. Scheper-Hughes, Nancy and Margaret M. Lock. 1987. The mindful body: a prolegomenon to future work in medical anthropology. Medical Anthropology Quarterly, N.S. 1: 6–41. Stoddard, Heather. 1988. Tibet from Buddhism to Communism. Government and Opposition 21: 76–95. Tagore, Rabindranath. 1992 [1917]. Nationalism. Calcutta: Rupa and Company. Taussig, Michael. 1980. Reification and the consciousness of the patient. Social Science and Medicine 14: 3–13. Trinlay, Palden. 1998. Bod Lugs Gso Rig gi Rgyan Mthong Mo Nad ’Gog Bchos Bya Thabs [Health measures for commonly seen sicknesses of women]. Lhasa: People’s Publishing House. Turner, Victor. 1961. Ndembu divination: its symbolism and techniques. Manchester: Manchester University Press. ———. 1968. The drums of affliction. Oxford: Clarendon Press.

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Unschuld, Paul. 1985. Medicine in China: a history of ideas. Berkeley: University of California Press. ———. 1992. Epistemological issues and changing legitimation: traditional Chinese medicine in the twentieth century. In Paths to Asian medical knowledge, edited by C. Leslie and A. Young. Berkeley: University of California Press, 1992. Young, Allan. 1976. Some implications of medical beliefs and practices for social anthropology. American Anthropologist 78: 5–24. ———. 1978. Mode of production of medical knowledge. Medical Anthropology 2(2): 97–124. ———. 1981a. The creation of medical knowledge: some problems in interpretation. Social Science and Medicine 15B: 379–386. ———. 1981b. When rational men fall sick. Culture Medicine and Psychiatry 5: 317– 336. ———. 1982. The anthropologies of illness and sickness. Annual Review of Anthropology 11: 257–85. Zimmerman, Francis. 1982. The jungle and the aroma of meats: an ecological theme in Hindu medicine. Berkeley: University of California Press. ———. 1992. Gentle purge: the flower power of Ayurveda. In Paths to Asian Medical Knowledge, edited by C. Leslie and A. Young. Berkeley: University of California Press.

12

Tibetan Medicine in Contemporary India: Theory and Practice Geoffrey Samuel

INTRODUCTION The cultures of many premodern Asian societies incorporated medical traditions with textual expressions of considerable antiquity. These range from the ¯ yurvedic Galenic-Islamic medicine of West Asia and North India, through the A and Siddha medical traditions of South Asia to traditional Chinese medicine, and include the traditional Tibetan medicine discussed here and in Chapters 10 and 11 of this book. One of the problems with gaining a clear perspective on these traditions, however, is the distance which often exists between the tradition as practised, and the theory given in the texts. All medical traditions carry with them ideas about disease, its causation and treatment, themselves typically embedded in wider sets of assumptions about the nature of human life and society. Yet medicine is above all a question of practice, and the conceptual structures implicit in that practice may differ extensively from the more theoretical and systematic presentations through which traditional Asian medical systems have become familiar in the West. My theme in this chapter is the relationship between theory and practice in traditional Tibetan medicine. Here “theory” refers primarily to the Gyu¨ Shi or “Four [Medical] Tantras,” the basic Tibetan medical texts, but also to Western presentations of Tibetan medicine, which are largely based on the Gyu¨ Shi as interpreted by contemporary Tibetan doctors. “Practice” refers mainly to observations by myself and Linda Connor during field research in Northern India with two Tibetan refugee medical clinics and their patients between June and August 1996.1

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The Four Medical Tantras are the central canonical texts of Tibetan medicine, and they remain the basis of training at the Men-Tsee-Khang2 in Dharamsala, Northern India, where traditional Tibetan medicine is taught today. However, their relationship with the actual practice of Tibetan medicine is complex and has received little attention.3 An important question is that of the nye´ pa, the three so-called humors which ¯ yurvedic do˚sa. These are often described as the basis correspond to the three A of Tibetan medicine, and they certainly form the basis of Western representations of Tibetan medicine as a holistic system concerned primarily with the balance of the organism as a whole. A related issue is the relationship between the diagnostic techniques and categories employed in contemporary practice and those given in the textual system. In both these, what we observed differed significantly from most published accounts of Tibetan medicine, and from the standard Western interpretations of the Tibetan medical system. At the end of the chapter, I try to explain these differences. Given the relative brevity of our research, my explanations are speculative. They include the nature of Tibetan medical training in India; the pluralistic context within which Tibetan medicine is nowadays practiced in India; and the complex interactions between Tibetan medical experts and Westerners in search of Tibetan medical knowledge. I begin by presenting a brief account of the context of Tibetan medicine in Dalhousie, our principal field situation. TIBETAN MEDICINE IN DALHOUSIE Most of our research was carried out in one specific Tibetan community, the refugee community of Dalhousie in Himachal Pradesh, 6,000 feet up in the Himalayas in Northern India. We also carried out a brief comparative study at a Tibetan refugee settlement in Delhi. Dalhousie is a small Indian town with a Tibetan population of about 500, most living in or close to the Tibetan settlement, which includes an Indian government-funded school, and a Handicrafts Center. The school has 600 Tibetan students, most of them from other Tibetan refugee settlements in India. There is one elderly reincarnate lama (whom I shall call the Rinpoch’e). He lives close to the main settlement, and plays a considerable role in relation to health issues, as in other aspects of Tibetan life in Dalhousie. There are also some monks at the other end of town, but they have little involvement with health issues. Dalhousie was one of the earliest Tibetan refugee settlements. It is now somewhat of a backwater, although only a few hours by bus from Dharamsala, which is the location of the Dalai Lama’s residence and the refugee administration and is the center of most aspects of refugee life. Few Dalhousie Tibetans are wealthy, and their health choices are dictated in many ways by their income limitations. Our research was centered at a small clinic with one doctor, a Buddhist monk who had been trained at the Men-Tsee-Khang, the traditional Tibetan Medical

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Figure 12.1. Men-Tsee-Khang Clinic, Dalhousie. Photo by Geoffrey Samuel.

and Astrological Institute in Dharamsala, and one pharmacist. This clinic, which is part of a network of clinics run by the refugee administration, dispensed traditional Tibetan medicine (po¨ men). We also spent some time with the previous doctor from this clinic, a layman who now runs a similar clinic in Delhi. During our seven weeks in Dalhousie we spent several hours most days in the clinic (see Figure 12.1). During this period around 135 patients, mostly Tibetans, visited the clinic, many of them several times. As it was a fairly quiet clinic, we had plenty of time to discuss cases with the doctor. We also interviewed eighteen of the patients at some length away from the clinic to get a picture of the total range of medical resources they used, and interviewed other major providers of health care to the community. These other providers are mainly biomedical—what we might refer to as Western medicine, though to the Tibetans it is “Indian medicine” (gyagar men). While large settlements, such as Bir (Monro 1996), have substantial Tibetanrun biomedical facilities, at Dalhousie these consist of a community health worker employed by the refugee administration’s department of health, and two school nurses. For biomedical treatment Dalhousie Tibetans are mostly dependent on local Indian resources. These include a charity-run clinic a few minutes’ walk above the settlement, a couple of doctors in private practice in the town, and drugs they purchase from the local pharmacies. There is a small government-run Civil Hospital with limited facilities, but serious cases are usually referred to the District Hospital three hours away by bus at Chamba, the Zonal Hospital at Dharamsala, or to Delek Hospital in Dharamsala, the latter

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¯ yurveda, homeopathy, and being the main Tibetan refugee biomedical facility. A other alternative healing modalities have little presence in Dalhousie. Tibetans ¯ yurvedic doctor in town, and when they speak do not appear to go to the one A of “Indian medicine” the reference is unambiguously to the local practices of biomedicine.4 HEALING MODALITIES IN DALHOUSIE: EMPOWERED SUBSTANCES, TIBETAN MEDICINE, AND BIOMEDICINE Most of the basic Tibetan ideas about health, illness, and fate are not really Buddhist, but derive from pre-Buddhist material reworked to some extent in Buddhist terms.5 They include a range of concepts (la, ts’e, yang, trashi, sog, wangt’ang, lungta) all referring to various kinds of energy, vitality, life-force, or good fortune, and another range of concepts (drip, do¨ n, no¨ pa, barch’e´ ) referring to obstacles, spirit affliction, and the like. This material exists in “theorized” and sophisticated versions, particularly in the astrological context, where the state of many of these quantities is calculated in detail and available in printed almanacs. In practice, most people’s ideas are much less formal and precise than this might lead one to expect, and we saw little in Dalhousie of the more sophisticated versions of such concepts. There was a general shared understanding, though, that certain types of illness result from low vitality and/or spirit affliction of some kind, often associated with a state of contamination (drip). Such problems are appropriately dealt with through the use of various jinden or sacred substances empowered by lamas or Buddhist deities. People may take jinden prophylactically if they feel in a vulnerable situation—for example, when selling sweaters on the streets of dirty and polluted Indian cities (a frequent winter occupation for Dalhousie Tibetans), or when going into an Indian hospital for the delivery of a child (Rozario 1996). In cases where spirit causation is suspected for an illness, people may try to confirm the nature of the problem through divination. In Dalhousie this is usually by the Rinpoch’e or one of the couple of local lay diviners, but people also go further afield in serious cases to visit a spirit medium at Dharamsala or a high-status lama elsewhere in India, such as sMin-ling gTer-chen at Clementtown or Saskya Gong-ma at Dehra Dun. Special Tantric rituals, such as the well-known ts’ewang (“life-empowerment”) ceremony (Samuel 1993, 259–264) might also be commissioned. Thus the Rinpoch’e conducted a ts’ewang during our stay for a small boy who had been suffering from fainting fits, and he provided a variety of other ritual services, such as supplying empowered water for purificatory purposes. Other kinds of illness are dealt with through traditional Tibetan medical treatment (po¨ men) or through biomedicine (gyagar men). The theory of Tibetan medicine will be considered further later. In practice, Tibetan medicine appears to function much like a conventional allopathic system, in that particular diseases

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Figure 12.2. Dispensary of the Men-Tsee-Khang Clinic. Photo by Linda Connor.

are countered for the most part by specific drugs, mostly made from herbal or mineral substances. The principal differences from Western medicine in practice are probably the modes of diagnosis (an elaborate system of pulse diagnosis, supplemented with ¯ yurveda, the digestive process urine analysis) and the emphasis on diet. As in A is seen as central to much disease causation, and so control of diet is seen as very important. Most patients get at least some dietary advice, though it is often fairly routine (“avoid chillis and sour foods”). The dominant mode of treatment is through drugs in the form of pills (rilbu) made from herbal and mineral ingredients.6 Usually two or three different pills are prescribed, to be taken at different times of the day. The clinic had around 130 different medicines, generally named for the principal ingredients and total number of ingredients (e.g. kyuru 25 has a total of 25 ingredients, with kyuru or emblic myrobalan as the principal one) (see Figure 12.2). The price is uniform and relatively low, though by no means negligible in terms of the average income; some patients receive medicine at a free or subsidized rate. A further class of pills (rinch’en rilbu or “Precious Pills”) is considerably more expensive. These, unlike ordinary pills, have to be taken under special ritually prescribed conditions and, like the jinden

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mentioned earlier, are strongly associated with the Buddhist-derived spiritual power of the lamas.7 Attitudes to traditional Tibetan medicine and “Indian medicine” (i.e., local biomedicine) varied among Dalhousie Tibetans, but most people appeared to view them as complementary, each having its own sphere of usefulness. We often heard that biomedicine acted quickly but did not cure the underlying problem and often had side effects, while Tibetan medicine took much longer, had no side effects, and eventually cured the problem. In fact, patients using Tibetan medicine often seemed oriented as much to maintenance as to eventual cure; another common comment was that at least with traditional Tibetan treatment the problem would not get worse. In practice, a number of specific problems, such as jaundice, high blood pressure, and tsadrip,8 were frequently treated by Tibetan medicine, while others (e.g., fevers, tuberculosis) were routinely treated by biomedicine. Some Tibetans expressed a strong preference for Tibetan medicine, which has associations with the culturally highly valued sphere of Buddhism, although only a minority of doctors are monks or lamas. PRACTICE AND DIAGNOSIS IN A TIBETAN MEDICAL CLINIC Traditional Tibetan medicine,9 as mentioned above, has been mostly presented in Western descriptions in terms of a “holistic” theory of humoral imbalance, based on a system of three nye´ pa or “humors” (lung, tr’ipa, pe´ ken) correspond¯ yurveda (va¯ ta, pitta, kapha, usually translated ing closely to the three do˚sa of A as “wind,” “bile,” and “phlegm”). Descriptions for Western readers (e.g., Dhonden 1986; Clifford 1989; Men-Tsee-Khang 1995) highlight this humoral theory, along with the complex procedures of pulse and urine diagnosis. The three nye´ pa certainly do form part of the practice of Tibetan medicine as we observed it. Whether they constitute the kind of humoral system generally assumed by Western commentators, in which illness is attributed primarily to an imbalance of internal bodily factors, is less clear. This model derives primarily from Galenic medicine and from its lineal successor, Islamic medicine. Its application to Tibetan medicine is somewhat questionable.10 It might be useful to provide a brief description of Tibetan medical practice as we observed it. At the clinics we knew,11 patients, mostly Tibetan but including some Indians, would enter the doctor’s consultation room individually, sometimes in the company of a family member or friend. (The doctors made only occasional home visits; most of the patients came to the clinic.) While some of the more assertive patients themselves initiated discussion with an explanation of why they had come, most encounters proceeded rapidly to the doctor reading their pulse and asking them questions based on his pulse diagnosis. Where the doctor felt that it was appropriate (in perhaps a third of the 150 or so consultations we wit-

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nessed), the patient’s blood pressure was read, using a sphygmomanometer and stethoscope. The doctor then wrote out a prescription—most often for two or three different pills (rilbu) from a range of about 130 stocked at the Men-Tsee-Khang clinics, to be taken daily at different times—which the patient collected from the pharmacist. Occasionally, if the drug of first choice had run out, a substitute was prescribed. Almost always, the doctor gave some dietary advice, such as to avoid hot or sour foods. At the conclusion of the consultation, the doctor completed a record book in which he listed the patient’s name, age, prescription, and problem. Regular patients usually also had record books of their own in which the doctor wrote the prescription, dietary advice, and occasionally other information, such as the patient’s blood pressure. Most consultations were quite brief, lasting perhaps five minutes on average. The two doctors we observed used pulse diagnosis in almost all cases, but made limited use of urine diagnosis, basically only where patients had themselves brought along urine specimens. Some other doctors regularly perform urine analysis, and expect patients to bring a specimen along.12 Where possible, we discussed the diagnosis and the logic behind the prescription with the doctor immediately after the consultation. Thus we accumulated a list of disease categories used in clinical practice and of pills and treatment applicable to each. In Table 12.1, I give a few brief examples from the Dalhousie clinic of the kind of data we obtained.13 This is a fairly representative sample of Dalhousie patients, though it deliberately excludes any of the substantial numbers of schoolchildren, who presented a different range of problems.14 “Diagnosis” is clearly a vague category; the diagnoses here reflect a variety of levels of theorizing from straightforward descriptions of symptoms (“pain in upper back,” “toothache”) to Tibetan disease terminology (lung, tsakar15). Where the doctor appeared to be using Tibetan language categories that were not other than simple equivalents of English terminology (“headache”), I have given the Tibetan term. The use of uncritical biomedical equivalents is a persistent problem in Western books on Tibetan medicine (including, perhaps especially, those written by Tibetan doctors). There is, of course, no reason to assume a one-to-one correspondence between biomedical and Tibetan disease categories. A systematic study of the differing equivalents offered by Western translators for disease terms in the Gyu¨ Shi makes it clear that there is in any case no consensus about these translations.16 As I have already suggested, some, but by no means all, of the diseases diagnosed are explicitly associated with one of the three “humors” (lung, tr’ipa, pe´ ken). For example, lung (often taken as equivalent to “hypertension,” and associated with high blood pressure) and tr’ipa (often rendered as “jaundice”) were quite common as diagnoses in the Dalhousie and Delhi practices. Hepatitis

Table 12.1 A Sample of Adult Patients at the Dalhousie Clinic, July–August 1996

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is common in India, and may well have been present in some of the tr’ipa patients. Lung patients regularly had their blood pressure taken and recorded by the doctor, but the figures often seemed quite moderate. “Blood pressure” (tr’agshe´ ), though freely used by Tibetan doctors and patients alike, is of course a biomedical category, not a traditional Tibetan one. Pe´ ken as such was a less common diagnosis, although pe´ ken mukpo, a condition which is said to involve several of the humors (but with pe´ ken dominant), came up fairly often. Another common complaint, p’owa (stomach pains, more precisely pain in the epigastric area) often seemed closely linked to pe´ ken. One can ask whether these diagnoses really indicate a humoral “imbalance” in the sense that a person familiar with the Galenic or Islamic system might ¯ yurvedic-derived discussion of these matters in the Gyu¨ assume. In fact, the A Shi is less than explicit on this point.17 The word conventionally translated as “humor” (nye´ pa ⫽ Skt. do˚sa) means “fault” or “weakness,” and in fact sometimes the word used in the Gyu¨ Shi is simply ne´ , “illness.” The textual concept appears to be that each of the nye´ pa is a potential cause of illness, accumulated throughout daily life and provoked into manifestation through particular circumstances (cf. She´ Gyu¨ ch. 9), rather than that the three nye´ pa should be in any way “balanced” in a healthy organism. My impression is that this is also close to the concept implicit in the usage of contemporary Tibetan doctors. Treatment may include the avoidance of factors (especially dietary factors) that provoke the manifestation of the particular nye´ pa, but it does not involve, for example, trying to strengthen other nye´ pa to restore balance. Indeed, since the other nye´ pa themselves bring about diseases of their own, this would be antitherapeutic. The nye´ pa, in other words, are exclusively negative in nature, although two of them (tr’ipa and lung) have names that are also names of substances ordinarily and normally found within the body.18 In this they appear to differ from the humors in the Galenic and Islamic systems, which have normal (balanced) as well as abnormal (unbalanced) forms. I should emphasize that I am not suggesting that the nye´ pa are unimportant in traditional Tibetan medicine, either in the premodern context or in practice among the refugees. They constitute important diagnostic categories, and the Gyu¨ Shi’s assertion that all diseases derive from the nye´ pa provides an important intellectual resource for intellectually-oriented practitioners attempting to find a rationale behind the system. The doctor at the Delhi clinic, for example, who was older and more experienced than his Dalhousie colleague, had been trained in Chinese-controlled Tibet, had a more intellectual approach to his work, and seemed to try harder to relate practice to the nye´ pa system. Neither he nor the texts, however, really describe a system of balance between the three nye´ pa such as Western translations and paraphrases suggest. Leaving aside the nye´ pa, other diseases noted in our Dalhousie and Delhi research can be roughly divided into those listed in the Gyu¨ Shi (e.g. k’eldrang ⫽ “cold kidney”) and those which are not (e.g. tr’agshe´ ⫽ “[high] blood pres-

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sure”). This leads to a consideration of the diagnostic categories in the Gyu¨ Shi, which, as mentioned above, is still the principal text used in the training of traditional Tibetan doctors at the Men-Tsee-Khang and elsewhere. ¨ SHI AND THE DIAGNOSTIC CATEGORIES OF THE GYU TRAINING OF TIBETAN DOCTORS The Gyu¨ Shi (“Four [Medical] Tantras”) consists of 154 chapters divided into four sections: 1. Tsa Gyu¨ (Root Tantra, 6 chapters) 2. She´ Gyu¨ (Explanatory Tantra, 31 chapters) 3. Men-ngag Gyu¨ (Oral Instruction or Oral Tradition Tantra, 92 chapters) 4. Ch’ime´ Gyu¨ (Additional, Subsequent or Final Tantra, 25 chapters)

The Gyu¨ Shi has received considerable attention from Western scholars, and substantial portions have been translated, including the entirety of the first two sections (Dhonden 1995, Clark 1995) along with a number of isolated chapters from the third and fourth texts.19 It remains the basis of contemporary medical training in the Dharamsala Men-Tsee-Khang, where it is studied along with two late-sixteenth-century commentaries by Desi Sangye Gyatso, the Be´ Ngo¨ n and Men-ngak Lhent’ap. Although usually described in English as the Four Tantras, the Gyu¨ Shi has the form of a single four-part text, presented as a dialogue between two interlocutors, and united by a frame narrative of the revelation of the text by the Medical Buddha (Bhais˚ ajyaguru) in a general style customary for Buddhist Tantric texts. While the term “Tantra” may have led some Westerners to assume a close connection with Vajraya¯ na or Tantric Buddhism, there is little about the text proper to suggest this. The Gyu¨ Shi is a medical not a Buddhist text, and while there are aspects of Tibetan medicine (e.g., the “Precious Pills”) with a close connection to Vajraya¯ n or Tantric Buddhism, these derive from sources other than the Gyu¨ Shi. Tibetan medical scholarship has long recognized that the Gyu¨ Shi, while presented as a single unified revelation of Indian origin, is in all probability a Tibetan text dating from the time of the semilegendary physician Yut’ok the Younger (twelfth century C.E., cf. Tsering 1980; Karmay 1989). It is in many ways typical in style of the gter ma or visionary literature which was being produced at this time (Samuel 1993, 294–302, 461–463), although unlike much of this literature, which consists of original creations or borrowings from unidentifiable sources, the Gyu¨ Shi’s sources are in part at least identifiable. Large sections of the work appear to be borrowed from a single source, the A˚s˚ta¯ n˙ gah¯ yurvedic text translated from the Sanr˚ idayasamhita ˚ ¯ of Va¯ gbhata. This is an A

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skrit and included in the Tibetan canonical collections (Emmerick 1977, 1987; Parfionovitch et al. 1992). ¯ yurvedic in inspiration. The Gyu¨ Shi is however by no means exclusively A Tibetan historical sources refer to the presence of Persian and Chinese medicine at the early Tibetan court, and traces of both of these appear to be visible within the text.20 Other sections would seem to represent the original explorations of Tibetan medical scholarship, though suggestions of a sophisticated Tibetan medical tradition going back to the mythological figure To¨ npa Shenrap (Drungso 1995) are probably exaggerated.21 Thus the Gyu¨ Shi contains various internal cleavages and areas of tension deriving from the explicit or implicit conflicts between material originating from different sources, and also between the relatively programmatic and theoretical chapters of the first two parts and the more practical and applied material of the second two. Some of these tensions are present within Va¯ gbhata’s own work, which also combines programmatic assertions of the origins of all disease within the three do˚sa with more practical descriptions of the individual diseases, their causes and treatment.22 In the Gyu¨ Shi these tensions are intensified, since the range of material included is far more heterogeneous. It would be interesting to examine in detail whether and how these issues arise in the course of medical training, but we do not have any extensive material on this topic. According to the doctor at the Dalhousie clinic, who studied at the Dharamsala Men-Tsee-Khang in the early 1990s, the syllabus consisted at that time of the Four Tantras along with their principal commentary, the Be´ Ngo¨ n (“Blue Beryl”) by Desi Sangye´ Gyats’o. During the four-year course, all four books of the Gyu¨ Shi were studied, along with the commentaries and a range of other, mostly nonmedical, texts. The first, second, and fourth Tantras were memorized, but only three of the ninety-two chapters of the third and longest Tantra (Men-ngag Gyu¨ ) were memorized, a point to which I shall return. In fact, only these three chapters were included in the doctor’s school copy of the Gyu¨ Shi.23 There appears to have been little practical training during this period, and it seems that clinical training took place (and still takes place) mainly during the graduate’s initial placement as an assistant to a doctor in an established Men-Tsee-Khang clinic. Turning now to the question of diagnostic categories in the Gyu¨ Shi, the first (and best studied) sections of the Gyu¨ Shi are the least helpful, since they contain general theory rather than specific material on diseases. More relevant material can be found rather in the third and fourth sections—the Men-ngag Gyu¨ and the Ch’ime´ Gyu¨ . The Men-ngag Gyu¨ does indeed consist of a sequence of chapters on different diseases with a discussion of their modes of treatment. There are ninety-two chapters, many of which deal with several different named diseases (see Dorjee and Richards 1981, 1985; Parfionovitch et al. 1992). These are divided into several named sections, including chapters on lung, tr’ipa, pe´ ken, and pe´ ken mugpo (combined) disorders (chapters 2–5), chapters on disorders arising from

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digestive problems (6–11), chapters on fever (12–17), on various external and internal parts of the body (28–43), diseases of children (71–73) and of women (74–76), diseases caused by spirits (77–81), wounds and injuries (82–86), and so on. Most chapters subdivide disease and treatment according to the cause of the disease. Frequently these include lung, tr’ipa, and pe´ ken but there may be additional causes or classifications on another basis. Specific drugs (very frequently combinations of five or six ingredients) are given in most cases, along with other kinds of treatment. For example, stomach diseases include lung disease of the stomach, tr’ipa disease of the stomach, pe´ ken disease of the stomach, and blood disease of the stomach, each treated with specific drugs (Dorjee and Richards 1985, 27). I have already mentioned that the Men-ngag Gyu¨ is the one part of the Gyu¨ Shi that is not learned by heart by Men-Tsee-Khang students. While many of the disease categories in the Men-ngag Gyu¨ were referred to in our fieldwork situation, many others were not, even when they might have been expected. Other, often Western-derived, categories took their place. Thus se´ je´ , the subject of chapter 11 of the Men-ngag Gyu¨ , is usually equated with “tuberculosis,” which is a very common problem among the refugees, but in practice Tibetans refer to “TB,” not se´ je´ , and the treatment given is primarily biomedical. In addition, few of the remedies prescribed in the Men-ngag Gyu¨ form part of the modern Tibetan pharmocopoeia, having been replaced by the more complex compounds typical of current usage. The Men-ngag Gyu¨ material would seem to be at the core of how Tibetan doctors manage the transition between textual study and clinical practice, and it would be useful to know more about how it is actually dealt with in the MenTsee-Khang training program. The Men-ngag Gyu¨ , both as part of the Gyu¨ Shi as a whole and as an independent text, has been the subject of a considerable number of Tibetan commentaries, but the best-known are undoubtedly the two used at the Men-Tsee-Khang, both written by the sixteenth-century regent to the fifth Dalai Lama, Desi Sangye´ Gyats’o. The Men-Tsee-Khang recently published a three-volume textbook on Tibetan medicine, the Sorig Lobpe´ (“Medical Textbook”), which covers the standard topics of the Gyu¨ Shi, but rearranges them somewhat, apparently adding material on areas not adequately covered in the original. The Dalhousie doctor had a copy of this text, and said that it was not studied directly when he was a student, but was used by students when studying the Men-ngag Gyu¨ . A similar but more radical rewriting of the Men-ngag Gyu¨ disease categories can be found in a text published in Lhasa in 1978, the Kyareng Sarpa (“New Dawn”), which includes an extensive treatment of anatomy according to the biomedical tradition, harmonizing it where possible with traditional Tibetan anatomy. The Kyareng Sarpa (doubtless one of the “hastily prepared, secularized textbooks” mentioned in Janes 1995, 20) incorporates a much more thorough rearrangement and restructuring of the Tibetan medical categories than the

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Sorig Lobpe´ . It was regarded as a useful if somewhat basic reference by the more experienced doctor at the Delhi clinic. Another text that seemed to form a kind of intermediate stage between the Gyu¨ Shi and clinical practice was a short guide to the problems for which each drug was used (Menjorgi Nu¨ pa, “Uses of Medical Compounds”), mostly taking the form of quotations from medical works in which the drug is discussed. I saw two rather different editions of this text, which consists of a list of standard Tibetan drugs, with a short verse from a text describing the properties of each, for example: SALJE´ AWA 15: If you take salje´ awa in the early morning /For a long time, it is an elixir for the eyes.24 PANG-GYEN 15: This excellent medicine, pang-gyen 15, /Is renowned for relieving feverish colds in the throat, /Where the breathing is uncomfortable, /For pe´ lung with pain in the upper back, /And especially for pe´ ken with fever.25

Further study of all these and other relevant texts, and of the actual training program in the Men-Tsee-Khang and other traditional Tibetan medical institutions, would seem necessary if we are to make sense of the relationship between the Gyu¨ Shi and contemporary practice. Two sections of the Gyu¨ Shi appear, however, to be of direct relevance to modern clinical practice: the pulse and urine diagnosis chapters of the Fourth Tantra, the Ch’ime´ Gyu¨ . These texts, unlike the Men-ngag Gyu¨ , are memorized by students, and, in contrast with most of the memorized material, they contain material of direct and obvious relevance. Urine and particularly pulse diagnosis are of major practical importance in how Tibetan doctors actually operate. It should be noted that ¯ yurvedic treatise. Indeed, neither of these chapters derives from Va¯ gbhata’s A ¯ yurvedic texts and appears to have pulse diagnosis is not treated in early A ¯ yurvedic system only toward the end of the first millenium become part of the A C.E. Both of these chapters have been presented several times in English summary form, presumably based on the Be´ Ngo¨ n commentary (Dhonden and Topgay 1980; Dhonden 1986, 75–103 and 113–130; Rapgay 1994a, b); the pulse diagnosis chapter has also been translated into French by Meyer (1990). The pulse diagnosis chapter is divided into several sections: prerequisite diet and behavior for physician and patient; time of examination; place of examination; degree of pressure to exert; how to read the pulse; constitutional (normal) pulse; seasonal pulse; seven extraordinary pulses; healthy and unhealthy pulses; general and specific pulses; pulse predictive of death; pulse indicative of evil spirits (do¨ n); and finding signs of longevity through the pulse of the soul (la). The subdivisions of the urine diagnosis chapter are similar and the two chapters give the appearance of having been written by the same author. Some of this material appears to be archaic or irrelevant, despite its prominence in Western presentations of this material. Thus while evil spirits are of

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some significance in Tibetan medicine (see Samuel 1999), they are generally diagnosed through the nature of the affliction, not through pulse or urine, and the long and complex list of spirits given in this section of the Ch’ime´ Gyu¨ bears little relation to current spirit diagnoses.26 As for the “seven extraordinary pulses,” which involve discovering the welfare of the family from the pulse of its most senior member, foretelling the consequences of attacking an enemy from the pulse, and the like, these are, as far as I can tell, completely absent from modern clinical practice. Such procedures, however, are of some interest, since they indicate the degree of overlap in Tibetan pulse and urine diagnosis between what we might call “diagnosis” and what we might call “divination.” In addition, the elaborate prerequisites specified in the opening sections of each chapter, such as a special diet, and avoidance of strenuous activity and sexual intercourse for the day prior to pulse reading, are not necessarily imposed in contemporary clinical practice. At Dalhousie, the clinic doctor simply read the pulse of each patient as he or she came into the clinic. Many of them had just climbed up a steep hill to get there, thus breaking the rule about avoiding strenuous activity. The critical passages of the pulse diagnosis chapter for everyday clinical practice are those on how to read the pulse, on healthy and unhealthy pulses, and on general and specific pulses. The first of these prescribes the manner of pulse reading, in which the doctor uses three fingertips of his left and right hand to read the pulse on the patient’s right and left wrists respectively. Since the two sides of each of the doctor’s fingertips are read separately, this yields twelve separate pulses. The details vary slightly between male and female patients, but the twelve pulses refer to heart, lungs, left and right kidney, liver, spleen, stomach, large and small intestine, gall bladder, urinary bladder, and seminal vessels or uterus. The section on healthy and unhealthy pulses explains how the ratio between pulse and breathing indicates the patient’s state of health. The norm is five pulses per breath; more indicates a hot disorder, less a cold disorder. The salience of the hot/cold distinction in the pulse and urine analysis chapters is noticeable, and if there is a humoral theory behind Tibetan medical practice, it would seem to be concerned with the balance between hot and cold rather than with any balance between the three nye´ pa. This links up to the importance of fevers in the Men-ngag Gyu¨ .27 In practice, allowance should be made for the patient’s normal pulse, so the more relevant part of this procedure is probably the specification that an irregular pulse under any of the fingertips indicates a problem in the corresponding area. In the section on general and specific pulses, six kinds of pulse are described as indicating a hot disorder (strong, expanded, rolling, quick, tight, hard) and six as indicating a cold disorder (weak, sunken, declining, slow, loose, hollow). Each type, singly or in combination, conveys information about the significance, age, and so on of the illness. These are the “general” pulses. The “specific” pulses indicate lung, tr’ipa, pe´ ken, and various combinations of these three

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nye´ pa. They also indicate disorders arising from blood, ch’user (“lymph” or “serum”), parasites, poisons, various kinds of fever, and the like. Some of these point, in effect, to specific chapters of the Men-ngag Gyu¨ , especially when taken in conjunction with indications of a problem in a particular part of the patient’s body. In the urine diagnosis chapter, the sixth section describes unhealthy urine in terms of various aspects read at three stages (when the urine is hot, lukewarm, and cold). The indications are similar to those from the pulse analysis: lung, tr’ipa, pe´ ken, compound, blood, ch’user; various kinds of fever; whether the complaint is new or chronic; and above all whether the disease is “hot” or “cold.” All in all, the classifications in these sections of the pulse and urine diagnosis chapters appear quite close to those employed by the Tibetan doctors we observed. CONCLUSION The material presented in this chapter has suggested several reasons for the discrepancies between the theory that is so salient in the Gyu¨ Shi (and in Western presentations of Tibetan medicine) and the much more pragmatic procedures of our North Indian clinics. The practicing doctor is primarily interested in a diagnosis leading to an appropriate treatment regimen. Here, the theory chapters of the Gyu¨ Shi are not particularly helpful, while the more apparently relevant material in the Men-ngag Gyu¨ seems to have been marginalized in the presentday curriculum. It would be interesting to know how far “studying the Menngag Gyu¨ ” at the Men-Tsee-Khang college today in fact means studying comparable material on disease categories that has been rewritten in the light of present-day needs. The three-volume Dharamsala textbook (Sorig Lobpe´ ) certainly points in this direction. However, much of the doctor’s working knowledge would seem to be learned in an apprenticeship situation after the formal book-based training has been completed. This situation is, as I noted earlier, very much one of medical pluralism. Traditional Tibetan doctors treat, for the most part, Tibetan patients who are regarded, or regard themselves, as being unsuited for biomedical treatment. They also treat Indian and Western patients who are already familiar with biomedical categories. A relationship with biomedicine is unavoidable. Tibetan tuberculosis cases go to the biomedical facilities, and the Tibetan doctor provides supplementary therapy where biomedicine has done the main job or been abandoned. It is no wonder that all Tibetans, including the traditional doctor, speak of “TB” rather than of the supposed traditional Tibetan equivalent. Likewise “blood pressure” is fully integrated in clinic practice at Dalhousie, and the sphygmomanometer is employed far more often than the traditional urine examination bowl (which, in fact, we never saw). The eclectic, pragmatic form of Tibetan medicine we observed in Dalhousie and Delhi seems, in these terms, a natural enough development.

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In fact, the twelfth-century text of the Gyu¨ Shi itself presents a medical discourse much more than a spiritual one. Spirit causation of illness, for example, for all of its presence in the pulse and urine diagnosis chapters, forms a relatively minor part of the Man-ngag Gyu¨ , and references to Buddhist teachings are largely confined to the Tantric frame-story of the work. It seems likely that that the founding of the original Mentsik’ang at Lhasa early this century, inspired in part by the thirteenth Dalai Lama’s encounter with British public health measures during his exile in India,28 marked a further significant move from the spiritual to the pragmatic in the practice of Tibetan medicine. Tibetan doctors were preadapted to the pragmatic encounter with Western biomedicine in India. Yet the move to India also led to the encounter with Westerners in search of Tibetan medical wisdom and so to the reconstitution of Tibetan medicine for Western consumption. The specific context of the encounter with the West, I suggest, goes some way to explain the Western image of Tibetan medicine as a holistic healing system. In a recent article, Jean Langford notes the “medley ¯ yurvedic literature published in English over the of ideological voices” within A last three decades: At different moments the authors seem to be involved in selling Ayurveda to North Americans, Europeans and cosmopolitan Indians either as holistic medicine, taking advantage of the international trend toward holistic health care, or as a source of new drugs for biomedicine, taking advantage of the endless expansion of the biomedical pharmaceutical repertoire. The literature often highlights Ayurveda’s emphasis on positive health and preventive care, its use of nontoxic herbs, and its concern with the whole person, while paradoxically also playing up the wonder drugs it can offer for certain biomedically defined diseases. Biomedical practitioners who take an interest in Ayurveda are also attracted either by the possibility of new drugs . . . or by holistic wisdom. (Langford 1995, 356)

Much of this is true for Tibetan medicine too, but given the salience of Tibetan Buddhism on the international spiritual scene, it is not surprising that the image of a holistic approach to health grounded in a deeply spiritual approach to life has become increasingly dominant. Here the opening sections of the Gyu¨ Shi, in which all illness is said to arise from the three nye´ pa (which are themselves seen as originating in desire, hatred, and ignorance, the three roots of sam ˚ sa¯ ric existence in Buddhist theory), allow a tacit shift to a humoral, holistic, and explicitly Buddhist framework. Tibetan medical clinics in South Asia catering primarily or extensively to Westerners, such as Dr. Yeshe Dhonden’s in Dharamsala, provide sites in which this kind of perspective can be validated and sustained. Here the procedures of pulse and urine examination are carried out meticulously, and the spiritual perspective, if not explicit, is strongly implied by a quasimonastic atmosphere. It will be interesting to see whether the increasing numbers of Westerners studying Tibetan medicine, often in specifically Buddhist contexts such as the medical college managed by Samyeˆ -Ling Tibetan

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Centre in Scotland, will in time produce a new branch of Tibetan medical practice that genuinely instantiates these holistic and spiritual perspectives. Traditional Tibetan medicine is a complex and heterogeneous system of thought and practice, and it is by no means encompassed by the Gyu¨ Shi and the Men-Tsee-Khang clinics. It is hardly surprising that one encounters different framings and presentations, and that its practitioners themselves vary in how they internalize and practice it. Further field research is certainly needed to reach a fuller and more representative picture of contemporary practice. Yet the divergence between Western presentations of Tibetan medical theory, and Tibetan medical practice as we observed it among North Indian refugees, is striking. I hope the above analysis has gone some way both to explain it and to provide the groundwork for a more situated, nuanced and demystified approach to this fascinating non-Western healing modality. NOTES 1. I would like the acknowledge the assistance of Mr. Damdhul, Dr. Shedrup, Dr. Nyima Tsering, Mrs Jampa Choedron, and many other members of the Tibetan refugee community. Further details of the project, which was supported by an Australian Research Council Project Grant (“Creative Synthesis in the Therapeutic Process: An Ethnographic Study of Tibetan Healing and Biomedicine,” 1994–97) may be found in Connor (1996); Connor, Monro, and McIntyre (1996); Monro (1996), Rozario (1996), and Samuel (1999). 2. The Dharamsala medical college and its affiliated clinics use the English spelling “Men-Tsee-Khang,” corresponding to the Tibetan mentsik’ang (Medical and Astrological College, see Glossary), the name of the medical college founded at Lhasa in the early twentieth century (see Chapters 10 and 11). 3. As Aschoff (1996) notes in the introduction to his bibliography, a high proportion of published Western work on Tibetan medicine consists, in effect, of summaries of the Four Medical Tantras (and mostly the first two, at that). Notable exceptions, apart from material on clinical trials of Tibetan drugs, and a small body of critical work on the Four Tantras examined later in this chapter, include Kuhn (1988, 1994) and Janes (1995). 4. For a slightly more detailed account see Samuel (1999). Delhi is obviously very different to Dalhousie in relation to the accessibility of other biomedical services, but we did not attempt to gather data in Delhi regarding their usage by Tibetans. 5. See Samuel (1993). I avoid the term “Bo¨ n” for this pre-Buddhist material for reasons explained in that reference. 6. The traditional recipes include animal ingredients as well, but the Men-TseeKhang at Dharamsala, where the medicines used in the Dalhousie clinic are made, claims to be eliminating these as far as possible in favor of herbal substitutes. 7. Some doctors also employ other techniques, such as cupping, bloodletting, or metsa (“gold needle moxibustion”), a procedure which involves a heated gold-tipped rod being applied momentarily to one or another specific point on the body. We saw cupping and metsa at Delhi, but the Dalhousie doctor did not use either of these techniques. 8. Tsadrip refers to a set of problems characterized by their afflicting one side of the body only, and varying from facial tics to partial paralysis. It is regarded by most Tibetans

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as being caused by spirit attack. I discuss the tsadrip syndrome in some detail in Samuel (1999). 9. In addition to the items referred to in the text and notes, see Aschoff (1996) for a general bibliography. ¯ yurveda (see below, notes 20 and 22, and Langford 1995) 10. Its applicability to A and to Chinese medicine (see, for example, Kuriyama 1994 on the complex and by no means entirely “internal” nature of “wind”) also raises problems. 11. This account is based mostly on the Dalhousie clinic where most of our research was carried out. The Delhi clinic differed mainly in the much larger number of patients (which limited our ability to discuss cases in detail with the doctor) and in the evidently greater experience and medical repertoire of the doctor. As noted earlier, the doctor at the Delhi clinic employed additional techniques, such as cupping or gold-needle moxibustion, which were simply performed on the spot in the consultation room. 12. I do not know if this happens in other Men-Tsee-Khang clinics. The two examples I encountered were in private clinics. 13. Author’s fieldnotes for July 9, 1996, patient P2; for July 10, 1996, patients P28, P9, P31, P32; for August 5, 1996, patients P112, P46, P114. 14. Generally referred by one of the school nurses, often for certification for absence from school. 15. For tsakar/tsadrip, see Samuel (1999). This patient is the fifth of the cases discussed there. 16. For example rgyu gzer (W), Men-ngag Gyu¨ ch. 25, is variously translated as “intestinal infection, such as colitis”; “dysentery”; “enteric fever (typhoid).” Gag lhog (W), ch. 26, is rendered as “inflammation associated with throat and muscle tissues”; “diphtheria or quinsy”; “scarlet fever, throat swellings and ulcers”; “fever caused by diphtheria”; “angina with muscular spasm”; and “ ‘delicate’ or ‘vital’ diseases of the flesh or throat.” 17. See, for example, Tsa Gyu¨ ch. 3, She´ Gyu¨ chs. 8, 9. English translations tend to introduce or imply ideas of humoral imbalance that are not clearly present in the original text. 18. Note that lung as one of the nye´ pa corresponds to Skt. va¯ ta, while lung in Tantric physiology corresponds to Skt. pra¯ n˚ a. The concepts have clearly come to overlap in Tibetan practice nonetheless. 19. Including Men-ngag Gyu¨ chapters 49 (Badaraev et al. 1981), 77–79 (in Clifford 1989), 79 (Emmerick 1987), and 90 (Emmerick 1990); Ch’ime´ Gyu¨ chapter 1 (Meyer 1990). In addition, Men-ngag Gyu¨ chapters 79 and 80 and Ch’ime´ Gyu¨ chapters 1 and 2 are paraphrased in Dhonden 1986. 20. Thus the scheme of solid and hollow organs is presumably a borrowing from Chinese sources (Meyer 1984). Pulse diagnosis could derive from Chinese or GreekIslamic medicine, while urine diagnosis suggests an Islamic source (cf. the extended treatment of urine diagnosis in Avicenna’s Canon, Shah 1966, 255–274). The status of blood and serum (W. ch’user) as supplementary “humors” again suggests a Greek-Islamic source (cf. Winder 1981), although as Meulenbeld (1984) has noted, blood appears to ¯ yurvedic texts also, despite the ideological act as a fourth do˚sa in some of the earlier A insistence on the primacy of va¯ ta, pitta, kapha. 21. Namkhai Norbu’s Drung, Deu and Bo¨ n (1989, 1995) contains some interesting material on the Bo¨ n medical tradition, which may contain more indigenous, or at any ¯ yurvedic, elements. Among other things, he notes that the Bo¨ n tradition refers rate non-A

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to five fundamental categories (W. tsha grang bad mkhris ’dus ⫽ hot, cold, phlegm, bile, and the “combination of the humours”) rather than the three of the Gyu¨ Shi (Norbu 1989, 284; 1995, 138). Norbu’s source here is the Siji, a text probably dating from the late fourteenth century but incorporating earlier material (Samuel 1993, 515). 22. Meulenbeld has noted how the “tridosa-doctrine” ˚ has become more and more ¯ yurvedic medicine developed, as scholars attempted to present A ¯ yurveda dominant as A as reducible to a unified body of theory (1984, 42–43). 23. The three chapters from the Men-ngag Gyu¨ that are learned by heart are two chapters on fevers (13, 14) and one on abdominal wounds (85). 24. Menjorgi Nu¨ pa 1, p. 58, see author’s fieldnotes for July 31, 1996. 25. Menjorgi Nu¨ pa 2, p. 39, see author’s fieldnotes for August 2, 1996. 26. If anything, the spirit-affliction chapters (77–81) of the Men-ngag Gyu¨ are more relevant. 27. Fevers, as one might expect, are primarily “hot” diseases, though the transition from “hot” to “cold” is of great importance. 28. A suggestion I owe to Mr Jamyang Norbu of the Amnye Machen Institute of Dharamsala.

REFERENCES, TIBETAN-LANGUAGE Be´ Ngo¨ n: gSo ba rig pa’i bstan bcos sman bla’i dgongs rgyan rgyud bzhi’i gsal byed d˚ u¯ ra sngon po’i malli ka zhes bya ba. Dharamsala: Bod gzhung sman rtsis khang, 1994. Gyu¨ Shi: bDud rtsi snying po yan lag brgyad pa gsang ba man ngag gi rgyud las dum bu dang po rtsa ba’i rgyud dang| gnyis pa bshad rgyud| bzhi pa phyi rgyud| tsha grang gal mdo dang| tsha ba ri thang ’tshoms kyi le’u| byang khog yul thig| mtshungs med yon tan mgon po’i gsol ’debs bcas bzhugs so| Dharamsala: Tibetan Medical Center, 1971. Kyareng Sarpa: gSo rig snying bsdus skya rengs gsar pa. Lhasa: Bod ljongs lha sa sman rtsis khang gso rig zhib ’jug khang, bod ljongs mi dmangs dpe skrun khang, 1978. Men-ngag Lhent’ap: See Sangs-Rgyas Rgya-Mtsho 1978, in main References list. Menjorgi Nu¨ pa 1: sMan sbyor gyi nus pa phyogs bsdus phan bde’i legs bshad ces bya ba. Dharamsala: Tibetan Medical Youth Congress, n.d. Menjorgi Nu¨ pa 2: sMan sbyor gyi nus pa phyogs bsdus phan bde’i legs bshad ces bya ba. Dharamsala: Bod gzhung sman rtsis khang, 1995. Sorig Lobpe´ : bod kyi gso rig slob dpe (3 vols.) Dharamsala: Bod gzhung sman rtsis khang gso rig mtho slob sde tshan, n.d.

REFERENCES, OTHER Aschoff, Ju¨ rgen C. 1996. Annotated bibliography of Tibetan medicine (1789–1995). Ulm: Fabri Verlag, and Dietikon, Switzerland: Garuda. Badaraev, B. D., E. G. Bazaron, M. D. Dashiyev, A. T. Aseyeva, and S. M. Batorova. 1981. Glang thabs (acute diseases of the organs of the abdominal cavity) and their correction in Tibetan medicine. English translation by Stanley Frye. Tibetan Medicine 4: 1–116.

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Index

Abu-Lughod, Lila, 134, 145 Agriculture, and health, 93–96 Ajirna, 89, 94, 104. See also indigestion Ama (undigested food), 91, 97 Anagnost, Ann, 173, 228 Arnold, David, 66, 86 Astrology, 234, 250, 256–57 Avicenna, 264 n.20 ¯ yurveda, 86–105 passim, 248, Ayurveda/A 251, 255–57, 259, 262, 264 n.10, 265 n.22 Barefoot doctors, 180, 228 Barrett, Robert, 131, 134, 139, 145 Baudrillard, Jean, 25 Beauty products, Ayurvedic, 103–4 Biomedicine, 78–79, 249–50, 253; effects contrasted with Ayurveda, 91–92, 94, 97, 103; effects contrasted with Tibetan medicine, 215, 252 Blood pressure (BP), 89–92, 104, 219 nn.8 & 10, 231, 252–53, 255, 261 Blood, purification of, 97, 104 Bo¨ n (Bon), 175, 263 n.5, 264–65 n.21 Bourdieu, Pierre, 10, 70, 72, 76 Buddhism, 29; and Tibetan medicine,

207, 229, 250. See also Tantric Buddhism Cancer, metamedical use of, 100, 105 n.6 Chawla, Janet, 79 Childbirth, 64–80 Christianity, in Korea, 29 Chronic illness, treatment of, 217–18 Ch’user (lymph, serum), 261 Colonialism: in India, 66–67; in Korea, 31 Comaroff, Jean and John, 131 Commodification: effect on relations of reciprocity, 119–20; of medicine and therapies, 15–18, 32; and mythology, 123 Commodities: incorporation into mythological systems, 123; Semelai exchange, 127 n.3; in songs, 122; Temiar exchange, 113, 118, 119–20 Confucianism, 28–29, 174, 182 Costumes, 50 Csordas, Thomas, 88 Cupping, 263 n.7, 264 n.11 Customary law, breach of, 141

276 Dai (indigenous midwife in India), 66–69 Dalai Lama: 13th, 240, 262; 14th, 248 Dalhousie, 248 de Certeau, Michel, 10, 14, 25, 31, 32, 33, 37, 70, 72, 79 Defecation, 104 Deforestation, 109–10, 117, 119, 120; and diet, 126; effect on ritual ornaments, 124–26 Deng Xiaoping, 182–83 Development: and modernity, 153; national, 27, 31; in Sarawak, 145 Dhatu (bodily essence), 90–91, 100, 103 Diagnosis, via pulse and urine, 251–53, 259–62 Diet: and deforestation, 126; restrictions during treatment, 119. See Also Pathya Divination, 46, 209, 250, 260. See also Fortune-telling Dongba (Naxi ritual priest), 175–76, 184 Dosha (dosa) (wind-heat), 91, 97, 252, 264 n.20, 265 n.22. See also Nye´ pa Dream songs, 109–10, 114, 117–19, 124; lyrics, 115–16, melodic structure, 114, 121 Drip (contamination), 250 Durkheim, E´ mile, 131, 222 Ecological sense of health, 85–87, 94–95, 101–3 Economic reforms, impact of, 203–7, 215, 218–19 n.7 Education, stresses associated with, 98– 100, 103 Engels, Dagmar, 66–67 Environmental degradation, 109, 120, 124– 26 Epistemologies for disease, 191 n.11, 233– 41, 252. See also Illness etiology Essentialism, and identity politics, 145–46 Expenses, medical, 27 Farquhar, Judith, 233, 242 n.10 Folklore studies, 4, 30, 32–33, 38 n.11 Fortune-telling, 176, 187. See also Divination Foucault, Michel, 164, 223

Index Gandhi, Mahatma, 8, 85–86, 101, 104 “Gastritis,” 94–95 Gedu¨ n Ch’o¨ p’el, 228–29, 242 n.7 Great traditions of medicine, 5, 6 Gu witchcraft, 176, 187 Gyu¨ Shi, 234, 247, 253, 255–63, 265 n.21. See also Medicine, Tibetan; Tantras, Medical Harrell, Steven, 191–92 Havik Brahmans, 87–105 passim Hospital(s), 45–46, 49, 142, 158, 166, 168 Hospital admissions, by gender, 167–68 Hospital staff, hostility to nonbiomedically trained personnel, 78 Humoral imbalance, 91 Humoral theory. See Medicine, humoral Hygiene, 179, 191 Illness etiology, 48–49, 61, 111, 113, 136, 144, 145, 158, 162, 208–13, 218; sorcery, 163–64. See also Epistemologies for disease; Medicine, humoral Indigestion, 89–92, 94–97, 99, 102–3 Infertility, 232 Injection, 46, 182 Intellectuals, in Korea, 29–30 Islam, 12, 42, 55, 61, 110, 117; Lombok variants of, 154–55, 166, 168 n.2 Janes, Craig, 232–33, 242 n.4 Japanese Occupation, of Korea, 29, 31; of Malaysia, 113, 114 Jinden (empowered medicines), 250–52 Klesha (kle´ sa) (Chinese foods), 213 Land alienation, 118, 120, 126 Landscape, 111–13 Language of se´ ance, 51, 54, 138–39, 149 n.11 Leslie, Charles, 5, 19 Le´ vi-Strauss, Claude, 138 Lijiang, 173, 177 Logging industry, Malaysia, 109 Longhouse, Iban, 135–36 Lung (“wind” humor in Tibetan medicine), 210 (Table 10.2), 211–13, 219

Index nn.8 & 10, 231, 234–35, 238, 253, 255, 257, 264 n.18 Mao Zedong, 177–82, 203 Marketplace, 117–18 marriage, 37 n.1, 47, 51, 54, 56–57 Marutse. See Womb bug Marutuvacci (midwife in Tamil Nadu), 71 ˙˙ Marx, Karl, 222 Massage, 158 Masturbation, 100 Mauss, Marcel, 222 Medical pluralism, 4, 9, 26–27, 103, 145, 171–90 Medicine, allopathic, 86, 89–92, 94, 96– 97, 102–3, 250. See also Biomedicine Medicine, Ayurvedic. See Ayurveda Medicine, Chinese, 31, 233, 257, 264 nn.10 & 20; in Korea, 175–77, 191, 233. See also Medicine of systematic correspondence; “Traditional Chinese Medicine” Medicine, colonial, 66–67 Medicine, cosmopolitan, 5, 19 Medicine, feminist critique, 64–65 Medicine, folk, 176, 179–80, 184, 187 Medicine, Galenic, 252 Medicine, herbal, 59, 74, 155, 175–76, 181, 184, 187, 262 Medicine, humoral, 48, 58, 176, 210–11, 219 n.9, 252, 255, 257–58, 260, 264 n.20. See also Ayurveda; Medicine, Chinese; Medicine of systematic correspondence; Siddha medicine; Tibetan medicine; “Traditional Chinese Medicine” Medicine, Indian. See Ayurveda, Siddha medicine Medicine, “Indian” (i.e., biomedicine), 249–50, 252 Medicine, integrated, 180 Medicine, Islamic/Persian, 252, 257, 264 n.20 Medicine, patented, 155, 168 n.4 Medicine, pharmaceutical, 159, 165 Medicine of systematic correspondence, 175–76, 179, 186, 188. See also Medicine, Chinese

277 Medicine, Tibetan, 176, 197–268; biomedicalization of, 232–33; conditions used for, 202, 213–15; interest outside Tibet, 207, 217, 262–63; research on in Tibet, 207–8 Medicine, Western, 180, 250–51. See also Biomedicine; Medicine, allopathic Men-Tsee-Khang, 248, 261, 263 and nn.2 & 6, 264 n.12 Mentsik’ang, 199, 203, 206–8, 218 nn.1 & 2, 224–26, 240, 242 n.3, 262, 263 n.2 Meulenbeld, Jan, 264 n.20, 265 n.22 Microsocope, use of, 231–32, 238 Middle class: in Korea, 29–30; in Malaysia, 42–43, 60 Midwives, 64–80 passim, 164 Migration, of Iban, 147 “Minor practices,” 70, 76 Modernities, alternative, 172–73. See also Modernities, multiple; Modernity, narratives of Modernities, multiple; 65–69, 79–80, 172, 223–24 Modernity: in Asian societies, 153, 167; and embodied experience, 116–17; as an epoch, 7, 152–53; and gender, 13; narratives of, 174–75, 177–79, 182–84, 189–90; theories of, 222–24 Morality, and medicine, 236, 238–41, 243 n.11 Moxibustion, 263 n.7, 264 n.11 Muhammadiyah, 154, 160, 163, 166 Mukkuvar, 71–76 Musical instruments, Temiar, 124 Nahdlatul Ulama, 154 Narratives, 190–91. See also Modernity, narratives of Nationalism: in Korea, 29; in Tibet, 216 Naxi people, 171–92 passim Ne´ (illness), 243 n.12, 255 Nepal, 30 Nye´ pa (three humors), 248, 252, 255, 257– 58, 260, 262, 264 n.20. See also Dosha; Medicine, humoral

278 Offerings, 44 Ong, Aihwa, 173, 189 Orang Asli (Malaysia), 112, 120 Pathya (dietary restrictions), 89–90, 95, 99 Payment, of healers, 45, 46, 47, 155; for medical treatment, 248, 251 People’s Republic of China (PRC), 171– 92 passim; civilizing/modernizing project, 177, 182, 190; good and bad tradition in, 177–78; nationalities policy, 173, 178, 183–84; science and superstition, 182 Perkins, Wendy, 65 Pigg, Stacy Leigh, 30 “Pills, Precious,” 206, 251, 256 Plantations, palm oil, 117 Pluralism, medical. See Medical pluralism Pollution, in childbirth, menstruation, etc., 70–72. See also Drip Popular religion, in Korea, 31 Practitioners, biomedical, 165–66 Prefecture, 199 Primary health care clinics, 156 Primordialism, 10, 11, 34, 60; and Iban, 145, 148, 149 n.13 Profitability, demand for. See Economic reforms, impact of Psychoanalysis, 130, 138 Public culture, 35–36 Recordings, 52, 111, 126, 127–28 n.4, 139 Resettlement projects, Orang Asli, 117, 120 Rinch’en rilbu. See “Pills, Precious” Rofel, Lisa, 173, 189 Sangye´ Gyats’o, Desi, 257–58 Santeria (New York), 60 Sanyi. See Shaman Saunders, Penelope, 69 “Scan,” 92, 105 Schools: Islamic, 155, 160; on Lombok, 160 Sedentarization. See Resettlement projects Semangat (Malay), 49, 57–58; (Temiar), 137, 138, 140–43, 146

Index Sensory modalities, and healing ceremonies, 123–26, 138–39, 140, 141 Shaman (sanyi), 175–76, 187 Shamanism, 4, 11–12, 42–62, 130–31 Shetty, Sandhya, 66–67 Short-term solutions, 91–92, 103 Siddha medicine, 72 Siddhas, Tamil, 71–72 Somatic complaints as indicating psychosocial distress, 89–104 Sorcery, 47 Spells, 47, 55, 56, 137, 149 n.8 Sphygmomanometer, use of, 231, 253, 261 Spirit explanations, rejection by medical professionals, 75–76 Spirit familiars (Iban), 139–40 Spirit guides (Temiar), 111, 113, 117–19; 120–21 Syncretism, opposition to, 145 Tagore, Rabindranath, 222 Tantras, Medical, 234. See also Gyu¨ Shi Tantric Buddism (Vajrayana), 229, 256 Tantric ritual, 209. See also Ts’ewang Television, 36 Thomas, Keith, 30 Time, industrial, 54 “Traditional Chinese Medicine” (TCM), 179–90, 192 Training, of shamans, 47, 54 Trinlay, Amchi, 225–34, 237–41 Tsadrip (tics, paralysis), 252, 263–64 nn. 8 & 15 Ts’ewang (life-empowerment ritual), 250 Tuberculosis, 258, 261 Ultrasound, use of, 231–32, 234, 237 UNICEF (United Nations International Children’s Emergency Fund), 7, 13, 157 Urbanization: in Korea, 30–31; in Malaysia, 42–43, 60–62 Va¯ gbhata, 256–57, 259 Vaidya (Ayurvedic practitioner), 87–104 passim

Index Vajra¯ ya¯ na. See Tantric Buddhism Vata (“wind” humor), 91. See also Lung Visesha, 88 Weber, Max, 222 Western medicine (WM), 189–91 Winder, Marianne, 264 n.20 Womb bug, 231–32, 237–38

279 Women, illnesses of, 224–38 World Health Organization (WHO), 7, 69, 157, 197, 203, 228 World War II, 113, 117 Young, Allan, 5 Zhongyi. See Medicine, Chinese

About the Editors and Contributors

LINDA H. CONNOR teaches anthropology at the University of Newcastle, NSW, Australia. She has carried out field research in Indonesia, North India, and Australia and has written on indigenous healing in the context of global transformation and modernity. With Timothy and Patsy Asch, she is the author of Jero Tapakan: Balinese Healer (1996), as well as a number of ethnographic films on Balinese healing and articles on healing and culture. She is coeditor (with R. Rubinstein) of Staying Local in the Global Village: Bali in the Twentieth Century (1999). GEOFFREY SAMUEL teaches anthropology at the University of Newcastle, NSW, Australia, and is an honorary professor of religious studies at Lancaster University (U.K.). He has written extensively on issues relating to Tibetan society, religion and music, and anthropological theory. He is the author of Mind, Body and Culture (1990) and Civilized Shamans: Buddhism in Tibetan Societies (1993), and coeditor of Tantra and Popular Religion in Tibet (1994) and Nature Religion Today (1998). VINCANNE ADAMS is Associate Professor in the Department of Anthropology, History and Social Medicine at the University of California, San Francisco. She is the author of Tigers of the Snow and Other Virtual Sherpas (1996) and Doctors for Democracy (1998), as well as articles on Sherpa and Tibetan culture and on health and politics in contemporary Tibet and Nepal. AMANDA HARRIS has recently carried out field research in Iban longhouse communities in Sarawak, East Malaysia, on the topics of healing, modernity,

282

About the Editors and Contributors

and transformations of Iban identity in the context of the politics of the Malaysian nation-state. CYNTHIA L. HUNTER has carried out work with nongovernment organizations on maternal and child health projects in Eastern Indonesia. Her research interests include ritual, illness, and healing in contexts of medical pluralism. She has written on the topics of maternal and child health, and national health services in Indonesian communities. CRAIG R. JANES is Professor and Chair of the Department of Anthropology, and on the faculty of Program in Health and Behavioral Sciences, University of Colorado-Denver. He has published extensively on research in medical anthropology and epidemiology among Samoans in California, U.S. industrial workers, and Tibetans in Lhasa. He is author of Migration, Social Change and Health (1990), and is coeditor (with R. Stall and S. Gifford) of Anthropology and Epidemiology: Interdisciplinary Approaches to the Study of Health and Disease (1986). LAUREL KENDALL is Curator of Asian Ethnographic Collections at the American Museum of Natural History, and also teaches in the Anthropology Department at Columbia University. She is the author of Shamans, Housewives, and Other Restless Spirits (1985), The Life and Hard Times of a Korean Shaman (1988), and Getting Married in Korea: Of Gender, Morality and Modernity (1996). She has also written articles on gender, ritual, medicine, and shamans in Korea, and with Diana Lee coproduced the video An Initiation Kut for a Korean Shaman. CAROL LADERMAN is Professor and Chairman of the Department of Anthropology at the City College of New York. Her books include Wives and Midwives: Childbirth and Nutrition in Rural Malaysia (1983), Techniques of Healing in Southeast Asia, coedited with Penny Van Esterik (1988), Taming the Wind of Desire: Psychology, Medicine, and Aesthetics in Malay Shamanistic Performance (1991), Main Peteri: Malay Shamanism (1991), and The Performance of Healing (1996), coedited with Marina Roseman. MARK NICHTER is Professor of Anthropology at the University of Arizona and Coordinator of the Graduate Program in Medical Anthropology. He has conducted long-term fieldwork in India and other parts of South and Southeast Asia, focused on issues related to ethnomedicine as well as international health. He is editor of a collection of essays, An Anthropological Approach to Ethnomedicine (1994), and coauthor (with Mimi Nichter) of Anthropology and International Health: Asian Case Studies (1996). KALPANA RAM is currently a Research Fellow in the Department of Anthropology, Macquarie University, Sydney. Her publications include Mukkuvar Women: Gender, Capitalism and Hegemony in a South Indian Fishing Community (1991), as well as papers on gender, feminist theory, and anthro-

About the Editors and Contributors

283

pology. She has coedited two books with Margaret Jolly (Maternities and Modernities: Colonialism and Postcolonial Experiences in Asia and the Pacific [1998], and Borders of Being: Citizenship, Sexuality and Fertility [forthcoming]). She has also coedited, with Kehaulani J. Kauanui, a special issue of Women’s Studies International Forum entitled Migrating Feminisms: The Asia/ Pacific Region (1998). MARINA ROSEMAN is Associate Professor and Research Coordinator at Pacifica Graduate Institute, Santa Barbara, California, and Research Associate in the Department of Anthropology, Indiana University. She is author of Healing Sounds from the Malaysian Rainforest: Temiar Music and Medicine (1991), coeditor with Carol Laderman of The Performance of Healing (1996), and has also published papers on Temiar music and healing. SYDNEY D. WHITE is Associate Professor of Anthropology at Temple University. She has published several articles based on her research in the People’s Republic of China on the politics of Naxi cultural identities and therapeutic practices in the Lijiang basin. She is currently working on a book entitled Narratives of Modernity in Socialist China: Naxi Identities, Medical Practices, and the State in the Lijiang Basin, 1949–1990.