Traditional Asian Medical Cultures Encounter
This article is written to encourage a discussion about the relationship between biomedical research methods and traditional Asian medical cultures. The encounter between these two is currently impelled by a variety of factors. After describing biomedicine, Indian Ayurveda and Tibetan medicine as distinct systems we would like to point out some important differences, and raise the question of whether these differences are so fundamental as to make biomedical research methods inappropriate. How far can the latter be applied to the former? In the course of this discussion we will also touch on issues of cultural history, the appropriation of traditional medical knowledge by the biomedical culture, and the economic pressures now being experienced around health care in mass societies, ending with some recommendations about the kinds of questions which those contemplating research in this area ought to consider.
Traditional Asian healing arts are the object of increasing interest in the West on the part of both patients and medical practitioners. This has given rise to more frequent calls for research into these ancient medical systems. These calls are made in the context of a number of profound transformations which Western medical research has undergone in recent years.
Physics, chemistry and mechanics no longer define the only acceptable frameworks for medical research. It now proceeds also in the fields of the humanities such as anthropology, history, psychology and philosophy. Topics such as the relationship between the patient and the doctor, the patient's subjective experience of his or her illness (Ger. Befindungsstoerungen), the relationship between cultural beliefs and patient behaviour, and even the effect of psychic healing procedures are now found in biomedical research journals. In many of these areas researchers have gone beyond biomedicine's traditional reliance on quantitative numerical data in favour of the exploration of the qualitative aspects of illness and healing. This expansion of new research approaches is often discussed in terms of the Nineteenth Century Germanic distinction between Natur-wissenschaften and Geistes-wissenschaften - the natural (physical) sciences vs. the humanities.
On the side of biomedical practice there are also important transformative trends. The paradigm of materialist Western medicine has lead to a notoriously high level of patient dissatisfaction. The search for new approaches in medicine has opened the door to non-European alternative arts of healing. There is now a distinct advocacy for treating the patient as a complete person rather than as a malfunctioning organism, to treat the whole illness rather than just the disease. The tremendous escalation of costs in the public health sector in the West has made more efficient health care a political priority. Preventive care has accordingly begun to play a more important role. The costs of treating chronic ailments and rehabilitating the disabled are stupendously higher than the cost of effective preventive care. The same economic pressures are driving a movement to define "health life-styles" and educate the public accordingly.
All of these trends contribute to the atmosphere in which the West has turned its attention to Asian medical systems. They, however, remain still marginal to the continued dominance of materialistic science as the ideological core of biomedical education, practice and policy-making.
Biomedicine and its Cultural History
In order to provide some background against which the appropriateness of biomedical research methods to traditional healing systems can be evaluated, we want to briefly review the nature and history of biomedicine as a particular culture of medical knowledge.
In Europe, the rise of empiricism, and with it of experimental science in the Seventeenth Century is an important root of biomedical epistemology. The development of experimental anatomy is a prime example of the way in which the application of empiricist principles transformed medical knowledge. Another crucial influence was the Late Nineteenth Century movement of positivism - the programme to reduce all knowledge to purely physical terms. This doctrine rapidly came to be fundamental to biomedicine - the insistence that all processes of disease and health can be reduced to physics and chemistry. To understand the vigour with which biomedical researchers seek to reduce traditional treatments to biochemical formulae, it helps to remember that its ideological roots lie in movements which were dedicated to replacing "superstition" with physical science. Seventeenth Century empiricism was a movement which sought explicitly to counter English beliefs in witchcraft and magic, and Nineteenth Century positivism was similarly a reaction against Germanic romanticism and idealism.
Later in this article we will argue that the end product of this historic transition is not by itself adequate for the investigation of traditional medicine in Asia.
Ayurvedic and Tibetan Medical Cultures
In the medical theories of Ayurveda (Knowledge of Life) in India, and Sorig (Science of Healing) in Tibet, everything that exists is understood to be composed of five elements (Sk. panca mahabhuta; Tib. `byung ba lnga): Earth, water, fire, wind and air. These elements are thought to be interwoven and mutually interactive. The distinctive constitution of each individual (Sk.prakrti, Tib. rang zhing) is due to the varying proportions of these elements. Health is understood as a continuum of balance and interaction among these five elements. Illness occurs if an imbalance is created by any of various mental, emotional, physical, dietary, behavioural, or climatic causes.
The diagnosis of illness is made in terms of the balance between three humoural principles, (Sk dosa, Tib. nyes pa). This balance is assessed through skilled questioning about the patient's symptoms, behaviour and state of mind, feeling their pulse, and observing their urine, tongue, and external appearance.
Humoural theories of this type have a history of more than 2000 years. It is interesting to note that at certain stages in its history European civilization produced medical systems which bore marked similarities to the traditional Asian systems. Both Plato's (c.428-c.347 BC) description of medicine as the science of health (hygieinou episteme) and the humoural theories of the classical Antiquity parallel similar principles in ancient Indian Ayurveda and the later developing Tibetan Sorig.
Those humoural concepts of medicine have supported the accumulation and codification of an incredible amount of empirical knowledge. Much of this knowledge is on record in Sanskrit and Tibetan medical literature which is still available to scholars. Other aspects have been transmitted through secret oral instructions in the various traditional medical lineages. These oral traditions are more difficult to gain access to.
The training of healers in these systems differs from the training which biomedical physicians receive. The Gurukul system - where students and teachers used to share, live and study in an ashram-like community - and instruction through family lineages were the traditional modes of medical education in most Asian cultures. The study of Indian and Tibetan medicine consisted of three stages: The first was listening the teacher read the medical text, (Sk. agama; Tib. rlung). This established the student's right to study the text and prepared his or her mind for insight into the tradition. The second was receiving ritual empowerment (Sk. abhiseka; Tib. dbang) to practise the esoteric aspects of the discipline. The third was receiving the secret oral instructions (Sk. upadesha; Tib. man ngag) which were supplementary to the texts. This last stage depended heavily on the personal relationship between teacher and student, and the demonstrated ability to lead a balanced and aware life was a prerequisite to it. These traditions emphasized the student's development of the sensitivity and awareness necessary to perceive the five elements and three humoural principles. They included both textual study and contemplative or meditative practice. The integration of these two aspects required maturity and self awareness on the part of both teacher and student.
The understanding of materia medica and pharmacology in these ancient systems is also quite different from that found in biomedicine. A given medicinal plant has to be picked at a certain time of the year at which the configuration of the five elements and three humoural principles in the environment maximizes its medicinal value. Other factors to be considered in gathering medicinal plants include the compass direction of the slope on which they are found, the position of lunar and planetary constellations at the time of gathering, the time of the day, the signs of specific birds and animals in the natural surroundings as well as the state of mind of the person collecting the plant. Different plants have to be washed, dried and preserved in different ways. All of these factors are understood to effect the medicinal power of the final drug. Once gathered, the medicinal value of a plant is assessed by taste. A skilled traditional physician can determine the proportions of five elements and the three humoural principles present in a plant in this way. The ability to do this accurately depends on the assessor's personal state of health and mental clarity. When it comes to processing the raw materials into medicines, specifically spiritual practices such as consecrations through the recitation of mantra and the admixture of materials carrying the blessings of great saints are often seen as essential contributions.
In general both Ayurveda and Sorig regard health as a matter of balanced living and understand illness in terms of models of humoural imbalance. They both emphasize preventive health care and both attend to the spiritual and philosophical aspects of medicine.
What is the state of these rich traditions in contemporary Asia?
Several factors are contributing to a crisis around the survival of these traditions in Asia.
During most of British colonial rule in the Nineteenth Century Ayurvedic training received no governmental support and was in decline. In the early days of the Indian independence movement in the 1920's the curricula of Indian Ayurvedic colleges were standardized in imitation of the British school system. A system of nationally uniform degrees in Ayurvedic medicine was established, and there was an attempt to adopt biomedical research methods to raise the prestige of Ayurvedic medicine. This imposition of Western educational models resulted in the near extinction of traditional Ayurvedic training. The spiritual aspects of Ayurvedic tradition almost vanished, surviving primarily in the family traditions of rural areas.
The spectacular growth of large Ayurvedic pharmaceutical firms, who sell extensively to the middle and upper classes of India's urban centres and are based on mass production, and mass media advertising, does not seem to be accompanied by a comparable spread in understanding of traditional Ayurvedic wisdom. Despite growing popular interest in Ayurvedic medicine in India's urban centres, the health policy officials who control the purse strings of huge budgets insist that the efficacy attributed to traditional remedies must be proven by scientific means before funds can be released making them more widely available to the urban population. This is not surprising given that such officials have been predominantly educated in the Western sciences.
Following the Chinese take-over of Tibet in 1959, Tibetan medicine has undergone a period of eclipse which might have been fatal had it not been for the survival of training programmes in Ladakh and Bhutan and the revival of one of Lhasa's greatest medical Colleges, the Men Tsee Khang (Tib. sman rtzis khang), in Dharamsala in 1969. As much as we should be grateful that this tradition is now on its way to a significant revival - with Tibetan medical training now also available in Sarnath and Darjeeling, we should also recognize the fact that the institutions which have arisen in the Tibetan exiled community have not succeeded in preserving the full scope and integration which were characteristic of medical education in Tibet prior to the Chinese invasion. There has been a tendency to leave the psychological and spiritual aspects of therapy to the Lamas and narrow medical practice to the prescription of drugs, trends which vitiate the holistic and spiritual aspects of Sorig. These days only a few Tibetan physicians combine the practice of medicine with spiritual exercises according to the old tradition. Instruction in materia medica and pharmacology, traditionally part of the training of every physician, have become a specialization. Being split off from the rest of the curriculum, the majority of the medical students do not undertake its study. (We are aware that there have been Tibetan medical training programmes in Lhasa and other parts of Tibet for many years but do not have reliable information on their curriculum.)
The dynamics of the biomedical traditional encounter in the Himalayan region and the Indian sub-continent seem to be different in rural as opposed to urban areas. In the former the use of traditional healers and remedies remains quite high. However, allopathic drugs are becoming more available even in these regions, and their prestige is putting traditional remedies on increasingly slippery ground. In both rural and urban areas people typically think that because traditional remedies are less expensive they must be less effective than more expensive allopathic drugs.
Another factor which powerfully conditions research into Ayurvedic and Sorig traditions is the environmental and ecological crisis spreading across the Himalayas and Indian sub-continent. The decline and even extinction of medicinal plants have finally become an active concern on the part of governmental agencies, pharmaceutical houses and traditional practitioners. Aside from the possibility of plant extinction, climatic changes and the pollution of the environment due to overpopulation and industrial wastes will inevitably alter the elemental compositions of flora and fauna. At some point those alterations will progress to such an extent that the ancient medical empirical data and descriptions of medicinal plants will lose their relevance, partly or completely. It is possible that the empirical aspect of traditional medical knowledge might then no longer be of service to mankind.
On the other hand it is also possible that traditional practitioners may be able to use their methods of assessing plant properties and their conceptual understanding of health and illness to update their knowledge of the medicinal properties of plant species as they change. This underlines the fact that traditional methods and understandings are more fundamental than knowledge of the properties of specific plants, and of more universal value.
These factors of ethnic displacement, the attendant revision of traditional pedagogy and curricula, the translation of Ayurvedic wisdom into mass-produced and mass-marketed products, the prestige of allopathic drugs in India and the Himalayas, the accelerating eradication of medicinal plant species and degradation of the environment comprise a situation in which research into traditional medical knowledge seems at once both urgent and extraordinarily difficult.
Critique of Biomedical Research as Applied to Traditional Asian Medicine
Now that we have outlined the main features of biomedical and traditional Asian medical cultures and discussed some of the pressures attending their current encounter with each other, we want to point out what we take to be some serious incompat-ibilities. The epistemology of biomedicine emphasizes research as the generator and confirmer of medical knowledge with a strong interest on the discovery of new knowledge. This programme is so vigorously pursued that the current consensus among biomedical scientists is that every five years they render 50% of their existing stock of knowledge obsolete. (Thus biomedical knowledge is said to have a "half-life" of 5 years.)
Traditional Asian medical cultures, in marked contrast, accept knowledge as delivered authoritatively by their canonical texts and oral traditions. It remains for the practitioner to determine how this knowledge should be applied in the actual gathering of medicinal plants, the compounding of medicines, and the treatment of patients.
All in all the biomedical notion of "research" seems to have no clear analogue in traditional Asian systems. This raises the question of what Ayurvedic or Tibetan medical "research" ought to consist of. In this regard we cannot overlook the fact that the large Ayurvedic pharmacies in India now regularly employ Western techniques of biochemical analysis to evaluate the pharmacological potency of plant stocks before they purchase from them. Does this constitute a dilution or loss of traditional Ayurvedic wisdom? Should Tibetan medicine follow the Ayurvedic example in this regard?
Despite these profound epistemological differences the research methodology which is most often applied to traditional systems is biomedical, and often exclusively biomedical. Even in India the majority of scholars and scientists engaged in assessing traditional medical systems tend to adopt Western scientific research strategies. On the basis of our brief review of biomedical and traditional Asian medical cultures we raise the following objections to this trend :
The analysis of the pharmacological activity of medicinal plants into "active" biochemical components has been a hallmark of biomedicine's appropriation of traditional remedies. As we have already noted the larger producers of Ayurvedic medicines now employ exactly this method to assess the potency of plants offered to them for purchase. But is a single, or few biochemical compounds really equivalent to the total "taste and potency" which Ayurveda and Sorig attribute to the plants which meet all their criteria for selection as materia medica? Are industrial extractions of these targeted biochemicals from large masses of mostly cultivated plant material really the equivalent to traditional medicines prepared according to all the requirements and procedures specified by Ayurveda or Sorig?
Clearly the reduction of the pharmacological potency of traditional remedies to chemical formulae leaves out vast areas of the traditional specification of materia medica potency. The biochemist ignores the factors which are traditionally taken as pertinent in the selection of a plant for gathering, and takes into account only the chemically definable aspects of its potency, neglecting such factors as the composition of elements in the plant material as a whole, the state of mind of the pharmacist, and spiritual aspects of medicine making.
To digress for a moment to the modes of pharmaceutical production which biomedical research seems to legitimize: From the traditionalist point of view the mass cultivation and industrial processing of medicinal plants would inevitably alter their elemental composition and therefore their healing powers. They would not regard the remedies produced in this way as the "same" as those produced according to traditional procedures.
This example underlines the way in which biomedicine's deletion of important aspects of traditional knowledge creates the possibilities for serious misrepresentations which can be damaging to the viability of traditional medicine. Biomedical researchers periodically announce the "discovery" of a new drug through the identification of a pharmacologically active compound from a traditionally used medicinal plant and its successful clinical trial. While it is certainly well to celebrate such feats as important additions to the biomedicine's therapeutic arsenal, it is profoundly misleading to present them as advances in the "understanding" of traditional medicine. This is especially so when such "active compounds" are presented - as they so regularly are - as the "real" reason that the traditional remedy worked or failed, an essentially political move which casts biomedical "knowledge" as superior to traditional "belief".
Similar deletions would attend the running of biomedical "clinical trails" on traditional remedies. The diagnosis of clinical subjects as having some particular disease would be based on biomedical procedures of examination and biomedical concepts of illness as defined by disordered chemistry, histology or mechanics. On both scores this approach would ignore aspects of the patient's situation which Ayurveda and Sorig would take as crucial to understanding and treating their illness. Patients would be defined as having the "same" biomedical diagnosis even though they might have constitutional differences in terms of the five elements and three humoural principles. Would the scientists conducting the trial be willing to administer the medicine to different patients on the different days which their individual constitution indicated as the most auspicious for achieving a cure? Would the mental state and background in spiritual practice of the doctor administering the medicine be taken into account? All of these are factors which Ayurveda and Sorig regard as essential to effective diagnosis and treatment.
In replying to these objections, advocates of the biomedical approach may say that they do not claim to evaluate the spiritual, environmental or constitutional aspects of these drugs or patients, that they are only interested in determining which biochemical constituents of the plants are "pharmacologically active" and in gathering statistics on the effect of such biochemically defined medications on biomedically defined states of disease. And they will be right in this contention. Our point is precisely that biomedicine's definition of the substances and conditions which are the objects of its research are so at variance with traditional Asian definitions of medicine, illness and treatment that the former ignores vast areas of the latter. We do not dispute that biomedical research can generate knowledge about the efficacy of plant derived biochemicals on biomedically defined disorders. Our point is that such results can be taken as a contribution to understanding traditional medical cultures in only the most oblique way. Given the political realities of biomedical ambitions to supplant traditional medical systems, such research results probably function more to promote the misunderstanding of those systems.
The above points establish the inadequacy of biomedical research as a sole means of evaluating traditional medical knowledge. We stress that this inadequacy is not simply a matter of incompatible epistemologies, (an objection which is readily and regularly finessed by the claim that biomedical knowledge is superior to that produced by traditional cultures), but is an unavoidable consequence of biomedicine's deletion of important aspects of traditional knowledge from its definitions of medication, illness and treatment.
Despite these epistemic incompatibilities and seemingly unavoidable systemic 20 errors we believe that the trends which we have cited in Western and Asian medicine make it inevitable that the full panoply of biomedical research methods will be applied to traditional Asian healing arts at some point. This will probably occur sooner than most traditional practitioners anticipate.
To briefly recap those factors :
From the West there is a growing interest in identifying traditional remedies which may be both more effective and less expensive than current allopathic treatments. There is also considerable popular interest in the philosophy and practice of Asian medicine.
From the East there is a palpable interest in the scientific identification, analysis and preservation of traditional remedies. A case in point is the Indian Department of Biotechnology's programme of establishing regional laboratories dedicated to this purpose. In addition to this there is a growing interest in Ayurvedic and Tibetan philosophy and treatment in some segments of the Indian population.
Given the momentum of these trends, it remains only for us to ponder the consequences of the steadily intensifying encounter between biomedicine and traditional Asian systems. How will it impact traditional forms of medical knowledge and training? Will Ayurveda and Sorig go the way of the traditional systems of medical knowledge which allopathy succeeded in wiping out in Europe and England? If biomedical research methods come to be accepted as the only means of evaluating Asian medical cultures, will this not promote neglect and loss of traditional ways of knowing? We believe that it is naive to assume that these things cannot come to pass. It therefore behoves those who value the traditional Asian systems to consider what might be done to ameliorate the potential for damage which is inherent in their encounter with biomedicine. How can the collision of such seemingly irreconcilable medical cultures be managed so as to yield mutual benefits?
Three Modest Proposals
Without attempting to provide comprehensive answers to these very complex questions, we offer three rather modest proposals :
One of the primary causes of inter cultural violence is the ignorance of the parties involved of one another's values and ways of thinking. Both Western and Asian scientists would benefit from a deeper knowledge of traditional medical systems and the opportunity to discuss research possibilities with traditional practitioners. And traditional practitioners would most certainly benefit from a better understanding of the biomedical avalanche which is almost upon them. It seems that an expanded dialogue between research scientists and traditional Asian medical practitioners would facilitate the ability of each side to negotiate mutually beneficial outcomes. If conducted with a modicum of respect and openness such a dialogue might facilitate innovations in research methodology which would minimize the misrepresentation of traditional knowledge and might lead to greater benefits for both parties.
In this regard we should take note of the recently established Hinduja Center at Columbia University in New York City, at which scholars such as Kenneth Zysk are working to facilitating dialogue and mutual understanding between Ayurvedic and allopathic physicians.
The field of medical anthropology has developed a distinction between "Illness" - meaning the totality of a social network's experience of medical dysfunction and treatment - and "disease" - meaning the biomedical view of illnesses and medical treatments as strictly reducible to physical, chemical and mechanical phenomena. This distinction has been quite helpful in establishing anthropologists' right to address the full range of thought, practice and experience found in non-biomedical systems of healing. By defining their area of study as clearly distinct from that of biomedicine, it has also freed them from the otherwise easily acquired habit of treating the assertions made by traditional practitioners as merely "beliefs" - "belief" being understood to be inferior to biomedical "knowledge" - a subtle but devastating denigration of the traditional. Those who are interested in studying Asian medical cultures as bodies of knowledge on their own terms, and would like to avoid reducing them either to biomedicine on the one hand or "belief systems" on the other, might find the "illness / disease" distinction of similar utility.
Finally we recommend that those contemplating research in the area of traditional medical cultures take the following questions quite seriously :
- What is the system of thought underlying the medical tradition which I would be investigating? What are its assumptions about knowledge and its acquisitions?
There is clearly need to supplement the biomedical approach with research methodologies which are capable of addressing those aspects of traditional medical cultures which the former unknowingly deletes. While history, anthropology, psychology and other fields have much to offer in this regard, it seems that some more specific accommodation of biomedical research to the features of Asian medical systems is also warranted. This accommodation is, of course, yet to be invented.
- How do those compare with the core concepts and epistemologies of biomedicine, or whatever other discipline I am deriving my research methods from?
- To what extent will these differences introduce systematic distortions and deletions into the way my research results portray of the traditional system?
- How far am I prepared to go in unlearning familiar concepts and adopting new perspectives in order to better understand traditional views of health and illness?
- Do I want to prove something which has been born in one system of scientific thought through transferring a research method from another system of scientific thought?
- How open am I to taking intuition, sensory perception and spiritual experience seriously as traditional modes of gaining knowledge?