Imagined Lives, Suffering, and the Work of Culture: The Embodied Discourses of Conflict in Modern...

CRAIG R. JANESDepartment of AnthropologyUniversity of Colorado at Denver

Imagined Lives, Suffering, and the Work ofCulture: The Embodied Discourses of Conflictin Modern Tibet

This article explores the cultural epidemiology 0/rlung ("loong") disor-der among Tibetans living in the cities and towns of the modern Chinesestate of Tibet. Rlung, glossed as air or wind, is the most important of thethree humors of the classical Tibetan ethnomedical system. Consideredby Tibetans to be contingent upon multiple social, emotional, and relig-ious phenomena, rlung disorders are fertile ground for the developmentof etiological discourses that incorporate the social and political crisesthat are part of the rapidly changing Tibetan plateau. In this essay I locaterlung disorder in a confluence of Tibetan ethnomedical constructions ofthe mind-body-universe linkage, in which rlung stands as the chief sym-bolic mediator, with ethnic conflict, rapid economic development, and thelocalization of global debates over Tibetan suffering and human rights.[Tibet, ethnomedicine, politics, economic development]

The Chinese have been destroyed by suspicion; the Tibetans have been destroyedby hope.

Common saying, Lhasa, 1991

If Tibet had to be conquered by a foreign invader, why couldn't it have been a richcountry like America or England? Then at least we'd have improvements likewater and electricity, and maybe even color televisions. Why did it have to be byone of the poorest countries in the world, one that only takes our resources?

Tibetan laborer, 1991

R lung (pronounced "loong") is the Tibetan term for wind or air and in med-ico-religious contexts is related to the "life force."1 If rlung is out of balancein the body, or if it is too slow or too quick in its circulation, a variety of

sometimes serious symptoms result, ranging from dizziness to high blood pressure,

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

391

392 MEDICAL ANTHROPOLOGY QUARTERLY

heart palpitations, dysphoria, and, ultimately, insanity. It is the most commonly di-agnosed humoral disorder in Tibet today. In this article I examine the culturalepidemiology of rlung disorder in modern Tibet. I also consider the degree towhich popular Tibetan conceptualizations of rlung disorder, that is, rlung dis-courses, have been widened to admit the politics of the cosmopolitan, Chinese, andTibetan engagements over Tibetan autonomy, independence, and human rights.

The starting points for this analysis are the different but, I argue, complemen-tary theoretical perspectives on the nature of culture and its relationship to experi-ence offered first by Obeyesekere (1985) and later by Appadurai (1991). In whathas become an influential essay on the relationship of culture to depression,Obeyesekere introduced the concept of work to assist an understanding of the proc-esses by which Buddhist culture normalizes depressive affect:

The work of culture is the process whereby painful motives and affects such asthose occurring in depression are transformed into publicly accepted sets of mean-ing and symbols . . . the constellation of affects . . . can, through the work of cul-ture, be transformed in a variety of directions—into Buddhism and spirit attackand no doubt into other symbolic forms also. [1985:147-148]

In such fashion, Obeyesekere argues, depressive affect in Buddhist cultures is con-textualized as insightful appraisal that the world apprehended through the senses isimpermanent, illusory, and unworthy of ego-involvement (i.e., attachment). Thework of culture in this sense is to elevate the pain and suffering of an individual na-ture to an occasion of reflection on Buddhist ontology, thereby, presumably, mut-ing and even transforming it into an opportunity for revelation. With thisperspective, the task for people becomes not how to avoid suffering or how to re-cover from it, but rather, how to suffer gracefully, employing and manipulating thesymbolic devices available for doing so. The idea of cultural "work" directs atten-tion to the constructed nature of reality as it pertains to affect and psychic suffering.For the anthropologist, this perspective nicely articulates the constructed, predomi-nately social nature of emotion, now the generally accepted orientation in psycho-logical anthropology (e.g., Lutz 1985; O'Nell 1996), and a perspective increasinglyacknowledged by psychiatric epidemiologists to explain cross-cultural differencesin psychopathology (e.g., Weissman et al. 1996).

The challenge in studing of the meaning of suffering is to identify and de-scribe how, and the avenues by which, culture works to transform painful feelingsinto publicly acceptable sets of symbols or, alternatively, to examine how indi-viduals seize upon and manipulate these symbols to articulate their distress inlocally meaningful terms. My emphasis is on the development of Tibetan medicinein interplay with the transnational flows of people, information, and public sym-bols that affect day-to-day life in the heavily touristed and rapidly changing Chi-nese-Tibetan cities of the Tibetan Plateau. Appadurai's (1991) comments are par-ticularly apt in this regard. He suggests that the study of cultural dynamics mustinclude reference to the phenomenon of deterritorialization: the character of mod-ernity whereby ethnic groups and communities, among other social formations,operate according to principles that transcend territorial boundaries and identities.Most importantly, a deterritorialized world, crosscut by currents generated by massmedia, tourism, migration, and capital, allows people in what were once

SUFFERING AND THE WORK OF CULTURE IN MODERN TIBET 393

circumscribed local communities to now envisage and imagine possible alternativelives. Appadurai writes:

More persons throughout the world see their lives through the prisms of the possi-ble lives offered by mass media in all their forms... fantasy is now a social prac-tice; it enters, in a host of ways into the fabrication of social lives for many peoplein many societies What is implied is that even the meanest and most hopelessof lives, the most brutal and dehumanizing of circumstances, the harshest of livedinequalities is now open to the play of the imagination. Prisoners of conscience,child laborers, women who toil in the fields and factories of the world, and otherswhose lot is harsh no longer see their lives as mere outcomes of the givenness ofthings, but often as the ironic compromise between what they could imagine, andwhat social life will permit The biographies of ordinary people, thus, are con-structions (or fabrications) in which the imagination plays an important role.[1991:198]

Suffering, subject to the definitional, transformative, and expressive proc-esses of cultural work, may itself be partly fabricated out of the imagined lives andpossible social existences to which Tibetans compare their own. Contemporary Ti-betan cultural patterns must therefore be seen as developing within a context inwhich an ironic compromise is apprehended, a compromise between cosmopolitanideas about the natures of Tibet, Tibetan Buddhism, Tibetanness, and Tibetan suf-fering on the one hand, and the realities of Chinese modernity on the other. Whatare the stakes held by the West for constructing the kind of suffering in Tibet pa-raded in the international media; and conversely, what stakes compel Tibetans toaccept or respond to such constructions (see Adams 1996a, 1996b)? Growingworld-wide debate over the Tibet question between the West and China, Westernfascination with Tibetan Buddhism, and a growing Western-spawned outcry over"human rights" are part of the total context in which Tibetans bring new meaningsto the pain and suffering expressed in rlung discourses.

In the essay that follows I present a cultural-epidemiologic analysis of rlungdisorders in central, principally urban, Tibet. I locate rlung disorder in a confluenceof Tibetan ethnomedical constructions of the mind-body-universe linkage—inwhich rlung stands as the chief symbolic mediator—with ethnic conflict, rapideconomic development, and the localization of the global debate over Tibetan suf-fering and human rights. I argue that the determinants of rlung disorder can befound in the social facts of structural discrimination and related economic injus-tice. Most importantly, the particular modes of its expression and representation inmodern, touristed Lhasa may deflect attention from these facts in favor of a princi-pally Western-based framing of Tibetan suffering which locates it in the destruc-tion of Tibetan religious culture, in the torture and imprisonment of its citizens, andin state oppression (Adams 1996c).2

Tibetan Medicine and Rlung Disorders

I have provided a general cultural outline and modern history of contempo-rary Tibetan medicine elsewhere (Janes 1995).3 Here I summarize the nature of theTibetan medical system, with particular reference to disorders of the humor rlung,and provide a brief description of the Tibetan medical system as it is presently or-ganized and deployed within the Tibet Autonomous Region (TAR) of China.


Classical Tibetan medicine combines South Asian and Middle Eastern natu-ralistic humoral theory with Buddhist principles and tantric practice. The three hu-mors of Tibetan medicine—phlegm (bad kan), bile (mkris pa), and wind or air(rlung)—represent the confluence of climatic, geographic, dietary, social-behav-ioral, spiritual, and supernatural forces. Although a classically naturalistic humoralsystem quite similar to Ayurveda, at remote causal levels Tibetan medical theoryinvokes the different modes of Tibetan Buddhism (Samuel 1993). Healing is ap-proached on three levels: the spiritual or dharmic, the subtle (vital) or tantric, andthe somatic or humoral (Clifford 1984; Rechung 1973). Dharmic healing is a spiri-tual practice aimed toward enlightenment, tantric healing is intended to align thevital energies (rlung) within the body which connect it to its phenomenal existence,and humoral medicine—the material elements of healing that constitute the mostvisible aspect of the tradition—balances elements, substances, and humors withinthe body that have gone out of equilibrium due to "improper" thought and behav-ior.

The pervasiveness of multiple modes of ethnomedical thought among Tibet-ans today, even among state-educated Lhasans, suggests a complex subjectivitythat integrates the mind-body with the social and natural universes in a host ofways. Illness experiences are matters of diverse origin, from diet and climate toemotion or mental agitations, as well as the actions of supernatural beings arousedin the course of social events and personal behaviors. In Tibetan medical theory,rlung is the integrator of such manifold forces; Tibetan physicians often describerlung metaphorically as the "king" or "integrating principle" of the mind-body. Inclassical Tibetan medical theory, the humor rlung is that which animates, gives riseto action, and brings sentience to physical matter. A young Tibetan physi-cian—educated in basic biomedicine as well as Tibetan medicine, the standardpractice these days (see Janes 1995)—described it in this way: "When one eatsfood, the heat or fire of the stomach digests it, breaks it down. But the digested foodcannot nourish without adequate rlung. Rlung is what allows the food to enter theorgans and muscles of the body and become the energy one needs to walk orthink."

Rlung imbalances may affect different parts of the body; the affected parts re-flect the mapping of different "kinds" or "levels" of rlung on particular eth-noanatomical systems. For example, in the brain, rlung (as srog- 'dzin-rlung) em-powers the senses, cognition, and emotion; in the chest, it gives rise to respirationand speech; in the heart, rlung compels the heart muscle to beat and the blood tocirculate; in the stomach and intestines, it causes the transformation of food intoenergy; and in the genitals, bladder, and colon, it empowers reproduction andelimination. Imbalances of rlung and changes to the character of rlung (slow mov-ing, quick moving, lightness, dryness, etc.) lead to dysfunctions in these eth-noanatomic regions. Imbalances have their own particular characteristics that de-termine which symptoms will appear and which will be the most troublesome. Forexample, rlung may not only be high or low, but also heavy/slow or quick. Com-mon symptoms are those that derive from disorders of rlung in the brain, heart, andchest. In the brain, rlung causes disordered thinking, depression, and insanity; inless severe forms, dizziness, insomnia, dysphoria, fainting, ringing in the ears, andimpaired sensory perception. In the heart, rlung contributes to palpitations, "heartswings," and a rapid, fluttering heart beat. In the chest area, rlung causes shortness


of breath and pain in the sternum, which often goes through to the upper spine(pain is especially significant between the sixth and seventh thoracic vertebrae).Rlung is also believed to be the force that maintains the movement of bloodthrough the body; hence, disorders of such movement, for example, high or lowblood pressure (the latter producing fainting, or "losing the power of the body"),are attributed to rlung imbalance. Rlung imbalances that affect the heart (calledsnying-rlung), the circulation of blood (high, low, or "variable" blood pressure,called khrag-rlung), and the life force (called srog-rlung) are more common. Se-vere and irremediable srog-rlung is synonymous with insanity; what we recognizeas clinical psychoses or depression are consistently identified as severe srog-rlungby Tibetan physicians and laypeople alike.

Rlung varies naturally between people and within an individual over one'slifespan. The amount of rlung one has is an inborn trait, part of one's essential char-acter. Inborn levels of rlung can be influenced by a number of things, ranging fromkarma to the behavior of the mother. One's essential character may be predisposedtoward or protected from rlung imbalance and, hence, rlung disorder, in the contextof otherwise shared social, behavioral, or environmental "insults." Rlung is alsothought to increase naturally as one ages, and to affect women more than men. It is"natural," according to Tibetan medical theory, for older people and women tomanifest, to an unequal degree, the problems associated with rlung imbalance. Oneof the sources for concern among contemporary Tibetan physicians is the degree towhich rates of rlung imbalance are increasing in younger people of both genders.

Treatments for rlung are largely similar to treatments for the other humoralimbalances: herbal medicines, dietary pre- and proscriptions, simple behavioraladvice, and Chinese-style acupuncture are most commonly prescribed (Tibetan-style acupuncture, insertion of small gold needles into the top of the scalp, is con-sidered superior, but rarely practiced these days in Tibetan clinics). On rare occa-sions rlung sufferers may be offered some simple, formulaic advice about"quieting one's thoughts" or managing or avoiding conflict with family membersor coworkers. Both physicians and patients, as I will discuss in detail below, arewell aware of the social salience of rlung, but this does not appear to be an explic-itly recognized feature of rlung diagnosis and treatment, at least not in governmentmedical clinics.

In its cultural productions and social manifestations, rlung is polysemantic.Intertwined in the classical medical texts—the rgyud-bzhi (the four tantras) and re-lated commentary—with the essential Buddhist teachings regarding the inevitablesuffering that derives from attachments to the world, in this case through desire('dod-chags), rlung also refers to the "life" principle or consciousness (the subtleor "vibratory" body) that is manipulated through tantric practice. In lay Tibetanterms, this life principle is subject to the actions of deities and often involves ideasabout good or bad fortune and polluting places and activities. Rlung discoursesthus invoke, often simultaneously, multiple modes of thought: classical Buddhistprinciples, elements of tantric practice, and a host of lay theories of this-worldlymisfortune (Janes 1995; Lichter and Epstein 1983). Rlung is central to a set ofbody-mind principles whereby culture "works" to push painful affect and bodilydis-ease along several significant cultural paths: Buddhist lessons about imperma-nence and the suffering created by attachment and desire, lessons about propermind and thought management, social lessons about kin reciprocity, and lessons


about the inherent vagaries of demons, spirits, and good or bad luck. Accordingly,physicians and their patients bring quite variable understandings to the sources ofrlung imbalance, ranging from narrowly framed ideas about ego attachments and"mismanaging thoughts" to articulations of profound personal and social crises.

Rlung disorders are among the most common brought to Tibetan medicalpractitioners, the majority of whom are employed in government hospitals andclinics throughout the TAR and in Tibetan counties and prefectures principally inXinjiang, Qinghai, Sichuan, and Yunnan provinces.4 Since 1980 there has been arapid development of Tibetan medicine in China (see Janes 1995). Centered inLhasa, the Tibetan medical college and the provincial Tibetan Medicine Hospitalof the TAR have trained thousands of Tibetan physicians. The training is, to someextent, both secularized and "scientized," particularly as Tibetan medicine strug-gles to maintain legitimacy in the face of the powerftil impetus to adopt Westernscience and biomedicine now characterizing medical traditions in China, althoughit remains to a degree rooted in the traditional tantras and related commentaries thatdate in "modern" form to the early 18th century. The Tibetan Medicine Hospital inLhasa now boasts more Tibetan physicians practicing in Tibet than at any time inTibetan history. Nearly every county medical facility and many townships haveone (or more) traditionally trained Tibetan physician.

"Like Trying to Lift the Sky with One Finger": Cultural Epidemiologies ofRlung

The polysemantic quality of rlung makes it an effective means to respond toand articulate the impacts of modernity of the Chinese variety or, increasingly andironically, Western desires for a certain kind of suffering Tibet. Contemporary andlargely secular interpretations of rlung tend to focus on social and personal disjunc-tures, disappointments, and dashed expectations; that is, in a kind of inversion ofclassical Buddhist thought, rlung stems from the corruptions of desire for thatwhich is considered culturally valued, appropriate, and cherished (Janes 1995).The potential for the explicit politicizing of rlung illness here is a potent one. Theextent to which rlung discourses have been opened up to admit purely political sen-timents was investigated through interviews with rlung sufferers, a comparablegroup of individuals attending Tibetan medical clinics who did not have a rlung di-agnosis, and a small group of Tibetan physicians considered to be experts in rlungdiagnosis and treatment (see endnote 2). I begin here with a description of theepidemiology of rlung in modern Tibet and then turn to a discussion of the mean-ing of rlung as articulated by these different groups. I direct attention specificallyto the sometimes subtle differences that emerge when comparing the epidemi-ological view constructed through systematic interviewing and analysis, whichwas largely consistent with physicians' views of rlung etiology and distribution,and the view of rlung as a diagnostic category articulated by Tibetan lay people.What follows is a mix of quantitative and qualitative findings. I begin with a pres-entation of the qualitative material.

Interview results coincided with physicians' perceptions in locating the great-est number of rlung cases among those with more formal state education and corre-spondingly demanding jobs in large government work units. A recurring themehere was not only the demanding nature of the positions, but, more subtly in some


cases, difficult day-to-day contact with Han Chinese, many of whom wield powerover the Tibetan staff.

Tsering is a 42-year-old worker in a foodstuffs factory in Lhasa. He has a historyof high blood pressure, which he terms khrag-rlung, and snying-rlung, an imbal-ance affecting the heart. When we interviewed him, he reported symptoms of up-per back pain and frequent insomnia. Tsering attributes his symptoms to his worksituation. He is in a managerial position, which he admits creates some worry forhim. Later in the interview he talks at some length about the injustices and dis-crimination he has experienced at work. It turns out that he has been in the samework unit for 25 years and has not achieved a promotion that he feels he deserves.Promotions in his company have been awarded on the basis of personal networksestablished with senior, principally Chinese, management. Despite his long yearsof service, his salary has remained low, and this in turn has placed significant eco-nomic pressure on his family.

Tsering is typical of a large number of rlung cases in that the demands of em-ployment and difficulties with Chinese supervisors are the main themes of his nar-rative. Like Tsering, most of the rlung sufferers we interviewed were principallyurban dwellers, were relatively well educated, and worked in the government sec-tor in clerical and administrative positions. All had firsthand and, in some cases,extensive contact with Han Chinese in their day-to-day working lives. Many hadbeen sent to China to work or study. Some were obviously struggling to maintainthe identity of the ideal "minority" celebrated in Chinese propaganda literature.Despite their sometimes quite high positions in work units and government offices,patients often expressed overwhelming feelings of immobility. Passed over forpromotions, experiencing systematic discrimination at the hands of Chinese super-visors, and, as a consequence, perceiving themselves to be both exploited and un-fairly deprived of access to promotion and salary increases, they felt stuck in un-tenable positions, were often angry, and had few (if any) available avenues forchanging the social context of their work lives.

The physicians we interviewed directed us to another group of rlung-suffererswho, like those above, had substantial contact with the Chinese. They, however,expressed a conflict at being caught between Tibetan and Chinese interests in oneway or another. Dawa is an important government official in the regional TAR of-fice that sets commodity prices, a controversial office, subject to some loathing onthe part of the Tibetan populace:

Clearly anxious and agitated when she sees the doctor, Dawa (age 54) launchesimmediately into a rapidly spoken litany of complaints, underscored by strongemotion: she is dizzy, her head aches almost constantly, she is frightened by herheart, feeling as if it were swinging wildly in her chest. She has trouble sleepingand when she does, she dreams of her father who died several years ago. Herbody, she says, is "unhappy." Her job is difficult and causes her much worry andanxiety. She is diagnosed with snying-rlung, which the doctor tells her is very se-rious. She needs to be hospitalized as soon as a bed opens up. The doctor tells her,"As long as you keep working your problem will continue."

Tenzing, a policeman, has quite literally found himself situated between Ti-betan sentiments and Chinese interests:


We spoke to Tenzing (age 53) in the hospital where he had been an inpatient for atotal of three months. His symptoms of rlung began four years ago and includechronic headache, unhappiness, anxiety, chest and back pain, dry mouth, insom-nia, dizziness, and a cold sensation in his lower back. He links the onset of thesesymptoms to the beginning of "troubles" in Lhasa between Tibetans and Chinesewhich put him "in the middle." He described the following series of events: Aboutsix years ago (this would make it about 1987-88; serious demonstrations began inearly 1987 and continued sporadically through March 1988, when martial lawwas imposed), his mother died, and he had to travel to his home village, about 50kilometers southwest of Lhasa, to take care of affairs. When he returned to Lhasahe said things seemed very chaotic and that there were a lot of "sounds" in the city,which made him very nervous. People were yelling and screaming and there weresounds of gunfire all over the city. It was at this time that he first noticed the ring-ing in his ears. Currently, anything that causes him to be nervous or anxious willintensify his symptoms. He's particularly sensitive to the insults he receives whenhe is on duty in the Barkhor (central market and circumambulation route of oldLhasa). He's hoping to be able to be released from work until he can retire.

Rlung sufferers, physicians, and Tibetan laypeople in general often referencewhat they call "family troubles" in discussing the probable remote causes of rlungillness. In narratives of rlung sufferers, presentation of family problems took threeforms. The first had to do with disappointments or concerns over children's lack ofsuccess; for example, that they did not finish school or were unemployed. The sec-ond source of family problems had to do with the behavior of a spouse. Drinkingproblems and unemployment were the two most commonly articulated themes.Third, informants sometimes characterized their family life as conflicted, with fre-quent arguments, a disruption of peace in the family, and, particularly for women,pressures from family members to live a life they did not particularly want to live(in terms of work, schooling, place of residence, etc.).

Phuntsok, age 25, is a clerical worker for a public security office in south-centralTibet. We talked with him at the Tibetan medical hospital in Tsethang. He tracesthe onset of his symptoms to the previous year when he had "many bad familyproblems," which caused him to become dizzy, occasionally fainting. The lasttime he fainted, he struck his head when he fell to the ground, fracturing his skull.He is very clear about the causes of his rlung, ticking them off on his fingers as hespeaks. First, his younger sister, with whom he is close and who studied at a pres-tigious banking school in China, was sent to far western Tibet. He considered thisunfair, but because his family does not have "backdoor" contacts, there was noth-ing they could do about it. Every time he thinks about it, he says, it makes him in-credibly angry. The anger often brings on dizzy spells. Second, his other sister ismarried to a "very bad man," which keeps this sister from tending to family obli-gations, particularly taking care of their elderly mother. Finally, he has had manyarguments with his fiance*e, causing the couple to separate and call off their mar-riage. He ruminates on all of these problems, particularly when he joins his workunit, over 400 km south of his home town of Tsedan.

Overt references to social or political conditions in the narratives of rlung suf-ferers was relatively rare when compared to discussions of employment, familytroubles, or economic problems. As with the sufferers of neurasthenia described byKleinman (1986), discussion of social changes and political factors were some-times invoked to explain current economic difficulties.


Nyima is a 68-year-old mother of four with no education who lives with her 38-year-old son, recognized as a reincarnate lama. Her father was involved in the Ti-betan uprising of 1959 and died in prison several years ago. Her husband was partof the Khampa resistance in eastern Tibet, but was captured and imprisoned in1957, and reportedly died of starvation with his compatriots sometime later. Shehas been subjected to a series of punishments and humiliations since that time: shewas given housing next to the toilet, which she was not allowed to use; she was notpermitted to work; and she had her livelihood, an old sewing machine importedfrom India by her late husband, confiscated and given to a work unit, where sheherself eventually went to work. Her son has not been allowed to join a monastery,and both now survive through begging. They have sold all of their remaining pos-sessions and are now desperately poor. For political reasons largely outside oftheir control, the usual forms of socioeconomic security promised by the socialiststate are not available to this family.

In a few cases, political events witnessed or experienced personally are re-lated explicitly by informants to the onset of their symptoms. Drolma, a young stu-dent at Tibet University, is such a case:

Drolma (age 22) presents symptoms of dizziness and headaches, accompanied byinsomnia and bad dreams. Her symptoms began, she says, three weeks before thevisit when she looked out her apartment window and witnessed a monk beingbeaten by police. After being knocked bloody and senseless, the monk wasdragged into a waiting van and driven off. She has not been able to avoid thinkingabout it since, and her mind "seems out of control," thinking over and over aboutthis obviously distressing event.

Table 1 summarizes the quantitative data on these rlung cases and a matchedcomparison group. About a quarter of the rlung sufferers related their condition ex-plicitly to political issues, framed principally as Chinese oppression and loss of Ti-betan autonomy, witnessing beatings and demonstrations, or personal experienceswith state discipline or terror. Family problems, especially problems with children,the alcoholism of a family member, and chronic unemployment of family mem-bers were presented as determinants of rlung symptoms by 37 percent. Proximatecauses related to strong emotions and/or failure to manage such emotions werecited as significant by 27 percent.

Table 2 presents the results of a simple and straightforward epidemiologicanalysis of the themes presented in the case studies above. In comparing rlung suf-ferers to a non-rlung suffering clinical sample matched by age and gender, it is pos-sible to appreciate the nature and potency of the social and economic risks thatarise in segments of the Tibetan population by virtue of Chinese modernizationprograms (discussed further below). The odds of having a rlung diagnosis in thisparticular study increase more than four-fold for those who have had experiencesin China or who are working in settings where Han Chinese hold many, if not most,of the supervisory positions. The risk increases over two-fold for those with a "pro-fessional" occupation or those who mentioned in their interviews that they had se-rious economic problems.5

Physicians' interpretations of rlung etiology and epidemiologic distributionare, as noted, often consistent with the epidemiologic perspective presented here.Physicians tell us that the prevalence of rlung, while always high, has increasedwith "modern social changes." Many cite the turmoil of*the cultural revolution as


TABLE 1Characteristics of individuals diagnosed with rlung imbalance, compared with

"controls," Lhasa, 1991-1993.

Characteristics

MenWomenMean Age

Marital statusMarriedSingleWidowed/divorced

Mean years of state educationMore than 6 years of education

Primary rlung diagnosissNying-rlungSrog-rlungTrak-rlungOther rlung

rLung Cases(N = 41)

202146

68%17%15%4

38%

42%20%22%16%

Controls(N = 38)

19%19%41%

68%21%11%2

18%

N/A

Chronicity of primary diagnosisOne year or less 32% 42%More than one year 68% 58%

Government or high-level work, 29% 13%unit administrative work

Experiences in China, in Army, in 46% 16%predominately Chinese work-unit

Unemployed 10% 11%Economic problems 27% 16%

having produced a near epidemic of rlung illness in the late 1960s and early 1970s.About one-half of the physicians identified social causation as primary to rlungdisorder. The following factors were the most frequently cited: rapid socialchange, the trauma of the Cultural Revolution and similar events, poverty ormoney worries, job problems or frustrations stemming from career immobility, an-ger and frustration over the current political situation, disappointments with chil-dren and other family members, and arguments and fights in the family.6

Other physicians expressed models of causality that emphasized Buddhistprinciples regarding the suffering that derives from attachment. These were expla-nations that emphasized individual psychological/emotional states that producedthe bodily symptoms of rlung such as anger, sadness, fright, and grief. Some notedthat rlung imbalance is a problem related to "narrow mindedness" or failure to"control the mind properly." That is, people who are inflexible, who in effect can-not cope, are most likely to develop flung.


TABLE 2Epidemiology of rlung: case-control analyses.

Cases = 41; Controls = 38 (matched by gender).

Characteristics Odds Ratio 95% Confidence IntervalsExtensive experience in China or 4.61 1.44-16.14*with Chinese in work situationsSignificant economic stress, lack 1.96 .64-6.32of advancementAt least a lower middle school 2.71 .78-9.71educationGovernment or work-unit 2.73 .86-10.99administrative position

* Statistically significant

In observations of 718 clinical exchanges conducted in 1991 and 1993, someform of rlung imbalance was the most commonly given diagnosis (18.2 percent)followed closely by the general categories of stomach ailments and "infection" (17percent each). The proportions of rlung patients seen were relatively consistentfrom one outpatient context to the next, with slightly higher proportions of rlungfound in urban areas and inpatient hospital settings. In 1993 we conducted twoseparate censuses of the Tibetan inpatient hospitals in Lhasa and Tsethang. Of allthe patients admitted, 22 percent had some form of rlung diagnosis. The averagestay for all patients treated at the Mentsikhang inpatient hospital is three months;our data showed that rlung patients stay a bit longer than this. The higher numbersof hospitalized rlung patients and the longer average stays of such patients is con-sistent with physicians' beliefs about the seriousness of rlung.

In the rlung cases we observed in both in- and outpatient settings, it is strikingto note the apparent trivializing by physicians of the concerns expressed by pa-tients. In this highly rationalized medical bureaucracy, where quantitative aspectsof patient encounters loom ever larger as justifications for state support and legiti-macy, physicians barely have time to get beyond the most superficial level of inter-action. With lines of patients snaking out the door, and many witnessing, indeedlistening intently to the encounter, the physician can do little except focus on theimmediate and individualized problem and apply the material "magic" of themedicines (van der Geest and Whyte 1989). This raises the problem of "medicali-zation," the transformation of problematic emotions and social disorders into sim-ple individualized problems containable by diet, herbal medications, and rest(Scheper-Hughes 1994). Yet there is widespread sentiment among lay people andphysicians that rlung is, at least in some form, a political consequent. The complexof proximate and remote causes specific to an individual narrative seems easilytransferable in general discussion to political discourses of how Chinese politicalhegemony causes Tibetans to suffer. Consider the following statements, takenfrom interviews with physicians and Tibetan lay people (non-sufferers of rlung):


Rlung is caused by the social situation. It is not fair or balanced, and yet people arenot free to do anything about it, so now everyone, young and old, has rlung. If yousee an official beating up local people, it causes pain, because there is nothing youcan do about it. It is like trying to lift the sky with one finger. One person can't doanything, and so they get pain in their body. [36-year-old male carpenter, Lhasa]

Great sadness and anger will cause rlung. Most people today have rlung becauseof the nature of society. These are very tumultuous times. Rlung used to be foundonly among old people. Now it is everywhere. It is a result of social immobilityand frustration arising from no freedom of movement. All Tibetans have prob-lems with rlung because they are not able to move about freely. [35-year-old malebureaucrat, Lhasa]

Rlung [is] more common nowadays because Tibet is no longer free. The Chinesegovernment is the government of rlung. The Chinese government makes peopleunhappy, and so rlung must be more common.... Tibetans have rlung becausethey are not free. [46-year-old male physician, Lhasa, cited in Janes 1995:31]

Rlung is common today because of the many changes in society and ways of life.It is most common in the city. People in the countryside do not think about the fu-ture or the larger picture, they only think about immediate things. They also havelittle education. Education improves one's awareness of the world. Seeing the bigpicture opens up people to attachments, worries, desires, and so forth. They aremore likely to develop a rlung imbalance. [56-year-old male physician, Lhasa]

It is tempting to read these statements as revealing rlung as a "medicalweapon of the weak" (Scheper-Hughes 1994; Scott 1985). However, the complex-ity and multiple layering of rlung etiologies in popular as well as professional dis-course, the highly flexible and fertile symbolic ground provided by rlung in apurely Tibetan cultural sense, and an epidemiologic profile suggesting that it is notnecessarily those with the least power who experience rlung argue against such asimplistic position. Following Ortner (1995), I suggest that Tibetans, as the subal-tern Other in this context, are not a unitary group. Internal divisions and tensions inTibetan society exist, many of which are class-based and predate Chinese contact.To assume that all Tibetans are alike is to dissolve these multiple divisions into aunitary subject and thereby miss the complexity that characterizes Tibetan re-sponses to their current political and economic situation. As an alternative, I directthe reader's attention to the details of the epidemiologic distribution of rlung: it is adisorder not of the weak, but of those attempting, in many cases, to be upwardlymobile. It is not a matter of political oppression as much as it is the denial of prof-fered equal rights to participate in China's rapid economic modernization on thebasis of ethnicity. Rlung in an epidemiologic sense is about the denial of justice tosome in a social and economic context that champions social equality. It is not dis-similar to so-called disorders of social change or "modernization" found world-wide (Christakis et al. 1994).

Yet what can we make of statements made by physicians and lay people alikethat certainly have the potential for politicizing rlung? One clue may be found inthe remarks of one of the physicians cited above: Tibetans, with increasing educa-tion, increasing awareness of the outside world, and increasing contact withcosmopolitan representations of the. Tibet question, are opened to new images ofthemselves. It was quite clear in many of our interviews, particularly with non-

Todd Marek


sufferers, that many Tibetans describe rlung in social and political terms, and to ar-ticulate such descriptions in the language of oppression is part and parcel of theWestern-Tibetan engagement—that is, to talk about personal or individual free-dom. To fully understand the multiple meanings and the political implications ofrlung, it is probably best to distinguish rlung imbalance as a diagnostic category,with a particular set of epidemiologic characteristics, from popular rlung dis-courses. Such discourses shape the polysemantic character of rlung in such a wayas to incorporate political ideas. Often filled with anti-Chinese and pro-inde-pendence rhetoric, rlung discourses are an articulation of imagined lives made pal-pable by the now pervasive cosmopolitan representations of a suffering Tibet.Epidemiologically, rlung is best characterized ironically as a disorder that stemsfrom the failure of the socialist promise. Popular rlung discourses, however, tendto frame rlung disorder as oppression by the socialist demon. To examine thesources of this contradiction, I turn to a consideration of the modern politicizationof everyday life in Tibet.

Ironic Compromises: Dharma Bums, Chinese Modernity, and Body Politics

There are a number of cultural players on the scene in modern Tibet, particu-larly in touristed Lhasa. Each deploys a distinctive representation of Tibet and Ti-betans, and each has a certain power to affect the local contexts in which daily lifeis conducted. On the one hand are the various institutions of the Chinese state thathave exercised direct control over Tibet since the 1950s. On the other are the multi-tude of individuals, interest groups, and organizations on the global scene that ex-ert a far more diffuse, but increasingly important, influence over Tibetan life andcultural identity. In this mix are Western tourists, who have a certain stake in main-taining an exotically religious Tibetan Other, Tibetan refugee communities and theTibetan government-in-exile, who find in Western exotic yearnings a voice fortheir own political agenda, and a block of right-wing Western political ideologueswho see in a certain kind of Tibetan suffering a useful way to demonize China.7Held firmly in the sway of these lines of interest and power are the Tibetans, hardlya homogeneous lot, who may struggle at a more fundamental, and, to the West atleast, poorly understood level for economic and social justice. As ourepidemiologic analysis shows, in the most simple terms, rlung represents the un-successful outcome of these struggles. How it is interpreted and represented by pa-tients, physicians, and, of course, anthropologists, is, however, in many ways aconsequence of the wider, largely non-Tibetan representational interests, each witha stake in constructing a different kind of Tibet and proposing a certain kind of Ti-betan.

Western concern with the "Tibet Question" has revolved principally aroundreligious and cultural expression; the stake is apparently in preserving aculturallydistinct and "authentic" Tibet untainted by the socialist modernity proffered byChina (Adams 1996b). This Westernized version of Tibet is often adopted and ex-ploited by the exile government in Dharamsala, India. A particularly illustrativeexample can be found in the conflict several years ago over the recognition of thereincarnation of a senior religious figure, ostensibly a matter with little real politi-cal importance. In 1995, the exile government in Dharamsala and the CommunistParty leadership in Beijing engaged in a heated debate over the reincarnation of the


Panchen Lama. In the end, the Party aggressively repudiated the Dalai Lama's rolein this affair and named its own reincarnation. Reportedly, the selection of the newPanchen Lama was subject to the final approval of the state council and the per-sonal endorsement of Li Peng, a principal of the Chinese Communist Party. Thus athoroughly atheistic, Marxist leader, associated by the West with the violent sup-pression of the Tiananmen uprising and in setting China's hard-line domestic pol-icy, has been thrust by these events into the role of Tibet's senior religious author-ity, which, were it not for the dire human consequences that such action portends,would be a delicious piece of post-modern irony.8

Why the state intervention? The political events surrounding the selection ofthe Panchen Lama are a culmination of recent efforts to repudiate the government-in-exile and attack the most internationally visible elements of Tibetan culture. It isthe most critical signal to date, in fact, that Beijing has chosen to abandon the re-form policy and promises of autonomy it made to Tibetans in 1980 and to turn backto the heavy-handed domestic policies it had promulgated in Tibet in the post-Cul-tural Revolution decade. Most significantly, the decision to repudiate formally andpublicly the Dalai Lama's cultural authority is indicative of China's bristling sensi-tivity to an increasingly vocal international community that is strongly invested ina culturally "authentic" Tibetan autonomy, an autonomy that for most—travelers,human rights activists, and anthropologists alike—is exemplified principally in thepractice of Buddhism.

Arguments over who has the authority to validate a reincarnation, a matterwhich to all appearances has little real political significance, thus represents deeperand more fundamental representational conflicts over the status of Tibetan culture.Playing politics with six-year-old boys is not just a capricious response of a para-noid regime (although this adjective may be appropriately applied in this case), butthe culmination of half a century of troubled Han Chinese and Tibetan relations,failing economic reforms, uncertainties created by the rapidly shifting sands ofChina's ethnic policy, and a shrill and escalating argument with the West over hu-man rights (Goldstein and Beall 1991; Mullin and Wangyal 1983).

This latter argument has driven issues of economic and social justice, just theproblems that Tibetans articulate on a day-to-day basis, and which, as I demon-strate, comprise the modern epidemiologic determinants of rlung disorder, to themargins of the debate. In fact, the political role of religion and religious institutionsin Tibet has been largely sustained by the increasing stature of the government-in-exile and, more importantly, a groundswell of support from the West (Goldsteinand Beall 1991). The growing popularity of Buddhism among the middle and up-per classes in Europe and North America, residual fascination with the "Shangri-La" myth (Bishop 1989), and the popularity of the Nobel Prize-winning DalaiLama, a figure with charisma and a quiet, wise charm that plays well in the West,has resulted in a crystallization of world opinion around issues of religious free-dom in Tibet, which is conflated by many Westerners with human rights and socialjustice.9 Western visitors to Tibet regard the monasteries as the font of traditional-ism, Tibetan culture, resistance, and sites of the most grievous human rights viola-tions.10 The Chinese have likewise maintained an interest in Tibetan religion, butthis is an interest driven principally by the desire to package and commodify ele-ments of Tibetan culture for sale to Westerners (Adams 1996b). Visits to what re-mains of the great monasteries around Tibet, now primarily state museums, are part


of the standard package tour. The fact that, although the state has tried to controlthe monasteries, they remain a locus of nationalist sentiment is, however, not loston the more independent young European and North American travelers, invari-ably pro-Dalai Lama, who stay, when permitted, in the Tibetan hotels in downtownLhasa. Among this group, conspiratorial visits to monks and monasteries, whereletters, photos, and occasionally documents related to government policy arepassed on for conveyance to Dharamsala and the West, are discussed with greatrelish.11 Such exchanges are the stuff of evening meetings in hotel courtyards andsmall Tibetan restaurants, with everyone feeling (with some naive delight, I sus-pect) part of "the resistance." They fulfill in a direct way the desire for a Tibetanauthenticity which rests within its once great religious institutions, as well as for adesired engagement with an Other that is suffering at the hands of a state bent onexpunging the influence of religion from daily life. The interplay of Western tour-isted desires around religion, independence, and Tibetan resistance results in arelative lack of engagement with those local issues that, for many Tibetans, areequally, if not more, pressing: lack of employment, perceived discrimination, cor-ruption of Han officials, and excessive government control over aspects of every-day life. Beyond the Western gaze, young Tibetans may be just as likely to articu-late desires for landcruisers, cellular telephones, and nights filled with karaoke asthey are to speak of dharma, freedom of religion, and the Dalai Lama (Adams1996b).

Western desires for an authentically religious Tibet recognized and exploitedby the Chinese for economic and political benefit create the potential for a Tibetanreligious participation in which nationalist resistance is just as great a motivationas is the earning of Buddhist merit. The past several years have seen China recog-nize this problem and take a number of steps to deal with it directly. The strong po-sition it took on the reincarnation of the Panchen Lama is evidence of the currentapproach.12

Perhaps ironically, religious expression might not have become so politicallycontentious if the economic reforms initiated in 1980 in Tibet by Chinese PremierHu Yaobang had been sustained. Tax relief and private ownership programs initi-ated at this time resulted in short-term increases in real income; however, these ad-vances have proven to be largely unsustainable. Subsidies to raise output initiallyfocused on state enterprises, rather than the rural, agricultural sector, benefiting theChinese cadre and immigrants who are disproportionately represented in such en-terprises. Furthermore, several writers have acknowledged that a substantial por-tion of these subsidies were invested in losing propositions (Sharlho 1992). Be-cause a large number of the employees of state enterprises are Chinese, a massivesubsidization in the form of extra benefits and wages is required to keep them in Ti-bet.

Two other factors impede economic development in Tibet. A heavy burden ofadministrative costs for the bureaucracy has siphoned off substantial portions ofstate funds that otherwise might have gone into subsidized rural projects. The Chi-nese duplicated in Tibet the governmental structures they had implemented in themore densely populated center of China, resulting in a per capita greater number ofgovernment staff at all levels of the bureaucracy than anywhere else in China. Evenmore money has been spent on what is termed Capital Construction Investment.These dollars, intended in part to aid development of transportation and


communication infrastructures, are also used for the construction of public build-ings. Since 1985 the majority of these funds have gone into nonproductive con-struction of office and government buildings in Lhasa. Today, Lhasa has office andmeeting space on a per-bureaucrat basis that exceeds the rest of China (Sharlho1992). The solution to these top-heavy impediments is, unfortunately, problematic.Bureaucracies are always difficult to dismantle; in Tibet this is doubly the case be-cause the majority of government officials and office staff are Chinese, and theywould either need to be absorbed into the underdeveloped local, industrial sector,or repatriated back to China.

While the development of rural agricultural and urban industrial sectorswould have provided opportunities for the Tibetan population, the infusion of sub-sidies into bureaucracy, already Chinese-run enterprises, and building programstended to favor the Chinese, and indeed, created the conditions for the rapid immi-gration of thousands of Han Chinese into Tibet between 1985 and the present. Inonly three months in 1985 alone, more than 60,000 official Chinese workers en-tered Tibet (Sharlho 1992). With a burgeoning Chinese population, demand forconsumer goods, Chinese food, and services far outstripped supply, creating theeconomic incentive for a wave of volunteer migration to serve immigrant Hanneeds (Goldstein and Beall 1991). This demand, coupled with reforms to thehousehold registration policy and various government incentives designed to fa-cilitate migration and small business development, has brought a huge influx of en-trepreneurs and "penny capitalists" into Tibet from all over China. Tibetans havenot been well positioned to take advantage of these entrepreneurial activities. Be-cause much of the business is controlled by networks of socially affiliated Chinese,Tibetans, with limited entrepreneurial skills, sometimes poor command of the Chi-nese language, and subject to continuing ethnic discrimination by Chinese officialsand employers, are virtually shut out of the subsidy-stimulated consumer econ-omy. A friend and colleague in Lhasa who has monitored this situation for yearsestimates that between 75 and 90 percent of all new business licenses are issued toHan immigrants. Today in Lhasa, the trade in Tibetan traditional ceremonialscarves and other ceremonial paraphernalia is controlled by Chinese merchants. Aphoto of the Dalai Lama, considered ironically by Western travelers to be a politi-cal symbol of a "free Tibet" and therefore carried into Tibet and given surrepti-tiously to monks in the monasteries, may be purchased in front of the importantJokhang temple in Lhasa for approximately 25 cents from a merchant who is al-most certain to be a Han immigrant.

The present local government has been loathe to intervene in the economy ina fashion that would open up access to jobs and other opportunities for Tibetans.After 1980, attempts to bring down officials appointed during the Mao era weresabotaged by the entrenched local leadership, composed principally of a militaryand pro-Chinese Tibetan cadre who rose through Party ranks during the CulturalRevolution. In 1985 a minority leader (from the Yi nationality) was appointed tolead the Party in Tibet, but he was never trusted or supported by those below him,and could thus never fully implement Beijing's policies. Local leadership couldnot be replaced; there were no Tibetans that Beijing trusted that could be appointedto Party leadership (Sharlho 1992). The extent of political reforms in Tibet werewindow dressing appointments of "rehabilitated" former Tibetan government offi-cials to non-Party government positions, particularly the TAR People's Political


Consultative Conference and the TAR People's Congress. While Tibetans may re-spect the public positions these non-Party leaders may take on certain issues, theyare not generally respected by the people, and are seen as handmaidens of Chinesepolicy. At present, all indications are that the TAR administration, supported by anincreasingly conservative and hostile leadership in Beijing, is resorting to some ofthe more severe political and economic means to suppress "splittist" attitudes inTibet since the Cultural Revolution.

With no access to economic opportunity and little chance for meaningful po-litical participation, Tibetans are becoming increasingly marginalized, in essenceforced to articulate their needs and their resistance to Chinese policies in the con-text of those Tibetan institutions that remain functioning: religion and medicine.With increasingly strident Chinese rhetoric on religion as a source of "splittism,"moves to more directly control the monasteries and monastic education, and the re-cent appropriation of reincarnation politics by the Party, medicine may remain theonly institution in which Tibetans can articulate, through the language of the body,dissatisfactions over modern life that are not interpreted as signs of nationalism.But what happens when the West, including Western anthropologists, turn theirgaze on medicine? What then will be the potential of medicine to safely containsuch sentiments? Rlung, with its polysemantic and fundamental tantric Buddhistattributes, is in many ways a perfect vehicle for expressing the suffering that someTibetans certainly experience under the conditions sketched out above. It is also auseful means for articulating the ironic compromises between the life they experi-ence and that which is held out to them as possible by China, Western tourists anddharma bums, and, of course, anthropologists. In the ironic spaces opened up byChinese and Western modernities, rlung represents more than lessons about thesuffering that stems from a failure to appreciate impermanence; it is a politicalstatement about the Chinese corruptions of legitimate desire.

Conclusions: Whose Corruptions?

Rlung is an idiom of distress (Nichter 1981). It is developed, via the produc-tive work of culture, as a statement of personal and social suffering that reflects amix of classical Buddhist ontology with the modern politics of Tibetan identity. Tolay people, this identity develops in part out of a sense of ironic compromise, an ap-prehension that day-to-day experience corresponds poorly with both Western andChinese representations of what Tibet and Tibetans are or should be. Lack of ac-cess to social and economic opportunity places Tibetans, in an epidemiologicsense, at risk. The physicians and institutions of Tibetan medicine, off the mainstages of political conflict, offer, in effect, safe havens to those who suffer rlung.Rlung provides an idiom for expressing the distress that might otherwise be seen aspolitical resistance, a dangerous play to a suspicious audience in these most dan-gerous of times.

The politicization of rlung is likely, though not necessarily, a contemporaryact. Evidence from studies in India suggests that disorders of the humor rlung,given its centrality to Tibetan constructions of the integrated principle of mind,body, and society, are subject to causal constructions that foreground a number ofprincipally social factors. What is happening in Lhasa today is simply an expan-sion of this particular tendency using a language that reflects the realities of


modern Tibetan life and of Tibetan encounters with Chinese attempts at social andeconomic transformation, but it is also a language which incorporates Westernideas about Tibetan suffering. When a prominent physician pronounces that the"Chinese government is the government of rlung," is he articulating common eth-nomedical discourse, is he playing to the Western anthropologist, or is he, throughthe processes of cultural work in this radicalized context, participating in thereshaping of rlung etiology so that it reflects transnational desires? This latter pos-sibility brings forth two important and related questions: to what extent do Westerndesires for a Tibetan Otherness, rooted principally in representations of Buddhistspirituality, create, equally, a desire for a certain kind and shape of Tibetan suffer-ing? To what extent do Tibetans, caught unquestionably in a situation of ethnic andsocial conflict, appropriate such desires in constructing their suffering, for us, theWesterners, the anthropologists interested in things cultural?

Rlung discourses, traditionally aligned with classical Buddhist principles re-garding suffering, appear in the process of being shaped by the cosmopolitan rep-resentations of a suffering Tibet, where suffering derives most vividly from a de-monized Chinese state that fails to permit practice of religion and free culturalexpression and resorts to imprisonment, torture, and other forms of bodily suffer-ing to enforce its will. Tibetans, for whom state oppression, and even imprison-ment and torture, are palpable aspects of day-to-day life, but who are rooted in eth-nic conflict, structural discrimination, and an absence of economic justice, mayseize on cosmopolitan constructions as one way to give some voice to their suffer-ing. A Tibetan medical system, a legitimate and highly rationalized branch of theChinese social service bureaucracy, provides an opportunity for some individuals,including some physicians, to articulate such suffering in forms that represent onlyminimal challenges to a state that is only too willing to resort to violence and im-prisonment. But the embodiment of suffering in this highly politicized context sug-gests that there is currently in process the hatching of a highly ironic subplot to Ti-betan medical pluralism. Tibetan medicine's shaping of rlung as a politicaldisorder, framed in Buddhist terms, may join with the cosmopolitan cultural repre-sentations of modern Tibet in a kind of radical ethnomedicalization to deflect andchannel social criticism away from its roots in day-to-day economic injustice.

If this process is completed, it will be a critical development. The Chinese re-sponse to Western critics of human rights in China is simply that individual rightsmust be secondary to the primary principle of economic equality, that issues of re-ligious freedom or cultural autonomy must not stand in the way of social advance-ment through economic development. As rlung discourses become more alignedwith Western perspectives on human rights in China, that is, as being rooted in thelack of individual freedoms and suppression of free religious expression, they willdeflect criticism from the critical economic issues that are precisely the most im-portant and sensitive to Tibetans and Chinese alike. In this confluence of transna-tional cultural forces and Tibetan suffering emerges an imagined life that is crystal-lized in stories about rlung. In these stories, the discourses of Western humanrights, fantasies of Shangri-La, and the global politics of human rights coalesce in aculturalist portrayal of suffering that may overlook, indeed mystify, the conse-quences of China's social and economic program on the plateau.


NOTES

Acknowledgments. The research upon which this article is based was funded in part bya grant from the National Science Foundation, BNS-9005811, and Faculty Grant and Fel-lowship awards from the University of Colorado-Denver. I wish to thank Vincanne Adams,Susan Blum, Kitty K. Corbett, and Geoffrey Samuel for their constructive comments on ear-lier drafts of this paper. I am particularly grateful for the valuable assistance of CherylReighter, Nawang Sherap, and Mahmoud Hosseini in collecting the data upon which this pa-per is based.

1. I have chosen to use here the classical transliteration system proposed by Wylie(1959), rather than alternatives (e.g., Samuel 1993) for the simple reason that it is perhapsless confusing to nonspecialist readers (e.g., confusing rlung, the ethnomedical category,with lung, the English term for an anatomical organ).

2. The research project upon which this paper is based was carried out over severalfield periods in the Tibetan Autonomous Region (TAR) of China in the roughly six years be-tween October, 1988, and August, 1994. Most of the interview data on rlung illness werecollected between July and November of 1991, and March and April of 1993. The primarygoal of the research was to conduct ethnographic research on Tibetan medicine as it was thenbeing practiced in the Chinese political and economic context. The research was sponsoredby the Tibetan Medical Hospital in Lhasa, which provided housing and logistic support, and,less directly, by the Tibet Autonomous Region Health Bureau. The research design includedcase studies of individuals seeking treatment at Tibetan medical facilities, interviews withTibetan physicians and government (Health Bureau) officials, and observations of clinicalinteractions. A random sample of 56 patients stratified by age, presenting symptoms, and in-stitutional locus of treatment were interviewed; these patients were drawn from an observa-tional exercise in which 718 clinical encounters in Tibetan medical facilities (rural andurban) were recorded. Forty practitioners of Tibetan medicine provided their career historiesand training experience, and 20 key informants, principally senior officials in the Health Bu-reau, the Tibetan hospital, and the Tibetan Medical College, provided information on healthpolicy, the history of Tibetan medicine more generally, and the professional explanatorymodel of rlung causation and treatment. In the context of the more general ethnographic pro-ject, rlung emerged as an important category of sickness that individuals, particularly practi-tioners, were eager to talk about. Follow-up interviews and case studies were developed atthis point with 42 individuals who were diagnosed by the formal medical system as sufferingfrom rlung. Additional in-depth interviews with ten Tibetan medical practitioners consid-ered "experts" on rlung were also completed.

The rlung case studies presented here were collected in the towns Lhasa and Tsethang.Lhasa is the capital and largest city of the TAR, with a Tibetan population of about 50,000. Itis here that the major Tibetan medical hospitals and training centers are located. Althoughthe majority of the patients at the Tibetan medical facilities are Lhasans, a substantialnumber of patients travel some distance to seek treatment in Lhasa. Lhasans are also ex-posed with greater intensity to the rapid social changes occurring in the region and are morelikely to articulate these as causal forces in their lay explanatory models of rlung disorder.Thirty-four of the 42 rlung cases collected were from the Lhasa area. The remaining fourwere collected in Tsethang, a small town and capital of Lhoka prefecture (Tibetan popula-tion of about 25,000), southeast of Lhasa in the Yarlung valley.

3. For general materials on Tibetan medicine, consult Clifford (1984), Finckh (1978),Parfionovitch et al. (1992), and Rechung (1973). In addition, the Tibetan Medical Centre inDharamsala, India, currently publishes a periodical as well as a number of topical publica-tions on various, primarily theoretical, aspects of Tibetan medicine. For a good, general in-troduction, the reader is referred to the work by Tsarong et al. (1981).

4. There has been some reappearance of physicians in private practice; nearly everycounty has a few "celebrated" practitioners who operate outside of the government sphere.


The Swiss Red Cross operation in Shigatse (Xigaze) is also involved in training traditionalphysicians and sending them to remote areas of the TAR (and elsewhere) where they will,ideally, be able to practice without government inputs.

5. The sample size here is rather small. As the confidence intervals indicate, only thefirst variable—contact with Han Chinese, and so on—is statistically significant. The re-maining odds ratios show positive trends, but cannot be assumed to reflect anything otherthan the chance introduced by the small sample.

6. It should be noted that family problems, in particular unemployment of youth, alco-holism, and violence, are linked by Tibetans to the current economic situation where thereare few opportunities for Tibetans, particularly Tibetan youth just out of school. Many ofthese unemployed young men and, to a lesser extent, women, can be found crowding thesweet tea shops in central Lhasa. As day shifts into evening, the drinking of sweet tea shiftsto cheap chang (Tibetan beer) and arak (distilled liquor). Alcoholism is becoming a seriousproblem.

7. The Tibet issue has attracted a number of conservative politicians in the UnitedStates and undoubtedly elsewhere. Senator Jesse Helms of North Carolina, notable for hissocial conservatism, has espoused the views of the Dalai Lama's government-in-exile. TheColorado Friends of Tibet organization is led by a conservative American lawyer.

8. The control of religious institutions and expression by China has continued to accel-erate. In the November 13,1996 issue of the official Tibet Daily, the government called for"large-scale" reforms of existing religious policy in Tibet, noting that "Buddhism must con-form to socialism, not socialism to Buddhism." The signed article stressed that all temples,monks, and nuns must "conscientiously accept" the leadership of the government and partyat all levels (World Tibet Network News 1996).

9. The existence of an internationally prominent exile government brings a new di-mension to the Tibet question, which makes it distinct from the issues faced by other minor-ity nationalities. Sharlho reports that, while he was a student at the Central NationalitiesInstitute, fellow Mongolian, Uighur, and Kazak students would often say, "If only we had a'Dalai Lama' on the outside like you do, then Beijing would care about us, too" (Sharlho1992:48).

10. A review, for example, of the human rights information put out electronically bythe Office of the Government in Exile in London typically features lists of monks and nunsthat have been arrested, purportedly tortured, or who have died in prison.

11. Recently, for example, the Tibet Information Network in London published atranslation of a document regarding the mandatory "reeducation of Sera monks," presum-ably passed by a monk to a foreign visitor and smuggled out of Tibet.

12. The Party newspaper, Renmin Ribao (People's Daily), still cautious on the subjectof the Dalai Lama, has acknowledged the relationship between religion, world opinion, andTibetan nationalism:

Centering on the work of searching for and confirming a reincarnated child for thePanchen Lama, we have waged a serious political struggle against the Dalai Lama.Supported by certain foreign forces, the Dalai Lama created various obstacles to thework of searching from the beginning. After repeated failures, he risked everything ina single venture and publicly and arbitrarily announced that he had confirmed a "soulboy" . . . this struggle is a continuation of our struggle against the Dalai Lama clique,which has lasted for more than 30 years. The essence of the struggle is whether oneshould protect the dignity of the law, the interests of the people, the unity of various na-tionalities, and the unification of the country, or violate the state law, hurt the people'sinterests, create splits among people of different nationalities, and sabotage the unifi-cation of the motherland... we should point out that the Dalai Lama merely relies onhis religious influence; however, some people in the world are using the Dalai Lama asa tool for opposing China and interfering in China's internal affairs in order to achieve


ulterior motives.... A qualified religious believer should, first of all, be a patriot. Anylegitimate religion invariably makes patriotism the primary requirement for believers.One can talk about love of religion only if one is a patriot. [ 1995]

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Accepted for publication May 4,1998

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