Students Name Student Number

Module Module Number Tutor Assignment Title

John Donegan 4356494 MSc, University of Wales / Peggy M Welch MSc Dissertation: An observational study of patients, practitioners and practice in clinical settings offering traditional Mongolian medicine in Mongolia.

The contents of this assignment are entirely my own work in accordance with the College guidelines in the Student Handbook Student Signature

Word Count Not exceeding the word limit stated in the assignment guidelines. See also the Written Assignments section of the Student Handbook

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An observational study of patients, practitioners and practice in clinical settings offering traditional Mongolian medicine in Mongolia.
Abstract This research is intended to provide a basic observation-based outline of traditional Mongolian medicine (TMM) as very little has been written about it in English.

In the absence of written sources, this information has been provided by field research in Mongolia, which involved speaking with practitioners, and observing clinical practice.

The research took place in early June 2011 after having organised a three week stay in Mongolia. During this period I was able to observe practice at the Manba Datsan, monastery hospital, and the Ulaanbaatar Suvilal (Ulaanbaatar traditional medicine sanatorium), to interview a number of practitioners and to supplement my written sources.

The main findings are that traditional medicine as practiced in traditional hospitals and sanatoriums is a pluralistic combination of a Mongolian adaptation of Tibetan medicine (which has its roots in Indian ayurveda), together with Traditional Chinese Medicine (TCM) acupuncture and moxibustion, and also elements of folk practice which preceded both. This is now incorporating Biomedicine into its framework, with patients observed bringing western medical records and diagnoses to consultations, and facilities being provided at TMM institutions for running western-style tests such as x-rays and blood tests.

Literature and interviews suggest that Mongolian adaptations to the traditional Tibetan medical (TTM) canon include the introduction of the concept of diseases caused by external conditions and the categorisation of many diseases into hot and cold (Bold, 2009, pp. 238-239). Extensive use is made of moxibustion for this purpose, although as I was there at the height of summer, it was the wrong time of year to observe this in practice.

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There was a strong presence of Buddhism in all the traditional medical practices I observed. The Manba Datsan is both a monastery and a hospital. The Ulaanbaatar Suvilal is a state-run facility but displays prominent Buddhist iconography and symbology throughout, and numbers of the senior medical and academic staff are Buddhist monks.

The therapies practiced include TTM drug treatment, based on herbs and minerals, TCM acupuncture and moxibustion, bloodletting, bodywork (massage), pulse diagnosis and bloodletting.

Pulse taking is seen as both diagnostic tool and therapy. It shows strong similarities to Chinese-style pulse-taking in some respects, most notably in the use of three fingers on each wrist to take the pulse, and the association of each position with one of the organs. It differs most obviously in the fact that different wrist positions are used for the pulse measurement.

During the course of my observation, I was able to gain some insight into patient behaviour, and self-diagnosis. The most striking thing was the social nature of the consultation process, with patients typically bringing family with them into the treatment room and involving them in the consultation process. This contrasts with typical clinical practice in the UK, where the emphasis on patient confidentiality means that except where children are being treated, friends and family are not usually involved in an individuals consultation and treatment.

My investigations shed light on an ongoing debate on medical pluralism. Many authors, referring to different areas of study, such as China and Tibet, view this as having a detrimental effect on traditional medicine practice. However, my research demonstrates that in Mongolia, pluralism is nothing new, and Mongolia has been adopting, adapting and incorporating new medical ideas since very early times, and indeed pluralism seems 'traditional'. While there's been exhaustive debate in the social sciences about the impossibility of making definite positivistic assertions about social reality, making it impossible to talk in terms of a continuum from non-pluralistic to pluralistic or fully traditional to fully biomedical, and placing what I've seen on that iii

continuum, my observations give an insight into the reality of plural medical practices in Mongolia.

Three weeks of observation added considerably to my understanding of traditional Mongolian medicine, but inevitably could only skim the surface of what is a deep, rich and ancient medical tradition, containing many individual areas that in themselves could be subjects for considerable detailed study.

Acknowledgements I would like particularly to acknowledge the invaluable help, insight, support and assistance of my supervisor, Trina Ward throughout the process of research, as well as from staff at the Northern College of Acupuncture, without which, I would have found it impossible to complete this dissertation.

Tsendpurev Tsegmid at the University of Leeds earns my thanks for helping me in her own time, to learn enough Mongolian to get by. I would not have been able to conduct my field research without her assistance.

I would also like to thank David Sneath at the University of Cambridge for being the inspiration for my research topic as well as for his help in providing contacts in Ulaanbaatar, and Lhagvademchig Jadamba at the National University of Mongolia for moral support and practical assistance while there.

I would also like to acknowledge Damdinsuren Natsagdorj, Lagshmaa Boldoo, Batnairamdal and Joergi Zoll for allowing me to observe and discuss the clinical practice of Traditional Mongolian Medicine while I was in Mongolia, and their patience in answering questions about what they were doing and why, that must, to them, have seemed very obvious. Also I need to thank Irene Manley of the Mary and Martha shop in Ulaanbaatar for her serendipitous kindness in introducing me to Joergi Zoll.

I would also like to thank Dr Kim Tae-Hun for his assistance in clarifying certain aspects of Mongolian blood-letting practice.

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Contents Abstract .......................................................................................................................ii Acknowledgements ....................................................................................................iv Contents ...................................................................................................................... i Figures ........................................................................................................................ii Tables .........................................................................................................................ii 1. 2. Introduction ......................................................................................................... 1 Rationale ............................................................................................................. 2 2.1 2.2 3. 3.1 3.2 3.3 3.4 4. 4.1 Why investigate Traditional Mongolian Medicine? ........................................ 2 Why this is an observational study ................................................................ 3 Traditional medicine, biomedicine and pluralism ........................................... 5 An overview of literature searches on Mongolian medicine .......................... 8 Historical perspectives in the literature ........................................................ 12 Advantages and limitations of ethnography as methodology ...................... 16 Preliminary preparation for the research ..................................................... 20 Learning the language .......................................................................... 21

Literature Review ................................................................................................ 5

Methodology ..................................................................................................... 20 4.1.1

4.1.2 Making contact with the Manba Datsan to secure consent and agree terms 21 4.1.3 4.1.4 4.2 4.3 5. In-country support regarding any language or cultural challenges ....... 22 Planning the direction of research ........................................................ 23

Ethical Issues .............................................................................................. 24 Details of fieldwork ...................................................................................... 24

Observations ..................................................................................................... 25 5.1 The theoretical framework by which practitioners describe, diagnose and treat complaints .................................................................................................... 25 5.1.1 5.1.2 5.1.3 5.1.4 5.1.5 5.1.6 5.2 5.2.1 5.2.2 5.2.3 Arga and Bilig (Yin Yang theory) .......................................................... 26 Chinese five element theory ................................................................. 27 Three element theory ........................................................................... 27 Diagnostic techniques........................................................................... 28 Principles of treatment .......................................................................... 33 Biomedical diagnosis in traditional clinical practice .............................. 34 Religious services for healing ............................................................... 35 Traditional drug therapy ........................................................................ 37 Pulse-taking as therapy ........................................................................ 39

What therapeutic techniques practitioners use ........................................... 35

5.2.4 5.2.5 5.2.6 5.2.7 5.2.8 5.3 5.3.1 5.3.2 6. 6.1 6.2 6.3 7. 8. 9.

External treatments .............................................................................. 39 Moxibustion .......................................................................................... 40 Blood-letting therapy ............................................................................. 42 Acupuncture ......................................................................................... 45 Golden needle therapy ......................................................................... 45 Presenting conditions and how patients describe illness ...................... 46 The socialising of consultation and treatment ....................................... 48

Patient behaviour ........................................................................................ 46

Discussion ......................................................................................................... 49 Reflections .................................................................................................. 50 A reflection on the process of research ....................................................... 54 Implication of findings upon practice, and future research .......................... 57

Conclusion ........................................................................................................ 59 Bibliography and references ............................................................................. 59 Appendix 1: email correspondence ................................................................... 63 10.1 10.2 10.3 10.4 Khii - Wind ............................................................................................... 68 Shar - Bile ................................................................................................ 68 Badgan - Phlegm ..................................................................................... 69 The seven constitutions ........................................................................... 70

10. Appendix 2: The qualities of the three elements and seven constitutions ......... 68

Figures Figure 1 The three elements used in TMM, showing qualities of each, and their relation to Bilig and Arga (Yin and Yang) ................................................................. 28 Figure 2 Eight Medicine Buddha shrine at Ulaanbaatar Suvilal ................................ 36 Figure 3 Physical layout of typical treatment session ............................................... 37 Figure 4 A traditional Mongolian moxibustion bundle ............................................... 41 Figure 5 MBLT equipment ........................................................................................ 43

Tables Table 1 Summary of databases searched and results ............................................. 11 Table 2 Breakdown of consultations observed by age and gender .......................... 25 Table 3 A summary of the qualities of pulses ........................................................... 33 Table 4 Types and qualities of Khii .......................................................................... 68 Table 5 Types and qualities of Shar ......................................................................... 69

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Table 6 Types and qualities of Badgan .................................................................... 70

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An observational study of patients, practitioners and practice in clinical settings offering traditional Mongolian medicine in Mongolia.

1. Introduction Traditional medicine in Mongolia is a field of study that is poorly researched in the West, or indeed, outside Mongolia, or the Inner Mongolia Autonomous Region of China1. A greater understanding of Mongolian medicine could offer benefits to clinical practice outside its land of origin. A greater insight into the reality of technique and practice would also add to the wider academic debates on medical pluralism in Asian and other societies, where traditional medicine and biomedicine exist side by side.

Since little basic information about Mongolian medicine has been written in English, and wholesale translation of sources in Mongolian is not practical, I decided the most useful research method would be to carry out field-based observational research, or in simpler terms, to go to Mongolia and find out for myself.

As my academic background from my first degree in 1985 is social anthropology, I determined to carry out ethnographic-style observational study of patients, practitioners and practice in a clinic practicing traditional acupuncture in Ulan Bator, Mongolia with myself as the observer. This is because ethnography is recognised as an effective research method for defining an issue or problem or system where its nature is unclear in advance of research and also for providing descriptive information in unfamiliar settings. I discuss this in greater detail below (see 2.2 and 3.4)

The aim of this was to provide qualitative information on what actually happens in a clinical setting providing Mongolian medicine. This would shed light on how people visiting practitioners describe their illness, how this matches how practitioners themselves describe and diagnose the complaints, and what therapeutic techniques practitioners use, as well as adding to the theoretical body of work on medical pluralism.
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See appendix 1 for details of personal correspondence with Sneath, Scheidt, Lo and Buell (Jan and Feb 2009)

2. Rationale 2.1 Why investigate Traditional Mongolian Medicine?

There is extensive academic discussion about medical pluralism namely how traditional medical practices and beliefs co-exist with biomedicine in societies where the traditional medicine was previously predominant and biomedicine has been more recently introduced.

This far reaching discussion looks at how concepts such as effectiveness and modernism affect practitioners, practice and patients in these societies. To date, there has been no substantial discussion of how this relates to medicine in Mongolia.

Mongolian medicine is seen as being strongly influenced by Indo-Tibetan ayurvedic medicine (Clifford, 1989), and having derived many of its techniques and diagnostic practices from Tibet, alongside the introduction of Buddhism. Acupuncture and moxibustion are included in the Five Medical Arts practiced by emchis, or traditional healers, alongside bloodletting, massage and hydrotherapy and drug therapies (Munkh-Amgalan & Tsend-Ayush, 2002).

When Mongolia fell under Soviet hegemony in the 1930, traditional medical practices were suppressed by the communist authorities. However, in 1999, the Mongolian government formally adopted a policy to develop traditional medicine (The Mongol Messenger, 2003), and this has led to the re-emergence of the discipline, and the setting up of institutions where it is practiced and taught.

Traditional Mongolian medicine is also practiced in the Inner Mongolia autonomous region within the Peoples Republic of China, which borders Mongolia. The autonomous region was established in 1947. The majority of the population in the region are Han Chinese, with a substantial Mongol minority. Here too, there was a suppression of traditional medicine during the Cultural Revolution, followed by a more recent period of government support and the setting up of teaching institutions (Inner Mongolia Medical College, n.d.). 2

From the start, I have been clear that this would be a preliminary investigation, which would provide qualitative information to help identify some of the issues for more detailed later studies, and thus provide a useful contribution to knowledge, and also, potentially, to my own clinical practice. However, on the specific issue of clinical relevance, it is worth making clear that this study seeks to look at technique and practice, not effectiveness.

2.2

Why this is an observational study

As I will illustrate further in my literature review, there is a lack of research in the West on TMM technique and practice. This information is intrinsically interesting, but I will also argue and demonstrate that TMM is pluralistic in nature and this will help shed further light on an area of significant academic debate. I therefore believe there is a justification for research which provides this sort of information.

To collect this sort of qualitative detail, ethnographic fieldwork, which is recognised as an effective means of gaining descriptive information in unfamiliar settings, seemed the most useful course of action, providing opportunity to make observations in a natural setting. This would be a clinic where these therapies would normally be carried out.

I had considered trying to obtain some useful information by entering into correspondence with an institution providing TMM or transcribing texts provided. However, on consideration and following some preliminary research on methodology, I did not consider this would be as effective as first-hand observation. It is generally accepted that the quality of information provided through observation and participation is greatly enhanced (Leach, 1982) (LeCompte & Schensul, 1999) (Hammersley & Atkinson, 2007), even accounting for the influence of the researcher on the situation observed and the influence, however mitigated, of their own personal and cultural assumptions (Angrosino, 2005).

I also discounted using a formal questionnaire or structured interview techniques. Classical studies by Otto Klineberg on Yakima Indians in North America and by SD

Porteus on Australian aborigines looking at the cultural limitations of IQ tests constructed in this way, indicate that such methods can have an inherent cultural bias which renders them inappropriate outside their original context (Haralambos & Heald, 1980). In addition, in my own research, as the nature of the topic was not clear in advance of the study, a questionnaire constructed in advance of direct observation could miss asking important questions. LeCompte and Schensul recommend ethnography where there is no preliminary clarity about the subject material (1999).

In this type of situation, ethnographers will employ a fairly open-ended approach to their research design, so as not to close off avenues of enquiry that become apparent during the research, or begin by trying to answer overly defined and/or inappropriate questions (Maxwell, 2004). Beginning with a general interest in an area of social or cultural life, they explore, refine and possibly transform their area of interest as the research progresses (Hammersley & Atkinson, 2007).

There is extensive discussion within medical anthropology literature about how sickness and illness and treatment are articulated in non-Western cultures. For my starting point, I took the areas of enquiry articulated by Weiss (1997) and Helman (2007) and which I discuss further in 3.4.

The strengths of my approach is that it provides qualitative data collected first hand at source in a normal setting for the activities being observed. It is also a flexible methodology designed to adapt to unfamiliar circumstances and unclear subject material. I would be making my observations in a study setting which is familiar with the needs of overseas students and there would also be a regular patient clientele.

The weaknesses include a combination of the theoretical and the practical. I discuss the theoretical difficulties in greater detail in 3.4, but relate primarily to well-reasoned theoretical objections to making positivistic, generalizable assertions in the area of social phenomena.

Practical difficulties include difficulties of access, including possible reluctance of some patients or practitioners to be involved. There is the barrier to understanding 4

created by reliance on the services of a translator to understand what is taking place. There are the costs of travel and accommodation, and these also involve difficulties in checking or re-checking information after the period of fieldwork had ended.

3. Literature Review 3.1 Traditional medicine, biomedicine and pluralism

Mongolian medicine constantly adapts to influences from other medical systems both other Asian medical systems and biomedicine. Its unique historical and political context will inevitably result in a variety of practices adapted to the local context of practice, leading to the question of what is Mongolian about Mongolian medicine.

This is a discussion which has been extensively conducted with reference to other traditional medical systems in Asia and elsewhere, though not hitherto in Mongolia itself. Nevertheless, many of the issues debated have a resonance with the situation in Mongolia.

It is perhaps useful to define terms at this stage to specify what is meant by medical pluralism in this context. The Encyclopedia of Medical Anthropology definition reads: in contrast to indigenous societies which tend to exhibit a more-or-less coherent medical system, state or complex societies have an array of medical systems a phenomenon generally referred to by medical anthropologists, as well as medical sociologists and medical geographers, as medical pluralism. (Ember & Ember, 2004, p. xxxv). It is worthwhile observing here that biomedicine itself can be seen as a plural rather than a singular entity, as ethnographers such as Annemarie Mol have argued (2002). Fbrega defines it as follows when individuals are able to distinguish between more or less separate ways of explaining and handling the medical, ways that differ in terms of basic propositions, explanatory mechanisms, procedures, and personnel, one can begin to speak more comfortably of medical pluralism. (1997, p. 12)

However, I have adopted the more recent definition used by Shih, et al for its simplicity and brevity, namely: [medical pluralism is] the employment of more than one medical system or the use of both conventional and complementary and alternative medicine (CAM) for health and illness (2010, p. 1)

This pluralism can be seen as negative. Some authors such as Neupert (1995) explicitly link biomedicine with modernity and TMM with ineffectiveness. He discusses how in his view, early mortality rates in Mongolia are linked with a view of biomedicine as essentially curative and the continuing high rate since modern technologies were introduced are because people continue to believe in traditional therapeutic patterns and self care (p. 35) rather than adopting these elements from biomedicine also.

Janes (1995) in talking about traditional Tibetan medicine (TTM) sees the integration of traditional medicine into the state health bureaucracy as having led to its transformation and conceptual reformulation. While there have been periods of promotion and suppression by the Chinese state, it is today seen officially, though with some internal dissension, as an inexpensive and more efficiently deployable system of health care than more expensive, principally biomedical alternatives. (p. 24). However, in the process, he describes this has led to TTM becoming disembedded from local contexts of practice.

This has the practical effect that medical care and training are transformed so that they are consistent with the epistemological, symbolic and sociologic attributes of biomedicine (pp. 24-25). This means that practitioners will often diagnose illness in terms of biomedicine instead of TTM (for example, diagnosing an illness as a disease of the gallbladder rather than an illness resulting from an imbalance of bile).

This is an argument further developed by Fan & Holliday (2007) who, looking at different systems of traditional medicine in China note that there is a prevailing position that where [traditional medicine] is [] integrated into healthcare systems, that modern scientific medicine (MSM) should retain its principal status (p. 454).

This has affected theory, technique and practice such that traditional medicine colleges have invested greater amounts of time and resources into teaching biomedical theories and technologies to the detriment of their own classics. Traditional medicine hospitals have often equipped themselves with advanced biomedical diagnostic and therapeutic facilities to scientise themselves and compete with MSM hospitals (p. 456). Physicians will often be required to administer dual diagnosis and dual therapy for their patients one according to traditional principles and one according to biomedical theory. Eric Karchmer shows a similar hybridisation within Traditional Chinese Medicine practice since the early 20 th century (2010).

The end result of this, they argue, is that a popular impression has been created that for most medical problems, MSM should do the main work, although TRM [traditional medicine] may offer some minor complementary assistance (Fan & Holliday, 2007, p. 456).

These analyses of pluralism suggest a competition for primacy between biomedicine and traditional medicines, although Scheid (2002) argues that often the distinctions and oppositions between the two are false, and a factor of the desire of many academics to identify distinctive cultural practices and create rhetorical opposition in their analyses.

This discourse, while not relating directly to Mongolia, does provide a context for my own study of patients, practitioners and practice. As TMM exists alongside biomedicine within the countrys healthcare system, the observation of patients practitioners and practice in a normal setting will provide an insight into how medical pluralism manifests in a Mongolian setting. It should be possible to ask questions about whether the influence of biomedicine is disembedding TMM from its local contexts of practice and/or leading to dual diagnosis in which the MM diagnosis is considered inferior.

3.2

An overview of literature searches on Mongolian medicine

My preliminary literature review quickly established that there is only a limited amount of published research in English on Traditional Mongolian Medicine (TMM).

However, while in Mongolia, I was able to supplement the limited information available outside the country by obtaining some small-run publications in Mongolian (Badarchin, 1989) (Dagdanbazar, et al., 2006) (Odontsetseg & Natsagdorj, 2010) and in English (Bold, 2009) (Manba Datsan Clinic and Training Centre for Traditional Mondolian Medicine, Otoch Manramba Mongolian Traditional Medical Institute, 2011), as well as being given steers by the people I interviewed on useful articles I had not unearthed prior to travel. The main work, and one which I shall be extensively referring to is Bold Sha ravs comprehensive work History and development of traditional Mongolian medicine, 2 nd ed, which I was alerted to by contacts while I was in Mongolia. Bold outlines the historical roots of Mongolian medicine in folk practices and subsequent cultural influences on it, from China and Tibet, and the more recent impact of state socialism during the communist era. Bold is currently a member of the Mongolian Academy of health sciences and an Academician (this is an honorary title for members of the Academy in Mongolia), so it is reasonable to consider his work academically substantial, though his referencing, in keeping with accepted norms in Mongolia, is less detailed than is the norm in the UK.

Bold is not cited much outside Mongolia, though Janes and Hilliard draw on him in their essay Inventing tradition: Tibetan medicine in the post socialist contexts of China and Mongolia (Janes & Hilliard, 2005).

In order to identify relevant literature, searches were carried out in May and June 2011 on the Pubmed, and ARRCbase databases and on Google Scholar. I made a further search on JSTOR in October 2012.

On Arccbase, I used the term Mongolia and received 0 results. As this was the most general possible relevant term, I did not consider it useful to refine my subject search. 8

On Pubmed, I used the terms {Acupuncture + Mongolia}, which produced 11 results and {Traditional + Medicine + Mongolia}. This produced 72 results. None of these were fully relevant, because they did not describe the therapeutic details about acupuncture that my research proposes to investigate, and other reasons as outlined in Fig 1 below.

Two results were partially useful. Bernstein, et al., (2002) survey the annual frequency of visits to Western and traditional medical practitioners in Darkhan, Mongolia by 90 people over the course of a year. They establish that a significant proportion of people still use the services of traditional practitioners, and that while there is no significant demographic difference between the two groups, people choose their practitioner mostly depending on the nature of their condition. The study is primarily quantitative, and does not provide details of the therapy or therapeutic relationship.

Kohrt, et al. (2004) conduct a detailed cultural epidemiology of the condition yadargaa a form of chronic fatigue found only in Mongolia. This is treated equally in Western and traditional settings. They adopt a framework called EMIC the Explanatory Model Interview Catalogue developed by Weiss (Weiss, 1997, pp. 235263), but again, the study is primarily quantitative, and provides no details of the traditional Mongolian therapies.

Because of the lack of useful data from these searches, a search was made on Google Scholar, using the terms {Acupuncture + Mongolia} and {Traditional + Medicine + Mongolia}. The produced thousands of articles, most of which were not relevant, and were thus discarded. An overview is included in Fig 1.

Restricting the search to material in English produced a large number of random conjunctions of search terms, but also one very useful journal issue (Ayur Vijnana vol. 8). There were two duplicates from the PubMed searches (Bernstein, et al., 2002) and (Kohrt, et al., 2004) and one article on veterinary acupuncture in Mongolia (Haffner, et al., 2004).

Volume 8 of Ayur Vijnana, is an Indian journal describing itself as A periodical on Indo-Tibetan and allied medical cultures is specially focused on Mongolian traditional medicine, and provides useful background information. I consider it to be credible in this broad context as the volume has an introductory foreword by the Mongolian ambassador to India, though it is possible that an ambassador could have a national bias in favour of promoting the traditional medicine of his own country.

Haffner, et al. (2004) write about the use in Mongolia of traditional acupuncture in the training of racing horses. While this is not directly relevant, it does highlight the cultural importance in Mongolian life of horses, and the use of traditional medicine in a veterinary as well as a human context.

My search on JSTOR included a general search on traditional medicine in Mongolia, but also broader searches to find critical material on wider academic debates relevant to my study. The searches on {Traditional + Medicine + Mongolia} and {{Traditional + Medicine + Mongolia} + Technique} did not provide useful results. The searches on {Traditional + Medicine + Pluralism} and {{Traditional + Medicine + Pluralism} + Asia} produced useful references for this area of debate though {{Traditional + Medicine + Pluralism} + Mongolia} did not. I discuss the results in greater detail in the section on pluralism.

Database Arccbase PubMed

Search date May 2011 June 2011

Search terms Mongolia Traditional, Medicine, Mongolia

Results 0 71

PubMed

June 2011

Acupuncture, Mongolia

11

Google Scholar

June 2011

Acupuncture, Mongolia

3360

Accepted/rejected/reasons / 61 rejected for being pharmacological studies of TMM drugs. 5 rejected for unclear subject content. 1 rejected for being of possible interest but in Chinese 2 partially accepted for background interest. 9 rejected as being outcomebased studies on acupuncture, and not describing techniques. 3 of possible interest, but in Chinese. 3,360. Taking the first 20 pages as a representative sample, I discounted all but four of these, as they were

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Google Scholar

June 2011

Traditional, Medicine, Mongolia

41,100

JSTOR

October 2012

Traditional Medicine Mongolia + technique

857/399

JSTOR

October 2012

Traditional medicine pluralism + Asia + Mongolia

4402/1495/89

either: 1. in Chinese, or 2. Were quantitative/outcomebased studies, 3. Did not appear to discuss techniques and practice, or 4 Appeared to be random conjunctions of search terms. 1 kept as of significant use. 1 kept as of background interest (veterinary acupuncture on Mongolian horses) 2 duplicating results from PubMed All rejected. Taking the first 20 pages as a representative sample, I could not find any of use, because they were either: 1. in Chinese, or 2. were quantitative/outcomebased studies where one of the research team was from Mongolia, 3. Were pharmacological studies of TMM drugs, 4. did not appear to discuss techniques and practice, or 5. Appeared to be random conjunctions of search terms. Too broad, so narrowed. JSTOR ranks by relevance and most of the higherweighted articles related to either pharmacology, which was outwith the scope of this research or to Chinese medicine in China during the period of Mongolian hegemony. Lower weighted articles of no relevance Initial search too broad, so narrowed. Including Asia, the higher weighted articles provided useful hits. Plus Mongolia, produced random conjunctions of search terms of no relevance.

Table 1 Summary of databases searched and results

Other than Bold. (2009) monographs on the subject were also hard to find. A search on the Library of Congress Catalog using the keywords Mongolia Acupuncture produced only one title, and this was in Badarchins book on acupuncture in the Mongolian language (Badarchin, 1989).

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Some background mentions of the Tibetan/Mongolian link are also made in literature on Tibetan medicine.

Because of the scarcity of information, prior to my field trip, I engaged in email correspondence with prominent members of IASTAM (International Association for the Study of Traditional Asian Medicine) and the Cambridge University Mongolia and Inner Asia Studies Unit (MIASU) (the director is a personal friend). I have reproduced some of this correspondence in Appendix 1.

The IASTAM correspondence served to confirm that Mongolian acupuncture and traditional Mongolian medicine are not widely studied in the West.

However, following some detective work on people on the IASTAM website, I was able to find leads to two researchers currently writing on Mongolian medicine in English. These include Buyanchuglagin Saijirahu from the University of Tokyo, who has written a number of papers on Mongolian folk medicine (Saijirahu, 2005) (Saijirahu, 2004) (Saijirahu, 2007) (Saijirahu, 2008a) (Saijirahu, 2009) (Saijirahu, 2008b) and also Matt King of the University of Toronto, who gave a paper at the 2009 IASTAM conference on Healing Acts as Conversion Narratives in Early Mongolian Religious Histories (King, 2009).

My correspondence with MIASU provided some useful pointers and background information.

While in Mongolia, I was directed towards the work of Kim Tae-Hun et al on Mongolian traditional-style bloodletting therapy, which has just been published (Kim, et al., 2011).

3.3

Historical perspectives in the literature

Saijirahu (2008b) and Bold (2009) also refer extensively to Jigmed, who has written extensively about Mongolian medicines long and diverse history, spanning the traditional nomadic pastoral lifestyle, a world-spanning empire and Soviet state socialism (1985).

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Bold (2009) and Jigmed (1985) have contrasting views of the historical stages of development of Mongolian medicine.

Jigmed, who is an Inner Mongolian author, outlines three. The first of these stages is from the first settlement of the Mongolian plateau to the 13th century AD and is characterised by the development and use of fermented mares milk as a therapy, bonesetting, balneotherapy and the use of skin and entrails for wound and disease treatment.

The second period is from the thirteenth to the sixteenth centuries and corresponds with the rise of the Mongolian empire and the great period of cultural diversity that resulted with the introduction of medical concepts from China to the east and the Islamic realms to the west.

The third period, from the sixteenth century onwards follows the introduction of Buddhism to Mongolia, bringing with it the Indo-Tibetan medical tradition of sowa rigpa. To these three periods, Saijirahu (2008b) adds a fourth period, from the start of the twentieth century onwards, characterised by the introduction of biomedicine. Bold, who is from Outer Mongolia prefers six, noting particularly during the last stages of the development of Traditional Mongolian Medicine, there are substantial differences between Inner Mongolia of China and Mongolia due to the political circumstances although they share a similar culture (2009, p. 18). Bolds stages start with the prehistoric period up to 209BC. This period sees the development of Mongolian folk medicine dhom, which was used to treat a range of injuries and illnesses in humans and herd animals, bonesetting, moxibustion and bloodletting, and shamanic healing. The second stage covers the Hunnu (Xiongnu) Empire to the Great Mongolian State2 (209BC to 1206AD). This sees the introduction of medical concepts originating in

This is Bolds preferred term for what is generally referred to in the UK as the Mongol Empire.

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China, including Yin Yang theory (which were translated as Arga and Bilig) and Five Element theory, and the development of a Mongolian pharmacopoeia based on the herbs and minerals available on the steppes.

His third stage is from the Great Mongolian State to the Third Flourishing of Buddhism3 (1206-1578). This sees the introduction of guidelines for the maintenance of public and personal health, dairy therapy (particularly using fermented mares milk), manipulation therapies, cud-application therapy, covering with skin therapy, entrails application therapy and further development of Mongolian pharmacology. The fourth period is from the Third Flourishing of Buddhism to the Peoples Revolution (1578-1921). This period sees the introduction and flourishing of Tibetan medicine and its adoption as the state religion, the development of hospitals around Buddhist monasteries practicing the Indo-Tibetan medical tradition which gradually became pre-eminent, as well as the adoption and incorporation of Chinese acupuncture and moxibustion, and towards the end of the period, of Biomedicine. Mongolian physicians such as Sumbe Khamba Isbaljor and Jigmeddanzanjamts expand on the Tibetan medical corpus to include new concepts such as the acknowledgement of external pathogenic factors and of hot and cold diseases.

The fifth stage is the Socialist period (1921-1990), broadly characterized with some minor exceptions) by the suppression of traditional medicine in favour of biomedicine.

The final stage is from the end of the Socialist period onwards (1990 to the present), which has seen a new systematic development of TMM and incorporation into the state medical system.

Comparing these two historical schemes, a few things are clear. Firstly, there is some difference of opinion over the age of some traditional therapies such as dairy therapy and entrails application therapy, but agreement that they originated before the introduction of Buddhist medicine.
3

This is a term Bold uses which I have not been able to find any definition of either inside or outside his book.

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Secondly, there is some divergence in the experience of Inner and Outer Mongolia from the 20th century onwards, with Outer Mongolia becoming part of the Soviet bloc, followed by its current post-Socialist government and economy, while China followed a divergent path to socialism, which it follows to this day. These divergent political paths have had similar but distinct impacts on the nature and practice of TMM. Most notably, in Mongolia itself, it can be seen as an expression of Mongolian nationalistic self identity after the country separated itself from Soviet hegemony (Janes & Hilliard, 2005) (The Mongol Messenger, 2003).

Thirdly, both schemes are agreed on the significance of the introduction of IndoTibetan medicine together with the introduction of Buddhism. Buddhism and medicine were very much part of a combined package and King (2009) elaborates on this in some detail. Based on research of historical records of the diffusion of Buddhism into Mongol lands from Tibet, he encounters a number of very important and widely recorded narratives in which a Buddhist master cures the malady of a particular khan.

The narratives describe how the effectiveness of their healing powers prove determining factors in the eventual acceptance of Buddhism by the leader in question (and by extension his people), having triumphed over traditions that failed to cure (such as Daoism, Confucianism or shamanism), or over competing Buddhist sects. In these, it is foremost the healing abilities of these figures that demonstrate their spiritual power and accomplishment, over and above other ritual or miraculous activity.

Finally, it is also clear that pluralism within Mongolian medicine is not a new phenomenon. TMM has incorporated elements from previously external medical traditions during several points in its history and has also adapted them to the Mongolian context.

15

3.4

Advantages and limitations of ethnography as methodology

When putting together my research proposal, my own natural inclination was that an ethnographic approach would be the most appropriate way of getting useful descriptive information on practitioners and practice in Mongolia. However, it is important to establish that this personal belief is academically supportable. LeCompte and Schensul describe how a primary difference between ethnography and other social and behavioural science methods of investigation is that ethnography assumes that we must first discover what people actually do and the reasons that they give for it before we can assign to their actions interpretations drawn from our own personal experience or from our professional or academic disciplines (LeCompte & Schensul, 1999, pp. 1-2).

They outline 10 conditions which individually or collectively would indicate ethnography as an appropriate research method: to define a problem when the problem is not clear; to define a problem when it is complex and embedded in multiple systems and sectors; to identify participants when the participan ts, sectors, or stakeholders are not fully identified, or known; to clarify the range of settings where the problem or situation is occurring at times when the settings are not fully identified, known or understood; to explore the factors associated with the problem in order to understand and address them, or to identify them when they are not known; to document a process; to describe unexpected or unanticipated outcomes; to design measures that match the characteristics of the target population, clients or community participants when existing measures are not a good fit; to answer questions that cannot be addressed with other methods or approaches; to ease the access of clients to the research process and products (LeCompte & Schensul, 1999, pp. 30-31).

This provides a good fit for my own research topic, since the nature of TMM practice is not clear, my aim is to document the process of what they do, I could have no clear certainty in advance what I might find out and where this might lead my investigations.

16

Classic and more contemporary texts such as Leach (1982), Haralambos & Heald (1980), Denzin & Lincoln (2005), Hammersley and Atkinson (2007) and LeCompte & Schensul (1999) highlight some of the complexities related to contrasting paradigms within ethnography that need to be considered.

In a simple world, I would be able to say that there is an objective phenomenon called medical pluralism, that by observing it objectively in a new context, namely Mongolia, I would be able to determine the degree to which it was present, according to agreed criteria, and on the basis of this, perhaps place it on a continuum and then make appropriate generalisations.

This positivist viewpoint as outlined by Denzin is based on a number of assumptions, namely: There is a reality that can be objectively interpreted; that the researcher as a subject must be separate from any representation of the object researched; that generalizations about the object of research are free from situational and temporal constraints: that is, they are universally generalizable (p. 44); that there is a cause and effect for all phenomena - there are no causes without effects and no effects without causes (p. 44); and (e) our analyses are objective and value-free (p. 44).

There are many criticisms of the positivist approach to the social sciences and the notion of naturalism or realism, namely that the ethnographer can represent social reality in a relatively straightforward way (Hammersley & Atkinson, 2007, p. 13), and have stemmed from the influence of post-structuralism and post-modernism and figures such as Derrida and Foucault. These are discussed in some detail in Gubrium and Silverman (1989) and Kendall & Wickham (2004).

As well as criticisms of an objective social reality, there are criticisms of the distinction between facts and values. This vein of criticism has come from a variety of sources, including Marxism, feminism and post-structuralism. There is advocacy for research which is openly ideological (Lather, 1986), militantly advocating an ethical perspective (Scheper-Hughes, 1995) or written from the standpoint of a particular group, particularly where they are subject to oppression (Denzin & Lincoln, 2005).

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Hammersley & Atkinson (2007) address this issue by calling on the ethnographer to recognise the reflexive nature of this kind of social research, to reflect on it, acknowledge it, and to use the fact that they are affecting and altering that which they are also observing and documenting and remark There is as little justification for rejecting all common-sense knowledge out of hand as there is for treating it as all valid in its own terms (2007, p. 16). This appeals to the intuitive truth that we are all able to make common sense assumptions about the world and how it will behave even where we cannot conclusively prove this objectively.

LeCompte and Schensul recommend a paradigmatic synthesis in which the ethnographer recognises that these diverse paradigms all contain useful elements which can and should be drawn on according to circumstances (1999, p. 55) and while it could be argued that this selection itself would have a distorting effect, this seems a practical way of addressing the issue.

Medical anthropology is a huge and diverse field. Within this, a number of sources describe approaches to looking at technique and practice.

The health belief model as outlined by Marshall Beckers considers lay belief models, with a focus on recommended health and illness behaviours and encouraging them to make appropriate utilisation of biomedical health facilities and considers peoples own judgements about susceptibility to illness (Rosenstock, et al., 1988).

This approach has been criticised by some anthropologists including Good (1986) (1994) for adopting a utilitarian explanation of illness behaviour and its implied assumption of a true medical knowledge held by biomedical health professionals.

Helman (2007) and Weiss (1997). both provide topics of enquiry for medical ethnographers which could be adopted as a starting point for my own research.

Weiss, (1997) is the originator of the Explanatory Model Interview Catalog (sic), which is used in cross cultural settings where semi-structured interviews can be conducted and is designed to address concerns about the cultural validity of biomedical investigations across cultures. This looks at patterns of distress, 18

perceived causes, help seeking and treatment behaviour, general illness beliefs and disease-specific queries. Helmans Culture health and illness (2007), provides a useful light framework for the observational research as well as providing a broad context of cultural differences in the experience of healing and medical practice. This includes asking how patients and practitioners conceptualise the structure and functions of their bodies, what explanatory models of illness patients and practitioners use and how patients behave in clinic. There are also wider issues such as how cultural attitudes affect diet, what makes someone a patient and what makes someone a healer, how gender and sexual behaviour are defined, and how this affects health. He also highlights the interaction between culture and pharmacology, whether ritual and belief affect perceptions of misfortune, what is considered normal and abnormal behaviour and cultural aspects of stress and suffering.

I also searched for guidance on the practicalities of conducting field research.

Emerson critiques the use of pre-structured observational studies, as they narrow and restrict the observers participation in the setting (1981, p. 352).

Levine, et al. (1980) outline five essential skills in an effective ethnographer. Firstly, there is the area of role management and ethics. This includes learning something about their own interactional skills and consciously applying this knowledge among unfamiliar people or in novel settings (p. 42). He also addresses the inevitability of encountering and needing to deal with dilemmas, noting that decisions in fieldwork including [ ] interactional and ethical ones can ultimately only be made by themselves, or in consultation with colleagues and that both self-confidence and consultation with other professionals are necessary if one is to be a successful fieldworker (p. 42). Ethnographers must be disciplined, analytic and idea-generating observers (p. 43). Recording of data must allow for multiple perspectives of the event, including such options as contemporaneous notes and observations along with a regular, more reflective digest account, perhaps made at the end of a day. 19

They describe how interviewing can include more formal methods, but in the most typical kind of field interviewing [] jawboning, the ethnographer sits around chatting with informants (p. 44).

The ethnographer must then, through data reduction and analysis, aims to elucidate patterns from this data.

These basic guidelines promoting immersive pragmatic disciplined observation, description and recording are echoed in more recent sources such as Hammersley & Atkinson, (2007) and LeCompte & Schensul (1999).

4. Methodology 4.1 Preliminary preparation for the research

My field work took place over the course of three weeks, 6-26 June 2011 in Ulaanbaatar, the Mongolian capital.

From their website, I had identified the Manba Datsan Training Centre of Traditional Mongolian Medicine in Ulan Bator (Manba Datsan Training Centre of Traditional Mongolian Medicine, n.d.) as a potentially interesting focus of my study. This was it has a website in English, is formally registered with the Mongolian government, and claims to take overseas students. These were all important due to my concern about language difficulties and cultural unfamiliarity.

I recognised that a period of field work in a different country would require preparation. The main preparation headings I identified in advance were: to make some arrangement to learn the basics of the Mongolian language; to make contact with the Manba Datsan and secure consent from them to carry out the research; to make arrangements for in-country support regarding any language or cultural challenges; to plan the direction of the research.

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4.1.1 Learning the language Clearly the fact that I dont speak Mongolian was going to be a hurdle for this kind of research. I was not going to have the time or funds to learn anything that would bring me close to fluency, particularly not technical fluency in an unfamiliar discipline.

However, I thought it was important to have at least the basics on the language, to be able to get by in simple situations and make myself understood in basic social circumstances. I made contact with the head of the University of Leedss department of East Asian studies in February 2010 to get some pointers on sources of language tuition. It was not until September 2010, following several polite follow-ups and some discreet but insistent prodding from my academic friend at Cambridge Universitys depa rtment of social anthropology, that I received a response.

I was finally put in contact with Tsendpurev Tsegmid, a Mongolian PhD student at the university, and she was able to provide me with weekly classes in Mongolian for three months, as well as advise me on many aspects of Mongolian culture.

4.1.2 Making contact with the Manba Datsan to secure consent and agree terms I considered it sensible to make contact well in advance of my field trip to initiate contact with the people I intended to visit, and iron out any potential issues, such as consent, as well as to discuss making the most effective use of my time and theirs.

I received an initial and positive response back from the Lama Natsagdorj, the principal at the Manba Datsan, saying they would be happy to help me, but not going into any of the preliminary details I had hoped for. I received a similar response to a second email I sent.

I queried this with my friend at Cambridge, to see if there was something I was doing wrong. His advice was as follows: The reply is um.. well, not unusual in Mongolia. (i.e. when he comes out we'll try to sort it out for him). As you know, things often happen in this 'karmic' way out there - much to the frustration of the orderly Romano-Saxon mind that

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likes to deal in pre-planned certainties! The problem is that it places you in a bit of a dilemma, to invest in the ticket without being certain you'll get the access you want. We could push them for some more firm commitment at this stage, but I think it won't solve the dilemma entirely since the best they'll probably get is 'it'll probably be OK, call me again when he gets out here'. (Sneath, 2011) This was certainly a wake-up call for me that a lot of the assumptions I might have about conducting research, based on a Euro/American social paradigm could not be relied on for this particular research Mongolians dont do things the way Im used to.

The practical effect of this was that I had to accept that my research would have to be much more fluid and flexible than I had anticipated when I was putting together my proposal, and that I would have to adapt much more to the situation on the ground when I arrived.

4.1.3 In-country support regarding any language or cultural challenges I was able to arrange for in-country support with Lhagvademchig Jadamba (Demchig) one of the postgraduate researchers at the National University of Mongolias department of social and cultural anthropology. Demchig is himself a former Buddhist monk, though without a medical background, and is fluent in English. He kindly agreed to help and advise me with any issues I encountered while in Mongolia.

The main in-country consideration which I had to take into account was that of financial incentives for access.

In addressing this, I followed the guidelines of Levine et al (1980), namely, to have the self-confidence to trust my own judgement after consultation with colleagues where possible. David Sneath and Demchig both advised me that discreet offers of money are a normal part of smoothing professional interactions, and that I should be aware of the likely need to do this in order to get access at the Manba Datsan.

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This advice proved correct. My initial contacts at the Manba Datsan were polite, but non-committal, and on Demchigs advice, I made Lama Natsagdorj a small donation of $100 towards the work of the Manba Datsan. Also on Demchigs advice, I made this in a traditional manner for donations to a temple, presented in a hadakh (holy silk scarf) held in both hands with the money on the right palm.

Natsagdorj thanked me for my kindness, and said it was only fair to try and assist me with my research as much as possible, and was indeed very helpful in providing access to the work of his hospital.

4.1.4 Planning the direction of research My intention throughout the period of field work, was to observe consultations and treatments carried out by practitioners on consenting patients. In order to make this an academic activity rather than a travelogue, I needed to give this some structure.

My main topics of enquiry, based on a synthesis of those identified by Helman (1990) and Weiss (1997) were: What treatments are carried out, why and how? How do patients and practitioners conceptualise the structure and functions of their bodies? What explanatory models of illness do patients and practitioners use? How do patients behave in clinic?

I followed the recommendations of Marcus (1997) and Angrosino (2005) that there should be a collaboration between researcher and subject as a way of moving past cultural and colonial bias. Marcus explicitly observes, ethnographic research is never reducible to the monologic voice of the ethnographer alone (Marcus, 1997, p. 92).

The only exclusion criteria was those patients or practitioners who did not wish to be observed.

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4.2

Ethical Issues

The ethical framework for my study was given approval by the Northern College of Acupuncture in 2010. It was based on the ESRC (Economic and Social Research Council) ethics framework (ESRC, 2009, pp. 1-2).I shared this with the Manba Datsan in advance to ensure that the ethics framework was considered appropriate in a Mongolian setting.

4.3

Details of fieldwork

The research itself consisted of the following: Interviews with Lama Natsagdorj, the Principal of the Manba Datsan medical monastery (audio); Lagshmaa Baldoo, senior lecturer in Acupuncture at the National Medical University of Mongolia (handwritten); supplementary interviews with students (handwritten); Batnairamdal, a lecturer at the National medical University, specialising in the Mongolian version of Indo-Tibetan medicine, about pulse diagnosis (handwritten); and Joergi Zoll, a self-employed acupuncturist from Germany, who has been practicing in Ulaanbaatar since the 1990s (audio).

Direct observation included two days of observation of consultations, treatment and facilities at the Manba Datsan; One day of observation of consultations, treatment and facilities at the Ulaanbaatar Suvilal (sanatorium). I saw a total of 23 consultations (audio).

I also corresponded by email and telephone with Bold Sharav, author of History and Development of traditional Mongolian Medicine (2009); Lagshshmaa and Joergi Zoll.

My information was collected in the form of 30 pages of handwritten contemporaneous notes, three hours of audio recordings, which have been partially translated and supplementary photography to illustrate various aspects of interest.

In addition to my contemporaneous field notes, I made more considered write-ups of each days activity on my laptop.

The breakdown of detailed observation of patient consultations was as follows

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Age band4 <205 20-29 30-39 40-49 50-59 60-69 70+ TOTAL

Numbers in age band 2 3 1 6 3 4 4 23

Male

Female

1 1

1 2 1

3 1 1

3 2 3 4

16

Table 2 Breakdown of consultations observed by age and gender

5. Observations Using the line of enquiry recommended by Helman, (2007), this section looks at what treatments practitioners use, why and how, and some elements of patient behaviour. For the purposes of narrative flow, I have ordered this as follows: i) An outline of the theoretical framework behind diagnosis and treatment (why) ii) An outline of those treatments I was able to observe (what and how) iii) Patient behaviour and experience of illness.

5.1

The theoretical framework by which practitioners describe, diagnose and treat complaints

Before describing those elements that might be considered traditional it is important to say that biomedical diagnostic tools and theories are a fully integrated part of what I saw. All the patients I saw were engaged to a greater or lesser degree with the biomedical system, and many of them would bring x-rays, MRI or ultrasound scans with them to the consultation to show the traditional practitioners.

This is based on my own approximate visual assessment, since I had no access to case notes and did not wish to intrude on the normal consultation by asking questions. 5 In both cases the children were accompanied by a parent, and permission was asked and given to observe the consultation.

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At the time of my visit, the Manba Datsan was expanding to build an extra hospital wing increasing its capacity from 24 to 80 beds, and including a range of modern scanning equipment.

I discuss some of the manifestation of pluralism in diagnosis in 5.1.6.

As well as Western diagnostic tools, there is widespread use made of Chinese TCM diagnostics, including five-element theory and yin yang (or arga bilig) theory, particularly within the context of acupuncture and TCM moxibustion.

The most widespread conceptual framework is Three Element Theory, which was introduced from Tibet, and is the theoretical basis for the bulk of TMM diagnostics. TMM also includes a number of practical diagnostic methods, which I will outline, paying particular attention to pulse taking, which differs from Chinese pulse taking in some detailed aspects.

I provide more detail on three element theory and the seven constitutions in Appendix 2.

5.1.1 Arga and Bilig (Yin Yang theory) Yin and Yang are known in Mongolia as Arga (Yang) and Bilig (Yin). Applying these concepts to the patient, their demeanour, the stages of their illness formed a fundamental part of the initial assessment of their patients and the understanding of their ongoing condition by Natsagdorj when I was with him.

In medical terms, Arga and Bilig were used identically in Mongolian and Chinese medicine to classify diseases as hot or cold. However, they are applied in conjunction with diagnoses made using Tibetan-derived Three Element theory diagnoses. This combination of diagnoses is an innovation introduced to Tibetanderived medicine by Mongolian physicians such as Sumbe Khamba Isbaljor and Jigmeddanzanjamts between the 16th and 19th centuries (Bold, 2009, pp. 236-239).

In this combination, two of the elements, Shar and Badgan, are given qualities of Arga and Bilig, and the third element, Khii, has neither (see fig 3 below.) 26

I observed this in practice most clearly in the cases of tongue diagnosis, pulse diagnosis and urinalysis, where qualities of Arga and Bilig are applied to different qualities of each (see 5.1.4 below)

5.1.2 Chinese five element theory Chinese five element theory is one of the theoretical tools used by TMM physicians. In my discussions with Joergi Zoll and Lagshmaa, they were emphatic that it is applied by them primarily in the context of TCM treatments they administer.

What is noteworthy to me, though, is that five element theory provides Mongolians with the concept of five Yin organs (Liver, Heart, Spleen, Lung and Kidney) and five Yang organs (Gall Bladder, Small Intestine, Stomach, Large Intestine and Bladder) which are used within three element theory also.

5.1.3 Three element theory Three element theory is the core of the TMM taught and practiced at the Manba Datsan and in the state TMM system. Following on from the Arga/Bilig assessment, the three elements form the major part of the differential diagnosis Natsagdorj was applying to his patients while I was with him.

These three elements, also called theoretical essences (Bold, 2009, p. 219) or three components (Kim, et al., 2011, p. 180) are Wind (Khii), Bile (Shar) and Phlegm (Badgan). These correspond with the equivalent terms rLng, mKhris-pa, and Badkan used in Tibet, from where they were introduced to Mongolia (Gonpo, 2011).

These three elements both oppose and support each other, in a state of dynamic tension. They are balanced in a healthy person, in which state they are known as the Three Healthy Conditions. If they become imbalanced due to a range of factors, including diet, behaviour, climate and a range of other external factors including infectious diseases, the result is ill-health, and in this case, they are known as the Three Disorders. According to Lagshmaa, there is no equivalent of the TCM concept of stagnation in the context of illness.

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Each of these three essences has its own qualities and effects, which are illustrated in brief in Figure 3.

Figure 1 The three elements used in TMM, showing qualities of each, and their relation to Bilig and Arga 6 (Yin and Yang)

See Appendix 2 for further details of Khii, Badgan and Shar.

5.1.4 Diagnostic techniques The detailed understanding of how the three elements interact provides the theoretical basis for the TMM understanding of disease. A number of specific techniques are used by the practitioner to arrive at an individual diagnosis.

Traditional diagnostic methods are based on observation, palpation and questioning to gain a sense of the current balance or imbalance of the three elements.

According to Natsagdorj, diagnosis involves the application off all the senses in order to ascertain the balance of the three elements and to identify the nature of a persons disorder.

5.1.4.1 Visual diagnostics These checks start with observation of the patient. When I was with Natsagdorj, he checked each of the 23 patients tongues at the start of every consultation. This was
6

This is my own rendition and adaptation of a diagram I saw on a number of wallcharts in Mongolia and in Kims article on blood-letting (2011).

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primarily for hot/Shar/Arga signs or cold/Badgan/Bilig. He added details of his observations to the handwritten notes each patient brought with him or her into the consultation room, which suggests that the ongoing qualities of the tongue are an important element in tracking the progress of a condition.

He asked me to look at the tongues of five patients where he considered them interesting and the patient was agreeable. These included three Shar/Arga tongues, which were yellow-coated and red, one Badgan/Bilig tongue, which was wet and pale and one khii tongue (belonging to a boy with epilepsy), which was pink and with a thin white coat. There are other visual checks, including the colour of a persons complexion, or of the sclera, which will vary subtly according to the relative balance of the three elements, as discussed above). Natsagdorj examined the eyes of each of his patients and recorded them similarly to the tongue diagnosis.

As well as specific details, the physician needs to gain an overall impression of the patients state of health by studying their general demeanour, posture, skin tone, strength of voice and emotional state.

5.1.4.2 Diagnosis by analysing excretions TMM pays great attention to interpreting variations in the bodily excretions. These include saliva, faeces, urine, sweat and vomit. For example, the saliva of a patient suffering from a khii disorder will often be thin with large bubbles.

Particular attention is paid to urine diagnostics, which Natsagdorj believes require a high level of skill to interpret effectively (Odontsetseg & Natsagdorj, 2010, p. 26). The Manba Datsan takes urine samples from most of its patients, and these are either taken at the hospital. However, it was also a notable characteristic of the hospital waiting area, that many of the patients had brought in samples taken at home and transported to the hospital in a variety of improvised containers. There is a room at the Manba Datsans hospital wing where these are stored and labelled for examination by practitioners and trainees. 29

Samples are usually made from the first urine of the day, and the patients had been asked to abstain the day before from drinking black tea, sour milk, airag (fermented mares milk) or alcohol, from eating spicy food, or from having sex.

The urine is observed at each of three stages for different qualities at each stage. These are known as the three times and nine characteristics

Hot and fresh urine is checked for its colour, vapour, odour and bubbles.

Cooling urine is checked for sediments and albumins. Cold urine changes in colour and character, and this is called tarnish. The time it takes to tarnish and the quality of the tarnish is considered diagnostically significant.

There are numerous subtleties, but the key characteristics showing elemental imbalances are: where there is a khii imbalance, urine is usually pale and has large bubbles; where there is a shar imbalance, urine will tend to be reddish-yellow, with a strong smell and a lot of vapour and; where there is a badgan imbalance, the urine tends to be cloudy, with little smell or vapour.

A reddish colour tends to indicate a hot disorder, and clear urine tends to indicate a cold disorder.

Urine samples in the storage and diagnosis room were kept in groups according to the day they were provided, which provided a simple practical way of differentiating the fresh, cooling and cold samples and while I was there, the practitioners came in to inspect the samples and make notes in what appeared to be the patients case notes.

5.1.4.3 Mongolian pulse diagnosis According to both Natsagdorj and Batnairamdal, pulse taking is considered the most sophisticated diagnostic technique. By using it, physicians are able to determine outer and hidden symptoms, recognise changes in the structure and activity of a 30

body not just after the illness has taken place, but also prior the illness [sic]. (Odontsetseg & Natsagdorj, 2010, p. 26)

Perhaps because of the strong overlap between TMM and Buddhism, there is a strong element of spirituality in the teaching of pulse taking. Natsagdorj described to me that in making a pulse diagnosis, it is important to learn and practice how to concentrate the mind at one point, and to learn to recognise different rhythms of heartbeat. He considered it essential that as well as understanding TMM, it was important to have an awareness of factors he considered related, such as natural science and astrology, and also to have learned special meditations including the Medicine Buddha meditation and the Pulse diagnosis meditation, which form part of the curriculum of students at the Manba Datsan.

There are some classical requirements for pulse taking which Bold outlines, which echo what Natsagdorj told me (Bold, 2009, p. 229). These include telling the patient to rest fully and have an empty stomach before their pulse is taken, in order to add clarity the relative balance of the Three Elements. Even better, the pulse should be read at sunrise. Any earlier, and the bilig quality of the moon will dominate and it could be possible to incorrectly diagnose too much khii or badgan. Any later, and the arga quality of the sun will dominate, and it could be possible to mistakenly diagnose too much shar.

The reality of practice does not conform with these ideal instructions. When I was with Natsagdorj, He was seeing patients within normal working hours and they had not been fasting. However, he maintained that it was still important to have an awareness of potential astrologically-influenced distortions in the pulse.

There are many superficial similarities between TMM pulse diagnosis and the TCM tradition I myself have been taught. As in TCM pulse-taking, the pulse is taken at three positions on each wrist, using the index, middle and ring finger. Also as in TCM, the six positions each correspond with the six Yin/bilig organs and the six Yang/arga organs, and the pulse at each point is considered to give details about the respective health of those organs.

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There are also differences. In TCM, the index finger is placed at the wrist flexure, and the other fingers are placed relative to that at a distance corresponding with the patients own finger width. By contrast, in TMM, the index finger is placed about a finger width proximal to the flexure, and a space is maintained between them equivalent to the length of a barleycorn.

As with TCM pulses, the qualities of the pulse are taken at three different degrees of finger pressure on the wrist. In TCM, these are known as Qi level, blood level and organ level. In TMM, they are known as skin level, meat level and bone level.

According to Batnairamdal, there are as many as 70 different types of pulse.

Firstly, there are the three healthy pulses, which are considered the starting point for the others, which are known as the male, female and neutral pulses. Both men and women can have any of these pulses they are named such because of their qualities, not because only one gender manifests them. There are also the diseased pulses, which fit into two broad categories pulses of hot and cold disorders, and pulses of the organs.

I summarise these pulses in the table below

Male Pulse Thick Bulky Coarse Neutral pulse Smooth Flexible Long waves Hot/Arga pulse Strong Expanded Rolling

Female pulse Thin Taut Rapid

Cold/Bilig pulse Weak Sunken Declining

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Quick Tight Hard

Table 3 A summary of the qualities of pulses

Slow Loose Hollow

I was not able to get concise descriptions of the qualities of the organ pulses from any of my informants, and I think this may be because they are less easily expressed in English.

When taking a pulse, the physician is supposed, classically, to first take the left hand pulse of a male patient, using his right hand to do so, and with a female patient, to take her right hand pulse with his left hand.

Here, as with the recommendations to take pulses at specific times of day, the reality diverges from the theory, and observing Natsagdorj with patients, he did not stick to this practice. I questioned him specifically on the point, and his explanation was that while the male/left, female/right stipulation was correct, he already had a fairly good idea of what pulses to expect from his patients based on his clinical experience, and therefore, he would took pulses first from whichever side he considered most useful. I pressed him for precisely what he meant by this, but he just smiled cryptically and called in the next patient.

My personal opinion is that at an advanced level of knowledge, which Natsagdorj unarguably has, practitioners feel confident in bypassing some of the detailed recommendations given to people at the beginning of their learning., as their technique has moved beyond this.

5.1.5 Principles of treatment Having used their theoretical framework and diagnostic techniques to arrive at a diagnosis, the practitioner must then embark on a course of treatment, and this too exists within a recognised structure.

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Bold outlines four broad areas of TMM treatment (Bold, 2009, pp. 230-231), which correspond with what Natsagdorj outlined to me in person. These are diet, behaviour, medication and physical therapies. I discuss the some of the realities of dietary behaviour in 5.3.

There are a host of subtleties within each of these areas, but the general principles are what Bold describes as generating and thinning-out (2009, p. 231), but which as best as I could understand equate to the TCM concepts of tonification and reduction. Physical therapies are divided into two types mild and rough therapy.

Mild therapies include treatments such as hot compresses, massage, oil rubs and balneotherapy.

Rough therapies include khanuur, TMM moxibustion (toonr) and TCM moxibustion, and acupuncture.

5.1.6 Biomedical diagnosis in traditional clinical practice Observing consultations with Natsagdorj and at the Ulaanbaatar Suvilal, it was clear to me that biomedical diagnosis is an integral part of the process.

Natsagdorj was keen to stress that the Manba Datsan has acquired a range of modern (his words) biomedical diagnostic facilities, and was in the process of acquiring more.

Four of the patients I saw with Natsagdorj brought medical records and scans from biomedical doctors or hospitals to the consultations for him to look at. This would seem to confirm that the information in these records and scans was meaningful to him and also that biomedical practitioners were content for such information to be shared with traditional medical practitioners.

In describing the conditions of the patients to me, Natsagdorj referred to biomedical conditions rather than corresponding TMM conditions. These included terms such as

34

oedema, lymphatic cancer, stomach cancer, gastritis, degenerative spondylosis, cirrhosis of the liver, kidney cysts, diabetes, epilepsy and arthritis.

I did not press him on his use of terminology as I did not wish to distort his use of language. Of course, it is possible that he chose his terminology expressly because he assumed that I would understand biomedical terms more easily than TMM terms as I was from the UK.

What is clear, however, is that he was familiar with the biomedical terms for the conditions experienced by the patients he was treating, was happy to use them in describing these conditions to me and chose to do so in preference to TMM terms.

5.2

What therapeutic techniques practitioners use

5.2.1 Religious services for healing Buddhism is at the heart of the medical institutions I visited. The Manba Datsan itself is a medical teaching monastery, and the role of Buddhist faith is at the heart of the healing process.

As you enter the building, the whole downstairs floor is a combination temple and dispensary. The room is dominated by a large frieze of the Eight Medicine Buddha, and the central floor area is occupied by between 10 and 20 monks. Their own handout (Manba Datsan Clinic and Training Centre for Traditional Mondolian Medicine, Otoch Manramba Mongolian Traditional Medical Institute, 2011) describes their purpose as follows The monks of our Datsan recite daily prayers, ceremonies, bestow blessings and perform meditation as well as serve the worshippers with ritualistic performance of exorcism to repeal misfortune and sickness and make astrological calculations. Usually we accept different prayers from the devotees.

To the left and right of this room are glassed-off counters staffed by admin, dispensary and medical staff. On the left, you can book healing services on chits that are given to the monks in exchange for a small donation of money.

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On the right, you can book a reading from some astrologers, or collect herbal prescriptions from the herbal pharmacy.

The religious theme is continued in less overtly religious settings such as the Ulaanbaatar Suvilal, which is part of the state healthcare system. There, they maintain a spacious shrine/prayer area to the Eight Medicine Buddha (fig.3), which was heavily used by patients and their families while I was there, and many of the medical and teaching staff are themselves monks, like Batnairamdal, one of my interviewees.

Figure 2 Eight Medicine Buddha shrine at Ulaanbaatar Suvilal

This religious presence even extends to inside the consultation room for example, Lama Natsagdorjs consultation room had both a large and a small shrine to the medical Buddha in it (fig 4)

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Figure 3 Physical layout of typical treatment session

Mongolians view their religious practitioners as professionals able to help in many questions of health and wellbeing. Lamas are service providers. They listen to patients' complaints and administer the corresponding sutras and exercises for it.

According to Joergi Zoll, in his experience, this use of religious services for healing is widely used, and in his view, just as much as acupuncture.

A notable feature of behaviour in the treatment room is the presence of family groups rather than just individual patients in many cases. I discuss this further below in 5.3.2.

5.2.2 Traditional drug therapy The majority of the treatments I saw at both the Manba Datsan and the UB Suvilal involved a drug prescription following diagnosis and assessment.

These medicines include decoctions of medicinal herbs, powders, pills and ointments. It may be the case that some TMM doctors manufacture their own remedies, but everyone I was able to observe uses commercially prepared products.

The Manba Datsan is one of these commercial producers, and runs a small workshop producing over 100 remedies. The remedies are produced according to

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standardised recipes registered and approved by Mongolias Ministry of Health and Social Security.

The medicines are made by students at the Manba Datsan under supervision, and include a variety of herbs, and materials of animal and mineral origin. The medicines are also consecrated and blessed according to traditional rituals.

The factory is partly automated, with machinery used to grind the ingredients to an appropriate consistency, or to compact into pills. Students manually measure out individual doses on graded spoons for one of the most common means of delivery in individual paper wraps.

The medications are issued from the in-house dispensary at the Datsan.

The UB Suvilal also has its own in-house medicine factory, and according to Bold there are six traditional medicine-manufacturing units currently in operation in Mongolia (2009, p. 195).

Bold provided me with a list of 30 of the most commonly used traditional medicines produced in Mongolia, together with their ingredients (though not proportions). These include a very wide variety of plant-based ingredients, some native to Mongolia, and others not. Animal-based ingredients include musk, seashell, pearl, coral and oxgallbladder. Mineral ingredients include calcium, gypsum, vermilion, and magnetite.

Drug treatments fall into two broad categories: 1. Relieving medicines which include decoctions, pills, herbal extracts, precious elements, powders, pastes, ash, alcohol and herbs. 2. Evacuating medicines, which include oils, emetics, oral and anal purgatives, nasal inhalants, and suppositories (Bold, 2009, p. 232).

Most of the patients Natsagdorj treated while I was with him were receiving TMM drug therapy, sometimes in conjunction with other therapies. Natsagdorj made some extremely strong claims for their effectiveness, including for one of his patients (who had bladder cancer) that the treatments had caused the malignant tumours to 38

disappear. As alternative health practitioners in the UK are legally forbidden from making claims to cure cancer, I was startled by this.

A detailed investigation of Mongolian traditional pharmacology is clearly a huge subject, which I have only scratched the surface of, and would be outside the scope of this dissertation.

5.2.3 Pulse-taking as therapy Pulse-taking is a major part of TMM diagnostics, and has both similarities and differences with TCM pulse-taking. I have already discussed pulse-taking as a means of diagnosis in 5.1.4.3, but it is worth mentioning pulse-taking as a folk therapy also.

Two of the patients I saw with Lama Natsagdorj were very keen for me to take their pulse as well as him something which struck me as unusual, but which Natsagdorj was happy to oblige.

I was discussing this a few days later with Joergi Zoll, who was able to give me an invaluable perspective as a long-time UB resident with an outsiders perspective, and he explained that in his own experience, taking the pulse (and the blood pressure also) is perceived as important and effective as a treatment. He explained that since he was known as an acupuncturist, it was not unusual for strangers in the street to stretch out their wrists towards him, to have their pulse read, as if it were a cure or a sutra. In his view, this is related to a widespread folk belief in the therapeutic power of touch by some practitioners.

5.2.4 External treatments The Manba Datsan has a number of baths in which people are treated with mineral muds and herbal infusions for a range of conditions.

One patient I saw was being treated with a herbal bath and mineral mud for his rheumatic illness, under supervision by a nurse. According to Bold (Bold, 2009, p. 114), these mud baths are made from mineral water mixed with mud naturally high in

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bragshun (bitumen), taken from one of a number of springs or salt marsh lakes in the countryside.

The patient I saw in the Manba Datsan received one of these baths every two days and for 50 minute sessions at a time.

Medicinal baths can be made from one of a number of animal products. The balneotherapy room I saw had a large tub of mutton broth, which I mistakenly thought was a medicinal soup, but was actually for adding to the healing bath along with shar-tos (clarified butter). This broth is also used as a compress for rheumatic pain.

Bold traces the use of externally-applied animal products back at least as far as the 13th century (Bold, 2009, p. 92), where the use of cud from freshly-slaughtered animals, fresh hides and fresh entrails were recorded as being used to treat a number of illnesses and wounds.

He also describes the contemporary use of milk, deer brain and magpie brain as folk treatments for facial revitalisation, and pig gallbladder as a dandruff treatment though I had no opportunity to observe either of these firsthand.

5.2.5 Moxibustion There are two types of moxibustion in use in modern-day Mongolia traditional Mongolian moxibustion toonr and TCM moxibustion.

Moxibustion is normally used to treat illnesses caused by Cold or Wind (in the TCM sense). As I was visiting in midsummer, to my great disappointment, I was not able to directly observe any moxa treatments due to the lack of people with applicable conditions at that time of year. This is clearly an area that would benefit from more detailed study at a later date.

However, I was able to discuss some of the distinguishing characteristics of Mongolian acupuncture with Lagshmaa and Joergi Zoll.

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Mongolians lay claim to having invented moxibustion and introduced the technique to the Chinese. Bold refers to a section from the Huangdi Neijing to support this view The North is the closing and storing region of the Heaven and the Earth, the people live on high hills and mounds with cold wind and freezing ice. The people love outdoor living and consumption of milk (nomads) and they mostly suffer from distension in the internal region due to accumulation of cold which should be treated by moxibustion and it is for this reason, that moxibustion therapy was originally developed in the North (Anon., 1990, p. 6). Bold asserts that this is a clear indication that the Chinese viewed Moxibustion as having been introduced by the dairy eating nomads to the north of the country, and this could only have referred to the Hunnu the Mongolians ancestors who were contemporary with the writing of the Huangdi neijing (Bold, 2009, p. 39). TMM moxibustion uses bundles of ground spices at the Ulaanbaatar Suvilal, these are typically composed of equal parts ground caraway, ground ginger and ground cinnamon, although according to Joergi Zoll, other substances, such as edelweiss can be used. These are wrapped in a small muslin bundle (see fig. 3 below).

Figure 4 A traditional Mongolian moxibustion bundle

These bundles are then heated in shar-tos (clarified butter) until fragrant, then allowed to cool just until they can be applied to the body without causing burns.

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They are then symptomatically applied to one or more of 177 belchir or moxibustion points. There are 22 belchir on the head, 25 on the hands and arms, 28 on the front side of the body, 80 on the back and 22 on the legs.

I was unable to obtain a diagram of the location of belchir, and none of the bookshops stocked a text on the subject that Lagshmaa recommended I consult for a detailed exposition (Dagdanbazar, et al., 2006).

Clearly, this is an subject area which warrants further investigation, though I would have to return to Mongolia during the colder months in order to do so.

In addition to TMM moxibustion, extensive use is made of TCM moxibustion in all its many variations, for a similar range of Cold and Wind-related illnesses.

One interesting characteristic, according to Lagshmaa, is the fact that while TCM moxibustion is applied to TCM points on TCM channels, this is often on the basis of a TMM diagnosis. Joergi Zoll gave me an interesting alternative perspective on this. As he saw it, except for those Mongolians who were trained in China, Mongol doctors are not well versed in diagnostics and differentiation of syndromes applicable for acupuncture. Therefore most Mongol doctors use acupuncture not systematically (as there is little basis for understanding the theoretical background fully, and having the appropriate differential diagnosis), but symptomatically.

I saw one example of this with a patient Natsagdorj, was treating. This was a boy of 10 who was being treated for epilepsy, and accompanied by his grandmother, who answered all his questions on his behalf. The boy was receiving drug therapy as his primary treatment, and this was on the basis of a complex TMM diagnosis. He was also concurrently receiving acupuncture on TCM acupoints recommended for epilepsy based on a much more outline TCM diagnosis of internal wind.

5.2.6 Blood-letting therapy Khanuur, or Mongolian blood-letting therapy (MBLT) is an extensively used therapy in Mongolian traditional medicine, and is a regular treatment at both the Manba Datsan and the Ulaanbaatar Suvilal. 42

Unlike the blood-letting that is sometimes used in TCM, MBLT removes much more substantial quantities, often as much as pint in a single treatment.

Figure 5 MBLT equipment

Typically, MBLT is commonly prescribed for people with Hot and Excess conditions, including a range of fevers, headaches, high blood pressure and some joint problems.

Patients are prepared for blood-letting for a variable number of days, depending on the judgement of the physician, though usually not more than five.

During this period, they are prescribed herbal formulas to assist in the treatment. Kim describes these formulas as Discriminating formulas (Kim, et al., 2011, p. 180), and in personal correspondence explains Discriminating formulas was the translation of (Chinese word for the explanation of Shar tang mainly). As I mentioned in the manuscript, blood-letting therapy in traditional Mongolian medicine is used in the presence of excess fire in the blood. Discriminating Formulas is to separate pathological blood from good blood and source qi which make a better effect in blood-letting process. I think if you know Shar tang then discriminating formula can be understood as it. (Kim, 2011) Shar tang is a herbal formula made from the fruits of Gardenia Jasminoides Ellis, Terminalia chebula RetzI and Melia toosendan Sieb. et Zucc in a ratio of 2:2:1.

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On the day of treatment, the area to be drained is swabbed with alcohol, or another antiseptic, and the vein to be let is isolated by use of a tourniquet a few tsoen (a thumb-knuckle distance used to measure locations for treatment) proximal to the heart. The vein is allowed to swell until it becomes numb, and is then incised, using one of a number of specially designed knives. These knives are not single-use disposable instruments, but are metal re-usable instruments which are sterilised after use.

Blood is then allowed to drain out until the quantity desired by the physician has been obtained. Usually, this is until the colour of the blood issuing has turned from a dark-colour, to a brighter red colour, which is considered more healthy.

Following this, the tourniquet is removed, the incision is cleaned and staunched, and the patient is released, either to their hospital bed, or to their home, where they are advised to rest, and to avoid stimulants such as strong tea or alcohol.

Kim, et al identify 19 commonly-used points for incision, depending on the condition affecting the patient and the individual diagnosis, though he says classical texts refer to at least 90 potential locations (2011, pp. 181-2).

According to my informant Joergi Zoll, MBLT remains a very popular treatment with Mongolian patients, many of whom, in his experience, actively seek vigorous treatments such as this. There is clearly scope for follow-up work on practitioners views on the use of bloodletting, particularly in the context of medical pluralism. TMM practitioners receive extensive biomedical training before going into practice, and following classic studies by PCA Louis and JJ Jackson showing that bloodletting increases, rather than decreases, mortality (Morabia, 1996), biomedicine takes an explicitly sceptical view of its therapeutic value.

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5.2.7 Acupuncture I was told very clearly by Lagshmaa, Joergi Zoll and Lama Natsagdorj that the acupuncture practiced in contemporary Mongolia is TCM acupuncture, and this was largely borne out in my own observations.

The Health Sciences University of Mongolia and Manba Datsan teach people TCM acupuncture, and the points and channels are the same as those in general use in China and elsewhere. Standard text books such as Monkhtuvshin and Altanzul (Monkhtuvshin & Altanzul, 1998) are pure TCM with no techniques or points specific to Mongolia.

Acupuncture is used in a wide variety of conditions, such that I do not propose to detail them individually.

What does mark out Mongolian practice, as with the use of moxibustion, is the symptomatic use of TCM acupuncture to people whose primary diagnosis has been on the basis of TMM theory.

Bold identifies piercing techniques as having been in use in Mongolia from the very earliest times (Bold, 2009) but whatever these techniques might have been, I was not able to see any evidence of them in current practice.

5.2.8 Golden needle therapy Khatgah emchinlee, or golden needle therapy is a traditional Tibetan medical technique that has become incorporated in TMM. It is also used in Bhutan, Nepal and other countries influenced by traditional Tibetan medical practice (Wangchuk, 2009). I dont include this as acupuncture, as although it involves the use of a needle, it has many characteristics of moxibustion, and is used in a different way.

The needles used in golden needle therapy are considerably larger and thicker than acupuncture needles, typically 6cm long and about 1.5mm wide. They are usually made of solid gold, although for some skin conditions, silver needles are preferred. 45

The needles are heated with candles until just before they become red hot, and are then applied superficially to one of a number of points on the head or body. Many of these points correspond to points on TCM meridians, though in my time in Mongolia, I was unable to confirm whether this was coincidental, or a result of shared transmission of ideas.

Golden needle treatment is a therapeutic option for a range of respiratory, orthopaedic, neurological and other diseases (Wangchuk, 2009, p. p64). However, I was told by Lagshmaa that this is a very uncommonly used treatment, because it is extremely painful, and patients dont generally like it.

I found this an interesting contrast with what I was told by Joergi Zoll about patients liking khanuur/blood-letting because of its vigorous nature, and can only speculate (not having received either) that it must hurt quite a bit. This is clearly an area that would benefit from further study at a later date.

5.3

Patient behaviour

5.3.1 Presenting conditions and how patients describe illness Before I went to Mongolia, I was interested to know whether there was a significant element of vernacular self-diagnosis which might show interesting differences to what Samir Al-Adawi describes as patients concepts of health, etiology, anatomical and physiological knowledge, diagnosis and treatment and management of abnormality (Al-Adawi, 1993, p. 67). One Mongolian folk-illness or culture-bound syndrome that I was interested to find more about was Yadargaa, or mental exhaustion, (although Kohrt, who has written an influential paper on it is equivocal as to whether or not it should or should not be considered as a culture-bound syndrome (Kohrt, et al., 2004).)

None of the patients I observed had presented with yadargaa. Lagshmaa considered yadargaa as a Mongolian term for what in England would be considered stressrelated illness.

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All of the patients attending the Manba Datsan came with biomedicine diagnoses, and discussed their conditions in those terms. Those I saw included people who had had, or were currently suffering from stroke, neurological pain, musculoskeletal problems, enterological problems, genitourinary problems, cancer, skin conditions and epilepsy.

Patients made some use of terms to describe their conditions that may be typical to Mongolia, and these include: My kidneys have dropped", or wandering kidneys, to describe lower back pain The kidney is br, so to have kidney trouble or painful kidneys is br vdkh Patients say 'minii br vdj bain' (my kidneys are hurting or sore) for all sorts of lower back pain or uncomfortable feeling in this area. High blood pressure - tsusny deed daralt - and / or "swelling on the head" to refer to head ache. "Turned yellow" as a catch-all term for hepatitis. To turn yellow is shar bolokh (to yellow become). Hepatitis is now called elegnii revsel (liver inflammation) but the older and wider used term is shar vchin ('yellow illness') for hepatitis and also yellow jaundice. "Inside is dirty" - dotor muukhai (inside horrible/foul) or dotor muukhairakh (infinitive) is to feel nausea. "Brain moved" - tarkhi khdlkh to describe concussion.

Digestive problems related to poor hygiene are common, as is severe constipation related to the typical Mongolian diet. This is high in fatty meat (usually mutton), dairy, and processed flour (in the form of noodles, or the dumpling wrappers used in the ubiquitous buuz and khushuu (boiled and fried dumplings filled with minced mutton) but with very low consumption of vegetables. On this point, Joergi Zoll remarked Vegetarianism is not part of the popular diet. People only want to eat meat and wheat. I often see patients with one bowel movement a week and though I will beg them to introduce just a few small vegetables into their diet, they just say bye-bye Ill try Western medicine if I push the point. (Zoll, 2011)

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It is worth noting that despite the prevalence of Buddhism in Mongolia, it is not associated with a vegetarian diet in the same way it is elsewhere in Asia or the west. Even monks and lamas will often not take vegetarian vows, and enjoy the same high meat diet as the rest of the population. I had first-hand experience of this when sharing a lunch of mutton noodle soup with Lama Natsagdorj while I was at the Manba Datsan.

Another regular presenting issue that would not be typical of people visiting complementary medicine practitioners (such as acupuncturists) in England is that of patients presenting with physical trauma sometimes the result of injuries sustained during hard manual labour, but often as a result of alcohol intoxication accidents or fights. In Joergi Zolls words, again, I often get asked to help treat the consequences of heavy drinking, but nobody ever asks for help with cutting down their alcohol intake, as its not considered unusual or harmful. I was not given similar observations by Lagshmaa or Natsagdorj, though possibly as native Mongolians, they would not have considered this remarkable.

5.3.2 The socialising of consultation and treatment In Mongolia, .the process of consultation and treatment is not a private and confidential transaction between patient and practitioner, but a social interaction which involves the family and friends of the patient throughout the process.

This expectation of a wider involvement of social networks in the therapeutic process is not typical just to Mongolia. Speaking of similar issues in treating North American Indians in mainstream hospitals, Daley and Daley note Health is not simply an individual issue; rather it is something of which the entire family is a part (Daley & Daley, 2003, p. 121).

I was able to see this very practically demonstrated in the Manba Datsan, whereby a patient would check with her husband or friend exactly where the pain was worst, or when the symptoms first appeared, or how they would comply with treatment. The family members or friends were also quite comfortable making unsolicited contributions to the consultation process. They are equally involved in the discussion about the treatment process and compliance with any associated instructions. 48

This indicates a very different attitude to patient confidentiality, as rather than wanting to keep patient information secret from others, the involvement by the patients family and friends is actively sought. This isnt to say that the individual dimension is lost. I appreciate that with my limited knowledge of the language and the constraints placed on understanding by the need for translation and the barriers of the associated costs that I may have missed subtleties and nuances. Nevertheless, it seemed clear to me from observing these interactions, that the patient remained the primary focus, and that the family members of friends took on a supporting role within generally understood limits. Kleinman, Eisenberg and Good describe how The medical encounter is but one step in a more inclusive sequence. The illness process begins with personal awareness of a change in body feeling and continues with the labelling of the sufferer by family or by self as ill. Personal and family action is undertaken to bring about recovery, advice is sought from members of the extended family or the community, and professional and marginal practitioners are consulted. (Kleinman, et al., 2006)

TMM recognises this social dimension of illness by embracing both the patient and his or her support network. Rather than just seeking to identify the causes of a disease and cure it, it is able to respond not just to the issues affecting the individual, but also, to his or her family and friends and their wider community. I saw numerous examples of this with grandparents and grandchildren, husbands and wives or pairs of friends taking part in and contributing to the consultation process.

6. Discussion My study has covered a wide range of subjects in what I hope has been enough detail to give people with no previous knowledge of TMM a working idea of its main concepts and techniques, and a sense of how it is practiced in Ulaanbaatar.

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6.1

Reflections

Traditional Mongolian Medicine is a pluralistic and diverse body of medical practice, which has incorporated and adapted a range of techniques over many centuries.

As a result of my clinical observations of patients, practitioners and practice, supplemented by interviews and in-country research I am now clearer about what this involves.

The largest component of this is Tibetan-derived ayurvedic medicine, which has been modified and expanded since it was introduced by Tibetan Buddhist missionaries in the 16th century, to suit Mongolian conditions, diseases and materia medica. This provides the basis of the theoretical framework used by the TMM physicians I engaged with in this research. TMM theory has also incorporated elements of TCM theory such as Five Element theory and Yin Yang theory. It is increasingly incorporating elements of Biomedicine, particularly modern diagnostic and scanning equipment.

I have also been able to identify specific techniques used with an indication of how and why they are applied.

The strong role of Buddhism in current practice is clear. This includes overt religious elements such as the use of religious services for healing, but also the ubiquitous involvement of Buddhist monks and institutions in the teaching and practice of TMM.

Acupuncture itself appears identical to TCM acupuncture, though the way it is applied in conjunction with TMM diagnoses is unusual.

There is a diverse range of clinical interventions used, including drug therapies, a Mongolian style of moxibustion known as toonr, bloodletting therapy khanuur and balneotherapy, which do not appear widely known In China or Tibet.

The use of heat treatments such as toonr could perhaps be seen as related to Mongolias harsh winter climate and a means to tackle conditions associated with cold. This was certainly the view of early writers in China as expressed in the 50

Huangdi Neijing (Anon., 1990) and would seem to be backed up by the fact that the use of toonr is mostly related to winter conditions. I would like to observe the clinical use of toonr in more detail, at an appropriate time of the year.

Khanuur has been used in Mongolia since the very earliest times, and is referred to in the earliest records of medical practice (Bold, 2009). However, in its current manifestation, there seem to me to be many similarities to the use of bloodletting in Western humoural medicine (Kerridge & Lowe, 1995), namely the relief of excess conditions associated with blood. Mongolian medicine was influenced by the teachings of classical Islamic medicine during the imperial period, which was based on Greco-Roman humoural theory, and it is interesting to speculate that there is a connection, though this would require further study.

Balneotherapy is considered a very early therapy and related to pre-Buddhist and Shamanic beliefs about the therapeutic properties of lakes and watercourses (Bold, 2009).

Patient behaviour includes a number of self-diagnostic expressions typical to Mongolia, and is characterised by the involvement of family and friends throughout the consultation and treatment process in a manner I have not seen in the UK, and could have wider significance in the way UK practitioners treat patients from other ethnic groups, and what is considered to be holistic treatment.

During the course of my research, I came ever more strongly to the opinion that a signature characteristic of TMM is its diversity of influences and a manifestation of medical pluralism which seems very Mongolian.

Saijirahu describes the development and current state of Traditional Mongolian Medicine in Chinas Inner Mongolia Autonomous Region as one with a continuous theme of pluralism (Saijirahu, 2008b). This very much echoes my own impressions of medical practice in Mongolia itself. Firstly, TMM is internally heterogeneous by this, I mean that the TMM physician is expected to understand and practice a range of different techniques, such as drug 51

therapy, moxibustion, bloodletting, massage and balneotherapy. These techniques are practiced in an integrated manner, and not in separate professional silos such as we might see in the UK.

It is also externally heterogeneous. The Tibetan-derived Buddhist tradition, which in my experience appears dominant, has incorporated elements from dhom folk medicine, such as toonr / moxibustion and khanuur / bloodletting. It has adopted and incorporated Yin and Yang (bilig and arga), Five Element theory and acupuncture.

The core Traditional Tibetan Medicine (TTM) elements are the same in many other countries: Tibet, parts of India, Bhutan, Inner Mongolia, and Qinghai (the Tibetan majority province of China). In these places, they are practiced as a separate discipline. TCM is also taught and practiced as a distinct discipline in most countries, such as China, Korea, Japan and the West. Traditional Chinese and Traditional Mongolian Medicine are both taught at Hukhhot, Tongliao and other Inner Mongolia universities in separate departments, in their respective languages (Inner Mongolia Medical College, n.d.). According to Joergi Zoll, who has attended these colleges, there is no cross-over of instructors and practitioners here, as the disciplines are considered too different (Zoll, 2011).Mongolia therefore appears unusual in that it freely mixes TCM and TTM despite the fact that elsewhere they appear to be considered theoretically incompatible.

This pluralism now seems to be operating with regards to Biomedicine. TMM is taught as part of the curriculum at the Health Sciences University of Mongolia and the state health insurance system supports the Ulaanbaatar Suvilal. The Suvilal is fully integrated into the health system, so TMM physicians can share medical records with colleagues in the Biomedicine hospitals, and dispense Biomedicine prescriptions to patients. The Manba Datsan is not a part of the state health system, but it also is investing in Western diagnostic equipment, so it can offer ultrasound and x-rays as well as traditional diagnoses.

Janes discusses how in Tibet, an effect of medical pluralism is TTM becoming disembedded from local contexts of practice and reconstituted as part of a 52

centralized system of technical accomplishment and professional expertise which in turn is expected to conform to the pervasive and powerful cultural standards of rational science and biomedicine (1995, p. 24). This is supported by Fan & Holliday in their investigation of pluralism in Tibet, Inner Mongolia and Xinjiang (2007). This manifests as an increasing importance of training students in biomedical theory and practice at the expense of traditional medicine classics.

The situation is not so clear cut in Mongolia. Natsagdorj describes the curriculum at the Manba Datsan as 60% TMM and 40% biomedicine. The balance of the curriculum at the National Medical University of Mongolia (NMUM) is reversed - 40% TMM and 60% biomedicine.

This shows diversity in the training base and what is considered appropriate from TMM practitioners. Lagshmaa adds the further important detail, that while the NMUM curriculum is weighted towards biomedicine, in clinic (she was referring to the Ulaanbaatar Suvilal), 75% of what they do is TMM.

Natsagdorj spoke about conditions to me in biomedical terms, but was clearly making diagnoses with TMM techniques. The widespread criticism of therapeutic bloodletting in biomedicine, does not appear to have affected the use and popularity of Khanuur. Nor does the situation Fan and Holliday describe whereby for most medical problems, MSM [modern scientific medicine] should do the main work, although TRM [traditional medicine] may offer minor complementary assistance (2007, p. 456) apply. Natsagdorj clearly considered the Manba Datsan to be taking an effective lead role in treating serious conditions such as cancer (see 5.1 and 5.2, above).

Scheid describes how TCM physicians in China have demonstrated their own diverse and distinctive paths towards modernization and an integration with biomedicine that sometimes struggled to resolve theoretical contradictions (2004). In Mongolia, any such struggles were not apparent to me, and the physicians I spoke with seemed completely comfortable with the current diversity of medicine in Mongolia.

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It seems to me that this is entirely in keeping with Mongolias demonstrable openness to external influences throughout its history and the immensely practical nature of most of the Mongolians I met on my visit. It is tempting to speculate that this may be related to their long tradition of nomadism, evidenced by the prevalence of many gers today even in conurbations like Ulaanbaatar. In Mongolia, medical pluralism is traditional.

As well as its pluralism, TMM seems to be much more of a social experience than any form of mainstream Western or alternative medicine in the UK. By this I mean the way that friends and family are engaged and contribute throughout the treatment process. Confidentiality is considered such an important value in the UK that it effectively cuts people off from their social networks during the process of treatment and diagnosis. It seems to me that the Mongolian approach is mo re truly holistic in that it recognises the social dimension of illness and addresses it as a natural part of the process of diagnosis and treatment.

6.2

A reflection on the process of research

The German field marshal Helmuth von Moltke is famously quoted as saying "No plan of operations extends with certainty beyond the first encounter with the enemy's main strength" (or more succinctly "no plan survives contact with the enemy") (Moltke, 1892-1912) in (Hughes, 1993, pp. 45-47).

While this research has not been a battle, and the people who I worked with in Mongolia during the course of this research were not by any means the enemy (quite the opposite, as their support made this research possible), the basic point holds true that it is normal to have to adapt ones plans to the realities one encounters when they are put into practice.

This has certainly been a continuing factor throughout this research. I had identified in my plan for analysis the importance of dialogue between ethnographer and those being observed, so that the direction of study could be flexible, open ended, and selfreflective. In reading these guidelines in my methodological sources, I had not understood quite what significant factors they would prove. I think that the academic

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convention of using calm, measured language strips such recommendations of a level of emotional urgency which those looking for a how to guide would find useful.

The practical reality was that everything took longer, or had to be done differently than I had envisaged, or developed down paths I had not anticipated.

This was starting to become apparent when I tried to agree how to make best use of my field research time in advance of my visit, and I had to adapt to the reality that this is not how business is conducted in Mongolia, and gamble that I would be able to make suitable arrangements in-country, once I could meet people face to face.

Once I had arrived in Mongolia, I had to adapt once again. I am by nature quite a reserved person, and needed to become considerably more outgoing in order to establish contact with experts in TMM and negotiate time with them in which to observe clinical practice and discuss their insights.

One illustrative example of this at its most basic, involved making my way by foot around Ulaanbaatar to find the Manba Datsan two days after my arrival, since a power cut at the National University of Mongolia had it impossible to make contact with Demchig, my in-country contact. Once Id found the Datsan, I then had to talk my way around security guards and administrators in order to get to speak with Natsagdorj, remind him of our correspondence and agree time to speak with him and observe clinical practice.

My plan had to adapt to the reality that while TMM is virtually unknown in the UK, it is an established part of academic knowledge in Mongolia. To leading experts in the field, such as Natsagdorj and Lagshmaa, the natural response to meeting someone who wanted to know more about their field of expertise would be to recommend they read a textbook. Explaining that there were no such textbooks available to UK scholars and that I was interested in primary observation and their personal insights into fundamentals required some sensitive negotiation.

One of my main contacts, Joergi Zoll was introduced to me completely by chance, as I had no knowledge of him beforehand. Had I not been talking with the Scottish 55

proprietor of Mary and Martha, a shop selling fair-trade tourist memorabilia, and happened to discuss my research with her, I would never have known that he existed. Yet as a Western-trained acupuncturist, who was involved with TMM professional and academic networks in Mongolia and Inner Mongolia, he was able to provide a crucial informed outsiders perspective to my studies.

What I have learned from this is threefold. Were I starting my research again from scratch, I would have included a preliminary visit to Mongolia to establish personal contacts and discuss directions of research on a face to face basis, as this is the way things are done. Having to factor this in would probably have been an insuperable barrier, since it would have made the research trip unaffordable. Having now been to Mongolia though, and made face to face introductions and contacts, I am in a considerably stronger position to carry out any future research.

Secondly, while abstract methodology is essential to provide structure and context, ethnographic research is all about people and relationships. Bringing your own personal qualities to bear to develop those relationships is essential to being able to carry out the research, and such contacts are people one needs to continue to cultivate after the immediate research is concluded. This now helps me make sense of the way my friend David Sneath (who is a professional anthropologist) talks about his own contacts amongst Mongolian nomadic herders as a precious resource.

Finally, the unexpected circumstances that were a regular feature of parts of my research, and the need to continuously adapt to them are not extrinsic to the process, but an intrinsic feature of the process. Chaos is a constant factor of any such research involving people from an unfamiliar culture, and looking back, it was never likely that I would have been able to go half way around the planet to ask people I did not know to share their time and expertise with me, and expect everything to go to plan.

Having now been through the process of organising and carrying out observational ethnographic research, I think I am in a much stronger position to carry out similar research in future, and would be much more confident in doing so, having acquired personal experience of the necessary skills and the likely pitfalls. 56

6.3

Implication of findings upon practice, and future research

I was clear in my introduction that I have been more interested in describing what TMM does rather than assessing whether it works. This complicates any consideration of what, if any, TMM techniques might make a useful contribution to my own clinical practice.

It is probably easier to identify those techniques which I consider unlikely to gain popularity outside Mongolia.

It is my opinion that alternative medicine patients in the UK are likely to prove squeamish about therapies involving the application of animal products such as are used in some balneotherapy treatments and in entrails therapy.

Khanuur / bloodletting is a significant part of the TMM tradition, but one I see no possible practical means of applying in a typical clinical setting. The amounts of blood extracted would almost certainly be considered unsafe to extract by anyone except a qualified Biomedicine doctor. If it were to happen in the UK, I think it likely that practitioners would be required to use single-use disposal instruments for the incision and extraction of blood, and there is no source for such instruments.

Disposing of the considerable quantities of blood legally and safely would also create practical difficulties for UK practitioners outside of a hospital setting.

Bloodletting is also considered to have a negative effect on patient health by most biomedical authorities in the UK.

As someone who makes considerable use of TCM moxibustion in my day to day practice, I am naturally interested in Mongolian toonr / moxibustion for how it might add further depth and character to my treatments. Having now discovered that toonr exists and that the best time of year to see it used is during the cold months of the year, I can now, when time and funds allow, make arrangements to return to Mongolia and observe its application in practice. I am particularly interested to

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determine how the process of heating the spice bundles and applying them to belchir is done and to learn more about the number, properties and location of belchir.

The social nature of the consultation and treatment experience is one that strikes me as incredibly important, not just for acupuncture clinical practice, but for clinical practice in all medical professions. The recognition that people from some ethnic groups consider it normal to bring family and friends to consultations and treatments leads me to consider whether the patient-centred one-to-one scenario typical of UK clinical practice, resulting from our own culturally-specific reasons of patient confidentiality, might also be discouraging patient engagement from some social and ethnic groups.

I also wonder whether there might be any effect on clinical outcomes by involving patients social support networks more closely in the normal process of consultation and treatment.

Drug therapy forms a substantial part of the repertoire of TMM physicians. I was only able to touch the outside edges of this considerable body of knowledge. A more substantial study of the TMM materia medica and how it is applied would be of interest, particularly to TCM practitioner in the West who practice herbal treatments in addition to acupuncture.

Having said that I have not been interested in whether TMM works or not, effectiveness is obviously a significant issue. In my analysis of my fieldwork I mentioned how Natsagdorj claimed to have been able to effect cures of some cancers, and he was similarly upbeat about the effectiveness of his treatments in other conditions not considered amenable to Western medical treatments.

There is clearly therefore, scope for patient outcome studies for different treatments in conditions, though adapting evaluative techniques designed for a western cultural setting would to a Mongolian setting would itself require some further study.

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7. Conclusion While all of these areas could be considered in considerably greater detail in future research, I believe I have been able to provide for the first time, a resource for future UK-based English speaking scholars in need of a starting point for further research into theories and techniques of TMM. I have also demonstrated that in Mongolia, medical pluralism is nothing new, and Mongolia has been adopting, adapting and incorporating new medical ideas since very early times, and indeed pluralism seems 'traditional'. This provides a new, Mongolian, dimension to the ongoing academic debate on medical pluralism.

ENDS

8. Bibliography and references Al-Adawi, S., 1993. A glimpse into traditional outlook towards health: A literature review. Journal of Medical Humanities, 14(2), pp. 67-79. Angrosino, M. V., 2005. Recontextualizing observation: ethnography, pedagogy and the prospects for a progressive political agenda. In: The SAGE handbook of qualitative research. s.l.:SAGE. Anon., 1990. A complete translation of the Yellow Emperor's classics of internal medicine. s.l.:s.n. Badarchin, D., 1989. uu t nuur asal. s.l.:Ulsyn Kh vl li n Gazar. Bernstein, J. A., Stibich, M. A. & LeBaron, S., 2002. Use of traditional medicine in Mongolia: a survey. Complementary Therapies in Medicine, 10(1), pp. 42-45. Bold, S., 2009. History and development of traditional Mongolian medicine. 2nd ed. Ulaanbaatar: Bold Sharav. Buell, P., 2009. A query about acupuncture in Mongolia [personal email correspondence]. s.l.:s.n. Clifford, T., 1989. The diamond healing: Tibetan Buddhist medicine and psychiatry. s.l.:Crucible. Crozier, R. C., 1968. Traditional Medicine in Modern China. London: Oxford University Press. Dagdanbazar, Bolortamir & Zina, 2006. Ulamjlalt anagaakh ukhanii zasal. Ulaanbaatar: B Dagdanbazar. Daley, C. M. & Daley, S. M., 2003. Care of American Indians and Alaska natives. In: B. JudyAnn, ed. Cross-cultural medicine. s.l.:American College of PhysiciansAmerican Society of Internal Medicine, pp. 95-128. Denzin, N. K. & Lincoln, Y. S. eds., 2005. The SAGE handbook of qualitative research. s.l.:SAGE. ESRC, 2009. Research ethics framework. [Online] Available at: http://www.esrc.ac.uk/ESRCInfoCentre/Images/ESRC_Re_Ethics_Frame_tcm611291.pdf 59

Field, M. G., 1973. The concept of the "health system" at the macrosociological level. Social Science and Medicine, 7(10), pp. 763-785. Foster, S. W., 1982. The exotic as a symbolic system. Dialectical Anthropology, 7(1), pp. 21-30. Frankenberg, R., 1980. Medical anthropology and development: a theoretical perspective. Social Science & Medicine: Medical Anthropology, 14B(4), pp. 197-207. Gonpo, Y. Y., 2011. The root tantra and the explanatory tantra from the quintessential instructions on the eight branches of the ambrosia essence tantra. 2nd ed. Dharamsala: Men-Tsee-Khang. Haffner, J. C. et al., 2004. Mongolian horses: training and racing. Journal of Equine Veterninary Science, 24(1), pp. 5-8. Hammersley, M. & Atkinson, P., 2007. Ethnography: Principles in Practice. 3rd ed. New York: Routledge. Haralambos, M. & Heald, R., 1980. Sociology: themes and perspectives. s.l.:University Tutorial Press. Helman, C. G., 1990. Culture health and illness. 2nd ed. Oxford: ButterworthHeinemann Ltd. Hughes, D. J. ed., 1993. Moltke on the Art of War: selected writings. New York: Presidio Press. Inner Mongolia Medical College, n.d. Inner Mongolia Medical College. [Online] Available at: http://www.immc.edu.cn/ [Accessed September 2010]. Janes, C. R., 1995. The Transformations of Tibetan Medicine. Medical Anthropology Quarterly, 9(1), pp. 6-39. Janes, C. R. & Hilliard, C., 2005. Inventing Tradition: Tibetan Medicine in the PostSocialist Contexts of China and Mongolia. [Online] Available at: http://www.mongoliacenter.org/docs/2005/janes_lecture.pdf [Accessed July 2011]. Janzen, J. M., 1978. The comparative study of medical systems as changing social systems. Social Science & Medicine, 12(2B), pp. 121-133. Jigmed, B., 1985. Mongkhol Anakhaqu Uqakhan-u Tobci Teuke (A brief history of traditional Mongolian medicine). Chifeng: Inner Mongolia Science and Technology Press. Kim, T.-H., 2011. Respose to your question: Mongolian traditional Medicine [personal email correspondence]. s.l.:s.n. Kim, T.-H., Basargard, L., Kim, J.-I. & Lee, M. S., 2011. Mongolian traditional style blood-letting therapy: A brief introduction. Complementary Therapies in Clinical Practice, Issue 17(3), pp. 179-183. King, M., 2009. Healing Acts as Conversion Narratives in Early Mongolian Religious Histories. s.l., IASTAM. Kleinman, A., Eisenberg, L. & Good, B., 2006. Culture, Illness, and Care: Clinical Lessons From Anthropologic and Cross-Cultural Research. Focus, Issue 4, pp. 140149. Kohrt, B. A., Hruschka, D. J., Kohrt, H. E. & Panebi, N. L., 2004. Distribution of distress in post-socialist Mongolia: a cultural epidemiology of yadargaa. Social Science & Medicine, Issue 58, pp. 471-485. Leach, E., 1982. Social Anthropology. s.l.:Fontana. Leslie, C., 1980. Medical pluralism in world perspective. Social Science & Medicine, 14b(4), pp. 191-195.

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Leslie, C., 1992. Interpretations of Illness: Syncretism in Modern Ayurveda. In: C. Leslie & A. Young, eds. Paths to Asian Knowledge. Berkeley: University of California Press, p. 177208. Leslie, C. & Young, A. eds., 1992. Paths to Asian Knowledge. Berkeley: University of California Press. Lock, M. M., 1980. East Asian Medicine in Urban Japan: Varieties of Medical Experience. Berkeley: University of California Press. Lock, M., n.d. Rationalization of Japanese herbal medication: the hegemony of orchestrated pluralism. Human Organization, 49(1), pp. 41-47. Lo, V., 2009. A query about acupuncture in Mongolia [personal email correspondence]. s.l.:s.n. Manba Datsan Clinic and Training Centre for Traditional Mondolian Medicine, Otoch Manramba Mongolian Traditional Medical Institute, 2011. Manba Datsan Clinic and Training Centre for Traditional Mongolian Medicine, Otoch Manramba Mongolian Traditional Medical Institute. s.l.:Manba Datsan Clinic and Training Centre for Traditional Mongolian Medicine, Otoch Manramba Mongolian Traditional Medical Institute. Manba Datsan Training Centre of Traditional Mongolian Medicine, n.d. Manba Datsan Training Centre of Traditional Mongolian Medicine. [Online] Available at: www.manbadatsan.mn/index_en.php?menuid=2 [Accessed September 2011]. Marcus, G. E., 1997. The uses of complicity in the changing mise-en-scne of anthropological fieldwork. Reflections, Issue 59, pp. 85-108. Moltke, H. G. v., 1892-1912. Moltkes Militrische Werke. Berlin: s.n. Monkhtuvshin, T. & Altanzul, O., 1998. Tavan makhbodiin soronzon z, z toonriin emchilgee. Ulaanbaatar: s.n. Munkh-Amgalan, Y. & Tsend-Ayush, G., 2002. Academician Tsend Haidav Innovator of Traditional Mongolian Medicine. AyurVijnana, Issue 8, pp. 28-31. Odontsetseg, G. & Natsagdorj, D., 2010. Onosh zui: Ulamjlalt anagaakh ukhaan. Ulaanbaatar: Otoch Manramba. Saijirahu, 2004. On Shamanic Healings of Qorcin Region in Eastern Inner Mongolia. Language, Area and Cultural Studies, Issue 10, pp. 157-176. Saijirahu, 2005. On Andai Therapy in Traditional Mongolian Medicine. Chinese Journal of Medical History, 35(2), pp. 105-109. Saijirahu, 2007. On the Development of Traditional Mongolian Medicine in the 20th Century Inner Monogolia. Chinese Journal of Medical History, 37(2), pp. 88-93. Saijirahu, 2008a. The Folk Healer in Medical Pluralism- A Case Study on Yasu Bariyaci in Eastern Inner Mongolia. Bulletin of Japanese Association for Mongolian Studies, Issue 38, pp. 19-34. Saijirahu, 2009. The Folk Healer in Medical Pluralism- A Case Study on Yasu Bariyaci in Eastern Inner Mongolia. Bulletin of Japanese Association for Mongolian Studies, Issue 39, pp. 31-38. Saijirahu, B., 2008b. Folk Medicine among the Mongols in Inner Mongolia. Asian Medicine, 4(2), pp. 338-356. Scheid, V., 2004. Sorting Out Tradition: The Ding Current in Chinese Medicine. [Online] Available at: http://www.volkerscheid.co.uk/downloads/Ding_Current.pdf [Accessed 20 January 2012]. Scheid, V., 2009. A query about acupuncture in Mongolia [personal email correspondence]. s.l.:s.n.

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Sneath, D., 2009. Inner Mongolian Acupuncture [personal email correspondence]. s.l.:s.n. Sneath, D., 2011. Manba Datsan details [personal email correspondence]. s.l.:s.n. The Mongol Messenger, 2003. The Mongol Messenger, Issue 44. Unschuld, P. U., 1985. Medicine in China: a history of ideas. Berkeley: University of California Press. Unschuld, P. U., 1992. Epistemological issues and changing legitimation: Traditional Chinese medicine in the twentieth century. In: C. Leslie & A. Young, eds. Paths to Asian medical knowledge. Berkeley: University of California Press, pp. 44-61. Wangchuk, T., 2009. Golden Needle Therapy (Serkhap). Menjong Sorig Journal, Issue 2, pp. 62-65. Ward, T., 2009. Feedback on DRP [personal correspondence]. s.l.:s.n. Weiss, M., 1997. Explanatory Model Interview Catalogue (EMIC): Framework for comparative study of illness. Transcultural Psychiatry, 34(2), pp. 235-263. Zoll, J., 2011. Acupuncture and moxibustion in Mongolia [personal email correspondence]. s.l.:s.n. Zoll, J., 2011. Interview with Joergi Zoll [Interview] (21 June 2011).

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9. Appendix 1: email correspondence

Correspondence with David Sneath, University of Cambridge, Mongolia and Inner Asia Studies Unit
From: <ds114@cam.ac.uk> To: "John Donegan" <john@johndonegan.com> Subject: Inner Mongolian acupuncture Date: 05 February 2009 19:28

Hi John, OK, it's not a whole lot, but this is what I have found out so far. My informants were 2 scholars (Altanbulag and Hurelbaatar) here at MIASU from Inner Mongolia, the latter an old friend who is here long-term. I assume this information is more or less right, but cannot be absolutely sure it is completely accurate in all respects. _________________________

Acupuncture is known as zuu tavih emchilgee in (Outer) Mongolia today, (i.e. zuu-placing treatment), but in Inner Mongolia (and I think in the past everywhere) called mngn juu (the z and j are interchanged in Inner / Outer Mongolian) - i.e. 'silver juu/zuu' (sometimes tmr juu - iron juu/zuu).

While it is possible that the Mongolian acupuncture practices may derive from Chinese traditions in some part, it was an element of the Tibetan corpus of medicine, introduced as part of the introduction of Buddhist monastic life in the 16-17th centuries (reaching their institutional peak 19th century). The main Tibetan text on this was translated into Mongolia as Drbn Undes 'The Four Basics/Bases' - the most famous 'medical textbook' studied by lama-doctors (as those who specialised in medicine are sometimes called).

Both Altanbulag and Hurelbaatar seem to think that the Mongolian acupuncture tradition as it existed and exists in Inner Mongolia really is distinct from the Chinese one, but quite how different the system is, they could not say. (The relationship could be slightly unclear since there is a separate art of bloodletting / boil-lancing which can also involve (thicker) needles). But, as far as they know there is a 'tradition' of Mongolian medicine called the Taban Jasal (Tavan zasal Outer Mongolian) or Five Treatments; one of these is cupping, one of these bloodletting, and another is acupuncture.

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There are, Hurelbaatar is sure, many books in Mongolian on the acupuncture practice, some of them from the experience of Mongolian practitioners of the past. He thinks the Mongol tradition probably uses somewhat thicker needles, concentrates more on joints, and makes greater use of 'flaming' needles - i.e. putting cotton or something on the ends soaked in butter and ignited (sounds lovely!!). He thinks some of these books might include diagrams (since it seemed to me that someone with limited access to translation from Mongolian old-script might be able to get some way by comparing charts of acupuncture points or some such, since more information is in the diagram not the text). Altanbulag thinks there is a bronze statue in a museum in Hohhot (capital of Inner Mongolia) which shows the points for Mongolian acupuncture; but can't say anything more about it. (But I found a paper on the Qing dynasty Golden Mirror medical text [Marta Hanson 2003 in the journal 'Early Science & Medicine'] and that shows a bronze acupuncture man presented by the Qianlong emperor to court doctors and it looks pretty useless to me for comparative purposes since the 'points' seems distributed pretty evenly over the whole body, and indeed this may be the sort of bronze statue Altanbulag is thinking of - i.e. it maybe Qing (Manchu-Mongol) rather than really just Mongol).

Both agree that there is an institute for the study of 'Traditional Mongolian Medicine' (as a local variant of the well-established Chinese state 'traditional medicine' sector). Hurelbaatar said this is in Tongliao (Liaoning area), having moved there from Hohhot in the early 1990s. He thinks they publish a journal etc. in Mongolian. If this is true, presumably they have text books, charts and so on - however arrived at (i.e. possibly just Mongolian versions of the [now standardised?] current Chinese ones).

That's about all I could get out of them. They'll have a look for any web-based info they can easily access on the subject. It seems to me that the main problem for a non-Mongolist such as yourself is the language, since even when you got the literature you'd need someone with good old-script & possibly even slightly technical Mongolian to translate it. But then I don't know how much 'raw' material a thesis of the sort you'll be writing will need. A quick look on JSTOR comes up with very little on Mongolian acupuncture (I mentioned the Qing paper, which does not really help) and actually very little even on Tibetan acupuncture (although the tradition is mentioned as such in one book review while noting, exasperatingly, that it is not dealt with in the text (about a book on Tibetan medicine).

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So, it may all be rather a slender and chancy basis for a thesis. Or, I don't know, it could be that on some technical matter of something like - say - existing studies of the different schemes for the location of chi-points the chart used by the Tongliao institute (assuming you could get it and the pattern was pretty recognisable) could show an interesting Mongolian variant that would let you conclude something or other with respect to the other debates... But you'd know about that.

OK, hope that's some help. I'll pass on anything else H and A come up with, just for your interest as much as for any other reason. Best of luck and let me know if there's something I can do.

Dave

---------------------------------------------------------------------------------------------------------Correspondence between Paul Buell (author), Vivienne Lo (University College London) and Volker Scheidt (University of Westminster)

From: <pbuell@speakeasy.net> To: "Volker Scheid" <scheidv@westminster.ac.uk>; "John Donegan" <john@johndonegan.com>; "Vivienne Lo" <v.lo@ucl.ac.uk> Cc: <pbuell@speakeasy.net> Subject: RE: A query about acupuncture in Mongolia Date: 13 January 2009 14:46

I, alas, can't help much.

There are a number of Mongols who are working on modern Mongolian medicine including a man whose name I forget who is on the IASTAM mailing list and posts frequently. He sent me some interesting papers but, alas, they are back in Seattle somewhere and I am in Berlin. Try posting an inquiry on the IASTAM list and he should reply. V, whatever happened to that Mongol lady working on the topic? Her dad was a practitioner, as I remember.

The best stuff is in Chinese, alas. I have many of the books but, like those papers, they are in storage. Any large library with an East Asia collection should have things of interest. The last issue of the IASTAM Journal has an article by one of the Buriats and they are doing good suff, mostly in Russian. Stuff from the MPR is hard to get and, of course, in Mongolian. Greatest interest there is in herbal and deitary medicine including a book being published in parts by

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Boldsaykhan. I got a volume from the New York Mongol people. It is in English and Mongolian

I will be doing MUCH more with this in the second Edition of A Soup for the Qan but the relevant material is not ready for the world yet. Suffice it to say that there is much more source material than I at first realized.

Better address for me is paul-david.buell@charite.de

Keep in touch and I will share more as my research develops.

PDB

On Tue Jan 13 4:45 , "Vivienne Lo" sent:

Message

Dear John Donegan,

Paul Buell's email is above. There are a few people working on Mongolian medicine. one of the best chapters I've seen on medieval medicine is Allsen, Thomas T. 2001. Medicine >in Culture and Conquest in Mongol Eurasia. Cambridge University Press, 2001., 141 -144. and these are some of Paul's: Buell Paul D. 1968. Some Aspects of the Origin and Development of the Religious Institutions of the Early Yan Period, unpublished MA dissertation, University of Washington.

Buell Paul, and Eugene Anderson 2000, A Soup for the Qan, London and New York, Kegan Paul International. > Buell, Paul 2007, How did Persian and Other Western Medical Knowledge Move East, and Chinese West? A Look at the Role of Rashd al-Dn and Others Asian Medicine 3, pp. 279-295.

He will tell you about others that mayb e relevant. There are some people working on more modern period, but i'll let you know if I come across them. Perhaps Paul can tell us.

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good luck,

Vivienne

-----Original Message----From: Volker Scheid [mailto:scheidv@westminster.ac.uk] Sent: 12 January 2009 18:10 To: John Donegan Cc: Vivienne Lo Subject: Re: A query about acupuncture in Mongolia

Hi

Thanks for your mail. Your project sounds very interesting but I am afraid I don't know much about Mongolia. I suggest you contact Paul Buell who is an expert on this part of the world and its history. I have not got his email at hand but that should be easy to find. Another person with useful contacts might be Vivienne Lo at UCL <v.lo@ucl.ac.uk>

Best wishes and good luck

Volker

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10. Appendix 2: The qualities of the three elements and seven constitutions 10.1 Khii - Wind Khii has many characteristics in common with Qi in TCM it is a dynamic and energetic essence, which is neither hot nor cold, and neither Arga nor bilig. Khii has five types and six qualities.

Khii Types of Khii Life sustaining khii, is located in the brain and supports swallowing, breathing, spitting, belching, sneezing, and the proper function of the mind and senses. Qualities of Khii It is light. This is both physically and metaphorically, so someone with a constitution that tended towards khii would see this expressed through a tendency to sing and dance, and to move and talk with fluency. It is mobile. Khii is able to move everywhere, just as wind (in the general sense) does. In pathological cases, this manifests in pain that is hard to locate, or an unstable state-ofmind. Khii is neither hot nor cold, and is therefore able to combine with shar (which is hot) and badgan (which is cold)

Ascending khii, located in the chest, responsible for speech, bodily vigour, skin tone and mental activity.

Pervasive Khii located in the Heart, and which is responsible for the function of the limbs and the opening and closing of bodily orifices, including the mouth, eyelids and anus. Supportive khii is located in the stomach and supports shar in the process of digestion and metabolism and in the formation of the physical substance of the body. Downwards-voiding khii, is located in the rectum and is responsible for defaecation, urination, ejaculation, menstruation and childbirth.

Khii is thin, and is able to pass through all the channels, holes and vessels within the body.

Khii is hard, and therefore is responsible for ensuring strong muscle tone and functioning organs.

Khii is rough, as opposed to the oiliness of shar and the smoothness of badgan. This manifests in a dry, taut skin tone.
Table 4 Types and qualities of Khii

10.2 Shar - Bile 68

Shar is hot and Arga. It has five types and seven qualities.

Shar Types of Shar Qualities of Shar

Digestive Shar, is located in the stomach and Shar is hot. It regulates the temperature and intestines, and its function is to support energy of the body. digestion, to break down and separate nutrients from waste. It keeps the body warm and provides energy for the other types of shar. Colour-regulating Shar, is located in the Liver Shar is sharp, and those with a constitutional and is responsible for the production and tendency towards Shar are considered to be regulation of Blood. proud, easily angered, intelligent and clear thinking. Determining Shar, is located in the heart and is responsible for hot emotions such as anger and desire, aggression, hatred, competitiveness and ambition. Sight Shar is located in the eyes and regulates vision. Shar is oily. It is responsible for the secretion of oil from the skin and an oily texture to the body.

Shar has lightness. Bold differentiates this from the lightness of khii by describing how this lightness has a Hot quality and links together all the functions of Shar (Bold, 2009, p. p223). Shar is pungent, and has a characteristic smell, which is evident in the perspiration, urine and faeces of people with an excess of Shar. Shar is smooth, particularly with respect to bowel functions, and people with a Shar constitution have smooth stomachs as a result. Shar is moist, and therefore Shar controls the release of all body fluids.

Skin Shar, is located in the skin and is responsible for healthy, lustrous skin.

Table 5 Types and qualities of Shar

10.3 Badgan - Phlegm Badgan is bilig and cold. It has five types and seven qualities.

Badgan

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Types of Badgan Supportive Badgan, which is located in the chest. This supports other types of Badgan.

Qualities of Badgan Badgan is heavy. It comprises qualities of earth and water, which are both heavy and therefore Badgan tends to sink, even when it originates in the upper body. Badgan is cold.

Decomposing Badgan, which is located in the upper part of the body. This is responsible for blending liquid and solid nutrients into a semi-liquid state. Sensory Badgan, which is located on the tongue and which is responsible for taste. Satisfying Badgan, which is located in the head and is responsible for increasing and satisfying the five senses. Connective Badgan, which is located in the joints and keeps them flexible.

Badgan is both oily and wet (as opposed to the oily quality of Shar which is a drier hotter oiliness) and is responsible for moisture in the body.

Badgan is blunt and cannot penetrate into the narrower channels of the body. It will therefore tend to accumulate and develop slowly. Badgan is smooth due to its watery oily quality, and creates softness. Badgan is steady and hard to move. Therefore disorders characterised by Badgan often tend to respond either slowly or not-at-all to treatment. Badgan is sticky, and therefore the body fluids and saliva of a person with a Badgan imbalance will tend to be stickier than those of someone without such an imbalance.

Table 6 Types and qualities of Badgan

10.4 The seven constitutions Whether in or out of balance, people are often seen as having a dominant elemental influence, which manifests in their character, archetypal behaviour and general health (Odontsetseg & Natsagdorj, 2010, pp. 83-84). These are khii dominant or unbalanced, shar dominant or unbalanced, badgan dominant or unbalanced, khii and shar dominant or unbalanced, khii and badgan dominant or unbalanced, and shar and badgan dominant. There is also a constitution where all three elements are out

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of balance, and this is known as bor and is usually seen in particularly severe conditions.

The last four are combinations of the first three archetypes in varying degrees, whereas the first three are considered the most important (Bold, 2009, p. 225). These archetypes are not just abstract notions, but, as Natsagdorj told me, they provide a structure for diagnosis by interrogation and observation.

Khii dominant people are considered to tend towards thinness and to have a bluetinged complexion. They have a fondness for singing, laughing, talking, arguing and dancing (this relates to the light quality of khii). They have a preference for sweet, sour, salty and hot tastes.

Shar dominant people are considered to tend towards having hair and bodies with a yellow tinge, and they have a medium build and height. They are noted for their great appetite and thirst, though they only eat in small portions. They are typically proud and easily angered (this relates to the sharp quality of shar). They like sweet, bitter, astringent and cool food.

Badgan dominant people are considered to tend towards fat bodies and a pale, sometimes greenish complexion, and to feel cool to the touch. They eat a lot, but tend not to feel hungry. They are not easily angered or provoked, even when harmed, and have a generous, forgiving nature. They like food which is hot, sour, astringent and coarse.

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