Traditional Mongolian Medicine: A study of patients, practitioners and practice
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Transcript of Traditional Mongolian Medicine: A study of patients, practitioners and practice
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Student’s Name John Donegan
Student Number 4356494
Module MSc, University of Wales
Module Number /
Tutor Peggy M Welch
Assignment Title 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
18834
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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 individual’s 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
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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. Introduction ......................................................................................................... 1
2. Rationale ............................................................................................................. 2
2.1 Why investigate Traditional Mongolian Medicine? ........................................ 2
2.2 Why this is an observational study ................................................................ 3
3. Literature Review ................................................................................................ 5
3.1 Traditional medicine, biomedicine and pluralism ........................................... 5
3.2 An overview of literature searches on Mongolian medicine .......................... 8
3.3 Historical perspectives in the literature ........................................................ 12
3.4 Advantages and limitations of ethnography as methodology ...................... 16
4. Methodology ..................................................................................................... 20
4.1 Preliminary preparation for the research ..................................................... 20
4.1.1 Learning the language .......................................................................... 21
4.1.2 Making contact with the Manba Datsan to secure consent and agree terms 21
4.1.3 In-country support regarding any language or cultural challenges ....... 22
4.1.4 Planning the direction of research ........................................................ 23
4.2 Ethical Issues .............................................................................................. 24
4.3 Details of fieldwork ...................................................................................... 24
5. Observations ..................................................................................................... 25
5.1 The theoretical framework by which practitioners describe, diagnose and treat complaints .................................................................................................... 25
5.1.1 Arga and Bilig (Yin Yang theory) .......................................................... 26
5.1.2 Chinese five element theory ................................................................. 27
5.1.3 Three element theory ........................................................................... 27
5.1.4 Diagnostic techniques........................................................................... 28
5.1.5 Principles of treatment .......................................................................... 33
5.1.6 Biomedical diagnosis in traditional clinical practice .............................. 34
5.2 What therapeutic techniques practitioners use ........................................... 35
5.2.1 Religious services for healing ............................................................... 35
5.2.2 Traditional drug therapy ........................................................................ 37
5.2.3 Pulse-taking as therapy ........................................................................ 39
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5.2.4 External treatments .............................................................................. 39
5.2.5 Moxibustion .......................................................................................... 40
5.2.6 Blood-letting therapy ............................................................................. 42
5.2.7 Acupuncture ......................................................................................... 45
5.2.8 Golden needle therapy ......................................................................... 45
5.3 Patient behaviour ........................................................................................ 46
5.3.1 Presenting conditions and how patients describe illness ...................... 46
5.3.2 The socialising of consultation and treatment ....................................... 48
6. Discussion ......................................................................................................... 49
6.1 Reflections .................................................................................................. 50
6.2 A reflection on the process of research ....................................................... 54
6.3 Implication of findings upon practice, and future research .......................... 57
7. Conclusion ........................................................................................................ 59
8. Bibliography and references ............................................................................. 59
9. Appendix 1: email correspondence ................................................................... 63
10. Appendix 2: The qualities of the three elements and seven constitutions ......... 68
10.1 Khii - Wind ............................................................................................... 68
10.2 Shar - Bile ................................................................................................ 68
10.3 Badgan - Phlegm ..................................................................................... 69
10.4 The seven constitutions ........................................................................... 70
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
1
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. 1 See appendix 1 for details of personal correspondence with Sneath, Scheidt, Lo and Buell (Jan and
Feb 2009)
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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 People’s 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.).
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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
4
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
5
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).
Fábrega 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)
6
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).
7
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 20th
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 country’s 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.
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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 Sharav’s
comprehensive work History and development of traditional Mongolian medicine, 2nd
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.
9
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. 235-
263), 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).
10
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 Search date Search terms Results Accepted/rejected/reasons
Arccbase May 2011 Mongolia 0 /
PubMed June 2011 Traditional, Medicine, Mongolia
71 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.
PubMed June 2011 Acupuncture, Mongolia
11 9 rejected as being outcome-based studies on acupuncture, and not describing techniques. 3 of possible interest, but in Chinese.
Google Scholar June 2011 Acupuncture, Mongolia
3360 3,360. Taking the first 20 pages as a representative sample, I discounted all but four of these, as they were
11
either: 1. in Chinese, or 2. Were quantitative/outcome-based 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
Google Scholar June 2011 Traditional, Medicine, Mongolia
41,100 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/outcome-based 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.
JSTOR October 2012
Traditional Medicine Mongolia + technique
857/399 Too broad, so narrowed. JSTOR ranks by relevance and most of the higher-weighted 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
JSTOR October 2012
Traditional medicine pluralism + Asia + Mongolia
4402/1495/89 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 Badarchin’s book on acupuncture in the
Mongolian language (Badarchin, 1989).
12
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 medicine’s long and diverse history, spanning the
traditional nomadic pastoral lifestyle, a world-spanning empire and Soviet state
socialism (1985).
13
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 mare’s 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).
Bold’s 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
2 This is Bold’s preferred term for what is generally referred to in the UK as the Mongol Empire.
14
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 mare’s
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 People’s
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.
15
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 Indo-
Tibetan 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.
16
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 participants, 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.
17
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).
18
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 people’s
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,
19
perceived causes, help seeking and treatment behaviour, general illness beliefs and
disease-specific queries.
Helman’s 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 observer’s 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.
20
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.
21
4.1.1 Learning the language
Clearly the fact that I don’t 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 Leeds’s 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 University’s department 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
22
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 don’t do things the way I’m 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
Mongolia’s 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.
23
This advice proved correct. My initial contacts at the Manba Datsan were polite, but
non-committal, and on Demchig’s advice, I made Lama Natsagdorj a ‘small donation’
of $100 towards the work of the Manba Datsan.
Also on Demchig’s 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.
24
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 day’s activity on my laptop.
The breakdown of detailed observation of patient consultations was as follows
25
Age band4 Numbers in age
band
Male Female
<205 2 1 1
20-29 3 1 2
30-39 1 1
40-49 6 3 3
50-59 3 1 2
60-69 4 1 3
70+ 4 4
TOTAL 23 7 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.
4 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.
26
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 Tibetan-
derived 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.)
27
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 rLüng, mKhris-pa, and Bad-
kan 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.
28
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 (Yin and Yang)
6
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 person’s
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 Kim’s article on blood-letting (2011).
29
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 person’s 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
patient’s 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 Datsan’s hospital wing where these are stored and
labelled for examination by practitioners and trainees.
30
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
mare’s 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
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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
patient’s 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 Female pulse
Thick Thin
Bulky Taut
Coarse Rapid
Neutral pulse
Smooth
Flexible
Long waves
Hot/Arga pulse Cold/Bilig pulse
Strong
Weak
Expanded
Sunken
Rolling Declining
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Quick
Slow
Tight
Loose
Hard
Hollow
Table 3 A summary of the qualities of pulses
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 (toonüür) 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
35
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.
36
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 Natsagdorj’s consultation room had both a large and a small shrine to the
medical Buddha in it (fig 4)
37
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 Mongolia’s 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 ox-
gallbladder. 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
39
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 outsider’s 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
40
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 – toonüür 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.
41
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.
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Unlike the blood-letting that is sometimes used in TCM, MBLT removes much more
substantial quantities, often as much as ¼ 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
分离汤 (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.
45
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 don’t 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.
46
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 don’t 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 stress-
related 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 böör, so to have kidney trouble or painful kidneys is böör
övdökh – Patients say 'minii böör övdöj 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 ürevsel (liver inflammation)
but the older and wider used term is shar övchin ('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 khüdlükh 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 I’ll 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 Zoll’s 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 it’s 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.
49
This indicates a very different attitude to patient confidentiality, as rather than
wanting to keep patient information secret from others, the involvement by the
patient’s family and friends is actively sought.
This isn’t 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.
50
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 toonüür, bloodletting therapy khanuur and
balneotherapy, which do not appear widely known In China or Tibet.
The use of heat treatments such as toonüür could perhaps be seen as related to
Mongolia’s 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
51
Huangdi Neijing (Anon., 1990) and would seem to be backed up by the fact that the
use of toonüür is mostly related to winter conditions. I would like to observe the
clinical use of toonüür 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 China’s 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
52
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 toonüür / 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
53
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.
54
It seems to me that this is entirely in keeping with Mongolia’s 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 more 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 one’s 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 self-
reflective. In reading these guidelines in my methodological sources, I had not
understood quite what significant factors they would prove. I think that the academic
55
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 I’d 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
56
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.
57
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 toonüür / moxibustion for how it might
add further depth and character to my treatments. Having now discovered that
toonüür 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
58
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
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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: Butterworth-Heinemann 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 Post-Socialist 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. 140-149. 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. 177–208. 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-scène of anthropological fieldwork. Reflections, Issue 59, pp. 85-108. Moltke, H. G. v., 1892-1912. Moltkes Militärische Werke. Berlin: s.n. Monkhtuvshin, T. & Altanzul, O., 1998. Tavan makhbodiin soronzon züü, züü toonüüriin 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: <[email protected]>
To: "John Donegan" <[email protected]>
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 møngøn juu (the z and j are interchanged in Inner / Outer
Mongolian) - i.e. 'silver juu/zuu' (sometimes tømør 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 Dørbøn 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.
64
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).
65
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: <[email protected]>
To: "Volker Scheid" <[email protected]>; "John Donegan"
<[email protected]>; "Vivienne Lo" <[email protected]>
Cc: <[email protected]>
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
66
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 [email protected]
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 Yüan 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 Rashīd al-Dīn 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.
67
good luck,
Vivienne
-----Original Message-----
From: Volker Scheid
[mailto:[email protected]]
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 <[email protected]>
Best wishes and good luck
Volker
68
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 Qualities 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.
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.
Ascending khii, located in the chest, responsible for speech, bodily vigour, skin tone and mental activity.
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-of-mind.
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.
Khii is neither hot nor cold, and is therefore able to combine with shar (which is hot) and badgan (which is cold)
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.
Khii is thin, and is able to pass through all the channels, holes and vessels within the body.
Downwards-voiding khii, is located in the rectum and is responsible for defaecation, urination, ejaculation, menstruation and childbirth.
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
69
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 intestines, and its function is to support digestion, to break down and separate nutrients from waste. It keeps the body warm and provides energy for the other types of shar.
Shar is hot. It regulates the temperature and energy of the body.
Colour-regulating Shar, is located in the Liver and is responsible for the production and regulation of Blood.
Shar is sharp, and those with a constitutional tendency towards Shar are considered to be 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.
Shar is oily. It is responsible for the secretion of oil from the skin and an oily texture to the body.
Sight Shar is located in the eyes and regulates vision.
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).
Skin Shar, is located in the skin and is responsible for healthy, lustrous skin.
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.
Table 5 Types and qualities of Shar
10.3 Badgan - Phlegm
Badgan is bilig and cold. It has five types and seven qualities.
Badgan
70
Types of Badgan Qualities of Badgan
Supportive Badgan, which is located in the chest. This supports other types 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.
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.
Badgan is cold.
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.
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.
Connective Badgan, which is located in the joints and keeps them flexible.
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
71
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 blue-
tinged 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.