Traditional medicine in Mongolia: contrast and continuity

This is the text of an article by me, about traditional medicine in Mongolia published in the November 2013 issue of The Acupuncturist magazine, pages 8-9.

Traditional medicine in Mongolia: contrast and continuity

In 2011, as part of my study for an MSc, I spent a month conducting ethnographic research and interviews with practitioners of traditional Mongolian medicine (TMM) in Ulaanbaatar. 

My aim was to gain insight into the reality of technique and practice and add to the wider academic debates on medical pluralism in Asian and other societies, where traditional medicine and biomedicine exist side by side. 

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

In contemporary Mongolia, TMM is taught as part of the curriculum at the Health Sciences University of Mongolia (HSUM) and the state health insurance system runs a number of traditional medicine sanatoria, such as the Ulaanbaatar Suvilal. TMM physicians share medical records with colleagues in the biomedicine hospitals, and dispense biomedicine prescriptions to patients.  

Buddhist monastery hospitals, or datsans are also significant providers of medical care, with the biggest one, the Manba Datsan, also responsible for the education of substantial numbers of TMM graduates (Manba Datsan Clinic and Training Centre for Traditional Mongolian Medicine, Otoch Manramba Mongolian Traditional Medical Institute, 2011).  

The core 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 most TMM physicians. TMM theory has also incorporated elements of TCM theory such as five element theory and yin yang theory. It is now increasingly incorporating elements of biomedicine. 

The strong role of Buddhism in 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. TMM encompasses a diverse range of interventions, including drug therapies, a Mongolian style of moxibustion known as toonüür, bloodletting therapy, known as khanuur, and balneotherapy. 

TMM pharmacology is an immense field, which I do not propose to discuss in this article, and acupuncture itself appears identical to TCM acupuncture, though the way it is applied in conjunction with TMM diagnoses is unusual. 

I was particularly struck by the use of moxibustion, which Mongolians lay claim to having invented and introduced to the Chinese (History and Development of Traditional Mongolian Medicine. Bold, 2009). There are two types in use in contemporary Mongolia, traditional Mongolian moxibustion - toonüür - and TCM moxibustion. 

TMM moxibustion uses bundles of ground spices, typically composed of equal parts ground caraway, ground ginger and ground cinnamon, although other substances can be used. These small bundles are wrapped in muslin, heated in shar-tos (clarified butter) until fragrant, then allowed to cool just until they can be applied to the body without causing burns. 

The bundles are 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. 

Khanuur has been used in Mongolia since the very earliest times, and is referred to in the earliest records of medical practice. However, in its current manifestation, there seem to me to be many similarities to the use of bloodletting in western humoral medicine, namely the relief of excess conditions associated with blood (Bloodletting: the story of a therapeutic technique. Kerridge and Lowe, 1995). 

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. 

Firstly, TMM is internally heterogeneous, by which I mean that the TMM physician is expected to understand and practise a range of different techniques.  

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. 

This pluralism now seems to be operating with regards to biomedicine. Janes discusses how in Tibet, an effect of medical pluralism is Traditional Tibetan Medicine (TTM) becoming disembedded from local contexts of practice and ‘reconstituted as part of a 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’ (The transformations of Tibetan medicine. 1995). This is supported by Fan and Holliday in their investigation of pluralism in Tibet, Inner Mongolia and Xinjiang (Which medicine? Whose standard? Critical reflections on medical integration in China. 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. In interviews with Abbot Natsagdorj, the principal of the Manba Datsan, and Lagshmaa Baldoo, senior lecturer in acupuncture at HSUM, they describe the curriculum at the Manba Datsan as 60 per cent TMM and 40 per cent biomedicine. The balance of the curriculum at the HSUM is reversed: 40 per cent TMM and 60 per cent 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 HSUM curriculum is weighted towards biomedicine, in clinic (she was referring to the Ulaanbaatar Suvilal) 75 per cent of what they do is TMM. 

TMM physicians speak fluently about conditions in biomedical terms, but are 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’ apply, with TMM physicians comfortable taking lead role in treating serious conditions such as cancer.  

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 (Sorting Out Tradition: The Ding Current in Chinese Medicine. 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. 

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/felt-lined tents today, even in conurbations like Ulaanbaatar. In Mongolia, medical pluralism is traditional.

 

 

 

Traditional Mongolian Medicine: A study of patients, practitioners and practice

In 2011, as part of my study for an MSc through the Northern College of Acupuncture, I spent a month conducting ethnographic research and interviews with practitioners of traditional Mongolian medicine (TMM) in Ulaanbaatar.

The Ulaanbaatar Suvilal where I conducted some of my research

My aim was to gain insight into the reality of technique and practice and add to the wider academic debates on medical pluralism in Asian and other societies, where traditional medicine and biomedicine exist side by side.

There has veen very little published about TMM in English, so I'm making it available here for those who mght be interested.

http://www.scribd.com/doc/184411614/Traditional-Mongolian-Medicine-A-study-of-patients-practitioners-and-practice

A little haiku for you

A few days back, I entered this little fella in a poetry competition run by some friends I do roleplay gaming with. It didn't win, but I like it anyway, so I'm sharing it with you.

Doing the right thing

A fragile thread guides my path through fog.
Carefully, I tread,
Lest it snap.

(The picture isn't mine)

How spin doctors (sometimes) save lives

On Tuesday, the coldest day of the winter so far, my central heating and hot water packed up.

Faced with daytime temperatures not creeping above zero Celsius dropping at night time as low as minus three I was braced for an extremely uncomfortable few days until I could get a repair sorted. The fact that I didn’t freeze is down to a few factors.

The obvious ones are that I’m fortunately able to afford a boiler maintenance and service policy. Thanks to those, I was able to get a plumber out at 9pm on a cold winter night on a snow covered hilly side-street in Pudsey to sort out the problem.

Less obviously though, I want to thank Gareth Wilce and the communications team he is part of at Leeds City Council. Yes, you heard me right. Communications professionals (often dismissed as ‘spin doctors’) aren’t the most well regarded professional group. The popular wisdom (which is never wrong, is it?) is that they are mostly slippery types who only have a distant acquaintance with the truth, and who make it their lives’ work to cynically manipulate public attitudes. I used to be one myself, and I can definitely say that I’ve never met anyone like that. Certainly in the public sector, the stereotype couldn’t get further from the reality.

Back to Gareth, who for the sake of transparency, I should make clear is a friend and former colleague. Throughout the course of last year, I could barely turn my head without getting bombarded with messages about Leeds City Council’s free home insulation offer for everyone in Leeds. Facebook, check; Twitter, check; local press, check; local radio, check. Rarely in my life have I been so comprehensively bombarded by messages urging me to take advantage of free home insulation before the winter hit.

The least I can do for Gareth after all this praise is use an unflattering image of him

These messages didn’t appear through magic and pixie dust. They appeared because of the hard work, skill and relentless persistence of people like Gareth and his colleagues, and the people at Yorkshire Energy Services, persuading journalists to keep mentioning it in the media, organising mailouts and using their social networks of friends and acquaintances to spread the message as widely as possible.

How does this relate to my own story? Well I was one of those people who took advantage of the offer. I got the insulation installed last Autumn (after some epic work with a friend to get the attic floorboards up to allow the insulation to be laid, but that’s another story) and have been grateful ever since. It’s made a noticeable difference to my fuel bills and to the general ability of my house to retain warmth. The thing that first struck me when I got home on Tuesday night was how (relatively) warm my house was after being left unheated for over 24 hours, and remembering how the house felt in previous years, I know for a fact that it was the insulation that made the difference.

According to the NHS, over 400 people over 65 years of age died last year through hypothermia . Insulation can make the difference between life and death, helping make fuel bills more affordable or eking out that extra bit of heat in an otherwise cold house. I have a few years to go before I fall into that age bracket, but I will one day, and there will certainly be vulnerable older people in Leeds who have taken up the offer this year through hearing about it in the paper, reading the mailshot, or being alerted to it by friends and relatives.

... and I mention this campaign, because I have had direct, personal and recent experience of it, but don't overlook all the other life saving campaigns organised by people working for the police, fire and health services.

So as far as I see it, spin doctors help save lives. Remember where you heard it first.

PS. If you want to know more about all the support available for Leeds residents who want to make their homes more energy efficient, check out http://www.wrapupleeds.co.uk/

How to describe Mongolia ...

... without using tired cliches?

It's been a while since my last blog post, and as some of you will know, I've been preparing for a long while to visit Mongolia to find out more about the country's traditional medicine.

Now I'm here, in Ulaanbaatar, the country's capital, and wondering how I can give a feel of the place for those of you who have never been.

Westerners who write about the country tend to use a number of very tired, very obvious cliches.

Cliche 1. Ulaanbaatar is a city of contrasts where shining new towers to capitalism rise above broken pavements, and sharp-suited executives pass by penniless herders forced to the city to beg following years of drought and harsh winters ...



... well the penthouse vs pavement analogy has always been overdone. Mongolia is a developing nation, and doesn't have a lot of spare money for infrastructure. While there are indeed contrasts - some of them quite significant - Mongolians on the whole seem quite an egalitarian nation, and where they can, people look after each other more than I've seen in England.

Cliche 2. Ulaanbaatar's potholed roads throng with motor cars, filling the air with a stifling petrol haze, and being driven with a carefree lack of attention to safety that owes more to Mongolia's celebrated passion for horseriding ...



... Mongolians like horses ... now they drive cars like they ride horses ... clever analogy, geddit? No, it's just another cliche. There's certainly a lot of cars, and they do indeed contribute to a lot of pollution in the air. People aren't always able to afford maintain them to standards we might take for granted in NW Europe. Many of the roads are quite potholed - I think it's an unavoidable consequence of damage caused by harsh winters and lack of funds for infrastructure. That means people have to drive quite creatively if they want to preserve their suspension.

Cliche 3. Ulaanbaatar, where the face of Chinggis Khan, who led his people to conquer one of the largest land empires in world history, gazes down from almost every public building and billboard ...



You do see quite a lot of Chinggis Khan in marketing literature, statues and tourist tat. After the end of communist rule in 1990, the government intentionally promoted Chinggis Khan as a figure of national pride and national unity, hence the public statues. It's not surprising there's a lot of tourist tat with him on it - for many people, 'Genghis Khan' is the only thing they know about Mongolia. That, and a strange belief that it's full of yaks (scratches head). However, Brits, of all people should understand the complexities behind any nostalgia for past imperial 'glory'.

So what would I say?

Most of my visit has involved research into Traditional Mongolian Medicine (TMM). I've seen some very knowledgable and helpful people and monastery clinics and the national university. They've been kind enough to give me bags of useful stuff to write up and learn from.



I've done a lot of walking around, since I've not really fancied making use of the ubiquitous informal taxi system in UB. Most places I need are in under 40 mins walking distance, though it can feel like more on a hot day. There's a lot of building works going on throughout, and a lot more businesses have spring up since I was last here in 2004.

There's also a lot of piety for the Buddhist religion, which has been re-emerging following years of state suppression under communism. As a result, there are even chains of vegetarian restaurants starting to spring up around the city (Try out 'Loving Hut' if you're over here at all - tasty, affordable and vegan if that's an issue for you. They make a lot of use of 'mock' meats, but do it quite well. They're funded by one of the Buddhist sects.)

I've not been able to get out of UB this time, which is a shame. The capital hosts about 45% of the country's population, but is only a tiny spec in a vast and varied country. I have a feeling that the hearts and souls of many Mongolians lie outside the city, even if the city is where they live. However, someone wiser than I would need to answer that properly.

One unusual thing for half the time I've been here has been some epic thunderstorms. I know a lot of people have welcomed them, since the country has been suffering from severe drought. Let's hope the weather is starting to take a turn for the better.

I'll write a bit more about the medical side of things when I feel inspired.

Lies, Damned Lies and Headlines (or why acupuncture is so safe)

I nearly leaped out of my chair in alarm the other day when I read a headline in The Guardian 'Dozens killed by incorrectly placed acupuncture needles'. How on earth, I wondered, had that happened, since I know how scrupulously safe professional acupuncturists are?

It is also completely at odds with the York Acupuncture Safety Survey, published in the British Medical Journal in 2001, carried out by Hugh McPherson of York University, which looked at nearly 35,000 treatments carried out by professional acupuncturists in the UK. The survey did not uncover a single serious adverse event (ie, something requiring hospital treatment) Even minor adverse reactions were rare - just 1.3 per 1000 treatments - most commonly fainting or nausea. To me, this seems pretty damn safe.

On reading the Guardian article, I quickly found out that the screeching headline was entirely misleading, and designed to create disproportionate alarm.

The article was based on a recent paper by Edzard Ernst, professor of complementary medicine at the University of Exeter, entitled Deaths after acupuncture: A systematic review. Ernst's paper indicates that worldwide, since 1946, there have been 86 deaths in which acupuncture was the probable cause, the vast majority of which were in China or Japan.

The causes of death Ernst lists include punctured lungs, or complications from the use of unsterilised needles. He says this shows the importance of adequate training for all acupuncturists.


Professional acupuncturists in the UK use only sterile single-use needles

So let's put this in perspective.
1. Throughout the whole world, there have been only 86 reported deaths from acupuncture in the last 64 years, though I would guess there will have been millions of acupuncture treatments over the same period.
2. Of that tiny number of deaths, most took place in China or Japan. China, certainly, during much of this period could not be classed as a developed nation, so the conditions of treatment or the provenance of the practitioners in those tiny number of fatalities is a matter of legitimate scepticism.
3. Nobody, but nobody makes use of re-usable needles anymore. They are all single-use sterile needles that come in blister packs from proper suppliers. You couldn't get the other sort if you tried, and who would? Seriously.
4. Needle training 101 for acupuncturists is to only needle at a shallow angle over the lungs, and to avoid needling completely if people are very thin, or there's the slightest risk. We take the safety of patients very very seriously.
5. Pretty well anywhere you go in the developed world, professional acupuncturists will belong to reputable professional organisations, such as the British Acupuncture Council, with strict requirements for training and professional skill. I myself had to study for three years and spend large amounts of time in clinic under supervision before I was qualified to practice. I still have to maintain continuous professional development to keep my skills and knowledge up-to-date. Acupuncturists are not dangerous cranks, they are trained committed professionals.

So ... if I look at the reality of professional standards in the UK and elsewhere, together with the weighty support of evidence for safety in McPherson's study, and set it against the rather contrived sense of alarm running through the Guardian article about Ernst's paper, and make a considered judgement about the safety of acupuncture, I know what conclusion I would make.

Acupuncture is demonstrably safe.

I hope you will agree.

An apple a day, or the pindoctor's chutney project

You can definitely tell the season is changing. The weather has turned, and all around Pudsey, and throughout Leeds, no doubt, fruit trees are begging to be picked before their contents go to waste.

I have the same issue myself every year with my apple tree. Here's a picture I just took of it:



It produces billions of the most wonderful eating apples every year, which utterly surpass my ability to consume, even when I pack bags of them for my friends.

This year though, I've been on a mission to preserve as many of them as possible, and have spent the last couple of weekends on a chutney-making extravaganza.

Here's a couple of good recipes you might want to try out.

Classic English Apple and Date Chutney
This is based on a special recipe handed down to me from Ma Sneath, my friend Dave's late mother, who was wise in the ways of chutney.

It's a lovely blend of sweet and sour tastes, which is just the kind of thing Chinese medicine advises for Liver/Spleen disharmonies - the kind of digestive disruption people often get when they are stressed.

Makes about 2.5 kilos
Ingredients:
2 Kg tart eating apples
0.5 Kg dried stoned dates
1 Kg onions
2 garlic cloves (optional)
2 chilis
0.5 Kg stoned raisins or sultanas
1.25 litres vinegar
0.4 Kg soft brown sugar (you should add another 0.15kg if you're using cooking apples)
1 to 2 level teaspoons salt
3 level teaspoons ground ginger
2 level teaspoons cinnamon
1 level tablespoon pickling spice; 6 cloves and 1 small bay leaf, all tied together in a muslin bag.

Method:
1. Peel core & slice apples
2. Peel & slice onions. Peel garlic
3. Coarsely chop apples, dates, onions, garlic, chilis and raisins/sultanas.
4. Put into saucepan with half the vinegar (preferably a non-metallic one)
5. Cover and simmer until fruit and vegetables are tender – about 30 minutes.
6. Add remaining ingredients and stir until sugar dissolves
7. Cook, uncovered, on a medium-low heat until the chutney thickens to a jam-like consistency, stirring occasionally (this probably takes a couple of hours, depending on your cooker settings)
8. Remove bag of spices then pot in sterilised jars and seal with a vinegar-proof lid.

This chutney is best left a month or two to mature somewhere cool and dry.

Hot South Indian Apple Chutney
I adapted this from a recipe using star fruit in Julie Sahni's excellent book Classic Indian Vegetarian Cookery.

It's a hot and vibrant chutney, redolent of the tastes of southern India. It's gorgeous in its own right, but from a Chinese medical point of view, it is just the sort of thing you'd want to pep up your meal in the early stages of a cold, to help you put on a sweat (Chinese call this 'releasing the exterior' which helps flush out pathogenic factors and invigorate the body's natural defenses when you are being attacked by an 'external Wind invasion'). I like this so much, I have difficulty waiting for the jars to mature!

It's definitely one for those who like heat though - not for anyone with a delicate digestion, nor those suffering from any condition which makes them feel hot or flushed, because the chili packs a punch.

Makes 450ml
Ingredients:
700g tart eating apples, peeled and cored
1 tablespoon of salt
2 tablespoons of cayenne pepper
1 teaspoon of turmeric
3/4 teaspoon ground asafoetida (you can easily get this at most Asian grocers, where it's usually kept in yellow plastic pots. Ask for 'Hing'
1/2 teaspoon of ground fenugreek seeds
125 ml light sesame or light vegetable oil (I usually add a couple of drops of the more easily available oriental dark sesame oil to ordinary vegetable oil)
1 teaspoon of black mustard seeds

Method
1. Finely chop or food process the apples and mix with salt in a non-metallic bowl.

2. Blend the cayenne, turmeric, asafoetida and fenugreek in a bowl, and set aside next to your cooker.

3. Heat the oil in a small enamel or non-metallic pan on a medium/medium hot heat. When hot, add the mustard seeds, and cover with a lid until the popping and splattering of the seeds subsides.

4. Add the mixed ground spices in one go, and give a quick stir, then immediately add the apples.

5. Lower the heat to medium and cook for 10/15 minutes or until the apples are reduced to a spicy pulp and the oil has begun to separate. The chutney should be bubbling throughout, and you'll need to keep stirring so it doesn't stick and burn.

6. Pot in sterilised jars and seal.

This one is ready to eat immediately, but like most chutneys, will benefit from being left to mature for a few weeks.