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.

 

 

 

A Rhapsody in Brown (or why you shouldn't be embarassed by your bowels)

Acupuncturists are fascinated with bowel movements. Any time you visit a practitioner, prepare to be asked searching questions about how often you go, when you go, whether your stools are loose or dry, or whether there are any unusual colours, smells, noises or other factors.

Why do we ask? Well the most obvious reason is it will tell us the state of your digestion, which is often a root factor in a host of other health issues. It is also not unusual for non-digestive health issues to have a knock-on effect on your digestion and defaecation.

One of the more frequent examples of this is that when we are run-down, are stools tend to be looser, and when we are stressed out, they can often dry out to little pebbles. In conditions like irritable bowel syndrome (there are different names for it in Chinese medicine, but IBS is familiar to most people), you will often see alternating diarrhoea and constipation.

Some people like me are quite happy to answer detailed questions about all manner of bodily functions, including bowel movements but I have no shame.

Others find it harder to talk about for a whole variety of reasons.

One thing I have often found helpful is referring people to a handy chart of stool consistency called the Bristol Stool Scale:



This is a handy way of bypassing discussions of 'how loose is loose', so that you can quickly identify where people are on the scale and get down to making a diagnosis and discussing a treatment plan.

It's also a good way of impressing your GP when you visit her. If she asks you 'how are your number twos today?' you can reply 'actually, it's more of a number three at the moment, though I had a six last week after a dodgy kebab.'

On the subject of colour, if your stools are bright red, it often indicates bleeding in the rectum. If they are a tarry black, it could indicate bleeding in the stomach or oesophagus. In either case, it's usually a good idea to visit your doctor to find out what's happening.

That's why I was more than a little alarmed a couple of months back when I turned to flush away that morning's offering, and saw it was bright maroon. After a moment's blind panic, I realised it was unlikely to to be the sign of a bizarre terminal illness, and a lot more to do with the beetroots I'd eaten the night before. D'oh!

Bon Appétit.

Pindoctor heal thyself

Of course, the thing about my own simple and eminently sensible advice about good sleep (zero marks for modesty today PP!) is that I need to take it myself sometimes.

Staying up until 1am reading my book is probably not the most sensible way of getting a full night’s sleep.

(I blame Steven Erikson for being too damn interesting. Dust of Dreams is his latest.)

Note to self: I must remember to write something on the use of pressure on the acupoint Zusanli to pep up your energy levels when tired. It’s the little hollow between the tibia and fibula about three inches/4 finger widths below the eye of the knee. Not advised if you’re pregnant though! Fortunately I'm not.

Sleep - how difficult can it be?

I often see people who have difficulty getting a good night's kip, and bad sleep can have a major effect on their quality of life.

I've certainly had those days and nights myself - lying in bed, with my brain refusing to switch off, followed by days feeling like my skull has been packed with cotton wool, and hoping nobody asks me to do anything clever or complicated.

Now Chinese medicine has loads to say on the subject of sleeplessness, and practitioners like me are always fascinated in the details of how an individual's insomnia manifests (there's books and books written on the subject, and I may go into further detail in a later post.)

But before we look at the bells and whistles, let's get the basics right. It often surprises me how many people overlook or are unaware of some of the fundamentals of restfulness.

1. Do you have a regular pre-sleep ritual? Something that gives a clear break between what you do when you're awake and what you do when you're ready for bed. For me, I try and make sure that there’s no distractions in the bedroom like PCs/TVs, and I have a half hour or so of reading before I sleep. Sometimes I’ll have a glass of hot or cold milk. Many people find a quick bath or shower before they get into bed is nice. It’s basic, but it does make a difference. Do something that allows you to wind down before you switch off the lights.
2. Try and get your evening meal out of the way two or three hours before bedtime so that it’s reasonably digested before you try to sleep. Unless you're a sleeping superhero, eating that chicken vindaloo with rice, naans and samosas five minutes before you get into bed will disrupt your sleep.
3. If you wake up, don’t fret about waking up - just accept it. Maybe get yourself a glass of water or milk, and read a bit more of your book until you feel tired (if you have a partner, try not to wake them up while doing this ... a dis-chuffed partner can also be a cause of sleepless nights!). Don’t make agonising about not being able to sleep one of the factors that’s keeping you awake.
4. Think about eye-shades or earplugs if light or noise are physically-controllable factors in the waking up.
5. A strong cup of coffee before bedtime really won't help (though a friend of mine swears blind to the contrary!) If you have difficulty sleeping, avoid caffeine in the evening, and think hard about cutting it out altogether.
6. Finding time for regular exercise on top of a busy life can be tough. It helps though.

If anyone else has any simple advice for good sleep, let me know.

Welcome to my blog

While it may sound strange, I woke up this morning, drew open the curtains, looked out of my window at the sun-dappled leaves of the trees in Fulneck and Tong Valley (the view from my window is great!), and thought 'Gosh! I really need to start a blog!'

So here it is ... the start of what I hope will become a shared compendium of my thoughts and your contributions on health, and life and stuff (particularly the stuff!)