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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)

2

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)

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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).

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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)

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Figure 3 Physical layout of typical treatment session

Mongolians view their religious practitioners as professionals able to help in many

questions of health and wellbeing. Lamas are service providers. They listen to

patients' complaints and administer the corresponding sutras and exercises for it.

According to Joergi Zoll, in his experience, this use of religious services for healing is

widely used, and in his view, just as much as acupuncture.

A notable feature of behaviour in the treatment room is the presence of family groups

rather than just individual patients in many cases. I discuss this further below in

5.3.2.

5.2.2 Traditional drug therapy

The majority of the treatments I saw at both the Manba Datsan and the UB Suvilal

involved a drug prescription following diagnosis and assessment.

These medicines include decoctions of medicinal herbs, powders, pills and

ointments. It may be the case that some TMM doctors manufacture their own

remedies, but everyone I was able to observe uses commercially prepared products.

The Manba Datsan is one of these commercial producers, and runs a small

workshop producing over 100 remedies. The remedies are produced according to

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standardised recipes registered and approved by 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.

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5.2.7 Acupuncture

I was told very clearly by Lagshmaa, Joergi Zoll and Lama Natsagdorj that the

acupuncture practiced in contemporary Mongolia is TCM acupuncture, and this was

largely borne out in my own observations.

The Health Sciences University of Mongolia and Manba Datsan teach people TCM

acupuncture, and the points and channels are the same as those in general use in

China and elsewhere. Standard text books such as Monkhtuvshin and Altanzul

(Monkhtuvshin & Altanzul, 1998) are pure TCM with no techniques or points specific

to Mongolia.

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

detail them individually.

What does mark out Mongolian practice, as with the use of moxibustion, is the

symptomatic use of TCM acupuncture to people whose primary diagnosis has been

on the basis of TMM theory.

Bold identifies piercing techniques as having been in use in Mongolia from the very

earliest times (Bold, 2009) but whatever these techniques might have been, I was not

able to see any evidence of them in current practice.

5.2.8 Golden needle therapy

Khatgah emchinlee, or golden needle therapy is a traditional Tibetan medical

technique that has become incorporated in TMM. It is also used in Bhutan, Nepal

and other countries influenced by traditional Tibetan medical practice (Wangchuk,

2009).

I 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.

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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.

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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: <ds114@cam.ac.uk>

To: "John Donegan" <john@johndonegan.com>

Subject: Inner Mongolian acupuncture

Date: 05 February 2009 19:28

Hi John,

OK, it's not a whole lot, but this is what I have found out so far. My informants

were 2 scholars (Altanbulag and Hurelbaatar) here at MIASU from Inner

Mongolia, the latter an old friend who is here long-term. I assume this

information is more or less right, but cannot be absolutely sure it is completely

accurate in all respects.

_________________________

Acupuncture is known as zuu tavih emchilgee in (Outer) Mongolia today, (i.e.

zuu-placing treatment), but in Inner Mongolia (and I think in the past

everywhere) called 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: <pbuell@speakeasy.net>

To: "Volker Scheid" <scheidv@westminster.ac.uk>; "John Donegan"

<john@johndonegan.com>; "Vivienne Lo" <v.lo@ucl.ac.uk>

Cc: <pbuell@speakeasy.net>

Subject: RE: A query about acupuncture in Mongolia

Date: 13 January 2009 14:46

I, alas, can't help much.

There are a number of Mongols who are working on modern Mongolian

medicine including a man whose name I forget who is on the IASTAM mailing

list and posts frequently. He sent me some interesting papers but, alas, they are

back in Seattle somewhere and I am in Berlin. Try posting an inquiry on the

IASTAM list and he should reply. V, whatever happened to that Mongol lady

working on the topic? Her dad was a practitioner, as I remember.

The best stuff is in Chinese, alas. I have many of the books but, like those

papers, they are in storage. Any large library with an East Asia collection should

have things of interest. The last issue of the IASTAM Journal has an article by

one of the Buriats and they are doing good suff, mostly in Russian. Stuff from

the MPR is hard to get and, of course, in Mongolian. Greatest interest there is in

herbal and deitary medicine including a book being published in parts by

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 paul-david.buell@charite.de

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

PDB

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

Message

Dear John Donegan,

Paul

Buell's email is above. There are a few people working on Mongolian medicine.

one of the best chapters I've seen on medieval medicine is Allsen, Thomas T.

2001. ‘Medicine’ >in Culture and Conquest in Mongol Eurasia. Cambridge

University Press, 2001., 141 -144. and these are some of Paul's:

Buell Paul D. 1968. ‘Some Aspects of the Origin and Development of the

Religious Institutions of the Early 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:scheidv@westminster.ac.uk]

Sent: 12 January 2009

18:10

To: John Donegan

Cc: Vivienne Lo

Subject:

Re: A query about acupuncture in Mongolia

Hi

Thanks for your mail. Your project sounds very interesting but I am afraid I don't

know much about Mongolia. I suggest you contact Paul Buell who is an expert

on this part of the world and its history. I have not got his email at hand but that

should be easy to find. Another person with useful contacts might be Vivienne

Lo at UCL <v.lo@ucl.ac.uk>

Best wishes and good luck

Volker

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.