CRAIG R.

JANES

Department of Anthropology University of Colorado at Denver

Imagined Lives, Suffering, and the Work of Culture: The Embodied Discourses of Conflict in Modern Tibet
This article explores the cultural epidemiology 0/rlung ("loong") disorder among Tibetans living in the cities and towns of the modern Chinese state of Tibet. Rlung, glossed as air or wind, is the most important of the three humors of the classical Tibetan ethnomedical system. Considered by Tibetans to be contingent upon multiple social, emotional, and religious phenomena, rlung disorders are fertile ground for the development of etiological discourses that incorporate the social and political crises that are part of the rapidly changing Tibetan plateau. In this essay I locate rlung disorder in a confluence of Tibetan ethnomedical constructions of the mind-body-universe linkage, in which rlung stands as the chief symbolic mediator, with ethnic conflict, rapid economic development, and the localization of global debates over Tibetan suffering and human rights. [Tibet, ethnomedicine, politics, economic development]

The Chinese have been destroyed by suspicion; the Tibetans have been destroyed by hope. Common saying, Lhasa, 1991 If Tibet had to be conquered by a foreign invader, why couldn't it have been a rich country like America or England? Then at least we'd have improvements like water and electricity, and maybe even color televisions. Why did it have to be by one of the poorest countries in the world, one that only takes our resources? Tibetan laborer, 1991

lung (pronounced "loong") is the Tibetan term for wind or air and in medico-religious contexts is related to the "life force."1 If rlung is out of balance in the body, or if it is too slow or too quick in its circulation, a variety of sometimes serious symptoms result, ranging from dizziness to high blood pressure,

Medical Anthropology Quarterly 13(4):391-412. Copyright 1999, American Anthropological Association. 391

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heart palpitations, dysphoria, and, ultimately, insanity. It is the most commonly diagnosed humoral disorder in Tibet today. In this article I examine the cultural epidemiology of rlung disorder in modern Tibet. I also consider the degree to which popular Tibetan conceptualizations of rlung disorder, that is, rlung discourses, have been widened to admit the politics of the cosmopolitan, Chinese, and Tibetan engagements over Tibetan autonomy, independence, and human rights. The starting points for this analysis are the different but, I argue, complementary theoretical perspectives on the nature of culture and its relationship to experience offered first by Obeyesekere (1985) and later by Appadurai (1991). In what has become an influential essay on the relationship of culture to depression, Obeyesekere introduced the concept of work to assist an understanding of the processes by which Buddhist culture normalizes depressive affect:
The work of culture is the process whereby painful motives and affects such as those occurring in depression are transformed into publicly accepted sets of meaning and symbols . . . the constellation of affects . . . can, through the work of culture, be transformed in a variety of directionsinto Buddhism and spirit attack and no doubt into other symbolic forms also. [1985:147-148]

In such fashion, Obeyesekere argues, depressive affect in Buddhist cultures is contextualized as insightful appraisal that the world apprehended through the senses is impermanent, illusory, and unworthy of ego-involvement (i.e., attachment). The work of culture in this sense is to elevate the pain and suffering of an individual nature to an occasion of reflection on Buddhist ontology, thereby, presumably, muting and even transforming it into an opportunity for revelation. With this perspective, the task for people becomes not how to avoid suffering or how to recoverfromit, but rather, how to suffer gracefully, employing and manipulating the symbolic devices available for doing so. The idea of cultural "work" directs attention to the constructed nature of reality as it pertains to affect and psychic suffering. For the anthropologist, this perspective nicely articulates the constructed, predominately social nature of emotion, now the generally accepted orientation in psychological anthropology (e.g., Lutz 1985; O'Nell 1996), and a perspective increasingly acknowledged by psychiatric epidemiologists to explain cross-cultural differences in psychopathology (e.g., Weissman et al. 1996). The challenge in studing of the meaning of suffering is to identify and describe how, and the avenues by which, culture works to transform painful feelings into publicly acceptable sets of symbols or, alternatively, to examine how individuals seize upon and manipulate these symbols to articulate their distress in locally meaningful terms. My emphasis is on the development of Tibetan medicine in interplay with the transnational flows of people, information, and public symbols that affect day-to-day life in the heavily touristed and rapidly changing Chinese-Tibetan cities of the Tibetan Plateau. Appadurai's (1991) comments are particularly apt in this regard. He suggests that the study of cultural dynamics must include reference to the phenomenon of deterritorialization: the character of modernity whereby ethnic groups and communities, among other social formations, operate according to principles that transcend territorial boundaries and identities. Most importantly, a deterritorialized world, crosscut by currents generated by mass media, tourism, migration, and capital, allows people in what were once

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circumscribed local communities to now envisage and imagine possible alternative lives. Appadurai writes:
More persons throughout the world see their lives through the prisms of the possible lives offered by mass media in all their forms... fantasy is now a social practice; it enters, in a host of ways into the fabrication of social lives for many people in many societies What is implied is that even the meanest and most hopeless of lives, the most brutal and dehumanizing of circumstances, the harshest of lived inequalities is now open to the play of the imagination. Prisoners of conscience, child laborers, women who toil in the fields and factories of the world, and others whose lot is harsh no longer see their lives as mere outcomes of the givenness of things, but often as the ironic compromise between what they could imagine, and what social life will permit The biographies of ordinary people, thus, are constructions (or fabrications) in which the imagination plays an important role. [1991:198]

Suffering, subject to the definitional, transformative, and expressive processes of cultural work, may itself be partly fabricated out of the imagined lives and possible social existences to which Tibetans compare their own. Contemporary Tibetan cultural patterns must therefore be seen as developing within a context in which an ironic compromise is apprehended, a compromise between cosmopolitan ideas about the natures of Tibet, Tibetan Buddhism, Tibetanness, and Tibetan suffering on the one hand, and the realities of Chinese modernity on the other. What are the stakes held by the West for constructing the kind of suffering in Tibet paraded in the international media; and conversely, what stakes compel Tibetans to accept or respond to such constructions (see Adams 1996a, 1996b)? Growing world-wide debate over the Tibet question between the West and China, Western fascination with Tibetan Buddhism, and a growing Western-spawned outcry over "human rights" are part of the total context in which Tibetans bring new meanings to the pain and suffering expressed in rlung discourses. In the essay that follows I present a cultural-epidemiologic analysis of rlung disorders in central, principally urban, Tibet. I locate rlung disorder in a confluence of Tibetan ethnomedical constructions of the mind-body-universe linkagein which rlung stands as the chief symbolic mediatorwith ethnic conflict, rapid economic development, and the localization of the global debate over Tibetan suffering and human rights. I argue that the determinants of rlung disorder can be found in the social facts of structural discrimination and related economic injustice. Most importantly, the particular modes of its expression and representation in modern, touristed Lhasa may deflect attention from these facts in favor of a principally Western-based framing of Tibetan suffering which locates it in the destruction of Tibetan religious culture, in the torture and imprisonment of its citizens, and in state oppression (Adams 1996c).2 Tibetan Medicine and Rlung Disorders I have provided a general cultural outline and modern history of contemporary Tibetan medicine elsewhere (Janes 1995).3 Here I summarize the nature of the Tibetan medical system, with particular reference to disorders of the humor rlung, and provide a brief description of the Tibetan medical system as it is presently organized and deployed within the Tibet Autonomous Region (TAR) of China.

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Classical Tibetan medicine combines South Asian and Middle Eastern naturalistic humoral theory with Buddhist principles and tantric practice. The three humors of Tibetan medicinephlegm (bad kan), bile (mkris pa), and wind or air (rlung)represent the confluence of climatic, geographic, dietary, social-behavioral, spiritual, and supernatural forces. Although a classically naturalistic humoral system quite similar to Ayurveda, at remote causal levels Tibetan medical theory invokes the different modes of Tibetan Buddhism (Samuel 1993). Healing is approached on three levels: the spiritual or dharmic, the subtle (vital) or tantric, and the somatic or humoral (Clifford 1984; Rechung 1973). Dharmic healing is a spiritual practice aimed toward enlightenment, tantric healing is intended to align the vital energies (rlung) within the body which connect it to its phenomenal existence, and humoral medicinethe material elements of healing that constitute the most visible aspect of the traditionbalances elements, substances, and humors within the body that have gone out of equilibrium due to "improper" thought and behavior. The pervasiveness of multiple modes of ethnomedical thought among Tibetans today, even among state-educated Lhasans, suggests a complex subjectivity that integrates the mind-body with the social and natural universes in a host of ways. Illness experiences are matters of diverse origin, from diet and climate to emotion or mental agitations, as well as the actions of supernatural beings aroused in the course of social events and personal behaviors. In Tibetan medical theory, rlung is the integrator of such manifold forces; Tibetan physicians often describe rlung metaphorically as the "king" or "integrating principle" of the mind-body. In classical Tibetan medical theory, the humor rlung is that which animates, gives rise to action, and brings sentience to physical matter. A young Tibetan physicianeducated in basic biomedicine as well as Tibetan medicine, the standard practice these days (see Janes 1995)described it in this way: "When one eats food, the heat or fire of the stomach digests it, breaks it down. But the digested food cannot nourish without adequate rlung. Rlung is what allows the food to enter the organs and muscles of the body and become the energy one needs to walk or think." Rlung imbalances may affect different parts of the body; the affected parts reflect the mapping of different "kinds" or "levels" of rlung on particular ethnoanatomical systems. For example, in the brain, rlung (as srog- 'dzin-rlung) empowers the senses, cognition, and emotion; in the chest, it gives rise to respiration and speech; in the heart, rlung compels the heart muscle to beat and the blood to circulate; in the stomach and intestines, it causes the transformation of food into energy; and in the genitals, bladder, and colon, it empowers reproduction and elimination. Imbalances of rlung and changes to the character of rlung (slow moving, quick moving, lightness, dryness, etc.) lead to dysfunctions in these ethnoanatomic regions. Imbalances have their own particular characteristics that determine which symptoms will appear and which will be the most troublesome. For example, rlung may not only be high or low, but also heavy/slow or quick. Common symptoms are those that derivefromdisorders of rlung in the brain, heart, and chest. In the brain, rlung causes disordered thinking, depression, and insanity; in less severe forms, dizziness, insomnia, dysphoria, fainting,ringingin the ears, and impaired sensory perception. In the heart, rlung contributes to palpitations, "heart swings," and a rapid, fluttering heart beat. In the chest area, rlung causes shortness

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of breath and pain in the sternum, which often goes through to the upper spine (pain is especially significant between the sixth and seventh thoracic vertebrae). Rlung is also believed to be the force that maintains the movement of blood through the body; hence, disorders of such movement, for example, high or low blood pressure (the latter producing fainting, or "losing the power of the body"), are attributed to rlung imbalance. Rlung imbalances that affect the heart (called snying-rlung), the circulation of blood (high, low, or "variable" blood pressure, called khrag-rlung), and the life force (called srog-rlung) are more common. Severe and irremediable srog-rlung is synonymous with insanity; what we recognize as clinical psychoses or depression are consistently identified as severe srog-rlung by Tibetan physicians and laypeople alike. Rlung varies naturally between people and within an individual over one's lifespan. The amount of rlung one has is an inborn trait, part of one's essential character. Inborn levels of rlung can be influenced by a number of things, ranging from karma to the behavior of the mother. One's essential character may be predisposed toward or protectedfromrlung imbalance and, hence, rlung disorder, in the context of otherwise shared social, behavioral, or environmental "insults." Rlung is also thought to increase naturally as one ages, and to affect women more than men. It is "natural," according to Tibetan medical theory, for older people and women to manifest, to an unequal degree, the problems associated with rlung imbalance. One of the sources for concern among contemporary Tibetan physicians is the degree to which rates of rlung imbalance are increasing in younger people of both genders. Treatments for rlung are largely similar to treatments for the other humoral imbalances: herbal medicines, dietary pre- and proscriptions, simple behavioral advice, and Chinese-style acupuncture are most commonly prescribed (Tibetanstyle acupuncture, insertion of small gold needles into the top of the scalp, is considered superior, but rarely practiced these days in Tibetan clinics). On rare occasions rlung sufferers may be offered some simple, formulaic advice about "quieting one's thoughts" or managing or avoiding conflict with family members or coworkers. Both physicians and patients, as I will discuss in detail below, are well aware of the social salience of rlung, but this does not appear to be an explicitly recognized feature of rlung diagnosis and treatment, at least not in government medical clinics. In its cultural productions and social manifestations, rlung is polysemantic. Intertwined in the classical medical textsthe rgyud-bzhi (the four tantras) and related commentarywith the essential Buddhist teachings regarding the inevitable suffering that derives from attachments to the world, in this case through desire ('dod-chags), rlung also refers to the "life" principle or consciousness (the subtle or "vibratory" body) that is manipulated through tantric practice. In lay Tibetan terms, this life principle is subject to the actions of deities and often involves ideas about good or bad fortune and polluting places and activities. Rlung discourses thus invoke, often simultaneously, multiple modes of thought: classical Buddhist principles, elements of tantric practice, and a host of lay theories of this-worldly misfortune (Janes 1995; Lichter and Epstein 1983). Rlung is central to a set of body-mind principles whereby culture "works" to push painful affect and bodily dis-ease along several significant cultural paths: Buddhist lessons about impermanence and the suffering created by attachment and desire, lessons about proper mind and thought management, social lessons about kin reciprocity, and lessons

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about the inherent vagaries of demons, spirits, and good or bad luck. Accordingly, physicians and their patients bring quite variable understandings to the sources of rlung imbalance, ranging from narrowly framed ideas about ego attachments and "mismanaging thoughts" to articulations of profound personal and social crises. Rlung disorders are among the most common brought to Tibetan medical practitioners, the majority of whom are employed in government hospitals and clinics throughout the TAR and in Tibetan counties and prefectures principally in Xinjiang, Qinghai, Sichuan, and Yunnan provinces.4 Since 1980 there has been a rapid development of Tibetan medicine in China (see Janes 1995). Centered in Lhasa, the Tibetan medical college and the provincial Tibetan Medicine Hospital of the TAR have trained thousands of Tibetan physicians. The training is, to some extent, both secularized and "scientized," particularly as Tibetan medicine struggles to maintain legitimacy in the face of the powerftil impetus to adopt Western science and biomedicine now characterizing medical traditions in China, although it remains to a degree rooted in the traditional tantras and related commentaries that date in "modern" form to the early 18th century. The Tibetan Medicine Hospital in Lhasa now boasts more Tibetan physicians practicing in Tibet than at any time in Tibetan history. Nearly every county medical facility and many townships have one (or more) traditionally trained Tibetan physician. "Like Trying to Lift the Sky with One Finger": Cultural Epidemiologies of Rlung The polysemantic quality of rlung makes it an effective means to respond to and articulate the impacts of modernity of the Chinese variety or, increasingly and ironically, Western desires for a certain kind of suffering Tibet. Contemporary and largely secular interpretations of rlung tend to focus on social and personal disjunctures, disappointments, and dashed expectations; that is, in a kind of inversion of classical Buddhist thought, rlung stems from the corruptions of desire for that which is considered culturally valued, appropriate, and cherished (Janes 1995). The potential for the explicit politicizing of rlung illness here is a potent one. The extent to which rlung discourses have been opened up to admit purely political sentiments was investigated through interviews with rlung sufferers, a comparable group of individuals attending Tibetan medical clinics who did not have a rlung diagnosis, and a small group of Tibetan physicians considered to be experts in rlung diagnosis and treatment (see endnote 2). I begin here with a description of the epidemiology of rlung in modern Tibet and then turn to a discussion of the meaning of rlung as articulated by these different groups. I direct attention specifically to the sometimes subtle differences that emerge when comparing the epidemiological view constructed through systematic interviewing and analysis, which was largely consistent with physicians' views of rlung etiology and distribution, and the view of rlung as a diagnostic category articulated by Tibetan lay people. What follows is a mix of quantitative and qualitative findings. I begin with a presentation of the qualitative material. Interview results coincided with physicians' perceptions in locating the greatest number of rlung cases among those with more formal state education and correspondingly demanding jobs in large government work units. A recurring theme here was not only the demanding nature of the positions, but, more subtly in some

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cases, difficult day-to-day contact with Han Chinese, many of whom wield power over the Tibetan staff. Tsering is a 42-year-old worker in a foodstuffs factory in Lhasa. He has a history of high blood pressure, which he terms khrag-rlung, and snying-rlung, an imbalance affecting the heart. When we interviewed him, he reported symptoms of upper back pain and frequent insomnia. Tsering attributes his symptoms to his work situation. He is in a managerial position, which he admits creates some worry for him. Later in the interview he talks at some length about the injustices and discrimination he has experienced at work. It turns out that he has been in the same work unit for 25 years and has not achieved a promotion that he feels he deserves. Promotions in his company have been awarded on the basis of personal networks established with senior, principally Chinese, management. Despite his long years of service, his salary has remained low, and this in turn has placed significant economic pressure on his family. Tsering is typical of a large number of rlung cases in that the demands of employment and difficulties with Chinese supervisors are the main themes of his narrative. Like Tsering, most of the rlung sufferers we interviewed were principally urban dwellers, were relatively well educated, and worked in the government sector in clerical and administrative positions. All had firsthand and, in some cases, extensive contact with Han Chinese in their day-to-day working lives. Many had been sent to China to work or study. Some were obviously struggling to maintain the identity of the ideal "minority" celebrated in Chinese propaganda literature. Despite their sometimes quite high positions in work units and government offices, patients often expressed overwhelming feelings of immobility. Passed over for promotions, experiencing systematic discrimination at the hands of Chinese supervisors, and, as a consequence, perceiving themselves to be both exploited and unfairly deprived of access to promotion and salary increases, they felt stuck in untenable positions, were often angry, and had few (if any) available avenues for changing the social context of their work lives. The physicians we interviewed directed us to another group of rlung-sufferers who, like those above, had substantial contact with the Chinese. They, however, expressed a conflict at being caught between Tibetan and Chinese interests in one way or another. Dawa is an important government official in the regional TAR office that sets commodity prices, a controversial office, subject to some loathing on the part of the Tibetan populace: Clearly anxious and agitated when she sees the doctor, Dawa (age 54) launches immediately into a rapidly spoken litany of complaints, underscored by strong emotion: she is dizzy, her head aches almost constantly, she is frightened by her heart, feeling as if it were swinging wildly in her chest. She has trouble sleeping and when she does, she dreams of her father who died several years ago. Her body, she says, is "unhappy." Her job is difficult and causes her much worry and anxiety. She is diagnosed with snying-rlung, which the doctor tells her is very serious. She needs to be hospitalized as soon as a bed opens up. The doctor tells her, "As long as you keep working your problem will continue." Tenzing, a policeman, has quite literally found himself situated between Tibetan sentiments and Chinese interests:

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We spoke to Tenzing (age 53) in the hospital where he had been an inpatient for a total of three months. His symptoms of rlung began four years ago and include chronic headache, unhappiness, anxiety, chest and back pain, dry mouth, insomnia, dizziness, and a cold sensation in his lower back. He links the onset of these symptoms to the beginning of "troubles" in Lhasa between Tibetans and Chinese which put him "in the middle." He described the following series of events: About six years ago (this would make it about 1987-88; serious demonstrations began in early 1987 and continued sporadically through March 1988, when martial law was imposed), his mother died, and he had to travel to his home village, about 50 kilometers southwest of Lhasa, to take care of affairs. When he returned to Lhasa he said things seemed very chaotic and that there were a lot of "sounds" in the city, which made him very nervous. People were yelling and screaming and there were sounds of gunfire all over the city. It was at this time that he first noticed the ringing in his ears. Currently, anything that causes him to be nervous or anxious will intensify his symptoms. He's particularly sensitive to the insults he receives when he is on duty in the Barkhor (central market and circumambulation route of old Lhasa). He's hoping to be able to be released from work until he can retire. Rlung sufferers, physicians, and Tibetan laypeople in general often reference what they call "family troubles" in discussing the probable remote causes of rlung illness. In narratives of rlung sufferers, presentation of family problems took three forms. Thefirsthad to do with disappointments or concerns over children's lack of success; for example, that they did not finish school or were unemployed. The second source of family problems had to do with the behavior of a spouse. Drinking problems and unemployment were the two most commonly articulated themes. Third, informants sometimes characterized their family life as conflicted, with frequent arguments, a disruption of peace in the family, and, particularly for women, pressures from family members to live a life they did not particularly want to live (in terms of work, schooling, place of residence, etc.). Phuntsok, age 25, is a clerical worker for a public security office in south-central Tibet. We talked with him at the Tibetan medical hospital in Tsethang. He traces the onset of his symptoms to the previous year when he had "many bad family problems," which caused him to become dizzy, occasionally fainting. The last time he fainted, he struck his head when he fell to the ground, fracturing his skull. He is very clear about the causes of his rlung, ticking them off on his fingers as he speaks. First, his younger sister, with whom he is close and who studied at a prestigious banking school in China, was sent to far western Tibet. He considered this unfair, but because his family does not have "backdoor" contacts, there was nothing they could do about it. Every time he thinks about it, he says, it makes him incredibly angry. The anger often brings on dizzy spells. Second, his other sister is married to a "very bad man," which keeps this sister from tending to family obligations, particularly taking care of their elderly mother. Finally, he has had many arguments with hisfiance*e,causing the couple to separate and call off their marriage. He ruminates on all of these problems, particularly when he joins his work unit, over 400 km south of his home town of Tsedan. Overt references to social or political conditions in the narratives of rlung sufferers was relatively rare when compared to discussions of employment, family troubles, or economic problems. As with the sufferers of neurasthenia described by Kleinman (1986), discussion of social changes and political factors were sometimes invoked to explain current economic difficulties.

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Nyima is a 68-year-old mother of four with no education who lives with her 38year-old son, recognized as a reincarnate lama. Her father was involved in the Tibetan uprising of 1959 and died in prison several years ago. Her husband was part of the Khampa resistance in eastern Tibet, but was captured and imprisoned in 1957, and reportedly died of starvation with his compatriots sometime later. She has been subjected to a series of punishments and humiliations since that time: she was given housing next to the toilet, which she was not allowed to use; she was not permitted to work; and she had her livelihood, an old sewing machine imported from India by her late husband, confiscated and given to a work unit, where she herself eventually went to work. Her son has not been allowed to join a monastery, and both now survive through begging. They have sold all of their remaining possessions and are now desperately poor. For political reasons largely outside of their control, the usual forms of socioeconomic security promised by the socialist state are not available to this family.

In a few cases, political events witnessed or experienced personally are related explicitly by informants to the onset of their symptoms. Drolma, a young student at Tibet University, is such a case:
Drolma (age 22) presents symptoms of dizziness and headaches, accompanied by insomnia and bad dreams. Her symptoms began, she says, three weeks before the visit when she looked out her apartment window and witnessed a monk being beaten by police. After being knocked bloody and senseless, the monk was dragged into a waiting van and driven off. She has not been able to avoid thinking about it since, and her mind "seems out of control," thinking over and over about this obviously distressing event.

Table 1 summarizes the quantitative data on these rlung cases and a matched comparison group. About a quarter of the rlung sufferers related their condition explicitly to political issues, framed principally as Chinese oppression and loss of Tibetan autonomy, witnessing beatings and demonstrations, or personal experiences with state discipline or terror. Family problems, especially problems with children, the alcoholism of a family member, and chronic unemployment of family members were presented as determinants of rlung symptoms by 37 percent. Proximate causes related to strong emotions and/or failure to manage such emotions were cited as significant by 27 percent. Table 2 presents the results of a simple and straightforward epidemiologic analysis of the themes presented in the case studies above. In comparing rlung sufferers to a non-rlung suffering clinical sample matched by age and gender, it is possible to appreciate the nature and potency of the social and economic risks that arise in segments of the Tibetan population by virtue of Chinese modernization programs (discussed further below). The odds of having a rlung diagnosis in this particular study increase more than four-fold for those who have had experiences in China or who are working in settings where Han Chinese hold many, if not most, of the supervisory positions. Theriskincreases over two-fold for those with a "professional" occupation or those who mentioned in their interviews that they had serious economic problems.5 Physicians' interpretations of rlung etiology and epidemiologic distribution are, as noted, often consistent with the epidemiologic perspective presented here. Physicians tell us that the prevalence of rlung, while always high, has increased with "modern social changes." Many cite the turmoil of*the cultural revolution as

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TABLE 1 Characteristics of individuals diagnosed with rlung imbalance, compared with "controls," Lhasa, 1991-1993. Characteristics rLung Cases (N = 41) Controls (N = 38)

Men
Women Mean Age Marital status Married Single Widowed/divorced Mean years of state education More than 6 years of education Primary rlung diagnosis sNying-rlung Srog-rlung Trak-rlung Other rlung Chronicity of primary diagnosis One year or less More than one year Government or high-level work, unit administrative work Experiences in China, in Army, in predominately Chinese work-unit Unemployed Economic problems

20 21 46

19% 19% 41% 68% 21% 11%

2 18%

68% 17% 15%

4 38%

42% 20% 22% 16%

32% 68% 29% 46% 10% 27%

N/A

42% 58% 13% 16% 11% 16%

having produced a near epidemic of rlung illness in the late 1960s and early 1970s. About one-half of the physicians identified social causation as primary to rlung disorder. The following factors were the most frequently cited: rapid social change, the trauma of the Cultural Revolution and similar events, poverty or money worries, job problems or frustrations stemmingfromcareer immobility, anger and frustration over the current political situation, disappointments with children and other family members, and arguments and fights in the family.6 Other physicians expressed models of causality that emphasized Buddhist principles regarding the suffering that derives from attachment. These were explanations that emphasized individual psychological/emotional states that produced the bodily symptoms of rlung such as anger, sadness, fright, and grief. Some noted that rlung imbalance is a problem related to "narrow mindedness" or failure to "control the mind properly." That is, people who are inflexible, who in effect cannot cope, are most likely to develop flung.

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TABLE 2 Epidemiology of rlung: case-control analyses. Cases = 41; Controls = 38 (matched by gender). Characteristics Extensive experience in China or with Chinese in work situations Significant economic stress, lack of advancement At least a lower middle school education Government or work-unit administrative position * Statistically significant Odds Ratio 4.61 1.96 2.71 2.73 95% Confidence Intervals 1.44-16.14* .64-6.32 .78-9.71 .86-10.99

In observations of 718 clinical exchanges conducted in 1991 and 1993, some form of rlung imbalance was the most commonly given diagnosis (18.2 percent) followed closely by the general categories of stomach ailments and "infection" (17 percent each). The proportions of rlung patients seen were relatively consistent from one outpatient context to the next, with slightly higher proportions of rlung found in urban areas and inpatient hospital settings. In 1993 we conducted two separate censuses of the Tibetan inpatient hospitals in Lhasa and Tsethang. Of all the patients admitted, 22 percent had some form of rlung diagnosis. The average stay for all patients treated at the Mentsikhang inpatient hospital is three months; our data showed that rlung patients stay a bit longer than this. The higher numbers of hospitalized rlung patients and the longer average stays of such patients is consistent with physicians' beliefs about the seriousness of rlung. In the rlung cases we observed in both in- and outpatient settings, it is striking to note the apparent trivializing by physicians of the concerns expressed by patients. In this highly rationalized medical bureaucracy, where quantitative aspects of patient encounters loom ever larger as justifications for state support and legitimacy, physicians barely have time to get beyond the most superficial level of interaction. With lines of patients snaking out the door, and many witnessing, indeed listening intently to the encounter, the physician can do little except focus on the immediate and individualized problem and apply the material "magic" of the medicines (van der Geest and Whyte 1989). This raises the problem of "medicalization," the transformation of problematic emotions and social disorders into simple individualized problems containable by diet, herbal medications, and rest (Scheper-Hughes 1994). Yet there is widespread sentiment among lay people and physicians that rlung is, at least in some form, a political consequent. The complex of proximate and remote causes specific to an individual narrative seems easily transferable in general discussion to political discourses of how Chinese political hegemony causes Tibetans to suffer. Consider the following statements, taken from interviews with physicians and Tibetan lay people (non-sufferers of rlung):

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Rlung is caused by the social situation. It is not fair or balanced, and yet people are not free to do anything about it, so now everyone, young and old, has rlung. If you see an official beating up local people, it causes pain, because there is nothing you can do about it. It is like trying to lift the sky with onefinger.One person can't do anything, and so they get pain in their body. [36-year-old male carpenter, Lhasa] Great sadness and anger will cause rlung. Most people today have rlung because of the nature of society. These are very tumultuous times. Rlung used to be found only among old people. Now it is everywhere. It is a result of social immobility and frustration arising from no freedom of movement. All Tibetans have problems with rlung because they are not able to move about freely. [35-year-old male bureaucrat, Lhasa] Rlung [is] more common nowadays because Tibet is no longer free. The Chinese government is the government of rlung. The Chinese government makes people unhappy, and so rlung must be more common.... Tibetans have rlung because they are not free. [46-year-old male physician, Lhasa, cited in Janes 1995:31] Rlung is common today because of the many changes in society and ways of life. It is most common in the city. People in the countryside do not think about the future or the larger picture, they only think about immediate things. They also have little education. Education improves one's awareness of the world. Seeing the big picture opens up people to attachments, worries, desires, and so forth. They are more likely to develop a rlung imbalance. [56-year-old male physician, Lhasa]

It is tempting to read these statements as revealing rlung as a "medical weapon of the weak" (Scheper-Hughes 1994; Scott 1985). However, the complexity and multiple layering of rlung etiologies in popular as well as professional discourse, the highly flexible and fertile symbolic ground provided by rlung in a purely Tibetan cultural sense, and an epidemiologic profile suggesting that it is not necessarily those with the least power who experience rlung argue against such a simplistic position. Following Ortner (1995), I suggest that Tibetans, as the subaltern Other in this context, are not a unitary group. Internal divisions and tensions in Tibetan society exist, many of which are class-based and predate Chinese contact. To assume that all Tibetans are alike is to dissolve these multiple divisions into a unitary subject and thereby miss the complexity that characterizes Tibetan responses to their current political and economic situation. As an alternative, I direct the reader's attention to the details of the epidemiologic distribution of rlung: it is a disorder not of the weak, but of those attempting, in many cases, to be upwardly mobile. It is not a matter of political oppression as much as it is the denial of proffered equal rights to participate in China's rapid economic modernization on the basis of ethnicity. Rlung in an epidemiologic sense is about the denial of justice to some in a social and economic context that champions social equality. It is not dissimilar to so-called disorders of social change or "modernization" found worldwide (Christakis et al. 1994). Yet what can we make of statements made by physicians and lay people alike that certainly have the potential for politicizing rlung? One clue may be found in the remarks of one of the physicians cited above: Tibetans, with increasing education, increasing awareness of the outside world, and increasing contact with cosmopolitan representations of the. Tibet question, are opened to new images of themselves. It was quite clear in many of our interviews, particularly with non-

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sufferers, that many Tibetans describe rlung in social and political terms, and to articulate such descriptions in the language of oppression is part and parcel of the Western-Tibetan engagementthat is, to talk about personal or individual freedom. To fully understand the multiple meanings and the political implications of rlung, it is probably best to distinguish rlung imbalance as a diagnostic category, with a particular set of epidemiologic characteristics, from popular rlung discourses. Such discourses shape the polysemantic character of rlung in such a way as to incorporate political ideas. Often filled with anti-Chinese and pro-independence rhetoric, rlung discourses are an articulation of imagined lives made palpable by the now pervasive cosmopolitan representations of a suffering Tibet. Epidemiologically, rlung is best characterized ironically as a disorder that stems from the failure of the socialist promise. Popular rlung discourses, however, tend to frame rlung disorder as oppression by the socialist demon. To examine the sources of this contradiction, I turn to a consideration of the modern politicization of everyday life in Tibet. Ironic Compromises: Dharma Bums, Chinese Modernity, and Body Politics There are a number of cultural players on the scene in modern Tibet, particularly in touristed Lhasa. Each deploys a distinctive representation of Tibet and Tibetans, and each has a certain power to affect the local contexts in which daily life is conducted. On the one hand are the various institutions of the Chinese state that have exercised direct control over Tibet since the 1950s. On the other are the multitude of individuals, interest groups, and organizations on the global scene that exert a far more diffuse, but increasingly important, influence over Tibetan life and cultural identity. In this mix are Western tourists, who have a certain stake in maintaining an exotically religious Tibetan Other, Tibetan refugee communities and the Tibetan government-in-exile, who find in Western exotic yearnings a voice for their own political agenda, and a block of right-wing Western political ideologues who see in a certain kind of Tibetan suffering a useful way to demonize China.7 Held firmly in the sway of these lines of interest and power are the Tibetans, hardly a homogeneous lot, who may struggle at a more fundamental, and, to the West at least, poorly understood level for economic and social justice. As our epidemiologic analysis shows, in the most simple terms, rlung represents the unsuccessful outcome of these struggles. How it is interpreted and represented by patients, physicians, and, of course, anthropologists, is, however, in many ways a consequence of the wider, largely non-Tibetan representational interests, each with a stake in constructing a different kind of Tibet and proposing a certain kind of Tibetan. Western concern with the "Tibet Question" has revolved principally around religious and cultural expression; the stake is apparently in preserving aculturally distinct and "authentic" Tibet untainted by the socialist modernity proffered by China (Adams 1996b). This Westernized version of Tibet is often adopted and exploited by the exile government in Dharamsala, India. A particularly illustrative example can be found in the conflict several years ago over the recognition of the reincarnation of a senior religious figure, ostensibly a matter with little real political importance. In 1995, the exile government in Dharamsala and the Communist Party leadership in Beijing engaged in a heated debate over the reincarnation of the

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Panchen Lama. In the end, the Party aggressively repudiated the Dalai Lama's role in this affair and named its own reincarnation. Reportedly, the selection of the new Panchen Lama was subject to the final approval of the state council and the personal endorsement of Li Peng, a principal of the Chinese Communist Party. Thus a thoroughly atheistic, Marxist leader, associated by the West with the violent suppression of the Tiananmen uprising and in setting China's hard-line domestic policy, has been thrust by these events into the role of Tibet's senior religious authority, which, were it not for the dire human consequences that such action portends, would be a delicious piece of post-modern irony.8 Why the state intervention? The political events surrounding the selection of the Panchen Lama are a culmination of recent efforts to repudiate the governmentin-exile and attack the most internationally visible elements of Tibetan culture. It is the most critical signal to date, in fact, that Beijing has chosen to abandon the reform policy and promises of autonomy it made to Tibetans in 1980 and to turn back to the heavy-handed domestic policies it had promulgated in Tibet in the post-Cultural Revolution decade. Most significantly, the decision to repudiate formally and publicly the Dalai Lama's cultural authority is indicative of China's bristling sensitivity to an increasingly vocal international community that is strongly invested in a culturally "authentic" Tibetan autonomy, an autonomy that for mosttravelers, humanrightsactivists, and anthropologists alikeis exemplified principally in the practice of Buddhism. Arguments over who has the authority to validate a reincarnation, a matter which to all appearances has little real political significance, thus represents deeper and more fundamental representational conflicts over the status of Tibetan culture. Playing politics with six-year-old boys is not just a capricious response of a paranoid regime (although this adjective may be appropriately applied in this case), but the culmination of half a century of troubled Han Chinese and Tibetan relations, failing economic reforms, uncertainties created by the rapidly shifting sands of China's ethnic policy, and a shrill and escalating argument with the West over humanrights(Goldstein and Beall 1991; Mullin and Wangyal 1983). This latter argument has driven issues of economic and social justice, just the problems that Tibetans articulate on a day-to-day basis, and which, as I demonstrate, comprise the modern epidemiologic determinants of rlung disorder, to the margins of the debate. In fact, the political role of religion and religious institutions in Tibet has been largely sustained by the increasing stature of the government-inexile and, more importantly, a groundswell of support from the West (Goldstein and Beall 1991). The growing popularity of Buddhism among the middle and upper classes in Europe and North America, residual fascination with the "ShangriLa" myth (Bishop 1989), and the popularity of the Nobel Prize-winning Dalai Lama, a figure with charisma and a quiet, wise charm that plays well in the West, has resulted in a crystallization of world opinion around issues of religious freedom in Tibet, which is conflated by many Westerners with humanrightsand social justice.9 Western visitors to Tibet regard the monasteries as the font of traditionalism, Tibetan culture, resistance, and sites of the most grievous humanrightsviolations.10 The Chinese have likewise maintained an interest in Tibetan religion, but this is an interest driven principally by the desire to package and commodify elements of Tibetan culture for sale to Westerners (Adams 1996b). Visits to what remains of the great monasteries around Tibet, now primarily state museums, are part

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of the standard package tour. The fact that, although the state has tried to control the monasteries, they remain a locus of nationalist sentiment is, however, not lost on the more independent young European and North American travelers, invariably pro-Dalai Lama, who stay, when permitted, in the Tibetan hotels in downtown Lhasa. Among this group, conspiratorial visits to monks and monasteries, where letters, photos, and occasionally documents related to government policy are passed on for conveyance to Dharamsala and the West, are discussed with great relish.11 Such exchanges are the stuff of evening meetings in hotel courtyards and small Tibetan restaurants, with everyone feeling (with some naive delight, I suspect) part of "the resistance." They fulfill in a direct way the desire for a Tibetan authenticity which rests within its once great religious institutions, as well as for a desired engagement with an Other that is suffering at the hands of a state bent on expunging the influence of religion from daily life. The interplay of Western touristed desires around religion, independence, and Tibetan resistance results in a relative lack of engagement with those local issues that, for many Tibetans, are equally, if not more, pressing: lack of employment, perceived discrimination, corruption of Han officials, and excessive government control over aspects of everyday life. Beyond the Western gaze, young Tibetans may be just as likely to articulate desires for landcruisers, cellular telephones, and nights filled with karaoke as they are to speak of dharma, freedom of religion, and the Dalai Lama (Adams 1996b). Western desires for an authentically religious Tibet recognized and exploited by the Chinese for economic and political benefit create the potential for a Tibetan religious participation in which nationalist resistance is just as great a motivation as is the earning of Buddhist merit. The past several years have seen China recognize this problem and take a number of steps to deal with it directly. The strong position it took on the reincarnation of the Panchen Lama is evidence of the current approach.12 Perhaps ironically, religious expression might not have become so politically contentious if the economic reforms initiated in 1980 in Tibet by Chinese Premier Hu Yaobang had been sustained. Tax relief and private ownership programs initiated at this time resulted in short-term increases in real income; however, these advances have proven to be largely unsustainable. Subsidies to raise output initially focused on state enterprises, rather than the rural, agricultural sector, benefiting the Chinese cadre and immigrants who are disproportionately represented in such enterprises. Furthermore, several writers have acknowledged that a substantial portion of these subsidies were invested in losing propositions (Sharlho 1992). Because a large number of the employees of state enterprises are Chinese, a massive subsidization in the form of extra benefits and wages is required to keep them in Tibet. Two other factors impede economic development in Tibet. A heavy burden of administrative costs for the bureaucracy has siphoned off substantial portions of state funds that otherwise might have gone into subsidized rural projects. The Chinese duplicated in Tibet the governmental structures they had implemented in the more densely populated center of China, resulting in a per capita greater number of government staff at all levels of the bureaucracy than anywhere else in China. Even more money has been spent on what is termed Capital Construction Investment. These dollars, intended in part to aid development of transportation and

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communication infrastructures, are also used for the construction of public buildings. Since 1985 the majority of these funds have gone into nonproductive construction of office and government buildings in Lhasa. Today, Lhasa has office and meeting space on a per-bureaucrat basis that exceeds the rest of China (Sharlho 1992). The solution to these top-heavy impediments is, unfortunately, problematic. Bureaucracies are always difficult to dismantle; in Tibet this is doubly the case because the majority of government officials and office staff are Chinese, and they would either need to be absorbed into the underdeveloped local, industrial sector, or repatriated back to China. While the development of rural agricultural and urban industrial sectors would have provided opportunities for the Tibetan population, the infusion of subsidies into bureaucracy, already Chinese-run enterprises, and building programs tended to favor the Chinese, and indeed, created the conditions for the rapid immigration of thousands of Han Chinese into Tibet between 1985 and the present. In only three months in 1985 alone, more than 60,000 official Chinese workers entered Tibet (Sharlho 1992). With a burgeoning Chinese population, demand for consumer goods, Chinese food, and services far outstripped supply, creating the economic incentive for a wave of volunteer migration to serve immigrant Han needs (Goldstein and Beall 1991). This demand, coupled with reforms to the household registration policy and various government incentives designed to facilitate migration and small business development, has brought a huge influx of entrepreneurs and "penny capitalists" into Tibet from all over China. Tibetans have not been well positioned to take advantage of these entrepreneurial activities. Because much of the business is controlled by networks of socially affiliated Chinese, Tibetans, with limited entrepreneurial skills, sometimes poor command of the Chinese language, and subject to continuing ethnic discrimination by Chinese officials and employers, are virtually shut out of the subsidy-stimulated consumer economy. A friend and colleague in Lhasa who has monitored this situation for years estimates that between 75 and 90 percent of all new business licenses are issued to Han immigrants. Today in Lhasa, the trade in Tibetan traditional ceremonial scarves and other ceremonial paraphernalia is controlled by Chinese merchants. A photo of the Dalai Lama, considered ironically by Western travelers to be a political symbol of a "free Tibet" and therefore carried into Tibet and given surreptitiously to monks in the monasteries, may be purchased in front of the important Jokhang temple in Lhasa for approximately 25 cents from a merchant who is almost certain to be a Han immigrant. The present local government has been loathe to intervene in the economy in a fashion that would open up access to jobs and other opportunities for Tibetans. After 1980, attempts to bring down officials appointed during the Mao era were sabotaged by the entrenched local leadership, composed principally of a military and pro-Chinese Tibetan cadre who rose through Party ranks during the Cultural Revolution. In 1985 a minority leader (from the Yi nationality) was appointed to lead the Party in Tibet, but he was never trusted or supported by those below him, and could thus never fully implement Beijing's policies. Local leadership could not be replaced; there were no Tibetans that Beijing trusted that could be appointed to Party leadership (Sharlho 1992). The extent of political reforms in Tibet were window dressing appointments of "rehabilitated" former Tibetan government officials to non-Party government positions, particularly the TAR People's Political

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Consultative Conference and the TAR People's Congress. While Tibetans may respect the public positions these non-Party leaders may take on certain issues, they are not generally respected by the people, and are seen as handmaidens of Chinese policy. At present, all indications are that the TAR administration, supported by an increasingly conservative and hostile leadership in Beijing, is resorting to some of the more severe political and economic means to suppress "splittist" attitudes in Tibet since the Cultural Revolution. With no access to economic opportunity and little chance for meaningful political participation, Tibetans are becoming increasingly marginalized, in essence forced to articulate their needs and their resistance to Chinese policies in the context of those Tibetan institutions that remain functioning: religion and medicine. With increasingly strident Chinese rhetoric on religion as a source of "splittism," moves to more directly control the monasteries and monastic education, and the recent appropriation of reincarnation politics by the Party, medicine may remain the only institution in which Tibetans can articulate, through the language of the body, dissatisfactions over modern life that are not interpreted as signs of nationalism. But what happens when the West, including Western anthropologists, turn their gaze on medicine? What then will be the potential of medicine to safely contain such sentiments? Rlung, with its polysemantic and fundamental tantric Buddhist attributes, is in many ways a perfect vehicle for expressing the suffering that some Tibetans certainly experience under the conditions sketched out above. It is also a useful means for articulating the ironic compromises between the life they experience and that which is held out to them as possible by China, Western tourists and dharma bums, and, of course, anthropologists. In the ironic spaces opened up by Chinese and Western modernities, rlungrepresentsmore than lessons about the suffering that stems from a failure to appreciate impermanence; it is a political statement about the Chinese corruptions of legitimate desire. Conclusions: Whose Corruptions? Rlung is an idiom of distress (Nichter 1981). It is developed, via the productive work of culture, as a statement of personal and social suffering that reflects a mix of classical Buddhist ontology with the modern politics of Tibetan identity. To lay people, this identity develops in part out of a sense of ironic compromise, an apprehension that day-to-day experience corresponds poorly with both Western and Chinese representations of what Tibet and Tibetans are or should be. Lack of access to social and economic opportunity places Tibetans, in an epidemiologic sense, at risk. The physicians and institutions of Tibetan medicine, off the main stages of political conflict, offer, in effect, safe havens to those who suffer rlung. Rlung provides an idiom for expressing the distress that might otherwise be seen as political resistance, a dangerous play to a suspicious audience in these most dangerous of times. The politicization of rlung is likely, though not necessarily, a contemporary act. Evidence from studies in India suggests that disorders of the humor rlung, given its centrality to Tibetan constructions of the integrated principle of mind, body, and society, are subject to causal constructions that foreground a number of principally social factors. What is happening in Lhasa today is simply an expansion of this particular tendency using a language that reflects the realities of

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modern Tibetan life and of Tibetan encounters with Chinese attempts at social and economic transformation, but it is also a language which incorporates Western ideas about Tibetan suffering. When a prominent physician pronounces that the "Chinese government is the government of rlung," is he articulating common ethnomedical discourse, is he playing to the Western anthropologist, or is he, through the processes of cultural work in this radicalized context, participating in the reshaping of rlung etiology so that it reflects transnational desires? This latter possibility brings forth two important and related questions: to what extent do Western desires for a Tibetan Otherness, rooted principally inrepresentationsof Buddhist spirituality, create, equally, a desire for a certain kind and shape of Tibetan suffering? To what extent do Tibetans, caught unquestionably in a situation of ethnic and social conflict, appropriate such desires in constructing their suffering, for us, the Westerners, the anthropologists interested in things cultural? Rlung discourses, traditionally aligned with classical Buddhist principles regarding suffering, appear in the process of being shaped by the cosmopolitan representations of a suffering Tibet, where suffering derives most vividly from a demonized Chinese state that fails to permit practice of religion and free cultural expression and resorts to imprisonment, torture, and other forms of bodily suffering to enforce its will. Tibetans, for whom state oppression, and even imprisonment and torture, are palpable aspects of day-to-day life, but who are rooted in ethnic conflict, structural discrimination, and an absence of economic justice, may seize on cosmopolitan constructions as one way to give some voice to their suffering. A Tibetan medical system, a legitimate and highly rationalized branch of the Chinese social service bureaucracy, provides an opportunity for some individuals, including some physicians, to articulate such suffering in forms thatrepresentonly minimal challenges to a state that is only too willing to resort to violence and imprisonment. But the embodiment of suffering in this highly politicized context suggests that there is currently in process the hatching of a highly ironic subplot to Tibetan medical pluralism. Tibetan medicine's shaping of rlung as a political disorder,framedin Buddhist terms, may join with the cosmopolitan cultural representations of modern Tibet in a kind of radical ethnomedicalization to deflect and channel social criticism away from its roots in day-to-day economic injustice. If this process is completed, it will be a critical development. The Chinese response to Western critics of humanrightsin China is simply that individual rights must be secondary to the primary principle of economic equality, that issues of religious freedom or cultural autonomy must not stand in the way of social advancement through economic development. As rlung discourses become more aligned with Western perspectives on humanrightsin China, that is, as being rooted in the lack of individual freedoms and suppression of free religious expression, they will deflect criticism from the critical economic issues that are precisely the most important and sensitive to Tibetans and Chinese alike. In this confluence of transnational cultural forces and Tibetan suffering emerges an imagined life that is crystallized in stories about rlung. In these stories, the discourses of Western human rights, fantasies of Shangri-La, and the global politics of humanrightscoalesce in a culturalist portrayal of suffering that may overlook, indeed mystify, the consequences of China's social and economic program on the plateau.

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NOTES

Acknowledgments. The research upon which this article is based was funded in part by a grant from the National Science Foundation, BNS-9005811, and Faculty Grant and Fellowship awards from the University of Colorado-Denver. I wish to thank Vincanne Adams, Susan Blum, Kitty K. Corbett, and Geoffrey Samuel for their constructive comments on earlier drafts of this paper. I am particularly grateful for the valuable assistance of Cheryl Reighter, Nawang Sherap, and Mahmoud Hosseini in collecting the data upon which this paper is based. 1. I have chosen to use here the classical transliteration system proposed by Wylie (1959), rather than alternatives (e.g., Samuel 1993) for the simple reason that it is perhaps less confusing to nonspecialist readers (e.g., confusing rlung, the ethnomedical category, with lung, the English term for an anatomical organ). 2. The research project upon which this paper is based was carried out over several field periods in the Tibetan Autonomous Region (TAR) of China in the roughly six years between October, 1988, and August, 1994. Most of the interview data on rlung illness were collected between July and November of 1991, and March and April of 1993. The primary goal of the research was to conduct ethnographic research on Tibetan medicine as it was then being practiced in the Chinese political and economic context. The research was sponsored by the Tibetan Medical Hospital in Lhasa, which provided housing and logistic support, and, less directly, by the Tibet Autonomous Region Health Bureau. The research design included case studies of individuals seeking treatment at Tibetan medical facilities, interviews with Tibetan physicians and government (Health Bureau) officials, and observations of clinical interactions. A random sample of 56 patients stratified by age, presenting symptoms, and institutional locus of treatment were interviewed; these patients were drawn from an observational exercise in which 718 clinical encounters in Tibetan medical facilities (rural and urban) were recorded. Forty practitioners of Tibetan medicine provided their career histories and training experience, and 20 key informants, principally senior officials in the Health Bureau, the Tibetan hospital, and the Tibetan Medical College, provided information on health policy, the history of Tibetan medicine more generally, and the professional explanatory model of rlung causation and treatment. In the context of the more general ethnographic project, rlung emerged as an important category of sickness that individuals, particularly practitioners, were eager to talk about. Follow-up interviews and case studies were developed at this point with 42 individuals who were diagnosed by the formal medical system as suffering from rlung. Additional in-depth interviews with ten Tibetan medical practitioners considered "experts" on rlung were also completed. The rlung case studies presented here were collected in the towns Lhasa and Tsethang. Lhasa is the capital and largest city of the TAR, with a Tibetan population of about 50,000. It is here that the major Tibetan medical hospitals and training centers are located. Although the majority of the patients at the Tibetan medical facilities are Lhasans, a substantial number of patients travel some distance to seek treatment in Lhasa. Lhasans are also exposed with greater intensity to the rapid social changes occurring in the region and are more likely to articulate these as causal forces in their lay explanatory models of rlung disorder. Thirty-four of the 42 rlung cases collected were from the Lhasa area. The remaining four were collected in Tsethang, a small town and capital of Lhoka prefecture (Tibetan population of about 25,000), southeast of Lhasa in the Yarlung valley. 3. For general materials on Tibetan medicine, consult Clifford (1984), Finckh (1978), Parfionovitch et al. (1992), and Rechung (1973). In addition, the Tibetan Medical Centre in Dharamsala, India, currently publishes a periodical as well as a number of topical publications on various, primarily theoretical, aspects of Tibetan medicine. For a good, general introduction, the reader is referred to the work by Tsarong et al. (1981). 4. There has been some reappearance of physicians in private practice; nearly every county has a few "celebrated" practitioners who operate outside of the government sphere.

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The Swiss Red Cross operation in Shigatse (Xigaze) is also involved in training traditional physicians and sending them to remote areas of the TAR (and elsewhere) where they will, ideally, be able to practice without government inputs. 5. The sample size here is rather small. As the confidence intervals indicate, only the first variablecontact with Han Chinese, and so onis statistically significant. The remaining odds ratios show positive trends, but cannot be assumed to reflect anything other than the chance introduced by the small sample. 6. It should be noted that family problems, in particular unemployment of youth, alcoholism, and violence, are linked by Tibetans to the current economic situation where there are few opportunities for Tibetans, particularly Tibetan youth just out of school. Many of these unemployed young men and, to a lesser extent, women, can be found crowding the sweet tea shops in central Lhasa. As day shifts into evening, the drinking of sweet tea shifts to cheap chang (Tibetan beer) and arak (distilled liquor). Alcoholism is becoming a serious problem. 7. The Tibet issue has attracted a number of conservative politicians in the United States and undoubtedly elsewhere. Senator Jesse Helms of North Carolina, notable for his social conservatism, has espoused the views of the Dalai Lama's government-in-exile. The Colorado Friends of Tibet organization is led by a conservative American lawyer. 8. The control of religious institutions and expression by China has continued to accelerate. In the November 13,1996 issue of the official Tibet Daily, the government called for "large-scale" reforms of existing religious policy in Tibet, noting that "Buddhism must conform to socialism, not socialism to Buddhism." The signed article stressed that all temples, monks, and nuns must "conscientiously accept" the leadership of the government and party at all levels (World Tibet Network News 1996). 9. The existence of an internationally prominent exile government brings a new dimension to the Tibet question, which makes it distinct from the issues faced by other minority nationalities. Sharlho reports that, while he was a student at the Central Nationalities Institute, fellow Mongolian, Uighur, and Kazak students would often say, "If only we had a 'Dalai Lama' on the outside like you do, then Beijing would care about us, too" (Sharlho 1992:48). 10. A review, for example, of the human rights information put out electronically by the Office of the Government in Exile in London typically features lists of monks and nuns that have been arrested, purportedly tortured, or who have died in prison. 11. Recently, for example, the Tibet Information Network in London published a translation of a document regarding the mandatory "reeducation of Sera monks," presumably passed by a monk to a foreign visitor and smuggled out of Tibet. 12. The Party newspaper, Renmin Ribao (People's Daily), still cautious on the subject of the Dalai Lama, has acknowledged the relationship between religion, world opinion, and Tibetan nationalism: Centering on the work of searching for and confirming a reincarnated child for the Panchen Lama, we have waged a serious political struggle against the Dalai Lama. Supported by certain foreign forces, the Dalai Lama created various obstacles to the work of searching from the beginning. After repeated failures, he risked everything in a single venture and publicly and arbitrarily announced that he had confirmed a "soul boy" . . . this struggle is a continuation of our struggle against the Dalai Lama clique, which has lasted for more than 30 years. The essence of the struggle is whether one should protect the dignity of the law, the interests of the people, the unity of various nationalities, and the unification of the country, or violate the state law, hurt the people's interests, create splits among people of different nationalities, and sabotage the unification of the motherland... we should point out that the Dalai Lama merely relies on his religious influence; however, some people in the world are using the Dalai Lama as a tool for opposing China and interfering in China's internal affairs in order to achieve

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ulterior motives.... A qualified religious believer should, first of all, be a patriot. Any legitimate religion invariably makes patriotism the primary requirement for believers. One can talk about love of religion only if one is a patriot. [ 1995]
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