Special Issue: Postcolonial Technoscience
ABSTRACT The ambiguous terrain of ‘fact-making’ in biomedical clinical research is
explored by way of an investigation of the criminalization of Tibetan medicine and
Tibetan medical practitioners who participate in the global pharmaceutical pursuit of
new medical products. Transcultural encounters between biomedical research
interests and Tibetan medical practitioners suggest the production of awkward
alliances between the state, markets, and measures of medical efficacy on an uneven
global playing field. Moving beyond the possibility that a postcolonial science will be
inherently hybrid, this paper seeks to uncover the inequalities of such hybrid-making
encounters. When ‘medical facts’ must be derived from ‘magical beliefs’ in the
centres of biomedical science, the state often intervenes to criminalize practitioners
of alternative medicine. But, when profits are to be made on the fact that ‘the
magical’ sells in alternative medicine, the state also makes it possible to shift
ownership of medical knowledge, sometimes by way of the randomized controlled
trial and the pursuit of active ingredients. The possibility of relocating the label of
‘crime’ is explored in this paper by way of an inquiry into processes that enable this
shift in ownership, and a relocation of what constitutes medical ‘fact’ versus ‘belief’.
Keywords fact-making, illegitimate magical beliefs, randomized controlled trials,
Tibetan medicine
Randomized Controlled Crime:
Postcolonial Sciences in Alternative Medicine
Research
Vincanne Adams
In his recent essay in The Nation [Le Carre (2001)], John Le Carre offers
the brief but useful suggestion that the military industrial complex
spawned by the last stages of decolonization1 is being replaced by a new
politico-industrial complex equally authorized by the vast perception of its
ability to ‘do humanitarian good’ (that is, protecting lives) and by huge
wealth, pathological secrecy, corruption and greed. Big Pharma – the
multibillion-dollar multinational pharmaceutical companies – Le Carre
argues, might be recognized as the replacement for nations at a time when
geopolitical relations between countries are no longer based on cold war
antagonisms and military posturing, but on such things as the messy yet
profitable business of ensuring patent protections, and winning debates
over not only who owns the knowledge used in the manufacture and sale of
sometimes life-saving drugs, but also who determines objective truths about
efficacy, medical benefit, and medical harm in these debates. The debates
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highlight the critical yet highly contested rôle played by scientific medical
inquiry in postcolonial times.
I focus on a nation – Tibet – that many argue is still colonized,2 yet also
participant in the apparatuses of opportunity, economy, domination, regulation, and what I will call ‘legal theft’ that were in some cases spawned
by, and in other cases merely sustained after, decolonization in the larger
global context.3 These apparatuses are supported by economics, biology,
ecology and health sciences (to name only a few of the scholarly fields) that
were deployed (post Bretton Woods) to promote development through
multilateral and bilateral aid programmes [Ferguson (1994); Escobar
(1995)]. They are accompanied by the sustained investments of multinational corporate firms that operated prior to and during colonialism but,
as Le Carre suggests, have come to depend even more in the postcolonial
era on the sciences of industry, economy and health (and, in the case of
multinational pharmaceutical firms, on practices of scientific truth-making
and patent-generating), to ensure a corner on the market of profitability.
Globally, Le Carre notes, these apparatuses of science and industry have
frequently served as substitutes for and, in all cases, influences upon
geopolitical diplomacy, displacing the ‘nation’ itself. But I show here that
their operational effects are neither benign nor balanced between nations
or cultures in the debates that such suggested erasure portends.
Within China, ‘development’ was mobilized as part of socialist nationmaking (often glossed as ‘modernization’), particularly in the regions it
considers remote and backward, where sciences of economy, industry and
health have often been tied to repressive forms of social control.4 The shift
to a post-socialist free-market system has ensured a rising presence of
multinational pharmaceutical investments in China, even in remote regions like Tibet – a fact that marks, in some cases, a shift to ‘productive’ (in
the Foucauldian sense) forms of power and discipline.5 It is in part the
increasing desire and enthusiasm among Tibetan doctors, pharmacists and
bureaucrats to participate in global pharmaceutical capitalism that have
spawned tensions around the meanings of ‘science’ when it comes to
matters like measuring the efficacy of Tibetan medicines, in contrast with
that of western or ‘biomedicine’.
In this paper, I explore some of the outcomes of transnational medical
encounters spawned by the circulation of Tibetan medicine inside and
outside of the Tibetan Autonomous Region (TAR), in domains already
colonized by multinational pharmaceutical interests and state regulatory
processes. I ask: what sorts of imbalanced outcomes have been produced
by the transnational circulation of Tibetan medicine, and do these instantiate the features of postcolonial science? Several contested sites are
made visible herein: as debates over what constitutes ‘magic’ versus ‘science’; in the relative force of markets versus state regulations in negotiating
medical truth; and, finally in the effects of decolonization in relation to the
rise of new carceral regimes that are articulated in and around scientific
truth claims, protection of consumers, and medical opportunism.
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I use as a framing instrument the idea of global ‘millennial’ or ‘casino’
capitalism [Comaroff & Comaroff (2000); Strange (1986)] – epithets that
capture the newest forms of risk-venture capitalist interests in postcolonial
geopolitical relationships.6 In particular, I am interested in the ways market
interests become wedded to, and in some cases undergirded by, scientific
knowledge practices that, long after colonialism, continue to serve as
instruments for producing globalized medical ‘truth’. Pharmaceutical interests speak in languages of medical science as they cross over geographic,
political and cultural borders in order to pursue profits in ways that are
sometimes unhindered by concerns that once obsessed colonial regimes.7
And these cross-overs can leave scars in the form of inequality and death,
not just of people but also of cultures, particularly when economic profits
are secured by legal instruments that deem some truth claims legitimate
and others illegitimate. But the question of who really loses and who risks
winning big is not as clearly answered as one might expect.
In this paper, I also explore the utility of the idea of ‘crime’ in relation
to the field of alternative medicine, as in the casino, in which the idea of
‘crime’ both hovers at the edge of the casino’s legitimacy, framing its ‘legal’
field of operation, yet also undergirding its operations to begin with (in the
sense that it is a publicly contested form of money-making, even if not
illegal in many states and nations). In particular, I explore the possibility of
reading ‘crime’ in multiple ways in relation to the market, shifting fields of
view, and attempts to read Tibetan medicine by way of ‘science’. There are
many meanings of crime to be found within these relationships, and each
poses new relations to scientific knowledge and power. In the end, I hope
to show that Tibet’s participation in the casino pharmaceutical economy
potentially disrupts belief in a postcolonial scientific method that could
provide an unbiased means of arbitrating medical truth globally. The
protean qualities of ‘crime’ become visible in relation to pharmaceutical
medical truth-seeking, first as the label moves from Tibetan medicine to
Tibetan practitioners of medicine, and then when it is thrown back on Big
Pharma itself by these same practitioners. First, though, I invite readers to
visit the ethnographic terrain for this inquiry by way of three short
snapshots. Although disparate in content, they collectively demonstrate the
kinds of encounters spawned by activities of a postcolonial science. Encounters like these generate the debates over criminality and truth outlined
in this study.
Disjunctures: Transnational Encounters in Postcolonial
Science
Publishing On The Exotic
In 1980, Dr Herbert Benson (of Boston’s Beth Israel hospital) met with
Yeshe Dhonden, then personal physician to His Holiness the Dalai Lama,
in the Tibetan’s exile home in Dharamsala, India.8 Dr Benson had traveled
in the late 1970s to this remote Himalayan location in order to determine
whether or not meditation practices of gtummo (inner heat) could be
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beneficial in helping patients with hypertension eliminate their deadly
symptoms. With electrodes in hand and permission from the Dalai Lama,
Dr Benson’s team hiked to the remote retreat caves of the Tibetan gtummo
practitioners where they disrupted a three-year isolation of the monk
meditators long enough to hook them up electronically to evaluate their
physiological indicators.
For the Tibetan practitioners, the goal of gtummo meditation was to
control the inner circulations of winds (rlung) that course through the body
along its central axis and tighten in knots at five locations, called chakras in
Sanskrit (skor lo, in Tibetan). Ultimately, gaining control over the movement of these winds is thought to be a function of mental discipline, of
single-pointed concentration upon transcendence of the emotional poisons
of aversion and attraction (among other things) that give rise to perception
and action. Enlightenment is believed eventually possible by way of this
yoga practice because it enables cessation of the emotions and actions that
produce karmic effects, the causes of rebirth. Visible proof that the monks
had successfully accomplished gtummo was their ability to dry wet sheets
wrapped around their loin-clothed bodies while practising this yoga outside of caves over the course of a snowy winter night.
For the visiting biomedical researchers, the meditation practices were
compelling not because they promised enlightenment but because they
posed a scientific conundrum that might provide publishable results. First,
how could it be shown that meditation actually produced physical effects
on the circulatory system? Second, how could such relationships be
explained? Third, why didn’t the monks die from hypothermia and freezing
(the predicted biomedical response for humans in such circumstances)?
Benson was able to use electrode and other biometric measures to show
that this meditation altered not just vascular function but also internal
bodily thermoregulatory systems of the meditators. He was not as easily
able to explain how this occurred, or why, ultimately, they did not freeze.
And so, despite Benson’s well-documented accounts of the practices of
gtummo and their corresponding effects on vascular regulation, his work
was never fully embraced by the biomedical establishment. Some of his
critics claimed that his evidence was not convincing. Others said that his
research method was flawed from the outset. Nevertheless, a different
group of scholars (from UCLA) would later take up the project once again,
this time exploring the biochemistry of gtummo meditators and generating
a new conundrum. Rather than explaining how mental processes might
effect vascular function, the new research would ask why it is that gtummo
meditators biochemically resembled patients suffering from severe depression, even though the monks themselves would attest to feelings of bliss
and euphoria while in this meditative state.9
Whose Outcomes Count?
Nearly a quarter century after Dr Benson’s first research, another attempt
to translate the efficacy of Tibetan medicine was undertaken by a young
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woman, a Chinese-born engineering student, named Fei Fei Li, from
Princeton University, who had taken an interest in Tibetan medicine. After
several months exploring possible research projects, she finally decided to
work with Tibetan physicians in the Digestive Division of Tibet’s
Mentsikhang (College of Medicine and Astrology, now a hospital) where
she and her Tibetan colleagues would run a clinical study of Tibetan
medical treatments for Helicobactor Pylori (HP) infection and its related
gastric symptoms.
Li pursued the research from two starting points. Working with Tibetan
physicians, she determined the Tibetan names for symptoms commonly
associated with HP in a biomedical nomenclature (including peptic ulcers,
reflux, diarrhoea, dyspepsia, and a range of other gastric symptoms), and
then determined the six most commonly used Tibetan medicines for these
conditions. From the biomedical side, Li obtained enough funding to use
state-of-the art uric acid tests that could detect the presence of HP by way
of breath samples that could be shipped weekly to Beijing for analysis.
After one year of research on a total of 60 patients, Li found that in all
cases, the Tibetan medicines eradicated the symptoms that biomedicine
has typically associated with HP.10 That is, by the Tibetan definitions of the
diseases and the symptoms used to determine these diseases, two kinds of
Tibetan medicine worked well to cure all of the patients. In the cases that
were pursued in a five-month follow-up, all symptoms were still eliminated. However, using biomedical measures showed that in no case was
Tibetan medicine able to eradicate HP. Rather than interpreting these
results as an opportunity to question the associations being made by
biomedical researchers between the defined symptoms and HP bacteria,
the Tibetan doctors involved in Li’s study interpreted the results as
evidence of the failure of Tibetan medicine, because it could not eradicate
the HP infection. The extraordinary loss of confidence in their own
medical techniques displayed by the Tibetan doctors was, in this case, tied
to an unswerving dedication to the idea that biomedicine offers scientific
truths that operate according to the same principles as their own ‘scientific’
medicine.
Li’s comment on her Tibetan colleagues’ perspective was telling. She
told me:
The sad part about the research is that they would never have even
considered HP an important measure if I had not done this research and
introduced the idea of HP to them in the first place.
A year later, she returned to do a long-term follow-up study of her
patients, and learned that a majority of the patients were still symptomfree. However, the hospital refused to support a full project to document
the extent of these outcomes on grounds that, as the head of the digestive
unit told her, ‘The research had already proven to be unsuccessful in
demonstrating the efficacy of Tibetan medicine’. This, despite the fact that
all the patients had been cured using Tibetan diagnostic measures.
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Playing to the Market
A final case offers a suitable entry point for the rest of this paper, and a
case that brings us closer to the inspiration for its title. In 1998, Dr Tenzing
Choedrak left his Tibetan College of Medicine and Astrology
(Mentsikhang) in Dharamsala, India, in order to travel to the United
States.11 His American hosts made contact with various AIDS organizations in New York City, enabling him to see some patients, and give them
free Tibetan medical treatments. In a language that identified agitated
winds, elemental earth depletions of heat, karmic predispositions to infections, and the moral underpinnings of sexual desires, Dr Choedrak provided his American audiences and patients with the remedies they sought
and knew they couldn’t find in conventional biomedicine.
A few days later, Dr Choedrak learned that one of his patients was a
‘fake’ who had lied about having AIDS. The patient was actually a reporter
for CBS, and his companion used a hidden camera to document the
treatment with Dr Choedrak. Within days, a damning exposé on medical
‘fraud’ was aired on national television, in which Dr Choedrak’s treatment
was featured. Back in India, when he recounted his story to his Tibetan
colleagues, Dr Choedrak said that his American hosts had received a
phone call warning that he ought to leave the country immediately or risk
arrest for practising medicine without a license. Dr Choedrak was put on a
plane for Europe the next day before finally reaching his exile home in
India.12
Postcolonial Possibilities of Science
The cases I use here suggest that the transnational circulation of Tibetan
medicine (both in Tibetan locations and in the United States) has produced the possibility of seeing this as contestation between two knowledge
systems. That is, while neither set of medical claims and practices is
discrete nor even entirely internally coherent (nor uniform) in reality,
attempts to translate between them create the appearance that each is
bounded, discrete, internally uniform, and different in contrast to the
other. The points of contestation are numerous, and frequently organized
around several basic questions: whose versions of medical efficacy are
correct? Whose terms of diagnosis are the most appropriate for clinical
research? Are both medical systems ‘scientific’? If so, how does one
deliberate between different claims to truth offered by each? If not, who
determines the boundaries of scientific legitimacy?
Questions like these are increasingly asked by Tibetan medical doctors
and scholars as they are brought into relationships with biomedical research and practice. Attempts to answer them show that neither the
systems nor the practices are discrete. They are mutually imbricated in the
project of healing, given the long history of cultural exposure, and mutually implicated in one another’s attempts to translate between systems,
both by processes of borrowing and cross-cultural epistemological inquiry.13 Nevertheless, although as varied in form and content in Tibet as in
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the United States and European nations [Berg & Mol (1998)], biomedicine in Tibet is often presumed to constitute a uniform package of
knowledge and techniques that can be compared, contrasted, and also
integrated with Tibetan medicine.14 One detects an echo of Indian and
Chinese medical scholars of earlier generations who sat on the edges of, or
in the full throes of, Euro-American colonialism, and who responded by
proposing alternative sciences based on their own traditions, all the while
internalizing biomedical professional forms and epistemology [Nandy &
Visvanathan (1990); Leslie (1976a); Prakash (1999)].15 The form of this
debate in Tibet produces enormous tensions around ideas about what
constitutes sacred knowledge and how it should or should not be shared,
what accommodations are required of this knowledge in view of political
demands, and assumptions about the uniformity of Western scientific
claims [Adams (2001b)]. What is missing from an inquiry focused on
epistemology alone, however, is the question of how such medical knowledge has become intertwined with markets and, with an eye on profit, the
politico-legal systems that serve such market interests.16 Given the contemporary forms of such encounters, we might ask: what is the rôle, if any, of
contested medical truths in the pharmaceutical corporate pursuit of marketable Tibetan drugs? When and how do legal systems become invoked to
legitimize scientific claims, and what are the politics of cultural knowledge
that underlie both the criminalization and profitability of some forms of
medicine within the United States?
Marketability and Criminalization
The final ethnographic snapshot presented above, in which a Tibetan
medical practitioner is criminalized for providing medical treatments to
inquisitive American patients, reveals one of the key features of the casino
economy: the qualities which legitimize it are the same as those which
potentially criminalize it. That is, the efforts to both criminalize and render
profitable certain forms of medicine, and not others, almost always also set
in motion a variety of discourses about ‘saving life’ and rendering suspicious those aspects of alternative medicine that can’t be scientifically
proven, especially those aspects attributed to ‘belief’.17 In the domain of
alternative medicine, however, popular belief in the spiritual healing qualities of Asian medicines constitutes a large part of their attraction among
consumers who suspect that the cultural differences available in Asian
medicines – that which ties them more closely to ideas about spirituality
and ‘belief’ – will give them a pharmacological advantage over existing
biomedical materia medica.18 For example, the 1998 First International
Congress on Tibetan Medicine in Washington, DC, opened with a short
introduction by His Holiness the Dalai Lama and a panel of holistic and
alternative medical experts who posed questions to him. While he surprised his panelists by beginning with the comment that Tibetan medicine
is not a religion but a science, his panelists systematically and respectfully
disagreed with him. They argued that in fact Tibetan medicine was
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distinctly poised to tackle the spiritual dimensions of health in ways that
western medicine could not.
The existence of belief in the spiritual dimensions of Tibetan medicine
promises extraordinary profits to those who gain the legal privilege of
marketing these medicines. In the summer of 2000, Johnson & Johnson’s
pharmaceutical division sent no less than three representatives to Lhasa,
Tibet, in order to attend China’s First International Congress on Tibetan
Medicine. Pfizer has an extensive research division that probes Traditional
Chinese Medicine (TCM) for new botanical-pharmacological resources.
Similar hovering by representatives from pharmaceutical companies
throughout the United States was seen at the 1999 conference on Tibetan
medicine held in Washington, DC. In Tibet, too, Tibetan doctors sit
perched and ready to pounce on the opportunities to market their medicines to US consumers.19 Having already developed the packaging strategies to meet export licensing requirements set by China’s interpretation of
international standards (including holograms and multiple layers of plastic
wrapping), there is some hope among these Tibetans that a direct channel
to United States markets will make them less dependent upon Chinese
pharmaceutical infrastructures of distribution, according to the Director of
Lhasa’s largest Tibetan pharmaceutical factory.20 But alternative medicine
is risky business.
Just as in the casino itself, casino capitalism ensures that criminality
lingers in and around the risk-taking and profit-making in alternative
medicine. The marketing of things like cultural difference is both the basis
for profitability,21 and the risk that mobilizes legal responses when these
products are seen as posing danger to life, because effects based on ‘belief’
are rarely scientifically provable, as I will show.22 In the mobilization of
Tibetan medicine, what is deemed ‘legal’ and ‘illegal’ is determined in
relation to an uncontainable domain of things spiritual, belief-based and
even, in some minds, the ‘magical’.23 Discerning between the scientific and
the magical/spiritual is itself a biopolitical function of the modern state.24
But when belief in the magical both organizes profit margins and is
augmented by the mysterious mechanics of contemporary global capitalism,
the label of crime that is deployed to regulate sales must be protean. That
is, crime must move around from target to target, but also in and around
the definition of what a ‘crime’ is in medico-legal framings. The definitions
change in relation to both markets and those kinds of knowledge that can
be deemed magical or non-scientific, and therefore illegal, because of the
special relationship that the state has to them through science. What was
considered criminal some 10 years ago in the form of distributing Chinese
herbal therapies in some states is not only legal now, but also regulated in
ways that criminalize those who do not distribute the forms of herbal
medicines that have been approved by the FDA. This, I suggest, might be
read as a different kind of magic that invokes criminality at critical
junctures where there is no credible witness as to what should or should
not be considered medically valid [Shapin & Schaffer (1985)].
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Money is where the magic is – in this case, in the ‘spiritual’ but
inexplicable, and also in the practices of exclusion made possible through
charges of criminality. Thus the state’s interest in regulating the ‘magical’ is
like its interest in defining itself through the bare (biological) life of the
citizen [as Agamben notes (1998): esp. 126–35]. This takes the form of a
biopolitics that has one eye on the market and the other on the definitions
of safety, truth and efficacy in the medical field. Keep in mind that today
Tibetan medicines are bought and sold on the health food market as
nutritional supplements, and it is partly this phenomenon that arouses the
charges of criminality and fraud by regulatory agencies. The director of the
Tibetan medical hospital in Lhasa was quick to point out to me in 1998
that there were already three Tibetan medicines available for sale in the
United States. The body of the citizen-patient is at risk of biological
toxicity by way of medical fraud and an unruly market that will sell
anything to medically gullible consumers.
Interestingly, the definition of the ‘life of the patient’ here expands to
encompass even his or her spiritual contamination by way of his or her
beliefs. A notion of life that is at once material and spiritual is generated in
the scientific and legal languages deployed to protect it. For example, in
the literature of some state-funded medical researchers, the public consumption of things like Tibetan medicine can only be based on irrational
belief and magical thinking because the theories of Tibetan medicine don’t
make scientific sense. The possibility that there may be a spiritual dimension to health and healing can be identified as a target for investigation and
a basis for criminalization (the public can’t protect itself, and so the state
must protect it). Anything less (for example, that Buddhas or deities might
be involved) is considered a sign of irrational health behaviour and potential risk. The biological life of the patient is put at risk by way of
uncontrollable beliefs in things that exceed scientific explanation. If the
public based its actions on the findings of science, the state would not
worry as much. Since the public does not, the state feels compelled to issue
laws that will protect citizens from their own beliefs. In the eyes of the law,
practising Tibetan medicine as medicine in the USA is a crime, forcing
practitioners to evade claims that this is what they do for their clients.
Patients who believe that Buddhas heal are accomplices in the fraud
(simpleminded at best, delusional at worst) the moment they take Tibetan
treatments (as medicines) that are based on what should properly be left to
the realm of priests, lamas and rabbis. Consuming patients become, in this
way, the agents who abet medical crime who are simultaneously the victims
of criminal profiteers (many of whom are from Asia), in the eyes of the law.
The state is able to make itself visible at this critical moment of the clinical
encounter by making sure that regulation of the use of Tibetan medicines
as either medicines or as health food/nutritional supplements is accomplished by way of scientific medical research backed by regulation of the
distribution and sale of these products.25 In order to stay on the market in
places like the United States, these medicines must be tested, screened,
and identified as non-toxic (at worst) or medically beneficial (at best). In
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order to prescribe these products as medicines, Tibetan practitioners must
submit their medicines to these tests. All other options become grounds for
criminalization.
The problem is, criminalizing Asian medicines makes it hard for the
state, or pharmaceutical companies, or anyone, to control the means by
which money is made on them. Thus the dilemma: how is the state to
protect its citizens while retaining for itself the rôle of arbiter of who
benefits from its potential profitability? Because money is where the magic
is, what also happens in this process is that the spiritual-magical must
sometimes also be included in framings of cures in a legal way by being
made over in terms that are biologically familiar. The solution points to a
process by which a reversal in the assignation of ‘magical thought’, ‘criminality’, and the profits that come with these in the field of alternative
medicine, might be seen.26 These, I suggest, instantiate postcolonial practices of science. How does this work?
What is a Good Scientist to Do?
Some say the year 2000 was a bonanza year for the field of Complementary
and Alternative Medicine (CAM) in the USA. The branch of the NIH
devoted to studies in CAM had a 1993 budget of US$2 million (it was
then the Office of Alternative Medicine) and, by March of 2000, it was
$68.7 million dollars (as the National Center for Complementary and
Alternative Medicine [NCCAM]).27 Operating under the dual pressures of
the new ‘evidence-based’ model of medical research (affectionately called
by my colleague ‘number crunching epidemiology’, but begging the frightening question: ‘What were they practising before?’) as well as the sensational 1993 studies of David Eisenberg revealing the financial commitment
of Americans to alternative medicine, the NIH finally jumped into high
gear for the rapid assessment of CAM. How could $13 million a year that
the American public was spending of its own out-of-pocket money on
alternative therapies be wrong?28 Then again, how could millions of people
believing in things like ‘humours’, ‘meridians’, ‘winds’, and the magical
powers of belief, or worse yet, in the potency of untested medicines with
unidentified active ingredients, be right?
The aim of this branch of the NIH (NCCAM) is fundamentally
conservative. The government’s concern is with those domains of cultural
excess – theories and modalities that exceed logic and scientific sensibility
and seem, by popular market demand, to be uncontainable. At the same
time, practitioners of such modalities want these government authorizations in order to obtain legal status and/or protection that will legitimize
their right to potential big winnings in medical profits and cures. Thus we
have a situation in which, when my colleague, the director of Lhasa’s
Tibetan Medicine Hospital, announced to me that they were already
selling three Tibetan medicines in the United States, I had to ask him if
they were for sale as ‘medicines’ or as health food nutritional supplements?
He wasn’t sure. I told him that I knew of only two research projects that
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had applied for FDA approval for testing Tibetan medicines in clinical
trials, and that these researches had not yet been completed, therefore they
couldn’t be marketing them as medical products. He was disappointed. He
went on to tell me that they were excited about the prospect of getting
scientists of Western medicine to validate the efficacy of Tibetan treatments.29 He wondered if I could make sure to send him the results of those
studies when they came out. I did not tell him, at that time, that studies
showing that Tibetan medicines did not work would likely jeopardize their
legal marketability on both the medical and health food market. Neither
study had thus far shown clinical benefits.
Good scientists in the United States and Europe know very well that
the strategies of research deployed by NCCAM and its satellite clinical test
operations in medical institutions around the country, and around the
world, need to sustain a consensual conversation about ‘scientific standards’. Tibetan doctors know this as well, although the temptation is to
note that perhaps the better term for both groups of medical researchers is
that they ‘believe’ in the necessity of consensual standards. In the case of
NCCAM’s director, Dr Steven Strauss, who spoke to a captivated audience of complementary and alternative medicine researchers in London’s
Wellcome Institute in 2000, there is little room for negotiation about the
gold standard: the randomized controlled clinical trial (RCT), preferably
double blind.30 There, and at a similar conference held in San Francisco in
2001,31 Strauss offered what he called ‘the NIH game plan’: ‘exploratory
things are tolerated so long as they have a scientific basis . . . Placebo
controls and the simplest designs are the best’.32
In Strauss’ vision of the game, all contenders can step up to the table
of clinical research where all potential treatments have an equal chance to
play: funding is allocated through stochastic review processes, called
‘grantsmanship’, and with funding secured, the RCT suggests an even
playing field where the best players (treatments) win. Outcomes are
allegedly all that count; the winner cures the most. Inclusion here is an act
of the modern globalized state-defining participants by their ability to
become subjects of a shared medico-clinical gaze. But, in this model,
underlying theories of humours, winds, karma, and elements that explain
diagnoses, treatments, or outcomes from the Tibetan perspective are
considered largely irrelevant to research. They constitute the ‘magical’
thinking that needs to be shed for medical legitimacy. But if this magical
excess constitutes what cannot be included, as an expression of the state’s
presence in the clinical laboratory, it is also in part what attracts many
American consumers to things like Tibetan medicine. Even if the stochastic
processes of testing via the NIH and FDA consider these unimportant for
the ante-up, they become at least superficially visible in the profit margins
for those who win property ownership of the medicines, at least according
to marketers in the industry.33
From the perspective of practitioners of Tibetan medicine, the standard of the randomized controlled trial is both seductive and problematic.
Seductive, because desires for approval by Western medical scientists
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sometimes belie the ability for these practitioners to see how uneven the
epistemological playing field really is. Problematic, because placing a bet
that their treatments will win in this game – and submitting to the logic
that unbiased science will offer definitive truths about treatment efficacy –
also renders them vulnerable in two ways. First, by entering into the
market, they are potentially criminalized by transporting into the market
both their drugs and their magical thinking. Second, entering the research
field exposes them to the theft of their intellectual property.
To see how this works, we must turn to the ‘house rules’ of this
medical research that both distinguishes itself from the ‘magical’ so forcefully, yet also looks to the magical in order to redefine and domesticate it
for sale. Who benefits from this domestication, and in the process, how
might we, in sympathy with foreign alternative practitioners, read it as a
kind of ‘crime’?
House Rules, No Exceptions:
First Rule
The first rule is that diagnostic categories are universal or, in other words,
we are playing with the same knowledge currency. It is often assumed that
in clinical trials the knowledge that is being used and the empirical basis
for that knowledge is shared cross-culturally. Why is this assumption a
problem? There is seldom a one-to-one correspondence between biomedical diseases and those identified in Tibetan medicine. What is called ‘a
symptom’ in one system may be called ‘the disease’ in the other, and vice
versa. The question that comes up for Tibetan practitioners is: whose
diagnostic categories are the most suitable for the randomized controlled
clinical trial? There is more at stake here than the question of whether we
are talking about different names for the same diseases (or that the
empirical foundation is the same even though the names we assign to them
vary cross-culturally). Translating between disease categories is a problem
of epistemology. Disease categories do more than identify biological symptoms; they identify unique approaches to bodily suffering, radically different models of anatomy, and logics of treatment protocols. They define
different empirical realities in any sense of the practical engagement with a
material universe. All of this un-translatability is effaced when a biomedical
disease is taken as the starting point and it is assumed that there will be a
Tibetan equivalent thereof.
For example, a ‘bile-related womb disorder’ (mngal nad mkhris gryur)
in Tibetan medicine has more than one biomedical equivalent, corresponding to a wide variety of imbalances that manifest in reproductive tract
problems labeled in biomedicine as a variety of different diseases and
symptoms: PID, STDs, cervicitis, dysmenorrhoea, chronic candida, and
more. This range of biomedical labels is needed partly because Tibetan
medicine classifies this disease in terms of old and new cases; when it has
been sitting a long time in the body, its symptoms change. A ‘bile-related
womb disorder’, when it is young, can have symptoms that resemble
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reproductive tract infections, but can develop over many years into growths
in the uterus.
Tibetan medicine looks for underlying patterns of imbalance that may
have systemic symptoms in the body emerging in different places at
different points in time. In contrast, biomedicine tends to focus on the
disease as an isolated phenomenon that can be targeted for intervention as
if it were free-standing in the body and frozen in time (or over time),
preferably as an acute disorder (though not always).34 Tibetan medicine
classifies diseases according to the humoral constitution of the patient and
its relationship to other simultaneous disorders, not on the basis of disease
resemblances between patients only. For example, a person with a ‘blood’
growth in the uterus may be diagnosed as having the growth because of
weak ‘downward expelling winds’ accompanied by strong ‘bile’ energy.
Another patient with a ‘growth in the uterus’ that looks just like the first
patient in an ultrasound diagnosis, will be diagnosed as having a ‘flesh’
growth from an overly strong ‘phlegm’ presence accompanied by ‘strong
winds’. Thus, two patients with the same biomedical disease can be seen as
having different Tibetan diseases.35 But, even if the patients are identified
with the same Tibetan disease, they may be diagnosed with different
etiological pathways, and so needing different treatments.36
Finally, Tibetan medical techniques of diagnosis (tongue, urine, pulse,
interrogation) and its explanations for diagnoses – including such things as
spirit causation, karma from actions in past lives, or even perceptions of
political repression/social conflict that are mediated by inner ‘winds’ – are
taken to be largely non- (or even pre-)scientific, and therefore not legitimate bases for making claims about valid diagnostic categories. The idea
that winds circulating within the body (responsible for movement of all
substances, for instance) might be affected by things like meditation and
belief in Buddha beings, by immoral behaviour in past lives, or by the
perception of nefarious spiritual entities wreaking havoc in one’s home or
in one’s heart (seat of the mind for Tibetans) is simply, at this point by and
large, beyond the purview of a scientific approach to alternative medical
efficacy.
One consequence of the complexity raised by such questions is that
outcomes in randomized controlled clinical trials are almost always based
on disorders named by biomedicine. Because it is assumed that disease
labels may change but diseases themselves are universal, few question whose
diagnostic instruments or labels should be valorized in clinical research
protocols. Yet, starting with biomedical diseases results in a disorganization
of the Tibetan approach, undermining the logic of its etiology and treatment resources, and making it most likely that it will not produce statistically successful outcomes. In the end, medicines that can’t show effectiveness in treating biomedical diseases are considered a failure. Practitioners
who use them are at risk of accusations of medical fraud.
In this domain, the spiritual aspects of Tibetan medicine that enable it
to ‘make sense’ of its failures and successes are excluded as rationale or
object for research design and analysis,37 but they are the points of entry
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for state regulations and restrictions on the practice of Tibetan medicine in
places outside of Tibet. A biopolitical instrument identifies the nonscientific as irrelevant to research design, but then also uses it to operationalize labels of criminality when there is failure to achieve therapeutic
biological effects.
But what happens when there is success? And, what if those domains
deemed irrelevant to a scientific explanation do become a focus for RCT
research simply because they are what the ‘public’ believes and what the
public is already purchasing? The promise of health benefits, like the
promise of monetary profits, also mobilizes the state which, by speaking
through research protocols and the FDA, is allowed to intervene by
requiring explanations that, in the end, give ownership to those paying for
the research. This sometimes means redefining and reclassifying ‘magical’
thought so that it speaks a language of pharmaceutical patenting, enabling
certain players to retain the privilege of managing its profits. I return to
this process below.38
Second Rule
The second rule at the casino of clinical trials is that evidence is incontrovertible; a well-designed RCT study will produce reliable evidence. One
finds that in the global arena of RCT research it is assumed that empirical
data produced in a well-designed randomized clinical trial will be reliable
and incontrovertible. What is wrong with this assumption? Both Tibetan
medicine and biomedicine make use of empirical evidence to make claims
about efficacy, but even when the same diagnostic instruments are used by
biomedical and Tibetan doctors, as is usually the case in outcomes research, each tradition may ‘read’ empirical data differently. For example,
during field research on Tibetan treatment of ‘growths’ in the ovaries in
Lhasa’s Mentsikhang, my American MD collaborator would frequently
interpret ultrasound evidence differently than our Tibetan physician collaborators.39 Ultrasound evidence, for example, would show persistence of
growths in the uterus, and to my American MD collaborator, this would be
taken as evidence that the Tibetan treatments had not been effective. But
the Tibetan doctors would frequently note that the ultrasound evidence
was not necessarily able to provide the most accurate measures of effectiveness of their treatments. The ultrasound evidence was not necessarily a sign
that the patient had not been cured, since the growths were understood
sometimes as symptoms of humoral imbalance, but not as diseases themselves [Adams (2002)]. If other diagnostic signs (urine, pulse, tongue)
suggested that the treatments had cured the patient, Tibetan doctors often
explained the ultrasound evidence by noting that residual evidence of
things like growths might be seen for a disorder that was already cured at
the root. Because Tibetan medicine takes a long time to show its effects,
they said, such residual evidence of former humoral imbalance is not
uncommon. Such disagreement over how to read physical evidence was
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not uncommon. Similar questions were raised by the work of Fei Fei Li, in
my second introductory ‘snapshot’.
Here the question that is seldom asked is: ‘whose outcomes count?’
Culturally contested medical claims are arbitrated according to maps that
oppose ‘magical’ or ‘non-scientific’ methods to ‘empirical’ methods that
are familiar enough to substantiate other biomedical models of the body
and health. Herein, theories of humoral roots of disease and cures without
ultrasound evidence are treated as ‘non-scientific’ – as based on belief and
even ‘magical thinking’. The exclusion of the former determines whose
outcomes count as ‘winners’, and whose claims get to be legalized. Herein,
legal claims are inserted as place-holders for medical truth, confusing the
terrain of a natural fact with political and economic priorities. If the
language of science is enlisted to establish exclusion of certain ‘magical’
claims about outcomes (when they are seen as failures), then when the
public persists in treating others of these medicines as if they are not
failures (by continued consumption), then medical research is once again
enlisted to explain the mechanisms of effect, leading to an interesting
inversion. The magical must suddenly be seen as in need of being explained – biologically, molecularly, cellularly, biochemically. This, I suggest, enables a shift of ownership of valid outcomes, a shift that becomes
most visible in the case of pharmaceutical products, which I turn to
now.40
Third Rule
The third rule adopted by clinical researchers in the alternative medicine
field is that treatments can be reduced to discrete lists of isolable active
ingredients. In fact, it is generally assumed that reliable remedies can be
reduced to a few basic active ingredients that can be evaluated singularly
for their effectiveness. This assumption ultimately opens up space for both
crimes and profits.
The RCT method advocated by NCCAM allows for Investigational
New Drug (IND) status for Tibetan medicines, but it also limits the
number of drugs and ingredients that can be tested in clinical trials. Here,
the question of to what extent Tibetan medical treatments can be modified
and still show positive benefits is raised. The model of singular magic bullet
drugs or treatments that can eliminate identifiable acute diseases runs
counter to the model of treatment for diseases that are humorally-based
and change as treatments progress, requiring subtle re-combinations of
sometimes over 60 ingredients and, for many patients, constantly shifting
combinations of different medicines.
Despite claims that ‘outcomes are all that counts’, NCCAM’s Dr
Steven Strauss advocates ‘identifying the active curative components’ by
use of the simplest study designs. This means using the same set of
treatments for each patient and limiting the ingredients in each medicine in
the study. In recent breast cancer trials for Tibetan medicine,41 efforts were
made to allow different types of treatment for each stage IV breast cancer
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patient enrolled in the study. But only 7 of the approximately 15 medicines
normally used by the Tibetan physician were allowed in the trials, and
many of the essential ingredients of even these medicines were ‘checked’ at
the customs border.42 Because singular active ingredients are presumed to
be the ultimate value of alternative pharmacopoeias, there is often an
assumption that one could eliminate other ingredients without affecting
their medical performance.43 Since some Tibetan medicines are compounded with over 60 ingredients, this can ultimately mean that a majority
of ingredients are considered irrelevant.
Tibetan medical practitioners readily agree to the terms of scientific
research presented by the NIH, because they generally assume that their
medicine is empirical in the same ways that biomedicine is empirical. In
the end, however, they often attribute poor results in outcomes-based
RCTs to limitations on use of their medicines and lack of understanding of
Tibetan medical theory on the part of foreign researchers.
Even if the medicines themselves are not restricted, however, a more
questionable process occurs in and through the NCCAM model. Obtaining IND status brings Tibetan medicines into the realm of legal and
therefore regulated medical use in the United States. The indirect effect of
the clinical trials regulations is that the FDA gives legal access to biomedical practitioners to use and prescribe Tibetan drugs while excluding
Tibetan medical doctors from having full legal rights to prescribe their own
medicines in the United States.44 In other words, as Kevin Ergil,45 Director
of Research for the Program in Oriental Medicine at Touro College in New
York, points out, the NIH research process legalizes use of Tibetan
medicines for American doctors while criminalizing Tibetan doctors for
dispensing them. Here, transgression determines the law, but the law can
commit a transgression of its own without sanction.
Although, currently, the FDA protects ingredient lists, in most research, screening for toxic substances and active ingredients still enables a
reclassification of medicinal components.46 Depending on the eventual
trajectory of research and funding opportunities, ingredients labeled as
‘products of nature’ can then be used in medicines made from slightly
different recipes at, for example, Pfizer, Merck, or Johnson & Johnson
laboratories, where they become patentable or trademarked by these firms
as products of their firm rather than as ‘products of nature’. The determination of what constitutes and what does not constitute a ‘product of
nature’ is never free-standing or objective but always fraught with a politics
of profit and cultural difference. ‘Taxol®’ is the Bristol-Myers version of
the active anti-cancer ingredient of the bark from Taxus brevifolia (the yew
tree), despite the fact that this ingredient is essentially a ‘product of nature’
[Goodman & Walsh (2001)]. Vandana Shiva (1996) makes the convincing
argument that this is an outright form of biopiracy to which few Asian
medical experts can respond with legal force.
Outside the FDA, Tibetan doctors are being lured into unfavourable
agreements with pharmaceutical firms that are conducting their own
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research on the benefits and active ingredients in the Tibetan pharmacopoeia. One of the Johnson & Johnson representatives in Lhasa (at the 2000
conference) told me about his company’s approach:
If we see good results for certain products – the best is active ingredients
only – then we can manufacture these and sell them in the West . . . Our
approach is very simple. It is too difficult to spend time thinking about or
trying to understand theories of the mind and winds and all that [he
waved his hand in circles around his head and squinched his face in an
expression of quizzical anguish]. If we can show that it works by our own
standards, then we can market it as a product . . . Also, we don’t bother
with the FDA anymore – it takes too long. With Asian medicines we
mostly just do the food supplement business now.
He went on to explain that they were in China because: ‘It is easier to do
the research on these medicines over here because there aren’t so many
restrictions by the government’, eliding the fact that it is precisely the US
government’s legal provisions that enable his company to gain profits from
these medicines.
When asked about what provisions were made to ensure that the
Tibetan doctors in Tibet would benefit from his company’s marketing of
the drugs, he said: ‘We work out an arrangement in Beijing about that. It is
all taken care of at the government level’. Before I could ask about such
things as percentages, or even about whether or not any of Beijing’s profits
found their way back into Tibet, he returned to the question of method for
the food supplement market:
Actually, there is a large appeal for Tibetan and Chinese herbals in the
USA, and we are very interested in finding new products for that market,
but we mostly want to find the active ingredients in these herbals. The
research is much simpler once we know the active ingredients.
No doubt, trademarking and patenting are also much easier that way.
Tapping into the public desire for Tibetan and Chinese herbals, though,
also requires in the case of Tibetan medicine that Johnson & Johnson figure
out how to pack the ‘magic’ and ‘spiritual’ into the pills. In doing so, it
must speak to both a reductionistic language of active ingredients and a
holistic language that imputes spiritual potency to products.
Many Americans have ideas about ‘authentic’ spiritual potencies invested in Tibetan medicines, and some of these are close to Tibetan views
on the sources of potency of Tibetan medical products. In Tibet, these
medicines are often rendered potent by tantric empowerments (carried out
by highly educated lamas who know these esoteric rituals). Much of the
Tibetan public believes that without these empowerments the pills are not
as potent as they would be, as just a compounded set of ingredients alone
[Adams (2001b)]. Americans pursuing cures through Tibetan medicines
often note that it is the ‘spiritual’ component of Tibetan medicines that
gives them their potency as well. At the same time, many consuming
Americans also want to know if these medicines offer a magical combination of ingredients that will surpass conventional biomedical/medical ingredients in providing cures. Thus pharmaceutical companies who wish to
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sell alternative medicines as nutritional supplements must target both
consumer interests. They undertake research that enables them to list the
active ingredients in the products they want to sell, while also usurping
ideas about spiritual benefits that come directly from the cultural and
symbolic capital of Tibet as a place of spiritual wealth.
Pharmaceutical companies are required to show that a substance is
non-toxic, and that it has some beneficial ingredients if such claims are
made. By finding the active ingredients, however, as part of RCT trials or
as part of the effort to screen for toxic elements, pharmaceutical interests
are able to shift ownership of medical products at the same time that they
shift ownership of the ability to market spirituality. Because Tibetan
practitioners do not have the ability to make these kinds of medical
scientific claims, or to do the research that will show this, pharmaceutical
companies offer to do so, settling it all ‘at the government level’. In the
end, the effort to locate active ingredients means, indeed, mobilizing
government and legal institutions that become the keys to transferring
ownership of the rights to market and sell Tibetan medicines.
The effects of this process are not unilateral. The sorts of questions
raised about attributions of efficacy in the US market also have an impact
on the way Tibetan doctors in Tibet think about their medicines. The
desire to attribute potency to singular active ingredients or combinations of
material products, rather than complex theoretical and ritual processes, is
also now present in Tibet, where debates about the necessity of tantric
empowerments for the medicines are now more prevalent than ever. These
debates are generated in part by the prospect of international marketing of
Tibetan medicines and legal regulations surrounding them in places like
the United States. So, for example, making the most popular drugs for an
international market (the precious pills, rinchen rilbu) has generated debates in Tibet about whether it is more important to standardize the
ingredients in the pills or to ensure they are blessed (given empowerments)
by the most powerful tantric adepts still living in Tibet who are authorized
to perform such rituals by the government. It has also generated a good
deal of suspicion on the part of Tibetan doctors, who have noticed that the
export of their medicines throughout China, by way of joint ventures with
Chinese pharmaceutical firms, has not necessarily funnelled profits back
into Tibet in any visible way.
Tibetans involved in this effort to participate in the global pharmaceutical market are not entirely aware of what they need to do to ensure
their own profits, nor do they know what their involvement with firms like
Johnson & Johnson will or will not do for them. Most often, they enter into
agreements with Chinese representatives of international pharmaceutical
firms and immediately lose control over research protocols, marketing
techniques, and profits, usually before they are aware that such protocols,
techniques or sales might be debated.
Kevin Ergil notes (in a personal communication) that the rituals and
the debates about potency are part of the dance of inclusion and exclusion
that is organized around ideas about (and hopes for) universal medical
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truths and facts. Herein the desire for marketable end-products leads to
inclusive practices of research (and desires to have the outcomes positive).
At the same time, desires for the potential profits generated therefrom also
lead to practices of exclusion, authorized in the United States by scientific
processes of renaming and the legal regulations tied to them that ultimately
enable a transfer of ownership of the intellectual property in countries like
this.
The process of converting medicinal substances that are in some sense
owned as the intellectual property of Tibetans into medicines that can be
patented and marketed by pharmaceutical firms is sometimes direct.
Johnson & Johnson hopes to enter into deals with the Tibetan institutions
that manufacture these medicines and indirectly assures them a percentage
of any profits. In the end, however, these arrangements enable the pharmaceutical firm to gain ownership of the medicines, because the Tibetans
involved do not know how to negotiate these business deals, nor how to
contest the research processes. The more indirect route for this conversion
is by way of biomedical research, RCTs, and the subtle unravelling of those
things called ‘Tibetan medical techniques’ into chemical substances, statistical effects, and investment-return obligations. Again, the story of Taxol®
is another exemplary case here in that it marks the conversion of a natural
product to a publicly-owned resource (by way of government-funded
research mechanisms) and eventually to a privately-trademarked product
owned by Bristol-Myers [Goodman & Walsh (2001)].
Even when pharmaceutical companies do not get involved in marketing Tibetan medicines, direct marketing of Tibetan herbal products also
poses risks that involve a return to the scientific methods now used in RCT
research. Increasingly, biomedical research groups are being funded (by
NCCAM among others) to evaluate the nutritional supplement market in
order, potentially, to weed out any products that contain suspicious ingredients. This includes any potentially toxic substances (or at least substances that are identified as such by RCT methods) being sold as nontherapeutic resources but being used as precisely therapeutic alternatives.
Often this research does not involve human subjects, but simply a screening of ingredients against known substances that have been established as
potentially harmful, by some measure.47 Despite the fact that Tibetans
have been taking these medicines in large quantities for many generations
without fatal outcomes, the presence of processed and decanted heavy
metals in many of these medicines poses the risk that without support and
political backing by pharmaceutical firms that convince the US government of the safety of these products (with metals removed), Tibetan
distributors of these medicines will be targeted for exclusion and criminalization, even before they are offered a place on storefront shelves.
The fancy games of language and risk-taking that make it possible to
decipher active ingredients and clinical effects, then, are also games that
ensure certain winners and certain losers, much of the time, and this has as
much to do with large-scale investment potential (and the ability to fund
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RCT research and screening) that is unavailable to most Tibetan practitioners. The process of converting intellectual property into trademark
property, as Coombe (1998) notes, almost always entails arbitration over
legitimate forms of knowledge that are based on the mis-recognition, or the
suppression of recognition, of cultural differences. In the case of Tibetan
medicine, cultural differences are construed as distinctions between science and religion, knowledge and belief, standards for evaluating efficacy
versus non-evidence-based therapeutic traditions, as if everyone involved in
these transactions shared similar ideas of the differences between and
definitions of these terms [Adams (2001a)].
In the end, Tibetan participants find they have much to lose either way
they play the game. Working illegally in the medical market (that is,
offering treatments as if they were medical therapies in the clinical setting)
puts them at risk of being identified as criminals by practising medicine
without a licence. Working through RCT methods in order to legalize their
treatments, however, also places them more at risk than the Western
investors who undertake (and receive funding for) this research both in the
sense that their remedies are likely to be seen as ineffective (because of the
exclusion of epistemological starting points) and in the sense that they run
the risk of losing ownership of their remedies (by processes of biochemical
reductionism and patenting). Finally, selling their remedies as non-medical
nutritional supplements reactivates the same issues of uneven (or culturally-biased) methodologies that are more likely to result in sanctions
against Tibetan remedies than support of them.
Controlled Crime
Nor, within this Enlightenment framework, may the aspirations of indigenous peoples to protect the cultural indicia of their heritage . . . be
adequately acknowledged. . . . The nexus of these difficulties may be
located at the heart of liberal legal discourse itself, its contradictions,
instabilities, and ambiguities – aporias ever more apparent in late-twentieth-century conditions. [Coombe (1998): 248]
Agamben notes that in the sovereign state . . .
. . . crimes . . . do not have the character of a transgression of a rule that is
then followed by the appropriate sanction. They constitute instead the
originary exception [by] which human life is included in the political
order [by] being exposed to the unconditional capacity to be killed.
[Agamben (1998): 85]
In Agamben’s reading of crimes, it is the act of inclusion and therefore
exposure to the ultimate sanction – the taking of life itself – that constitutes
a crime of its own. In the same way, we might consider that at the nexus of
knowledge, science, legalisms, and politics forming alternative medicine
research, the inclusion of Tibetan medicine exposes its practitioners to just
this sort of crime. One crime might be seen in the fact that Tibetan doctors
are thought to be transgressing rules (concerning legal rights to practise
medicine, or not, in the United States). Practitioners are labelled as
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criminal by way of testing regimes and criminal sanctions because the state
needs to protect unwitting customers from harm, and possible death. But
another crime might be thought of as a crime committed by the state: by
including Tibetan medicine in its legal purview, Tibetan medical practitioners become the means by which the state articulates its exceptional
privilege of deeming what is criminal while also, by that means, enabling
theft of the intellectual property from Tibetan doctors.
I have titled this paper ‘Randomized Controlled Crime’ because, from
the perspective of critical observers of research on Tibetan medicine in the
USA context, the idioms of ‘randomization and control’ ensure the façade
of equal access and objective standards while also prioritizing a biomedical
model through exclusion of the so-called ‘magical’ and ‘spiritual’ aspects of
Tibetan medicine. The criminalization of practitioners of Tibetan medicine
is putatively both the cause and result of efforts to test the scientific validity
of Tibetan treatments, but the more compelling injustice is the way in
which the politics of knowledge that are deployed in and through government and private sector research as the ‘gold standard’ indirectly constitute
a form of ‘crime’ that is built into postcolonial modern power. This
biopolitics conflates biological facts with legal privileges and ownership of
profits. It continually defines objects of scientific/legal concern by pushing
that which is deemed spiritual or magical either out of the picture or into a
form that is biological – about life itself – and therefore both patentable
(enabling a shift in ownership of the knowledge and product) or sanctionable for posing threats to human health (in the case of the
practitioners).
The idea of a ‘crime’ then might be understood broadly in this context
as tied to cultural sensibilities about ‘scientific legitimacy’ and to state
instruments for regulating the market and the profits of alternative medicine. When scientific claims are organized around profit margins masked in
a rhetoric of risk reduction to consumers, then the labels of ‘criminality’
and ‘fraud’ can be easily deployed against those whose knowledge claims
differ or stand in the way of profits.48 If things like ‘winds’, ‘karma’,
‘elements’ or ‘humours’ are also empirical, in RCT research they are less
so than things like ‘placebos’ and ‘molecular mechanisms’. These are what
the NIH and AMA perceive as the audacious risk that mobilizes the
response of criminality, but since the market directs the terms and conditions of legitimacy for medicine in the USA, another ‘magical’ event has to
occur. Research techniques must either strip the ‘magical’ qualities from
Tibetan medicines and find their ‘scientific’ worthiness, while at the same
time stealing its profits for US/Western industries by deeming the ‘scientifiically-proven’ use of these medicines ‘legal’ and legitimate, or, research
must appropriate the magical and spiritual qualities of Tibetan medicine
and shift their ownership to those agencies able to show, scientifically, that
they work. It does not always work this way, as surely Big Pharma is as
often embattled with the FDA over its rights to market drugs the government considers dangerous as are practitioners of alternative medicines. At
the same time, from the perspective of Asian practitioners who are in the
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midst of cutting deals with Big Pharma, and simultaneously exposing
themselves to the scrutiny of the RCT litmus test for medical legitimacy, it
often does work this way.
The elaborate languages of science in alternative medicine research,
from ‘clinical tests’ and ‘controlled trials’ to ‘power calculations’ and
‘toxicity standards’, function exclusively as instruments for legal scientific
truth-making. But the facts produced by these languages and ritual trials
are, on the one hand, rigid instruments for excluding certain profit-making
possibilities, and alternative medical possibilities. They are also, ultimately,
biodegradable. They rapidly decompose because they remain as wedded to
market demands as they are to sources and RFAs (Requests for Applications) put forth by the NIH and NCCAM offices, which are themselves
constantly changing. By defining itself in opposition to the ‘spiritual’ or
‘religious’, the RCT is, in some sense, always up for grabs because it must
push this domain of the non-scientific to the outside at the same time that
it must envelop it.
The presence and enormous public consumption of alternative medicines (for perhaps all the ‘wrong’ reasons) have created a situation wherein
there is no ‘reliable witness’ by which to establish the legitimacy of profitmaking around medical truth. Some might argue that this situation has
always been present in medicine. But, today, the stakes for claiming truth
are high. The tension between market desires, on the one hand, and the
demands for safety and efficacy espoused in a climate of ‘evidence-based’
medicine, on the other, work against each other, constantly destabilizing
priorities for medical research in keeping with market trends. Like Boyle’s
air-pump, described by Shapin & Schaffer (1985),49 the RCT must itself
be able to produce a form of ‘witnessing’ that can establish medical truth.
The model of the randomized controlled clinical trial is desirable because
it is believed able to establish reliability. It is believed able to provide
credible evidence of both safety and efficacy no matter what its object of
study, and no matter what sorts of exclusions it demands.
This witnessing, I suggest, constitutes a kind of magic of its own and a
crime of another sort. One dimension of the magic is in the belief in (the
sacred power of) the model of the RCT itself, particularly its inexplicably
enigmatic placebo. Another magic is the inversion of ownership that occurs
by discrediting the ‘spiritual’ dimensions of Tibetan medicine while simultaneously appropriating the profitability of this aspect of the medicine
through research programmes that redefine the languages of efficacy in
terms of active ingredients, psychological biochemistries and, sometimes,
packaging labels that give the appearance of spiritual authenticity when
turned into trademark or patent products. The magic here is also like
‘crime’ in its double sense. Criminality is invoked by establishing that
something uses ‘magical’ as opposed to ‘scientific’ reasoning. At the same
time, ‘criminalizing’ Tibetan doctors enables a potential transfer of ownership of medical remedies to those who are in a position to both deem what
is medically efficacious and what is not. Establishing governmental approval legitimizes MD prescriptions and criminalizes Tibetan ‘prescription’
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of these remedies, while failure in RCT research potentially criminalizes
prescription and sale (even as nutritional supplements) of Tibetan medicines by Tibetan practitioners. But participation in these regimes of truthmaking enables the ‘theft’ of Tibetan remedies by way of their reduction to
active ingredients.50 Ultimately, it is this process that also enables Johnson
& Johnson Pharmaceuticals, among other multinational pharmaceutical
firms, to sell these products more easily (in forms that are rendered nontoxic) than Tibetan doctors and/or the original producers of these
remedies.
Taking risks is as much a part of the cultural politics of truth and legal
medical privilege as it is part of the identity politics of consumers in late
capitalism.51 Consumers sometimes use alternative medicine because of an
identity politics that compels them to embody their alternative choices in a
form of risk-taking [Lau (2000)], even while others choose alternative
resources because of their own ‘evidence’ that it works, or because of the
evidence provided by the FDA and the AMA. Even in the absence of
scientific evidence of efficacy, some consumers will use alternative medicines. But such consumers are denied remedies if the FDA deems them
illegal. Tibetan practitioners stake bets at randomized controlled trials
because they not only believe in their medicines but also because they
desire the cultural capital that comes from being brought to the high-stakes
table of international visibility and legitimacy in the medical field. Subjecting themselves to government surveillance by undergoing scientific scrutiny for possible approval by the FDA and NCCAM, however, seldom
gives practitioners this opportunity. Rather, it engages them in the criminal
apparatus of the late-capitalist state. It pulls them into casino-like biopolitical economic and scientific arrangements that blur distinctions
between legal ‘rights’ and financial priorities, ‘fears of magical thinking’
and ‘facts of biological toxicity’, all the while ensuring profits and shifts in
ownership that frequently end up, in the eyes of doctors like Tenzing
Choedrak, looking like crimes of another sort.
If Dr Choedrak’s presence in the USA is partly a result of decolonization (one could trace the causes of his exile and eventual visit to the USA
all the way back to the cold war machinery that augmented China’s rôle in
Tibet), then what can be said of decolonization’s rôle in including him or
his medicine in this new global system? If decolonization elsewhere ushered in a need to sustain the rationalizing and bureaucratizing instruments
of colonialism without the presence of a foreign sovereign, then perhaps
one way this has been accomplished is by way of the languages of science
and politico-legal regimes that make use of these languages to arbitrate
inclusion of various forms of cultural difference. For sure, the processes of
postcolonial science are not as clear-cut as those of colonialism, both in the
sense that the research might be seen as posing greater risks (for Tibetans
and perhaps for patients) than was true during a colonial era. Moreover,
postcolonial science is less assured in its exploitation-via-science than
colonial sciences were,52 at least in some ways. It is often forced, by the
market, to address and embrace those aspects of medicine that fall outside
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of its formal purview initially, at least. Moreover, operations of postcolonial
science are accountable, increasingly, to international courts of law in
which even Tibetan doctors might petition for rights.53 Finally, it might be
seen as more protean in the ways it can shift the scientific terms by which
the label ‘crime’ is localized and then ‘re-located’, as market needs arise
and as new medical facts are produced, than was true for colonial
science.
In other ways, there is continuity in the arrangements of capitalmaking and exploitation with an era of colonialism, even in the sense with
which those who risk to lose much more than any others (the Tibetans),
are such ‘willing’ participants in the game. Similarly, there are surely
colonial instances of a double assignation of crime; double standards today
enable those who are able to both colonize and monopolize knowledge and
scientific practices to exclude others by way of carceral regimes in the
globalized ‘state’. This is especially true when that globalized state uses
biomedical research protocols as a foundation for establishing universalist
claims about medical efficacy and toxicity.
In the arrangements of postcolonial science, as Le Carre suggests, Big
Pharma plays an important rôle, not just because these companies sometimes influence the terms of modern diplomacy, but because they negotiate
the terms and conditions of membership in the economy as well. Although
Big Pharma itself often finds itself pitted in battle against federal regulatory
agencies (particularly the FDA), it as often finds itself a pleasant bedfellow
in the machineries of government-funded biomedical research. This arrangement relies on the presence of the nation-state to criminalize (and to
globalize their reach), but this is perhaps because the public generally
refuses to play by the rules of science – consuming medicines that aren’t
proven, believing in things like healing images of Buddhas or in names of
diseases or patterns of treatment that simply don’t make biomedical sense
(and certainly can’t be tested simply). In this case, the invocation of clinical
trials becomes essential to the effort to control and obtain profits.
This is where a disruption or ‘crack’ in the belief in a globalized
postcolonial science might be seen. Postcolonial conditions that arouse
desires for purchasable cultural difference in medicines (the difference that
could make a difference) exceed the terms of science that are used to
regulate these flows and establish medical truth. The public does purchase
Tibetan treatments, even if they are not medically proven. But the use of
clinical trials also exceeds medical science, and is deployed as part of the
legal infrastructure in the United States by way of the FDA – and its
evidence-based producers of truth about toxicity and threats to life itself –
in order to ensure that the public is protected from its own worst tendencies. So, despite their enthusiasm for validation within biomedical science,
Tibetan doctors who actually participate in clinical trials sometimes see
these cracks, and feel their delegitimizing effects. They are included in the
game, but potentially criminalized for doing so, and the price of admission
is the risk of losing their ownership of their products and knowledge. This
process makes visible the unevenness of the playing field upon which
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various medical experts contend for profits and legal protections, suggesting that certain scientific claims may work to benefit some persons (defined
by a national or sovereign terrain) more than others.
Notes
I gratefully acknowledge the generous support of funding from Princeton University, the
University of California San Francisco (REAC), the Wenner Gren Foundation for
Anthropological Research, and the National Science Foundation. Additional insights for
this paper were made possible under funding for a different project from the NICHD
(Network for Women’s and Children’s Health). I also am grateful for the assistance of
Angela Ranzini, MD, Yangdron Kelzang, Fei Fei Li, the physicians and colleagues at
Lhasa’s Mentsikhang. I also want to thank the participants at the Postcolonial
Technoscience Workshop (May 2001) for their insightful comments and suggestions for
revisions, particularly Warwick Anderson, Donna Haraway, Anna Tsing, Paul Rabinow,
Stacy Pigg, Lawrence Cohen, Nicholas King, Helen Verran, Gabrielle Hecht, Philippe
Bourgois, Adele Clarke and Barry Barnes (and please forgive me if I miss others who
offered comments). Finally, thanks are owed to Kevin Ergil for his insights on similar and
other processes that occur with Traditional Chinese Medicine in the United States. Thanks
also to three of the four anonymous reviewers of this paper for their constructive
suggestions on how to improve it. That I received comments or research collaboration from
those named here in no way suggests that the ideas presented here represent their views.
1.
2.
3.
4.
5.
6.
Particularly its triangulation of 1st-2nd-3rd world/democratic-communist-formerly
colonized political techniques. The book Le Carre’s essay is at least in part based on is
his The Constant Gardener [Le Carre (2000)], a fictionalized account of the murder of a
young activist by a pharmaceutical conglomerate that was attempting to cover up its
deadly clinical trials in a rural African nation.
Colonized, if one subscribes to the view held by many Tibetans within and outside of
Tibet proper, but certainly not if one subscribes to the view held by the government of
China and many of its citizens.
The ethnographic materials used in this essay have been collected since 1992 at
multiple sites, including Lhasa (in the Tibetan Autonomous Region [TAR]), the exile
Tibetan community in the United States, a variety of international conferences on
alternative medicine, interviews with key figures in the Complementary and Alternative
Medicine (CAM) research field, as well as an observational study of Tibetan medicine
for treatment of women’s disorders in Tibet.
‘Modernization’ is not a sufficient term for all of the different movements that have
been advanced by the government to modernize the country. See Anagnost (1997),
Rofel (1999) and Farquhar (2002) on the many shifts in mechanisms of state
modernization in China, and Schein (2000) on some of the ways these have been
deployed in minority regions.
Yang (1994) outlines the utility, and lack thereof, of Foucauldian models of repressive
versus productive power in relation to the Chinese state. I do not investigate this shift
here, but note that the effort to modernize in China has depended on the hope that
citizens will at some point no longer require the heavy hand of a repressive state in
order to ensure political stability. Evidence that this has at least in part been achieved
lies in the fact that many Tibetans are as committed to the idea that ‘science’ offers a
universal means of knowing medical truths as one finds in industrialized Western
countries like the United States.
That is, I don’t think risk-venture capitalism is new, or more significant in geopolitical
relations than in the era prior to and during colonialism, but the penetration of its
effects in various scientific fields is new. China’s socialism is in large part a response to
colonial incursions, and so might be considered a postcolonial state, and I consider
Tibet an internal colony that nevertheless participates in the forms of postcolonial
science found elsewhere in the poorer nations of the world.
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7.
8.
9.
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That is, despite the many inequalities and exploitations found in colonial regimes, they
were also accountable for the welfare of subjected populations in ways that new
multinational firms are not.
This meeting was reported at the time in an article in The New York Times Magazine
[Cherry (1980); see also Benson et al. (1982)]. Elisabeth Stutchbury also offered a
brief account of the meeting in December 1996, in an unpublished paper delivered at
the ‘Healing Powers and Modernity in Asian Societies’ Workshop (Newcastle, NSW,
Australia). She was present in India during Dr Benson’s visit. I have myself been
following the research described in this paragraph since 1981.
Charles Raison (then at the Neuropsychiatric Institute at UCLA, now at Emory
University) presented this work at the First International Congress on Tibetan
Medicine, in Washington, DC (7–9 November 1998). His analysis focuses on the
relationship between thermoregulation and the biochemistry that underpins both
depression and euphoria in relation to possible adaptive mechanisms in human and
animal physiology.
I take this information from my own participation as a colleague, teacher and informal
consultant in her research.
Dharamsala is the exile home for the first wave of Tibetans who fled Tibet with His
Holiness the Dalai Lama in 1959. These Tibetans fled after about eight years of life
under the communist government of China (PRC) and increased presence of the
People’s Liberation Army on the plateau. Tibetan exiles live in many different countries
today. This paper includes information collected among exiles as well as among
Tibetans still in the Tibetan Autonomous Region of China (which, in this paper, I refer
to as ‘Tibet’).
I was told this story by one of his students, who had witnessed the recounting of events
(Eliot Tokar, New York City, Chagpori Institute). This Tibetan doctor had established
American contacts of his own, and was now attempting to put together a lecture tour
on the relationship between Tibetan astrology and medicine.
Tibetan doctors travelled to India and throughout the Himalayas during the era of the
Raj, and were exposed to Western medical ideas and practices: see Adams & Dovchin
(2000) and Adams (2001b).
Also, Adams & Li (forthcoming) discusses at greater length how the category of
‘biomedicine’ is problematic both in terms of its name and its practices in this context
of China. Although many of the textbooks used to teach biomedicine in Tibet contain
information that is similar to that found in textbooks in the United States, the practices
of ‘biomedicine’ (or what Tibetans call, interchangeably, ‘western medicine’, ‘outside
medicine’ and ‘Chinese medicine’) in Tibet is often unrecognizable as such when
compared with similarly identified procedures within the United States. I do not take
biomedicine to be a uniform or essential set of practices, although that is often how it
is regarded among some of my Tibetan colleagues.
For more on this encounter in Chinese medicine, see Farquhar (1994); and on the
political implications of this in other contexts in the world, see Harding (1998).
Coombe (1998) asks how legal infrastructures make it possible to arbitrate cultural
differences to the advantage of some and not others. Her work on copyrights usefully
expands this inquiry in relation to the rôle of patenting, which I turn to later in this
paper.
Exploring these politics is not a project I undertake in order to establish the legitimacy
of alternative medicine, but rather in order to explore the ways in which ‘legality’ versus
‘criminality’, ‘authenticity’ versus ‘fraud’, ‘magical thinking’ versus ‘scientific method’,
serve to delimit privilege and denial in the playing fields of a postcolonial world and a
globalized economy. Rabinow’s (1996) description of this as a form of biosociality is
suitable here, in the sense that our institutions of sociality are increasingly organized,
made liveable, and mapped, by way of our readings/makings of ‘biological’ life, and
death. The other influence on this work is Agamben (1998), who (if I read him
correctly) has suggested a way to connect biopolitics to the ambiguities of sovereign
law. The rule of the ‘exception’ on which sovereignty is built is also a basis for a
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political, social (and economic, I would add) infrastructure that is built around the
exceptional sacredness of life itself; thus arbitrations over life and death are not
extraordinary, but are built into the ordinary domains of sociality.
See, for another example, the DateLine television presentation of the UCSF-based
breast cancer research clinical trial of Tibetan medicine (the Principal Investigator was
Debu Tripathy, MD), in which patients selected for the study described their hope that
Tibetan medicine’s attentiveness to holism and spirituality will give them an advantage
that they cannot find in biomedical responses to their disease.
This information comes from field research among Tibetan doctors that I have been
conducting since 1993, at the Tibetan College of Medicine and Astrology (Hospital
and College) in Lhasa.
One could read this as an internal colonial resistance of sorts.
For a more complete exegesis of this argument, see Root (1995).
A case in point for this is the study of the positive effect that distant prayer is shown to
have on patients. This study is both applauded by many in the alternative medicine
community for its ability to confirm the need to expand scientific explorations into this
area, and largely vilified among those who oppose the findings and the funding, on
grounds that it suggests a loss of scientific rigour in this field.
I use ‘magical’ here in the sense that I believe it is used colloquially in most US
medical science institutions, as contrasting with ‘scientific’, in the sense that it was
taken by early ethnologists as a pre-scientific form of logical thought (along the lines of
Frazer). It may be ‘rational’ (Evans-Pritchard), but cannot approximate scientific
thought because it requires a leap of faith – belief – as opposed to empirical evidence,
to be explained.
This is most clearly visible in the research problem of the ‘placebo’. See Harrington
(1997), who explores Judaeo-Christian questions of spirituality in relation to
exploratory biomedical sciences.
I do not suggest by this that state-funded medical endeavours are solely devoted to or
unambiguously engaged in opposition to patients’ use of unproven medications. There
are branches of federally-funded research devoted to ensuring patients’ rights.
Lawrence Cohen (1994) has called this domain an ‘epistemological carnival’, giving it
some of the same features of casino capitalism, because research in alternative medicine
can be seen as a game that involves a gambler’s risk, the spectacular and seductive
allure of not only great profits but also remarkable cures for terminal or intractable
diseases, and odds that are clearly stacked against certain players more than others.
From Kirsten Georgi, ‘Commission on CAM’, Acupuncture Today, Vol. 3, No. 2 (July
2001) (available from 396 Broadway, New York, NY 10013).
This is the figure offered by David Eisenberg [cited in Martin (1994): 89] for the
amount of money that Americans spent, beyond insurance coverage, for alternative
medicines for themselves or their family members.
Tibetan doctors and medical scholars are not uniformly committed to the idea of a
universal science, nor are they uniformly committed to the promise of confirmation
within Western medical frameworks, although that is the dominant perspective these
days: see Adams (2001b).
This is based on Steven Strauss’ presentation at the Wellcome Institute’s Workshop on
Complementary and Alternative Medicine, held at the Wellcome Institute (London,
7–9 December 2000).
The International Scientific Conference on Complementary, Alternative & Integrative
Medicine Research, co-sponsored by the UCSF Osher Center for Integrative Medicine,
Harvard Medical School, and the Department of Medicine, Beth Israel Deaconess
Medical Center (San Francisco, 17–19 May 2001).
This is taken from his plenary speech to the London Workshop (see note 30).
Advertisements I have seen for Tibetan medicines in China make use of both an
‘exotic’ and ‘mystical’ dimension of Tibetan medicines (visible in brochures that use
glossy photographs of the remote snowy lands of Tibet, its monasteries and religious
figures), as well as claims to the scientifically established reliability of these drugs
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(revealed in photographs of modern factory equipment, laboratories, and text that
attests to the most modern of research methods in producing, testing and standardizing
these medicines).
Again, I do not suggest that this constitutes an essential form of biomedical practice. I
use it as a heuristic point of comparison in emphasis between the systems, not as an
indicator of how biomedicine is always, in every case, deployed. It is ironic that despite
the fact that new fields of microbiology increasingly adopt ecological perspectives that
view viral migrations and their long-term effects on populations in more ‘chronic’
disease frameworks, clinical trials in alternative medicine research remain committed to
acute models of disease.
Farquhar (1991) offers an excellent example of how this works in traditional Chinese
medicine.
The difference might be understood in terms of the relative degree to which the
diagnosis connects various social worlds together to the physiological state. In
biomedicine, the first shift in the birth of the clinic was the shift in diagnostic gaze
from the ‘life of the patient’ to the ‘life of the disease’. This is accompanied by the
growth in institutional biomedical focus on the way that more and more of social life is
organized around biomedical concerns (epidemiology for example does this, along with
public health and family medicine), but primarily by way of the disease category and
label. Even ‘genetics’ has become a basis for the organization of social life: see Rabinow
(1996) on biosociality. Tibetan medicine places more of an emphasis on diagnosis of
the social condition prior to the disease itself than the reverse, in which the disease is a
basis for pathologizing social life.
For example, the significance of using different treatments for patients with similar
diseases in Tibetan medicine is related to problems that some patients have because of
karmic predispositions that show up in humoral character, or because of things like
wind imbalances (discussed in terms of perceptions of social discord, greed, sense of
loss or unfulfilled desires, among other things). With some practitioners (mostly outside
of Tibet), the simultaneous treatment of spirit causes of diseases (with exorcisms) is
prescribed and considered necessary for cure.
Some examples of this can be found at one of the NIH Centers for the Study of
Alternative Medicine at the University of Arizona, as well as at Harvard and Stanford,
in which efforts to map the mysterious dimensions of things like the placebo, the effect
of prayer, wellness groups, and the ‘energies’ of therapeutic touch are first reduced to
psychological processes and then studied for their biochemistry. The case of efforts to
map the neurophysiology and biochemistry of gtummo practitioners is a good example
of this.
This research took place in 2000, with support from UCSF, with Dr Angela Ranzini
(UMDNJ), funded by NSF and UCSF’s REAC Award. In Tibetan medicine, there are
nine types of ‘growths’. We found seven equivalents for these in biomedical diagnoses
(molar pregnancy, fibroids, cysts, endometriosis, cancer, polyps, ectopic pregnancy),
but for two types, there are no equivalents in biomedicine.
So, for example, a clinical trial of Tibetan medicines might deem that medicine
ineffective for treatment of a single disease, thereby restricting it from the medical
therapeutic market. It cannot be sold as a drug for that disease. But, it can still be sold
as a nutritional supplement on the health food/alternative market. If trials and research
deem such medicines toxic, then they are excluded from sale on the health food/
alternative market. If, on the other hand, the public consumption of alternative
medicines leads to public claims that they work to benefit patients, then the effort to
explain these positive effects often requires use of scientific language and investment by
researchers who can transform these medicinal substances into pharmaceutical
products. Renaming them as medical ‘drugs’ can enable a shift in ownership.
Being conducted at UCSF: Dr Debu Tripathy (personal communication, February
2000).
Many Tibetan medicines are banned from the market in the USA because they contain
mercury and other heavy metals, despite claims that Tibetan medical processing (taking
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several months of heating, and decanting) renders the dangerous contents of these
metals non-toxic. One wonders, off hand, how so many Tibetans could survive the
mercury poisoning that is imputed as a potential of these Tibetan drugs, given the
popularity of these medicines among Tibetans.
A similar process was revealed in the work of Jurgen Aschoff, a neurologist from the
University of Ulm, Germany, who studied Tibetan medical treatment for migraines and
explained effectiveness by reducing the treatment to the active ingredient, aconite: see
Aschoff et al. (1997).
That is, only Tibetan doctors who are putatively delivering their medicines on behalf of
the Principal Investigator MD who has legal permission to prescribe these medicines
are allowed to do so.
Kevin Ergil has been involved with research and practices of TCM in the United States
for over 20 years, and is a constant source of original insight on matters of translation
and epistemology in this field.
The FDA collects ingredient lists from the Tibetan providers and is obliged not to
share them with other researchers. In almost all the cases I have read about [see
Aschoff & Rosing (1997)], the pursuit of active ingredients makes the ingredient lists
public anyway.
The University of Medicine and Dentistry of New Jersey [UMDNJ], for example, has a
team of researchers exploring the food supplement market for oestrogen-containing
products. Several alternative medicine journals are now devoted to this sceptical cause
as well; see, for example, The Scientific Review of Alternative Medicine (Amherst, MA:
Prometheus Books). I do not mean to underestimate the benefit of such approaches in
being able to eliminate harmful products from the market. Nor am I suggesting that
Big Pharma is not often on the other side of the fence from the FDA and regulatory
agencies, since large pharmaceutical firms and their specific projects are often the target
for FDA regulations. The arrangements that enable Asian doctors to be excluded from
profits sometimes ally them with Big Pharma and sometimes pit them against Big
Pharma, and ally instruments of the state to pharmaceutical interests. The
arrangements linking together Big Pharma, government sanctions, and scientific claims
about efficacy sometimes do produce this lopsided configuration of power, which leads
to the distinct disadvantage of Tibetan doctors. At other times, things are not so neatly
lined up this way.
In his work on Indonesia, Seigel (1998) makes the point that criminalization works as
an instrument of media-based popular control for an authoritarian regime. A similar
process occurs with state-regulated regimes of medical research in the USA, but the
stakes are quite different and the instruments for criminalizing are different. The
similarity is that efforts to protect the ‘public’ must also criminalize those it deems, by
scientific research, ineffective or ‘dangerous’ to the public. We might think of this as
part of the ‘magic’ of the millennial state [Coronil (1997); Taussig (1997)], relying on
not just a theatrical and ritual excess but also on excessively powerful techniques of
differentiation which criminalize the ‘magical’ while authorizing its reclassification
under regimes of scientific legitimacy. Eliminating the magical by performing a certain
‘magic’ of its own. The Comaroffs (2000) have argued recently that organized forms of
criminal activities authorized by millennial capitalism can be understood in moral
frameworks invested with cultural sensibilities that are themselves authorized by a
displaced and refracted class consciousness. Identity and cultural politics become the
basis for participation and resistance within the casino of late capitalism, not class or
conditions of labour. Scientific regimes and clinical trials might also be studied with
this theoretical framing in mind. Again, Tibetan practitioners, no less than medical
scientists working at NCCAM, are enamoured of the idea of a universal gold standard.
It is this magical belief in the fairness of the system that authorizes the research itself.
It is also the allure of magic-like profits that attracts them to the table.
I refer to their argument about how, in the absence of credible witnesses as to genuine
phenomena of science, the air pump and other technologies served this purpose
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through demonstration. The technologies enable the simultaneous creation of ‘science’,
and of the social context that allows specific empirical claims to carry validity.
My thanks to Michael Lynch for this phrasing of the kinds of crimes identified herein.
Following Comaroff & Comaroff (2000).
I borrow some of this phrasing from one of my anonymous reviewers, who senses an
‘iron cage’ of biopiracy in this analysis. Again, I note that the alignment of Big Pharma,
government, and RCT research interests does not always work in favour of Big
Pharma, but it usually does.
The neem producers in India who have attempted to challenge Big Pharma over
ownership of the intellectual property used in the development of commercial
fertilizers, using the neem plant, offer a case in point here [see Shiva (1996): 69–73].
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Vincanne Adams is Associate Professor of Medical Anthropology in the
Department of Anthropology, History and Social Medicine at the University
of California, San Francisco. She is the author of two books: Tigers of the
Snow and Other Virtual Sherpas (Princeton UP, 1996) and Doctors for
Democracy (Cambridge UP, 1998).
Address: Department of Anthropology, History and Social Medicine,
University of California, PO Box 0850, 3333 California Street, Suite 485, San
Francisco, California 94143–0850, USA; fax: +1 415 476 6715; email:
[email protected]
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