Buddhist medicine in occupied Tibet

In 1949, China invaded Tibet without provocation; Tibet is still occupied, and the Dalai Lama's government is in exile in India. Kieren Bong spent his elective in a Buddhist monastery there

I was warmly received and presented with a hada (white silk scarf) on arriving at Lhasa's Gongkar airport. Two men helped me with my luggage, and soon we were on our way to the capital of this ancient Buddhist country. The 95 km journey from the airport to Lhasa gave us ample opportunity to get acquainted, and I saw some of the most spectacular landscapes on earth. On arriving in Lhasa, I felt lightheaded and overwhelmed by the intensity of the sun. Two days later, when I was well acclimatised, we left for the monastery.

Oral or intravenous

In Tibet's largest and best preserved monastery, the hospital is a small but organised community run by 14 Tibetan monks who are doctors. Two are highly experienced, each with 36 years' experience in medical practice; two are junior doctors in the making; one is an ultrasonographer; one is a radiologist; four are pharmacists; and four are doctors responsible for other less specialised work (such as fixation of intravenous cannulas). The hospital is equipped with an x ray machine, an ultrasound machine, an electrocardiograph, two sphignomanometers, and two stethoscopes. The short stay ward had four beds for monitoring patients with subacute problems; a treatment room for carrying out straight-forward procedures, such as replacement of dressings and tooth extractions; a pharmacy; a laundrette; and a shower room. Within the same compound there were two storage warehouses for herbs and other ingredients for making Tibetan natural herbal medicine.

In the summer, the hospital was open from 9 am to noon Monday to Saturday, and reopened between 3 pm and 6 pm on Mondays, Wednesdays, and Thursdays. It tended to be busier in the morning. Apart from the two most senior doctors, all the Tibetan doctors take turns to be on call for 10 days, during which they are required to stay within the hospital compound; it is their duty to deal with any acute cases within the monastery.

On average, the two most senior doctors see 100 patients a day in summer. This number doubles in winter and inevitably strains the capacity of the hospital to the maximum. Every day, doctors decide between two treatment plans--oral or intravenous--for the patients who line up to see them. Those taking oral drugs collect their prescription from the pharmacy and leave. Those with intravenous regimens are helped with the setting up of drips. Western medicine--such as the use of antibiotics (both intravenous and oral) and supplementation with multivitamins--has been introduced, and efforts have been made to try to integrate this with Tibetan medicine, which is not easy.

DERMOT TATLOW/PANOS

Where did you get that hat, Mr Monk?

The rise of Mandarin

Despite the growing popularity of Mandarin, Tibetan is still the most spoken language in Tibet. Since the controversial invasion by China, Mandarin has been introduced and subsequently made compulsory in schools. As a result, virtually everyone in younger generations speaks fluent Mandarin. The exposure to the Chinese language in the early days did come in handy. But it was a Tibetan phrase book which got me through my daily communication with the monks and, most importantly, with my patients. I struggled, but it was part of the fun and excitement. It was amazing how easy it was to break the ice with only a few words of Tibetan. I never failed to put a smile on the patient's face with the phrase "tashi delek" (hello). Occasionally, I had the luxury of an interpreter, who happened to be one of the few Tibetans to have had the opportunity to go abroad to India to study English. He was eager to practise his English, and I was struggling to convey what I wanted to say to the patients. We became good friends.

Being the first foreigner to be allowed to stay in Tibet's largest monastery, I was inundated by visitors in the evenings. The monks enjoyed watching me, and they roared with laughter with my every move. It was hard to believe how much attention my electric toothbrush could draw. I devoted two hours every evening to teaching English; it was a big challenge as the monks had never been exposed to the Latin alphabet, but they were determined to learn a new language.

Buddhism and Western medicine

I saw patients every day, but it took me twice as long for each patient because of the language barrier. I also spent a lot of time trying to better understand traditional Tibetan medicine. It is a fascinating subject with thousands of years of history. My stay within the monastery gave me many opportunities to talk about Buddhism with the senior monks. Buddhists believe life consists of four phases--birth, old age, illness, and finally death. Death is just part of the cycle, and hence they confront death with courage. It was fascinating to witness the integration of Buddhism into the practice of medicine. The Tibetans believe ailments and the severity of an illness are influenced by "karma" (merits) accumulated in past lives. Management plans, therefore, must include relieving the patients from their bad karma from the past, while not forgetting to focus on good deeds to ensure better health in the future.

DERMOT TATLOW/PANOS

Prayer flags across Tibetfis

Unfortunately, none of the doctors at the monastery had had the opportunity to study the fundamental subjects that make up the practice of medicine. Interpretation of abnormal radiographs was nearly impossible for the radiologist, because he had little familiarity with human anatomy. Similarly, the ultrasonographer found it difficult to distinguish normal images from abnormal ultrasound images. The lack of knowledge in pathology and physiology makes it a challenge for the doctors to correlate symptoms with underlying pathology, never mind to extrapolate the list of symptoms to gauge the severity as well as urgency of the disease. Often, making a diagnosis was a guessing game. I was asked to teach one of the doctors how to take and interpret an electrocardiogram. It was a difficult task, if not impossible; he had no idea about normal anatomy, physiology, or electrophysiology of the cardiovascular system.

Traditional medical practice in Tibet takes a different approach compared with the West. We are so used to being told to treat the patient as a person and not a disease ("biopsychosocial theory"). In other words we must not neglect the biological, psychological, and social elements when dealing with a patient, be it as a cause or an effect of the disease. Tibet is different. Patients are not followed up, making it impossible to know outcomes or the effectiveness of treatments. Improving the management of patients with similar conditions is deemed impossible.

Western medicines put much emphasis on patient centred care, whereby patients are given autonomy over their methods of care and treatment. Patients are encouraged to participate as much as possible in the decision making. Sound knowledge of the disease is essential to make informed decisions and to participate in the management regimen, and this can be achieved by providing leaflets, patients' own research, and discussions with their doctors. At the monastery hospital, the number of patients was so high that each patient got little time. Being one of the few hospitals to provide almost free consultations as well as almost free prescriptions, it was inundated with patients from relatively disadvantaged social backgrounds.

Doctors depend on the patients to tell them if there are any coexisting conditions which might contribute to the symptoms or worse still aggravate them. Patients' medical or surgical history, drug and family history, and other relevant details such as allergies and personal and social history are not properly documented. Interactions between different drugs are well recognised in the failure of some treatment regimens. On the other hand, some symptoms may well be the side effects of drugs taken by the patients.

Lack of laboratory equipment meant it was not possible to isolate the micro-organisms thought to be causing the disease, prohibiting the prescription of antibiotics specific to the cause. Often, broad spectrum antibiotics were given for petty conditions. I wonder what the rate of resistance of some types of bacteria to antibiotics is. Lack of patient education means low compliance in finishing courses of drugs. Doctors are often left perplexed, and some diagnoses could not be made without proper investigative techniques. That said, without proper knowledge and training in clinical micro-biology, a sophisticated tool would end up like the electrocardiograph, sitting around for years collecting dust.

Respect

I have the utmost respect and admiration for all the Tibetan doctors. They work hard and, without the slightest doubt, are a group of highly competent and conscientious doctors. Taking into consideration the financial constraints and the lack of opportunity, they practise exceptionally well. They recognise their limitations, but these do not deter the monks from taking full advantage of what is available to them.

Living in the monastery with the lamas (monks) gave me the opportunity to experience a different way of living. Also, working in the hospital gave me the opportunity to see a different environment with people from different backgrounds and cultures. I also found out more about Buddhism. I fell in love with Tibet and the Tibetans; I hope to revisit this snowy land soon.