Sowa Rigpa Research Articles

The transnational Sowa Rigpa industry in Asia: New perspectives on an emerging economy

This article advances the hypothesis that “traditional” Asian pharmaceutical industries are rapidly growing in size and prominence in contemporary Asia, and identifies a lack of empirical data on the phenomenon. Addressing this gap, the article provides a quantitative outline and analysis of the Sowa Rigpa (Tibetan, Mongolian and Himalayan medicine) pharmaceutical industry in China, India, Mongolia and Bhutan. Using original data gathered through multi-sited ethnographic and textual research between 2014 and 2019, involving 232 industry representatives, policy makers, researchers, pharmacists and physicians, it assembles a bigger picture on this industry's structure, size and dynamics.Revealing a tenfold growth of the Sowa Rigpa pharmaceutical industry in Asia between 2000 and 2017, the study supports its initial hypothesis. In 2017, the industry had a total sales value of 677.5 million USD, and constituted an important economic and public health resource in Tibetan, Mongolian and Himalayan regions of Asia. China generates almost 98 percent of the total sales value, which is explained by significant state intervention on the one hand, and historical and sociocultural reasons on the other. India has the second largest Sowa Rigpa pharmaceutical industry with an annual sales value of about 11 million USD, while sales values in Mongolia and Bhutan are very low, despite Sowa Rigpa's domestic importance for the two nations.The article concludes with a number of broader observations emerging from the presented data, arguing that the Sowa Rigpa pharmaceutical industry has become big enough to exert complex transformative effects on Tibetan, Mongolian and Himalayan medicine more generally. The quantitative and qualitative data presented here provide crucial foundations for further scholarly, regulatory, and professional engagement with contemporary Sowa Rigpa.

Mainstreaming Marginality

Abstract This article examines the “mainstreaming” of Sowa Rigpa (Tibetan medicine) into primary healthcare in Ladakh, Himalayan India. It explores fields largely overlooked by existing studies of medical integration, such as the social dynamics of public health facilities, the effects of limited drug supplies, and changes in medicine production. Although Sowa Rigpa practitioners experience aspects of their integration as positive, it is also forcing approaches toward prescription practice, patient care, and pharmaceutical production that are at odds with their clinical, social, ethical, and practical grounding. The article argues that integration is exacerbating existing inequalities while creating new forms of hardship and marginality. However, paradoxically, only by occupying such marginal spaces can the amchi continue practicing Sowa Rigpa in a recognizable form. The article later reflects on what the Ladakhi case tells us about the Indian government’s policy of “rational integration” and contributes to debates concerning subaltern therapeutic modes and medical pluralism.

An integrated medicine of Bhutan: Sowa Rigpa concepts, botanical identification, and the recorded phytochemical and pharmacological properties of the eastern Himalayan medicinal plants

IntroductionBhutanese Sowa Rigpa medicine (BSM) has established unique pharmacopoeias that describe ethnotaxonomical concepts, classification systems and descriptions of medicinal plants. BSM was integrated with modern health care system in 1967. BSM uses medicinal plants, minerals and animal products as the main ingredients of the formulations used for treating various disorders. This study was aimed to highlight interesting ethnotaxonomical concepts of BSM and identify and document medicinal plants from the two remotest regions of eastern Himalayas of Bhutan – Merak and Sakteng. MethodsEthnopharmacological data was gathered from the pharmacopoeias, published monographs and research papers on Bhutanese medicinal plants. Medicinal plants diversity was surveyed using the convenience sampling methods. A literature review on the phytochemical content of the medicinal plants and their pharmacological activities was carried out using plant databases, PubMed, SciFinder and Google Scholar. ResultsA very interesting ethnotaxonomical concept of BSM has been translated into English terminologies from the traditional pharmacopoeia. A total of 50 alpine medicinal plants belonging to 25 families and 39 genera in 13 study sites between Merak and Sakteng were documented. Only 12 medicinal species were identified as priority species or are currently used at Menjong Sorig Pharmaceuticals for formulating 48 different medicines. ConclusionsThis study described the ethnotaxonomical concepts, classification and description of medicinal plants in Bhutan and botanically identified 50 alpine medicinal plants from 13 different study sites under Merak and Sakteng regions. About 12 of them were currently used as ingredients in BSM formulations and 35 species were studied for their phytochemical and pharmacological properties.

Humanitarianism from Below: Sowa Rigpa, the Traditional Pharmaceutical Industry, and Global Health

ABSTRACT In this article I explore, for the first time, the relationship between Sowa Rigpa (Tibetan medicine) and global health, tracing “the global” in ethical discourses and pharmaceutical innovation practices of Tibetan medical practitioners. I argue that Sowa Rigpa’s engagement with the world and its global health activities outside China can be understood as a form of “humanitarianism from below,” while its industrialization in China aligns with global health in different ways. In providing new insights into recent developments of Sowa Rigpa, I aim to decenter the notion of humanitarianism and contribute to a broader understanding of global health.

Defined Small Molecules Produced by Himalayan Medicinal Plants Display Immunomodulatory Properties.

Plant-derived compounds that modulate the immune responses are emerging as frontline treatment agents for cancer, infectious diseases and autoimmunity. Herein we have isolated 40 phytochemicals from five Bhutanese Sowa Rigpa medicinal plants—Aconitum laciniatum, Ajania nubegina, Corydalis crispa, Corydalis dubia and Pleurospermum amabile—and tested 14 purified compounds for their immunomodulatory properties using a murine dendritic cell (DC) line, and cytotoxicity against a human cholangiocyte cell line using xCELLigence real time cell monitoring. These compounds were: pseudaconitine, 14-veratryolpseudaconitine, 14-O-acetylneoline, linalool oxide acetate, (E)-spiroether, luteolin, luteolin-7-O-β-d-glucopyranoside, protopine, ochrobirine, scoulerine, capnoidine, isomyristicin, bergapten, and isoimperatorin. Of the 14 compounds tested here, scoulerine had adjuvant-like properties and strongly upregulated MHC-I gene and protein expression whereas bergapten displayed immunosuppressive properties and strongly down-regulated gene and protein expression of MHC-I and other co-stimulatory molecules. Both scoulerine and bergapten showed low cytotoxicity against normal healthy cells that were consistent with their immunoregulatory properties. These findings highlight the breadth of immunomodulatory properties of defined compounds from Bhutanese medicinal plants and show that some of these compounds exert their mechanisms of action by modulating DC activity.

Traditional Medicine in Bhutan

The Himalayan kingdom of Bhutan is an independent state situated between China and India. It emerged as a unified polity in the early 17th century under the rule of an exiled Tibetan religious leader and much of its elite culture, including its medical traditions, were brought from Tibet during this period. The Bhutanese Traditional Medical system subsequently evolved distinct characteristics that enable it to be viewed as a separate part of the Himalayan tradition of Sowa Rigpa (̒the science of healing̓), which includes what is now known as Tibetan Medicine. After coming under the influence of the British imperial Government of India at the beginning of the 20th century, Bhutan was occasionally visited by British Medical Officers from the Indian Medical Service, who accompanied British Political Officers on diplomatic missions there. But when the British withdrew from South Asia in 1947 there were no permanent biomedical structures or even fully qualified Bhutanese biomedical doctors in Bhutan. Since 194 7, Bhutan has evolved a state medical system in which their Traditional Medicine is an integral part and patients have the choice of treatment under traditional or biomedical practitioners. With particular reference to the role of The Institute of Traditional Medicine Services in Thimphu this paper discusses the history, structures and practices of traditional medicine in Bhutan, including its interaction with biomedicine.

Geopharmaceuticals of Himalayan Sowa Rigpa medicine: Ethnopharmacological uses, mineral diversity, chemical identification and current utilization in Bhutan

Ethnopharmacological relevanceGeological materials, such as minerals, have a long history of usage as ingredients in multicompound formulations of Himalayan Sowa Rigpa medicine – as well as in its localized form of Bhutanese traditional medicine (BTM) – for treating various disorders for over thousand years. Yet, hardly any scientific research has been done on their ethnopharmacological efficacy and chemistry. Aim of the studyThis study documents and correlates the rarely explored ethnopharmacological and chemical identification of various minerals and their ethnomedicinal uses in BTM formulations for the first time. Material and methodsA five stage cross-disciplinary process was conducted as follows: (1) a review of classical literature of Sowa Rigpa texts (Tibetan medical texts, pharmacopoeias and formularies) that are still in use today; (2) listing of mineral ingredients according to Sowa Rigpa names, followed by identification with common English and chemical names, as well as re-translating their ethnomedical uses; (3) cross-checking the chemical names and chemical composition of identified Sowa Rigpa minerals with various geological mineral databases and mineral handbooks; (4) authentication and standardization of Sowa Rigpa names through open forum discussion with diverse BTM practitioners; (5) further confirmation of the chemical names of identified minerals by consulting different experts and pharmacognosists. ResultsOur current study lists 120 minerals as described in Sowa Rigpa medical textbooks most of which we were able to chemically identify, and of which 28 are currently used in BTM herbo-mineral formulations. Out of these 28 mineral ingredients, 5 originate from precious metal and stone, 10 stem from earth, mud and rocks, 8 are salts, and 5 concern ‘essences’ and exudates. ConclusionsOur study identified 120 mineral ingredients described in Sowa Rigpa medical textbooks, out of which 28 are currently used. They are crucial in formulating 108 multicompound prescription medicines in BTM presently in use for treating more than 135 biomedically defined ailments.

Sustainable Utilization of Medicinal Plants of Ladakh and Lahaul-Spiti of Trans-Himalaya

<p>Cold arid and high altitude region of the trans-Himalayas (Ladakh & Lahaul-Spiti) is a unique region of the world where all non-native living beings experience noticeably hostile environments that make their survival much challenging compared to their respective natural dwelling niches. The region is characterized by extreme temperature variation, low precipitation mostly in the form of snow, thin atmosphere with high UV-radiation, less oxygen availability, high wind velocity, sparse plant density and fragile ecosystem. Interestingly, these adverse environmental conditions are ideal for the growth of valuable medicinal plants. Like other parts of the Himalaya, Ladakh and Lahaul-Spiti are also the treasure house of several unique medicinal plants which form an indispensable ingredient of local traditional system of medicines especially <em>Sowa Rigpa</em> System (<em>Amchi</em> system of medicine) since ages. </p>

The Pharmaceutical Assemblage: Rethinking Sowa Rigpa and the Herbal Pharmaceutical Industry in Asia

Cutting-edge anthropological research on pharmaceuticals aims to trace the connections that link our health and subjectivity, via the drugs we ingest, to contemporary forms of science, governance, and market practice. Yet this research is mostly limited to biomedical pharmaceuticals, ignoring the vast and rapidly growing “traditional” pharmaceutical industry, which connects contemporary forms of culture, capitalism, and politics in arguably even more interesting ways. Addressing this gap, this programmatic essay proposes the concept of the “pharmaceutical assemblage” as a way to assess the traditional pharmaceutical industry as part of Asia’s growing knowledge industry sector and the global pharmaceutical nexus. Taking the emerging Sowa Rigpa (also known as Tibetan medicine) industry as a particularly illustrative example, the article outlines an interdisciplinary approach to study this industry as a larger, transnational entity with its own role and dynamics. Identifying and discussing four major domains of the Sowa Rigpa industry—raw materials, drug-manufacturing processes, the market, and intellectual property rights—this article argues that the concept of the pharmaceutical assemblage can generate a much-needed bigger picture of traditional medicine and a fresh perspective on the confluences of culture, health, economy, governance, and the environment in contemporary Asia.

Pharmacological, ethnopharmacological, and botanical evaluation of subtropical medicinal plants of Lower Kheng region in Bhutan

BackgroundThe Bhutanese Sowa Rigpa medicine (BSM) uses medicinal plants as the bulk ingredients. Our study was to botanically identify subtropical medicinal plants from the Lower Kheng region in Bhutan, transcribe ethnopharmacological uses, and highlight reported pharmacological activities of each plant. MethodsWe freely listed the medicinal plants used in the BSM literature, current formulations, and the medicinal plants inventory documents. This was followed by a survey and the identification of medicinal plants in the Lower Kheng region. The botanical identification of each medicinal plant was confirmed using The Plant List, eFloras, and TROPICOS. Data mining for reported pharmacological activities was performed using Google Scholar, Scopus, PubMed, and SciFinder Scholar. ResultsWe identified 61 subtropical plants as the medicinal plants used in BSM. Of these, 17 plants were cultivated as edible plant species, 30 species grow abundantly, 24 species grow in moderate numbers, and only seven species were scarce to find. All these species grow within the altitude range of 100–1800m above sea level. A total of 19 species were trees, and 13 of them were shrubs. Seeds ranked first in the parts usage category. Goshing Gewog (Block) hosted maximum number of medicinal plants. About 52 species have been pharmacologically studied and only nine species remain unstudied. ConclusionLower Kheng region is rich in subtropical medicinal plants and 30 species present immediate economic potential that could benefit BSM, Lower Kheng communities and other Sowa Rigpa practicing organizations.

Animal-derived natural products of Sowa Rigpa medicine: Their pharmacopoeial description, current utilization and zoological identification

Ethnopharmacological relevanceThe Bhutanese Sowa Rigpa medicine (BSM) uses animal parts in the preparation of numerous polyingredient traditional remedies. Our study reports the taxonomical identification of medicinal animals and the description of traditional uses in English medical terminologies. Aim of the studyTo taxonomically identify the medicinal animals and their derived natural products used as a zootherapeutic agents in BSM. Materials and methodsFirst, the traditional textbooks were reviewed to generate a list of animal products described as ingredients. Second, animal parts that are currently used in Bhutan were identified. Third, the ethnopharmacological uses of each animal ingredients were translated into English medical terminologies by consulting Traditional Physicians, clinical assistants, pharmacognosists, and pharmacists in Bhutan. Fourth, the animal parts were taxonomically identified and their Latin names were confirmed by crosschecking them with online animal databases and relevant scientific literature. ResultsThe study found 73 natural products belonging to 29 categories derived from 45 medicinal animals (36 vertebrates and 9 invertebrates), comprising of 9 taxonomic categories and 30 zoological families. Out of 116 formulations currently produced, 87 of them contain one or more extracts and products obtained from 13 medicinal animals to treat more than 124 traditionally classified illnesses. Only five animal ingredients were found available in Bhutan and rest of the animal parts are being imported from India. ConclusionsOut of 73 natural products described in the traditional textbooks, only 13 of them (some omitted and few substituted by plants) are currently included in 87 formulations of BSM.

Plant matters: Buddhist medicine and economies of attention in postsocialist Siberia

Buddhist medicine (sowa rigpa) in Siberia frames the natural world as overflowing with therapeutic potencies: “There is nothing in the world that isn't a medicine,” goes a common refrain. An exploration of sowa rigpa practitioners’ committed relations with the plants they make into medicines challenges human-centric notions of efficacy in anthropological discussions of healing. Their work of making things medicinal—or pharmacopoiesis—centers on plants’ vital materialities and requires attention to the entanglements among vegetal and human communities and bodies. Potency is thus not the fixed property of substances in a closed therapeutic encounter but the result of a socially and ecologically distributed practice of guided transformations, a practice that is managed through the attentive labor of multiple actors, human and otherwise. In Siberia, pharmacopoiesis makes explicit the layered relations among postsocialist deindustrialization, Buddhist cosmologies, ailing human bodies, and botanical life. [plants, environment, medicine, postsocialism, Buddhism, Buryatia, Russia] Тибетская медицина (Сова Ригпа) в Сибири представляет окружающий мир, как обильный источник терапевтических свойств: «в мире нет ничего, что не могло бы быть лекарством,» гласит распространённая цитата из коренного учения по тибетской медицине. Исследование отношений экспертов в области тибетской медицины к растениям, которые они используют для составления лекарств помогает переосмыслить антропоцентрический подход к вопросам лечения. Труд, требующийся для создания «лекарственности»—описанный здесь как «фармакопоэзис»—концентрируется на витальной материальности растений, и освещает взаимосвязь человеческих и ботанических сообществ и организмов. В данном контексте, эффективность лекарства не является фиксированным атрибутом веществ в определенных терапевтических ситуациях, а экологически и социально распределенной практикой направляемых изменений, которые контролируется разными социальными акторами. В Сибири, фармакопоэзис делает очевидным сложное пересечение постсоциалистических процессов, Буддистского осмысления мира, переживания болезней, и жизнедеятельности растений. [растения, экология, медицина, постсоциализм, Буддизм, Бурятия, Россия]

Taxonomical Identification of Himalayan Edible Medicinal Plants in Bhutan and the Phenolic Contents and Antioxidant Activity of Selected Plants

In this study, 71 species of edible medicinal plants belonging to 49 families were identified. These medicinal plants (beside therapeutic applications in Sowa Rigpa medicine) are used as food, fruit and vegetables in Bhutan. Five Himalayan medicinal plants were further studied for their phenolic content and antioxidant activity. Hypecoum leptocarpum Hook. f. & Thompson contained maximum phenolic content. The antioxidant activities were determined by DRSA and FRAP assays from water and methanol extracts. Overall, among five plants investigated, Lepisorus contortus (Christ) Ching, H. leptocarpum and Podophyllum hexandrum Royle gave good yield of phenolics content and best antioxidant activity. This study demonstrates that edible medicinal plants could be a potential source of natural antioxidants that can boost the immune system.

The recognition of Sowa Rigpa in India

In 2010, the Government of India officially recognized Tibetan medicine as an ‘Indian system of medicine’ called ‘Sowa Rigpa’. This article documents the processes that led to Sowa Rigpa’s recognition, and situates them at the confluence of economic interests and political strategies within a larger historical and cultural context. Recognition emerges here as a twofold process that makes Sowa Rigpa legible to the state while simultaneously facilitating its incorporation into the market as capital. Previously an inalienable part of Tibetan and Buddhist Himalayan cultural heritage, Sowa Rigpa could now be legitimately claimed or appropriated as cultural, political, or economic capital, giving rise to tensions over ownership and control. Tracing how Sowa Rigpa’s recognition transformed from an initial struggle for protection to one over control, this article offers a critical new perspective on the recognition of cultural heritage, India’s pluralistic health care system, and the Asian traditional pharmaceutical industry.

Naming and forgetting

Sowa Rigpa is generally translated as ‘the science of healing’ and often used synonymously for ‘Tibetan medicine’. Historically, Sowa Rigpa can be considered a borrowed term from Sanskrit, accompanied by an adopted sense of ‘science’, which initially signified all forms of medicine known to the Tibetan world, regardless of their place of origin. Over the centuries, Sowa Rigpa became linked to local, indigenous, and ‘enskilled’ practices; later, to nationalist political sensibilities; and of late to cultural belonging. The term evokes territoriality, claims to ownership of knowledge, concerns over sustaining national identities, and considerations about how place-based healing practices and material resources relate to the globalizing ideas about traditional Asian medicines. Textual and ethnographic analyses and interviews with practitioners from China, India, and Nepal show how Sowa Rigpa exists at once as a marker of shared intellectual and cultural histories and forms of medical practice and as a label for a globally circulating medical system with distinct interpretations. Looking at Sowa Rigpa as operating in de- and reterritorialized global spaces makes visible how, why, and to what end modernity forgets (Connerton 2009), thereby allowing for broader conclusions applicable to other medical contexts.

Positioning Sowa Rigpa in India

The years leading up to the recognition of Sowa Rigpa (Tibetan medicine) by the Government of India in 2010 saw unprecedented interaction between various branches of the tradition and the state apparatus. These interactions grew particularly intense during March 2008, when two conferences focusing on related issues took place. The first referred to ‘Tibetan medicine’ and was organised by Tibetan exile institutions, while the second spoke of ‘Sowa Rigpa’ and was hosted by a coalition of Himalayan Indian associations. Through detailed ethnography of these events, this article examines the way in which a medical system was discursively constructed and positioned on the brink of state enfranchisement. It shows how ‘discourse coalitions’ and antagonisms formed during these events, and enquires as to the implications of these for the balance of power in Sowa Rigpa and for its positioning in relation to the Indian state, technoscience, and the growing market for traditional medicines.

The Efficacy of Collaboration: Tibetan Medicine Across Countries and Conversations

First delivered as a plenary lecture at theictam viiicongress in September 2013 in South Korea, this paper discusses two interdisciplinary and collaborative workshops focusing on Tibetan medicine (also known as Sowa Rigpa) in contemporary contexts. The first event, which took place in December 2011, brought together nearly 40 practitioners of Sowa Rigpa from the greater Himalaya and Tibetan regions of the People’s Republic of China (prc), along with four anthropologists, for intensive, interactive discussions on pharmacology by making medicines together. The second event, which took place in October 2012 in Xining, Qinghai Province,prc, involved practitioners, educators, and researchers from the Arura Group, one of the leading Tibetan medicine institutions in theprc, with researchers from the United States, Europe, andtar(Tibet Autonomous Region) for in-depth discussions about integrative clinical research and the place of the humanities and social sciences in the study of traditional medicines. Both events were supported, directly or indirectly, by the International Association for the Study of Traditional Asian Medicine (iastam), and abided in spirit with the mission of this organisation, namely, to bring scholars and practitioners of Asian medicine together for mutual exchange. While the Kathmandu event emphasised hands-on learning and the co-production of both knowledge and things, the Xining workshop provided Tibetan medical colleagues in theprcwith the opportunity to engage with broad discussions, at once methodological and epistemological, about the meaning, purpose, and aims of research on traditional medicines today.

Coproducing Efficacious Medicines

This article emerges from a workshop titled “Producing Efficacious Medicine: Quality, Potency, Lineage, and Critically Endangered Knowledge,” held in Kathmandu, Nepal, in December 2011. An experiment in collaborative event ethnography (CEE), this workshop brought together Tibetan medicine practitioners (amchi) from India, Nepal, and Tibetan regions of the People’s Republic of China, with anthropologists who have been working with amchi for decades. This workshop focused on practitioners who still compound and prescribe their own medicines, in an era when such practitioners are declining in number due to rapid commoditization of Tibetan medicines, shifts toward standardized mass production, institution-based education, and the implementation of pharmaceutical governance regimes derived from biomedicine. The workshop aimed to encourage knowledge exchange between diverse practitioners and generate new, collective, and more nuanced anthropological knowledge about Sowa Rigpa epistemology, history, theory, and practice. Our method of choice was collaborative event ethnography formulated as a workshop in the most literal sense of the word: a space where artisanal forms of praxis were honored and where material things—medicines—were collectively made. This article discusses how this CEE experience departs at the level of scope, structure, and implications from other collaborative, event-based ethnographic practice described in the anthropological literature.

Wish-fulfilling jewel pills: Tibetan medicines from exclusivity to ubiquity

Despite the recent growth of social science literature concerning the traditional medicine industry in Asia, insights into the contemporary dynamics of so-called ‘classical formulae’ remain relatively scant, as do studies of small-scale, less capitally intensive and technologically advanced modes of production. This paper seeks to address these gaps by considering a single Sowa Rigpa (Tibetan medicine) formula known as Samphel Norbu, or ‘wish-fulfilling jewel’, which appears in numerous texts and is today among the most popular Tibetan medicines in the world. Drawing primarily upon long-term fieldwork in Himalayan India, the paper follows Samphel Norbu's rise from exclusivity to popularity and examines the ways it has been transformed in the process, both materially and in its economic, social and clinical significance. The paper shows how Samphel Norbu acts as a marker of inequality between different groups of healers, and examines the role the medicine played in the development of commercial pharmacy and the proliferation of complex medicines. Tracing out wide variations in the medicine's formulation, composition, mode of production and pattern of circulation places the issue of multiplicity at the centre of analysis, and leads to a questioning of the assumptions that underpin the category ‘classical formula’. The paper reflects upon the repositioning of such formulae within emergent configurations of knowledge, power, industry and market, and on their transformations and transformative effects both over time and in the present moment.

How Tibetan Medicine in Exile Became a “Medical System”

Tibetan medicine or Sowa Rigpa was largely ignored in classic publications on “Asian medical systems.” This article contends that one important reason for this oversight was that Tibetan medicine had not yet managed to establish itself as a recognizable medical system at that time. This has changed only recently with ongoing political and economic processes through which Tibetan medicine in exile has been transformed, since the 1990s, from a regional health tradition into a globally recognizable and clearly defined and delimited medical system. After some reflection on the notion of medical systems, this article focuses on the events and interests that led to the establishment of the Central Council of Tibetan Medicine in early 2004, which can be regarded as the official establishment of Sowa Rigpa as a medical system. The discussion then moves on to the consequences of this development for Tibetan medicine in exile at large, and for its most powerful institution, the Men-Tsee-Khang, in particular. The outcome of wider exile Tibetan political aspirations, Sowa Rigpa's “embodiment” as a medical system also has direct medical and pharmaceutical dimensions, manifesting most importantly in efforts to regulate and standardize its syllabi, clinical practice, and pharmaceutical production. The article gives in-depth insights into some of the most important recent developments in Tibetan medicine in exile, its economic and political organization, and the role of its main institutions.