2.1 ENSAYOS FÍSICOS
2.1.4 ENSAYO DE FATIGA
One o f tlie areas for which tlie Tibetan Delek Hospital and the M en-Tsee-Khang saw possibilities for co-operation was the treatment o f mental illness am ong newcomers and the Tibetan torture survivor ‘rehabilitation programmes’. The Tibetan Transit School was set up in 1993 to help new refugees who could not be absorbed into regular schools (because o f age or language difficulties). They are given a three-year long course focusing on English, Tibetan and Matliematics. When I left Dharamsala there were plans to extend this into a five-year course'^^.
The treatm ent o f mental illness is a traditional area o f co-operation between indigenous medical systems and biomedicine, biomedical practionners endorsing the idea that culturally appropriate care is particularly im portant for sufferers o f mental illnesses and psychological trauma linked to torture (Littlewood 1992). This section will specifically focus on tlie co-operation between allopathic and traditional medicines in cases o f mental illnesses as it takes place in the Transit (or Soga) School for newcomers.
Students o f the newcomers’ adult educational centre the Soga School in Norbulingka, were described to me by allopathic doctors as particularly prone to psychosomatic illnesses. M ost o f them are aged between 18 and 30 and have undergone major hardships during the crossing to exile. The students were a major subject o f concern am ong the biomedical doctors at the Tibetan Delek Hospital, who often expressed regret at not being able to do more tlian their weekly visit to the school. Both the M TK and Delek doctors involved in the care for Soga students described their interaction with the students as very satisfying from botli a professional and personal perspective. O ne M TK female doctor said she felt extremely sad for the students, and that she could feel their
own sadness and difficulties by tlie strong rlung symptoms they manifested. She said: when I take the patient’s pulse, usually it takes some time to find the personal pulse, then find the disorder, but with Soga patients, they have so much rlung, it is the first thing you sense w hen you take their pulse’.
The school’s barracks were a cluttered and closed environm ent o f bunk beds where intimacy could only be achieved by pulling blankets around one’s bed, and space for personal belongings was kept to a minimum: a few boxes for clothes and objects only were kept by the bed. When looking into some o f these im prom ptu cubicles, one might see a tew plastified pictures o f family members, poems and postcards. Two students showed me scrapbooks, which comprised o f letters in Tibetan and English, often poems and short proverbs, and writings in Chinese. Many entries in tlie two diaries I saw were letters to be sent back home which were never actually tom out o f their notebooks. Some English poems were written in the form o f love letters to girlfriends, expressing the loss, longing, and tlie nostalgia for home. O ne man displayed a picture o f his girlfriend, a Tibetan teacher in Lhasa, in a staged photograph where she posed in a cinematic Chinese collar dress with a sun umbrella in a photographic studio. The boys’ dormitories were as ordered as army barracks, but the space near and around the beds was replete witli neatly arranged personal belongings that betrayed deep nostalgia and attachments to home.
The school environment, adding to the trauma o f exile and resettlement, can therefore be considered a strong exacerbating factor in the development o f psychological disorders and mental illnesses. Despite the fact that school residents have access to traditional Tibetan medicine, tlieir first port o f call on healtli related matters is usually the local health worker. Students told me they didn’t have much time to speak with the doctors, w hether Tibetan or foreign, because they were on ‘rounds’ or ‘just passing through’. This was however n o t identified by them as the primary motive for dissatisfaction. They resented tlie scarcity o f the visits and the fact that it was so difficult for them to arrange a trip to Delek for serious health problems. But tlie hospital is essentially ill-equipped to deal with mental health problems and thus physicians often have recourse to Men-Tsee- Khang doctors for not readily identifiable mental illnesses or suspected cases o f depression. A t Soga, some allopathic doctors talked about the not unusual discovery o f a patient referring to ‘pain in tlieir neck, stiffness in tlie arms and the upper body’. O ne
doctor explained: ‘We could not diagnose any muscle stiffness, but it turned out that this patient has been tortured, and having dreams and disturbances, had lost his job and was unable to m eet his families’ needs. We see so many o f these in Soga’. H ere the psychosocial com ponents o f illness are clearly identified and related to the physical symptoms expressed by the student.
The two institutions, Delek and tlie MTK, compete in the care o f newcomers from the Soga transit school. Both clinics hold weekly visits to the school, where they are equally popular. Upon one such visit, an M TK doctor saw approximately 75 patients in a day, which she considered to be quite a low turnout.'^'^ Both allopathic and M TK doctors would do some o f the more routine check-up work, visiting the school on two week rotations. A great num ber o f Soga patients, they said, were subject to rlung disorders, especially men. Similarly to cases observed by Janes in a Lhasa hospital, refugees in Dharamsala, particularly newcomers and torture survivors, are considered to be extremely susceptible to rlung disorders. Likewise, the widespread equation o f rlung
imbalances with mental afflictions was also often commented upon in Dharamsala. M ost o f tlie biomedical doctors, both foreign and Tibetan, were aware o f this association and even directly questioned the patient on whetlier they felt they had any rlung problems, sometimes surprising the patient who had not envisaged this possibilit)c
It was not made clear to me which o f Delek or the M TK had institutionalised visits to the Soga school, but I was told that it was Delek that had sought out the M T K ’s c o operation for cases which tliey saw as more ‘psychological’. Delek therefore w ent along with tlie M TK ’s claim to provide holistic treatment and culturally appropriate therapies. The association between the M TK ’s doctors and Delek in Soga was regularly emphasised by Delek. Wliile the M TK doctors felt a responsibility to treat Soga patients because they were ‘more at risk’ than any other group o f the Tibetan population, some privately resented Delek’s definition o f their approach as ‘the just talking approach’, a form o f counselling. This was naturally not intended as an insult to M TK doctors’ skills as practitioners, but rather as an acknowledgement o f the validity o f culturally appropriate treatment and tlie importance o f conversing about their psychological state o f mind. MTK doctors not did o f course see tlieir treatm ent o f Soga patients as ‘just talking’. Male doctors especially emphasised the efficacy o f Tibetan medicine in diagnosing discrete diseases and thus staked a claim to clinical efficacy beyond the benefits o f ‘just talking’.
The two female doctors I saw practising there seemed more inclined to see benefits in letting patients suffering from rlung vent their feelings, and considered it a critical part o f their intervention.
The co-operation o f Delek and the M TK in tlie treatment o f "transit diseases’, as they became known, therefore revealed another side o f the relationship between the two institutions. Through the treatment o f patients they had in com mon, practitioners at botli institutions were able to compare their interventions and began to engage in an interpretative exegesis o f tlieir respective clinical practices.
4.9. Sum mary
As can be seen from the previous sections, healthcare among Tibetan exiles can only be understood at tlie crossroads between plural systems and exigencies. Tibetan traditional medicine is undergoing radical modifications both in exile and in the TAR. Meanwhile, the M TK is shaping the overall Tibetan medical practice, imposing its particular blend o f institutionalisation and strongly defend its own interests vis-à-vis other practitioners. The medically plural scene o f Dharamsala defines both opportunities and constraints for therapeutic management. Botli opportunities and constraints are managed in local terms, for instance with the use o f diviners, or in going back and forth between allopathic and traditional practitioners. Plurality is therefore as constraining as it is enabling, depending on the degree o f agency expressed by the patient and the varied strengths o f the therapeutic management groups involved in decision making. Although Dharamsala patients view traditional and allopathic medicine as complementary, interviews with local practitioners reveal clashes in competing claims to clinical efficacy, where the M TK seeks to define its status as a key provider o f "culturally adequate’ healthcare for the exile community.