This article was originally published in the International Encyclopedia of Public Health, published by Elsevier, and the attached copy is provided by Elsevier for the author's benefit and for the benefit of the author's institution, for noncommercial research and educational use including without limitation use in instruction at your institution, sending it to specific colleagues who you know, and providing a copy to your institution’s administrator.

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Traditional Asian Medical Systems E Hsu, University of Oxford, Oxford, UK R L Barrett, Emory University, Atlanta, GA, USA ã 2008 Elsevier Inc. All rights reserved.

Pluralism and Professionalization It would be difficult to find an Asian medical system representing a single, pristine tradition. In theory, major systems can be distinguished by certain teachings and texts. In practice, however, the boundaries between them can be highly permeable and difficult to define. Moreover, healing traditions often overlap with one another, in theory and practice, just as they overlap with the so-called Western systems of biomedicine. As with most of the world, patients and practitioners in communities throughout Asia are known to combine their medicines and therapies. Ethnographers often refer to this phenomenon as medical pluralism. The major Asian medical systems became known as such primarily because of revivalist movements among the rapidly growing middle classes in colonial and postcolonial India (Attewell, 2007; Sivaramakrishnan, 2006; Langford, 2002), reformist efforts in Republican and Communist China (Lei, 2002; Taylor, 2005), and other nationalistic endeavors in Japan (Oberla¨nder, 1998), Korea, and elsewhere (Leslie, 1976; Leslie and Young, 1992). Proponents of these movements emphasized that the therapeutics they offered were not piecemeal folk medical practices, but formed a ‘system’: they had a long history, a large archive of theoretical and clinical treatises, a codified materia medica, and they distinguished, as does scientific medicine, between diagnostics and treatment, in addition to their acknowledged contributions to preventive care. Contemporary Asian medical systems trace their roots to the ancient Asian sciences (Sivin, 1987; Farquhar, 1994). Their transmission need not be confined to oral transmission within secret lineages or in personal relations to mentors but can be taught and examined in the classroom (Hsu, 1999; Schneid, 2002), and their correlative reasoning accounts for causality, as do the modern sciences, just in subtler ways (Unschuld, 1992). Nationalistic sentiment provided the incentive that led to the nationwide standardization of each of these Asian medical systems and thereby transcended the regional parochialism of family traditions, which became known as Ayurveda (‘science of life’) and Unaani Tibb (literally, ‘Greek medicine’) in South Asia, traditional Chinese medicine (zhongyi) in China, of which acupuncture and moxibustion (zhenjiu) is the most widely known subdiscipline, kanpo (literally, ‘Chinese recipes’) in Japan,

hanbang (also literally ‘Chinese recipes’) in Korea, sowa rigpa (‘science of life’) in Tibet, and so forth. Unaani practitioners, known as hakims, trace the humoral precepts of their system to the Hippocratic and Galenic teachings of ancient Greece. These teachings were incorporated with the health-related statements of the prophet Muhammad (Tibb u Nabbi) and further developed during the medieval flourishing of the Ottoman and Moorish empires (Sheehan and Hussain, 2002). Unaani returned to occidental Europe by way of the modified works of scholars such as Al Razi (Rhazes) and Ibn Sina (Avicenna). But it retained its Islamic framework in Mughal South Asia, where it came into contact with Ayurvedic medicine. Ayurveda derives its physiology from the Samkhya school of Hindu philosophy, but is similar to Unaani in its approach to human variation and model of illness as an imbalance of humorlike doshas. Some of these similarities arose independently; others may be the result of cultural diffusion between medical systems. For example, there is some evidence that Unaani Tibb influenced Ayurvedic methods of pulse reading (Leslie, 1992). Ayurveda, in turn, had a very strong influence in the development of Tibetan medicine in the Himalayan north and the Siddha and Kalari systems in the Dravidian south ( Janes, 1995; Scharfe, 1999; Zarrilli, 1998). Transregional flows of technology, knowledge, and people have also shaped the many currents of Chinese medical learning, of which the standardized contemporary form has as its core the five phases theory (wuxing). Notably, this theory was in antiquity attributed to an otherwise unknown figure, a certain Zou Yan, which ignited a controversy over its origins (Needham, 1956: 232–246). Yan’s five phases theory was systematically applied to medicine by the Yellow Emperor’s main interlocutor, ‘Qibo,’ a name that as Paul Unschuld suggests may be a Chinese approximation of ‘Hippocrates.’ It is likely that in China, just as on the Indian subcontinent, transregional knowledge flows played a significant role. The most widely known subdiscipline of Chinese medicine is zhenjiu (acupuncture and moxibustion). Acupuncture involves needling according to an elaborate medical rationale, which frames bodily processes mostly in terms of yinyang and qixue (breath and blood) and occasionally also in terms of wuxing (five phases). Moxibustion involves cauterization with crushed Artemisia vulgaris leaves according to

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the same rationale. Although today many practitioners are only familiar with acupuncture, cauterization was, at an earlier stage than acupuncture, systematically applied within the therapeutics of the Han dynasty (206 BCE–220 CE) as is evident from manuscript recordings unearthed from a tomb, closed in 168 BCE, located near Mawangdui in the southern parts of central China. The subdiscipline of zhenjiu was practiced within one of the four imperial medical departments in the Tang dynasty (618–907 CE) and one of 13 in the Song dynasty (960–1279 CE). The Tang dynasty also recognized the subdiscipline anmo (pressing and rubbing) massage. Although this subdiscipline disappeared in the Song dynasty, it is part of the official Chinese medical curriculum today, along with tuina (pushing and pulling) massage. The Tang and Song Imperial Medical Institute also included a medical department for incantations, but in the secular modern world of medicine these are no longer considered part of Chinese medical treatment (Hsu, 2007a). As Buddhism spread throughout Asia in medieval times, so too did scholarly medical learning. The Japanese system of kanpo traces its roots to the Tang dynasty, when traveling Buddhist monks and government-sponsored scholarly expeditions transferred knowledge of medicine, philosophy, and the sciences from mainland China to Japan. In the 1500 years that followed, Japanese scholarpractitioners not only refined their exegeses of the Chinese classics but also founded their own schools (e.g., Kuriyama, 1999), which has resulted in a thriving plurality of contemporary practices (Lock, 1980; Ohnuki-Tierney, 1984). Hanbang in Korea may also have roots in the Tang dynasty, although it generally traces its textual tradition to the times when the Korean script was invented in the seventeenth century ( Jeon, 1998). Sowa rigpa (gSo ba rig pa) is a more syncretic medicine. While Mahayana Buddhism spread primarily from China into Tibet from the eighth century onward, the basic traits of sowa rigpa theory in extant texts from the twelfth century mainly build on Ayurvedic teachings (Meyer, 1981). Thus, Tibetan theories about illness causation relate to the three Buddhist vices of the mind (desire, anger, and delusion), while the Tibetan three nyepa (Nyes pa), five jungwa (‘Byung ba), and seven lu¨sung (Lus gzungs) correspond to the Ayurvedic three dosha (vata, pitta, kapha; wind, bile, phlegm), five elements, mahabhuta (earth, fire, water, wind, and ether/space) and seven dhatu (‘tissue types’). However, Tibetan sphygmology resembles Chinese teachings and Tibetan urine analysis is reminiscent of the Greco-Arabic (Khrom) school. The pluralism of Asia’s many medical systems contrasts with the simple dichotomies of ‘traditional Eastern medicine’ versus ‘modern Western medicine.’ It may sometimes be necessary to use the term traditional medicine on an operational basis, but care must be taken not to erase the differences within such a category, or to assume

common differences with a single system of biomedicine. Asian medical traditions may include university-trained and fully licensed professionals, as well as local forms of herbalism, ritual healing, and shamanism in its widest sense. Further, many practitioners are dual-trained or cross-trained in biomedicine. For instance, in the People’s Republic of China, students of traditional Chinese medicine are required to learn biomedical principles just as students of biomedicine must learn about acupuncture and general medicine (Unschuld, 1985). In India, many Ayurvedic and Unaani physicians are known to order biomedical laboratory tests and prescribe antibiotics. It is not uncommon to find Indian biomedical physicians practicing extended pulse readings and prescribing Ayurvedic diets (Waxler, 1984), or Indian patients preferring certain biomedicines because the color of the capsule corresponds to a concept of heat or coldness (Nichter, 1980). White coats and stethoscopes are ubiquitous across the Asian medical professions and many herbal medications are now packaged and sold in much the same manner as biopharmaceuticals (Bode, 2004), particularly in recent years, where folk and elite medical practices have been amalgamated into commercialized medications competitive on the global health market (Frank, 2004). These patent (or formula), medicines are easy to consume and easy to apply as they treat ailments arising from popular understandings of Western and Asian medical learning, such as sugar (diabetes), pressure (hypertension), arthritic pain, or overweight (Hsu and Høg, 2002). Their ingredients sometimes are derived from classical formulas, sometimes from family secrets or local folk recipes. They are sometimes mixed with vitamins or other pharmacologically active substances, such as steroids or aspirin. Their composition takes account of Asian scholarly medical rationale, folk knowledge, and the Western medical sciences (Hsu and Stollberg, forthcoming). In the light of all this it is apparent that East and West are no longer adequate points of orientation in the medical marketplace.

History and Textual Traditions Transregional knowledge streams are well documented (for medieval times) in the rich corpus of Dunhuang medical manuscripts (ca. sixth through eleventh centuries; Despeux, forthcoming). These manuscripts date from the time of Buddhist expansion. This was also the period when the first book of the most fundamental text of Chinese medicine, Suwen (the first book of Basic Questions), or The Yellow Emperor’s Inner Canon (Huangdi nei jing), was presented to the imperial throne as the standard examination text in 672 CE. The Suwen concerns medical theory, cosmology, ethics, lifestyle, longevity, and illness prevention. It also provides detailed discussion of named medical disorders and their etiology, diagnosis, and

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treatment. Contrary to its traditional dating into the third millennium BCE, the textual material it contains presumably dates to between the last three centuries BCE and first three centuries CE. Much like the second book in the Inner Canon called Lingshu (Numinous Pivot), which in its current form is based on a text retrieved from Korea in the Song dynasty, the therapy it discusses most frequently is acupuncture (Needham, 2000). Chinese therapeutics with decoctions (tangye), that is, water in which a variety of plant, animal, and/or mineral ingredients ( yao) have been simmered, were developed in the same medical circles as the diagnostic methods of investigating the complexion and pulse (maise) in the third century BCE and early Han dynasty (Yamada, 1998). Presumably, doctors then attended primarily to emotional distemper among the upper ranks of society, processes conceived largely in terms of yinyang imbalances. By the time Zhang Zhongjing compiled the Shanghan zabing lun (Treatise on Cold Damage and Other Miscellaneous Disorders) in 196 CE, however, yinyang imbalances accounted for a wide range of pathological processes in the body, and, in his particular work, fevers. In the Song dynasty, the Treatise was edited into three separate books, the Shanghanlun (Treatise on Cold Damage Disorders), Jingui yaolu¨e (Essentials in the Golden Casket), and Maijing (Pulse Canon), all of which are central to clinical medical practice today. The Shanghanlun became the core text of kanpo in Japan (Agren, 1986), and the Maijing the best-known text in early modern Europe. These books accounted for individual patterns of disorder, which in traditional Chinese medicine have been redefined as ‘distinguishing patterns’ (bianzheng). These distinguishing patterns do not describe diseases but rather ‘patterns of disorder’ particular to individual persons. Their rationale, which links diagnosis to treatment in a comprehensive and holistic way, has in recent years also integrated knowledge from contemporary currents of learning. Ayurveda traces its textual origins to the Vedas, the earliest scriptures of Brahminical Hinduism. In particular, the Atharva Veda (ca. 700 BCE) describes human anatomy, and the etiology and treatment of certain diseases. The three canonical Ayurvedic texts written in the golden age (ca. 800 BCE–700 CE) include the Caraka Samhita, which may have been a redaction of the older Agnivesha Samhita. The Caraka Samhita covers core principles and eight divisions of internal medicine. The Susruta Samhita is a surgical text that includes procedures for cosmetic surgery, trauma surgery, cataract and prostate removal, and the repair of fistulas. The most recent commentaries of Vagbhata (ca. 700 CE), which include the Ashtanga Hridaya and Ashtanga Sangraha, relate to the subjects described in the Caraka and Susruta Samhitas (Wujastyk, 1998; Zysk, 1991, 1996). Although these texts continue to be cited and taught today, it should be noted that

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Ayurvedic medical practice has been subject to numerous adaptations throughout its development (Trawick, 1991; Leslie, 1992; Obeyesekere, 1992). The Gyushi (Four Tantras) is the central work of sowa rigpa. According to legend, it was introduced into Tibet by an Indian bodhisattva, but most historians trace it to Yu Thong the Younger from the twelfth century CE. Tibetan medical students still memorize this text today, even in government-regulated institutions like the Mentsikhang of Lhasa. The Blue Beryl of the seventeenth century is also widely taught, particularly due to its plates of illustrations (thankas), which depict the textual contents of the Gyushi (Meyer, 1992). Finally, within the Korean medical tradition, the medical encyclopedia Tongui bogam (Precious Mirror of Eastern Medicine), compiled by Ho Chun, deserves particular attention, as some historians maintain that it is even more comprehensive than Li Shizhen’s famous Bencao gangmu (Systematic Materia Medica) of 1596, from which it evidently drew. The latter compiled knowledge from a wide range of scientific and medical writings about natural sources (plant, animal, mineral, human) and also various artifacts used in ritual and medicinal treatment (Bray, 1993). Contemporary practitioners of Asian medicine often (Me´tailie´, 2001) cite the aforementioned texts for having the authority of ancient knowledge. But despite their long histories, some of these texts have undergone substantial transformations and their interpretations have changed significantly. Even the texts of the most renowned physicians are often subject to many different interpretations. Several ethnographies of traditional Asian medicines have discussed how textual knowledge is integral to medical practice. Farquhar (1987) has always emphasized the centrality of practice and experiential knowledge ( jingyan), and also highlighted the important role of medical case records ( yi’an) (Farquhar, 1992), as they allow for an accumulation of experience through individual case material (see also Bray, 1995; Furth, 1999; Cullen, 2001). It should be noted that texts on medical theory have a prescriptive tone and may have been written in a subjunctive mood, expressing possibilities and probabilities rather than describing facts. Hsu (1999: 88–127) discusses in detail different modes in which these texts are quoted in medical practice and creatively interpreted (linghuo zhangwo) and how this affects the doctor’s position of authority.

The Body Ecologic In Asian medicine, the body dwells in its environment: many Asian medical concepts have ecological meanings as well. Hot and cold do not merely describe tactile qualities of a mammalian skin or qualities of an ingested drug, but also the environment’s climate and weather and one’s own

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feelings and emotions (Kuriyama, 1993). In Asian medicine, the body may be enveloped by skin (Despeux, 1996), but the skin is porous and permeable to exchange with its surrounding environment marked by seasonal changes (Kuriyama, 1994). Thus, the body in Ayurvedic medicine changes with the three seasons, the monsoon, the dry and the cold season (Zimmerman, 1987). The body in Chinese medicine resonates with the five seasons (Hsu, 2002), which are brought on by the winds blowing from the five directions (Hsu, 2007b). Asian medical reasoning often considers what might or should come into being rather than taking into account only material structures that already exist. Asian medical practitioners describe bodily processes with a flowery vocabulary (Kuriyama, 1999a). Sometimes these terms are used in a vague and general sense, and sometimes in a polysemic sense, which means that they can have many distinct meanings specific to particular situations. In Chinese medicine, for instance, yin is sometimes used to denote any quality that is put in opposition to yang. Yin can be the dark and shady, the humid, the lowly, the earthy, the female, as opposed to yang, which is the light, the dry, the one on high, the heavens, and often is considered pure and male (Ots, 1990). In other contexts, the term yin can be used in a polysemous way. Yin denotes blood in a nourishing context, or water in the context of opposition to fire (Porkert, 1974). One hesitates to say that Asian medical terms are ‘technical’ ones, for the latter should be unambiguous and clearly defined. Asian medical vocabularies, by contrast, thrive on ambiguity and unspoken connotations, which often have moral or political overtones. For instance, the term yin can be used much like the English word ‘lowly,’ which has negative moral connotations in certain contexts. In other contexts, yin is like the word ‘earthy’ and thus has positive connotations, such as Mother Earth or life-giving waters. Historically, such terms were developed in settings in which traditional patriarchic authority prevailed, and doctors conversed with only a genteel clientele. A doctor attending to these clients would not want to be precise and blunt, nor too general and vague, but polite and polysemic (Hsu, 2000). To complicate these linguistic issues, the colloquial meaning of a term often differs from that of the Asian medical specialist. The common vocabulary between local healers and their clientele, in contrast to Western medical professionals’ unintelligible Latin, helps to explain why local forms of medicine persist in the modern world. However, as the ethnographer’s language skills improve, it becomes evident that the same word can have different meanings for the learned Asian medical doctor and the patient. So, if a Chinese medical doctor attributes a woman’s complaints of lethargy and nausea to ‘blood depletion’ after an abortion, the blood he refers to is not merely the blood that she lost during and after the

operation; it is a more abstract term, with some of the connotations listed above for the term yin. Even if in such a case, the patient and doctor do not share entirely the same understanding, their encounter does not call into question the patient’s worldview as biomedical Latin does. The notion of balance is a central theme in all scholarly Asian medical traditions. Balance need not mean equilibrium or homeostasis, notions central to the biological understanding of living organisms. Nor does it entail a material balancing of humors or fluids with different qualities, like hot and cold, dry and wet, as the term humoral medicine appears to imply. Rather, balance is a more dynamic concept with moral overtones. In contrast to egalitarian societies that celebrate feasting and the shared experience of ecstatic dancing and drinking, the scholarly Asian medical traditions that evolved among the literate elite in stratified societies emphasize regularity in food intake, sleep, and sex. Health was a matter of social distinctiveness and personal conduct. Asian medical philosophies may be appealing to the middle classes in modern nation states precisely for this reason. Asian medical reasoning further entails politics and history. Notions of ‘treatment’ are likened to those of state ‘control’ (cf. zhi in Chinese; sarkari in Hindi): functions of the internal organs are compared to offices in the imperial administration, and channels within which humors, winds, and heat flow are compared with irrigation canals. Political history has been naturalized. In Ayurveda, the positive value of the dry ( jangala) and the negative value of the wet (anupa) reflect the political history of the Arian conquest: the dry Deccan plateau provided ‘fertile’ lands for the invaders of the Indian subcontinent, while the wet rainforests were best avoided (Zimmerman, 1987). In a similar vein, the adherents of what later became known as the wenbingxue (‘warmth-factor school’) in Chinese medicine had geopolitical reasons for arguing that since the ancient Zhang Zhongjing was from the North, his principles for treating ‘cold damage’ disorders were accordingly unsuitable for the delicate bodies of the southerners in the urbanized lower Yangtze basin of the late Ming dynasty (1369–1644) (Hanson, 1998). Furthermore, the culinary arts, distillation, pickling, and other food technologies have provided schemas for understanding bodily processes, particularly with respect to digestion. The ‘fires of digestion’ ( jataragni) are a central element of Ayurveda and other Indian medical traditions, transforming medicines and food alike into their essential components for internalization (Barrett, 2008). Ayurveda, Unaani, and Chinese medicine conceive of digestion as a cooking process, in which food becomes gradually more refined, until it reaches the end stage of the most essential bodily constituent, semen (Good, 1994: 88–115). The refined rises, a process well known from distillation and the dregs are left behind and excreted. If foodstuffs accumulate in the stomach and are not

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transformed, one experiences the heat of heartburn, like that generated in a compost heap. In summary, in Asian medicine, the processes in the body are understood in terms of culture-specific relations to the environment, from mundane cultural practices such as cooking and gardening to political history, morality, and religion.

Religious and Ritual Healing There are many Asian healing traditions that challenge the distinctions between Western categories of religion and medicine. In Ayurvedic anatomy, the body has five sheaths ranging from the most material (gross body) to the most etheric (subtle body), each reflecting and influencing the state of the others. The Ayurvedic subtle body is most closely related to a concept of the soul that is often, but not always, considered to be a diminutive form of the mysterious divine (Larson, 1993). Unaani Tib regards the physical body as a microcosm of the universe, which is made up of concentric spheres both natural and supernatural (Good and Delvecchio Good, 1992). In Chinese medicine the human body is also sometimes conceived of being layered – sometimes it has six warps, sometimes four sectors, sometimes layered tissues ranging from the pore pattern on the body surface to the bones as the innermost structure. Processes in the human body resonate with those of the environment, and although it is not generally explicitly stated, the spiritual is considered immanent to these natural processes; a person’s ‘spiritmind’ (shen) resides in the heart and shines out through the eyes, while the hun soul resides in the liver and the po soul in the lungs. In each of these traditions of Asian medical learning, physiology and cosmology are as linked as the human is to the divine. Consequently, the treatment of the body may be indistinguishable from that of its immanent spirit. There are also many Asian religious traditions that promote healthy living as a foundation for spiritual development. The classical system of yoga is a well-known example of this. Indeed, people often associate yoga with physical postures (asana) and breath work (pranayama), but these exercises are only two of eight stages toward achieving an advanced state of psychospiritual consciousness (Alter, 2006). The practice of Siddha medicine in the southern Indian state of Tamil Nadu employs a similar but more extreme methodology, seeking an advanced spiritual state through a stepwise withdrawal of senses and immortalization of the body (Scharfe, 1999). In contrast to Siddha, the Malayali system of Kalaripayattu engages the sensory world as a martial art in which the practitioner gradually gains esoteric knowledge with psychophysical advancement (Zarilli, 1998). With the economic reforms in the People’s Republic, the meditative practices of qigong and taijiquan started to

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gain rapidly in popularity (Chen, 2003; Palmer, 2005). Taijiquan (supreme ultimate boxing) is considered adequate for elderly bodies, within which qi is diminished and flows slower; qigong (working with the breath) is more appropriate for younger bodies; and students of traditional Chinese medicine attend classes on the officially approved form of qigong called yangshenggong (working for nurturing life). Meditation is considered an indispensable aspect of acupuncture and massage, and the practitioners who engage in such manual techniques that directly regulate the flow of qi cannot afford to be qi deficient. Their meditation replenishes qi and ensures effectiveness in therapeutics. In the past, Chinese medical doctors would engage in daily meditation, today called ‘soft qigong’ (ruan qigong), which involved ‘stillness’ ( jinggong) and strengthened the ‘inner qi’ (neiqi). In contrast, the internationally popular forms of qigong are derivatives of ‘hard qigong’ ( ying qigong), which can be traced to traditions of practitioners of the martial arts. These forms involve ‘movement’ (donggong) and strengthen the ‘outer qi’ (waiqi ), and thus enhance physical performance. Nevertheless, there are an enormous variety of Chinese meditative practices available worldwide and it can be difficult to discern which features of these practices could be considered qigong. In the global marketplace, patient demands are shaping the practice of Indian and Chinese meditative traditions, as they shape the medical traditions. At an esoteric level, many studies have examined the social and psychotherapeutic efficacy of spirit possession, exorcism, and ritual healing against sorcery. By taking on the spirits of certain deities, ritual healers in a South Indian fishing village have the freedom and authority to resolve conflicts in families and villages under the auspices of removing a curse from certain patients/clients (Nuckolls, 1992). In Sri Lanka, both Hindus and Muslims conduct pilgrimages for healing by the deity Kataragama and his possession mediums; those who find relief often return to conduct trancelike austerities and may even heal and advise others as mediums themselves (Obeyesekere, 1981). Some argue that such rites represent a kind of psychotherapy, allowing the patient to confront repressed fears and emotional conflicts (Kakar, 1982). In China, as in India, such dissociative states may serve as socially sanctioned outlets for the expression of psychosocial problems that would otherwise be unmentionable (Kleinman, 1980). Similarly, the attribution of spirits or sorcery allows patients to avoid the social stigma of psychiatric diagnoses, which are often associated with incurability and moral failings (Kleinman, 1980). Ritual healing and religious explanations can be a source as well as a cure for the social stigma of certain diseases. Hansen’s disease, or leprosy, is a classic example of a condition in which the social stigma is often much worse than the disease itself. Leprosy is only mildly

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contagious and curable with antibiotics, yet people suffering from it are often branded as lepers for life and ostracized from communities throughout Asia (Barrett, 2005). Contributing to this problem, certain Ayurvedic texts such as the classic Caraka Samhita include sins committed in previous lives among its potential etiologies (Weiss, 1980). Infertility can be severely stigmatized as well, and infertile women are often blamed for casting an evil eye (nazar lagna), causing otherwise healthy children to become sick by jealously gazing at them (Inhorn, 1994). Even when diseases are not overtly stigmatized, religious blame can nevertheless be implicated. Embedded within Hindu religious traditions, Ayurveda recognizes the role of karma in human disease such that suffering may present an opportunity for spiritual liberation. Consequently, vaidyas have debated the ethics of treatment when the health of the body may be at odds with the health of the soul (Weiss, 1980). Hakims have had similar debates. The prophet Muhammed states that Allah has not given humankind a disease without also providing a cure. Yet it is difficult to determine at what point during an intractable illness the duties of the healer to the patient conflict with the will of Allah (Sheehan and Hussein, 2002). Salvation and healing do not always work hand in hand. Conflicts notwithstanding, Asian ritual traditions can serve an important role by ascribing meaning to the human experience of disease, even when the patient is undergoing biomedical treatment. For instance, an X-ray or biopsy can point to a given disease, and a physician can explain how it arose, but a ritual healer can explain why it arose in a certain patient at a certain moment in his or her life. Such explanations can play an important role in the alleviation of illness, the lived experience of a disease (Kleinman, 1978). In addition, ritual healers can serve as important sources of referral and legitimacy for professional healers (Glucklitch, 1997). This is especially the case for professional healers who work under the patronage of religious organizations. Finally, it should be noted that certain combinations of religion and medicine can influence the pluralistic behaviors of patients and practitioners. For example, a cultural model of dawa aur duwa (‘medicine and blessing’) treats medicines as a kind of ‘sacred food’ (prasad) such that the identity or form of a given medication or medical system is secondary to its role in the transmission of healing power from provider to patient. This approach allows for the widest possible range of therapies insofar as the characteristics of specific medicines are not as important as those of their healers. Moreover, because it is often easier for the layperson to evaluate the sincerity of healers rather than the theoretical merits of their medical systems, dawa aur duwa presents an opportunity for quality control when faced with a confusing array of medical services and limited resources with which to obtain them (Barrett, 2008).

Safety and Efficacy of Traditional Asian Medical Treatments Although many Asian medical systems still retain the label ‘traditional’, particularly throughout Asia itself, once transferred into Western biomedical landscapes, they have been reclassified as complementary and alternative medicines (CAM). Within this classification, they have been subjected to a great deal of scrutiny as heterdox forms of medicine, particularly with respect to issues of safety and efficacy. Aside from issues of malpractice, biomedical professionals are concerned about the safety of herbal, animal, and mineral drug prescriptions. Patients often perceive traditional Asian medicines as safe because they are developed from natural sources. But if a substance is efficacious, it can also have side effects and be administered in ways that are harmful. There are several plants of the Asian materia medica, which contain substances that have been proven efficacious through biomedically recognized research methods. Examples include qinghao, a Chinese preparation of A. annua containing artemisinin, a substance known for its antimalarial properties (McIntosh and Olliaro, 2007). Curcumin, a substance found in tumeric that is commonly used in Ayurveda-prescribed diets and medicines, has been shown to reduce oxidative damage and the formation of amyloid plaques in animal studies of Alzheimer’s dementia (Lim et al., 2001). However, other studies of Ayurvedic efficacy are equivocal and identify the need for further research (see Hardy, 2001; Park, 2005). Recently, a Chinese weight-reducing pill that contained the Chinese herb Aristolochia fangchi was found to produce renal failure and the need for kidney transplants in some patients (Nortier et al., 2000). Senior Chinese doctors, who commented on these incidents, expressed awareness of the potency/poison of Aristolochia. In this particular case, Aristolochia erroneously was used for substituting another Chinese medical drug, Stephania tetrandra. In discussions on ‘Aristolochia nephropathy,’ it became apparent that more attention needs to be paid to the culture-specific modes in which traditional drugs are administered. Cross-culturally, highly potent and/or poisonous drugs are often used together with other medications that evacuate the digestive tract, a process that can hinder the absorption of the herb’s potent/poisonous substances in large quantities (Etkin, 1988). In the case of the Chinese weight-reducing pill, a well-known potent/poisonous ‘traditional’ herb had been used in a newly devised ‘modern’ formula. Its daily application made it highly toxic. These kinds of incidents reveal that research on Asian medical drug quality, dosage, forms of application, toxicology, and synergies need to be combined with ethnographic recordings of their traditional application. Sometimes, a semantic rather than chemical analysis is necessary. Thus, the atomic absorption spectroscopy of

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Chinese ‘herbal balls’ (used for treating fever, rheumatism, apoplexy, and cataracts) found traces of mercury and arsenic (Espinoza et al., 1995). Whereas contamination with heavy metals and other impurities can indeed point out faults or negligence in the pill’s production process, it deserves further exploration as to whether in this particular case the modern ‘herbal ball’ is a derivation from the medieval ‘longevity pill.’ If so, it would be problematic to equate the ancient Chinese notion of ‘longevity’ with that of ‘long life.’ It is well known in Chinese studies (e.g., Strickman, 1979), but perhaps less so in esoteric health circles, that Tang ascetics who retreated into the mountains intentionally poisoned themselves with longevity pills in their quest of becoming immortals. In view of the above, anthropologists have advised the public health policy makers who are involved with the regulation of the health market to shift the focus from substance control to educational criteria. An undue focus on substance control leads to an unnecessary criminalization of traditional Asian practitioners (Adams, 2002). Rather than focusing on the chemical analysis of innumerable substances only, which requires technologies, know-how, and finances beyond the reach of many governments, particularly in the southern hemisphere, anthropologists have urged policy makers to focus on the practitioners’ education in traditional Asian medicine as primary concern for the licensing and legitimation of their practice. More research is necessary to determine to what extent well-trained Asian medical professionals can make contributions to Western health care, as they already seem to do in the domain of primary and palliative care. Trials concerning their costeffectiveness have yielded promising results; for instance, in the long term (after 2 years), a combination of conventional treatment and acupuncture for lower back pain (10 sessions during first 3 months) is significantly more efficacious than only conventional treatment (Thomas et al., 2006) and, ultimately, more cost-effective (Ratcliffe et al., 2006). The double-blinded randomized control trial (RCT) has become the gold standard for evaluating drug efficacy in biomedicine, and this gold standard has also been applied to the evaluation of traditional Asian medicines. However, very few Asian medical interventions satisfy these criteria. For example, the acupuncture randomized trials (ARTs) and the German acupuncture trials (GERAC), which significantly proved acupuncture’s efficacy for headaches (Linde et al., 2006) and lower back pain (Brinkhaus et al., 2006), did so by simplifying the rationale of acupuncture to rigidly implemented standard needling techniques that are beyond recognition for the learned acupuncturist. Does this indicate that Asian medical treatment basically relies on the so-called placebo effect? Research on the placebo effect has shown that it can be achieved through personal relationships, the meaning encoded in the packaging, and many other factors (Kaptchuk, 1998). The concept of a placebo and double-blinded RCTs are useful for

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identifying which of two drugs with similar effects is more efficacious, but not for evaluating the overall situation of the holistic kind of treatment that traditional Asian medicines aspire to provide. Medical scientists and practitioners themselves have noted that RCTs provide valid and reliable results only for an idealized average person and that they cannot account for variation in human populations. They furthermore agree that RCTs are not suitable for evaluating surgical techniques. Where the legitimation for surgery is derived from a powerful imagery of body mechanics, Asian medicines aim at keeping bodies intact (bodies that are considered unique to each person), and Asian medical treatment can be interpreted as a manipulation of temporality as it often has by design several stages and rarely is based on one quantifiable magic-bullet intervention (Farquhar, 1992; Hsu, 2005a). Anthropological research has highlighted that Asian medical treatment often has a ritual structure akin to rites of passage. Thus, the first phase of Asian medical treatment often aims at shaking the patient’s usual sense of self, often with violent therapeutic methods. In panchakarma treatment patients must first rid themselves of impurities in the body through vomiting and diarrhea (Zimmerman, 1992), in acupuncture the practitioner is expected to inflict an unusual if not painful sensation through needling (Hsu, 2005b). The second, liminal phase of a treatment is typically marked by fluidity between the usual boundaries of self and other, and practitioners then often apply soothing, nourishing, and energy-boosting therapeutic techniques. The third phase of treatment is characterized by the patient’s reintegration into society.

Conclusion Studies in the social, natural, and medical sciences on traditional Asian medicines are still in their infancy. Landmark publications in the field of medical anthropology are Charles Leslie’s (1976) Asian Medical Systems, which highlight how history, education, changing demographics, and political-economic systems – such as the rise of the bourgeoisie in India, and the seizure of power by the Communist Party in China – gave rise to professionalized forms of literate medical traditions. A decade later, Leslie and Young (1992) explored the same range of medical traditions with a focus on the particularities of their reasoning and on how they legitimated their claim to being scientific. More recently, two volumes have investigated these traditions from the vantage point of current globalization trends. Alter (2005) points to the need to transcend the focus on the geographically bound nation-state and its corresponding medicine and ask instead when, why, and

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how medicine can extend beyond the borders of its nationalistic legitimation. Hsu and Høg (2002) emphasize the need to pay more attention to patients and their agency in the context of studying traditional Asian medicines. Patients play an important role in the shaping of contemporary Asian medical treatments, especially their commodified versions that currently are competitive on the neoliberal health market. More needs to be done, particularly on Asian ritual healing and its interface with scholarly traditions and on the toxicology, ethnopharmacology, and ethnobiology of traditional Asian medicines to do justice to their material aspects. See also: East Asia and Pacific States, Health Systems of; Medical Pluralism; South Asia, Health Systems of.

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