An American Internist's Thoughts on Tibet

May 31, 2007
Philip R. Alper, MD

Internal Medicine World Report, March 2007, Volume 0, Issue 0

Dr Alper is Clinical Professor of Medicine, University of California, San Francisco, Visiting Scholar, Hoover Institution, Stanford University, and practices internal medicine in Burlingame, Calif.

Did I recently travel to Tibet to discover the meaning of life? Well, not exactly. But I did harbor an intense curiosity about a place that is 3 times the size of California yet has less than half the population of minuscule Israel and still seems to always be in the news.

There is a joke about a jaded Westerner who does travel to a mountaintop in Tibet to meet a guru who will tell him the meaning of life. The joke isn’t that funny, so I’ll go no further with it other than to note that it gives tacit recognition to the idea that religion and Tibet seem close to being synonymous. Of course, here I am speaking of Tibetan Buddhism and the Dalai Lama, who, in a departure from conservative tradition, recently visited Stanford Medical School and is doing a joint project with the Neuroscience Institute on the physiology of meditation, using the most advanced magnetic resonance imaging techniques.

The Dali Lama fled Tibet for India many years ago, when the Chinese government declared Tibet to be an integral part of China and asserted its right to control religious life in the “Tibet Autonomous Region.” As I would come to learn, the story is exceedingly complex, and considerable ethnic tension remains between the mainstream Han Chinese and native Tibetans. (The latter actually most closely resemble Peruvian Indians in looks, dress, and even the kind of jewelry they wear.)

A military invasion (or suppression of a rebellion, depending on the point of view) in 1950 and 1951 has been followed by a large influx of ethnic Chinese into Lhasa, the capital city. Much has been done to improve the infrastructure of the region since then. Less has been done to integrate the populations. Stereotypes abound. As one Tibetan put it, “The Chinese think we are lazy and stupid, and we think they are rude and overly materialistic.” Nevertheless, Tibetans send their children to China for the best educational opportunities. One such student was asked what Tibetans eat. She answered, “Sand—it cleans out our digestive organs” and rocked with laughter as she recounted how her deadpan explanation actually convinced a couple of her classmates.

The truth is that both China and Tibet remain quite primitive across wide reaches of their territory. We found this as we traveled through Yunnan in southwest China, gradually climbing by motor coach over the course of nearly a week to acclimatize ourselves to Tibetan altitudes—12,500 feet in Lhasa and 4000 feet higher in some places we visited. (The new train from Beijing to Lhasa also crosses the mountains at 16,500 feet, but as part of a faster 48-hour itinerary. Despite oxygen provided by mask to all passengers, one early passenger did not survive the trip.)

I have to admit that wondering how I would do on “the roof of the world” did attract me. Not that we were going to do any trekking. In fact, the Stanford Alumni Association, with whom I traveled (though not an alum myself), provided comfortable buses and hotels, if not always the most delectable meals. However, there was no avoiding flights and flights of monastery stairs and high-altitude walks. I was glad I brought rubber-tipped walking sticks, which were especially useful on uneven steps and pavements. The hardier specimens among us took short but daunting optional climbs around some of the sites. I was satisfied to stick with the basic program, though an 81-year-old retired Army colonel and his wife turned out to be among the toughest climbers.

The indigenous population was startling in their adaptation to a difficult environment. For example, in a mountain pass between Lhasa and Gyantse, isolated homes were scattered around Turquoise Lake, seemingly oblivious to the 4.5-mile–high altitude and the paucity of people. Nearby, a herd of yaks crossed an ice field, as if that was a perfectly normal thing to do. Everywhere we went, the people were black-haired, copper-skinned, and had rosy cheeks—looking both sturdy and healthy. Without dentists, full mouths of white teeth were typical. Poverty is endemic, but it does not interfere with the pervasive quiet dignity of Tibetans.

Of course, looks can be deceptive. Death rates in infancy and from infectious diseases remain high. Traditional methods such as using mothers-in-law as midwives in rural areas create status issues that continue to make childbirth dangerous. Such traditions often interfere with the efforts of organizations like One-Heart, a volunteer American association whose representatives we met with, and who are dedicated to improving obstetrical practices in Tibet.

But it is the place of religion in life that makes the most profound impression on visitors. Wherever we went, pilgrims on foot, in carts pulled by tractors, or in trucks were making pilgrimages to monasteries sometimes hundreds of miles away. Prostrating themselves on the ground to accumulate greater merit in this life to be favored in the next life was commonplace. Indeed, we saw one pious pilgrim repeatedly push a handcart containing his possessions forward, then retrace his steps only to recover the same distance in a series of full-body prostrations accompanied by the constant chanting of prayers. He nearly met his end because he did it on a major road. I suspect his apparent fearlessness relates to a belief that losing one’s life while committing pious acts is no bad thing.

Immersed as we are in the language of self-interest, it is startling to see hordes of people all spinning their prayer wheels, chanting, and counting off the number of prayers offered on rosary beads in an almost mathematical search for spiritual perfection. The process intensifies in the vicinity of favored monasteries, such as those in Lhasa, Shigatse, and Gyantse. Additional merit is earned by circumambulating—walking in clockwise circles—around the holy sites. The larger the circular path taken, the greater is the merit.

Once within the monasteries, offerings are made with yak butter spooned into flaming votive bowls, or with money placed in front of selected Buddhas in favorite chapels. The haste with which this is done, including a fair amount of jostling, is as surprising as the presence of monks selling tickets for the right to take pictures.

Historically, the seat of Tibetan power lay in its monasteries, and even today the support of monasteries is clearly viewed as worthy by Tibetans, if suspect by the Chinese. However, things seem to be changing. China is increasingly intrigued by arguments in favor of preserving its ethnic heritage. Monks are modernizing and, perhaps following the Dalai Lama’s example, there is greater interest in the outside world. We saw more than a few carrying cell phones and sporting jeans and sneakers under their robes.

All of which raises the question of the role of religion as a way of life. Tibetan fatalism has not led to great progress in public health or individual healthcare. But perhaps it strengthens inner peace, harmony, and a sense of belonging that are health-promoting. Can devotion and modernism be combined? Yes, at least in the case of one Chinese-educated Tibetan I spoke with. He has an expert-level job and still does his daily devotions at home, including full-length prostrations. Only he likes to think of these as analogous to tai chi or yoga movements—healthy in their own right.

My personal experience with religion in healthcare is limited to using religious metaphors and terminology to better communicate with plainly religious patients. Our profession has erected a firewall between religion and medical science. This is probably just as well, because of the inherent inequality in the doctor–patient relationship. So, no proselytizing is good. It is less clear whether deliberately avoiding an appeal to patients’ existing religious feelings is equally good, particularly in dealing with illness and disability.

These and many other medical and moral questions stand out all too clearly in the intense sunlight that illuminates the roof of the world.

e-mail: philipa@ucsf.edu