The medical establishment at Gyantse in the 1905–10 period consisted of a British officer of the Indian Medical Service, a Hospital Assistant, a Compounder [of medicines], and a khalassi (dresser), along with a sweeper and a coolie. The status of the British officer was clearly expressed in financial terms. He received an annual basic salary of 7,200 rupees per annum, while the indigenous employees received 1,400 rupees between them.29 Medicines were supplied to Gyantse by the Government of India, but financial considerations were always paramount in its administration of the posts in Tibet, which meant that there could be large discrepancies between the equipment and medicines requisitioned by the Gyantse Medical Officers and the actual supplies received. In 1907, for example, a precise and detailed list of sixty required specialist surgical items was submitted from Gyantse, but a greatly simplified and considerably more economical list of fifteen items was actually sanctioned.30 Such economies must have impacted on the efficacy of biomedical practice at Gyantse.
The British officers in Tibet and other Political Department postings filed annual reports on the establishments under their jurisdiction, most of which have survived. The reports from the hospital at Gyantse vary somewhat in regard to the details they record, but collectively they do provide a valuable resource for the analysis of health conditions in a distinct Himalayan location over a specific period of time.
The first report from Gyantse states that in the first ten months of the hospital's existence, 58 operations were carried out under general anaesthesia, with one death recorded. Respiratory and heart diseases were noted as being rare there, with much of the Medical Officer's workload consisting of treating wounds and accidents, although “boils, ulcers and various diseases of the skin” are recorded as forming 23 per cent of all cases treated, with venereal diseases forming 15 per cent of the total.31 Unfortunately the report does not provide the total number of cases treated, although Steen does record that a temporary dispensary he opened for eight days while on a visit to the larger nearby town of Shigatse, treated between 500 and 600 cases in that time.32
In his Shigatse report, Steen noted the prevalence of eye diseases, which were among a number of conditions that could be improved by British surgery.33 There was an indigenous treatment for cataracts, but a later report states that “[m]any eyes are destroyed by the native method of treatment (firing)”,34 and this was to be one area in which considerable success was achieved by the British. As O'Connor had suggested, the restoration of a patient's sight had an immediate and lasting impact on local thinking, and thus was valuable propaganda for the British system.
The annual dispensary report for 1906–7 records that the Gyantse hospital treated 369 patients, of whom 34 were inpatients, with 24 operations carried out. The principal conditions treated were “general and local injuries”, which totalled 60, syphilis, with 55 persons treated, and ulcers, which totalled 32 cases.35 The figures for the 1907–8 period are not available,36 but the following year's report indicates that 23 per cent of patients were suffering from venereal diseases. While these were curable, the process was then a lengthy one and the Tibetans proved unwilling to continue the treatment after the immediate symptoms had vanished.37
In the 1909–10 report a total of 3,428 patients are listed as being treated, of whom 14.6 per cent were suffering from venereal diseases. A report was then submitted for the period 1 April to 31 December 1910, after which the reports were submitted on the basis of the calendar year. That abbreviated 1910 report breaks the figures down into two categories, outpatients, of whom 40 of 444 (9 per cent) were suffering from syphilis, and inpatients, totalling 65, of whom 31 (47.7 per cent) were similarly afflicted. Two of these inpatients were removed from the hospital by relatives and are presumed to have died of the disease.38
The treatment of venereal diseases was to continue to be a mainstay of the Gyantse Medical Officers' workload. Their reports indicate that while the Chinese soldiers then in Tibet made up a high percentage of those suffering from these conditions,39 venereal diseases were endemic in the country.40 But the medical issue of greatest concern to the Government of India at that time was not venereal disease but smallpox, for the Indo-Tibetan trade routes were also routes by which epidemics could be carried across the Himalayas by traders and pilgrims. A serious outbreak of smallpox in the year 1900–1 was known to have devastated central Tibet, with 3,000 to 5,000 monks alone reported to have died of the disease in Lhasa. The epidemic had then spread south, causing hundreds of deaths in the Gyantse region. The Government of India had responded by closing the main passes from central Tibet until arrangements were made to vaccinate all persons crossing the frontier, an action which contributed to a significant slump in the cross-border trade for that period.41
By the early years of the twentieth century, the imperial medical authorities in India had considerable experience in the implementation of smallpox vaccination campaigns.42 They were acutely aware that vaccination potentially aroused cultural or other forms of resistance, but its efficacy was undoubted. The benefits of its extension across the frontier into Tibet were thus summarized by the Director-General of the Indian Medical Service: “Vaccination seems to be very desirable from a humanitarian point of view and will in some degree protect our territory from the introduction of smallpox. It is also a means of impressing the natives.”43
In this case, however, the fact that “the natives” were not citizens of British India was a significant issue. Whereas the Political Officer responsible for the imperial government's relations with Sikkim, Bhutan and Tibet could, to a very large extent, enforce British will in the former two states, Tibet was in no way a part of British India and remained outside his authority (although the imperial frontier officers from Younghusband onwards sought to establish greater British domain there). This meant that, whereas vaccination campaigns quickly followed the introduction of British authority in Sikkim, and to a lesser extent Bhutan (where, unlike Sikkim, there were no permanent European residents), the process in Tibet was more sensitive. As a state outside British Indian authority, Tibet could not be forced, but only encouraged to vaccinate its people.
The position was also complicated by the fact that despite Tibet's semi-independent status at that time, the Chinese claimed it as being a part of their empire, and one or two Chinese ambans (diplomatic representatives) were stationed in Lhasa to enforce the Emperor's will. The British Government officially acknowledged that Chinese position, and particularly in the period up to 1912–13, when all Chinese officials were expelled by the Tibetans, the Government of India had to deal with the Chinese as the suzerain power in Tibet. This was not always easy, the Chinese were hostile to a British presence there, and sought to undermine the authority of the British agents. As a part of that campaign they argued that the British vaccination campaigns constituted impermissible interference in Tibet's internal affairs.
The value of vaccination against smallpox was, however, becoming known to the Tibetans. During the Younghusband mission vaccination seems to have been offered to any Tibetan who requested it. We know that this had some influence on the Himalayan élites, for among Younghusband's party was the soon-to-be King of Bhutan, who acted as a high-level intermediary on the mission. He was impressed by his observations of the results of biomedicine in general and vaccination in particular, later requesting that these be introduced into Bhutan.44 A similarly positive impression was presumably created in the minds of at least some of the Tibetan peoples.
The support of local élites was essential to the process of introducing vaccination in areas outside the direct control of the Government of India—that is, the Princely States and neighbouring regions. In both Sikkim and Bhutan the British had formed alliances with the local rulers and gained their support for vaccination programmes. Thus they sought an alliance with a similar figure of authority to promote vaccination in Tibet. Tibet's ruler, the Dalai Lama, had fled to Mongolia as Younghusband's troops advanced on Lhasa, but the British identified a suitable alternative candidate in the Panchen Lama, Tibet's second highest religious figure. The Panchen ruled over his court in Tibet's second biggest town of Shigatse, a day's ride from the British post at Gyantse, and in the immediate aftermath of the Younghusband mission, O'Connor devoted considerable effort to befriending the Panchen Lama. He spent much of his time in Shigatse rather than at Gyantse, and succeeded in persuading the Panchen to visit India for three months in 1905–6. There he sought to ensure that the Lama was treated with considerable respect while at the same time being impressed by the nature and extent of British power.45
Among those accompanying the Panchen Lama in India was Captain Steen, and he escorted the Panchen back to Shigatse on the return journey and remained there for several weeks—presumably in case the Lama manifested symptoms of any diseases acquired in India.46 That was a very real danger; among the many members of the Tibetan's party who had become ill on the journey was the Panchen Lama's uncle, who died of malaria in Darjeeling. He had, however, failed to take the medicines provided by Steen, and the Gyantse diary, in headmasterly tone, claims that “The Lama and other Tibetans thoroughly understand that his death was due to his neglect to follow Captain Steen's advice, or to take European medicines”.47
The Panchen Lama and his large entourage were vaccinated against smallpox before they went to India, and on his return to Tibet Steen reported that he had held a lengthy conservation with the Panchen “chiefly about medical topics and rifles.” He noted that “In regard to the former, he expressed a wish that I might introduce vaccinations into Shigatse”.48
We need, however, to treat these British reports with some caution; it was common practice for the imperial officers to persuade indigenous rulers to agree to, or to adopt, a particular policy favoured by the imperial power, but to attribute the credit for the initiative to the local ruler in order to avoid any charge of interference in internal affairs. The initiatives in fact developed from a complex interplay of personal relations, aims, ideas and circumstances.49
Steen had in any case already instituted a vaccination programme in Gyantse, nearly a year before his “discussion” with the Panchen Lama. Around 1 May 1905, local employees, servants and followers attached to the Gyantse Agency were vaccinated. Subsequently, as Steen reported:
The Jongpen [local administrator] and leading men of the town and district were then approached and the methods and value of vaccination fully explained to them. Some had heard of it, others had not, but all agreed that it would be a great blessing if such a terrible disease could be prevented. Since then these leading men have rendered great assistance by explaining the nature of vaccination to their people and encouraging them to come forward.50
Steen trained three Tibetans in vaccination and by 31 December 1905, 1,320 children had been vaccinated in Gyantse and the surrounding neighbourhood.51 Vaccination in and around Gyantse continued until December 1906, when the local Chinese representative suddenly claimed that this programme constituted British interference in Tibet's internal affairs. Although his claim rested on the objection that vaccination was compulsory,52 and was only one of a number of objections to British activities in Gyantse that he raised at the time, the Government of India accepted the need to avoid any suggestion of such interference, and vaccination ceased.53
In April 1907, however, the local administrators in western Tibet requested the assistance of British Indian vaccinators to control an outbreak of smallpox there, and vaccination resumed at Gyantse late in 1907.54 That the Chinese objections were part of a larger struggle to expel the British from Tibet is further indicated by the fact that in September 1908 the Chinese amban ordered the vaccination of all Tibetans.55 In other words, the Chinese objections were not to vaccination itself but to the British sponsoring the vaccination.
When the British resumed their vaccination programme in 1907, it was carried out by two Tibetans whom they had trained (although it is unclear if these were the same men trained by Steen). In the 1909–10 year this pair carried out 389 vaccinations,56 and the Gyantse Medical Officer confidently reported that the next outbreak of smallpox would demonstrate the efficacy of vaccination.57 He seemed to be proved right in the following year when an outbreak of smallpox caused numerous deaths in Lhasa and Shigatse, but few in Gyantse. The number of vaccinations carried out that year leapt to 2,131, as might be expected. But these figures conceal difficulties with the vaccinators. The two Tibetans were found to be taking bribes not to vaccinate people, and were sacked. Only one suitable candidate was found to replace them, and he died soon after in Shigatse of unspecified causes while vaccinating there.58
The British sources generally paint a bright picture of Tibetans keen to embrace vaccination. Thus in reports around the time of this outbreak we read that the
Tibetans are very appreciative of the value of vaccination; during one month representatives from villages, many of them five days journey from Gyantse, came to hospital to say that smallpox was raging with them, and asking that the vaccinator be sent out.59
But a subsequent report clarified the nature of the Tibetans' enthusiasm for vaccination. They were, it stated, “reluctant to undergo vaccination unless the disease is actually amongst them”.60
Thus, amidst the confident and optimistic accounts of biomedical progress in Tibet, there are indications that, as in India, there was some indigenous resistance to the smallpox inoculation process in Tibet. The fact that the vaccinators were being bribed not to vaccinate people also lends weight to the Chinese allegation that some form of coercion was used in the process.61
Steen had felt it necessary to emphasize that:
No compulsion of any kind, it is needless to say, was resorted to. When the people saw that the application of the vaccine caused little or no discomfort and when they understood that the measure was intended to prevent smallpox the children were brought forward quite voluntarily.62
Similarly, in official correspondence, the Panchen Lama's acceptance of vaccination was frequently quoted as evidence of Tibetan acceptance, as was the request from the western Tibetan authorities in April 1907. But an obituary of Lieutenant-Colonel Kennedy (which was apparently written by a contemporary British agent in Gyantse), notes that Kennedy “also vaccinated a large number of the local inhabitants, at first by guile and persuasion, but later at their urgent request”.63
While the British sources also describe a Tibetan reluctance to undergo hospitalization, surgery under anaesthetic, and continuing treatment for venereal disease after the elimination of immediate symptoms, no other aspect of biomedical practice appears to have encountered such active resistance as vaccination. In the absence of Tibetan sources, their perspective is difficult to analyse. Tibetans did not have the gender and caste purity concerns that affected the issue in India.64 Tibetan women were not socially isolated from contact with men and thus their status was not, as it was in India, threatened by contact with a male vaccinator. Nor did Tibetan society base social gradations around notions of purity and impurity in the manner of the Indian caste system, where the introduction of a cultivated serum into the high-caste body threatened loss of caste status.65
Given that Tibet was not under British imperial control, it is also difficult to locate a Tibetan parallel to the relationship between nationalism and resistance to biomedicine that developed in India. There was a clearly distinguishable Tibetan identity historically based around elements such as shared dress, diet, language, and mythologies such as the Gesar of Ling saga. But this was generally only expressed vis-à-vis a foreign “other” in a society where the primary identity was local or regional. Thus the Tibetans at that time lacked a sense of nationalism in the modern understanding of that term as linked to the European concept of a “nation-state”; one with fixed borders and a single political authority holding a monopoly over state use of force and relations with foreign powers. “Tibet” included enclaves under foreign authority, and a variety of political and administrative formations that contested centralizing power and carried out dealings with foreign powers without reference to Lhasa.66
Tibetan resistance to vaccination may be best located in the indigenous context of resistance to innovation, for Tibetan society at that time was overwhelmingly conservative and resistance to innovation was characteristic.67 This is not to be understood in such simplistic terms as a “static” or “traditional” society but was rather an expression of an active and articulated policy deriving from a particular Buddhist world-view of Tibet as the home of Buddhism under the special protection of the Bodhisattva Avalokiteśvara, and thus as an ideal land. Resistance was therefore, not to vaccination as “foreign”, or as an expression of a colonial power relationship, but rather to altering the status quo as established by the Buddha. In that sense it was a religious objection.
Adding to the potential for resistance in the Tibetan reception of biomedicine was the fact that the main preservers of the existing social structure were the monastic powers, among whose ranks, as we have noted, were those whose income (and status) derived from their knowledge and skilful practice of the Tibetan medical system. With the influence which the monasteries enjoyed throughout Tibetan society, these monks were potential leaders of opposition to biomedicine (and other aspects of modernization) and where the British sources do indicate resistance to their medical innovations, it is the monks who are blamed. The 1911 report, for example, states:
This comparatively few number of patients is explained by the opposition of the Lamas, who put obstacles in the way of people coming for treatment. The reason is not far to seek, as the dispensary interferes with the fees of the Lamas who are exorcists for all manner of ghosts and demons to whom disease and even injury are universally ascribed.68
There was a general tendency for the British to demonize the collective body known as “the monks” and to attribute all Tibetan resistance to them, rather than to acknowledge broader socio-economic concerns. In practice, the British distinguished those monks—in particular the élites such as the Panchen Lama—with whom they established good relations. But they recognized that the core of opposition to their presence came from the monastic community, whose status their modernization project threatened.69
While monastic opposition was part of a wider political problem for the British, it was also an issue of genuine medical concern to the IMS officers. They found that it was only when the monks “have experimented and failed that the patients come to the dispensary. The result is that some of the cases are very serious”.70 This problem was to be common throughout the British period, but particularly in these early years it seemed that Tibetan patients, or their indigenous physicians, often—or generally—used biomedicine as a strategy of last resort.
The advice of a monastic physician, novelty, chance, or economic circumstance may all have led Tibetan patients to resort to the IMS dispensaries. But while receiving biomedical treatment, many of the patients doubtless continued with indigenous therapies, particularly in regard to the religio-medical aspects of their understanding of disease causation, and their uptake of the new system was selective. The evidence for the Tibetans' continuing resort to indigenous practitioners suggests that we might need to read the records of treatment at biomedical facilities as indicative not of overall local health patterns, but only as a record of those conditions Tibetans regarded as best treated within the biomedical system.
The increasing attendance at the IMS dispensaries does suggest, however, that the efficacy of biomedicine at least in regard to specific conditions such as smallpox or cataract surgery gradually came to be acknowledged by the Tibetans.71 Modern anthropological studies indicate that Himalayan patients may regard biomedicine as effective in the worldly sphere but continue with indigenous practices regarded as effective in the other-worldly sphere,72 and this may well have been the case with the Tibetans at that time. The ultimate result, however, was increasing Tibetan resort to, and familiarity with, the concepts of biomedicine.
In this early period there is no evidence for the interaction between the Tibetan and biomedical systems that was to develop in the late colonial period and which has been a feature of more recent medical history. There was no official communication or interface between the systems and little in the way of private initiatives. Biomedicine was culturally foreign to the vast majority of Tibetans, and this early period saw multiple elements of resistance to that foreign system, albeit that that resistance was not expressed in terms closely equating to that arising in India. Yet whether for reasons of cost, efficacy, or as a part of the wider process of the introduction of modernity, biomedicine did slowly increase in popularity between 1905 and 1910, paving the way for further Tibetan uptake of that system in later years.