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Alex McKay, Their footprints remain: biomedical beginnings across the Indo-Tibetan frontier, International Institute for Asian Studies series, Amsterdam University Press, 2007, pp. 312, €47.00 (paperback 978-90-5356-518-6)
Alex McKay has written a useful and inspiring text on the arrival and reception of biomedicine in the Indo-Tibetan region—a topic that has no book-length precedent. His focus is not on any and all European medical practices in the region, but specifically on the form of biomedicine emerging primarily in the late nineteenth and early twentieth centuries. His geographic net is also extensive, focusing on the Tibetan regions of the Himalayas, including Tibet, Sikkim, Bhutan, but not exhaustive, excluding Nepal and Ladakh. Using British source materials, McKay takes us on a wonderful journey into remote clinics filled with missionaries, British trade officers and Tibetan-speaking patients, and into an exploration of the rationale behind the uptake, and rejection, of this new medical repertoire. With sometimes breathtaking examples from accounts of practitioners who seemed to have in some cases kept exacting records of patients, ailments and even ethnographic analysis of their work, we are given an original illustration of a complex medically plural world. It is clear that from the beginning, biomedicine was enmeshed in local debates over not simply what treatments were useful but also over what these practitioners and practices might have meant to people on the verge of dramatic social transformation, especially in Tibet post-Younghusband expedition. The slowness of uptake of biomedicine in most of these regions in the early twentieth century stands in stark contrast to the rapid growth and extensive use of it by the end. Similarly, what appears to be some resistance to integration early on stands in contrast to the integration that flourished later, where lamas enter hospital wards for ritual services in order to accompany surgeries and other inpatient treatments.
The question of what rationale and logic explains local responses to and use of biomedicine runs throughout the book, and is explored comparatively and in a more analytically rigorous way at the end. Here, despite a subtle misreading of governmentality as state-funded health care and an insistence that “power relations” probably played a negligible role in the use patterns of biomedicine, in the penultimate chapter, McKay's clear coverage of the historical record makes a strong case for a much more complicated analysis. The cases demonstrate that biomedicine was received in the Indo-Tibetan world sometimes as offering what appeared to be “miracle” cures, as in the case of treatments for smallpox, goitre, worms, injuries, and venereal diseases, and at other times as a practical alternative to ailments that lingered and found no cures through use of indigenous practitioners (but which it is not clear were treated any better with biomedicine). In other instances, McKay's sleuthing illustrates that biomedicine was clearly also a tool for and even perhaps sometimes a key focus of diplomacy and political expansion for both missionary and imperial interests. The absence of colonial state funding for clinics or training practitioners does not, however, mean that modern state regimes were not involved in clinical decision-making on the part of patients or that they were not indirectly part of an apparatus that would generate new notions of subjectivity among these users. The wealth of materials describing the ways in which biomedicine was viewed as a route to upward social mobility and at other times rejected, by lamas, for example, because it was seen as a competitor for lucrative payment, makes the story of biomedical use patterns much more complicated than simple notions of pragmatism or availability.
Scholars of the region and of Asian medical systems, from history, anthropology, area studies and beyond, will enjoy this compilation of the historical record on this topic. The book's complement would be in an extensive exploration of the available materials from non-English language sources and contemporary ethnographies, particularly surrounding questions of the local perception of these practices and their utility, or lack thereof, and thus a more thorough reading of how things like blessings from lamas might serve as more than “psychological” therapy for inpatients in biomedical clinics. However, these limitations are well known to the author and they do not undermine or lessen the significance of the materials presented herein. Their footprints remain will serve as a useful text for the long run, although one might guess from its content that the footprints do not simply “remain” but in fact left the imprints for a path that is very large and very paved today.