A Tibetan Medical Perspective on Irritable Bowel Syndrome more

Special Focus on Women fs Health A Bimonthly Publication for Health Care P r a c t / t i oners Vol. 4, No. 5, October 1998 □ Alleviating Menopausal Symptoms With Black Cohosh □ Prevention of Cancers in Women □ Natural Approaches to Asthma □ Dietary and Lifestyle Changes for Cardiac Health □ Tibetan Medicine: An Overview □ Apache Traditions of Healing □ Tibetan Medicine for Irritable Bowel Syndrome □ Four Ayurvedic Herbs □ Stony Brook's New ACM Center n How Do Naturopathic Drug Formularies Work? □ Rx:RN: Nurturing Your Healing Self A Tibetan Medical Perspective on irritable Bowel Syndrome Building A Means of Discourse for Integrative Medicine Eliot Tokar and Ah an a Vora Introduction Ahighly regarded Tibetan physi- cian in West Bengal, India, recent- ly said that he was wary of the negative effects when younger Tibetan doctors feel they must address Western medical diagnoses. He said that such information does not help the doctor to make an accurate Tibetan medical diag- nosis and instead spreads the hegemony of Western medicine. This is a persuasive argument. As eco- nomics and the influence of Western medical approaches endanger the more classic, holistic approach of traditional medical systems, the most important issue regarding Tibetan medicine is its complete preservation. Already, Tibetan medicine is beginning to be promoted as a hot new commodity in the new alterna- tive medicine industry. In this environ- ment the use of classic treatment protocols will increasingly give way to the use of Tibetan herbal pills as an over- simplification of Tibetan medical treat- ment. This creates a scenario easily exploitable by the growing nutriceutical industry that is always looking for poten- tial new products. The active cooperation of various sys- tems of medicine is an important goal, but a hasty integration will limit us to a "Disney World" version of these vast and varied medical approaches. That is, we will find ourselves using only some of the form and some of the substance of com- plex traditional systems of natural medicine squeezed into easily maketable and salable forms. "Complementary medicine" has already become a ubiqui- tous term in current discussions of alter- native medicine. Simply creating a field of "complementary medicine" as a new industrial category does not honor the intelligence expressed by the American people for the past three decades through their grassroots effort to investigate and use alternatives in healthcare. However, adopting the isolationist per- spective of the aforementioned Tibetan physician is not the only way to preserve Tibetan medicine. We must work to understand the system and teach its true meaning so that health care consumers can discern what is real and what is com- mercial. Before a system of truly comple- mentary medicine can exist in the United States, the essence of traditional natural medicine practices needs to be properly understood by allopathic health profes- sionals and more fully incorporated into American sensibilities. The first step in that process is developing a means of dis- course so that lay people, allopathic physicians, and practitioners of tradition- al natural medicine can speak to and edu- cate each other. To begin establishing a complemen- tary approach to medicine, we must cre- ate a common language through which traditional doctors and allopathic doc- tors can communicate clearly about their disciplines. For example, traditional Asian medicine is not about acupuncture points, herbal remedies, or other thera- peutic devices. Rather, it is about the sci- entific, cultural, and spiritual knowledge that gives rise to and defines the clinical indications for those applications. Creat- ing such a language is a complex but essential task that, at worst, is over- looked and at best is attempted in an intellectually and scientifically inade- quate fashion. The following example is offered as an illustration. A meeting was recently held at Columbia University New York, New York with two Ayurvedic physicians and a group of Western health professionals. In the question-and-answer session one Western practitioner, who was working at a hospital unit that utilizes complemen- tary medicine, asked the Vaidyas if and how they treat multiple sclerosis (MS). They answered that they did treat MS and then attempted to explain their approach to treatment. As they spoke, the American practitioner posed numerous additional queries regarding the details of MS. As this happened, the discussion became progressively obtuse and frustrating. Based on my experience in traditional Asian medicine, I offered the comment that the Vaidyas were actually not diag- nosing or treating MS because it does not exist as a diagnostic category in Ayurvedic medicine. I recommended that we share some case studies of their own patients with a Western diagnosis of MS and discuss in detail the condition they had diagnosed and the results of their treatment. The discussion immediately became a more organized and clear dia- logue. It ceased to have the tone of an inquisition or the strain of a person strug- gling to fit the wrong size shoe onto the opposite foot. After the meeting the Indi- an doctors told me, "this often happens to us at meetings of this kind where we are asked about Western diagnoses. To accommodate the Western doctors we answer, but it is never adequate." Western diagnoses such as irritable bowel syndrome (IBS), cancer, and dia- betes are not in fact illnesses; rather, they are conceptual descriptions of the etiolo- gy of illness with related treatment proto- cols. When we appreciate this point, the 343 344 ALTERNATIVE & COMPLEMENTARY THERAPIES—OCTOBER 1998 IBS is the most common gastrointestinal disease in Western clinical practice. Eliot Tokar (right) and his teacher, Dr. Yeshi Donden (left). Dr. Labsang Tenzin is seated left concepts of Tibetan medicine or any other system of medicine can be considered on equal terms with the concepts of the Western model. Only then can we create a language that enables meaningful dia- logue among different medical systems. The development of such a language is an often ignored prerequisite for an effective integrative analysis. This article contributes to this language of discourse with the long-term objective of creating such an analysis. As a starting point in building this language, the condi- tion defined by Western medicine as IBS provides an example of a useful model for comparative analysis with the same condition as defined by Tibetan medicine. IBS: Diagnosis and Treatment in Western Medicine According to Harrison's Principles of Internal Medicine, irritable bowel syn- drome (IBS) is the most common gastroin- testinal disease in Western clinical practice.1 Its etiology is not clearly under- stood by Western medicine, and it has no known organic disease as its basis. Psy- chological conditions ranging from stress and anxiety to deeper disturbances fre- quently trigger exacerbations of symp- toms.1 Compared with the general population, patients with IBS have an increased frequency of psychiatric diag- noses including personality disorders, anxiety, depression.1 Symptomatically, IBS is experienced as either abdominal pain, intermittent diar- rhea or constipation, bloating, and excess gas.3 IBS is a disorder of motility or sen- sory function in the gastrointestinal tract, often leading to rapid transit of food to the small intestine. 1/3 A diagnosis of IBS is supported by symptomology of a chronic and intermittent nature, an absence of physical signs of deterioration, and emotional stress.4 The rest of the diagnosis is established based on the exclusion of other conditions, such as infection, neoplasia, thyrotoxicosis, obstruction, and malabsorption.1 IBS is considered treatable but not cur- able.1 Dietary treatment includes fiber supplements, osmotic laxatives, and easi- ly digested carbohydrates.3 Symptoms can be medically controlled with antidiar- rheals, prokinetic agents, tricyclic antide- pressants and/or anxiolytics.1 Because IBS is thought to be incurable, patients are advised to adapt to the symptoms.4 In cases of great severity or where patients do not respond to treatment physicians often recommend psychotherapy, hyp- notherapy, or biofeedback.1 Comparative Diagnosis Figure 1 illustrates a basic difference in the diagnostic approaches of the Tibetan and Western systems. Consider two pyra- mids, one inverted and the other upright. Western diagnosis can be graphically rep- resented by the inverted pyramid. In the process of performing a Western diagno- sis, the physician begins by considering the broad spectrum of a patient's chief complaints, history of present illness, past medical history, and social history. The Western physician then progressively narrows the differential, eliminating what is regarded as extraneous or secondary. Finally, a singular definition of disease is reached, such as IBS. Once this diagnosis is established, information about treat- ment options and expected prognosis can be accessed from statistical and experi- mental research tested in study popula- tions. However, in this approach very little is understood about the difference between one individual with IBS and another individual with the same diagno- sis. Beyond the subjective observation of the Western physician, no satisfying explanation is available regarding why individual patients experience the disease differently, with varying symptoms, course, prognosis, and quality of life. Tibetan diagnosis can be graphically represented by the upright pyramid. At the apex of the pyramid is the individual. The Tibetan physician places a particular emphasis on individuality because all ill- nesses are rooted in each patient's unique background and situation. This concept of the individual is then expanded to include the chief complaint, accompany- ing symptoms, and relevant medical, per- sonal, dietary, and spiritual history. Through this process, the physician per- ceives the broader complex that charac- terizes the illness. Once the illness is diagnosed on such terms, the root cause of the entire complex of symptoms and conditions can be understood. It is this root cause of illness in addition to the ALTERNATIVE & COMPLEMENTARY THERAPIES—OCTOBER 1998 345 The Tibetan physician places a particular emphasis on individuality because all illnesses are rooted in each patient's unique background and situation. acute symptoms that Tibetan physicians diagnose and treat. In this approach, each patient's diagnosis, treatment plan, and prognosis are determined on an individu- al basis. Therefore, what might be per- ceived as one disease in Western medicine is actually perceived as a range of conditions in Tibetan medicine. Diagnosis of the Condition in Tibetan Medicine It follows that the etiologies and mani- festations of illness can be understood within several diagnostic categories in Tibetan medicine. These categories relate to three principal systems that give rise to and regulate all functions of the body and mind: Liing (Wind), Tripa (Bile), and Bad- ken (Phlegm). Below is a rudimentary description of the three systems and a brief discussion of their relation to the diagnosis of IBS. The three principal systems that create and sustain all the body's functions (Lung, Tripa, Badken) are created at various stages of development in the womb by an interaction of the mind's developmental process and the five physical elements (discussed later in the section on diet). Embryologically, the mind acts as the basis for the creation of each individual's three principal physical systems. A mate- -rialist view of the world, based on igno- rance of a spiritual perspective, is inherently related to Lilng. In Buddhism, stress can be defined at its most basic level as the conflict created between the pursuit of worldly desires ;^nd the inevitable limitations in fulfilling ithese desires. Therefore, stress is a reac- tion rather than a response to given cir- cumstances. This reaction results in psychologic and physical reactions which disturb Liing. The results of stress can include improper diet, harmful lifestyle (e.g., erratic sleep habits), and poor adap- tation to one's physical environment (e.g., overexposure to cold in winter or to heat in summer). TBS is frequently triggered by an emo- tional stress reaction resulting in symp- toms such as diarrhea and/or constipation. Therefore, a characteristic etiology of this condition is the distur- bance of what in Tibetan medicine is called Liing (Wind). Liing gives rise to all circulation in the body. As the basis of cir- culation, it is associated with processes of the human organism characterized by movement, from the intangible (e.g., thoughts) to the physical (e.g., nerve impulse, blood, and lymphatic circulation and movement of chyme through the digestive and excretory systems). A disturbance of Lung can occur alone or in combination with dysfunctions of one or both of the other principal systems. When it occurs alone, this disturbance is termed a Liing disorder. Typical symp- toms of such a disorder include erratic and diffuse pain, lower back and hip pain, dry skin, abdominal distention, con- stipation, diarrhea, anxiety, anorexia, depression, mood swings, insomnia, psy- chosomatic disorders, irregular blood pressure, and metastasis of tumors. The second principal system is Tripa (Bile). Tripa is associated with thermoreg- ulation, metabolism, vision, liver and gallbladder function, and blood produc- tion. It allows the mind to function with discriminating intelligence. A distur- bance of this system can include such conditions as anger, hypertension, vomit- ing, gastric acidity, hepatic dysfunction, and the development of fast-growing tumors. Eliot Tokar (left) and his teacher, the Tibetan lama and physician Dr. Trogawa Rinpoche (right). Cases of IBS defined by the basic Liing disorder in combination with a Tripa dis- order are called Liing/Tripa disorders. They can include symptoms such as errat- ic episodes of hypertension, sharp pains that move around the body, fluctuating fevers, reflux, regurgitation, and a combi- nation of symptoms of both Liing and Tripa disorders. Biidken (Phlegm) is the third principal of physical and psychologic function. It is associated with the proper breakdown of food in the initial stages of digestion, the maintenance of the body's internal fluids, and the proper functions of the senses overall. Typical manifestations of Badken disorders can include a sensation of phys- ical or mental heaviness, kidney disor- 346 ALTERNATIVE & COMPLEMENTARY THERAPIES—OCTOBER 1998 The first consideration in treatment is the principle that all illness ultimately originates in the mind. This does not mean that all illness is psychologic or psychosomatic. ders, hypotension, slow metabolism, hypersensitivity to cold, weakness, diar- rhea, the development of soft cysts, and slow rumor growth progression. If the case of IBS is characterized by a Liing disturbance combining with the principal system of Badken, it is called a Liing/Badken disorder and is character- ized by an inability to break down foods properly at the initial stages of digestion. In this case, the IBS is accompanied by symptoms such as hypersensitivity to cold, mucus or undigested food in the stool, excessive urination, and a combina- tion of Liing- and Bflrffet-derived patholo- gy- Finally, if the condition derives from a complex dysfunction of all three main principal systems mentioned above {Liing, Tripa, and Badken), it is termed a Badken Mukpo (literally brown phlegm) disorder and reflects a combination of liver and stomach dysfunction that chron- ically undermines digestive and assimila- tive processes. This results in a variety of symptoms, including intestinal pain, sour vomiting, indigestion, nausea, lack of appetite, blood in the stool, and constipa- tion. In more severe cases, or if left untreated, this condition may lead to tumorigenesis. Appropriate diagnosis of the condition is determined through an interview and physical examination, in which the patient's history and presenting symp- toms are elicited. Next the physician ana- lyzes a urine sample, feels the 12 distinct pulses on the radial artery of each wrist, observes the tongue and the sclera of the eyes, and, if necessary, applies pressure to appropriate points on the body. Treat- ment is then tailored to address the spe- cific etiology of the individual's condition. Treatment in Tibetan Medicine Treatment is specific to each of the four diagnostic categories. The first considera- tion in treatment is the principle that all illness ultimately originates in the mind. This does not mean that all illness is psy- chologic or psychosomatic. Rather, it means that, due to ignorance, we misper- ceive the nature of reality and act in ways that create suffering, such as illness. Given this basic principle, when treating an illness, physicians begin by recom- mending specific behavioral and lifestyle modifications. If this is not sufficient, then physicians work at the level of dietary therapy. If these are not enough to cure the problem, physicians use herbal medicines or, if needed, physical thera- pies such as acupuncture. As stated by Dr. Trogawa Rinpoche, the treatment ulti- mately must fit the patient; that is, treat- ment must be formulated in a manner that can and will be effective for that indi- vidual. Behavioral Modification Behavioral modification can include meditation instruction, spiritual advice, counseling, exercise, or the reorganization of habitual patterns such as sleep habits and eating schedules. Initial stages of meditation generally include simple breathing practice and working with one's thoughts in a manner that calms the mind. Meditation then evolves beyond that point to include spe- cific contemplations and visualizations, which begin a process leading to a new understanding and perception of the world. This aspect of the treatment may vary slightly with the diagnosis. For example, in the case of Liing disorders, meditation may be specifically directed toward understanding the impermanent nature of physical phenomena as a cure for materialism and attachment. In the case of Tripa disorders, emphasis may be placed on generating a deep feeling of love and compassion as a cure for aggres- sion and anger. In Badken disorders, med- itation will focus more on developing wisdom as a cure for ignorance. What follows is a basic meditation for people experiencing anxiety and depres- sion, which are fundamentally Liing dis- orders. Because it calms Liing, this meditation can be helpful in some etiolo- gies of IBS. After awakening in the morn- ing, patients are asked to sit with their backs to the sun in a place where they can look at the clear blue sky. If this is not possible, they can simply visualize the clear blue sky in their minds. Patients are then taught some simple breathing prac- tice. When thoughts arise, they must not try to suppress them or to become involved with them; rather, they should allow them to arise in the mind and pass away. Such relaxing practices allow patients to focus and calm their minds. Patients are then asked to look at the sky, taking particular notice of its expanse into infinity. Next, they are told to focus on their minds and locate their conscious- ness. Then, on the exhalation, they are taught to project their consciousness out of the body and into the sky where the consciousness diffuses into an infinite blue expanse. Although it is very basic, this meditation begins to train patients who are gripped with mental turmoil to let go of their thoughts. In Tibetan medicine, this grasping onto thoughts is considered an exacerbating factor of anxi- ety and depression. Physical activity, lifestyle, exercise, and habits are also considered. For example, ALTERNATIVE & COMPLEMENTARY THERAPIES—OCTOBER. 1998 347 Food is analyzed based on its qualities and nature as defined by a five-element theory. Patient Individual Direction of diagnostic analysis Diagnosis of Diagnosis of illness complex and its root cause disease Figure 1. Graphic description of difference between Tibetan and Western medical diagnosis. patients with Liing disorders are told to pay special attention to regularity of lifestyle (e.g., eating, sleeping, and excre- tory function), find time for calm activi- ties and socializing, and exercise in ways that promote good overall circulation, using techniques such as yoga. An indi- vidual who suffers from a Tripa disorder should stay away from situations causing conflict. Such people should avoid direct, excessive exposure to the sun and engage in physical activities that relax them. Patients with Badken disorders should keep warm and perform vigorous exer- cise such as running or dancing. Swim- ming is not appropriate if it involves immersion in cold water. In the case of a combined disorder such as Badken Mukpo, behavioral modification is tailored to the particular form the illness takes. Diet In recommending an appropriate diet, Tibetan physicians consider which types of food are harmful and which might be beneficial, the amount of food to be eaten, the number of meals per day, and the proper meal times. Food is analyzed based on its qualities and nature as defined by a five-element theory. All of the material that makes up our universe is based on the qualities of five basic ele- ments that are described in the ancient physics depicted in the texts of Tibetan medicine. Ancient Tibetans lived in direct contact with the natural environment. They understood through experience and study that the forces manifest in nature directly correlate with and influence the functioning of the human organism. In the theory of the five elements, we see an effort to define the qualities of the basic forces that exist in nature. Once defined they are named for their most identifiable manifestations: earth, water, fire, wind, and space. The characteristics and there- fore the nature of all matter then result from the qualities of these elements indi- vidually or in combination. Specific arrangements of the five ele- ments that occur during embryologic development form the three basic princi- ples of physical function (Liing, Tripa, Badken). This is important because the taste of different foods, their resulting natures, and therefore their effects on the human organism are also dictated by the specific arrangements of elements that make up the food. This principle enables practitioners to think intelligently about diet and health relative to each individual patient's lifestyle, environment, and health condition. The recommended diet for IBS varies significantly depending on the specific etiology experienced by the individual patient. Because stress is a significant trigger in IBS, Liing is usually a con- tributing factor. Therefore, a proper therapeutic diet must usually treat Lung imbalances. Depending on the presence of imbalances of Tripa and/or Badken, additional foods must be added to or removed from the diet. Liing Diet. Patients benefit from a diet of heavy nutritious foods, such as meat, cheese, butter, and soups made with bones (e.g., chicken soup). In the case of a Liing/Tripa disorder, or some Badken Mukpo disorders, or if the patient is a veg- etarian, animal-based foods can be replaced with other foods. Substitutes include avocadoes, vegetable-, legume-, or grain-based soups, onion, asparagus, and oats. Foods that are irritating or "rough" in nature should be avoided because they would impede or distort the movement and circulation that is essential for the function of Liing. These include foods that are burned in cooking or processing (e.g., grilled meat, over-toasted bread, coffee, chocolate) because they induce stagnation of the circulatory energy; sugar, molasses, and artificial sweeteners; puffed grains such as rice cakes; monosodium gluta- mate; improperly processed foods (e.g., distilled vinegar, low-grade soy sauce); and green tea. These foods, which might otherwise be benign or useful, are con- 348 ALTERNATIVE & COMPLEMENTARY THERAPIES—OCTOBER 1998 Herbal treatments range from simple to very complex, in a compound using approximately 3 to I 50 herbs per formula. Additional References rGyud Zhi Dharamsala, India: Tibetan Medical & Astrological Institute, 1994 She/ Gong Shel Prang Dharamsala, India: Tibetan Medical & Astrological Institute, 1994 Gso Rig Tin Tig Gees Bsdus: A Treatise On Tibetan Medicine , By J. Kon sPrul Leh, Ladakh, India: Mrs. D.W. Tashigang, 1983 Boi Dur sNon Po By sD. S. rGya mTstio Leh, Ladakh, India: T.Y. Tashigangpa, 1973 The Healing Power of Mind '; By T. Thondup Boston: Shambala Publications, 1996 Lectures on Tibetan Medicine By L.D. Khangkar Dharamsala, India: Library of Tibetan Works & Archives, 1986 .Tibetan Medicine (gSo-rig), Vols 1-12 [ Dharamsala, India: Library of Tibetan I Works & Archives, 1980-1989 Guide to the Exhibition on Tibetan Medicine & Astrology ■ Dharamsala, India: Men-Tsee-Khang, 1995. Tibetan Medical Paintings: Illustrations to the Blue Beryl Treatise of Sangye Gyamtso By Y. Parfionovitch, G. Dorje, and F. Meyer New York: Harry N. Abrams, Inc., 1992 traindicated in this situation for two rea- sons: (1) because they are irritants causing an exacerbation of stress-related symp- toms, and (2) because they impede proper circulation in the body. Tripa Diet. These patients observe the Liing dietary guidelines when appropriate while incorporating additional principles that are tailored to the Tripa condition. In this case a simple vegetarian diet is suit- able, including legumes, potatoes, cumin, coriander, fenugreek, artichoke, bitter veg- etables (e.g., dandelion), and turnips. Foods that are heating in nature should be avoided. These include peanut butter, mustard, spices, garlic, ginger, onion, alco- hol, meats (especially lamb), oily and greasy foods, and soups made with bones. Badken Diet. These patients adopt a heating diet with respect to both the nature and the temperature of the food. For example, they consume hot water, cooked foods, pomegranates, sheep cheese, yogurt, radish, honey, ginger, and garlic. They avoid cold drinks and raw foods such as salads, potatoes, tomatoes, eggplant, bell peppers, and sugar. Badken Mukpo Diet. Badken Mukpo is the combined dysfunction of all three energies. This is a complex chronic condi- tion in which each of the imbalances ulti- mately affects the digestive and metabolic functions. The diet includes fresh, cooked foods to facilitate the severely compro- mised digestion that is typical of this con- dition. Recommended foods include fresh meat, dairy products, vegetables, fruits, and whole grains. This condition is exac- erbated by garlic, tomatoes, eggplant, bell peppers, and foods that are aged, fer- mented, cured, smoked, sour, chilled, oily, or processed. Herbal Medicines If the above approaches are not sufficient in relieving the condition, herbal medicines are prescribed. In Tibetan medicine, herbal treatments range from simple to very com- plex, in a compound using approximately 3 to 150 herbs per formula. Each formula or set of formulas is prescribed to fit the mani- festation of the disease and the evolving condition of the individual patient. As a result, herbal medicines often need to be modified at each visit. Typically, two to four formulas are pre- scribed, to be taken each day at specific times. Morning remedies commonly include those for Badken disorders or digestive disorders. Afternoon remedies are typically used to treat Tripa disorders. Remedies given in the late afternoon or evening are usually given to treat Liing disorders. Ultimately, the organization of the prescription is based on both the doc- tor's judgment and the patient's lifestyle. Although prescriptions are specifically tailored to each case, some herbs are more frequently found in formulas applicable to cases defined as IBS by Western medicine. For example, a set of three herbs (Terminalia chebula, Terminalia beleri- ca, and Emblica officinalis) are often given together as a mixture or included as ingredients of a complex formula. Additional herbs are typically pre- scribed for each individual's condition. Herbs such as Aquilaria agollocha, asofedi- ta, Saussurea lappa, Areca catechu, car- damom, nutmeg, and clove are often found in Lung disorder medications.5 Swertia chirata, Saussurea lappa, and Berberis are commonly used in Tripa disor- der formulas.5 Badken disorders are com- monly treated with pomegranate seeds, Piper longum, black salt, cardamom, and cinnamon.5 Commonly used ingredients for relevant Badken Mukpo disorders are Saussurea lappa, Emblica officinalis, pomegranate seeds, cardamom, Piper longum, Veronica ciliata, and calcite.5 ' Physical Therapies Other therapies may also be used if the above approaches are not sufficient. They include: Massage. Massage is calming and pro- motes good circulation. For cold condi- tions such as Liing and Badken disorders, massage oils should be heating in nature, such as sesame oil or mustard oil. Tibetan acupuncture. Tibetan medicine has its own unique acupuncture system. In addition to the application of needles ALTERNATIVE & COMPLEMENTARY THERAPIES—OCTOBER 1998 349 Herbs such as Aquilaria agollocha, asofedita, Saussurea lappa, Areca catechu, cardamom, nutmeg, and clove are often found in Liing disorder medications. Tibetan physicians also use moxibustion, which may be used in conditions such as Bcidken and Liing. Inhalation therapy. This modality is best illustrated by the medicinal use of incense formulated specifically to treat Liing con- ditions. When indicated, patients are pre- scribed such incense and asked to inhale the smoke as it diffuses into the air during times of the day when the Liing predomi- nates, such as in the late afternoon and before bedtime. Conclusion The process of introducing new ideas regarding medicine and creating a new, integrative paradigm is already present in the history of Tibetan medicine. Centuries ago, before Buddhism entered Tibet, Tibetans like all ancient people had some degree of medical knowledge. According to traditional sources, in the beginning of the fourth century many new ideas regarding medicine began to enter the country. At first influences came from India in the form of what is now called Ayurvedic medicine, as well as more spir- itual and psychologic systems from Bud- dhist and other sources. Around the 7th to 8th century, government-sponsored conferences were held in Tibet, where doctors skilled in the medical systems of China, Persia, India, and Greece came to present and debate their ideas on health and the treatment of illness. Those with superior abilities were invited to stay and contribute to the country's medical knowledge base. It was not until the 11th century that this knowledge was integrat- ed into a unified system. This system con- tained a synergy of various principles of physical and psychologic medicine imbued with a spiritual understanding. For the past 30 years the American peo- ple have said that the medical system that has dominated this country for most of this century is not wholly adequate. The recent explosion of interest in alternatives in health care from allopathic doctors, researchers, the government, and industry creates two possibilities. One is a renais- sance atmosphere in which doctors, researchers, and independent practitioners of natural medicine meet on equal ground, freely exchanging ideas, experience, and knowledge and thereby creating great ben- efit for patients. The other is evidenced by the new presence of people in the health care industry who are seeking to co-opt and control this renaissance through profession- al, political, legal, and commercial means. People must learn to negotiate the land- scape of alternative health modalities. However, Americans need a better under- standing of the theory and practice of these disciplines before their efficacies can be truly understood. When understanding is achieved, Americans can gain benefit from Tibetan medicine's insights into how to maintain health and cure illness, based on centuries of accumulated knowledge of the spiritual, ecological, psychologic, and physical aspects of health. Given the speed of developments in the modern world, it will probably not take us the seven centuries the Tibetans utilized to create a new paradigm of integrative medicine. However, we must not allow the agenda to be set by the rapid pace of economics and technology that has nega- tively affected our American health care system. The above material is an illustra- tive example of how diagnoses can be understood across two disciplines. Addi- tional dialogue is required to explain the meaning of basic concepts such as "blood quality," "slow metabolism," or "sweet taste" in Tibetan medical terms. More work needs to be done to create a lan- guage that allows for clear and construc- tlve dialogue between systems. Practitioners of natural medicine need to become more sophisticated in the lan- guage of allopathic medicine rather than using it as an inaccurate convenience or as a way to pass in the health care system. Allopathic physicians and researchers need truly to understand the approach of natural medicine rather than seeing it as a collection of therapeutic devices that can be cut and pasted into the existing paradigm. When this work is fully accom- plished, we can reach a point where dif- ferent systems of medicine can act independently or in a complementary fashion where appropriate for a patient's condition. Once freed from the dangers of hegemony and dedicated to equality, "complementary medicine" will fulfill its promise in broadening American health care. □ References 1. Lynn, R.B., Freeman, L.S. Irritable bowel syndrome. In: Fauci, A.S., et al. (eds.), Harri- son's Principles of Internal Medicine, 14th edition. New York: McGraw-Hill, 1998, pp. 1646-1648. 2. Glanze, W., et al. The Mosby Medical Encyclo- pedia. New York: Penguin Books, 1992, p. 433. 3. Heuman, D., Mills, A., McGuire, H. Gastroen- terology. Philadelphia: W.B. Saunders, 1997, pp. 121-122. 4. LaMont, T.J., Isselbacher, K.J. Irritable bowel syndrome. In: Isselbacher, K.J., et al. {eds.), Harrison's Principles of Internal Medicine, 13th edition. New York: McGraw-Hill, 1994, pp. 1421-1422. 5. Tsarong, T.J. Handbook of Traditional Tibetan Drugs: Their Nomenclature, Composition, Use and Dosage. Kalimpong, India: Tibetan Medical Publications, 1986, pp. 1-88. Eliot Tokar is a New York City-based practi- tioner of traditional Asian medicine. Ariana Vora was the 1997-1998 National Coordina- tor of the American Medical Student Associa- tion's National Project on Complementary and Alternative Medicine. She is currently a student at Mt. Sinai School of Medicine, New York, New York.