Introduction
On a plain on the outskirts of Mandalay,Footnote 1 the last royal capital of the Burmans,Footnote 2 located at the core of Myanmar, stands a majestic white building which contrasts with the one-storey brick houses and the green fields of the neighbourhood. A large sign at the front indicates that it is the ‘University of Traditional Medicine’. Close by, and part of the same compound, is also a traditional medical hospital, a medicine factory, a medicinal plant garden, and a museum.
When I attempted to visit the University as part of my study on the state project to ‘valorize traditional medicine’, the quintessence of which this complex represents, I was denied access to the building for reasons related to ‘concerns about foreigners appropriating our local knowledge for themselves’. Fair enough, I said to myself, reflecting on how much this attitude was in tune with the historical and social background of the project.
The valorization of ‘Myanmar traditional medicine’ (taing-yin hsay pyinnya, ‘knowledge of the medicine of the country’) is a project that was launched by the Burmese government in 1953 in the aftermath of independence from the British. Later supported by the World Health Organization (WHO), it is still ongoing. This project consists of integrating traditional medicine within the national health system alongside biomedicine (ingaleik hsay pyinnya, ‘knowledge of the medicine of the British’), and institutionalizing, standardizing, and ‘modernizing’ the training, practice, and production of medicines.
The government justified this project by asserting the importance of protecting traditional medicine: a precious ‘national heritage’ that had contributed to maintaining people's health for centuries but which was vanishing, partly because it had been neglected by the British but also because it had been passed down through a plurality of lineages using an esoteric language. The government wanted traditional medicine to attain the standard and popularity of Western medicine and also to fill the gaps where Western medicine was inaccessible. We read here about a public health goal tinged with a certain anti-colonialist sentiment, which was very much part of the nation-building process happening at that time. Indeed, the valorization of traditional medicine was presented in official discourses as an important contribution to the building of a unified and independent nation, committed to the preservation of traditional culture while also being modern and developed (ibid.)
The valorization—via institutionalization and modernization—of traditional medicine to achieve the double goal of improving the public health system and contributing to nation-building has been attested to and studied in many other Asian and Southeast Asian countries (see below). In the case of Myanmar, though, no such study exists. With my work I therefore intend to fill this gap by examining the specificity of the context of Myanmar using heritage studies as my analytic lens. In particular, I argue that another unspoken motivation was hidden in this valorization project: the Burmanization of the country. Indeed, in the context of Myanmar, to unify the country means to Burmanize it—to grant domination and control of the Burman majority over the country's minorities. I argue and want to show that the valorization of traditional medicine is part of this very process of Burmanization, as much as it represents an effort to gain independence from the West and an attempt to improve public health. The aim here is to examine how these different forces coexist and contrast with one another, alongside the obligation to comply with biomedical practices and requirements, and to show how this interplay shapes the valorization of the country's medical heritage.
To carry my reflection forward, I adopt the suggestions of Bindi (Reference Bindi2013), Perrin (Reference Perrin2013), and Calderon (Reference Calderón2013), as well as of Bideau and Kilani (Reference Bideau and Kilani2012), that a heritage is shaped according to the image of the state that the actors involved want to display, and which they craft according to specific agendas and constraints. According to Bindi and Perrin, the transformation of the heritage is performed through ‘selective transmission’ (Bindi Reference Bindi2013, 3) whereby the only elements selected are those which convey the aspects of identity that represent the culture one wants to foreground, as also shown by Ashworth (Reference Ashworth, Brosius and Polit2011) and Brosius and Polit (Reference Brosius, Polit, Brosius and Polit2011), while those perceived as problematic are excised. Equally interesting is the fact that, as Bindi (ibid.) argues, this selective process is often hidden by the heritage-making process itself, which gives the illusion of consent, deadening the multivocality as well as the differences that characterize both the agents of the process and its receivers. A similar idea is also expressed by Bideau and Kilani (Reference Bideau and Kilani2012) who state that heritage and heritage-making have different meanings for different people, but that the tensions arising from this are made invisible in the application. In the Myanmar context, Kraak (Reference Kraak2018b, 1010) suggests that ‘intentions are often not one-dimensional but multi-layered and might be strategically foregrounded or hidden, depending on the context’.
I maintain that in order to better understand the ‘agendas and constraints’ shaping the valorization of traditional medicine, it is important to pay attention to the phenomenon of Burmanization in that it represents the socio-political ecosystem in which the process is carried out. Moreover, Burmanization, very much like the valorization of traditional medicine, is, strictu sensu, the valorization of a heritage—the making of a heritage—at the expenses of others, as compellingly shown by Houtman (Reference Houtman1999).
Myanmar is composed of a central region inhabited mainly by Burmans, who are the main ethnic group of the country, and several peripheral regions and states inhabited by minority ethnic groups: Rakhine, Chin, Kachin, Mon, Kaya, Karen, and Shan. The main religion of the country is Theravada Buddhism, which is embraced by approximately 89 per cent of the population. Groups of Muslims, Hindus, and Christians are scattered everywhere, but the Kachin and Chin states host the largest concentration of Christians, while Rakhine state and Yangon host large Muslim communities. Myanmar had a succession of royal dynasties before being colonized by the British between 1886 and 1948. Soon after independence, the military junta seized power, holding on to it until 2011 when a semi-civil government was established. The democratic transition—at least in name—was completed in 2015 when the National League of Democracy overwhelmingly won at the polling booths.
Ever since independence, Myanmar politics has been characterized by strong centralization and a hierarchical relationship between the centre and its periphery, with the central government, constituted of Burmans, trying to dominate the other states and regions. The perpetration of control and homogenization has followed different routes, including internal displacements and the systematic persecution of ethnic minority peoples, the negotiation of ceasefires with ethnic minority groups, a ban on teaching many minority languages in schools (Philp and Mercer Reference Philp and Mercer1999, 28), and replacing the names of streets and buildings around the country with Burman names (Philp and Mercer Reference Philp and Mercer2002, 1599; Houtman Reference Houtman1999, 47). This process of domination has become stronger since the 1980s and 1990s, with the coming to power of Ne Win and later Than Shwe. A strong political propaganda for national unity centred around the precepts of one ethnicity, one religion, and one language was then launched (Pum Za Mang Reference Mang2016, 60 and 69). The idea that was promoted is that all people in Myanmar share the same blood as they all descend from a Mongolian tribe,Footnote 3 and that it was the British who divided them. The main unification tool used by the rulers from that time onwards was what Houtman has termed the ‘Myanmafication’ of Buddhism, the nationwide valorization of the Burman-Buddhism cultural heritage, through the building and restoration of monuments and temples (Houtman Reference Houtman1999; Rozenberg Reference Rozenberg2001, 108 and 116), including in areas in open conflict with the regime (Hayami Reference Hayami2011, 1102), and the neglect, even destruction, of the heritage of minority groups (Philp and Mercer Reference Philp and Mercer2002, 1601; Muzaini and Minca Reference Muzaini, Minca, Muzaini and Minca2018, 1).
The choice of Buddhism as the tool of unification and domination rests on the fact that Buddhism is the religion of the majority and represents the hinge on which Burman daily life revolves. Buddhism also represents a powerful source of legitimation, which is what the government was missing. By building and repairing pagodas, post-independence rulers provided people with the opportunity for merit-making; in doing so, they also situated themselves in a continuous line from the monarchs, who historically embraced the role of promoters and supporters of the religion (Houtman Reference Houtman1999; Kraak Reference Kraak2018a, 116). Moreover, the focus on Buddhism was also related to the attempt to tighten state control over the monastic order and religious practices, which led to the formation of the Buddhist reform council—the Congregation of the Sangha of All Orders for Purification, Perpetuation and Propagation of the Sasana—by Ne Win's regime in 1980. As described by Hayami (Reference Hayami2011, 1091), the state was alarmed by the increase in popularity of politically inclined monks and of religious millenarianist and messianic groups practising esoteric arts, notably magic diagrams and alchemy. It thus started a ‘purification’ campaign intended to divorce Buddhism from these secular ‘worldly practices’ so as to bring it back to its supposed original purity and focus on ‘otherworldly goals’ (Tosa Reference Tosa and Skidmore2005).
The strict connection between the state and Buddhism has extended beyond the military, although in a less overt way, for instance, in Aung San Su Kyi's promulgation of Buddhism as a tool for the revolution of the spirits (Houtman Reference Houtman1999). Moreover, with the economic opening up of the country, most notably from 2011, the emphasis on Buddhism has also become a strategy to attract tourists and to gain international appreciation and recognition (Philp and Mercer Reference Philp and Mercer1999, 35), demonstrating how spiritual capital can be translated into, and manifest itself as, economic capital (Yew-Foong et al. Reference Yew-Foong, Hsiao, Peycam, Yew-Foong, Hsiao and Peycam2017, 4).
By valorizing selected aspects of cultural heritage as described in the previous paragraphs, the state has tried to create a sense of shared history and continuity with the past, a sense of national identity (Philp and Mercer Reference Philp and Mercer2002), in order to build that ‘imagined community’ that is a nation (Anderson Reference Anderson1991). In fact, Myanmafication was intended as a ‘civilization act’ (Houtman Reference Houtman1999, 92) aimed at moulding ‘a coherent, Burmese [Burman], Buddhist identity shared by all inhabitants of the modern country through the elimination or synthesis of racial, cultural, and religious difference’ (ibid., 44).
At the same time, one should not forget that building a strong Burmese national identity was not only important for the government in order to maintain its grip on the country, but also to protect it from the external threat from ‘neo-colonialists’ and ‘cultural imperialists’, and to preserve its ‘Asian’ values (Philp and Mercer Reference Philp and Mercer2002, 1592). This protectionist attitude has been reflected in the economic sector too, which has had the consequence of precluding foreign investment and international aid. This started to become apparent only in 2008, in the aftermath of the cyclone Nargis. The paradox is that, despite attempts to be independent from the West, the West has always remained, and is increasingly, part of the game. Works on heritage, focused on the restoration of Buddhist temples and on urban architecture, show that the preservation of heritage always implies a dialogue with the West. With globalization and the establishment of UNESCO, the need to comply with Western criteria in order for a cultural object to be internationally legitimized has increased, all the more so since the country started promoting tourism in 1996 (with the ‘Visit Myanmar’ year) and to expand its economy beyond its national borders (Kraak Reference Kraak2018a and Reference Kraak2018b; Philp and Mercer Reference Philp and Mercer2002). Something different, but also very significant, is happening in the context of urban planning, another major aspect of nation-building. In the cities of Mandalay and Yangon, the decision has been made to keep old, religious, monarchical, and colonial buildings, but also to build new, modern ones. This choice resonates with the image the state wants to project of a modern and developed society which nevertheless respects tradition. It is also a strategy to attract tourists, to whom this mix is appealing (Girke Reference Girke2015; Lin Roberts Reference Lin Roberts, Yew-Foong, Hsiao and Peycam2017).
The fact that the valorization of traditional medicine has been implemented in this context of Burmanization is not trivial. Acknowledging this context, the promotion of traditional medicine as a ‘national heritage’ cannot be read as anything other than a political act. I argue, and want to show, that the creation and spread of a national medicine is part of this very process of Myanmafication, much like the spread of other aspects of Burman civilization, notably Buddhism. I maintain that medicine, like Buddhism, represents a source of legitimacy, power, and civilization. Yet, like Buddhism, medicine is subject to the pressures of globalization, forcing its compliance with global norms which, for medicine, are dictated by WHO. Medicine, though, at least in the form of medical products, differs—to a certain extent—from Buddhist architecture in terms of its mobility and commerciality, which inscribes it in a market with a life on its own, dictated by its own rules and values (Coderey and Pordié, Reference Coderey and Pordié2019). Medicine further differs from Buddhism in regard to the position it occupies in the country's political economy. With the main preoccupation of the state having always been the maintenance of power and control over the periphery, its political economy has been managed accordingly, with most of the GDP going to border controls, defence, economic activities enriching the army, or ensuring its legitimacy such as sponsoring Buddhism, with precious little directed to sectors such as health and education. Until today, the health sector has seldom received more than 2.8 per cent of the GDP (Coderey Reference Coderey, Simpson, Farrelly and Holliday2017). Thus, Burmanization, as the context in which the valorization of traditional medicine is carried out, shapes the project in its motivations but also in its limitations.
In this article, I thus reflect on the valorization and promotion of Myanmar traditional medicine as a national heritage and examine how the nation-building process coexists and contrasts with its inscription within a global system of biomedical governance in the shaping of the medical heritage. Embracing the concept of ‘selective transmission’ proposed by Bindi and Perrin, I interrogate the question of which medical heritage is valorized in Myanmar, which aspects are selected, as well as which are excluded and why. In particular, I examine how this selection deals with ethnic and religious diversity, with Buddhist hegemony, and with the modern-tradition dyad of the need to preserve tradition but also to comply with biomedicine. Given that the core role of Myanmafication is the valorization of Buddhism, I also ask how medicine and the nationalization of medicine relates to Buddhism. This is all the more important given that Buddhism is increasingly promoted as otherworldly, separate from worldly practices, which is how medicine is categorized.
To do so, I will describe the implementation of the project across all its phases and discuss how it has evolved over time, in tune with the political and economic transformations of the country. After all, as Smith (Reference Smith, Hsiao, Yew-Foong and Peycam2017, 16) reminds us, ‘heritage is a cultural performance, in which the meaning of the past for the present is continually recreated and reinterpreted to address the political and social needs and problems of the present’. Describing the project and its evolution will reveal to what extent the project has been successful in meeting its goals.
To complement this first part, I will now examine how people—healers and manufacturers—have responded to this valorization project, thus providing their own contribution to its success or failure. It is all the more important to take this response into consideration, given that the project comes from the state, that it is a top-down imposition, and that heritage and heritage-making are about the selection, inclusion, and exclusion, as well as legitimation and delegitimation, of people, knowledge, and practices and is thus likely to be contested (Philp and Mercer Reference Philp and Mercer2002, 1588; Smith Reference Smith, Hsiao, Yew-Foong and Peycam2017, 26). I will thus examine how the project has been integrated into people's lives, or, in Girke's (Reference Girke2015, 76) terms, how the ‘thin heritage’—the technocratic discourse—has affected the ‘thick heritage’—the lived heritage.
The study of the valorization of traditional medicine in the Asian context
Most of the authors who have studied the phenomenon of the valorization and promotion of traditional medicine in other Asian countries highlight the association of the project to nation-building which, in most cases, corresponds to the detachment from colonial powers (see Adams Reference Adams, Nichter and Lock2002; Pordié Reference Pordié2009; Samuel Reference Samuel2013; Saxer Reference Saxer2012 and Reference Saxer2013 on Tibetan medicine; Monnais, Thompson and Wahlberg Reference Monnais, Thompson and Wahlberg2012 on Vietnamese medicine; Salguero Reference Salguero2016 on Thai medicine; Xu Reference Xu1997; Hsu Reference Hsu1999, Reference Hsu2001; Taylor Reference Taylor2005 on China; and Ma Reference Ma2010 on Korea). In most cases, what is stressed in the nation-building process is the fact that the valorization of traditional medicine takes shape through a paradoxical relationship with the West and the medicine it introduced. Indeed, the project of valorization often originates as a nationalistic response in reaction to and as a defence against biomedicine and the West. That said, with biomedicine being the global standard by to assess the value of other medical traditions, adapting to the biomedical system is the only way for traditional medicine to be legitimized (Adams Reference Adams, Nichter and Lock2002; Saxer Reference Saxer2013; Craig Reference Craig2012; Pordié Reference Pordié2011).
All authors stress how this political game creates a tension between the need to preserve and highlight one's specificity and the obligation to conform to biomedicine, which actually requires giving up part of that specificity. And this is all the more so given that traditional medicines and biomedicine rely on epistemes and paradigms which are different, if not incommensurable (Kuhn Reference Kuhn1970; Saxer Reference Saxer2013; Craig Reference Craig2012). Most agree that something is lost in the process of adaptation—notably through the reduction of ingredients and the neutralization of magico-religious aspects (Adams Reference Adams, Nichter and Lock2002; Pordié Reference Pordié2009; Samuel Reference Samuel2013; Saxer Reference Saxer2012 and Reference Saxer2013). However, others see this as a gain. For instance, Laurent Pordié and Jean-Paul Gaudillière (Reference Pordié and Gaudillière2014) have previously shown how manufacturers have reinvented their products by integrating new elements from the biomedical paradigm, in order to make them more efficacious and marketable. It must be said, however, that not all authors see this transformation as an expression of colonization from Western medicine; Taylor (Reference Taylor2005) and Wahlberg (Reference Wahlberg2014) both highlight that although biomedicine represents a hostile and oppressive force, it was nevertheless valued as a symbol of science that could enhance local medicine through modernization and the eradication of elements of superstition and quackery.
The tension between protecting oneself and accepting change has been negotiated differently by different countries, depending on their local, specific socio-political-economic configurations and manufacturers’ market ambitions, suggesting that there is a recontextualization of standardized ‘global forms’ (Collier and Ong Reference Collier, Ong, Collier and Ong2005, 4; Saxer Reference Saxer2013). Although most scholars recognize that the pressure to adjust to biomedical standards is real, some studies—mainly on Tibetan medicine (Adams Reference Adams, Nichter and Lock2002; Saxer Reference Saxer2012 and Reference Saxer2013)—show that the tradition is sometimes able to negotiate some space for itself, either by relying on the limitations and weaknesses of regulatory systems or by taking advantage of the notion of heritage, as in the case of Tibetan ‘precious pills’. Although produced with purified mercury and gold, in opposition to the Chinese Good Manufacturing Practices Guidelines and drug laws, this medicine is still very much in circulation.
Few scholars, however, have addressed the fact that the valorization of traditional medicine is also related to the second dimension of the nation-building project: the need to unify and control the local population and how this relates to the obligation to conform to biomedical standards. For most countries, building a unified nation occurred through the domination by one group—often the ethnic majority—and the subjugation of other ethnic groups. To my knowledge, only Wahlberg (Reference Wahlberg2014) discusses what this means on the ground: that the medical traditions of the dominant group were favoured over those of minority groups. What has not been explored in previous studies, which I intend to reflect upon in this work, is how the domination inherent in the nation-building project has been articulated in relation to the obligation to conform to biomedical standards.
The literature also shows that different countries diverge considerably in the ways in which they developed this project and in the level of success they had, depending on the actors involved and their engagement, the way the project was received by the people, and specific economic and geographic configurations.Footnote 4 Given the socio-political context described above, the case of Myanmar is so significantly different from the other countries that it provides an important element of comparison. What has not been reflected upon, and which I intend to discuss, is the relationship between the institutional project regulated by the state and the development of the market, in particular, to what extent they go in the same direction and to what extent they contrast with each other, especially in relation to nation-building.
The myth of a national medicine
In 1953, five years after gaining independence, the Burmese government started its project to valorize traditional medicine. Looking back at the motivations grounding the project, General Than Shwe (2010, reported by the Myanmar Times, 6 December 2010) explained that Myanmar traditional medicine is:
a heritage with high historical value […] national medicine which has been used and developed according to Myanmar's climate patterns, geographical features, culture, customs and traditions, preserved in the course of Myanmar history since monarchical periods.
He further commented that this heritage was declining because it had been neglected by the British who instead privileged the medicine they had introduced, but also because of the multiplication of lineages and schools transmitting knowledge via a quite esoteric—and thus barely accessible—language. At least two aspects of this statement are historically wrong and reflect an attempt to rewrite history by hiding both its complexity and the political motivations behind the project. The first one regards the very existence of a national medicine, and the second is the assertion that this medicine had been neglected by the British.
The national medicine the government is referring to—the one it wanted to valorize—did not actually exist at that time. In fact, when the Burmese government initiated its valorization programme, there was not one national medicine, but rather a plurality of medical traditions associated with different geographical regions, ethnic groups, and religions. For its valorization project, the Burmese government only considered the medical traditions of Buddhist groups, wilfully neglecting all others. This means that the medicine the government intended to valorize and spread was not a national medicine that included all those different traditions, as the term taing-yin hsay (‘medicine of the country’, ‘local medicine’) chosen to define it would suggest, but the medicine of the Buddhist regions, of the Burmans, which it intended to make national. I maintain that the expression ‘taing-yin hsay’ not only unifies and flattens the differences, but also marks the local character of the medicine, its difference to the one brought by the colonizer. That said, the expression used in the official translations in English is ‘traditional medicine’ since this is the denomination mainly used by global health actors to refer to this kind of medicine. This expression also has the advantage of providing the illusion that it has ancient roots and that it is part of the entire country's heritage. To be really precise, it was not even ‘the medicine of the Buddhist regions, of the Burmans’ that the state wanted to valorize, but only part of it. There is thus a second level of selection, which will be clarified in the following sections where I will describe the implementation of the project. To better appreciate such selection, here I will briefly describe what this medicine from Buddhist-Burman communities consisted of before being formalized and, to a certain extent, still consists of outside formalization.
The traditional medicine of the Buddhist regions is a kaleidoscopic ensemble of concepts and practices conveyed through a multiplicity of lineages of masters, schools, and manuscripts, constantly reshaped by daily practice. In this ensemble it is possible to distinguish three main fields of practices.Footnote 5 First, the use of food and natural remedies of vegetal, animal, and mineral origin for the prevention and treatment of natural diseases (yawga), caused by an imbalance of the elements of the body (fire, air, water, and earth) under the impact of unfavourable karma, mental stress, a change in climate, or ingestion of inappropriate food. This knowledge is partly based on Buddhist medical knowledge, Ayurveda, and other local knowledge. If a basic understanding of dietary principles and home-made remedies (called hsaymidaw or ‘quick fire remedies’) is widespread among the population, only specialists who have been trained by a master have the necessary skills to deal with many kinds of disorders. These specialists make their diagnosis by observing the patient, enquiring about their symptoms as well as alimentary and sleeping habits, testing the pulse, and making astrological calculations. Treatments include indigenous remedies they prepare themselves by using raw materials collected from the forest or purchased at the market. Some masters only prepare their remedies under auspicious planetary conditions and recite some verbal formula to further increase their efficacy. A second common therapeutic tradition is the art of massage and bone-setting (a hneit pynnyia). This art is often passed down through generations of families but can also be learned from masters, sometimes in combination with knowledge of herbal medicine. A third local healing tradition consists of a set of practices known as weikza (lit. ‘knowledge’) (Rozenberg Reference Rozenberg2001; Coderey Reference Coderey2012; Patton Reference Patton2018). These include the recitation of verbal formulae, the distribution of medicines produced through alchemical processes, and the delivery of small paper or metal sheets inscribed with numbers or letters with Buddhist or cosmological meaning that the patient must ingest or wear as amulets. Although weikza techniques are also used to cure natural diseases, they are primarily employed to protect and cure people from supernatural aggressions (payawga) emanating from spirits, witches, or sorcerers. Besides their therapeutic functions, these practices are also supposed to help the practitioner acquire supernatural powers and become a weikza—one who is able to extend one's life until the arrival of the next Buddha and directly enter nirvana through his worship. Weikza practices are the object of specific training that required initiation into a semi-secret congregation called ‘gaing’, originally founded by an accomplished weikza. Some congregations have a messianic and millenarianist dimension as they are centred on a weikza deemed to be the future Buddha or the king of the universe who will come and restore peace by promoting respect for Buddhist law (Schober Reference Schober1988; Pranke Reference Pranke and Lopez1995). This dimension became particularly intense during the period of colonization and several groups were established at that time, motivated by the wish to protect the nation and their religion from the British (Ferguson and Mendelson Reference Ferguson and Mendelson1981).Footnote 6 It continued to persist long after independence, given the dissatisfaction of the people with the country's rulers (Rozenberg Reference Rozenberg2001; Foxeus Reference Foxeus2011). Because of this, the state has seen in these groups a potential threat to its authority and has always tried to marginalize them. Ferguson and Mendelson (Reference Ferguson and Mendelson1981, 74) affirm that under Ne Win, the state tried to limit the weikza by censoring all books related to them and forbidding members of these groups from naming the future king. In 1979, the regime banned the rising Shwei Yin Kyaw Gaing, a popular esoteric sect, and arrested its leader, who had gained a large following, including among politicians and merchants (Hayami Reference Hayami2011, 1096).
The second historical error present in Than Shwe's statement is the reference to ‘neglect from the British’. In fact, it is not entirely true that the British neglected traditional medicine. As described by Aung-Thwin (Reference Aung-Thwin2010, 152–155), the British actually paid a certain amount of attention to it, and even envisioned the possibility of integrating it into the health system. In 1928, plans for the formation of a Burmese Medical Council, a Medical Research Board, the opening of teaching hospitals, and the introduction of standardized training, which only included subjects ‘considered as medical’ (that is, only herbal medicine), had actually begun. Yet, as also noted by Aung-Thwin (Reference Aung-Thwin2010, 164–165), this project was as much an initiative to protect this tradition as it was a state attempt to control the movement and influence of indigenous healers. That said, this plan was never realized. In 1930–32, the strongest anticolonial rebellion the country had ever witnessed exploded in Lower Burma and spread right up to the Shan state. The leader of this rebellion Saya San promised supporters that as their new king, he would restore the authority of the Burmese monarchy, revitalize the Buddhist religion, and expel the British. He also assured his followers that they would be protected by his magical charms and tattoos. As argued by Aung-Thwin (Reference Aung-Thwin2010, 170–171), in the eyes of the British, this event created a strong connection between healing powers, especially tattoos and charms, and the Burmese impulse to resist authority. Any idea of the possible integration of indigenous medicine within the existing health-care system was thus abandoned. Although the project was never realized, my data suggest that that plan provided the groundwork for the institutionalization later carried out by the Burmese government. In particular, as we will see, the conflation of ‘non-medical’ elements with those that threatened order, already seen with the British, play key roles in shaping the process. This legacy, however, has never been officially recognized by the Burmese government, either in public speeches or in written documents. I maintain that this omission is motivated by the wish to perpetuate the myth of British neglect and to justify the project by presenting it as a benevolent solution, crafted by the local government to repair the outcome of that neglect.Footnote 7
Valorization of traditional medicine
In 1953, a Traditional Medicine promotion office and a Traditional Medical Council were created to coordinate and manage the project to valorize traditional medicine. Later, in 1989, the Department of Traditional Medicine was established as a separate department under the auspices of the Ministry of Health. It is important to highlight that the Ministry of Health operates according to the criteria of Western medicine, as it operates in collaboration with the WHO. This hierarchical structure thus strengthens biomedical domination over traditional medicine, which, as we have seen, was already part of British plans. It was further amplified after the 1970s, after the project received the support of the WHO in 1970.Footnote 8 This biomedical hegemony does not, however, eliminate the state's motivations regarding nation-building.
In the following sections, I will describe the implementation of the different components of the project: the institutionalization, regulation, and ‘modernization’ of the teaching, medical practices, and production of medicines. I intend to show that such implementation is shaped by the interplay and confluence between the need to cope with the biomedical framework and nation-building aspirations, while being limited by a context economically unfavourable to medicine and with a limited capacity for implementing regulations.
Institutionalization and standardization of medical training
The first initiative taken by the promotion committee was the institutionalization and standardization of traditional medicine training. An institute of traditional medicine was opened in 1967 in Mandalay, followed by a second one in Yangon. Later, in 2001, a university was opened in Mandalay, leading to the closure of the other two institutes. Mandalay was the last capital—the political and cultural centre—of the kingdom of Burma before the arrival of the British and was, and still is, the centre of Burman-Buddhist culture. The universities of Western medicine were based in Yangon, the British capital of colonial Burma. I argue that, by choosing Mandalay, the government not only intended to highlight the local and traditional character of the medicine taught there and its difference from that brought by the British, but also to emphasize the domination of Burman culture over those of minority ethnic groups. The exclusion of the minorities is strengthened both by the centralization of the educational provision and the fact that the training is conducted in Burmese and English, which makes it difficult for those from remote regions and those who do not speak Burmese to attend.
A highly ranked doctor from the institute, with whom I spoke in 2014, explained to me that the curriculum for these institutes had been crafted by the Traditional Medicine Council, in collaboration with a group of specialists in both traditional and Western medicine. A closer look at the curriculum suggests an attempt to create a ‘hybrid medicine’ (Taylor Reference Taylor2005, 14) which preserves traditional aspects, giving it a local and Asian flavour, while also trying to comply with a Western-based idea of what medicine is and which is also exempt from the elements perceived as potentially threatening to the power of the state. This is done by selecting what we could call ‘good’ heritage and separating it from ‘bad’ heritage through a process of ‘purification’ and by adding new components chosen for their scientific and/or internationally recognized character.
The curriculum, the doctor explained me, includes three main fields. The first is the ‘core of traditional medicine’. Initially three nara, or ‘methods’, were selected as representing this ‘core’: betissa nara (Buddhist medical knowledge concerning the body and the dichotomy of hot and cold), detissa nara (the medical knowledge of Ayurveda with its conception of disease in terms of imbalance among three dosas: kapha, vata, and pitta), and nakarta nara (astronomy and astrology). These three methods were used to provide dietary prescriptions and to compose remedies using ingredients of vegetal, animal, and mineral origin for the cure of natural disorders. In 1976, a fourth nara was added: the weikzandara nara, conceived of as the use of alchemical products to cure natural diseases.
It is important to highlight that weikza practices were initially excluded and that in the second incarnation, only one of them—alchemy—has been added, in a ‘purified’ version at that. That weikza practices were excluded is unsurprising: they are incompatible with the Western conception of medicine and out of sync with the image of modernity that the state desires to exhibit to the world. Moreover, they are also perceived as a potential threat to the power of the state. This begs the question of why, in its second incarnation, was alchemy added? When asked about this, the highly ranked doctor mentioned above explained that ‘the Traditional Medicine Council realized that it was important to keep also alchemy because that too was part of traditional medicine and especially because they realized—and it had been proven—that it was really powerful’. If this statement suggests an acknowledgement of the value of heritage, one could argue that magic diagrams and mantra were as much a part of it. I suggest that alchemy was the only weikza practice that could be integrated into the curriculum because, unlike other techniques that were used almost exclusively for the acquisition of extraordinary powers and protection against the supernatural, alchemy was used to cure natural disorders, which are the only ones recognized by the biomedical paradigm. Moreover, alchemical remedies are—by their nature and modality of action—closer to biomedical drugs than diagrams and mantras, whose modality of action is more esoteric. Given that the ambition of the valorization process is for traditional medicine not only to complement but, hopefully, to even surpass biomedicine, we could read here an attempt to ‘fight Western medicine on its own terms’ as Lei (Reference Lei1999) has suggested regarding Chinese practitioners (Taylor Reference Taylor2005, 27). This seems all the more plausible given that, as we will see, alchemy is mainly used to cure diseases that are incurable with biomedical methods, most notably HIV. It is also possible that by submitting the practice to a standardized system of training, the state was hoping to reduce its potential dangers and the risk that people might be harmed, since, according to Western medicine, heavy metals are toxic. Finally, I believe that by supporting a more scientific version of the practice, the state may have hoped to contribute to the marginalization of the original version and its millenarianist nature which was growing in parallel to the dissatisfaction people harboured against the military junta. Whatever the reasons for the inclusion of alchemy in the curriculum, the fact that it happened shows that there are limits to the submission to and compliance with the biomedical frame, and that the anti-colonial dimension still has a certain weight in the selection process. It also shows that the neutralization of a practice does not always happen through its elimination or exclusion, but sometimes also through its inclusion and transformation.
Besides the ‘core of traditional medicine’, two other fields are a part of the curriculum. First are subjects taken from Western medical science: chemistry, physics, biology, botany, zoology, and biomedical diagnostic techniques—added, I maintain, to make traditional medicine more modern and scientific, hence closer to international standards. Second, panchakarma (Ayurvedic massage) and Chinese acupuncture were added, I suspect, to strengthen the ‘Asian character’ of this medicine and to support its legitimacy and respectability by connecting it to the two most respected and internationally recognized Asian medical traditions to which those techniques belong.
Despite the hybrid character of the medicine that has been created, it is still presented as ‘traditional’. Despite the diverse origins of its different components, only the local roots and entanglement with Buddhism are underscored in both the textbooks and discourses by state authorities.
The regulation and institutionalization of medical practice
The second step of the valorization process consisted of the regulation and institutionalization of medical practice. In order to ensure that only the ‘good heritage’—the knowledge taught at the state institutes—would be passed on and practised and to ‘reduce harm caused by quacks’ (traditional doctor, Mandalay, 2014), the Department of Traditional Medicine established a licence and introduced a law whereby only people holding that licence would be allowed to practise. My informants explain that initially the licence was granted to individuals who had completed their training in one of the state-run teaching institutes, to traditional doctors who had attended a short training course in one of the health centres dispersed across the country, as well as to experienced masters over the age of 80 whose healing skills had been attested to and proven. In 2008, however, the Department of Traditional Medicine changed the law and established the university as the only viable way to obtain a licence; all other avenues, lineages, and schools were outlawed. This regulation increases centralization and marginalization, while invalidating the actors who for centuries have been the main vehicles of local medical traditions.
Information concerning the legal obligation to possess the licence in order to practise spread all over the country. That said, all my informants agree that the pressure is significantly higher in urban than in rural areas where there is greater tolerance of the presence of these traditional practitioners, given that they are usually the only medical resource available. In addition, the government has always kept an eye on weikza congregations—a clear sign of an attempt to further separate medicine from weikza and thus protect the authority of the state.
In addition to this main regulation, the Department of Traditional Medicine has also prohibited traditional doctors from administering injections, performing surgery, as well as from treating cancers and HIV. According to traditional doctors with whom I spoke, the reason is that ‘biomedical doctors want to have the prerogative over those techniques and diseases’, while biomedical doctors argue that ‘these rules are intended to prevent traditional doctors from harming patients’. If this prohibition can be seen to indicate a certain mistrust of traditional practitioners, it also represents an attempt to reinforce the boundaries between the two medicines and to confine traditional medicine to a position of inferiority, thus limiting its potential progress. While attempts to cure HIV with traditional medicine is a rather recent practice, dating only to the last 20 years or so, the use of injections seems to be a much older one, as attested to by the use of this technique by members of the Abidammadaungta, a specific movement within traditional medicine. The technique consists of producing a liquid from plant extracts and injecting it into a patient's body. In 2014, I visited one of the schools of the Abidammadaungta, located outside Mandalay, which had closed its doors in 2000 because of the ban and is now in a state of abandonment. Nevertheless, my observations are that the enforcement of such regulations is generally quite weak elsewhere, and the state intervenes only in case of serious problems, for example, if someone dies or is seriously injured following the intervention of a traditional practitioner.
Medical practice has not only been regulated but also, progressively, institutionalized. Starting from the 1970s, several public services such as hospitals and clinics have been established around the country, staffed by individuals trained in one of the state-run institutes. The majority of these staff also open private clinics in order to supplement the low salaries they receive in the public sector, further integrating the discourses they represent within their respective communities.
In 2008, there were a total of 14 hospitals in the country, distributed in the capitals of the different states and the main towns, as well as 43 district clinics and 213 township clinics (Skidmore Reference Skidmore, Skidmore and Wilson2008, 195). With the reform of the health system launched by former President Thein Sein in 2011, 19 additional hospitals and eight township clinics have been built, as reported to me by the directors of two township clinics. This is said to be motivated by the intention to provide health care to every citizen and to fill the gap existing in biomedical services. However, I contend that the establishment of these services in all states, including those inhabited by minority groups whose medical traditions have not been considered in the formalization project as well as those still fighting against the Burman army, is also a tool of Myanmafication, a strategy of integration and domination, much akin to the installation of Burman Buddhist pagodas in non-Burman territories (Houtman Reference Houtman1999; Hayami Reference Hayami2011, 1102). Traditional medical institutes, very much like pagodas, are a symbol of power which mark a territory, inscribing an element of Burmanness in the local community. Burmanization is strengthened by the fact that the staff operating these services are often Burman or, at least, Buddhist. This strategy echoes that of installing Burman monks connected to the regime as heads of important local monasteries in ethnic states, such as in the case of the Mon state (as described in Hayami Reference Hayami2011, 1092). The fact that medical institutes, like pagodas, also bring, ideally, some benefits in the form of health provision, much like merit-making, suggests that they also represent a strategy for legitimation. In both cases, the political intention behind the act is hidden behind, or least runs in parallel to, the official one. If the political message communicated through the establishment of these services has often been ignored, it has occasionally been challenged, notably by minority groups, through the building of their own, local, traditional medical services. The fact that this second option occurs mainly in the case of the Kachin and Karen, the most virulent opposers of the central government, is not trivial and suggests the nationalistic and identitary component of the phenomenon.
The fact that the political aspect is prioritized over the medical seems to be demonstrated by the condition of such services. Although it is the state that has developed these services, it continually fails to provide them with sufficient financial support, leaving them in rather poor conditions in terms of staffing, equipment, and supplies of medicine. Unlike Buddhism, medicine does not occupy a privileged place in regard to state funding and, unlike Buddhist monuments, traditional medical clinics do not represent economic capital as they hold no attraction for tourists.
The medicine practised in these services is mainly focused on herbal medicines and massage, and therefore largely reflects that taught in the state institutes. In my observations of several consultations in the hospital in Thandwe, my main field site, doctors establish their diagnosis by observing the patient and enquiring about their symptoms, their sleep, eating, and digestive habits. They also test the patient's pulse and blood pressure using a stethoscope and blood pressure meter respectively. Once they have identified the disorder, they give the patient some medicines along with dietary suggestions. The medicines used by this service are ready-made products, in the form of powders provided by a state-owned factory located in Mandalay. The use of mantras and diagrams is absent, given that these techniques are not taught in public institutes. Interestingly, astrology and alchemy are banned from public health-care facilities: both are considered ‘non-scientific’, and alchemy, additionally, is ‘potentially dangerous to human health because of the toxic component of its substances’, as several doctors explained. The ban on these practices contrasts with the fact that both of them are taught at the university. This suggests that in the services, the state's need to conform to biomedical criteria is stronger, given that medical services are institutionally integrated into the global system of governance whose rules are monitored through a reporting system. Significantly also, embracing the biomedical criteria is concordant with the image of the modern state that the government wants to display.Footnote 9 Private services, on the other hand—precisely because they lack such exposure—are minimally regulated and exempt from any explicit rules regarding the use of astrology and alchemy. Moreover, the large number of private healers, and the absence of a reporting system, decreases the possibility of a strict control system, especially in the semi-urban and rural areas.
Preservation of natural resources and regulation of medical products
The third sector that has been the object of the state's attention is that of medicinal products. Here, the emphasis has been on the preservation of natural resources and the development of a quality control system.
The state has opened nine medicinal gardens—the largest of which was founded in the capital Naypyidaw in 2008—with the intention of preventing the disappearance of precious resources and of making good quality raw materials easily accessible to public factories. In addition, the government has been trying to raise awareness of the importance of protecting natural resources, not only, but certainly also, for nationalistic purposes. At a conference of traditional medicine, which took place on 5 December 2010, the chairman of the National Health Committee stated (as reported by the Myanmar Times, 6 December 2010):
So, I would like to urge you traditional medicine practitioners to conserve the nation's sources of herbs and medicinal products with a sense of national cause to avoid possible extinction and to ensure sustainable production of traditional medicines without reliance on foreign products.
Another initiative by the government was the opening of two museums of traditional medicine, one in Mandalay, and the other, more recent one in the new capital of Naypyidaw. These museums mainly display raw materials from animal, plant, mineral, and aquatic sources used in traditional medicine, alongside herbarium sheets, with the aim of allowing the public to learn about the roots and the current situation of medical practice. It would seem to operate in-between an educational and a memorial space: a place to preserve the memory of the past, of what existed before, and which has now evolved. More than other aspects of the valorization project, the museification of medical knowledge seems to operate as an instrument of patrimonialization. Indeed, as Philp and Mercer (Reference Philp and Mercer2002, 1598) remind us, ‘museums play a crucial role in conserving and displaying the nation as they are sites for the dissemination of particular constructions of “knowledge” produced by those in power’.
Besides these efforts at preservation, the Department of Traditional Medicine has taken a series of initiatives meant to improve the quality and safety of medicinal products and to increase their accessibility to the population. This effort has grown in parallel with the development of the medicinal market, which has occurred independently of the state project. Although this development is far from negligible, it is, by far, less important than those of other Asian countries, such as China, India, Vietnam, and Tibet. The circulation of Myanmar medicines is still very much limited to within the country, and when it does cross the borders, it is mainly to neighbouring countries—notably Thailand, China, Malaysia, and Singapore—where there is a significant Burmese diaspora.
With the development of the market, two kinds of products have been brought to the fore: powdered medicines and manufactured products. Powdered medicines are available in parahsaysain (traditional medicine shops) which exist in all villages and city markets. Shops buy the powders from retailers based in Yangon and Mandalay, which are supplied both by local agents who collect material from different parts of the country and by import/export companies trading with India, Bangladesh, Pakistan, Indonesia, China, and Singapore. Interestingly, most people, including many traditional doctors, ignore this trade and are convinced that medical products should be composed solely of local ingredients. This idea is also supported by the government and conveyed in public discourse, in order to perpetuate a ‘myth’ of local, indigenous medicine.
The Ministry of Health regulates and controls this circulation in two ways, described to me in detail by several shop owners and doctors. First, in order to open a traditional medicine shop, one needs to have a licence and for one's medical knowledge to be certified. Secondly, a standard manual containing 57 formulae, each intended for a specific category of disease, is distributed by the Department of Traditional Medicine to every shop. The regulation and standardization of both the distribution, and the combination, of medicinal substances, is intended to grant wider accessibility to good and safe medicines. It is, however, undeniable that this standardization supports the weakening of interregional, interfamilial, and interpersonal differences in the name of an emerging pan-national medicine.
As for manufactured products in the form of powders, balms, and tablets, the Department of Traditional Medicine owns two factories, one in Yangon and the other in Mandalay, that receive their supplies mainly from gardens owned by the Department of Traditional Medicine. They produce tablets that they distribute to the local market and powders they supply to the public services. However, the main bulk of the manufacturing industry is privately run, mainly by families of traditional doctors, some of whom can be traced back to the time of the kings. These manufacturers obtain their materials from retailers, private agents, and private medicinal gardens. They distribute their medicines to the local market through parahsaysain all over the country and, in the case of some—rare—prosperous companies, also to the international market.
With the intention to ‘enable the public to consume genuine quality, safe and efficacious traditional drugs’, in 1996 the Ministry of Health promulgated the traditional medicine drug law, stating that drugs produced in the country have to be registered and that the manufacturers must have licences for production. These are granted only to manufacturers operating in compliance with the Good Manufacturing Practice guidelines established by the WHO, which specify, among others, that the products should be made of a limited number of ingredients, that the ingredients must be natural, that chemicals and toxic substances (such as heavy metals) are allowed only up to a certain limit, and that all ingredients have to be listed on the packaging.
As a traditional doctor from Thandwe pointed out, ‘these regulations place several limitations on manufacturers, given that traditional pharmacopeia often requires the use of many ingredients, sometimes even of a whole plant’. Moreover, these norms completely exclude the alchemical products which not only contain heavy metals but are made with secret formulae. Hence, even if the industrial sector does not stipulate the standardization of the formulae, as it does for the powders, it does impose a certain conformity with biomedicine. This reminds one of the dilemma presented by scholars working on the restoration of Bagan, where the compliance with UNESCO criteria would mean a departure from the local understanding of restoration: such measures would preserve—‘fix’—the monument as it is, or was in its original form, but erase the living dimension of the heritage (Kraak Reference Kraak2018a and Reference Kraak2018b). In the case of medicine, compliance would lead not only to a certain standardization, but to the fixity of an already transformed object.
However, almost everyone agrees that controls are neither regular nor efficient, and in some cases laboratory checks are omitted. Some successful manufacturers from Yangon, well connected with the government, comment that inspectors are often more permissive with them than with others.
In order to further standardize and control the knowledge and practices of traditional doctors, especially in the matter of medicinal products, beginning in 2000 the Department of Traditional Medicine has been organizing an annual conference where the main members of the Association of Traditional Medicine discuss their new products. Moreover, the country participates in conferences on traditional medicines organized by ASEAN since joining in 1997 (traditional doctor, Yangon, 2014). Here too, the aim is ostensibly to share knowledge and to work towards the harmonization of regulatory practices at the international level. This move, I assume, is also motivated by the desire to strengthen the connection with other Asian medicines and also to seek regional and international recognition, something that has become increasingly important since the country opened its economy to improve its economic integration in the region. These conferences are also an opportunity for the authorities to imbue in practitioners a sense of the national cause. For instance, in the message sent by Senior General Than Shwe to participants at the 11th Myanmar Traditional Medicine Practitioners Conference in December 2010, we read:
The government has been dedicating itself to nation-building tasks hand in hand with the entire people in its bid to enable the discipline [and the] flourishing modern and developed Union of Myanmar to keep abreast of other countries in the international community. In that regard, boosting production of healthy and fit human resources is necessary for the nation…
As a particular branch of studies is something to be proud of for the national races of the Union possessing the spirit of love for the nation and the race […]
I would also like to urge medical doctors and traditional medicine practitioners to work together … to do your bit in building a new nation.
All of the foregoing cumulatively suggests that under the guise of protecting a national heritage, the state is actually crafting a new national heritage which maintains traditions but also is intended to strengthen its Asian character and, perhaps more importantly, its attempts to comply with biomedical criteria of efficiency, quality, and safety. In this way, it hopes to defend local identity, in tune with anticolonial and anti-Western sentiment, but also to be accepted by the international community. This combination opens the possibility of legitimation, but also of resistance and defiance, as in the case of alchemy. Moreover, thanks to a certain compliance with biomedicine, the newly created medicine is also free from ethnic specificities and supernatural or esoteric components, which are perceived by the state as a threat to its own power and to the image of a united and modern nation it aspires to project to the world. Biomedicalization thus goes hand in hand, and supports, nation-building and the Burmanization of the country. This said, we must note that by explaining this ‘modernization’ through the narrative of biomedical power, the state continually masks the political motivation of the project, namely Myanmafication through the valorization of a ‘purified version’ of Burman-Buddhist medicine.Footnote 10
Now, the low priority of the medical and health sectors, coupled with lax enforcement of regulations, the implementation of Myanmafication through the creation of a national medicine is fraught with limitations, creates gaps where manufacturers, sellers, and doctors jostle to their advantage, as I will discuss in the following section.
Heritage as locus of resistance: beyond the state-built heritage
How have healers, doctors, manufacturers, and sellers responded to the valorization project? The ensuing section will focus on people's perceptions of the biomedical dominance and nation-building agenda inherent in the project, and their reactions to the neutralization of regional and lineage traditions, and the consequent marginalization of the more spiritual and esoteric components of the practice.
The majority of practitioners and manufacturers involved in my study highlight that the institutionalization and regulation of traditional medicine has been shaped by the biomedical frame, attributing this to the dominant position biomedical doctors occupy within the health ministry and to the government's slant towards biomedicine rather than traditional medicine. They corroborate the subservience of traditional medicine to biomedicine by referring to the fact that biomedical doctors head the university, biomedical subjects are privileged in the curriculum, and alchemy, astrology, and injections administered by traditional medical practitioners are banned. While most agree that the standardization and regulation of the production of medicines increase their scientificity and safety, they also concur that it severely hampers the operation and organic expansion of traditional medicines.
Compared to the frustration over the apex position granted to biomedicine, there is, overall, much less concern over the ‘nationalistic’ and ‘unificatory’ thrust of the project. It is acknowledged that the institutionalization project is fundamentally a Burman operation, led by Burman people, favouring Burman practitioners, and disseminating the Burman medical tradition at the cost of the others, but only a scant few discern the move as a part of nation-building. In the same vein, the attenuation of regional differences through homogenization of the practice and the elimination of its more esoteric and spiritual components are measured against the biomedical yardstick rather than viewed as an attempt by the government to neutralize aspects that could potentially threaten its authority and the image of a modern state.
When we look behind these opinions, largely shared by the majority, the practical responses, in terms of compliance with the new system, vary greatly between individuals. This usually depends on their position in the medical and political system, their medical or commercial aims, their ideological principles, and the material conditions in which they operate.
Practitioners of traditional medicine working in public services, whose thoughts and actions are the most strongly shaped by the state regulatory system, are the ultimate ‘products’ of the institutionalization process. Highly influenced by their training, they usually embrace a standardized and, to a certain extent, modernized approach to herbal products. They generally perform their duties as they were taught to because they are both subject to a reporting system and the public exposure they attract. Their frustration stems from the limited resources the state allocates to them, which prevents them from providing a quality service and from improving their practice. A doctor from Yangon remarks: ‘The medicine we receive from the state factories are far from meeting the demand, so we often rely on products we buy from the market and we then combine them by ourselves.’ Ironically, where practice is supposed to be the most standardized, much space is left to individual initiative. The same doctor complains: ‘Our medicine has great potential; we could develop new medicines but for this we need to do research; unfortunately we do not receive any money for it, so we always work with the same medicines … The problem is that the Ministry of Health is dominated by Western medicine; we are at the bottom of the hierarchy.’ If many practitioners seem not to give weight to the prohibition on astrology and alchemy, others register concern, particularly for alchemy which is ‘banned on the justification that heavy metals are toxic’, explains a doctor from Mandalay. ‘Actually this is true,’ he states, ‘but through the alchemical process the harmfulness of the elements disappears.’ This ban is felt to be all the more unfair, given that alchemy is believed to cure HIV. This doctor, and others like him, are experimenting with this technique in their private practice.
Practitioners of traditional medicine who operate in the private sector are less restricted by regulations, and even when these apply, they are barely enforced. They therefore use their freedom to practise according to their own principles, with a great tendency to maintain individual, familial, and regional traditions, and to use practices banned in the public sector. This is mainly true for specialists trained outside official institutions, who prescribe ad hoc medicines according to methods imbibed from their masters, using powders purchased at the market. This is, however, also true for doctors trained in state-run institutes, although they rely mainly on ready-made compounds in the forms of pills or powders. For instance, a registered practitioner from Thandwe always first tries to cure her patients by prescribing the standard powders, but if there is no improvement, she resorts to adding other components, relying on an ancient manuscript inherited from her grandfather.
The absence in the private sector of explicit rules that ban astrology and alchemy leaves the door ajar for the inclusion of these techniques and many practitioners integrate them into their practice, primarily because they believe in their efficacy. Many practitioners, especially those who studied outside the university system, use astrology, which many young university graduates consider irrelevant, to determine dietary and medical prescriptions. The use of alchemy, though, is much rarer, especially among licensed healers. A practitioner explains: ‘it is a very difficult practice and at the university we just learn the basics; in order to learn more, one needs to have a further training with some “external” masters, but these are becoming rare’. Doctors involved in this practice have usually learned the art from a master external to the state system, who operates in a clandestine manner. This is notably true for those who claim to cure HIV, which is specifically proscribed. Some, however, take more risks and sell their medicines from their homes, at the market, or through other doctors. These are mainly those who, somewhat ironically, have a connection with the government, as well as those who have attained international recognition, which works as form of protection. By far the most significant case is that of the late U Shein, the most well-known alchemist in the country: he claimed to have cured several HIV patients, including foreigners, and used to show his visitors medical reports proving this, alongside several awards and diplomas granted by foreign universities. It is difficult to explain why the state does not intervene to enforce the law in these cases. Beside the weakness of the regulatory system, it is also possible that that the military gains something from this practice, for example, bribes or alchemic medicine itself. Many individuals, including those in the military, are said to use this product for rejuvenating and life-extending purposes. Moreover, we should not exclude the possibility, admittedly purely speculative, that the non-interference of the state is intentional, motivated by the nationalistic will to allow the spread of rumours about the efficacy of traditional medicine in curing HIV, thereby highlighting its superiority to Western medicine.
Doctors operating outside the system are those who are more concerned about the loss of an efficacious medical heritage, including those associated with minority ethnic groups, as a consequence of the institutionalization process. They nevertheless show a certain resignation in this regard because they see that the continuity of the tradition is problematic even outside the formal system. Indeed, as a doctor from Thandwe comments, ‘new generations are not interested in learning this practice; they want to go abroad, or have some modern job’.
Turning our attention to the production and circulation of medicines, with regard to powdered medical products we see that the standardization and centralization imposed by the government on traditional medicine has partially achieved what it set out to do. However, standardization is countered by diversification and dispersing forces, often tinged with resistance. As following the standard manual is not obligatory, the seller enjoys a certain freedom. If it is true that the majority of shops I visited have plastic bottles labelled according to the mixtures they contain, the contents of the bottles do not always correspond to what is prescribed in the manual: many sellers try to improve the formulae by adding other materials based on their own medical knowledge and the characteristics of the patient, climate, and other factors. Many rely solely on family manuals passed down through the generations, of which they are evidently very proud. Remarks I can attest to include: ‘ancient Rakhine’, ‘from my grandfather who was a great traditional doctor’, and ‘of my family who belongs to the lineage of doctors from the royal tradition’.
If the regulation of powdered medicines limits the variety of formulae, it does not affect their content, at least not in a way that undermines the very principles of traditional medicine. This is unlike that of manufactured medicines, where many manufacturers are concerned since they believe that biomedicine-based regulations are ‘incommensurable’ (Kuhn Reference Kuhn1970) with traditional medicine, and that their application involves a significant transformation of the products and the loss of important aspects. Many manufacturers believe that ‘it is the property of traditional medicine to use a plurality of ingredients, this is where the efficacy lies … and this is also how we neutralize toxic components’.
Complying with WHO guidelines and state regulations not only requires a certain acceptance of submitting to a biomedical ethos, but also involves significant economic resources. Money is needed to purchase and set up equipment that meets quality control requirements, apply for licences, and pay for tests. Under these circumstances, very few manufacturers actually—or can even afford to—comply with the regulations. Those that do usually harbour export ambitions, as export/import controls are particularly strict. The most interesting case is that of Fame Pharmaceuticals. Founded in 1994, Fame produces mono-ingredient herbal medicines and food supplements by using organic material grown in special gardens. It has over 300 factory employees, including scientists, doctors, pharmacists, biochemists, botanists, microbiologists, and traditional medicine specialists. In January 2003, Fame received a GMP certificate from the Myanmar Ministry of Health. Thanks to its compliance with GMP guidelines, the circulation of its products has expanded across borders, but the efforts and requirements to meet that compliance have also rendered the products too expensive and largely inaccessible for the majority of the population. Now, even though the government presents Fame as the exemplary traditional medicine, the majority of the populace views it otherwise. Most people I have spoken to do not consider these medicines to belong to traditional medicine as, in their words, the latter always comprises a combination of multiple ingredients. This shows how compliance with biomedical criteria can lead to the loss of an original identity and the acquisition of a new one.
Fame and its ilk are the exceptions that prove the rule. The greater swathe of manufacturers ignore or only partially follow the regulations. Compliance is directed at achieving registration in order to enter the official circuit and thus expand the accessibility of one's products, yet it is only partial so as to avoid tampering with the identity and efficacy of the medicines. I contend that the vast majority of the 2,578 registered manufacturers and 12,712 registered drugs fall in this category. Many manufacturers use more ingredients than those allowed, including plants with toxic components or alchemical products containing mercury; others enhance the efficacy of their products with pharmaceuticals that are not declared to the control office, nor mentioned on the label. A manufacturer explains: ‘If we list all the ingredients, everybody could reproduce our product; we want to protect our formula.’ If some of these additions are innovations, in the sense that these formulae do not exist in the traditional pharmacopeia, or fraudulent if pharmaceuticals are added, others are just attempts to protect the traditional paradigm and efficaciousness of the product. Some choose the middle path, complying with the regulations for market-borne products, and bypassing them for products aimed at the illicit circuits, in the manner described by Saxer (Reference Saxer2013) for Tibetan medicine. In any case, licit circuits come to cover illicit ones. While weak controls and corrupt agents facilitate the bypassing of regulations, the choice to do so is motivated by commercial and medical logics, tinged with defiance towards biomedical authorities. As stated by Quet et al. (Reference Quet, Pordié, Bochaton, Chantavanich, Kiatying-Angsulee, Lamy and Vungsiriphisal2018, 15): ‘alternative routes, corrupt practices and other forms of arrangements are rather pervasive, sometimes inescapable and deeply embedded in official regulatory processes’.
Many practitioners and manufacturers also continue to resort to other traditional, mainly religious, practices to further increase the efficacy of their products and hence ensure they retain their competitive edge. The most common practice to empower medicines is the recitation of Buddhist formulae (gatha), mainly used by doctors operating in the private sector and by manufacturers working in the industrial setting. Even the young business manager of one of the main pharmaceutical companies states: ‘one of the 11 payeik (protective formula said to be recited by the Buddha), the Bosenthout, is very powerful for health issues. While preparing the medicine, I often recite this payeik or listen to a recorded version of it, using the CD player in the room next to the one where I am working!' Moreover, spiritual, supernatural, and mainly Buddhist power, alongside the presence of religious and devotional images, is channelled towards the medicines and medical practice. Indeed, today, as in the past, medicines are produced, distributed, and prescribed under Buddha's altar. In every house, clinic, hospital, and factory, the presence of the Buddha's altar grants protection and success to the medical practice.Footnote 11 Even doctors who cure with ready-made compounds stress the fact that the efficacy of medicines greatly depends on the compassionate attitude of the practitioner and on his capacity to follow the Buddha's disciplines by respecting Buddhism's main precepts, practising meditation, and being involved in meritorious activities. Hence, even though acquiring compounded powders means that traditional doctors participate in the national standardization and the disenchantment of their practices, they simultaneously personalize these products by transforming them through their religious practices.
Drawing their efficacy from spiritual and other invisible forces, these practices remain largely untouched by the regulations, which have focused mainly on the tangible materiality of practices, as this is the only aspect whose efficacy and safety can be scientifically proven. The threat in this case has come from institutionalization itself as it has drawn medicines out of the ritualistic context in which they were originally prepared and distributed. Despite this, these practices have not disappeared but instead have been adjusted to the new production environment. The main change is that these practices emanate almost exclusively from Buddhism, in line with the emphasis the state puts on the connection between traditional medicine and Buddhism, even as they play down traditions, namely weikza and astrology, which, over time, have come to be perceived as backward superstitions. The same trend of Buddhicization is attested to by divination masters and spirit mediums as well (Coderey Reference Coderey2012). In both cases the transformation might well be attributed to the anti-superstition campaign conducted by the Burmese state since the 1980s.
The standardization and modernization of, and disenchantment with, medicine brought about by the process of institutionalization is thus countered by healers and manufacturers who maintain the diversity of the techniques used, alongside the more spiritual and esoteric aspects of medical practice. Other forces also support this diversification, the most relevant of which is the market, as argued by Quet et al. (Reference Quet, Pordié, Bochaton, Chantavanich, Kiatying-Angsulee, Lamy and Vungsiriphisal2018, 5) elsewhere in Southeast Asia. In fact, the market's very existence relies on diversity and visibility. It thus offers manufacturers the opportunity to capitalize on the traditional identity of their medicines by pushing them to create brands, names, and logos, and to advertise on posters and billboards, the TV and radio and, more recently, websites. Names and logos of the brands as well as images on the packaging and advertising material extensively use traditional symbols, whether regional (the Kachin mountains), cultural (a woman wearing a traditional dress), or religious (a Buddhist temple or a peacock, symbol of the sun and the king). These symbols are either a testimony to the commitment to tradition or a strategy to facilitate circulation—or both at the same time. These symbols appeal greatly to both the local and diasporic clientele which see in them a source of efficacy, authenticity, and legitimacy. For instance, a friend from Yangon praises the efficaciousness of Kachin medicines as ‘they are produced with ingredients from remote and high and thus untouched places’. In this way the market offers the opportunity to make (more) visible something that otherwise remains invisible to the public: the production process—and the regional, spiritual, and esoteric knowledge that goes into it. For instance, the most well-known anti-flu/anti-cold medicine is called abahta (father-son). The owner of a retail shop in Yangon, a close friend of the founder of this medicine, told me that the formula of this remedy was communicated to that person by a spiritual entity through an appearance during a visit to a pagoda. The use of aba (an honorific title often associated with weikza), suggests the possibility of a weikza being at the origin of the medicine; at the same time, it suggests the spiritual virtue of the manufacturer as weikza are deemed to contact only individuals of great Buddhist morality. The supposed supernatural origin of a medicine adds extra value to an otherwise ordinary registered medicine circulating in the market. If the galenic and the shape of the medicine as much as the inscriptions on the packaging (listing the ingredients and the symptoms, which may even be in biomedical terms) reassure the customer that they are purchasing a modern—and thus safe and quality—medicine, names, logos, and images satisfy the thirst for tradition and spirituality. It is the hybrid character of the medicine—its blending of what local people perceive as representing modernity and tradition—that grants it its success (Van der Geest and Whyte Reference Van Der Geest and Whyte1989). This reminds us of the juxtaposition of old and new buildings in Yangon, or the addition of a traditional component to a new building, where the old is there to authenticate the city landscape and the new to indicate modernity and development (Philp and Mercer Reference Philp and Mercer1999, 37).
The use of traditional symbols in branding and advertising, regardless of the motivation behind it—a marketing strategy or an attempt to protect the traditional identity, or both—contributes to resisting the standardization imposed by the international guidelines and by the state's project to formalize, institutionalize, and Burmanize traditional medicine. Moreover, given that branding and advertising favour larger circulation, what truly emerges as national is not so much a standardized version of medicine from Burman regions, as desired by the government, but a plurality of medical traditions belonging to different regions and lineages.
Conclusion
L'Histoire s’écrit avec une grande H, one could say, to paraphrase Georges Perec. This sentence could apply to few other countries more than to Myanmar, where the hache has been used across history, particularly since the acquisition of independence, to select peoples, knowledges, and practices worth maintaining, while marginalizing others in the name of constructing a unified, modern nation. Selected elements of Burman-Buddhist culture are valorized and spread across the country in order to mould a coherent identity which dominates, absorbs, or deletes those of the other minority groups. Valorization thus goes hand in hand with domination. This study has shown how the valorization of Myanmar traditional medicine is an integral part of this project. The hache used by the state to shape the country's medical heritage was controlled by a duel agenda: nation-building, alongside compliance with the expectations of global medicine. The same tool allowed both goals be met. The advantage of using the same tool for both goals is that one can mask the other. Indeed, although the selection process has to do with both the biomedical frame and the unification plan, it is officially justified only through the need to comply with biomedical criteria, while political motivations, notably the domination aspect, are concealed. The medical discourse allows the state to depoliticize the process.
The paradox of having to use biomedicine, a symbol of the colonizer, to valorize traditional medicine, a project that actually started as a form of revenge against that very colonizer, is partially solved by the fact that biomedicine is recuperated as a symbol of power, domination, and legitimation, in much the same way that colonial buildings are maintained in the cityscape (Girke Reference Girke2015; Lin Roberts Reference Lin Roberts, Yew-Foong, Hsiao and Peycam2017). Moreover, adopting the biomedical framework allows for a legitimized competition or fight with biomedicine as both speak the same language (Lei Reference Lei1999).
The elimination from medicine of all the esoteric components, that is, the separation between medical and non-medical (superstition, magic), functions in a very similar way, particularly in relation to the purification of Buddhism from ‘worldly practices’. Under the auspices of valorizing medicine and Buddhism, the government attempted to gain control of them and the aspects it saw as threatening to its authority. It is only once they have both been ‘purified’, and become harmless, that the state stresses its connection to the Buddhist origin of Myanmar medicine, in order to accrue legitimacy and respect and, again, to use medicine as a powerful tool for the Myanmafication of Buddhism.
I have shown that the actual implementation of the project is fraught with limitations in the context in which it unfolds, wherein traditional medicine occupies a lower position within the political economy. The grey area created by ambiguous regulations and the inherent weakness of the regulatory system leaves enough room for traditional diversity to subsist, although in a renovated form. To put it differently, the ‘thinness’ of the hegemonic action allows for the survival of thick heritage.
Manufacturers and healers perceive less the nation-building project than the dominating power of biomedicine endorsed by the state. Hence their response is not just to accept or oppose the different ideas on producing medicines, but to take a political stance, making the medical heritage a locus of resistance, very much like other spaces (Philp and Mercer Reference Philp and Mercer2002, 1589). In the same way as the state recuperates biomedicine for its own purposes, so do healers and manufacturers, either as a counterposed element to defend the authenticity of their practice or as a way to preserve their medicines’ identity and efficacy but under a cover of legality. In either case, they contribute to maintaining diverse—and always flexible and fluid—heritages, supported in this by the diversifying and centripetal force of the market which operates against the nationalization of a monolithic identity. Yet, paradoxically, part of this fluidity is the current trend to Buddhicize one's practice, something which somehow suggests a certain success of the state's mission.
Walking in front of the hospital of traditional medicine in Thandwe, a friend comments ‘a thu’ (‘it's fake’), in that ‘as [for] all medical services, it is just there as a show-off strategy of the government to pretend to care about citizens’ health, but it is actually empty’. This, and the lack of trust in the military with whom these buildings are still associated in the minds of people, explains why these services are barely visited. The same can be said for the temples of Bagan where the renovations and reconstructions are sometimes disapproved of as a symbol of the previous unpopular military regime, which was known for forced relocations, oppression, and the use of violence (Kraak Reference Kraak2018a, 117). People still prefer turning to the more traditional (now illicit) practitioners who continue to exist and practise in all their diversity and eclecticism. More and more popular is the purchase of confectioned medicines from the market, as shown by the ubiquitous presence of their colourful boxes in people's houses. With the political situation in the country still unstable, and with little money going to traditional medicine, an improvement of those services in the future is difficult to predict. On the contrary, economic growth and an increase of foreign investment might contribute to the expansion of the medicine market, which could even become a tourist attraction in the future as it is in other countries such as India and Tibet. This, though, would mean the need for a stronger compliance with biomedical criteria.Footnote 12 Such a shift would certainly bring further transformations in their form and meanings as this living heritage would move into a new phase of economic integration.
