Sienna Craig is an Associate Professor of Anthropology at Dartmouth College. Her work focuses on understanding the ways ‘traditional’ medical systems interact with biomedicine.
Sienna Craig is the author of what to me is one of the most interesting recent books in medical anthropology, Healing Elements: Efficacy and the Social Ecologies of Tibetan Medicine. There are fascinating parallels between the challenges that herbal medicine is facing in the United States and the transformations Tibetan medicine is undergoing in Tibet and Nepal. Our conversation below just touches on the depth and complexity she explores in her book.
Sienna has been actively involved in supporting Tibetan doctors and, with several other anthropologists, she organized a workshop for Tibetan doctors from across the Himalayas to discuss what makes medicine efficacious and to prepare different remedies together. The ten-minute video of the workshop offers a rarely seen perspective of Tibetan doctors discussing questions of spirit and efficacy as they prepare plant medicines – it’s fascinating! Sienna is also the author of Horses Like Lightning: A Story of Passage Through The Himalays, a more personal account of her first years living in Mustang, a poet, and a mother. She lives with her family in eastern Vermont.
Ann: In your book, you talk about how efficacy is produced at the intersections of ritual action and pharmacology, with distinct social ecologies. Can you talk a bit about what you mean by this? What does it mean on a practical level?
Sienna: For something to work it means it performs well in a particular context, biological, experiential, social. At the most gross level, for example, if I take Advil, sometimes it feels like it works right away. Other times I feel worse. Is Ibuprofen efficacious against pain? Does it mean that that molecule is effective? At the most basic level, is it effective all the time or only at a particular moment? 
To me, it is a combination; there is also the ritual act of doing something to feel better to alter your state of being. It is hard to separate out what occurs on a cellular level and how you experience what occurs. And it is also hard to determine what causes either of those experiences.
Take Advil. It is something you can measure – there is a molecule in the system. But there is a gap between the ability to measure that molecule in the system and the experience of it. There are also side effects that aren’t side effects just other effects. I could feel nauseous. Is that due to the Advil molecule? Or is it because of something else?
Understanding how medicine, any medicine, works in the body is far more complex and nuanced than we are led to understand. The medicines are embodied, by which I mean that they live within us not just as a separate biochemical entity but as something that we respond to in ways that are not simply biological and not simply mental or emotional but both of these, and more. Whether it is Elderberry or Advil, we are doing something, ingesting, taking in a substance to promote wellness and alleviate suffering. I’ve never been comfortable with the idea of something being “just mental” or a placebo. I am more interested in the intersection between what is embodied and how we think about it. Medicine and its range of effects are not always or simply working on body or mind – one or the other. We lose something when we draw a stark line and say a medicine has an effect or does not have an effect.
I am interested in thinking about the range of ways we can account for efficacy. You might notice positive effects of ingesting a substance. You might conduct a biochemical analysis. You might taste the herb, etc., assessing the vitality of the plant material in a way that is not directly comparable to what can be measured by liquid chromatography, for example. But what is important here – and what often gets lost – is that all of these ways for assessing the capacity to produce a desired outcome are all equally important information. But because of our cultural histories, we tend to see more clearly quantitative measures, to value them more. They somehow seem more “real.”
I think this has to do more broadly with what we do with generalizable information and with standards. It’s very hard to extract ourselves from the models that have formed our way of thinking about evidence. Of course, we can point to many reasons from drug safety and research ethics, why we need to develop and adhere to standards regarding what is/isn’t effective. However, we tend to forget that standards often signify not the very best practice, but the best possible practice given a set of constraints and a range of varying conditions.
In a way, standards are a lowest common denominator of acceptable practice: they are something that seems reasonable, given what we have come to know about a particular drug or plant, an educational benchmark or a clinical indicator. We tend to think about standards as ideals for which the bar has been set high, but often it is an average bar – something that a range of diverse and sometimes conflicting stakeholders can agree upon.
In contrast, we tend to place individual or even personalized knowledge as the lowest form of evidence in part because it is not – and perhaps even cannot be – standardized. Meta-level analysis in which the results of many clinical trials are aggregated are the “gold standard” of Evidence Based Medicine, but, arguably, we should consider medical knowledge that deals with the nuanced, individualized forms of embodied practice – the art of medicine, the ability to discern what a patient needs – as being above the bar of standards rather than below the bar or not even worth measuring. 
But this isn’t what happens. We tend to idealize standards as the best practice. In fact they tend to be the most commonly acceptable dumbed down practice because that is what has been able to be agreed upon by diverse groups of people.
Ann: Are you talking about Good Manufacturing Principles (GMP)?
Sienna: Yes, but not only GMP. I’m also talking about the idea that this particular herb, say, is good for that condition. Sure, such an assertion is true at a certain level. But individual herbs are much more effectively used by an individual client, recommended by a particularly skilled practitioner who is acting on and through that client. Also, bodies change over time. They are moving targets that don’t stay tied to a set of recommendations written on the side of the bottle. Standards cannot capture the inherent flexibility – the need to be flexible – that medical practice, particularly with living matter as your pharmacy, can demand.
Ann: Can you talk a bit about what you observed with the impact of GMP on the production of Tibetan medicine in China and Tibet (Sienna’s discussion of her visits to these factories in her book is fascinating)?
Sienna: I think it is similar to what is happening in the U.S. Nepali doctors who visit the factories in China are at first incredibly impressed with the shiny factories: this is modernity! They know they can improve their practices with respect to cleanliness and particulate matter that gets mixed into their formulas. Whether or not it impacts the overall quality of their medicine is an open question, but they know they could be more careful and precise. For these reasons they know there are things they can improve and
Ann: Are you talking about Good Manufacturing Principles (GMP)?
Sienna: Yes, but not only GMP. I’m also talking about the idea that this particular herb, say, is good for that condition. Sure, such an assertion is true at a certain level. But individual herbs are much more effectively used by an individual client, recommended by a particularly skilled practitioner who is acting on and through that client. Also, bodies change over time. They are moving targets that don’t stay tied to a set of recommendations written on the side of the bottle. Standards cannot capture the inherent flexibility – the need to be flexible – that medical practice, particularly with living matter as your pharmacy, can demand.
Ann: Can you talk a bit about what you observed with the impact of GMP on the production of Tibetan medicine in China and Tibet (Sienna’s discussion of her visits to these factories in her book is fascinating)?
Sienna: I think it is similar to what is happening in the U.S. Nepali doctors who visit the factories in China are at first incredibly impressed with the shiny factories: this is modernity! They know they can improve their practices with respect to cleanliness and particulate matter that gets mixed into their formulas. Whether or not it impacts the overall quality of their medicine is an open question, but they know they could be more careful and precise. For these reasons they know there are things they can improve and benefit from by adopting some of this technology.
And grinding herbs by hand is back breaking work, so having a machine do the work of pulverizing plants is helpful.
But they are also quick to recognize that smaller scale producers struggle to afford and adopt these new forms of technology. Many of the doctors with whom I work also recognize that GMP can’t be separated from questions of over-harvesting and species depletion. GMP pays a certain kind of attention to the quality of the medicine, but the things GMP standards reveal is quite different from how “good” quality medicine might be defined by a senior doctor.
GMP asks: how uniform is this capsule? A senior doctor asks: is this medicine going to help this particular patient? Is the potency and quality of the materia medica good enough? How were the plants harvested? Where were they harvested? These types of questions aren’t necessarily relevant or even germane in the context of biochemical pharmaceutical production – the scientific and cultural context in which and for which GMP regulations were first developed.
In a sense, we could say that the origin stories of these types or classes of medicines are different. But we tend to operate under the assumption that what works in the biomedical model should work with things that have different origin stories, different ways of coming to life. And that just isn’t always the case.
Ann: And intention… how does that play into it and how can you measure that?
Sienna: It matters in how doctors and patients perceive or pay attention to intention behind medicine making. Practitioners may or may not pay attention to things like how the medicine is made, how its quality has fluctuated over time, even what kind of person is running the herbal storage unit, how a company is sourcing materials, or how knowledgeable those on the frontline of quality control are about the plants they are purchasing.
Likewise, patients may pay more attention to where or by whom a a 
medicine is made if they know that some make better medicine than others; and this “knowing” about the quality of one medicine over another is a judgment about intention – the intention of the producer / practitioner. And yet today this question of intentionality sometimes gets lost in market demand. Once you have a market – which is a blessing and a curse – you have to keep on producing to meet demand.
Here Tibetan medicine has some interesting parallels with the herb industry because in this country Tibetan medicines are labeled as supplements not medicine. They are available online or, in a sense, over the counter. This means that there is a different structure around pricing, supply, and demand.
Even so, just as prescription practices for pharmaceuticals are changing and more pharmaceuticals are being prescribed, the logic around herbal supplements is changing, even though there is a different logic and different economic considerations governing the herbal medicine markets. The herbalist doesn’t structure or constrain how a client accesses medicine in the ways that a doctor does. There are different gatekeepers. And often, most often probably, people don’t even go to an herbalist… they self diagnose… and so are sometimes even more at sea…
Ann: How has your research impacted your teaching, what issues do you feel are most important to pass on to your students?
Sienna: Two things. First, I want them to become more aware of the ways they make assumptions about what is effective, to think about what we take for granted in therapy, any kind of therapy, not just ingesting medicines, and to understand that these assumptions shape their relationship with their own body, their own experience with medicine and therapies. I want my students to think about how they use medicine and the assumptions they make about this use.
Second, I want them to seriously consider non-biomedical ways of knowing as realways of knowing. This is a big one – to get them beyond thinking that anything that is not biomedical is inferior or exotic, or something that is interesting on a cultural level but not seriously something that can heal or address specific health questions. More broadly, I want my students to think in more cross-cutting ways about fields we think of as discrete: health and the environment, for example.
by Sienna Craig
Ann: And how does it impact how you care for yourself? Your daughter?
Sienna: I’ve always been hesitant to take pharmaceuticals, but that’s primarily for personal reasons, because of how I was raised. I’ve certainly taken a fair amount of Tibetan medicine, even when I was pregnant, and I have always been open to that. I think being around Tibetan doctors has given me more sympathy for the lives that biomedical doctors in our political economy lead. Both the Tibetan doctors with whom I work and the doctors in the U.S. healthcare system are both vulnerable in different ways. While the doctors I work with are socioeconomically and politically marginalized, many doctors in the U.S. are constrained by the political economy of medicine in this country, the structural constraints placed around care.
In terms of caring for my daughter. I’ve never been that keen to medicate her, but I’ve not had a bad biomedical experience with her care – at least so far. Honestly I feel relatively educated in Tibetan medicine, less well educated about non-biomedical choices and approaches in this country. When I face a wall of tinctures and supplements, I’m not really sure what to do. So I ask friends who can help me. Luckily I’ve never had the moment where these different approaches come into conflict.
Ann: But maybe they don’t necessarily have to come into conflict, that just as we separate health and the environment, we’ve been told these are in conflict but really each has its place.
Sienna: Yes, that it is just a misperception of how separate they are. We put up ideological walls so quickly when in fact things are much more fluid. I remember an experience once of Tenzin, a Tibetan doctor in Lo Mothang (Mustang District, Nepal), whose mother was quite sick. He was giving her an IV with glucose saline in a village in Lo Mothang. 9/10 of the effectiveness was the way he was administering the IV, but it was also about the medicine itself. His empirical experience had led him to know this. He did other things for his mother as well, but he didn’t not do something because it hailed from a different medical system. There were no big barriers.
Thank you, Sienna, for taking the time to speak with me. More information about Sienna’s work can be found at her website.