The Acupuncture Project at the Watchet Jivitadana Sangha Hospital
Lecture to the Britain-Burma Society 7th Feb 2013
By John Hamwee
A few miles downstream from Mandalay and on the opposite bank of the Irrawaddy river, is the Watchet Jivitadana Sangha Hospital - Watchet being the village, Jivitadana meaning the gift of life and Sangha referring to a community dedicated to the practice of Buddhism. In January, in front of the hospital, a huge sandbank stretches far out into the water, but in the rainy season the river laps at the hospital walls and sometimes floods the acupuncture clinic on the ground floor.
If you had stood on this spot in late November 1885 and looked out over the water you would have seen the British fleet sent all the way from Portsmouth via Calcutta to conquer what was then known as Upper Burma. You'd have seen a line of steel grey ships anchored in the main channel, extraordinary incongruous beasts towering over the local teak boats of that time - though you'd only have seen the back end of the fleet because the front of it, moored by Mandalay itself, was five miles away; an enormous convoy, carrying mortar, guns, ammunition, tents, food, medicines, clothes, servants, sailors, clergymen and ten thousand soldiers. And if you'd been there as the fleet sailed upstream you might have glimpsed the names of the two leading ships and with a wry smile noted the typically British way of colonising a country; for one ship was called the Kathleen and the other the Irrawaddy.
Behind the hospital, then as now, the steep escarpment, bristles with a host of golden pagodas. It reminds me a little of those seventeenth century engravings of London seen from the river, the skyline packed with the steeples of Wrens's churches. But these are the hills of Sagaing, the centre of Burmese Buddhism, and the home of hundreds of monasteries. And then as now, walking the paths through these hills, you see almost as many monks and nuns as you do villagers and lay people. It is as if there is a kind of balance here between the worldly and the spiritual, a balance which you cannot help but feel; an atmosphere which marks it out from anywhere else I have ever been. And it is this remarkable atmosphere which pervades the hospital. I'm going to tell you a bit about this place and what it does, but what I hope is that among the detail and the stories, I can communicate some of this atmosphere to you.
About thirty years ago one of the monasteries, the Kyaswa monastery, got a new head monk or Sayadaw. It seems as if Sayadaws come in different guises, a bit like the heads of Oxford and Cambridge colleges, some of whom are scholars while others are worldly, establishment figures This Sayadaw was a young man of real organisational ability who would have no difficulty being the Managing Director of a large public company in the West. As you can see, he's up with new technology too. One of the first decisions he made was that his monks, and the villagers of Watchet nearby, needed a hospital. The nearest one at the time was about twelve miles away, a considerable journey for anyone on foot or in an ox cart and a daunting one, of course, for someone who needed hospital treatment. With especial help from a former student who had become a prominent businessman in Rangoon, he started the first phase of what has now become five phases of construction.
Each time I go there the hospital has expanded. At the moment it has eighty beds, a small operating theatre, a very busy eye clinic with a laser machine, a path lab capable of doing the most important blood tests, an X ray unit which does 1500 a year, an acupuncture clinic and, under construction right now, a new wing for the practice of traditional Burmese medicine. It treats outpatients with minor eye problems, does dentistry, has a general ward for acute cases, and a smaller ward for infectious patients - workers in the jade mines suffer especially from Tuberculosis. Forty nine people work there regularly, doctors, nurses and admin staff, and all this without any Government money and in a land where, according to the World Health Organisation's figures for 2010, spending on health care is the lowest in the world at 2% of GDP - that's $34 per person per year. In this context, to build, equip and maintain a hospital on this scale is a truly remarkable achievement.
Then there the are parties of Westerners who turn up - the acupuncture group, four or five of us, the eye surgeons from Australia - a bunch of old friends, retired from practice, for whom, as they told me, the visit to Watchet is a highlight of their year. In three weeks in December they saw sixteen hundred patients and did over five hundred operations - treating a huge range of conditions from cataract surgery to corneal abrasions - it is so dusty there in the dry season - to detached retinas. Then there are the heart surgeons from Japan, recruited, when the Sayadaw taught there one year - I've never met them, but apparently they are well funded and bring sophisticated equipment each year. There is a very smooth gastro-intestinal surgeon, born in Italy of Chinese parents, and group of dentists from Denmark.
The Sayadaw started it, and indeed still devotes huge amounts of time and energy to the hospital, but there are two other people who have been crucial to its success. The first is an American called Steven Smith who first turned up at the monastery in 1986. He was already a serious student of Buddhism and a Dharma teacher in the West, following a spell in Thailand as a member of the Peace Corps. Incidentally, I can't help an aside here about this American institution of Peace Corps. It gave exemption from compulsory military service to a number of young people provided they went to underdeveloped countries to do worthy projects such as teaching English, building schools and so on. The idea was that these young people would spread the virtues of the 'American Way', and make the locals predisposed to support American interests. What the legislators hadn't foreseen, of course, is that it might work exactly the other way round. For many of the young people who went to South East Asia, like Steven Smith, became deeply interested in Buddhism, and brought it back to America where it now has many millions of followers.
While Steven was there he became friendly with a local monk and his new friend showed him around. He was impressed by the hospital but he could also see its limitations; for example, there were no trained nurses, it had only two part time doctors, and it was by no means adequately hygenic. Then he saw that the village school was tiny, with not nearly enough room to teach all the local children, and anyway it was closed for almost all the rainy season because it flooded. Finally he discovered that the local nuns were struggling to survive - compared to their male counterparts they had precious little support locally and no wealthy donors at all. He decided to help with all of these things so when he got back to the States he started a charity called Mettadana - Metta means loving kindness in Pali, and Dana, once again, is a freely given gift - one made with no wish for reciprocation. To date, Mettadana has paid for the building of a road from Sagaing to the hospital at the cost of more than $75,000 dollars, has trained nurses and provided staff for the hospital, has supported the acupuncture programme very generously, has set up a clean water system for the monastery, provided a large new primary school - higher up the hill than the old one - is currently constructing a secondary school, and provides for many nuns.
It is worth adding that throughout this time it was not possible to send money to Burma through the banking system, so he and his friends would bring it in, packed in many small separate bundles in their luggage, in pockets, even in socks. Every time they went through customs at Rangoon their hearts were in their mouths, expecting to be stopped and searched and for the money to be confiscated, but it never was.
Steven wasn't alone in this - many others deserve credit too - but he found a particular way of doing it which has made all the difference Each January he or one of his co-teachers would lead a meditation retreat at the monastery and those who had learnt from him in the West would come - about twenty or more at a time, most of them highly educated young people and some of them doctors too. And, like so many who spend any length of time in Burma, including me, lots of them fell in love with the place and set about seeing how they could help.
And what is crucial is that they did so in the spirit of the retreat; that is, they had understood the centrality of Dana in Buddhist teaching - how the monks and nuns depend on it for their every meal - (Just think! No fridge! No store cupboard! Well, I was brought up Jewish...You can imagine what my mother thought of that idea). Anyway, the monks and nuns go out every day with their bowls and beg their food - which is Dana at work and at its most acute. And these young Westerners got it; they understood the crucial importance not just of giving but of the motivation for giving - of the attitudes of both parties. If you give in order to feel worthy or generous or important, or to receive gratitude or thanks in return, well that has a particular quality to it - it tends to elevate the giver and makes the receiver somewhat subservient. If on the other hand, you give because someone else being hungry is the same as you being hungry - then there's just hunger and the need to relieve it - no superiority, no imbalance; in fact, no big deal. As one of them said, 'The monastery needed clean water just as I needed clean water, and I happened to know how to install pumps and filtration systems and the like - so of course I did it.'
Before I say more about how this works in the context of the hospital I want to introduce the third of my cast of characters - and a real character he is too. He is a doctor not of Western medicine but of traditional Burmese medicine, living and working in Mandalay. He is the organiser of the acupuncture project, the human dynamo, the rascally U Win Ko.
His role in the story started about thirteen years ago when one of the young retreatants, Michael Zuker, who happened to be an acupuncturist, left the retreat and walked down the hill to the hospital to have a look round. He found patients whom he thought would benefit from acupuncture, so he started to turn up for an hour or so every day to treat them. At that time U Win Ko was working at the hospital as a volunteer and he saw what Michael was doing and was interested.
Now there is no real tradition of acupuncture in Burma despite the long border with China. To some extent that is because Burmese traditional medicine has close affinities with the Ayuvedic medicine of India; perhaps it owes something to a certain cultural hostility to the Chinese. Anyway, it is not common. So U Win Ko persuaded Michael to return the following year to teach a group of doctors of traditional medicine both with lectures and with patients in the hospital.
Since then, U Win Ko has set up the acupuncture clinic at the hospital and has organised for a party of Western acupuncturists to visit each year, sometimes twice a year, for two or three weeks at a time, to treat people every day and to teach the next generation of acupuncturists in just the way he was taught (10. This is me, in the clinic, explaining something about a heart condition). And for the rest of the year he makes sure the clinic is staffed with volunteers on two days a week. The numbers now are impressive. Over the course of last year two thousand three hundred and two patients were treated in the acupuncture clinic - more than a hundred on a busy day. (If you are thinking that the numbers don't add up, many of these two thousand odd patents have multiple treatments in a year.
I want to break off here to tell you a bit about my own experience at the hospital. It started when Steve Smith asked me if I would go and work there. I remember his words to this day. He said, 'You will have to take at least three weeks off (and as a self employed practitioner that means three weeks' loss of income), you will work harder than you have ever worked in your life, you will live in extremely basic conditions, and you will have to pay all your own expenses getting there and back.' I said it was an unusual offer. Hard to refuse in a way. But I said that I would have to be mad to accept. 'Yes,' he replied. He's like that.
So on my first day I arrived at the hospital about half an hour before the start - I wanted to get the feel of it before anyone else arrived. Ha! I had to almost push my way through the small corridor leading to the clinic for it was packed with people seeking to register for treatment; there were lots of young Burmese acupuncturists in the small adjacent staff room; and on every one of the fifteen beds in the clinic (there are about double than number now) was a patient, most of them surrounded by three or four friends or relations who had brought them there. It was very crowded, it was very noisy, it was hot, and the day hadn't even started.
I thought it would be better not to think too hard about it but to just hold my nose and jump. So I walked up to the first bed and instantly six or seven of the acupuncturists joined me to translate. Since then I've really tried to lean the language and I certainly know some essential phrases, but intonation isn't easy. I have to say that when I utter my choice pieces to the patients - for example 'say shaw baa', meaning 'please relax' I am met with blank incomprehension. Then the student says it for me and the patient understands, of course, and grins up at me and repeats 'say shaw baa' in exactly the way I've just said it.
So this first patient had a shoulder problem. I knew I needed to establish my authority as the experienced practitioner from the West, as the teacher, so I gave a short disquisition on shoulders and shoulder pain and announced that I would needle a particular point, Large Intestine 14, 'It's just here,' I said, 'under the bone'. I put my finger on it to demonstrate. 'That's not 14,' said one of the students, a young woman who didn't look much older than 14 herself, 'It's 15'. I chuckled suavely. 'Oh I don't think so...' She seized me by the wrist, dragged across the clinic to the staff room, drew me up in front of a chart of acupuncture points, indicated the diagram of the shoulder, and there it was - she was quite right - it was Large Intestine 15.
So that was me blown, before I'd even treated a single patient. And then, on top of that, as I opened an unfamiliar packet of needles in order to do Large Intestine 15, I managed to drop them all on the floor - and needles are expensive for the Burmese. It was an awful moment. I could imagine them thinking 'Who is this guy?' I wondered how on earth I was going to get through the day. But I did, of course. There was no option. Normally, here, I see a maximum of eight people a day, very occasionally nine. That first morning I treated twenty four people, and I taught as I went along. It was exhausting but it was exhilarating too, and by lunchtime I was hooked.
I want to talk a bit more generally now about the acupuncture clinic and its work. First, the patients. I suppose about a third of them are monks and nuns who do not pay for treatment. They are usually a delight to treat because their spirits are so bright and clear - which is not something I see all that often in my patients at home. On the other hand they are in terrible shape physically. Lots of them have back pain; most of them have bad knees, many of them have heart problems, and the vast majority have high blood pressure - and so, of course, a lot of them are suffering with the after-effects of a stroke. It is - I know it sounds ridiculous - but it is a bit disappointing. Somehow, coming as I do from such a relentlessly materialistic culture and seeing, in my clinic, the effect that has on peoples' health, I rather wanted things to be better for these monks and nuns - who are free from all the pressures we encounter and who are genuinely dedicated to the relief of suffering. But there it is - expectations; always trouble.
And I can see some of the reasons why. They live in a small and rather tight community from which there is no escape, and frustrations must build up, sometimes intolerably. They spend long long hours in sitting meditation, with knees crossed into a position that they are really not designed to hold. And none of them take any exercise whatever. When I suggest it, they look at me as if I'm talking of the benefits of space travel or deep sea diving.
The rest are mainly local agricultural workers and there are a few shopkeepers. They pay 1,500 Kyat for a treatment which, as far as I can tell, is more or less a daily wage of most of them. So it isn't cheap by any means.
The vast majority of patients have serious complaints, often chronic, and they bear them with such calmness and good temper that it is a privilege to be with them. Back pain is endemic - partly from working in the fields, no doubt, but more, I think from riding on motorcycles at high speed over unmade roads. That pressure, up and down on the spine, really isn't good. A few years ago I was taken round Mandalay on the back of a scooter - there was no cushion just three or four metal crosspieces - whenever I think about it I can still feel them.
There are the normal common problems - migraines, period pains, depression, digestive problems and so on - though interestingly in the whole time I've been there I've never once seen a patient with a skin complaint). But we also treat conditions we acupuncturists never see in the West, either because they don't exist here or because they would be treated with Western medicine. I'm thinking of a shoulder, dislocated three years before and which hadn't been put back; of a girl of seven or eight with a strange kind of flaccidity in one arm - the muscle having wasted away; of a woman with a huge tumour on the side of her face, there is nerve damage from malaria and snake bites and another woman, in her fifties I suppose, who belched deeply, loudly and incessantly - to the great amusement of the whole clinic. Actually, as an aside, every now and then, not often, you do get the kind of instant results that shows you what an extraordinary system of medicine this is. I thought of one point, at the end of her second toe, and needled it. Although I understood the theory I was as surprised as everyone else when the belching stopped immediately. She seemed bemused. And there was a man with massively swollen genitals, and a woman who seemed fine in all respects except that she couldn't move her tongue.
And finally there was a woman of thirty six of a women I remember well. She was the last one of the busiest day I've ever had there - and that is really busy - and I was exhausteed. She said she wasn't sleeping well - she did look tired - and was finding it hard to work normally. I took her pulses and looked at her tongue and I'd ever come across anything like it in my life A challenge like that was the very last thing I wanted. Anyway, I asked a few questions but none of her replies helped me to see what might be the matter. Finally, I thought to ask if she had children - perhaps something had happened in her pregnancy or childbirth - and she said 'Yes, twelve.' No wonder I couldn't work out what was going on.
And in talking about the patients I have to include their helpers too - for their kindness is an inspiration. Just one example, an elderly monk being carried in by three young teenage monks because his left side had been paralysed by a stroke. As he waited, and he had to wait a long time, they sat with him, supported him, wiped his mouth regularly where he dribbled, and then one of them went off and brought his lunch, and the others fed him, and it was all done with such patient loving kindness, it touched my heart. Not an unusual experience in the clinic.
And it isn't just the patients and their carers who warm the heart, so too do the young practitioners. It's the power of Dana again. They are all volunteers, giving freely of their time and expertise. It isn't easy for them to take days away from their own clinics, days of income lost, and quite a few of them have young families, to support - and others, elderly parents. And although they are all qualified and capable they are eager to learn more. What teacher wouldn't want students like that? They make me explain a treatment before I do it and sometimes, half way through my explanation I realise, and they know, it doesn't really make sense (they love these moments). I learn such a lot when that happens. So they are my teachers too - and in recognition of that I dedicated my recent book on acupuncture to them.
And they never miss an opportunity to laugh. Here's an example. Two of the key diagnostic tests in acupuncture are the state of the patient's tongue and the state of his pulses. What I always do is to carry out one test, make my diagnosis on that basis alone, then guess what the other test will show. If I am right, if my guess is correct, then I can be pretty sure that my diagnosis is right too - and if I am wrong, it forces me to think again and think harder. The students love the moment when I say to them - 'So the pulses are like this and therefore the tongue will be thin, dry and with a yellow coat'. Then the patient sticks out his tongue and - lo and behold, it is fat and wet and has a white coat. They fall about laughing. They just think it's hysterical.
One last thing to tell you about. The Sayadaw comes from a village a few hours South of Mandalay, and three years ago he asked us if we would go there for a week, after our time at the hospital, and treat the villagers there. We agreed. It has been an extraordinary experience. Getting to it isn't entirely straightforward. But it's very beautiful when we get there. We work in the monk's dormitory - they clear out for the day - and it is busy. There's a line of ten patients - I have to kneel down to take their pulses and treat them, and it hurt my knees so I have to carry a pillow with me - which they all think funny too. I start at one end of the line and work my way down. By the time I get to the end, the first patient has gone and been replaced and I go down the line again. It got so full in there we had to have an overflow.
We made a dreadful mistake here, the first year. We saw so many people who hadn't had enough medical attention and therefore needed two, three or four treatments that we kept telling them to come back. The first day we had about a hundred patients, which was manageable. By the fifth day we had over four hundred.
The Sayadaw himself turned up on the last afternoon to see how it was all going and pronounced himself pleased. 'Very good,' he said, 'One week extension.' We weren't sure if he was joking - but it was no joking matter. We were all completely exhausted and anyway we had planes to catch and homes to go to. As the elder of the group I was deputed to tell him that this was not possible. 'Oh,' he said, with the faint surprise of someone who is not used to having his plans questioned, 'Maybe next year,' he said. 'Maybe,' I replied.
I think 'maybe' has a slightly different meaning to the Sayadaw and to us. But then, if he had taken 'maybe' for an answer I don't suppose the hospital and its acupuncture clinic would be there now.
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