This article is about the preservation and development of the localized form of Tibetan medicine known as amchi medicine or Sowa Rigpa in the Himalayan region of Ladakh. The article discusses the traditional position of the amchi, the practitioner of this system of medicine, and how that position has changed over time. The rapid development of Ladakh in the last few decades has brought about fundamental changes in traditional social and economic patterns. These changes have led to challenges for the amchi system and various responses to overcome these challenges. The article focuses primarily on the work of one amchi, Tsewang Smanla, who is also a coauthor of the article. Smanla's training and practice are discussed, along with the various projects he has directed that aim to support and develop the amchi tradition in Ladakh. Keywords Tibetan medicineÁLadakhÁmedical pluralismÁmodernityTraditional medical practitioners in the Himalayan region of Ladakh are known as amchi (am chi). The system of medicine they practice is a localized form of Tibetan medicine, referred to in Ladakh as "amchi medicine" or by the Tibetan name Sowa Rigpa (gso ba rig pa), "the science of healing." The prestige in which the medical system and it practitioners are held is reflected in the meaning of the word amchi, which is derived from the Mongolian am-rjay, meaning "superior to all." This article has two authors: Tsewang Smanla, a Ladakhi amchi, who alongside his own work as a practicing amchi has spent the last twenty-seven years working on various projects to support and develop amchi practice in Ladakh, and Colin Millard, a medical anthropologist. Millard first met Smanla in 1991 when he was carrying out research on amchi practice in Ladakh for his undergraduate dissertation in anthropology at Edinburgh T. Smanla (*) Yuthog Foundation, Smanla