Bhutan in a Box

Published on December 12, 2015
A month training emergency personnel at Bhutan’s central hospital proves to an up-close-and-personal look at the mountain nation that has been dubbed “the last Shangri-La.”

Buddhist monks on their cell phones (Photo by Kenneth V. Iserson, MD)

Although I had been warned that the landing at Bhutan’s Paro International Airport was one of the most difficult in the world, I was only semi-prepared for the aerobatic gyrations our aircraft took when maneuvering to line up with the tiny runway. I later learned that pilots only have visual cues as they thread between mountain peaks and then drop to target the small landing strip. Once safely on the ground, my real adventure began—working with and helping to teach “general medical officers” (ie, physicians) who work in the country’s largest emergency department (ED).

As I descended the airplane stairs, I came face-to-face with the airport terminal, a traditional Bhutanese building, over which loomed a huge billboard photo of the current king and his predecessors. This was to leave no doubt in anyone’s mind that Bhutan is still a kingdom—the last of the traditional Himalayan kingdoms that is still independent (unlike Sikkim, Assam, and Tibet) and ruled by a king (unlike Nepal). An 18,000 square-mile oval, Bhutan is less than twice the size of Pima County, Arizona, in which I live. Hemmed in by Tibet (China) and Sikkim and Assam (India), it is within spitting distance of Nepal and Bangladesh. In the north lie the Himalayan peaks; the south is tropical and the east is ruggedly rural. No one seems to be certain how many people live there, although the best estimate is around 734,000 residents, according to the 2015 World Factbook published by the U.S. Central Intelligence Agency.

Emerging from the small terminal, I faced a horde of taxi drivers and guides collecting visitors and soliciting business in multiple languages. All the men were dressed in gho, the traditional robes; women wore kira, long skirts with jacket tops. Mistakenly, I thought their dress was for tourists. I soon found that the Bhutanese commonly wear traditional garb, including many of the hospital’s physicians and nurses. Often referred to as the last “Shangri-La,” the fictional Himalayan site in James Hilton’s 1933 novel Lost Horizon, Bhutan is the only country to promote Gross National Happiness (GNH) as official public policy. Open to tourism only since 1974, it has added modern conveniences very gradually; television and the Internet were outlawed until 1999. Today, in the two larger cities, cell phones ring constantly and there is widespread Internet access and cable television in multiple languages.

Most foreigners come to trek through the spectacularly diverse landscape and to experience the culture: people in traditional dress and houses built in traditional styles, often adorned with large fertility penis illustrations. Although the country is small, a rudimentary highway system of narrow, winding roads with no guard rails, often stubbornly clinging to steep mountainsides and plagued by frequent landslides during the rainy season, makes travel onerous and somewhat dangerous.

My visit to Bhutan had been arranged through Health Volunteers Overseas, an NGO that has been active in Bhutan for years. Based at the Jigme Dorji Wangchuck National Referral Hospital (JDWNR) in the capital, Thimphu, my month-long volunteer position was to work, teach, and consult with the physicians in their busy ED.

In that position, I received a grand tour of the entire Bhutanese population. Since this was the country’s only tertiary care and teaching hospital, all patients referred from other regions of the country automatically came first to the ED. Thus, in the large, box-like ED, we saw patients from every part of the country—from the highest reaches of the Himalayas to the jungles bordering India.

The Next Generation

One of the benefits of this month was the opportunity to work with an amazing group of nine ED-based general medical officers and a bevy of industrious nurses. Most of these physicians had recently graduated from medical schools in Sri Lanka, India, and Cuba, among others (at that time, Bhutan had no medical school of its own), and most were doing an internship/social service year while they awaited a government-sponsored residency position in another country (Bhutan currently has no residency programs).

After selecting students for medical school on a merit-based system, the government then pays for their education and requires them to work for the government on their return. Officials can send these tyros anywhere in the country, including extremely remote areas. Their working environment could be a Basic Health Unit, a District Hospital, or one of the country’s four larger hospitals.

Work Languages

One of the amazing things about working in Bhutan is that, while the hospital’s work language is officially English, all the physicians and most of the nurses speak at least four languages: English, Dzonga (the language most common in Thimphu), Tibetan, and Nepali. Many also speak at least one other language—often one from Eastern Bhutan. Although there are at least 13 languages in this tiny country, the ED personnel could approach a patient or family member and immediately identify a coworker who also spoke that language. That was the case with a Buddhist nun from a remote region who presented after a grand mal seizure. Since not more than 100 people spoke her language, we had to await one of the staff internists, who also spoke that language.

Cultural Experience

My big plunge into the local culture was purchasing and attempting to wear a gho. My Western roommate helped me put it on, but, as I walked to work, all the children I passed stared and giggled. Upon arriving at the ED, the nurses quickly hustled me into their break room and re-draped my robes. As they explained, expert assistance is essential, since the gho must be draped exactly right or you get the reaction I did. If it is draped correctly, you receive smiles, nods and compliments. While I found the belt almost suffocating, the front flap formed the biggest pocket in the world. It’s so big that cameras, wallets, and keys disappeared in the huge space. And, if you’re wondering what you wear underneath, it’s the same as the Scotsmen. In the summer months, Bhutanese men wear little or nothing (being a prudish Westerner, I wore shorts); in the winter, they often wear long underwear.

During my few free weekend days, I was able to appreciate some of Bhutan’s amazing sites. There was almost no place where pointing a camera wouldn’t result in great pictures. Truthfully, though, it took quite a bit of effort to get up to the Taktsang Pahphug monastery, also known as Tiger’s Nest—one of the most awesome sights in the world. Even so, the lasting images I carry with me stem mainly from working alongside the wonderful Bhutanese doctors, nurses, technicians and students—and very interesting patients.

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