Saturday, 1 February 2020

Emerging infectious diseases and Bhutan: the case of 2019-nCoV

The worst pandemic in recent history was the 50-100 million deaths caused by the Spanish flu in 1918-1920. Bhutan was not spared from this pandemic where FM Bailey, the resident Political Officer in Gangtok wrote in his annual report that influenza had spread throughout Bhutan and that there were many fatal cases.

In the 1967 global outbreak of smallpox where 15 million people contracted the infection and 2 million died, there were 14 reported cases in Bhutan and the source was linked to the outbreak in neighbouring Assam. These events show that diseases know no boundaries and emerging diseases pose real challenges.

Emerging diseases
There are 1,400 human pathogens and about 30 new infectious agents that were previously not experienced by humankind have been identified in the last three decades. These, called as emerging infectious diseases pose public health challenges by presenting as new diseases, appearing in new geographical locations or with new clinical features, and occurring in epidemic or pandemic scales.

Why are diseases emerging?
The emergence of new diseases depends on the factors that make up the epidemiologic triad: the host (human or animal), agent (pathogen), vector (that transmits the agent to the host) and the environment.

SARS epidemic in 2002-2003, MERS outbreak in 2012 and the present Wuhan outbreak of 2019-2020 were caused by the evolution of new infectious agents. Development of resistance of agents to drugs or pesticides such as drug-resistant tuberculosis, HIV and malaria, and pesticide resistant malaria are some examples.

Ecological changes and human invasion of forested areas have been linked to diseases such as the Nipah virus (nearest reported outbreak near Bhutanese border was in Siliguri, 2001), scrub typhus and Japanese Encephalitis. International trade and travel are linked to the rapid spread of infectious agents. For example, travel from Hong Kong to Toronto by one person with SARS-CoV resulted in 128 SARS cases in a local hospital. Similarly, a single patient with MERS-CoV from Saudi Arabia who came to South Korea resulted in 186 MERS cases. Human behaviour involving close contact with civet cats were linked to the emergence of SARS and bushmeats (smoked animal meat) involving bats were associated with the emergence and spread of Ebola.

Combating emerging infectious diseases
Emerging and re-emerging infectious diseases will continue to challenge modern health systems. Outbreaks such as Ebola and the novel coronavirus in the affected countries have led to prolonged disruption of social and economic activities. Case recognition, case management, and active contact tracing are essential in controlling the initial outbreak of infectious diseases. This requires active public health intervention along with strong surveillance and laboratory networks, research and development, and sharing of information and partnership with centres with expertise. With increasing cross border travel, global cooperation is crucial to contain emerging infectious threats. The World Health Organization proposed the International Health Regulation 2005 to regulate global efforts in combatting common threats.

International Health Regulation 2005
The International Health Regulation 2005 is a set of international laws that govern identification, surveillance and reporting of diseases that may be a Public Health Emergency of International Concern (PHEIC). Bhutan is a signatory to the IHR and has dedicated national framework for surveillance and reporting of internationally notifiable diseases (SARS, Smallpox, New influenza viruses, Wild-type polio) and other notifiable diseases that may be a Public Health Emergency of International Concern. The present 2019 novel coronavirus outbreak, now declared a PHEIC, is a case example of the threats of global emerging infectious disease to the social and economic security of our country.

The 2019-novel Coronavirus
In December 2019, there appeared a cluster of pneumonias of unknown cause in Wuhan, China. By January 2020, it was identified that the disease was caused by a new type of virus, named by the World Health Organization, as the 2019-nCoV. This new virus has spread to 20 countries outside China with known human-to-human transmission. There are more than 9,000 confirmed cases and more than 200 fatalities with the number increasing by each hour.

The 2019-nCoV infection causes symptoms ranging from fever, cough and flu-like illnesses to more severe forms such as pneumonia and respiratory distress requiring intensive care support. While its fatality rate is lesser than other coronaviruses, it will pose significant clinical challenge as this virus has sustained human-to-human transmission.

The outbreak in China happened around the time when many Bhutanese travel to Thailand, India and Nepal. Pilgrimage sites in India and Nepal experience heavy traffic of visitors from many Asian countries, mostly from China. Back at home, the tourism industry is being sensitized on the preventive measures on the travel-related spread of the infection.

How do new coronaviruses emerge?
Coronaviruses have been long considered inconsequential pathogens. They (Human Corona Viruses named HCoV 229E, NL63, OC43, and HKU1) cause 10-30% of the upper respiratory tract infections (common cold) that are self-limiting in adults in the USA. However, two highly pathogenic types of coronaviruses emerged: Severe Acute Respiratory Syndrome Corona Virus (SARS-CoV) in Hong Kong in 2002-2003 and the Middle Eastern Respiratory Syndrome Corona Virus (MERS-CoV) in Saudi Arabia in 2012. SARS spread to 30 countries in Asia, Americas, Europe with 8,439 cases and 812 deaths within 7 to 8 months with an economic loss estimated USD 10-30 billion. The MERS-CoV infection has been reported from 27 countries with at least 722 deaths. Both these viruses have originated from animals and spill over to humans have caused human infections.

The origin of the 2019-nCoV has not yet been confirmed but like the SARS and MERS CoV, it is likely a spillover from zoonotic sources. However, with sustained human-to-human transmissions reported with MERS and 2019-nCoV, the virus can spread virtually to any place on earth due to human travel. The 2019-nCoV has predominantly lower respiratory symptoms and is spread through cough and close contact with infected individuals.

The medical and scientific community are still trying to understand the 2019-nCoV and the novel coronavirus infected pneumonia as more clinical and medical information are published in medical journals.

Bhutan’s response to prevent 2019-nCoV entry
The Ministry of Health has led the multisectoral response in the prevention of the entry of the novel coronavirus into the country. This involves screening persons with symptoms of influenza such as fever, cough and malaise. The health workers are sensitized on the detection of cases. The Royal Centre of Disease Control, Thimphu has issued guidelines on the collection of samples from suspected cases and the hospitals are altered on the contingency plan to isolate and provide care of cases if detected. The government has issued travel advisory to avoid travel to countries.

Both the mainstream and social media are playing important roles in the sharing of information on the symptoms of the novel coronavirus infection and individual-level preventive measures such as washing hands and use of face masks. Rumours and misguided information play a very destructive role in such outbreaks and hamper public health intervention measures.

Care of infectious diseases requires trained professionals and specialized centres such as infectious diseases hospital. For the time being, the Ministry of Health has identified specific centres and emergency teams for the isolation and treatment of novel coronavirus infected cases if detected.

While there are multiple versions of epidemiologic projections on how and when the present coronavirus infection will end, it has also tested the response of the present development of our health system to countering emerging and re-emerging infectious diseases. Emerging diseases will continue to challenge in modern health systems in different forms and times.

Contributed by Dr Thinley Dorji 

Postgraduate student in MD Internal Medicine at Armed Forces Medical College, Maharashtra University of Health Sciences, Pune, India. Email: 

Thursday, 21 February 2019

Two Karmapas and its lessons for Bhutan

Buddha’s Not Smiling – This is the second book that I have read on the lineages of trulkus. The first one was on the Dalai Lamas and now on the Karmapas.

Image result for two karmaps together
At the centre of this book are Thrinley Thaye Dorje (L) and Ogyen Thrinley Dorje who met for the first time in October 2018.

The Karmapas were the first to establish a trulku system, three hundred years before the Dalai Lamas appeared. The first Karmapa, Duesum Khyenpa, was a contemporary of Phajo Drugom Zhipo in Bhutan. The trulku system is a unique feature in the form of Buddhism that is present in the Himalayan and Tibetan region.

Trulku system appeared at a time when Buddhist monasteries started owning large properties and influenced local administration and politics. Monasteries operated labrangs which are like a monastic corporation. As labrangs gained influence in politics, politics tried to influence which lamas headed the labrangs. Influential leaders would place the monk of their favour as the abbot of monasteries.

To keep politics away, the Karmapas reincarnated in the form of trulku and served to promote dharma and safeguard their labrangs. Until a trulku came of prominence, regents would take control of the monasteries. As seen with Dalai Lamas (my other post), the gap between the death of one and until the attainment of majority of the next was a period of uncertainty. This was the period that was prone to politics.

This book on the controversy of two candidates for the 17th Karmapa sheds light on several important issues. This event was the playground of various political powers trying to use the reincarnate of the Karmapa for their own political gains. We see that the reincarnate is exploited both by the lamas themselves, the aristocrats and elites of influence and finally party politics.

At the time when events unfolded, Sikkim was one of the new states in India where democracy and party politics were new. Though religion and politics are separate under the Indian constitution, we can see how Buddhist lamas and their followers are used to garner votes (much like how popular Hindu sadhus are used in current Indian politics).

This brings me to appreciate two merits that I see in Bhutan. The Central Monastic Body has trulkus in them upholding the dharma activities, but when it comes to administration, the head of the monastic body, the Je Khenpo is selected based on merit. This gives two advantages. There is a continuity of leadership and guidance – we have had seventy Je Khenpos since Zhabdrung Ngawang Namgyal appointed the first one in 1651. The politics and baggages that come with the recognition of trulkus, should there be any, are left at the level of the individual and it does not affect the system.

The second is keeping religion above politics under Bhutan’s constitution. The Karmapa case ends in a tragic damage on both sides. Neither the lamas nor Chief Minister Nar Bahadur Bhandari benefit out of politicking. This is a case study that unfolds in settings very much familiar to Bhutan and it is a good read. I recommend this book to all.

Note: This is the fifth book on the two candidates for the 17th Karmapa. As clearly as it is mentioned in the book, it is not for ordinary people like us to make a judgement on who the real reincarnate is.

Sunday, 26 August 2018

The debate that set the tone of discourse

Bhutan is into its third parliamentary elections. Today, there was the much awaited presidential debate between the four political parties. This was a historic debate and will be remembered for what and how it contributed to strengthening the process of democracy in Bhutan.

This presidential debate helped present two unique aspirations of the people of Bhutan and set the ‘tone’ of discourse.

First, the monarchy is sacred and well beyond and above politics. In the institution of monarchy lies the common aspiration of the people. Sometimes, not talking too much about what we truly respect is a sensible and a mature show of respect. In this debate, there was no taking chawang from the portrait of His Majesty and no overt use of the theme of royalty.

Second, the debate was centred on the functions of the Government as an executive branch. It was a talk of only internal matters of the country. There was no mention of foreign relations and it sends out a clear message that Bhutan has a stable foreign policy under the Royal Government. This takes away the chance of foreign powers playing pawns with political parties in Bhutan. The distinction between the ‘Government’ and the ‘Royal Government’ was something which I learned recently.

Democracy is taking its shape and form in Bhutan. Palden Drukpa Gyelo!

Thimphu, 26 August 2018

Thursday, 15 March 2018

The dragon returns to space from whence it came

In celebration of science and Bhutan-1
Science as a universal language
Science is a universal language without borders. In science, what is being discovered and contributed to the scientific literature and the scientific community is more important than who has done it.
In a society where education was traditionally given in monastic institutions with a heavy inclination towards Buddhism, science in its modern subject form has been a part of school curriculum for a long time in Bhutan. Over a century of modern education (2013), the science curriculum, as well as science itself, has undergone evolution. Many of us are second or third generation Bhutanese who have studied science in school.
With the force of globalisation, science and technology such as the use of smartphones and social media apps, have become ubiquitous in Bhutan. The reverse wave of this technology has found ardent users from even the older generation, many who did not receive any formal education. This speaks of the universality of the use of science in the aid of daily lives in a country that is still deeply rooted in its culture and tradition.
In the academic pursuit of science and technology, Bhutan now has university centres that pursue both fundamental and applied sciences. Many of the government and private centres perform technical functions with the application of science. These ranges from bioscience in health, agriculture and forestry; physical sciences in geology and mining; technological sciences in hydropower and natural resources; engineering and architecture in structures and construction, and many more. While the benefits of applications of science should be made available, we should equally put effort in sustaining the scientific appetite among citizens.

Science and national identity
Science and technology are used not only to make lives better, cure diseases and grow more food, but are also used as a display of military strength. Scientific prowess is now used as a national power, with physical boundary, and is sufficiently clear from the following examples.
In 1957, when the erstwhile Soviet Union launched the first man-made satellite Sputnik into orbit, more than exploring space, it served as a national pride of being one step ahead of the United States. This influenced the United States government to spend so much out of the national exchequer on space programme primarily to make leaps ahead of the Soviets. This led to many important discoveries but was also an aggressive competition with the temperament of the Cold War.
Since then, the temperament of space competition has cooled down but its use as a show of national power and interests is still relevant. One recent event is the launch of Mangalyaan, India’s mission to the Mars in 2014. Though India was criticised for spending on space programme where it has so many other areas to prioritise spending, this stellar success by the Indian Space Research Organisation has proved the importance of using modern technology not only for its intended applications but also as a tool of national identity. It put India ahead of China and Japan in successfully launching a Mars mission on its first try. And after this India went on to launch the South Asia Satellite in 2017 that has prowess and geostrategic advantage over the entire South Asian subcontinent.
Science, despite its universality as a language, has always taken the colour of national identities in the spirit of transnational collaboration and cooperation. The names of elements in the Periodic Table in Chemistry have honoured many countries and scientists. Such honours are Gallium named after France (Latin name for France is Gallia), Germanium after Germany, Polonium after Poland and Scandium after Scandinavia, Moscovium after Moscow. All these elements that make up the matter in the universe were discovered in Europe and America. However, when Japan was credited to the discovery of one new element, the other Asian countries celebrated in jubilation. The element was named Nihonium (Nihon is a common Japanese name for Japan) in 2016 and this is one contribution from Japan to the scientific literature and knowledge of humankind, apart from the many Nobel laureates it produced in the recent times.

A facet of national identity in modern times
Bhutan is at a period of transition from a traditional society to a modern one. The symbols of national identity in Bhutan – its Drukpa culture and Buddhism, the language, the national dress and traditions – are relevant and efforts are needed to preserve them. These themes are becoming more important for Bhutan than ever in the face of globalisation and integration of external influences in the lives of our people.
In addition, science and technology have taken a significant position in the national identity of modern Bhutan. The golden langur, an endangered species found only in Bhutan has in its name the word Bhutan – Trachypithecus geei bhutanensis. Rhododendron kesangiae is named in honour of Her Majesty the Royal Grand Mother Kesang Choeden Wangchuck; Rhododendron zhidey has the Dzongkha term zhidey for peace for which His Holiness the Je Khenpho conducts many prayers. In 2017, our national flower was found to be a new species of blue poppy called Meconopsis gakyidiana, a befitting tribute to the pursuit of Gross National Happiness (gakyid) as a national priority. Another decoration to the national identity is Spathoglottis jetsuniae, an orchid to honour Her Majesty The Gyaltsuen Jetsun Pema Wangchuck.

Bhutan’s space programme
With the farsighted vision of His Majesty The King, Bhutan is ready to launch its first satellite Bhutan-1, into space in 2018. Built with the technical help from the Japan Aerospace Exploration Agency, with Bhutan-1, Bhutan will join its two neighbouring countries, China and India, as a space-faring country though ours is at a scale far smaller than the China National Space Administration or the Indian Space Research Organisation. This is a historic moment the dragon, Druk, returns to space from whence it came to bless this tiny Himalayan Kingdom.
With His Majesty’s vision and Bhutan-1, it has shown that no dream is too big for a country as small as Bhutan. Bhutan-1 marks one small step in science and a giant leap in Bhutan’s identity, the dragon orbiting in space.

In the times of Pema Lingpa, Zhabdrung Ngawang Namgyel and Desi Jigme Namgyal national identity was constructed from the opportunities of their times. In the 21st century, Bhutan must act upon the opportunities found in contemporary times. In addition to our age old tradition and cultures, Bhutan should also walk the frontiers of science and technology.
The importance of taking Bhutan at the frontiers of science and technology is not only for its role in the benefit of mankind but also as one of the Principles of State Policy (Article 9.23) in our Constitution: The State shall encourage free participation in the cultural life of the community, promote arts and sciences and foster technological innovation. Juxtaposed against spiritual heritage (Article 3) and culture (Article 4), the makers of our Constitution have given us ample space and freedom to pursue science and technology.

Contributed by 
Dr Thinley Dorji 
(medical doctor), Jigme Dorji Wangchuck National Referral Hospital
Disclaimer: The views expressed are personal and do not represent that of any institution.

Published in the Kuensel, 10 March 2018.
Accessed at

Thursday, 1 December 2016

Constitution of India – Dr Ambedkar’s Contribution

After India was born as an independent nation on 15 August 1947, its greatest achievement in its early years was the framing of its constitution that provided the social, political and economic framework that led to its emergence as a vibrant and dynamic democracy as well as an emerging regional power in south Asia.

When the first government of independent India took charge, under the guidance of Mahatma Gandhi and the first Prime Minister of India Pandit Jawaharlal Nehru, the gigantic task of laying out the constitutional framework was given to Dr Bhim Rao Ambedkar.

The Constitution Drafting Committee appointed by the Constituent Assembly on 29 August 1947 was chaired by Dr Ambedkar. Though the committee had six other members, Dr Ambedkar who was the chief architect, through his vision for a just and equal society, laid out an elaborate constitution. The Constitution of India was adopted on 26 November 1949 and it accommodates diverse culture, language, religion and ways of life of 1.25 billion people to this day.

Life of Dr Ambedkar
Dr Bhimrao Ambedkar (14 April 1891 – 6 December 1956) was born as a low caste and was subjected to socioeconomic discrimination in his early years. He however excelled in school and went to earn doctorates in law and economics from renowned universities abroad. He was one of the political leaders during the independence movement who advocated for social inclusion and integration of all Indians in the post-independence era to bring about the union of India.

His work included promotion of education especially among the untouchables, called the Harijans or Children of God by Mahatma Gandhi.

Basic features of the Indian Constitution
The structure of the Constitution of India comprises of the preamble, 25 parts with 448 articles, 12 schedules, 5 appendices and has accommodated 100 amendments, making it the world’s longest constitution. A reason for the length of the constitution is because it incorporates the experiences of all leading constitutions of the world as Ambedkar had said, “there was nothing to be ashamed of in borrowing because nobody holds any patent rights in the fundamental ideas of a Constitution.”

It provides sovereign power of governance to the people of India where it is declared in its Preamble that the constitution was adopted and enacted by the people.

It establishes a parliamentary form of governance where the State is headed by the President and the Government is headed by the Prime Minister. The Prime Minister of India and his council of ministers are accountable for all of their actions to the Parliament.

The constitution guarantees fundamental rights to its people such as right to equality, right to freedom, right against exploitation, right to freedom of religion, cultural and educational rights, and right to constitutional remedies.

The constitution through its Directive Principles of State Policy lays down guiding principles for framing of laws and principles both at the union and at state levels. These are not justiciable rights of the people but are fundamental to create social and economic conditions, through laws, plans and programmes, under with citizens can lead a good life.

The judiciary under the Indian constitution enjoys independence from the executive and legislature.

Shaping the Indian Constitution
Dr Ambedkar played a significant role in shaping the social framework of independent India. His views on social justice, equality and inclusion, and fundamental rights were shaped by his education in law, economics and politics and by his personal life and active participation in dialogue and negotiation during the independence movement. Thus, Dr Ambedkar’s constitution offered a wide range of constitutional safeguards and guarantees such as socio-economic rights, civil liberties, freedom of religion, the abolition of untouchability and the prohibition of all forms of discrimination among others.

Dr Ambedkar’s vision of democracy
Dr Ambedkar’s vision of democracy was based on the fundamental idea of “government of the people, by the people and for the people.” The constitution provided the political and legal framework at two levels: the union government and the Supreme Court at the centre and the state governments and the High Courts forming a federal structure.

The Members of the Parliament at the centre and the Members of the Legislative Assembly in the states are elected through universal adult suffrage allowing people’s participation.

Dr Ambedkar also viewed that democracy was only a means to the end of achieving social progress and economic development. He called upon those elected to power to govern with ethics, morality and constitutional morality, which is to abide not just by the legal provisions of the constitution but also to the spirit of the constitution. The Indian constitution is thus rigid to preserve its basic framework and spirit, but also flexible to have accommodated 100 amendments thus far.

The Constitution of the Kingdom of Bhutan
When the Bhutanese Constitution was drafted, His Majesty the Fourth Druk Gyalpo commanded that it was wise to study constitutions from other countries. Dr Ambedkar’s vision and philosophy has found inspiration among the writers of the Bhutanese constitution that was deliberated with people from twenty dzongkhags and was adopted by the people of Bhutan on 18 July 2008.

Our constitution that is structured with the Preamble, 35 articles and 4 schedules is the world’s shortest. It establishes a Democratic Constitutional Monarchy with parliamentary democracy, institutionalizes monarchy, and commands the conservation of environment and preservation of culture among others. It also enshrines the Principles of State Policy with the overall directive to “promote those conditions that will enable the pursuit of Gross National Happiness.”

The former chief justice of Bhutan, Sonam Tobgay has said that “Bhutan wanted a rigid Constitution that would withstand untimely amendments” and allow its sprit to mature and nurture a vibrant democracy.

The constitutions of India and Bhutan establish democracy, the former the oldest, the latter the youngest, as a means to further social transformation in the former and realise Gross National Happiness in the latter through the principles of state policies and other framework enshrined in them. The writers of our constitution had a vision for better times and prosperous nation in posterity but it is subject to the lot of people who implement it.  

However good a Constitution may be, it is sure to turn out bad because those who are called to work it, happen to be a bad lot. However bad a Constitution may be, it may turn out good if those who are called to work it, happen to be a good lot.
– Dr BR Ambedkar

Written by Dr Thinley Dorji (MBBS)

This is adapted from the essay written on the life of Dr BR Ambedkar on his 125th Birth Anniversary Celebrations in April 2016 organized by the Nehru-Wangchuck Cultural Centre, Indian Embassy, Thimphu, Bhutan.

This article was published by the Embassy of India in Bhutan in the Kuensel on 26 November 2016.

Miracles from doctors

Until recently, doctors in Bhutan were indispensable. It is no longer the case. Now, Bhutan has 244 doctors, 957 nurses, 514 health assistants and many others that provide service to the people (AHB 2015). There are several hundreds more undergoing training in neighbouring countries and they will join in the service of the nation soon.
            More doctors joining the service in Bhutan is only one aspect of socio-economic development of Bhutan. Bhutan is now professionalizing its human resources in fields such as law, economics, engineering, agriculture, geology, etc. And not to forget, people have easy access to information through mass media and social media.
            The health sector has achieved tremendous successes in multiple health indicators since the introduction of allopathic medicine in 1961. The life expectancy has increased from 49 years in 1994 to 68.9 years in 2010, infant mortality rate decreased from 102.8 to and 30.0 per 1000 live births in 2012 and maternal mortality rate decreased from 770 to 86 per 100,000 live births in 2012. Bhutan has also achieved multiple successes in the Millennium Development Goals. How was Bhutan able to achieve so much success in a short span of time? All through this time, Bhutan had acute shortages of both financial and human resources while giving free healthcare to all.
            While we have achieved commendable success in serving our people well. As a result, it was natural for people to have increased expectations from the doctors, nurses, technicians and the health system as a whole.
            An example: A person in the village wants to be seen by a doctor; a person in the district wants to be referred to Thimphu hospital; a person in Thimphu wants to be referred abroad. Now people rather wish to be seen by a specialist than by a generalist or a junior doctor.

The health system in Bhutan – what all of us must know
There are several health systems that exist in our country. The allopathic system of western medicine was established in 1961. The indigenous medicine and many other local practices have been here for thousands of years. The Ministry of Health promotes all of them. Each is an alternative choice to the people.
            Health is a delicate condition. If you are healthy now, you can fall sick – so the preventive sector, the public health measures like prevention of tuberculosis, vaccination programmes, sanitation and hygiene programmes. And for those who are sick, their health needs to be restored – so the curative sector, the hospitals, comes into picture.
            The hospitals in Bhutan are three tiered. The Basic Health Units and District Hospitals are the nearest to the people and are staffed by MBBS qualified doctors and nurses (not all BHUs). If a case needs to be seen by specialist doctors and need better facilities for patient care, they are referred to the Regional or to the National Referral hospitals.

JDWNRH as a teaching hospital
Since 1974, the JDWNRH has been a hospital that provided training to nurses and technicians. In 2012, internship programme for MBBS graduates was instituted and residency programme instituted in 2014. Since then, in many of the departments in JDWNRH, there is a hierarchy of doctors who look after the in-ward patients.
The intern doctors are junior-most doctors who have graduated with MBBS from Sri Lanka or Bangladesh, registered under the Bhutan Medical and Health Council. These doctors, otherwise, would have qualified to work as intern doctors under respective medical councils in Sri Lanka or Bangladesh. The Intern Medical Officers are made to work in many disciplines of medicine and treatment such as medicine, surgery, obstetrics and gynaecology, paediatrics including radiology, ophthalmology, dermatology, community medicine, etc. This programme is to give exposure to the Bhutanese context in order to produce general doctors who can serve as jack of all trades in the district hospitals.
In the next hierarchy are the residents, who are undergoing a four year specialist training in major departments such as medicine, surgery, obstetrics and gynaecology, paediatrics and ophthalmology. The residents are those under training to be a master of one.
There are specialists in many fields providing expert opinions in patient care. They are the masters in their specialised field.
The road to having good specialist doctors begins with good intern doctors. If our country needs more specialist doctors, for example, to perform kidney transplant in Bhutan, we need at least few vascular surgeons, nephrologists, intensivists, etc. who will come from the pool of current junior doctors.

Do all cases need to be seen by a specialist?
Not all cases of patients need to be seen by specialists. There are cases that can be treated by a general doctor and many people in the district hospitals get good quality care from general doctors. In fact, in Sri Lanka, a country barely richer than Bhutan in terms of per capita income, most people are happy with the care given by their General Practitioners (GP), the general doctors. These GPs sort out the minor problems and the specialists get time to do what they are intended for.
            Therefore, for our patients in districts to get good quality care, it is essential for general doctors to be competent in solving the problems that are solvable at the district levels.

What else is different in the three tiers of hospitals?
Besides the staffing structure described above, these three tiers of hospitals have different capacities to provide service. More number of drugs and better technologies are available at referral hospitals for the care of patients.

The core of medical ethics
Allopathic medicine is a collection of best practices and scientific evidence collected from the times of Hippocrates till now. Hippocrates (460 – 370 BC) is the Father of Medicine and every health institution bears his portrait or his pedestal.
            A doctor is bound professionally by the Hippocratic Oath to do to the best of his capability for the best to his patient. In Bhutan, our cultural values of jampa, nyingje and jangchub sem are our guiding principles.
            In addition, there are four principles of ethical medical practice:
            (1) Beneficience: It demands that the health care provider should only do what is good for the patient. A doctor may, based on his clinical judgement, decide that a chest x-ray is of little use to the patient, while many an instance, people wish for a lok-par because they do not know what, why and when an x-ray in necessary to be conducted for a patient.
            (2) Non-maleficience: It requires the health care provider to do no harm to the patient. If a case is not within the capacity of one doctor to manage it, it is his responsibility to involve someone who is competent (someone senior, or someone from another department) to manage the disease condition.
            (3) Autonomy: Like everyone else, the patient or the guardian of a minor has the right to decide whether to accept the treatment. However, the right to decide for themselves must come with proper understanding of the disease and the treatment by the patient. However, currently in Bhutan, there is no specific legislation that explicitly gives autonomy to patient.
            (4) Justice: The healthcare provider must think how best to provide justice. For example, to produce an x-ray image, it requires what is called a plate on which image is formed. If at a hospital where the government supplies limited number of plates, why should a doctor do an x-ray on a patient who does not require it?
            However, the medical world is full of exception and anomalies. Supposedly, if a doctor didn’t do the chest x-ray and failed to diagnose a chest disease, the patient can sue him in the court of law.

When can a patient sue a doctor?
Currently, there are no specific laws that protect the patients or the doctors. If a patient feels aggrieved due to the care provided by a doctor, can you sue a doctor? Generally, in other countries, four of the following elements need to be established to prove that there was medical negligence of medical malpractice on the part of the doctor:
            (1) Doctor-patient relationship: There must be an established doctor-patient relationship. If someone died while a doctor was just passing by his house, the relatives cannot sue him for not doing anything because he was not his treating doctor.
            (2) The doctor commits an act of commission or omission: The patient party feels that an act of commission or an omission has caused them harm.
            (3) The person has suffered harm due to the doctor’s acts.
            (4) The causality of harm to the person is established that it was due to the doctor’s acts. The event of a hurt to patient or death of someone can be of many causes. In the court of law, the reasoning of medicine is applied to establish that it was the doctor’s act that resulted in death.

When does death occur?
A marvel of human body is that it has its ability to correct things if they go wrong. However, this physiological ability to self-correct fails when there is compromise beyond a point of no return. The role of a doctor is to prevent the derangement from reaching this point.

Grief reaction
The loss of a loved one is a life-changing event in one’s life. There is a series of emotional states a person goes through called the ‘grief reaction’. The stages are first denial of the event, followed by anger, bargain, depression and finally acceptance. The whole process in a normal person is complete by maximum six months. If the grief reaction lasts beyond six months, it is not normal.
            In our culture, the period of mourning and funeral lasts 49 days that brings kith and kin in an event of show of social support that helps the relatives sail through the bereavement phases. As doctors, we should be mindful that the event of death that occurs in our wards, and that the hospitals herald a series of events in the lives of close relatives.

The human value of life
A man is a social animal. We have a closely knit society with kith and kin that come together in the event of illness. Doctors are entrusted with social and professional mandate to preserve life. With increased expectations of an ever more informed society, there is an increasing demand for doctors to deliver god-like miracles to all ailments, be it of the body or of the mind.

Dr Thinley Dorji
The views expressed in this article are that of the authors’ and does not represent that of any of the organisations mentioned.

Published in the Kuensel, 05 November 2016

Friday, 15 April 2016

Zhabdrung’s Bhutan 400 years later

On the eve of Zhabdrung kuchoe, today, it took me to Drukgyal Dzong in Paro, right next to the Chinese border on the west. What remains of ruins now was once a glorious dzong (fortress). The massive structure reminded me of Zhabdrung.

Who was Zhabdrung as a person? When he came to Bhutan 400 years ago in 1616, he came into a land that did not stand the chance of survival for it was ruled by local chieftains and lords in each valley. What Zhabdrung did was to bring all of them under the Drukpa rule and gave the idea of nationhood to Bhutan. He must have been a powerful man, highly charismatic and his leadership is beyond words.

Drukgyal dzong is perched on a rock and this massive structure is entirely build with stone slabs. The walls are so huge that at some points they are more than a metre thick. It has an inner courtyard with the central tower that was photographed by John Claude White in the early 1900s. The tower stands today, but its collapsed inside. What looks like a small tower on one face is actually a large rectangular structure. The chambers around the dzong are so huge that I could imagine the lives of monks and courtiers in history.

It also has secret passages that served as both escape routes and to draw water. I am interested to learn the actual mechanism how they drew water. Pray the archaeologists shed light on this. These escape routes also have small caved in windows. The apertures of these windows are small on the outside to prevent the bullets from getting in, while the aperture is larger on the inside. I imagine soldiers must have died in these escape routes.

It has watchtowers at least on two directions, the north and the west. The Taa dzongs stand and such round structures were built with such mastery. The overall architecture is masterpiece. Whoever the architect was, it represents that Bhutanese had ingenuity that made the Drukpa nation survive 400 years.

Drukgyel Dzong renovation: With the birth of the Gyalsey, His Majesty and the Royal Government have started work to renovate the dzong to its former glory. What is special about this is that it marks four centuries after this man named Zhabdrung came to Bhutan and established what led to current Bhutanese nation. The dzong is in its initial state of assessment. We have Bhutanese geologists drilling the rocks to assess its foundation, Bhutanese architects studying the ruins and faces of the dzong, and other experts.

Restoration of this dzong will give rise to an architectural masterpiece and restore the glory of the Drukpas over their victory over the war with the Tibetans and Mongols.

Written in reverence to Zhabdrung, who came to Bhutan in 1616 and started work that led to the rise of the Bhutanese nation, the Wangchuck kings and now a happy and flourishing Bhutan.