MIND, BODY AND SPIRIT – HEALTH CARE IN BHUTAN
Bhutan maintains a rich fusion of modern and traditional health care under the same roof.
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fter a hectic day at the hospital, I was watching the November evening fade into cold darkness when a knock sounded at my door. I opened the door to be greeted by my neighbour, looking rather distressed. “My uncle collapsed suddenly…around noon today,” explained my neighbour. “Please come.”
As I was ushered into a small bedroom, I could hear the cymbals, the drums and horns of monks performing religious rites in the choesham (altar room). On the bed was an elderly man, unconscious, his breathing erratic and labored. The room was thick with the smoke of burning butter, herbs and medicinal incense. When I peeled back the blanket and lifted the patient’s arm to measure his blood pressure, an egg rolled our from under his armpit. Surprised, I lifted the other arm there, nestled tight in the armpit, was another egg! I could see that the local healer had already been here.
In the struggle between life and death, Bhutan’s health systems have evolved into a fusion of traditional and modern in a symbiotic blend of ritual practices, religious rites and modern medicine. I completed my examinations without breaking the eggs.”He probably had high blood pressure for some time. I think he suffered a serious stroke that has ruptured a blood vessel in his brain. That’s why he cannot speak or move. Was he on any medication?”
“Yes. About a year ago he started treatment,” said his nephew. “After taking medicine from the hospital, he decided to take indigenous treatment at the ITMS.” The Institute of Traditional Medicine Services (ITMS) in Thimphu is the only hospital and training centre for indigenous physicians. Although there was no formal health care system in much of Bhutan’s history, there is a rich tradition of indigenous medicine, based primarily on herbal treatment. While the government invested heavily in developing an allopathic health care system, it also ensured the survival of our traditional practices. In ancient scriptures, Bhutan was a rich source of medicinal herbs not only for local needs, but also for the practicing physicians of Tibet which had many renowned centres for traditional medicine. Many Bhutanese physicians refined their art of healing in Tibet and returned to Bhutan to ply their skills and continue the traditions through the generations.
When planned development began, the nascent indigenous system expanded to the current network of one national traditional hospital and 19 indigenous dispensaries scattered across Bhutan. The modern and the traditional exist as dual, yet complementary, systems of health care under the same roof. Therefore, it is not uncommon that a patient would consult both the modern and indigenous physician and collect herbal and allopathic medicines.
“The stroke is quite severe. He will need immediate hospitalization.” I said. “By the way, what did the astrologer say?” “We’re told that it is Za (an evil force).”
Prior to the advent of allopathic medicine, illness was dealt with through a mix of fatalistic beliefs, complicated rituals, and a strong dose of faith in religious rites and offerings. Not much has changed despite advent of modern medicine.
From barely one hospital in the whole country in the early 1950s, Bhutan established a network of 29 hospitals, 166 Basic Health Units and 455 Outreach Clinics, catering to a population of less than one million. A wide range of curative, preventive and promotive health services are offered through this network. They include immunization, maternal and child health, family planning, and treatment of common ailments.
I accomplished the patient to the Thimphu General Hospital which is also the referral Hospital for the whole of Bhutan. He was admitted to the intensive care unit. With rapid infusion of several medicines, his blood pressure normalized within two hours, but the damage done to the brain matter cannot be reversed easily. We have no neurosurgeon in Thimphu. So we even discussed the possible need to evacuate the patient to Culcutta in India. Apart from providing free health care services and facilities to all its citizens within Bhutan, the Royal Government also pays for treatment outside Bhutan for conditions that cannot be treated within the country.
Meanwhile, at the home of the patient, offerings and prayers continued throughout the night. But alas, the patient’s condition took a down turn from which there was no return. His last breath was carried away on the tinkling of religious bells and the sound of prayers at his beside.
At times like these, there is always a hint of regret that we could have done more had we had more technology and skilled manpower. The achievements in the health sector have, however, been remarkable. Between 1984 and 2000, the maternal mortality ratio declined from 770 per 100,000 live births to 225. Infant mortality reduced from 102.8 per 1000 live births to 60.5, and life expectancy rose from 45 years to 66 in the same period. However, like the struggle with this patient, Bhutan’s health care system will face other struggles in the future. Improved primary health care increases the pressure on the secondary and tertiary levels of health care. As people live longer, chronic conditions will demand more advanced services and infrastructure which, in turn, will drive costs even higher.
As Bhutan marches steadily into the 21st century, problems of urbanization, adverse environmental conditions and changing life-styles will place increasing stress on the existing systems. HIV/AIDS and the sustainability of free health care for all will emerge as major challenges to the current altruistic and single provider health care system of Bhutan.
As I parted company with my neighbour, I shook his hand and whispered, “I’m sorry about your uncle.” “It’s his time, I guess,” he philosophized. “We are happy that he had a happy life and we did what ever was possible.
By Pem Namgyal, a medical officer for vaccine-preventable diseases at the World Health Organisation in New Delhi.