The twelve year old boy I will call Tshering began to suffer panic attacks after a girl in his class died.  He is from a small village in the eastern part of Bhutan.   Dr. Allen, the HVO volunteer psychiatrist, one of two psychiatrists in the country, asked me to see him.  It was about a week after I had arrived in Thimphu.
       I had already given my first lecture on hypnosis to children, to the Pediatric residents, interns and attendings, on my first full day at JDW National Referral Hospital.  After quickly dispelling myths about modern clinical hypnosis  - No, it is not like the hypnosis show you saw in India - No, it is not a form of mind control - It is a lot like meditation, with a specific therapeutic goal in mind - I was surprised about how fascinated everyone here is in learning more about it.
       It is not as if clinicians here don't have other things to worry about:  like very ill children dying on a regular basis, for example, or seeing the throngs of parents and babies amid the chaotic queues of the OPD.  And though they are Buddhists, it is not as if meditation is a part of their culture. In Mahayana Buddhism, practiced here, the monks do the meditation for the lay people, in periods of 3 days, 3 months, or 3 years.  As in the U.S., 5 minute meditation sessions are now often held at the beginning of school days, but mindful meditation practice is actually more established in the States.

      The Psychiatric ward is at one end of a an old long row of attached departments, some with ambiguous names like "Voluntary Counselling Services - access restricted", and "Heath Help."  There are benign uniformed guards posted outside, as they are on the stairwells in the hospital.  It is kitty cornered from the ornate archway that marks the entrance to the hospital and a woman's collective that sells water, soda, and mom's, 30N ($.5)) for 5.  They are served by friendly women who pick them out of big thermoses.  They wear plastic gloves, which makes the process seem very hygienic, though the grounds are littered everywhere with garbage, which dogs sometimes pick through.
        Inside the ward is a small anteroom, a check in room, an "ECT" room with a table for electroshock therapy, a lounge big enough for meeting with a patient and a parent, and the patient rooms.  There are 8 of them, and depending on the census, they may be coed.  A 21 year old on whom I consulted had to share a room with an old man who spoke word salad.  Upstairs, there is a large conference room. Like most all buildings in Bhutan, there is no central heating, so it is usually chilly, and dark.
        I saw met Tshering in his room and led him to the lounge.  Ugen, a therapist in training, accompanied us.  Ugen wanted to videotape the session but, when I asked the boy his permission, he declined.  Ugen wanted us to see the boy alone, but when I asked Tshering, he asked that his mother come with us.  I think patient autonomy is a concept somewhat foreign to Bhutan.
       The session itself was difficult, because, as often happens, Tshering's mother was as anxious as he was - maybe more so.  Also, though his English was fluent, I'm sure he dreamt, and thought and felt in the Bhutanese language: Dzonka.   I found out that he was concerned not only where the girl "had gone" when she died, but about his friends with whom he played football (which we call soccer.)  He thought that many of them were "weak"  By this he meant thin.
      I was able to teach him to imagine him and his friends playing football -- all of them healthy and strong.  I also utilized a story from my trek.  In the beautiful 4200 meter village of Laya, a fellow trekker and I joined in a football game on the school's muddy, rocky field.  It had been raining, off and on, as it had been my entire trek.  But then it cleared, and a double rainbow appeared which spread from one end of the village to the other, looking east to the Himalayan peaks.  The weather is a good metaphor for our feelings.  It can change from bad to good, from cloudy to sunny at any time.
      Tshering was entering the developmental stage of abstract thought.  A very bright boy, he was pondering  not only about our own mortality, but about the origins and extent of the universe, and other questions which have no definite answers.  Like all anxious people, he was having a very difficult time with uncertainty.  That night, as I was thinking of things I could have introduced to our session, I recalled my own early adolescence, and how I first realized with certainty how our lives were finite.
The Buddhist concept of rebirth was obviously not comforting to this young man.
         I later found out that he was being bullied in school, and had a difficult time with his father.  During my month here, I have been impressed that though our cultures are very different, the universal struggles among children and adults, are the same.

          I was asked a half dozen times to lecture about hypnosis during my stay here.  The first talk was on my first full day of work -- to the pediatric attendings and house staff.   I showed them a video of my working with an 18 year old patient of mine with Down Syndrome - whom I shall call Bethany.  I had seen Bethany as a patient all her life.  She had many of the problems of kids with Down Syndrome _ mental retardation, with severe speech problems, tonsillar hypertrophy, and sleep apnea, recurrent ear infections, failure to thrive as an infant, followed now by obesity, and recurrent skin infections. Because of some bullying, and a fear of the alarm bell, she had developed school phobia.  She would deal with her anxiety by going to the girl's room and taking off all her clothes.  Then she would be sent home.
         She also would call her imaginary friend Megan, and Jesus, on her cell phone, on the way to school.  This was not that surprising, since her developmental age was around five.  Her dad took away her cell phone as a punishment for not going to school.  The first intervention I made was to have dad give back her cell phone.  These "primary interventions" are as important as the "secondary interventions" we make as doctors or therapists.
         Then I taught Bethany simple breathing techniques, with the use of a stone I gave her as an anchor.  She was able to learn to breath away her worries.  I said that she call her "friend" Megan for help.  She could also call Jesus.  I always encourage my patients to draw from their spiritual and religious traditions, if they are meaningful to them.  She also enjoyed thinking  about "my guy" - Brendan - her "boyfriend" at school.
         All this took one 1/2 hour session in the office.  Since Bethany's symptoms were so dramatic and debilitating,  I gave her a prescription for prozac as well.  Her mother never needed to fill it.  Within one week she was going to school without problems, utilizing my suggestions.
         I saw Bethany once more for her school phobia -- two weeks later.  This was the session I taped.  She showed how she used the stone I gave her to help herself. I reviewed with her how she has learned to "blow out" her worries and fears. She held her breath, puffed her cheeks out and expelled loudly to demonstrate - saying "stupid stupid Matt" (the boy who had bullied her), and "stupid stupid bell".
As I had her breath slowly and calmly, I suggested that she was a brave and strong and smart young woman.  I meant it.  She was not intelligent in the traditional sense, of course. But she was a good student when it came to self hypnosis --- learning to use it to help herself much more quickly and effectively than others with much higher IQ's.  
        Then she did something very surprising.  "Listen," she said.  She cradled her arms over her stomach and rocked them back and forth.  I looked over to her mother, who was helping to translate the session for me.
         "She's remembering the pictures of when I was pregnant with her," her mom said.
          "Listen," Bethany said, pointing.  He mom knew what she was getting at.
          "She didn't like my maternity dress I wore."  We both laughed.
          "Listen," Bethany said, one more time.  She put her hands up and together, and opened her eyes wide as if discovering the world for the first time.
          "She's remembering how she would look when she was a baby, looking out when I held her," her mother interpreted.
          "I was your doctor then too,"  I told Bethany.  "And you can remember those comfortable feelings whenever you need to."
            It was an amazing moment.  Here I was with a young person with cognitive and language delays so significant that most therapists would never even attempt to see her. After all psychotherapy, by definition, is talk therapy.   And it was very difficult to understand anything Bethany said.  But here she was, demonstrating age regression to create an affect bridge to a time of comfort at the time of her birth, and even before birth.  And she came up with all these solutions herself!
          After my comment, Bethany entered a deep trance that she maintained for about 5 minutes. She then opened her eyes.
          "She really does practice," her mom said, smiling. "She goes to her room and uses the stone… She does do well."
           Bethany said something else I didn't understand.  "She's saying Thank you for the stone," her mom said.
           "Thank you for using the stone,"  I said.
           Then, pointing at me, Bethany said "You're the best doctor ever!"
           "You're the best patient ever!"  I said.
           My teacher and mentor Michael Yapko, with whom my wife and I completed an 100 hour three part workshop this past Spring was asked if patients or clients can really recall and utilize the ideas we introduce in one session of hypnosis for the rest of their lives.
           "How long can a good idea last?"  he asked, rhetorically.
            Forever, of course.
     
           Showing this video, to physicians, to the staff of the Psychiatry ward, and to the staff at Ability center - the first and only developmental center in Bhutan - was helpful for many reasons.  Though some of them had limited knowledge of English, they could understand what was going on.  They smiled and nodded at the recognition we all share - of the importance of recalling moments  of comfort and security to aid us in dealing with challenges and worry.
         This was true, especially at the Ability center.  It was founded 4 years ago by Beda Giri, a physical therapy assistant who's daughter died of a rare neurodegenerative disease.  Beda is a dynamic and resourceful leader who has gotten together a staff of one social worker with an MSW and 5 other staff members.  She has attracted support from non profit organizations and a social and developmental pediatrician from the University of California at San Francisco, Brad Berman.  "Dr. Brad" is an experienced HVO volunteer who has become a kind of mentor to the center - visiting and teaching here on several occasions, and skyping with the staff in consultation. He also had sound words of advice for me before I came to Thimphu.
            Ability is run out of a small but tidy storefront a 5 minute walk from the hospital. Started as a support group, it has grown into a place where children with a diverse assortment of problems ranging from cerebral palsy to ADHD to autism come for group therapy, play with other children, and information sessions for parents.
         I was asked to come lead several of these.  Since all the therapists have no formal education beyond high school, and there are no speech language pathologists in Bhutan, I was a welcome figure at these sessions.
         The questions were sometimes challenging.  For example, our HVO coordinator from the hospital brought here son, with autism to see me.  "Will he get better, doctor?" she asked.
         Another mom asked how she could get her daughter to talk.  Her daughter was three and had profound hearing loss from birth.  She was essentially deaf.  I asked when the hearing loss was diagnosed.  At the age of 6 months, her mother answered, through a translator.  Did she ever have hearing aides?  I asked.  She did, her mom said but then they were broken, and she was on a waiting list to get new ones.
        NGO's now view Bhutan, with a median per capita income of $2000, and large potential revenues from hydroelectric power, as a middle income country, according to the new WHO representative Orellana Lincetto, who had a few of us over for dinner last night.   So a lot of the aide that the kingdom has previously depended on is being withdrawn.  There is no money for a new census of health statistics in the country. (Good records of almost any important measure, from infant mortality rates, to deaths from rabies or suicide are lacking).  There is also apparently no money for hearing aides, band aides, thermometers, or many important medications that frequently run out on the wards, in the OR, and in the clinics.
        Some of the questions have had very obvious answers.  For example, a mother asked why her hyperactive child with cerebral palsy was always hungry.   I asked about his diet.  After some back and forth through translators, I realized that his mom was only feeding him vegetables.  This on the advice of a lama.  According to tradition, children with seizures should not eat pork nor eggs; children with mental retardations or physical disabilities like CP should not eat meat, eggs, or any protein.
       "Your child is always hungry," I said, "because he is starving…  The lama is wrong. Children need protein."    After ascertaining that the family was not vegetarian, I said that her son needed meat, and eggs.  He was probably hyperactive because he is iron deficient.  
       A recently published text on the history of medicine in Bhutan, written by a Bhutanese pediatrician and Danish public health expert, states that a survey showed that "100%" of the children of Bhutan are iron deficient!  I wonder how they actually know, because laboratory measures of serum iron levels are not performed here.  The blood would have to be sent to India.  Blood counts,which measure anemia, are done.
      I said that she should go to the OPD to get Dexorange, the local iron preparation for her child.
I asked (through the staff member who was translating) if she understood.  She did.  But despite repeating myself emphatically several times, I'm not sure she was convinced.
      This morning, I am going with an Ability staff member to a school.  Ability provides consultation to the schools for children with developmental disabilities, learning problems, autism, and ADD.  So I should get ready.
      So much more to write about the rich experiences I've had bringing clinical hypnosis to this mountain kingdom, which did not even practice western medicine until the 1970's.   This includes my work with my eldest patient yet, nearly a century old.  Pretty unusual for a pediatrician!   Will write about this in Part II.


     

       

On the way to the hospital, sounds of chanting monks, bells, and trumpets

         It has been over a week since my last post:  a busy one.  Yesterday, the Jewish Sabbath, was a day of relative relaxation for me.  The intern and Dr. Tashi were tired, after spending two hours in the early hours trying to resuscitate yet another baby who had come into JDWNRH with pneumonia, and who suffered respiratory failure and then cardiac arrest.

        They were not successful.  It was our eight death in two weeks.   Pneumonia is the leading killer of children in the world. It claims the lives of two million kids a year, most of them in developing countries like Bhutan.  

        The baby might have also suffered from meningoencephalitis, like so many young patients here.  Last Monday we let an infant die quietly, her heart rate and breathing slowing to a stop in the PICU, who had this diagnosis.  Her pupils had been fixed and dilated.  This death was especially difficult for me, because she had been doing better for a while.  The dopamine to support her blood pressure, and mannitol for her cerebral edema had been weaned off.   I had allowed her to begin to nurse again.  

             Her father had asked me,  "Will she be ok, Doctor?"

             Doctors have a lot of authority here.  Students stand when I arrive to give a lecture.

             "I can't say for sure," I said. "But it is a good sign that she has begun to nurse again." I'm sure that being a loving parent, the "good sign" is what he remembered.

                           Dr. Jimba, Dr. Tashi, nurse anesthetist Pema and PICU staff

             I worked hard preparing a lecture on encephalitis last week - not that there was that much to say.  Even the most  sophisticated research, with the most esoteric labs available, done under the auspices of the California Encephalitis Project, have revealed specific pathogens in only 16% of cases.  And, like Ebola, there is no cure for any of them.

        Shelly told me the news about the doctor with Ebola in New York.  I haven't watched TV, 

browsed the web, or listened to the news since leaving home September 13.  I've tried to avoid news feeds on Facebook (with only partial success, since I have wanted to keep up with friends.)  I haven't read a newspaper except for the local paper "The Kuensel" which is the state paper in Bhutan. It only has local news -- lots of stuff about "their Majesties" travel and so on.    I can't say I've missed any of it.  One does not have to search far for one of the reasons for the relative happiness of people here:   the absence of the constant negative nasty news, attacks on our President (blamed for Ebola, no less!), anxieties and fears about everything, daily reminders of the corporate takeover of both our political system and our healthcare system.

        Here in Bhutan, they DO worry about global climate change.  But there should be a lot more anxiety about illness and death.   After all, these deaths from encephalitis qualify as an outbreak.  But this does not make the news here. Record keeping is not good. There are no respiratory nor contact precautions.  Neither are there gowns, gloves, nor masks, except in the NICU.  
           Orellana Lincetto, the bright, experienced new WHO representative to Bhutan, who I had over for dinner a week ago Friday, said there is a plan in place for caring for a case of Ebola if it does strike Bhutan. But much more important measures in preventing the spread of infectious disease would be things like putting screens on windows in the hospital to keep flies out, providing soap for all the sinks, and fixing the sinks in the out patient pediatric clinic.   Right now the one in Chamber 2, my usual exam room, spits and sputters and threatens to explode, but doesn't produce a stream of water. We go through a lot of hand cleanser.

 Scenes from the OPD waiting area.  The signs warn of the dangers of polio.

         I joined the intern in the OPD.   We admitted two children: a two month old with pneumonia, and a 20 month old with severe stunting, microcephaly and cerebral palsy, from a small village.  This child had been "lost to follow up"  and had had no care for his malnutrition, developmental delays, or spasticity.  She turned blue and stiff from a severe breath holding spell when we looked at her ears.

          The previous day, I had admitted a normal child about the same age who began to seize while waiting in the queue to be seen.  She had a febrile seizure.  

                                                  Patients and families with us in the OPD

I went to check on her on the ward and a child we had diagnosed with Kawasaki's Disease.   This 3 year old boy was now sicker.  He had developed pneumonia, probably nosocomial (hospital acquired). Dr. Tashi had put him on a new antibiotic.  He has had a fever for two weeks now.   His rash, which had disappeared, was back.  

Grandmother with prayer beads chanting and nurse improvising with webbing to hang IV as no IV set ups were available

            I asked a nurse for a bandaid for a cut I had.  The hospital does not have the money for them, so here she is in the treatment room, picking out some gauze I can tape on instead. 

          Dr. Tashi was in the PICU.  She was reviewing all the recommendations for Kawasaki Disease on her tablet.  The physicians here are as plugged in to Up-to-Date, Medscape, the AAP Red Book and other sources of the most recent medical guidelines and research as my colleagues back home.  In fact, there is now, a new program, Pemsoft, installed by a former HVO pediatrician, Kathy Gallagher, who came here as a tourist last week.  It is being provided free to developing countries by the group KidsCare. The problem is, of course, that many of the recommendations for tests and medications are impossible to follow here, since they just aren't available. They have to improvise with what they have. 
          As I have every day, I checked in on a 10 year old boy in the second bed in the PICU.  He has been in the hospital for two months.  He has a rare and serious form of glomerulonephritis which has caused renal failure.  He has been on hemodyalysis his entire hospitalization.   Now he has developed cardiomegaly and pulmonary edema.  He was in respiratory failure.   Three days ago, Dr. Tashi had suggested intubation, but his father, who has been at his bedside constantly, refused.   He has been given maximum amounts of oxygen by mask instead.   
          He is somewhat better today, clinically, after more morphine and lasix. One of the routine measurements back home would be arterial blood gases.  But the machine that does this measurement in the hospital is frequently "down", and the kits they have in the PICU here don't match the machine.  Besides, he is "jumping around" too much, and the experienced nurse anesthetist, Pema, who runs the unit fears sedating him too much. The heads of department in the hospital have approved his going to Calcutta for a kidney transplant.   
         "He is going on Monday" Pema said.  
          "By medical transport?"  I asked "Helicopter?"
          "No, on Druk Air"  he said.
          "On a regular passenger flight?"  I asked.
          "Yes," he said.  "With me. It's difficult, in peak tourist season. We had to wait for an open seat…
           "It's kind of funny actually," he smiled.  "We book as many seats as we need.  I have the IV and the tubing hanging.  This flight is a short one.  I go on many many flights.   I've had to go to Bangkok with a patient who had been on a ventilator.  I had to bag him the whole way.  Six hours."
           He shook his hand to show how tiring it was.  "The oxygen tanks on board are too small.  We have to bring our own."

           I chatted with Dr. Tashi in the little cubicle where we take breaks for tea, momo's and rice.  We were joined by a cardiologist interested in seeing the movie "Fed Up".  I brought a copy of the DVD here to Bhutan.  My plan was to show it to as many people as I could, hopefully the Health Minister who I met last year with Shelly.  In a country as small as Bhutan, with no fast food chains, and virtually no fat people, there is a chance to prevent the obesity epidemic which is wreaking havoc on the health of American citizens, as well as the Chinese, and virtually every developed country. 
               My dream is that maybe the Bhutanese will be motivated to pass a tax on soda and other sugary foods, the way Mexico and other countries are doing.  
                An ounce of prevention is worth a pound of cure.  Literally.
               It doesn't look like the  meeting with the Health Minister will happen.  And physicians have been too busy thus far.    But I did show it to the third year nursing students at the Royal Institute of Health Sciences (RIHS). 
          I introduced it as a cautionary tale.  "You don't have this problem,"  I said to the waiting students,  "But this is what can happen if you give up the traditional Bhutanese diet for the the junk food we eat in the States."
           They had waited for me for 40 minutes.  (As often seems to happen here, I was given the wrong time for the showing.  I've also been given the wrong places, had lectures cancelled at the last minute, told to meet a contact person who was not there, searched the spacious offices in the RIHS for the person I was supposed to meet, finding they were all empty as the faculty or administrators were all "at meetings" or "running errands")
           The students were patient.  They stood up when I entered the room.  I was served tea in a china cup, cookies and fruit.   I joked to the student helping me that here I was, showing a movie about the dangers of sugar, enjoying sugary snacks.  The student didn't get the humor.  Often jokes get lost in the translation to another language or culture.
           But young people here certainly have a sense of humor.  It's perhaps a little different from ours.  They were transfixed by the film.  They had a lot of good questions.  But during the movie, when there were scenes of a very obese girl crying repeatedly, students laughed.  A Butanese friend said that people think is funny when someone cries "too much".

                                  Students, and a dog who wandered in, watching "Fed Up"

            And tonight I was on my way to what turned out to be a wonderful nursing school talent show to which I was invited - it was as if my friend and I were at an arts and music school production, filled with traditional Bhutanese, Tibetan, and Hindi song and dance, lots of hip hop, and everything in between, with lots of cheering and merriment -- when a young man with severe spastic diplegia passed by with his walker, accompanied by two friends.  It was dark.  He fell over the lane divider as he entered the hospital parking lot.  He and his two friends laughed as they all struggled to get him to his feet.   I asked if I could help them.  
           "No thank you sir, Karincha-la" one young man smiled, as they succeed in righting their friend. Then still smiling, they continued on their way. 

        The cardiologist warned us both of the dangers of the deep fried snacks Dr. Tashi and I were eating, brought by the nurses from the Hindi festival happening this last week.  Stores and offices in India have been closed; noises of firecrackers and flickers of red and white sparklers fill the air at night.  I enjoyed the sweet greasy dough anyway, marveling at how the cardiologist looked so cool and smart in his crisp white coat and sweater vest in the heat of this tiny anteroom.   We talked about the film showing.  I also asked for an extra hour in which I could offer some suggestions to the Pediatric staff, based on the research I did for my lectures during my month here, and my years of experience as a pediatrician in the Unites States. 
            Dr. Mimi is away, after being invited their by a former volunteer.  I said Good bye to her after spending  a short time the previous day with her in the development clinic.  She asked for my advice on a child with Williams Syndrome and ADHD, and a child with severe autism.   I told her about the solid scientific evidence that eliminating artificial food coloring helps reduce hyperactivity and other symptoms of ADHD.
             She said that she was sorry that we had so little time to talk during my stay.
         "You must come back again," she smiled, "for a third time.  Three shall be your lucky number! "

                                         Dr. Mimi discussing a patient with me in the Developmental Clinic

            Dr. K.P.  is rarely available as he is interim president of the new graduate school of medical education.   Which will leave Dr. Tashi as the only pediatrician in the hospital (outside of the two neonatologists, both of whom are unpaid).  Unless the one pediatrician in the south of the country can be brought here.   But that is currently "in process".
            
            Soon I was off to my last stop of the day:   the Psychiatric ward, to follow up on a 21 year old woman admitted yesterday.   I was asked by the American psychiatrist volunteer, Dr. Allen, to see her. She had a long history of "giddiness", treated as seizures, but often a sign, if not the only sign, of depression here.   She had stopped speaking after having an argument with her mother.
           It's amazing how interested everyone here has been in my skills in clinical hypnosis --- from nurses, to physicians, to therapists, to patients.  In my 25 years at Baystate Medical Center back home, and in my 22 years at my private medical practice, I have never been asked to speak about these skills or my clinical experience in helping hundreds, if not thousands of patients.  But here, I have been asked to lecture about hypnosis to nurses, nursing students, community health workers, psychiatric staff, and pediatricians, and to see patients ranging in age from 11 to 96!
             More on this in the next post.

    

       

       An infant died during our morning rounds this week.  He was the fifth child to die in a week at JDW Referral Hospital.
       "We are the only referral hospital in Bhutan," Dr. Mimi, the head of the department, and one of three pediatricians in the hospital, explained. (We all go by our first names with the appellation "Dr."  I am called "Dr. Dave")  "We get all the sickest children."
       The senior resident Dr. Jimba and I were making our rounds in the ward.  Dr. Mimi was busy in the PICU.  We came upon a baby I shall call Sonam ( --- no chance of violating HIPPA - which doesn't exist in this country anyway; half the population, both males and females, are named Namgay, Tsering, Sonam, or Tashee).
             He had been in the hospital since long before my arrival.  He was born with congenital hydrocephalus. He had a ventriclo-peritoneal shunt to drain the fluid from his brain placed in India, but it had failed.  He had two revisions, which had also failed.  Dr. Tashee (the male neurosurgeon, not the female pediatrician Dr. Tashee) had approached me during my first week here, in the PICU, to ask my advice regarding intra thecal amikacin to treat a shunt infection.  The baby had had recurrent infections.   He was barely conscious.
               Dr. Tashee and Dr. Mimi, had both explained, "We have discussed the prognosis."   I had met his young parents.  They were quiet, calm, and respectful, like almost all the parents here.  They never had any questions.  They probably had asked them all already.
              Now the patient was in a bed in one of the 6 bed units on the Pediatric Ward.
                "Dr. Mimi has discussed it with the parents,"  Dr. Jimba explained.  "We should not perform CPR on this child".  I asked Dr. Jimba if this meant "Do not resuscitate" and he said Yes.   I said that we also include a "Do not intubate"  (DNI) order as well.
                 Dr. Jimba said "We don't have such orders here".  Doctors simply discuss the patient's prognosis with the parents, every day.  Then they reach an agreement.
       I looked a the baby. He was on oxygen by nasal CPAP but his pulse oximetry was now in the seventies.   He was in respiratory failure.  He had bandages over his hugely swollen head.  His chest was sunken.  He looked grey.   I listened to his lungs.  We reviewed the situation with the parents.  We went on to the next patient, moving clockwise to the other half of the room, past the one TV set in the unit, which was hardly ever on.
       Minutes later, one of the nurses, who are called sisters (or brothers) here, asked us to come quickly.  The child's breaths were agonal.  He was dying.   Dr. Jimba explained what was happening to the parents.  The father gave the baby a few drops of a clear potion.
        "This is to help the child on his way to his next life," Dr. Jimba said.
         Two sisters fiddled with different sized ambu masks, but I told them to put the masks away.  I asked them to call Dr. Mimi, so that she would know what was going on.  She was unavailable, we were told, minutes later.  She was trying to resuscitate a dying child in the PICU.
          I sat with the baby as he passed away.  I told Dr. Jimba and the parents that his heart had stopped.
         Anyone who believes in the stereotype that the Bhutanese do not show their feelings have never sat with parents of a dying child here.  The young dad cried has he held his baby.  His mother wept, hugging the father's shoulders.  Of the deaths I have witnessed it was among the most heart rending.
         Traditionally, everyone has at least one monk in their family, Dr. Jimba explained.  One of the sons has usually fulfills that role.  As family size shrinks from an average size of 5 or 6 to 2 and the culture modernizes, this tradition is fading. But everyone usually has their own monks to call upon.  This family was no exception.  Three men with shaved heads, sandals and red robes entered the room.
They began to chant by the baby's bedside.  An aunt joined the family.
        We continued our rounds.  The next patient was a two year old boy who had been in the hospital for a month.   (There are no "quality assurance" people here heckling us every day to kick  patients out, because "the insurance company will deny payment."   Health care is free.  There are no insurance companies.)   The boy had an undiagnosed weakness of both lower extremites, so that he had stopped walking and difficulty crawling. The weakness was preceded by a non specific viral illness. He was in no pain.   He had lost his patellar reflexes. A lumbar puncture was negative.   He had been waiting for an MRI of the spine, but the one MRI machine in the country was unavailable for two weeks.  Nerve conduction studies are difficult to get here.
        Dr. Mimi had asked for a "neurology consult".   This is in quotes because there are no neurologists in Bhutan.  There was a HVO neurologist, Dr. Doug, from Colorado who was here for a month.  (He so impressed the Bhutanese medical staff that they asked him to move here.  They offered him five times the salary of the average Bhutanese doctor, but that is still ten times less his income as a doctor in the States.) He does not see children, however, so he asked me to consult.
               After reading everything I could find about pediatric neuromuscular disorders (in the western literature - the vast majority of medical literature is published in the west)  I concluded that the child had Guillain Barre syndrome - perhaps the chronic form called chronic inflammatory demyelinating polyradiculoneuropathy (CIDP).  The cerebrospinal fluid is supposed to have an increased amount of protein in Guillain Barre, but the CSF can be normal in certain cases, said Dr. Doug, with whom I discussed the case.  The one problem was that the weakness is supposed to be ascending, from the toes to the head.  The boy had neck weakness, as well,  but no paraplegia of his respiratory muscles.  He was having no problem breathing, or eating.  His cardiac function was normal.  Still I thought that G-B was the diagnosis.  I proposed the currently accepted treatment,  daily intravenous immune globulin, for five days.  Dr. Mimi agreed.  I thought I was pretty smart.
      The boy did not get any better.  Finally he had the MRI of his spine.  It showed an inflammatory lesion of his third and fourth lumbar vertebra.  The disc space was normal.
      An orthopedist was consulted.   Like most of the surgical specialists here, he was wearing a white coat instead of the tradition kho.
       "This is typical tuberculous of the spine,"  he explained in a soft spoken but confident manner.   "We see this all the time.  Probably someone in the family had TB."
         Yes, the mother said, the father had had TB.  We hadn't bothered to find this fact out.   This diagnosis is not in the pediatric literature on neurological disorders.  I realized, not the for the first time, how biased the medical literature is towards the developed, resource rich nations.  The orthopod suggested triple therapy for TB.  No, it wasn't necessary to biopsy the spine.  He didn't even feel a PPD skin test was necessary; the appearance on MRI was so typical.  The neck weakness was due to a second tuberculous lesion in the cervical spine, he said.   We could get an MRI of the C spine to prove it.
           In the bed across from us, the monks were still chanting.  One of them was supporting the parents with his hands.  They were quietly weeping.  The other families in the room all knew what was happening.  The sisters had brought in a partition to give the family privacy but the much of what was going on was still clearly visible.  The other families were curious but quiet and respectful.  They kept their distance.  The sisters asked us permission to remove the tubes and wires from the baby's body.  Dr. Jimba went to fill out the death certificate.
            Dr. Mimi came to help him.  The child in the PICU had died as well.  He had been transferred here with some form of meningoencephalitis, a a viral infection of the brain and spinal fluid.  Then he suffered aspiration pneumonia, respiratory failure, and arrested.
          I was reminded of an infant we had rounded on the previous week.  She had been diagnosed twice with pneumonia at a regional hospital, then was thought to have congestive heart failure.  She was transferred to JDW.   The diagnosis was problematic, because she had no heart murmur.  Her chest X-ray looked normal to me.  But still he seemed to do a bit better, on two medicines, aldactone and lasix, used to treat heart failure.  His oxygen saturations increased.  She had also been placed on two more antibiotics.
           However, the next morning, Dr. Jimba arrived exhausted for my weekly Thursday morning lecture.  He was on call when this patient arrested.  She could not be resuscitated.   Dr. Mimi thought that the infant perhaps had botulism.  The family is Nepali.  It is common practice among parents of this ethnic group to feed their infant's honey, which may carry botulin spores.  In the U.S. we warn parents against giving baby's honey until the first year of life at all their well child visits.  However, well child visits in Bhutan do not exist --- only sick visits, and vaccination clinics (see previous post).
        "All these children who have died (except the infant whose death I had witnessed) are from the South, from the border region.  They get a lot of meningoencephalitis."  Dr. Mimi explained.   "When they get sent to us, they are very sick."
            Many of these young children develop seizures.  They are all treated with combinations of dilantin, phenobarbitol, and sometimes diazepam.   There is no EEG machine with which to diagnose epilepsy.  They are treated empirically. Without the laboratory facilities to identify viruses, it is impossible to tell what the pathogen is.
              These patients are in addition to those who come in with seizures from cisticercosis, scrub typhus, or japanese encephalitis virus (three infections which can be diagnosed here).  A baby with JE virus has been on a ventilator for two months.  She moves her eyes to look at us but has lost all use of the rest of the muscles of her body. Then there are the patients with nephrotic syndrome due to diseases like mesangial proliferative glomerulonephritis -- rare diseases that would probably not even be handled by the nephrologists at my medical center back home.  These patients would be sent to Childrens Hospital Medical Center in Boston.   Congenital heart disease (CHD), is diagnosed clinically with the help of sometimes echocardiograms that are read by technicians, not cardiologists.  The three pediatricians here send about 40 children a year to India for surgery for their heart conditions, but take care of these children themselves until they are ready for surgery.
         
          I'm not sure if it is the culture, or being away from everyone and everything to which I am accustomed, but I have never been so aware of the yin and yang of life.
          My roommate is a good and decent person.  Yet he is quiet, serious.  We play no TV nor music.  We can go for long periods without talking as he works on his lectures.  On the other hand,  my wife - herself a warm and gregarious person with many friends - tells me, in the evenings after work,  "You are a talker!  I'm tired after work.  I like to just watch a show on TV.  But you need to talk!"
          So this, along with having a roommate for the first time since medical school, is an adjustment.  We both see the good and difficult sides of ourselves, I am sure.
           Bhutan itself is among the "greenest" in the world.   Yet there is garbage everywhere and gutters with open sewage running down below our apartment.
            At JDW Referral Hospital, the pediatricians are among the brightest I have met everywhere.  Yet without the diagnostic tests, specialists, medications and facilities we take for granted, they sometimes by necessity take a "shot gun" approach.
            Hygiene has improved dramatically in Bhutan, but I still have seen cockroaches and flies in the PICU.  (They don't tend to kill them because Buddhists value all life.)  Signs everywhere in the hospital warn against spitting doma, the potent beetle nut lime mixture that turns teeth red, chewed nearly universally here.  A sign on the doors at the entrance to the nursery warns to keep the doors closed, to keep mosquitoes out.   In the outpatient pediatric department, garbage is swept up in big piles at the end of the day.  Each exam room has a table with a sheet and a pillow which are not changed between patients.  Families and children wait in long queues to be seen --- obviously a breeding ground for contagion.
          They usually arrive at the exam room without having there temperatures or weights measured.  They have histories of fever without temperatures having been taken at home --- since no one owns a thermometer.  The patients then have to be sent to "Chamber 6" - the treatment room - to have these important measurements done.  Last week, the day the boy with the VP shunt died, I was supervising a new intern.  We were seeing complicated patients -- like a baby with prolonged jaundice, who had been put on thyroid replacement for hypothyroidism which might have been transient.  (There is no newborn screening to pick up inborn errors of metabolism).  He was on about 5 other medications.  We saw another baby sick with vomiting, peeling skin, and large lumps popping out of his body, which turned out to be abscesses.    
              I was trying to teach him how to look in ears.   All children have waxy ears here.  It's the hard dry kind that is hard to clean out.  Yet it is essential to look at the tympanic membranes to diagnos an ear infection (otitis media)..  Here children are sent "to ENT" for ear cleanings.  Judging by the number of kids who have waxy ears (about 100%), I think there is a lot of guess work when it comes to diagnosing otitis.
            Dr. Mimi had told me that sick babies should have their temperatures taken before they arrived at the exam rooms.  I went out and talked to the young woman at the intake window, and the nurse.  She pointed out that she was the only nurse there that day, and there was only one working thermometer in the clinic.  She had to do updrafts, and rehydration therapy as well.    There is a shortage of nurses.   Yet Bhutan does have the money to send patients who need expensive cancer chemotherapy and liver transplants to India.
              And there is no evident shortage of uniform guards - most of them young women, who line the stairwells between every floor. There are usually three of them, together.  Why the guards?  There are no security problems.   The prime minister led the "Move for Health" march last weekend without any guards.   He passed a law that no politicians should have any security personnel when they move around the country.  The fourth king himself (K-4, he is called) frowns upon having security when he takes bike rides or hikes.  (Instead the army will practice surveillance on the king, and set up check points.  "The king has just passed" they will radio to each other.)
          "They should get the guards to take the temperatures!" Rebekkah,  a nurse anesthetist volunteer suggested.
          It is a country of contradictions.  
          I talked to the Cuban medical officer stationed in the OPD. Did he have this problem?
No.  But I'm not sure how often he takes temperatures.  
         The previous prime minister had close ties with Cuba.  To help with the doctor shortage here, he contracted with Cuba to have them send physicians here.  They are put up in hotels until they are oriented and learn enough English, then paid to practice here in various capacities for a year.
         I had a suspicion the Cuban doctors were the ones prescribing antibiotics for children with colds. I could not tell for sure, since I can not read anyone's signature.  Antibiotics are for bacterial infections, not viruses.  They don't not help, and may cause harm, leading to side effects and antibiotic resistance.        
One of lectures I have given was on pneumonia, and upper respiratory infections (colds, or URI's).  Unfortunately, none of the pediatric attendings could make it.
       I had pointed out that cold and cough medicines do not help children with URI's either.  They have have never been proven to help.  These drugs can cause serious side effects.   One of them, phenylpropanolamine, has been banned in the U.S. The WHO guidelines call only for the use of saline nasal drops and warm liquids for kids with colds.   Yet over the counter (OTC) cough and cold  medicines are still regularly prescribed here.  
           The doctors say that the parents here want to get a medicine from the doctor.  I told the residents I have worked with that this was the situation in the United States.  But one can simply explain to parents that colds and other viruses will go on their own, thanks to our immune systems.  The body heals itself.  Sure enough, the residents have found out that I was correct.   The parents here as smart as those back home.  They left the resident and me with prescriptions for salt water nasal drops only, without complaint.   And, I pointed out, this will save the Bhutanese medical system thousands of dollars.
          This is an important issue for a nation that only spends 3.5% of its budget on health care, yet promises free health care for all!
          The Cuban physician on duty, Dr. Gabriel was a friendly enough fellow, though he wore a mask, and refused to shake my hand, presenting only his arm to me.  There is a widespread fear of spreading infection here.  With good reason:  my roommate has been sick.  The volunteer Dr. Larry upstairs has been sick.  The pediatrician Dr. Tashee was out sick last week.  Dr. Jimba was out sick.  The intern had been sick.   The OPD is a regular rainforest of infection.
         He denied prescribing antibiotics for colds.  
         At 1:30 pm, I checked outside the door of our exam room.  The intern and I were the only ones left in the OPD.  The nurse and the Cuban doctor, and the intake staff had gone home early.  The clinic is supposed to run until three pm.  All doctors are civil servants here.  They work, officially, from 9-3.
         "They must have had CME"  Dr. Tashee explained, when I saw her.
          And I had to leave, for a hypnosis consult with a patient who turned out to be 96 years old.  More on this in the next post….
           
       


     
 
         
         
 

             I was sitting in the living room of my new friend Sonam's apartment.  He had invited me to the first birthday party of his daughter (also named Sonam).  It was a small two bedroom apartment, but cozy and comfortable with pink walls, silk curtains hanging in the doorway, a few large oak chairs, but mostly wool carpets for us to relax on.
              He had picked me up after a hike I had taken that morning with two other volunteers.  We had climbed to new Chhokhortse goempa, a center of calm and contemplation overlooking Thimphu valley.  I "talked" with a welcoming beatific monk dressed in orange robes, using my very limited Dzonka, and his very limited English.  "This is my home," he smiled.  "The king's home", he explained pointing up the hillside to another older complex.  Wherever we travel, the king seems to have a home.   He has one near Sonam's apartment building.  To reach the building, we drove down a dirt road that resembled the surface of the moon. It was a hardly a road at all.  His hubcapless light blue Maruti subcompact kept bottoming out.
         "Does the king go down this road?"  I asked.
          "No", he said.  "The king has a paved road.  Over there" he pointed.  "A private road. Just for the king".
           Sonam called me his "Number one guest".  "My parents are so proud of me that I have invited a doctor".  His parents had travelled from the village of Trashigung in Eastern Bhutan where Sonam grew up.  They are farmers.  Sonam's mother died when he was young; his father remarried.  Sonam had to leave school to help support his younger siblings.  His parents spoke the local dialect, sharschop.  They spoke no English and limited Dzonka.  I met them, and his extended family, which seem to grow by the minute as dozens of friends and family arrived.
                While waiting, we had little corn flake snacks, a cucumber dip (flaming hot, of course, with red peppers), sweet dough bits, tea and beer.  While waiting - as always in Bhutan - I met a variety of interesting people. They included a friend of Sonam's, who was working, 3 months out of the year, as a tour company operator.  He said that though he was happy, as were most Bhutanese, there was lots of stress, which he dealt with by taking the rest of the year off to go to India.  And he planned on retiring in his 50's.  "I will work hard now, but after crossing 55 years…. Old, no?"
             When I said I was 59, he acknowledged that on the farms, 59, 70 or 80, even 90, could be young, because of the life they led.   And Sonam's father and step mother did look very young.      Sonam's friend observed, "From here, complexion, we can see.  Happy, no?"
                Also there was the landlord, a body guard and landscaper for the fourth king who had left his wife for an American woman with whom he lived in New Hampshire for 13 years while running a landscaping company, before returning to build apartment buildings, and rejoin his patient wife and family (All he seemed to recall of NH and the US was Mt. Washington "The weather was very bad".)      Then there was a friendly relative, and employee of the health ministry, there with his wife. I sat between them on the floor for a time, as he drank most of a bottle of wine.  But I left when he was leaning so far over onto me that I thought I might end up toppling over to his wife on my other side.      Finally, there was another friend, a politician, recently voted out of office.  Like so many people I have met all over the world, he greatly admired President Obama.  "He is a very very good President!   I look at all his speeches, and I make my speeches just like him!    He is a very good man!..  "  He also appreciated Western religion, though he remained a faithful Buddhist.  "I like Jesus very much!   He was a VERYgood man!"
            Some of these conversations happened after the birthday cake, and explosion of a confetti gun (which scared none of the small children), and finally, after two hours, the serving of food amid much merriment and celebration.  We had no sha (beef),  oak aha (pork fat), and ge ju ( river weed soup).  During the entire evening, a television played in the corner This interested me because I haven't watched TV in a month.  My roommate Ashoff and I live a quiet life.   No TV, no music (except a little from my iPhone when I make dinner) - just the symphony of dieseling cars and
barking dogs at night.
                This being Bhutan, they weren't watching an episode of Breaking Bad.  They were watching a show about the fifth king, Jigme Khesar Namgye Wangchuk.  No commercial interruptions, of course. It was a rerun - his coronation, from 2006. It was in the big soccer stadium in Thimphu. It was a very extravagant affair, with lots of traditional dance - one the king himself performed in - world dignitaries,  and so on.   Friends and families at the party were transfixed.   I found out the next day that this was the sixth anniversary of his ascension to the throne. His father, the fourth king, Jigme Singyei Wangchuck, vigorous at age 51, had stepped down - not wanting to risk dying in office relatively young, as his father and grandfather had.  The fourth member of the Wangchuk dynasty also established a parliamentary democracy, headed by a prime minister - whom I had met that day.
           I had gone to the "Move for Health" annual walk sponsored by the World Health Organization  and the government.  We gathered 15 km from the capital city at 7am.  The goal was to raise awareness of "non communicable diseases" and to raise money for Bhutan's Health Trust fund.  As the the nation advances, it receives less charity from NGO's and so must find other ways to fund vaccinations for example.  (Though Bhutan still depends heavily on donations - whether it be the work of HVO volunteer doctors, Gardasil, or HPV vaccine, donated by Merck and co., and so on).  There were large crowds of excited students in uniform, government workers, and others.
        We mobbed the back of a pick up reaching our hands in the air for caps or T shirts.  "Madame, Madame,  L please.   Madame.  M!"  I got one of the M's.   Dr. K.P  had already given me a cap.
        Then we arranged ourselves in an auditorium, and waited for the prime minister, in front of a stage, empty except for a table with a yellow awning, seats and the chief abbott of Thimphu.  I was seated in the front row with Dr. K.P., the chief representative of Jaico, the Japanese Friendship Association, and Ministry staff.  We stood up and bowed slightly when the ministers, and head of the opposition entered.  I talked with a 50 something retired government employee on my left.  I was wearing my white coat and HVO identification badge.  I explained that just as all the Bhutanese were wearing their uniforms - kho's, I was wearing mine.
           "Doctors are next to gods," he said "The gods heal people but doctors help them".
            I observed the anti smoking posters which I have seen throughout the country.   They featured "smoking man", a collage of a person with one gangrenous foot hanging off, a hole where his left cheek used to be and other grotesque images which would have been banned in the squeamish US.
          "Many of the people, they can't read," the man said.  "You have to scare them".
          Then I talked to the man on my right.  He was an engineer and forester who works in the Agriculture ministry.   He talked about Bhutan as a green nation.
          "The farmers are organic by default, actually" he said.   "Only 3 percent of the farmers use chemicals.   They have found that many of the weed killers imported from India for the rice crop are adulterated; they don't even work."   They would rather farm the old fashioned way.
           "Even though they are less productive," this agriculture expert explained.  The government is trying to help by bringing roads, and mechanized equipment to farms.   And irrigation, especially tricky in Eastern Bhutan where farms are located up steep dry hill sides.   "It's difficult to build waterways up the sides of mountains," he said.   Farms everywhere are sandwiched between mountains, and are usually no more than 30 or 40 hectares.
            "Only 3% of the land in Bhutan is arable" he said.  "We're trying to change that to 8"
            "72 % of the land is forest," he continued, "We are a cachement area.   There is no exportation of lumber.   We are carbon neutral." And Bhutan is one of the ten top regions for biodiversity in the world,  he said.
            As for Bhutan's people, "they are happy, relatively, because of the family structure.
As long as you have a roof over your head and two square meals a day."
            "Two?"  I asked.  "I always thought it was three."
             "Two," he said,   "but three if you are a farmer".
             "People will work for each other without pay.  Only for lunch"   That old fashioned communal way of life.
             We had waited about an hour for the prime minister.  Finally, he arrived, with a flourish.  We rose in respect.   We were served breakfast:  Hot buttered tea and a dish of rice and hot peppers.   We waited for the monk to chant prayers in the style of the Tibetan throat singers, used here, before eating and drinking.    Then we listened to speeches from the ministers and the PM's  --- or they listened, and I daydreamed, since it was all in Dzonka.   I did recognize the frequent mention of "non communicable diseases".   At the conclusion of the ceremony,  Dr. K.P,  said Hello to me and vanished behind the stage.  I went outside and was caught up in a chute leading out to large gate. Escaping the crush of students, I rushed to the front of the parade, where the Prime Minister, a very fit looking man in a charcoal grey kho was leading the procession. His wife was by his side.  They were holding hands.
                  I quickly lost site of the other ministers and, jogging at times to keep up, followed the PM.  There was no body guard.  The others along side and behind him and his wife appeared to be ordinary people, like myself.   Everyone was in high spirits, including the policemen who accompanied us.  They are all much thinner then the police I am used to.   And they don't carry guns. They were directing us to stay to the left, so that traffic, including the ever present large Indian construction trucks festooned with ribbons and colorful sayings meant to bring good luck on Bhutan's treacherous road, could pass, even if only by inches, to our right.     Everyone, including the health minister, Tandin Wangchuk, who I met later, joined in the fun.
      "Left, La, Left!" (La is the expression used universally for sir). " Left!"  People were singing and laughing, even as we had to concentrate to keep up with the fit prime minister.   I ran in from to take a picture.
       Then I noticed a distinguished looking couple.  They were the first caucasians I had seen all day.  I heard the husband, tall, and grey haired tell someone he was 59, turning 60.    "So am I" I said.
We started to talk.  His wife,  Orellana Lincetto is the new World Health Organization representative to Bhutan.  She is a neonatologist.   She spent 5 years in Mozanbique, developing, among other things the protocols the WHO uses worldwide to prevent hypothermia in newborn infants.  After seven years in Geneva in which they were raising children, she had just been sent to her new post here.
      I asked her some questions, including why the WHO continues to suggest ampicillin and gentamicin as first line treatment for pneumonia for hospitalized patients. (The antibiotic ceftriaxone may be given only once a day, is better absorbed by the lungs, and does not run the risk of renal damage). But mostly I listened as she, and her husband talked about their fascinating lives, living around the world.
           After an hour and a half we stopped abruptly.  The prime minister had led such a fast pace, that we were now ahead of schedule, despite the late start.  Things would not be ready for us when we arrived in Thimphu. So the PM, Dr. Lincetto, and other dignitaries sat under a tent drinking more hot butter tea and rice with peppers, while the rest of us waited, for about a half hour.  Then we were off again.
            I met Minister Wangchuk.   I asked his permission to walk with him.   We talked about his name.  He explained that many Bhutanese had taken the surname Wangchuk, but the only people who historically ever had last names were the royal family.  And they have been Wangchucks, with a final "ck".  He, Dr. Lincetto and I discussed healthcare in Bhutan.  Or, I should say, they did.  I listened.  I was well aware of my lower station in this trio.  But Minister Wangchuk did say that he would give his concluding speech at the Clocktower in English as well as Dzonka, so I would know what he was talking about.   At around noon we arrived at the gates to the city of Thimphu.    Burning incense and prayer flags, as well as bottles of tropical fruit juice and hot milk for all, and more snacks around round tables for the dignitaries.
          The final walk to the clock tower was tough.  I had trekked for 14 days over high mountain passes, but I had never walked for over an hour on hot pavement through the urban sprawl which are the environs of Thimphu.  I was getting tired of talking too, even though I met an engineer who told me he was also a philosopher. He had just written a book.  He said that the Bhutanese are relatively happy, but that "all happiness is relative" and not the concern of philosophers like him anyway.  He is more interested in looking below the "inner surfaces" of things.   He could not really explain to me how he had become both an engineer, an author, and philosopher after growing up in a little village in Eastern Bhutan, not even speaking Dzonka, only Sharschop.  Maybe his upbringing was was motivated to him to do all those things.  He was a fast walker, and did not want to wait while I took pictures.
         I walked alone for a while amidst teenage students.  Then, suddenly:
         "Hi, Dr. Dave!"    It was Sonam -appearing out of nowhere.  It was his daughter's first birthday the next day.   And I was invited as his honored guest.    Yes, he would be happy to accept my invitation for dinner as well.  Did we have music, he asked.  He was not a sportsman, but loves to sing and dance -- any kind of music.   I played him samples from my I phone:   Bhutanese music,  Shaggy, Bonny Raitt.   I found myself again longing for my wife Shelly:  We love music, all kinds.  And we love to dance together.
     
        I've learned that the curve of history is viewed as circular, not linear in Bhutanese culture and in other Asian cultures.  So do many of my days seem to be here in this country --- filled with chance, coincidence, and (perhaps) karma. Unexpected and even magical occurrences and happenstance seem to fall from the sky.
        And while the pace of transformation in Thimphu, the adoption of the internet, of Western pop culture and American name brands and food products and consumer items seems to be happening at breakneck speed, some things like the absolute reverence for the royal family seem to be engraved in gold.   How does this affect the society's views towards reform and advance in its health care system?
       At the final ceremony at the clock tower, I rejoined Dr. K.P and Dr. Dowa, a visiting neonatologist from Japan.  We watched and listened as musicians played and sang, traditional music, karaoke style. Minister Wangchuk spoke in English as well as Dzonka as promised.  The theme was again about how non communicable diseases:   hypertension, diabetes, traffic accidents, cancer, and alcoholism and drug use represented the new morbidity and mortality in Bhutan, as they do in the West.   I was to have an unexpected chance to address a couple of these issues two days later.
                But now I found myself nodding off.  I bought a 100Nu "recharge" for my phone,  treated myself to a wonderful haircut and 45 minute head,neck and shoulder massage (all for about $6) and took a nap, before meeting my guide and friend Tsering for diner.

         
         

       It's been a busy week spent navigating the somewhat Byzantine though always friendly healthcare bureaucracy at the JDW Referral Hospital.   I realized that pediatricians have nothing to do with well child care in Bhutan.  Newborn babies are seen for group visits by nurses at the Reproductive Health Center, a low long building that also houses a hand therapy unit, a TB clinic, which stands incongruously next to the "Health Help" and "Voluntary Counseling" centers.  They are continuous with a bungalow which is the  Psychiatric ward, where I ended up today using hypnosis to help 12 year old boy with panic attacks.

        So yesterday, I went to see Dr. KP (Kinzang P. Tshering), a pediatrician and interim president of the University of Medical Sciences of Bhutan, located in another quiet building filled with spacious quiet offices where one is served milk and tea. Dr. KP  is a kind and distinguished gentleman. He had worked on a curriculum for Pediatric residents with Dr. Brad Berman, an academic developmental pediatrician who has been in Bhutan 3 or 4 times, and had lots of good advice for me before I arrived.
         Dr. KP directed me to Deki Pem, the director of the nursing school.  Deki was interested me teaching the nurses about development, nutrition and safety in children.  She was also interested in me showing the film "Fed Up" which I've brought here as a sort of cautionary tale about what could happen if Bhutan gives up it's traditional diet for the sugar laden fast food wasteland that has become the standard for the majority of Americans.
        I then met Dr. Nirola, the only psychiatrist in Bhutan.  Dr. Nirola was quite interested in me teaching the psychiatry and counseling staff about clinical hypnosis.  
         My next stop was the Reproductive Health Center, where I met Dr. Sonam Ugen, who has a PhD in public health.  She supervises, both the clinic where children are weighed and given their vaccines, as well as vitamin A, and deworming, periodically until the age of 5.  Down the hall there is another clinic where babies are seen with their mothers for breast feeding support and developmental screening -- but only for the first 6 weeks of life.  
            There is also a nascent adolescent program.  Teens typically don't go to doctors in Bhutan.  There is no education around pregnancy prevention, abuse, STD's, drugs or alcohol.  Traditionally, young people do not speak up about sexual abuse. Dr. Sonam is trying to change that. She and her staff are currently doing "sensitivity" sessions in local schools.  She is interested in my helping with Peer support programs. I told her about Straight Edge, and the Students against Drunk Driving (SADD).  She wrote it all down.  She was also interested in my helping bring a developmental screening tool that they could begin using in their clinics.
        I was content yet a bit blown away.  Here were these leaders in child health at the major hospital in this country, open and welcoming to an outsider like me coming in and making suggestions that would make major changes in their pediatric health care system.  Tired and hungry, I walked back "home" to my apartment in the International House, past the chorten where locals circumnavigated 3 or 108 times (both are propitious), past sun flowers, schools, fences and bus stops.

         I headed up the trail through picturesque gardens of corn and squash.  Also past an open sewer gutter that, as our HVO handbook puts it, "reminds you what the 'G' in GNH stands for".  Up by the apartment buildings, there were kids and dogs all around.  I spend many sometimes fruitless hours, admonishing parents to "kick your kids outside" away from TV and video games.  At least in the little piece of Bhutanese urban life I'm experiencing, that doesn't seem to be a problem.  Kids were playing with the dogs, kicking soccer balls in the alley ways, hanging out on balconies.  One boy in his traditional school uniform, practiced his guitar.

          In the background I could hear the mesmerizing sound of traditional oboes and drums.  Tangles of electrical wires hung improbably across alleys, along with impromptu clothes lines. It reminded me of the big festival in Cusco, Peru, where one of the big floats in a parade had to stop while several men had to manipulate a long Y shaped pole to gingerly lift a power line that was blocking the way. All the dogs seemed content.  Someone had left a dish of food for the them.  It sat partially eaten next to a little pile of dog vomit. I've never seen any dog poop however.   Though some of them converse through the night, our dogs are quite discrete in this regard.
        Then it was off across the "expressway" (four lane divided road with small breaks for pedestrians and two underground crosswalks that are only for the adventurous), down an alley to the Heritage Hotel's gym and swimming pool. Upon my arrival,  I "splurged", paying about half the price of a night's stay in a hotel room, for a month's membership.  Surprisingly for a hotel health club, I've been the only chillip there.  I've enjoyed meeting the locals, including a young guy who swims there every day.  He had spent four years in Canada going to school, swimming, and earning part time pay as a male model.  The young moms who bring their kids to swim there obviously enjoy talking to him.  He told me that this is really the only place to swim in Thimphu.  There is a larger public pool at "swimming pool junction", next to the youth center run by a caucasian llama who helps street kids, but it is dirty, he said.
                 "Dirty" is somewhat relative, because the water in this pool is so cloudy that it is difficult to see the tips of my fingers as I swim, or the concrete wall that divides one end into a section for children with bars that are missing.  "This is a developing country" he explains to me.  Still the pool is relaxing and warm.  The showers are great.  There is a clean western style toilet.   Even if it always seems to be missing toilet paper.  Today I asked the girl at the counter for some. "Please bring it back sir,"she requested "because they may misuse it".   Who are "they"? I wondered.  How would they "misuse it?"  I had visions of toddlers unrolling the stuff and winding it around their necks, or teenagers getting drunk and having fights with it.
        But I've learned not to ask to many questions here.  I swam my relaxed mile, showered and left.   It is always dark going home.  "Watch out for the alleyways after dark," Jonah had warned me.  He told me about getting his cell phone and pocket money lifted a while back by some young toughs, though, surprisingly,  he smiled as he related the story.   The alleyway is short, however.  And there was a mother dog, with her litter, nursing.  It reminded me of how the mothers in the clinics, and in public are refreshingly relaxed about breastfeeding their babies -- often nursing during during exams in the OPD.

                 I arrived home.  My roommate Ashok was there.  I told him about my day, before calling my wife Shelly.   There was discouraging story to share.
        There was a child I rounded on in the Pediatric ward that morning.  She was admitted for severe failure to thrive.  She weighted about 7 kg at two years of age.  Her head and length were in the tiny range too.  Another mother, whose child I had diagnosed with Guillain Barre syndrome the day before was doing the tube feeds.  Then the child's mother came back.
               I asked if her daughter was a happy child.  The mother gave me a quizzical look.  No, her other two children were ok, but this child was an unhealthy one.  The "brother" there, a male nurse ,said that this mom had been out drinking.  She is an alcoholic.  I looked at the little girl again.  Small head size, developmentally delayed, with a smooth upper lip.  She had the typical signs of fetal alcohol syndrome.  
              I asked if anyone was doing anything for this mother.  He said, Yes, a doctor the day before had taken care of her laceration when she had fallen down, drunk, the day before.   I asked if there is anything else we could do.  The brother said, yes, if she wanted she could go to detox.  After her child was discharged.  I asked the mother, with the nurse translating, if she knew the harm her drinking had done and was doing to her daughter.  The mother shrugged and looked away.  She didn't think she was doing anything wrong.  She obviously didn't care.  I worried as she put her child on her back and walked into the hall. There are no hospital social workers in Bhutan.  There is no Department of Children and Families.  There is no system or procedure for helping a child like this. There was no mention of any social history at all in the scribbled notes in the chart, only "severe FTT".
             I asked the mother about the father.  He is a drinker too, and not in the picture.   Are there any grandparents?  No.   For the first time since I had arrived at the hospital, I was angry.  Giving this child high calorie tube feeds and sending her back to this mom is like resuscitating a drowning victim then shoving her back into the water.  I asked Dr. Mimi, the head of the department, if there was anything we could do.  She shrugged.  "No" she said.  (Though there was a mention of "FAS", finally in the chart the next day).   I asked Dr. KP, when we met if there was anything in the curriculum about issues like alcohol and FAS.  "No" he said.  These "psychosocial" topics are not discussed, yet.   "It is a problem with the culture",  the pediatric resident Dr. Jimba told me later.
            Alcholism is not just a problem with Bhutanese culture, of course, but in cultures around the world.  But it is a very big problem here.  I would not be so presumptuous as to suggest how to address it. Yet.  And though I have embarked on an adventurous and unconventional seven weeks as a community pediatrician, I am constantly humbled by those who have done so much more.
            There is my future son-in-law, Drew, for example.  He risked his life serving our country as a soldier in Iraq.
            There is my younger daughter Liza.  Always shy as a girl, she grew into a young woman who spent a year after college teaching English in southern Ecuador --- living in a little roach infested apartment without hot running water, above her "host family", walking to work everyday through a run down section of a run down city.
              Or my colleague Jane Cross, one of my dozen partners at Holyoke Pediatrics.  An advocate for education in international health, she regularly goes on rotation in Central and South America, and in India, active on the boards of several community agencies aiding teen girls when she returns.
          Then there is my roommate Ashok:. An anesthesiologist who used to direct an ICU and regularly serve at open heart and liver transplant cases at the University of Washington Medical Center in Seattle, he now works part time in order to pay for his volunteer stints abroad.  He served with Doctors without Borders in Haiti, numerous times, including a week after their earthquake. He also has worked in southeast Asia, after the big tsunami, in North Korea, and in Libya, during the Arab Spring.   He recalls the sounds of shelling there, every night. Our apartment is like a 5 star hotel compared to his usual posts.
           In fact, all of the HVO volunteers have lived lives full of adventure and commitment to providing and improving healthcare to patients around the world.   I'm enjoying getting to know all of them.  Here are some of the group, at a farewell potluck dinner for Doug, who was the only neurologist in the country during his time here.