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.