Tuesday, November 11, 2014

        I have been home from Bhutan for a week.  Still fresh in my mind is the drive across the Muller Bridge into Holyoke on that first day.   I was in the left lane.  A car sped up to my rear bumper.  I moved into the right lane, but not before the other driver, obviously impatient, made a motion to pass me on the right.  I had already begun my lane shift, however, so I went to the right lane.  Then, in about 20 seconds, across the bridge, I stopped behind a line of cars waiting to turn right.  I noticed, too late,  that the car that had just passed me wanted to cut in front of me to turn right, but I was already moving.
As he pulled in behind me, I could see his angry face, and his raised middle finger.
        Road rage.  I had forgotten what that was during my two months in Bhutan.  In fact I'd forgotten what rage was.   If it exists in Bhutan, I never saw it.
        Actually I did see road rage in Bhutan.  Once.  It was at the second road block of the day, on the major east west highway, above Punakha.  My roommate and I were traveling with my guide turned friend Tshering.  We had set off to join our fellow volunteers.  They had left earlier that Saturday morning with Kinley Dorje.  He is the head physiotherapist at JDW National Referral Hospital.  He had  invited us to his country home in the village of Wangdue, situated on a pleasant hillside of rice paddies, above Punakha.  We had arranged to go rafting on the male branch of the Punakha River the next day.
       We had a slow start, since the road closure for lane widening right outside Thimphu was supposed to happen from 12:30 to 2, but they decided to close it early, at 11:30.  So the 3 of us turned back into Thimphu for lunch at a little Indian restaurant.  Then we made our way over Dochu La, with its 108 chortens honoring the soldiers who died in Bhutan's only war.
            It was 2003.  Indian separatists from Sikiim had ensconced themselves in the jungles of the South.  They refused to leave.  The king "K-4" himself led the troops.  The war lasted about a week.  Actually only one day, according to an army captain I met in Chibitse, during my trek.  Despite the fact that the front was about 1000 miles long.  The rest of the week was "clean up" according to the captain.  He believes that there was something supernatural about what happened - similar to what happened when the Tibetans invaded Bhutan from the west, in the 17th century.
           According to legend, the founder of the kingdom of Bhutan Shabdrung, had one line of Bhutanese soldiers exit in formation from one door of the massive Punakha Dzong, then secretly circle around, enter the dzong, and exit again. So the Tibetans thought that the army was a lot larger then it was.  The Tibetans wanted and artifact, one of the relics of the guru who had brought Buddhism to Bhutan.  When their army reconnoitered,  Shabdrung, in full view of the Tibetans, pretended to throw the relic into the Punakha River.  But it was just a fake.  There is a long history of stories that support the view that Butan is protected from outside enemies by the deities.
           The view from the pass, of the high Himalayan peaks, as seen from the hill of chortens and prayer flags, was stunning. Then came a series of typically hair raising hair pin turns downs towards Punakha.   The second road block came an hour or two later.  It was already 4:30 pm.  The road was going to be closed for about another hour, for widening (we think).  So a drive that would take about an hour in the U.S, would take us more than five.  
          But no one in the line of cars, tourist buses (what we called vomit vans)  and dressed up lorries from India, were complaining.   Roadside stands, already set up by entrepreneurial vendors, lined the road.  We bought roasted corn on the cob.  I met an American woman who was kicking around a soccer ball with the son of her Bhutanese boyfriend.  She was on her third stint as a volunteer helping on the business side of the Youth Development Fund, established by the queen (one of them) to assist needy youth.  We got to talking. She later invited me to a traditional dinner at the Folk Heritage Museum in Thimphu, but she had to cancel because the queen invited her to dinner.
           At last, we got ready to move.  A small banged up car from behind squeezed around us, nearly cutting us off, narrowly avoiding a lorrie.  It had a Tasmanian Devil painted on its bumper which read "Changsu Charlie".  The driver waved his fist comically out his window.  Then he drove straight at a truck coming towards him,  ahead of us.  No one honked.  This crazy driver then had to back up right towards us, to let the truck by.
          "That's a cab driver from Changsu" Tshering chuckled.  "Everyone knows him.  He's crazy".
Road rage is so rare in Bhutan, that the one driver who exhibited it is known as a clown, someone to be laughted at,  throughout this part of the country (if not the whole country).
          "I don't think I'd take a ride in his taxi!"   I said.

Monday, November 3, 2014



        I am being driven to the airport in Delhi.  It is hard to believe that after two months I will be returning to life in the United States.   I have at least a few posts of my vivid memories of life in the kingdom of Bhutan left in me, however.
       Right now, I’m zipping through early morning traffic.  From my very short stay here, Dehli seems to be a lot like midtown Manhatten used to be 30 years ago:  dirty, crowded and polluted.  The constant haze is so thick that buildings more than two blocks away appear ghostly grey.  And with 18,000,000 people, Dehli is more crowded than NYC.  And instead of taxi’s there are the green and yellow 3 wheeled tuk tuks, power and telephone lines tangled spaghetti like along sets of poles, and one hospital, clinic, and dental office after another.  There must either be a lot of sick people here, a lot of doctors making lots of money or both.  I’m on my way to the Indira Ghandi International Airport.  The one tourist site I “saw”, despite the Taj Mahal, was the prime minister’s home.  My driver Ravi pointed the tall fence out from the road as we sped past it at midnight. 
         “That was the home of the prime minister Indira Ghandi” he said. 
          “She was assassinated,” I remembered.
           “She was killed by her body guards.  In 1984.They were Sikh… She said something against the Sikhs, and… he did it.  There were two of them. It was 1984”
             He then went on to describe how her son was blown up by Muslim militants.  A woman put a booby trapped garland of flowers around his neck.  “It was detonated remotely” he said.  I had that gruesome picture in mind when we finally reached the entrance to the road of the Shanti Home—my home for the night.  It was roadblocked after midnight. “For security” Ravi said.
          After a rough fretful night with four hours sleep (more on this later), I left for the Indira Ghandi International Airport.  It’s my least favorite airport in the world.  Doesn’t it bring bad karma to name your airport after a prime minister who was assassinated by her own body guards?  Is that why there are soldiers with guns checking my papers about a dozen times before I get to the gate – always checking my passport and print copy of my e ticket and eyeing me suspiciously several times before letting me through? (And why call them e tickets if they have to be printed?  Why not go back to paper tickets?)  Or the long rows of airlines labeled A to Z in lines perpendicular to the entrance, without any identifying information? With an information desk manned by an  unfriendly and uninterested person who mumbles a letter unintelligibly when I ask where Druk Airlines (coming) or British Airlines (going) is before getting back to her cell phone call?
         Leaving Bhutan, there are soldiers guarding the gate to the airport, and no one but passengers are allowed in the terminal.   But the various security rules are easily bent.  Both on this departure and the one last year, when I went with my wife, I needed to get more cash to pay for gifts I bought.  There were beautiful hand woven “silk on silk” scarves for $44 US, all profits going to the Tarayama Foundation, started by the Queen Mother (3rd wife of the 4th king).  The Tarayama Foundation provides assistance to the poor of Bhutan, especially women.  Instead of the usual duty free junk sold at other airports, the airport in Paro has booths that sells handmade crafts in support of charities like this one. Though one is not supposed to go back through security and immigration once you are checked in, I was allowed to go back to get to the ATM. 
             I had already gotten Dr. Tashi’s husband, who works for Druk Air, to call the station manager to allow me to bring aboard my 25 kg above Druk’s 20 kg limit without charge, since I had worked “diligently on the service of the kingdom of Bhutan”, as his text I showed at check in read.  What followed was a dance with a guard at the door to the terminal and my friend’s brother Ratu, who is a DJ for a local radio station, and owner of a large (for Bhutan) grocery store (dry and canned goods only, no produce.  The hundreds of grocery stores in Thimphu don’t mix them up.)    Ratu’s brother drove me to the airport from Thimphu, at 6 am, an hour each way.   No matter  how much I protested, he did not permit me to give him a tip or help pay for gas.  “My brother would be very angry with me.  He feels bad that he can not do more to help.”   This the attitude of most of the friends I have made in Bhutan..
           Then, coming through security again, they found my pocket knife which had somehow made it through the first time.  I had forgotten it in my camera bag. 
         “No problem,” said the guard, with whom I had chatted the first time I went through. “I will take care”.  After filling out several forms, and talking to several different people, he gave me a form to give to the cabin crew on my arrival in Dehli, to retrieve my pocket knife from them.

          Bhutan is so close to and dependent on India in so many ways:  politically, economically, culturally, that in some ways it is a mountainous northern state of the 2 billion person nation to the south.  But as far as the fundamental vibe  of these countries, from my limited experience, they seem very different.  
          Bhutan, small, and isolated and impenetrable for years, has seen virtually no political violence.  (The exception was the repression and expulsion of Nepali nationals in the late eighties and early nineties – rooted in the fear of the “tragedy in Sikkim,  and the invasion of Tibet.  This remains a black spot in Bhutanese history.)
            Politicians, by decree, travel in country without bodyguards or security.  I described, in a previous post,  how even the king travels alone.  “K-4”, who abdicated the throne to his son, is known for his political savvy: he invented the term gross national happiness.  But his dad, K-3 was no slouch either.  After seeing Tibet invaded and subsumed by China, with the world barely blinking an eye, he knew that Bhutan had to end its isolation.  He encouraged the population to learn English, with the help of teachers, like Jamie Zeppa, who wrote “Beyond the Sky and the Earth.”
            I’ve begun reading this fascinating book during this flight home.  I can’t begin to compare my experience to the enormity of hers:  she was here as a young woman, less than half my age, 25 years ago, before there were roads, electricity, running water, never mind television or cell phone service, to much of the country.  She was posted in a remote part of eastern Bhutan for two years; I was based in the capital city (after trekking up North) for only a month.  But I’m surprised by the similarities:
            Actually, before I could get very far into the book, a teen aged girl several rows up from me fainted in her seat.  The flight attendants rushed to see her.  She swooned in her seat, then complained of a headache.  I rushed up there too.
            “Bring her up to a place you can lie her down,” I said and "get her feet up." 
           The girl was now crying. Her dad, a big, calm and gentle guy, carried his daughter to the space between our cabin and first class.  (“You always wanted to travel first class, didn’t you!” her dad joked, a bit later.)
           Before I could do much though, the flight attendant insisted I come to the galley. She and a colleague opened a big metal first aid kit, with about 5 compartments.  I was interested in the compartment with a stethoscope and blood pressure cuff, but she needed to get to the section with the indemnity form, which I needed to read.  I was held harmless in case of legal action stemming from my intervention, to the tune of $8.5 million.  I came to the aide of an elderly woman on a flight 20 years ago who was suffering from chest pain and shortness of breath.  That airline simply upgraded my ticket on my return to first class.   That was before lawyers, insurance companies, “quality assurance” officers, and electronic medical record manufacturers took over the practice of medicine in the West.
            “You’d be surprised how many incidents we’ve had on board where no one wants to get involved,” the flight attendant told me later.  “Everyone’s afraid to, these days.”
              I was surprised.  “That’s just my instinct,” I said.  “When we become physicians, we take an oath to help people”   Certainly that kind of medico legal worry would be ridiculous in Bhutan.  And after helping care for critically ill children in septic shock, respiratory failure, seizures, and encephalitis, caring for a healthy English girl who had simple vasovagal syncope (faint) did not seem very difficult.
             By the time I returned from the galley, she was awake and talking to her dad. She had been having the start of a panic attack and was still hyperventilating.  She had a headache.  I took more of a history.  She had suffered headaches since May, had a normal brain MRI “just to make sure”, had been treated for sinusitis, for the headaaches, but still  had these occipital headaches and neck pain, for which osteopathic manipulations had helped somewhat.     Occipital headaches and neck pain in an anxious teen = tension headache.   
            I’m always surprised how often in the U.S., and Bhutan, and now, in the U.K., tension headaches are misdiagnosed as sinusitis or allergies.  Even though the symproms are completely different.  Medical doctors are trained to give pills, not teach skills.  And there are good pills for sinus infections and allergies.  There are no good pills for recurrent tension headaches.
              What is good for headaches?   Relaxation.  Meditation. Hypnosis.  So I established a little rapport by joking with her and her dad about my time in Bhutan, saying “Nga ya ming Dr. Dave.”“Che ga ming gatchemo?”   (My name is Dr. Dave.  What’s your name?) and “Che ga de ba yeuh” (How are you), telling her to say “Nga lejeun be yeuh”(I’m fine).  I talked with her about her interest in lacrosse.  And about how my younger daughter used to faint when she was nervous about an exam the next day. Then I taught her diaphragmatic breathing, as I’ve done hundreds and hundreds of times with young people: In to the count of three, out to the count of 5 (Mississippi), through pursed lips, whistling.  Soon the color was returning to her face, and she was feeling much better.
            The blonde female flight attendant came back, saying “Can I get you anything Doctor, any coffee or tea,” she says in melodic lilt,  “I’ve got to come back in a minute and get your details.” She gave my elbow a double squeeze, as she did the first time she checked in on me.  She is attractive, about my age.  Her name is Rita.  She is Irish.      
            “My mother named me after Rita Hayward.  That’s showing my age, isn’t it?”
             It has been a long time since I have seen by wife.  It has been a long time since I have been touched by a woman, except for my $3 haircut, beard trimming and head, neck and shoulder massage at the Orchid hair salon near Karma Coffee, and the serious non English speaking saleswoman who sold me the gho, at a store filled with hundreds of rows of cotton, wool, and silk of every color and pattern available.  The woman hugged her arms around me to get the pleats right before whipping the belt around my waist and tying it so the folds of extra fabric hung perfectly to form the kangaroo pouch in which Bhutanese men seem to be able to carry anything from cell phones to wallets, from apples to pints of K5 liquor.
       I went up a few rows to check on “my patient” (though her official “care” was handed off to a medical team, on the ground in London, evidently.  I assume they don’t have much to do right now).  I talked with the family a bit.  They have two daughters like I do.  Pretty girls, like mine.  Chatting with this nice family from St. Albans, UK made me realize how much I miss my daughters.
        They thanked me for helping out.  “It was brilliant” her mother said. Her parents and I plan to stay in touch via email.
         I decided the next trip we take should be to the UK.

       As in Jamie Zeppa’s day, the ebb and flow of life in Bhutan, the way of seeing the world, still revolves around Buddhist principles and practice: Prayer flags, stupas, chortens, temples everywhere.  People walking around mumbling with prayer beads, and tashi go mangs (miniature temples). The sounds of trumpets, and monks chanting.  Monks are everywhere in their red and occasionally saffron robes.
        The day before I left Bhutan, I went with two staff members from the Ability Developmental group to observe the special ed class.  The grounds of this secondary school is the nicest place I’ve seen in Thimphu --- and I’ve seen most of this city during my month here.  Students plant trees and shrubs, and have built a rock garden, in honor of the king’s inauguration.  They have reused some of the plastic water bottles seen everywhere by painting them and stringing them up as fencing.  They have grown the first real lawn I have seen in Thimphu.  All garbage is picked up.  It was a loud and cheerful place when I was there. Older students in their crisp uniforms were coming out to play and gossip.  Groups of girls were going off campus, holding hands, to get bags of chips to eat.
          There is a tradition of service for students here.  The custom of preparing meals for teachers, and, in remote villages, taking care of them (as they did for Ms. Zeppa, in her book) has changed, according to my Bhutanese friends.  But they still come in on Saturdays and before school to tend gardens, clean up, and present short presentations on community projects.
         After that I went to buy a gift for my wife at the National Textile Institute.  The institute’s two buildings are probably the most spacious, modern, and western of any in the country. By statute, the exterior of these buildings have trefoil windows, painted designs of flowers jewels, and wooden beams like all buildings in the country.  But inside are clean hardwood floors, and, unlike every other edifice I’ve e,xperienced (besides the new Royal Institute of Health Sciences Building) this one has large windows to let in lots of sunlight.  One building houses the museum of woven goods and embroidery.  The other building houses design studios and a large workshop and classroom for young women learning to weave in the traditional styles and designs.
            According to Michael Charamella., the weaving done in Bhutan may be the most intricate in the world.  The women use silk from India, which is often raw, meaning the silk is taken from a cocoon which is already vacated so the silk worm is not killed, in keeping with Buddhist practice not to harm any sentiment beings. They often use native dyes.  The weaver may take a year to make some of the most intricate sheets of fabric that make up a kira. 
           Michael is typical of the fascinating people I have met here.  I met his girlfriend Jessica first, while I was walking to the Golden Budda one afternoon with my friend Ratu.  She had just arrived.  Michael is 35, a tall blonde handsome guy who dresses in a work shirt, khaki’s and down vest.   He is from North Carolina. His mother is a skilled weaver, which is how he learned about textiles. He was hired as the contractor to build a third office building that will be the profit making part of the complex.  He learned all his building skills after college, while earning a masters in teaching. He built houses, learning carpentry, electrical, plumbing and design skills,  then spent a year in South America teaching English, then lived in India and trekked in Nepal before meeting the billionaire who is funding almost the entire budget of the National Textile Center.  How has he done so much in his young life?
           “I just keep moving,” he answered.
            He disagrees with the assessment, made mostly by the Bhutanese themselves, that “we’re lazy;  the Bhutanese have no work ethic.”  So important projects, like the road work that cosumes 35% of the nation’s budget, is farmed out to Indians.
            “I like to hire young Bhutanese guys” he said, “’Specially from the East.  They’re hard workers, man.  They’re from the country and have moved to the big city, so they want to prove themselves.  They want to learn.  They soak up skills, electricity, plumbing.  But they’re bad in math.  In construction we use math all the time.  ‘Specially geometry, angles and measurements”.
             He is here for two years.  While he was giving me a behind the seen tour of the institute, we ran into Jessica, who had brought over a young Danish woman also doing skilled volunteer work.                  There is a whole network of young men and women here whom I have met. There is the former HVO volunteer doing research on children with disabilities for UNICEF.  And a young woman splitting time between Cambodia and Bhutan preserving antiquities.
           Or a woman I met while stuck at a road block descending into Punakha, playing soccer in the middle of the road with the son of her Bhutanese boyfriend: she is helping with the finances and administration of the Youth Development Fund – began by the queen to help with poor children and expanded by the beloved “Chilip Lama” Penchen, who works with the growing cadre of tough street kids addicted to drugs in Thimphu.  Or people like the nurse anesthetist’s husband Lindsay, whois  documenting the forest cover of Bhutan through core sampling, sifting through lists trees which might only have names in Scharshop, Nepali or any one of a dozen languages besides English or Dzongkha. 
             I have gotten to know Rebekah and Lindsay well in the last few weeks.  They are here for a year.  They have an apartment two floors above mine.  They love the view.
Lindsay pointed out the house below. 
            “That’s where Yunan and her husband (who live on the first floor with several kids and a cousin) grew up, he said. That’s when Thimphu was mostly rice paddies.”
            The three story building has plaster walls which are crumbling and a roof in disrepair.  We have our share of problems in our apartment: dark stairwells with dank smells, an Asian toilet that doesn’t flush, an improvised rubber tube for a drainpipe that feeds onto (not into) a drain under the sink that gets blocked and floods, “creepy crawlies” like the fleas from the dogs who enjoy life with us:  I think I would do pretty well in the “How many flea bites do you have?” competition Jamie Zeppa had with her teacher friends in Eastern Bhutan 25 years ago.  
        But our apartment is modern and luxurious compared to the building Lindsay pointed out.   Even  here in “the big apple” of Bhutan, there is still sometimes little separation between earth and building, between old and new, with one growing organically from the other, like the fungus of the cordyceps growing improbably from the body of a caterpillar.
            Rebekah and Lindsey are raising their three daughters here – one is their biological daughter, two are adopted.  They all love playing outside with the international and Bhutanese kids that inhabit our apartment complex, and the many dogs that roam free, inside and outside the building, living high off the hog on leftovers and garbage, while women hang meat and clothing out to dry, and a boy practices guitar on a balcony.  
            Their family recently had a bonfire and party to celebrate Rebekah’s birthday. A good number of this expat community were there.  It was a few days before Halloween.  They carved pumpkins. It was a friendly lively event filled with us kids of all ages, from the U.S, India, Japan, and, of course, Bhutan. On Halloween, Rebekah and the girls came trick or treating in costume.
            I joked that I had my costume, a gho that I had just taken off, after wearing it to introduce the film “Fed Up”   -- my modest effort to save Bhutan from the scourge of obesity that has swept the rest of the world.  Dr. Tashi and I discussed the film with the medical superintendent, who has his offices next to the medical director, and a hospital supervisor.  I’m not sure what any of them do. But the superintendent has the bearings of a true Administrator:  He is quiet, tall, with short greying hair, with  a commanding and somewhat intimidating presence.  
             He thought that the film was important  enough to issue an “order” saying that “Dr. Dave has brought the American film Fed Up about the obesity epidemic.  Therefore all staff is commanded and invited to come”.  
            It was my last afternoon of my stay in Bhutan.   I spent a half hour trying to get that gho on.  One really needs three hands, at least.   When I arrived, the kindly resident, Dr. Jimba, said, “Dr. Dave, it isn’t right.  Let me help you.” 
          So there we were at the entrance to the conference room above the OPD, 40 people waiting for me to start the DVD, my gho unraveled, Dr. Jimba with his arms around me, helping me get those two pleats right in the back and tying me back up, my kangaroo pouch folded properly in front.  
              The film was well received, even though Dr. Allen joked that I should have brought popcorn.  The neurosurgeon Dr. Tashi, resplendent in the army uniform with medals that he likes to wear, thought that this is “an important film”.   I was happy that along with the nursing students, a good number of the medical staff had now seen it.  Dr. Tashi offered to take the DVD, copy it, and share it up with higher ups in the various ministries.   I felt satisfied that I was making at least a small difference, on a number of levels, in this small but unique and wonderful country.
            Since Dr. Tashi had left the ward early before finishing rounds on the ward, I joined her and the intern Dr. Rintzen to help finish, during the last hours of my month in Bhutan.

            The showing of the “Fed Up” fed my the growing ambiguity I’ve felt about westernization or Americanization that many volunteers complain is polluting the quaint traditional culture of Bhutan .
            What Jaimie wrote in her book:  “When change does come everyone has time to get used to it” is not true anymore.
            As the 20 something nephew of Yunan, who lives with her family downstairs told me, “the government only allowed television 10 years ago.  Now we have wifi.  We barely have time to adjust, before we have to adjust again.”
            But as Jaimie also points out “I cannot say that development is bad and that people should go on living the way they have always lived, losing four out of eight children and dying at fifty.”  The lowering of the infant mortality rate in Bhutan is nothing short of remarkable.  In 1984, the infant mortality rate was 103/1000.  By 2013, the rate of infant death had  fallen to 31-42/1000 (the rates are uncertain because record keeping is still not good).  In 1984, the child mortality rate under five was 160/1000. In 2013, the young child death rate dropped to 36/1000.
            Yes the increasing consumption of soda and other western junk food is harmful.  But volunteers like myself can bring solutions, as are presented in this film, on how to maintain the good parts of their traditional diet (lots of vegetables, fruit, rice – maybe a little less, cheese, meat but small amounts) in the face of urbanization and western development.
           And though the Americanization of traditional Bhutanese culture is unfortunate, it is not unfortunate be that American exchange students are a constant presence at the Royal Thimphu College.  When I went there to discuss “sex, drugs, and rock and roll” at each of four hostels (dormitories),  Americans could share their perspectives to help break taboos about discussing the largely hidden problem of sexual and physical abuse, drug and alcohol abuse, and the denial and lack of acceptance of   of gays and bisexuals in this traditional society.
        It is certainly not bad that a young energetic contractor from North Carolina can bring the American ideas about modern building techniques, industrial design, and efficiency here, with the goal of helping to maintain the traditional art of Bhutanese weaving.   He has already discovered some bad leaking pipes rotting the outside stairs next to the large plate glass windows with matching interior stairs in the museum, and is replacing them.
       Here is a story that I found funny in retrospect:  Kauchilla, the always sweet and solicitous volunteer coordinator for HVO at JDWNRH was our go-to person for problems with visa’s, work permits, travel permits, and any problems we had with our HVO apartments.
         Aschof and I had plenty.  For example:  Two outlets burnt out, the plug on a space heater melted, burning a finger, my Asian toilet did not flush, the kitchen sink didn’t drain, our kerosene tank for our stove leaked, one of our fluorescent lights burnt out, and the one in my bedroom was failing, creating its own little headache inducing light show as it blinked on and off.
           Kauchilla would say, “Oh yes sir, I’ll send the electrician up today.”
         The next day, when I found the light was still broken, she would say, “Were you there at three, sir?”
         “No we were still at the hospital”, I’d say.
         The conversation went on like this for several weeks. Nothing was fixed.
          Kauchilla was out sick, several times, though I saw her in between at the Ability center.   She was one of the parents who came in for a consult with me, for her son, who has autism.
          “Will he get better, sir?” was her question for me.
          Finally, three days before the end of the month, I went to her office a final time.  I was with my friend and colleague Dr. Tashi.  I asked about the broken stuff in the apartment again.  Kauchilla said something in Dzongkha to Dr. Tashi. 
            “She says that she is not responsible for the apartment,” Dr. Tashi said.”only the visas and work permits.  You have to speak to the hospital superintendent”
             “Where is he?” I asked.
              Kauchilla pointed sheepishly to a man at the other end of the office.
              I knew better by now even to ask the obvious question: Why didn’t she tell me this a month ago?!  I would get a blank stare and an Indian head bob.
              It would be helpful if the traditional way of always wanting to please others, especially others in positions of authority, even if meant lying to them gave way to the American style of doing things.  “Hey, you’re talking to the wrong gal.  Your man is over there!”
            And it is certainly not a bad thing that the presence of American psychiatrists and psychotherapists, and Americans and Europeans in general, are introducing the idea that is ok to talk about feelings.  The Buddhist principle that suffering is universal and striving for material success is the source of that suffering is something that we in the West would be wise to learn from.  But when suffering in silence “comcs out sideways” (to quote one of my mentors in hypnosis, Dr. Dan Kohen) as debilitating somatic symptoms, leads to severe depression, or suicide, it is important to learn other ways of dealing with these feelings. 
            One of them is using clinical hypnosis --   which the Bhutanese health providers I have met have been very enthusiastic.   Of course, one of the trends leading to anxiety and depression in Bhutan is Westernization:  urbanization, break ups of families, and the loss of traditional culture. The problem is complex.

              But the traditional culture still thrives, as it did in Jamie Zeppa’s day.  On my last day, I resolved to visit the “naming temple” where parents bring their newborn infants to receive names from the monks.  As in Jamie’s day, infants are given one, two, or three names at birth.  There is no family name, except “Wangchuck” (spelled with a “ck”) for the royal family. 
            Most first names – like Sonam, Kinley, Tshering, Namgay – can be given to boys or girls.  I have friends and colleagues who are men or women with the same first names. The same is true for second, or third names.  Particular combinations, go for boys, or girls.  For example, my friend, Namgay Dorje has a name only used for boys.   Some of the combinations have beautiful meanings like lotus flower.
            Sometimes a person may choose to use the initials of his names, like Dr. KP.  His wife, Dr. Yoriko is from Japan but she only uses her first name; she thinks her family name is too difficult to pronounce.  On the other hand, her colleague and fellow neonatologist, Dr. Dowa, also from Japan, uses her last name because they feel that her first name, “Yuri” is so close to “Yori” that it would cause confusion in distinguishing them apart.
           I was running short of time, so I took a taxi from downtown.  The taxi driver and his friend in the front seat had no idea how to get there, but agreed to try to find it for 60 nultrum (1$).  
               I had spent the month walking everywhere.  In Thimphu no one uses GPS, since there are no street addresses. Some of the major "lans" (streets) have names posted on faded scattered signs, but everyone simply uses landmarks to get around.  Maps were fairly useless too. To get to our apartment, one headed up to "Swimming Pool Junction" then looked above the Jigu Dorchey bakery.  Most downtown spots were found according to their relationship to the Clocktower Square or the Traffic Circle kiosk, home of the traffic cops with the dancing hands.  It was refreshing to go back to the old fashioned system of asking directions (constantly) and using my sense of direction.
             I knew I could get to the temple on my own two feet, but directing the cab was something else: The sanctuary is located on the steep slope facing downtown, on which the road curve in erratic switch backs, some ending in dead ends or veering back down towards town.   But looking straight up at towards the ridge above, I was able to locate it.
            The temple is among the most ancient in town.  The part facing the hills is falling down, and there are piles of rubble.  The central portion is surrounded by 108 prayer wheels that the Bhutaneses spin, walking in a clockwise direction.  Inside an entry way on the eastern side is a big prayer drum, and a man in a a ragged gho who was eating snacks, and seemed to be collecting money.  There are always  many opportunites to give offerings of nutrum at the temples.  The loud sounds of horns, flutes and chanting emanated from the small temple.  
              I entered.  To my right, a half dozen monks and two young boys in red robes played instruments and chanted.  The men stared at me.  When I made an offering of money, and looked at the old man who was standing at the entrance to the inner sanctuary, he gave me an Indian head shake, that was definitely more shake than nod.
          I came out into the anteroom.  Several parents were there, with their babies on their backs.   I introduced myself to one young mother, saying that I was a baby doctor and interested in  seeing how children received their names.  She said “Wait a minute” and  went inside.
           In a minute she came out.  “You can go inside”.
            I entered with her.  Some of the students were reading from sheet music.  The sound of the instruments and chants was mesmerizing.   I sat for several minutes, absorbing the beauty and solemnity of this place, where babies were given the name or names they would carry with them for life. I presented another small offering of money.  I went to the entrance of the inner sanctum, but the young mother first said that the monks “were busy” inside, then said “there you can not go”.
            I assume she meant that that room, with the Buddhas, butter lamps, and offerings of chips and fruit was for parents and babies only.  But to paraphrase one of the favorite sayings in Bhutan, perhaps  I will never know. Mystery was an ever present part of my life here. 
         I was able to get a splash of holy water from one of the monks, and for extra measure, I got an additional blessing, the kind so popular at the tsechu:  a firm bop on the head from the head monk who seemed to be in charge of the small orchestra.
            I figured I could use all the blessings I could get for my departure, for my 24 hours in Dehli, for my long trip home, and for my reentry to life back home.

           As it was, I could have used a few more blessings.  I foolishly decided to take the advice of my roommate, who was stationed with the Indian army in Agra at one time, and Allan, who visited Agra 14 years ago with his wife, and visit the Taj Mahal, though I only had an afternoon to travel from Delhi and back.   I was not used to the chaos of Agra, trucks piled high with people, tuk tuks 3 abreast coming straight at us.  We had to hire a guide to get us in past the thousands of Indians in the queue, still celebrating Dewalli.  There was rough frisking from guards, and pushing and shoving among the mobs in the mausoleum.  Many people were illegally taking photo’s.  The police were frantically blowing whistles, but they could move no more than the rest of us, so could catch no one.
            I was ready to fend off aggressive street vendors, and pick pockets, but I had grown soft in Bhutan where sales people passive to a fault. I fell prey to the sales pitch of an Iranian shop owner. My guide delivered me to him, asking if I wanted to see “how the Taj Mahal was made”.  He sold marble tables inlaid with jewels. They were pretty but overpriced.  I bought one, then he convinced me to trade that table for a larger one.  Driving home through heavy truck traffic late that night, horns blaring constantly for four hours, I regretted my decision.  I canceled the order by email when I got to the hotel.   My bad mood lasted through most of the night, and I got little sleep.  However  now, I can look back, think about my foolishness in following the advice of those colleagues. 
            And as usual, I take heart in the small moments that are the valuable parts of any travel that give a little insight into the lives of real people.  On the way back, the driver suggested we stop for supper at a little roadside restaurant lit by a red neon sign.  Inside, young couples and families were enjoying 200 rupee trays of dal, vegetables, paneer, and chapati.  I joined them.  My driver did not, as it was a fast day for him.  As I ate alone,  I observed several booths around the room.  One sold momo's, another pastries.  Then there was the fish massage booth.  There was a young guy with his bare feet dipped in a fish tank.  Hundreds of little fish pecked away at his toes, feet and ankles.  I asked him and his friends about it.  Yes, the fish give a real massage.  For only 150 rupees.  For 20 minutes. Would I like one?  If I had more time, I would have taken them up on it. 
            And I can choose to remember the beauty of this monument to love, the palace milky white as if dissolving into the dusk, the calm and the quiet as we walked back along the garden to the east, the view through the trees, the eagles flying across the dome and the minarets.  Perhaps I have been bathed in Buddhism for long enough this time to laugh at the silliness of the mild discomfort I suffered for several hours, compared to all he suffering and torment in the world, and even laugh about it.  I am reminded of the boy with cerebral palsy, who fell in front of me under the hospital gate as we walked to the nursing student variety show, who laughed about it with his two friends.  Laughed and laughed.

             “We are taught that if we suffer, we have to accept it,” my friend, the physiotherapist Kinley Dorje said.  “So we (often) laugh instead of cry”.  

Saturday, November 1, 2014

        It was the middle of the morning in the OPD.  There was a long queue of patients out the door.   In came a young woman and her sister.  “Sister July told me to come here” Juliana, a nurse practitioner, had come here with her husband, an orthopedist.  We had gotten to know each other while working on the standards for the physical exams of neonates done by the nurses in the newborn clinic, and going to the Royal tlhimphu College to speak with the students about drugs, alcohol, stress, and other health related issues.  
        I asked the young woman her name and age.  Her name was Mimi. She was 22. That’s ok, I thought.  I see patients up to 21, and some a little older.  It told them to meet me at the Reproductive Health Center at 2pm.  When I arrived, two older women accompanied the two women.  One was very old.  Mimi explained that this woman was to be my patient.  She was to be my patient. She was 96 years old.   Her problem was hiccups.  She had been hiccupping for days without stop. 
       I thought for a moment.  How could I send them away?  The old woman whom I shall call Jedsuen lived with her daughters and grandchildren.  Bhutanese society is traditionally matrilineal.  Husbands move into their brides’ family homes.  Daughters typically inherit family property. 
      Moreover, children take care of their parents, and grandparents in their old age.  There are no such things as nursing homes, retirement homes, assisted living facilitates or any of the other euphemistic terms for places old people go to live out their last remaining years in the our country.  
        Jedsuen wore a full-length kira, of earth colors that matched her leathery skin. Over that she had a green toga; over that was a purple down coat – commonly worn in cooler weather here. She wore a pink headscarf.  Though she was stooped and walked with a cane, she was surprisingly nimble, as we had to hop up onto a bench in the garden courtyard to which I had led the group.  (Though the average Bhutanese man is my size – very short – and most Bhutanese women are equally petite, outdoor benches seem to be made for NBA players; I would need stilts to use the urinals).   As commonly happens in Bhutan, the problem was not as it seemed either.  Hiccups were not her chief complaint.  Asthma was.  Also: leg pains, not surprising for someone who was 96 years old.
         The old woman had lived all her life in a small village in the South, not far from Galipeau, growing rice and vegetables.  Women do much of the farm work in Bhutan.  She had worked dawn to dusk.   I have seen women on the street carrying heavy metal rice threshers on their backs.  They are as strong as the husky fellows I see in the Holyoke Y weight room back home.   The first Westerner to visit Bhutan, Father Estevao Cacella, from Portugal, noted in 1627: “The land and climate are very healthy (healthier than India).  There are many old people, who look healthy and vigorous.”  Of course, to make it past infancy in those days, one had to be sturdy.  The infant mortality rate, when first recorded in 1984, was 103/1000; one can assume it was higher than that in 1627.  (The infant mortality rate now is between 32-41/1000; poor record keeping precludes a precise figure.)
         With here great niece translating (her granddaughter was now absorbed with messaging on her IPhone), I taught Jedsuen some careful diaphragmatic breathing.   Though she was not hiccupping, she was wheezing mildly, and was a little short of breath.  I could hear the sound of the monks’ chants and trumpets from the chorten not far from the hospital.  I suggested that she could remember the temple from her village and the peace it brought her.  She was Nepali but Hindu shrines are remarkably similar to Buddhist shrines here.  After all, Buddhism sprang from Hinduism, the oldest organized religion in the world.  I suggested she imagine herself in a garden, here or in her village.  Children often enjoy the image of the respiratory tree as an actual upside down tree, the leaves of the alveoli opening and closing with our breaths.  I suggested Jedsuen imagine this.  Her wheezing lessened, though her breath quickened.  I asked how she felt. 
            “Sleepy”, her great niece translated.
             I then told a story about my grandmother.  My mother’s parents, Mayme and Murray Gillette, were very close to me.  My father worked very long hours as a well-known professor of periodontics at Columbia University.  We saw little of him.  My grandfather was a peddler on the streets of New York, who made a small fortune as a haberdasher.  He lost it during the Great Depression, but made some of it back.  He always wore a three-piece suit with a gold pocket watch and chain, and a natty kerchief in his suit pocket.   He spoke fake French to my grandmother who he liked to call the most beautiful girl in the world.  He had a heart condition, which, in those days, meant he was not to do any physical activity.  But he still grabbed my grandmother by the hand and pull her up to dance.
         “Now Murray, you know what the doctors said,” my grandmother chastised.
          My grandparents would come up every Thursday from Weehawken, N.J., in my grandfather’s finned silver Cadillac.  They would take us out to Daddy Michaels for milk shakes, and buy seven layer cakes at White Plains bakery. 
           In the summer we would go to there summer place in Tannersville.   It had a coal stove in the kitchen, a living room filled with books by Somerset Maugham and similar writers, and an old-fashioned icebox in the adjoining garage.  The view from the backyard of the Catskill Mountains was pretty enough that artists used to ask to paint from their backyard.  My grandfather, and Uncle Sam would dress in their coveralls to go out to do important yard work, like pulling the weeds from the cracks in the sidewalk.  I still remember the smell of my grandfather’s garden tools as he oiled them, and the taste of my grandmother’s borscht with sour cream.
            After my grandfather died, my grandmother lived until she was 97 in their duplex in Weehawken.  I would take my daughters to visit her, picking up tiramisu at an Italian bakery on the way.   My grandmother would make us tuna sandwiches, and tell us stories.  Like how she would see Frank Sinatra’s mother at the hairdresser in Hoboken, and how my mother got their phone number.  My mother, a great lindy hopper in her youth, was a bobby soxer.   She reached Mrs. Sinatra over the phone and said, “I love your son!”
          “You leave my son alone!”  Mrs. Sinatra said.
           When utilizing hypnosis as a tool, or in any therapeutic relationship, it is essential to have rapport with the patient or client.  How does one achieve rapport?  By tapping into our personal experiences, and then using them to understand the commonality of all experience among human beings, despite the vast differences between cultures.
            So I talked about my grandmother, and our visits. My grandmother suffered debilitating arthritis in her later years.  But I described how my grandmother would become absorbed in the memories of her interesting and long life, and how being with her grandchildren lifted her spirits.  This helped to alleviate her suffering.
          Jedsuen was transfixed by this story.  Her eyes closed, her breathing became slower, easier.  Soon she was asleep.  At the end of the session, I woke her up.  She said that her breathing was easier, more comfortable.  And her legs felt better.  I had never noticed hiccups anyway, so I didn’t bring them up.  I suggested, of course, that she practice as often as she could, with her great niece helping if necessary.
         Her granddaughter finished with her phone calls, and gave me her phone number, and invited me to join her and her friends at Karma’s Coffee.  Karma’s Coffee is the nicest of the “chillip bars” in town, with comfortable cushioned chairs, great coffee, and jazz playing all day.  Flirting is one of the favorite hobbies in Bhutan among all age groups.  I declined but thanked her for the invitation.

             My next consult came from Dr. Allen.  I had already given a lecture to their staff on using hypnosis for anxiety.   I had begun with a group hypnosis session that the workers in the room much enjoyed.  One of the male therapists that he went into a deep trance, with total amnesia for the ten-minute session – though he was not sleeping.  Traditionally called somnambulism, this kind of trance indicates a high degree of hypnotizability.   I found this to be a not uncommon experience among the students I taught.    
          I taught the maxim – taught to us by Michael Yapko – that all of us ask questions about the future, but those who suffer from anxiety disorders don’t have any answers.
And anxious people tend to overestimate the risks of the future, and to underestimate their own resources.  They cannot tolerate ambiguity.  To overcome anxiety, one must address all those issues.  I also talked about depression and its relationship to anxiety.
           Anxiety is the leading mental health problem among children.  Anxious children tend to become depressed adolescents and adults.   This is because depressed people use the past to predict the future, according to Dr. Yapko, and other experts in the field.  And for anxious people the future is filled with danger, both real and imagined.  This is why our culture, fueled by the 24 hour news cycle, is a hot house of worries: everything from comets hitting the earth, the person next door catching the Ebola virus, how President Obama will take everyone’s guns away, while the real dangers, like global climate change leading to one natural disaster after another, are denied.   Repression and denial are defense mechanisms that work well for those real worries.
          The mental health workers are beginning to learn cognitive behavioral therapy (CBT) and other forms of psychotherapy.  This is due to the presence of HVO volunteer staff, like Dr. Allen, and other visiting professionals, like the Australian psychologist George Burns (no not THAT George Burns) an Australian psychologist and friend of Yapko’s, who wrote the book 1001 Healing Stories…  George Burns has been to Bhutan many times, sometimes with an entourage of students with him.  The mental health worker Uden said that Dr. Burns led a group hypnosis session in the woods behind the Golden Buddha.  Built with gold leaf from China, this stature is the largest Buddha in the world.  After three years, the exterior work is done.  The interior is still under construction.  It is an impressive site.  
            But when I emailed Dr. Burns, he said that he has not taught clinical hypnosis yet in Bhutan, because “they have to learn good psychotherapy yet.”   He did allow that he thought it would be ok for me to use and teach clinical hypnosis for medical indications, because this would be for pain relief, not psychotherapy.  However hypnosis is a psychological procedure.  Furthermore, the mind and body are inextricably linked.  Use of hypnosis for any reason is all about altering perceptions, developing new cognitive skills, and realizing how feelings affect bodily sensation.  In other words, it’s psychotherapy.

         Dr. Allen called me the day after this lecture.  Could I come over right now to see a patient?  It was a 21-year-old woman whom I shall call Sonam. After an argument with her mother she had stopped talking the day before.  No, I said, I was in the middle of the OPD clinic, with a poor confused intern, and the usual chaos surrounding me.  But I could come in an hour or two.
        “Ok,” he said, “I’m just going to go ahead and admit her anyway. Everyone is admitted here” Without private insurance companies, there is no barrier to admission.
Even though it means sharing rooms, bringing your own sheets and clothes, and having family members bring food in to eat.  (Rumor has it that the already modest culinary budget at JDWNRH is being siphoned off by an unethical hospital administrator).
           I went to see Sonam later that afternoon.  She was sharing a room with the aforementioned elderly schizophrenic man.
         “She just stopped talking,” her mother said. “Before 5 yesterday afternoon, she was normal.  Then she just stopped.  She used to talk, now she doesn’t”
           Hysterical symptoms are common in Bhutan.  “It’s like psychiatry in the United States, 50 years ago,” Dr. Allen observed.  “I see conversion disorders all the time.”
           People don’t tend to complain about sad feelings.  Instead they suffer somatic complaints.  “Giddiness”, in which patients complain of light-headedness, roll their eyes, and seem to faint, is the most common syndrome.  This constellation of symptoms is apparently often treated as seizure.
           This was the case with Sonam. She lived in a small village in the eastern part of the country. There was “an evil step mother” involved, but the young woman was now living with her mother.  Sonam had a history of depression.  She had been treated with amitriptyline, and older tricyclic antidepressants, and one of the small handful of psychiatric medications available in the kingdom.  She had also been on Dilantin for seizures.
          I said to Sonam, “Though you are not talking right now, I bet you are able to write.”     We went to the lounge with Kinley the therapist and translator, and her mother, whom Sonam motioned to join us.   I asked Sonam when her symptoms began.  She wrote 5pm.  I asked how she was feeling then.  She wrote “sad”.  I asked how she slept last night, and she wrote, “I didn’t” She’s very tired, Kinley said. Her mother repeated several times how she had been able to talk, and then she wasn’t.
        Then Sonam began to list to the side in her chair.  Her eyes rolled up.  “She’s having one of her seizures,” her mom said.
         One of the distinguishing characteristics of a seizure is that the person is not responsive to verbal or tactile stimuli during the episode.  
         “I know you are tired” I told her, “but I can help you.”
          I instructed her in simple breathing exercises, and then used a hypnotic induction I learned from David Patterson, a psychologist from Harborview Medical Center in Seattle, who has treated army veterans and others with severe burns.  He wrote the text “Clinical Hypnosis for Pain Control”.  It involves grounding the patient to the present moment in time. I said, “You’re sitting on the chair, your feet are on the floor, you’re breathing in and out.   Your feet are on the floor, you’re breathing in an out, you can begin to feel comfortable and relaxed.”
          By repeating what is called the “Yes set”  (no one could argue that she is not sitting and breathing), one can begin to introduce suggestions for comfort.  Sonam shifted slightly in her chair, and her eyes steadied.  I gave suggestions that she could be in control of her mind and body, repeated over and over.   At some point during this time, I had her mom leave the room, because her anxiety was not helping matters.
         After the giddiness had abated, I asked Sonam if she wanted to continue.  When Kinley repeated, “She is very tired, she wants to rest”, I said, “I know that.  You need to rest.  And I’m going to teach you some ways of helping yourself get the rest you need and deserve.”
        I went on to suggest that Sonam go to a place of comfort, rest, and safety.  I mentioned a bunch of places I like (mountain streams, forests, etc.), but when I asked her what she was experiencing, she wrote “my own bed”.  This is a common favorite place for many adolescents.  I then went on to make suggestions for comfort, and control and safety, and said that with her many years of experience talking, I’m sure she will remember how.  Sonam cleared her throat, and made some slight gasping noises, as if trying to talk.
         I mixed in suggestions about knowing that she could “have a voice” in things affecting her life.
         I then told a story, about my own daughter Liza, who spoke barely a word until she was two years old. She received speech therapy until third grade.  She also was painfully shy in her years.  But then by secondary school and high school, she blossomed.  She made lots of friends, became secretary of her eleventh and twelfth grade classes, and graduated Phi Beta Kappa from the University of New Hampshire, with a double major in international relations and psychology, fluent in both English and Spanish.  But we can still go for long stretches of time when we are together when she will say little.
        “She knows how speak, and speaks very well,” I said, “but she only talks when she has something to say.”
          Kinley noted the next day, that Sonam was paying very rapt attention when I spoke these words.
          Ending the session, I asked Sonam if she would like me to come back to see her the next day. 
         “Yes” she whispered.
          I arrived late the next morning, Saturday.  I had been with an intern in the OPD again.  It had been another busy session.  The nurse on duty said that Sonam was talking again, participating in a group session that morning.  I had her come in the lounge to see me.  Sonam did not remember the details of why she stopped talking.  But she did tell me some of the details about her life.  She lived with her mother, and did not work nor go to school.   She said she could not because she had been depressed for years.
         Depression as a disability is something I am used to hearing about in the States.   As Robert Whitaker documents in “Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America”, as we have developed an increasing number of medicines to treat depression, anxiety and bipolar illness, the numbers of adults and children (especially children) on the social security disability rolls has skyrocketed.   And as Michael Yapko points out in “Breaking the Barriers of Depression”, the idea of depression as a disabling disease can be a self-fulfilling prophecy. 
         I suggested to Sonam that one of the best things she could do to help herself is to get out of bed and to call a friend, get some fresh air and exercise, go back to school. As Dr. Yapko emphasized in his sessions with us, “Why don’t people who are depressed do the things they need to do to help themselves?  Because they don't FEEL like it.”
        “They have to learn not to focus on their feelings.”

          I said Goodbye to Sonam.  She left the hospital that morning.  Time will tell if she breaks her own pattern of depression.  But she was able to learn, quickly, that she could learn to break her own “seizures” or “giddiness” and to “have a voice again.”