I''ve been home almost three months now.   But as my good friend Ed Perry, who is the reason I ever learned about Bhutan, said "this trip stayed with me on a deep level".
        It's the middle of a snowstorm "of historic proportions" and work is called off.  My wife has CNN to listen to the constant news, amid commercials for drugs like humera ("may cause lymphoma and susceptibility to certain fungal infections, Call your doctor now!")  The news, of course is all about the storm.  Lots of warnings:  not only against driving, but even walking outside.  "Because the ground may be uneven".  I was just out shoveling our walk, which evidently was a dangerous thing to do.  And there is no coastal flooding or massive power outages, yet… but who knows what may happen in a few hours.  
         I think of Michael Yapko's definition of anxiety: Using ambiguous information in the present to make the worst projections about the future.
         We could think about how we might lose power soon (and for us that means losing water since we have a well with a pump) or we could enjoy the plump cardinals at our feeders, and the antics of the acrobatic squirrel hanging upside down on our expensive "guaranteed" squirrel proof feeder, enjoying himself on the nuts and seeds spiked with special red pepper powder from the Amherst Farmers Supply, also "guaranteed" to keep these voracious critters away.
         "Must be Mexican squirrels you have" the woman at Hadley Garden Center laughed, when I went there yesterday to buy some burlap and twine to cover my last unprotected rose bush.
          I plan to pay attention to the bird feeders and not the TV.  But millions of housebound northeast Americans will spend the day with CNN overdosing them on angst and apprehension.  Instead of ads for humera, the pharmaceutical companies could more profitably show ads for the serotonin reuptake inhibitors and other anxiety drugs rake in billions of dollars for them every year.
           The last phone call I made last week had to do with a patient with chronic dizziness. Her mom wanted a referral to a pediatric neurologist.  In children, chronic dizziness, unless it is really vertigo (a sensation of the world spinning around you, as if you are in the center of a merry-go-round) is almost never a sign of a significant medical disorder.  As with this patient, it is often related to stress.
          I thought of patients in Bhutan.  Dizziness, called giddiness there, is quite common.   In fact, according my fellow volunteer, Dr. Allen, who increased the number of psychiatrists in the country from one to two, depression and anxiety in Bhutan is usually manifest  as dizziness and other somatic symptoms.  (See previous posts).  
         Dizzy patients don't get to see neurologists there, because there are none.   They may be seen by the one Bhutanese psychiatrist, who may diagnose them as having a seizure.  This diagnosis is tough to prove there, because electroencephalograms, or EEG's, are not available.  Patients will either get put on one of two anticonvulsants available, or the one antidepressant available (an older medication called amitryptiline) and told they WILL GET BETTER.  And they usually do, often in one day.
          Why could I not cure my patient so easily? I worked with her for over a year, having specialists "rule out" organic illness (there were other somatic complaints as well).   I sent her to therapists.  I employed clinical hypnosis to try to help her calm herself.  I reassured her.
          What is different about Bhutan?   Is it just that doctors are still viewed as gods there, which makes the placebo effect so much stronger?
           Could it be that the daily news there was more focused on the fourth king's 60th birthday celebration, than local weather calamities? They certainly have bad meteorologic events:  a big earthquake caused significant damage to about a quarter of the buildings in the country several years ago, late monsoon rains virtually ruined their rice crop two years ago, and rains and the increasing snow melt from global warming regular wash out roads throughout the country.
           Could it be the Buddhism that pervades all aspects of their lives?
 I'm reminded of two incidents:   I showed the movie "Fed Up" to nursing students there.  It is about the obesity epidemic in the U.S.  I brought it there to show this hard hitting film to whomever would watch it.  There are virtually no fat people in Bhutan.  There are also no fast food chains, and almost no processed foods and "food products" - basically just food:   rice, vegetables, fruits, meats.   "Fed Up" focuses on the story of three obese kids in the U.S.  One of them is a sad 12 year old girl, who is often seen crying as she talks.  By the third time she appeared, the nursing students in the audience began to chuckle, and even laugh out loud.
         Why are these otherwise kind, polite and sensitive young people laughing at this poor girl?, I thought.
          These nursing students invited me to their annual talent show, which turned out to be a wonderful evening of Bhutanese, Tibetan, Nepali, Hindi, Bollywood and hip hop dance and song.  As I was walking through the gate of the JDW National Referral Hospital, on my way to this talent show, I saw a young man with a slow spastic gait, walking ahead of me, with the help of a walker and two friends.  He probably has cerebral palsy, I thought.  Suddenly he tripped and fell on the divider under the gatehouse to the hospital.  He and his friends broke out in laughter, and continued to laugh as he struggled to get up, with their help.
      "May I help you?" I asked.
      "No sir, thank you" they said.
      I asked Kenley, the perceptive and well read physiotherapist who hosted us at his country home above the town of Punakha, home to the beautiful historic dzong situated on the forks of the male and female tributaries of the Punakha Chha (river) about these incidents.
      "In Buddhism, we are taught that suffering is part of life," he explained.  "So we must accept it. One way to accept suffering is to laugh.

                             Jomohlari, in Jigme Dorji National Park.  This area gets some serious snow.

       Part of the problem in this country is not that people are anxious all the time, but they get anxious about the wrong things.  It is amazing to me that with each 24-7 coverage of each storm or other "extreme weather event" with which the U.S, and the world is increasingly hammered with, there is no mention of why these "events" are becoming so common and so extreme:  Global climate change.
       There is cursory analysis of climate change in the media now, but not while these storms, floods, and fires are happening.  Why?   Is it thought to be in bad taste?  Not even the environmental groups, like Bill McKibben's 350.org.   Instead of concentrating on issues which are far away and abstract for most folks, like the Keystone Pipeline, why not focus on the weather outside?   And to remind people that this snowstorm is not because of the earth getting colder, but because the earth is getting warmer, melting the Arctic ice cap and shooting all the frigid air that is released down our way?
          In Bhutan, by contrast, where people are remarkably equanimous about day to day weather events, concern about climate change is everywhere, front and center.  The tiniest villages I trekked through had signs about the latest climate change news posted in health centers. They know it is a health issues.  There is a national climate change council.  Mining it's extensive copper reserves is outlawed because this would disrespect and damage the earth. Bhutan preserves two thirds of its forest land as forever wild. Lumber may only be used domestically.  There are even concerns about the number of trees cut down to make prayer flag poles (prayer flags are as common as Red Sox caps in Boston).   Plastic bags are outlawed.  The government has plans import thousands of electric vehicles, even though there are no recharging stations in any of the far flung towns, save the capital, Thimphu.  
       And since this tiny country is dependent on the melting Himalayan snows for the hydroelectric power that supplies all its electricity -- sale of which is its major source of income, outside of tourism, they have reason to worry about global warming.  And they have done much to address it.   According to a minister in the department of natural resources,  Bhutan is already "carbon neutral".  We have much we could learn from them.
   
         Of course, they have much they could learn from us. About pediatric intensive care:  Maybe Karma, Kinley, Ugyen  and the other children from Decholing, Pelethang, Khangdang and other districts of Bhutan would be alive if they had the medicines, personnel,  and technology we have to treat infections, shock, and brain injury.
         The extent of the problem of alcoholism, which is probably the biggest cause of morbidity and mortality in Bhutan, is just being recognized.  Chithuen Phendey Thokpa, whom I met at my former guide and friend Namgay Dorje's house (where his wife made a delicious feast for me, served up in their small but comfortable apartment) is a prominent contractor who had just met with the king to discuss development issues.  A recovered alcoholic himself, he had joined the first chapter of AA in the country.  But he said that it should not be called AA since no one is anonymous in Bhutan; people "know each others business", knowledge which they usually use to help each other.

                                            Namgay Dorje, his wife and two children

       Chithuen pointed out that Bhutan is not necessarily happier than anywhere else.  The king (K-3) established a policy of GROSS national happiness, he explained. "It's from the perspective of the whole country; it's not on the individual level."
         I met a mother named Pema, mother of Kenzay, whom I saw in the OPD.  The OPD is not a happy place, overall.  It is dark and dirty.  Long queues form outside the little offices called stations.  Patients may have travelled for two hours, to wait in these lines, just to have blood tests results read.
But I never saw people complaining.   Pema spoke excellent English because she and her family had moved to the Bay Area of California, and were back here visiting, when Kenzay got sick.  (Health care is universally free to all, visitors and residents alike).   She acknowledged that she preferred the healthcare system in the United States.  "It's much more modern. They know how to find out what's wrong with you and treat you.
       But where do you think people are happier?  I asked.
       "In Bhutan," she said.  "People are always running around in the U.S.  They're always anxious about this and that.  There is never enough time just to be together."