Friday, June 12, 2015

     

            Traditional Bhutaneses Medicine Expressed on the Leaves of a Lotus Tree
       
          I'm attending a conference, established 18 years ago by my mentor, Karen Olness.  Dr. Olness wears two hats.  Wearing her hypnosis hat, she and her colleague Dan Kohen literally wrote the book on pediatric hypnosis. Her accomplishments in this field add up to more than any of us achieve in a lifetime. But she wears a second hat:  that of an expert in international health - specifically, helping out children after humanitarian disasters.  After decades spent helping out kids and their families after wars, floods and famine all over the world, she established this conference, "Management of Humanitarian Emergencies:  Focus on Children, Women and Families.  A Course in Disaster Preparedness."
         Fortunately, Bhutan has not seen the kind of humanitarian emergencies that have risen geometrically in the last few decades.   But with the total number of people at risk for humanitarian emergencies at 2-3 billion, with 50 countries either facing long term humanitarian crises or at serious risk of them, with over 51 million refugees in the world, the largest since World War II, and natural disasters in the United States happening on a regular basis since the first really big one - Hurricane Katrina, it makes sense for a pediatrician to learn how to help out.   And the earthquake in Nepal, which killed 9000 people and left 3 million homeless, occurred on the same narrow Himalayan seismic shelf which Bhutan sits on. The earth is folded up like an accordion in this region.  
           Since bringing her husband and young children to a refugee camp in Laos in the 1980's, then establishing the first pediatric residency in that country, Dr. Olness began Health Frontiers, an NGO that specializes in tending to the psychological and emotional needs of children and their families affected by natural disasters, war, and famine.  The faculty and participants here reflect her selflessness, creativity and courage.  I've become friends this week with Dr. Hem Sagar Rimal, the first developmental pediatrician in Nepal, his wife Archana, the only psychologist in their hospital in the east of the country, and Raj Pandey, a neonatology fellow here at Rainbow Babies and Children's Hospital.  Raj's town, in the Gandaki district, was at the the epicenter of the earthquake.  He flew back a week after the quake to help out. 
           Over dinner at a restaurant in Cleveland's Little Italy with the three of them, Raj recounted farms being cut up into slices with big rifts down the middle, and advising villagers on how to start rebuilding homes. 
         "Do you have an engineering degree as well?" I asked.
         "No," he smiled.  "It's called being a doctor in Nepal.  I take care of premature infants here," he said "but back home I took care of a 91 year old woman.  If there is no one else you do what you can."
         And what does he want to do next?   His dream is to establish a system of primary care medicine in his home country.  As in most developing countries, there is only acute medical care.  "So people wait until they are too sick to seek care, or go to emergency facilities" Raj explained.  (Sounded like the health care system in too much of the United States, still, I thought)  He wants to help build a system where preventative health care will be paramount.

         Dr. Hem as vice principal of the Nobel Medical College Teaching Hospital organized relief efforts in his area.
         "But the communication was very bad," he said.  "We had neurosurgeons and all sorts of specialists, only to find that the government was flying all the victims to Kathmandu."
         He and Archana most wanted to talk about their two sons.  As specialists in child development, they thought it was not surprising that their younger son mainly showed fear after the earthquake, but their older 16 year old son, mainly wanted to DO something.  Rather than study for his final exams, he insisted on organizing relief efforts among fellow students, that resulted in truckloads of supplies being sent to earthquake victims.
        When Dr. Hem described this to the group in the lecture hall, his eyes glassed over with emotion.  This is the only time I saw any of them display outward grief over the destruction and suffering they had witnessed.
        Dr. Hem and his wife preferred to talk about the previous four weeks.  This was their first trip to the United States.  They had been to Los Angeles, San Francisco, Las Vegas, Louisville, New York, and Washington before coming here.
        "What is your favorite city?" I asked.
        "Well we really liked visiting the White House," he said. "but our favorite place was Las Vegas."
        "Las Vegas?"  I asked "… do you gamble?"
        "No," he replied. "But we loved the way the city rises out of the desert, with the mountains and the sun in the background."
        And they were enchanted by the Grand Canyon.
        "That was fabulous," he and Archana said.

        They were mostly interested in hearing about my life, and my travels and work in Bhutan. In passing, I described the incidents (depicted in a previous blog) about the nursing students who laughed over the obese girl's crying when I showed the film "Fed Up", and the young man with cerebral palsy, who laughed, along with his friends when he fell walking to the hospital.   They looked at me with curiosity.   
            I said that one of my Bhutanese friends explained that since, in their Bhuddist tradition, they believe life is suffering, we need to be able to laugh at ourselves when we endure pain or sadness.  I immediately regretted telling this story, for obvious reasons. 
          "We are not like that," they explained --- a response which gave me more admiration for the good humor and generosity of spirit they displayed in the face of so much adversity.
           We talked about the history of Bhutan and how many people of Nepalese origin were expelled from the kingdom.  
           "60,000 of them were accepted by the United States" Dr. Hem said - a laudable gesture which led to other countries welcoming them as well.  
           The ethinic Nepalis from Bhutan are "more Nepali than the Nepalis" he laughed.  I told him that the Irish say this about Irish Americans in our country.
           He seemed to harbor no resentment towards the way his countrymen were treated in Bhutan.
           "They (the Bhutanese) are our brothers and sisters," he said.
And he said that the Nepalese people greatly appreciated that the government of Bhutan, led by its prime minister had sent a delegation to their country with one million dollars (US) in aide.
         
          But Bhutan was also busy this past month achieving a milestone, according to a facebook post by my friend Namgay Dorji. The kingdom set the Guinness World Record by planting 49,672 saplings in 57 minutes!  These 100 volunteers, working at breakneck speed, broke the previous record held by the Indian state of Assam. How each of these volunteers planted about 496 trees in one hour is anyone's guess!

           Our lectures have concentrated on disaster relief, but all the speakers have acknowledged that long term reconstruction, building of infrastructure, and maintaining a safe and healthy environment are what is needed in the long term.   Bhutan's policy of Gross National Happiness is the perfect example of this philosophy.


       

Tuesday, January 27, 2015

      

     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."


    

Sunday, December 21, 2014

                                 The Wheel of Life from the Traditional Medicine Institute - Thimphu

                I'm still wondering what it is about the experience in Bhutan that makes me feel as if I tomorrow I will be waking up in that bare apartment again with the dogs in the hall, getting the space heaters going for warmth, hearing the sounds of the trumpets and monks chanting from the chorten.
It's not as if I don't enjoy being home with my wife, my own dogs and friends.  It's the reentry into our health care system that been challenging.
               Soon after my arrival home I attended an evening meeting at Baystate Medical Center (BSMC).  Pediatricians in the Pioneer Valley are being wooed by a PHO (physian's health organization) from the Boston area, called PPOC (Pediatric Physician's Organization at Children's Hospital)   PPOC is run by pediatricians.  It also functions as an ACO (accountable care organization) that "manages lives"- keeps track of costs per member per month.  Naturally, that has concerned BSMC, which, through it's PHO, has been the contracting organization for our group, and many of the pediatricians in the area.  Will pediatricians who are part of the PPOC refer to Childrens Hospital in Boston instead of Baystate? they worry.   Many pediatricians are of course attracted to the idea of a pediatrician led group, that will have this specialty at its focus, instead of having kids health as a virtual afterthought behind the cardiac surgeons and others who bring in far more money to BSMC.
              Complicating matters is the fact that two months ago, Baytate was unable to agree to a contract with Boston Medical Center (BMC)- Healthnet -- the leading managed care organization for Medicaid/Mass Health in the Commonwealth.  BMC Healthnet are the insurers for a third of our patients.  So as of December 1, one third of my patients will no longer be able to access care at Baystate Children's Hospital.  Baystate Children's Hospital has the only pediatric emergency department in our area, the only wards that admit children for hospital care, the only pediatric nurses, the only neonatal intensive care unit, and employees almost all the pediatric sub specialists in Western Massachusetts.
             Adding to this disastrous situation is the fact that since Holyoke Pediatrics contracts through Baycare, all our Healthnet patients have had to change insurances or find new pediatricians.  As of December 1.  (Since then, there has been a month long extension of this deadline and talk of Baystate starting its own pediatric ACO).
              The meeting location had been changed from a comfortable, dignified and venerable meeting room in a wing of the old hospital to what was unfortunately a more appropriate setting:  a windowless featureless classroom in an office building that houses the staff of the contractors at Baycare.  It's the place for bean counters.
           I found myself locked out of the building.  They had forgotten to keep it open for stragglers.  A fellow pediatrician from another group was also locked out.  I texted one of my partners Jane Cross but there was no response.  The intense presentations and conversations were in full flight, and, Jane (or Dr. Jane, as she would be called in Bhutan), sitting in a middle row, was too embarrassed to make her way out of the crowded room to let me in.  However, a few minutes later, a black limousine pulled up by the curve  in front of us.  An African American driver opened the door for a distinguished looking African American man dressed in a fine black suit.  He introduced himself as a vice president from Children's Hospital (I have since forgotten his name)  He was late because of traffic out of Boston. He was due to address the group shortly. I texted Jane back:  You'd better come down to let us in.  An important guy from CHMC is here.   She came right down.
            Upstairs I went looking for a rest room.   My memory of the administrative offices here were correct, and my criticisms of the JDW Referral Hospital, which I wrote in my outgoing survey, were correct.  JDW's clinics and inpatient areas were mostly dark, and depressing, and unclean by western standards.  Yet the new postgraduate medical center building, has sunny modern offices large enough to roller skate around. Here, the opposite is true.  Except for the adolescent unit, housed on the 6th floor in a dark old wing of the hospital, the patient areas are bright and cheery.  The Pediatric Intensive Care Unit has shimmering colorful fluorescent lights.  The brand new out patient clinic, though housed in a former warehouse district, has a bright atrium not unlike that of the Museum of Modern Art in New York.  But the many offices housing everyone from administrators to telephone operators to medical records staff are mostly drab and dingy.  These offices were no exception.  Outside the meeting room was a buffet with crudités , mushroom and hot dog canapés, and salad, and fruit.  I had a little of each.
The only left to drink was coke.  I had a cup.
         The atmosphere in the meeting was tense.  Pediatricians and administrators from private practices expressed their frustration with the fact that some of our poorest patients were being treated like pawns in these contracting disputes, and may soon be left without adequate pediatric care.  BMC Healthnet had evidently not negotiated a contract with Children's Hospital Bay either.  And it became clear that the PPOC and Baycare had not been meeting together at all to try to figure out what was the best for the health of young people of Western Massachusetts but were trying to garner our contracts.
        I thought of how much of the day of a doctor in the U.S. is spent worrying about the dizzying alphabet soup of agencies that manage the private health care system here.  Which ACO or PPO will contract with which health insurance companies.  What medicine, specialist, procedure, or mental health professional each of these companies will pay for (which is always changing).  Whether our patients can afford the burgeoning copays for physical therapy and other important services (they frequently can't).  And this is in Massachusetts which, with "Romneycare", the precursor of Obammacare, has better coverage than most of the nation.  I thought of how a growing percentage of our day, is spent entering data to satisfy the "meaningful use" guidelines, which are often meaningless.  How little how any of this has to do with taking care of sick people, or helping healthy people stay well.

                                     Dr. Tashi and Staff in the Pediatric Intensive Care Unit

          And I recalled the last case presentation I heard in Bhutan, by one of the two pediatric residents I supervised in Bhutan, Dr. Kalpina.  I baby with the typical stigmata of Down Syndrome was born in a small village in the Mongar district.  Since no chromosomal testing is available in the country, the diagnosis is made clinically.  Like many newborn infants with Trisomy 21, the infant had troubles with sucking and feeding.  He had a murmur, presumed to be a ventricular septal defect.  The child also had a white blood count of 45, 000, with numerous immature forms including lymphoblasts.  This combined with a low platelet count, and anemia, led to an initial diagnosis of congenital leukemia. The baby was treated for possible sepsis and observed.  The white blood cell count gradually fell to a normal level, and the platelets increased; with the help of a transfusion, the anemia resolved.
          Dr. Kalpina led us to a diagnosis of transient myeloproliferative syndrome, which unlike the previous fatal diagnosis, resolves on its own.  I asked about getting a bone marrow aspiration, just to make sure.
          "You probably wouldn't know about this",  Dr. Tashi explained, apologetically.  "But the family doesn't have papers"  He belongs the Nepali minority, who are undocumented residents.
            Unlike here in the U.S, no one calls them "illegals".  They still get free health care and education.  But, Dr's Tashi and Kalpina (a Nepali herself) explained, unlike Bhutanese citizens, they don't get to be sent to India for free medical care not available in their country --- like bone marrow aspirations for infants.
            This was the only problem in access to care, the only thing approaching the endless complex web of insurance hassles that are part of our  health care system the entire time I worked in Bhutan.
             During the two months I was away, I drank water that had to be boiled, consumed produce bought from street vendors, including raw carrots and apples,  drank hot buttered yak tea, and shared a traditional picnic lunch on a hot day with new local Bhutanese friends, but never suffered any gastrointestinal upset.   That night after the Baycare meeting, I was sick to my stomach all night.  Maybe it was bad raw carrots combined with coke.  But it could have had more to do with the rot in our health care system than the rot in the buffet.

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”.