MY VIEWS

2025-08-21T22:32:00.000-07:00

Looking Back, Looking Within: A Journey Through Bhutan’s Mental Health Landscape

I began my journey as a medical doctor in 1989, a time when Bhutan’s health system was still in its early stages of development. As a young medical officer, I moved across five different postings over 13 years. Those years shaped my identity as a doctor and taught me the value of service, resilience, and humility. Yet, when I look back on that period, one thing stands out with a quiet but unsettling weight: I do not recall ever treating a patient for the psychiatric conditions that now dominate my daily practice.

It was only later, after training and returning as Bhutan’s second psychiatrist, that I began to question this silence. Did mental illness not exist in those days? Or did we, as medical professionals, fail to recognise it?

In my memories, I can still see “odd” figures wandering the streets — men and women who behaved strangely, muttered to themselves, or lived in hidden corners of the community. They were the ones people avoided, the ones children were warned against as potentially dangerous. At the time, we had no framework to understand them. Mental illness was not part of our diagnostic vocabulary. Alcohol use, meanwhile, was dismissed as a weakness of character and a lack of discipline. We had no tools, no interventions, and no hope to offer.

Our focus in those days was elsewhere. We were young doctors serving in a young nation, where communicable diseases, maternal and child health, safe drinking water, sanitation, and nutrition were our urgent priorities. Public health campaigns — immunisation, malaria control, iodine deficiency, leprosy eradication, and family planning — consumed our attention and rightly so. Hospitals were places people turned to only when local healers and shamans could not provide relief. Our task was to win their trust in modern medicine, to prove that science and compassion could complement tradition.

Yet, beneath this progress, a hidden suffering remained unaddressed. Only years later, after serving as a psychiatrist for more than two decades, do I recognise how much we might have missed. Mental illness was there — in silence, in stigma, in shadows — but it went unseen, unnamed, and untreated.

Today, the picture is very different. Thousands of people come forward seeking psychiatric help, each story unique, each pain deserving of recognition. Families, schools, and workplaces are more open to conversations about mental health. Awareness campaigns, training programs, and media discussions have brought the invisible into the light. Sometimes, though, I wonder if in our effort to destigmatise mental health, we may have swung the pendulum too far in the other direction.

I find myself reflecting on whether we have created a kind of over-reliance — a belief that every stress, every worry, every difficulty must be solved by professionals like us. While clinical care is essential, I firmly believe that true mental well-being also requires personal responsibility, resilience, and community support. People must learn not only to seek help when needed but also to nurture their own coping skills and inner strength.

After 36 years in Bhutan’s health sector — 20 of them as a psychiatrist — I remain humbled by the journey. From days when mental illness was invisible to today, when it is openly discussed, we have come a long way. Yet the work is far from over. We must continue to expand services, reduce stigma, and strengthen care. But equally, we must empower individuals to take ownership of their mental health, to recognise that healing is not only in hospitals and clinics but also within families, friendships, and the choices we make every day.

As I reflect on this path, I realise that the greatest lesson of all has been to look beyond symptoms and statistics, and to see the human being in front of me — vulnerable, complex, yet resilient. That, perhaps, is where true healing begins.

Short Autobiography

2018-05-09T08:08:00.002-07:00

I was born on 4 January 1961 to Dip Bahadur Nirola and Kaushila Bhandari as their eldest child in a small village called Nainatal, under Dalim ‘geog’[i] (block) in Samdrup Jongkhar, Eastern

Bhutan

. I have one younger brother and four younger sisters, one youngest sister died in 1989. Prior to their marriage our parents had actually lived at Surey in Gelephu. Our father was a widower with a daughter and our mother was a widow with one son. They had fallen in love, and against all odds, got married. Because of this unique marriage we have one half-brother and a half-sister. My early education started in 1968 in a small primary school at our village. In fact this was the school which our father started in 1950s after he got elected as the ‘gup[ii]’ (village headman). He had ardent desire to educate all the children of our village. He probably regretted his own inadequacy in education due to lack of opportunity. However, in spite of his ability to just read and write Nepali language without formal training in grammar, he was very popular person during his time. He is still fondly remembered by many people of our village as a dynamic gup.

The school was initially situated near our house but because our father wanted it to be accessible to many more children, got it shifted to almost an hour’s walk away, at Dalim. This is actually the centre of the whole block. Due to this I had problem walking the distance, which got solved later when I was made to stay with one of the teachers, Mr. A. T. Sill, an Assamese. So by the age of 9 or 10 I had started living independently and this acted as some sort of survival training for me to cope up with harder life I was to lead later.

In 1972 my father started showing some signs and symptoms of a chronic lung disease. I had observed him making visits to some health centre in

Assam

and I had also noticed that he was taking lots of medicines. Occasionally he would bring out blood streaks in his sputum. I just wondered rather than worry for I was too small to gauge the gravity of the problem. Day by day his health deteriorated and the blood in sputum became more copious. When I look back I realize that he had a serious illness, probably Pulmonary Tuberculosis or lung cancer! He could not get the treatment he required due to lack of health facilities in those days. Finally he succumbed to the disease sometimes in June or July that year. We were left with our pregnant mother who was expecting another child over and above the existing seven; this was not to last long!

Whether it was our fate or our parents’ love for each other, our mother joined our father in the heavenly abode within a gap of about three months. She could not survive the heavy post partum haemorrhage following retention of placenta after the birth to our youngest sister. I remember many people trying to help her; some to the extent as to try manual removal of placenta without any modern day aseptic precaution! Nothing helped though and after three days of delivery she was no more! The complication could have possibly resulted due to too many parity, age and severe lack of maternal and child health services in those days. This sad picture would always guide me to be more compassionate and extra cautious towards women in labour later in my career as a doctor.

Following the death of our mother we landed up in great trouble. We had become orphans without any guardian! All the well wishers got together and convened a meeting immediately after the funeral of our mother. We were to choose a guardian from among many uncles and our half brother, Ghana Shyam Thapa, who was by then living with his wife and a child in a separate house. Our father had one brother, and six half brothers from mother’s side; his brother being Karna Bahadur Nirola. After a lot of deliberation our half sister, 2 years senior to me, the eldest in the group, made the decision to choose Karna Bahadur uncle (we call him father now) as our guardian. He never had a very cordial relationship with our father because of his (uncle’s) short temper. However, he had no option but to accept a bunch of tiny orphans, eight in number, as young as three days to fourteen years old. He already had four of his own kids, oldest being fourteen and youngest just a year and a half. His wife was expecting another child very soon! There were a total of 12 children to take care of. Now I awe at his ability to have kept his mental frame intact in spite of the enormous task of taking care of twelve helpless souls!

In the mean time I continued my study and completed the fourth standard, the highest level of education available at our village during those days. Our father’s last wish before he expired was that I should be allowed to complete ‘matric’ (matriculation[iii]). He knew I was an intelligent boy and probably could manage to study up to that level. Arthaman Rai was the idol from our village in those days. He had completed matriculation and had joined government job. All of us aspired to become something like him and do government service.

In order to pursue further studies I was to go to another school, some 200 kilometres away from home, at Tashigang in East Bhutan. I was sent to Tashigang along with Shanti Ram

Nepal

. Tashigang had a Central School with classes up to eleven. Two students from Dalim were already studying there, Suk Bahadur Subba and Shanti Ram Rizal (late). The principal, Mr. K. P. Nair, was a very strict person and he readily doubted quality of education in the smaller primary schools. Thus without any regard to our transfer certificate or any interview, two of us were admitted in class four again. Life in hostel was not so attractive, but having had the experience of living away from home and being an orphan now, I didn’t feel lonely or home sick any time. Suk Bahadur Subba acted as my mentor during that period and also later in life. He helped me cut firewood, made me do my home work, woke me when I needed to be awake and disciplined me when I tended to become mischievous. Now I realize that he was the person who shaped me as a teenager and put me in the right path. I could achieve this much all because of his guidance and inspiration! He remains the most adored person in my life. A year later I was fortunate to get the company of my closest friend, Rabilal Pokhrel (uncle by relation) who joined me in class 5. We spent those troubled teenage years together arm in arm, competing healthily in classes and scoring the highest in examinations. Two of us have cried together, worked together to earn pocket money, and spent most formative years of our lives together. We worked hard and passed class 8 Common examinations in 1977. We continued to be classmates until we went to two different professions after completing ISC-12[iv]. He is now an Electrical and Electronic engineer heading the Area 1 of Bhutan telecom as Area manager.

Within two years of our admission some crises happened at our school (I have not been able to comprehend even today) and it suddenly got downgraded to a Junior high school. All the students from class 9 and above got transferred to Paro and Monger; Suk Bahadur Subba, thus, left too. Mr. O. P. Arora from

India

came as our new principal. He was a nice and friendly person unlike Mr. Nair who was very fond of wielding a stick!

In the mean time back home things were not so good. Our aunt, who was pregnant when I left for Tashigang, delivered a baby boy and due to some post-natal complication she too had expired. This gave our uncle a lot of mental stress. He became irritable and abusive due to which my brothers and sisters had to face immense amount of wrath. They suffered a lot! Now I realize that it must have been the most difficult time in my uncle’s life. Inability to take care of two infants, our youngest sister was given to our ‘thuli-ama[v]’. Thuli-ama readily adopted her as her own daughter and gave all the love and affection she lacked so far. Of course, she lived a very short but happy and healthy life. She expired at the age of 16 while she was studying at Pemagatshel in class 8 due to Typhoid fever. Paradoxically, the year was 1989, the same year that I qualified as an MBBS doctor. Unfortunately my medical knowledge was of no use to her for I got the news of her death and not the illness!

In that stressful period of our uncle’s life, some people claimed that our father had taken loan from them. In order to clear the debts our herd of about 30 water buffalos and our famous ‘Gopal’ horse had to be sold. At that very moment the government objected for the amount of land we had and a substantial portion was confiscated; the remaining was shared between my brother and me.

In an attempt to find solace our uncle married to a lady from Chirang. They subsequently had three children out of the new wedlock. Our uncle’s life seemed to change thereafter. He built a new house, he started living more luxurious life than before and people attributed this to the wealth he acquired from his late brother along his children. He dismantled our old family house and we saw the materials being utilized to make the new house. He, however, always insisted that our parents left nothing except some land and eight of us; we had to believe that. I escaped the harder lives my sibling had to lead at our uncle’s house not out of choice but because I was away at ‘not-so-comfortable, hostel in Tashigang. It may seem a little mean on my part for not being able to give up my studies for farming to support my brothers and sisters but I had my father’s words to keep. I had to pass ‘matric’!

After completing our class 8 examination we were supposed to go to Sarbang Central School but Rabilal and I requested Father Mackey for seats at Sherubtse College in Kanglung (22 Km south of Tashigang). Sherubtse (‘the peak of knowledge’) was the highest seat of learning at that time and to get a seat there was a great privilege. Since two of us had topped the class, Father Mackey readily accepted us. We became ‘Sherubtsian’ in February 1978; the same year Father left Kanglung to start a new High school at Khaling (another 20 km south of Kanglung).

In 1979 I finally fulfilled my father’s dream by completing ICSE[vi]-equivalent to older matriculation. However, by then I was determined to continue my studies as long as I could; I wanted to be a professional- an engineer or a doctor. With sheer hard work and some luck (actually I am more of a lucky person than hard working when it comes to studies!) I passed the ISC-12[vii] with good percentage. I stood second, after Dr. Duptho Wangmo, in the science group. Dr. Duptho is a Gynaecologist at Military Hospital, Lungtenphu, Thimphu. I qualified for a seat for MBBS at Armed Forces Medical College (AFMC) in Pune,

India

. I joined AFMC in September 1982 and became a proud U-batcher of the Institute. With one extra year due to poor performance in my final year, I completed my MBBS in November 1987. Thereafter, I completed my one-year internship from Command Hospital (Eastern Command), Calcutta on the 28^th of February 1989. It was during the internship atCalcutta that I made another good friend, Dr. Kashinath Sharma. We not only made our internship days enjoyable but also made our stay at Calcutta a memorable moment in our lives. Dr. Hari Prasad Chhetri and Dr. Sonam Dorji were with us too.

I joined the civil service of Royal Government of Bhutan in March 1989. My career began at Thimphu General Hospital where I spent very little time before I got transferred to Kalikhola. By late 1989, the political disturbance in the south was surfacing and this prompted the government to raise a militia force. In the processes all the graduates and class 12 pass-outs were to be given militia training. Since I belonged to the graduates of 1989, I also had to undergo that training of three weeks’ duration. I enjoyed the training very much because of very good company we had during that period.

In the mean time I fell in love with Paizeen, whom I knew for almost 4 years, she being the sister-in-law of a close friend and accomplice, Mr. Suk Bahadur Subba (the same person who shaped me during the teenage years). I got married to her on 14^thFebruary 1990, incidentally the Valentine's Day. She was working as a draftsperson in the Department of Public Works in Thimphu. In the same year that we got married she was transferred to Engineering Cell of Central Zone at Gelephu. This impelled me to request for a transfer to Gelephu hospital, which I got without any problem. The problem in the south got further impetus and by late 1990 there were demonstrations in the all the southern ‘dzongkhags[ix]’. Many southern Bhutanese thus got involved in the pro-democracy agitations. However, I felt that the time was not right for such a drastic act; even the method that was used to motivate the people for the agitation was mostly threats of death. Many innocent people reluctantly took part in the demonstration and later suffered a lot. Government took a very stern action towards the agitators in particulars and to all the sympathisers in general. Numerous arrests were made, people were imprisoned and tortured. Many innocent people got scared and left the country. The ones who left the country, around 100,000 lived in Eastern Nepal until most of them got resettled in different parts of the world including the United States of America.

Because of the political problem the Zonal Office got closed and my wife too got transferred to Thimphu once again. She was pregnant that time with our first child. We got separated for sometime when we needed each other’s company the most. During that period she started showing symptoms of pre-ecclemptic toxaemia, a pregnancy related condition. I wanted to be with her but I was refused transfer to Thimphu. Fearing a disastrous consequence, we decided that she resigned from the job. A few months before the delivery of our daughter she bid farewell to the job he had held for the last 9 ½ years to become a homemaker! Our daughter, Preeti had to be delivered by a caesarean section on 29^th of August 1991. Dr. B. M. Pradhan was kind enough to perform the caesarean duly assisted by myself at Gelephu Hospital.

By November 1991 the government had decided to transfer all the loyal southern Bhutanese civil servants to the northern dzongkhags. This way I landed up in Punakha in November 1991 to work as the District Medical Officer. The health centre where I initially worked was just a 10-bedded Basic Health Unit grade 1. Ultimately it got upgraded to a new 20-bedded hospital, which was constructed under funding from German Bhutan Hospital Foundation- a non-governmental organization, and inaugurated in 1996.

I was fortunate to have taken part in the planning stage of the new hospital in the capacity of the DMO. I was also fortunate to work in there as the first DMO along with Dr. Schmidt, a German doctor. After a long stay of around 5 ½ years at Punakha Basic Health Unit and just a few months of privilege of working in the new setup, I got transferred to another very old hospital at Trongsa in Feb 1997. Trongsa hospital up- gradation was also underway that time, so I got involved in site selection and planning of a new district hospital with modern amenities funded by the DANIDA. By 1998 we completed the planning process and in 2000 the construction works began. The hospital got completed in December 2003 and was inaugurated on 17^th December, coinciding with our national day. Dr. Man Bir Ghising, who later died in a road accident, was the first doctor to work in the new hospital as DMO.

While in Trongsa we went to have our second child after 8 years of long gap since Preeti was born. We opted for an elective caesarean section and took help of Dr. (Mrs) Norbu in Thimphu. We had a bouncy boy, Adeep on 25^th of June 1999. Incidentally, this was the year which marked the starting of cable TV and internet services in

Bhutan

In 2001 my post graduate studies got approved due to which I was sent to Jigme Dorji Wangchuck National Referral Hospital in Thimphu to work in the Psychiatry department until my confirmation came through. I worked under the guidance of Dr. Chencho Dorji, the only Psychiatrist in

Bhutan

, for one and a half years in the Psychiatry department. I got exposure to all sorts of psychiatry illnesses in

Bhutan

and this amplified my interest in the field of psychiatry. While working there I also got a chance to take part in the first ever Mental Health survey conducted in

Bhutan

. Besides, I was also involved the analysis of data.

After a long wait of 1 ½ years, finally in September 2003, I got the confirmation about my seat for PG in Psychiatry at Bangabandhu Sheikh Mujib Medical University in Dhaka, (former IPGMR[x])

Bangladesh

. I joined the university on 9th September 2003. Getting back to study after a long gap of 14 years was almost a nightmare! Again, to stay alone, away from family was equally traumatic. However, by December 2003 my family joined me in Dhaka and gave me company throughout my post-graduation. Our daughter sacrificed our company and stayed at Phuentsholing to continue her studies. Of course she did enjoy the holidays with us every six months. Except for a supplementation in part 1 examination, I managed to pass all my examinations in time and finally graduated in April 2006 as Psychiatrist with Master of Philosophy degree. I have climbed another rung in the career ladder of my life!

From May 2012 was undergoing a training program conducted by the Colombo Plan Asian Centre for Certification and Education for Addiction Professionals and completed the basic level course in November 2013. I sat for a certification examination and qualified as International Certified Addiction Counsellor. I am also one of the regional trainers for the same course.

Over the period I have been able to gain trust in my profession and I am currently holding various positions in the government organizations. Beginning of 2014 left me alone to handle psychiatry department at JDWNRH after Dr. Chencho Dorji left for Australia on a two years long leave. He is now back and we also have a new lady Psychiatrist, Dr. Ugyen Dem. I am currently heading the department of Psychiatry. With the establishment of Khesar Gyalpo University of Medical Sciences of Bhutan, I am now a teaching faculty in the capacity of Professor at the University.

My brother, Om Prakash Nirola, graduated from Shree Ram College of Commerce,Delhi in 1990 with Honours in Economics. He passed the Royal Civil Service Commission examination for graduates and joined the Civil service in 1991. He recently completed his MBA from the Netherlands. He is married to Tek Kumari Kharel and has two sons. The first child was a daughter, who had cerebral palsy due to kernicterus during infancy. She lived to be four year old when she finally left us all for the heavenly abode. Om resigned from the Civil service to join one on the renowned organizations in Bhutan, Druk Holding and Investments [http://www.dhi.bt/] in Thimphu. He completed his MBA from the Netherlands.

Out of five sisters, three could not get education. They were married off and sent to their in-laws. As mentioned earlier, the youngest one expired in 1989. The second youngest, Hema Devi, graduated with diploma in Agriculture from Natural Resources Training Institute (NRTI) at Lobeysa. She is worked as Research Assistant at Agriculture Research Centre in Yusipang, Thimphu until she resigned to join a private firm Druk Horticulture as its Chief Executive Officer. She is married to Kharga Basnet, an Agriculture graduate, from the

Philippines

, currently a working in the US. They are blessed with one son and a daughter. They are currently living in Thimphu. Her email address: hemanirola@yahoo.com. Hema has upgraded her qualification and graduated in 2013 with B.Sc degree Agriculture in College of Natural Resources (the erstwhile NRTI)

Our foster father, Karna Bahadur Nirola suddenly fell ill in April 2009 and his health continued to deteriorate further. He had multi-organ failure and succumbed to the illness and left for the heavenly abode on 20th November 2009 at 8:30 a.m. in the ICU of JDWNR Hospital. He was +78 years old by then. His body was taken to his home at Bhangtar where he was cremated on 22nd November 2009.

My daughter has graduated from Pailan School of International Studies in Kolkatta with Bachelor degree in Media Science. After working at different organizations, including a year's work in Dubai, she is working at Bhutan Spirit Sanctury Resort at Shaba, Paro. My son is undergoing bachelor's course in Airlines, Hospitality and Tourism at Lovely Professional University, Jalandar, Punjab, India.

Life is full of twists and turn; it is up to you to negotiate or take a shortcut!

[i] Geog= A smallest administrative unit, also referred as block consisting of a number of villages under one headman or ‘Gup’.

[ii] Gup= Block head

[iii] Matric= Short for matriculation, an educational qualification equivalent to Secondary School Certificate (Class X).

[iv] ISC-12= Indian School Certificate (Class 12)

[v] Thuli-ama= mother’s elder sister

[vi] ICSE= Indian Certificate of Secondary Education (Class 10)

[vii] ISC-12= Indian School Certificate (Class 12)

[viii] JDWNRH=Jigme Dorji Wangchuck National Referral Hospital

[ix] Dzongkhag=District

[x] IPGMR=Institute of Postgraduate medicine and research

A LOST CHILD: THAT'S ME!!

2015-10-19T22:36:00.001-07:00

I realise that I have completed 54 years of my life. They say a cat has nine lives, but a human being has only one, unless you are a reincarnation. As I have not yet been recognized as a ‘trulku’ by anyone, I guess this is my only life. How nice! Having grown up as an orphan, living mostly in a student hostel, having embraced science to build my career to become a psychiatrist at the age of 45 years, I have not been convinced well to embrace any single religion or faith. Wait a second; I am, but not an atheist in the real sense of the word. I was born as a Hindu; I am still among the flock of Hindus and behave like one among them. I always tick ‘Hinduism’ as my religion, whenever and wherever forms and dossiers require me to do so.

I was fortunate to be very young, rustically naïve and, perhaps, ‘pure’ from an orthodox Hindu perspective to have been able to perform the final rites of my parents at the tender age of 12. As I was a long way from any exposure to modern worldly ways, I was able to meet the stringent dietary and daily protocols that would have been difficult today. If I had to do that now, perhaps my mind would question a lot of things. Is it really necessary to omit salt for 13 days? Why do I have to take only one meal? Why does wearing footwear in any way hinder? All in the name of liberating the souls of my departed parents.

I lived in student hostels most of my formative years. The same child who used to worship cows during Diwali was eating beef in the hostels of Trashigang and Kanglung schools. The child who used to fear being touched by a pig in order to avoid losing his caste started enjoying ‘phakpa sha’. The child who was ordained to believe that alcohol was the beverage of the lowest caste started liking a drink or two. If alcohol would define caste, then today I would be at the nadir of the caste system. Doesn’t matter though, as I don’t believe in it! Nothing really happened; perhaps I am lucky to have been born in Bhutan, a Buddhist country, or else I would have been ‘lynched’ by now for declaring that I have taken beef, a la Dadri.

When I was young, in the name of religion, a he-goat used to be sacrificed during Dushera. The goat used to be identified well in advance as the one belonging to ‘devta’ and the offering was for Durga. Of course, we enjoyed the meat afterwards. Back in school, we learnt prayers written in “chokey”, which the Dzongkha teacher made us memorize and recite line by line. It still happens in our schools! When I got scared at night I used to recite ‘Om, Mani, Padme Hung’! Even today, it is the only ‘mantra’ that I know or have learnt the most. When I get shit scared, my pounding heart goes ‘Om, Mani…’

My parents were straightforward Hindus; practiced what was passed on from generations, and the rituals were also pretty straightforward. I still don’t know whether some of the rituals should be practiced! By the time I became 10 or 11 my father suddenly discovered the influence of ISKON. One day he came home with a slate carved with ‘Harey Rama, Harey Rama, Rama, Rama, Harey, Harey! Harey Krishna, Harey Krishna, Krishna, Krishna, Harey, Harey! I remember reciting that over hundred times. Nothing happened!

Around the same time, Vaishnavism came to our village from Surey, Gelephu. It required people to sort of get baptized by getting branded with ‘shankha’ and ‘chakra’ on each deltoid or thereabout. After that people were expected to live in purity – meaning becoming pure vegetarian, not mixing with people of other faith, etc. As the village headman (gup), my father refused to accept people converting to Vaishnavism.

By around 1975, Vaishnavism finally penetrated our village after the death of my parents. In fact, all my paternal as well as maternal uncles, my siblings, cousins and most of the Brahmins in my village embraced Vaishnavism. However, not everyone turned vegan.

This was the time my mind started questioning beliefs, faiths and religions. I keep hearing people say that ‘god is one’, even Facebook says so. But I also keep getting a message that ‘my god is better than your god’, or ‘my way is the best way to hit god’. At times I feel like a lost child; lost and stranded in the middle of nowhere asking for direction to reach my destination. But the directions are too many and mostly contradictory! How the hell will the lost child reach his destination?

Faith and religion are as confounding as is portrayed in the Bollywood flick ‘P.K’ One set of people believes that cows will help you cross the river to heaven – a mere touch of its tail is enough – after you die. Others have no problem eating beef. Yet others believe that some ‘mantra’ or ‘knowledge’ given by a particular guru will deliver you straight upstairs. While some think that pork is dirty meat, yet many enjoy eating it. Some say ‘don’t eat meat, for it is equal to cannibalism’; others advise that meat is very nutritious and the best source of protein. Some say, ‘oh you believe in that’? Then you have not gotten the real ‘gyan’! Anyone who has not received the gyan is not going to be liberated ever. You will remain as a restless soul after you die’.

Some say, ‘my guru is god, just believe in him and you will be liberated’. Some say, ‘just close your eyes and meditate and you will attain nirvana’ Some say, ‘look at the ash produced by my ‘Bhagwan’ out of thin air. Lick some of the ash and smear some on your forehead, you are done’. Producing things out of thin air is a roaring business and a vibrant profession in the world. Famous magicians such as David Copperfield and P.C Sorkar have produced many more things than mere ash, yet their audience does not claim that they are gods. So much claim, but the fact is I am yet to see these pretenders fly to heaven!

The primary essence I see in all of these is - be a nice person, help other human beings, be kind, don’t cheat, be simple and be satisfied. Perhaps all these can be summarised into four virtues: no anger, no jealousy, no greed and no hatred.

If this is the real essence, I think only Gautama Buddha summarised it the best, at least for me. I see that people cheat others and perform grand rituals to neutralize the cheating. While people try very hard to be devout and religious in the hope of liberation, rituals following the death of someone seem to be still necessary. Sometimes an ailing person may not be provided with the basic care and food while still alive, but is served the most sumptuous of meals once he is dead. Talking of dead, some say you need to burn the dead to liberate the soul, others believe that it has to be kept until the day of final judgement. Some believe that the soul is liberated in 13 days; others believe it takes 49 days.

Confusions abound! Each believer, though, claims to have a solid answer, sometime even challenging to show proof. Yet god doesn’t seem to come in one colour, race, appearance anywhere and say, ‘hey don’t get confused; here I am’.

PARENTS-CHILDREN CONFLICT: A REFLECTION!

2015-10-15T10:25:00.000-07:00

In the recent years I have been witnessing a rapid rise of conflict among children and their parents. These conflicts are leading to various behavior issues in the children and young adults. Many youth are seen to be frustrated, depressed, anxious and at times outright violent against self. Frequency of attempted suicides has increased over the years and many young people have perished. Postmortem psychological assessment of those who have committed suicides most of times fails to reveal the psychological issues. There are many instances of impulsive acts of self-harm. A minor reprimand, scolding or interception has led to the drastic consequence like suicides.

The psychological resilience of our youth seems to have reduced to a bare minimum. They don’t seem to be able to accept anything which is beyond their liking. They seem to be all the time rebellious against the parents, the teachers and the society at large. We are facing a big challenge of frustrated and angry new generation. The religious values and protective cultural norms are no more effective. I have been having lots of questions, and most of these are unanswered. What is the root cause for all this! Where are we going wrong and who is at fault? Seriously, it is high time that we did a psychological anthropological study to find this out, but still lack the capacity.

Being a Psychiatrist working at the National Referral Hospital, I have been faced with a lot of issues related to the youth and children. On many occasions I have been put in a dilemma to strike a balance. I Just sit and reflect! Someday my reflections may generate a hypothesis for a more scientific study.

Recently I was invited to a panel discussion for celebration of the Fiftieth Anniversary of Yangchenphug Higher Secondary School and I was one of the panelists from the adult-side. The topic for the discussion was “It’s my life. Let me have it my way”. Very bold but a nice topic; it was the voice of the youth asking for their rights. They have been educated, they know their rights, they want freedom and they want to question and resist the age-old techniques most parents resorted to in order to discipline their children. While we agreed to the children’s view, we also quizzed them if they also knew their responsibilities? Sir Michael Rutland summarized this beautifully with an analogy of the driving culture that is evident in Thimphu. He said, the topic reminded him of the motorists in Thimphu where everyone thought “It’s my life. Let me have it my way”. He said, “If this was the case, there would be no traffic rules or policemen, people would be hitting each other and the result be disastrous!” He reminded the children to exercise their rights within a limit and to be cognizant of their responsibilities.

From this panel discussion I came to realize that while most of the children have now learnt their rights from the western perspectives, the parents have not evolved according to the needs of the time. To me, most parents lack parenting skills. We try to use the same old disciplining techniques that our parents used on us. We still believe that physical punishment is needed to correct a child; we still believe that we can impose our views onto our children and they will believe blindly. The most affected are those parents who are residing at the cities because most children back in the villages are still listening to their parents without much questioning. They still adjust to the village life and are not very alien to their parents in their views.

I can recollect those days when we were children how we were punished physically in every setting, from home to the school. We were made to “grow up” into adults much faster than the modern children. We are made responsible at a much younger age. We learnt a lot of survival skills that a farmer needed in life. Every child from the age of 8 or so had an assigned chore which was expected to be carried out without any cue or question. If we failed to perform our assignments, we would invite punishment. We grew up believing that our parents and our teachers had the right to discipline us! We believed that we deserved punishment if we deviated from our responsibilities, unlike the current generation that believes that they have the right “NOT TO BE PUNISHED”. In fact, sometimes I feel that those punishments “immunized” us to become mentally stronger and made us more resilient to stresses in life. Of course, I don’t believe physical or corporal punishments should be used as means of “psychological immunization”.

On the other hand, we as parents do not realize that ours was a totally different life in those days. Most of us grew in the villages, for we didn’t actually have any cities until the last two decades or so. Therefore, we didn’t have the distractions that are prevalent these days, especially in the cities. We didn’t have social functions that attracted us; we didn’t have “downtowns” to hit after schools; we didn’t have internet, televisions or computer/video games to entice us; we didn’t have discotheques, restaurants or other hangouts, nor did we have the pressure of drugs. The overall competitiveness in life was less tough, jobs were readily available and our needs were bare minimum.

Our children and youth are in a different world all together, they have all these; besides they also have the “rights” that most of us never heard of as children. Pressure to perform well in school is very high; they have to compete for limited seat available for scholarships. Many parents still are financially challenged to educate their children’s privately. They, therefore, pressurize their children further to exhaustion. Some parents still secretly wish their children to fulfill some of their unfulfilled dreams. The education system has become academic oriented and every child is expected to at least complete Middle secondary school. We don’t acknowledge the fact that every individual is unique in his/her abilities and mental capabilities; we expect every child to be the same in intelligence and skills. We have a tendency to compare our children with the children of relatives and neighbours; we don’t mind demeaning them in front of their peers or embarrass them in the public. We don’t realize that our children are more sensitive to these issues than we were when we were younger! We are highly judgmental and don’t communicate effectively with our children. When a child expresses that he/she is depressed, we try to ask “WHY?” rather than listening and trying to help. We sometimes even tell them to “die” if they cannot do what is expected of them. Children are not allowed to make their own decisions and parents impose their decisions onto them. We want to create the hierarchical boundaries in the family and refuse to take into confidence the opinion of our children thus alienating them further from us. Our children have to fall back on their peers for a lot of things because we are too busy to sit with them and listen to them. Peers can be helpful but they can also be harmful, especially if they happen to be into drugs or alcohol.

While I fully acknowledge that the children are right in saying “It’s my life. Let me have it my way”, I also want to caution that rights without responsibilities can ruin anyone. An individual is but a unit of a society at large, thus an individual cannot exist in isolation. Society runs on rules and regulations, families have their own unwritten rules that a child must respect. An immature mind of a child may not be able to make a correct decision; therefore, guidance from elders and more experienced people in their lives is necessary. There are multiple examples to prove that immature decisions are detrimental to a child and can ruin the life. These are manifested in the form of teenage pregnancies, delinquency, criminalities, theft, murder, substance use, alcohol use, gang fights, personality problems, etc., and the list can be exhaustive!

We need to strike a balance in order avoid conflict between the parents and children. There is no other way to improve our younger generation. Blaming each other is not going to lead us anywhere. The need of the hour for all of us is to reflect on how we deal with our children. The Home environment is the most immediate environment for a child. It needs to be peaceful, safe, friendly, accommodating, loving and caring and most of all very comfortable for a child. For a child the parents should be like friends, protectors, facilitators, teachers and confidantes. Our children have become modernized; they are more aware, very sensitive and highly impulsive. As parents, we must not expect our children to revert back to our generation but we must evolve forward and learn parenting techniques that are practical and suitable to the current generation. We are the bridge between the old and the new generation and we must teach our children to be better parents to their children. We must help them grow mentally healthy so that at no point in time should they have despair and opt to leave this beautiful world prematurely!

CHASING HAPPINESS

2011-07-20T08:48:00.000-07:00

Long ago when I was in the village, I was a contended young boy. Happiness was easy to find. We did not require wealth to buy happiness! Small things in life use to give us enough happiness, and our parents didn't have to struggle to make any one of us happy.

Rice with some vegetable curry would be the most delicious food. We would look forward to special occasions such as Diwali and Dashera to have a meal with meat. Having had the opportunity to have such specials food during those occasions would make us really euphoric! Three good meals that kept our stomachs full were enough to make us satisfied. We didn't even know that the foods that our children eat today ever existed! We simply knew that foods were grown in the fields and needed a lot of hard work to produce. We didn't have any clue about foods being sold in restaurants until much later. On the way to Tashigang, where I went to study after graduating from my village school, we saw people eating in hotels and restaurants but we didn’t have much privilege to dine in those. We generally carried rice with us to be cooked where ever we put up overnight.

We were made to believe that wearing clothes was primarily to protect us from weather and to protect our modesty! We didn't have the slightest knowledge about any fad or fashion, nor did we have the choice for any colour or design. We would get a new pair of clothes during the festive season and that too came after a long wait of one year. A new pair of clothes used to bring lots of joy for us. We would go visiting relatives during those days showing off our new dresses.

Everyone walked bare feet, including the domestic animals, so question didn't arise of not wearing any foot wears. Walking barefoot was, therefore the norm of the society. I learnt to wear flip-flops only after I joined the school at Tashigang. I bought my first pair of block-heeled shoes sometime in 1977 after I earned enough money for it working as a labourer during school winter break. I felt myself at the top of the world at the feeling of walking about 3 inches above ground!

Entertainments that amused us and gave us extra dose of happiness were simple things, such as school concert, rice paddy harvesting season, going around playing "Dewshi" during Diwali nights, watching a pair of rooster or bull fighting, watching football matches in the rain etc. We were fortunate to have a small Sony radio which used to sing a variety of Nepali songs for us every day and that was one thing that really amused my. For elders, happiness perhaps was more evident when they grew more crops, when the cattle population grew or when there was birth of new family member! Religious congregations during weekends, where people chanted of religious songs, seemed to make them elated for long.

Things have become different now and I have to be constantly chasing HAPPINESS in this modern era of materialism! I do not seem to be able to catch it though. The salary I earn has to be shared among many of us in the family, not only my own but also my relatives' because I am the first generation of salary earner. I have many more new things to acquire but I always run short of budget. There are number of desires which are unfulfilled and make me NOT HAPPY! For example, I don't have a house to call it mine, keep aside having a building in Thimphu; I simply have a tiny little Alto car when my friends move around in SUVs like Tucson and Prado; I wear mostly Bangladesh made garments and have not been able to afford designer dresses; my meals are as simple as they used to be when I was a village boy except that I may be taking more meat items now; I cannot afford the balanced diet of enough protein, minerals and vitamins, consisting of plenty of vegetables, meat, eggs and fruits, as learnt in Medical school.

There are many reasons for me NOT to be HAPPY! My children are not securing first position in their classes and that makes me unhappy. My neighbour has a better sofa sets, bigger and latest television set, iPad, iPhone and whatnots which I have not been able to buy and that makes me unhappy. The desires are limitless; list of things I want is unlimited.

I am not the only lone citizen of the GNH (Gross National Happiness) country who aspires to be happy. There are many, may be the entire population, who would try to be happy with the DESIRE for innumerable things that have become part of our lives particularly in an urban setting. We have a large number of so called educated youth who are roaming the streets of Thimphu and Phuentsholing after graduating from Middle secondary schools, thanks to the free basic education in our country! Having got the taste of urban life no one likes to go back to the villages where life is tough. The job market is highly competitive and almost saturated. These tenth grade drop-outs have desires like anyone else. But how would they then fulfil those desires without resorting to theft, burglary, mugging, and fraudulence?

We have yet another category of youth that has become difficult now. They are the ones who are onto alcohol and drug abuse. They probably are the ones who come from broken families, or families which are busy trying to earn a living and do not have much time to monitor their children. There are others who are so affluent that they simply keep their children pleased with money but have no TIME for them. These are the ones who frequent the bars and discotheques, creating nuisance at times. In spite of such obvious privileges they enjoy, they seem to be always ANGRY and far from HAPPY!

Buddhism teaches us that "desire is the main cause of suffering" and not desiring will make us HAPPY but who listens to this and who practises it? When everyone else is competing in the rat-race, nobody would sit back and watch others gathering wealth? Given the opportunity everyone would like to be the wealthiest person in the world! But will that wealth bring HAPPINESS to these people, or is HAPPINESS still out of reach even to them? May be, I guess their desires would still be unmet and they may continue to be UNHAPPY!

On retrospect, I would rather prefer to go back in time when I was a village boy contented with the small things that came my way bringing little packages of HAPPINESS now and then!

Happiness in depression

2010-08-05T00:17:00.001-07:00

Bhutan, the land of Gross National Happiness, has been seeing an increasing number of patients with depression, especially from the rural areas. Mental illness, particularly depression, is viewed as a paradoxical mental status for a country which is trying very hard to make the concept of GNH a reality. Being one of the two psychiatrists in Bhutan, I find it really hard to answer questions many visitors ask me about the reason behind increasing number of people suffering from depression. I really do not have any evidence to give an answer right away, however, when I reflect, I cannot help but highlight some factors which might have significant effects on the psyche of our older generation making them stressed and depressed.

We have seen rapid modernization and development over the last four decades. People got exposed to modern ideas, lots of information on health and education was given to them, and many other modern concepts became evident which were unknown until then. Schools were built everywhere. Children of school going ages were encouraged to get enrolled in schools with promise for better future for them. People learnt to take advantage of the family planning services that were extended to every household to cut the family size to a manageable level. “Small family, happy family” was a dream everyone aspired to have! Young parents in the eighties and nineties wanted all their children to go to school. They wanted them to study hard and get government jobs. For those who went to school, there was smooth sailing all the way. While few managed to do graduation, most got educated up to high school level and got into smaller jobs. The more brilliant ones pursued higher education to become professionals, and yet others achieved bigger positions in the civil service. All in all, none of them returned to the villages to live with their parents.

The young parents of those days have become aged now and they are staying back at the villages. Having educated all their children, there is now no one to help the parents in the farming work. The government encourages the villagers to cultivate their land and the “Gup” (village headman) makes sure it is done, at times forcefully. There is no excuse for keeping the land fallow, not even the frail health of the owner. In absence of ready labour force in the form of children and relatives, there is no option for the parents but to toil and toil until they get fully exhausted. To be a farmer in Bhutan, especially where mechanization is unknown, is perhaps the most difficult job than anything else. The day to day work in the field is manual and tiresome.

The global warning is a reality and the impact is obvious. This year alone there were several flash floods and landslides damaging substantial amount of arable lands and crops. Unpredictable weather conditions such as untimely rainfalls, storms, hail storms and drought are other factors that keep a famer always worried. The food grains, product of their hard toil, are never safe until harvested!

To make the matter worse, we have been seeing a number of wild animals increasing over the last few decades; we may call this the adverse affect of conservation of forest and preservation of the environment! People not only have to work hard to grow the crops but have to stay awake in the nights to protect them from wild animals, at times paying with their own lives!

In such a scenario, there is definitely a constant flow of stress hormones, and it is but understandable for a farmer to feel severely stressed. This stress causes a lot of harm to the mind and the physique of a villager. No wonder then, are we, getting more and more depressed people now, even though we would like them to be happy.

There is another factor now in the recent days and that is the rural urban migration, and the educated generation sticking to the urban centres. Life becoming difficult at the villages with all those odds most prefer to earn a living in the cities, even if it is just hand to mouth. They stick to the urban centres, establish a family and then get entangled in the webs of modernization. The salary they earn is limited, and the so called necessities in the towns and cities are many. Every day there is a new thing to be acquired, and the desire for materialist achievements is a never ending! Even if somebody wants to help their parents they become helpless. Few afford to send money to their parents, and most cannot afford to do that too. The attachment with the parents slowly gets distant and the dreams of the parents of a ‘small and happy family” becomes a remote and fading illusion.

Some children who are really concerned about their parents would like them to stay with them in the cities. But for the parents who have always lived in the village, it becomes a great plight to stay in apartments inside big buildings where 12 to 15 families live but never interact! The children seem always busy either trying to make a living, or glued to the television! No one seems to interact much with each other, and the conversations are always brief and precise. The way of life they find in the urban areas is beyond the imagination of a person who has always lived in the village minding his agricultural land and farm. Back home they are used to interact with their neighbours freely, share the common interests among them and help each other in almost every occasion. The building, even though, has as many households and people as in a small village, there is no sense of belongingness. They soon start feeling homesick and prefer to go back to their “home” and live with their dear neighbours where they find more warmth emotionally and feel closer to them than their offspring!

It is, therefore, too much of an expectation for these physically and emotionally fatigued lots to be happy. Philosophy alone will not bring about happiness, and to expect happiness in depression is ridiculous! We need to find out the multiple factors associated with depression and address them effectively if we want to take these rural folks out of the blues!

Women and depression:

2009-11-27T09:09:00.000-08:00

Over the recent times a lot has been happening to boost the status of women in the society. Women now shoulder greater responsibilities and are capable of doing almost anything that men can do. In spite of these social advancements women still remain vulnerable to number of mental illnesses and depression is the most common one. Women mostly present with unexplained physical symptoms, such as tiredness, aches and pains, dizziness, palpitations and sleep problems.

The common symptoms of depression are Persistent sad or low mood, Loss of interest or pleasure in usual activities, including sex, Restlessness, irritability, or excessive crying, Feelings of guilt, worthlessness, helplessness, hopelessness, pessimism, Sleeping too much or too little, early morning awakening, Appetite and/or weight loss or overeating and weight gain, Decreased energy, fatigue, feeling "slowed down", Thoughts of death or suicide, or suicide attempts, Difficulty concentrating, remembering, or making decisions, However, not everyone with depression experiences all of these symptoms, and the severity of the symptoms may vary from person to person. In order to consider depression as a disorder, the symptoms must persist for more than two weeks and should interfere with one’s work or family life.

Major depression and dysthymia (chronic depressed mood) affect twice as many women as men. This two-to-one ratio exists regardless of racial and ethnic background or economic status. Many factors unique to women are suspected to play a role in developing depression. These can be reproductive, hormonal, genetic or other biological factors. Abuse and oppression due to gender biases and certain psychological and personality characteristics are also some other factors. However, it has not been possible to pinpoint any the specific cause for depression as many women exposed to these stress factors do not develop depression.

Scientific studies done in many other countries show that higher incidence of depression in females begins in adolescence. This is due to the fact that roles and expectations change dramatically during adolescence. Other stresses of adolescence include forming an identity, confronting sexuality, separating from parents, and making decisions for the first time, along with other physical, intellectual, and hormonal changes. These stresses are generally different for boys and girls, and may be associated more often with depression in females. It is also suggested that men and women differ in their expression of emotional problems. While men choose to self medicate by taking alcohol or drugs, women tend to express these through emotion, thus becoming depressed.

Adulthood has its own share of stresses for women. These are major responsibilities at home and work, single parenthood, and caring for children and aging parents. Even in a married relationship women carry a greater share of child care and household responsibilities. Role conflict sometimes becomes an issue too. Women at times need to choose between family and work responsibilities, often having difficulty in deciding about which choice is the "proper" one!

Unlike men, women go through many reproductive events. Menstrual cycle, pregnancy, the post pregnancy period, infertility, menopause, and sometimes, the decision not to have children are various reproductive events they go through. All of these events can bring fluctuations in mood which can include depression in some women. Although the specific biological mechanism explaining hormonal involvement in depression is not known many researchers have confirmed that hormones have as effect on the brain chemistry leading to changes in emotions and mood. Because of this many women experience certain behavioral and physical changes associated with phases of their menstrual cycles. In some women, these changes are severe, occur regularly, and include depressed feelings, irritability, and other emotional and physical changes called premenstrual syndrome. During the post delivery period women are more likely to suffer from depression. Postpartum depressions can range from transient "blues" following childbirth to severe, incapacitating, psychotic depressions.

Pregnancy, if desired, does not lead to depression and having an abortion does not appear to lead to a higher incidence of depression either. However, women with infertility problems may be subject to extreme anxiety or sadness, most of the time aggravated by cultural beliefs where infertility is considered ominous. Teenage pregnancy or young motherhood is also a risk for depression due to the increased stress. Housewives who depend on their husbands for financial needs can become uncertain especially when they have abusive husbands. Frequent domestic violence and apathetic attitude of parents and siblings towards married daughters or siblings can lead to helplessness and hopelessness.

Untreated depression can lead to suicide but even severe depression can be highly responsive to treatment. Of course, believing one's condition as "incurable" is often part of the hopelessness that accompanies serious depression. Indeed, treatment is not to eliminate life’s inevitable stresses and ups and downs but to enhance the ability to manage such challenges and lead to greater enjoyment in life.

Silence behind domestic violence

2009-11-27T09:08:00.000-08:00

Domestic violence is also known as domestic abuse, spousal abuse, child abuse or intimate partner violence. It can be broadly defined as a pattern of abusive behaviours by one or both partners in an intimate relationship such as marriage, dating, family, friends or cohabitation.

The commonest form of domestic violence seen in Bhutan is spousal abuse, particularly, violence against the wife by her husband. In the recent times we have been seeing an increasing number of such cases. Many women visit the forensic unit and the psychiatric OPD of JDW NR Hospital for various problems which include physical injuries and mental trauma.

The Royal Government of Bhutan has been doing a lot lately to elevate the status of women in the society and alleviate their sufferings. There are now a number of agencies taking care of the needs of the women. The National Commission for Women and Children, RENEW (Respect, Educate, Nurture and Empower Women), and the Child and Women protection unit of the Royal Bhutan Police are such organizations.

In absence of a scientific study, it becomes difficult to pinpoint one single cause for spousal abuse in Bhutan; however, it is not so difficult to guess some of the possible causes. Alcohol seems to be the most important cause followed closely by gambling. The other causes would be personality mismatch, jealousy, financial dependence of a woman on her husband, emotional factors, helpless situation etc.

Alcohol is not only the main culprit by itself, it is also an indirect cause for other mental illnesses leading to more abuse and violence. Most common form of mental disorder in alcoholics is morbid jealousy, also known as pathological jealousy or “Othello syndrome”. Persons suffering from this condition can have unshakable belief that their partners are unfaithful; it can be so severe that the sufferer may even kill the spouse for this.

Even though we have so many organizations to protect these victims of abuse and violence, why are not all coming out to seek help? Although it is appropriate to find the cause for domestic violence, it is also equally important to find out the reasons for their helplessness. What could be the reasons for them to be so secretive? Why do they prefer to hide and weep behind closed doors?

While I may be wrong, I feel these are some of the reasons for the silence behind the domestic violence:

1. Financial dependence:
Due to disparity in education in the past more males are employed in Bhutan than women, thus women are more dependent financially on their husbands. Financial dependency makes women vulnerable to feel obliged to their husbands. Men take advantage of this situation and victimize their wives to comply with their wishes, be it unreasonable and unjustified.

2. Social customs:
In some ethnicity, especially in a patriarchal society, the girls once married belong to the in-laws. They will have nothing to do with their own parents and siblings except for some emotional attachment. In Hindu society, for example, the daughter becomes the “property” of the in-laws. The girl will relinquish her “clan name” to adopt the one from her husband. Such customs can make the women highly susceptible for abuse and violence. Even when the relatives know that their daughter or sister is abused they hardly offer help to mitigate the problem. She is not even welcomed to her parental home when she is thrown out by her husband thus making her helpless and hopeless.

3. Emotional factors:
Women tend to be more emotionally attached to their children because of which they would not mind to continue the relationship for the sake of their children even though there is constant oppression from the husbands. Many women take the role of protector for their children from the abusive husbands, in the process suffering more and more.

In contrary to the general notion that Bhutanese women have equal status and rights as their male counterparts, they are more dependent on their husbands for almost everything. That is why most women suffer silently without even mentioning about the abuse and violence to anyone, not even to their treating doctor. Some women even go to the extent of concealing the real cause of their physical injuries with which they come for treatment. Even though they may be going through severe mental depression, they will rather complain about physical symptoms, such as aches and pains, chronic headaches and insomnia.

Unless we take care of the factors leading to the “silence” women will continue to suffer quietly within the four walls of their houses. They will continue to be the victims of violence and abuse. If we don’t protect our daughters, sisters and our women relatives from their abusive partners, we will never be able to empower them!

Experiment with tobacco

2009-08-17T23:29:00.000-07:00

Experiment with tobacco

It was in 1970, I was 9 years old and was studying in class II, my father wanted me to attend a private school some 2 hours’ walk from our village at Diklai. We usually got about two months summer holidays and my father wanted me to take extra lessons to be able to top the class. To reach Diklai we had to cross a river which had a huge log of timber laid across it for a bridge. The children from this village had difficulty in attending the only village school which was situated at Dalim, about 3 hours walk. Probably that was the reason for setting up of that private school. The school was a mere shabby shed of thatch roof with bamboo mats as walls, large enough to accommodate around 30 children. There were no rooms for different classes so everyone attended the same class, a multi-grade style. There was just one teacher who may not have had any qualification beyond the sixth standard. Whatever it was, I had to attend that school along with a cousin brother Chakra Bahadur Thapa.

During one of the classes at Diklai, I saw a student of my age taking khaini (chewing tobacco). I knew for sure it was tobacco but I could not imagine a boy of nine taking it regularly. I had seen my father taking khaini but he was an adult and probably it was right for him to indulge in that habit; but a boy doing that was unimaginable!

I had seen how my father used to procure his quota of khaini. He used to buy long leaves of dry tobacco from Assam and it was processed manually into palatable ‘khaini’. I had almost mastered the art of processing it, for I had assisted my father on many occasions. The leaves were chopped finely, some lime (calcium carbonate) was added and it was rubbed vigorously between the palms, occasionally sprinkling water onto it. When done, it used to be packed in an air tight long cylindrical container with a sallower compartment on the other end for some extra lime. On numerous occasions I had helped him process the ‘khaini’ but it never occurred to me that I should try. To me, tobacco chewing was the privilege only the adults were entitled to.

However, when this classmate of mine took it so casually I got interested too. I asked him why he was taking it and he said that it gave him some sort of pleasurable sensation. He also asked me if I wanted to try. At first I hesitated but later I thought, why not? We were sitting right at the back of the class and the teacher was quite unaware of what was going at the back. That boy took out a small polythene pouch from his shorts’ pocket gave me a pinch of tobacco from it on my palm. I had seen my father holding the tobacco between the forefinger and the thumb, and almost imitating him in my imagination, I did the same thing. I took the entire amount between my forefinger and thumb of the right hand, with the left hand I parted my lower lip from the gums and made a receptacle to hold the tobacco and carefully placed it there. As directed, I was to keep the tobacco there until all the ‘juices’ got extracted. Slowly I could feel the bitter and strong taste of tobacco flooding the floor of my mouth. I had the urge to spit but I had to experience the pleasure and I was not supposed to spit out. I swallowed about ten millilitre of oral secretion dressed with tobacco juice with utmost difficulty. The next swig was not so bad but within no time I started experiencing some strange feelings. My head started reeling, I was feeling tremulous and my limbs became listless. I was nauseated and would vomit any moment. I wanted to get up but my feet were too weak by then. I took the help of my hands and with great effort stood up, swaying back and forth. I gathered courage to request the teacher to go out. I said I was feeling unwell. I barely managed to reach a spot just out of earshot for other to hear me retching, and brought out everything! The khaini came first followed by the rice and buttermilk I had for breakfast and then the gastric juices; when nothing was left inside, the bitter bile came out! I was totally exhausted but slowly I started feeling better in the sense that my head was stable, the tremulousness had gone by then and I regained the strength in my limbs. That was almost near death experience to me!

TEENAGE PREGNANCY

2009-06-28T06:13:00.000-07:00

We hear of considerable number of school girls getting pregnant and leaving their studies. Number of abandoned infants were found in Thimphu, some alive and others dead. These all point to one thing, unwarranted teenage pregnancy, a consequence of human sexuality. This article is, thus, intended to highlight issues of teenage pregnancy so that the psychology of adolescent sexuality and its consequences are understood in a better perspective.
Teenage is defined as the period from thirteen to nineteen years of age. Teenager or teen is a person whose age in this age group. The word is of recent origin, only having appeared in the mid 20th century. Equivalent words in other languages may apply to a larger age bracket, including (at least some) preteens; e.g. tiener in Dutch officially from 12, colloquially from 10. Teenager can be divided into two groups: Early Teens- Age 13-15 and Late Teens- Age 16-19. Teenage pregnancy is, therefore, the pregnancy that occurs in girls under the age of 20.
The problem of teenage pregnancy is considerably worse in the United States than in almost any other developed country. Among developed countries, the United States has one of the highest birth rates for women under 20. A detailed study comparing Canada, England and Wales, France, The Netherlands, Sweden, and the United States suggested that the problem of teen pregnancy in the United States may be related to less sex education in schools and lower availability of birth control services and supplies to adolescents. We have no such survey to substantiate the claim that teenage pregnancy is a problem in our country. Nevertheless, from whatever interaction I had with School Health in-charges during workshops, the problem exists and is likely to increase over the period of time.

In the recent times two important trends concerning adolescent sexuality have been observed. First, that the sexual intercourse among teenagers in increasing quite rapidly, particularly since 1970s. Second, the increase is more pronounced for girls than boys. Why is this happening? The most obvious answer is a gradual reversal of the sexual double standard. Historically, boys were freer to engage in sexual intercourse. Over the past thirty years teenage girls have become much more sexually active. Many teenagers do not plan to have intercourse. Often they feel that sex is something that happened to them, not something they chose to do. Probably this is the reason shy a sizable percentage of teenagers have negative feelings about sexual experiences, particularly the first one. It is reported that only 25% of the girls ever report feeling excited about their first act of intercourse, whereas nearly 50% of the boys report being excited; sixty three percent of the girls were actually afraid in contrast to only 17% of the boys reporting the same feeling.

For most teenagers one of the unintended consequences of sexual intercourse is the risk of pregnancy. Teenagers become pregnant following sexual intercourse with other teenagers or with adults. Thousands of adolescent girls face the difficult choice of terminating their pregnancies or giving birth with little in the way of emotional or financial support. For teens who give birth, there is a rough road ahead. Teenage mothers are more likely to leave school early and to experience difficulty finding adequate employment than women of similar backgrounds who delay childbirth. Often facing parenthood before they are emotionally ready and without the support of a spouse, these young mothers are also likely to encounter problems in early parent-child relationships. Moreover, many have to face prejudice and stigma from the hostile communities, and sometimes even from their unreasonable parents, which can hurt their morale severely. However, researchers have found that certain degree of resilience develops among teenage mothers and this is a plus point for later in life many show the capacity to recover both emotionally and economically.

At first glance, the frequency of teenage pregnancy is perplexing when contraceptives are so readily available these days. Why do, then, the adolescent boys and girls, fail to use them? The reason is, teenagers are sometimes remarkably unaware of how conception occurs. Many simply do not understand that pregnancy is related to sexual intercourse and a woman’s menstrual cycle. Research has shown that in societies that provide adequate information and access to contraceptive devices, the abortion rates are much lower.

When adolescent lack information, they tend to engage in sexual practices that can lead directly to pregnancy. They may practice birth control infrequently or not at all, or seek counsel of peers, who often provide incorrect information. Parents can offer much more reliable information about pregnancy, but unfortunately most parents in our society do not consider this necessary. We are a shy society and therefore treat talking sex as a taboo. Even the enlightened stratum of our society most parents do not share this information adequately. Therefore, most adolescents do not learn about sex from their parents but turn to peers, who are equally ignorant.

Unprotected sex has always involved the risk of pregnancy, but we now know that it can also lead to diseases like AIDS and hepatitis B and C, all of them do not have a cure. In spite of so much information is available in the internet and from various health sources, adolescents have shown few signs of practicing “safe sex” on a large scale. Unfortunately, we sadly foresee that these deadly diseases will become ever greater threat as today’s adolescent become young adults. Sound education about adolescent sexuality may be the best hope for effective solution.

UNDERSTANDING ADOLESCENTS

2009-06-28T06:07:00.000-07:00

Adolescence is the period of psychological and social transition between childhood and adulthood. The World Health Organization (WHO) defines adolescence as the period of life between 10 and 19 years of age. In contrast, in the United States, adolescence generally begins at age 13, and ends at 20. "Adolescence" is a cultural and social phenomenon and therefore its endpoints are not easily tied to physical milestones. The word derives from the Latin verb adolescere meaning "to grow up." The ages of adolescence vary by culture. As a transitional stage of human development it represents the period of time during which a juvenile matures into adulthood.

Adolescence is not a universal state. Rather, it is as invention of modern societies that emphasize a transition between the carefree childhood years and the more complex responsibilities of adulthood. Most cultures regard people as becoming adults at various ages of the teenage years. For example, Jewish tradition considers males to be adult members of the community at age 13 and females at age 12, and this transition is celebrated in the Bat Mitzvah for girls and the Bar Mitzvah for boys. Young Catholics have the sacrament of confirmation and then are full members of the community. Usually, there is a formal age of majority when adolescents formally become adults. For example, Japan's celebration of this is called seijin shiki ("Adult ceremony"). However, in a traditional society like ours, adolescence is hardly a distinct period in person’s life. As soon as a child grows up to be able to do certain chores that most adults do, he is considered an adult. Some youngsters start taking all the responsibilities of a grownup as soon as they step into the teenage. Issue of adolescence is thus more applicable to the educated and the modern society.

Adolescence is characterized by profound biological, psychological and social developmental changes. The biological onset of adolescence is signalled by rapid speeding up of skeletal growth and the beginnings of physical sexual development. The psychological onset is characterized by acceleration of cognitive development and consolidation of personality formation. Socially adolescence is a period of intensified preparation for the coming role of young adulthood. It is a time of adjusting to the bodily changes, of new relationship with members of the opposite sex, and of emerging intellectual powers.

By virtue of schooling and disposition, adolescents often find themselves pondering and debating major social and political issues. Many find that adolescent years as a time of confusion and despair. They can have conflicts with parents, anxiety about scholastic performance, and pressure for peer recognition. However, not all encounter serious problems in personal adjustment, nor do they hold sharply negative attitudes towards their parents.

The conflicting opinions may result from the different ways that adolescents respond to the teenage years. Some react by challenging and testing authority, whereas others adjust relatively easily. Should there be a legal drinking age? Is premarital sex wrong? Adolescents debate these issues with great passion and a probing intellect. Risk-taking behaviour is very common at this age. It can involve alcohol, tobacco, and other substance use. Promiscuous sexual activity, which is especially dangerous in view of the risk of acquired immune deficiency syndrome (AIDS), and accident-prone fast driving are common.

What would prompt the adolescents to behave this way? One reason is that risk taking seems to be natural component of the teenage years. Adolescents often maintain an unrealistic sense of their own vulnerability. They believe that little enduring harm will come their way. Death and disability are things for the older people to worry about. Even more curious, however, is the tendency of the adolescents to assess incorrectly the likelihood that misfortune will befall on them. For example, they at times erroneously conclude that risks such as pregnancy following unprotected intercourse, or addiction from drug abuse are less likely to occur. Adolescents do not lack the logical abilities, but despite that, they often act irrationally, even to the point of endangering their own lives. Personal needs sometimes cloud the judgement of adolescents and lead them to engage in extremely risky actions.

At the beginning of adolescence, thinking usually becomes abstract, conceptual, and future oriented. Many adolescents show remarkable creativity, which they express in writing, music, art, and poetry. Creativity is also expressed in sports and in adolescents’ interests in the world of ideas, humanitarian issues, morals, ethics and religion. A major task of adolescence is to achieve a secure sense of self. Identity diffusion is a failure to develop a cohesive self or self awareness. Adolescent identity crisis is partly resolved by the move from dependency to independence.

Understanding adolescents is a difficult task. “No, I can do it myself. Don’t tell me how long my hair should be. Don’t tell me what to wear”. This negativism is a renewed attempt to tell parents and the world that young persons have minds of their own. Negativism becomes an active, verbal way of expressing anger; adolescents may seize almost any issue to express their independence. However, most teenage can negotiate the demands of school and family life with little disruption. Therefore, serious mood and behaviour disturbances during adolescence should be considered potential symptoms of mental illness and be investigated.

The school experience accelerates and intensifies separation from the family. More and more adolescents live in a world unfamiliar to their parents. Home becomes just a base; the real world is the school and the most important relationships, besides the adolescents’ family, are with persons of similar ages and interests. Adolescents attempt to establish a personal identity separate from their parents but close enough to the family structure to be included. Although adolescents tend to depend on peers for day-to-day support, the social support provided by the parents has a stress-buffering effect in emergency situations. Adolescents often view themselves through the eyes of their peers, and any deviation in appearance, dress code, or behaviour can result in diminished self-esteem. Parents must be aware of the sudden, frequent changes in friendships, personal appearance, and interests but must not show the authority to change that.

Parents of adolescents have their own problems. In addition to having to deal with the turmoil that accompanies the adolescent development, parents of adolescents are usually middle aged and must also make adjustment to work, to marriage, and to their own parents. Many difficulties surround adolescents’ need to assume increased independence from home, a move that can be threatening to parents who cannot let go and who want to maintain control of their children. Some parents may be unable to set limits of behaviour; others act out their hidden or unconscious fantasies through the lives of their children.

In spite of these possibilities, parents of adolescents report few major altercations and get along with their children. For most part, adolescents are receptive to parental approval and disapproval, and most adolescents and their parents can bridge the generation gap successfully. When they do not, the failure may arise from mental disorders in children, parents or both. Mental disorders are often associated with delinquent behaviour, rebelliousness, and academic failure – all of which may contribute to family disharmony.

Doctor-patient relationship:

2009-06-04T08:02:00.000-07:00

Can you hear the tension in this encounter? Why are doctors and patients so often at odds? Why are both expressing more frustration and less satisfaction? This is what research has to say about doctor-patient relationship:

If you’re wondering why so many hospital visits turn into a tug of war, it’s partly because doctors and patients are on different ends of the rope.

• To the doctor, illness is a disease process that can be measured and understood through laboratory tests and clinical observations. To the patient, illness is a disrupted life.

• The doctor’s focus is more on keeping up with the rapid advances in medical science than on trying to understand the patient’s feelings and concerns. Yet patient satisfaction comes primarily from a sense of being heard and understood.

• Many doctors do not see the role of physician as listener, but instead view their function more as a human car mechanic: Find it and fix it. Yet patients often feel devalued when their illness is reduced to mechanical process.

• Doctors feel frustrated, even betrayed, when patients withhold pertinent information. Yet patients who use alternative medicine, for example, may not tell their doctors for fear of ridicule or being labeled as flaky or gullible.

Patients aren’t perfect either.

Some patients described as “frustrating” by doctors:
• Do not trust or agree with the doctor.
• Present too many problems for one visit.
• Do not follow instructions.
• Are demanding or controlling.

It has been observed that:

• Patients who use the doctor as a scapegoat for their anger at the illness are less likely to get good care

• A patient who is consistently rude and irritable will almost certainly not receive the same medical care as a patient who conveys more positive attitudes.

What must the doctor do to improve the relationship?

• Doctors must cultivate a patient-centered partnership. The patient desires to be known as a human being, not merely to be recognized as the outer wrappings for a disease.

• To improve patient compliance, work on mutual trust.

• Research confirms that the health of the doctor-patient relationship is the best predictor of whether the patient will follow the doctor’s instructions and advice.

• Respect patients as experts in the experience of illness.

What must the patients do?

• Be willing to demonstrate the attitudes that you want from your doctor. For example, if you would like more give and take in the relationship, demonstrate your own flexibility by offering to negotiate and make concessions. Patients can be a powerful agent for change of a physician’s behavior.

• While medical science has limits, hope does not. If a patient is ready to be helped, even a little, and grateful for the marginal, it enhances the doctor’s commitment to fostering a relationship between equals. Only such a relationship, bonded by understanding and respect, can deepen into a true healing partnership.

• Accept realistic treatment goals. Many chronic diseases can be managed, but not cured. In this age of hype, patients have come to expect the impossible; Doctors frequently grope in the dark, not because they are delinquent in learning, but because the science is not there. But even when a cure is impossible, healing may be possible

In spite of all these problems, there is reason for hope. Yes, doctors and patients will always be on opposite ends of the healthcare system, but that doesn’t mean they can’t pull in the same direction

Psychiatry: not just a “short question”!

2009-05-29T09:02:00.000-07:00

Twenty years ago when I joined Medical College it was beyond my imagination that patients suffering from mental disorders could be treated. By the time I reached my final year at the college we learnt a few things on mental illnesses but we actually had to prepare for one “short question” for the medicine examination. Many medicos didn’t bother to learn the subject for it really didn’t matter whether one was able to answer the “short question”. Thus when I came out as a doctor I had very little knowledge on mental illnesses and almost no skill to treat people from suffering from it. I had to work in the districts of Bhutan, all alone, managing patients suffering varied conditions from common cold to cancer! However, I didn’t come across many people suffering from mental disorders. The only mental condition I ever treated was hysterical conversion disorder the female students of High School used suffer from. I believed fully on the theory of Sigmund Freud and didn’t think it was really necessary for us to delve into their problems very much, thus the treatment used to be crude and rough!

The violent “psychotics” always scared me and I dared not get closer than ten metres from them. It didn’t occur to me that they required medical help and I thought police was the right people to “take care” of them. Moreover, this type of patients was very rare in the districts though Thimphu had quite a few psychotics roaming the street. They dwelled on the pavements and lived on whatever few compassionate Bhutanese offered them. Barring these, I didn’t ever imagine that people in Bhutan could suffer from conditions like depression and anxiety, and how could anyone suffer from mental stress anyway?

Taking alcohol and smoking marijuana, I thought was not an issue at all. Alcohol is a socially acceptable drink and very few oldies used to smoke marijuana earlier, therefore, these could never be problem as far as I was concerned.

Having worked mostly in the district I didn’t think of any other speciality than Public health for my post graduate studies. I was so engrossed in immunization, mother and child health, water and sanitation, etc., that “psychiatry” was never in my agenda. In 1999 Dr. Chencho Dorji came back from Srilanka qualifying as the first psychiatrist. By 2001 he had conducted training workshops for all the District Medical Officers so that we could roughly diagnose the common mental disorders. This was the first time I was ever exposed to real psychiatry. I, sort of, started liking the subject. When he was looking for someone to send for post graduation in psychiatry, I readily accepted.

Now I am here in Jigme Dorji Wangchuck National referral hospital as the second psychiatrist of the country. I find things quite different today. Daily I see around 7 to 8 patients suffering from different mental problems. There are patients suffering from conditions like anxiety, depression, mood disorder, psychosis, somatization disorders etc. Significant numbers of school children are stressed today. Possibly they have to study many of subjects and there is a tough competition every where. There are youngsters who are unemployed and frustrated, a lot of them hooked to drugs. Many of them abuse alcohol too and they are having considerable psychological problems.

Alcohol, which was considered a social drink, is taking its own toll. Many civil servants have become alcoholics and many are suffering from cirrhosis of liver. The small psychiatric ward in our hospital is already over burdened with alcoholics who require detoxification and management of withdrawal symptoms. Alcohol has become a social scourge now and it requires a strong commitment from Public Health to deal with it.

I found out that the psychotics who used to be handled by the police are in fact more docile than the sane people. They actually needed a lot of care and social support. However, there is always delay in starting treatment for them. They are subjected to various other modalities of treatment from rituals to faith healing before they are brought for psychiatric consultation. Similarly, cases of domestic violence, which used to be ignored in the past, are surfacing now. Many depressed patients seem to somatize their problems and move from one physician to another looking for a cure from the wrong hands. They suffer many years of pain before they reach the right place. Psychiatric disorders still bear a stigma; therefore, many people decide to defer consultation till very late. They even despise the doctors who refer them to a psychiatrist.

Now I realize that psychiatry is not just a ‘short question’ in the medical examination but a very important speciality today. In this ever competitive era more and more people are likely to suffer from psychological stress and the role of psychiatrist will become increasingly crucial.

Un-civic right

2009-05-29T08:55:00.000-07:00

“Pristine Himalayan Kingdom”, “the last Shangri-La on earth”, and one of the “most exotic tourist destinations on the globe” are some of the names we have acquired over a period of time for our beautiful country, Bhutan.

With over sixty five percent of virgin forest, small well planned population and a well reputed governance Bhutan indeed is a place of envy for many. We have now even got a new name, the land of “Gross National Happiness”.

Having born on the same year when planned development activities started in Bhutan, I have been the product of the development itself. I grew up from a village boy to become a psychiatrist of the National Referral hospital. During my growing stage I also witnessed the rapid development of our country.

From a small village of wooden shingle-roofed shanty village Thimphu has now become a concrete jungle. With a population of one hundred thousand and numerous cars, Thimphu has transformed into a real metropolis.

When development is so rapid, we sometimes fail to really catch up with all aspects of development. One such aspect is CIVIC sense. In spite of modernization of infrastructures, rapid urbanization and education we have not progressed when it comes to changing our old habits. We are stuck to our old habits when it comes to civic sense. Even though we now live in cities we still carry on with our old village habits.

There are numerous examples of lack of civic sense in our society. It would be alright, for example, to spit ‘doma’ anywhere in the village as most of the places are barren ground but the same thing would look ghastly if done on concrete building walls. Because of our failure in adaptation to the new setting we still spit every where including the nooks of the hospital corridors.

Littering is another serious problem; we do not think twice before throwing garbage. We throw it any where and everywhere. In spite of numerous garbage bins posted at different places in the city there are hardly anyone using them. We ride nice grand “Prados” but we still throw our left-over out of the widows, be it on a freshly swept Norzin Lam! We don’t seem to require toilets to relieve ourselves either, for we still think buildings are there in lieu of bushes to do that! Besides we don’t even have the threats of the wild animals that we had back in the villages, nor do we have to worry about the leeches.

In spite of the most modern communication facilities like cell phones and internet we still prefer to “shout” when we need to call someone in distant. So much so, we also use the car horn to call someone by honking even at the oddest hour of the night. We don’t care even if it disturbs the whole locality. For our convenience no one really seems to bother us in these matters. We are free to do what we want when it comes to un-civic things; even the police don’t seem be concerned at all! No one dares point a finger if you are seen peeing by the wall at the hospital entrance; after all “it is no one’s business to disturb you”!

Being Buddhist we seem to be compassionate even to those people who dirty the public places. We have an easy way out, we simply say, “If government doesn’t bother, why I should?” We fail to acknowledge the fact that we are part of the government. I have never seen anyone telling anything to any person dirtying the town. I have not even seen the so called “sanitary inspectors” doing their job. Is it because we don’t have the right to right the wrong but only have the right to do everything wrong when it comes to un-civic things?

Toilet revolution

2009-05-12T05:39:00.000-07:00

The Toilet Revolution

An article on “toilets” may seem a little weird but to think of it, toilets are actually important parts our lives. Having worked as a primary health care professional for over a decade I had the opportunity to witness the slow but obvious “toilet revolution” that took place over the years. Besides, Bhutan’s the primary health care services have been applauded by the World Health Organization for its successful implementation of water and sanitation programme among many others. Toilets have become even more important today than ever before, especially so after the World Toilet Organization was established in 2001. This article is just a reminiscence of my own experience of graduating from the open field defecation to using the modern toilets.

Way back in the early sixties, when I was a child we didn’t have a toilet in our house. In most villages we do not have toilets inside the houses even today, but at least we have sanitary latrines almost in every household. In those days when we didn’t have the concept of toilets, we had to relieve ourselves on top of boulders, under trees or inside the bushes. My earliest recollection of a “toilet” (if I can call it), was of a relatively flat stone located some fifty feet away from our house which could accommodate at least three of us siblings at once. This stone was positioned in such a way that the faeces would fall directly from the edge to the slope below. At times a group of siblings would sit together gossiping and relieving ourselves. In fact we would enjoy defecating together rather than ‘solos’. Open defecation would be a problem only when it rained, firstly we would get soaked in the rain, and secondly we would fall prey to blood sucking leeches. Other problem was the stray mongrels which would appear behind us without warning to devour the fresh excreta, at times even offering to clean us up! It was not only children who defecated this way but even the adults would disappear inside thick bushes with pot full of water to relieve themselves.

Cleaning used to be done with either a piece of stone or a stick. My own choice was the leaves of wormwood shrubs which used to be available aplenty. Using leaves was not always safe either for at times they would harbour the leeches which would get stuck at odd places! Further, we needed experience to find the right kind of plants for one could land up using stinging nettle or other irritant species of plants with terrible consequences. Even though our parents seem to use water for cleaning themselves they somehow didn’t think it was important to teach us the technique. It took us a while to teach ourselves to use water for cleaning

I graduated to a slightly different type of toilet when I had to stay with one of my teachers in the village school. The teacher with whom I stayed was an Indian gentleman from Assam and he had made a makeshift type of toilet with shallow pit curtained with old gunny sacks. I also learnt that I had to carry a bottle of water to clean myself after defecation. A few of the villagers later copied this type of toilet, and we also had one near our house later. “Gunny sack toilets” remained in vogue for some times to come. At least, this was the type of latrine we had in our village until much later.

I came across a different type of toilet when I went to Trashigang in 1973 for my higher education. Most houses had pigs kept in the ground floors of their houses and there used to be a balcony type of projection for toilet right above where the pigs used to be. We later named this type of latrine as “hanging toilets”. The faeces would drop straight down for the pigs to feed on. I wonder whether that was an innovative way of recycling food that was so scarce in that part of the country! On the contrary, because of that unhealthy practice, life cycle of tape worms was highly successful in infesting and making us anaemic. The gunny sack toilets had not reached the villages of Trashigang. Cleaning with water was virtually unknown even among the adults, and the most commonly used materials were stones, sticks and waste papers.

Trashigang School, however, had proper sanitary latrines with wash basins and running water. In spite of that most of us seemed to lack proper education on sanitation. Most of our friends had not been able to wean away from using stick and stones into using water for cleaning. That was apparent from the fact that the toilets used to be blocked most of the time forcing us to revert back to the open fields. I, particularly, have a very vivid picture of the toilet that was right next to our dinning hall which once got so badly chocked that the whole area was flooded and the faeces were floating all around making the entire area awful. I guess sweepers were hard to find in those days thus making maintenance of toilets the most challenging job for the school authorities. Even today we have to import sweepers from Bihar in India. Even though people in the towns were exposed to better toilets by then, the villages remained without proper toilets until many years later.

When I joined the Ministry of Health as a medical doctor in 1989, the sanitation in the villages had hardly changed. In spite of rapid growth of modern houses with attached toilets in the towns and cities, villages were still either at the “open field” or the “hanging toilets” level. Even in towns and cities most of the public toilets remained blocked due to poor maintenance. Most public toilets used to be choked with faeces strewn all around without much space for someone to even squat. People would rather relieve by the roadside than inside the chocked toilets. I still remember the unsightly sight of human excreta along the stretch of road between Wangdue town to the Tencholing gate!

In 1991 when I became a district medical officer I found out that one of the important public health activities in the districts was to improve sanitation. The health workers went around the villages teaching people to make simple pit type latrines to the more sophisticated pour flush types. They also made sure that people used them. There were people who just constructed for the sake of it and stocked their commodities in them. Those who didn’t comply had to be warned of dire consequences, at times giving the threats of administrative actions against them. We had to take the help of the district administrators on our endeavour to achieve cent percent latrine coverage as this had become a very important indicator for public health achievement. We also went around educating people about the bad effect of keeping animals in the ground floor of houses. We urged them to make separate sheds for animals and we told them not to use the old ‘hanging toilets’ which sent stools flying all the way down. Our efforts paid off, and by 2000 we had succeeded in achieving almost 100% latrine coverage.

Looking back, I can see the evolution of toilets from the open fields to gunny sack structures to simple pits to ventilated pits to pour flush to water closet, and the most recent western type of commodes, as a real “toilet revolution”. In spite of such progress, at the end of the day we still find our public toilets unsanitary; they are still clogged with sticks and stones, and we still find faeces scattered on our footpaths even in cities! Somewhere something seems to be amiss! I wonder whether we are slipping back in time! Or have we failed to evolve along with our toilets?

From Discotheques to…?

2009-05-11T09:28:00.000-07:00

From Discotheques to…?

It seems many of us are enthralled by Western culture, and the present generation is too keen to adopt it. Besides fashion, the younger generation also has the tendency to imitate the lifestyle of the youths of the west. Dancing or ‘rocking’ (as it is often referred as) is not only the most preferred pastime or leisure, but has become a way of life among the youth. To meet their demands, the ingenious entrepreneurs have established discotheques almost everywhere. Besides the entertainment part, these are also the places where persons with varied personalities get together. There are healthy young men and women who genuinely visit these places for entertainment, while there are also an equal number of unemployed and disgruntled youths who visit them to drown their sorrows. When alcohol and other abusive substances are so easily available, many of the consumers tend to be under the influence of these substances. Under such circumstances, a person’s mind loses judgment and confrontations happen at slightest of pretexts. People do not even hesitate to commit the most grievous crimes. In the recent times we have already heard of many such instances where crimes have been committed after or during such gatherings. We also hear that these discotheques are dangerous places! People are worried to venture out in the late evenings because certain youths are making the streets hostile.

I am in no way against ‘entertainment’. In fact healthy mixing of young people is desirable and dancing is definitely a healthy habit for the mind. However, the most worrying aspect is the consequences we have encountered recently in the form of spates of crimes. As per the Kuensel report, there were increased number of fights, assault and substance abuse cases occurring at night, and such cases mostly started from a discotheque or a bar. Juvenile delinquency is a serious issue and unless we focus our attention to such trivial thing as discotheque, where actually lies the ‘beginning of misbehaviour,’ we will not be able to contain it. In order to address this issue we have to look at it from different angles.

I am in no way an expert in the field of juvenile criminology but I am just attempting to think a little aloud so that all of us who are concerned about our young children’s behaviour can synchronize our thoughts together and do something useful. Here are some of my loud thoughts; let us make our children less hostile and more responsible citizens of our country.

The government’s recent order which has made it mandatory for all the discotheques to employ private security personnel or ‘bouncer’ and the requirement for the clients to identify themselves prior to entry into the discotheques is a very welcome move. I am sure this is going to be effective in curtailing some of the innate problems of youth targeted businesses

However, all of us as responsible citizens have different roles to play so that we can entertain ourselves safely! The youngsters should refrain from consuming any illegal substance and they should limit the use of alcohol. It is normal for young people to lose temper easily even at slightest of provocation but we should learn to control anger. They should always remember that discotheques are for enjoyment and not for antisocial activities. If they are irritated or extremely annoyed with someone and there is a possibility of that person attending the same party, it is best to stay at home. Many of us tend to be more courageous after consuming alcohol, therefore, we should always remind ourselves that we are after all social animals and not some sort of beasts! There are different ways of settling personal matters with people and discotheques should never be used for such purpose. Defaming these night clubs, which are established for your own entertainment, will eventually lead to their closure and you will be deprived of the pleasure which most desire.

Parents have the important responsibility to shape the future of their children. By turning a blind eye towards the long absences of their children from home will indirectly reinforce their behaviour. To deny any adverse reports about their ward from any quarter is equally detrimental. The youngster should be allowed certain privileges but rationing of time is very important. There is no harm in allowing the youngster to attend discos occasionally, but we should ensure that the youngster returns home safe and sound after these gatherings. Unless we do our duty as parents, there is no use ruing, crying and blaming someone else for their child’s misbehaviour if it results in a crime.

The discotheque owners should remember that theirs is solely entertainment business and not a place to promote illegal substances and promiscuity. They should have the responsibility to make healthy citizens but not junkies and criminals. They should respect the laws of the Kingdom and make necessary arrangements to counter antisocial activities in their places.

Our cities are small and comparatively less number of people lives here. Government can do more; constant policing by the regular police force should be carried out in and around these places. Opening and closing time should be strictly monitored. More strict laws on night activities should be put in place in order to curb all antisocial activities. Police patrolling should be more meticulous and anyone found loitering at odd hours should be apprehended and punished if needed. Our police force is able enough and we have seen its efficiency in carrying out the drive in promoting national dress code. If they do this job with equal jest, I am sure we will be able to live in the ‘Shangrila’ for many more years to come!

The Beginning

2009-05-11T09:09:00.000-07:00

Well, I think there is always a beginning for everything and this is the beginning of my blogging. I don't really have much ideas but I am sure I can leave some footprints which will make me look back at a later date and see how I managed to keep myself occupied.

The basic idea for me is to keep my essays here for all to read and may be give some comments!