Royal Grandmother

My last post was about Dr Aubrey Leatham, a leading pioneer in cardiology and the development of pacemakers. Dr Leatham, along with others, like Dr Albert Craig, had been invited to Bhutan by Her Majesty the Royal Grandmother, Ashi Kesang Choeden Wangchuck, to care for His Majesty the Third King.

Between then and now, Her Majesty the Royal Grandmother has also spearheaded innumerable programs to care for the health of the people. They include, among many others, the introduction of, for the first time in Bhutan, drugs to fight leprosy and tuberculosis.

What’s more, Her Majesty, now in her eighties, continues to work to improve healthcare and alleviate the sufferings of our people. Just last week, Professor Ian Frazer, the scientist credited with developing the HPV vaccine, was in Thimphu at the invitation of Her Majesty.

The human papillomavirus causes cervical cancer, a leading cause of death among Bhutanese women. So Professor Frazer’s work and the HPV vaccine have contributed immensely to improving the quality and length of the lives of our women.

But the vaccines are expensive. They currently sell for US$ 120 per shot in the market, and a full course, consisting of three doses, costs a whopping US$ 360. Luckily, under Her Majesty the Royal Grandmother’s patronage, the Ministry of Health’s extended program of immunization has received US$ 32 million worth of HPV vaccines from the Australian Cervical Cancer Foundation.

The program to prevent cervical cancer began three years ago. That is when girls, throughout the country, started getting the HPV vaccines. The idea is to cover all women … and to put an end to cervical cancer.

For this, and for much more – for introducing modern healthcare in Bhutan, for eradicating leprosy among our people, for controlling tuberculosis – I humbly thank Her Majesty Ashi Kesang Choeden Wangchuck, Royal Grandmother.

Do what’s right

Nothing to sing about

After more than a year of chronic drug shortages, the prime minister has asked the health minister for a report on the problem. I’m surprised. Hospitals throughout the country have been facing a serious shortage of drugs for more than a year. The problem has been widely reported and analyzed by the media. The  opposition party questioned the government during the 7th session of the Parliament. And the National Council questioned the government during the 8th session.

So I’d have thought that the prime minister would be well aware of the problem. I’d have thought that would have discussed it thoroughly in the cabinet, and that he would, in fact, have already decided how to address the problem. It looks like I am wrong. The prime minister still does not seem to understand the extent of the drug shortage problem. That’s why he’s only now asked for a “comprehensive report”.

The pubic, however, has a fairly good idea about the extent of the drug shortage problem. That’s because most people, at one time or the other, and especially the poor, have suffered because of the shortage of drugs in our hospitals. That’s also because the media have done a remarkable job in keeping us informed about the problem. Here, as an example, are links to stories that just one of our newspapers, Kuensel, has published on the issue of drug shortages.

Yes, a heart patient has died. The health ministry has defended itself, claiming that the heart patient had died because of other complications. But her parents insist that she died because she didn’t have medicine. They insist that their daughter died because of the shortage of drugs.

The health minister has not accepted responsibility for the death of the heart patient. But, like it or not, he has to accept responsibility for the overall drug shortage. Like it or not, he has to accept responsibility for the suffering caused to countless patients throughout the country. Like it or not, he has to accept that he is unable to solve the drug shortage problem, a problem that emerged during his watch.

The prime minister should read the health ministry’s report that will, no doubt, blame ACC and RAA and DRA and suppliers and others for the perennial drug shortage. But he should also read what the media has reported, consistently and conscientiously, during the last year. And he should listen to the many stories of suffering that patients have had to endure.

And then he should do what’s right: ask the health minister to step down.

Pound foolish, penny wise

But not literally

Being too cautious with small amounts of money now, could cost you a lot of money later. All of us are familiar with this universal truth. In fact, there’s a well known idiom for it: penny wise, pound foolish.

But what about the opposite? What if you spend a lot of money  now, and end up having to count every penny later? That would be foolish, plain and simple. No idiom is needed, and none exists, to describe such fools.

The government spend more than US$ 10 million to hire McKinsey. That works out to about Nu 500 million.

The government spent more than Nu 500,00 million and, last week, they announced, with pride, that, in 2011, they realized a savings of Nu 370,110 from cement rebates.

I don’t know whether to laugh … or to cry.

Health on drugs

Causing suffering

The Health Ministry has admitted that they have a problem: they have not been able to maintain an adequate supply of drugs to our hospitals. As a result, patients have had to postpone or even forgo medication. And doctors have been forced to direct their patients to private pharmacies, which, many times, have also been frustratingly out of drugs.

Worse still, the Health Ministry has admitted that they still do not know how to resolve the drug shortage issue, a problem that has reached chronic proportions during the past year. So they’ve announced that, as an interim measure, they will send officials to buy drugs directly from manufacturers in Bangladesh.

I suspect that the officials who’ll be going to Bangladesh will be mainly, if not entirely, ministry personnel, most of them from the Drugs, Vaccines and Equipment Division (DVED). If that is so, that could very well be the problem – a central agency unable to keep up with the growing and changing needs of referral hospitals in general, and the Jigme Dorji Wangchuck National Referral Hospital in particular.

DVED is the Health Ministry’s central procurement agency. They buy, stock and distribute drugs and equipment to hospitals throughout the country. That’s a lot of work, work that just gets more complicated as more people use the health system. Between receiving orders for drugs from individual hospitals to supplying them with the drugs is a logistical nightmare that includes compiling and approving orders from the field; tendering and awarding procurement contracts; receiving, verifying and storing drugs; and finally, distributing them to every hospital and clinic, throughout the country. And all that must be done within the framework of the government’s tight financial rules and regulations.

DVED’s centralized operations have served the nation’s health system faithfully till now. But the health system has changed drastically since the establishment of referral hospitals. And DVED would now find that procuring and delivering drugs to the new and growing referral hospitals is an increasingly difficult and complex matter, especially when their main task is still to service all the other hospitals throughout the country.

So it’s time to decentralize procurement, at least for referral hospitals, and definitely for JDWNR hospital. And why would JDWNR hospital be able to do a better job? Incentives.

When drugs run out, hospital staff take the flak. They are the ones who interact with patients every day, and the ones who, as far as patients are concerned, are at fault if hospital services are not adequate. So it is in the interest of hospital staff – nurses, doctors, technicians and administrators – to ensure that drugs, especially essential ones, are always available. Ministry officials, including DVED staff, cannot, and will not, share the same levels of concern.

So decentralize drug procurement. Allow JDWNR hospital to acquire drugs without having to deal with the bureaucracy of the ministry. Otherwise, be prepared to face more serious drug shortages, more frequently.

In fact, decentralize equipment procurement too. And all personnel matters, including training. And finance. And administration. Make the nation’s biggest and fastest growing hospital fully and truly autonomous. That way, hospital staff would feel a sense of control, a sense of ownership, a sense of purpose. And that would drive them to realize their full potential and to achieve their vision.

But the Health Ministry must regulate them. And make them fully accountable. That way, services would improve, drug shortages would drop, and the health sector’s biggest disease – widespread corruption – would finally be contained for proper treatment.

Photo credit: Kuensel

Positive people

Doing their part

Wangda Dorji made history yesterday morning. He revealed that he is HIV positive. And by doing so, he became the first Bhutanese person to publically disclose that he is inflicted with HIV. He made his announcement and shared his painful story with the guests who had gathered to commemorate World AIDS Day.

Later, in the evening, four more people joined Wangda Dorji. Tandin Wangchuk, Pema Dorji, Sithal Chhetri and Tshering Choden, Wangda’s wife, also revealed that they have HIV. They, along with Wangda, who is the executive director of “Lhaksam”, a nonprofit support group for HIV patients, shared their personal stories on live national TV.

They told us about the torment they felt when they found out that they were infected with HIV. They told us about the agony they had to overcome knowing that they had infected others. And they told us about the suffering they have to endure due to the stigma of HIV/AIDS and widespread social discrimination.

They also told us that they had decided to come out in the open to ease the suffering of other HIV patients, and to educate the rest of us on the realities of HIV/AIDS.

The five of them are extraordinary people. They are brave beyond measure. They have suffered more than most of us ever will. And now, by making their identities and their stories publicly known, they risk exposing themselves to even more prejudices and discrimination.

But their courage has already boosted the fight against HIV/AIDS. They have given the disease a human face – a face that tells us that HIV is not a death sentence; a face that assures us that HIV patients are regular people who live full and productive lives; a face that implores us not to needlessly discriminate against those who have HIV.

They’ve done their part. Five positive people have come out in the open and, just like that, they have demystified HIV/AIDS.

The question now is, will we do our part? Will we learn about the disease? Will we join the fight against it? But most of all, will we treat the five of them, and others like them, as normal human beings?

Photo credit: Kuensel

Legalize abortions

Last month I posted a poll asking if abortion should be legalized in our country. Thank you for participating in the poll. And thank you for your views, both for and against legalizing abortion.

55% of you said yes, abortion should be legalized.

38% of you said no, abortion should not be legalized.

And 7% of you said, “I don’t know”.

I don’t know. That, apparently, is the government’s position too – they don’t seem to know.

When asked about abortions, the prime minister reportedly accepted that our laws are “causing certain problems and deaths to mothers.”

He added that, “The debate on the issue will go on, and it would be interesting to see the kind of discourse the media promote.” But that “No initiative will be taken by the government for the time-being.”

What? The government will do nothing? The government will take “no initiative” even though abortions cause “deaths to mothers”?

That is irresponsible.

Be responsible. Take a stand. Do something!

To prevent abortion from causing “problems and deaths to mothers” either make sure to stop abortion completely – through a combination of tough laws, sex education, family planning and contraception. Or make sure to legalize it.

But it’s not possible to put a complete halt to abortions. Just look at how many of us travel across the border to undergo abortions even though we know that they are dangerous and we know that they are illegal. And think about why emergency contraception pills are in such high demand. (A medical shop in Thimphu claims that, when they were allowed to sell emergency contraception pills, the I-Pill was a fast-selling drug, second only to Sinarest).

So legalize abortion. But do so with strict term limits, guidelines and procedures. And to reduce the number of women opting for abortions in the first place, increase sex education, family planning, counseling and contraception use.

Our drinking problem

Not funny

We have a drinking problem.

We reportedly consume 7.5 liters of alcohol per person per year. Much of that is served in the more than 3,000 licensed bars that we have. That works out to one bar for every 250 people. And that does not take into consideration the large-scale production, sale and consumption of home brewed alcohol throughout our country.

That’s why alcohol abuse is a leading cause of non-communicable diseases. That’s why alcohol-related diseases make up a whopping 27% of all hospital inpatients. That’s why they account for a staggering 58% of all inpatient mortality. That’s why alcohol was the top killer in 2010.

We have a drinking problem. And the government realizes it. So in order to discourage the habit, they recently increased taxes on alcohol.

Total taxes on beer produced domestically or imported from India have doubled from 50% to 100%

And total taxes on beer imported from other countries have increased from 150% to 200%

The increases in beer prices will, no doubt, discourage us from drinking beer. But that, ironically, may encourage us to drink more locally produced hard liquor.

Why? Because taxes on the more popular locally produced liquors have not gone up proportionately. In fact, taxes on Special Courier, Black Mountain Whisky and Changta Whisky have not increased at all – not even by 1%. And taxes on Rock Bee Brandy and Sonfy Liquor have only marginally increased by 10% and 15% respectively.

So expect our people to drink less beer, a beverage that generally has less than 6% of alcohol by volume. And expect our people to drink more whisky, brandy and Sonfy all of which typically contain about 40% of alcohol.

We have a drinking problem. And it’s about to get worse.

Thimphu’s lifestyle

In 2007 the Ministry of Health conducted a survey in Thimphu to assess the state of non-communicable diseases in the capital. The results showed that we live dangerously. For example:

  • One out of every five adults consumed tobacco – they either smoked or used smokeless tobacco.
  • One third of the adult population consumed alcohol regularly. One third of them were associated with hazardous drinking and binging.
  • Most adults did not exercise to meet minimum health requirement. More than three-fourths of adults did not get any exercise at all during their free time.
  • Two thirds of the adult population did not eat adequate fruits and vegetables.

The results also showed that our sedentary and indulgent lifestyles were already causing needless suffering. For instance:

  • One out of every ten adults was receiving treatment for hypertension. One fifth of the adult population had raised blood pressure.
  • One tenth of the adult population was either diabetic or suffered immediate risk of developing diabetes.
  • Over half of the adults were overweight.

That was the story back in 2007. I wonder how it would look like today. It’s time for another survey, the results of which will probably force us to take non-communicable diseases seriously.

But some data is already available. The following table, prepared by Dr Gampo Dorji of the Department of Public Health, shows a disturbing trend.

An inconvenient truth

Last week, on the 8th of July, Bhutan Today reported that the Phuentsholing hospital received four post abortion complication cases in just one month. All the abortions had been performed across the border, in Jaigon. All four cases were life-threatening.

This week, on the 14th of July, Kuensel reported that a young woman died in Phuentsholing hospital from post abortion complications. The abortion had been performed on the 11th of July, in Jaigon, just three days after the Bhutan Today article.

Many of our women have lost their lives attempting abortions. Many, many more have suffered life-threatening complications caused by abortions. And countless others have undergone the trauma of abortions in dangerous clinics across our border.

The media have done a remarkable job informing the public about the reality of abortions, especially about abortions that go wrong. But still, the subject is taboo.

We know what’s happening. But we chose to ignore the truth.

This cannot continue. We must talk about it. This conversation will, no doubt, be uncomfortable, even difficult. But for the sake of our women – for the sake of our sisters and our daughters – we must accept what’s going on. And we must look for solutions.

What do you think?

Should we legalize abortion? Or should we explore other solutions? Please give me your views. And please take the poll.

Our health is in our hands

A powerful team

It’s the tourist season. And at mealtimes, tourists across our country – in restaurants and in dining tents – will regard, with some amusement, their guides roll and set aside small balls of rice.

“Bhutanese way of washing hand!” our guides will declare referring to their pre-meal rituals. Some of the tourists will, as always, give it a try, and end up, as always, with streaks of black starch on their hands. The other tourists will laugh. And the guides will attempt to explain how we, Bhutanese, “dry clean” our hands.

This traditional way of “washing” our hands may generate some fun. But it can be very problematic too. The Ministry of Health has identified the common cold and diarrhoea as the top two diseases infecting our people. And both of them spread easily when hands are not washed properly and regularly. Last year, hospitals around the country treated more than 300,000 incidences of the common cold and more than 92,000 incidences of diarrhoea and dysentery. Tragically many children, especially those below five, still succumb to these diseases.

Health experts say that washing hands with soap reduces the incidence of diarrheal diseases by half, and acute respiratory infections by 25%. That’s a huge reduction in needless suffering, one that we could very easily profit from. Just think about it: the simple act of washing our hands with soap – especially before eating or after using the toilet – can improve the quality of our lives immeasurably. It can also prevent many unnecessary premature deaths. But that’s not all: washing hands with soap can also fight the spread of many skin infections, other respiratory diseases,  intestinal worms and numerous other infections.

Yes, we could continue “washing” our hands with rice. But, let’s do so only after we’ve first washed them with soap.

Today, October 15th, is Global Handwashing Day!