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Cardiologist in the Land of the Thunder Dragon: A Medical Mission to Bhutan

2012; Elsevier BV; Volume: 109; Issue: 8 Linguagem: Inglês

10.1016/j.amjcard.2011.12.004

1879-1913

John D. Cantwell,

COVID-19 Clinical Research Studies

In recent years, I have been intrigued by reading about Bhutan (Figure 1) , the Shangri-La Himalayan kingdom wedged between India and China. When an opportunity arose to join the Flying Doctors of America medical mission there, I promptly volunteered, along with my wife, Marilyn. Several things fascinated me about Bhutan. It is the only country in the world where one cannot buy cigarettes (the fourth king decreed that they were bad for one's health). Citizens face a 2-year prison sentence if caught smoking anywhere other than the rare designated areas. The king also banned plastic bags, noting that they were not good for the environment. In 2008, he even did away with an autocratic form of government, installing a parliamentary democracy, turning the figurehead kingship over to his son, Jigme Khesar Namgyel Wangchuck, aged 31 years. The latter attended prep school at the Phillips Academy and college at Wheaton and got his master's degree at Oxford. His favorite sport is basketball, which he plays for an hour multiple times a week. I presented a basketball jersey from Duke University (where I once played) and a signed photo of Duke and Olympic coach Mike Krzyzewski to Tokey Dorji (Figure 2) to pass along to the king as a small wedding gift (he had recently married a pretty 21-year-old “commoner” and was away on his honeymoon). Tokey coached the fifth king in high school and is now secretary general of the Bhutan Basketball Federation, charged with promoting the sport throughout the country. Bhutan is about the size of Switzerland, 200 miles wide and 90 miles north to south, with a population of 60% now. Bhutan is sometimes referred to as an “upside-down country.” The number 13 is considered lucky, for instance. Children sometimes greet visitors by saying, “Bye-bye.” There are more monks than soldiers in the country. Penis paintings adorn many buildings, said to ward off “malicious gossip and evil.” The paintings are rather incongruous in a country so modest that kissing in public is frowned upon. The fourth king had 4 wives, all sisters. Men are required to wear ghos (which are bathrobe-like outfits) during the week. Women wear colorful kiras. Bhutan was first opened to outsiders in 1972. In the late 1980s, a young local farmer saw his first white person, “a sight so terrifying that he'd run for his life.”1Salak K. Trekking Bhutan's higher planes.Adventure Mag. 2008; 10 (95–99): 64-73Google Scholar An airport opened in 1984. The Druk Airways flight into Bhutan, from Bangkok, Thailand, was said to be the scariest in the world, as the landing strip was short, supposedly like a large driveway, and ringed by mountains. We found these descriptions to be highly exaggerated, as our flights were quite pleasant. Our medical campsite was in an underserved region in south central Bhutan (Figure 3) . The serpentine roads to that location posed some concerns, after reading that “driving in Bhutan is not for the meek. Hairpin turns, precipitous drop-offs (no guard rails), and a driver who firmly believes in reincarnation makes for a nerve-racking experience.”2Weimer E. The Geography of Bliss. Hatchette Book Group, New York, New York2009Google Scholar This was not exaggerated. Although our driver was very careful, there was barely room for 2 vehicles to pass during our 2 days of 12-hour drives. A project was under way to widen our road, by setting off dynamite in the inner stone walls and then bringing in bulldozers to push the boulders down the 2,000- to 3,000-foot outer edge. This periodically led to delays of 30 to 60 minutes. Thimphu, at an elevation of 7,600 feet and the world's only capital city without a single traffic light, has a population of 100,000. It can provide culture shock to folks arriving from rural areas, with “the cacophony of dogs barking, horns honking, and jackhammers hammering.”3Pearson S. Cosmic whiplash.Outside Mag. 2006; 31: 108-119Google Scholar In recent times, Bhutan has received a lot of publicity for its emphasis on “gross national happiness” rather than gross national product, the focus of most other countries. Murders are almost unheard of. The devout Buddhist people “have such a strong believe in Karma that robbery is unthinkable.”1Salak K. Trekking Bhutan's higher planes.Adventure Mag. 2008; 10 (95–99): 64-73Google Scholar Their ingredients for happiness include giving, loving, and being content with who you are, things a young man learns along his walk to Thimphu in the movie Travellers and Magicians. One hand-painted sign we observed stated, “When the last tree is cut, when the last river is emptied, when the last fish is caught, only then will man realize that he cannot eat money.”2Weimer E. The Geography of Bliss. Hatchette Book Group, New York, New York2009Google Scholar There is only 1 psychiatrist in the whole country. The main problem he deals with is anxiety, probably related to the evolving cultural changes. The name “Thunder Dragon” relates to a sect of Buddhism. When consecrating a new monastery in the Himalayas in the 12th century, the head monk “heard thunder, which popular belief holds to be the voice of a dragon (druk).”4Brown L. Mayhew B. Arminston S. Whitecross R.W. Bhutan. 3rd ed. Lonely Planet, Melbourne, Australia2007Google Scholar The organization was founded in 1990 by Allen Gathercoal, who has a doctorate in divinity. To date, >7,000 doctors, dentists, physician assistants, nurse practitioners, registered nurses, and pharmacists have provided free medical and dental care to individuals in developing countries. The mission is straightforward: “to provide medical assistance and hope to as many of the poor and needy as we are able to reach we fly medical and dental teams to wherever the needs takes us.”5Gathercoal A. Flying Doctors of America printed material.2011Google Scholar In 2011, in addition to Bhutan, the leader took Flying Doctors of American personnel to Guatemala, Peru, Russia, the Solomon Islands, Cambodia, and Myanmar. Each team member contributes to cover the cost of transportation, lodging, and expenses. Our medical, nursing, and dental team of 17 (Figure 4) gathered at our hotel in Paro to sort and organize the drugs we brought (Figure 5) . After the arduous 2-day drive, averaging only 18 miles per hour, we reached the small town of Yebilaptsa (population 2,000) and set up our campsite on the soccer field of a nearby school (Figure 6) . We worked out of a 20-bed hospital a short walk up the hill. Over the next 3 days, I saw an average of 40 patients per day (Figure 7) . Some walked for as many as 4 days to see an American doctor. Others came by bus or on horseback. Although I was featured as a cardiologist, I saw mainly general internal medical problems, the most common of which was gastritis. The Bhutanese chew betel nuts, eat a lot of chili peppers and spicy foods, and consume tea and alcohol in excess at times.Figure 5Our nurses, Heather and Anne, sorting and organizing our medical samples.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Our campsite in Yebilaptsa.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 7Patients waiting in front of my medical office in Yebilaptsa.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Disrobing the men dressed in ghos and the women in kiras took almost as long as the examinations themselves. Despite the availability of local nurse-translators, history taking was difficult. Marilyn worked in the pharmacy (Figure 8) , helping dispense the medications we brought and some from the local supply. Next door was a room filled with jars of “traditional” herbal products. The most prevalent cardiovascular problem I encountered was hypertension, seen in 19% of my patients. Histories of rheumatic fever were noted in 2% and evidence of postrheumatic valvular heart disease in an additional 3%. One patient had previous electrocardiographically documented short runs of supraventricular premature beats. Another had chronic ventricular trigeminy, without an accompanying cardiac murmur. Chest pain was the main complaint in 6% of patients, only 2 of which possibly reflected angina pectoris. I was asked to consult on an 86-year-old lama (monk), who was paying $3 per day for a private room (general medical care with hospitalization in wards is otherwise free). He had chronic stable heart failure, type 2 diabetes with peripheral neuropathy, and well-controlled hypertension. I noted atrial fibrillation, with rate control on a β blocker and digoxin, and embolic preventive therapy with aspirin, because warfarin and blood monitoring were not available. Several teenage students from the nearby school came to our luncheon at the camp to interview us for a school project. We, in turn, asked each student what he or she hoped to do after school. One, Samnath Gurung (Figure 9) , indicated that he wanted to become a doctor, specifically a cardiologist. I gave him my e-mail address so we could keep in touch. Our most severe case was a 28-year-old man who for several days had noted myalgias of the legs, followed by seemingly mild upper respiratory symptoms. The local doctor in Zhemgang had treated him with decongestants and amoxicillin. Despite this, he rapidly progressed to the acute respiratory distress syndrome. A chest x-ray was obtained (Figure 10) , and our emergency room specialist inserted an endotracheal tube, instituted broad-spectrum antibiotics intravenously, and added vasopressor agents in a valiant attempt to save his life. Transport via ambulance for a 15-hour ride to the 350-bed hospital in Thimphu was attempted, but the patient was too unstable and died shortly thereafter. We subsequently learned that 1 of his roommates had died in a similar scenario 3 weeks previously. Our team requested an autopsy (the first ever done in this little hospital). A medical examiner came from Thimphu, and we sent tissue and blood samples to the Centers for Disease Control and Prevention, to be sure we were not dealing with an impending infectious epidemic. The Centers for Disease Control advised, in the interim, that medical staff members and other close contacts with our patient be covered with our limited supply of oseltamivir and ciprofloxacin. Their special pathogens laboratory did not detect any specific pathogen (such as dengue fever, influenza A, leptospirosis, or Rocky Mountain spotted fever), so the cause of death was not determined. For the last 2 days of clinics, our team migrated 1 hour away to the town of Zhemgang (population 5,000). The 2 young deceased patients were from this city and had ≥3 other roommates whom I evaluated. None had symptoms of leg pain or upper respiratory problems. Our dentists were busy, pulling >300 teeth. They did not have the facilities to do additional dental work, which was sorely needed. Back in Thimphu, several of us visited the hospital, named after the third king, who had it built in the 1960s as part of his modernization program. Sixty-four of the 350 beds are for medical patients, and 6 of the 67 physicians on staff were medically trained. Besides the 1 cardiologist (Figure 11) , who also does renal dialysis, the only other subspecialist was a gastroenterologist. A nephrologist will join the staff in a year. We visited the 12-bed emergency area and the 16-bed intensive care unit. Technicians do 7 to 8 echocardiographic studies daily. Most of the latter reflect postrheumatic and congenital lesions. Patients with suspected pulmonary emboli can undergo computed tomographic angiography, with only 1 confirmed case in the past year. In 2010, the cardiologist saw only 7 patients with myocardial infarction. A functioning treadmill was lacking, as was ambulatory electrocardiographic monitoring. Each medical room consists of 6 beds. Men and women are intermingled if necessary. Cardiologist Yeshey Penjore received 5.5 years of medical school training in northern India, followed by a similar period of cardiologic training in Bangladesh. He gets 30 vacation days per year but is usually too busy to use many of them. He anticipates some future teaching opportunities in the new medical school, sponsored by India and with initial class of 50 students. Dr. Penjore asked me to see a 48-year-old woman who had a prosthetic heart valve and had experienced a cerebellar stroke 1 week earlier. Her international normalized ratio had gotten out of range, and a computed tomographic scan of the head revealed the hemorrhage. Her heart rhythm was regular, and I did not detect a murmur. Our final day was spent hiking up a steep path for 2 hours to the famous Tiger's Nest (Figure 12) . This monastery is 1 of Bhutan's most sacred religious sites, currently housing 4 monks. According to legend, Guru Rinpoche “flew to the site on the back of a tigress to subdue a local demon” in the 8th century.4Brown L. Mayhew B. Arminston S. Whitecross R.W. Bhutan. 3rd ed. Lonely Planet, Melbourne, Australia2007Google Scholar Regarded as the second Buddha, he is credited with introducing the religion to Bhutan. A medical mission to Bhutan was both interesting and enlightening. Although the medical services we provided seemed temporary, our presence did show the people of Bhutan that we care about them. We exchanged information with the few physicians we encountered, and I received an update on the treatment of rheumatic fever, a disease I had not seen in decades.