A cousin died a week ago. He was a healthy, optimistic, 33-year-old father of two little kids. Some remember him having once said he had never taken a pill in his life. When I received the news of his passing, I could not believe it. As the reality slowly sank in, however, I phoned my brother in the village to ask for more details. The cousin was contesting in the local elections and had visited the local government office to submit his documents the day before he died. On his way back, he had stopped to talk with his friends and relatives. A man of a few words, he rarely directly solicited our support in the elections. That fateful morning, he had woken up early. In agrarian hamlets, it is the season of harvest. In the village, some seasonal labour is not monetized. They barter services. They wake up early and start work at the crack of dawn and work till about 11 am. That makes the morning shift. He was to go for a morning shift work at a neighbour’s. Having nudged his wife from sleep, he went to the kitchen to build a fire at the hearth. In villages, they prefer fire for cooking. Electricity-cooked food doesn’t taste good, they complain. Others think electricity isn’t safe. What happened after he went to the kitchen nobody knows. He built a fire. He must have collapsed sitting on a wooden block by the hearth, and then struggled to free himself from the grip of the unexpected. His feet fell into the fire and four toes were burnt to stubs. One flip-flop he was wearing was burnt, too.
Despite the heartbreaking details, I had a glimmer of hope that he might have just fainted and resuscitation would help revive him. A health official from a local health unit checked for the signs of life in his body. No, he was gone. He was cremated at the bank of the Toorsa river. His funeral services, as per the Hindu tradition, are almost over. People who loved him are collecting themselves by adopting forced stoicism. But questions remain. What caused his death? He was healthy, after all.
Today a friend messaged me saying his relative suddenly died. He, too, died suddenly. By suddenly, we usually mean the person who died was doing fine, healthy, and died without forewarning of it as a disease. Such sudden deaths, the friend suspects, could result from our health and lifestyles. Bhutanese don't want their health screened unless they are sick. We are proud when we say we have not once visited a hospital. My father, who had taken to smoking in his preteens, would say he hadn’t visited a hospital. A few years ago, he got ill. His stomach troubled him. But he kept it to himself, hoping the pain would go away. But it only intensified. When he finally shared about it and we rushed him to a hospital, the doctors diagnosed him with a gastric ulcer. He was the luckier few; he received the timely medical intervention and the worst possible was averted.
Biological bombs in us
Non-communicable diseases are one of the biggest killers in the world. In Bhutan, NCDs (cardiovascular diseases, stroke, diabetes, cancer, and chronic respiratory diseases) are major public health concerns. The risk factors for NCDs are growing stronger. Alcohol is widely used by people of all age groups. You can purchase and consume alcohol as you can any ordinary market commodity. A few control measures are in place, but they don’t work. The other two major risk factors include sedentary lifestyles and dietary habits, which are changing for the worst.
A study by the World Health Organisation tells Bhutanese people are less active than they used to be. Inadequate physical activity is the highest among the youth aged between 15 and 17 — a worrying fact for a country with over 50 percent of people under the age of 30[1]. The study also says work-related activities, especially rural-based, contribute the highest to the reported physical activity averages. The coincidental gains from the work-related activities are already declining, however. Bhutan is rapidly urbanising and people are moving out from villages to add hands to the country’s fledgling but still preferred secondary and tertiary sectors of the economy. By 2050, only about 40% of Bhutanese people will live in rural areas. Add to that the increase in lifespan. The more elderly people there are, the higher the risks of a non-communicable disease epidemic. The indications are clear: a sizeable portion of the population is moving into the red zones of NCDs.
A Bhutanese public health expert writes that the dietary shift from a traditional diet rich in fibre and vegetables to a western diet high in fats, salts, and sugars has raised heart disease, hypertension, and stroke in Bhutan. The youths have a greater proclivity to eat those foods. Studies show the low-cost foods available in fast food stalls are linked to obesity. Low-cost, instantly gratifying food items are not uncommon in Bhutanese markets.
According to WHO, over 56% of deaths and 21% of premature mortality in Bhutan are related to NCDs. Many Bhutanese live with biological time bombs that are ticking away. NCDs or their risk factors live deep in our bodies and daily lives like some visceral secrets. When their symptoms show, we treat them at home instead of seeing a doctor. Years ago, my mother would often fall sick. Her head would throb with stabbing pain, and a sudden heaviness would grip her body. Her heart aches were persistent. We consulted shamans; enlisted witch doctors’ help. They had things to say about her sickness — the ancestral dead seeking deliverance, a malevolent forest spirit demanding propitiation, or a local witch who had scattered a few morsels of cursed soil on our courtyard. They performed séances. We did everything they asked us to do: we sacrificed chickens, performed pujas to deliver the dead caught in the limbo between death and rebirth, and propitiated spirits. Nothing helped. It was only after we had exhausted the recourse available in the village that we went to a hospital. By then, she was too weak to walk. Carrying her on a makeshift stretcher fashioned out of bamboo fibres, we braved the moody subtropical monsoons and forests for two days before we finally brought her within the touch of science. Not the local witch, family dead, or a malevolent spirit, but undiagnosed hypertension was the reason for her spasms of headache, heartache, and the heavy grip.
We lack a scientific temperament
Our deep convictions are not touched by science. Mobile phones, television, radios, and a host of electronic paraphernalia have touched and invariably changed Bhutanese communities and lifestyles. Science did seep in, after all. But we are divided between our traditional convictions and new realities science has marshalled. Often the traditional convictions prevail over scientific reasoning, even when it’s a question of life and death.
Again, I go back to the archive of family history. An uncle was beaten up by a belligerent mob of ghosts when he had bravely walked alone one night across a small rivulet around which many paranormal activities were reported. With a brilliant bamboo-splint flambeau held in his hand, he was walking up after crossing the rivulet river when he saw a queue of ghosts in white on both sides of the path. He did not remember how he had delivered himself to his home. He took ill that very night. His health declined quickly. He spat pus. He could not eat. The shamans suspected the ghosts had beaten him up and stolen his soul. After languishing with rapidly destructive sickness for 21 days, he died. In the 1980s, ghosts, more than anything, were held responsible for untimely deaths in villages. His story thickened, by a chapter, the anthology of our hair-rousing tales we tell at family gatherings. But did the ghosts really kill him?
Still, we don’t want to go to hospitals. Hospitals are for the sick. If a healthy person visits a hospital, he is certainly hiding some sickness he is ashamed to reveal. This is a common thought many of us entertain.
What can we do?
Bad habits die hard. Many of them result from increased income and urbanisation. We can’t undo them. But we can’t ignore them either. We must institute innovative and collaborative strategies to ensure a healthy population. We must enlist the support of the individual citizen and collective units at all levels of society.
Bhutanese towns are growing congested. Constructions and vehicles have eaten into the free spaces. Built-environment is pushing us toward total sedentary lifestyles. City and town planning, therefore, need to prioritise public health concerns as well. Open spaces for physical activities are an essential part of green cityscapes. Cycling lanes, for example, are a good way to start. The few cycling lanes we have are usurped for vehicle parking. And people gradually ride themselves into NCDs. Such impediments must be removed by creating proper parking spaces. Cycling tracks and walkways complement the country’s much-publicized goal of carbon neutrality.
Perhaps annual targeted health screening services must be made available to vulnerable groups. Though it may be a costly affair initially, in the long run it will accrue benefits.
For a sustainable positive result, however, building scientific temperament is essential. We need to wean ourselves from our unscientific convictions. The scientific temperament of citizens is indispensable not only in terms of population health; it is a necessary prerequisite for a healthy democracy, multiculturalism, and ideals of equity, and justice, among others. Mass education programs must educate people on healthy lifestyles and the benefits of seeking medical help instead of resorting to the traditional recourse of shamanism, faith healers, and other healing practices, most of which are at best quackery.
The right kind of information works well. My father and many others of his age had heard on their radios that Americans had landed on the moon. They scoffed at the news. To them, it was some crass joke, naked and clear. But as more information reached to them, as the local village school teacher explained that scientific feat as a marvel of the Christian civilization, as the village men opened their minds, they gradually and grudgingly accepted that someone had indeed stepped on the lunar surface. They stopped beating drums and blowing horns to chase away the evil that swallowed the moon during lunar eclipses. My mother, too, knowing she lives with hypertension, swallows her tablet before running off to see a witch doctor when the headache or the heavy grip descends on her.
We live at the edge of diseases that could explode and inflate public health expenditure. We must act fast. Many sudden deaths, like my cousin’s, may be a result of something within us, originating in our lifestyles and in our dietary habits.
[1] According to the 2017 Population & Housing Census of Bhutan, the median population age was 26.9.
