Friday, November 27, 2009

Women and depression:

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

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!

Monday, August 17, 2009

Experiment with tobacco

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!

Sunday, June 28, 2009


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.


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.

Thursday, June 4, 2009

Doctor-patient relationship:

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

Friday, May 29, 2009

Psychiatry: not just a “short question”!

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

“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?

Tuesday, May 12, 2009

Toilet revolution

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?

Monday, May 11, 2009

From Discotheques to…?

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

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!