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!