Bhutan Research Articles

Yield of Brain MRI in Clinically Diagnosed Epilepsy in the Kingdom of Bhutan: A Prospective Study

BackgroundPeople with epilepsy (PWE) in low- and middle-income countries may not access the health resources that are considered optimal for epilepsy diagnosis. The diagnostic yield of magnetic resonance imaging (MRI) has not been well studied in these settings. ObjectivesTo report the diagnostic yield of brain MRI and identify clinical associations of abnormal MRI findings among PWE in a neurocysticercosis-endemic, resource-limited setting and to identify the proportion and putative structural brain causes of drug-resistant epilepsy. MethodsPWE were prospectively enrolled at the Jigme Dorji Wangchuck National Referral Hospital in Bhutan (2014-2015). Each participant completed clinical questionnaires and a 1.5-Tesla brain MRI. Each MRI was reviewed by at least 1 radiologist and neurologist in Bhutan and the United States. A working definition of drug-resistant epilepsy for resource-limited settings was given as (a) seizures for >1 year, (b) at least 1 seizure in the prior year, and (c) presently taking 2 or more antiepileptic drugs (AEDs). Logistic regression models were constructed to test the cross-sectional association of an abnormal brain MRI with clinical variables. FindingsA total of 217 participants (125 [57%] female; 54 [25%] < 18 years old; 199 [92%] taking AEDs; 154 [71%] with a seizure in the prior year) were enrolled. There was a high prevalence of abnormal brain MRIs (176/217, 81%). Mesial temporal sclerosis was the most common finding (n = 115, 53%, including 24 children), exceeding the number of PWE with neurocysticercosis (n = 26, 12%, including 1 child) and congenital/perinatal abnormalities (n = 29, 14%, including 14 children). The number of AEDs (odds ratio = .59, P = .03) and duration of epilepsy (odds ratio = 1.11, P = .02) were significantly associated with an abnormal MRI. Seizure in the prior month was associated with the presence of mesial temporal sclerosis (odds ratio = .47, P = .01). A total of 25 (12%) participants met our definition of drug-resistant epilepsy, with mesial temporal sclerosis (n = 10), congenital malformations (n = 5), and neurocysticercosis (n = 4) being the more common findings. ConclusionsThe prevalence of abnormalities on brain MRI for PWE in resource-limited settings is high as a result of a diffuse range of etiologies, most commonly mesial temporal sclerosis. Drug-resistant epilepsy accounted for 12% of the referral population in a conservative estimation.

Infant and young child feeding (IYCF) practices and nutritional status under 2 years of age in Bhutan

In South Asia, while childhood undernutrition persists, overweight is gradually becoming common. IYCF practices (e.g., exclusive breastfeeding, timely complementary feeding, diet diversity) promote healthy growth, but little is known about IYCF and their link to children's nutritional status in Bhutan, explored here in data collected during the 2015 Bhutan National Nutrition Survey. In this nationally‐representative survey, household (HH) membership and socioeconomic status (SES), youngest preschool child anthropometry and derived WHO/UNICEF IYCF indicators were assessed. IYCF and anthropometry data were available for 441 children &lt; 24 mo of age. Length‐for‐age (LAZ), weight‐for‐length (WLZ) and weight‐for‐age (WAZ) Z‐scores were derived relative to the WHO reference. 15%, 5% and 12% of children were stunted, wasted and underweight (&lt; −2 Z), respectively, while 6% were overweight (WLZ &gt; 2). HH assets owned (e.g., TV, 66% and sofa set, 28%) reflected an SES above neighboring Nepal and Bangladesh, but 40% of mothers had no schooling. Exclusive breastfeeding (BF) to 6 mo was reported by 52% of mothers and 92% and 61% reported continuing breastfeeding through the 1st and 2nd years, respectively. Timely introduction of complementary foods was reported for 93%, while only 18% of children met the minimum dietary diversity cutoff (≥ 4 food groups in past 24 hrs). Survey design‐adjusted regression analysis suggested girls were far less likely than boys (referent) to be exclusively breastfed under 6 mo of age: OR=0.2 (95% CI: 0.1–0.9). SES was associated with complementary feeding diet quality: ORs of reaching minimum dietary diversity were 5.3 (1.1–25.2) and 7.8 (1.3–46.9) in HHs classified into the 4th and 5th vs 1st quintiles of a wealth index. No IYCF indicator was associated with stunting or wasting, while exclusive and predominant BF &lt; 6 mo and continued BF to 2 years were protective against overweight (OR=0.1 (0.0–1.0), 0.1 (0.0–0.6) and 0.0 (0.0–0.4), respectively). Acceptable breast and complementary feeding practices along with low rates of under‐ and over‐nutrition suggest a situation of moderately low nutritional risk, but sex differences in breastfeeding practices, protective effects for overweight of BF according to guidelines and close associations between SES and complementary food quality suggest directions for potential programmatic interventions.Support or Funding InformationUNICEF Regional Office for South Asia, Kathmandu, Nepal

Book Review: Venkat Pulla (Ed.), The Lhotsampa People of Bhutan: Resilience and Survival

Book Review: Venkat Pulla (Ed.), <i>The Lhotsampa People of Bhutan: Resilience and Survival</i>

Notes on five, mainly high-altitude species of Chinese Neckera, with an updated key to Neckera sensu lato in China

Abstract This paper presents new distributional records of five Chinese species of Neckera Hedw.: N. bhutanensis Nog. (new to Sichuan and Yunnan), N. borealis Nog. (new to Xinjiang), N. himalayana Mitt. (Yunnan, new to China), N. setschwanica Broth. (new to Bhutan), and N. xizangensis Enroth (new to Sichuan and Yunnan, the first reports of the species since type material from Xizang). Maps showing the distributions of the treated species in China and an updated key to the Chinese species of Neckera sensu lato are provided.

The Factors Affecting Success of Small Agro-Enterprises in Bhutan

The Factors Affecting Success of Small Agro-Enterprises in Bhutan

“Like a Pot without a Handle”: Law, Meaning and Practice in Medieval Bhutan

Le droit au Bhoutan avant l’avènement de Shabdrung Ngawang Namgyal (1594-1651) est présenté dans un grand nombre de sources comme n’ayant pas existé. Ce qui n’est pas entièrement juste. Basé sur une série de sources écrites, cet article avance que cette affirmation reflétait la lutte constante pour le pouvoir que se livraient les chefs et les aristocrates locaux. Les inquiétudes exprimées par ces derniers suggèrent que les gens du peuple attachaient de l’importance à la stabilité et à un juste équilibre entre les impôts et les corvées avec un recours contrôlé ou limité à la violence. L’instauration d’une administration centrale forte et le contrôle accru des Drukpa, qui conduisirent à la création du Bhoutan, répondirent, pour un temps, aux problèmes posés par ces querelles endémiques. Le système de gouvernement établi par le Shabdrung s’affaiblit après 1774. Après plus d’un siècle de guerre civile, durant lequel l’augmentation des impôts obligea de nombreuses familles à émigrer, l’établissement de la monarchie en 1907 apporta la stabilité.

Policy and governance to address depression and suicide in Bhutan: The national suicide-prevention strategy.

Suicide and mental disorders are a growing public health issue in Bhutan, due in part to a rapidly transitioning society. The burden of suicide has been recognized by the Royal Government of Bhutan and, as a result, it introduced the country's first ever national suicide-prevention plan in 2015. The 3-year action plan takes a holistic approach to making suicide-prevention services a top social priority, through strengthening suicide-prevention policies, promoting socially protective measures, mitigating risk factors and reaching out to individuals who are at risk of suicide or affected by incidents of suicide. This article documents Bhutan's policy and governance for addressing depression and suicide within the context of its national suicide-prevention strategy, examines progress and highlights lessons for future directions in suicide prevention. Since the endorsement of the 3-year action plan by the prime minister's cabinet, the implementation of suicide-prevention measures has been accelerated through a high-level national steering committee. Activities include suicide-prevention actions by sectors such as health, education, monastic communities and police; building capacity of gatekeepers; and improving the suicide information system to inform policies and decision-making. Suicide-prevention activities have become the responsibility of local governments, paving the way for suicide prevention as an integral mandate across sectors and at grass-root levels in the Kingdom of Bhutan.

ブータン王国における道路斜面防災点検の災害要因の定量的評価

ブータン王国は国土の約95％が標高600m以上の山岳国である．同国では道路が主要な交通・輸送手段であるが，国土の大部分が険しい山岳地帯で，十分な斜面災害対策が実施されていないため，道路のいたる所で斜面災害が頻発し他地域から断絶される地域が発生し，農作物出荷や人の移動に支障をきたしている．

Gross National Happiness and Gender as the Fundamental Policy in the Kingdom of Bhutan

Gross National Happiness and Gender as the Fundamental Policy in the Kingdom of Bhutan

Pressure–temperature–structural distance relationships within Greater Himalayan rocks in eastern Bhutan: implications for emplacement models

AbstractIn the Himalayan orogen, Greater Himalayan (GH) rocks were buried to mid‐ to lower‐crustal levels and are now exposed across the strike of the orogen. Within the eastern Himalaya, in the Kingdom of Bhutan, the GH is divided into structurally lower (lower‐GH) and upper (upper‐GH) levels by the Kakhtang thrust (KT). Pressure–temperature estimates from lower‐ and upper‐GH rocks collected on two transects across the KT yield similar P–T–structural distance trends across each transect. In the eastern transect, temperatures are similar (from 730 to 650 °C) over a structural thickness of ~11 km, but peak pressures decrease from ~10 to 6 kbar with increasing structural level. In comparison, peak temperatures in the central Bhutan transect are similar (from 730 to 600 °C), but pressures decrease from 10 to 6.5 kbar with increasing structural level over a structural thickness of ~6 km. The structurally highest sample reveals slightly higher pressures of 8.0 kbar in comparison to pressures of ~6.5 kbar for samples collected from within the KT zone, ~4 km below. Within each transect, there are increases in pressure ± temperature within the overall upright P–T gradient that may demarcate intra‐GH shear zone(s). These P–T results combined with evidence that the timing of initial melt crystallization becomes older with increasing structural level suggest that the intra‐GH shear zones emplaced deeper GH rocks via progressive ductile underplating. These shear zones, including the KT, likely aided in the initial emplacement and construction of the GH as a composite tectonic unit during the Late Oligocene to Early Miocene, from c. 27 to 16 Ma.

A cross-sectional survey of population demographics, the prevalence of major disease conditions and reason-specific proportional mortality of domestic cattle in the Kingdom of Bhutan

We describe the population demographics, rudimentary measures of reproductive performance, the prevalence of major disease conditions and reason-specific proportional mortality for cattle owned by villagers in 16 dzongkhags (districts) in Bhutan based on the findings of a cross-sectional study carried out between March 2012 and May 2014. The animal health issues that were of concern for livestock owners are also identified. Study households were selected using a stratified, two-stage cluster design. Districts (dzongkhags) formed the strata. Villages within dzongkhags were the first sampling stage and households within villages the second sampling stage. All cattle within each selected household comprised the study population.Questionnaires were collected from 409 households with 1480 standing cattle. A total of 71.0% (95% CI 67.9%–74.1%) of the standing cattle population were female and the median age of cattle was 5 years (Q25 3 years; Q75 7 years). Exotic breeds of cattle (Jerseys, Brown Swiss, and their crosses) comprised 41.4% of the cattle population with local breeds making up the remainder. Although exotic breeds of cattle had a significantly lower age at first calving (median 4 years) compared to local breeds (median 4.8 years) there was no significant difference in the number of calving events per cow for the two breed groups. Diarrhoea was the most prevalent disease condition with 2.8 (95% CI 1.5–4.6) cases per 100 animals followed by bovine enzootic haematuria with 1.9 (95% CI 1.0–3.3) cases per 100 animals. The most frequently cited cause of death was misadventure (proportional mortality 26.2%, 95% CI 15.7%–39.2%) followed by old age (17.8%, 95% CI 9.5%–29.4%). A lack of access to adequate fodder and pasture was the animal health issue that was cited by interviewees most frequently.We provide no evidence that exotic breeds of cattle have superior reproductive performance compared with local breeds. The major cattle health concern cited by interviewees, lack of access to fodder, is likely to contribute to suboptimal productivity and the relatively high incidence of bovine enzootic haematuria in this population. We propose that a prospective cohort study of Bhutanese cattle is warranted to more fully elucidate factors affecting the productivity and longevity of cattle in Bhutan.

Reducing stunting in Bhutan: an achievable national goal.

The kingdom of Bhutan is a tiny country, landlocked between the two Asian giants of India and China, and has a population of about 762 864 (Bhutan at a glance 2014). Despite the very small size, the country has made remarkable progress towards modern development since initiating planned development in the 1960s. Bhutan has also experienced rapid progress in many of the key determinants of nutrition and health.

TRADE IN SOUTH ASIA IN THE NAME OF SUB-REGIONAL TRADE CORRIDOR

The development of the corridor for the Bangladesh, Bhutan, India, and Nepal (sub-regional) Motor Vehicle Agreement is rooted in the formation of the South Asian Growth Quadrangle (SAGQ), a collective organization established by the four South Asian nations. To meet its goal, SAGQ was tasked with improving cross-border connectivity, boosting trade among member countries, and strengthening sub-regional economic integration. The strategic location of North East India implies that the sub-regional corridor will significantly impact the development of the region. over the past 20 years, despite dedicated programs and attempts from multiple stakeholders within the SAGQ to promote development within sub-regional, not enough has happened to facilitate regional trade, transport, and the movement of goods and people across the region. Consider the existing state of affairs: intraregional trade among South Asian countries accounted for only 5 percent of their trade in 2015. This low level of regional integration in South Asia is manifested in poor intraregional investment. Higher levels of integration to ensure smooth access to regional and international markets is even more important for smaller, less developed, and landlocked nations such as Nepal and Bhutan.

PROSPECT AND SO FAR DEVELOPMENT OF BBIN CONNECTIVITY

Bangladesh, Bhutan, India, and Nepal, BBIN countries have signed a sub-regional Motor Vehicles Agreement (MVA) for smoothing easy cargo movement across their borders on June 15, 2015. It is likely to reduce trade transaction costs meaningfully and may be an operative tool to realise their trade and investment potentiality. In the attempt, it will create new economic opportunities, mainly in border areas and, through their joint effect will help to promote workable and inclusive development through engagement groups and increase in purchasing power. The BBIN MVA has put in space a respectable structure for smoothing transit and transport within four nations of Bangladesh, Bhutan, India and Nepal. It has properly capitalized on the present political thump for sub-regional addition and rapidly placed on the table a framework that can provide a much-awaited push towards economic integration for the sub-region. This paper talked about how BBIN MVA Connectivity comes to the existence and history of this Sub-regional cooperation. Secondly, objective and purpose of signing BBIN sub-regional MVA agreement. Thirdly, what is the issues have been discussed and finally, the prospect and so far development of BBIN sub-regional cooperation.

Healthcare and happiness in the Kingdom of Bhutan.

Bhutan is a small landlocked country measuring 38,394 km2,(1) with a population of 745,153.(2) It recently celebrated 108 years of monarchy; however, the country introduced its first constitution in 2008.(3) When the current King of Bhutan, Jigme Khesar Namgyel Wangchuck, was crowned in 2008, Bhutan was transformed into a unitary parliamentary constitutional monarchy.(2) The second and reigning Prime Minister of Bhutan, and the political head of the country, is Tshering Tobgay. Bhutan is divided into three regions (Western, Central and Eastern) and has 20 districts called dzongkhags. Bhutan’s currency is the ngultrum (Nu) and its value is on par with and pegged to the Indian rupee. The major sectors that contribute to Bhutan’s economy are tourism, agriculture, forestry and the sale of hydroelectric power. According to the 2011 National Health Accounts, its gross domestic product (GDP) per capita was USD 2,121.(2) Bhutan is known for measuring its happiness with the Gross National Happiness (GNH) Index. The term was coined by the fourth king of Bhutan, Jigme Singye Wangchuck, in 1972 to show his commitment toward building the economy in a sustainable manner, based on Buddhist spiritual values and well-being.(4) The Constitution of Bhutan also expresses the importance of GNH, as it states “the state shall strive to promote those conditions that will enable the pursuit of Gross National Happiness”.(5) GNH has four underpinning pillars and nine domains (Fig. 1).(4) Open in a separate window Fig. 1 Flowchart shows the four pillars of Gross National Happiness (GNH).

Alcohol and economic development: Observations on the kingdom of Bhutan.

Bhutan is a small country undergoing rapid social change arising from income growth, urbanisation and Western cultural influence. Markers of poverty, namely infectious disease and infant mortality, have improved dramatically. The attention of health authorities is now focused on the non-communicable disease and injury burdens, to which alcohol consumption is a major contributor. The paper draws on official data to characterise the consumption of alcohol and related harm, and the nature of the alcohol market, with commentary on crucial aspects of availability policies and drink-driving regulation that need reform. Kypri K, Dorji G, Dalton C. Alcohol and economic development: Observations on the kingdom of Bhutan. Drug Alcohol Rev 2017;36:333ȃ336.].

The Way to Bhutan

The Way to Bhutan

WHERE DID BHUTAN'S GROSS NATIONAL HAPPINESS COME FROM? THE ORIGINS OF AN INVENTED TRADITION

The Kingdom of Bhutan has attracted international attention for adopting “Gross National Happiness” (GNH) as its national development policy. The central notion is that gross national happiness is more important than gross national product; the four pillars of GNH are sustainable economic development, good governance, preservation of the natural environment and preservation of the national culture. This paper traces the historical origins of the concept of Gross National Happiness and finds that GNH is newer than the literature and the propaganda usually suggest. Close study of GNH's origins and salience over several decades reveals evidence of the invention of a tradition, in Hobsbawm and Ranger's terms [Eric Hobsbawm and Terence Ranger (Eds.), The Invention of Tradition. Cambridge: CUP, 1983]. The meteoric rise over the last 15 years of GNH as Bhutan's official ideology is a key part of the Bhutanese state's efforts at nation building in the context of rapid and disruptive social and economic change in a highly plural society.

Silk Roads in the Kingdom of Bhutan and the Development of a National Heritage Inventory

A UNESCO project, Support for the Preparation for the World Heritage Serial Nomination of the Silk Roads in South Asia, afforded the opportunity to research evidence for Silk Roads exchange in South Asia. The first part of the paper explores the challenges of archaeology in the Kingdom of Bhutan, located on the southern slopes of the eastern Himalayas. GIS-based approaches to model earlier settlement patterns and trade routes are considered. This led to a discussion with Bhutanese colleagues, in the Division for Conservation of Heritage Sites (DCHS), regarding the need for a digital national heritage inventory: to help manage and protect heritage resources, and to improve the communication of the rich heritage of the country to its people. The second part of this paper explores some of the issues around that debate, and the steps taken to implement the chosen solution: the Getty Conservation Institute/World Monuments Fund ARCHES heritage inventory system.

The Paradox of Happiness: Health and Human Rights in the Kingdom of Bhutan

The Paradox of Happiness: Health and Human Rights in the Kingdom of Bhutan