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A festival crowd shows off the colorful robes and long socks that are the national dress of Bhutan.
Courtesy of HVO, Laura White, photographer

AAOS Now

Published 12/1/2008
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Elizabeth M. Watson, MD

Orthopaedics in the land of the thunder dragon

In 20 years, Orthopaedics Overseas has transformed orthopaedics in Bhutan

History was made this year in the Kingdom of Bhutan. The archaic though idyllic country, nestled in the heart of the Himalayas and governed for centuries by a succession of kings, held its first democratic election in March 2008. Just the simple concept of voting to choose the country’s leadership has brought a child-like excitement to the people.

Most remarkably, the driving force behind the movement toward democracy was the former king, Jigme Singye Wangchuck, who ruled from 1972 until December 2006, when he handed the throne over to his son. Beloved by all, the former king has been the steadfast driving force guiding Bhutan through a tricky balancing act of preserving its culture and identity while accepting certain progress and modern influences that have benefited the country.

Volunteers with Orthopaedics Overseas (OO), a division of Health Volunteers Overseas (HVO), have had an interesting vantage point for seeing the changes in Bhutan. The first volunteer, Robert E. Stein, MD, arrived in 1990 and established the program after negotiations with the Bhutanese ambassador to the United Nations. He continues to serve as the site’s program director, and the program is regarded as one of Bhutan’s most successful NGO (nongovernmental organization) programs.

Since Dr. Stein’s first visit, 165 orthopaedic volunteers have served on 214 different assignments, and HVO’s presence has expanded to include a physical therapy program. Due to the success of both programs, additional negotiations are underway to establish a nurse anesthesia training program in the near future.

Not like Kansas
The Bhutan that I encountered on my first visit in 1998 was a charming and fascinating throw-back in time both culturally and medically. I flew from the international airport in Bangkok on Druk Air, the government-owned airline of Bhutan. The airline’s entire fleet consisted of just two planes, the only planes allowed into and out of the country at the time.

As we cut through the dense clouds over the Himalayas, the plane took a severe downward angle and made a sharp U-turn to descend into the mountain-lined valley and deliver us to a sunny little airstrip lined with colorful prayer flags.

The airport terminal was a small structure made of beautifully hand-carved wooden beams that depicted Buddhist symbols. Monks in red and airport officials in royal-looking, colorful robes and long socks, the national dress of Bhutan, greeted us as we deplaned. Like Dorothy, I thought, “I am not in Kansas anymore.” The fairy tale continued throughout the rest of my stay.

Advances in orthopaedic care
When the first OO volunteers came to Bhutan, they found no trained orthopaedic surgeons, cast technicians, C-arms, computed tomography (CT) equipment, or magnetic resonance imaging (MRI) machines. General surgeons handled basic orthopaedic trauma cases; patients with complex conditions were sent to India for care. The guidance, input, and support provided by a series of OO volunteers has enabled orthopaedic care to advance over the years.

A festival crowd shows off the colorful robes and long socks that are the national dress of Bhutan.
Courtesy of HVO, Laura White, photographer
In the orthopaedic ward, an anxious mother sits with her child after hand surgery.
Courtesy of HVO

On my second visit to Bhutan in 2004, I saw many of these changes first-hand. The charm, the peaceful Buddhist influence, the soft nature of the people, the people’s pride in their culture and in their king had not changed. But orthopaedic care had. The operating room (OR) now had a C-arm, which did not always work but, when it was operational, enabled surgeons to improve the placement of hip fracture plating (previously done by open feel). It allowed percutaneous rather than open treatment of pediatric supracondylar fractures and improved intramedullary rodding of long-bone fractures.

The entire outpatient clinic had been modernized. The new building included two rooms dedicated to orthopaedic patients, including a formal cast room. A new physical therapy building was equipped with specialized tables, ultrasound machines, hot wax baths for hand therapy, and special equipment for pediatric cases. The “ortho house”—the volunteer’s residence—now had televisions with satellite access to BBC and other world news stations.

Dr. Stein credits the interactions with OO volunteers as the catalyst that empowered local providers to see what level of care was possible in Bhutan and that brought about improvements in the patient care. Through this partnership, Bhutan now has four trained orthopaedic surgeons; two of them even have additional training, one in sports medicine and arthroscopy and one in spine surgery. Patients are rarely sent to India now.

The OO program has also trained orthopaedic cast technicians and physician assistants. The equipment available now includes a myriad of hardware for fracture work, the C-arm for the OR, a CT scan machine, and an MRI machine for the clinic. A new national hospital is being built adjacent to the grounds of the older hospital to modernize the clinics and the ORs.

Times have changed
“We have gone from no Bhutanese orthopaedists to four, from no orthopaedic technicians to many,” says Dr. Stein. “We now have television, the Internet, cell phones, and taxis. The government peacefully was transformed from a strict monarchy to a constitutional mon­archy with democratic elections.

“Of more dubious distinction,” he continues, “you can now find ultra deluxe hotels with rooms for $1,000 per night. Back in 1990, the highest priced room was $50 per night. Today, trekking companies galore take people through the mountains. My, how times have changed!”

Bhutan—the land of the thunder dragon—and OO inevitably must progress and grow. But I am confident that Bhutan will never lose the Buddhist charm nor the love for its culture, its people, and its king, even as it flowers in its newly established democracy. And I hope that I can return with OO to see that progress.

Elizabeth M. Watson, MD, practices in the San Francisco area. She can be reached at emwatson@usa.net

For more on Bhutan...
Take advantge of an opportunity to hear Dr. Gado Tshering, Health Secretary with the Ministry of Health in the Royal Government of Bhutan. Dr. Gado will be the featured speaker at the Orthopaedics Overseas 50th anniversary luncheon during the 2009 AAOS Annual Meeting in Las Vegas. For details and reservations, or to learn more about volunteering in Bhutan or other overseas opportunities, contact Health Volunteers Overseas at (202) 296-0928.