The Differences in Health Care and CultureA Comparison between Bhutan, Nepal Refugee Camps and the United

States Chet Nath Timsina 2011 National Refugee Healthcare Conference

Brief introduction about Bhutan Bhutan is a tiny dot on the world map. It has an area of 39,000 square kilometers and is surrounded by China to the north and India to the south, east and west. With a total population of approximately 700,000 people (52.5% male and 47.5% female), nearly one-sixth of them have been evicted since the early nineties. Like America, Bhutan is also a land of immigrants. Its chief population is comprised of Ngalongs, Sharchops and Lhotshampas1. Ngalongs are the ruling elites whose ancestors fled from the Druk Ralung province (in Tibet) during the civil war. Sharchops are of Tibeto-Burman origin and Lhotshampas are of Nepali origin. Bhutan was brought under theocratic rule by Shabdrung Ngawang Namgyel2 in 1635 A.D. and was subsequently ruled by his incarnations and reincarnations until the dawn of the 20th century. He established a dual system of governance where the Je Khenpo was in-charge of religious matters and
the Desi (Deb Raja) was in-charge of state affairs. In 1907, Ugyen Wangchuck- an administrator of

Tongsa province in Bhutan fought a battle and proclaimed the nation- a hereditary kingdom declaring himself as the first monarch. Today, Jigme Khesar Namgyal Wangchuck is the fifth hereditary monarch. Since 2008, the country has become a constitutional monarchy with the king as the head of the state and prime minister as the executive head of the government.

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Inhabitants of southern Bhutan which typically refers to the Nepali speaking population in Bhutan. Shabdrung was born in Druk Ralung in Tibet in 1593 AD and had fled to Bhutan in 1616 AD. Page 1 of 13

Presence of ethnic Nepali community in Bhutan The history dates back to 1624 A.D. when the first batch of Nepalese was officially taken (during the period of Shabdrung in Bhutan and King Ram Shah in Nepal-then Gorkha) to Bhutan for settlement in order to create farming lands in the South of Bhutan and to build monasteries/dzongs3 in different parts of Bhutan. With this formal invitation, many more joined the early settlers in the fertile land of southern Bhutan over the course of the subsequent centuries whereas Ngalongs, Sharchops and other small tribal groups chose to occupy the northern belt of the country. Early in 1948, when some prominent Nepali speaking individuals declared the formation of Bhutan State Congress4 (the first political party established in Bhutan), the government not only evicted those individuals but also put a permanent ban on the inflow of ethnic Nepalese into Bhutan. This is the first time the monarchy feared the political threat from within its borders and felt the need to control the growing ethnic Nepali population in Bhutan. Subsequently, the country first enacted its Nationality Law in 1958. This law recognized the southern Bhutanese of Nepali origin also as true and equal citizens of the country and resolved to streamline the total population of the country for the nations development. The Nepalese community continued providing the compulsory free labor for building dzongs (monasteries) and other infrastructures particularly constructing roads and bridges throughout the country. They cultivated land and farmed animals producing sufficient food for the nation to nourish.

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Administrative office building. This party was not allowed to operate and subsequently formation of any political or non-political parties was banned in Bhutan until 2008. Page 2 of 13

The country established its home ministry in 1961 and began to document and record the presence of its citizens in a formal way. The third king was given a high recognition by the citizens for establishing a National Assembly, opening doors to the outside world, making remarkable progress in the holistic development of the country and for declaring that the king could be impeached by the two-third majority vote of the national assembly members. In 1977, with fourth king on the throne, the royal coterie revised the Nationality Law by enacting the Citizenship Act and made it difficult for ethnic Nepalese to get naturalized for citizenship. After the first national census5 was conducted in 1980, citizenship cards were issued for the first time. Almost all the ethnic Nepalese in Bhutan (16 years and older) who could prove to have resided in Bhutan for more than 20 years were considered nationals and were issued the citizenship cards. Core causes of eviction 1. Revocation of citizenship The census and citizenship issuance data revealed a dominant presence of the Nepali community (Lhotshampas) in the south. Their excellent performance in schools, colleges, civil service exams, etc. created fear in the ruling elites that this segment of the population would compete in every matter at the national level. In addition, the self-sufficiency and economic enhancement by the Lhotshampas through farming and the creation of businesses within the most fertile flatlands of the south attracted the attention of the royal policy makers. The growing popularity of the Nepali language and socio-cultural influence amongst the other ethnic groups raised a bitter concern in the royal government. The government abruptly nullified the earlier provisions of the
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Although the first census was conducted in 1969, it did not cover all the districts. Page 3 of 13

Nationality Law and adopted the Bhutan Citizenship Act 1985 and implemented it retrospectively from 1958. This Act cancelled the citizenship acquired earlier by most of the southern Bhutanese and divided family members within a household into several categories declaring some members as citizens and others as non-nationals. Non-nationals were warranted to leave the country as soon as possible. 2. One-Nation One-People Policy The government adopted a One-Nation One People policy and began ethnic cleansing targeted specifically at the Nepali community. The king declared his mother tongue, Dzongkha, to be the national language. Tradition dress worn by the Ngalongs (ruling elites) became the national dress of Bhutan and was required to be worn by citizens at all times. The Nepali language was dropped from the curriculum, text books were burned and Nepali teachers were unjustly terminated from their jobs. 3. National Security Law- targeting ethnic Nepalese When the southern Bhutanese representatives appealed the king to reconsider citizenship issues, they were put into prison. In 1990, the southern Bhutanese organized themselves and took to the streets demanding the restoration of citizenship and fundamental human rights. The government cracked down mercilessly and asked people to leave the country warning of dire consequences. Meanwhile the government developed its National Security Law which applied the term antinational to all those who took part in the peaceful rally and who spoke against the king. This law classified all anti-nationals as non-nationals. Following the demonstrations in the south, all schools were closed and were turned into army barracks. Major health centers and hospitals were closed for the ethnic Nepalese. Thousands of demonstrators were arrested and put into
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prisons. Many died in the prisons. Over 200 of them remain there still, languishing in the prisons without any fair trial. 4. No objection certificates Following the peaceful rallies, the government required ethnic Nepalese to obtain a No Objection Certificate from the police department for new admission into the schools, for continuing education, for any kind of job and for obtaining business licenses. This new requirement prevented an alarming number of children from going to school, prevented adults from being hired for jobs or from obtaining business licenses, drivers licenses, etc. 5. Voluntary migration In order to sweep out all ethnic Nepalese from Bhutan, the government adopted a policy of signing voluntary migration forms under duress and coercion. This voluntary migration form was printed in Dzongkha, a language that many people could not read or understand. Many people filled out the form ignorantly, while others were forced to sign under at gun-point. Seeking refuge in Nepal When the Lhotshampas began to flee the country, they entered into India and sought refuge there. At the request of the Bhutan government, the Indian police loaded individuals onto trucks and dumped them across the border in east Nepal. The Nepalese government initially gave asylum to approximately 50 individuals but the number of Bhutanese in the camps in Nepal rose to about 90,000 by the end of 1993. Nepal housed these individuals in bamboo-thatched temporary shelters within seven refugee camps supported by UNHCR.

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Efforts to resolve the Bhutanese refugee problem 1. Initiatives by the Bhutanese refugees The Bhutanese refugees have been fighting peacefully since the time of eviction for the repatriation of all the Bhutanese refugees to restore their dignity and honor. Major efforts consisted of the following: writing appeals, lobbying in the UN General Assembly, lobbying with the powerful nations like the U.S., U.K. Australia, India, etc. for mediation, and direct voluntary repatriation through appeal marches and long marches to Bhutan. Unfortunately the results of these efforts have not resulted in repatriation but instead have led to the imprisonment of many refugees in India and Bhutan over many years. Individuals who participated in these peaceful initiatives for repatriation received permanent injuries and in some cases lost their lives. 2. Initiatives from Nepalese government Once Nepal granted asylum to the Bhutanese refugees, the government started negotiations with Bhutan and began bilateral talks to resolve the issue. Bhutan eventually agreed to sit for the talks and from 1993 to 2003, 15 rounds of formal bilateral ministerial level talks were held. Both governments agreed to do a joint verification of the people in the camps. But after completing verification of the refugees in one of the seven camps, the Bhutanese team unilaterally declared the results on December 2nd, 2003 which were unacceptable to the refugees or the host government. Since then, despite the several requests from Nepal government to resume the talks and the verification process, Bhutan has always denied and the process has been in deadlock. 3. Initiatives from the international community

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Strong resolutions were passed in the UN General Assembly, European Union and other international bodies several times over the last two decades urging Bhutan to repatriate its citizens. The U.S. has also been trying to persuade Bhutan to take back its citizens. The U.S. Department of State issues annual reports on Bhutan on a regular basis. U.S. dignitaries who visit Bhutan bring up the issue of refugees with the officials of Bhutan. Despite these efforts Bhutan has been able to withstand international pressures through its support from India. The Indian government has been taking the side of Bhutan for its own direct benefits consisting of hydroelectricity projects in Bhutan and a vote-bank in the UN. Third Country Resettlement Program- As Part of Durable Solution In 2006 the UNHCR and other core countries that fund humanitarian support of the Bhutanese refugees came up with the idea of bringing a durable solution to this long standing problem. The options for durable solution identified included: 1. Repatriation to Bhutan for those willing to go back despite the existing conditions 2. Integration into Nepal for those willing to be assimilated in the country of asylum 3. Third country resettlement for those not interested in options 1 or 2 The government of Bhutan did not accept the repatriation option and the government of Nepal was not willing to assimilate the refugees into Nepal. However, the core countries and the UNHCR announced the option of third country resettlement. Given their limited options, the vast majority of refugees began applying for resettlement because they did not want to continue living in the sub-normal conditions in the camps. The U.S. government announced that it would welcome over 60,000 Bhutanese refugees over the course of five years. Additional countries
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such as Canada, Norway, Denmark, Australia, New Zealand, the Netherlands and England also announced that it would welcome a smaller number of Bhutanese refugees as well. As of December 14th 2010, approximately 34,129 Bhutanese refugees have been resettled in the U.S. Those who have come here are scattered nationwide in different cities. The numbers of other refugees resettled are as follows- 2,333 in Canada, 2,168 in Australia, 498 in New Zealand, 326 in Denmark, 279 in The Netherlands, 273 in Norway and 111 in the UK. Medical Practices in Bhutan Bhutan is able to provide free medical facilities in the country through the money it collects in taxes (from its people) and through donations and grants received from the international community. Services are not easily accessible to the people in the villages as the health centers and hospitals are in towns and cities which are far-flung from the villages. As of 2009, there are 31 hospitals, 181 Basic Health Units and 176 national and non-national doctors. People practice traditional spiritual healing and herbal treatments before they resort to the last option of receiving services from Basic Health Units and the hospitals. Most women give birth in their homes with the aid of neighborhood elderly women mainly because there are no transportation systems. Immunizations for infants and children were accessible beginning in the late eighties. Diarrhea, cholera, typhoid, dysentery, malaria, conjunctivitis, cough, sore throats, migraine, ear infections, pneumonia, etc. are frequently diagnosed medical problems in Bhutan. Article 9/21 of The Constitution of democratic Bhutan has reiterated to continue to provide free access to basic public health services in both modern and traditional medicines.

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Medical Care in Bhutanese refugee camps in Nepal The UNHCR came on site to support the refugees in September of 1991. It took some time to organize its support system for several months because it needed to design and develop the mechanisms to deliver support services. Additional time was required to procure, store and deliver materials through lengthy channels. The first six month of life in the refugee camps were horrible. People built their own small tarpaulin/plastic tents to sleep in. There was no clean drinking water and no built toilets which forced people to use adjacent forests for their toiletry needs. People did not have enough food to eat a decent meal. Nepali health centers were not accessible to the refugees. There was a record death of 14 refugees in one day due to the lack of medical intervention prior to the UNHCRs arrival and implementation of medical support services. As the UNHCR came into the camps, and adopted other non-profit organizations as its working partners, it was able to establish offices within the camps and to deliver the support services considerably sooner than expected. Eventually basic health units and health centers were established in each camp. Complex medical cases requiring immediate attention were referred to the local hospital. Critical medical cases (for young women, children and youth) were referred to regional and national hospitals. Referrals for treatment in regional and national hospitals for elderly adults were not easily given. Most of the treatment expenses for these cases were paid for by the UNHCR. Cases which were not covered by the UNHCR were paid through donations by the refugees. For the most part, all basic treatments were given to the refugees- despite some limitations in the refugee camp situation. Nepali citizens who were living in the refugee affected areas also had access to the basic health services of the refugee camps.
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Major Medical Problems in the Camps in Nepal Diarrhea, cholera, typhoid, dysentery, conjunctivitis, cough, sore throats, migraine, ear infections, pneumonia, tuberculosis, etc. were frequently diagnosed medical problems in the refugee camps. Some medical conditions such as acute respiratory infection (in the childrenmostly infants), tuberculosis and asthma (in adults) were acquired in the camps due to the poor living conditions in the camps rather than being brought over from Bhutan. Anxiety, depression, trauma and hysteria are some of the main mental conditions observed in the camps however, these conditions were never treated or given medical attention or intervention. Poor Conditions of Living in the Camps in Nepal 1. Lack of enough and nutritious food: The Bhutanese refugees in the camps in Nepal depend solely upon the relief aids provided by World Food Program and UNHCR. Food items provided depend mostly with the availability of funding provided to these agencies. Refugees are not officially allowed to work outside the camps and do not have any means to earn money for buying other basic food or non-food items. Some refugees defy the imposed rules and find informal work outside the camps on local farms, construction sites and within private schools. While in Bhutan, most of the refugees had their own agricultural farms (crops as well as livestock) and had never experienced a dearth of food. They ate fresh food grown on their own farmland. They would yield enough crops to support themselves and in many cases would sell considerable quantities of produce to generate extra cash for buying non-food items or to build properties. The sudden decrease in the quality and quantity of food items in the camps came as a
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shock to many individuals and families. Owing to this, some became sick due to an imbalanceddiet and others experienced some levels of trauma. While living in the camps the refugees missed major food items such as a fresh variety of vegetables, meat, milk, butter, eggs, yogurt, fruits, juices, etc. If a family is able to earn money (defying the law of the country of asylum) then that family could buy and have some of these items occasionally. Because of the lack of nutritious food for almost two decades, a large chunk of this population is feared to develop deficiency and diseases sooner or later. 2. Air Pollution Huts within the refugee camps are clustered together. As many as 20,000 refugees live in less than a quarter mile radius. The smoke from the burning charcoal (used as a fuel to cook food) makes the camp dark, dusty and suffocating during common cooking times (before 9 am and after 4 pm). The smoke generates a strong odor and immediately causes cough, watery/irritation of the eyes, difficulty breathing, low visibility, etc. Its long-term effects are not yet known. 3. Lack of water Although efforts are made to provide clean and sufficient water to the refugees living in the camps, there is always a scarcity of water for bathing, washing clothing and for general housekeeping.

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Differences in the Medical Care (in the camps versus in the United States) Point of difference Camp U.S. Challenges

Insurance

No insurance-have to accept the available free care or pay the full cost Always walk-in

Health insurance is widely prevalent & utilized Mostly by appointments

Acquiring and keeping health insurance

Approach to Care Center Physical check-ups

Ability to set, cancel or attend scheduled appointments Lack of familiarity with annual check-ups & reluctance to visit PCP when not absolutely necessary Understanding importance, obtaining timely immunizations and proper record keeping

Seldom practiced

Regularly practiced

Immunizatio ns

Not mandatory

Required for individuals attending school (primary, secondary, higher education) or for employment Regularly for cleaning and as necessary for other purposes Utilized less oftenif at all

Dental Services

Occasionally for extraction or filling. Seldom for cleaning

Understanding importance of dental exams, routine cleaning and availability of emergency care Traditional medicines unavailable, difficulty accessing PCP or appropriate medical care Lab locations, sample collection process and purpose for conducting tests when no signs/symptoms of sickness appear

Practice of Traditional Healing Laboratory Testing: Blood, Urine, Stool, etc.

Highly adopted

Not done until serious illness presents itself

Done on a regular basis and in some cases mandatory for employment or schooling

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Choice with respect to preferences of PCP or hospital Interpreting services

No freedom to choose

Freedom to choose

Identifying and registering with a PCP or particular hospital

Not necessary

Services offered through telephone or in-person

Patients are not used to accessing interpreting services, difficulties in telephone interpretation, gender or relation issues English terms not understood. Patients anticipate doctors will ask questions to determine health status

Explanation of symptoms and use of medical terminology Medication

Nepali medical terminology used and understood. Doctor inquired about health issues

English terminology used. Patients expected to explain health issues

Doctors explained in detail and tested patients on understanding of prescribed medicines (dosage and refills) Referrals and approval required unless paying out of pocket for services

Doctors rely on pharmacy to explain

Understanding different types of medicines available (OTC), process of prescribing, purpose, dosage, PRN, refills etc. Patients have a hard time understanding how to obtain care outside of PCP appointments- whether to use 911 or ER services, unfamiliar with urgent care centers

Emergency care

Services available 24/7 through 911, urgent care centers, walk-in hours or by appointment

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