Ian Barrows, Class of 2016, George Washington University School of Medicine and Health Sciences

1. Centralized Innovation on a National Scale: Integrated Western and Traditional Healthcare in Bhutan Ian Barrows, Class of 2016, George Washington University School of Medicine and Health Sciences Bob Morrow, MD, MPH, FACPM, Battelle Memorial Institute and GWU School of Medicine and Health Sciences

2. Part I: Bhutanese Traditional Medicine Overview

3. National Healthcare System • Established in 1967 • Incorporating both Western medicine and traditional Bhutanese medicine, known as gSo-ba-rig-pa • All healthcare free of charge • Bhutanese constitution states under Article 9, Section 21: “The State shall provide free access to basic public healthservices in both modern and traditional medicines.” • Is it a truly integrated system?

4. Background on gSo-ba-rig-pa • Derived from Tibetan Buddhist medicine • Original texts describing gSo-ba-rig-pa are known as the rGyud-bZhi, the four tantras, or “The Secret Quintessential Instructions on the eight branches of the ambrosia essence tantra” • Four tantras originally coming from Buddha Shakya Muni (625-544 BCE), likely written down in the 4th century ACE • Guru Rinpoche first brought Tibetan medicine to the Bhutan region in 746 ACE • Physician Tenzing Drukda permanently established gSo-ba-rig-pa in Bhutan in the late 1600s

5. gSo-ba-rig-pa and Health • In Buddhism, health requires balance within the body • Believe that all imbalances originally stem from ignorance • Ignorance leads to misapprehension, in turn leading to attachment, hatred, and delusion (the three poisons) • Disorders of attachment are known as rLung (pronounced loong) disorders • Hatred disorders know as mKris-pa (pronounced tee-pa) • Delusion disorders are known as bad-kan (bekan) disorders

6. Attachment or rLung Disorders • Attachment, such as desire, greed, or jealousy, comes from the genital organs • Results in neutral or wind disorders such as breathing and mental disorders • Those above age of 40 often present with rLung disorders

7. Hatred or mKris-pa Disorders • Hatred originates in the liver/gallbladder, and manifests itself as a hot disorder • Related to the element fire • Related to bile and blood sicknesses, headaches, and vision problems • Adults age 17-40 are most susceptible to mKris-pa disorders

8. Delusion or Bad-kan Disorders • Delusion from the brain can lead to phlegm related illnesses which are cold in nature • Often affects the stomach and joints • Related to the elements of earth and water • Children are often more prone to bad-kan disorders

9. Major Presenting Complaints • Diabetes • Hypertension • Arthritis • General aches • Tinnitus • Digestive problems (gastritis) • Chronic skin disorders

10. Diagnosis • Can involve: • History taking from patient • Physical exam • Reading of pulse • Urine analysis • 250+ patients seen a day at the National Traditional Medicine Hospital (NTMH), only four on average bring in urine samples

11. Pulse Taking From www.tibetanmedicine-edu.org

12. Urine Analysis

13. Treatment • First line treatment of behavior and lifestyle modifications • Second line treatment of medications • Final line of therapy includes bloodletting, gold needle, herbal bath, or hot compression • Treatment often begins immediately with medications or therapy

14. Medications • Medications are often prescribed in sets of three, and each medication is characterized by its hot, neutral, or cold nature • Opposite nature medications treat opposite nature disorders • 94 medications currently produced • Specific ingredients, ratios, production instructions, etc. come from the original Buddhist texts (mostly the Fourth Tantra) • Produced using plants, minerals, and animal parts collected throughout Bhutan and India

15. Medication Dispensary

16. Medication Production • All traditional medications produced at Menjong Sorig Pharmaceuticals, a part of the Institute of Traditional Medicine in Thimphu, Bhutan

17. Education • Traditional physicians are known as drungtshos • Training involves 5 years in the classroom and 6 months of clinical training at the Institute of Traditional Medicine

18. Part II: Integration

19. Aspects of Integration • Integrated administration at Royal Ministry of Health level • Integrated funding at government level • Practices of Western and traditional medicine often offered at same locations • How then is it actually functioning after 50 years?

20. Healthcare Statistics Ministry of Health Annual Health Bulletin 2013: • 194 Western physicians • 35 drungtshos (traditional physicians) • 131 692 cases presenting for traditional care in 2011 • 1 990 958 cases presenting for Western care in 2012 • 250 patients seen per day at NTMH, compared to 80 per day in 2005

21. Methods of 6 week observational investigation, 2013 • Observational research at the National Traditional Medicine Hospital (NTMH) • Shadowed traditional physicians as is done in our medical school curriculum • Interviewed administrators, department heads, researchers and practitioners • Rotated through all departments of the NTMH • Participated in integrated psychiatry program with Dr. Nirola and Drungtsho Ugyen at the National Referral Hospital,  both in Thimphu, capital of Bhutan

22. Traditional Hospital (NTMH)

23. Traditional Hospital

24. Traditional Hospital

25. National Referral Hospital

26. Phuentsholing District Hospital

27. Observations • No patients referred from western physicians during six weeks of observation • Patients present with western medical records, not because of referrals, but due to lack of satisfaction with western treatments or physicians • Drungthos unable to interpret and fully understand western notes • Western physicians limited exposure to traditional medicine • Limits integration and effective collaboration, treatment, and communication at practice level

28. Mental Health Collaboration: a program for better integration • Physicians recognize problems with integration, so initiated model Mental Health Integration program • Traditional physicians attending grand rounds in the psychiatric department of the National Referral Hospital • Western physicians simultaneously learning about traditional medicine’s approach to mental health

29. Mental Health Collaboration: a program for better integration • Hope to improve communication and understanding of counterpart’s practice • Establish efficacy of Western versus traditional medicine for treatment of specific disorders • Serve as model for future collaboration and improved integration

30. Conclusions • Integration and multiple medical practices provide more options to patients • Neither traditional nor Western teachings provide complete understanding of the human body, yet both offer unique insights • Traditional medications important for future drug discovery • Scientific and evidence based evaluation of treatment outcomes of traditional medicine remains to be performed • These integration problems not unique to Bhutan, but also seen in Taiwan, China, Singapore, and India as noted by Chunhuei Chi

31. Thank you

32. References • Chunhuei Chi. Integrating traditional medicine into modern health care systems: Examining the role of Chinese medicine in Taiwan, Social Science & Medicine, Volume 39, Issue 3, August 1994, Pages 307-321, ISSN 0277-9536, http://dx.doi.org/10.1016/0277-9536(94)90127-9. • World Health Organization. The Promotion and Development of Traditional Medicine. WHO Technical Report Series No. 622. World Health Organization, Geneva, 1978.