Ethno-medicinal uses and cultural importance of stingless bees and their hive products in several ethnic communities of Bhutan.

BACKGROUND: Indigenous and non-indigenous people in subtropical and temperate areas of Bhutan share an intricate relationship with stingless bees for diverse purposes including ethno-medicinal uses. Stingless bees hold significant importance in the realms of social, economic, cultural, and spiritual aspects. Bhutan's cultural traditions demonstrate a strong bond with the environment, exemplified by the regular use of honey from stingless bees for remedies such as treating the common cold, cough, and sore throat. METHODS: Ethnographic research was conducted to document the ethno-medicinal uses and cultural importance of stingless in Bhutan. We deployed semi-structured interviews with stingless beekeepers and honey collectors including traditional healers who perform religious rituals for curing and preventing physical and mental illness. RESULTS: We documented 22 different uses of stingless bee honey in food, medicine, veterinary medicine, crafts, beliefs, and religious purposes. The relative cultural importance (RCI) of stingless bees among Bhutan's ethnic communities was assessed through our calculations. It was determined that these bees hold notably greater significance for the Lhotshampa communities compared to other ethnic groups in Bhutan. This finding demonstrates the dependence of Hindu ethnic communities on natural resources in their everyday life. All participant communities largely exploit these bees through destructive extraction practices. They often find the natural nests in nearby forests, transfer them as a log hive to their backyards, and practice traditional meliponiculture. CONCLUSION: The ethnic communities of Bhutan use stingless bees for various purposes and the local knowledge are persistent. However, significant efforts should be made to address the ethno-medicinal, ecological, biological, and commercial perspectives of meliponiculture in Bhutan.

Rate and risk factors of inadequate endometrial tissues after endometrial sampling among Bhutanese women at the national referral hospital of Bhutan: a cross-sectional study.

INTRODUCTION: Women presenting with abnormal uterine bleeding needs careful and thorough assessment including ultrasound examination of endometrium and histopathological assessment of the endometrial tissues. The objective of this cross-sectional study was to determine the rate and the factors associated with inadequate endometrial tissues after endometrial sampling using MedGyn® pipette among Bhutanese women at the colposcopy clinic, Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Bhutan. METHODS: This cross-sectional study was conducted at the colposcopy clinic, JDWNRH, Thimphu between October, 2021 and March, 2022. Women included in this study underwent endometrial sampling using MedGyn® pipette without anesthesia as an office procedure. Data were collected using an interviewer-administered questionnaire and results extracted into a structured pro forma. The histopathology reports were extracted from the Department of Pathology and Laboratory Medicine, JDWNRH using the unique Bhutanese citizenship identity card number of the study participants. RESULTS: Inadequate endometrial tissues were noted in 27% (33 out of 122 cases). Among 89 patients with an adequate endometrial tissue, histologic results were normal in 30 (33.7%), benign pathology in 22 (24.7%), atrophy in 10 (8.2%), and hyperplasia in 27 (30.3%). In a univariate analysis, menopausal state (OR 1.6, 95% CI 0.708-3.765), overweight and obese (OR 1.6 95% CI 0.640-3.945), unemployed (OR 1.7, 95% CI 0.674-1.140), nulliparous (OR 1.7, 95% CI 0.183-15.816), primipara (OR 5.1, 95% CI 0.635-40.905) and use of hormonal contraception (OR 2.1, 95% CI 0.449-10.049) were associated with increased risk of inadequate endometrial tissues. On multivariate regression analysis, nulliparity (OR 1.1, 95% CI 0.101-12.061), overweight and obesity (OR 1.4, 95% CI 0.490-3.917), use of hormonal contraceptives (OR 2.2, 95% CI 0.347-13.889), and junior surgeons (OR 1.1, 95%CI 0.463-2.443) were found to be associated with inadequate endometrial tissues. However, the above associations were not statistically significant (p > 0.05). CONCLUSION: The rate of inadequate endometrial tissue following endometrial sampling using MedGyn® pipette was 27.0%. Factors associated with an increased risk of inadequate endometrial tissue after endometrial sampling were menopausal state, overweight and obese, unemployed, nulliparous, primipara and use of hormonal contraception.

Rural-urban inequalities in health care utilization in Bhutan: a decomposition analysis.

BACKGROUND AND OBJECTIVE: On the trajectory towards universal health coverage in Bhutan, health equity requires policy attention as significant disparities exist between urban and rural health outcomes. This paper examines health services utilization patterns, inequalities and their socio-economic determinants in rural and urban areas and decomposes the factors behind these differences. METHODS: We used the Bhutan Living Standard Survey 2017 to profile health services utilization patterns and equalities. We employed two different decomposition analyses: decomposition of mean differences in utilization using the Oaxaca-Blinder decomposition framework and differences in the income-related distribution in utilization using recentered influence function regressions between rural and urban areas. RESULTS: Significant differences exist in the type of outpatient services used by the rural and urban population groups, with those living in rural areas having 3.4 times higher odds of using primary health centers compared to outpatient hospital care. We find that the use of primary health care is pro-poor and that outpatient hospital resources is concentrated among the more affluent section of the population, with this observed inequality consistent across settings but more severe in rural areas. The rural-urban gap in utilization is primarily driven by income and residence in the eastern region, while income-related inequality in utilization is influenced, aside from income, by residence in the central region, household size, and marriage and employment status of the household head. We do not find evidence of significant mean differences in overall utilization or inequality in utilization of inpatient health care services. CONCLUSIONS: While the differences in average contacts with health services are insignificant, there are prominent differences in the level of services availed and the associated inequality among rural and urban settings in Bhutan. Besides, while there are obvious overlaps, factors influencing income-related inequality are not necessarily the same as those driving the utilization gaps. Cognizance of these differences may lead to better informed, targeted, and potentially more effective future research and policies for universal health coverage.

Demographic risk factors for extra-pulmonary tuberculosis: a rising public health threat in Bhutan.

BACKGROUND: Recently, extra-pulmonary tuberculosis (EPTB) has been increasingly reported in Bhutan, rising from 26% in 2001 to 39% in 2010. In 2016, almost half (49%) of all reported TB cases were classified as EPTB. Thus, this study was conducted to understand the epidemiology and identify risk factors contributing to increasing notification of EPTB in Bhutan. METHODS: A case-control study was conducted by recruiting all 110 cases of nationally notified EPTB (Extrapulmonary bacteriologically confirmed/EPBC) as cases and 235 Pulmonary TB (Pulmonary bacteriologically confirmed/PBC) as controls. Data were collected on socio-demography, clinical and diagnostic, behavioral and lifestyle and environmental exposures using a structured questionnaire between April and September, 2018. RESULTS: The median age of the cases was 25 years, ranged 9-79 years. Lymphatic TB was predominant (n = 78; 70.91%) followed by genitourinary TB (n = 4 (3.64%). The likelihood of EPTB decreased with increase in age (p = 0.023). The odds of EPTB in females was 1.65 times higher than the males (p = 0.038). Increase in Body Mass Index (adjusted odds ratio (AOR): 1.1; 95% confidence interval (CI): 1.052-1.200) and urban residency were (AOR 1.6; 95% CI 1.016-2.805) were found to have higher odds of developing EPTB. CONCLUSION: Females, urban residents, and those with higher BMI are at increased risk of developing EPTB. These at-risk groups can be used to target limited public health resources to control EPTB in Bhutan.

Efforts toward the Elimination of Visceral Leishmaniasis in South Asia: A Review of Progress in Bhutan.

Leishmaniases are a group of diseases under the category of neglected tropical diseases targeted for global elimination. However, they continue to pose major clinical and public health problems, especially among those living in poor socioeconomic conditions. Here, we summarize leishmaniasis elimination efforts in Bhutan. Between 1994 and 2022, Bhutan recorded 54 cases of leishmaniasis across 14 of its 20 districts. There are seven species of Phlebotomus and three species of Sergentomyia sand flies documented in the country. At a subnational level, all endemic districts recorded a visceral leishmaniasis annual incidence <1 per 10,000 population, meeting the regional elimination targets. Serological testing with ELISA and molecular testing with polymerase chain reaction were established at the Royal Center for Disease Control in 2022. A leishmaniasis prevention and management guideline was adopted in 2023 to aid clinicians in diagnosis and management. Active and passive case surveillance was integrated with the national infectious disease early warning and response system. Risk-based entomological surveillance and control have also been prioritized. Climate change may play a major role in rendering districts in the temperate zone favorable for vector proliferation. The country's medical university introduced a diploma course in medical entomology in 2023 to augment the human resources needed for vector surveillance efforts. However, leishmaniasis elimination lacks dedicated programmatic management amid competing priorities for resources against other infectious diseases. Leishmaniasis elimination requires a targeted and programmatic approach in Bhutan, including cross-border collaborative efforts with neighboring Indian states. Bhutan remains highly committed to achieving leishmaniasis elimination targets.

A new species of the Anopheles barbirostris complex (Diptera: Culicidae) from Bhutan.

Anopheles sarpangensis Somboon, Namgay & Harbach is described as a new species of the Barbirostris Complex of the subgenus Anopheles Meigen. The adults differ from other species of the complex in having wings with a prehumeral pale spot on the costa, foretarsomere 1 with an apical pale band more than half as long as foretarsomere 5, midtarsomeres 1 and 2, and occasionally 3 and 4, with incomplete apical pale bands, and abdominal sterna with many white scales as in An. campestris Reid, An. saeungae Taai & Harbach, and An. wejchoochotei Taai & Harbach. The pupa and larva are indistinguishable from the pupae and larvae of other species of the complex. Phylogenetic analysis revealed that COI sequences form a clade separate from clades consisting of the sequences of other species of the complex. The immature stages were commonly found in fishery ponds in foothills at low to moderately high altitudes in the Sarpang District of Bhutan.

Respiratory syncytial virus among hospitalized patients of severe acute respiratory infection in Bhutan: Cross-sectional study.

Introduction: Respiratory syncytial virus (RSV) is a leading cause of lower respiratory tract infections worldwide, particularly in young children. In Bhutan, respiratory disease continues to be among the top 10 diseases of morbidity for several years. This study aimed to estimate the prevalence of RSV among hospitalized patients with severe acute respiratory infection (SARI) in Bhutan. Method: Respiratory specimens were collected from SARI patients of all ages in 2016 and 2018 following influenza surveillance guidelines. Specimens were tested for influenza and RSV, human metapneumovirus, adenovirus, and human parainfluenza virus types 1, 2, and 3 using real-time reverse-transcription polymerase chain reaction assay. Descriptive statistics were used to analyze the result in STATA 16.1. Result: Of the 1339 SARI specimens tested, 34.8% were positive for at least one viral pathogen. RSV was detected in 18.5% of SARI cases, followed by influenza in 13.4% and other respiratory viruses in 3%. The median age of SARI cases was 3 (IQR: 0.8-21 years) years. RSV detection was higher among children aged 0-6 (Adj OR: 3.03; 95% CI: 1.7-5.39) and 7-23 months (Adj OR: 3.01; 95% CI: 1.77-5.12) compared with the children aged 5-15 years. RSV was also associated with breathing difficulty (Adj OR: 1.73; 95% CI: 1.17-2.56) and pre-existing lung disease, including asthma (Adj OR: 2.78; 95% CI: 0.99-7.8). Conclusion: Respiratory viruses were detected in a substantial proportion of SARI hospitalizations in Bhutan.

Seasonal Hyperacute Panuveitis (SHAPU) in Bhutan.

PURPOSE: To report the first series of Seasonal Hyperacute Pan Uveitis (SHAPU) from Bhutan. METHODS: We retrospectively analyzed the patients with clinically diagnosed SHAPU treated in the referral center in the last 5 years. Data included demographics (age, sex, laterality), region, time of presentation (year, season) and treatment received. RESULTS: The series included 3 males and 2 females. The mean age was 16 years. Three patients had presented in autumn of 2021, and two in autumn of 2019. Four patients presented within 2 weeks of the onset of symptoms. All patients had either exposure or contact with white moths. All patients presented with unilateral sudden painless reduction in vision and low Intraocular pressure. Four patients required vitrectomy. The final visual acuity of 3 patients was >6/36, and one patient was 6/60. CONCLUSIONS AND IMPORTANCE: The time of presentation and early treatment intervention are crucial in achieving good visual prognosis in SHAPU.

Comparison of Laboratory and Non-Laboratory-Based 2019 World Health Organization Cardiovascular Risk Charts in the Bhutanese Population.

The World Health Organization (WHO) recommends the use of color-coded cardiovascular disease (CVD) risk charts for CVD management. This study evaluated the agreement between the laboratory and non-laboratory 10-year CVD risks based on 2019 WHO CVD risk-prediction charts. The agreement of CVD risk scores among 40- to 69-year-old Bhutanese population stratified by gender and age groups (<60 and ≥60 years) was determined via weighted kappa statistics. In the general population, there was substantial agreement between the two CVD risk score charts for all ages and <60 years but a moderate agreement for participants aged ≥60 years. In males, substantial agreement was observed in all ages and in <60 years and moderate agreement in ≥60 years. In females, both the predictions showed substantial agreement in all ages and <60, but a moderate agreement for ≥60 years. The non-laboratory-based risk charts can be used interchangeably with laboratory-based charts for predicting 10-year CVD risk in resource-constrained countries like Bhutan.

Context dependent cognitive development in Bhutanese children.

We assessed risk/protective factors for cognitive development of Bhutanese children (504 3-5 year-olds, 49% girls, major ethnicities Ngalop 26%, Tshangla 30%, Lhotsampa 34%) using a non-verbal test of cognitive capacity (SON-R) and primary caregiver interviews. Cognitive capacity was related to the family's SES and whether the family belonged to the primary Buddhist majority ethnic groups (Ngalop or Tshangla) or primarily Hindu minorities (Lhotsampa). In majority families more engagement in Buddhist practices was associated with higher cognitive capacity in children. Minority children were more impacted by parents autonomous-relatedness values. Results demonstrate that cognitive development is dependent on the financial and educational context of the family, societal events, and culture specific risk/protective factors that differ across sub-groups (majority/minority, culture/religion).

Challenges in the management of high-altitude illnesses and emergencies in Bhutan and Nepal.

Many popular tourist attractions and trekking routes in Bhutan and Nepal are situated between 3000 and 6000 m in elevation. High-altitude emergencies are becoming more common and medical providers must be aware of the practical and medical issues in managing these disorders. We reflect on the challenges in providing high-altitude emergency medical services in Bhutan and Nepal.

Introducing seasonal influenza vaccine in Bhutan: Country experience and achievements.

Bhutan successfully introduced multiple vaccines since the establishment of the Vaccine Preventable Disease Program in 1979. Surveillance and subsequent introduction of influenza vaccination became a public health priority for the Ministry of Health following the influenza A(H1N1)pdm09 pandemic. Sentinel surveillance for influenza in Bhutan began in 2008, and a study of severe acute respiratory infection was conducted in 2017, which found the highest influenza burden in children aged <5 years and adults ≥50 years. Following review of surveillance and burden of disease data, the National Technical Advisory Group presented recommendations to Bhutan's Ministry of Health which approved influenza vaccine introduction for all five high-risk groups in the country. Upon the official launch of the program in June 2018, the Vaccine Preventable Disease Program began planning, budgeting, and procurement processes with technical and financial support from the Partnership for Influenza Vaccine Introduction, the United States Centers for Disease Control and Prevention, the Bhutan Health Trust Fund, and the World Health Organization. Influenza vaccination for high-risk groups was integrated into Bhutan's routine immunization services in all health care facilities beginning in November 2019 and vaccinated all populations in 2020 in response to the COVID-19 pandemic. Coverage levels between 2019 and 2022 were highest in children aged 6-24 months (62.5%-96.9%) and lowest in pregnant women (47.7%-62.5%). Bhutan maintained high coverage levels despite the COVID-19 pandemic by continued provision of influenza vaccine services at health centers during lockdowns, conducting communication and sensitization efforts, and using catch-up campaigns. Bhutan's experience with introducing and scaling up the influenza vaccine program contributed to the country's capacity to rapidly deploy its COVID-19 vaccination program in 2021.

The Himalayan uplift and evolution of aquatic biodiversity across Asia: Snowtrout (Cyprininae: Schizothorax) as a test case.

Global biodiversity hotspots are often remote, tectonically active areas undergoing climatic fluctuations, such as the Himalaya Mountains and neighboring Qinghai-Tibetan Plateau (QTP). They provide biogeographic templates upon which endemic biodiversity can be mapped to infer diversification scenarios. Yet, this process can be somewhat opaque for the Himalaya, given substantial data gaps separating eastern and western regions. To help clarify, we evaluated phylogeographic and phylogenetic hypotheses for a widespread fish (Snowtrout: Cyprininae; Schizothorax) by sequencing 1,140 base pair of mtDNA cytochrome-b (cytb) from Central Himalaya samples (Nepal: N = 53; Bhutan: N = 19), augmented with 68 GenBank sequences (N = 60 Schizothorax/N = 8 outgroups). Genealogical relationships (N = 132) were analyzed via maximum likelihood (ML), Bayesian (BA), and haplotype network clustering, with clade divergence estimated via TimeTree. Snowtrout seemingly originated in Central Asia, dispersed across the QTP, then into Bhutan via southward-flowing tributaries of the east-flowing Yarlung-Tsangpo River (YLTR). Headwaters of five large Asian rivers provided dispersal corridors from Central into eastern/southeastern Asia. South of the Himalaya, the YLTR transitions into the Brahmaputra River, facilitating successive westward colonization of Himalayan drainages first in Bhutan, then Nepal, followed by far-western drainages subsequently captured by the (now) westward-flowing Indus River. Two distinct Bhutanese phylogenetic groups were recovered: Bhutan-1 (with three subclades) seemingly represents southward dispersal from the QTP; Bhutan-2 apparently illustrates northward colonization from the Lower Brahmaputra. The close phylogenetic/phylogeographic relationships between the Indus River (Pakistan) and western tributaries of the Upper Ganges (India/Nepal) potentially implicate an historic, now disjunct connection. Greater species-divergences occurred across rather than within-basins, suggesting vicariance as a driver. The Himalaya is a component of the Earth's largest glacial reservoir (i.e., the "third-pole") separate from the Arctic/Antarctic. Its unique aquatic biodiversity must be defined and conserved through broad, trans-national collaborations. Our study provides an initial baseline for this process.

Human rabies encephalomyelitis in the background of rabies outbreak in animals in Gelephu, Bhutan, 2023: a case report.

BACKGROUND: Rabies continues to pose significant public health challenges in many developing countries including Bhutan. A probable case of rabies was admitted to our hospital and its reporting led to the uncovering of an outbreak in domestic and wild animals. We discuss the challenges in the diagnosis and management of rabies in a resource-limited setting. CASE PRESENTATION: A 35-year-old male presented with intermittent fever, bilateral lower limb weakness that was rapidly progressive, urinary incontinence with episodes of palpitations and sweating. He had sustained a Category III bite on the right lower thigh with four bite marks, inflicted by a stray dog. He had received post-exposure prophylaxis with intra-dermal anti-rabies vaccine. On initial examination, the patient was in distress but cooperative for the interview. He had pulse rate ranging from 60 to 100/min with episodes of diaphoresis and palpitations, but with normal capillary blood glucose. In the lower limb, the muscle power was zero with absent tendon reflexes in the lower limb and impaired abdominal reflex below T10 level. He had hyperaesthesia below T8, hydrophobia, aerophobia and photophobia. He had multiple spontaneous fasciculations in both the thighs and right deltoid and these later involved the intercostal muscles, neck and face muscles. He had altered sensorium and desaturation for which he required mechanical ventilation. Polymerase chain reaction for rabies virus was negative in cerebrospinal fluid and saliva. Rabies virus neutralizing antibody was negative in cerebrospinal fluid but had high titres in the serum. He received Human Rabies Immunoglobulin after admission. He was managed in the intensive care unit and died 23 days later. After this case was notified, a rapid response team was deployed in the field, and uncovered rabies outbreak in animals in the locality. CONCLUSIONS: This case called for a serious evaluation of the country's efforts in achieving zero rabies deaths by 2030. The management of this case identified several critical areas of context-specific interventions in Bhutan. There is also an urgent need to improve diagnostic capabilities at the national reference laboratory and enhance the technical competencies of healthcare workers in the management of dog bite cases.

Determinants of Neonatal Mortality in Bhutan: A Case-Control Study.

More than half of Bhutan's under-five mortality is attributed to neonatal deaths. Despite this, there is a lack of local evidence on determinants of neonatal mortality. It is critical to generate new evidence to accelerate interventions to achieve sufficient reduction of neonatal mortality rate in line to sustainable development goal target 3.2. Thus, this study was aimed at exploring determinants of neonatal mortality in Bhutan. A case-control study was performed with reported neonatal deaths from hospitals and primary health centers between 2018 and 2019. A total of 181 neonatal deaths were included as cases along with three corresponding controls. Epidata and STATA were used for data management and analysis, respectively. A multivariable model was fitted to identify determinants of neonatal mortality. History of obstetric complications (odds ratio [OR] = 3.53; 95% confidence interval [CI] = 1.48-8.42), intrapartum complications (OR = 3.86; 95% CI = 1.71-8.74) gestational age (OR = 8.07; 95% CI = 2.89-22.52), and Apgar 1 minute (OR = 4.40; 95% CI =1.83-10.59) were associated with neonatal death. Therefore, quality of care during pregnancy and childbirth besides promoting supportive family environment is essential to reduce neonatal mortality.

Lessons and Best Practices on Risk Communication and Infodemic Management during the COVID-19 Pandemic in Bhutan.

During the recent COVID-19 pandemic, risk communication and community engagement (RCCE) were instrumental in inducing behavior change in tandem with the evolving evidence and phases of the pandemic. Infodemic management also became one of the areas where much emphasis was laid in Bhutan's response to the COVID-19 pandemic along with other critical response strategies such as surveillance, contact tracing, quarantine, isolation, and testing. Over the past 3 years of the pandemic, much has been learnt about the significance and impact of RCCE. In this article, the authors will highlight some of the methods and practices that were implemented to manage public information and also share experiences with regard to RCCE over the course of Bhutan's response to the pandemic. Furthermore, it will also outline some of the media and risk communication mechanisms that were in place before Bhutan's response to the COVID-19 pandemic.

Malaria outbreak along the India-Bhutan border town of Saralpara, Assam, India.

BACKGROUND & OBJECTIVES: A remarkable progress is being made in the South-East Asia region in reducing the burden of malaria. While all countries are committed to malaria elimination, continued transmission at and across international borders poses a threat to achieving this goal. METHODS: We investigated an outbreak of malaria in the India-Bhutan border area in a district of Assam state, India. A line listing of cases occurring during the outbreak period was made and a house-to-house survey was carried out to identify additional cases in the community. Entomological investigation consisted of light trap collection of vectors. Patients and health workers were interviewed to obtain information on the possible mode of transmission and ongoing inter-country collaboration across the border. RESULTS: Between October 21 to November 18 2022, 37 cases of malaria (all Plasmodium vivax), were diagnosed in Saralpara area of Kokrajhar district of Assam, bordering Bhutan. Of these four were diagnosed in Sarpang hospital, Bhutan. Median age was 20 years (range 3 to 70 years). Male to female ratio was 1:1.2. In addition, 6 individuals with asymptomatic malaria were detected in the community through an active case finding campaign. No cases were however reported on Bhutan side of the border. Anopheles culicifacies and An. annularis were identified from light trap collection. Saralpara is a remote and forested area where most of the residents are poor and engaged predominantly in farming activities. Being a harvesting season, they tend to stay overnight to protect their harvest from elephants. The health authorities in India and Bhutan exchanged information regularly at district-to-district level on the outbreak including through available and easy modes such as WhatsApp, telephone as well as electronic mail and collaborated in coherently implementing preventive measures on both sides and in managing the cases. INTERPRETATION & CONCLUSION: The outbreak of malaria in Saralpara demonstrates the risk of malaria outbreak in remote and forested areas, with possibility of spill over to the other side of the border. The fact that two countries had excellent inter-country cross-border collaboration and prior commitment thereby preventing further transmission of malaria to Bhutan can serve as a best practice for cross-border control of malaria and other communicable diseases.

Aversive Reaction Between Disulfiram and Betel Quid Among Inpatients With Alcohol Use Disorder in Bhutan: A Preliminary Study.

Betel quid (BQ) is commonly used in the Asia-Pacific region. Disulfiram is prescribed for people with alcohol use disorders (PwAUDs) after the completion of detoxification as an alternative to rehabilitation. This prospective observational study reported the aversive reactions and common symptoms of disulfiram and BQ in PwAUDs. Participants included PwAUDs admitted to the psychiatric ward at the Jigme Dorji Wangchuck National Referral Hospital for detoxification, who were on Disulfiram and using BQ at the same time. Aversive reactions between disulfiram and BQ were observed for 100 patients over a year. Twenty participants showed aversive reactions between BQ and disulfiram. Common symptoms included sweating, diarrhea, dizziness, tremors, palpitations, shortness of breath, nausea and vomiting, and headache. Since PwAUDs in Bhutan are inducted on disulfiram after detoxification, and most use BQ simultaneously, this study will help inform health care providers to educate people about the aversive reactions of disulfiram and BQ.

The presence of wild edible plants and determinants influencing their harvest, consumption, and conservation in south eastern Bhutan.

DEFINITION: Wild edible plants (WEPs) grow naturally in self-maintaining ecosystems. WEPs are harvested for consumption, sale, and medicinal uses. We hypothesize that WEPs play a major role in supplying food and generating income for the rural people in a world that is increasingly recognising its emerging conservation issues. We tested this hypothesis by identifying the reasons for harvest, consumption, and conservation of WEPs using focus group discussion, field observations and questionnaire surveys in south eastern Bhutan in late 2019. METHODS: Focused group discussions were held with the local people to identify reasons for harvest and consumption of WEPs. Data on the identified reasons for harvest, consumption, and conserving WEPs were determined using a questionnaire survey with ranking scales for a set of 76 randomly selected households. Representative field-observations and questionnaire surveys were carried out in villages close to forests. Parts of the plant used, how these were consumed, harvest season, and plant (life form) were recorded. The data was subjected to a Kruskal-Wallis rank sum test and weighted averages calculated. RESULT AND CONCLUSION: A total of 120 WEPs belonging to 63 families (including Agaricaceae) were reported. Most of the WEPs recorded were trees (45.0%) then herbs (25.8%), vines (13.3%) and shrubs (10.8%). The commonly consumed plant parts were the fruit (43.3%), shoots (28.3%) and leaves (20.8%). The purposes for harvesting and consumption, conservation of WEPs were significantly (P<0.001) different, while the motivations for collecting WEPs were not. The motivation for collecting WEPs were family consumption > sale > medicinal uses > preservation for future use > insufficient food from cultivated source's. The two most important strategies for conservation were to domesticate the WEPs and cultivate in forests. The findings reveal valuable lessons and insights about the reasons for harvesting, collection, consumption, and conservation of WEPs.

Healthcare in the Himalayan Kingdom of Bhutan: Lessons for the United States and other western healthcare systems.

Bhutan has demonstrated a trajectory of advances in healthcare, while still remaining true to its culture and traditional forms of medicine. Most recently, Bhutan gained international attention when it implemented a strategic Covid-19 vaccination programme that protected a greater percentage of its population than observed in Western industrialised nations. This accomplishment supports the idea that there are lessons from Bhutan to be shared with the rest of the world. In this work, we delineate our observations of the Bhutanese healthcare system, based on field observations in several Bhutanese cities, and results from surveys of Bhutanese physicians. We identify a number of unique practices that influence patient compliance, health education, and access to care in the Bhutanese system, that may be of particular interest and applicability to other healthcare systems. These include housing multiple health services at one location, fully funded medical visits, using non-physician teachers for health education and use of Gross National Happiness (GNH) measures in care.