BY SONAM ONGMO, TEJ PARIKH in Foreign Policy
After 25 years of service, Bhutan’s first and longest-serving psychiatrist—one of only four in the entire country—has retired. He did so with some trepidation. Chencho Dorji, 60, has come to accept that there are many things he cannot control.
“I don’t want to bang my head against the wall anymore,” he said earlier this summer, referencing growing drug- and alcohol-related mental health problems in the remote Buddhist kingdom. “I know my service has made a difference, so I will not stop working for this cause.” He is already working on awareness campaigns and is keen to open a model rehabilitation center for those recovering from addiction.
In a country known for its development philosophy of Gross National Happiness, which places the well-being of people above gross domestic product, the substance use pandemic has become a glaring issue.
Despite its vision for sustainable growth, the Himalayan nation has struggled to stay ahead of change. In recent decades, the path to modernization has been fraught with social dislocation, limited economic opportunity, and rising exposure to alcohol and pills, which has led to an increase in addiction cases.
Dorji fears that a lack of commitment to the problem from the government and limited public understanding could make it worse.
Alcoholism is already the biggest killer in Bhutan, according to a recent government report. It is responsible for over 50 percent of patient deaths in hospitals, with many more going unreported. Meanwhile, over 70 percent of suicide cases in the country are linked to drug and alcohol addiction. Indeed, Bhutan—which has a population of around 800,000 people—ranks in the top third of countries by suicide rate globally, according to the World Health Organization (WHO).
Drug use is a growing concern among Bhutan’s youth. A national survey in 2017 found that around two-thirds of university students use their pocket money to buy alcohol, drugs, and other substances. And drug overdose cases in hospitals have been ticking up over the years. In 2017, police in the country’s capital, Thimphu, arrested around 600 people in connection with the abuse, possession, and illegal transaction of controlled substances, the highest in recent years. And with over 10 percent of those ages 13 to 17 using marijuana, Bhutan has among the highest proportion of adolescents currently using the drug in WHO’s Southeast Asia region.
The burden on Bhutanese society is huge. The country’s official statistics agency reports that the socioeconomic cost of alcohol amounted to 5 billion ngultrum, about $70 million, in 2014—four times higher than the revenue alcohol sales bring in returns in revenue.
Bhutanese will often admit that alcoholism and drug addiction are, indeed, a major problem in their society. After all, many person in the country has lost a relative, friend, or acquaintance to excessive substance use. But few are likely to speak up.
For some, the silence is part of a resigned acceptance of an increasingly routine way of life; for others it is about preserving the Himalayan kingdom’s pristine image as the last Shangri-La. “Drinking is sort of embedded in our culture—after all, alcohol features in every religious occasion, and we accept these traditions without questioning it,” said Kesang, whose brother died from a drug overdose at 18 and whose name has been changed to protect his privacy. “Either that, or we have given up on our government [treating] it as a national emergency,” said Kesang, who struggles with alcoholism himself, adding that while officials often talk zealously about the country’s challenges, action is thin on the ground.
Health workers, civil society organizations, and ordinary citizens share his sentiment. But Tandin Chogyal, once a senior program officer for the Mental Health and Substance Abuse program at the Ministry of Health, said he feels the government had done all it could.
He pointed out that WHO endorsed a global alcohol policy in 2010 encouraging member states to take community-led action, and Bhutan did create a task force soon after, following a spate of alcoholism-linked suicides. Yet a nationwide agenda took a further six years to be approved by the government. “There is a very laid-back attitude while lives are at stake and families affected. There isn’t enough commitment,” said an official who wanted his name withheld. Many remain unaware if the national plan is being implemented or not—and, if it is, how effectively.
“We have policies and legislations, rules and regulations, but when it comes to implementation, I think we are not very effective,” said Damber K. Nirola, a doctor at the Thimphu Hospital. Even then, laws alone will do little to resolve what is a complex social problem.
It has been less than 60 years since the landlocked, mountainous country, nestled between India and Tibet, opened up to the outside world with its first motor road. TV and the internet only arrived in 1999. Since then, traditional ways of life have been transformed, and policymakers have not been able to respond to the changes fast enough.
With development came rapid rural to urban migration, one of the fastest in South Asia, according to the United Nations Development Program’s 2009 human development report. Many people, particularly from the younger generations, have been eager to leave behind their subsistence farming backgrounds in rural Bhutan for education and employment opportunities in cities.
Many people, particularly from the younger generations, have been eager to leave behind their subsistence farming backgrounds in rural Bhutan for education and employment opportunities in cities.
This has led to villages, communities, and extended family structures breaking down, Nirola said. It has also driven an increase in mental health issues, including personality disorders in young people, which, according to Dorji, has exacerbated substance use and led to a vicious cycle of addiction.
This may explain why despite the Gross National Happiness policy, Bhutan still only ranks 95th out of 156 countries in the 2019 World Happiness Report.
The initial challenge is the access to addictive products. Domestic alcohol production and outlets have dramatically increased in recent years. This, according to Dorji, has contributed to the exponential growth in alcoholism and drug use.
Official figures suggest there is one bar for every 90 people. Meanwhile the lucrative production of hard liquor by the government remains the elephant in the room.
While the sale and production of local home-brews are not permitted, for sanitary reasons, industrial production is legal. The alcohol industry’s effective marketing and distribution system means liquor is quickly penetrating all corners of the country.
There are a total of seven breweries, four private and three operated by the Army Welfare Project Ltd., a commercial enterprise of the government. The four private breweries produce beer with an 8 percent alcohol limit, while the Army Welfare Project produces mostly hard liquor, around 80 percent of which is exported.
While revenue from the sale of alcohol is significant, it does not cover the economic losses incurred as a result of alcohol-related harm, loss of productivity, and premature deaths, according to the government’s own report.
“We aren’t here to control production, and prohibition has never worked, but we try to convey to [the Army Welfare Project] that they can help us in providing some services for alcoholism through public education and supporting rehabilitation centers,” Dorji said. “There has to be some corporate social responsibility.”
Kesang, who says he has relapsed time and again, said that while the bulk of government products are being exported, the 20 percent or so that remains for domestic consumption is still doing damage. “Most Bhutanese I know cannot afford imported drinks so, like me, they drink only locally produced hard liquor like Rock Bee,” he said.
Bhutanese society then, it seems, is faced with a conundrum. “At the end of the day, people like to hold the drinker responsible,” Nirola said. “And that is a problem, because when it comes to drugs or prescription pills, the suppliers are hunted and punished, but when it comes to alcohol, supplying it doesn’t seem to be a problem. Something has to change.”
When it comes to drug addiction, it is the excessive use of prescription medication that has been the main problem. According to Dorji, the habit became widespread after students studying outside the country picked it up in the early 1980s. Marijuana grows wild in Bhutan, but its use has always been minimal. The most frequently used and trafficked drugs are painkillers and sedatives containing synthetic opioids, which are more potent than natural ones. Most are produced in India, with which Bhutan has open borders.
Dorji emphasized that community-based approaches to addiction and mental health treatment are the only way forward in a society that lacks resources, expertise, and government interest. “The problem with mental health and addiction is that by the time patients break down, families are burnt out,” he said.
“If you have a large hospital to accommodate patients, then families will drop them off and never come back. Asylums are not the answer,” he added. He believes training to develop mental health care knowledge across the country, so patients can be treated in their own communities, would be more effective.
Dorji recounted a story of how in the early 1980s, a foreign psychologist working in Bhutan recommended opening a 200-bed treatment center in Bumthang. The plan was endorsed by health officials only to be annulled by the king, who believed he had a better understanding of what the country needed.
The money was redirected toward plans for a 40-bed rehabilitation center instead. But that was then downgraded, several times, by health officials to a single psychiatric ward, then to a renovation of the current facility, and down finally to a simple paint of the existing ward. “So we left it at that,” Dorji said. Further highlighting the lack of direction from the government, another official said, between the Bhutan Narcotics Control Authority board members did not meet at all from 2014 to 2017.
“The problem is that boards in Bhutan treat their duty as a social obligation and often lack an interest in their responsibilities. Nobody asks difficult questions,” he said. “Boards should be the driving force that lead NGOs to do their work.”
This year, newly elected Prime Minister Lotay Tshering, a former surgeon, increased the salaries of health and education officials. Whether this will change anything is yet to be seen. Meanwhile, health officials and those recovering from addiction say that even as the government targets prevention and cure, the country is lagging behind in its efforts in aftercare. The lack of economic opportunities to absorb the droves of people arriving in cities from rural areas also needs to be addressed.
“Many of the users return from rehabs only to be left with no jobs. Many of them are on their own, don’t have an education or skills,” said one person recovering from addiction. “Most of the time I see them going back to selling drugs to support themselves and then relapsing.”
Dorji pointed out that if people fail to prioritize mental health issues and continue to stigmatize, rather than support, those addicted to alcohol and drugs, nothing will change. Until awareness and education grows nationally, he said, Bhutan’s addiction problems will only get worse.
“If you look at Bhutanese politics today, campaigns completely ignore civil servants, the most intelligent group in society, and focus directly on villagers who have little understanding of what is really needed to change society for the better,” he said. “Politicians don’t give importance to it, and people don’t seem to demand it either.”
Sonam Ongmo is a journalist from Bhutan. Twitter: @sonamwongmo
Tej Parikh is a global policy analyst and journalist. He was previously an associate editor and reporter at the Cambodia Daily. Twitter: @tejparikh90