By Julia Jenkins, DO, FAAFP, MMM

In November 2019, my husband, Todd, and I set off on the adventure of a lifetime as volunteers for 3 months in the Kingdom of Bhutan. We are both medical professionals; I am a hospice and palliative care physician and my husband is a mental health therapist. We had been looking to do international volunteer work that combined both of our professional skills for quite some time and found our perfect fit with Health Volunteers Overseas (HVO), an international medical education organization, and the ASCO International Cancer Corps (ICC). ICC is a partnership between ASCO and HVO to facilitate the exchange of medical expertise, develop training programs, and build long-term, supportive relationships between ASCO and the clinicians who provide cancer care in countries that have an HVO/ICC presence.

As I was going through the application and interview process, I learned of a pilot program that established a home-based palliative care program for patients with cancer in the Thimphu Valley. The pilot started in 2018 as a collaboration with the Lien Collaborative for Palliative Care, a project to enhance palliative care leadership and capacity in low-income countries. The pilot program has additionally been supported by HVO and ASCO with volunteer physicians and nurses who specialize in oncology and hospice and palliative care.

Establishing effective palliative care in a low- or middle-income country is filled with complexity in execution. The pilot program focused on patients with cancer located in the Thimphu Valley. The palliative care team is led by the surgical oncologist and comprises three talented nurses. The nurses do home visits focused on symptom management and coordination of care and are often accompanied by a Buddhist lama who provides spiritual support, prayer, and blessings for patients and their families.

Bhutan is often referred to as the happiest country on earth. Gross National Happiness (GNH) is a concept by which the Bhutanese live. The term was coined in 1972 by the Fourth King of Bhutan, Jigme Singye Wangchuck, who said in an interview, “Gross National Happiness is more important than Gross National Product.” Since that time, the Bhutanese government has used the GNH Index to measure the collective happiness and well-being of their population. While Gross National Happiness is a way of life for the Bhutanese, it does not remove the fact that they are people, just like you and I, who suffer from the same day-to-day problems as all people around the world. In Bhutan, cancer diagnoses are often made at later stages of disease and require travel to either the capital city of Thimphu or to India for treatment. The symptom burden can be heavy for both patients and families, who are often uprooted to care for their loved one in temporary housing.

I was incredibly honored to be able to help provide care for patients alongside three talented nurses, Yangden, Nima, and Ambika. They took me under their wing and helped orient me to the shops and markets of Thimphu as well as help me to purchase a traditional Bhutanese kira and tego to wear. Wearing the traditional clothing of Bhutan was quite an honor for me, and patients were thrilled to see me walk into their homes wearing it.

The palliative care program initially started with home visits twice weekly, which we were able to expand to three times weekly during my time with the team. As a team, we worked to establish the following palliative care parameters:

Bhutanese will benefit by:

• Improved pain and symptom control
• Decreased unnecessary suffering during treatment
• Avoidance of suffering during the dying process
• Achieving a sense of control over their illness
• Relief of the burden placed on family and attendants to the terminally ill patient
• Strengthened relationships with loved ones
• Having access to spiritual care in their homes when they are too ill to travel to a temple
• Decreased need for hospitalization
• Improved quality of life
• Decreased harm and suffering caused by non-beneficial care

The health care system will benefit by:

• Decreased need for patients to seek treatment at the hospital or outpatient department for symptom management
• Appropriate utilization of medication, staff, and physical resources
• Decreased cost associated with non-beneficial treatment of the dying patient
• Improved access for patients needing acute care, assessment, and hospitalization
• Improved patient satisfaction in the care provided to them

While these goals sound very familiar for U.S.-based health care teams who are well versed in quality improvement projects in a resource-rich environment, the reality of medical practice in a low-resource country creates its own unique challenges.

One particular challenge that stands out for me was the availability of medications. Bhutan has a limited formulary and supply of medications, with all medications needing to be imported, often only annually. The establishment of palliative care resulted in an increase in the use of medications such as morphine, leading to subsequent shortages. For the first 6 weeks of my time in Bhutan, we had no morphine to dispense to our patients. I was impressed at the incredible resourcefulness of the palliative care nurses, patients, and families in navigating this complex situation.

Patients quickly grew to recognize the benefit of palliative care and sought out the team for support of both their medical needs and their emotional and spiritual needs. I was fascinated to witness the complex rituals performed by the lamas. One memorable patient told me, “In Bhutan, religion and medicine are intertwined.” When we arrived in a patient’s home, the whole neighborhood would often gather for these blessings. I brought home with me many special treasures bestowed upon me during these visits: a piece of cloth from a guru’s robe, seeds blessed by thousands of monks thousands of times, prayer inscriptions, prayer flags, and cords knotted with blessings blown into them.

I am honored to have had the opportunity to participate in the development of such a meaningful program for the Bhutanese. During my time in Bhutan, I collaborated with other physicians with HVO, the World Health Organization, the Bhutan Cancer Society, the International Red Cross Society, and the Ministry of Health. We were able to set forth a plan for continued development and expansion of palliative care over the next several years. This truly was an experience of a lifetime for me. I made many lifelong friends, learned more than I ever could have imagined, and as a result there is no doubt in my mind that I have become a better physician.

Dr. Jenkins is a family medicine and hospice and palliative care physician and an ACO medical director in central Iowa. She has a strong background in both clinical medicine and administration with a focus on outcome-driven leadership and patient-centered care. Her personal interests include hiking, cooking, and world travel. Disclosure.