Tiempo Climate Newswatch, Climate and Health in Bhutan

	Dago Tschering and Gyambo Sithey identify the main areas in which Bhutan is at risk from adverse climate change effects on health.
Higher morbidity and mortality from extreme weather and climate events and an expansion of vector-borne and water-related diseases are expected. The authors consider that the sector’s primary role lies in emergency preparedness for damage control and that the health sector’s participation in all areas identified as vulnerable to the adverse effects of climate change must be recognized.
Dago Tshering is environment education officer for the Royal Society for Protection of Nature in Thimphu, Bhutan. Gyambo Sithey is a consultant with the Centre for Research in Thimphu, Bhutan.

The Kingdom of Bhutan is sandwiched between the world’s most populous countries, India and China. The terrain is among the most rugged and mountainous in the world. The Himalayas form a formidable natural boundary in the north and the plains of India border the southern part of the country.

Bhutan’s climate is influenced mainly by the monsoon, which blows in from the Bay of Bengal, local topography and the variation in elevation as one moves from south to the north. In general, Bhutan has three distinct climatic zones: the southern foothills, the inner Himalayas, and higher Himalayas. While southern Bhutan is generally hot and humid, the central inner Himalayas have a cool climate. The inner Himalayan Mountains in the northern borders of the country experience severe alpine climate conditions and are under perpetual snow.

Modern medical care in Bhutan began in the early 1960s. Since then, the Royal Government has been providing free healthcare services and it has been the national health policy to provide an integrated, equitable, cost-effective and well-balanced health services to all Bhutanese. Following the World Health Organization’s Alma-Ata Declaration on primary healthcare, the Royal Government chose to use primary healthcare as its core thrust to reach the rural population scattered over the rugged mountainous terrain of Bhutan. Bhutan has, therefore, committed itself to the ideals of "Health For All". Currently, there are 1.8 doctors per 10,000 people and 14 hospital beds per 10,000 people.

Bhutan’s resident population is 634,982 with 69.1 per cent of the population still residing in rural areas. The Total Fertility Rate has reduced from 5.6 in 1994 to 2.6 in 2005. The rate of growth (the difference between the number of births and deaths in a population) is 1.3 per 1000 population, compared to 3.1 in 1994. The infant mortality rate has been reduced to 40 per 1000 live birth from 70.7 per 1000 live births in 1994. Access to safe drinking water in the community is an important parameter as there is a high association between safe drinking water, hygiene, sanitation and morbidity. Currently, 84 per cent of households drink from piped water either within the house (22.7 per cent) or from outside the house(61.5 per cent). In terms of sanitation, only ten per cent of the houses do not have toilet facilities; 90 per cent have either an independent flush toilet or pit.

Acute respiratory infection and diarrhoeal diseases lead in the ten most common diseases in the country. Following these, skin infection, viral and/or bacterial intestinal infections, gastritis and peptic ulcer, conjunctivitis, malaria and other infectious diseases are most prevalent. Acute respiratory infection alone contributes to an average 20-25 per cent of the morbidity cases, followed by diarrhoeal diseases contributing to another 10-15 per cent of the morbidity cases. The top three diseases alone contribute to 40-50 per cent of the overall morbidity cases in Bhutan.

Mortality data for Bhutan are still very limited. Although routine collection of annual vital statistics has been a regular activity of health centres, data quality and coverage remains highly questionable due to various reasons like under-reporting. The accuracy of the diagnosis of a disease for the underlying cause of deaths is another weak area in the mortality data. Cardiovascular disease, cirrhosis of liver and accidental injuries are the most common causes of mortality. Malignancy is another emerging cause of death, though the incidence of communicable diseases like acute respiratory infection, diarrhoeal/dysentery and tuberculosis remains high.

Climate change health impacts

Changes in world climate would impact human health. While some health impacts would be beneficial, most of the impacts will probably be adverse. In Bhutan, there are three major areas of concern.

First, there would be higher morbidity and mortality from extreme weather and climate events. Four types of floods are common in tropical Asia: riverine floods, flash floods, glacial lake outburst floods and breached landslide-dam floods. Flash floods are common in the foothills, mountain borderlands and steep coastal catchments.

Second, there could be an expansion of vector-borne diseases. Many vector-borne diseases are sensitive to ambient temperature and precipitation. Even small changes in temperature and precipitation, or in vegetation, host populations or water availability, may increase or decrease the distribution and abundance of vectors, especially at the margins of their distribution, thus potentially changing their range.

Finally, there would be an increase in water-related diseases. As noted earlier, diarrhoeal diseases are one of the major causes of morbidity and mortality in a developing country such as Bhutan.

A mountainous region in Bhutan

Current public health concerns

Dengue, encephalitis, airborne environmental pollutants/asthma, diarrhoeal diseases (cholera) and malaria are all sensitive to climate change and are of particular public health concern in Bhutan today.

In Bhutan, dengue fever was first diagnosed and reported in July 2004 when an alarming number of people reported to Phuntsholing hospital with fever and rashes. Although the mosquito vectors Aedes aegypti and Aedes albopictus were known to exist in the southern regions, this was the first time that the disease was suspected and investigated.

A significant number of encephalitis cases have been reported from various hospitals around the country. The majority of them are caused by viruses and it is suspected that Japanese Encephalitis might be one of significant ones. Frequent outbreaks occur in neighbouring states of India.

Anecdotal data from medical doctors’ indicate an increased number of asthmatic cases every year. It is suspected that changes in the environment due to rapid urbanization and climatic changes could be relevant factors.

Diarrhoeal disease continues to be a major problem affecting the survival of the children in this country and remains one of the top causes of morbidity.

Finally, malaria is the second most fatal communicable disease in Bhutan and has been claiming about 18 lives (average) annually since 1995. Although there has been a significant reduction in the malaria case load, the case fatality ratio is still high.

Priorities for action

We consider that, as far as adverse climate change is concerned, the health sector’s primary role lies in emergency preparedness for damage control. In this respect, it is imperative to recognize the health sector’s participation in all areas identified as vulnerable to the adverse effects of climate change. In this regard, we recommend revisiting the Bhutan National Adaptation Programme of Action (0.6Mb download) in the context of health. Currently, the health area is confined to emergency medicine and this needs to be extended to cover health information and management for climate-sensitive infectious diseases.

There is a need to sensitize and become aware of the effects of climate change on human health among stakeholders. It would be beneficial to integrate meteorological data into the Health Information Management System for statistical analysis in respect to climate/seasonal diseases and gear towards developing an early warning system for probable outbreaks. Installation of weather stations in all of Bhutan’s malaria-endemic districts would ensure accurate meteorological data.

It is also necessary to develop guidelines and indicators for assessing morbidity, mortality and other health information (hygiene, sanitation, mental state and so on) of the population suffering from natural calamities. These key health statistics are required for immediate intervention as well as for surveillance and evaluation of affected communities.

Further information

Dago Tshering, Royal Society for Protection of Nature, Post Box 325, Drimen Lam, Thimphu, Bhutan. Fax: +975-2-323189. Email: dtshering@rspnbhutan.org. Web: www.rspnbhutan.org.

Gyambo Sithey, Centre for Research Initiative, Post Box 1358, Changangkha, Thimphu, Bhutan. Email: gsithey@yahoo.com.

On the Web

The report on which this article is based is available on-line on the Capacity Strengthening of Least Developed Countries for Adaptation to Climate Change Programme website, along with other national studies on climate change and human health.

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