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Cultural Profiles

Bhutan

Background

Bhutan is an ethnically diverse country: it is comprised of the Ngalong in the west, the "central Bhutanese," the Sharchop in the east and the Lhotshampas or Nepali-Bhutanese in the south.

Lhotshampas is a term that other Bhutanese use to refer to Nepali-Bhutanese, the refugees which Canada has been accepting from Bhutan. The refugees do not prefer this term; rather, they like to be recognized as either Nepali-Bhutanese or Bhutanese.


Map: US Central Intelligence Agency

Bhutanese refugees are ethnic Nepalese whose origins trace to the eastern part of Nepal. In the late 1980s, with the formation of pro-Nepali-Bhutanese political parties, the Bhutan government perceived the Nepali-Bhutanese people as a growing threat. The Bhutan government introduced a series of repressive citizenship laws and "Bhutanization" policies which led to the political, economic, and cultural exclusion of the Nepali-Bhutanese people. This included denationalization of ethnic Nepalese as well as tightened requirements for obtaining and retaining their citizenship.

Additionally, in 1989, the government introduced a "one nation, one people" policy which restricted the practice of Nepali-Bhutanese culture by requiring Bhutanese to adopt a national dress code of Drukpa culture, and to terminate the use of Nepali language instruction in schools. Before this policy, Nepali-Bhutanese were allowed to wear their ethnic clothes, which are saris for women and daura suruwal for men. When the Nepali-Bhutanese revolted against the government for such encroachments on their civil rights, the government responded harshly to protests and public demonstrations by suspending public services such as schools and health services in the southern region. By 1992, only a small population of the Nepali-Bhutanese people remained in Bhutan.

Bhutanese refugees were not permitted to set up permanent refugee camps in India and were transferred en masse to Nepal. In Nepal, the refugees were divided into seven United Nations High Commissioner for Refugees (UNHCR) camps in Jhapa and Ilam districts in the southeastern region. Neither Nepal nor Bhutan were willing to give legalization/citizenship to this population, resulting in the refugees living in this state of liminality for over two decades. 

UNHCR Refugee Camps

Most of the refugees from Bhutan who arrived in Nepal between 1990 and 1993 were recognized on a prima facie basis by Nepal. With the large resettlement programme initiated in 2007 (see Resettlement of Refugees in Canada for further details), the dynamics of refugee camps changed significantly. The following are current challenges faced by the UNHCR operations at the refugee camps:

  • Maintaining services due to the departure of many skilled refugees

  • Various types of long-standing psychosocial issues due to the marginalization of this population

  • Questions of child custody and divorce need to be addressed prior to the departure of refugees for resettlement

  • Sexual and gender-based violence in the camps remain ongoing

  • The presence of the refugees from Bhutan in the seven camps has at times been perceived as harmful to the environment and the economic prospects of the host community.

  • The perception that services available in the camps are better than those for nationals has also led to resentment from refugee host communities

  • Political instability and sporadic violence throughout the eastern region continue to interfere with UNHCR operations


Resettlement of Refugees in Canada

A large-scale resettlement program was initiated in 2007 with the aid of seven countries, including Canada. When the resettlement movement first started, there were 108,000 Bhutanese refugees in the camps. As of August 2011, this population has grown to over 113,000 due to births. The seven countries have agreed to resettle 70,000 people.

In May 2007, the Government of Canada announced that it would resettle up to 5,000 Bhutanese refugees over the next 3-5 years. As of March 31, 2011, nearly 2,600 Bhutanese refugees had already arrived in Canada with additional arrivals continuing throughout 2011-2012.

 

Health Issues of Bhutanese Refugees

B12 deficiency

Found in 27-64% of Bhutanese refugees. From the NIH factsheet: clinical signs and symptoms include megaloblastic anemia, fatigue, weakness, constipation, loss of appetite, weight loss, numbness and tingling in the hands and feet, difficulty maintaining balance, depression, confusion, dementia, poor memory, and soreness of the mouth or tongue. The neurological symptoms of vitamin B12 deficiency can occur without anemia, and can be irreversible. 

Screening:

  • In the March 25, 2011 MMWR, CDC recommended that all Bhutanese refugees be given nutrition advice and supplemental B12 for minimum 30 days upon arrival in the country. Those with clinical manifestations should be tested for serum B12, and, if deficient, for underlying causes (including H.pylori).
  • The Minnesota Department of Health has slightly different recommendations: screen ALL Bhutanese refugees with a serum B12.
  • Bridge Clinic's approach is that, given the prevalence of B12 deficiency in the US studies, the prevalence of B12 deficiency-like symptoms (fatigue, depression, poor memory, numbness etc.) in our population anyway, the cost of eliciting the symptom history (clinical time, interpreter cost), and the fact that not all patients screened by nurses return to Bridge, we add serum B12 levels to the routine nursing screen for all Bhutanese.

 Treatment:

  • Recommended dosages vary. Those with significant neurological symptoms should receive initial IM injections of 1000ug vitamin B12, followed by oral doses of 1000-2000 ug/day. Those without neurological symptoms are typically prescribed 1000ug PO OD.
  • Logistically, IM injections are difficult to organize for our patients, so flexibility is needed.

 

Strongyloidiasis

The Cdn Guidelines on Immigrant Health do not recommend routine screening for the Bhutanese, as they are not from Southeast Asia, but South Asia. However, serology should be done if eosinophilia or symptoms (abdominal pain, diarrhea, pulmonary symptoms, urticarial rashes to buttocks/waist) are present (Pat Walker MD - Centre for Int'l Health, Minnesota)

 

TB

Per the BCCDC, the estimated incidence of sputum-smear positive TB in camp is 242/100,000. (Recall that high incidence is >15/100,000). If Canada committed to accepting ~5,000 of the refugees over 5 years beginning 2009, we can expect to see about 12 cases of active TB across the country (excludes latent cases).

 

Lice

Several cases were diagnosed on pre-departure screening.

 

Hearing impairment

See here.

 

Mental health | Suicide

CDC report: An Investigation into Suicides among Bhutanese Refugees in the US | 2009 – 2012 

Also see the CDC Bhutanese Refugee Health Profile.

Special Notes for Clinicians

  • Bhutanese refugees approach medical care from an emergency perspective rather than as a preventative health care measure. Many refugees are not familiar with concepts of primary healthcare and only seek healthcare if complications arise. They also believe that medications are to "cure" sickness and therefore may not be compliant with medications for chronic diseases. Additionally, many consult with traditional healers along with modern medicine, and the use of herbs and home remedies is common.
  • Address the importance of oral and dental health
  • Many Bhutanese are vegetarian; therefore proper nutrition counseling is important.
  • There are high rates of depression, generalized anxiety and post-traumatic stress disorders from this population due to their traumatic experiences.
  • Traditional gender roles that influence one's independence and empowerment are often challenged as many women are required to be responsible for their own care and well being for the first time in their lives (see gender roles for further details)

Culture and Traditions of Bhutanese Refugees

The following is some general information on Bhutanese refugees' culture and traditions, which may be followed to varying degrees by the individuals settling in Canada. 

Ethnicity

Nepalese

Religion

60% Indian-and Nepalese-influenced Hinduism; 27% Buddhist; 10% Kirat and 1-7% Christians

Traditional Clothing

Women - saris. Men -  daura suruwal.

Language

Nepali; 35% have functional knowledge of English

Birth and Wedding Traditions

Children named on 11th day after birth

Hindu boys perform “Bratabandha” (symbolic representation that a boy is mature enough to perform his duties) starting at the age of 8

Polygamy is not common but is practiced

Women move to husband’s house after marriage

Cultural practice related to Death

Cremation is practiced

Hindus mourn for 13 days and avoid salt, turmeric and oils in food. Only ghee (clarified butter) is used

Sons shave heads and wife and son wear white for 1 year. Woman does not wear red after the death of her husband

No festivals, no weddings, no social events during this year.

Remarriage is not common among widows.

Food

Many are vegetarian

Mainly rice along with legumes, vegetables

Eat twice a day (10am and 7pm) and tea (with a lot of sugar) during the day

Fasting for religious purpose is common

Packets of noodle soup (high in sodium) are common in refugee camps

Gender Roles

Patriarchal society: men earn the money and makes decisions

Women are responsible for household work

Women and daughters eat last and men and male children eat first

Men and women don’t touch in public

Shaking hands between men and women is not common (but is not restricted)

Women are considered untouchables during their menstrual period and after given birth.

Res

References

Central Intelligence Agency. The World Factback – Bhutan. Date modified: September 27, 2011
https://www.cia.gov/library/publications/the-world-factbook/geos/bt.html

Citizenship and Immigration Canada. Backgrounder – Bhutanese refugees. Date modified: May 22, 2007.
http://www.cic.gc.ca/english/department/media/backgrounders/2007/2007-05-22.asp

Citizenship and Immigration Canada. Resettling Bhutanese Refugees – Update on Canada’s Commitment. Date modified: August 23, 2011.
http://www.cic.gc.ca/english/refugees/outside/bhutanese.asp

Great Brook Valley Health Center. Bhutanese Refugees. http://www.umassmed.edu/uploadedFiles/fmch/Community_Health/Community_Health_Toolkit_Draft1/Bhutanese%20Cultural%20Presentation%20%205_10_2010%20SS.pdf

International Rescue Committee. The health of refugees from Bhutan. February 2009.
http://www.cal.org/co/email_discussion/Attachments/IRC-Bhutanese_Health_FactSheet.pdf

Shrestha, C. New Issues in Refugee Research. Power and politics in resettlement: a case study of Bhutanese refugees in the USA. The UN Refugee Agency, Policy Development and Evaluation Service. May 2011. http://www.unhcr.org/4dca7f129.html

The United Nations Refugee Agency. Bhutan. 2010 UNHCR country operations profile --Nepal.
http://www.unhcr.org/cgi-bin/texis/vtx/page?page=49e487646&submit=GO

 

 

Written by Sue Chen, UBC medical student (November 26, 2011)
Reviewed/updated by Martina Scholtens MD (May 22, 2012)

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