Bhutanese Profile

Country of Origin, History and Politics

The Nepali Bhutanese, or Lhotsampas (“People of the south”), are a community of approximately 120,000 ethnically and culturally Nepali people. The first report of Nepalese origin in Bhutan was around 1620 when Shamdrung Ngawong Namgyal (a Tibetan lama who unified Bhutan) commissioned a few Newar craftsmen from the Kathmandu Valley in Nepal to make a silver stupa (monument) for his father, Tempa Nima. There are no references to any further movement of people from Nepal to Bhutan until the beginning of the 19th Century.  They were invited to populate the lowlands of southern Bhutan in the mid- to late- nineteenth and early twentieth centuries.  Contact between the Druks (Bhutanese) in the north and the Lhotsampas in the south was limited.  Despite living in Bhutan for up to five generations, the Lhotsampas retained their highly distinctive Nepali language, culture, and religion.  However, they did participate in public life and politics, even attaining positions of significant leadership.
  The Lhotsampas coexisted peacefully with other ethnic groups in Bhutan until the mid 1980s, when Bhutan’s king and the ruling Druk majority became worried that the growing Lhotsampa population could threaten the majority position and the traditional Buddhist culture of the Druk Bhutanese.  The government therefore initiated a campaign, known as “One country, one people,” or “Bhutanization” to cement Bhutanese national identity.  The policies imposed the Druk dress code, religious practices, and language use on all Bhutanese regardless of prior practices.  These changes negatively impacted the Lhotsampa people, because they did not wear the same traditional dress, practice the same religion, or speak the same language as the northern Bhutanese.  The use of the Nepali language was prohibited in schools, many Nepali teachers were dismissed, and textbooks were burned.

By the late 1980s and early 1990s, a crisis had developed.  Human rights violations, including detention, imprisonment without trial, and torture, were not infrequent.  In addition, stringent and unrealistic requirements for proving citizenship were imposed on the Nepali Bhutanese, most of whom were denied recognition of their citizenship even when they were able to provide documentation.  By the end of 1992, the vast majority of the approximately 100,000 ethnically Nepali citizens of Bhutan had fled or been forced out of the country, mostly into refugee camps in Nepal, where many remain to this day. 

The combined stress of failed bilateral talks between Bhutan and Nepal, nearly two decades of life in the refugee camps, and poverty, created significant strife between those Lhotsampas who wanted to immigrate to the USA or another Western country and those who felt that accepting resettlement was equivalent to accepting defeat and would make them less able to advocate for the right of return to their country of origin.

                        Geography, Economy, and Agricultural Practices

In the late nineteenth century, immigrants from Nepal began moving to the southern lowlands of Bhutan.  This is a generally temperate area, with abundant, though imperfect, land for farming. 

The majority of the Lhotsampa economy, prior to their expulsion from Bhutan, was based on agriculture.  Predominant crops included wheat, rice, oranges, lemons, sugar cane, peas, squash, soybeans, and especially lentils.  Farm animals included buffalo, cows, and goats.  Household pets are rare, and dogs are considered to be worthless, to the point where it is an insult to compare a person to a dog. 

                   Language

Prior to their expulsion from Bhutan, the Lhotsampas had lived in Bhutan for up to five generations.  As a result, most members of the Lhotsampa community are multilingual.  At home, Nepali (a language related to Sanskrit) is spoken, but most Lhotsampas also speak the Bhutanese language, Dzongkha.  Although not all Lhotsampas had access to school, those who did were exposed to English at an early age, since it is the national language of instruction in Bhutan.  Even the younger Lhotsampas, who largely grew up in the camps, have been regularly exposed to English.  Thus, many feel relatively comfortable communicating in English, although they note that American English, especially when spoken quickly, can be very challenging for them to understand.  

                   Interpersonal Relationships

A Lhotsampa person is generally known by a first name and a family name. Children are usually given two first names at birth or within the days following. The first name is given to the child by a priest. The second name is given by the parents, which is the name used on the birth certificate.  Parents may decide that only one name is needed if they like the priest’s name choice.  Parents also decide which of the two names the child will go by.

Like the Nepalese in Nepal, the Nepalese from Bhutan divide themselves into castes; a person’s family name often denotes the caste to which s/he belongs.  The caste system creates a social hierarchy, identifying individuals’ position in society and influencing their choice of spouse, as well as other social relationships.  Caste also typically dictates an individual’s choice of profession and role in society.  Among more traditional Lhotsampas, members of different castes do not visit each other’s homes, pray together, or share meals. In the U.S., caste is no longer an issue.

Living arrangements typically include many members of an extended family, and the younger generation assumes the responsibility of caring for elderly relatives.  Within a family, respect is owed to elders, particularly – and regardless of age – by a daughter-in-law to her mother-in-law. The Lhotsampas remove their shoes upon entering a house and consider it good manners to offer tea to any guest.  Eye contact during conversation is standard and is not a sign of disrespect.

                   Marriage, Family, Kinship

Traditional marriages take place between members of the same caste and are arranged by the parents of the bride and groom.  Typically, when a boy reaches the age of 7 or 8, his parents will begin seeking his bride.  When they have reached an agreement with the parents of the chosen girl, preparations for the marriage begin (usually around the age of 7 or 8, though sometimes up to the age of 14). 

Weddings are great celebrations.  Families spend up to a month preparing food and drink, including rice, lentils, a kind of sweetened bread that resembles a doughnut, and a special kind of pickle, called dhulae achar.  They also go to the forest to collect many sacks of leaves, which they press and stitch into ceremonial plates that will be used during the wedding celebration.

The wedding celebration occurs at the home of the bride and includes prayers and rituals led by a group of Brahmin (priests), as well as ceremonial drum playing, which is traditionally performed by members of the lowest caste.  The bridegroom brings clothes, jewelry, and a bead necklace to the bride’s home, signifying her married status.  After the wedding, the bride travels to the bridegroom’s home for a few days.  Then she will return home until she reaches the age of 15 or 16, at which time she will move permanently into the home of her husband and his family.  Upon marriage, the woman takes the family name of her husband. 

There have been many changes in the Lhotsampa community in the last two decades, and the tradition of arranged child marriage is fading due to Western influences, displacement and refugee status, and improved education for girls and young women.  Many young people are choosing their own partners, and improved secondary and tertiary education, which were available to a significant proportion of the refugees in the Nepali refugee camps, has resulted in career and personal choices that are quite different from those available in traditional Lhotsampa society.

                        Gender Roles

Traditionally, women participate in equal measure to men in the hard labor associated with farming and other work outside of the home.  In addition, women are the primary caregivers for the children in the family and are expected to do virtually all the housework and cooking.  An exception is the four-day period during each month, at the time of the woman’s menses, when she is expected to rest.  Because she is considered unclean during this time, she may not touch, prepare, or serve any food or drink, and there is a widely held belief that any fruit tree touched by a menstruating woman will become sick and cease to bear good fruit.  During this time, other women in the household may take over her work, men may cook and clean, or, where economically feasible, the family may choose to pay a woman from outside the family to prepare meals and help keep the house in order.

In the U.S. women and men are adopting the American way of life, with women and men sharing family and household responsibilities and women working outside the home. Many are planning to go to community college but first need to take ESL classes in order to be proficient enough in English to enroll.

                        Family and Kinship Structure

The average family size ranges from 6 to 8 children. Family is one of the highest priorities among the Lhotsampa people.  Doors are usually open, and members of the extended family, as well as friends and neighbors, will come and go quite freely.  Meals typically include anyone who happens to be at the house at the time. 

The community is very tightly knit, and people remain closely connected throughout the life cycle. The elders in the community command deep respect and affection.  Very often family issues, health problems, and financial issues are first discussed with the elders in the family.  The elders, in turn, may decide to involve additional community elders to deal with the situation and/or find solutions to the problems.  The community is generally patriarchal in structure; sons are expected to take care of their parents and provide for them financially and emotionally.

Within the family, there are strong bonds of love and obligation.  A daughter-in-law is obligated to care for her mother-in-law (regardless of her age or state of health) from the moment she joins the family.  The new bride’s priority must be to keep her mother-in-law happy by preparing food, doing her washing, and massaging her legs in the evenings.  This tradition is fading with the transition to life in the refugee camps and now with the beginning of the transition to life in the USA; however, respect and courtesy will still define this relationship.  In the U.S., the demands of work on the younger generation make it difficult to care for elders in traditional ways.  

                   Sexuality, Reproduction, and Pregnancy

Women were required to receive routine prenatal care while in the refugee camps in Nepal.  Prior to that, prenatal care was limited (mostly by distance from a physician or clinic), but used when available.  Women typically worked in the fields and in the home throughout their pregnancies. 

Contraception is now widely accepted and used except by a very few highly traditional individuals.  Sexual practices, sexuality, and gynecological conditions, however, are awkward for Lhotsampa women to discuss, particularly those in the older generations, and they may feel more comfortable talking about these topics with female providers.  There is limited understanding of the concept and value of preventive health care, particularly among women, many of whom may never have had a mammogram or pap smear in their lives.

In traditional Lhotsampa society, sexuality is a taboo subject, and the ubiquity of sexuality and sexual images in the American media is a cultural shock for many members of the refugee community, especially the elders.  Women, particularly younger and/or more educated ones, do discuss sensitive topics amongst themselves, but almost never with elders, male friends, or family members.  Sex education did not really have a place in Lhotsampa culture or education, but was standard in the refugee camps; therefore, most refugees under about the age of 35 have been exposed to a relatively standard, if limited, sex ed curriculum.

                        Childbirth

Childbirth practices have changed with changing access to medical care.  Typically, wherever available, medical care (either in-hospital birth or midwife-attended home birth) has been sought.  Particularly in remote areas prior to the expulsion from Bhutan, however, home birth with or without a lay midwife was the norm, and some children were even born in the fields where their mothers were working.  According to the individuals interviewed for this article, infant mortality was significant, although statistics are not available.

                        Postpartum Practices

After giving birth, a new mother traditionally rests for eleven days.  During this time, she will stay with the baby and nurse the baby, but she does not perform any work or prepare any food.  On the eleventh day, the child is named, and a purification ritual, which consists of sprinkling a holy mixture of cow’s urine, yoghurt, milk, a seed named til, and grass on the mother and her home, will be performed by the Brahmin.  After this time, the mother will return to work.  When the Lhotsampas lived in Bhutan, the mother would often leave her child alone in the home while she went to collect water or work in the fields, although another common practice was to use a cloth to tie the baby on the back and carry water for the day’s work at her side.

Infants are typically breastfed exclusively for the first six months of their life.  At six months, solid food (usually rice) is started, a transition called pasni.  In Bhutan, if the mother did not have breast milk, babies were typically fed cow’s milk from a bottle; however, in the refugee camps, baby formula (known by its brand name, Unilitto) was widely available.

In Nepal and Bhutan, when babies begin crawling, they are massaged with mustard oil and are placed in the sun to give them strength.

                        Child Rearing Practices  

Children are generally taught by “guidance” – explanation and example – and are rarely subjected to physical punishment.  At the age of 7 for girls and 8 or 9 for boys, the formal transition to adulthood occurs.  Girls are given their first sari before puberty and take increased responsibility for household work, while boys receive a symbolic holy thread from a Brahmin in their community.  At that time, the Brahmin formalizes the teaching a boy has received from his parents: he tells the boy never to tell lies, to be studious, never to steal, and to respect his elders. The receipt of the holy thread and teachings has traditionally been taken very seriously and marks the transition from boyhood to manhood. 

In the U.S., elders may increasingly take on responsibilities of childcare while the mother and father work outside the home.

                   Nutrition and Food

Many Lhotsampas, like most other Hindus, are vegetarians, although there are certainly exceptions to this rule.  The World Food Program (U.N. food agency) supplies food rations to tens of thousands of Bhutanese refugees in Nepal.  Staple foods include rice and lentils, known as dal. 

Supply of other foods in the refugee camps was limited, whereas, in Bhutan, the season and farming practices determined other foods that were consumed at various times of the year.  Specifically, most Lhotsampas will not touch or eat beef or pork, as this is considered sin in the Hindu religion.  It is therefore essential to be respectful of these dietary restrictions when counseling Lhotsampa patients about nutrition. In addition, when religion prohibits touching beef or pork, work in meat processing plants is not feasible. Some members of the younger generation may not adhere to these restrictions.

Meals are generally eaten together as a family. However in the U.S., individuals may be more likely to prepare and eat meals alone in order to balance the demands of work and competing schedules. The kitchen of the home is traditionally considered a sacred space and should not be entered without permission. The kitchen not regarded as sacred here in the U.S. The caste system is at the root of this belief, intended to keep persons of lower caste from entering. The caste system has disappeared among the community here in the U.S.

                   Religious Beliefs and Practices

The majority of the Lhotsampa people are Hindu, in contrast to the northern Bhutanese, who are almost exclusively Buddhist.  However, significant minorities among the Lhotsampas are Buddhist or Christian.  Among Hindus, religious leaders and teachers are chosen early in life and taught by the previous generation of Brahmin.  They have many responsibilities in the community, including teaching the next generation, leading ceremonies such as weddings and baby-namings, and providing prayer leadership to members of the community on a regular basis.  Practices among Buddhists or Christians are largely dictated by their individual religion.

In the U.S., assistance from resettlement agencies typically ends just a few months after refugees arrive in the U.S., rarely enough time for individuals and families to successfully establish themselves in their new lives.  Christian churches (many of them Protestant) have been a source of much-needed support for Lhotsampa refugees, inspiring a sprit of conversion and leading some families to choose baptism.

In the Seattle metropolitan area, there are three Hindu temples where Hindu Lhotsampas worship. They are in Kent, Maple Valley, and Bothell. 

                   Death and Dying

The Lhotsampa Hindus believe that reincarnation occurs after a period of 84 million years.  Those who have acted well during their lifetimes will be reincarnated as human beings, while those who have acted badly will be boiled in oil in hell and then reincarnated as dogs. 

At the time of death, members of the deceased person’s immediate family spend thirteen days in formal mourning. This is challenging for those in the U.S. who are employed and do not have bereavement leave.  Some Lhotsampa have lost their jobs after taking time off to observe the mourning period.  The deceased person’s sons traditionally isolate themselves in one room of the house and are not allowed to speak to female family members or other friends, extended family members, or neighbors.  The mourners shave their heads and dress in white cloths that are not permitted to have any stitching.  They smear the floor with cow dung and then cover it with straw; this is the surface they will sit and sleep on for the duration of the thirteen-day period of mourning.  They will refrain from eating salt or meat, and generally will limit their intake to one meal of plain rice per day, as well as fruit, pickled ginger, lemon, and water.   The women in the immediate family will engage in similar rituals, but they must be separated from the men.  The ritual mourning activities are believed to assist in the purification of the deceased family member’s soul, allowing a smooth transition to heaven, where he or she will await reincarnation.  If mourning is not performed properly, there is a risk that the deceased person’s spirit will not be able to make the transition to the afterlife and will remain on earth in the form of a ghost to disturb the living.

                   Traditional Medical Practices

Traditional medical practices vary by religion, region of origin, and socioeconomic status.  The more educated and/or higher socioeconomic status members of the Lhotsampa community tend to prefer Western medicine to traditional, but this preference is not universal, and it is not uncommon to try one pathway first and then the other if the first does not achieve the desired results. 

The practice of using home remedies to deal with illness is very common.  Many times people will try one or two home remedies seek external medical help only if their symptoms worsen or do not resolve. Examples of common home remedies include basil for the treatment of cough, colds, and certain kinds of pain; garlic, turmeric, ginger, and cardamom for stomach pains; and heated mustard oil for massages to relieve muscle pain in the elderly.

Traditional healers or shamans are called dhami-jakhri.  Their skills include being able to enter into a trance and sometimes speak in languages they have not learned, reading leaves and rice to diagnose illness and recommend cures, and chanting incantations to heal their patients.  Sickness is generally seen as an imbalance of passions or a result of the influence of evil spirits, and the dhami-jakhri focus their attention and prescriptions on re-establishing balance to bring about cure.  Core methods of healing include incantations and reading rice, although they may also include prescribing special diets, sprinkling hot water on the patient, or touching the patient with a meaningful object, such as a yak’s tail.  Lhotsampa refugees, particularly more educated members of the community, may require encouragement and explicit statements of acceptance before they will share their use of traditional healing modalities with their Western-trained healthcare providers.  

Hindus who are ill may seek the assistance of a priest to perform a cleansing ritual called a puja.

                   Concepts of Health and Disease

                        Disease / Cause

karma ko phal / bad karma

graha dasha / planetary positions affect life

pitri and kul deota / The ancestors are not doing well; their spirits may affect you. The spirits must be propitiated to get them to a better place.

bhoot pret / ghosts and spirits

bokshi lagnu / witches, witchcraft

satho janu / loss of soul, especially when very small: “Don’t shout loudly, the baby may lose his soul.”

aahar (from Ayurveda) / what you eat affects your body

aachar (from Ayurveda) / what you do (e.g., exercise, smoking, drinking alcohol) affects your body

behar (from Ayurveda) / how you live and the environment affect your body

                        Common Remedies

jhar phuk  / mantra chanting, blowing air into the mouth

graha jap and puja / read planets

                        Types of Traditional Healers

dhami jhakri / shaman

vaidhya / traditional Ayurvedic healer

drungtso / traditional Tibetan healer

                   Experience with Western Medicine

In Bhutan and Nepal In Bhutan, most Lhotsampas were exposed to both traditional medical practices and Western medicine, available through the government-run health care system. Although members of rural communities often had little access to Western medical care, it is typically, though not universally, the preferred type of care among Lhotsampas.  In the refugee camps in Nepal, health care was limited and sometimes sporadic, depending largely on the availability of international aid agency volunteers and supplies; however, basic interventions were almost always available and were preferred over traditional medicine by the majority of the Lhotsampas with whom I spoke.

Challenges facing the health care provider include patients’ limited familiarity with the concept and practice of preventive health care (e.g. routine well child care, mammograms, pap smears), as well as cultural factors that may impede delivery of reproductive and other health services.  Generally speaking, community members often avoid seeking medical services unless they are gravely unwell.  The reluctance to seek care may be exacerbated by the fact that refugees receive seven months of Medicaid coverage upon their arrival, but are unlikely to have adequate employer-sponsored health insurance coverage after this time.  Refugees will also likely be unfamiliar with state and federal programs providing health care coverage and services for children, pregnant women, the disabled, and the elderly.

Traditional gender roles significantly impact health care utilization.  For instance, women may hesitate to discuss their own health problems, but express deep concern regarding the health of their spouses and children.  The refugee community would benefit greatly from preventive health care orientation programs, which would assist them in understanding the services available to them, as well as the implications of neglecting their health.

Common health concerns among Lhotsampa refugees, most of whom will have seen loved ones suffer or die from preventable causes, include malnutrition, depression and other mental illness due to forced displacement and cultural alienation, poor oral health, and reproductive and gynecologic care.

In the United States At the time of writing, the majority of Lhotsampa refugees have been in the U.S. for between one and eighteen months.  When asked whether they felt they could trust American medical providers, they unanimously agreed that they had had good experiences with medical providers here and that they were convinced doctors and other care providers with whom they had interacted had their best interests at heart.  They were acutely aware of the differences in resources (e.g., diagnostic testing, variety of medicines and treatments available) between the refugee camp and their new home.

Reportedly, there is some frustration with the health care system in the U.S.  When clinics require that patients make appointments weeks in advance to see a doctor, some patients then feel forced to seek more immediate care in an E.R.  Patients have high expectations of medical doctors and may experience dissatisfaction when a provider seems rushed, impatient, or impolite in an encounter. Some Lhotsampa refugees, particularly young- and middle-aged adults, are finding it difficult to access affordable health care coverage and services, once their resettlement benefits run out.  This age group does not usually qualify for other assistance as may be available to children and seniors.    

Western concepts of mental health and illness may be unfamiliar to Lhotsampas.  Traditionally, mental illness is known as a stigmatizing condition in which a person is considered “crazy”.

                   Transition to Life in the USA and Common Acculturation Issues

Life in the United States represents an almost unimaginable change for most refugee immigrants, and it is no different for the Lhotsampas interviewed for this article.  Many have at least some proficiency in English, but many others speak little or no English and have skills that are not relevant to the U.S. labor market. There has been no exposure to computers as the refugee camps do not have electricity. Many do not know how to drive, so transportation to places of work, clinics, and other sites is a great challenge.  Although they have largely been able to find the necessary ingredients to make foods they feel comfortable eating, shopping in an American grocery store can feel quite overwhelming.  Certain things that Americans take for granted, such as soda, were described as “something that was in the display case at the refugee camp, but it wasn’t for us.”  Upon tasting soda, the Lhotsampas interviewed for this article decided they didn’t like it anyway. Due to the fear, trauma and persecution they have undergone with the Bhutanese government and the fear of the police, Lhotsampa refugees are afraid and fearful about calling the police for assistance or seeking any help from them.

There are many aspects of American culture that are in stark contrast to some of the core practices and values of Lhotsampa culture.  For instance, the tendency of American families to retreat into the privacy of their own homes is quite different from the Lhotsampa practice of welcoming anyone into their home without advance notice.  The concept of privacy, and the value that is placed on it in American culture, is new and may be perceived as somewhat strange.  In addition, the culture of consumerism, the language differences, and the overt presence of sexuality (e.g., on television) are all significant culture shocks common for recently arrived Lhotsampa refugee immigrants.

Isolation, substance abuse, domestic violence, depression and other mental health issues are common major concerns in refugee communities, especially where people have not been able to find jobs and resettlement benefits have ended.  A Lhotsampa refugee community leader in Seattle expressed worry that his community will be facing these same issues.

In the refugee camp, many Lhotsampas were exposed to Indian culture and language via radio and geographic proximity to India.   Social circles commonly included Indian friends who didn’t understand Nepali language and so communication would happen in Hindi.  After initial resettlement in the U.S. in places like Seattle, Austin, St. Antonio, Houston, Syracuse, Rochester, and Atlanta, secondary migration of Lhotsampa refugees to other cities and states with large established Indian communities is happening. Pennsylvania, Baltimore, Chicago and Indiana are some of these places.   It is estimated that as of February 2010, 850-900 Nepali Bhutanese (Lhotsampa) refugees are living in Washington State, 700 in King County in cities including Kent and Seatac, and approximately 25,000 Lhotsampa refugees have resettled in the U.S. overall.    

                   Recommendations for Assisting Refugees

·      Empower refugees as soon and as much as possible.

·      Provide support groups.

·      Develop culturally-appropriate elder programs.

·      Pay special attention to vulnerable groups such as the elderly, widows, the mentally and physically disabled and those who have experienced torture.

·      Provide long-term case management services to vulnerable groups.

·      Provide access to community gardens.

·      Enlist the assistance of Hindi speakers, if interpretation services are limited, as most refugees speak Hindi (especially the younger generation) and have been exposed to Indian culture.

·      Educate the host community about the historical and cultural background of the refugees.

·      Organize and conduct cultural competency programs for service providers and other personnel who need to come into contact with the community

·      Refugees have high expectations of American clinicians. Many expect to be greeted kindly and that the provider will take a little time to establish rapport. It is important to give refugees the opportunity to ask questions.