Lesson from the Neighbour: How Bhutan out-vaccinated the world

The Lunana area of Bhutan is remote even by the standards of an isolated Himalayan kingdom: It covers an area about twice the size of New York City, borders far western China, includes glacial lakes and some of the world’s highest peaks, and is inaccessible by car. Still, most people living there have already received a coronavirus vaccine. Vials of the Oxford-AstraZeneca vaccine arrived last month by helicopter and were distributed by health workers, who walked from village to village through snow and ice. Vaccinations proceeded in the area’s 13 settlements even after yaks damaged some of the field tents that volunteers had set up for patients. “I got vaccinated first to prove to my fellow villagers that the vaccine does not cause death and is safe to take,” Pema, a village leader in Lunana who is in his 50s and goes by one name, said by telephone. “After that, everyone here took the jab.” 

Lunana’s campaign is part of a quiet vaccine success story in one of Asia’s poorest countries. As of Saturday, Bhutan, a Buddhist kingdom that has emphasised its citizens’ well-being over national prosperity, had administered a first vaccine dose to more than 478,000 people, more than 60% of its population. The Health Ministry said this month that more than 93% of eligible adults had received their first shots. The vast majority of Bhutan’s first doses were administered at about 1,200 vaccination centers over a week-long period in late March and early April. As of Saturday, the country’s vaccination rate of 63 doses per 100 people was the sixth highest in the world, according to a New York Times database. That rate was ahead of those of the United Kingdom and the United States, more than seven times that of neighbouring India and nearly six times the global average. Bhutan is also ahead of several other geographically isolated countries with small populations, including Iceland and the Maldives. 

Dasho Dechen Wangmo, Bhutan’s health minister, attributed its success to “leadership and guidance” from the country’s king, public solidarity, a general absence of vaccine hesitancy, and a primary health care system that “enabled us to take the services even to the most remote parts of the country.” 

“Being a small country with a population of just over 750,000, a two-week vaccination campaign was doable,” Dechen Wangmo said in an email. “Minor logistic issues were faced during the vaccination but were all manageable.” All of the doses used so far were donated by the government of India, where the drug is known as Covishield and manufactured by the Serum Institute of India, the world’s largest vaccine producer. Bhutan’s government has said it plans to administer second doses about eight to 12 weeks after the first round, in line with guidelines for the AstraZeneca vaccine. Will Parks, the representative in Bhutan for UNICEF, the United Nations agency for children, said the first round was a “success story, not only in terms of the coverage but also in the way the vaccination drive was executed collectively, from the planning to the implementation.” 

“It involved participation from the highest authority to local community,” he said. 

The campaign has relied in part on a corps of volunteers, known as the Guardians of the Peace, who operate under the authority of Bhutan’s king, Jigme Khesar Namgyel Wangchuck. In Lunana, eight volunteers pitched field tents and helped carry oxygen tanks from village to village, said Karma Tashi, a member of the government’s four-person vaccination team there. The tanks were a precaution in case any villagers had adverse reactions to the shots. 

To save time, Tashi said, the team administered vaccines by day and walked between villages by night — often for 10 to 14 hours at a time. The yak damage to the tents was not the only hiccup. Some villagers did not initially show up to be vaccinated because they were busy harvesting barley or because they worried about possible side effects. “But after we told them about the benefits, they agreed,” Tashi said. As of April 12, 464 of Lunana’s 800 or so residents had gotten a first dose, according to government data. The population figure includes minors who are not eligible for vaccines. Health care in Bhutan, a landlocked country that is slightly larger than Maryland and borders Tibet, is free. Between 1960 and 2014, life expectancy there more than doubled, to 69.5 years, according to the World Health Organization. Immunisation levels in recent years have been above 95%. 

But Bhutan’s health system is “hardly self-sustainable,” and patients who need expensive or sophisticated treatments are often sent to India or Thailand at the government’s expense, said Dr. Yot Teerawattananon, a Thai health economist at the National University of Singapore. A government committee in Bhutan meets once a week to make decisions about which patients to send overseas for treatment, Yot said. He said the committee — which focuses on brain and heart surgery, kidney transplants and cancer treatment — was known informally as the “death panel.” “I don’t think they could cope with the surge of severe COVID cases if that happened, so it is important for them to prioritize COVID vaccination,” he said, referring to Bhutan’s health authorities. Bhutan has reported fewer than 1,000 coronavirus infections and only one death. Its borders, tight by global standards even before the pandemic, have been closed for a year with few exceptions, and anyone who enters the country must quarantine for 21 days. 

That includes the prime minister, Lotay Tshering, who received his first vaccine dose last month while in quarantine after a visit to Bangladesh. He has been supporting the vaccination effort in recent weeks on his official Facebook page. “My days are dotted with virtual meetings on numerous areas that need attention, as I closely follow the vaccination campaign on the ground,” Tshering, a surgeon, wrote in early April. “So far, with your prayers and blessings, everything is going well.” The economy in Lunana depends on animal husbandry and harvests of a so-called caterpillar fungus that is prized as an aphrodisiac in China. People speak Dzongkha, the national language, and a local dialect. Last year, the drama “Lunana: A Yak in the Classroom” became the second film ever selected to represent Bhutan at the Academy Awards. It was filmed using solar batteries, and its cast included local villagers. Lunana’s headman, Kaka, who goes by one name, said the most important part of the vaccination campaign was not on the ground but in the sky. “If there hadn’t been a chopper,” he said, “getting the vaccines would have been an issue, since there’s no access road.”