Sanctuary Gateway Tours and Trek

21/04/2026

Bhutan — a land where nature, people, and wildlife live side by side in peaceful harmony, creating a balance that feels both rare and beautiful.

21/04/2026

Dochula Pass is home to the Druk Wangyal Chortens (108 chortens) built in 2004 by Ashi Dorji Wangmo Wangchuck.

They honor Bhutanese soldiers who died in 2003 and symbolize peace. The number 108 represents purification in Buddhism, making the site both spiritual and meaningful.

18/04/2026

Bhutan — a land where peace isn’t just a word, but a way of life.
Often known as the happiest nation on earth, it’s a place where time slows down, nature breathes, and life feels beautifully simple.

12/04/2026

Our Kidneys Are Failing Us— And We Are Failing Our Kidneys by Dr. Sonam Kelzang

Every month, approximately twelve new Bhutanese patients are diagnosed with chronic kidney disease (CKD). Every year, some of them progress to end-stage renal disease and must travel abroad—to India or Thailand—for a kidney transplant that our country cannot yet provide. They leave behind families, livelihoods, and in many cases, their savings. Many do not return. Wit global CKD prevalence of 14.2%, it has quietly become one of the greatest disease burden in Bhutan. This is not a statistic buried in a medical journal. Isn’t it national emergency hiding in plain sight?.¹
And yet it does not have to be this way. The majority of CKD cases are preventable. The kidneys fail for reasons that are deeply intertwined with how we live, what we eat, what we chew, and whether we know the state of our own blood pressure and blood sugar. In Bhutan, each of these factors is operating at a scale that should alarm every citizen, every health worker, and every policymaker.
This article is written not for specialists, but for every Bhutanese man and woman who owns a pair of kidneys—which is to say, everyone. It is time we talked about what we are doing to ourselves, and what we can do differently.

A DISEASE ROOTED IN LIFESTYLE
The kidneys are extraordinarily efficient organs. Roughly the size of a fist, each filters about 180 litres of blood per day, regulating blood pressure, balancing electrolytes, and clearing metabolic waste. They tolerate a remarkable amount of stress. But they do not forgive neglect indefinitely.
In Bhutan, hypertension and diabetes are the two leading causes of CKD.¹ The 2019 WHO STEPS Survey found that 28% of Bhutanese adults are hypertensive—more than one in four of us is walking around with blood pressures that are silently scarring the delicate filtration network of the kidney.² Meanwhile, the clustering of NCD risk factors is alarming: more than 85% of Bhutanese adults are exposed to at least one risk factor, and over half carry two or more simultaneously.³
Hypertension left uncontrolled for years stiffens the tiny arterioles that feed the kidney's filtering units. Diabetes, by flooding the blood with glucose, glycates proteins in those same vessels and destroys them systematically. The kidney does not complain loudly until two-thirds of its function is already lost. By then, the damage is largely irreversible. Prevention is not just preferable—it is the only genuinely effective strategy we have.

THE DOMA PROBLEM NOBODY WANTS TO DISCUSS
Bhutan has a doma problem. Approximately 45% of Bhutanese adults chew doma (fermented areca nut with betel leaf and slaked lime).⁴ It is offered at weddings and funerals, after meals, and between prayers. It is woven into the fabric of Bhutanese social ritual so thoroughly that questioning it can feel like questioning culture itself.
But the medical evidence has become impossible to ignore. A 2018 meta-analysis in International Urology and Nephrology found that betel nut users carry a 44% higher risk of developing CKD compared to non-users—independent of age, diabetes, hypertension, and other confounders (OR 1.44, 95% CI 1.08–1.92).⁵ A separate study found an even higher adjusted odds ratio of 2.57 for CKD in male betel nut users.⁶ Beyond CKD, doma is now recognised as the primary driver of oral, pharyngeal, and oesophageal cancers in Bhutan.⁴
Cultural practices evolve. Bhutan's relationship with to***co is an instructive precedent: we enacted one of the world's first to***co bans and dramatically reduced smoking prevalence. Doma deserves a similarly frank national conversation—not driven by moralism, but by evidence. Offering doma to a guest is an act of generosity; offering it knowing its harms is something we must collectively reconsider.

SALT, DIET, AND THE URBAN SHIFT
The average Bhutanese adult consumes 8.3 grams of salt per day—nearly double the WHO-recommended maximum of 5 grams.² Excess sodium is a direct driver of hypertension and exerts independent stress on the kidneys. Ema datshi, our beloved national dish, is generous with salt and cheese. Urban diets are increasingly supplemented by processed foods, instant noodles, and packaged snacks imported across the border—all high in sodium.
Compounding this is the collapse of fruit and vegetable intake. Between 2007 and 2019, the proportion of Bhutanese with inadequate fruit and vegetable intake rose from 64% to 87%.⁷ This is a dietary emergency. A diet rich in whole grains, legumes, and vegetables reduces the risk of hypertension, diabetes, and obesity—the upstream drivers of CKD. A diet stripped of these foods does the opposite.
Problem alcohol use is also rising, increasing from 3.1% in 2007 to 8.1% in 2019,⁷ and alcohol is independently associated with hypertension.⁸ The picture that emerges is of a population undergoing rapid nutritional and behavioural transition—rural diets displaced by urban convenience—with the kidneys bearing the long-term cost.

THE HYDRATION DEFICIT
A simpler, often overlooked contributor to kidney disease is chronic under-hydration. The kidneys require adequate fluid to flush solutes, prevent crystal formation, and maintain healthy tubular function. In Bhutan's high-altitude climate, dehydration is common yet rarely recognised. Low fluid intake is strongly associated with nephrolithiasis (kidney stones), and recurrent stone disease is itself a recognised cause of progressive CKD through repeated episodes of obstruction and infection. The recommendation is straightforward and costs nothing: drink adequate clean water throughout the day—at least 2 to 2.5 litres for most adults.

PAINKILLERS AND THE UNSPOKEN NEPHROTOXIC BURDEN
Non-steroidal anti-inflammatory drugs (NSAIDs)—ibuprofen, diclofenac, naproxen—are among the most commonly used medications in Bhutan, often consumed without medical supervision for headaches, joint pain, and musculoskeletal complaints. Chronic or high-dose NSAID use causes renal papillary necrosis and analgesic nephropathy, a form of chronic interstitial nephritis that is entirely preventable.
Traditional herbal preparations (Sowa Rigpa medicines) also warrant attention. While many are safe and have been used responsibly for centuries, some formulations contain heavy metals or herbal compounds with documented nephrotoxic potential. Patients must be encouraged to disclose all traditional medicine use to their physicians, and prescribers must ask. The kidneys do not distinguish between conventional and traditional toxins.

KNOW YOUR NUMBERS
One of the most alarming features of CKD is its silence. A patient can lose more than 50% of kidney function without experiencing a single noticeable symptom. Similarly, the majority of Bhutanese with diabetes or hypertension are undiagnosed. A 2023 study found that 64.3% of Bhutanese with diabetes had unmet needs for care.⁹ In a population where hypertension prevalence exceeds 28%—and where hypertensive patients have a 27% prevalence of CKD in regional data—this diagnostic gap is a direct pipeline to kidney failure.⁴
The message is simple: every adult should know their blood pressure. Every adult over 35, or anyone overweight or with a family history of diabetes, should know their blood sugar. The cost of a glucometer strip and a blood pressure cuff is trivially small compared to the cost of dialysis or transplantation. Bhutan's network of Basic Health Units reaches even remote dzongkhags. If community health workers are empowered to screen, educate, and refer—the silent epidemic can be interrupted before it reaches the kidney.

WHAT MUST CHANGE: A FRAMEWORK FOR ACTION
Prevention of CKD in Bhutan requires action at three levels simultaneously: individual behaviour, community practice, and health system policy.
At the individual level, every Bhutanese person can reduce their risk by controlling blood pressure and blood sugar through diet, physical activity, and prescribed medication; reducing salt and processed food intake; increasing fruit and vegetable consumption; staying well-hydrated; avoiding unsupervised NSAID use; quitting or reducing doma and to***co; and attending health check-ups annually after the age of 35.
At the community level, this means normalising conversations about doma in a health context without cultural shame; community leaders and religious institutions modelling reduced doma use; schools integrating kidney health literacy into the curriculum; and BHU staff conducting regular blood pressure and urine dipstick screening in village outreach sessions.
At the policy level, Bhutan's Ministry of Health should consider mandatory CKD risk factor screening as part of every routine health encounter; salt reduction targets in institutional catering and food labelling; expansion of the PEN (Package of Essential NCD Interventions) programme with explicit kidney health endpoints; a national CKD registry to replace the current vacuum of epidemiological data; and accelerated investment in in-country dialysis capacity and the development of a domestic kidney transplant programme—a vision already articulated through ongoing discussions at JDWNRH.

GROSS NATIONAL HAPPINESS AND THE KIDNEY
GNH's four pillars—good governance, sustainable socioeconomic development, environmental conservation, and cultural promotion—are rendered meaningless when our citizens are losing kidney function at 12 new diagnoses per month and dying of a preventable disease. Health is not merely a pillar of GNH; it is its precondition. We cannot be happy without healthy kidneys any more than we can be happy without a functioning heart or a breathing lung.
The philosophical infrastructure of happiness that Bhutan has built is admirable. But philosophy must be accompanied by physiology. A nation that leads the world in happiness indicators must not trail in kidney disease prevention. The two are not separable.

CONCLUSION
Chronic kidney disease is not inevitable. It is the endpoint of years of uncontrolled hypertension, undiagnosed diabetes, excessive salt consumption, daily doma chewing, insufficient hydration, and unsupervised medication use—all modifiable, all preventable. Bhutan has the universal healthcare infrastructure, the community health network, and the political will to mount a credible prevention campaign. What is needed now is urgency, health literacy, and honest national dialogue about the habits that are slowly destroying our kidneys.
We have built a country that aspires to the happiness of its people.

Let us now build a country whose people are healthy enough to be happy.


REFERENCES
1. Abraham G, Varughese S, Thandavan T, et al. Chronic kidney disease hotspots in developing countries in South Asia. Clin Kidney J. 2016;9(1):135–141. doi:10.1093/ckj/sfv109
2. World Health Organization. Noncommunicable Disease Risk Factors: Bhutan STEPS Survey Report, 2019. WHO; 2019. Accessed February 2024.
3. Wangchuk D, Viriyathorn S, Wangchuk S, et al. Alarming prevalence and clustering of modifiable noncommunicable disease risk factors among adults in Bhutan: a nationwide cross-sectional community survey. BMC Public Health. 2017;17(1):1049. doi:10.1186/s12889-017-4989-x
4. Patel A, Patel M, Tshering P, et al. Chewing Doma (Fermented Betel Nut): Culture versus Cancer? Asian J Cancer. 2024;13(1):1–3. doi:10.1055/s-0043-1764216
5. Wang M, Yu SY, Lv ZT, Yao Y. Betel nut chewing and the risk of chronic kidney disease: evidence from a meta-analysis. Int Urol Nephrol. 2018;50(6):1097–1104. doi:10.1007/s11255-018-1819-8
6. Kuo YC, et al. Association between betel-nut chewing and chronic kidney disease in men. Br J Nutr. 2008;100(3):679–681. doi:10.1017/S0007114508911594
7. Phetphoom N, Kusreesakul W, Tangcharoensathien V, et al. Trends in behavioral and biological risk factors for non-communicable diseases among adults in Bhutan: results from cross-sectional surveys in 2007, 2014, and 2019. Front Public Health. 2023;11:1192183. doi:10.3389/fpubh.2023.1192183
8. Phuntsho K, Neupane S, Subramanian SV, et al. Noncommunicable diseases risk factors in Bhutan: a secondary analysis of data from Bhutan's nationwide STEPS survey 2014. PLoS ONE. 2021;16(9):e0257385. doi:10.1371/journal.pone.0257385
9. Karmacharya BM, Shrestha N, Dhungana RR, et al. Cascade of diabetes care in Bangladesh, Bhutan and Nepal: identifying gaps. Sci Rep. 2023;13:10437. doi:10.1038/s41598-023-37519-w
10. Shrestha N, Mishra SR, Ghimire S, et al. Burden of chronic kidney disease in the general population and high-risk groups in South Asia: A systematic review and meta-analysis. PLoS ONE. 2021;16(10):e0258494. doi:10.1371/journal.pone.0258494

03/04/2026

02/04/2026

02/04/2026

I’m continuing my story about my trip to 🇧🇹 and meeting its monarchs (on the photo Igor and I are with His Majesty King Jigme Khesar Namgyel Wangchuck in 2015)

Part 2

…I performed twice. The first was at the Royal Palace in the presence of both monarchs and the entire royal family—a very large one, by the way. The second performance took place the day after the first, live on local television.

But I’ll start with our arrival. Or rather, our landing. A month before our flight, I started reading the posts of the few visitors to Bhutan and learned that Paro Airport is considered one of the most dangerous in terms of its location and the peculiarities of takeoff and landing. Only Bhutan’s Drukair, Royal Bhutan Airlines flies there, with a fleet of just four planes, and only eight pilots are cleared to fly. These are aces, literally, having undergone long and arduous training.

I was scared. Yes, I’ve been flying for many years, I’ve flown all over the world, but sometimes it’s a bit scary. And the news about the airport’s complexities added to my anxiety. I expressed my concerns to my hosts very gently.

They responded, “There’s no need to be afraid. Our airport is over thirty years old and has never had an accident.

Besides, the father of our Queen Jetsun Pema Wangchuck is a pilot, a pilot for . Do you really think Her Majesty would allow her father to continue working in a profession with mortal risk if there was such a risk? I mean, being a pilot is always a risk, but that has nothing to do with our flagship airline. So fly with pleasure.” (By the way, this phrase is spoken by the senior flight attendant on an airplane before a flight.) And we went.

Day 1
The flight there involved three transfers, an overnight stay in Delhi, and in morning to Bhutan with a stopover in Kathmandu,Nepal. The return flight was even more difficult, with a full day in Delhi.

The first thing that struck me upon boarding the Druk Air flight to Thimphu was the strange discrepancy between the engine sizes and the aircraft’s dimensions. Simply put, the engines looked too big for the small Airbus A319…

To be continued…
From my book “God is Everywhere”

02/04/2026

Bhutan – the Land of the Thundering Dragon🇧🇹
I still think it’s my most unusual experience!

In November 2015, I visited the incredible Bhutan. I was invited to be a special guest at the celebrations of the King Father’s 60th birthday. But in fact, I received the invitation to come to Bhutan and perform my sand story a year and a half before the celebration. All this time, intensive preparations for the celebration were underway – both in Bhutan and in my studio.

The initiative to invite me as a special guest came from the current King His Majesty King Khesar Namgyel Wangchuck👑

He asked me to recreate in sand the history of this extraordinary Kingdom and the life of his father, who dedicated himself to his country. When we met with His Majesty, he told me he’d been following my work for a long time and was a subscriber to my YouTube channel... Frankly, I didn’t know what to say...I’d certainly never heard anything like that from the King:)

Bhutan is one of the most countries in the world, until recently isolated and closed to tourists. This tiny Kingdom, surrounded by the , thanks to its geographic and political isolation, avoided involvement in the global wars of the 20th century.

The country’s development began in 1972, with the accession of Jigme Singye Wangchuck, now known as the King Father.

The 4th king of the dynasty, Jigme Singye Wangchuck, ascended the throne in 1972 and introduced a number of reforms. Foreign journalists and tourists were allowed into Bhutan.The King sought to provide the country with infrastructure (electricity, telephone and radio communications, roads)

In 1998, the King transferred executive power to the cabinet, ensuring turnover and rotation of senior officials. In 2002, national television was established in Bhutan.

In recent years, has achieved significant success; the prosperity is gradually improving, infrastructure is being improved and modernized.

The King Father gained fame in the West by formulating goals of increasing “Gross National Happiness” for Bhutan rather than increasing the Gross National Product.
To be continued…
From my book “God’s Everywhere”

01/04/2026

01/04/2026

On any given day, Bhutan seduces travellers with its colourful culture, woven around ancient temples on high mountains, people wearing traditional dress on the streets, fiery hot chilli dishes, and an unfalteringly brazen humour. Come and find your happy place.

01/04/2026