The Index Case of COVID-19 in Bhutan

On March 5th, 2020 a 76-year-old American tourist with abdominal bloating, loss of appetite and diarrhea became the first case of COVID-19 to be diagnosed in Bhutan. Although initially presenting atypically, over the subsequent days his clinical progression followed a more classic pattern seen across the world with hypoxia and respiratory distress ultimately requiring intubation and vasopressor support. The case caught the attention of the King of Bhutan, and his progress was followed closely by the nation, as public health policy changes were rapidly enacted; all of the index case’s contacts were quarantined, the country’s border was closed down and a 21-day facility quarantine was instituted for everyone entering the country. The patient’s family worked with the U.S. State Department to arrange for a complex medical evacuation across the globe and repatriation back to the United States where on his arrival he was the first known case of COVID-19 in the hospital and state. He ultimately made an excellent recovery.

This index case of COVID-19 in Bhutan juxtaposes a high profile case in a resource-limited setting where political will and resultant allocation of clinical resources were crucial in the ultimate excellent outcome. This case provides food for thought on the broad use of instiutional guidelines within individual settings, perceptions of risk at the societal and individual level, and sheds light on the story of a small country’s initial interventions which ultimately led to a highly successful public health campaign against COVID-19. This unlikely story demonstrates one example of the numerous, often unspoken, characters whose contributions are vital to individual stories of success (and at times heartbreak) in this dynamic global shared experience of the COVID-19 pandemic.