59.4 percent of Bhutanese chew doma
Chewing Doma—a combination of areca nut and betel leaf— is deeply ingrained in the Bhutanese culture. Even if considered unhealthy and a dirty habit, among many, it is largely tolerated.
It is everywhere, presented as a gift, a token of gratitude or offerings in most of our rituals and ceremonies. Doma is addictive, but the delight of chewing it comes with a price. Areca nut (doma) consumption is associated with serious health risks, including oral, pancreatic, and liver cancers. It is also linked to metabolic syndrome, diabetes, hypertension, and obesity.
A national health survey conducted in 2023 found that 59.4 percent of Bhutanese aged 15-69 years consume doma or areca nut-containing products (AN or ANCP) like Supari, Shakila, and Rajnigandha. Among frequent users, 45 percent consume it daily, while 55.6 percent use it non-daily.
The survey revealed that the prevalence of areca nut use is nearly equal between men and women, with 60.2 percent of men and 58.7 percent of women being current users. Over half of Bhutanese youth aged 15-24 are also current users, with the highest prevalence (64 percent) among those aged 25-39 and the lowest (51 percent) among those aged 55-69.
The last NHS, conducted in 2012, found that 43.9 percent of Bhutanese aged 15-75 years used areca nut in the form of betel quid, reflecting an increase of 15.5 percent by 2023. NHS is carried out every 10 years. HHS 2023 findings were discussed during the four-day health workshop organised by WHO and the Ministry of Health from July 30-to August 2 in Paro.
The 2016 Global School–based Student Health Survey (GSHS) in 2017 assessed the prevalence of areca nut use among students aged 13-17 years at 65.8 percent, with 48.9 percent chewing doma. The Global Youth Tobacco Survey (GYTS) in Bhutan, 2019, indicated that 56.9 percent of adolescent students aged 13-15 years consumed “betel nut or various products containing it.”
Science vs culture
The International Agency for Research on Cancer classifies the areca nut as a Group 1 human carcinogen. Despite its addictive properties, making it the fourth most commonly used psychoactive substance after tobacco, coffee, and alcohol, its health implications are severe. Areca nut chewing is a leading cause of oral cancers and is linked to other cancers, such as pancreatic and liver cancers. The national incidence of head and neck cancers remains among the top five by site.
Areca nut consumption is deeply woven into Bhutanese culture and is widely available in the form of betel quid, known locally as “doma khamtok (a packet containing six or seven quid of areca nut and betel leaf smeared with lime),” and various industrially processed products like Shakila and Rajnigandha, imported from neighbouring countries.
A 2016 national school health survey found that about 58 percent of students consume these packaged products. However, Bhutan currently lacks policies or laws to regulate the promotion and use of areca nut, even among children, according to health ministry and the World Health Organization (WHO) officials in Bhutan.
The survey assessed AN or ANCP use among people aged 15-69, categorised into current, former, and never users, along with the frequency of consumption. It noted that the percentage of daily users increases with age. Moreover, individuals with higher secondary education or lower are more likely to be current users compared to those with higher education levels.
Despite the grave health risks, doma pani remains deeply entrenched in Bhutanese society. Its cultural significance is undeniable. Some believe it was introduced by Zhabdrung Ngawang Namgyel, the unifier of Bhutan, while others trace its origins to the 8th century when Guru Rinpoche is said to have replaced cannibalism with this practice.
In this symbolic transformation, the betel leaf is said to represent the skin, the areca nut the heart, and the lime the brain, with the resulting red juice symbolising human blood. These narratives justify and reinforce the deep-rooted Bhutanese penchant for chewing doma, encouraging its consumption as a vital aspect of social and cultural life, according to Dr. Karma Phuntsho (PhD) in his statement to the Mandala text collection titled “Doma Pani: A Stimulating Experience.” “Such beliefs justified the strong Bhutanese penchant for eating doma and encourage the consumption of doma as an important aspect of social culture,” he stated.
Considering its addictive nature, according to health officials, it is the fourth most self-administered and universally abused psychoactive substance and a widely accepted masticatory product after nicotine, ethanol, and caffeine.
Four Kinds
of Betel Leaves
A few decades ago, the Sunday market in Thimphu used to be flooded with locally grown or wild leaves (pani – rata or shingpan and trodom in the sub-tropical forests of Bhutan. The rata is a creeper with small leaves, while trodom is similar to the imported one. In recent years, rata and trodom , however, have been substituted by the imported Bangala Pata and Mithra Pata.
Despite the known health risks, doma remains an integral part of Bhutanese rituals and daily interactions.
On the other hand, the government has been encouraging farmers in the tropical regions to cultivate areca nut to generate additional income. Many farmers in the southern dzongkhags have replaced more than half of their paddy fields and orchards with areca nut trees.
Areca nut is one of the major fruits grown in the country.
The production status of areca nut as of 2023 is 11,409 MT, worth Nu 330 million, produced from 2 million bearing trees.
While areca nut is mainly exported, it is also consumed in the domestic market, according to the agriculture minister.
“We export about 7,000 MT worth Nu 206 million, and the remaining goes to domestic markets or processing,” said Lyonpo Younten Phuntsho
Contributed by
Rinzin Wangchuk