By the late 1940s, biomedicine was firmly established in Sikkim and was attracting ever-growing numbers of patients to the IMS dispensaries in central Tibet. But in Bhutan, biomedicine still remained largely unknown and it was only in the post-colonial period that any biomedical structures developed there. As will be seen, Bhutan's tardy adoption of the new system was due to two factors. Firstly, the state was closed to Christian missionaries and thus to missionary medicine and, secondly, as Bhutan was of little or no economic or strategic importance to British India, it received only minuscule development assistance.

Bhutan is situated to the south of the Tibetan Autonomous Region of China, bordering the Sikkim, Bengal, and Assam regions of India. Covering an area of ca. 18,000 square miles, it has a current population of ca. 1.2 million people, most of whom are Buddhists. A unified Bhutanese state emerged as a distinct entity after the arrival of Shabdrung Ngawang Namgyal (1594-1651) from Tibet in 1616. He was a leading figure of the Drukpa Kargyu school of Tibetan Buddhism and became the first ruler of modern Bhutan, which has maintained an independent identity and national existence since that time.

After visits by the Tibet-bound Bogle and Hamilton in 1774-75, and Turner and Saunders in 1783, Bhutan, like Tibet, closed its frontiers to Europeans in 1792. Relations between Bhutan and the British then deteriorated and war broke out in 1864-65. The Bhutanese proved hardy opponents, able to repel the imperial forces from their mountain strongholds and the British were also hindered by the medical environment in which malaria and other fevers were rife. Of the 5,000 men they dispatched to fight the Bhutanese, 480 died of disease and, ‘nearly as many more subsequently from the effects of the campaign, although 1,300 men were sent away on sick leave’. But modern weaponry proved triumphant and the campaign ended with the Treaty of Sinchula, which brought Bhutan under British influence. They agreed to refer frontier disputes to the British and ceded lowland territory to the imperial government in return for an annual subsidy. Having secured that section of their northern frontier and with no possibility of the mountainous Bhutanese terrain offering passage for modern armies to or from Tibet, the British subsequently left the state largely untouched.