How can one not feel joy in a place called Land of the Thunder Dragon, the traditional name for Bhutan, the tiny landlocked South Asian nation south of Tibet known for introducing the world to the gross national happiness index.

If emptiness is your idea of happiness, as is mine, there’s not much to dislike. The nation’s total population is less than 700,000, compared with 30 million for neighbouring Nepal. Famously insular, the largely Buddhist Kingdom of Bhutan introduced incoming air travel only in 1983 and television and internet in 1999. A mere 60,000 tourists visit each year. It joined the United Nations in 1971, but held democratic elections (after decades of monarchy rule) for the first time just seven years ago.

It’s largely its notion of gross national happiness (versus gross national product) that has put Bhutan on the map, spawning a happiness industry. Never mind how elusive the concept of happiness is. Within countries in Europe, for example, as The Economist recently reported, a step up in income is a step higher in happiness. Except that the poorest Danes are happier than the richest Greeks. On the other hand, poor but ascending Bangladesh ranks third lowest on the recent global happiness index—which judges happiness by positive answers to questions like do you feel well rested today? Well respected? Did you smile or laugh a lot yesterday? With questions like these, and living in South Asia, it’s hard not to think the expression of happiness is deeply culture bound.

But it’s the health of Bhutan I’m interested in, and even on the tourist trail it’s clear that health needs are considerable and the healthcare is limited.

In fact while much is made of the gross national happiness goal, very little has been documented about Bhutan’s health. A simple PubMed search of article titles generates just 79 for Bhutan in the last five years (compared to 1654 for the admittedly bigger Bangladesh). An attempt to pull up Bhutan on the IHME interactive MDG trends map left me a bit confounded. A commentary in The Lancet last month lauded Bhutan’s placement of happiness at the centre of its development goals, in contrast to the traditional rigid focus on economic growth, but said little about health. A development agenda driven by happiness values of good governance, environmental sustainability, and cultural diversity feels very right. But what does a focus on happiness do for Bhutan’s health?

Major advances are well-acknowledged—life expectancy rose from 37 to 66 years between 1960 and 2005 and infant mortality fell from 203 to 40 deaths per thousand live births. Fertility is now 2.28 (as a comparator, India’s is 2.5) and there is universal coverage of child immunisations. In apparent response to a growing burden of (preventable) cervical cancers among women, the government has now vaccinated 90% of girls against HPV. Remarkably, Bhutan was the world’s first country to ban the sale of tobacco (though on a recent trip to western Bhutan I saw many people smoking).

Gains are mostly due to available but basic health services, and improved water and sanitation. In 1961, for example, there were just two hospitals, two doctors and two nurses; now there are more than 31 hospitals, 178 community “BHUs” (basic health units), and hundreds of outreach clinics for remote areas. Even so, the medical care, while free, is limited and there is widespread use of traditional and herbal medicine and astrology.

Malnutrition seems a main health challenge. Non-communicable diseases are on the rise and unhealthy diets are now said to be the biggest risk to Bhutan’s health. That a third of children are stunted is perhaps the most striking. Mortality gains are impressive, as is the clear uptake of family planning. But the rates of stunting will have long term and negative consequences—on cognitive potential, educational achievement, economic prospects—for the next generation of Bhutanese, and may handicap a developing nation faced with growing challenges of debt, urbanisation, and unemployment. Average annual income per capita remains just $2000. Worrying issues like drug and alcohol addiction and mental health disorders are beginning to surface in international health data but are largely absent from official Bhutanese health reports.

And then there’s the troubling problem of human rights. Rights, indisputably tied to happiness (and health), are absent from national data and debates. That Bhutan’s ethnic Nepalese minority, comprising a full 20% of the national population, experience discrimination, are denied full citizenship rights, and faced a controversial expulsion described as akin to “ethnic cleansing” in the early 1990s have been documented by the international media. But a muzzled local media refrain from criticising the King and Royal Government for fear of censure.

So is it correct for me to assume the direction of travel should be greater health equals greater happiness?

The regular and mandated national surveys by the Centre for Bhutan Studies and Gross National Happiness seem to rest on the opposite assumption—that happiness generates good health. But only 41% of Bhutanese in the most recent survey are happy. Of nine happiness domains, good health contributed most to gross national happiness. And when asked what their key sources of happiness are, both good health and access to health services featured in the Bhutan peoples’ top 10. With poverty, human rights, and nutrition key determinants of health and appearing to falter in Bhutan, perhaps more focus should be on health rather than happiness.

Jocalyn Clark (@jocalynclark) is executive editor of the Journal of Health, Population and Nutrition, and other external publications at icddr,b (a global health research organisation in Dhaka, Bangladesh). She was a senior editor at PLOS Medicine and assistant editor at The BMJ.

Competing interests: The author has no further interests to declare.