Saturday, December 19, 2009

A visit to Lao-China Friendship Hospital.

When we visited Laos in August, I went without any prior contact, since I knew nobody in the country, but still, I wanted to get a glimpse of what health care looks like, and listen to the actual health care workers in the country. So, one afternoon, we negotiated with a 'songthaew' driver to take us to Luang Prabang Provincial Hospital, more commonly known by locals as the 'Lao-China Friendship Hospital', or simply the 'Chinese' hospital.

Located off the main road four kilometers south of the city on a seven-hectare land, the hospital was completed in 2004 with assistance from China, as its name implies. It was already during the late hours of the afternoon, so the outpatient department had already closed and many staff gone home. Although without any contact beforehand, the staff at the counter in the deserted main hall kindly allowed us to walk around the hospital. Upon starting our 'tour', we noticed that all of the emergency exit signs and fire hydrant labels were written in Chinese and English only, and without Lao, no wonder the locals call it the 'Chinese' hospital.

While we were walking, we came into a nurse, who was apparently about to go home, and she was kind enough to let us hear about the hospital and her job. The hospital is divided into four major departments: inpatient, outpatient, labor room, and pediatrics. The outpatient clinic includes internal medicine, surgery, pediatrics, obstetrics and gynecology, family planning, otorhinolaryngology (ear-nose-throat), dentistry, and emergency. Depending on the day, the hospital sees about 25 to 100 patients per day, with Monday getting the highest number. Its medical staff comprises 97 nurses, 27 physicians, plus 10 volunteering nurses from South Korea. Some common medical problems include common cold, respiratory infections, cardiovascular disorders, gastroenteritis, and accidents. She said that an increasing number of people do not take enough exercise, something I am used to hearing in other parts of the globe as well.

After going through the examination rooms, we visited the ANC, or the antenatal care department, which they say is the busiest part of the facility. At least three staff must constantly be present here, so they are currently working on a 24-hour-work-and-24-hour-rest rotation. For vacation, they get 10 days off per year. According to them, the busiest months are February, March, May, and June, before the rainy season starts. Here we met some nursing students, who told us that they have a 2.5-year program. There were no medical students, but we found out that is because the sole faculty of medicine in Laos is in Vientiane, the capital.

For the patient, there are two often-encountered problems in the medical scene, although they do represent larger underlying issues. One is the lack of medicine matching that of international standards. In recent years, foreign aid, especially from China and Japan, has helped hospitals to update their out-dated facilities and equipment, and bring up more health care professionals, however, there still are often cases where the patient is asked to travel down to the capital of Vientiane, almost 500 kilometers away on a recently-paved mountainous road. And even at there too, the patient is often asked to cross the 'Friendship Bridge' to receive further treatment at a Thai hospital. In emergency cases, such as major traffic accidents, this clearly does not work. And, obviously the patient would have to pay for all of the transportation costs, and the fees skyrocket if you need to be transported across the border.

This leads to the second issue: money. Universal health care is still non-existent, so even in public hospitals the patient needs to pay. The same goes with ambulance, where patients pay by the kilometer, like a taxi. If she or he gets admitted, the average fee per night for a normal room is 40,000 kip (about US$4.80), but that is not easy for a country where people live on an average 10,000 kip (about US$1.20) per day, though the economic disparities are great. People who live in Vientiane, the nation's capital, are the richest, where over 50% of households have cars and 40% have air-conditioners, while next comes those living in the capitals of the provinces, like Luang Prabang, and the poorest are the farmers who live in the mountains and the countryside. According to the staff, patients who have financial difficulties paying fees may submit a request to receive aid from the government, but again, one needs to travel down to the capital to do so. It is not surprising that the 150 beds at Luang Prabang hospital are never near full.

The government seems to have started working on these issues over these few years, and is in the process of not only setting up a clinic in every village, but a primary school, and encouraging more villagers to have their children enrolled. Of course, the families would have to give up on earnings that would be made through having the child work instead and understand the long-term significance of education, so it's not easy, but at least they wouldn't have to walk hours to go to school anymore. They are also working to put more emphasis on preventive medicine, and moreover, health-building through community participation. Things have only started to change, and it will certainly take a long time, however, the interesting point about Laos is that they are going through the process at the same time their economy is developing, something other economically-developed nations went through at separate times, with economic development coming first.

Sunday, September 20, 2009

Strolling in Luang Prabang.

Between the mountains covered with jungles in north-central Laos lies the city of Luang Prabang. It is situated where the Nam Khan River flows into the Mekong River, well over 400 kilometers north of Vientiane. Every dawn, lines of monks dressed in orange robes walk through the streets to collect alms, and along with the Buddhist temples and the simple concrete buildings, the atmosphere seems to resemble that of its neighbor Thailand at one glance. Even the language is very similar to that spoken in 'Isan', the northeastern part of Thailand. The cuisine is similar too; Tam Mak-Hung (papaya salad) is basically the same as Som Tam, and they eat that with Khao Niaw (sticky rice), and it even goes along with Kai Yang (roasted chicken).

However, if you look carefully, the decorations of the temples are different, architecture reflecting the days of French colonization still remains in many houses, and most of all, its social systems, including education, health care, and welfare is like those of its neighbor decades ago. Education is essentially free for public primary school (five years), junior high (three), and senior high (three), but the percentages of children enrolled are 84.2%, 54.4%, and 34.2%, respectively. And, since the country does not keep track of personal identification records, the actual age a child gets enrolled varies. The number of years for university education varies from two to seven depending on the majoring subject, however, none are free. Free health care is not available, but government aid may be issued if you travel all the way down to Vientiane and ask for it.

I paid a visit to this landlocked country in the Indochina Peninsula in August. Registered a World Heritage Site by the UNESCO in 1995, the compact city of Luang Prabang is a nice and calm place to spend a couple of days. Besides the symbolic temple of Wat Xiengthong and the hill of Phousi, where you can get a picturesque view of the entire city, there are many so-called 'speed boats' that take you up and down the Mekong to various nearby villages and the buddha-adorned caves of Pak Ou, while 'songthaews' or 'tuk-tuks' (same nomenclature as Thailand!) can take you to the beautiful waterfalls of Tat Kuangsi. At night, nearby villagers, including the Hmong, come out to sell various goods, creating a bustling street market scene.

The recent influx of tourists to this economically underdeveloped nation has given birth to a plethora of bed-and-breakfast's and restaurants that satisfy a westerner's taste buds, however, this happened after restaurants catering for the locals came in, ironically. Families were and are still not too used to eating outside the home. So, it wasn't easy for me to find local food with a local taste at a local cost. Even the packaged foods, most, if not all of them, are imported from Thailand. People say that the more north you go, the more products from China and Vietnam you will find. But basically, there are only a few mass-produced goods (not to miss the famous Beer Lao!) packaged on Lao soil. What I personally liked the most was the Khao Soi (different from the Thai cuisine with the same name) I found being served at a 'street picnic table' right beside the Mekong. I even went for a second on the following day.

Friday, July 17, 2009

Mae Sot and Route 105.

In the northwest of Thailand on the Moei River border with Burma lies the small town of Mae Sot, the westernmost town of Tak province. The town is not only interesting for being a trade post between Burma and Thailand, but also for its diverse ethnicity: Thai, Burmese, Karen, Rohingya, Karreni, Mon, Kachin, and many other minority groups from across the river. Take a stroll in the market and you will notice that Thai is not necessary the major language spoken here. Due to the ongoing conflict between the Burmese military junta and the many ethnic minorities that inhabit the land along the border with Thailand, thousands have crossed the river and settled in villages and refugee camps along the border near Mae Sot.

A Muslim community is also present in Mae Sot, together with a mosque. One of my good old Thai friends lives in Mae Sot and she and her husband took me to a small cafe on a corner near the mosque. They make rot-tii-oo and tea at this place which seems to have become a pleasant get-together place for the locals to chit-chat during the early hours. Rarely will people be able to find any rot-tii-oo left after 10AM.

As of 2006, Tak province is home to 480,000, of which 150,000 are originally from outside the nation. And of that, approximately 80,000 are refugees that have either been registered or in the process of being so. Those who have managed to cross the border, most of whom are undocumented, have found shelter in border villages and refugee camps set up by the UN or other NGOs. And many of those who are not registered as a refugee work in the many factories near Mae Sot on a very low pay scale, though much better than in the land they came from. Meanwhile, Burma's population stands at around 47 million, of which Karens account for 7 million, the largest 'minority' group. Well over 600,000 have been displaced in camps within their country.

Naturally, Mae Sot is also the 'hub' for the many NGOs that work along the border to assist the endless number of refugees. Among them is a health care post called Mae Tao Clinic (MTC). Set up in 1989 by Dr. Cynthia Maung, herself a Karen who fled from Burma after the crushing of the '8888 Uprising' by the military regime, the clinic caters for those who travel across the border in seek of medical assistance, since there is none, if any, accessible, affordable health care available in Karen state (around 0.5% of the GDP is spent on health care), and for those who have already settled on the Thai side, but could not access health care because they are undocumented immigrants or simply for the lack of money. I met a lady who had walked for over a month from near Yangon, where she lost all of her family members in the deadly cyclone Nargis. She was suffering from PTSD (post-traumatic stress disorder).

Staffed with 530, of which 260 are health care professionals, and many of whom themselves are originally from across the border, the clinic is visited by approximately 400 every day, totaling over 120,000 patients per year. Although now well-known and attracting donations from all over the globe, the budget still remains extremely tight with an ever-increasing number of patients and a lot of issues have yet to be solved. Its in-patient facilities are still infection-prone, especially to the likes of tuberculosis, and more and more refugees give birth here, meaning more and more stateless children.

About 90 kilometers north of Mae Sot on Route 105 lies the refugee camp of Mae La, the largest of them all, housing 37,000 registered refugees and no less than another 30,000 unregistered ones. Because Thailand is not a member of UN's Convention Relating to the Status of Refugees, a person who wishes to be registered needs to be approved by both the UNHCR (UN Refugee Agency) and the Thai Ministry of Interior. With temples, churches, mosques, graveyards, schools, libraries, markets, and even a university, Mae La is like a huge refugee 'city', and so surprisingly, life here is not the worst for those who are registered, since they are eligible to receive food aid as well as space for housing, at no cost. Bored with nothing to do but unable to leave the camp nor return to their mother land, many couples fill the time to make babies, and family planning has become a seriously important topic. Others apply to live in a third country, while a handful work for the NGOs within the camp.

I visited one of Shanti Volunteer Association's (SVA) libraries, where children were forgetting their darker days and enjoying the time for learning. However, a boy who seemed unable to join the flock caught my attention. According to the staff, he had only arrived a couple of weeks ago, but just received the news that his father, who was also on the way, was killed in a fighting between Burmese government troops, the Democratic Karen Buddhist Army (DKBA), and the Karen National Liberation Army (KNLA), the military arm of the Karen National Union (KNU), which has been fighting for independence of the Karen state (in their words Kawthoolei). Whether or not that news was true is unsure, however, the extensive 'underground' information network of the people cannot be underestimated. And, the Thai cellphone can be used near the border even if it's on the Burmese side, as well.

Those who have been caught by the Burmese military or the DKBA have reportedly been forced to hard labor or simply 'used' as human walls in the event of fighting. In June, DKBA troops raided a Karen school, forcing students to flee to the jungle. 89 of them managed to reach Thai soil, however, nine of them caught malaria on the way in this naturally high-risk area for this fatal mosquito-borne disease. In the same month, near the Thai village of Mae Salit Luang landed four mortar shells launched from the Burmese side, prompting the Thais to increase border security. On June 15, the KNLA headquarters in Manerplaw fell to the Burmese army, and in May-June alone, no less than another 4,000 crossed the border.

'Chronic emergency' is the term many use to describe this region's volatile situation, which has not improved, or only deteriorated, since the conflict broke out in 1949.

Thursday, April 23, 2009

A visit to Sanyukai.

Poverty. What does it mean?

Many say it's about not having enough money to make a living, while some others put it in a different way: they are people who have not only lost their money, but also their families and all their trustworthy social relationships, as well as self-esteem and pride. While a good portion of the general public in other countries still see Japan as the darling of economic prosperity, and even the typical Japanese are not too aware, the poor population has been slowly increasing over the years, and at a quicker pace more recently. Poverty does exist in Japan, and it does in Tokyo.

In April, I paid a visit to Sanyukai again, a non-profit organization (NPO) that runs a free clinic, provides temporary housing, clothes, and food for the homeless. Located in the heart of Sanya district, an area that has become synonymous with poverty and homelessness, the group has been carrying out outreaches to hand out clothes and food, and so-called 'clinic tickets' for those who seek medical consultation for over a decade. The clinic is totally free (one of only two free clinics in Japan for the homeless), but naturally, it's sometimes not easy for a person to come and drop by, but reaching out to them and giving them these 'invitations' not only encourages them to come but also "makes them feel easier" to do so, says one staff. Situated in the northeastern part of the huge bustling city, Sanya has been a home for many who work on a daily wage basis, taking advantage of its proximity with factories in the area and the abundance of rediculously-cheap hostels.

So what did I do? I participated in one of the outreaches they carry out on Wednesdays and Thursdays. Why? Because I like it. And this phrase means much more than it's said. I go to Shinjuku every day, and it's not too difficult to find a homeless there since nearby Shinjuku Central Park is home to a good number of them, so I have always felt that they are part of the picture I am in in some way. But what is there that I could do by myself? If I do have some leftover food I am not going to eat it, could I give it to them? But what would that do to their self-esteem? Do they really want that? After all, unlike in the U.S., begging is not common here. We belong to the same world, the same society, but there is something that is separating us. But through the outreach, I can be of some help and talk to the homeless without hesitating, and it really gives you the feeling that as if it not only opened the door for them but for yourself too. It's like this: they are near you but not as near as it seems, but you've finally found a way to step closer to them. Surprisingly, many seem to be happy even when we just say "hello, how's it going?". They've got lots of things they want to talk with you. That smile on their faces I don't forget.

What is poverty? What is homelessness? I've been thinking about this for a while, and ironically, Mr. Hiroshi Goto, one of the staff there, pointed out something that I had heard before two years ago from a staff working in a homeless shelter in San Francisco: we shouldn't really 'categorize' them as homeless, but as people who have had various difficulties in the past that led them to how they are now. And that's true. They have come different ways. The 'issue' for each of them is different from person to person. And in the U.S., add to that those who have willingly chosen to become homeless. But there are things they have in common too. They have no money, no shelter, nobody to rely on, and have been deprived of dignity and self-respect.

The number of people living under government aid, called the Temporary Assistance for Needy Families, has been increasing, and at a faster pace now with the slowing global economy. Back in 1992, that number was 585,972, but it reached 998,887 in 2004 and surpassed 1,000,000 in 2005, and as of March 2009, it stood at 1,168,306. Now, especially in these unsure times, it is not so difficult for a person to take a moment or two to think about poverty and take that as an issue that is not unrelated. With just a combination of some accidents, wrong-doings, or unfortunate consequences, anyone could find him/herself without a home. However, we must also keep in mind that the real homeless, the 'true' poor, have been deprived of all they could be, including friendships, families, and even their self-esteem. Whether that is the responsibility of the individual, or another, or the society, or more than one of those, varies from person to person. But we have to understand. And I think there is something we can do.

Sanyukai is not merely a group that gives out a hand to the homeless, but one that is helping the absolute poor and using several creative ways at different levels to help the homeless empower themselves and become self-dependent. The true poor are deprived of their family and friends, and it starts from re-building relationships or making new ones. Every day, Sanyukai puts seats and some tables in front of their compact three-story building, and it acts as a place of gathering for the homeless. Sipping a cup of green tea that Sanyukai serves, they come and tell about the meal they had the evening before or joke about the noisy neighbor cat that wouldn't let him go to sleep. It's a place for socializing and relaxing, and up to around 15 people can be seen on some days. Some stay for lunch and eat with the staff. Whether it's a staff or a visiting homeless, everyone eats the same food here. And many of them visit on a routine basis, some even every day, so it is also an effective way for the staff to see who didn't appear on a day and try to find out what happened.

Last month, Sanyukai was ordered by the metropolitan government to stop handing out its weekly free meals in one of the areas, after local residents filed a number of complaints saying the outreaches attracted more homeless and that "children are afraid" of them. One of the continuing challenges is how to have the local community understand their activities. There is a quote from a book by French writer and aviator Antoine de Saint-Exupéry. "Men travel side by side for years, each locked in his own silence or exchanging words which carry little or no fright, until danger comes. Then they stand shoulder to shoulder. They discover that they belong to the same family."

Saturday, February 28, 2009

A glimpse of a university hospital.

Time flies.

Hmm... I think I've been using this word too much lately. But it's true, times really does fly. So here I am, finished with all the clinical rotations, something which I had so much expectations of just a year ago. Did it meet my original expectations? Well, that's another question. But nonetheless, I did learn quite a few things, was able to see and talk with many patients, and was able to get a glimpse of what a physician's everyday life here is like, working in a 1,000-bed university hospital located in the heart of one of the most important business districts in Tokyo: Shinjuku.

I have believed and still do, that working in a university hospital means you have to take part in educating and nurturing the next generation of physicians, and that is not an option but a responsibility. And until I started my clinical rotations, I had believed that those who don't do too much or refuse to carry out that part don't have enough passion and enthusiasm, and therefore are working in the wrong place. But... that view has changed. Most physicians here, especially those in the upper 20s to 40s, whether an internist or a surgeon, or a pediatrician or a obstetrician/gynecologist, are super busy.

Arriving at work before 8AM, their day often starts with a conference in the morning, followed by a visit to the in-patient ward, and then on to run the morning portion of the out-patient department (OPD), or head to the operation rooms instead if that's a surgeon. The lines of patients in the waiting room are seemingly endless, while some operations can easily take five or six hours, naturally. When do they have lunch? Well, they're lucky if they can get a meal at noon. The schedule for the afternoon doesn't look too much different, except for some more case conferences and lectures by older doctors or advertisement sessions by pharmaceutical companies. When do they finish all that? Maybe 6PM. Okay, can the doctor go home? Not so fast... because all the paperwork and some medical records are waiting to be processed by nobody but the physician. After that is 'free time' for the doctor, where he/she can work on research papers or make a PowerPoint for the next day's lecture for students, etc. It's not rare to see a doctor working well over 12 hours. Or, is he/she on-call for the night? Well, that adds another 10 hours or so, and on to another day. You don't get rests here after on-calls.

And yes, to add to that, the pyramid of hierarchy in Japanese university hospitals is still present. You have to do as your boss (professor) says, and that is often a must. Some would even be too concerned about writing research papers or simply trying to make their daily work appeal to the chief professor of your department, since he/she would be the only person who can help you get promoted to a higher academic status. If the professor doesn't like you, tough luck. Yes, it's all about faculty politics. And then, on the other hand, you also have to help young doctors who have this long list of questions for you to answer. A physician in the upper 20s to 40s are kind of stuck in between the old and the young.

Hmm... yes, a physician working in a university hospital has three major responsibilities; providing medical care, research (often for academic status), and education. But does the doctor really have enough time for all of that? And especially when considering the fact that doctors working in university hospitals in urbanized areas get one of the lowest salaries among doctors in the country, how much would that do to the enthusiasm of the physician? What's the incentive? Now that I have seen some of the reality in a university hospital, I even feel sympathy for some of them.

When doctors start quiting, that is probably a tipping point, a beginning of a vicious cycle; quitting means more tasks for those who are left.

Sunday, January 18, 2009

Go to the people.

Go to the people,
Live among them,
Learn from them,
Love them.
Start with what they know,
Build on what they have;

But of the best leaders,
When their task is accomplished,
Their work done,
The people all remark:

- Yen Yang Chu (1893-1990)