Friday, October 31, 2008

A visit to Ban Rong Ta Tee.

During August 10-12, 2007, which is already over a year ago, the "Intergration of Health and Social Development: Thailand's Experience" program run by Mahidol University's ASEAN Institute for Health Development (AIHD) took us to Ban Rong Ta Tee, a village located in the northern part of Lan Sank District, Uthai Thani Province, in central Thailand. We would be home-staying in that village with the respective families for three days and two nights, carry out a small research by interviewing the villagers about what we wanted to know about, and come up with some kind of conclusion to present. Never did I think that that experience would have a tremendous impact on the way I see things...

Dr. Chokrachan Chairoeksuksan, a family medicine physician at Lan Sak Hospital, gave us an overview of how health care is provided in this rural area, in its most effective and efficient way possible. Lan Sak District is divided into six sub-districts (tambol), which in turn are made up of 84 villages. Primary medical care is taken care of at the 'primary care level', which is the local public health center, 10 of which are spread throughout the district. If the medical issue could not be solved there, the patient would be referred to the 'secondary care level', which is in this case Lan Sak Hospital. If further specialized care is necessary, that is the responsibility of the 'tertiary care level', which is in this case Uthai Thani Hospital, the largest public health care facility in the province.

The public health center in Ban Rong Ta Tee community is one of 10 in the district and serves 5,263 people and 1,122 households. There are 104 health volunteers working in the villages and they play a key role in promoting health. Those who tend to act as leaders in their neighborhood, are more conscious about health, and are willing to receive some essential medical care training, would be a good candidate for a health volunteer. They would be responsible for connecting the villagers and the health center, including taking patients there when they need the help or gathering villagers to the health center for health promotion activities. There are no physicians at the health center and just five people (manager, community health worker, nurse, nurse's aid, janitor) run the center. The mobile physician team comes here once a month. I became good friends with the nurse, Wanrob Klomlit, who everyone calls Rob, maybe partly because he's the same age as I am.

Now, when we carried out our interviews in the village, our group decided to ask questions about the number of members in the household, their jobs, income, food habits and change over years (if any), their favorite foods, past medical history, smoking and drinking habits, education received, and what they would do in case of an illness. It was really interesting. Truly. Although each household was different, household after household, we started to get the bigger picture of the village. What kind of people live here? What are the strengths of the people? What are the weaknesses or the issues that underlie? What can be done by themselves to overcome those issues?

So our group's research theme was this: the effect of lifestyle change on the community. We focused on the villagers' lifestyles, especially food habits and health care habits. And as we carried out are interviews of the villagers household by household, we realized that between generations, there lay some differences. So, to have a better glimpse and understanding, we decided to categorize the villagers into three generations; the first of which we defined as 50 years old and over, no-longer-working-in-Bangkok generation, the second would be 30-49 years old and the working-in-Bangkok generation, and the third is defined as up to 29 years old, the young workers and the children. Here, when I mention "working in Bangkok or not", I mean by the phenomenon where the working age group are increasingly getting jobs in the huge bustling capital of this kingdom, instead of working in their local hometown villages. So when visiting a household, it was not uncommon for us to see a family of grandparents living with their grandsons. Their parents? Down in Bangkok, or Krung-tehp, as the Thais call the capital.

Generally comparing the generations, we found out that basically everyone eats and likes the traditional Thai food, such as the som-tum (papaya salad), kao-man-gai (boiled chicken on rice), seafood, etc, but we found out that the third generation likes western fast food as well or even more, such as pizza, french fries (chips), or candy bars. Younger people like to drink beverages such as coke too and consume more fried food. In terms of health care, there were almost none who did not believe in contemporary medicine. Everyone had good relations with the health center and would generally accept any kind of general treatment, whether western or oriental/traditional medicine. In Thailand, herbal medicine is officially recognized by the public and the government. Some elderly still relied on things such as ointment made by themselves from resin or herbal fruits that are not seen in health care facilities, but after all, if they have been living with it for decades and they're happy with them, and don't have health issues, why tell them to stop.

All in all, we saw two major issues in the community. A risk of lifestyle-related diseases akin to those now a problem in western countries, among the second and third generations is the first. Many in the second group already had past histories of hypertension, high cholesterol, diabetes, cancer, etc. The second is, with more and more younger generations going to Bangkok and deciding to live their for a long term, the village population is aging, which could lead to decreased livelihood or even the collapse of the community in the end.

However, there were certain strengths as well. The smoking and drinking population is not so large (Buddhism and monks have a big effect), they have a good environment with lots of nature, clean air, no traffic jams, and a relatively stress-free life, especially when compared to Bangkok. And even if many of the second generation move down there, there are still some that choose to remain in the village, and with the Thai tendency to regard their parents and families highly, those in Bangkok are unlikely to stay there forever, at least for now. Many village homes are centered around the health center and the adjacently-located primary school (elementary school), and the relationship between the health center staff and the villagers is good. They know each other well and the villagers feel easy about visiting, thanks partly or largely to the health volunteers.

Rong Ta Tee Health Center has a variety of health promotion activities such as the mosquito project (over 92% of homes now use measures to keep mosquitoes out of their water), aerobic exercise on weekends, elderly persons' education for self-help, breast and cervical cancer prevention, diabetes and hypertension project, HIV/AIDS project, increasing well-being project, developing exercise leaders project, and promoting good health among the elderly project. Now, we felt that they should now put more effort in aiming some projects at the first generation, the young. They should take advantage of the proximal location. Also, they should start thinking of ways to re-develop the community by means of creating new values, such as community-oriented small businesses. Doing this with existing resources both material-wise and manpower-wise would be a key.

But so, how did all this have a 'tremendous' impact on the way I see things? Well, I guess I learned two big things. One is that, the economical power of a community does not necessarily reflect the quality of life (QOL) of its people. In other words, it doesn't mean that if a family is not financially rich, they are not happy, and vice versa. Whether it's those living in Bangkok, Tokyo, or London living a daily life in the bustling streets full of stress, do all of them look like they are living a happy life? Through the interviews, I truly felt that many families in the community are living a happy life, in spite of some of their economic status being not so high at all compared to the average Thai. Happiness and economic development: they're not unrelated, but they don't necessarily come together. The other thing I learned is how much a people can get things done together themselves with minimal top-down type professional aid. With the health volunteers playing an important role, many villagers knew how to take care of themselves, and knew what needs to be done and who to go to in the event of a health problem. There were lots of on-going community involvement activities that are facilitated by the people.

Community-oriented, people-centered health care through community organizing and building, unlike those hospital-oriented, physician-centered medical care seen in economically developed regions. That is a critical part of primary health care (PHC), as the WHO said together with UNICEF at the Alma-Ata conference back in 1978. Health care for the people by the people... there are lots Japan and the western communities should learn. :-)

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