A visit to Inazusa.

Now part of the city of Shimoda, Inazusa is a peaceful countryside village on the Izu Peninsula, the easternmost part of Shizuoka prefecture. It actually occupies almost half of the city area, but its population is just over 10% of the city's, standing at 2,855 as of 2008. 35% of them are over 65 years old, which is a little above the average rate for a Japanese countryside village. Many of them are farmers, but nowadays they run other businesses alongside to make both ends meet. In April, I had the opportunity to visit Inazusa Clinic, a relatively new clinic that was set up just five years ago by JADECOM (acronym for Japan Association for the DEvelopment of COmunity Medicine), one of few health care organizations putting effort in bringing health care to rural, isolated areas in Japan.

Inazusa had a clinic that was funded by the city of Shimoda until 2002, when the sole physician of the clinic neared the age of 90, and without a doctor to take over the job, was forced to close down. So the village went without a doctor for three years. People who could drive traveled 20 minutes south to central Shimoda, where they could find some privately-run clinics. Accompanied by two nurses and two clerks, Dr. Hajime Kawasaki is the head of Inazusa Clinic, and he kindly accepted my one-week visit. Because I didn't have too much time, I wanted to spend the time to know the village and its people, and at the end of the week be able to 'draw a picture' of how the community looks like.

The first place I went to to meet the villagers was Ryusouin. This little local temple has been holding what it calls 'Temple Wellness Renko' (traditional exercise) sessions, where locals come to do exercise with the the monk, who interestingly has a bachelor's degree in physical education. In a rural area like Inazusa, during the 'obon' (Japanese Buddhist custom to honor the ancestor's spirits) season or whenever a funeral takes place, the family of the deceased along with the monk walk through the town visiting each and every home so the deceased can bid farewell. And the monk here found out that there were many who complained about back pain or joint pains, and together with the awareness that he himself was lacking exercise, came up with the idea. About 10 people come to each session, which takes place four times a week, and pay 500 yen per session that runs for about one hour followed by chit-chat time with tea and sweets. Asking the participants, not all of whom are locals, they say they come to talk with the charming monk, more than for the exercise. The monk says that he hasn't been able to attract the people who he really feels he needs to do exercise with, especially more locals, and that certainly is an issue to be solved. Also, citing the temple's proximity to the clinic, he says he has many ideas he might want to try together. Monks could play an important role in bringing a community together, like in Buddhist countries such as Thailand.

Another place I visited was the local nursing home called Azusa-No-Sato, which literally means 'the village of Azusa'. Like many other similar facilities in Japan, it also operates so-called 'day care' activities where the elderly who live with their families at home come to spend a day to play, take a bath, and socialize with the fellow elderly, not only to have them enjoy time, but to spare some break for the care-giving families. The national elder-care insurance is where the money for the service comes from, and the families would usually pay about 2,000 yen (JPY) per day, though funding for the insurance comes partly from the insured's past monthly payments. Because the nursing home's service includes picking up as well as dropping them off, I had a chance to get a glimpse of the actual homes and the areas the people live in. For the staff, it's not an easy job. It requires lots of energy, both physically and mentally, and considering their often below-average salaries, I had the impression that many workers in this field were not enjoying their work. However, it was different, at least here. Yes, the staff were always thinking and doing what they have to, but still, they were enjoying joking and playing around with the elderly as well, in a genuine sense. A staff said, "This is not the kind of job you can continue if you don't enjoy it. I really like my job."

In Inazusa, or like in many other places, farmers have always naturally formed informal groups with fellow farmers nearby, like a neighbors' small gathering. Many of them would have lunch together, chit-chat, or even do some leisure traveling when they can spare the time. One of those groups, which calls itself Chalette, has interestingly founded a small 'manju' (Japanese traditional pastry with sweet red soy bean paste filling) shop. They say they wanted to do something different, something they enjoy doing, and something they can continue doing, and that's when they realized members in the group were good at making Japanese traditional pastries. So they collected 100,000 yen and started this shop. Conveniently located along a road that connects Shimoda and towns on the other side of the peninsula, the now well-known shop earns enough to fill the members' piggie banks. When they sell out, they sell out, but they don't increase their job because they want to enjoy it and don't want it to become a burden on them. "Family comes first. Job comes second."

Another group of farmers founded a community farmers' market called 'Kimagure Shop', which literally means 'the range of products and price is up to the mood of the day'. When crops are harvested, it normally goes through a number of wholesale dealers before it reaches the consumer, and along the way the cost adds up and is represented in the price. So, what this community market does is farmers directly come from the fields to drop off their products, specify a price, and the market sells them off here, and 88% of the income goes back to the producer. This way, the farmers get bigger margins but the consumer gets them for less than what they would pay in an ordinary supermarket. Plus, the products are consumed relatively locally. So the products sold depend on the season, and now over 90 producers, not only farmers but local bakeries and flower shops, drop the market. It's becoming a place where not only the people of the community gather, but chit-chatting between the locals and travelers as well, being located alongside a main road.

Inazusa is certainly a typical rural village, but does have many encouraging activities run by the locals that are helping to sustain happiness in the community. :)

A visit to Nagi Family Clinic.

During the final week of August 2008, I had an opportunity to stay with Dr. Akira Matsushita, the family medicine physician at Nagi Family Clinic, one of Nagi town's only two medical facilities. A larger hospital in nearby Tsuyama, which is a 40-minute drive, is the only in the region offering tertiary medical care.

Nagi is a small town in Okayama, situated in the partly mountainous region of this rural prefecture in the southwestern part of Honshu, Japan. A 15-minute drive will take you to the border with Tottori prefecture. Sarcastically nicknamed 'the Ginza of Nagi' by some, the central part of the town is not bustling at all, with only two supermarkets (closing at 7PM), one convenient store, a tiny locally-owned bookshop, an elementary school, one pharmacy, the town office, and the clinic. Home to 6,690, Nagi's population has been decreasing year after year, just like many other rural towns and villages where younger generations have decided to move to not-too-distant urbanized areas such as Okayama city, Kobe, or Osaka, in search for better jobs, a wider choice in academics for their children, or simply a more convenient lifestyle.

So, why did I visit the clinic? Well, after seeing various types of community-based health care in the U.S., Thailand, Scotland, and Tokyo, I wanted to have a glimpse of what rural health care is like in a place far from the country's capital or any other big city. The closest to Nagi is Okayama city, which is more than a two-hour drive. Dr. Matsushita, well-known among general practitioners in Japan for family-oriented primary medical care and medical education in family medicine, happened to be the former attending of a doctor at my university's general medicine department who I am very fond of, Dr. Hiroyuki Saito.

Now what's so special about this clinic? Well, to put it in a single sentence, Nagi Family Clinic knows its patients very well, and that is very, very well. The doctors take a considerable amount of time in listening to the patients, some of whom make visiting the clinic part of their weekly schedule just to have someone to talk with. You may think that is wasting time, but if that is helping the patient stay happy and actually healthy by means of making the patient think and recall what happened in the past week, that is not necessarily correct. All the medical records have been digitalized and are online on the clinic's server, and that has enabled them to create the 'electronic family tree', where when you look at a patient's medical records, you can also see the family members and their medical records at the same time, which is a handy tool that helps to make medical care more family-oriented. The doctor can interact with the patient with all that background of the patient in mind. Another special feature I noticed is that, every single staff, including the paramedical workers, know so much about the patients. Their medical issues, their character, their habits, and so forth.

So, my week at the clinic and town enabled me to get a glimpse of who and what kind of people live here, the social issues that underlie, and how health care is done in this small rural town, from different perspectives, as Dr. Matsushita kindly made it possible for me to spend time not only with the clinic staff but also with the social worker at the nearby town office and staff at the local non-profit organization (NPO) called Kazamakura, which offers services for the elderly including home-visiting nursing care and driving them to health care facilities. A low-fare local town loop bus was introduced recently, but for the elderly, bus-stops are often still too far from the home to walk to, and you don't have the option of a taxi in this rural part of the prefecture. Like in many other rural areas of the country, the over-65-years-old population is growing there too, now exceeding 25%.

The Japanese Self Defense Force (JSDF) base and training grounds play a large role in supporting the local economy (the JSDF even pays a certain amount to the town for each and every single bullet fired) in a town where apart from one construction company's factory are only small local businesses and agriculture. And that factory is currently amid a dispute with the people living nearby, who are complaining of the exhaust that comes from the factory chimneys causing respiratory problems, though company officials claim they are meeting all environmental standards. It is a bittersweet situation for the local government, which finally succeeded in inviting this first company to make a factory in town but that is now having conflicts with the locals.

Every week, a 'community care meeting' is organized at the family clinic, which is a gathering attended by staff from the homes for the aged in the town, the local town office, Kazamakura, the local pharmacy, and the clinic, to discuss the latest health matters and try to solve them through cooperation and close coordination. For example, they would talk about s 90-year-old lady living in the southern part of town who's dementia has recently deteriorated and needs more frequent home-helper visits, or how to make efficient and sustainable safety nets for the elderly living alone and far from the center of the town. This town, being small, means human resources are limited, but on the other hand it could also be an advantage, as it makes it easier for them to communicate with each other, coordinate closely, and make decisions fast. And including the aforementioned clinic staff, everyone knows the town people very well. Truly a form of community-based holistic care.

People of Nagi are bright. I don't know, but every time I visit countrysides, I can't help myself from getting the impression that people in rural areas generally seem to be happier than those living in the busy mega cities. And the elderly in Nagi, yes, some are surely vulnerable to illnesses, but there are still many 80-year-olds and even 90-year-olds working in the fields from sunrise to sunset. One old man told me, "yes, I'm way past 65 (retirement age), but working in the fields is what I enjoy and that is my living".

Good communication and cooperation is there with the health care staff and happiness and livelihood are not yet lost with the people. Yes, many small villages and towns have chosen to merge with their neighbors due to financial uncertainties, and no doubt there will be challenges ahead for Nagi as well, but with all the strengths plus a touch of creative thinking, I believe they could well be poised to become a good example of rural community holistic care. :-)

A visit to Hinohara Village Clinic.

Hinohara Village is part of Tokyo, located in the northwestern corner of the huge city. The place neither looks like Shinjuku with the jungle of 50-story buildings nor Azabu with all the four-star restaurants and residences of the affluent, but more like a gathering of homes in a mountainous countryside. From central Tokyo, it takes two and a half hours by train to reach the nearest station and a bus ride from there that takes a further 40 minutes.

I had an opportunity to visit the village clinic here on the 25th of February. Two doctors work here, one of whom I know from a primary medical care seminar that took place last September, Dr. Aizawa, and when I asked him whether I could visit to see what health care in a remote area is like, he kindly gave me a nod. So on this morning I got up at 5:00am (still a bit dark around this time of the year), hopped on the train, and headed for Musashi-Itsukashi, the station nearest to the village. And since there are only six bus round-trips between the station and the village, Dr. Aizawa was kind enough to pick me up on the way from his home to the clinic.

The road winds between the mountains along a river, and I realized a lot of snow still remains. There are so many cedar trees on these mountains, many so close to each other, and Dr. Aizawa tells that these were planted in the 1940s for war, but have been left as they are ever since they became unnecessary soon after. The population of the village is now around a little over 2,850 people, with an amazing decreasing rate of 4-5% per year in recent years, with last year's number being 3,000, and the year before a little under 3,200. People over 65 account for 41% and families of the young generation continue to move to urban areas, no wonder there's no high school and the number of students in the village's sole middle and elementary school stand at 30 and 90, respectively.

This day was a relatively easy day for the clinic staff, which is comprised of one office personnel, one medical technologist, three nurses, and two doctors, as they only had about 30 outpatients. The clinic has a small inpatient ward that can accommodate two, but is usually only used in emergencies since a general hospital is about a 40-minute drive from here. Unlike the big hospitals in the urban areas, patients who come here complain of a variety of disorders, from common problems such as simple chest pain caused by falling down, or common colds, to major diseases such as diabetes and other lifestyle-related disorders or pneumonia.

In the afternoon, I had an opportunity to see what is called an "Oushin", which is a house call where a doctor goes and sees the patient at his or her home. I saw a similar activity at Ukima Clinic. (See post 2007/11/20) But unlike in the urban areas of Tokyo, the houses are so far apart, Dr. Aizawa says it could take well over 30 minutes to reach the home. Fortunately today, the house that gave us the call was close enough. It was a big 2-story house with an old couple living together, their children having already moved out to the urban areas with their families, leaving many rooms unused. The husband could not walk anymore, so his wife was taking care of him. Dr. Aizawa adds that many homes are too large, and since only a few live in them, many are cold even inside the house. There are sometimes severe cases, such as when they found a handicapped elderly living alone in a large house on top of the mountains with malnutrition.

Although the current state of health care here could not be said convenient, Dr. Aizawa says that it's much better than that of villages in other prefectures. Local governments in Tokyo are eligible to receive a considerable amount of financial assistance from the metropolitan government, partly due to the fact that they have made it a rule to place at least one doctor for each and every single local government, including small villages with a few hundred people. Meanwhile, not far from Hinohara Village is the countryside of Yamanashi Prefecture, where he says health care is in a "much worse condition". He added that you can even notice the difference in the quality of the road pavement when crossing the border.

There's much more he talked about this day, especially about his early years as a doctor in the remote islands of Tokyo floating in the Pacific. But for now, I'll stop here. Through this visit, I was able to get a general idea of what health care in a remote area is like, at least in Tokyo. I should visit other prefectures too. I would like to thank the kind staff at the clinic for making this visit possible. :-)

Looking back at 2007.

Time flies.

Oh boy, I wonder how many times I've said this phrase on this blog. But well, it's true. But it's also true that this year was full of meeting new friends and discovering my interests... and myself.

In spring, I participated in VIA's (a non-profit based in San Francisco and on the Stanford University campus) Exploring Health Care program to learn about health care in the USA and in the Bay Area in general. Along with medical students and undergraduates thinking of going that way, we hopped around the area to see hospitals, clinics (both private and free), homeless shelters, shadow doctors' rounds, participate in class to get a taste of what medical education is like there, and much much more over a period of 2 weeks.

The gay clinic called the Magnet, located in the heart of Castro, the gay mecca of the country, is what sparked me into community-based health care, or in other words health care that involves the entire community. What's amazing is that it's not merely a clinic but has the potential to act as a catalyst to bring a people together and empower them as a whole. I'll talk about this much more in detail another time...

And this summer, I found myself in a 11-day primary health care (PHC) training program at Mahidol University's ASEAN Institute for Health Development (AIHD) in Thailand. Along with nursing school students from that country, we followed a highly-concentrated course to see health care in the urban areas of Bangkok (including the slums), go up 4 hours by bus to the rural areas in Uthai Thani Province and stay in a village to do some epidemiology field work 'for beginners', and do a presentation at the end with our groups.

The rural area home-stay and the interviews and other interactions with the villagers totally changed how I think, and this is where PHC and community-based health care got on me. Again, I have to save another time to tell this in detail...

And last but not least, DOCS (acronym for Development of Clinical Skills), which we formed with the former participants of the Exploring Health Care program in our university to get a head start and practice clinical skills, played an important role in my life this year. We found energetic, passionate, student-caring doctors who were willing to teach us, in a university where we once felt finding those kind of mentors was devastating. Moreover, the activities led me to knowing general medicine, family medicine, and primary medical care, which then led me to Ukima Clinic, a community-based clinic up in northern Tokyo. (See post 2007/11/20.)

The more I look back at this year, the more the activities I was involved in get connected in one straight line. Compared to a year ago, I couldn't have imagined myself where I am now. This year helped me discover what my true interests are in (at least for now), and now I can much better describe the bigger picture of the doctor I have in mind for my future.

Wishing everyone a happy holiday season and another great year! :-)

A visit to Ukima Clinic.

When I contacted Dr. Fujinuma to ask whether I could see Ukima Clinic, a community-based clinic operated by the Tokyo Hokuto Health Co-operative, he happily nodded. So, on November 6th, I had the chance to visit the clinic I had been wanting to visit since spring.

I invited three friends who also participated in the Exploring Health Care program this March at Stanford University and University of California San Francisco (UCSF) and now belonging to a clinical skills practice group called DOCS (acronym for Development of Clinical Skills), which we formed after knowing how much clinical experience the medical students on the other side of the 'big pond' are exposed to.

So that morning, the day there started out in the outpatient clinic. Of course, it was our first ever time shadowing a doctor, so there was so much to learn, both in terms of knowledge and the way the doctor interacts with the patient. However, what I felt here most strongly is that health care is truly patient-oriented, in other words, even if patient A and patient B have the same health issues, the medical treatment or the approach taken by the physician may not necessarily be identical.

For example, there's not much hope in persuading an alcoholic or a heavy smoker to quit or reduce the amount if he insists he earns money to drink or smoke, respectively, and if that is the ultimate joy for his life. However, a different approach may be taken towards a person who is more willing to care more for his own health. A woman who smokes five cigarettes a day to refresh herself during break at her work says she is aware that it's not good and she's thinking of cutting the amount, but just couldn't make the move. So, then the physician would actually show her some other ways of refreshing, for example drinking tea or coffee or having a light snack, and chatting with her fellow workers. Naturally, there are exceptions, but in general, the doctor does what makes the patient most happy.

In the afternoon, we participated in what is called an 'Oushin', which is a house call where a doctor goes and sees the patient at his or her home. This is a very interesting form of health care, since you really have the chance to see the environment the patient is in, including the lifestyle and the socio-economic background. There are households with various status, from seriously poor ones to rather wealthy ones. In this afternoon we visited seven.

There was a family where the only person in the house was a 90-year-old lady lying all day in the bed, having only one grandson living with her to look after her when he doesn't have work. Other members of the once big family have either died or are literally 'missing'. The house looked as if it's going to crumble with a couple more earthquakes (yes, common in Japan), and the physician, now used to visiting this home, told us the places in the room where the floor had become too weak to support us. There was also a relatively wealthy-looking family, living in a mansion. Nicely dressed ladies (apparently sisters) had gathered to look after their mother who had become ill. This was a first-time visit for this patient, so the doctor goes through the explaining and all the communication with the patient's family thoroughly and carefully with detail. After the visit, she added that it's essential to build a favorable first impression, since that leads to trust and will ultimately have a substantial effect on the future relationship with the family.

So the day ended roughly eight hours after we arrived at the clinic in the morning, though the physicians still had some paperwork left including reviewing the patients' medical records. It was a day where I had the chance to truly understand that there actually are various kinds of people with various backgrounds. I mean, I knew that by words, but this experience enabled me to put those words in my own context. It is often said that the socio-economic disparities have widened in Japan, but still not to the extent of those seen in the U.S., Europe, or developing nations, however, disparities do exist and those are not minute. It is all the more important to understand the true needs of the patient, considering the background and the environment of the patient, and think about what happiness means for each of the patients, and tailor health care to help them become happier.

At the end, Dr. Fujinuma summarized the day by giving us a small lecture about what primary health care (PHC) is, and what strategies the clinic is taking to make the community more happy as a whole. Through this talk, three key words got connected in one straight line in my mind: primary health care (PHC), public health, and community building and empowerment. There's a whole another story to this, so I'll stop here for now. :-)

International Health Co-operative Forum.

The International Health Co-operative Forum was held today in Shinjuku, Japan. It's the 3rd forum after Tokyo 1992 and Manchester 1995, and the theme of this occasion was to decide on the global objectives of the co-operatives' approach to health care, especially after the birth of regional health co-op organizations such as the International Health Co-operative Organisation (IHCO) and the Asia-Pacific Health Co-operative Health Organization (APHCO).

We first had a general assembly featuring some very interesting speeches, one of which I will discuss later, and then we divided into five sectional meetings: world's health co-ops, primary health care, poverty and international cooperation, coping with aging societies, and international exchange of people. I decided to participate in, you've guessed it, the primary health care meeting.

There I met Dr. Yasuki Fujinuma, one of four guest speakers for this sectional meeting. Actually, I've met him before, at a primary health care workshop which was held at the end of September. He's currently the director of Center for Family Medicine Development (CFMD), and also works at the Ukima Clinic, a community-based primary health care clinic located near Akabane in northern Tokyo, and is actively involved in both improving medical education and developing primary health care in Japan. Ukima Clinic is one of the clinics I have an eye on, as it is doing very interesting health care activities at a community-based level. I hope to visit the place sometime next month. Anyway, the part of his speech that caught my attention was when he talked about the near-term plans of primary health care in health co-ops. He talked about three.

One, he stated the need for clinical training in primary health care clinics. He showed us some numbers, and it was something we could nod at. If there were 1000 patients, 88 of them would be going to local clinics while only 0.3 would be paying visits to university hospitals, but the reality is, most of the young doctors train in university hospitals and others alike, the ones that provide specialized, so-called tertiary health care. Clearly, there is a definite need to do at least some training at the community-based, primary health care level.

Secondly, he mentioned that the health co-op should take part in more international activities, taking advantage of the fact that there are co-ops around the globe. In primary health care, you look at the patient as a whole, not just the disease, so it's all the more important to know and understand the socio-economic and cultural backgrounds of the patient. International staff exchanges and training sessions would surely provide an opportunity to see patients with various backgrounds and also have a look at what cross-cultural health care is like. The infrastructure already exists and works around the globe, so networking those is the key here, and I believe the recently-formed IHCO and APHCO can play a pivotal role in this.

And thirdly, he urged that more research be done on primary health care, and also stated that the quality of co-op's primary health care activities must be improved. After all, medicine is still a world where the more specialized skills you have, the higher your authority. In other words, areas like primary health care where you need more of a broad knowledge than specialized knowledge in a certain limited area are not so highly regarded, at least in Japan, so the people need to show with undeniable evidence that primary health care is something that plays an essential role in health care. The co-op's primary health care activities need to be improved too, since obviously you need trust from the people and the community, and quality is what builds it.

When I heard Dr. Fujinuma's talk, I just purely felt moved, and encouraged, as those were exactly what I had in mind. Primary health care, community-based health care, cross-cultural and international health care, education, networking of people and organizations... all of these words I've been thinking about suddenly got connected in one straight line. It's really exciting and encouraging when you meet these energetic people who share similar ideas with you, and especially if that person is already starting to get some things done.

Can't wait to visit Ukima Clinic... :-)