A glimpse of the Philippines from Negros.

In early March, I had the opportunity to visit Negros Occidental province in the Philippines, thanks to Dr. Yasuhiko Kamiya at Nagasaki University and the Japan Association for International Health's Student Division (JAIH-S). I was based at Bago Health Center in Bago City, about a 30-minute drive south of Bacolod City, the capital of the province. The kind staff at the health center allowed me to stay at one of their houses, and I stayed with Joseph Aunzo, who is a nurse at the office, and his family. Every morning, it's not the alarm clock that wakes you up but the chickens that start crying no later than 6AM. I headed off to the office with Joseph every morning by 8AM and had days full of observing the many activities not only of the health center, but of schools, local villages, non-profit organizations, etc.

Due to the fact that I only had a week in the region, my primary goal for the visit was know the daily lives of the people who live in the area, and get a glimpse of the social aspects, such as the cultural, economical, political background of the community that they belong to. And from there, with a health-oriented perspective, I wanted to see what the problems, or the weaknesses, of the communities are, how the people themselves are feeling, and what they are actually doing to tackle these issues. I also had the opportunity to meet some local politicians, and wanted to know how the government sees the communities and what they are doing.

One day, I was with Dr. Kamiya, and we made a home-visit to a nearby village. This house was the home of a child with cerebral palsy, one of many disabled children Dr. Kamiya had been personally supporting for many years. He not only donates older wheelchairs and fixes those that are broken and reuses them, but listens to the child, the family, and discusses with them what can be done. The house was an ordinary house that you find anywhere in the rural areas in this part of the country, and though not affluent, the family had been taking care of the child for well over 10 years, ever since he became handicapped. However, the family didn't have enough money to buy medicine. There are established non-profit organizations, such as Negros Occidental Rehabilitation Foundation Inc (NORFI) and Volunteers for the Rehabilitation of the Handicapped and the Disabled (VRHD), both based in Bacolod, but they obviously cannot be permanent solutions. On another day, when we visited another village, the people there had listed the five major issues in the community, and the lack of money to purchase medicine and the insufficient number of health-care professionals made up two of them.

In the Philippines, the population is still growing at a fast rate. Families make many children so as to have them work and increase the household income. Catholic being the major religion, ever since the Spanish colonization days, may not be helping as they discourage contraception. Many people who worked in the health center also came from big families, some of them having seven siblings. When I visited a local elementary (primary) school, there were children full of smiles playing around, but some were saying to me "I don't have money to pay for lunch", "my house doesn't have a shower", "... because we're poor". Or were they seeing me as a donor? Comprised of six years, about 10 to 15% don't make it through the curriculum due to financial reasons, according to the teachers. The schools is trying to find scholarships, but obviously, there aren't enough. Yes, poverty, in terms of lack of cash, is an important issue and lies at the root of many problems, however, it was unfortunate that I wasn't able to feel the local people's will to do something creative to help the situation.

I asked the staff at the health center and the hospital. Here, the local government needs to find budget to lure health-care professionals to this area. Because there isn't enough cash, there isn't a sufficient number of them, especially physicians. For example, Bago Municipal Hospital, the only public general hospital in the area, had 50 beds and an emergency room (ER), but there were only five physicians. There were, however, plenty of nurses. However, many of them are working without pay, and there's a background story to this. In the Philippines, about 40,000 new nurses pass the license exam (out of 100,000 total), but that is more than the demand. And even if you are in a relatively high position, such as a chief nurse, you still only earn about US$400 per month. So, what is happening is many are moving out to work in Europe, the U.S., and more recently the Middle East, especially Saudi Arabia and United Arab Emirates. From there, they send part of their income back to their families still living in the Philippines. The nurses who are working without pay are those trying to keep up with their nursing skills while preparing to work abroad. In Ma-ao, the village I visited, there was one physician, which is rather rare, because there are many public clinics that don't have a physician nor a nurse, and a midwife is carrying out all the diagnosis and treatment.

So, what's the government doing? Ever since the Philippines became independent from the U.S., politics have never been stable, effectively slowing down the issue of bringing affordable, if not universal, health care. Staff at the health center do say that "the government is putting at least some effort and its gradually starting to improve", but its certainly far from catching up. When I visited, it was near general elections so lawmakers had once again pretty much halted lawmaking and shifted to election projects. And every time an election happens, vote buyouts are very common, and the locals use the money to help pay for their daily expenses, including health care. The people say they don't have money. The government says they don't have money either. So who does? Of course, there are the huge multi-national corporations and related politicians, who have a hold of much of the country's wealth. Some Filipinos sarcastically put it this way: the Pareto principle (80% of wealth is in the hands of 20% of the population) is more like 95% to 5% for the Philippines.

It was a short stay for me, but I was able to meet a variety of people. However, as I mentioned earlier, the lack of money is at the root of many problems, but many people have stopped their thinking there. Yes, financial support is important, but that's an issue that will be around all of the time. What's important is how creative the people in the community together as a whole can become to overcome hurdles, including money, to make their daily lives happier. Yes, it's not easy, and it's not accomplished in just days or weeks. Some staff said that foreign visitors coming and praising the work the villagers do helps them gain confidence and move on. I guess that is important as well, but eventually, the people should be doing the things because they together feel the need to do so, not because somebody from another country is saying they're doing a 'good job'. When a people together become able to address its own issues, and creatively use their strengths and resources to tackle them, that is when a village starts to become truly independent, and it is what leads to empowerment and social development.

However, I want to make sure I am not saying the people have lost vitality. Yes, there are many who have fled overseas, but, there are many who have chosen to stay, even though their salaries are only a fraction of their counterparts in Europe or the U.S. They love their hometown, they don't want to be far from their families, or they have a strong passion for the work they do. Conversations with Nona Obando, the chief nurse at the health center, and Dr. Ramon were memorable, especially because I felt how much passion and pride they have not only for their responsibilities, but their home city. These altogether are invaluable assets to the local community and what helps it keep going. And then again, even for the people who have fled overseas, their feelings for their families and hometowns are the same. I have seen people in Japan and the U.S. who have lived for over 10 years without returning, but still continues to send money back to their families.

Immigrants are there all over the world, and ever more so with globalization. Whether documented or not, they all come because they want to make their daily lives better, because they want to support their families. And their longing to live in their hometown does not change. I would like to express my appreciation for Dr. Kamiya, JAIH-S, Nona, Joseph, Dr. Ramon, Dr. Pilar, and all the staff at the Bago City Health Center for their kindness and letting me have this opportunity.

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.

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.

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."

A visit to The Royal Infirmary of Edinburgh.

My first visit to Scotland, and Great Britain. It was months ago when I decided to participate in the three-week 'English for Medicine' course offered at the University of Edinburgh's (pronounced 'yeh-dinbra') Institute for Applied Language Studies (IALS), and what made me do so was that I wanted to see the Division of Community Health Sciences and meet a professor named Dr. Raj Bhopal there to seek some advice about how I should pursue my area(s) of interest. Having interest in family medicine and public health with a clinical taste, I also wanted to take a look at how general practitioners (GPs) work and get a general idea of the health care system there.

As in other countries as well, the U.K. has both public and private hospitals, the former of which is run by the National Health Service (NHS), a non-profit organization funded by the government but independent from, paper-wise. Now, in Japan, patients have the freedom to choose the hospital or clinic they wish to visit. Whether it's your local clinic or a university hospital or the cancer center, it is basically up to you to decide where to go, however, this is not the case in Great Britain. If you become ill and wish to see a physician, unless you have a contract with a private health insurance company, which will allow you to have access to a private hospital, there are only two ways you can see a physician: see your GP or end up in the accident and emergency department (A&E). GPs are allotted a certain population in an area, meaning from the patient's point of view, you are automatically determined who your local health care provider is depending on where you live. Only when your health problem cannot be solved at the GP or A&E clinic that you first have the chance to see a specialist, in the form of referrals written by your GP.

A GP has two major roles: an expert in general medicine providing primary medical care, and a gatekeeper of resources. The former role includes not only the clinical part (inside the clinic and also visiting homes), which includes pediatrics, maternal health, referring patients to specialist hospitals, and follow-up of patients with chronic illnesses, but also a variety of other tasks for community health, such as prevention and health promotion, and sex education and family planning. But in reality, most of the GPs in populated areas only have time to do the clinical part, which can be understood from the fact that patients are made to wait an average one week from when you make your phone call to the point of your appointment. No wonder an increasing number of patients, who can afford, are choosing private hospitals. If you're referred to a specialist, it will likely add more weeks or even months to that.

The GPs' latter task, as a gatekeeper of resources, is in two perspectives. A GP has to prevent inappropriate use of treatments and 'control' the patients' demands, thereby saving financial resources, and also guide the patient to the right care they need, as in referring to the appropriate specialist, thereby saving human resources. However, because of this, there are many GPs who face a dilemma, as they are also the closest health care personnel for the patients, and speaking out for them is the basis of a GP's job.

So, when I had an opportunity to follow Dr. William MacNee, a consultant physician and professor of respiratory and environmental medicine at the Royal Infirmary of Edinburgh (RIE), I wanted to focus on not only how he interacts with the patients but also how he communicates, or exchanges information with the patients' GP, system-wise, as good communication is vital between the specialist and the GP as well in a health care system like the U.K. Oh, how do I know him? Well, Dr. Patrick Barron, the passionate professor in charge of the International Medical Communications Center (IMCC) at my university, kindly introduced me to him.

In a typical medical consultation here, the physician only jots down notes, instead of scribbling on the official medical records, which makes reading them a decipherment for others. After the patient leaves the room, the physician will read aloud and record on a tape what he wants written in the official records. The tape will then be duplicated, with one copy going to the patient's GP and the other to the physician's (or the department's) secretary for transcription on to the electronic medical records. The one going to the GP is labeled urgent (red) or not (blue). This system saves a considerable amount of time for the physician, though that means more work and some medical knowledge needed for the secretary.

The RIE is a specialist hospital, so there are no GPs, except for those in the A&E. Tracing its roots back to 1729 as the oldest voluntary hospital in Scotland, it was incorporated into the NHS scheme in 1948, and the current facility, located south-east of the city, was completed in 2003 for 190 million British pounds and boasts 900 beds. Due to its location, it also serves Midlothian and East Lothian. Adjacent to the hospital is the medical school of the University of Edinburgh, which the hospital has maintained close ties with for years. Some noteworthy features of the facility include a 24-hour A&E unit, the Simpson Centre for Reproductive Health, giving birth to 6,000 babies each year (largest in Scotland), and the Scottish Liver Transplant Unit. In the hospital's main hall are banks, eateries, a general store, a bookshop, a barber, and the patients' information center. Brochures and pamphlets covering a variety of topics, from information of diseases to informed consent, or self-help guides, such as how to deal with stress, can be found here and the good thing is all are free for the patient to take home. Very useful and interesting.

Finally, I would like to share some phrases and expressions I heard in the patient-physician interactions, especially from Dr. Gourab Choudhury, who is Dr. MacNee's registrar. I spent the morning following him on the day I was at the RIE. When a patient kept on complaining over and over about how her dyspnea was so severe, he used the phrase "Oh dear." several times. It's sometimes not easy to think about how to react when your patient keeps on complaining, and I thought this was a nice and simple way to express sympathy. Another phrase is "Let's take it on from there.", which he often used when he was finishing up the medical consultation. I often find it difficult to find an appropriate phrase to end the conversation with a patient, but here it is, a simple, convenient expression with a positive-thinking meaning and a touch of sympathy. :-)