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.

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:
WE HAVE DONE IT OURSELVES.

- Yen Yang Chu (1893-1990)

A visit to RTIC and Ta Nao Si Health Center.

On March 27th, I was able to visit Rajanagarindra Tropical Disease International Centre (RTIC) and Ta Nao Si Health Center, in Suan Phueng district, Ratchaburi province, near Thailand's western border with Burma (Myanmar).

How did it happen? Well, a very good old friend of mine from my high school days in Maryland, U.S. took me there. He was one of my best friends there, but an year after I returned to Japan he also needed to go back to his home country, Thailand, and as our lives got busier, our emails became sporadic. However, as our lives progressed, so did information technology, and one day he invited me to Facebook, a social networking service (SNS) which is especially popular among university students in the U.S. with well over 85% of them being members. We've been in close touch ever since, and I had a chance to see him this spring for the first time in nine years.

He majored in public health and epidemiology in university, and as that implies, shares a lot of common interests with me. We could go on talking for hours and hours, until our tongues became numb. And... he is also a humanitarian junkie. He's a highly-motivated, passionate, yet kind and thoughtful person who always used to talk about how he wanted to do good for his country and its people. So well, when I asked him if I could take a peek at some places he know that can be visited during my time frame there, he happily offered me to take me here.

RTIC, or the Suan Phueng Research Unit, run by Mahidol University's Faculty of Tropical Medicine and supported by the Tropical Disease Trust Fund under the Princess Galyani Vadhana, is one of the faculty's research stations for conducting research on tropical diseases. The facility's primary activities are (1) provision of health services (especially against infectious diseases) for the local people, (2) field epidemiology training for students from not only the faculty but from other countries as well, including Cambodia, Vietnam, Laos, and Burma, and (3) research of infectious diseases (mainly malaria) in the area.

Suan Phueng is a small district in Ratchaburi Province, located on the border with Burma, which is just a 15-minute drive from RTIC. It has an area of 2,545 square kilometers, consists of seven sub-districts with 8,254 households and a population of 66,972. Over 90% of the population are mainly Thai-Karen of low socio-economic status, some of who do not carry Thai identity cards. Along with 13 health centers, they also have a community hospital with 30 beds, about 30 minutes from RTIC. Common health issues of the people living in this area include malaria, dengue hemorrhagic fever (DHF), filariasis, tropical skin diseases, intestinal helminthiasis, and malnutrition.

When we visited, Dr. Maneeboonyang of Mahidol University was on duty at RTIC and he happily welcomed us and gave a brief tour of the center. According to him, this area has the highest prevalence of malaria in Thailand at around 12-13%. The kingdom is one of only a handful of countries that have succeeded in eliminating and controlling this notorious mosquito-borne disease, however, it still remains a big issue along the border with Burma. But still, the situation has been improving, since prevalence was around 30% only a decade ago, with at least one person in every single household having malaria in one of the hamlets. According to Dr. Maneeboonyang, RTIC sees 10 patients per day in the dry season (January - April) and over 30 during the rainy season, and out of that, about two and six people are diagnosed with malaria, respectively.

After the tour, he was kind enough to take us to Ta Nao Si Health Center, which is one of 13 health centers in Suan Phueng district. It provides primary medical care, immunization, and antenatal care for the local residents. We had a chance to have a short talk with the public health officer there, and according to him, the top three common diseases in the village are malaria, diarrhea, and flu, though hypertension (high blood pressure) and diabetes are becoming a problem especially among the elderly.

At the end, we had an opportunity to drive around the village to see some homes of the Thai-Karen, which look different from the traditional Thai examples. It was not long before the sun was starting to set and so we had to leave the area (local roads are without pavement and lights), but the staff at RTIC were kind enough to offer me to visit again, next time staying for a few days. And there is also Tak province, sometimes called the "humanitarian aid mecca of Thailand", and the Thai-Burma border area there, about an eight-hour drive from Bangkok. I definitely have to and sure will come back again.

Many thanks to my friend. :-)

JAIH-S International Health Training Camp 2008.

I was given an opportunity to participate in a four-day global health training program that was carried out by the Students' Division of the Japan Association for International Health (JAIH-S) from March 13th to the 16th. The main aim of this annual program is for the participants to be able to (1) create an image of what working in the global health field is like, and (2) know what you can do and how to start it.

We had lectures done by people currently working at the front lines in this field, including staff from the International Health Center Japan, a tropical medicine researcher, an epidemiologist, officers from the Ministry of Health, Labor, and Welfare (MHLW), and health specialists from NGOs, JICA (Japan International Cooperation Agency), and UNICEF. The lectures were followed by many group activities including discussions, debates, and a PCM (project cycle management) workshop which we had to work on through a night to complete.

My impression? Well... frankly speaking, I felt a little weird throughout the program. Of course, all the participants were highly-motivated, deep-thinking, yet thoughtful people who had gathered from around the country, and without question, the chats with them were really stimulating and one of those memorable times. However, most, if not all of them, were drawn by the terms 'global health' or 'international health', while on the other hand, my interest doesn't necessarily have to go beyond the border, as my 'theme' is community-based health care or primary health care (PHC). Yes, often times, these words have been talked about more in the developing communities rather than the industrialized ones so no doubt it does have a 'global health' taste to it, however, when you take a close look at the developed communities, you actually do see many forms of community health, and plus, there are many things these communities around the globe can learn from each other.

And, another reason for my feeling not right is probably due to the fact that many of the speakers have already literally abandoned the clinical part of being a physician. In other words, many of the doctors in this field do not see patients anymore at a hospital or clinic. Yes, it is true that so-called logistic-type jobs are more needed than specialized people like doctors or nurses. For example, when you take infectious diseases, the main underlying issues in the developing communities are more basic, such as sanitation or health education, and tackling these issues is the most radical solution. Treating patients and prescribing drugs is also a job that can not be cut, but it does little in terms of remedying the bigger picture. So what's needed in the field of international cooperation? Leadership, management, communication skills, and creative thinking. It's what one of the lecturers said, and I agree.

However, at this point, I have no thought of abandoning the clinician's work. Well, that's what I am studying medicine for right now! To obtain specialized skills. Yes, I am interested in public health, community health, and doing positive things for the bigger public, but I want to do that through interacting with the patients. So the image of my future I have right now could be called 'clinical epidemiology-based community health'. In other words, through interacting with the people, know the community, know its strengths, weaknesses, and hidden potentials, and do something creative to bring out their strengths to make the community happier as a whole, with the people in the community. This training program helped me reaffirm my interest.

By the way, I had a chance to talk with Dr. Honda, the founder and current chair of SHARE, the biggest non-profit organization in Japan specializing in international health cooperation, and I was deeply moved by his talks, as he and I had so many common interests... his 'theme' also sounded like community-based health care and primary health care (PHC). :-)

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! :-)

AIHD 2007 reunites in October.

I really like these people.

And I think these people truly like each other. Almost three months have passed since the Primary Health Care (PHC) program at the ASEAN Institute for Health Development (AIHD) at Mahidol University, Thailand in August, but we're still close together. We're holding dinners and parties at least once a month, and the members just keep on coming. The October dinner was held on the 23rd, and one came from Nagoya by shinkansen, another came from Fukuoka, 900 km from Tokyo, just for the event. Two others dropped by at 10PM after finishing work and training, respectively, just to have a few moments to see who's here and what's up with them.

Just amazing. I wonder what got us so hooked up with each other... and no doubt I'm one of them. We had 37 Japanese in the flock in Thailand, and of course, not all of us come to join these events, but every time we get together, there's at least a dozen members, and what's both surprising and amazing, is that that number keeps on going up time after time.

And, we're all with different backgrounds. Not only are we comprised of medical or nursing students, but also people who already work, either in the medical field or somewhere else, or students from totally different areas of study (at one glance different, but actually connected). But there's some kind of intrinsic common factor that's keeping us together... :-)

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... :-)

Am I interested in international cooperation?

Am I interested in the field of "international cooperation" or "international health"?

The answer is yes, and also no.

Nowadays, an increasing number of young people talk of wanting to become involved in international cooperation. Of course, it sounds interesting, and I'm sure it is. You can definitely use your English skills for those who are good at it, or it'll still give you opportunities to train it if you aren't as good. You'll probably get to travel overseas and get to know many people from other cultures and backgrounds too.

But, there always has to be an objective, I think. At certain points in our lives, we find things that we want to do. Things we want to devote our time, energy, and the resources that we have in. And I think these are the things that we truly yet naturally feel that we should do. If that's something that involves a country other than your home country, that's something "international", right? If that's a not-for-profit kind of work you do with people from other countries, that can be called "international cooperation", right? If that has something to do with health care, that's "international health", right?

The point I want to make clear is that when I talk of "international cooperation", it's just a character of the picture I want to be a part of. We're doing things that we want to do and as a result, that could be seen, or classified in other words, as "international cooperation", but I think there's nothing more to that term. It's just one way of categorizing.

To make a long story short, my interest is in using health care as a tool or a catalyst to bring a people together and bring more happiness. This I'll probably talk about another time... but anyway, if this thing I'm thinking about is outside Japan, then I guess it can be called "international health", but it's not because it can be called that way that I'm interested in this. :-)