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. :-)

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! :-)

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... :-)