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.

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 Wat Phra Baht Nam Phu.

Last summer, on August 8th, I had an opportunity to stop by the Wat Phra Baht Nam Phu, which translates to 'the temple of Buddha's footprints'.

At least one million Thais have been infected with HIV/AIDS since the first reported case in 1984. The rate was increasing at an alarming rate in the 1990s, however, with the society at that time not well aware of what was becoming a major social issue, those affected were cast aside and left to die. Situated in Lop Buri province, 120 kilometers north of Bangkok in central Thailand, the temple was turned into what it is now, an AIDS hospice, by a Buddhist monk named Alongkot Dikkapanyo back in 1992. Since then, the facility has expanded to accommodate 400 beds from an initial number of eight, thanks to the temple's extensive public relations strategies bringing in donations amounting to the equivalent of millions of dollars. Photos of the temple’s sick and emaciated patients adorn posters and donation boxes across the nation and television stations from around the globe visit to film documentaries. Wat Phra Baht Nam Phu is currently home to over 200 HIV-infected adults, and has been for a number totalling 10,000 over the past, most of whom died from the illness.

The temple's activities have always been controversial in recent years. Tourists from mostly western nations visit in thousands every week, taking tours that are guided by some of the relatively-healthy AIDS patients. They go through the wards where the relatively-weak AIDS patients are, without much explanation, and continue on to the 'Life Museum', a collection of dozens of mummified corpses of dead AIDS patients, who according to the staff, agreed to be put on exhibition prior to their death. That is followed by the crematorium, which is surrounded by what seem to look like sculptures or other pieces of art made from the bones and ashes of those who have been cremated here. Then they walk to a hall which houses a Buddha surrounded by piles of sandbags, or 'ash-bags', which contain the ashes of those who were cremated but have not yet found relatives to take it home. Visitors also have an opportunity to see a dance show done by AIDS patients too. And after all that, they leave behind tons of donations.

Yes, the hospice provides care and 'protects' those suffering from AIDS, but what is it doing to how people see HIV/AIDS patients? Dead AIDS patients whose bodies are not taken back by their relatives become sandbags or pieces of art, or part of the exhibits in the museum that has little explanation of the bodies. Those who are weak, and in their twilight of their lives, simply lie on the bed as tourists pass by giving them that look in the eye. You can often see the visitors covering their mouth upon entering the ward, then swiftly moving through wordlessly. Many don't even say hello. Those who are still relatively healthy host the tours or performances for the visitors, helping to attract more donations. I can't help myself from feeling that all of these together only exacerbate prejudice.

In Thailand, more than 400,000 have died from AIDS, however, it is also one of the few countries to have successfully curbed its epidemic with awareness campaigns, and later pioneered the widespread distribution of anti-retrovirus drugs (ARVs), which slow the progress of the incurable disease. In the 1990s, up to 100 patients died at the temple every month, but now, that number has been reduced to about 10. According to UNAIDS, fewer than 17,000 infections were reported in the country in 2006, compared with 143,000 in 1990, but officials are worried that the rate could climb again. HIV prevalence among intravenous drug users and sex workers remains high, while condom use among Thai teenagers is shockingly low. No time should be spared to come up with a new way to spread awareness.

In Thailand, generally speaking, monks are highly respected. Much more than the government, to be sarcastic. I believe that when it comes to bringing social awareness, they have a vital role to play. :-)

A visit to Magnet.

So, I often talk about community health... but what is it that started everything?

It all started on March 24th, 2007, when I paid a visit to Magnet, a clinic located in the heart of the Castro neighborhood in San Francisco. I was then on a program run by VIA (Volunteers in Asia), a non-profit organization (NPO) originally based at Stanford University. With men walking down the sidewalks holding hands, a movie theater showing dramas of love between men, and shops whose walls are covered with posters of naked men, it was not a scene that you are used to seeing.

The Castro came of age as a gay village following a controversial 'Summer of Love' in the next-door Haight Ashbury district in 1967. The gathering brought tens of thousands of middle-class youth from all over the United States. The neighborhood, formerly known as Eureka Valley, became known as the Castro, after the landmark theater by that name near the corner of Castro and Market Streets. The community was hit hard by the HIV/AIDS crisis of the 1980s, and beginning at that time, city officials began a crackdown of bathhouses and launched initiatives that aimed to prevent the spread of AIDS. Today, kiosks lining the streets have posters promoting safe sex and testing alongside those advertising online dating services, and the city of San Francisco is home to around 100,000 to 200,000 homosexuals.

Asking about the roots of the community, many bring up the name Harvey Milk, a gay rights activist and the first openly gay man elected to San Francisco's Board of Supervisors, or to any substantial political office. He was elected in 1977 representing District 5, which included the Castro. However, I felt that another, more recent activity was helping to bring the gay people together and empowering the community: Magnet.

Although a clinic, it does not look like the conventional one in your neighborhood. The front side of the building facing the street is glass, instead of a wall with small windows, allowing everyone who walks by to have a view of the interior. As soon as you enter, a clean room with leather sofas and tables and a corner that resembles an Internet cafe greets you. A large bulletin free for anyone to post events in the community is near the corner and artwork of gay men adorn the walls with metallic coating. The examination rooms are located at the rear of the one-story building, however, for privacy these rooms are lined with walls and not glass, of course.

Founded by the 'Castro Guys', a group of health care professionals who were gay, Magnet's vision is to promote the physical, mental, and social well-being of gay men. Run by gay men (all staff are gay and half of them are HIV positive) for gay men, it offers free sexual health services such as confidential HIV antibody testing, testing and treatment for syphilis, chlamydia, and gonorrhea, and hepatitis A and B vaccination. Other than for sexual health, it provides services such as ear acupuncture, chair massage, hypnotherapy, general mental health counseling, and a flu clinic. Although financial support was scarce in the beginning, now it is supported by a major pharmaceutical company which pays roughly 80% of the costs, and the rest is paid for by donations from the people in the community.

However, in addition to providing sexual health services, Magnet holds a variety of on-going community activities. This ranges from book readings and art exhibits (as mentioned earlier) to town hall forums and health chats, or karaoke and dance nights to gay weddings. And even when there are no particular events, people drop by the clinic just to chat with others or share stories. In other words, Magnet acts as not a mere clinic, but more like a community center that brings a people together in an affirming environment that embraces the diversity of the culture that exists. This is a place where gay men can access resources and make connections and friendships between each other that not only helps to promote individual health but also community health.

Magnet is an example of community health, but to be more exact, this is a form of primary health care (PHC), as defined by the World Health Organization (WHO). It is health for the people, by the people. Everyone walking on the streets of the Castro knows the Magnet. I was utterly amazed at the potential of how a small clinic can bring together a people who have been isolated and considered socially-handicapped by the rest and act as a catalyst in empowering the community as a whole. It serves as a place to meet people and bring everyone... the entire community together. Like a magnet, it truly lives up to its name, or much more than that.

So this is how everything started for me. Community empowerment for the people by the people through community building and organizing, with a touch of creative thinking and facilitation, in this case, from a health care perspective. Simply exciting. :-)

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). :-)

Social entrepreneurship.

I'm seeing this word more and more often these days...

A glimpse of the word may give you a weird feeling, as the words "social" and "enterprise" aren't often seen in the same sentence... well, at least until now they weren't. But today, an increasing number of people in Japan are showing interest in doing something for the society. Hence the popularity of jobs in the fields such as international cooperation. However, up until maybe a couple of years ago, these activities were thought to be exclusive to the non-profits and the government. Well, times have changed.

We have many global issues. Some of them are small, while others are bigger. Many people notice them, and some of them stand up and say "I've gotta do something about this." However, for them to really get down in the mud and get some things done takes more preparedness than just saying it, because (1) you need a lot of time, (2) you need manpower, and (3) you need to make your own living. But one who is willing to do all of this while simultaneously staying true to the passion to work for these global, social issues, I call a "social entrepreneur".

Whether it's a private business or a non-profit organization, it must be a sustainable one for it to continue pursuing what it has to do. You need time, manpower, finance, and those resources also have to be managed effectively and put into use in the best way possible. So, I believe a business-like approach is essential for the non-profits too, the only difference between a business being whether its ultimate mission is to make money or to make positive changes to the society.

But then again, existing businesses are also changing. Long term survival in the industry has become more challenging than ever before. They need to thoroughly understand who their customers are and what they truly want. They all need to find their niche. And, catering to the specific needs of those people can sometimes also be considered doing something for the society. Ah... heading towards becoming "social enterprises"?

Of course, all of this depends on how one defines the word "society". And though many organizations will still remain like an ordinary NPO or an ordinary business, I believe the differences and the disconnects between those two will continue to erode, in a very positive sense. :-)

Comparing the non-profit sector.

With organizations such as Peace Corps and Teach For America getting a lot of attention nationwide, I don't think it's an overstatement to say that the non-profit sector has grown to become one big industry in the United States. Over 1.6 million non-profit organizations (NPOs)... now that's an amazing number.

How about in Japan? Um, not so close. Well... not close at all.

Of course, comparing the numbers directly is unfair and incorrect, since the term "non-profit organization" varies between countries. For example, in the US, hospitals, universities, and religious groups are also categorized as NPOs by the laws over there. But even considering that, there's a vast difference.

Why? Well, I've come up with 3 major reasons.

One, there's no Bill Gates in Japan. Many people in Japan have been complaining of economic disparity in recent years, and though it is true that the gap between the rich and the poor is widening, the difference is still minute compared to other so-called developed countries. After all, Japan has a tendency of giving equality priority over fairness, but this leads to another story so I'll stop with this here... Anyway, when I say there's no Bill Gates, I mean by there are no billionaires in Japan. So compared to the US, there is much less money people can give away.

Two, there's a big difference in law. While I've already pointed out that the definition of NPO covers a more extensive area in the US, there's another big difference: tax. In the US, if you donate to an NPO, you're exempt from paying tax for the amount that you donated. In Japan you're not. Actually, a similar law exists, but has only been applied to about 30 NPOs so far. Simple, but big difference. No wonder big companies and billionaires in the US give off a lot of money to foundations and other NPOs if they don't have any big business plans for the near term.

Three, the culture and values of the people are different. I can list many examples here... One example is, in Japan, though many people are often angered by the way the government handles its responsibilities, the people still put a lot of trust on them. For instance, in the US, the majority of people would prefer to cooperate with NPOs than a government-affiliated organization such as USAID, but in Japan, many would prefer to work with JICA (the Japanese counterpart of USAID) than NPOs. Same with the regular private, business sector. For example for cellphones, the majority of people still prefer to use NTT, the successor to the communications arm of the government.

The religion is different. Donations and charities play a key role in religious activities in the US such as in Christianity, and religion also remains a big part in one's life, or at least bigger than in Japan. Here, the majority of people don't care too much, which can obviously be seen from the fact that there are as many Buddhist temples as Shinto ones and many people don't have preferences about which to go to. Of course, this is more complicated than I've said, but I won't get off track for now. People donate to temples, but the money flow stops there. The temples don't do charity kind of work. I also feel something like a natural "charity culture" in Christians.

Then there are differences in values. I think more people care about being socially responsible in the US than in Japan. Again, this is just a comparison and I don't mean everyone in the US does and everyone in Japan doesn't. But, here in Japan, more people are concerned about how to make their own lives better. However, this is starting to change though... which is the good news. An increasing number of companies are teaming up with NPOs and publishing corporate social responsibility (CSR) reports. Of course, some do this for the sake of building a better corporate image, but nonetheless, when few companies start, others will have to follow... :-)