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.

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 Ban Rong Ta Tee.

During August 10-12, 2007, which is already over a year ago, the "Intergration of Health and Social Development: Thailand's Experience" program run by Mahidol University's ASEAN Institute for Health Development (AIHD) took us to Ban Rong Ta Tee, a village located in the northern part of Lan Sank District, Uthai Thani Province, in central Thailand. We would be home-staying in that village with the respective families for three days and two nights, carry out a small research by interviewing the villagers about what we wanted to know about, and come up with some kind of conclusion to present. Never did I think that that experience would have a tremendous impact on the way I see things...

Dr. Chokrachan Chairoeksuksan, a family medicine physician at Lan Sak Hospital, gave us an overview of how health care is provided in this rural area, in its most effective and efficient way possible. Lan Sak District is divided into six sub-districts (tambol), which in turn are made up of 84 villages. Primary medical care is taken care of at the 'primary care level', which is the local public health center, 10 of which are spread throughout the district. If the medical issue could not be solved there, the patient would be referred to the 'secondary care level', which is in this case Lan Sak Hospital. If further specialized care is necessary, that is the responsibility of the 'tertiary care level', which is in this case Uthai Thani Hospital, the largest public health care facility in the province.

The public health center in Ban Rong Ta Tee community is one of 10 in the district and serves 5,263 people and 1,122 households. There are 104 health volunteers working in the villages and they play a key role in promoting health. Those who tend to act as leaders in their neighborhood, are more conscious about health, and are willing to receive some essential medical care training, would be a good candidate for a health volunteer. They would be responsible for connecting the villagers and the health center, including taking patients there when they need the help or gathering villagers to the health center for health promotion activities. There are no physicians at the health center and just five people (manager, community health worker, nurse, nurse's aid, janitor) run the center. The mobile physician team comes here once a month. I became good friends with the nurse, Wanrob Klomlit, who everyone calls Rob, maybe partly because he's the same age as I am.

Now, when we carried out our interviews in the village, our group decided to ask questions about the number of members in the household, their jobs, income, food habits and change over years (if any), their favorite foods, past medical history, smoking and drinking habits, education received, and what they would do in case of an illness. It was really interesting. Truly. Although each household was different, household after household, we started to get the bigger picture of the village. What kind of people live here? What are the strengths of the people? What are the weaknesses or the issues that underlie? What can be done by themselves to overcome those issues?

So our group's research theme was this: the effect of lifestyle change on the community. We focused on the villagers' lifestyles, especially food habits and health care habits. And as we carried out are interviews of the villagers household by household, we realized that between generations, there lay some differences. So, to have a better glimpse and understanding, we decided to categorize the villagers into three generations; the first of which we defined as 50 years old and over, no-longer-working-in-Bangkok generation, the second would be 30-49 years old and the working-in-Bangkok generation, and the third is defined as up to 29 years old, the young workers and the children. Here, when I mention "working in Bangkok or not", I mean by the phenomenon where the working age group are increasingly getting jobs in the huge bustling capital of this kingdom, instead of working in their local hometown villages. So when visiting a household, it was not uncommon for us to see a family of grandparents living with their grandsons. Their parents? Down in Bangkok, or Krung-tehp, as the Thais call the capital.

Generally comparing the generations, we found out that basically everyone eats and likes the traditional Thai food, such as the som-tum (papaya salad), kao-man-gai (boiled chicken on rice), seafood, etc, but we found out that the third generation likes western fast food as well or even more, such as pizza, french fries (chips), or candy bars. Younger people like to drink beverages such as coke too and consume more fried food. In terms of health care, there were almost none who did not believe in contemporary medicine. Everyone had good relations with the health center and would generally accept any kind of general treatment, whether western or oriental/traditional medicine. In Thailand, herbal medicine is officially recognized by the public and the government. Some elderly still relied on things such as ointment made by themselves from resin or herbal fruits that are not seen in health care facilities, but after all, if they have been living with it for decades and they're happy with them, and don't have health issues, why tell them to stop.

All in all, we saw two major issues in the community. A risk of lifestyle-related diseases akin to those now a problem in western countries, among the second and third generations is the first. Many in the second group already had past histories of hypertension, high cholesterol, diabetes, cancer, etc. The second is, with more and more younger generations going to Bangkok and deciding to live their for a long term, the village population is aging, which could lead to decreased livelihood or even the collapse of the community in the end.

However, there were certain strengths as well. The smoking and drinking population is not so large (Buddhism and monks have a big effect), they have a good environment with lots of nature, clean air, no traffic jams, and a relatively stress-free life, especially when compared to Bangkok. And even if many of the second generation move down there, there are still some that choose to remain in the village, and with the Thai tendency to regard their parents and families highly, those in Bangkok are unlikely to stay there forever, at least for now. Many village homes are centered around the health center and the adjacently-located primary school (elementary school), and the relationship between the health center staff and the villagers is good. They know each other well and the villagers feel easy about visiting, thanks partly or largely to the health volunteers.

Rong Ta Tee Health Center has a variety of health promotion activities such as the mosquito project (over 92% of homes now use measures to keep mosquitoes out of their water), aerobic exercise on weekends, elderly persons' education for self-help, breast and cervical cancer prevention, diabetes and hypertension project, HIV/AIDS project, increasing well-being project, developing exercise leaders project, and promoting good health among the elderly project. Now, we felt that they should now put more effort in aiming some projects at the first generation, the young. They should take advantage of the proximal location. Also, they should start thinking of ways to re-develop the community by means of creating new values, such as community-oriented small businesses. Doing this with existing resources both material-wise and manpower-wise would be a key.

But so, how did all this have a 'tremendous' impact on the way I see things? Well, I guess I learned two big things. One is that, the economical power of a community does not necessarily reflect the quality of life (QOL) of its people. In other words, it doesn't mean that if a family is not financially rich, they are not happy, and vice versa. Whether it's those living in Bangkok, Tokyo, or London living a daily life in the bustling streets full of stress, do all of them look like they are living a happy life? Through the interviews, I truly felt that many families in the community are living a happy life, in spite of some of their economic status being not so high at all compared to the average Thai. Happiness and economic development: they're not unrelated, but they don't necessarily come together. The other thing I learned is how much a people can get things done together themselves with minimal top-down type professional aid. With the health volunteers playing an important role, many villagers knew how to take care of themselves, and knew what needs to be done and who to go to in the event of a health problem. There were lots of on-going community involvement activities that are facilitated by the people.

Community-oriented, people-centered health care through community organizing and building, unlike those hospital-oriented, physician-centered medical care seen in economically developed regions. That is a critical part of primary health care (PHC), as the WHO said together with UNICEF at the Alma-Ata conference back in 1978. Health care for the people by the people... there are lots Japan and the western communities should learn. :-)

Banning fast-food in low-income communities.

On July 29th, the Los Angeles City Council voted unanimously to place a moratorium on new fast-food restaurants in South Los Angeles, an impoverished swath of the city with a proliferation of such eateries and above-average rates of obesity and diabetes. The action, which is yet to be signed by the mayor, is believed to be the first of its kind by a major city to protect the health of a people in a community, in this case, a low-income neighborhood.

An area with a population of 500,000 people, most of whom are African Americans and Hispanics, 28% of families here live on a budget of under 20,000 U.S. dollars a year. According to a report by the Community Health Councils, 73% of restaurants in this district are fast-food eateries, compared with 42% in West Los Angeles. These eateries alike are popular choices especially among the economically-handicapped. And not surprisingly, 30% of adults in this area are obese, compared with 19.1% for the metropolitan area and 14.1% for the affluent Westside, the Los Angeles County Department of Public Health found out.

The year-long ban of new fast-food restaurants is intended to give the city time to attract restaurants that serve healthier food. Often referred to the 'Food Apartheid' by the health-conscious, the number of stores selling fresh foods is less than a quarter of that in other areas of the big Californian city. Research has shown people will change eating habits when different foods are offered but cost is a key factor in low-income communities. If you are running on a low income, or don't even have a job, and you don't have a car or other means of easy transportation, fast-food restaurants in the neighborhood serve as a cost-saving and convenient option. Although depending on what products you choose, it is not difficult to eat three meals a day for under five U.S. dollars total. Cheap, unhealthy food and lack of access to healthy food is a recipe for obesity.

However, some people in the community believe this is not enough to solve the issue. Many people are aware that fast-food is unhealthy and it is not that they don't have any supermarkets selling fresh foods. Formerly called South Central Los Angeles, this is a part of town whose name was replaced by the current one in 2003, as 'South Central' had become almost synonymous with urban decay and street crime. One pointed out that local gangs dominate some areas near the supermarkets, and people wouldn't dare to take the risk of getting robbed, beaten, or shot. The same could be said for the supermarkets, as their numbers are actually dwindling, because they don't want to risk being attacked and robbed by the gangs. To add to that, even if the crime rate is lowered, many people in the area don't know how to cook, as they have never learned how to.

The ordinance comes at a time when governments of all levels are increasingly viewing menus as a matter of public health. By the year 2030, it is estimated that 86.3% of Americans would be obese. L.A.'s ban, which can be extended by up to a year, only affects stand-alone restaurants, not eateries located in malls or shopping centers. It defines fast-food restaurants as those that do not offer table service and provide a limited menu of pre-prepared or quickly heated food in disposable wrapping. It exempts so-called 'fast-food casual' restaurants, which do not have drive-through windows or heat lamps and prepare fresh food to order, such as El Pollo Loco, Subway, and Pastagina.

Meanwhile, representatives of fast-food chains said they support the goal of better diets but believe they are being unfairly targeted, claiming they already offer healthier food items on their menus. Not surprisingly, the California Restaurant Association and its members are considering taking a legal challenge to the action.

A former gangster in the area has said the ordinance would bring minimal change, and for fundamental change, it has to be done by the people in the community... and this is an idea that lies at the roots of primary health care (PHC). :-)

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). :-)

Looking back at 2007.

Time flies.

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

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

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

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

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

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

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

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

A visit to Ukima Clinic.

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

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

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

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

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

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

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

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

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... :-)

Thanks for reminding me.

The other day I was talking about doctor-patient relationships with one of my friends who goes to nursing school, and it helped me remind myself of the image of the doctor I want to become.

Clinical rotations and training have started for her, and right now she's rotating through general hospitals to local clinics and health centers, while also shadowing nurses who are involved in various kinds of health care. And that day, she was complaining that some doctors really only look at the disorders the patients have and not the patients. In other words, these doctors are more focused on diagnosing and treating the disease, not the patient.

Then I thought... do I want to be that kind of doctor?
Well, I don't think so, but not to mean any offense to those doctors.

After all, I believe the doctors who immerse themselves in facing the diseases rather than the patients are the ones who bring new breakthrough technologies and advances in medicine. I also feel that many surgeons belong to that category too, as they're more like artisans or craftsmen, spending a significant portion of their life just to build up skills, sometimes just to treat only a couple of diseases. But that's still necessary, no question.

But the picture of the doctor I have in mind is more like a general practitioner, and probably more general and broader than the term actually means. I'm not attracted to craftsman-type doctors, and this just comes from my tastes, you either like it or not. I want to be able to serve people with various backgrounds. Not sure why, but I guess it has something to do with the fascinating discoveries and thoughts I've had in the past through meeting many people, many of which have helped me shape what I am now. Through examining the medical problem of the patient, I want to interact and understand more about the patient, including one's socio-economic background. If this is done at a certain community-based level, I have a feeling it would enable you to see the strengths of the community, as well as the social issues that are underlying.

Well, in conclusion, whether the doctor focuses on the disease or the patient, I don't think it matters much as long as it makes the patient happier than before. And as long as the patient is happy, what form or type of approach the doctor follows is up to the doctor's personal preference. The doctor should be happy and comfortable too, about not only what he does, but also how he does it. Anyway, there will always be a need for both types of doctors.

I've always been interested in combining the characteristics of general medicine and public health in a clinical manner. You know how you want to face your profession, but there are times when that picture gets blurred, and this recent talk with my friend helped me see it clearly again. Many thanks to her. :-)

Two months since Thailand's experience.

Time flies.

Already almost 2 months are about to pass since I participated in a primary health care program at the ASEAN Institute for Health Development (AIHD) in Thailand. The facility is on Mahidol University's Nakhon-Pathom campus.

When the program was over, my heart was filled with something... a strong passion, a strong will to do something. Of course, the program had a big impact on me, and that impact will probably be as big as making changes in my life in a very positive sense... but I'm not sure whether this was the direct reason for me feeling that strong something. It also kind of felt as if I were rushing.

Maybe I was too excited during the program that I wasn't able to "switch" that mode back to reality even after being pulled back into my everyday world? I came up with new ideas that I may want to try, and maybe I got too excited about them? Or, maybe I felt frustrated that I still didn't have the capability to start turning those into reality? After all, I'm still a university student, without profession nor money. Maybe all of these reasons?

It's like this... I had this liter of fuel in me, and I continued to burn it through the program, but the more I burned it, the more I was refueled. But after the program was over, all of a sudden, I was left with all this fuel but nothing to burn it for. It's like you all of a sudden have a big empty space.

I made really good friends during the program too. Maybe I just simply felt sad that itwas time to say good bye for now? The program itself ran for only 11 days, but by the time it was over, I felt as if I had known these participants for months, or even years. I had the opportunity to do some really deep, interesting, and stimulating talks with some of them. Those friends might turn out to be really close partners in the future, maybe some of them even closer than now.

Well, am I still excited? Yeah... of course. Why not? But, I have to be cool-headed, think ahead, and plan out things carefully. While there are things I can do for the society now, now's a time for me to put building my profession at the top of my to-do list. I need to and want to invest time in the future now. Meanwhile, I'd like to look back and share how the program had such a big impact on me, and may have on my future... maybe on another day.

Ah... how I enjoyed talking over those bottles of Singha... "Chai-yo" :-)

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. :-)