A visit to Inazusa.

Now part of the city of Shimoda, Inazusa is a peaceful countryside village on the Izu Peninsula, the easternmost part of Shizuoka prefecture. It actually occupies almost half of the city area, but its population is just over 10% of the city's, standing at 2,855 as of 2008. 35% of them are over 65 years old, which is a little above the average rate for a Japanese countryside village. Many of them are farmers, but nowadays they run other businesses alongside to make both ends meet. In April, I had the opportunity to visit Inazusa Clinic, a relatively new clinic that was set up just five years ago by JADECOM (acronym for Japan Association for the DEvelopment of COmunity Medicine), one of few health care organizations putting effort in bringing health care to rural, isolated areas in Japan.

Inazusa had a clinic that was funded by the city of Shimoda until 2002, when the sole physician of the clinic neared the age of 90, and without a doctor to take over the job, was forced to close down. So the village went without a doctor for three years. People who could drive traveled 20 minutes south to central Shimoda, where they could find some privately-run clinics. Accompanied by two nurses and two clerks, Dr. Hajime Kawasaki is the head of Inazusa Clinic, and he kindly accepted my one-week visit. Because I didn't have too much time, I wanted to spend the time to know the village and its people, and at the end of the week be able to 'draw a picture' of how the community looks like.

The first place I went to to meet the villagers was Ryusouin. This little local temple has been holding what it calls 'Temple Wellness Renko' (traditional exercise) sessions, where locals come to do exercise with the the monk, who interestingly has a bachelor's degree in physical education. In a rural area like Inazusa, during the 'obon' (Japanese Buddhist custom to honor the ancestor's spirits) season or whenever a funeral takes place, the family of the deceased along with the monk walk through the town visiting each and every home so the deceased can bid farewell. And the monk here found out that there were many who complained about back pain or joint pains, and together with the awareness that he himself was lacking exercise, came up with the idea. About 10 people come to each session, which takes place four times a week, and pay 500 yen per session that runs for about one hour followed by chit-chat time with tea and sweets. Asking the participants, not all of whom are locals, they say they come to talk with the charming monk, more than for the exercise. The monk says that he hasn't been able to attract the people who he really feels he needs to do exercise with, especially more locals, and that certainly is an issue to be solved. Also, citing the temple's proximity to the clinic, he says he has many ideas he might want to try together. Monks could play an important role in bringing a community together, like in Buddhist countries such as Thailand.

Another place I visited was the local nursing home called Azusa-No-Sato, which literally means 'the village of Azusa'. Like many other similar facilities in Japan, it also operates so-called 'day care' activities where the elderly who live with their families at home come to spend a day to play, take a bath, and socialize with the fellow elderly, not only to have them enjoy time, but to spare some break for the care-giving families. The national elder-care insurance is where the money for the service comes from, and the families would usually pay about 2,000 yen (JPY) per day, though funding for the insurance comes partly from the insured's past monthly payments. Because the nursing home's service includes picking up as well as dropping them off, I had a chance to get a glimpse of the actual homes and the areas the people live in. For the staff, it's not an easy job. It requires lots of energy, both physically and mentally, and considering their often below-average salaries, I had the impression that many workers in this field were not enjoying their work. However, it was different, at least here. Yes, the staff were always thinking and doing what they have to, but still, they were enjoying joking and playing around with the elderly as well, in a genuine sense. A staff said, "This is not the kind of job you can continue if you don't enjoy it. I really like my job."

In Inazusa, or like in many other places, farmers have always naturally formed informal groups with fellow farmers nearby, like a neighbors' small gathering. Many of them would have lunch together, chit-chat, or even do some leisure traveling when they can spare the time. One of those groups, which calls itself Chalette, has interestingly founded a small 'manju' (Japanese traditional pastry with sweet red soy bean paste filling) shop. They say they wanted to do something different, something they enjoy doing, and something they can continue doing, and that's when they realized members in the group were good at making Japanese traditional pastries. So they collected 100,000 yen and started this shop. Conveniently located along a road that connects Shimoda and towns on the other side of the peninsula, the now well-known shop earns enough to fill the members' piggie banks. When they sell out, they sell out, but they don't increase their job because they want to enjoy it and don't want it to become a burden on them. "Family comes first. Job comes second."

Another group of farmers founded a community farmers' market called 'Kimagure Shop', which literally means 'the range of products and price is up to the mood of the day'. When crops are harvested, it normally goes through a number of wholesale dealers before it reaches the consumer, and along the way the cost adds up and is represented in the price. So, what this community market does is farmers directly come from the fields to drop off their products, specify a price, and the market sells them off here, and 88% of the income goes back to the producer. This way, the farmers get bigger margins but the consumer gets them for less than what they would pay in an ordinary supermarket. Plus, the products are consumed relatively locally. So the products sold depend on the season, and now over 90 producers, not only farmers but local bakeries and flower shops, drop the market. It's becoming a place where not only the people of the community gather, but chit-chatting between the locals and travelers as well, being located alongside a main road.

Inazusa is certainly a typical rural village, but does have many encouraging activities run by the locals that are helping to sustain happiness in the community. :)

A visit to Lao-China Friendship Hospital.

When we visited Laos in August, I went without any prior contact, since I knew nobody in the country, but still, I wanted to get a glimpse of what health care looks like, and listen to the actual health care workers in the country. So, one afternoon, we negotiated with a 'songthaew' driver to take us to Luang Prabang Provincial Hospital, more commonly known by locals as the 'Lao-China Friendship Hospital', or simply the 'Chinese' hospital.

Located off the main road four kilometers south of the city on a seven-hectare land, the hospital was completed in 2004 with assistance from China, as its name implies. It was already during the late hours of the afternoon, so the outpatient department had already closed and many staff gone home. Although without any contact beforehand, the staff at the counter in the deserted main hall kindly allowed us to walk around the hospital. Upon starting our 'tour', we noticed that all of the emergency exit signs and fire hydrant labels were written in Chinese and English only, and without Lao, no wonder the locals call it the 'Chinese' hospital.

While we were walking, we came into a nurse, who was apparently about to go home, and she was kind enough to let us hear about the hospital and her job. The hospital is divided into four major departments: inpatient, outpatient, labor room, and pediatrics. The outpatient clinic includes internal medicine, surgery, pediatrics, obstetrics and gynecology, family planning, otorhinolaryngology (ear-nose-throat), dentistry, and emergency. Depending on the day, the hospital sees about 25 to 100 patients per day, with Monday getting the highest number. Its medical staff comprises 97 nurses, 27 physicians, plus 10 volunteering nurses from South Korea. Some common medical problems include common cold, respiratory infections, cardiovascular disorders, gastroenteritis, and accidents. She said that an increasing number of people do not take enough exercise, something I am used to hearing in other parts of the globe as well.

After going through the examination rooms, we visited the ANC, or the antenatal care department, which they say is the busiest part of the facility. At least three staff must constantly be present here, so they are currently working on a 24-hour-work-and-24-hour-rest rotation. For vacation, they get 10 days off per year. According to them, the busiest months are February, March, May, and June, before the rainy season starts. Here we met some nursing students, who told us that they have a 2.5-year program. There were no medical students, but we found out that is because the sole faculty of medicine in Laos is in Vientiane, the capital.

For the patient, there are two often-encountered problems in the medical scene, although they do represent larger underlying issues. One is the lack of medicine matching that of international standards. In recent years, foreign aid, especially from China and Japan, has helped hospitals to update their out-dated facilities and equipment, and bring up more health care professionals, however, there still are often cases where the patient is asked to travel down to the capital of Vientiane, almost 500 kilometers away on a recently-paved mountainous road. And even at there too, the patient is often asked to cross the 'Friendship Bridge' to receive further treatment at a Thai hospital. In emergency cases, such as major traffic accidents, this clearly does not work. And, obviously the patient would have to pay for all of the transportation costs, and the fees skyrocket if you need to be transported across the border.

This leads to the second issue: money. Universal health care is still non-existent, so even in public hospitals the patient needs to pay. The same goes with ambulance, where patients pay by the kilometer, like a taxi. If she or he gets admitted, the average fee per night for a normal room is 40,000 kip (about US$4.80), but that is not easy for a country where people live on an average 10,000 kip (about US$1.20) per day, though the economic disparities are great. People who live in Vientiane, the nation's capital, are the richest, where over 50% of households have cars and 40% have air-conditioners, while next comes those living in the capitals of the provinces, like Luang Prabang, and the poorest are the farmers who live in the mountains and the countryside. According to the staff, patients who have financial difficulties paying fees may submit a request to receive aid from the government, but again, one needs to travel down to the capital to do so. It is not surprising that the 150 beds at Luang Prabang hospital are never near full.

The government seems to have started working on these issues over these few years, and is in the process of not only setting up a clinic in every village, but a primary school, and encouraging more villagers to have their children enrolled. Of course, the families would have to give up on earnings that would be made through having the child work instead and understand the long-term significance of education, so it's not easy, but at least they wouldn't have to walk hours to go to school anymore. They are also working to put more emphasis on preventive medicine, and moreover, health-building through community participation. Things have only started to change, and it will certainly take a long time, however, the interesting point about Laos is that they are going through the process at the same time their economy is developing, something other economically-developed nations went through at separate times, with economic development coming first.

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. :-)

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. :-)

A visit to RTIC and Ta Nao Si Health Center.

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

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

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

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

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

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

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

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

Many thanks to my friend. :-)

A visit to Hinohara Village Clinic.

Hinohara Village is part of Tokyo, located in the northwestern corner of the huge city. The place neither looks like Shinjuku with the jungle of 50-story buildings nor Azabu with all the four-star restaurants and residences of the affluent, but more like a gathering of homes in a mountainous countryside. From central Tokyo, it takes two and a half hours by train to reach the nearest station and a bus ride from there that takes a further 40 minutes.

I had an opportunity to visit the village clinic here on the 25th of February. Two doctors work here, one of whom I know from a primary medical care seminar that took place last September, Dr. Aizawa, and when I asked him whether I could visit to see what health care in a remote area is like, he kindly gave me a nod. So on this morning I got up at 5:00am (still a bit dark around this time of the year), hopped on the train, and headed for Musashi-Itsukashi, the station nearest to the village. And since there are only six bus round-trips between the station and the village, Dr. Aizawa was kind enough to pick me up on the way from his home to the clinic.

The road winds between the mountains along a river, and I realized a lot of snow still remains. There are so many cedar trees on these mountains, many so close to each other, and Dr. Aizawa tells that these were planted in the 1940s for war, but have been left as they are ever since they became unnecessary soon after. The population of the village is now around a little over 2,850 people, with an amazing decreasing rate of 4-5% per year in recent years, with last year's number being 3,000, and the year before a little under 3,200. People over 65 account for 41% and families of the young generation continue to move to urban areas, no wonder there's no high school and the number of students in the village's sole middle and elementary school stand at 30 and 90, respectively.

This day was a relatively easy day for the clinic staff, which is comprised of one office personnel, one medical technologist, three nurses, and two doctors, as they only had about 30 outpatients. The clinic has a small inpatient ward that can accommodate two, but is usually only used in emergencies since a general hospital is about a 40-minute drive from here. Unlike the big hospitals in the urban areas, patients who come here complain of a variety of disorders, from common problems such as simple chest pain caused by falling down, or common colds, to major diseases such as diabetes and other lifestyle-related disorders or pneumonia.

In the afternoon, I had an opportunity to see what is called an "Oushin", which is a house call where a doctor goes and sees the patient at his or her home. I saw a similar activity at Ukima Clinic. (See post 2007/11/20) But unlike in the urban areas of Tokyo, the houses are so far apart, Dr. Aizawa says it could take well over 30 minutes to reach the home. Fortunately today, the house that gave us the call was close enough. It was a big 2-story house with an old couple living together, their children having already moved out to the urban areas with their families, leaving many rooms unused. The husband could not walk anymore, so his wife was taking care of him. Dr. Aizawa adds that many homes are too large, and since only a few live in them, many are cold even inside the house. There are sometimes severe cases, such as when they found a handicapped elderly living alone in a large house on top of the mountains with malnutrition.

Although the current state of health care here could not be said convenient, Dr. Aizawa says that it's much better than that of villages in other prefectures. Local governments in Tokyo are eligible to receive a considerable amount of financial assistance from the metropolitan government, partly due to the fact that they have made it a rule to place at least one doctor for each and every single local government, including small villages with a few hundred people. Meanwhile, not far from Hinohara Village is the countryside of Yamanashi Prefecture, where he says health care is in a "much worse condition". He added that you can even notice the difference in the quality of the road pavement when crossing the border.

There's much more he talked about this day, especially about his early years as a doctor in the remote islands of Tokyo floating in the Pacific. But for now, I'll stop here. Through this visit, I was able to get a general idea of what health care in a remote area is like, at least in Tokyo. I should visit other prefectures too. I would like to thank the kind staff at the clinic for making this visit possible. :-)