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 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. :-)

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). :-)

Autumn leaves and climate change.

Autumn... trees are starting to change color, like a rendering of warm colors on a canvas. Temperatures have gone down, and I notice it's almost the end of November. Time flies.

Last Monday, I paid a visit to Kita-no-maru Park near the Imperial Palace in Tokyo. Spent maybe about an hour or two sitting on the bench, gazing at the picturesque scenery adorned with beautifully colored trees, while some little nursery children played with parents and other people sat on the lawn reading books or just taking a nap. Calm, quiet, and peaceful. Birds flew from a tree to another from time to time.

An oasis in bustling central Tokyo.

When you talk of autumn leaves in Japan, Kyoto is the first place that comes to mind. The former capital of Japan is just purely beautiful during this season. The scenery of numerous history-rich artistic temples with a balanced mix of red, orange, yellow, green, and sometimes pink and purple leaves is just simply magnificent.

However, peculiar things are starting to happen in Kyoto. The autumn period is becoming shorter and shorter year after year. Compared to half a century ago, leaves now start to change color two weeks late, and leaves fall off the trees a week late, shortening the "autumn leaves season". Why? It doesn't take a rocket scientist to guess... the temperatures at Kyoto have risen, widely thought to be the result of global warming. According to records, the average temperature of Kyoto is three to four degrees (Celsius) higher today than in the Meiji period, about a century ago.

Kyoto is where the international community agreed on a protocol to reduce greenhouse gases, and the host country promised to cut 6% by 2012 from the 1990 level. However, the reality is emission has increased by more than 8%. Experts note that the Japanese industries had already gone through a series of rigorous cost cutting measures in the 1980s through developing new technologies, thus cutting carbon emissions, so much of the current plans focus on taking advantage of the Kyoto Mechanism, such as emissions trading (ET) and joint implementation (JI), and also promoting and persuading offices and homes to save more energy.

We, as individuals, need to act now. For our future, not only to help our environment but also in order not to lose trust from the rest of the world. There are lots we can get done if we all do it. :-)

Get some exercise and make a difference to your day?

I don't know why, but there are times when I can't concentrate in anything. I know what I want to do, and what I need to get done, but at those times, I either just don't have a will strong enough to do them or simply have no energy. It's nothing like agony, but something like chronic exhaust. Don't know why...

I had also been having sleeping problems until recently. Of course, living a rigorous and irregular schedule probably wasn't helping that at all, but still, I just couldn't get to sleep. I would go to bed, yawn, hoping to fall asleep... but then I would start thinking about all these things from what to do tomorrow to things I want to do in the future. Hours would pass away, and the next time I see the clock it's like four in the morning. No wonder I heard some birds starting to sing.

So today, I decided to go jogging with some of my friends who make it a routine to do it twice a week. We went to Yoyogi Park, one of the three or four big chunks of nature in cramped and bustling Tokyo. A nice day, 20 degrees celsius, beautiful blue sky, a weather not so common in the middle of October. It really helped me get refreshed, after all, I realized I hadn't really taken any exercise for a month or two. Boy, how just putting a pair of sneakers and going jogging with a couple of friends made the day so much different. After that I went to Jimbocho (an area in Tokyo with 150 bookstores) to search for a Japanese-Thai-English dictionary, and went on to Akihabara (an area in Tokyo with as many electric appliance stores) to do my part-time job.

I guess it's important to take some exercise from time to time, for reasons some of which I'm not sure of. Well, don't know how much difference it's going to make to tonight's sleep, but I think I'll go to bed now, hoping I have more concentration tomorrow. I've got to study dermatology... :-)