A visit to Sanyukai.

Poverty. What does it mean?

Many say it's about not having enough money to make a living, while some others put it in a different way: they are people who have not only lost their money, but also their families and all their trustworthy social relationships, as well as self-esteem and pride. While a good portion of the general public in other countries still see Japan as the darling of economic prosperity, and even the typical Japanese are not too aware, the poor population has been slowly increasing over the years, and at a quicker pace more recently. Poverty does exist in Japan, and it does in Tokyo.

In April, I paid a visit to Sanyukai again, a non-profit organization (NPO) that runs a free clinic, provides temporary housing, clothes, and food for the homeless. Located in the heart of Sanya district, an area that has become synonymous with poverty and homelessness, the group has been carrying out outreaches to hand out clothes and food, and so-called 'clinic tickets' for those who seek medical consultation for over a decade. The clinic is totally free (one of only two free clinics in Japan for the homeless), but naturally, it's sometimes not easy for a person to come and drop by, but reaching out to them and giving them these 'invitations' not only encourages them to come but also "makes them feel easier" to do so, says one staff. Situated in the northeastern part of the huge bustling city, Sanya has been a home for many who work on a daily wage basis, taking advantage of its proximity with factories in the area and the abundance of rediculously-cheap hostels.

So what did I do? I participated in one of the outreaches they carry out on Wednesdays and Thursdays. Why? Because I like it. And this phrase means much more than it's said. I go to Shinjuku every day, and it's not too difficult to find a homeless there since nearby Shinjuku Central Park is home to a good number of them, so I have always felt that they are part of the picture I am in in some way. But what is there that I could do by myself? If I do have some leftover food I am not going to eat it, could I give it to them? But what would that do to their self-esteem? Do they really want that? After all, unlike in the U.S., begging is not common here. We belong to the same world, the same society, but there is something that is separating us. But through the outreach, I can be of some help and talk to the homeless without hesitating, and it really gives you the feeling that as if it not only opened the door for them but for yourself too. It's like this: they are near you but not as near as it seems, but you've finally found a way to step closer to them. Surprisingly, many seem to be happy even when we just say "hello, how's it going?". They've got lots of things they want to talk with you. That smile on their faces I don't forget.

What is poverty? What is homelessness? I've been thinking about this for a while, and ironically, Mr. Hiroshi Goto, one of the staff there, pointed out something that I had heard before two years ago from a staff working in a homeless shelter in San Francisco: we shouldn't really 'categorize' them as homeless, but as people who have had various difficulties in the past that led them to how they are now. And that's true. They have come different ways. The 'issue' for each of them is different from person to person. And in the U.S., add to that those who have willingly chosen to become homeless. But there are things they have in common too. They have no money, no shelter, nobody to rely on, and have been deprived of dignity and self-respect.

The number of people living under government aid, called the Temporary Assistance for Needy Families, has been increasing, and at a faster pace now with the slowing global economy. Back in 1992, that number was 585,972, but it reached 998,887 in 2004 and surpassed 1,000,000 in 2005, and as of March 2009, it stood at 1,168,306. Now, especially in these unsure times, it is not so difficult for a person to take a moment or two to think about poverty and take that as an issue that is not unrelated. With just a combination of some accidents, wrong-doings, or unfortunate consequences, anyone could find him/herself without a home. However, we must also keep in mind that the real homeless, the 'true' poor, have been deprived of all they could be, including friendships, families, and even their self-esteem. Whether that is the responsibility of the individual, or another, or the society, or more than one of those, varies from person to person. But we have to understand. And I think there is something we can do.

Sanyukai is not merely a group that gives out a hand to the homeless, but one that is helping the absolute poor and using several creative ways at different levels to help the homeless empower themselves and become self-dependent. The true poor are deprived of their family and friends, and it starts from re-building relationships or making new ones. Every day, Sanyukai puts seats and some tables in front of their compact three-story building, and it acts as a place of gathering for the homeless. Sipping a cup of green tea that Sanyukai serves, they come and tell about the meal they had the evening before or joke about the noisy neighbor cat that wouldn't let him go to sleep. It's a place for socializing and relaxing, and up to around 15 people can be seen on some days. Some stay for lunch and eat with the staff. Whether it's a staff or a visiting homeless, everyone eats the same food here. And many of them visit on a routine basis, some even every day, so it is also an effective way for the staff to see who didn't appear on a day and try to find out what happened.

Last month, Sanyukai was ordered by the metropolitan government to stop handing out its weekly free meals in one of the areas, after local residents filed a number of complaints saying the outreaches attracted more homeless and that "children are afraid" of them. One of the continuing challenges is how to have the local community understand their activities. There is a quote from a book by French writer and aviator Antoine de Saint-Exupéry. "Men travel side by side for years, each locked in his own silence or exchanging words which carry little or no fright, until danger comes. Then they stand shoulder to shoulder. They discover that they belong to the same family."

A glimpse of a university hospital.

Time flies.

Hmm... I think I've been using this word too much lately. But it's true, times really does fly. So here I am, finished with all the clinical rotations, something which I had so much expectations of just a year ago. Did it meet my original expectations? Well, that's another question. But nonetheless, I did learn quite a few things, was able to see and talk with many patients, and was able to get a glimpse of what a physician's everyday life here is like, working in a 1,000-bed university hospital located in the heart of one of the most important business districts in Tokyo: Shinjuku.

I have believed and still do, that working in a university hospital means you have to take part in educating and nurturing the next generation of physicians, and that is not an option but a responsibility. And until I started my clinical rotations, I had believed that those who don't do too much or refuse to carry out that part don't have enough passion and enthusiasm, and therefore are working in the wrong place. But... that view has changed. Most physicians here, especially those in the upper 20s to 40s, whether an internist or a surgeon, or a pediatrician or a obstetrician/gynecologist, are super busy.

Arriving at work before 8AM, their day often starts with a conference in the morning, followed by a visit to the in-patient ward, and then on to run the morning portion of the out-patient department (OPD), or head to the operation rooms instead if that's a surgeon. The lines of patients in the waiting room are seemingly endless, while some operations can easily take five or six hours, naturally. When do they have lunch? Well, they're lucky if they can get a meal at noon. The schedule for the afternoon doesn't look too much different, except for some more case conferences and lectures by older doctors or advertisement sessions by pharmaceutical companies. When do they finish all that? Maybe 6PM. Okay, can the doctor go home? Not so fast... because all the paperwork and some medical records are waiting to be processed by nobody but the physician. After that is 'free time' for the doctor, where he/she can work on research papers or make a PowerPoint for the next day's lecture for students, etc. It's not rare to see a doctor working well over 12 hours. Or, is he/she on-call for the night? Well, that adds another 10 hours or so, and on to another day. You don't get rests here after on-calls.

And yes, to add to that, the pyramid of hierarchy in Japanese university hospitals is still present. You have to do as your boss (professor) says, and that is often a must. Some would even be too concerned about writing research papers or simply trying to make their daily work appeal to the chief professor of your department, since he/she would be the only person who can help you get promoted to a higher academic status. If the professor doesn't like you, tough luck. Yes, it's all about faculty politics. And then, on the other hand, you also have to help young doctors who have this long list of questions for you to answer. A physician in the upper 20s to 40s are kind of stuck in between the old and the young.

Hmm... yes, a physician working in a university hospital has three major responsibilities; providing medical care, research (often for academic status), and education. But does the doctor really have enough time for all of that? And especially when considering the fact that doctors working in university hospitals in urbanized areas get one of the lowest salaries among doctors in the country, how much would that do to the enthusiasm of the physician? What's the incentive? Now that I have seen some of the reality in a university hospital, I even feel sympathy for some of them.

When doctors start quiting, that is probably a tipping point, a beginning of a vicious cycle; quitting means more tasks for those who are left.

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. :-)

Farewell to an old local friend.

January 22nd marked the last day of regular revenue operations by Tokyu's 8000 series train.

I've lived most of my life in Japan near the Toyoko, Denentoshi, Oimachi Lines, and grew up watching the train's stainless side look and hearing the unique thundering sounds. Whether it's a train you use every day or a local shop or restaurant you visit regularly, these are things that are usually taken for granted, things that you don't really stop to think about. But once you know they're going to be gone soon, you suddenly realize that times are changing. You miss these things you've never missed or even cared to think much about before.

The 8000 series started service in 1969 and for almost four decades served the people of Tokyo and Yokohama on the Toyoko Line, which connects the two big cities, hence its name. These series of trains were the most technologically-advanced of its time, being the first to be controlled digitally, enabling trains to run on tighter schedules, and has claims to being the first in the world to incorporate a field system chopper circuit which made regenerative brakes possible. With its length being 20 meters, it was also much longer than the commuter trains of its time, helping to make way for Japan's economic growth of the 1970s.

On January 13th, the gradual replacement of the series by newer, more advanced types was completed for the Toyoko Line with much fanfare, where amazingly over a thousand people from local residents of all ages to train afficionados gathered to bid farewell to the grand old workhorse. Truly a sign that it was loved by everyone. The last remaining example (ironically the first to roll off the production line), which served the Oimachi Line, a 10.4-km local route in southwestern Tokyo, was retired on February 22nd.

Tokyu Corporation has transferred many of these trains to Izukyu, a wholly-owned (but financially-troubled) subsidiary in Shizuoka Prefecture carrying holiday-makers to resorts on the Izu Peninsula. A handful have also been donated to Indonesia as part of Japan's official development assistance (ODA) to help set up Jakarta's railway infrastructure.

Adios. :-)

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. :-)

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. :-)

An evening in Shinjuku's good old backstreet.

A block still retaining post-war Showa era style, near bustling Shinjuku Station, houses over 30 "nomiya", or Japanese-style counter bars. It's called Omoide-Yokocho, which translates to something like "the backstreet of the good old days". The small community truly lives up to its name.

On October 28th, after we had the patient assessment workshop, I decided to go for a glass of beer and a light snack in Omoide-Yokocho with two of my friends who also participated in the activity. It's Sunday night, so not all of the nomiyas are open, and if you want to see how it is when it's busiest, Friday night would be best. So we walked down the small but lively alley and hopped into one named Asadachi. Many nomiyas call people walking by to come in, but this place didn't, so we just said why not.

This place had a very interesting, or to some maybe peculiar menu. They had raw pig and cow liver, testicles, penis, and uterus, while also boasting frogs, whale meat, fish, and many kinds of shellfish. Most of these could also be served cooked. A wide choice of rare alcohol was also offered, like "sake" made from aloe, snakes, lizards, etc... but with all of this, the two-hour talk with the owner of this place was so interesting that it made the menu irrelevant.

When he talked, he talked as though if he had met everyone from everywhere. And he closely looked into the other's eye when talking, and continued to look into it even after the other had shifted his eye somewhere else. Very observant he was... he really reads people's expressions. He's met all kinds of people, from TV superstars to politicians and company executives to front-line employees. They all come here to babble about what's up in the world they belong to, and that's why he knows a lot about them... And maybe because he has seen the eyes of so many that, he says he can read one's personality just by looking into the eye.

A 68-year-old actor came in while we were there, and says he has been a regular visitor for over a decade. The owner knows a lot about his life... that he was a playboy when he was young though having a wife, did ordinary desk work in his 40s and 50s at an insurance company, but decided to become an actor after he retired at 65.

The owner told us many things... but the one that seems to have been carved in my mind is "What's most important is your heart, but just that won't get you anywhere... you have to be clever, maybe sometimes even cunning or sly..." Hmm, maybe so. :-)

Lunch time in Japanese med schools.

Lunch time in Japanese medical schools is interesting.

Our university is in a highly-developed area, a very urban area, so most of the students go out and buy their lunch. We have an extensive selection to choose from... many kinds of food, meaning a wide range in prices too. Students with relatively more cash don't hesitate to and tend to hop into relatively high-class restaurants, while the ordinary (like me) are always trying to find the cheapest food around. Sometimes is fine, but sticking with with those affluent people for lunch everyday would easily put me into bankruptcy in a matter of days.

So what happens is, rich students tend to hang around with rich students, and ordinary students tend to hang around with those of its kind. And they become good friends... not that it is causing any problems (so far), but I just thought it's an interesting phenomenon... :-)