Strolling in Luang Prabang.

Between the mountains covered with jungles in north-central Laos lies the city of Luang Prabang. It is situated where the Nam Khan River flows into the Mekong River, well over 400 kilometers north of Vientiane. Every dawn, lines of monks dressed in orange robes walk through the streets to collect alms, and along with the Buddhist temples and the simple concrete buildings, the atmosphere seems to resemble that of its neighbor Thailand at one glance. Even the language is very similar to that spoken in 'Isan', the northeastern part of Thailand. The cuisine is similar too; Tam Mak-Hung (papaya salad) is basically the same as Som Tam, and they eat that with Khao Niaw (sticky rice), and it even goes along with Kai Yang (roasted chicken).

However, if you look carefully, the decorations of the temples are different, architecture reflecting the days of French colonization still remains in many houses, and most of all, its social systems, including education, health care, and welfare is like those of its neighbor decades ago. Education is essentially free for public primary school (five years), junior high (three), and senior high (three), but the percentages of children enrolled are 84.2%, 54.4%, and 34.2%, respectively. And, since the country does not keep track of personal identification records, the actual age a child gets enrolled varies. The number of years for university education varies from two to seven depending on the majoring subject, however, none are free. Free health care is not available, but government aid may be issued if you travel all the way down to Vientiane and ask for it.

I paid a visit to this landlocked country in the Indochina Peninsula in August. Registered a World Heritage Site by the UNESCO in 1995, the compact city of Luang Prabang is a nice and calm place to spend a couple of days. Besides the symbolic temple of Wat Xiengthong and the hill of Phousi, where you can get a picturesque view of the entire city, there are many so-called 'speed boats' that take you up and down the Mekong to various nearby villages and the buddha-adorned caves of Pak Ou, while 'songthaews' or 'tuk-tuks' (same nomenclature as Thailand!) can take you to the beautiful waterfalls of Tat Kuangsi. At night, nearby villagers, including the Hmong, come out to sell various goods, creating a bustling street market scene.

The recent influx of tourists to this economically underdeveloped nation has given birth to a plethora of bed-and-breakfast's and restaurants that satisfy a westerner's taste buds, however, this happened after restaurants catering for the locals came in, ironically. Families were and are still not too used to eating outside the home. So, it wasn't easy for me to find local food with a local taste at a local cost. Even the packaged foods, most, if not all of them, are imported from Thailand. People say that the more north you go, the more products from China and Vietnam you will find. But basically, there are only a few mass-produced goods (not to miss the famous Beer Lao!) packaged on Lao soil. What I personally liked the most was the Khao Soi (different from the Thai cuisine with the same name) I found being served at a 'street picnic table' right beside the Mekong. I even went for a second on the following day.

Mae Sot and Route 105.

In the northwest of Thailand on the Moei River border with Burma lies the small town of Mae Sot, the westernmost town of Tak province. The town is not only interesting for being a trade post between Burma and Thailand, but also for its diverse ethnicity: Thai, Burmese, Karen, Rohingya, Karreni, Mon, Kachin, and many other minority groups from across the river. Take a stroll in the market and you will notice that Thai is not necessary the major language spoken here. Due to the ongoing conflict between the Burmese military junta and the many ethnic minorities that inhabit the land along the border with Thailand, thousands have crossed the river and settled in villages and refugee camps along the border near Mae Sot.

A Muslim community is also present in Mae Sot, together with a mosque. One of my good old Thai friends lives in Mae Sot and she and her husband took me to a small cafe on a corner near the mosque. They make rot-tii-oo and tea at this place which seems to have become a pleasant get-together place for the locals to chit-chat during the early hours. Rarely will people be able to find any rot-tii-oo left after 10AM.

As of 2006, Tak province is home to 480,000, of which 150,000 are originally from outside the nation. And of that, approximately 80,000 are refugees that have either been registered or in the process of being so. Those who have managed to cross the border, most of whom are undocumented, have found shelter in border villages and refugee camps set up by the UN or other NGOs. And many of those who are not registered as a refugee work in the many factories near Mae Sot on a very low pay scale, though much better than in the land they came from. Meanwhile, Burma's population stands at around 47 million, of which Karens account for 7 million, the largest 'minority' group. Well over 600,000 have been displaced in camps within their country.

Naturally, Mae Sot is also the 'hub' for the many NGOs that work along the border to assist the endless number of refugees. Among them is a health care post called Mae Tao Clinic (MTC). Set up in 1989 by Dr. Cynthia Maung, herself a Karen who fled from Burma after the crushing of the '8888 Uprising' by the military regime, the clinic caters for those who travel across the border in seek of medical assistance, since there is none, if any, accessible, affordable health care available in Karen state (around 0.5% of the GDP is spent on health care), and for those who have already settled on the Thai side, but could not access health care because they are undocumented immigrants or simply for the lack of money. I met a lady who had walked for over a month from near Yangon, where she lost all of her family members in the deadly cyclone Nargis. She was suffering from PTSD (post-traumatic stress disorder).

Staffed with 530, of which 260 are health care professionals, and many of whom themselves are originally from across the border, the clinic is visited by approximately 400 every day, totaling over 120,000 patients per year. Although now well-known and attracting donations from all over the globe, the budget still remains extremely tight with an ever-increasing number of patients and a lot of issues have yet to be solved. Its in-patient facilities are still infection-prone, especially to the likes of tuberculosis, and more and more refugees give birth here, meaning more and more stateless children.

About 90 kilometers north of Mae Sot on Route 105 lies the refugee camp of Mae La, the largest of them all, housing 37,000 registered refugees and no less than another 30,000 unregistered ones. Because Thailand is not a member of UN's Convention Relating to the Status of Refugees, a person who wishes to be registered needs to be approved by both the UNHCR (UN Refugee Agency) and the Thai Ministry of Interior. With temples, churches, mosques, graveyards, schools, libraries, markets, and even a university, Mae La is like a huge refugee 'city', and so surprisingly, life here is not the worst for those who are registered, since they are eligible to receive food aid as well as space for housing, at no cost. Bored with nothing to do but unable to leave the camp nor return to their mother land, many couples fill the time to make babies, and family planning has become a seriously important topic. Others apply to live in a third country, while a handful work for the NGOs within the camp.

I visited one of Shanti Volunteer Association's (SVA) libraries, where children were forgetting their darker days and enjoying the time for learning. However, a boy who seemed unable to join the flock caught my attention. According to the staff, he had only arrived a couple of weeks ago, but just received the news that his father, who was also on the way, was killed in a fighting between Burmese government troops, the Democratic Karen Buddhist Army (DKBA), and the Karen National Liberation Army (KNLA), the military arm of the Karen National Union (KNU), which has been fighting for independence of the Karen state (in their words Kawthoolei). Whether or not that news was true is unsure, however, the extensive 'underground' information network of the people cannot be underestimated. And, the Thai cellphone can be used near the border even if it's on the Burmese side, as well.

Those who have been caught by the Burmese military or the DKBA have reportedly been forced to hard labor or simply 'used' as human walls in the event of fighting. In June, DKBA troops raided a Karen school, forcing students to flee to the jungle. 89 of them managed to reach Thai soil, however, nine of them caught malaria on the way in this naturally high-risk area for this fatal mosquito-borne disease. In the same month, near the Thai village of Mae Salit Luang landed four mortar shells launched from the Burmese side, prompting the Thais to increase border security. On June 15, the KNLA headquarters in Manerplaw fell to the Burmese army, and in May-June alone, no less than another 4,000 crossed the border.

'Chronic emergency' is the term many use to describe this region's volatile situation, which has not improved, or only deteriorated, since the conflict broke out in 1949.

A visit to Sanyukai.

Poverty. What does it mean?

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

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

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

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

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

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

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

A 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.

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 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. :-)

Flying into the sunset.

On October 29, 2008, Northwest Airlines became a wholly-owned subsidiary of Delta Air Lines, after the U.S. Department of Justice (DOJ) approved their merger on that date. The name of the Atlanta, Georgia-based mega carrier, which takes its name from the Mississippi River delta, will be the surviving brand. Although it will still take some time for them to merge completely, including combining operations, frequent flyer programs, seniority lists, Northwest's aircraft have already started to be repainted into Delta's livery, signaling the beginning of the end of a long history that has continued since its founding on September 1, 1926.

The year 2008, along with many other recent years, saw a number of carriers going into the history books, with some going out of business while others being bought out by others. From record high fuel prices to extreme competition and now a global recession, the aviation environment is becoming more harsh and unforeseeable than ever before. For the mighty incumbent flag carriers too, there is no safe haven. In Europe, former major airlines, some of which are now but a shadow of its glorious past, are being amalgamated into the big three: Air France, British Airways, and Lufthansa (Germany). KLM is now part of Air France; Austrian Airlines, bmi (British Midland), Swiss International Air Lines are now owned by Lufthansa; Iberia (Spain) is discussing a merger with British Airways; others that are so far 'left out' such as SAS (Scandinavian Airlines) face an uncertain future and Alitalia (Italy) ran out of cash. Established low-fare carriers easyJet and Ryanair continue to thrive with their rigorous cost-saving measures, but have felt pinches with strong competitors and other low-cost newcomers.

The same is happening in the U.S., despite at a slower pace. Once a trademark for air travel, Trans World Airlines (TWA) is now part of American Airlines, Phoenix-based America West Airlines acquired troubled U.S. Airways (retaining the latter carrier's name) in 2005, and after the announcement of the Delta/Northwest merger, Continental Airlines decided to switch loyalty from Air France/Delta-led Skyteam Alliance to Star Alliance, agreeing to cooperate comprehensively with United Airlines. The low-fare market is dominated by AirTran Airways, jetBlue Airways, and the mother of all low-cost carriers Southwest Airlines, and many new entrants who have dared to challenge have failed, though tiny Allegiant Air seems to have found its own niche, for the time being. And Alaska Airlines? Where are they heading for?

From March 30, 2009, Northwest's crew will start wearing Delta's uniforms, and rumors have it that they will start standardizing the interiors of the aircraft then, including replacing Northwest's WorldTraveler in-flight magazine with Delta's Sky. Frequent flyer programs WorldPerks and SkyMiles are planned to be combined by the end of next year. On the last day of TWA's operations at San Diego on December 1, 2001, a Northwest crew joined them on the radio frequency saying "we sure are going to miss hearing your call-sign"... probably little or never had they imagined that the same day would come for them just a couple of years later. I find Northwest's product on international routes superior among U.S. airlines that I have flown on before, including their acceptable meal service, warm and charming flight attendants, enjoyable in-flight entertainment (IFE), affordable fares, and a good mileage program. I will surely miss those red tails lined up at Narita Airport.

So long, NWA. :-)

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. :-)