Banning fast-food in low-income communities.

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

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

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

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

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

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

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

A visit to Wat Phra Baht Nam Phu.

Last summer, on August 8th, I had an opportunity to stop by the Wat Phra Baht Nam Phu, which translates to 'the temple of Buddha's footprints'.

At least one million Thais have been infected with HIV/AIDS since the first reported case in 1984. The rate was increasing at an alarming rate in the 1990s, however, with the society at that time not well aware of what was becoming a major social issue, those affected were cast aside and left to die. Situated in Lop Buri province, 120 kilometers north of Bangkok in central Thailand, the temple was turned into what it is now, an AIDS hospice, by a Buddhist monk named Alongkot Dikkapanyo back in 1992. Since then, the facility has expanded to accommodate 400 beds from an initial number of eight, thanks to the temple's extensive public relations strategies bringing in donations amounting to the equivalent of millions of dollars. Photos of the temple’s sick and emaciated patients adorn posters and donation boxes across the nation and television stations from around the globe visit to film documentaries. Wat Phra Baht Nam Phu is currently home to over 200 HIV-infected adults, and has been for a number totalling 10,000 over the past, most of whom died from the illness.

The temple's activities have always been controversial in recent years. Tourists from mostly western nations visit in thousands every week, taking tours that are guided by some of the relatively-healthy AIDS patients. They go through the wards where the relatively-weak AIDS patients are, without much explanation, and continue on to the 'Life Museum', a collection of dozens of mummified corpses of dead AIDS patients, who according to the staff, agreed to be put on exhibition prior to their death. That is followed by the crematorium, which is surrounded by what seem to look like sculptures or other pieces of art made from the bones and ashes of those who have been cremated here. Then they walk to a hall which houses a Buddha surrounded by piles of sandbags, or 'ash-bags', which contain the ashes of those who were cremated but have not yet found relatives to take it home. Visitors also have an opportunity to see a dance show done by AIDS patients too. And after all that, they leave behind tons of donations.

Yes, the hospice provides care and 'protects' those suffering from AIDS, but what is it doing to how people see HIV/AIDS patients? Dead AIDS patients whose bodies are not taken back by their relatives become sandbags or pieces of art, or part of the exhibits in the museum that has little explanation of the bodies. Those who are weak, and in their twilight of their lives, simply lie on the bed as tourists pass by giving them that look in the eye. You can often see the visitors covering their mouth upon entering the ward, then swiftly moving through wordlessly. Many don't even say hello. Those who are still relatively healthy host the tours or performances for the visitors, helping to attract more donations. I can't help myself from feeling that all of these together only exacerbate prejudice.

In Thailand, more than 400,000 have died from AIDS, however, it is also one of the few countries to have successfully curbed its epidemic with awareness campaigns, and later pioneered the widespread distribution of anti-retrovirus drugs (ARVs), which slow the progress of the incurable disease. In the 1990s, up to 100 patients died at the temple every month, but now, that number has been reduced to about 10. According to UNAIDS, fewer than 17,000 infections were reported in the country in 2006, compared with 143,000 in 1990, but officials are worried that the rate could climb again. HIV prevalence among intravenous drug users and sex workers remains high, while condom use among Thai teenagers is shockingly low. No time should be spared to come up with a new way to spread awareness.

In Thailand, generally speaking, monks are highly respected. Much more than the government, to be sarcastic. I believe that when it comes to bringing social awareness, they have a vital role to play. :-)

A visit to Magnet.

So, I often talk about community health... but what is it that started everything?

It all started on March 24th, 2007, when I paid a visit to Magnet, a clinic located in the heart of the Castro neighborhood in San Francisco. I was then on a program run by VIA (Volunteers in Asia), a non-profit organization (NPO) originally based at Stanford University. With men walking down the sidewalks holding hands, a movie theater showing dramas of love between men, and shops whose walls are covered with posters of naked men, it was not a scene that you are used to seeing.

The Castro came of age as a gay village following a controversial 'Summer of Love' in the next-door Haight Ashbury district in 1967. The gathering brought tens of thousands of middle-class youth from all over the United States. The neighborhood, formerly known as Eureka Valley, became known as the Castro, after the landmark theater by that name near the corner of Castro and Market Streets. The community was hit hard by the HIV/AIDS crisis of the 1980s, and beginning at that time, city officials began a crackdown of bathhouses and launched initiatives that aimed to prevent the spread of AIDS. Today, kiosks lining the streets have posters promoting safe sex and testing alongside those advertising online dating services, and the city of San Francisco is home to around 100,000 to 200,000 homosexuals.

Asking about the roots of the community, many bring up the name Harvey Milk, a gay rights activist and the first openly gay man elected to San Francisco's Board of Supervisors, or to any substantial political office. He was elected in 1977 representing District 5, which included the Castro. However, I felt that another, more recent activity was helping to bring the gay people together and empowering the community: Magnet.

Although a clinic, it does not look like the conventional one in your neighborhood. The front side of the building facing the street is glass, instead of a wall with small windows, allowing everyone who walks by to have a view of the interior. As soon as you enter, a clean room with leather sofas and tables and a corner that resembles an Internet cafe greets you. A large bulletin free for anyone to post events in the community is near the corner and artwork of gay men adorn the walls with metallic coating. The examination rooms are located at the rear of the one-story building, however, for privacy these rooms are lined with walls and not glass, of course.

Founded by the 'Castro Guys', a group of health care professionals who were gay, Magnet's vision is to promote the physical, mental, and social well-being of gay men. Run by gay men (all staff are gay and half of them are HIV positive) for gay men, it offers free sexual health services such as confidential HIV antibody testing, testing and treatment for syphilis, chlamydia, and gonorrhea, and hepatitis A and B vaccination. Other than for sexual health, it provides services such as ear acupuncture, chair massage, hypnotherapy, general mental health counseling, and a flu clinic. Although financial support was scarce in the beginning, now it is supported by a major pharmaceutical company which pays roughly 80% of the costs, and the rest is paid for by donations from the people in the community.

However, in addition to providing sexual health services, Magnet holds a variety of on-going community activities. This ranges from book readings and art exhibits (as mentioned earlier) to town hall forums and health chats, or karaoke and dance nights to gay weddings. And even when there are no particular events, people drop by the clinic just to chat with others or share stories. In other words, Magnet acts as not a mere clinic, but more like a community center that brings a people together in an affirming environment that embraces the diversity of the culture that exists. This is a place where gay men can access resources and make connections and friendships between each other that not only helps to promote individual health but also community health.

Magnet is an example of community health, but to be more exact, this is a form of primary health care (PHC), as defined by the World Health Organization (WHO). It is health for the people, by the people. Everyone walking on the streets of the Castro knows the Magnet. I was utterly amazed at the potential of how a small clinic can bring together a people who have been isolated and considered socially-handicapped by the rest and act as a catalyst in empowering the community as a whole. It serves as a place to meet people and bring everyone... the entire community together. Like a magnet, it truly lives up to its name, or much more than that.

So this is how everything started for me. Community empowerment for the people by the people through community building and organizing, with a touch of creative thinking and facilitation, in this case, from a health care perspective. Simply exciting. :-)

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. :-)

JAIH-S International Health Training Camp 2008.

I was given an opportunity to participate in a four-day global health training program that was carried out by the Students' Division of the Japan Association for International Health (JAIH-S) from March 13th to the 16th. The main aim of this annual program is for the participants to be able to (1) create an image of what working in the global health field is like, and (2) know what you can do and how to start it.

We had lectures done by people currently working at the front lines in this field, including staff from the International Health Center Japan, a tropical medicine researcher, an epidemiologist, officers from the Ministry of Health, Labor, and Welfare (MHLW), and health specialists from NGOs, JICA (Japan International Cooperation Agency), and UNICEF. The lectures were followed by many group activities including discussions, debates, and a PCM (project cycle management) workshop which we had to work on through a night to complete.

My impression? Well... frankly speaking, I felt a little weird throughout the program. Of course, all the participants were highly-motivated, deep-thinking, yet thoughtful people who had gathered from around the country, and without question, the chats with them were really stimulating and one of those memorable times. However, most, if not all of them, were drawn by the terms 'global health' or 'international health', while on the other hand, my interest doesn't necessarily have to go beyond the border, as my 'theme' is community-based health care or primary health care (PHC). Yes, often times, these words have been talked about more in the developing communities rather than the industrialized ones so no doubt it does have a 'global health' taste to it, however, when you take a close look at the developed communities, you actually do see many forms of community health, and plus, there are many things these communities around the globe can learn from each other.

And, another reason for my feeling not right is probably due to the fact that many of the speakers have already literally abandoned the clinical part of being a physician. In other words, many of the doctors in this field do not see patients anymore at a hospital or clinic. Yes, it is true that so-called logistic-type jobs are more needed than specialized people like doctors or nurses. For example, when you take infectious diseases, the main underlying issues in the developing communities are more basic, such as sanitation or health education, and tackling these issues is the most radical solution. Treating patients and prescribing drugs is also a job that can not be cut, but it does little in terms of remedying the bigger picture. So what's needed in the field of international cooperation? Leadership, management, communication skills, and creative thinking. It's what one of the lecturers said, and I agree.

However, at this point, I have no thought of abandoning the clinician's work. Well, that's what I am studying medicine for right now! To obtain specialized skills. Yes, I am interested in public health, community health, and doing positive things for the bigger public, but I want to do that through interacting with the patients. So the image of my future I have right now could be called 'clinical epidemiology-based community health'. In other words, through interacting with the people, know the community, know its strengths, weaknesses, and hidden potentials, and do something creative to bring out their strengths to make the community happier as a whole, with the people in the community. This training program helped me reaffirm my interest.

By the way, I had a chance to talk with Dr. Honda, the founder and current chair of SHARE, the biggest non-profit organization in Japan specializing in international health cooperation, and I was deeply moved by his talks, as he and I had so many common interests... his 'theme' also sounded like community-based health care and primary health care (PHC). :-)

Goodbye to a flying sports car.

Fleet rationalization is happening everywhere in the commercial aviation industry. With fuel prices sky-rocketing, airlines are doing whatever they can to cut costs, and fleet simplification is one of them.

That is no exception with the airlines of Japan too. When Japan Airlines (more commonly referred to by its ICAO three-letter code JAL) and Japan Air System (JAS) merged in 2002 to take on All Nippon Airways (ANA), which had and still has the biggest share of the domestic market in terms of passenger numbers, it not only created an initial series of coordination problems but also a diverse fleet as well, as the two only had one aircraft type in common. Operating more aircraft means more maintenance work, a larger spare parts inventory, more training of its employees, etc, which adds to costs.

For example, the competitors in the short-haul market are the Airbus A320 family, Boeing's 737 family, and the McDonnell Douglas (merged into Boeing in 1997) MD-80/90 series. Production of the latter was terminated not long after its takeover by its former arch-rival, so essentially the A320 and 737 have the market all to themselves now.

JAL had been operating a substantial fleet of 737s, while JAS had been loyal to the Long Beach-based manufacturer, operating the MD-80 and also acquiring the advanced MD-90s in the mid-1990s. So the merged airline operating two (or three) major types for the short-haul sector was naturally deemed uneconomical, and the decision was made to acquire newer 737s to eventually replace the Douglas twin-jets. JAS operated the MD-81, MD-87, and MD-90, and the first to say farewell became the MD-87.

First delivered to JAS on June 3, 1988, the fleet eventually built up to eight aircraft. The MD-87 is basically a MD-82 (a MD-81 with more powerful engines) with a shortened fuselage, compromising capacity for longer range and better take-off and landing performance. JAS acquired these 117-seat jets, sometimes nicknamed the "flying sports car" for its superior climbing performance, to bring jet age to the local regional airports in Japan with limited runway length. These markets had long been served by the Japanese-built NAMC YS-11 turboprop airliner.

After the merger, all eight were repainted in JAL's new "Arc of the Sun" corporate livery which was developed by Landor Associates, however, as the merged airline took delivery of more newer 737s, it was only a matter of time before retirement. So the first of eight was withdrawn from service in October 2007, and the ultimate aircraft is now planned to operate its last revenue flight on March 31, 2008, flight JL1386 from Nanki-Shirahama to Tokyo's Haneda airport. All were already withdrawn from scheduled service by the end of February, and have since been operating mainly as back-up equipment.

The MD-87 was never the most popular jetliner like Boeing's venerable 747, but it did have its own niche, and brought jet age to the regional airports in Japan, boosting tourism. It surely will be missed by its crews, employees, and those local airplane spotters. Fortunately, many are now finding a new lease of life in Thailand with low-fare airline One-Two-Go (a subsidiary of Orient Thai Airlines), instead of being reduced to piles of metal somewhere in the southwestern USA where many older jetliners end their life.

Farewell, sports car in the sky. :-)

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. :-)