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. :-)

How should we save more lives from cardiac arrests?

During the second week of September, I was in the Department of Emergency Medicine as part of my clinical rotations. Our university hospital focuses primarily on tertiary emergency medicine, therefore, only the most severe patients are carried into the ER here, such as cardio-pulmonary arrests (CPAs). However, there are exceptions, including cases where the ambulance had been refused by other hospitals, which is unfortunately, not rare at all. Through my four days here, there were some things I felt and thought I would like to share.

In emergency medicine, a CPA patient is defined as one who is unconscious, whose breathing cannot be seen, heard, nor felt, and pulse cannot be felt at the common carotid artery. When this patient is carried in, we basically follow either the Immediate Cardiac Life Support (ICLS) or Advanced Cardiac Life Support (ACLS) guidelines and attempt cardio-pulmonary resuscitation (CPR). However, through the days I was there, out of a total of seven CPA patients carried in, none recovered from coma and one reached recirculation but did not regain consciousness. The hospital admits 350 to 400 CPA cases per year, and circulation returns in approximately 50 of them, and total recovery is 10% of that, and that means a single digit number.

When one falls into CPA, which part of the human is most quickly damaged? The brain. Not only is it a damage, but an irreversible one. It is said that if recirculation could not be achieved within five minutes of CPA, chances of full recovery declines to 50%, and after 10 minutes, that plummets to somewhere extremely close to zero. With this considered, in the U.S., some local authorities have begun to adopt the termination of resuscitation (ToR) guideline. It supports termination in the out-of-hospital setting subsequent to failed basic life support (BLS) resuscitation by emergency medical services (EMS) personnel if all of the following are true: (1) no return of spontaneous circulation prior to transport; (2) no shock given prior to transport; and (3) arrest not witnessed by EMS personnel.

Our university hospital concentrates on tertiary emergency medical care, so in other words, patients carried in are those whose chances of full recovery are close to none. But no matter how the situation is, ER personnel will do whatever they can do to resuscitate. In Japan, the average time it takes for an ambulance to reach the site after the 119 call is seven minutes, and it takes 30 minutes from the time of arrival at the site to reach a hospital. It doesn't take a rocket scientist to see that that is well beyond the 5 minute 50-50 tipping point.

Without doubt, knowing the ICLS or ACLS procedure is a must for all health care providers. However, chances of a CPA patient being saved is extremely low, unless someone at the site knows BLS and carries it out. What I would like to clarify here is that yes, knowing the ICLS or ACLS guidelines and being able to perform it is important, however, teaching people the basics of emergency medicine and making sure they can perform BLS promptly and appropriately is the way to significantly cut the number of lives lost from CPA. The good news is, BLS seminars are becoming more common, and organizations from corporations to governments are placing automated external defibrillators (AEDs) here and there. Now, we also need to focus on how to help people keep up with their BLS skills. :-)

A visit to The Royal Infirmary of Edinburgh.

My first visit to Scotland, and Great Britain. It was months ago when I decided to participate in the three-week 'English for Medicine' course offered at the University of Edinburgh's (pronounced 'yeh-dinbra') Institute for Applied Language Studies (IALS), and what made me do so was that I wanted to see the Division of Community Health Sciences and meet a professor named Dr. Raj Bhopal there to seek some advice about how I should pursue my area(s) of interest. Having interest in family medicine and public health with a clinical taste, I also wanted to take a look at how general practitioners (GPs) work and get a general idea of the health care system there.

As in other countries as well, the U.K. has both public and private hospitals, the former of which is run by the National Health Service (NHS), a non-profit organization funded by the government but independent from, paper-wise. Now, in Japan, patients have the freedom to choose the hospital or clinic they wish to visit. Whether it's your local clinic or a university hospital or the cancer center, it is basically up to you to decide where to go, however, this is not the case in Great Britain. If you become ill and wish to see a physician, unless you have a contract with a private health insurance company, which will allow you to have access to a private hospital, there are only two ways you can see a physician: see your GP or end up in the accident and emergency department (A&E). GPs are allotted a certain population in an area, meaning from the patient's point of view, you are automatically determined who your local health care provider is depending on where you live. Only when your health problem cannot be solved at the GP or A&E clinic that you first have the chance to see a specialist, in the form of referrals written by your GP.

A GP has two major roles: an expert in general medicine providing primary medical care, and a gatekeeper of resources. The former role includes not only the clinical part (inside the clinic and also visiting homes), which includes pediatrics, maternal health, referring patients to specialist hospitals, and follow-up of patients with chronic illnesses, but also a variety of other tasks for community health, such as prevention and health promotion, and sex education and family planning. But in reality, most of the GPs in populated areas only have time to do the clinical part, which can be understood from the fact that patients are made to wait an average one week from when you make your phone call to the point of your appointment. No wonder an increasing number of patients, who can afford, are choosing private hospitals. If you're referred to a specialist, it will likely add more weeks or even months to that.

The GPs' latter task, as a gatekeeper of resources, is in two perspectives. A GP has to prevent inappropriate use of treatments and 'control' the patients' demands, thereby saving financial resources, and also guide the patient to the right care they need, as in referring to the appropriate specialist, thereby saving human resources. However, because of this, there are many GPs who face a dilemma, as they are also the closest health care personnel for the patients, and speaking out for them is the basis of a GP's job.

So, when I had an opportunity to follow Dr. William MacNee, a consultant physician and professor of respiratory and environmental medicine at the Royal Infirmary of Edinburgh (RIE), I wanted to focus on not only how he interacts with the patients but also how he communicates, or exchanges information with the patients' GP, system-wise, as good communication is vital between the specialist and the GP as well in a health care system like the U.K. Oh, how do I know him? Well, Dr. Patrick Barron, the passionate professor in charge of the International Medical Communications Center (IMCC) at my university, kindly introduced me to him.

In a typical medical consultation here, the physician only jots down notes, instead of scribbling on the official medical records, which makes reading them a decipherment for others. After the patient leaves the room, the physician will read aloud and record on a tape what he wants written in the official records. The tape will then be duplicated, with one copy going to the patient's GP and the other to the physician's (or the department's) secretary for transcription on to the electronic medical records. The one going to the GP is labeled urgent (red) or not (blue). This system saves a considerable amount of time for the physician, though that means more work and some medical knowledge needed for the secretary.

The RIE is a specialist hospital, so there are no GPs, except for those in the A&E. Tracing its roots back to 1729 as the oldest voluntary hospital in Scotland, it was incorporated into the NHS scheme in 1948, and the current facility, located south-east of the city, was completed in 2003 for 190 million British pounds and boasts 900 beds. Due to its location, it also serves Midlothian and East Lothian. Adjacent to the hospital is the medical school of the University of Edinburgh, which the hospital has maintained close ties with for years. Some noteworthy features of the facility include a 24-hour A&E unit, the Simpson Centre for Reproductive Health, giving birth to 6,000 babies each year (largest in Scotland), and the Scottish Liver Transplant Unit. In the hospital's main hall are banks, eateries, a general store, a bookshop, a barber, and the patients' information center. Brochures and pamphlets covering a variety of topics, from information of diseases to informed consent, or self-help guides, such as how to deal with stress, can be found here and the good thing is all are free for the patient to take home. Very useful and interesting.

Finally, I would like to share some phrases and expressions I heard in the patient-physician interactions, especially from Dr. Gourab Choudhury, who is Dr. MacNee's registrar. I spent the morning following him on the day I was at the RIE. When a patient kept on complaining over and over about how her dyspnea was so severe, he used the phrase "Oh dear." several times. It's sometimes not easy to think about how to react when your patient keeps on complaining, and I thought this was a nice and simple way to express sympathy. Another phrase is "Let's take it on from there.", which he often used when he was finishing up the medical consultation. I often find it difficult to find an appropriate phrase to end the conversation with a patient, but here it is, a simple, convenient expression with a positive-thinking meaning and a touch of sympathy. :-)

Oban and the Isle of Iona.

On a weekend in August this summer during my stay in Edinburgh, I had a chance to see the Scottish outskirts of the Highlands and Islands. That is when I visited the town of Oban and the Isle of Iona.

Built on a crescent-shaped bay on the Firth of Lorne, Oban is an important base for those who wish to explore the West Highlands and the islands of the Inner Hebridges in the western part of Scotland. It is a typical Victorian holiday town and has a lively nightlife scene throughout the summer, with good pubs and ceilidhs (pronounced 'kay-lees'), which is traditional Scottish dancing. A picturesque small town, and I mean small that you can virtually become familiar with all the nice cafes and restaurants in one day. And providing the weather is favorable, the view of the bay from the waterfront at sunset is simply beautiful.

On a morning, together with my friends, we walked down from our modest accommodation in Oban to the port, where we caught a ferry to haul us to the Isle of Mull. Our bus came with us too. Upon arriving on the relatively large piece of land, we hopped on the bus for a bumpy ride to Duart Castle, situated on the east side of the island. Home of Clan MacLean, it was built in the 14th century and went through several military conflicts like many other Scottish castles before being abandoned in 1751. It was restored in 1911.

After touring through the castle, we traveled down to the southwest tip of the island where another ferry was waiting for us, though this time the ship was small and the trip was short. Leaving the bus behind, we crossed the body of water over to Iona, an island regarded by many as a very special and sacred place because of the arrival here of St. Columba in 563 AD. Columba came from Ireland and was a descendant of the country's kings and queens. He established a Christian church here and soon began to convert the heathen Picts of Scotland to the Christian religion. Soon, Christianity spread throughout the land and its strong position was confirmed when Columba was granted the power to crown Aidan as King of Dalriada, establishing a royal line of kings and queens of Scotland. Simply said, Iona is the birthplace of Christianity in Scotland.

But even without considering that, Iona feels like an island that has a special something. I personally do not follow any particular religion, however, the island is so beautiful and peaceful that it truly calms you down and refreshes your mind, though of course, only if you have the weather with you. Sea water is so transparent here that you can see the ocean bottom from the deck of the ferry upon approaching the island's sole port. There is one village on the island which everyone calls 'The Village'. A few shops and cafeterias, the compact but sufficient port, and houses make up the village, though the island's Abbey is located five minutes from here by walking. The villagers say that until a couple of years ago, cars didn't even exist on the island. It is so small that you can walk to any corner. Roads wind between fenced but large pieces of hilly grassland, where sheep bask and graze in the sun. When you are walking, you feel as if time has stopped. Magnificent, beautiful, spectacular... it seems like any word fits to describe in some sense, but doesn't in another.

Oban and Iona... truly places I would like to visit again sometime in my life. :-)

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. :-)