Introduction to the Primary Health Care Project in Laos
*All affiliations and titles in the video are current as of the 2016 academic year.
Keio has a long legacy of medicine, which began with its School of Medicine more than a century ago in 1917. The Faculty of Nursing and Medical Care followed just after the turn of the millennium in 2001, and the concept of what Keio terms “team medicine” began just over ten years ago with the addition of Keio's third medical faculty—the Faculty of Pharmacy—in 2008. Team medicine refers to a comprehensive patient diagnosis considered by a group of health professionals and is an essential aspect of the patient-centered medical care for which Keio is known. In team medicine, doctors, nurses, and pharmacists come together to tackle the challenges of medicine as a single team, which led to the launch of the Inter-Professional Education (IPE) Program, founded to deepen medical students’ understanding of team medicine and teach them how the faculties can better cooperate and learn from one another. One of the IPE Program’s longest running and most prominent projects is the Primary Health Care Project in Laos, a valuable experience-based program that gives medical students the opportunity to conduct real-world medical fieldwork in Laos.
Primary Health Care Project in Laos
During the Primary Health Care Project in Laos, students spend 10 days in Laos participating in medical and primary health care activities in both urban and rural areas. Intended for students of the School of Medicine, Faculty of Nursing and Medical Care, and Faculty of Pharmacy, the program includes a 14-part pre-departure training and lecture series to teach students as much as possible about Laos before they enter the country. These introductory lectures help students think about how to approach health care activities in Laos from their respective fields of expertise.
The Lao People's Democratic Republic, commonly known as Laos, is located in Southeast Asia and has a tropical, monsoon climate that is divided into a rainy season and a dry season. Precautions must be taken year round against mosquitoes that carry dengue fever and malaria. Due to a lack of medical facilities and personnel, the Japan International Cooperation Agency (JICA) has long provided international aid to the country to help remedy its relatively low standards of health. Through the Primary Health Care Project in Laos, students are able to visit the offices of organizations that oversee support throughout Laos, including JICA and the World Health Organization (WHO).
Students also receive in-country lectures that provide firsthand information on the current state of health care in Laos, including the successes and struggles of working to meet both the United Nations’ Millennium Development Goals and Sustainable Development Goals, as well as observe local medical institutions and participate in maternal and child health support project activities. An exchange with students at the University of Health Sciences, Laos, which is conducted entirely in English, is another chance for students to deepen their knowledge as health professionals who will be responsible for shaping the future of international medicine.
“Laos is somewhere I had never considered visiting before, but this program brought it to my attention. I wanted to see for myself what life was like in a developing country,” explains Kohei Furuya, a fifth-year student at the Keio University School of Medicine. He applied to the program after hearing about it from a good friend. “I was very surprised to learn that the maternal mortality rate in Laos is 40 times higher than it is in Japan,” Furuya says.
Minako Kido, a third-year student in the Faculty of Nursing and Medical Care, initially came to Keio University because of her interest in international midwifery. She enrolled in the IPE Program for the opportunity to get hands-on experience in international health care support.
“Even before university, I knew that Keio was dedicated to international medical research. I enrolled in Keio's IPE Program hoping to participate in as many international projects as I possibly could,” Kido says. The program’s latest project was focused on the field of maternal and child health. Students were even able to witness a live birth during their clinical internship at a hospital in Salavan Province in the south of Laos.
“The hospital had delivery rooms, but there were no doors, leaving new and expecting mothers completely exposed from the hallway. Even a curtain could have made a world of difference. It made me think about how necessary it is to protect a patient's privacy,” Kido added.
It seems that there were many things that stood out in the eyes of a nurse. “There were quite a few things that I didn’t notice until we were actually at the hospital.” The days were filled with discussions as students from each faculty shared their insights on how they thought they could help improve conditions at each of the places they visited.
Maria Ishibashi of the Faculty of Pharmacy was shocked to see hospital custodians counting pills. She explained that such a situation might be unavoidable when considering local customs, culture, and the current state of medical treatments.
“There is a definite sense of community in the villages. At night, the villagers would gather together around the hookah, but I realized that was also the time when they would share the latest news and information with each other. And even though I didn’t understand the language, I felt that they treated me like a member of their community. In the village, everyone helps each other and their lives are closely connected. If someone in the village gets sick, their family and neighbors all pitch in to take care of them. I really felt how strong the bonds were between people there. It was certainly strange to see custodians counting pills and handing them out to patients. And I have to say I was surprised to hear that the reason was that they were simply understaffed. It was something of an eye-opener when someone at the hospital told me that ‘you don’t need to be a doctor in order to count.’ It made me realize that if we are to think about the development of medical care in a country like Laos, where the bonds between people are so strong, we couldn’t just dismiss everything they were doing differently.”
During their 10 days abroad, students spend two nights and three days in a remote village and stay with local families while conducting sanitation and hygiene education at a school in the area. Students visit the same elementary school every year, so they inherit techniques and equipment from former project participants and have an opportunity to add their own ideas and improvements. One of these ideas was a hand washing station at one of the elementary school. Current students heard that the station had been built two years prior, in 2016, but upon arrival at the school they found that parts of it were either rusted or broken. It seems that many villagers had used it to wash vegetables, but there was no sign that children had used it to wash their hands. Upon further investigation, students decided to fix the now defunct hand washing station. They repainted it, swapped broken parts for new ones, and brought in soap, a rare commodity in the area. They then taught the children how to use the station to wash their hands, once again teaching the children the importance of washing their hands and explaining to the teachers how to maintain the equipment.
You can see similar facilities gone to waste everywhere you go. “I repeatedly saw medical equipment—some from Japan—left in a state of disrepair. Much of the equipment was broken, like stethoscopes and dental hygiene devices. When equipment breaks, locals often don’t have the parts or the know-how to fix it, rendering it unusable. Still, health professionals in Laos have no choice but to make do with the limited resources at their disposal. Through this project, I came to realize that we can’t think about medicine in terms of developing and developed countries. In international medicine, we have to consider the problems of each nation on an individual basis. Laos has its own unique mechanisms and methods for medical development,” says Kido.
“I also heard that much of their medical equipment was useless during power outages. The same goes for the hand washing station, but even the best equipment is meaningless if it can’t be maintained locally. While I know it is often necessary to bring advanced technologies to developing countries, I now fully realize the importance of considering what the most sustainable medical care options are. Soap, for example, is the biggest sanitation issue at the elementary school we visited. Since it’s hard for the villagers to get soap on a regular basis, we have to think of other means of sanitation… And that’s one of the biggest issues I brought back home with me,” says a concerned Furuya.
Tomoko Koike, Associate Professor at the Faculty of Nursing and Medical Care, launched the Primary Health Care Project in Laos in 2011. “This program allows students to participate in primary health care activities while, at the same time, gain valuable hands-on experience in sustainable medical solutions and learn a team approach to international health. When students from the standpoints of medicine, nursing, and pharmacy all come together, they gain the ability to look at things more holistically―a skill that is essential to effective medical treatment,” she states.
“There is something extremely valuable to be learned from these three faculties coming together to conduct joint activities related to international health,” she continues. With international health, students face new challenges that they would not otherwise experience in Japan. In order to pose solutions to these challenges, they must first get a multi-dimensional, comprehensive picture of a situation to grasp the problems and phenomena behind the issue itself. They must also understand cultural differences and respect diversity before they can propose alternative solutions that will be sustainable for the local community, which is where communication plays a large supporting role.
“Medicine is comprised of very different perspectives and approaches that vary between the medical sciences, nursing, and pharmacy. The future of medicine depends on these multilateral perspectives, not solely on the specialized perspective of any one individual alone. If you look at a cone from the side, for example, you’ll see a triangular shape, but if you look from the bottom, all you’ll see is a sphere. Only when you integrate multiple perspectives can you perceive the three-dimensional shape of an object.
The students who participate in this program transcend years and fields of study to discuss a variety of issues. Students achieve tangible results when they experience learning and working as a diverse team to tackle real-world issues. You could say we’re building the skills that are essential to contemporary medical care, where team medicine plays a vital role,” says Prof. Koike.
Prof. Koike also tells students that this kind of international medical experience can be a great impetus for solving domestic issues as well.
“This isn’t a one-way street for developed countries to help developing countries. I want students to use this project to really think about what they can learn from developing countries. The choices that developing countries make regarding regional medicine and healthcare policy, for example, can show us how to work with limited budgets and resources. Japan should not be dependent on advanced equipment to provide primary care, and when considering the country’s current labor shortage in the healthcare industry, we should think about leveraging the power of the local community for prevention education outreach. We can also spread methods of lay medical care and other assistance that non-experts can provide. This is something that Japanese society must learn from Laos, as Ishibashi illustrated when he saw firsthand what results are achievable when local residents use the power of community for sustainability. Developing countries may end up giving us the hints that we need to innovate and improve medicine and nursing care in Japan.
Prof. Koike also says that students change over the course of the program. “Looking back at the participants in the program, I see that most students get over their initial culture shock and start to realize the merits of the local culture within the first two days. As they deepen their understanding of a specific culture and society, they start to question their own opinions and value systems and become able to think about what kind of behaviors can lead to sustainable development,” she says.
“Some students use this experience as a springboard into regional medicine. Others find role models in the health professionals from JICA and WHO that they meet on the program and go on to participate in other training programs and projects abroad. I am hopeful that many of them can achieve their goals of working in the international health field in the future,” Prof. Koike concludes.
As part of the three-faculty IPE Program, the Primary Health Care Project in Laos, is sure to continue to contribute to the future development of internationally minded health professionals in Japan and beyond.