As mentioned on an earlier post, riding motorcycles with out helmets and road safety in general is one of the top 5 public health problems in Thailand.  Currently, to combat this problem there is a law requiring the person driving the motorcycle to wear a helmet.  However, this means that the passenger, who oftentimes is a child, does not have to wear a helmet.  It is extremely common to see a parent wearing a helmet with their 2 year old child in front of them with no helmet on.  As a parent this would really scare me!  This would definitely not be allowed in the U.S.  The Thai Health Promotion Foundation still has a long ways to go to increase safety on motorcycles.  This is one of the main ways of transportation and the majority of accidents that happen involve motorcycles.  Unfortunately, these are usually fatal.

Another safety issue that the Thai Health Promotion Foundation is working towards improving is wearing seat belts.  Currently it is a law for the driver and front seat passenger to be buckled.  The problem is that this law does not seem to be enforced.  As far as the backseat goes, they usually don’t even have seat belts.  Can you even imagine that?  It was the weirdest sensation going to buckle my seat belt in the taxi and not being able to.  The goal of the Health Promotion Foundation is to enforce the current law and also work towards making it a law to buckle up in the back seat.  In order to pass and enforce this law they will first have to work to change the Thai norm of not buckling up.

Since Bangkok is surrounded by a major river another safety issue is children drowning.  Every year several children drowned in the river.  An intervention that the Thai Health Promotion Foundation has worked on is teaching children how to swim.  To make this intervention accessible for the children and parents they create swimming pools in the river by putting up nets around an area and teach the children to swim right by their homes.  This has significantly decreased deaths due to drownings and has been an effective intervention.

A rapidly increasing problem in Thailand is obesity among both children and adults.  We were able to go to one of Bangkok’s main parks, Lumpini Park to see the efforts that are taking place to keep the Thai people active.  This park is similar in importance to the Thai people as Central Park is to New Yorkers.  It has a trail all around the park where there were hundreds of joggers navigating the trail.  A major form of exercise that Thai people love is aerobics.  The city pays aerobic teachers to lead open aerobics in the park.  They get on a stage and start to play their music and do their routine and then hundreds of Thai people join along.  As we were walking around we also saw an outdoor gym with weight machines that anyone can use.  Of course the majority of the people using the weight machines were men, if not all of the people.  Seeing this type of community exercise made me wish that we had more activity in the parks around our communities.  It is a great idea to get people moving and participating in the fight against obesity.

As we met with the Thai Health Promotion Foundation they discussed how they are currently working on a policy that will ban added sugar and soft drinks in Thailand.  This will be a great environmental change that will influence the millions of Thai people.

The Thai Health Promotion has been putting major effort into helping with tobacco efforts.  Out of 65 million people in Thailand 10 million are smokers.  In an effort to start reducing the number of smokers they have completely banned smoking ads on T.V.  Thailand also became the 4th country to put pictures of the effects of tobacco on cigarette packages.  Through anti-smoking ads, produced by the Thai Health Promotion Foundation, they have been able to reach thousands of Thai people and are starting to change norms.  They also were able to get a comprehensive ban on tobacco at sporting events which includes absolutely no tobacco ads or commercials.  Since they implemented the 2% alcohol and tobacco tax they discovered a link between an increased cigarette tax and a decrease in smoking rates.

Alcohol abuse is also a serious problem in Thailand.  As a country they have the world’s 5th highest alcohol consumption.  Before the Thai Health Promotion Foundation no particular group was in charge of alcohol control.  The foundation is working on bans on alcohol.  Currently after 10 advertisements alcohol companies are able to advertise.  The foundation also produces many graphic and realistic anti-alcohol commercials on T.V.  They are working on a major campaign to stop giving alcohol as a present.  This is a Thai tradition and they are trying to change this norm.  There are many other campaigns they are working on including a “No alcohol day” during the first day of the 3 month Buddhist lent.  This has been effective in the past because the majority of Thai people are Buddhist and follow their beliefs.

While staying in Bangkok we stopped at the Thai Health Promotion Foundation.  It was formed 9 years ago to help improve the health of the Thai people.  They cover a population size of 66.7 million.  They focus their strategies on using a triangle model that balances knowledge, policy, and social participation to successfully accomplish their interventions and solve health problems.

The top 5 health problems they are currently working on are:

• High blood pressure
• Riding motorcycles with out helmets
• Unsafe sex
• Smoking/tobacco use
• Alcohol consumption

They work with the Thai Health governing board to accomplish what they need to.  The Prime Minister is the chair of the board with a total of 21 members.  Half are from ministries and half are independent experts.  The Thai Health Promotion Foundation gets their budget from a 9.2% liquor and alcohol tax which comes to around 80-90 million dollars.

They allocate their budget accordingly:

• 29% is spent on tobacco, alcohol, and physical activity
• 16% is spent on health risk factors
• 14% is spent on social marketing
• 10% is spent on the community
• 8% is spent on health literacy
• 7% is spent on an open grant
• 5% is spent on health service systems
• 5% is spent on health promotion in organizations

It was interesting to talk to one of their directors about the 7% they spend on an open grant.  Every year they allow members of the community to create a community intervention of their choice.  After going through all the applications they narrow it down to one intervention and award the person the grant to implement the intervention.  They continually are updated with the progress of the intervention.  This allows the people in the community to start voicing their concerns about the health of their communities and gives them the opportunity to make a difference.  It is a great idea!

The Thai Health Promotion Foundation has made major progress in a short amount of time.  After the foundation was established they were able to pass 9 major policies in 4 years compared to the 5 health policies in 50 years.

On our last couple days in Chiang Mai we took an all day bus ride up to the golden triangle.  The golden triangle is at the Northern border of Thailand where Laos, Burma, and Thailand all come together.  The only thing that divides them is a river.  This location has been one of the most extensive illicit opium-producing areas of Asia and of the world since the 1920’s.  Until the early 21st century when Afghanistan became the world’s largest producer of heroin, most of the world’s heroin came from the Golden Triangle.

While we were at the Golden Triangle we stopped by the opium museum where we were able to go through the history of the opium wars and see the struggles Thailand has had with illicit opium production.  A couple decades ago the King and his mother came to the northern border to help fix the problem.  Many of the people produce opium because they are able to make a decent living.  Therefore, to fix the problem the King worked with the people and provided them with an education.  To replace their former work he taught the people how to farm effectively and how to do agriculture.  This gave them a chance to stop producing opium because they could provide a living through farming.  It was successful and helped to decrease the problem around the border.  However, growing and selling opium is still a major problem today and needs more attention.  Through out the centuries it has caused major violence among the people through drug wars a long with serious drug use and opium addiction.

The opium is made from the white liquid found in the poppy plant.  Therefore, along the border there are millions of poppy plants.  Opium is a narcotic which previously has been used to relieve pain or dull the senses.  It slows down the bodies system.  In the early 1900’s morphine (an opium derivative) was even used in coughing syrup for children.  No wonder they calmed down!

While still in Chiang Mai, we drove to the countryside to meet with a monk who has been extremely involved in improving the health of his community members.  He has dedicated his life to this cause.  He is an advocate of Public Health and holds many different community interventions.  He  is also a member of the CAB (the local leaders who discuss whether or not the RIHES interventions are a good idea for the public).

One of his main focuses is helping to reduce the stigma for HIV+ community members.  He is able to reduce stigma by educating community  members on HIV and conveying that those who have HIV are still normal people.  He also provides work for HIV+ community members who aren’t able to find a job.

Another interesting thing he does in the community is that when adolescents are struggling with substance abuse, their parents send them to the Wat for rehabilitation.  He helps them overcome their addictions.

This monk is very well-known and respected among the community.  He has also received many awards from the King and royal family.  It was inspiring to see the changes he has made in the community.

After visiting the community hospital we were able to stop by the Church of Christ in Thailand to discuss their AIDS ministry, also known as CAM.  It was established by a group of Christian leaders who were concerned about AIDS in Thailand.  The AIDS ministry works in Northern Thailand.  Their overall goal is for the church and community to unite to provide a hollistic approach.  Their objectives are to provide service and encouragement to reduce stigma.  They develop processes for prevention, protection, and problem-solving related to HIV.  They mostly target youth because AIDS is continually increasing among the younger youth.

The activities they provide are: home based care, counseling, training of trainers, HIV education and prevention, networking, and peer group support.  With the home based care their staff regularly visit families affected with HIV and provide some medical advice.  With the counseling they advice people both in person and over the phone.  Their HIV education promotes abstinence but they are also very realistic and advocate condom use.

They are able to accomplish all of their AIDS ministry through volunteers. When we met with the director there was a woman who had been in Thailand for 9 years volunteering with this program.  She was from England and had picked up the Thai language quite well.  They also brought in a man named Tahwee and a woman named Wanda who are both HIV+.  The woman lost her first husband and two oldest sons within 3 years to AIDS.  This program was able to reach out to her.  She discussed how at first she was very hesitant but as she became better acquainted with the volunteers she grew to trust them.  Now she is one of the volunteers and she is trying as hard as she can to reduce the stigma caused by AIDS.

One of the days we were in Chiang Mai we were able to take a bus ride out to a rural community hospital.  The hospital has several different sections including a building for traditional treatments, an emergency room,  psychiatric center, dental office, maternal section, and so forth.  This hospital has only 2 doctors to cover a population size of 20,000.  Currently there are also 3 pharmacists and 1 dentist.  The mission of this hospital is: to use a holistic approach, standard care, high quality service, and to work together to achieve their desired results.

At this particular community hospital they put a major focus on pregnant women.  Last year they were able to completely eliminate cases of HIV+ pregnant women.   In previous years they put a major emphasis on family planning by using mainly the birth control pill and IUD’s.  Because of this major emphasis they now have a higher death rate than birth rate.  Their family planning has become too good and families are continually having less and less children.

One of the main differences between this hospital and our hospitals in the U.S. is their focus on traditional medicine.  Traditional medicine is even included in their universal health care coverage.  At this community hospital they had a separate building for people to go and receive a Thai traditional massage.  They believe this helps to cure many illnesses and diseases.  We were lucky enough to be able to receive one of these massages.  Although you assume it would be a pleasant experience, it was quite difficult to put on a smile.  I’m not sure if I have ever felt that much pain before in my life.  The Thai women stand up on the bed and apply over 50 pounds of pressure on pressure points around your neck and back.  These women have strong hands!  In this building there were also stacks of different herbs used for healing.  The next building they took us to was for acupuncture treatment.  There was a woman lying on a bed with several needles sticking out of her body.  The head nurse grabbed her records to show us what this woman was being treated for.  Something like that could never happen in the United States; records are always private.  The nurse opened this woman’s records up and showed us she was being treated for HIV/AIDS.  We were even allowed to take pictures.

Overall the hospital was in good condition but it wasn’t quite in the same condition as our local hospitals.  Also, because the doctors are over 20,000 people they are extremely busy and people were waiting around for hours.  The Thai nurses wear cute little hats similar to the hats nurses in the United States wore in the early 1900’s.  In their maternal section I noticed that all the beds are placed in the same room.  There is not much privacy through out the hospital.  There was one private birthing room with an old T.V. for anyone who was willing to pay $20 a night. 

In our meeting with Dr. Suwat he taught us about Thailand’s health care system.

First he went over the structure of the system, specifically the four main levels of care.  The bottom level is the primary health care level. At this level the government provides health to the local people through village hospitals.  If a Thai person had a cold or a flu they would come here for basic treatment.  The next level up is the primary level and here we find community health centers for a larger population size.  If the situation is more serious, such as giving birth, the patient will come here.  The second level is secondary care where we find the general hospitals.  These are for the more serious injuries and accidents.  Problems that cannot be treated at the primary level.  Our top level is tertiary care which includes the regional/ university hospitals.  These are the last resort for treatment including difficult surgeries and other serious medical tasks.  By having this structure of health service systems it decreases the costs of health care.  Patients who need to be seen for a mild problem, such as a cold can be treated locally instead of at the major hospitals with the well-trained doctors.

Dr. Suwat also discussed with us the current health care statistics:

• Since 2002, 80% of Thailand’s health care has been provided by the government.
• The other 10-20% is covered by private health care.
• Only 4% of Thailand’s GDP goes to health care unlike the United States who spends 16% of our GDP on health care.
• In order to receive health care Thai people must be registered. In the villages by the border there are 200,000 hill tribe people who are not able to receive health care because they are not registered citizens of Thailand.

Following this discussion on health care we were curious about the situation of doctors and we found out the following information:

Tuition for medical school is the same price as it is for other schools because the government helps cover the higher costs.

However, because the government helps cover the costs after medical students graduate they must work for the government for 3 years, usually in a rural setting.  Salaries are the same as many other professors but they get packages to compensate which include benefits like free health insurance for the private practices, having their children’s education paid for, and so forth.  To increase their salaries, many doctors open up a private practice at night.  However, since this can only be effective in the cities and not the rural areas, making working in the city more desirable, the government offers higher salaries for doctors in rural areas.  The typical age of retirement is 60 although professors work until they are 65.  From 60+ doctors receive 70-80% of their last earned salary each month until they pass away.

Below is a picture of one of the doctors in a rural community hospital.

Dr. Page, a public health professor at BYU, was able to get an ORCA student mentoring research grant that allowed me and three other health related students to travel to Thailand.  It was about a 2 week educational trip that allowed us to meet with Thai professors, research staffs, secondary schools, health clinics, doctors, nurses, the public health foundation, and other health related outlets.  We were able to see what happens in the inside.  This blog will share some of these health insights that came directly from the Thai people.

The first city we arrived in was Chiang Mai.  After adjusting to jet lag our first stop was at the Research Institute for Health Sciences (RIHES) at Chiang Mai University.  We were fortunate to meet with the director Associate Professor Suwat Chariyalertsak, MD, DrPH who relayed the following information:

RIHES conducts biomedical, clinical, epidemiological and behavioral research on priority public health topics of concern to Thailand and its neighboring countries.  This Research Institute focuses on studies that will be able to shape the national health and social policy and that will produce findings that will have an immediate and practical benefit for Thailand.  RIHES has 3 main goals: 1) Conduct research relevant to the local context. 2) Carry out research training 3) Serve as a resource center on public health issues.  The major focuses of the research program are infectious and tropical diseases such as HIV/AIDS, malaria and dengue.  After years of hard work in Thailand AIDS has majorly decreased from 10-15% in 1993 to 1-2% currently.  Out of the 65 million people in Thailand only 600,000 are currently HIV+.  However, RIHES also focuses on substance abuse

including opiate and methamphetamine addiction; pollution and environmental health and human nutrition and metabolism.  Ten to fifteen percent of the current Thai population struggles with obesity or a metabolic syndrome.

The main collaborator of RIHES is John Hopkins and the majority of their funding comes from the United States.  Some of the methods they use at RIHES are community mobilization, post test support service, and mobile voluntary counseling and testing.  To communicate to the public the type of research they are doing they use many different strategies.  The main strategy used is WE T.V., a local cable station.  They also frequently use the radio.  For each specific program they are implementing they create a CD and send that CD in to each local radio station, not just the Chiang Mai station.  A website is updated frequently with new program information and a CAB newsletter is sent out every 2 months.  They make the newsletters simple so they are easy to read for a person with no medical background.

One of the main ways they are able to successfully implement the necessary programs for their local communities is because they have an established Community Advisory Board (CAB).  These CAB members work closely with community activists and religious leaders to develop understanding and trust in the community.  They enlisted former volunteers in RIHES research to share their experiences and assist in outreach.  The local CAB members discuss if the research will be safe for participants and what programs they believe their communities need.  An example of a CAB member is a monk from a nearby community.  The monk is able to relay messages from his community to the CAB.  This is a very effective method.

A current research project that RIHES is implementing in northern Thailand is Project Accept (PA-THAI). This is a community-level behavioral intervention focused on reducing HIV seroincidence along with reducing the stigma that comes from AIDS.  This intervention focuses on accepting those with HIV/AIDS and helping to improve their lives.  They are implementing this project in 48 communities.  It is going to be a six year project.