Rural island medicine in Minamidaito island, Okinawa, Southwest of Japan

By Ryuichi Ota

I am a young Japanese family physician working in rural areas of Japan. Training for Japanese family physicians has officially started recently, so there is a variety of training systems, though sometimes not always so systematic. I became a physician in Osaka and moved to Okinawa, southernmost part of Japan to become a rural island physician. I have experienced many fruitful things on my island to become a real rural physician. It can be said that rural islands and the citizens educate the physicians. This time, I want to introduce my experience in Minamidatio island, one of the rural islands, as a young rural physician.

I have worked as a young rural physician on a rural Japanese island. It is located in the most southeastern part of Japan. Its name is Minamidaito island, and it is located in Okinawa prefecture. It is about 400 km away from the mainland of Okinawa prefecture. By ship, it may take 14 hours from the mainland. Even if you use an airplane, it may take 1.5 hours. On this island, the population is about 1,400, and most of them work as sugarcane farmers. There is only one clinic without beds appropriated for admission. There is only one doctor, nurse and medical clerk. I went to this distant rural island after finishing my 3-year basic medical residency program, and I have been there for three years now. Is this a rare case in the world? This working style may be controversial in Japan. However, the experience as a young rural physician may affect their future as a physician in an effective way.

The responsibility of a solo physician in a rural island

First, the feeling of responsibility as a physician may increase. For example, on a rural island like my case, a physician has to take care of various kinds of illnesses. All of the patients there have to go to a clinic to get specific care, even if they do not like to go there. The rural physician cannot avoid studying various kinds of medical issues. Emergency cases are especially stressful for rural physicians. At rural island clinics, there are not enough instruments to treat the patients for a long time. The rural island physicians have to transfer their emergent patients to general hospitals on the mainland of Okinawa if they need long admissions or ICU care. However, to transfer the patients, doctor helicopters are needed. It takes 3 hours to reach the distant islands like my island (Ohta & Shimabukuro, 2017b). The rural island physicians must care critical patients until the arrival of the helicopters. The worse thing is, the duration of emergency may depend on the weather. The emergency case in summer was challenging for me. In one day in summer, one patient came to my clinic with the chief complaint of shortness of breath. He voluntarily stopped regular visits to my clinic one year ago. His past medical history was chronic obstructive lung disease. His symptoms had started a few days ago, which gradually exacerbated to the point where he came to the clinic. The vital signs were the blood pressure of 84/40 mmHg, heart rate of 132 beats/min, respiratory rate of 45 breaths/min, oxygen saturation of 79% in ambient air, the body temperature of 37.6 and Glasgow coma scale of E3V5M6 (total 14/15). I listened to his lung sounds, bilateral lung sounds, I diagnosed him with severe pneumonia causing septic shock. Soon, I intubated him and prepared for transportation. However, it did not come at once. This season, Okinawa is attacked by a lot of typhoons, and this year was not rare. This time, one big typhoon was approaching my island, and this prohibited doctor’s helicopter from coming to my island. To make matters worse, the typhoon approached the mainland of Okinawa after passing through my island. As a result, I had to observe this patient with only three members and restricted medical instruments (Ohta & Shimabukuro, 2017b). Without a ventilator, a nurse, a medical trainee, and I performed hourly vital sign measurement and did manual ventilation. Fortunately, his condition was stable with oxygen, antibiotic, and vasopressor. 27 hours after his arrival, he was transferred to a general hospital in mainland of Okinawa.

Diagnostic skills of rural physicians

Also, their diagnostic skills may be improved upon. It is only one physician, and he or she has to diagnose patients with vague symptoms or with certain diseases which they have not experienced yet. They may feel particular pressure and study hard. As they can get a lot of medical information by using the internet and communicate with their senior physicians via a social network, they may be able to approach their patients with various sources of help. For example, when I encountered patients with rheumatoid arthritis following ciguatera poisoning (Ohta, Shimabukuro, & Kinjo, 2017) or with vague bilateral shoulder pain leading to the diagnosis of Parsonage-Turner syndrome (Ohta & Shimabukuro, 2017a), I could diagnose them with literature reviews and my colleagues’ help. Through this process, rural physicians may become competent in diagnosis and inter-physician communication.

Challenge to community-based medical education

Second, a rural island may be a good practical learning situation for medical students and medical residents. They can learn specific things in various medical situations. Through the learning in rural islands, they may learn multiple important issues as physicians. There are many kinds of research to clarify the learning topics in rural areas, especially about community-based medical education (CBME). As learning contents have been shown to depend on the situation, we did one qualitative study to inquire about the learning contents of medical residents in Minamidaito Island. Through this research, we were able to identify four categories: a strong connection among the Islanders, the necessary abilities for rural physicians, islander-centered care, and the differences between rural and hospital medicine(Ohta & Son, 2018). In contrast to hospital medicine, various kinds of learning occurred in deep relationships with the Islanders. Furthermore, we clarified that the learning contents of medical students on this island, as a result, were alike. Rural physicians can learn not only medical issues but also CBME. They may acquire the possibility to become medical educators.

First trial of community-oriented primary care

Third, community-oriented primary care (COPC) should be mandatory in rural islands. Especially, in Minamidaito Island, there is only one physician and a nurse. They are the only medical resources. They have to collaborate with the members of the community to improve community health conditions. There are various stakeholders in the community. Empowering them may drive COPC. The stakeholders may play the central role in community health improvement. For example, public health nurses specialize in community health. They can analyze their communities and find various approaches to improve health conditions there. Their collaboration with medical staff in clinics may improve quality of life. There are two public health nurses on Minamidaito Island, for both pediatrics and older people. The public health nurse for pediatrics is interested in pediatric wheezing because of sugarcane harvesting. Through my collaboration with her, we were able to do a prospective cohort study. As a result, it was discovered that there was some cause and effect relationship between pediatric asthma and sugarcane harvesting (Ohta, Mukoyama, Fukuzawa, & Moriwaki, 2017). Additionally, we make up the specific approaches to diabetic patients on a rural island by using their feelings comparatively. Also, by collaborating with the public health nurses for older people, we were able to increase the opportunities for older people to have a dialogue with each other and share information about their conditions. Through COPC, rural physicians are able to learn the skills for how to approach communities such as leadership and empowerment, and how to analyze and make progress the community condition such as research skills.

The ecology of medical care in a rural island

Besides, an ecology of medical care in clinics is essential for understanding islands’ medical conditions. It is important to know what kinds of symptoms and diseases are common when medical staff inquire into information on epidemiology and do various interventions in communities. Also, the comparison of this data over several years may be useful for knowing the change in the prevalence of medical conditions there. For example, we collected the patients’ data based on International Classification of Primary Care-2 (ICPC-2) between 1990 and 2015(Ryuichi Ohta & Makoto Kaneko, 2017). As a result, in addition to the common cold, the frequency of asthma attack and other chronic diseases increased. This fact might lead to the consideration of the effects of aging population and the deteriorating air pollution. Rural physicians can express their opinions based on precise data and motivate their communities to improve their health conditions.

How to control negative emotion as only one physician in a rural island

At last, rural physicians need effective emotion control. On rural islands of Okinawa, every physician is only one medical staff that can perform medical treatment. They are special there, so rural citizens look at them as a physician wherever and whenever the citizens see the physicians. Additionally, they may feel the negative emotion in interprofessional collaboration. These conditions may lead to the physicians’ stress and negative emotions. Based on our research, rural physicians feel negative emotions in differences in recognition between rural physicians and patients, invasion of professionalism, suppression by one’s role as a rural physician, discordance with multiple occupations, and relationships with unfamiliar hospital physicians(R. Ohta & M. Kaneko, 2017). Also, to relieve negative emotions, time flow, refection, acceptance of islanders’ characteristics, and growth through their role were suggested(R. Ohta & M. Kaneko, 2017). Through rural experiences, physicians may improve their ability to control their negative emotions by recognizing the existence of controlling methods.

Working at rural islands, although there are lots of difficulties for your generation, can give various fruitful experiences for the future. Not related to their foreground carrier, these experiences can make them more balanced physicians and happier than ever.

References

Ohta, R., & Kaneko, M. (2017). Effects of practicing in remote Japanese islands on physicians' control of negative emotions: A qualitative study. J Rural Med, 12(2), 91-97. doi:10.2185/jrm.2934

Ohta, R., & Shimabukuro, A. (2017a). Parsonage-Turner syndrome in a patient with bilateral shoulder pain: A case report. J Rural Med, 12(2), 135-138. doi:10.2185/jrm.2933

Ohta, R., & Shimabukuro, A. (2017b). Rural physicians' scope of practice on remote islands: A case report of severe pneumonia that required overnight artificial airway management. J Rural Med, 12(1), 53-55. doi:10.2185/jrm.2925

Ohta, R., Shimabukuro, A., & Kinjo, M. (2017). Rheumatoid arthritis following ciguatera poisoning: A case report. J Rural Med, 12(1), 50-52. doi:10.2185/jrm.2921

Ohta, Ryuichi, & Kaneko, Makoto. (2017). Health Problems in a Rural Island of Okinawa: Changes Over 25 Years. An Official Journal of the Japan Primary Care Association, 40(3), 143-149. doi:10.14442/generalist.40.143

Ohta, Ryuichi, Mukoyama, Chikako, Fukuzawa, Yasunori, & Moriwaki, Yoshihiro. (2017). Relationship between Pediatric Wheezing Attack Frequency and Sugarcane Harvest Work: Prospective Cohort Study. An Official Journal of the Japan Primary Care Association, 40(1), 21-26. doi:10.14442/generalist.40.21

Ohta, Ryuichi, & Son, Daisuke. (2018). What do medical residents learn on a rural Japanese island? Journal of Rural Medicine, 13(1), 11-17. doi:10.2185/jrm.2950

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Ryuichi Ota is  a Japanese Family Doctor based in a rural remote island. 

Curatorship: Mayara Floss

Watercolor

Carnaúba dos Dantas - Brazil

Your eyes have

A non-defined color

And, perhaps because of this,

You ​can see the other tones in everything

From the cold gray

Of few shades,

That I coldly plan,

You can identify a small

Sick pink

That motivates my grit

In the green-water lies

That I tell to please you.

You only see the red

Bloody one

That burns me!

You see the invisible notes

With your eyes

Which color, then,

My mother,

Is the soul

That I have mixed

With mine?

__________

Alexandre Dantas is a doctor, teacher and writer. He was born and lived most of his life in one of the driest backlands of Brazil - where he returned 4 years ago, working as a rural doctor. He created the project "A Medicina Rural" on Instagram (@amedicinarural) in order to give visibility to the rural spaces in which he works and voice to the people who live in them.

Je suis étudiant!

Another intense afternoon at the clinic. Malnutrition and infections are already routine work.

Suddenly arrives a young man of 8 years of age and, well articulated in his words, appears and speaks directly with me, in French: Je suis étudiant!

Son of the arid land of Ambovombe, the little boy tells me about the difficulty in school because he can not see the blackboard. He struggles but has headaches.

He is the only child who attends school for all the children I attended in the entire first week of work. His case was not the priority and seemed absolutely far from our possibilities at the moment. However, #FraternitywithoutBorders was his and his grandmother's only hope

I took a deep breath. I had to do something. And I did...a modified Snellen test was enough to diagnose myopia. Concerned, I tell the translator..."He needs glasses, but we can not offer."

As we have learned in the FWB, we are many united hands working for Love. Dani, my translator and right arm (and left too!) Showed readiness to respond that we had a chance. The next day, we were all going to talk to the priest who had received a mission from the Catholic Church the week before. We introduced the FSF and we got another partner.

A week later, he and his grandmother return to the clinic. Main complaint: a little hand holding a package, a smile that can not be restrained on the lips and a tight hug from anyone who never loses HOPE to see it happen!

Janaina doing the modified Snellen test with the patient during her work 
in Madagascar

Janaine Camargo is a family doctor and works at the NGO Fraternity Without Borders in a rural area in Madagascar

Translated into English by: Bianca Silveira
Posted and Edited by: Ana Júlia Araújo

Beginning of Success to Reach Health Care to Rural Communities with Extremely Low Resources and Access Problems

Shakuntala Chhabra

Social accountability in health care and medical education has been the hallmark of Kasturba Health Society, Sevagram, which runs Mahatma Gandhi Institute of Medical Sciences, Sewagram in Wardha District of Maharashtra, India. KHS also runs a Nursing School, Nursing College and Kasturba Vidya Mandir (School for children) in the same campus. Institute’s birth is also the consequence of social accountability by none other than Mahatma Gandhi, in the form of a 2 bedded dispensary in 1938 in the village Sewagram where there was a epidemic of Cholera and women and children were finding it difficult to get treatment. The sapling has now grown into a blooming tree with nearly 1000 bedded well equipped, Kasturba Hospital at Sevagram village in the centre of country. Expanding health services to Melghat region in Amravati, Maharashtra, is another step towards social accountability in health and education. The step was taken in view of rural communities sufferings.

In view of the problems of high maternal, perinatal, infant and child morbidity / mortality step was taken to help rural community. So government of India and Government of Maharashtra were approached with the proposal for Mother and Child / Multispecility Hospital at Utawali, but delays in the system were worrisome. So it was decided to do whatever was possible. Agriculture land was bought more than dozen no objections were procured and plans of hospital as expansion of existing institute in the nearly district was planned.

Fortunately a Mumbai based charitable trust “Shri Brihad Bhartiya Samaj” came forward with the generous donation for the building and major equipments for the proposed hospital. Before this hospital could be built a beginning was made on first January 2012 by alterations / additions in the existing building of a minihospital constructed by KHS, Sevagram some years back where a physician and ophthalmologist deputed by KHS were working. A make shift birth area, operation theatre for caesarean section, hysterectomy and other surgeries was done. Other needed changes were made in the building and equipments / instruments were procured. In the existing guest house in the campus, alterations and additions were made so that the health teams could stay for 24/7 for emergency services. A nearby hut was converted into kitchenette, dining area cum office. A mini-library and online Maharashtra University of Health Sciences library were made available for every one to remain updated. Sports too were arranged and mobile phones and televisions to make the life of health providers in the hilly forestry region with access problems little easy and to try to reduce the general reluctance of health providers to work in the region. Now since Feb 2016 a reasonably well equipped. Multispeciality Dr. Sushila Nayar Hospital in Utawali has come up with basic facilities available in much better way with reasonability comfortable place for the health provider team in the building. A building with 4 flats and some land have been procured in the vicinity keeping in mind needed accommodation during the development.

With the guidance, support and help of KHS/MGIMS, Sewagram the team of Obstetrician – Gynaecologist, Paediatrician, Anaesthetist, Physician, Medical Officers, Interns, Administrative Officer, Nurses with other paramedical staff have been managing emergencies and day to day problems in outpatient, inpatient and operation theatre, 24/7 days. While paramedical administrative staff has been exclusively appointed, doctors are deputed in rotation from head quarter, the medical institute in the near by district, a dozen doctors are always available. Author as officer on special duty with support of management and a big number of colleagues at base institute are trying since beginning their best, from buying agriculture land to health services now in a reasonably equipped hospital. Caesarean sections, minor and major gynaecological surgeries are being performed in addition to normal and instrumental births. Everybody is trying to give his/her best with whatever available in the given circumstances with limited resources. The very first caesarean section was performed on 21st January, 2012, mother and baby discharged healthy in a week. The first hysterectomy with removal of a uncommon cancer of ovarian tumor ‘Struma Ovari’ performed on 15 February, 2012 and the woman doing well, 6 years. Now services for prevention of blindness complete eye care are also being provided.

Everybody is trying to give his/her best with whatever available in the given circumstances with limited resources.

There is good understanding and cooperation between Sub District Hospital Primary Health centres of Government of Maharashtra and our centre.

While trying to do whatever we could, we have had many challenges, many practical difficulties and have also realised that though. nutrition, anaemia, poor health, are responsible for many problems, their causes are deep, in the social and economical conditions, in the nonavailability of food, in ignorance, when the food is available, gender bias, unemployment, addiction and many other issues. Hindrances also include lack of awareness, lack of resources to seek services at health facilities and their own faith concepts of traditional healing, beliefs and disbeliefs. Sometimes making the patient stay in the hospital for her own good or her child’s good is a tough job, testing the patience, the best of counselling skills and dedication. 

We realized within months of opening the hospital unless Community based services, community motivation, mobilization and behaviour change, were done not much was going to change. So a step was taken in this direction way back in Feb 2013, just a year after starting the services. Now seven nurse midwives provide community based antenatal services, advocacy about intranatal, postnatal, neonatal care in the villages. We started with 52 villages in February 2013 and 13 more were added from July 2013, a total of 65 till recent past. Later 35 more have been added from April 2016 and 40 more in August 2017, making a total of 140 villages. The team visits villages 5 days a week. Medical officers posted under Rural NGO posting scheme of the Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha used to run Community Based health clinics in these villages with the nurses, in rotation while services at base hospital at Utawali. However the current rules of postgraduates medical admissions with national eligibility examination, no medical officers are available. Some laws for some good spoil other good work. So interns of the Institute in the near by District at Sewagram  are posted in rotation for 15 days, task shifting. So while each NM visit their assigned village, once in a month, doctors run clinic in assigned villages by covering 7 villages in one visit by one doctor. Things will change. It needs some time before awareness will come in the tribal population and their many unlisted social and economical issues are really addressed.  

Now seven nurse midwives provide community based antenatal services, advocacy about intranatal, postnatal, neonatal care in the villages.

Diagnostic cum therapeutic camps have been made annual event. First camp was held in March 2012 with 226 patients, February 2013 the number was 1036, in 2014 February it was 1107, in 2015 it was1883 and 2016 it was 2197. In 2017 attempts were made to help differently abled and 216 needy were help. In 2018, 3872 Surgeries have been performed on camp days and left over cases are operated within days of camp, some at Utawali and complicated at the institute at Sewagram. Camp for Cleft lip Cleft Palate was also conducted in December 2014. Attempts are being made to help Elderly women and elderly men too for diagnosis and therapy of illnesses, including noncommunicable diseases, (Hypertension, Diabetes and Cancers) vision problems. Research was done with help from US based Global Health through Education and Service, (GHETS) Indo Canadian Institute from Canada. Now Mumbai based philanthropists including Jan Kalyan Trust help in services for elderly. Research about ‘Abortions’ under Indian Council Of Medical Research, New Delhi Disability Detection program was done and Aids, including Wheel chairs provided to nearly 225 people. Now beginning has been made for trying to make adolescent, young school drop outs learn skills to become self sufficient, with support from Jan Kalyan Trust Mumbai. Camps for cataract surgery are being done. 

Research is being done about effects of Bio-fuel mass on health of family specially mothers and new born with plans for providing and Chimneys related to Agriculture status and malnourishment, low body mass index, Anaemia, Vit A deficiency etc. There are plans for Family Life Education Program for Adolescents, Preconception literacy and care also, finding how Wellness can be created for them.

Presently the biggest need is of finances so that in the reasonably equipped, furnished hospital, free services can be provided to the real poor, especially mothers and babies in emergencies. It is not possible for KHS, Sevagram to provide free services to everyone without support. Though services are provided to everyone, who reports, irrespective whether the patient can pay or not, it is not possible to Declare free services due to lack of resources. Also financial support is needed for providing children the needed nutrition at home till the time they are in a position to become self sufficient. Major issues are also awareness of many things, access issues and safe water, working on their beliefs and disbeliefs.

____________________________________

Shakuntala Chhabra is an meritus Professor - Obstetrics Gynaecology, Chief Executive Officer - Woman Child Welfare, Officer Special Duty - Dr. Sushila Nayar Hospital, Melghat. In addition to DGO, MD, Diploma - Advanced International Maternal Health Sweden, Certificate Courses- Maternal Child Health, U.K, Problem Based Learning- Netherlands, others- Logistics Management, Teaching Training, Human Resource Management etc. Receive the awards: FIGO’s Distinguished Community Emergency Obstetrics, Best Teacher, MUHS, Nashik. Short term WHO Consultant, Technical Consultant, Technical Temporary Advisor - WHO. Supervisor for SIDA. Member of Women’s Health Task Force, Network TUFH, USA. Member of World Rural Health Council 2018. Special Interest- Maternal health, Social Obstetrics, Gynaecological cancers, Health Professionals education.

Curated by Ana Júlia Araújo and Mayara Floss

On my Skin

On my Skin

She opened the door of the health unit almost sensing something that morning. In the Rural Health Unit, about 100 kilometers away from the nearest reference center. A newly appointed doctor....and the farmers of the region saw in those hands a ray of hope. "The doctor listens to us."

Maybe this was the beginning of a cry about the future on her face. When she was in the office with another patient, somebody knocked the door, "Doctor, please come fast". The nurse was already gloved, a woman in great pain, laboir pain. Upon touching down the cervix, it was 5cm dilated. Fetal heartbeat flickering and Ineffective contractions.

Labor without progression was sensed. Oxytocin, orientations, everyone entering the small emergency room. Got everyone out of there to take a deep breath and called the 911.

"The ambulance can only get there in two hours, it is in another displacement." The calculation was not difficult... Two hours to come plus two hours to cover the 100km made 4 long hours. Can we handle it? Will the baby be born before that? We ask for priority, but the whole state needs priority.

Deep breathing, medications, salines, change of position, but still it is only 6cm of dilation in the first hour. The Fetal Heart Beat slowed down. They call the ambulance. "I need it for now." It doesn't arrive.

It did not come, it did not happen, it did not progress and it was not born.

Some colleagues would say, "it is her fault that she chose to work where she has no recourse". But is there a way to have a hospital in the countryside? To have an anesthetist team in the middle of the green of the corn? To have a team with obstetrician? Pediatrician? There, where the soy is planted?

Several will condemn "it is the doctor's fault, who went there," but would the unborn child stop herself being born or would the mother stop going into labor because they were in the countryside? Would the countryside stop existing just because there are no qualified professionals in it?

The baby was not born, the baby did not survive. Everyone hears the fetal heartbeat fade away without recourse, no training, no legislation, no doctor adequately trained for more than 60% of Brazil's population living in rural areas. While the ambulance did not arrive, a sigh, a tear.... A fatality? Could we have avoided this?

From birth to mourning. To err is human, to kill and to die is human too. But a doctor in the rural area without training is inhumane.

Warm regards,
Mayara Floss

Review by: Nisanth Menon
Translated into English by: Bianca Silveira

Posted and Edited by: Ana Júlia Araújo

Link to Portuguese text: http://balsa10.blogspot.com/2018/05/na-minha-pele.html?q=mayara+floss

Mayara Floss is a young doctor working in a rural area: Cunha Porã (SC), Brazil. She Co-creator of project 'Health Education League'.  She is the creator of the Rural Family Medicine Café to provide a forum to discuss Rural Health – a forum for students, young doctors and experienced professors and GPs from all world. She is the student representative of the WONCA Working Party on Rural Practice. She also co-created with Pratyush Kumar the project 'Rural Health Success Stories' and writes a weekly blog of Popular Education, Arts and Health - the Ferry Street of 10.

Ruralices

Amber Wheatley and Mayara Floss

The experimental short movie produced by Mayara Floss and Amber Wheatley called "Ruralices" received the award for best original background at the FISFA - International Short Film & Arts Festival during the 15th WONCA World Rural Health Conference, New Delhi with voice of Amber Wheatley and the music of Lucio Yanel and sonoplasty by Mayara Floss.

"My first job as a junior doctor in South West Wales involves a 1 hr and 15 min journey by bus from my apartment in the city centre to the hospital in Llanelli. My colleaguess often commented on how difficult it must be because the public transport in Wales, particularly the most western you go, is notorious for having problems. Make no mistake this is absolutely true but it also provided me with two unique opportunities; 1) I took the same bus as the people living in the community so I understood all too well the issues of getting to hospital when you relied on public transport and 2) I got to watch the sunrise every morning as I moved from an urban setting to a suburban setting. During my commute I had more time than at any other point in the day to be alone with my thoughts and take it what was going on around me. I also used this time to catch up on reading, writing and social media. Before medical school I wrote songs and poetry in my spare time but medical school seemed to kill all my creativity. I was slowly starting to reclaim it when one day looking at a photo from the Ruralices instagram page, I was overcome with inspiration. Dr Mayara Floss started the Ruralices page to capture and share images of the daily life of a rural doctor. Each of the pictures I knew held a story and that story inspired these poems". - Amber Wheatley

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Amber and Mayara are Young Doctors and ambassador of Rural Seeds. They are committed and passionate about rural health, arts and writing.