Berkley Center

“Bad sight” our guide prompts us, leading us through the door an unknown house, unannounced yet unhesitant. Her role as a Village Health Volunteer gives her a unique visibility in the community. For 13 households in the village, she is the personal health resource, modelling years of debate on the role of primary health care around the world. Throughout Thailand, each trained volunteer disseminates health information to and monitors the health status of around 15 families in his or her community. Supporting these volunteers, the Health Promoting Hospitals construct the first tier of public medical care. Located in each sub-district, or tambon, these hospitals are the first stop in the national insurance referral system and provide basic allopathic and traditional care close to the home of each Thai citizen.

During a study visit to the Health Promoting Hospital, an English man named Martin came to act as translator. As a 20 year resident of the area, however, his insights into Thai culture and Thai views on health proved even more valuable than his language skills. The low level of dependence on physicians provided a way for the resource-strained Thai health care system to expand access in the population, but I did not sense that the community focus of the system represented an intervention from above. Individuals volunteering for public health? Communal priorities over individual privacy? Thailand, it seemed, could be a public health dream.

Martin confirmed many observations, pointing to the parallel influences of collectivist culture and Buddhist values as essential sources of support. Before Western studies of public health ever reached Thailand, citizens sought care and advice at local Buddhist temples and continued to do so as urban expansion created severe disparities in access among the population. Martin further attributed the ability to communally seek solutions to the gentle temperament praised in the Buddhist religion. In general, a Thai will avoid confrontation—not from a fear of individual repercussion, but from a concern for overall harmony, he shared.

Though implications of these dynamics on health intrigued me, my 20 years within American individualist culture shone brightly when I questioned what this censorship of feelings meant for individual “freedom”? Freedom, he asserted, was the ability to have true choices in life. Before settling in Thailand, he attended one of the top universities in the world, graduated with honors, and was offered a spot in a doctoral degree study program. To most, he lead a life bound for success and the “freedom” perceived to accompany it. It was not until he became a farmer in rural Thailand, however, that he felt he understood freedom. In the relationships he formed in Thai society, he was opened to the choices of the community. He expressed that individualist cultures commonly view relationships as constraints on choice. In collectivist cultures, relationships become opportunities, and it is our own abilities that limit us. “It’s not right or wrong, just different,” he concluded.

Although Buddhist values may lend themselves well to the goals of public health officials, Thailand certainly has not perfected a system yet. Health reforms occur frequently, and the rapid transition from a population with communicable diseases to a population developing chronic disorders challenges the system’s adaptability. The emphasis on local care brings antibiotics over the counter, for example, leading to widespread misuse of the medications. Likewise, social stigma can be impossible to avoid in the midst of such a relaxed sense of privacy.

My discussion with Martin helped me recognize that striving for health, in its simplest definition, means striving for good relationships. Relationships with the plants and animals that provide nourishment, with the systems that bring that sustenance to you, with the doctor that can relieve your suffering, with the friends and family that suffer with you, and all the other relationships whose maintenance we depend on for survival. By entering a culture on the opposite end of the spectrum of individualism, I am starting to realize just which relationships I have been ignoring. Individualism can help perfect some relationships, while collectivism leads me to form others. A perspective from both sides encourages complete health. With this balance in mind, I may be learning all that the Buddhist idea of “walking the Middle Way” truly implies. The challenge for Thailand—and all those in public health—is how to get people up and walking.