When I attended the Confederation of Medical Associations in Asia and Oceania (CMAAO) meeting in Kanchanaburi,Thailand, last September, I was instantly transported back to my army training in the late 80s. I was then attached to the School of Combat Engineers as a medical officer and was sent by my commanding officer to be the battalion medical officer for a combat engineer battalion exercise.
I remember boarding the chartered Airbus on the Paya Lebar Air Base tarmac with my battalion and landing at Kamphaeng Saen military airport in Nakhom Pathom. I recall a bone-jarring three-hour ride in a Land Rover from the airport to the army base. This time, the journey was very different with a chauffeur-driven SUV on the new highway from the Suvarnabhumi Airport to Kanchanaburi. For those who have no idea of the claim to fame of this far-flung province of Thailand near the Myanmar-Thailand border, it is home to the notorious "Death Railway".
The meeting begins
At the meeting itself, we were privileged to have the guest speaker, Sir Michael Marmot, deliver the Takemi Oration. The oration was named after the long serving president of the Japan Medical Association and visionary – Dr Taro Takemi, who also has a programme named after him at the Harvard School of Public Health.
Sir Marmot is a champion of social determinants of health. He is well known for being the leader of the second Whitehall Study conducted between 1985 and 1988. The first Whitehall Study launched in 1967 established the difference in cardiac riskfor those in lower pay grades versus those in higher pay grades. Men in the lower pay grades (eg, messengers and doormen) had three times higher mortality than men in higher pay grades (eg, administrators). The second study had a cohort of men and women, and the study looked at the relationship between job grades and prevalence of angina, ECG evidence of ischemia and symptoms of chronic bronchitis.
Sir Marmot's oration highlighted the inequalities of money, power and resources that tend to breed conflict, which in turn tends to increase political, economic and social insecurity. These themes resounded with all of us as we are faced with the backlash from recent events such as the US election, Brexit, and nearer to home – the rise of xenophobia, and extreme right- and left-wing movements in neighbouring countries. The printing of trillions of dollars in the post Lehman era has certainly not helped with inequality spiralling in many countries.
Updates from the associations
One of the important aspects of the CMAAO meeting is where member countries share their perspectives on the various problems they face. Australia told us how their GPs are facing cuts in their incomes due to a freeze of inflation indices on their Medicare funding over the last few years. This is despite the fact that GPs continue to provide great value to the health system in terms of good outcomes.
India wrestles with its imbalance of genders due to ultrasound sex determination. Bangladesh and Nepal told us about assault on doctors, and Japan informed us of their efforts in the recent Kumamoto earthquakes, while Nepal faced similar issues with earthquakes in 2015.
Korea shared that conglomerates are lobbying the government to gain more access to the healthcare system via the legalisation of telemedicine. Malaysia continues to struggle with the oversupply of medical students amid the proliferation of medical schools. Myanmar told us how rapid democratisation in their country has led to higher expectations and demands on their healthcare system. However, medical defence protection is non-existent and there is also a shortage of healthcare professionals in remote regions. Thailand continues to struggle with its universal healthcare rolled out in 2002. The effect on massive surge of healthcare usage has led to funding issues and the resignation of rural doctors and nurses.
After two intense days of meetings, presentations, discussions and hammering out a resolution, we finally took our leave and headed to Bangkok by car. Along the way, we stopped by the infamous "Bridge over River Kwai". When I was there some 36 years ago as a young medical officer, I was taken by how surreal it was visiting the bridge with its calm and peaceful quiet in the bright sunshine, juxtaposed with the knowledge that inhumane atrocities had taken place in this picturesque setting. Back then, there was no one at the bridge save for the few of us who visited to pay our respects to a sombre yet iconic site.
Today, a tourist town has virtually sprung up in and around the bridge with several hundred tourists clambering all over the bridge. This, coupled with fleets of tourist buses, multitudes of stalls hawking all manner of souvenirs, blaring Thai pop music and loud horns as traffic snarls, overwhelms the obviously inadequate road infrastructure.
In short, we have learnt a lot about the various national medical associations' predicaments and challenges; we have renewed our old ties and made new friends. I have also had a throwback to three decades ago and saw major improvements in the lives of the people in this distant outpost of the Kingdom of Thailand. As I return home to Singapore, I am yet reminded of the inequalities that exist between the provincial regions and the capital city of Thailand; the inequalities that contrast between us and our neighbouring countries; and even in Singapore, the inequalities between the different strata in our own society.