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Buddhist monks as community health workers in Thailand
0277.9536183 $3.00 + 0.00 Pergamon Press Ltd
Sot. SC;. Marl. Vol. 17, No. 19, pp. 14X5-1487, 1983 Printed in Great Britain
BUDDHIST
MONKS AS COMMUNITY WORKERS IN THAILAND
HEALTH
SANT HATHIRAT Department
of Medicine,
Ramathibodi
Hospital,
Mahidol
University,
Bangkok
10400. Thailand
Thailand. Buddhist monks and temples are scattered throughout the country even in the rural poor. There are approximately one temple and four monks for every two villages of about 1000 people. If Buddhist monks are able to expand-their roles to health care and education, Buddhist temples will automaticallv become community health oosts and ‘Health for All by The Year 2000’ will be achieved within 5-10 years in Thailand. Therefore, a iolunteer monk-training program has been carried out and about 2000 graduates have returned to their community to disseminate primary health care. However, a systematic and ‘industrialized’ approach is necessary to get some visible impact on the health of the rural . Thai population. Abstract-In
INTRODUCTION
The famous ‘bare-foot doctors’ of the People Republic of China is preceded by the indefeasible ‘bare-head doctors’, the Buddhist monks. Although psychological (mental) and spiritual treatments have been the predominant practice given by most monks, traditional and herbal remedies have also been administered by some. The re-establishment of Buddhist monks as community health workers in Thailand will be described.
BACKGROUND
AND REASONS
Buddhism is the predominant religion in Thailand. More than 95:/i) of the population are Buddhist. The remaining are Islamic, Christian and other less well known sects [I]. There are nearly 26,000 Buddhist temples, 200,000 monks and 100,000 novices scattered throughout the country [2]. Therefore, in a country with approx. 50.000 villages, there are approx. I temple and 4 monks for every 2 villages of about 1000 people. Buddhism is a religion quite different from Islam and Christianity, because it does not need the belief or faith in a supreme creator and it teaches a scientific (problem solving and reasoning) way of life. Although Buddhism in Thailand is mixed with Brahmanism and Hinduism, its basic principles still prevail and are practiced by most Thai. Therefore. Buddhist temples, in addition to being the religious centers. have also been the socio-cultural, educational and therapeutic centers for Thai villagers for hundreds of years. However, King Rama V, in an attempt to modernize the country rapidly to avoid Western colonialism, centralized the administrative, educational and health care systems. Thereafter, the roles of Buddhist temples in education and health care have gradually declined but still persists. Pra Jaroon Panjant, the abbot of the ‘Krabok Cave Temple’ has recently received the Magsaysay Award for his role in taking care of hard-core drug addicts by faith and herbal remedies. The rapid influx of material civilization from the Western world has badly shaken Thai way of life. It
has changed the simple (natural) way of living-being happy and content in life and nature-into a materialistic, rat-racing and more selfish way of life [3,4]. Buddhist’s economics: ‘small is beautiful’, has changed to ‘consumption economics’: to consume more is powerful. Modern (Western) medicine has firmly established itself from the time of King Rama V, about a 100 years ago. And later, the Rockefeller Foundation’s interference in Thai medical education and health care has abolished Thai traditional medicine from the governmental health services [5, 61. As a result, the health care system and health education in Thailand have become more and more centralized, hospitalized, urbanized, mystified, expensive and inaccessible to the majority (8O’i/,) of the population who are poor or live in the rural areas. The health care system has become a rapidly money-craving and moneyspending machine, creating more patients and more consumption and being more or less accessible only to the urban population [6, 71. In order to reverse this trend of health care, many attempts have been made to change the medical curriculum, to ‘dehospitalize’ health care, to relocate health resources and others; but all are in vain. After the Thai Student Revolution in 1973, a group of doctors, pharmacists, educators, philosophers and pragmatists took advantage of the political atmosphere to organize a monk-training program in health care. The reason for choosing Buddhist monks as trainees is the fact that they are the most respected, disciplined and unselfish community leaders. In addition, Buddhist temples, scattered throughout the country even in the ‘most’ rural poor, can be instantly used as community health posts if the abbots have the knowledge of and the motivation to encourage primary health care. In the past, monk training in health care would have been impossible. The political atmosphere after the Thai Student Revolution was so liberal and vocal that it suppressed any conservative ideas which tried to centralize or limit a fairer distribution of wealth, knowledge and other resources. Unfortunately, the era of the Thai Student Revolution ended in 1976 after a military blood-bath and an
1485 S7M 17119
b
SANT HATHIRAT
1486
extreme swing of the political atmosphere to the right. Under martial law and a very conservative government which took any liberal idea as communistic or communist-inspired, the program automatically ceased after training about 100 monks from different provinces of Thailand. When the political atmosphere eased in 1979, a renewed monk training program in health care has been established with the help of: (1) The ecclesiastical head of the central and southern ecclesiastical regions of Thailand. Although he is quite old, he is still active and ranks fourth in the ecclesiastical hierarchy. With his help, the abbots and the ecclesiastical heads of the privincial subdistricts. districts and regions under his command, have been invited or persuaded to attend the monk training course and to establish a drug cupboard for community use in each temple. (2) The Maha-Chulalongkorn College for clergical education. The monk training course has been incorporated into the final days of the monk curriculum. Most of the graduated monks will be missionaries for community development in the rural areas.
COURSE
AND CURRICULUM
The course and curriculum health care are:
for monk
training
in
(1) Duration: The first course in 1975 lasted 3 weeks. The second course in 1976 lasted 3 months. The latter included clergical administrative and community development models and techniques, The lengthy training course caused serious difficulties to the organizers and the trainees. Therefore, the renewed monk, training program which has been re-established in 1979 has been reduced to a 5-day-course for the abbots and ecclesiastical heads and a 2-week-course for the student monks. (2) Contents: The contents of the monk training course in health care are: (2.1) motivation session. (2.2) concepts of primary health care. (2.3) prevention of diseases including water supply, sanitation, immunization and other controls. (2.4) treatment of health problems including first aid, symptomatic and supportive treatments and herbal medicine. (2.5) promotion of health including nutrition, reduction of mental stresses and family planning. (3) Training methods: Lectures, demonstrations, discussions including questions and answers, and practice are the learning experiences in the course. (4) Trainers: The trainers are volunteered professionals from medicine, nursing and public health fields. (5) Evaluation: The evaluation is done in 3 categories: (5.1) session evaluation: The trainees evaluate the efficiency of the session and the possibility that they will be able to use the acquired knowledge in their community. (5.2) Follow-up evaluation: After the trainees return to practice the primary health care in their community for a period of time, they are re-evaluated by questionnaires and visits by a group of professionals. (5.3) Refresher course evaluation:
The trainees are re-evaluated when they are invited to return for refresher courses. (6) Finunce: Training takes place in two large Buddhist temples situated in Bangkok. Lodging and training facilities are available free of charge at the temples (Buddhist temples are usually built and maintained by the community). The trainees pay their own traveliing expenses. Meals are provided by donation from the almsgivers, relatives and friends. (Almsgiving to monks is one of the highest aims in Buddhist tradition). RESULTS
Between 1975 and 1976, before the military revolution, two classes of about 100 monks were trained, no follow-up evaluation was done, because of the political atmosphere after the military revolution. From late 1979 to the present time, there have been two categories of monks trained in health care, namely: (1) The abbots and ecclesiastical heads. Eighteen classes or about 1600 Buddhist abbots and ecclesiastical heads have been trained during the past 2 years. Although the follow-up evaluation has not yet been completed, preliminary results (Table I) show that the majority of the trainees have understood and practiced primary health care to a great extent except for the dispensing of herbal drugs and actual medical care. The latter has not been emphasized in the monk training course. because the course is too short to include medical practice. Only first aid, symptomatic and supportive treatments and correct usage of drugs are emphasized. The beneficiaries of this program as indicated by the preliminary results are the villagers (53’;/,) and the monks and novices in the temples (47:/,). (2) The monk graduates. Four classes or about 400 monk graduates of the Maha-Chulalongkorn (Clergical) College have received the added primary health care course. Follow-up evaluation of this group has not yet been done. Apart from the direct benefit to the community as stated above, the monk training program in health care has resulted in an increased acceptance by the conservative elements of the country including those in ecclesiastical hierarchy, politicians and professions about the role of Buddhist monks in health care. This is shown by more liberalization of the ecclesiastical Table 1. Preliminary results of the follow-up evaluation of the health care training for Buddhist abbots and ecclesiastical heads showing the percentage of the trainees who understand and practice primary health care at different degrees Degrees of impact High Low None Increase understanding of primary health care Give health education Improve or educate nutrition. sanitation and environmental problems Dispense modern drugs Dispense herbal drugs Give medical care
82 66
17 33
I 1
57 75 40 29
34 21 45 57
9 4 15 14
Buddhist
monks
as community
rules, more cooperation and less criticisms from the professionals and decreasing criticisms in the public media. This may lead to the expansion of health and medical knowledge to other public servants such as the community chiefs and teachers. PROBLEMS
The rather slow pace of the monk training program in health care is due to two major causes: (1) The lack of full-time organizers, planners, supporting facilities and resources. (2) The lack of advertisement, political lobbying and public campaigns. These may result from the voluntary basis by which this program is organized and implemented. And, all volunteers in this program are more or less occupied by their routine work. FUTURE PLAN
A systematic ‘industrialized’ approach for the monk training program in health care has been planned and tried in vain. More political lobbying and public campaigns are necessary to persuade the government to take over the program and to make it
health
workers
in Thailand
1487
a national policy such that the monk training can be done locally in every province. Foreign intervention or influence either in the form of grants or suggestions may be required to change the government’s attitude, although this program has tried to keep itself away from political and foreign influences, and to be self-reliant and communitysupported from the beginning. REFERENCES of Public Health. Thailand Health Profile. I. Ministry Department of Public Health. Bangkok. 1980. 2. Wasi P. Buddha’s teaching and the society. Folk Doctor Mug. 4, S&83. 1982. 3. Thailand on its decline? SOC.Sci. Rec. (Bungkok) 9, No. 6, 12-59, 1971. 4. Hathirat S. The hopeless patients. J. med. Ass. Thai 55, 543-547, 1972. 5. Donaldson P. J. Foreign intervention in medical education: a case study of the Rockefeller Foundation’s involvement in a Thai medical school. In/. J. Hith Sew. 6, 251-270. 1976. 6. Hathirat S. Modern medicine in Thailand to-day: problems and treatment. J. med. Assoc. Thai. 61, Suppl. 3 17-24, 1978. 7. Illich 1. Limits to Medicine. Medial Nemesis: The Expropriation of Health. Penguin Books, New York. 1977.
Sot. SC;. Marl. Vol. 17, No. 19, pp. 14X5-1487, 1983 Printed in Great Britain
BUDDHIST
MONKS AS COMMUNITY WORKERS IN THAILAND
HEALTH
SANT HATHIRAT Department
of Medicine,
Ramathibodi
Hospital,
Mahidol
University,
Bangkok
10400. Thailand
Thailand. Buddhist monks and temples are scattered throughout the country even in the rural poor. There are approximately one temple and four monks for every two villages of about 1000 people. If Buddhist monks are able to expand-their roles to health care and education, Buddhist temples will automaticallv become community health oosts and ‘Health for All by The Year 2000’ will be achieved within 5-10 years in Thailand. Therefore, a iolunteer monk-training program has been carried out and about 2000 graduates have returned to their community to disseminate primary health care. However, a systematic and ‘industrialized’ approach is necessary to get some visible impact on the health of the rural . Thai population. Abstract-In
INTRODUCTION
The famous ‘bare-foot doctors’ of the People Republic of China is preceded by the indefeasible ‘bare-head doctors’, the Buddhist monks. Although psychological (mental) and spiritual treatments have been the predominant practice given by most monks, traditional and herbal remedies have also been administered by some. The re-establishment of Buddhist monks as community health workers in Thailand will be described.
BACKGROUND
AND REASONS
Buddhism is the predominant religion in Thailand. More than 95:/i) of the population are Buddhist. The remaining are Islamic, Christian and other less well known sects [I]. There are nearly 26,000 Buddhist temples, 200,000 monks and 100,000 novices scattered throughout the country [2]. Therefore, in a country with approx. 50.000 villages, there are approx. I temple and 4 monks for every 2 villages of about 1000 people. Buddhism is a religion quite different from Islam and Christianity, because it does not need the belief or faith in a supreme creator and it teaches a scientific (problem solving and reasoning) way of life. Although Buddhism in Thailand is mixed with Brahmanism and Hinduism, its basic principles still prevail and are practiced by most Thai. Therefore. Buddhist temples, in addition to being the religious centers. have also been the socio-cultural, educational and therapeutic centers for Thai villagers for hundreds of years. However, King Rama V, in an attempt to modernize the country rapidly to avoid Western colonialism, centralized the administrative, educational and health care systems. Thereafter, the roles of Buddhist temples in education and health care have gradually declined but still persists. Pra Jaroon Panjant, the abbot of the ‘Krabok Cave Temple’ has recently received the Magsaysay Award for his role in taking care of hard-core drug addicts by faith and herbal remedies. The rapid influx of material civilization from the Western world has badly shaken Thai way of life. It
has changed the simple (natural) way of living-being happy and content in life and nature-into a materialistic, rat-racing and more selfish way of life [3,4]. Buddhist’s economics: ‘small is beautiful’, has changed to ‘consumption economics’: to consume more is powerful. Modern (Western) medicine has firmly established itself from the time of King Rama V, about a 100 years ago. And later, the Rockefeller Foundation’s interference in Thai medical education and health care has abolished Thai traditional medicine from the governmental health services [5, 61. As a result, the health care system and health education in Thailand have become more and more centralized, hospitalized, urbanized, mystified, expensive and inaccessible to the majority (8O’i/,) of the population who are poor or live in the rural areas. The health care system has become a rapidly money-craving and moneyspending machine, creating more patients and more consumption and being more or less accessible only to the urban population [6, 71. In order to reverse this trend of health care, many attempts have been made to change the medical curriculum, to ‘dehospitalize’ health care, to relocate health resources and others; but all are in vain. After the Thai Student Revolution in 1973, a group of doctors, pharmacists, educators, philosophers and pragmatists took advantage of the political atmosphere to organize a monk-training program in health care. The reason for choosing Buddhist monks as trainees is the fact that they are the most respected, disciplined and unselfish community leaders. In addition, Buddhist temples, scattered throughout the country even in the ‘most’ rural poor, can be instantly used as community health posts if the abbots have the knowledge of and the motivation to encourage primary health care. In the past, monk training in health care would have been impossible. The political atmosphere after the Thai Student Revolution was so liberal and vocal that it suppressed any conservative ideas which tried to centralize or limit a fairer distribution of wealth, knowledge and other resources. Unfortunately, the era of the Thai Student Revolution ended in 1976 after a military blood-bath and an
1485 S7M 17119
b
SANT HATHIRAT
1486
extreme swing of the political atmosphere to the right. Under martial law and a very conservative government which took any liberal idea as communistic or communist-inspired, the program automatically ceased after training about 100 monks from different provinces of Thailand. When the political atmosphere eased in 1979, a renewed monk training program in health care has been established with the help of: (1) The ecclesiastical head of the central and southern ecclesiastical regions of Thailand. Although he is quite old, he is still active and ranks fourth in the ecclesiastical hierarchy. With his help, the abbots and the ecclesiastical heads of the privincial subdistricts. districts and regions under his command, have been invited or persuaded to attend the monk training course and to establish a drug cupboard for community use in each temple. (2) The Maha-Chulalongkorn College for clergical education. The monk training course has been incorporated into the final days of the monk curriculum. Most of the graduated monks will be missionaries for community development in the rural areas.
COURSE
AND CURRICULUM
The course and curriculum health care are:
for monk
training
in
(1) Duration: The first course in 1975 lasted 3 weeks. The second course in 1976 lasted 3 months. The latter included clergical administrative and community development models and techniques, The lengthy training course caused serious difficulties to the organizers and the trainees. Therefore, the renewed monk, training program which has been re-established in 1979 has been reduced to a 5-day-course for the abbots and ecclesiastical heads and a 2-week-course for the student monks. (2) Contents: The contents of the monk training course in health care are: (2.1) motivation session. (2.2) concepts of primary health care. (2.3) prevention of diseases including water supply, sanitation, immunization and other controls. (2.4) treatment of health problems including first aid, symptomatic and supportive treatments and herbal medicine. (2.5) promotion of health including nutrition, reduction of mental stresses and family planning. (3) Training methods: Lectures, demonstrations, discussions including questions and answers, and practice are the learning experiences in the course. (4) Trainers: The trainers are volunteered professionals from medicine, nursing and public health fields. (5) Evaluation: The evaluation is done in 3 categories: (5.1) session evaluation: The trainees evaluate the efficiency of the session and the possibility that they will be able to use the acquired knowledge in their community. (5.2) Follow-up evaluation: After the trainees return to practice the primary health care in their community for a period of time, they are re-evaluated by questionnaires and visits by a group of professionals. (5.3) Refresher course evaluation:
The trainees are re-evaluated when they are invited to return for refresher courses. (6) Finunce: Training takes place in two large Buddhist temples situated in Bangkok. Lodging and training facilities are available free of charge at the temples (Buddhist temples are usually built and maintained by the community). The trainees pay their own traveliing expenses. Meals are provided by donation from the almsgivers, relatives and friends. (Almsgiving to monks is one of the highest aims in Buddhist tradition). RESULTS
Between 1975 and 1976, before the military revolution, two classes of about 100 monks were trained, no follow-up evaluation was done, because of the political atmosphere after the military revolution. From late 1979 to the present time, there have been two categories of monks trained in health care, namely: (1) The abbots and ecclesiastical heads. Eighteen classes or about 1600 Buddhist abbots and ecclesiastical heads have been trained during the past 2 years. Although the follow-up evaluation has not yet been completed, preliminary results (Table I) show that the majority of the trainees have understood and practiced primary health care to a great extent except for the dispensing of herbal drugs and actual medical care. The latter has not been emphasized in the monk training course. because the course is too short to include medical practice. Only first aid, symptomatic and supportive treatments and correct usage of drugs are emphasized. The beneficiaries of this program as indicated by the preliminary results are the villagers (53’;/,) and the monks and novices in the temples (47:/,). (2) The monk graduates. Four classes or about 400 monk graduates of the Maha-Chulalongkorn (Clergical) College have received the added primary health care course. Follow-up evaluation of this group has not yet been done. Apart from the direct benefit to the community as stated above, the monk training program in health care has resulted in an increased acceptance by the conservative elements of the country including those in ecclesiastical hierarchy, politicians and professions about the role of Buddhist monks in health care. This is shown by more liberalization of the ecclesiastical Table 1. Preliminary results of the follow-up evaluation of the health care training for Buddhist abbots and ecclesiastical heads showing the percentage of the trainees who understand and practice primary health care at different degrees Degrees of impact High Low None Increase understanding of primary health care Give health education Improve or educate nutrition. sanitation and environmental problems Dispense modern drugs Dispense herbal drugs Give medical care
82 66
17 33
I 1
57 75 40 29
34 21 45 57
9 4 15 14
Buddhist
monks
as community
rules, more cooperation and less criticisms from the professionals and decreasing criticisms in the public media. This may lead to the expansion of health and medical knowledge to other public servants such as the community chiefs and teachers. PROBLEMS
The rather slow pace of the monk training program in health care is due to two major causes: (1) The lack of full-time organizers, planners, supporting facilities and resources. (2) The lack of advertisement, political lobbying and public campaigns. These may result from the voluntary basis by which this program is organized and implemented. And, all volunteers in this program are more or less occupied by their routine work. FUTURE PLAN
A systematic ‘industrialized’ approach for the monk training program in health care has been planned and tried in vain. More political lobbying and public campaigns are necessary to persuade the government to take over the program and to make it
health
workers
in Thailand
1487
a national policy such that the monk training can be done locally in every province. Foreign intervention or influence either in the form of grants or suggestions may be required to change the government’s attitude, although this program has tried to keep itself away from political and foreign influences, and to be self-reliant and communitysupported from the beginning. REFERENCES of Public Health. Thailand Health Profile. I. Ministry Department of Public Health. Bangkok. 1980. 2. Wasi P. Buddha’s teaching and the society. Folk Doctor Mug. 4, S&83. 1982. 3. Thailand on its decline? SOC.Sci. Rec. (Bungkok) 9, No. 6, 12-59, 1971. 4. Hathirat S. The hopeless patients. J. med. Ass. Thai 55, 543-547, 1972. 5. Donaldson P. J. Foreign intervention in medical education: a case study of the Rockefeller Foundation’s involvement in a Thai medical school. In/. J. Hith Sew. 6, 251-270. 1976. 6. Hathirat S. Modern medicine in Thailand to-day: problems and treatment. J. med. Assoc. Thai. 61, Suppl. 3 17-24, 1978. 7. Illich 1. Limits to Medicine. Medial Nemesis: The Expropriation of Health. Penguin Books, New York. 1977.