Politics and Society
“People outside any particular community cannot really solve the community’s public health problems. They have to solve these by themselves”: in conversation with Professor Tomohiko Sugishita
Professor Tomohiko Sugishita doesn’t believe in drive-by kindness. Starting from when he was a newly-minted medical doctor taking care of the medical needs of 2 million Malawians at the height of the HIV epidemic in 1995, Professor Sugishita has always believed in sinking deep roots into a community and helping it help itself. He recently sat down for an interview with veteran Kenyan journalist Wycliffe Muga and opened up about what lit his fire for medicine, his long years of medical practice in Africa and why he has come to believe in the “unlearning process”.
Professor Tomohiko Sugishita has led an accomplished life, devoting much of it to improving health care provision in some of the neediest parts of Africa. After graduating from Medical School of Tohoku University in Japan, Professor Sugishita worked for Japanese hospitals as general surgeon and cardiac surgeon. In 1995, he joined Japanese Overseas Cooperation Volunteer as a medical doctor in the national hospital in Malawi.
After the volunteer work, he pursued his Masters in Public Health from University of Harvard and Masters in Medical Anthropology from University of London. His career as JICA Health expert started in 2002 in Tanzania. Until he joined Tokyo Women’s Medical University, he had been a senior advisor to JICA HQ for 10 years. He was a chief advisor to Strengthening Management for Health in Nyanza Project between 2009 and 2013.
Here he is in conversation with Kenyan journalist Wycliffe Muga:
Q: Maybe we should start with you telling us how you got started in working in Africa, and the road by which you came to focus on the continent.
A: When I was just ten years old, and I was watching TV, I was so surprised when the BBC broadcast about a famine in Ethiopia. This was actually the first global broadcast of the scene of this famine. I was so shocked because young, small schoolchildren just the same age as me, were shown. My shock was like this: here I am, believing that the world is a beautiful place. But the film showed me that a child the same age as me was nearly dying. He had been left behind.
Nobody was coming to help him. At that moment I thought that the world is completely different from my imagination. And maybe I should do something for the world to change those disparities. For although we were different people in different nations we were the same age. If I had been born in Ethiopia, I would maybe cry, but there would be nobody to help me. This was simply not good enough. So really it is the unfairness of the world which inspired me to become a doctor.
But that is not all. My grandfather was a doctor too, and went to the battlefield during World War Two. He told me lots of stories about how things were during wartime. He did amputations without anesthesia, on soldiers who had been very badly injured. He did this many, many times both for Japanese soldiers and enemy soldiers. Also he himself got so many tropical diseases.
When he died, and his body was lying in our old home, it had on the soldier’s uniform he had worn during the war. It was then 40 years after the war. But he obviously still believed that that was his special moment. That what he had done in sacrificing himself during the war really mattered. It was not a matter of going to war. It was a question of what he did for humanity.
So that also inspired me and made me want to be a doctor, so that I too may have a chance to do something for humanity.
Q: So what happened after that?
A: Then I went to medical university. And still I was, highly motivated to go to Africa. After graduation, I felt I should learn quickly about surgery. Because at that moment I thought: surgery can do everything. So if I was to be an effective physician, I had to be equipped to work as a surgeon.
So I went to train in the best hospital in Japan as a surgeon. And after that, I felt I was ready to go to Africa.
At that time many NGOs were also working in Africa – especially Medicins Sans Frontieres – but they only provided short periods of support. Only the Japan International Cooperation Agency (JICA) and Japan Overseas Cooperation Volunteers were providing at least two years of opportunity to work for hospitals. And there was one position open in Malawi at that time for a surgical specialist. This was roughly six years after my graduation, and I was really confident that I could go alone to Malawi, and work there.
Q: And what did you find when you got to Malawi?
Well at that time, HIV prevalence in Malawi was about 39% of the entire adult population of the southern part of the country. That was in 1995. HIV infection had spread everywhere. I went to Zomba Central Hospital, which is a major hospital in Malawi. About 400 kms from the capital city, Lilongwe. There was only one Japanese volunteer as well as doctor, which was me. I had to cover by myself, a population of about two million.
I started setting up the team. Trained the clinical officers and nurses. And so I got my surgical team. Thereafter I did more than 3,000 major operations over a period of three years. Every day and every night, I was doing surgical operations. And as the hospital got a good reputation, more and more people came to the hospital. It had a bed capacity of just 400, but we soon had 1,200 in-patients. So many people were coming to the hospital.
But that was a very exciting time for me. Working 24 hours a day, 365 days a year. And I must say that I somehow enjoyed working so hard.
Many of the people who came to see me were already in the terminal stages of HIV-related health problems. Some had Kaposi sarcoma; others opportunistic infections; cancers; lymphoma; etc. And I had to operate, as some were already bleeding inside, or something had ruptured inside them.
So I had to do also deal with those people living with HIV – more than 1,500 cases. But in many cases, the results of the surgical operations were not so good. Because by then their immunity was very low. That is why recovery was very difficult, and often involved multiple surgeries. I had to operate again and again – and yet finally the patient died.
Q: This must have been very difficult to sustain?
A: Yes. With time I got exhausted. But I had to keep on. Every day there were people relying on me in that hospital.
Then, I realised that I have to go out to the community first. To see what was happening in the community. And there I met many traditional healers; and there were also churches; so many things were happening in the villages. And there I found a very strong resilient society coping with HIV. Western medicine was not helping – for the sake of longevity. They did not necessarily want to live a very long life. They wanted to live a good life. They were already HIV positive. There were no ARVs available.
That hit my mind very strongly – prevention is than cure; better than any treatment; the society has to be more strong. Otherwise hospitals and doctors cannot help them.
Well at that time, HIV prevalence in Malawi was about 39% of the entire adult population of the southern part of the country. That was in 1995. HIV infection had spread everywhere.
Q: So what followed from this insight?
A: This is actually what led me to go to Harvard. I read about Prof Paul Farmer, especially in his book. I wanted to learn more from him. I learned a lot from him. Also from Dr Jim Yong Kim, currently the president of the World Bank, who at that time was an associate of Paul Farmer.
Those two really helped me. I had actually been enrolled at the Harvard School of Public Health. But I just commuted to the classes taught by Paul Farmer and Jim Yong Kim.
At that time they had already established Partners In Health. So very many people would come together and there we would discuss a lot about Haiti, South America, the Soviet Union; etc. This was around the year 2,000.
This is then, where I was first exposed to public health policy. But in a strange way I did not really like public health in that context. It was all about statistics, numbers – it was really a kind of what I might call an “air battle”. It was not a “ground battle”. So I asked Paul Farmer for advice, and he suggested that I go to the UK and learn about medical anthropology. How this can determine the outcomes of health.
Q: Isn’t Dr Paul Farmer also an anthropologist?
A: Yes he is. But he did not recommend to me an American university. He said I should aim for the UK, because the UK has a long relationship with Africa, both bad and good. It was in the UK where I could find the kind of anthropologists who often take 30 years or 40 years doing their research. And I could then get involved with those people. It was one of the most exciting periods of my life.
Q: I am aware that one of the things which you have finally focused on and done some pioneering work on is the community approach to public health, This, more than anything else, requires effective communication. Would you agree?
A: Well, to a degree I believe that we – as people outside any particular community – cannot really solve their public health problems. They have to solve these by themselves. By their own determination. We can only give some examples or some actions – but no resources. That is very important. Their problem is their problem. It is not an outsider’s problem. The outsider does not have the responsibility to solve this problem.
But I would want to work with any such community if they should need me. With that commitment I can do anything. So first of all I would be waiting for them to stand up themselves. I also believe in an “unlearning process”. I have come to feel that learning can actually make people blind. And that “unlearning” is the way to get to the truth. That is the most important thing for any society.
You have to think about what the future is for any society. And in this, having a shared vision is very important. Each community has to have its own vision – an outsider cannot create this vision for you. So discussions and deliberation – those dialogues – are very important.
Out of these come concrete ideas, and possibly, an innovative future. And then, maybe, an outsider with resources can figure out which parts he can support. But he has to support their vision – never his own idea of what their vision should be. I would call that a “learned” as opposed to a “post-colonial” discourse. I am totally opposed to Westernization dominating everywhere. Every people have to be allowed their own decision making.
I believe that we – as people outside any particular community – cannot really solve their public health problems. They have to solve these by themselves
So I promote dialogue rather than discussion. Continuous talk. This leads to “design thinking” which accommodates different people’s voices.
That is what I am trying to convince even JICA, which already has such an agenda. But I say, “Please go to the people, and sit down with them, and find out what future they want, of which I can maybe help some part.”
That is a good part of the lessons I learned from what I experienced in Malawi.
Q: Which are the other Africa countries you have worked in apart from Malawi?
A: I have worked in over 20 countries in Africa. But mainly, I spent six years in Tanzania, four years here in Kenya; and also visiting several countries, mostly Ghana, Sierra Leone, Sudan, and Zambia. Closer to Kenya I have worked in Somalia, Sudan, and Uganda. Most of this involved giving advice to ministries, and also some project formulation and improvement.
Professor Tomohiko Sugishita, is a professor of International Affairs and Tropical Medicine, Tokyo Women’s Medical University, Japan.
Wycliffe Muga is a Kenyan writer and veteran newspaper columnist.