I attended the 9th International Health Cooperation Fieldwork Fellowship Program for Japanese medical students supported by the Sasakawa Memorial Health Foundation as an attending advisor from August 8 to August 18, 2002. Participants were given a two-day lecture program in Japan; first day at the International Medical Center of Japan and the second day at the Tama Zensho-en Sanitarium, along with an eight-day tour in the Philippines. The study tour included lectures at the Western Pacific Regional Office (WPRO) of the World Health Organization (WHO), a visit to the Medical School of the University of the Philippines, an observation visit to the child and maternal health program of the Japan International Cooperation Agency (JICA) at Tarlac and Angeles, and a visit to the Jose Rodriguez Memorial Hospital for Leprosy in Tala. I attended the first international fieldwork fellowship as a medical student, so this was the second time I was involved in the program after an eight-year interval.

As Dr. Fujio Otani mentioned at the beginning of this program, this program is aimed to give students the chance to experience what international health is like, to meet and talk to outstanding people in the field whom they would otherwise rarely get a chance to, to discuss with each other regardless of the university each participant is from, and to make friends in Philippines. Students are also expected to gain insights into medicine in a social context, together with health and disease from this very educational program. Thirteen medical students and one student majoring in occupational therapy were selected among about 100 applicants from all over Japan. Forty-one students who were not selected to attend the whole program participated at least in the program in Japan. The eligibility criteria include sufficient English communication skill, strong interest in international health and social medicine, and some experience in international health cooperation or research activity in such field. Many students had a wide range of interests covering clinical medicine, family medicine, or peace activity, besides international health, Students provided detailed reports about the program, so my report focused more on with what I thought the students should gain from this program.

"Fieldwork is probably an experience in which you go and see, and have your own feeling about a place, the people, or things happening there. A different person probably would have a different feeling and view of what the problems are. However, no action to solve a problem can start without a person that sees the fact as a problem. Fieldwork can not only give you an opportunity to see the problem but situate the problem, which always exists there, within yourself." This is a part of the essay I wrote when I earlier attended the program as a student, and my idea about the problem has not changed since then.

One student said with his eyes filled with tears and his voice high at Tama Zensho-en that he had never been taught that this kind of place with such history exists. He was very sensitive enough to notice the long history of sorrow in this unusually vast place. Dr. Eiichi Matsuo from the Leprosy Research Center of the National Institute of Infectious Diseases, said in his lecture that though Hansen disease is an infectious disease, overreacting to the fact that it is contagious might have been one cause that led to discrimination and prejudice against the disease. And the real problem may lie within ourselves. Therefore, we have to study history, and we have to change. Otherwise, the same kind of tragedy may happen, he remarked frankly to us at lunchtime. The words of the student may reflect his changed sense that he is somehow connected to the problem. This interaction with the student reminds me of the lecture on the first day when Dr. Toru Honda, Representative of Services for Health in Asian & African Regions (SHARE), said that indifference is the biggest problem of all. And the student must have also realized that health and disease cannot be understood without considering it within a social context.

Dr. Yuji Kawaguchi, Director of WHO Kobe Center (WKC), told us in his lecture that there is a mountain of problems in the world. Prof. Keazo Kiikuni, Board Chairman of Sasakawa Memorial Health Foundation mentioned that the late Mr. Ryoichi Sasakawa, the founder of the Nippon Foundation, did much to solve the problems of Hansen disease because of his firm and critical view of the problem of the disease which originated from his unique understanding of the history of the disease in Japan and his personal experience related to the disease. As Dr. Kawaguchi said, there are many problems; however, this does not necessarily mean they are real problems to you. In other words, they are just some facts of the real world unless you view these facts as problems and start some action against them. In my view, a really critical mind about any problem is for your eyes to see the facts and yourself, analyze the facts and then act on them. Have you experienced changed yourself in this regard?

During the discussion time at the International Medical Center of Japan, Dr. Akira Endo from the Ministry of Health, Welfare and Labor (MHWL) emphasized that shaping a specific question to solve a difficult problem would be an important ability for one's career. Similarly, Dr. Koji Okamoto from MHWL said that it is important to prepare to learn about whichever the field you may be in order to solve the problems in question. Dr. Toru Honda, from SHARE also emphasized that the important thing in international cooperation is to teach people how to learn to learn, or to give such education as to make people notice problems around them by introducing the words of P. Drucker, "NGOs do something very different from either business or government. Its "product" is neither a pair of shoes nor as an effective regulation. Its product is a changed human being. "This, in itself, is true in your case.

Dr. Kawaguchi said that many health-related problems we are now facing around the world need cooperation to be solved. In the discussion time, cooperativeness was emphasized as an important disposition of those who hope to work in the field of international cooperation. Prof. Kiikuni touched the point of management as an important skill that medical professionals should have, by answering to a question, "what are some good thing students interested in international health should learn", by a student participant. Dr. Kawaguchi also referred to the same topic in his lecture. Dr. Ricardo Ramos, Tarlac Provincial Health Officer, humorously mentioned the importance of cooperative work in dealing with difficult problems by quoting the popular Japanese cartoon BOLTES V, in which five independent heroes combine to fight against a powerful enemy.

When the late Mr. Ryoichi Sasakawa first donated funds to WHO for the purpose of leprosy elimination, the Director-General of WHO at that time, Dr. Hafdan Mahler, asked him whether WHO could use the fund for smallpox eradication as well. Mr. Sasakawa replied that he would not say anything about how the money was utilized because it was a gift to Dr. Mahler. Prof. Kiikuni introduced this anecdote, and then stated the significance of acting flexibly. He also referred to the fact that it is important to learn the skill of making people change their attitude, or to be able to interest people.

The exposure to different cultures is especially remarkable in international cooperation. Throughout the program, the students were given opinions of many teachers for leading a successful life. Dr. Shigeru Omi, Regional Director of WPRO/WHO, mentioned freedom and responsibility. Freedom, for example, exists only as a choice under given circumstances, and responsibility is one's effort to respond to the given circumstances. In other words, we must become the masters of our own life by earnest and serious struggle with ourselves, he said. Dr. Katsutoshi Saruta from the Bureau of International Cooperation of International Medical Center of Japan, warned students against trying to find short cuts, an easier way, or the royal road. He emphasized that taking care of tasks right before us, or that should be done at that moment is a very important thing. And he told the students that each patient they will encounter in internship should be the first consideration, and having contact with the patients is very important. Although physicians are liable to be in authority figures in clinical practice, we have to bear in mind that a one-to-one relationship is always the fundamental aspect of our life. Dr. Sakutaro Tanino, former Ambassador to the People's Republic of China, said in his lecture entitled "Asia and Japan; international cooperation of Japan," that it is both important to have a liberal mind and willingness to make the effort to accept different ideas, and to have our own ideas. And we should grow into mature individuals that make our counterparts feel that they want to meet us again.

In the first day in Philippines, still with a tense atmosphere, Ms. Kumiko Anada, journalist living in Manila, took us to Smoky Mountain, a poor area where people live around or in the garbage heap, making a living from the garbage. We found children there filling the street, laughing with their beguiling smiles. In Sabana, an NGO to educate the children of Smoky Mountain, we were moved by the beautiful songs sung by the children and their smiles. One student noted that he could not fight back the tears. From having ridden the train, bus, and jeepney of Manila all that day guided by Ms. Anada, we thought we had somehow become closer to the viewpoint of the Filipino. When we visited Angeles to see the nutrition improvement project, however, one mother said to me, "Can we go home? Did you come here to see poor people?" It astonished me at that time, but I realized later that what shocked me most was finding myself that I might have been hoping to see poor and miserable scene.

At our last meeting on the final night, the students discussed the theme, "What is Happiness" in the presence of Dr. Sumana Barua, currently a WHO medical officer, who had greatly contributed to the coordination of this program. To the question raised by one student as to whether we were motivated to action in international cooperation by the idea of helping unhappy people, every student expressed their feelings, opinions, and questions. What is the happiness of people? Are people in the developing world unhappy? Is poverty unhappy? Is there any help or cooperation to make people happy? Is happiness a standard of judgment to conduct international cooperation? Is there obvious unhappiness? It is impossible to understand happiness in terms of figures such as the infant mortality rate or life expectancy at birth, isn't it? Is it possible to define happiness only in terms of the individual? Is happiness different from health? Is it acceptable to remove things from which people suffer to make them happier? What is the difference between the happiness of an individual and the happiness of a group? And am I happy? What should I do to become happy? One student said finally that we have to think about what makes us happy. He continued his comment that he would feel happiness in himself by getting in contact with someone who needs help and by knowing the person is becoming happier. The importance of natural or unaffected manner was also emphasized by Dr. Moriyasu Tsuji that neither demanding gratitude nor acting extremely humble is desirable. Making contact in a natural manner is the attitude most encouraged.

As many teachers mentioned, fellowship is a starting point. As another theme at our last meeting on the final night, students presented their future career plans assuming that they would wish to work with WHO, JICA, or NGO. It may depend on an individual's concrete interests, ambition, content and nature of the task, income and other working conditions, or a family. However, Dr. Shigeaki Hinohara, who gave a lecture entitled "The Good Samaritan" at the first International Cooperation Fieldwork Fellowship in 1994 in which I participated, told us to get involved in the problems as if we were diving into the ocean. Dr. Barua repeatedly emphasized the importance of putting ourselves on the spot, in other words, in the field where the real problem is happening. The guiding principle in the activity of the Nippon Foundation requires you to buckle down to creative work, being free of precedents, and acting rapidly without fear of failure. Thus, please actively and boldly dive into that ocean of problems. This is something I must tell myself as well.