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News Learning from low income countries

From looking at cells to looking at systems

BMJ 2004; 329 doi: (Published 11 November 2004) Cite this as: BMJ 2004;329:1128
  1. David Weatherall
  1. Oxford

    Prawase Wasi started his career as a clinical scientist and rose to become one of the great reformers of the Thai healthcare system. David Weatherall describes his journey

    I first met Prawase Wasi in 1966 on a visit to Thailand on behalf of the World Health Organization to assess the extent of the problem of thalassaemia and related diseases. Prawase was one of a group of extremely lively young clinical scientists in the haematology department at Siriraj Hospital, Bangkok. He had been trained in medicine and haematology at Mahidol University and had spent a further period with Matthew Bloch in Colorado and with Lionel Penrose at the Galton Laboratory in London, learning haematology and genetics. Our meeting was the beginning of a longstanding friendship and scientific collaboration.

    On my many subsequent visits to Bangkok Prawase always organised a round table discussion about our joint research and about the clinical problems of his patients with thalassaemia. By then it was clear to me that as well as his deep devotion to his patients with thalassaemia his medical interests were becoming much broader and oriented to public health.

    Prawase Wasi—public health reformer

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    As he put it to me recently, “As a doctor I had to witness great suffering of the people, particularly of the poor, stemming from poverty, disease, failed bureaucracy and politics, and inadequate health services, both in quantity and quality. What to do about it seemed extremely difficult, perhaps beyond imagination.”

    The problems that faced Prawase in the 1970s in trying to help the Thai population were particularly challenging. Even by 2000 more than three quarters of Thailand's population of 61 million lived in rural districts. In the 1970s many of the villages were extremely isolated, and the nearest medical care, if any, was a considerable distance away. At that time available primary care for the bulk of the population was very limited.

    To help deal with the problem, about 25 years ago Prawase established the Folk Doctor Foundation, which published the Folk Doctor magazine—a handbook for self care and learning materials so that villagers could educate themselves and be better able to take care of themselves and to evolve their own simple public health measures.

    Prawase has always held that community development is the basis for improving the quality of health in Thailand in an integrated manner. For many years he has been chairman of the Local Development Foundation, which carries out extensive work on community health development. This work is now a major part of Thailand's healthcare programme and has led to a major improvement in the quality of health in the villages.

    As well as his community work Prawase has used his influence widely at university and governmental levels. As professor of medicine and vice rector of Mahidol University he became aware that academic medicine in Thailand lacked any evidence base for clinical practice. He firmly believed that this was leading to a decline in the quality of clinical care and teaching and in the sensible use of medical resources. He therefore pioneered the development of evidence based medicine in Thailand.

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    Prawase Wasi: “As a doctor I had to witness great suffering of the people, particularly of the poor”

    He was also appointed chairman of the National Epidemiology Board, which was established to promote the formulation and practice of knowledge based health policy. The work of this board later formed the basis for a major national forum for the reform of health systems.

    The reform programme was Prawase's major contribution to the health of the Thai population. Taking a typically broad approach he interpreted health as physical, mental, social, and spiritual wellbeing. He believed that reforming health care could not be carried out without a knowledge of systems. Therefore he established the Institute of Health Systems Research 12 years ago.

    Using the work of the institute as his basis he negotiated with the government to create the National Health Systems Reform Committee, which is chaired by the prime minister and which has spent the last three years drafting the National Health Act for the reform of health care in Thailand. It has now been approved by the cabinet and is going before parliament. The act includes establishing mechanisms to implement reforms of the health system so that preventive medicine and medical care are available to the whole population.

    For four years Prawase was also chairman of the advisory committee for health research of WHO's South East Asian Regional Organization. In that capacity he has participated in many international forums on health research and development.

    Prawase is a devout Buddhist and has an intense desire to help the poor people of his country. His work has played a critical role in improving the health of poor people.

    I once had the opportunity of seeing Prawase's persuasive powers in action. Our Oxford University team had been invited to join a research programme, initiated by Kenneth Warren and the Rockefeller Foundation, entitled “The Great Neglected Diseases of Mankind.” In an effort to persuade the foundation that thalassaemias are among the “great neglected diseases” I invited Prawase to come to New York to tell the foundation of his experiences in Thailand. He ended a brilliant summary of the huge problem that thalassaemia presents in his country with the words, “God has allowed these serious genetic diseases to affect many of the people of Thailand; now Dr Warren and the Rockefeller Foundation have a remarkable opportunity to correct His work.” Needless to say, we got the support that we asked for.

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