Health and education: First steps in medical awareness concerning health issues in Lao schools
Editor’s note: Ms Shirin Ud-Din finished her Master’s Degree for teaching English and biology at secondary school in January 2020 and went started her 18-month teacher traineeship in February 2021. She concluded her studies during Covid-19 and therefore chose to write her Master thesis about “Emergency Remote Teaching: Challenges and benefits for German lower secondary schools in the region of Karlsruhe during the digital school term 2020“, which was published and announced as a full-text on our “Research” page in March 2021.
Ms Ud-Din was a member of Team VI and worked at Ban Phang Heng Lower Secondary School in the spring of 2018. In autumn 2018 she accompanied Team VII for two weeks to help them settle into their Lao work and routines, and she has written several articles about her work and experiences in Lao P.D.R. since.
Back in Germany, she joined a “Model United Nations” group locally, then nationally, and, one year later, internationally, and for this received financial support by the Stiftung der Deutschen Wirtschaft  (Foundation of German Business). She was elected as Head Delegate of a team of 15 students who represented Lao P.D.R. in the National Model United Nations in the United Nations Assembly Hall in New York for one week in April 2019. To help prepare the group, the new Lao Ambassador to Berlin, His Excellency Mr Phomma Boudthavong, invited the delegation to his Embassy for a preparatory conference and Lao dinner. We celebrated their reunion at our 6th Lao-German Friendship Feast in Karlsruhe on 10 July 2020, and you will be able to listen to Ms Ud-Din’s screencast report about their NMUN work in New York in a new post soon.
Presently, she is co-editing a book on the challenges of digitization related to society as a whole in the context of schools.Â
This article is a summary of Ms Ud-Din’s Bachelor thesis “Health and education: First steps in medical awareness concerning health issues in Lao schools“, also posted on our Research/ full-texts page. As a student of English and biology, she became strongly interested in health education and medical awareness during her internship in Ban Phang Heng and found many ways to explore and research the subject on-site. Her new tandem-teaching contacts in Laos helped her gather data for her thesis – something that more and more volunteers and their tandem-partners started doing over the subsequent years – as you can see on the Research full-text page. Â
First steps in medical awareness concerning health issues in Lao schools
1 Lao health system: Not a country-wide system
3 Modern medicine vs. Lao traditional medicine
4.1 Medical awareness teaching through international influence in Lao schools
5 Current situation: Covid-19 in Laos
When I applied for the “Bi-directional teaching and learning” project as a volunteer in Team VI in 2017, I was also in my last semester of my Bachelor degree. The final milestone of my Bachelor’s programme for pre-service secondary school teachers was the Bachelor’s thesis. The more time I spent preparing for my stay in Laos, the more interested I became in the country. After many interesting discussions with Prof. Isabel Martin, it was clear to me that I definitely wanted to write my final thesis about this country.
Since I studied biology as well as English, I wanted to combine both subjects. On the one hand, the topic needed to be related to school, or education, and on the other hand, I also wanted to take a look at the medical system in a “developing” country.1 This is how I came to take a closer look at the health system in Laos, which was repeatedly brought to light in “our” three Lao schools through preventive measures. I wanted to find out how the pupils in Laos are educated in terms of health and hygiene in their schools and which measures were implemented by the state.
It is important to mention that the schools that are supported by the Angels for Children Foundation (AfC) are much better equipped than regular state schools in Laos because of the funding of the AfC Foundation over many years. (Ban Sikeud Primary School was awarded the prize of “Best primary school in the country”.) Other schools in Laos, especially in rural areas, look completely different, and also work differently.
There is little scientific literature in this field. This, however, did not matter as I did not only want to do pure literature research anyway. I wanted to do scientific work myself. For this purpose I decided to do qualitative research,  in which I conducted expert interviews with Lao people and German expats2 living in Laos to obtain detailed information. It is worth mentioning that this thesis was written in 2018, before the Corona pandemic. However, in the last paragraph I will provide information about the situation in Laos during the pandemic in terms of health.
1Â Lao health system: Not a country-wide system
Public health services were free of charge from 1975 until the mid-1990s. Since 1996, every Lao person who wants to get access to public health services must pay a user fee. In 1999, the Ministry of Labour and Social Welfare introduced a social security scheme (SSO) to regulate costs for health care for workers in the formal private sector. Employers had to come up with five percent of the costs and on the other side their employees with 4.5 % of their salaries (Camara, Zhang, and Policy 2013, 4).
Health services for the public sector have been available since 1993. They are financed by the civil servants’ contribution of 6% of their salary and, if necessary, increased by the state treasury. The public sector and the formal private sector can consider outpatient treatments as well as in-patient care. One last group, the informal sector, could not and cannot benefit from these schemes although this group would need it the most. Looking back in 2000, the average that the Lao government spent for health care per citizen each year was US$ 11.50. Compared to the neighboring country Cambodia with US$ 19 per person, the expenditure was very low. This means that it was not possible to provide good health care services for the whole population (ibid.).3
It is also interesting to know that half of the governmental spending was for the salary of health care staff as well as the building of new facilities. As the costs for hospitals are very high due to material and surgeries, it happens that they charge patients with high service fees and high prices for medicine. For the informal sector it was and still is impossible to consider going to a doctor because of the lack of money. The consultation of a doctor in case of illness often means financial ruin for a family. Because of this reason many Laotians tend to not visit a doctor (ibid.).
Universal health coverage is the first step towards an effective health system. There are various forms of health insurances in Laos, but not many Laotians can afford to pay for them. In most cases, Laotians are not willing to pay for an insurance on a regular basis if, firstly, they are not ill, and, secondly, as they would have to face constant expenses. Average Laotian citizens cannot afford to invest in their health. As a result, they face high costs in the event of illness, some of which they cannot bear on their own. Help from relatives and the village is often necessary (World Health Organization 2014, 44).
The following figure gives an overview of the support which health insurances get through funds, donors, ministries, and organizations.
Another problem is the centralization of health institutions, most of which can be found in larger cities. This means that people from rural areas, some of whom have no access to roads or need to take cover long distances, have few opportunities to receive treatment for health issues at all. Although there are health centers in rural areas, they are most of the time insufficiently equipped with qualified health workers. In addition, these workers are not regularly available. The reasons for this are low salaries, poor education training, and the unattractiveness of working in the countryside (Camara, Zhang, and Policy 2013, 7). The average salary of a Laotian amounts to 160 $ (lowest income) per month. Visiting a doctor can cost the same amount of money of an average salary, or even more, depending on what treatment is given, said one of my interview partners.
According to the World Health Organization (WHO), it is currently estimated that 93% of the population can reach a health facility in less than 90 minutes. It is still a long way to go, especially when a person is seriously ill. However, the very high cost for medical services deter most and thus risk serious illnesses that remain untreated and cause death (World Health Organization 2015, 20).
The health institutions which are provided in Laos are pharmacies, doctors’ practices, hospitals either governmental or private, foreign hospitals, and health centers. All of them maintain medical help for patients. In the capital Vientiane, one will find four general hospitals and three hospitals with specializations (four of them are foreign hospitals).  Next to that, hospitals in regional and provincial areas can be tracked down to 16 in total and 130 in district areas. In total, there are 860 health centers in Laos.Â
The figure below lists the organisational structure of the Ministry of Health with its different health institutions in Laos (Camara, Zhang, and Policy 2013, 12).
There are different types of hospitals in Laos, but first and foremost one can say that they are not few. In addition to governmental hospitals, there are also private clinics or hospitals and foreign hospitals. There are eight central hospitals in Vientiane and four regional hospitals in the provinces. Besides that, there are also countless private clinics, which have higher standards and are therefore more expensive.
The eight hospitals consist of the Mahosot Hospital, Friendship Hospital, Mother & Child Hospital, Traditional Medicine Hospital, Rehabilitation Centre, Eye Treatment Centre, Dermatology Centre, and the Tubercolosis Centre. All facilities are located in the capital Vientiane. Not many of the above-mentioned hospitals have an internet website (Camara, Zhang, and Policy 2013, 6).
Governmental hospitals are usually well equipped with good material and equipment. Also important is the staff, which sometimes includes specialists. Most of these hospitals are over-crowded and there are long waiting times as well as a small number of beds for inpatient treatment. There are only 0.8 hospital beds per 1.000 inhabitants available (World Health Organization 2014, 82).This shows the small number of possible inpatient treatments. In addition, there are also high treatment costs that patients have to pay if they do not have an insurance, especially if they have to stay in hospital.
Private hospitals were established during the change to a market economy in the 1980’s. According to the latest WHO numbers, there are 222 private clinics throughout Laos. There is no difference between a “clinic” and a “hospital”. Most private hospitals can be found in the capital, but there are also several in other the provinces. The difference to governmental hospitals lies firstly in the costs that patients have to bear by themselves and the better service they receive (World Health Organization 2014, 81).
Secondly, private hospitals do not receive any governmental help, which makes the treatment expensive in contrast to governmental hospitals. Private clinics were created by the poor situation of hospitals run by the government, which are often overcrowded, coupled with poor service. They made it their mission to offer a much better, more professional and quicker service from what governmental hospitals offer. Only people with higher income (20 % of the population) can afford this option of treatment, while people with lower income (80 % of the population) have to be satisfied with the most necessary treatment at governmental hospitals. As mentioned before, private clinics are paid by the patients on their own, either by out-of-pocket payment or by reimbursement in case the patient has a private insurance (ibid.).
Besides the governmental and private hospitals, there are many foreign hospitals, mostly located in the capital Vientiane. Those are mostly private, which means that patients are confronted with out-of-pocket payments. The treatment, service, and quality of material are of a higher standard than in governmental hospitals. The Alliance International Medical Centre is the newest and is part of the Wattana Hospital Group of Thailand. The hospital offers services for various medical fields such as diabetology, cardiology, pediatrics, and gynecology (J&C Services).
The French Embassy Medical Centre offers consultations, dentistry, laboratory analysis, physiotherapy, and psychotherapy. It is open around the clock and the physicians also offer home visits to the patients. The Australian Embassy Clinic (which closed after I wrote this thesis)offered consultations only during their opening hours. With its English-speaking staff and good medical equipment, all of them are often visited by foreign immigrants or travelers. Not only English is spoken: They advertise their hospitals with staff that speaks Thai, Russian, or French (ibid.).
A small number of Laotians take advantage of hospitals in Thailand, which are not far from Vientiane or Savannakhet, for example. The higher qualifications of some of the doctors as well as the better service attract more and more Laotians with high income to take treatment in their neighboring country. Especially more serious diseases are treated in Thailand, such as cancer, heart diseases, or oral surgeries. This result was conducted when I interviewed German author Mr Michael Schultze, a Laos-expert who has lived in the country for 30 years.
In contrast to larger towns such as Vientiane with its large number of hospitals, there is hardly any possibility to get medical treatment in many mountainous areas. As already mentioned, this is due to decentralisation.4 Nevertheless, not only the long distance to the hospital in mountainous regions is a big problem for many Laotians. Usually there is also a lack of hygiene, lack of qualified staff, and uncaring service.  While most hospitals in the capital city are well equipped, for example with a computerised tomography (CT) device or an X-ray machine, rural facilities do may not have bandages to adequately treat the injured patients. The general problem is the lack of technical equipment. Surgeries can hardly be performed in such areas, most of the patients have to go to larger hospitals. It is not uncommon that medicines that should always be on site are not available and are then difficult to obtain. This topic becomes particularly important when it comes to the Unexploded Ordnance (UXO). Laos is the most heavily bombed nation per capita (2 million tons of bombs were dropped on Lao P.D.R. in the Second Indochina War). To this day, (too) many unexploded bombs remain scattered across the country, endangering the lives of many people working in agriculture in particular, and still killing dozens every year.
3Â Modern medicine vs. Lao traditional medicine
A great barrier to medical progress is the religious faith in connection with Lao traditional medicine. Lao traditional medicine is made from herbs, flowers, bark and wood, and has a long history. Especially in rural areas, traditional medicine is often used, on the one hand for religious reasons in which the traditional medicine has a strong connection to their belief, and on the other hand, due to the distrust in modern medicine, which is reinforced by a lack of biological knowledge (Johnson 2002, 126). This is not denigrate traditional medicine at all – however, exclusive trust in herbs evidently blocks the use of conventional medicine.
The history of Lao traditional medicine goes back to the twelfth century, whereas pharmaceutical drugs were first introduced during the French colonization in 1893. To this day, Lao traditional medicine is a type of treatment that is widespread, whether in the city or in rural areas (World Health Organization 2001, 159).
As it belongs to the cultural heritage of Lao P.D.R., it was and still is of great importance for the country to preserve this. Therefore, the Traditional Institute of Traditional Medicine was opened. The institute focuses on carrying out studies on plants and their effects. In addition, various plants belong to the inventory of the institute, which are also tested for species protection and medical production (Sydara et al. 2014, 1263).
Conventional medicine is expensive, traditional medicine on the other hand is not. Due to the affordable prices and centuries of experience, people like to use this type of medicine. They assume that allopathic medicine only suppresses the symptoms of a disease and does not cure them – while traditional medicine does. Lao traditional medicine is a good alternative to allopathic medicine for Lao people. Also the use of sauna, massage, and acupuncture have a place in this treatment (ibid.).
In addition, old people who suffer from pains in the legs often consult her for help. Most products need to be boiled in water for a while and then drunk hot afterwards. This saleswoman recommends using the products until the customers feel better, but she also recommends not only to use them when they are ill, but also for prevention. The clientele are mostly Lao, but Chinese and other foreigners passing by also buy products from her stand. (If you want to find out more about Hmong medicine culture, try reading The Spirit Catches You and You Fall Down. A Hmong Child, Her American Doctors, and the Collision of  Two Cultures, written by Anne Fadiman).
As an “LDC” (“Least Developed Country”, a status Laos aims to leave behind by 2026)  with little expenditure for health, Laos receives a lot of support from foreign aid organizations. These organizations try to improve the life situation especially of children and help people in need, i.e. the poor in rural areas, where there is a lack of education and health care. With the support of external organizations, it was possible to implement hygiene rules so the country folk could protect themselves from communicable diseases. With international support and volunteers, Laos made great medical progress in recent years. Organizations that support the country  are The Swiss Red Cross, UNICEF and the GIZ. The German-Lao Friendship Society also works closely together with the Lao Red Cross.
4.1 Teaching medical awareness through international cooperation in Lao schools
The support installed at schools leads to new daily habits that accompany pupils throughout their lives. Not only the pupils benefit from this, but also their family members and villagers. Healthy lifestyles can be passed on through the children in order to prevent preventable diseases. It is also important that children visit school regularly so that they can follow the lessons. Through common illnesses in Laos such as diarrhea it is evident that many pupils cannot attend important lessons at school (and teenage girls may have to stay at home during their menstruation, for lack of sanitary pads). Therefore, the goal of the organizations  is to keep the children healthy, support access to clean water and the use of clean sanitary facilities. Thus, the pupils learn about new thematic fields such as hygiene, cleaning rituals, and infectious diseases, which are also interesting for them and are arranged as group activities.  An important example ist the Global Handwashing Day (Global Handwashing 2017).
On every 15th of October, Global Handwashing Day is celebrated by more than 200 million people in over 100 countries. As handwashing is nowadays a ritual in over 400 Lao schools that pupils follow every day, celebrating it is fun for them and teaches them at the same time the importance of it. Since 2008, Global Handwashing Day is celebrated in Laos and is a reason for many schools in the country to organize big parties. UNICEF, Unilever, the World Bank, and many other organizations initiated this day to raise awareness of infectious transmitted diseases and show the advantages of handwashing (ibid.).
Another notable initiative is the tooth-brushing project at Ban Sikeud Primary School, which was initiated by Madame Gerlinde Engel. Shortly after the founding of the Angels for Children Foundation, she asked around to find out if the people in the village brushed their teeth. It turned out that not even one pupil owned a toothbrush. She saw that many pupils had toothaches and caries and brought them to a dentist, or rather brought a dentist to them. Tooth decay is a very common issue in Laos. Her personal encounter with so many children with rotting teeth led to the decision to build up a water supply pipe on the schoolyard, in order to start a new tooth-brushing ritual at school, at 10 a.m. every day.
A memorable moment for Madame Engel was when she asked graduates if they would continue brushing their teeth even if after leaving school: They said, “Madame, we brushed our teeth these last five years, now we will keep on brushing our teeth!” This clearly shows the positive results of her project, which became an official “Model School” in Laos.
In summary, it can be seen that many medical facilities have already been established in Laos to take care of people in need of treatments. The biggest challenge is their decentralization. Access to the health system is still difficult for the majority of citizens due to lack of money or because they live in remote villages. With the help of foreign partners such as the Swiss Red Cross, the GIZ, or the Angels for Children Foundation, free programmes have been facilitated and integrated.
Teachers are doing their best to teach pupils about hygiene and health. However, the health system and its availability to all citizens is still in need of further work, effort, and funds. After all, the majority of the schools in Laos are located in rural areas:
From my perspective, and judging from the results of this research, the challenge begins with health insurance: There is no statutory health insurance in Lao P.D.R. in place (yet). In Germany, by contrast, every citizen has to have a health insurance (and can have one) while in Laos it is subject to everyone’s one responsibility or means. As mentioned above, according to the WHO, so far only 20 % of the population have covered their health with an insurance. The Ministry of Health aims to achieve to reach all citizens by 2025. Therefore they established the National Health Insurance in 2019, which makes a visit in a health institution more inexpensive. Still, Laotians have to pay a certain amount for their visit, but the costs are definitely lower than before (heath center: USD 0,55, district hospitals: USD 1,10, central hospitals: USD: 2,20, provincial and regional hospitals: USD 1,60). To promote the new scheme, TV advertisements are broadcast.
During my research, I also experienced that the belief in Lao traditional medicine is deep-rooted and very strong. Laotians tend to take traditional medicine first before using pharmaceuticals anyway. It remains to be seen whether this would change once everyone was able to access insurance. It was interesting to learn about the differences between Laos and European countries and the respective attitudes to medicine, but from my Western perspective it was difficult to comprehend at first.
What became clear to me, however, while conducting my expert interviews in Laos was that the people in this country are very happy with their lives, with or without a good healthcare system, and probably much more so than citizens in western countries with excellent healthcare.
5 Current situation: Covid-19 in Laos
Lao P.D.R. reacted fast to the Covid-19 pandemic by shutting the down country when the virus broke out in March 2020 – meaning lockdowns, travel bans, and home quarantine. Until April 2021 the country counted 49 cases since the breakout. This number got crashed because of a infection in a karaoke bar in Vientiane during the Lao New Year celebrations, evidently caused by illegal border crossings of infected citizens. Since then, the number of cases rose to 17,555 (as of 14th September 2021). Until the 11th of September 2021, 37 % of the Lao population received at least the first shot of the vaccination, which is an important step for the country (especially Japan and the U.S. donated millions of doses of vaccines to Lao P.D.R.).
For schools, there was a general closure until September 2020. When the pupils returned to the schools they were faced with hygiene measurements as we know them from the western part of the globe. Face masks, keeping distance of 1,5 m, and handwashing became part of the regular school day. Thus, the pupils did not share their desks anymore. However, the reopening of schools scheduled for 1 October has just been postponed until further notice, due to rising infections numbers following the return of migrant Lao workers from Thailand over the summer.
My wish for the country is that every citizen gets free health insurance and access to medical aid, so that they firstly get good treatment in case of illness and, secondly, do not have to face high costs just for preserving their health.
Text by S. Ud-Din
Photos by V. Botthoulath, I. Martin, S. Ud-Din & J. Zeck
Notes
1 The term “developing country” comes from technical and everyday language. As Prof. Martin already described in a note to a previous article, the terms “developing” and “undeveloped” are created by the ones who see themselves as “developed”, meaning “privileged”: “The binary of “developed countries” and “undeveloped” or “underdeveloped countries” is a value statement rooted in eurocentricism and colonialism; the criteria by which a country is deemed developed are chosen by those who deem themselves to be developed.”
A “developing” (“underprivileged”) country is thus characterised by malnutrition of the population, poor health status of the population, high unemployment, above-average population growth and inadequate state infrastructure. These are more often than not linked to the after-effects of Colonialism. At a time when decolonisation is increasingly being discussed, this term should therefore be replaced or at least considered sensitively – it is no way used in this article to degrade the country of Lao P.D.R.
2Â The term “expat” (Engl. “expatriate”, from lat. “ex patria”, “out of country”) describes a person who lives outside their native country.
3Â The abbreviation “ibid.” (lat. “ibidum”, Engl. “just there”) represents a reference that was cited in the reference before.
4Â The term “decentralisation” in a geographical sense means that institutions that are important for everyday life are located in the centre (i.e. big cities) Â and not in isolated places.
ReferencesÂ
Camara, B. O., Y. L. Zhang, and Lee K. Y. S. o. P. Policy (2013). Extending Healthcare to the Informal Sector in Laos. Case studies in public policy and public administration: Lee Kuan Yew School of Public Policy. https://​books.google.de​/​books?id=j9tEnQAACAAJ
Fadiman, Anne (1997). The Spirit Catches You and You Fall Down. A Hmong Child, Her American Doctors, and the Collision of  Two Cultures. New York: Farrar, Straus and Giroux.
World Health Organization (2014). Lao People’s Democratic Republic Health System Review. Lao P.D.R.: Ministry of Public Health Thailand.
Johnson, Sharon K. (2002). “Hmong Health Beliefs and Experiences in the Western Health Care System”. Journal of Transcultural Nursing 13, no. 2: 126–32. 10.1177/104365960201300205.
 World Health Organization (2001). “Legal Status of Traditional Medicine and Complementary/ Alternative Medicine: A Worldwide Review”. http://​apps.who.int​/​medicinedocs/​pdf/​h2943e/​h2943e.pdf.
 Sydara, K., Xayvue, M., Souliya, O., Elkington, B.G., & Soejarto, D.D. (2014). “Inventory of medicinal plants of the Lao People’s Democratic Republic: A mini review”. Journal of Medicinal Plants Research, 8(43): 1262–74.
Websites
Global Handwashing (2017). “GIZ celebrates Global Handwashing Day 2017 in Lao PDR”. https://​globalhandwashing.org​/​global-handwashing-day/​get-involved/​submit-events/​view-events/​giz-celebrates-global-handwashing-day-2017-in-lao-pdr/​ (last accessed 23 July 2018)
J&C Services. “Energy and Mines Growth Boost Laos”. http://​jclao.com​/​energy-and-mines-growth-boost-laos/​ (last accessed 31 January 2021)
World Health Organization Western Pacific Region. “Immunization”. http://​www.wpro.who.int​/​laos/​topics/​immunization/​en/​ (last accessed 31 January 2021)
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