The 1973 Ramon Magsaysay Award for Community Leadership

BIOGRAPHY of Krasae Chanawongse

Modernization and expansion of medical services has progressed steadily in urban Thailand while lack of such services has persisted in the countryside. Inadequate facilities chronically inhibit real medical work in rural areas. Health promotion requires dealing with a mass of people rather than individual patients, making a rural doctor's work more a supportive service than a medical practice. KRASAE CHANAWONGSE knew these and other discouraging conditions firsthand yet from his school days had the will and the desire to serve his hometown people.

KRASAE was born on March 1, 1934 to a poor family of Chinese Thai descent in Ban Muang Kao, Muang Phon District, Khon Kaen Province in northeastern Thailand. The sixth of eight children, he finished only second grade before he had to leave school to earn a living. He was nine years old.

KRASAE became an apprentice without pay in a shop near his home selling forest products. The shop owner, who collected rainwater in a tank, allowed the boy to sell some of it at the railway station mornings and evenings so he would have a little money. When the shopkeeper moved to Bangkok two years later he gave KRASAE a Chinese New Year's gift of 100 baht (US$5).

Finding no prospect of other work in his hometown, KRASAE went to Udorn Thani to live with a sister and brother-in-law. There he made deliveries to customers from his sister's small grocery shop, served as her bill collector and helped her order goods from Bangkok. In the evenings he joined a Chinese language class and was the best student.

Two years later when his father died, KRASAE returned to Muang Phon to stay with his mother and his sisters and brothers still at home. The eldest brother took care of the family business—trading and small scale construction—and another brother had the local liquor and newspaper distribution agency. KRASAE became his delivery boy. Though he was diligent and hardworking, his future was not promising.

A change for the better occurred when the principal of the private Intharabumrung School near his home, noting KRASAE's good nature, honesty and industriousness, took a fancy to him and invited him to join the school. KRASAE wanted to attend classes but wondered whether he could learn after being out of school for so long. "Let us try," the principal replied. "Because you are very industrious, I think you can keep up with the others. If you are interested in learning, that is enough."

KRASAE passed the fourth grade examination and was admitted to the first grade of secondary school. In the first month his marks were the lowest in his class in mathematics and English, but, convinced his protégé could learn to study again, the principal tutored him morning and afternoon. He passed the year-end examination and continued through the fourth secondary grade.

KRASAE's diligence won him notice a second time, on this occasion from the congressman of his province who was a close friend of his eldest brother; the congressman invited him to stay in his home in Bangkok and continue his studies in the capital. KRASAE had never dreamed he would live in the "city of angels"—the meaning of the Thai name for Bangkok which is Krung Thep.

Upon completion of his fifth and sixth secondary grades at Amnueysilp School, and his final two secondary grades at Triam Udom, he was admitted at age 20 to the two-year premedical course in the Faculty of Science at Chulalongkorn University. His certificate from this course, and a bare pass in the entrance examination, enabled him in June 1956 to enroll in the Faculty of Medicine of Siriraj Hospital University of Medical Sciences, from which he graduated with a degree of Doctor of Medicine on October 1, 1960. His eldest brother had paid for his tuition in Bangkok and KRASAE had worked as a tutor of twilight classes at Wat Kaewfa public school to earn the money for his other expenses.

In his preparatory and medical schools KRASAE was considered a bright student but his marks were not high because he was absorbed in extracurricular activities. He was editor of the Triam Udom school newspaper, chairman of the Debating Club of the Faculty of Science at Chulalongkorn, and member of the executive board of the forum of five universities. In his final year at medical school KRASAE was "most proud" to have published Veja Nisit (Medical Student), the college yearbook, for less than half the usual cost by buying the paper himself and having the printer press and fold it for binding into a book sized to fit the folded sheets. He also headed a fund-raising campaign for the Association of World University Service. These experiences were later to make dealing with people, local government officials and politicians easier, and they taught him the value of written and pictorial records.

As a medical student KRASAE thought often of the villagers in his home district—with infections and diseases and no doctor— and he decided to return and serve even though he was aware of the problems he would face. He knew that in rural areas a doctor's income was low, wives missed city conveniences and the education of children was difficult. He knew also that many doctors became frustrated because they used only 25 percent of the knowledge they had gained in medical school—spending most of their time treating common illnesses, of which 70 percent were gastrointestinal or pulmonary— and that rural positions were looked down upon. In Bangkok, on the other hand, he could "gain wealth like other medical doctors." However, when a classmate, hearing of his intention to go back to his upcountry home, asked why, KRASAE replied simply that he wanted to live quietly, not giving his true reasons which he thought would not be understood: "I was born there. I would like to go back. If everybody [trained in medicine] from Muang Phon District lives in Bangkok, the district will be left as a place of sickness—there will be no change, even for a century." Another spur was the death of a sister-in-law from toxemia of pregnancy because of inadequate medical care. The brother who was her husband had helped pay for his education and he felt a debt to return.

In Muang Phon District, located 3 00 kilometers northeast of Bangkok, most of the people were farming families living in villages. Their main crops were rice and kenaf (fiber used for rope). Harvests were poor because of dry, sandy, salty soil and inadequate irrigation. The average annual per capita income was US$55 compared to the national average of US$130. Low productivity, combined with illiteracy, disease and a high birth rate, made for a depressed, backward community. The town of Muang Phon was ordinary. The main street was a mixture of small shops selling tinned goods, matches, candles and notions; a few bigger shops housed branches of Bangkok businesses and there were the inevitable coffee and noodle shops and a rundown moviehouse.

The Municipal Health Center was a box-like one-storied wooden building which had been constructed in 1938 in the compound of the District Office, near the community market. There was no doctor's residence and the salary offered a doctor was poor; the doctor who finally had come to Muang Phon in 1951 had stayed only one year and no doctor had accepted a position there for eight years. The Center had been staffed intermittently by a public health warden, a nurse or a midwife who stayed a year or two and offered rudimentary services.

When the mayor took KRASAE to see the Health Center he admitted it was in very bad condition but added that, if KRASAE would come to stay, the people would help recondition it for they felt the need of a doctor. KRASAE agreed to serve as Municipal Doctor, a commitment he had already made to himself, but before settling in at his post he accepted an invitation to go to Japan for two months to attend a Quaker Seminar on Student Volunteers.

KRASAE began his work in Muang Phon in 1961 as an inexperienced new doctor, ranked Grade III by the Ministry of Public Health, with strong motivation but no illusions. He was confident that treatment of the common illnesses required no extraordinary knowledge or capability and that, if he could get the college yearbook published at half price, he could surely find ways to achieve the more important job of rebuilding and expanding the Health Center.

People remember that when KRASAE first came, he worked from dawn to dusk to whitewash and clean the Center in order to make it a pleasant place. His sincerity and courtesy to all—superiors, peers and those under him—won him adherents. To all visitors and patients, who came in increasing numbers, the young doctor talked of his program for a new center that would also be a hospital. Meeting with village leaders he pointed out that Muang Phon District had a population of more than 140,000. If each person contributed just one baht (five U.S. cents) they could have a first class health center and he would stay as doctor. The village headmen accepted his challenge and together they raised more than expected. People earning four to five baht a day gave not only one baht but sometimes three to five!

Next focusing his campaign on the town KRASAE asked the businessmen to a meeting. The Health Center, he explained, was the property of everyone and, since the villagers had contributed for the main building, would the businessmen not also help? From them came money for two inpatient buildings with 10 beds each; the new center would have the hospital facility he was striving for.

In 1962, KRASAE was promoted to medical rank Grade II and construction began on the new center one kilometer away from the old site. A sturdy concrete building for administration offices and clinic and two frame buildings for general and maternity patients were built at a cost of 282,000 baht, of which 50,000 came from the municipal budget and 232,000 from private contributions. Opened on January 16, 1963, the new Muang Phon Municipal Public Health Center quickly drew more patients than the small staff—one nurse, a young sanitary inspector, a midwife and a janitor—could handle.

Appreciating that Muang Phon—which belonged to the category of smallest municipalities in Thailand—had limited funds and authority, KRASAE recognized that, just as he had turned to the private sector for money for improvement, he would have to seek other than municipal sources to augment his staff. Also, he had sensed from the outset that a rural doctor must involve himself in the community, gain the people's confidence and enlist public support in every way possible. "No matter how modest their share," he emphasizes, the people "must have a feeling they are participating voluntarily for their own good. That is the reason I asked for one baht." In 1963, he printed a Muang Phon Directory, "a who's who of the community," which lent an aura of importance to the leaders and others who had helped him.

The doctor now introduced a new method of recruitment that was both thrifty and strengthened community participation. At a conference with the district chief, education officer, teachers and headmen to discuss the staff shortage, he requested the teachers and headmen to ask girls with sixth to eighth secondary grade education, and no jobs, to become nursing volunteers without pay. It would be a great service, he argued, and also advantageous for these young women who were "too educated to work in the rice fields but too little educated to become office workers." To KRASAE's "surprise and joy" one village headman sent his own daughter and niece. Three other girls soon appeared and since then there has been no shortage of volunteers. With time and training most girls learned to help in the labor, examination and treatment rooms, and at the reception desk. After volunteers worked for six months a ceremony was held where they received certificates of appreciation from the mayor; thereafter they were paid five baht per day for their services. Some volunteers were later sent to the provincial hospital for further training in labor and dressing room care and in the preparation of instruments.

One difficulty KRASAE had not anticipated was patients leaving the Center at night. Learning that these patients were very superstitious and believed there were ghosts in the Center, he enlisted the help of businessmen and more affluent citizens of the town to construct badminton and tennis courts close to the inpatient wards, organized a sports club and had himself elected secretary. "In this way," he explains, "we drew a number of people into the hospital grounds. Since the playgrounds had to be lighted in the evenings when we had matches, there was a festive atmosphere and patients were entertained watching the games. After a while, patients stopped disappearing in the evenings. Now people from town and the hospital staff use these facilities anytime they want. Of course I did not tell them about the ghosts. I told them to be progressive . . . [that] we must have sports we can play here."

Reports reaching Bangkok of KRASAE’s success in enlisting community cooperation and support, and of the service he was extending to rural folk, prompted the Municipal League of Thailand in 1963 to send him for two weeks to observe public health services in Taiwan and the Philippines. In 1964, the American Friends Service Committee invited him to attend its two-month international seminar in Madras, India, and to observe the treatment of tropical diseases in Calcutta. He received a grant from the American Friends Service Committee in 1965 to participate in a seminar and to study community medicine in East Pakistan for one month. These exposures abroad proved so useful in terms of ideas and techniques that he determined to miss no opportunity to expand his knowledge in this way.

On August 16, 1965, KRASAE married Penkae Kasemsuvan, a lovely city girl who had been his university classmate. She had been working as a doctor in a Bangkok hospital. Soon after arriving in Muang Phon she joined the district hospital in Khon Kaen.

By 1966, with completion of the Friendship Highway that ran one kilometer west of the Health Center, patients began coming for treatment from outlying villages and nearby provinces, and injuries from frequent car accidents were a growing strain. KRASAE coped with onlookers at accidents by giving them chores. Persons with some education or position were asked to quiet accident victims who had not been injured by making them take aspirin, others to fan patients, play with the children or give drinking water to relatives. It was not rare to hear later in coffee shops people boasting that they had helped the doctor because there were more patients than he could attend to.

Lack of operating facilities posed an increasingly urgent problem. After several patients sent to Khon Kaen Hospital for emergency operations died on the way, the municipal council and KRASAE decided upon an Emergency Building equipped for all but major operations. For this second concrete building KRASAE raised 85,000 baht from the public; 50,000 baht came from the municipal budget. Later in 1967 the municipality allocated 100,000 baht to construct an addition to the main administration clinic building to include an X-ray room, dental clinic, storage and supply room, and quarters for a doctor and a nurse. The municipality also provided for a kitchen and laundry building.

In fiscal year 1967-1968, the Center treated 23,798 persons, providing outpatient and inpatient medical care, immunizations, laboratory examinations and maternal and child health care (for each registered pregnancy, two home visits, one Center visit, delivery, two postnatal visits, sick infant care for six weeks to one year and two well baby visits; for preschool children two home visits and examination of all schoolchildren). City sanitation also fell under KRASAE’s supervision. The work involved inspection of industrial plants, the hotel, food shops, the public market, slaughterhouse and cemetery; examination and certification of food handlers; poisoning rats and destroying unwanted dogs. KRASAE and his staff also gave talks at schools and group meetings on preventive medicine and nutrition.

In 1965, the Girl Guide Association of Thailand responded to KRASAE’s request to train three of his volunteers in patient care and social welfare work; the volunteers returned from Bangkok with new ideas, enthusiasm and willingness to work. KRASAE also developed mutually beneficial relationships with two training institutions in the province. Since 1966, the Khon Kaen Midwifery School has sent the Center four groups of two students each who stayed for six weeks. For the Center this means an additional staff for six months each year of two midwife trainees who work as they learn. Similarly, since 1967, the provincial Sanitary and Health Training Center has sent three groups of six or seven male nurses' aid trainees who stay at the Center for three weeks. These students receive a total of six months' training and after graduation are sent to remote communities to help with minor medical problems and to assist visiting mobile health teams. KRASAE uses the example of these two in-service training arrangements—that have strengthened the trainees' commitment by exposure to community health needs—to argue that the acute shortage of doctors in rural areas might be lessened if medical students spent a period of training at rural health centers, learning by actively assisting in the treatment of patients.

KRASAE has had foreign assistants as well. A Student Christian Center (SCI) nurse was so impressed by the work she saw being done at Muang Phon that she recommended her organization provide KRASAE with professional volunteers. A Dutch nurse and an English laboratory technician worked at the Center from 1966 to 1968 and in 1970 a nurse-midwife and a medical technician arrived from England.

Sustained performance and growth of the unusual community supported medical service continued to bring the doctor new experiences and opportunities as well as promotion. In 1967, he was appointed chief of the Thailand Jaycees delegation to the International Jaycees Conference in Korea. In 1968 he became a Grade I doctor and received the Takeda grant from the Medical Association of Thailand to study accident surgery for three months at Juntendo University in Tokyo, at the end of which time he received a Diploma in Surgical Emergency. Also in 1968, he was given a Colombo Plan grant for a year of postgraduate study at the London School of Hygiene and Tropical Medicine which enabled him to earn a Diploma in Tropical Public Health. KRASAE’s wife accompanied him to England at their expense to do postgraduate study in public health herself.

His wife returned to Thailand in July 1969 while he proceeded to the United States to join 39 other participants—chosen from 400 applicants worldwide—in a seven-week Harvard International Seminar. Though he had been away from Muang Phon for much of the past year and a half, KRASAE felt he must take advantage of this all-expense-paid opportunity to discuss current problems with contemporaries from other countries. After the seminar he traveled to Washington D C. to observe government administration.

While KRASAE was absent, services at the Muang Phon Public Health Center fell off sharply. The number of inpatients could be accommodated in one ward, therefore the other ward was appropriated by the municipality for temporary offices until the new municipal building was completed. When he returned on September 4, 1969 with new ideas and new confidence, KRASAE immediately set to work to rebuild and extend the municipal health services. People who had been awaiting his return came in large numbers, patient wards filled again and the staff worked long hours and weekends.

Awaiting KRASAE on his return was the good news that in July 1969, Pravat Ketlekha, a wealthy woman of Muang Phon, in memory of her husband Phra Sripolarat, had donated 50,000 baht for construction of a ward for private patients and had asked KRASAE to make arrangements with the municipality and manage the implementation of her gift. Construction of the Sripolarat Building began on February 2, 1970. A few days later, an accidental fire in the Sripirom maternity ward burned that wooden building to the ground. KRASAE quickly arranged to rebuild this ward for even with the old 10-bed Preecha Pisitkasem Building and the new 25-bed Sripolarat Building there was insufficient space to meet the growing demand.

The Ministry of Public Health in 1970 took over the administration and operating costs of the Muang Phon Health Center and appointed KRASAE as its director. Noting the striking community acceptance and support of modern medical practice in the district the ministry also asked KRASAE to design a pilot family planning program for the countryside and to provide data and statistics for the ministry to work with.

The Thai population was then increasing at a rate of 3.3 percent per year—the highest in the country's experience. Alarmed by the prospect of a population of over 100 million before the year 2000—and the obstacle this rapid increase would be to economic and social development—the Thai cabinet in March 1970 had approved appointment of a 22-member National Family Planning Committee, chaired by the Minister of Public Health, to study and coordinate implementation of a nationwide voluntary population policy. KRASAE’s assignment was authorized by this committee.

The scope of his pilot program, KRASAE decided, would be the three district centers of Muang Phon, Nong Song Hong and Wang Noi, and the 22 surrounding villages. He would use a person-to-person motivational approach. Indicative of the importance he gave to personal contact was his campaign title, "Tell the People." The resulting program, which reflected his conviction that family planning can only be effective if closely integrated with maternal and child health activities, is now a model for the nation.

Availing himself of the staff and the jeep of the Center, KRASAE set up a mobile team that first held meetings and discussed problems of travel and communication with village leaders, then traveled to the villages to show films and give health talks. At the same time, 22 wellknown residents of the towns and villages involved were employed as home visitors. Trained for one month at the Center in health education and family planning, they were sent back to their own communities to persuade people to come to the family planning clinic at the Center and to follow up on all new family planning acceptors. Each home visitor spent one day each week helping at the Center, and always accompanied the mobile team to his home district. A nurse-midwife frequently traveled with the mobile team, taking along a supply of simple drugs in order to treat minor ailments in the villages visited.

General entertainment films, and even those concerned with population control and health problems, and health talks were popular with the villagers who normally had scant diversion after their work in the fields; they contentedly watched and listened for hours. Evidencing the success of these visits was the number of people who sought family planning advice at the Center.

Monthly meetings were begun for the general public at the three district centers, with the aim of involving as many people as possible in discussions of family planning and community health. Over 1,000 people attended the first meeting on abortion and birth control held in the large Muang Phon community center. A panel comprised of a doctor, teachers, housewives, a Buddhist monk and health educators discussed the issues and answered questions from the audience. Adding importance to this meeting was KRASAE’s arrangement to have it televised. For the public meeting in Nong Song Hong on sex education and family planning the panel leader was a senior psychiatrist in the province. Discussion centered on the stresses and difficulties associated with large families. Response was good. At the meeting in Wang Noi on "More Children, More Problems," leaders from surrounding villages took part in discussion of the basic facts of family planning. These meetings helped bring the communities together and made them aware of the family planning help available.

Monthly meetings were also arranged with 20 village headmen. These key figures in village life—whose cooperation was essential— were given lectures on family planning by the health educators and encouraged to relay their new knowledge to the people of their home villages. As a result of these meetings the mobile team sent out by KRASAE was met in each village by the headman, who had arranged a suitable location for it to operate and had publicized its coming in his own and neighboring villages so that a large crowd had gathered.

Finally, school headmasters were invited to three days of lectures on a wide variety of subjects relating to health education, family planning and their effect on development. Two days of observation followed, involving visits to hospitals, the provincial television studio and Khon Kaen University. Since the headmaster is customarily a respected and influential figure in a Thai village, and usually works with the headmen in general management of village affairs, the 40 headmasters who took this course by mid-1972 were considered important motivators.

Statistical evidence shows that KRASAE’s approach has been successful. From January 1971 when two methods of birth control were first introduced—the pill and the IUD (intrauterine device)—the number of acceptors increased steadily, from 60 accepting the pill in the first month, to 250-280 per month toward the end of 1972 The number of pill revisits—i.e., clients coming back to the Center for an additional supply—increased from 100 to 680 per month in the same period. IUD insertions also increased from roughly 50 per month to 200-250.

With the family planning effort well launched, KRASAE in 1971 accepted an East-West Center grant to attend a one-month International Development of Youth Seminar in Hawaii and a second one-month seminar in Davao City, Philippines on community development and social structure sponsored by the American Friends Service Committee The same year KRASAE received the Award of the Medical Doctors Association of Thailand. The proud municipal leaders of Muang Phon reminded newsmen that it was very rare for a rural doctor to be singled out for such distinction, and expressed the hope that his work would inspire others to serve in rural communities. The award citation states "Dr. KRASAE has used his ability and knowledge to innovate and develop medical service for the municipality with perseverance and sacrifice and with the unswerving determination to improve the lot of the rural population . . . . He has also appealed to and induced the population to be aware of the participation among themselves to build and preserve the health center so that it is a real community property."

This and earlier national attention prompted many publications to carry articles about KRASAE and in September 1971 he was invited to speak to the staff and students at the Siriraj School of Medicine and Nursing He stressed that rural people should decide what kind of medical service they need and what their priorities are, and "the doctor should work only along those lines." To avoid conflict he urged new doctors going to rural areas to involve provincial medical officers in new projects and allow them to "feel big." He admitted that he was not able to give people much help medically because of lack of adequate equipment, but his interest in their medical and domestic problems had made them feel he could "solve all problems." "Rural people in my experience are cooperative," he noted. "What they need is initiatives, and doctors in rural areas have to provide them . . . . Diligence, thrift and flexibility in adapting oneself to the peoples' way of life are three essentials for doctors to succeed in rural areas."

A personal project also demanded KRASAE’s attention at this time. When he and his wife returned from abroad in 1969 they agreed she would not go back to the Khon Kaen Hospital but would care for their child, a son who had been born shortly before their departure.

Yet I "knew she was unhappy not being able to practice her profession," he relates, "so, with the help of her parents and money we borrowed we had a private hospital built." The two-story 25-bed Niwatsomboonvej Hospital opened in 1972. It is within two kilometers of the Health Center and situated just across the yard from their spacious, but not luxurious, residence so that his wife can keep an eye on their children—their son now aged five and a daughter aged two. The charges at the hospital are the same as at government subsidized clinics; charges are lower for poor patients and often such patients are not asked to pay at all.

In 1972 Muang Phon became the first municipality in Thailand to have a First Class Maternal and Child Health Center integrated with its Public Health Center. With this added function, the Center staff expanded to two doctors, four nurse-midwives, two nurses' aids, five volunteers (including two from SCI), one sanitarian, one clerk, one administrator, two typists, one janitor and two cleaners, plus the 22 home visitors. However, the increasing load of family planning acceptors, and the growing number of patients—some from remote districts and other provinces—forced KRASAE to reduce home "follow-up" visits to a minimum.

In July 1972 the Ministry of Public Health selected KRASAE to participate in a five-day international seminar on family planning in Tokyo at which he presented a report on his "Tell the People" campaign that was bringing about voluntary population control in his three pilot districts.

Widely recognized as a model, the Muang Phon Public Health/ MCH Center was the subject of study in a course offered in 1972 at the Faculty of Tropical Medicine and Health of Mahidol University in Bangkok. During a field trip students from throughout Southeast Asia spent five days with KRASAE’s staff (KRASAE was in Tokyo). Objectives of the visit were to gain a better understanding of rural public health problems, observe health center work and applied programs, gain experience in various kinds of diseases prevalent in rural areas and witness at an early stage the transition in health problems due to the construction of irrigation dams and the introduction of electricity.

The Journal of the Department of Medical and Public Health Services in January 1973 devoted an article entitled "Our Personnel" to KRASAE, who was the first among the department's nationwide roster of 40,000 doctors, nurses and public health officers to be so honored. The criteria used for his selection were listed as: good conduct both in service and in private life; outstanding achievement with supporting evidence; concern for society above personal interest; and recognition by the community in which he lives as well as the outside community.

When asked to discuss his work KRASAE always emphasizes that because rural areas are poor the rural doctor must maintain a lower standard of living than the urban physician, in order to prevent comparison between his life style and that of his patients. When people accept the doctor, he adds, they consult him on everything, not only on health problems. The rural doctor "must be patient, interested . . . . and must study the environment and the political situation so he can be a full member of the society. He must appear at social functions and not keep himself apart. He must not only conduct a medical service but encourage people to participate in that service and consult with teachers on health education."

His own ready accessibility no matter what the economic status of a patient or the hour of the day—whether he is at lunch, in conversation with government officials or at play with his children—has earned him the title "real peoples' doctor." He is said to be as easy to find as a "glass of iced coffee"—the refreshment most readily available in cafes and roadside food stalls.

Gregarious by nature, KRASAE likes to mix with people, whether at international conferences or in remote rice fields. Each day he tries to v