COOPERATIVE PROGRAM FOR ASIAN PEDIATRICIANS

The first pediatric department in Japan was founded in 1889 at the University of Tokyo by Prof. Tukasa Hirota (1). It was only 23 years since the cessation of Sakoku, the national seclusion policy, when modern pediatrics started in Japan. In order to absorb the growing knowledge of modern medicine, a substantial number of physicians went to Europe and the United States. Shibasaburo Kitasato who discovered the pest-bacillus (1894) and pure culture technique for corynebacterium tetanus, and Hideyo Noguchi who isolated Treponema pallida from the brain of patient with cerebral syphilis (1913) were among those enthusiastic young medical researchers. It should be noted that the success of these young medical researchers owed very much to the warm acceptance of their mentors in Europe and the United States. For example, Prof. Flexner in the University of Pennsylvania, the mentor of Hideyo Noguchi, accepted a young researcher from Japan who visited his office without any appointment or recommendation letters. Without their warm and generous attitude toward these young physicians and researchers from Japan, then one of the developing countries in Far East Asia, they could not have been successful. Now Japan has developed one of the most efficient medical systems in the world. People in Japan are enjoying one of the lowest infant mortalities and longest life expectancies in the world (2). We realized that now it is we, who should offer such generosity toward young physicians in neighboring countries. With that incentive, young pediatricians in our department started inviting young Asian pediatricians to Japan every year to provide chance to see the medical systems in Japan and enable them to communicate each other. In this review, we introduce the activities of CPAP and the response to this program from the participants. We also address the possible implication of such program as CPAP to the internationalization of medicine. Objectives
The objectives of CPAP are to provide a place for young pediatricians in Asian countries to communicate, exchange opinions and views about the problems they are confronting and promote mutual understanding and friendship. It is not aimed to transfer some special medical knowledge or technologies to the participants. In that respect, this program is quite different from those sponsored by Japan International Cooperation Agency (JICA). For pediatricians in developed country, it is not so difficult to attend medical meeting in foreign countries, and they have many chances to study medicine abroad. However, for young relatively unexperienced pediatricians in the less developed countries, it is quite difficult and even impossible to come out of their own countries. Although it is not difficult for pediatricians in developed Asian countries to visit their neighboring countries, they have surprisingly little chance to do so. Political barriers between countries have often hampered their potential communication and friendship. CPAP is only made possible by the unique situation of Japan, where both economical as well as political stability exist. In addition to the invitation of pediatricians from Asian countries, CPAP has been sending medical students to Asian countries where they visited the former participants of CPAP. So CPAP is encouraging Japanese medical students to learn medical situations of the neighboring Asian countries.
Thus the ultimate goal of CPAP is to construct a stable network of pediatricians among Asian countries by providing a place for young Asian pediatricians to develop mutual understanding and friendship.
Qualification of participants
The required qualification to participate CPAP is as follows;
(1) The participant should be younger than 40 years of age and has no experience of studying abroad.
(2) The participant is preferably working at a regional hospital or health center in the rural area.
(3) The participant should be able to communicate in English.
As described in the objectives, the main purpose of CPAP is to give chance to those who otherwise have little chance to come out of their own countries. We should mention however that we are having participants from Taiwan, Malaysia and Korea, where they could easily afford to come to Japan. The selection of the participants are done at the steering committee meeting. Applicants who want to learn some specific technique or knowledge are usually not chosen because of the nature of the program. Previous experiments and achievements are usually not counted as the qualification of being the participants. The numbers and countries of applicants and participants are listed in Table 1.

Actual Schedule of CPAP
The actual schedule of CPAP is shown in Table 2. CPAP has been trying to show the most ordinally medical practices in Japan. We do show new medical technologies and equipment if asked, but that is not our main intention. During the short stay in Japan, the participants are spending several days in regional hospitals, visiting university hospital, childrenÕs hospital and rehabilitation center. They also learn maternal and child health care service by visiting health centers. They experience home-stay and see the average life style of Japanese pediatricians. As clearly seen in the schedule, there are no teaching session. Instead, sufficient time is allocated for discussion among the participants and Japanese pediatricians, medical students. Much time is also spent to learn about the national and employeeÕs medical insurance system.
In order to deepen our understanding about the medical situations in neighboring Asian countries, we have been sending medical students to Asian countries where there are former participants of CPAP are working. We introduce Japanese medical students to the former participants and ask then to show their routine work to Japanese medical students. We also provide some financial support to these students to enable them to travel easier.
CPAP has been circulating a bulletin twice a year among those who cooperate the activity of CPAP. In the near future English version of the bulletin will be circulated among the former participants of CPAP, thus activating the lasting mutual communication.

Organization
Since CPAP is basically a non-government organization (NGO), its members are entirely composed of volunteers. Pediatricians, medical personnels, and medical students make up most of the members. Every decisions are made at the steering committee meetings held several times a year. Those who could attend the meeting have right to vote for the agenda.

Funding
Although its office is located in the department of national university hospital, its activity has been entirely dependent upon the donation from various sources. The alumni association of the department of pediatrics is the main body of donation. CPAP has also been supported by many private companies and individuals.

Response from the participants
So far CPAP has been inviting 36 pediatricians from 11 countries. At the end of each years program, the participants were asked to submit a questionaire-style report. Table 3 show the questions asked to the participants and the responses from the participants. Although complimentary remarks were inevitable, most of their comments and criticism in the report were frank and straightforward. For example Table 4 shows their criticism about Japanese pediatric medicine. While they valued some of the features of medical systems in Japan as shown in Table 5, they did not overlook the shortage of nursing staffs, excessive medical testings and overwork of medical personnel, the issues currently being debated in Japan. It is of interest that hard working Japanese pediatricians impressed them more than any other features of Japanese pediatric medicine. What they thought most different in Japan as compared with their own countries are listed in Table 6. Medical insurance system is listed at the top, followed by medical budget, medical education of the people, medical low and maternal and child health policies. Medical equipment and technologies are rated low, suggesting that high technology medicine is not their priority concern. Table 7 lists the items which the participant wanted to introduce to their countries. As seen in the table, they want to establish a sound medical insurance system in their own countries.
Several Japanese medical students had been visiting the institutions and hospitals where the previous participants are working. With the supervision of the former participants, they learned the medical situation as well as social and cultural background of Asian countries, which is a sine qua non to participate in the international cooperation in medicine in the future.

Discussion
It has been said that we are living in the era of internationalization. Owing to the national success in economics, Japanese foreign aid is ranked second to the United States. It is not surprising that expectation to the contribution of Japanese pediatricians in international child health promotion has been growing in recent years. Unfortunately, our experience in the international cooperation in pediatrics has been immature, and we need more experience and exposure to international health. Those who would like to participate in international medical cooperation should learn many things before they start the cooperation. The techniques and knowledge of international cooperation such as appropriate technology transfer and logistics are of course very important. However, we believe good relationship between the medical personnels involved in the cooperative projects is equally important. By facilitate the mutual understanding among pediatricians in Asian countries, CPAP could contribute in making cooperative project in Asian region easier and smoother.
Since we are inviting about 10 pediatricians every year, the cumulative number of the participants will reach more than 100 by the end of this century. By circulating bulletins, we are trying to maintain a long lasting relationship among the participants. It is hoped that cooperative studies or projects such as comparison studies on child health among Asian countries involving the previous participants will be undertaken in the near future.